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We explored girls’, teachers’, and janitors’ perspectives and evaluated the acceptability, feasibility, and potential for sustainability of the piloted disposal system.

Like other low- and middle-income countries, Bangladeshi schools lack facilities for girls to change and dispose of their menstrual absorbents.

tratifier.

A Female WASH Access Index was created by combining numerous indicators specific to female WASH needs, using principal component analysis (PCA) [51]. The Female WASH Access Index included six WASH items: 1) main water source, 2) sanitation facility, 3) bathing facility, 4) access to menstrual health materials, 5) basic hygiene facility, and 6) solid waste disposal facility. The PCA score was transformed to a 0 to 1 index using a percentile function, where 0 represents the worst observed value and 1 represents the best. Index results are described as points.

Every month, women and girls require access to menstrual materials to manage bleeding, private facilities to change menstrual materials, bathing facilities, clean water, toilet paper and/or soap and water to wash and dry themselves, and soak, wash, dry and/or dispose of used materials [19,20,21,22]. Without access to the necessary supplies and services for managing menstruation, women are at a greater risk for diseases, including urinary tract infections and toxic shock syndrome [23]. Female refugees face significant barriers; dignified, private and safe menstrual management is difficult, as they often have to share sanitation or hygiene facilities with males, multiple households, or with strangers [20, 24]. This has been associated with sexual harassment and gender based violence (GBV) in refugee camps and settlements)

Many refugees face challenges accessing basic services including water, sanitation and hygiene (WASH) services [3,4,5,6,7](p), which increases their risk of mortality and morbidity

Most camps have improved sanitation, albeit often shared and with poor privacy. Most households had access to soap, but few had dedicated hand hygiene facilities. Households with women of reproductive age had lower access to basic sanitation. The Female WASH Access Index summarizes and compares female access across camps. Households with disabled or elderly members, and fewer members had poorer WASH access.

Little attention has been given to understanding the ways in which MHM contributes to school absenteeism and other gender disparities in Zambia.

Menstrual hygiene management requires availability of and access to clean and absorbent menstrual material, privacy, water and soap, and disposal facilities for used menstrual materials

For instance, a study in Kenya found that cleanliness of school latrines reduced the odds of absenteeism [3] and others suggest that one in ten school-aged girls in low and middle income countries fail to attend school during menstruation or drop out of school at puberty due to the absence of menstrual hygiene management (MHM) facilities [4,5,6,7].

Girls complained of friction burns on their inner thighs during their long journey to school due to chaffing of wet non-absorbent material used to make menstrual cloth. Girls preferred to dispose used menstrual materials in pit latrines and not waste bins for fear that they could be retrieved for witchcraft against them. Though traditional leaders and female guardians played a pivotal role in teaching girls MHM, they have not resolved challenges to MHM among schoolgirls.

The notion that a basic WASH standard should be in place – so that women can urinate, defecate and manage menstrual blood flow with privacy, safety, and comfort while participating in informal or formal work in a given context – has not been specifically included in the 2030 Agenda for Sustainable Development. However opportunities exist in the Sustainable Development Goals

2.4 billion people globally have no access to improved sanitation facilities. Of them, 946 million defecate in the open

One study noted women in textile factories used discarded factory cloths as MHM materials, with such rags often doused in chemicals, possibly causing irritation

In rural contexts in LMIC, women contribute extensively to the agricultural sector. Of all women working in sub-Saharan Africa and South Asia, 60 % work in the agricultural sector [4]. When these women menstruate, their workplaces pose particular challenges, such as a lack of sanitation facilities, being remotely located, or having very long workdays in the fields. These in turn preclude girls and women from having the time or privacy to attend to their MHM needs.

Currently, the drivers behind menstruators’ choice of disposal and washing practices are often not documented and rarely considered when WASH facilities are designed.

Menstrual health and hygiene (MHH) are an integral part of public health, recognized by an increase in research on this topic in the past decade [e.g. 1,2], and the recent definition of menstrual health [3]. Within the MHH space there has been a lot of research into the provision of menstrual materials, and subsequent interventions that provide those who menstruate with both reusable and disposable materials [4–6]. However, there has been less research into what happens once these materials have been used; the full lifecycle of these materials has often not been documented. Understanding the full lifecycle of menstrual materials is especially important for those designing the infrastructure of water, sanitation and hygiene (WASH) programs, including, but not limited to, toilets, bathing facilities, washing and drying facilities, incinerators, and solid waste management services.

with the aim to inform water, sanitation, and hygiene (WASH) programming on better facility user designs and waste management practices to support the menstrual hygiene needs of women and girls, and the environment.

. An underlying reason could be the lack of clarity and consensus over how menstrual waste is classified (for instance, as solid waste, hazardous waste, or bio-medical waste), which makes it difficult to offer clear guidance on how best to discard used products, leading to inappropriate and unsafe disposal practices [9] House [4] notes that menstrual hygiene friendly infrastructure includes “clear mechanisms for collecting and disposing of menstrual waste,” but does not elucidate what these mechanisms could be. Incorporating MHM considerations to include waste management into WASH sector planning will advance goals to ensure safety, dignity, and deliver demand-generated designs for women and girls by responding comprehensively to their biological needs [10]. Better MHM is important for sanitation access, sustained facility use, and for gender equity. Improved access to culturally acceptable MHM in sanitation facilities enables women and girls to fully engage in education and at the workforce [11].

Shared and public facility maintenance is frequently a source of environmental health risks due to poor hygiene. In countries where there are many stigmas and taboos around menstruation, poor waste management on-site creates anxiety and stress.

Menstrual hygiene management in the water and sanitation sector is not formally defined in the Sustainable Development Goals (SDGs). However, clear linkages are framed here to include: SDG3 (physical health and psycho-social well-being for women and girls), SDG4 (quality education for girls), SDG5 (gender empowerment and equality), SDG6 (water and sanitation), and SDG12 (responsible consumption and production for the environment).

A Zimbabwean study found that cloth and cotton wool were the most widely used materials (Averbach et al. 2009Averbach, S., N. Sahin-Hodoglugil, P. Musara, T. Chipato, and A. van der Straten. 2009 Duet™ for menstrual protection: A feasibility study in Zimbabwe. Contraception 79:463–468. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]), while in Tanzania, 60 percent of women interviewed reported using cloth (Allen et al. 2010Allen C. F., N. Desmond, B. Chiduo, L. Medard, S. S. Lees and et al. 2010 Intravaginal and menstrual practices among women working in food and recreational facilities in Mwanza, Tanzania: Implications for microbicide trials. AIDS & Behavior 14 (5):1169–1181. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]). In similar low-income settings in Bangladesh, Nepal, and India, women also most commonly use reusable cloth, and their priority, therefore, is for hygienic and private washing and drying facilities, rather than appropriate disposal systems (

There is increasing evidence that MHPs—mainly rags, disposable pads, and tampons—are finding their way into water-borne sanitation systems globally, causing blockages and system failures.

Rapid urbanization and market penetration are increasing the availability of disposable, nonbiodegradable sanitary pads in low-income countries, where demand for improved sanitation coverage is simultaneously expanding (Sebastian, Hoffmann, and Adelman 2013Sebastian, A., V. Hoffmann, and S. Adelman. 2013 Menstrual management in low-income countries: Needs and trends. Waterlines: International Journal of water, sanitation and waste 32 (2):135–153. [Google Scholar]; UNICEF and WHO 2012UNICEF and WHO. 2012 Progress on Drinking Water and Sanitation: 2012 Update. New York: UNICEF. [Google Scholar]).

Globally, women’s choice of products for absorbing menses and their related disposal methods—such as reusing, burning, or dumping products in the garbage or in sanitation systems—are likely to be shaped by local knowledge and taboos relating to menstruation, as well as by personal preferences and available resources (Delaney, Lupton, and Toth 1988Delaney, J., M. J. Lupton, and E. Toth. 1988 The Curse: A Cultural History of Menstruation. Chicago, IL: University of Illinois Press. [Google Scholar]; Sumpter and Torondel 2013Sumpter, C. and B. Torondel. 2013 A systematic review of the health and social effects of menstrual hygiene management. PLoS ONE 8 (4): e62004. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]).

Cost-effective, convenient, and sustainable solutions are needed to meet the menstrual hygiene needs of girls and women in low-income settings, and interest in this area among researchers and advocates in the development and education sectors is growing

Until now, most rural women have used pieces of old saris or other textiles, such as discarded bed linen.

How a society deals with menstruation can reveal much about how it perceives women (Laws 1990Laws, S. 1990. Issues of Blood: The Politics of Menstruation. London: Macmillan. [Crossref], [Google Scholar])

My critique hinges on the fact that the attempts to focus on menstruation have, however, been through a medical lens alone, leaving aside possible different views of menstruation and subsuming alternative and less commercial ways of managing this essential biological function.

When the rapidly increasing popularity of disposable pads is also considered, it is clear that environmental and public health consequences could be serious if suitable infrastructure, products, and services, are not made available to women.

There would appear to be a paradox between the conceptualisation of menstrual blood as filthy, disgusting, shameful, and dangerous, whilst being simultaneously revered for healing. Drawing on theories of dirt and disgust can help to explain this apparent contradiction.

Both pads and cloth require eventual disposal; pads are disposed after each use, and cloth is ultimately disposed when the material is worn out through repeated washing and no longer absorbs liquid. Pads generate a considerably larger volume of menstrual waste than cloth, which is often reused for months or years. Most participants disposed of their pads and cloth either by burning them, or by discarding in pit latrines.

The higher volume of waste created as a result of using disposable pads was seen as a negative aspect by some women, who felt that cloth was safer and left them less at risk of ufiti.

Several women kept their menstrual cloths in case they were required by an ill or injured family member, even after they were worn out and no longer functional in their original sense. One woman required permission from her husband before discarding menstrual cloths, as they were considered so valuable.

Small amounts of menstrual blood remaining in the menstrual cloth after washing (as evidenced by staining and discolouration of the material) was believed to give the cloth medicinal qualities; cloth which had never been used to absorb menses, or ordinary blood, were not thought to have the same effect.

‘Menstrual blood is filthy. It is not like the regular human blood. It stinks, so for others to see it is not good at all’.

as Elizabeth [late teens, suburb, pit latrine, pads] described: ‘When I use the toilet, maybe I have spilt some blood and I didn’t check and see it, and my dad enters the same toilet, he may feel disgusted… it doesn’t bring respect’.

The two most common menstrual absorbents used by participants were disposable shop-bought sanitary pads (42%), and menstrual cloths (42%), the latter made from pieces of old clothing or blankets, used to absorb blood, and then washed, dried, and reused.

conversational interviews with 31 female participants between the ages of 19 and 63, living in the city of Blantyre, Malawi

in Blantyre, Malawi–pit latrines, flush toilets, and urine-diverting dry toilets (UDDTs). Pit latrines are the most common type of toilet facility in Blantyre, used by 78% of the population, followed by flush toilets (21%) [20]. UDDTs are relatively uncommon, used by less than 1% of the population, but are promoted in Blantyre and more widely across Africa by advocates of ecological sanitation. These are a type of resource-recovery toilet that separates urine and faeces at the point of use by diverting urine into a tank or into the ground and allowing faeces to fall into a dehydration vault. Water and solid waste should not enter the faecal vault of a UDDT as this can compromise the dehydration process [21]. The particular ways in which these three sanitation facilities facilitate or hinder management of menstruation are examined, with the aim of providing insights into improved service design.

Similarly, a preference towards disposal of menstrual waste in pit latrines can hamper the economic viability of the pit emptying sector, and impede the recovery of value from faecal sludge in the form of agricultural nutrients or energy [14, 18, 19].

this infrastructure must reflect local norms and preferences around menstruation, rather than being merely replicated in different contexts

Infrastructural services that provide waste disposal and/or privacy—including water supply, sanitation and bathroom facilities, and solid waste collection—all play into women’s experiences and practices of menstruation

For example, in particular contexts, menstruation can affect women’s participation in religious life [4, 5] and can cause a degree of withdrawal from public life, ranging from the avoidance of crowded places [6] to total isolation [7]. Some menstruating women may be expected to abstain from cooking, washing, or household chores [3, 7], whilst others do not refrain from anything at all [