Introduction

Menarche is the onset of menstruation and marks an important benchmark in the growth of females,^[1] which is normally attained between 11 to 16 years of age.^[2] It is the threshold which the body crosses and enters the active phase of reproduction, which is established by onset of menstruation along with various changes in the physiological and anatomic activities of the body that transform little girls into young women. Of all the changes that occur in the female, menstruation is by far the most significant one. It leads to anxiety, discomfort and in many cultural practices carries with it a taboo restricting many girls from various social, cultural and educational activities.^[3], ^[4]

In many cultures of India and the world, menstruation is still considered something unclean,^[5], ^[6], ^[7], ^[8] bad and even cursed.^[9] It is surprising and also saddening to note what mental agony all young girls have to go through during the menstruation phase due to these cultural habits.^[10], ^[11] Girls typically miss a major chunk of the (20%) school attendance after attaining menarche in India, due to the non-availability of clean washroom facilities.^[12], ^[13], ^[14], ^[15] Furthermore, the school dropout rate has been shown to increase after menarche.^[16], ^[17], ^[18], ^[19] Menstrual hygiene is something which should be taught to girls right from the beginning, so that they lead a happy and healthy life, which would later transcend into a healthy reproductive career.^[20] The social and cultural taboos create a barrier for easy and free talk and practices related to the menstrual hygiene that should be followed by a female.^[11], ^[21], ^[7] Lack of infrastructural planning for these taboos, reaffirms this barrier.^[17], ^[18], ^[22], ^[19] It is the responsibility of health care workers, policy makers and family members to ascertain, that their daughters feel safe, happy and confident during their transcending into adulthood. The girls need not be ashamed of a natural phenomena, and which is an important step for their health.

Objectives

The study was conducted with the objective of assessing the knowledge and awareness about menarche and menstrual cycle among the general population especially females. Further, to study the prevailing practices of menstrual hygiene among the adolescent girls. The study also included various sociocultural restrictions and taboos under practice in relation to menstruation and to evaluate the reasons and their solutions in improving the present situation of female hygiene practices in India.

Materials and Methods

A semi structured, questionnaire based survey was conducted among adolescent girls aged 11-18 yrs from nearby schools of a Medical Institute, with the help of postgraduate students and medical interns. After the survey an educational and awareness talk on the hygiene practices to be ideally followed by each female was discussed and elaborated.

The present study was conducted in the department of Obstetrics and Gynecology, Index Medical College, Indore. It was a community based cross sectional study conducted in the schools adjoining and near the institute. Ethical clearance and permission was obtained from the institutional ethics committee. The study period was 3 months and conducted between November 2019 to January 2020 in the schools near Index Medical College Hospital and research center, Indore, Madhya Pradesh.

The study was conducted in a written paper based question answer format, after getting permission and approval from the school authorities. Consent was obtained from the students and their parents for participation in the study. The data was collected using a semi-structured questionnaire printed in both Hindi and English. Postgraduate residents and MBBS Interns after approval formalities from school authorities arranged for a meeting with girls on a set date and after collection of the filled forms were entered into Google forms software. Windows office was also used for manual assessment of data.

Girl students from classes 6^th to 12^th were provided with an assessment form which included demographic data and health, hygiene and cultural practices related questions. They were explained about each question and full confidentiality was maintained. The student were provided with adequate time to fill up the questionnaire. After the survey a talk and presentation was given to educate the participants about the basics of menstruation and various measures to maintain health and hygiene during that period, followed by a question and answer session for discussing and clearing their doubts.

In the inclusion criteria all girls between age groups of 9 to 18 years were the target participants. Girls aged less than 9 years or more than 18 years were excluded from the study. Even girls or their parents who did not give their consent were excluded from the participants group.

Results & Observations

A total of 478 girls, from 8 schools participated in the present study. [Figure 1] shows the distribution of the participating girls. Majority of the girls were of 14 years of age. [Figure 2] shows the pattern of girls as per their religion. 90.9% girls were Hindu. Rest 9.1% was constituted by other religion girls - Muslims, Buddhists, Sikh, Christians and Parsi.

Parent’s education is also an important aspect of child’s education, perception as well as understanding. ([Figure 3], [Figure 4]). 24.30% fathers were graduates while majority of the mothers 30.8% were uneducated. This scenario carries an important landmark in the child’s mental status as evident in this study. 88.2% participating girls had attained menarche at the time of start of study. ([Figure 5]).

An interesting observation was related to the awareness among these girls about menstruation. 56.4% participants had awareness about menstruation even before having their first period. This could be attributed to education from mother and also awareness by the peer groups. 40.3% developed self awareness after having their first period. ([Figure 6]) A mixed pattern of reaction was noted in relation to the first menstruation. Although there were overlapping reactions but the majority 30.5% got worried and tensed. Next in line was insecurity as reported by 28.5% girls. An interesting point to note was that 15% girls commented on sexuality stating that boys too should face this issue ([Figure 7]).

Social and peer group taboo alongwith family pressure was evident when the question of restrictions during the menstrual phase was put forward to them. 38.6% responded mentioning that they were not allowed to pray during those days while next in line were girls 28.4% stating that were not permitted to attend religious functions ([Figure 8]). Other restrictions included – limitations to do routine household activities, had to sleep on a different bed, were not allowed to play or move outside.

The girls also displayed various health issues during their menstrual phase. The different complaints reported included abdominal pain (20.5%), mood swings (15.0%), heavy bleeding (13.3%), weakness (11.5%), fatigue (11.5%), headache (10.8%), backache (8.2%), less bleeding (4.7%), and miscellaneous in 4% girls ([Figure 9]). Sharing of their health problems was an important issue among the girls. Their best companion was mothers and peer group friends followed by their sisters, teachers or the doctors. ([Figure 10]).

[Table 1] shows the hygienic measures and practices during the menstrual phase. Numerous ill practices were followed by the participant girls. For example disposal of pads or clothes were done in an unhygienic or improper manner. Majority 82.2% threw the used cloth or pad in the dustbin after wrapping in old paper or newspaper. 16.4% threw it in open dustbin without any cover, while 1.4% reused the clothes after washing. ([Table 1]). Taking a daily bath during the menses and cleaning of the private parts all carried social taboos along with them. 90.4% took daily bath even during their periods. Rest 9.6% responded by stating no or didn’t prefer to answer. Similarly, 98.6% cleaned their private parts during the menstrual phase. Some used only plain water while others used soap, antiseptic solution or hygienic wash solution for cleaning. ([Table 1])

A comparative table with those of the published literature is depicted in [Table 2].

The survey showed that 56.4% females were aware about menstruation before attaining menarche, and 88.20% had attained menarche at the time of study. 68.5% of the respondents had mother as first informant, 40.3% knew about menstruation only after getting their 1^st period. Regarding their feelings 28.5% felt insecure, 18.4% had anxiety and, 30.5% were worried about menstruation. Coming to their perception 95.5% considered menstruation as a natural process, while 3% felt it as a disease or abnormality, or having cursed 43.8% could identify uterus as the source of bleeding Rest 56.2% could not clarify on the bleeding source. 98.6% used sanitary during menstruation, 1.4% used old cloth. 98.6% cleaned their private parts during menses of which 75.3% used only water. Only 78.1% girls had the facility to change pads in their school, of which only 58.9% changed pads during the school hours. 90.4% took a regular daily bath during the menses. It was surprising to note that 38.6% girls were not allowed to pray during their menses and 28.4% weren’t allowed to attend religious functions. 5% were not permitted to attend school, 8.3% were not allowed to sleep on their regular bed, and 11% became untouchable and were asked not to touch family members. 5% girls were restricted from playing outside and were not even allowed to go out of their home. 81.3% shared their menstrual health problems with their mother.

Discussion

The above study and many more have brought to light the need for awareness programs and educational platforms to talk about the basics of female hygiene and how to economically achieve them.^[17], ^[18], ^[22] Since mothers were found to be the sole source of information about menstruation for maximum girls^[23], ^[24], ^[25] and even the first person they would confide into in case of any health problem, it is of utmost importance that mothers are educated about the same and taught hygiene measures to take care of themselves and their daughters.

It was observed that not all schools had clean toilet facilities along with disposal and cleaning facilities,^[18], ^[22] infrastructural planning should be undertaken to make schools and most buildings to aid and support the basic facilities to maintain female hygiene. The social taboos are a very important factor in making girls feel inferior or untouchable,^[11] which should be eradicated by introducing dialogues and awareness. For this purpose local leaders, religious leaders and celebrities should be involved by the government in helping to spread the awareness and also promote hygienic measures. Sanitary pad vending machines should be installed in easy to access locations and buildings for public use. These machines dispense pads at a cheap rate, thus providing an easy access to each girl and woman.

Along with this, proper disposal facilities should be made available, and installing special bins in buildings and schools to inculcate the habit of adequate disposal of used pads should be promoted.

This study and others conducted to understand the perception of menstruation among females and society has led to understanding that still menstruation is not taken as a natural process, but rather as a curse and menstruating girls and women are being put under a lot of restrictions due to such practices. Also lack of proper infrastructural facilities are a reason why so many girls drop out and restrict their attendance at school after menarche and much still needs to be done in this field to ensure smooth and healthy transition of adolescent girls into adulthood.

Conclusion

The present study is a very pertinent one highlighting both the prevailing social taboos on one end as well as the newer mind set of the girls and their parents related to the menstrual phase. Even few schools have adopted to the newer concepts and requirements. Good number of girls have started using hygienic and disposable sanitary pads as against the unhygienic cloths. Sanitisation during menses, proper disposal of the used pads, mental balance are other important aspects indicating a major change in the scenario. However, existence of stigmas such as banning girls from praying or attending any religious functions are important and to be considered.

Source of Funding

None.

Conflict of Interest

The authors declare no conflict of interest.