Innovative Ways of Dealing With Menstrual Health Among the Marginalized Communities in Kenya

Globally, there are 1.8 billion young people and the majority live in developing countries. Approximately half of them about 900 million are adolescent girls and young women. Notably, the adolescent girls have huge untapped potential, unfortunately most of them are marginalized and vulnerable. This paper discusses menstrual health challenges facing the adolescent girls and innovative ways of dealing with it. Menstruation is a natural process that every woman experience in her life time. More particularly, it is one of the physical changes that occur in girls at the start of puberty. However, in the developing countries menstruation is associated with myths and beliefs which lead to feelings of shame, stigma and anxiety. Besides, the girls lack adequate knowledge on how to handle menarche and the prohibitive costs of sanitary pads. Worldwide, studies have reported that more than 50% of girls have inadequate menstrual health facilities with high proportions reported in the rural areas. In Sub Saharan Africa, it is estimated that one in ten girls misses school during menstruation. In Ghana, it is estimated that 11.5 million women experience poor sanitation. In Kenya, 1 million girls miss over six weeks of school in a year due to lack of access to affordable sanitary pads. The marginalized communities are adversely affected. Innovative ways of dealing with menstrual health have come up though it experiences inadequate coordination, funding and awareness. In Rwanda, Sustainable Enterprises is working with communities to turn discarded banana fibers into affordable biodegradable sanitary pads and provides menstrual education. In Kenya, Zana Africa uses local agricultural products to produce affordable sanitary products. The use of menstrual cup has been associated with fears such as loss of virginity, cultural beliefs that forbid girls from touching their reproductive organs, limited resources such as soap and water. The paper recommends that awareness need to be created on the existence of innovative products, linkages and partnerships to be enhanced to ensure that the girl has access to the facilities. Beyond that, there is need for investment in research to unearth more sustainable products. Finally, a multipronged approach that encompasses government institutions, community, parents and development partners should be adopted. This enhances effective sustainable solutions. Key Words; Menstrual Health, Innovative Ways, Adolescent Girl, Marginalized, Kenya. INTRODUCTION Globally, there are approximately 1.8 billion young people living in the world and the majority live in the developing countries. About 900 million are adolescent girls and young women. The statistics show that approximately 113 million adolescent girls live in India, of this 54% are unaware of menstruation before they have their first menarche, 77% do not know that the uterus is the source of bleeding and 45% believe that menstruation is normal. Menstruation is a natural process though it is linked with misconception and practices and is still regarded as unclean and dirty. The way an adolescent girl reacts to menarche depends on the awareness and the knowledge given and this can have a lasting impact on her response to the event of the menstruation. This is further complicated with the lack of facilities affecting the girls in Birech, J. (2019). Innovative Ways of Dealing With Menstrual Health Among the Marginalized Communities in Kenya. Advances in Social Sciences Research Journal, 6(2) 265-274. 266 URL: http://dx.doi.org/10.14738/assrj.62.6168. developing countries. Notably in India alone, 63 million girls lack the adequate menstrual health facilities. According to Sommer (2013), such facilities should consist of clean menstrual management material that absorbs menstrual blood, privacy, use of soap and water for washing hands and having unlimited access to facilities to dispose of used material. It should be done with dignity and without discomfort or fear. However, he acknowledges that there is absence of guidance, facilities and materials for school girls to manage their menstruation in low and middle income countries. Research has shown that poor menstrual health contributes to inequity, increasing exposure to transactional sex to obtain sanitary items, this has long term consequences such as girls dropping out of school and early pregnancies. This greatly affects the future of the girl child a factor prevalent in the marginalized countries (Sommer et al 2016, House et al 2012). In the Sub Saharan Africa one in ten girls misses school during their menstruation period , accounting to approximately 20% yearly, many girls drop out altogether (UNICEF and WHO 2013 ). In addition, approximately 17 million girls are out of school, most of whom end their formal education after reaching puberty. According to UNICE, of the 121 million school age children that are not in school, the majority 65 million are girls. The magnitude of the numbers can mask the uniquely personal nature of the challenge many girls face in attaining education. In Ghana, it is estimated that 11.5million women lack hygiene/sanitation management that adequately separate waste from the human contact. In Ethiopia, like in many parts of the developing world, Menstrual Hygiene Management is one of the critical challenges adolescent girls face while they are in school (Tsegaye,2011). A study conducted in four districts in southern Ethiopia revealed that the school environment is not conducive especially for Menstrual Hygiene Management. The study showed that girls use unhygienic rags during menstrual period and have little knowledge on how to keep personal hygiene during menstruation. The study also revealed that menstruation is seen as a taboo by communities and school teachers. Parents do not provide information and guidance on Menstrual Hygiene Management which leave school girls without assistance on how to manage their menstruation hygienically. The same study disclosed that 70% of adolescent school girls miss 2-3 school days each month, which in turn has a significant impact on their school performance. Studies have consistently revealed that girls attending school in several remote rural areas stayed at home the entire length of their periods due to fear of soiling themselves in the presence of others. They used discarded cloth, which they felt offered insufficient protection on the long walks to school, which in turn prompted them to stay at home (Linda 2009). As mentioned earlier, In Kenya, 1 million girls miss over six weeks of school in a year due to lack of access to affordable sanitary pads. The Girl Child Network conducted a need assessment on gender equity and equality following the introduction of Free Primary Education (FPE) the study revealed that a girl who is absent from school due to menstruation is likely to lose 13 learning days equivalent to two weeks. This has an impact on the transition to the next class, the self esteem of the girl and the academic performance (Girl Child Network 2003) The foregoing discussion shows glaring challenges the adolescent girls face in the developing countries. The discussions below focuses on the Kenyan context, highlighting the challenges and the innovative ways of dealing with menstrual health. The challenges are grouped into three , the socioeconomic, sociocultural and inadequate knowledge on menstrual health. SOCIOECONOMIC FACTORS One of the greatest challenges facing Kenya and other developing countries is poverty. Kenya has a population of 44million people, 42% live below poverty line. Nearly one in two people in Advances in Social Sciences Research Journal (ASSRJ) Vol.6, Issue 2 Feb-2019 Copyright © Society for Science and Education, United Kingdom 267 rural Kenya are poor compared to only three in ten in the urban area. Given that most of the population, 70% live in the rural areas, poverty is still a rural phenomenon according to the Kenya National Bureau of Statistics. This simply shows that many girls cannot afford to pay for hygienic absorbing material, pain relieving medicine and the adequate disposal of used materials. In some rural areas girls use rags and leaves as an alternative to sanitary pads,( Lukalo 2010).Notably, certain qualities that those living in the developed countries such as the United States of America consider basic such as healthcare, education, clean water and sanitation are luxuries for those living in Kenya. Lack of these essential facilities puts the adolescent girl in a precarious position. The cost of sanitary wear and towels is beyond the reach of many girls who are living in poverty, most of them end up missing school. According to UNICEF, one in ten school girls in Africa miss class frequently or drop out completely out of school due to their periods and they substitute pads or tampons for less safe and less absorbent materials such as rags, newspapers or bark, WHO and UNICEF (2013). Citizen Kenya, (2013) showed that Girls in Marigat, Baringo county Kenya, do not afford sanitary towels, it was one of the districts that had not benefitted from free sanitary towels programme rolled out by the ministry of Education in Kenya. The girls missed school during their menses and opted to use goat skins, chicken feathers, soil and even leaves during their menses . Valentine Atieno a 13 year old girl narrated that before she was introduced to Ruby cup she was using rags and newspapers during her periods, as her mother could not afford sanitary pads. She usually stayed at home during menstruation because she was afraid of the too frequent leaks that made boys and other girls in school laugh at her (Weigaard, Julie, 2013). A study carried out by FAWE on sexual maturation in Kenyan, Ghana, Uganda, Zimbabwe found out that menstrual materials used by girls during menstruation depended on the family’s socio-economic status. The study showed that girls who were fortunate to access cloth reportedly did not have enough of it, thus resulting in sharing of the menstrual cloth with other girls. The absorptive capacity of the product determined how secure the girl felt and the level of mental concentration in class work ( FAWE 2003) . Reportedly, the girls who used ‘Always’ pads only worried about the period pains and cramps while those who used rags or cloth constantly worried about potential “accident” of soiling their clothes. The physical and mental discomfort forces the girls to stay away from school during the duration of the menses. Studies show that most girls from poor backgrounds are forced to stay away from school during menstruation period while boys continue learning, a situation that creates a margin gap in performance between the two genders, they cannot compete well with the boys, their self esteem is affected among other inhibitions (Matovu, 2011). Poor sanitation facilities is another factor that is a hidden barrier to girls’ education. According to UNICEF (2008) the child-friendly schools, which provided privacy and hygiene facilities for girls through separate toilets for boys and girls as well as water and wash areas, tended to attract and retain students at a comparatively higher rate, especially the girls. This is because separate toilets not only provide privacy but also encouraged girls who are menstruating to attend and remain in school where they are able to attend to their feminine hygiene needs and manage their period discreetly (Muchemi, 2007). Studies have shown that many schools in Kenya do not have lockable toilets, access to flowing water for washing hands. Estimates on access to private , improved sanitation in Kenya shows 31% of urban population and 39% of rural population , slightly over 21 million people still use unsanitary or unshared latrines. Approximately 18% of rural populations in the country still practice open defecation, WHO , UNICEF (2015). An assessment of existing WASH facilities in schools in rural Kenya shows that only 60% have acess to water for hand washing and 2% had soap. While 84% of schools had gender separated toilets , 77% did not have locks, This puts the girls in a disadvantaged situation. Kelly( 2014), Mason (2013). Studies show that the Arid and Semi Arid Birech, J. (2019). Innovative Ways of Dealing With Menstrual Health Among the Marginalized Communities in Kenya. Advances in Social Sciences Research Journal, 6(2) 265-274. 268 URL: http://dx.doi.org/10.14738/assrj.62.6168. communities are the most marginalized due to poor sanitation , many of them drop out of the formal education system due to lack of basic facilities in schools such as toilets and sanitary facilities. Notably, the number of girls enrolled in upper primary progressively decreases towards upper classes . In addition, the girls lacked adequate options for safe and private disposal of menstrual waste in the rural areas, only 1% of girls are able to dispose their menstrual waste in a safe environment , Kelly, (2014) . (Mbatia, 2003:53,Akoth (2004) and Odhiambo (2004). Studies have consistently shown that menstruation causes discomfort and high incidences of pain for majority of women. It can cause shifts mood, depression, vomiting, pyrexia, endometriosis, hemorrhage, migraines, anemia and fibroids (Donimirski, 2013). It is reported that more than 10% of young women on their menstruation are incapacitated for up to three days due menstrual discomfort, (Pullon.et al., 1998). The burden of dysmenorrhea is greater than any other gynecological complains. Though mild and moderate cases of dysmenorrhoea could be treated by reassurance and Paracetamol, it is acknowledged that the effect of menstrual disorder and discomfort on a woman’s life could be so severe as to confine the woman to bed ( El-Gilany et al 2005), Patel et al (2006) Davis et.al (2001 ). SOCIO-CULTURAL FACTORS Studies show that girls who are on their menstruation are being restricted in some activities for fear that they may contaminate others, menstrual blood is considered dirty and harmful. In most African communities, menstruating girls are not allowed to be in the kitchen, to cook, to wash dishes, to participate in games. Some are not even allowed to enter into their parents’ bedroom. This enhances stigma and the girls perceive menstruation as shameful and harmful, (Kotoh 2008). Quite striking is the restricted control which many women and girls have over their own mobility and behavior during menstruation including myths, misconceptions, superstitions and taboos concerning menstrual blood and menstrual hygiene. Compounded with early marriages in some cultures forces many girls to stay away from school when they start menstruating, either permanently or temporarily (UNICEF,2005; GAPS & FAWE,1999). The girls are therefore deprived their right to health and education. Various studies show that girls fear to wash themselves adequately in school, clean their reusable sanitary pads due to a fear of harassment and cultural inappropriateness. To make matters worse the boys tease and laugh at the girls especially when they spoil their clothes due to leakage. The cultural restrictions affect the psychological wellbeing of the girl as well as the possibility of using different types of menstrual devices such as the menstrual cup seen as culturally inappropriate. (Sommer et al., 2013.). INADEQUATE KNOWLEDGE AND UNDERSTANDING ON MENSTRUAL HEALTH The family is the primary agent of socialization, the parents have a responsibility of teaching their children about their sexuality but studies have shown that it is a taboo to discuss matters concerning sex in some cultures. This this leads to lack of understanding and inadequate knowledge on menstruation. Besides many young girls don’t even know about menstruation before their first period and have nobody to discuss with about this important change in their bodies. “The sexual and disgust connotations of menstruation make it a taboo subject for girls to raise, even with their mothers (Sompter & Torondel, 2013). Additionally, those who know or found out have a poor physiological understanding of menstruation. There is also a culture of silence around menstruation leading to the menstrual process being viewed as a women weakness. Pre-menstrual awareness to girls is very important (UNICEF,2007). Menstruation is a biological inevitability in human nature, therefore preparing women and girls on how to respond to menstruation issues without demeaning their dignity is an educational imperative. Over decades, women including those in Africa settings and elsewhere have been taught that having periods is shameful and this narrative has got to change (UNICEF, 2007. The need to have good Menstrual Hygiene Management awareness is the key in preparing the girls for Advances in Social Sciences Research Journal (ASSRJ) Vol.6, Issue 2 Feb-2019 Copyright © Society for Science and Education, United Kingdom 269 menstruation. According to (Tsegayo et al., 2011) there is need for government to sensitize people about the social and cultural constructions of menarche to make it better experience for girls. Psychological and physical barriers have to be handled in order to lessen their impact on girls schooling, and the existing social structures have to be strengthened so as to create a better learning environment for girls. Further the possibility of forming girls clubs which constantly monitor the sanitation infrastructure would be a great action towards gender parity in schooling. Menstrual studies should be integrated in puberty studies in the science classes to reduce shocks and discomforts associated with menarche. Similar to findings by Bharadwaj (2004), poor Menstrual Hygiene Management emanates from the beliefs and attitudes within schools and the community and is worsened by other factors like poverty and lack of supporting infrastructure. The Menstrual Hygiene Management approaches have to deal with the physical, emotional and cultural aspects in order to have meaningful impact and this can well be done if its spearheaded by Government as a key stakeholder, (Ten, 2007). INNOVATIVE WAYS OF DEALING WITH MENSTRUAL HEALTH However, all is not lost, more and more organizations have come up with innovative solutions to help the adolescent girls deal with menstruation in a more dignified manner. The use of menstrual cups is one of the innovations that help keep the girls in school. Femme International provides school girls with menstrual cups, the menstrual cups collect blood and are emptied when it is removed. It can last upto 12 hours, the cup is made of silicone and can last for ten years. African Population and Health Research Centre carried out a study on the suitability of the menstrual cup among the adolescent girls in Kenya. It was found out that women would engage in activities more freely, it was cost effective. The problem of purchasing the pads on a monthly basis was no longer a challenge and that the focus shifted from the burden of costs to that of cleaning and sterilizing it. In addition, the menstrual cups use less water for cleaning as compared to reusable pads. It also reduces the temptation to solicit funds from transactional sex in order to have funds to purchase the pads ( Steward, K, et al 2009). However, studies have also established that the menstrual cup is faced with challenges of limited access to water, participants in the study found it problematic to change when there was no water , they preffer to stay with the cup the whole day so that they could change at home. It was also found out that the toilets are not lockable hence lacking privacy and security. In the slums of Korogocho they could not access the toilets at night, forcing them to change in the house and retain the waste for disposal the next morning in the sewage point ( APRHC (2010). It is important to have some privacy when changing the cup. Sometimes, changing it needs extra care and caution which means one can take long in the washrooms. It is worth noting that the menstrual cup is an alternative technology that helps women deal with menstruation in a dignified way, but water and sanitation need to be strengthened. When using the cup one needs to maintain a high standard of hygiene especially during insertion, removal and general cleaning. As discussed earlier, the infrastructure in most schools need to be strengthened, most of the toilets are not lockable, lack water for washing hands and this poses a health risk. A study done in Kenya on menstrual cup showed it reduced chances of embarrassment on the girls because it minimized the risk of soiling the clothes. It also reduced the burden of purchasing the pads every month. However, it faced challenges due to limited access to water, toilets, privacy and security. It was also found to be culturally unacceptable (Mwita, 2013). The Period Panties For Girls is another innovation which is designed for empowerment and purpose. The drive behind it is BeGirl . It also designs the reusable period panties and pads for girls. Be Girl is working to close the gap in education that comes about when girls miss school or drop out. It designs and produces the Flexipad which can be filled with safe and absorbent Birech, J. (2019). Innovative Ways of Dealing With Menstrual Health Among the Marginalized Communities in Kenya. Advances in Social Sciences Research Journal, 6(2) 265-274. 270 URL: http://dx.doi.org/10.14738/assrj.62.6168. materials washed and then dried up indoors in less than one hour. Their products are comfortable, environmentally friendly and leads to 70% reduction in water used for washing in one year. Another important innovation is the Sustainable Health Enterprise (SHE) based in Rwanda. It is a locally owned enterprise which manufactures affordable, ecofriendly menstrual pads. It is made from local, absorbent and affordable banana fibre. Apart from distribution, they train community health workers on how to provide education to both boys and girls about puberty and menstrual hygiene.SHE’s first advocacy campaign ‘Breaking the Silence’ brought the taboo of Menstruation to national attention as a result, the government of Rwanda included in its 2001 budget to procure sanitary pads for schools. The ministry of Education further pledged to support Menstrual Health Management as part of the national school health and nutrition plan. SHE also invests in a scalable franchise model employing women entrepreneurs to manufacture and distribute affordable, eco -friendly menstrual pad by sourcing local, inexpensive material ( banana fibres). SHE has also created a new market, creating jobs all across the value chain, from the banana farmer through the pad assembler to the pad distributer. Rwanda like any developing country, is faced with poverty. SHE notes that in Rwanda, it is estimated that 36% of the girls who miss school do so because the pads are too expensive. The rags they use combined with lack of accessible safe water supply are unhygienic and potentially harmful. SHE therefore with its market based approach is responding to the demand and strengthening capacity in Rwanda to improve access, quality and affordability of disposable sanitary pads. A commendable innovation indeed which can be replicated in other parts of Africa. AFRIpads is a social business in Uganda that specializes in the local manufacture and global supply of cost effective reusable pads. It also contributes to the development of a Ugandan rural industry that empowers its 90% female staff with productive employment. AFRIpad is also a recipient partner for a number of buy-one’ give-one programme with sustainable business enterprise in Canada, U.S and Australia. The Menstrual man is another innovation which is unique because it involves man, It is invented in India by Arunachalam Murugantham who was shocked by how his wife was managing her monthly period. He purposed to create a more affordable sanitary pad, he even wore the pad himself mimicking menstruation with goat blood to test his designs. In India only 12%of women use commercial products due to their prohibitive costs. He developed a low cost method to produce pads using pulverized wood fibre and build the model machine, a simple machine to be operated and maintained in India villages. After developing the model, he began to distribute to the villages, each machine employs ten women and can produce upto 250 pads . The women make and sell to the customers, as they give them information on how to use the pads. Another innovation is by Zana Africa Foundation. It produces and sells low cost high quality sanitary pads that are made for the African female. According to Zana Africa four of every five East African Girl do not have consistent access to sanitary pads and the girls rely on hygienic materials such as raqs and leaves. ZanaAfrica uses local agricultural resources to produce affordable pads. They reach women and girls in small towns and remote areas. Two brands are being produced, the Safi pads that target women and the Nia pads that are distributed to girls for free through organizations. Besides producing affordable pads, they also give health education to both boys and girls. The above innovations and others which may not have been brought out go a long way in helping the marginalized adolescent girl go through menstruation in a dignified manner. Research has shown that some of these interventions have helped girls stay in School. In a study in Ghana 120 girls between the ages of 12 and 18 were enrolled in a non-randomized trial of sanitary pad provision with education. Girls either received puberty Advances in Social Sciences Research Journal (ASSRJ) Vol.6, Issue 2 Feb-2019 Copyright © Society for Science and Education, United Kingdom 271 education alone, puberty education and sanitary pads, or nothing (the control group). After three months, providing pads with education significantly improved attendance among participants, and after five months, puberty education alone improved attendance to a similar level. The total improvement through pads with education intervention after five months was a 9% increase in attendance. While this study is small-scale, it indicates that puberty education even if unaccompanied by menstrual Health materials can have an impact on education, (Montgomery,P et al (2012). Regrettably these interventions are constrained to scale up due to lack of resources. On the other hand, reusable pads come with its own challenges. Oftentimes reusable pads can cause significant health problems when not cleaned properly. Social stigma and taboos inhibit the girls from washing the pads , they even feel embarrassed when drying , this poses a risk of reusing the pads when still damp causing reproductive infections and illness. The resilient nature of the adolescent girls in marginalized communities is commendable. The Kenyan government through the ministry of Education is trying its best to meet the girl child in school. The overall goal of the Ministry of Education in Kenya is to provide equal access to education for both boys and girls irrespective of their Socio-economic Status. The issue of gender equality and equity is in line with the Constitution of Kenya 2010 and the Basic Education Act 2013 and Kenya Vision 2030. In Kenya, it is estimated that 2.6 million girls require support to obtain menstrual hygiene materials. Approximately 300,000 of them owing to cultural practices particularly in arid and semiarid regions, would require both sanitary towels and underwear at an estimated cost of 2.6 billion. To address this problem, the Ministry of Education initiated the School’s National Sanitary Towels Programme with the objective of keeping the girl in School and increasing their access, participation and performance in Education. The Sanitary Towels Programme has the following components: • Provision of Sanitary towels to school girls • Training of teachers on hygienic usage and disposal of sanitary towels • Monitoring and evaluation. The programme has been in place since 2010. However, the programme is still faced with challenges, the cost of sanitary towels remains high. Lack of underpants to support use of sanitary towels. The persistent cultural practices that hinder girls from pursuing education such as Female Genital Cutting (FGC), early marriages and early pregnancies. The programme is faced with poor coordination, and lack of accountability so that all the needy girls do not have access to the sanitary pads provided by the government. The teachers, however, need to be encouraged to be actively involved in the coordination and monitoring of the programme for its effectiveness. Studies shows that there is limited evidence of approaches to teachers’ engagement and professional development that effectively address the specific demands of life skills education delivery that is beyond knowledge content (UNICEF, 2012). According to UNICEF effective delivery is dependent on participatory approaches and learning methodologies. Notably, delivery of Life skills education has often been donor driven. This, however, should be linked to governments in order to ensure acceptability and sustainability. The paper recommends consistent creation of awareness on the existence and importance of innovative ways of dealing with menstrual health, that is, the provision of affordable sanitary pads to the girls so as to keep them in school. Collaborations and Networking between various countries in Africa and beyond should be strengthened.This enhances replication of innovations in other countries as long as it is culturally acceptable. In my view, SHE enterprises in Rwanda seems a sustainable option and should be replicated in Kenya. Birech, J. (2019). Innovative Ways of Dealing With Menstrual Health Among the Marginalized Communities in Kenya. Advances in Social Sciences Research Journal, 6(2) 265-274. 272 URL: http://dx.doi.org/10.14738/assrj.62.6168. The infrastructure should be a priority in the marginalized communities. The schools should be equipped with clean and safe water and hand washing facilities. Adequate sanitation facilities such as lockable and clean toilets should be provided. In other words, a healthy social environment which values respect and human dignity should be promoted. Linkages and Partnerships with the development partners and the NGO’s should be encouraged and strengthened. These agencies not only help to demystify and reduce the taboos around menstruation but they also support the governments in developing countries with funding. There should be dialogue between the various stakeholders in society, the girls, the mothers’ teachers and the peers which include the boys. This will help the girls to appreciate menstruation as a natural process and discuss any challenges that come with it in an open way. On the other hand the mothers and the teachers should be encouraged to be more understanding to the girl child and support them without condition during menstruation. Investing in research is encouraged to unearth more innovative ways of dealing with menstrual health. The governments should provide funding to the existing foundations such as Zana Africa in Kenya towards producing more affordable sanitary products and education on menstruation. This will strengthen the capacity of the foundation to reach more girls and women among the marginalized communities in Kenya. Since 2011, with the help of Zana Africa, the Kenyan government has allocated more money to distribute free pads to school girls. But this programme has not always been implemented well. Sometimes pads are not enough and the supplies run out quite fast. This requires close monitoring, accountability and transparency for better implementation. Finally, a multipronged approach that encompasses government institutions, communities, parents, teachers and development partners should be adopted. The stakeholders’ should play a critical role in ensuring that the innovative ways become sustainable. In conclusion, it is important to note that menstruation is here to stays since it is a natural process. Children are born every day. Therefore, the governments should come up with sustainable inbuild mechanisms that deal with this process. Ultimately, governments are responsible for the health of their citizens, this includes menstrual health. References Alexander, Kelly et al, (2014) Water Sanitation and Hygiene Conditions in Kenya Rural Schools . Are Schools meeting the needs of Menstruating girls? Water 6, n0.5 (2014) : 1453-1466 Adams Hillard, P.J (2008) Menstruation in Adolescents. What is normal? Medscape Journal of Medicine 10.12:295304 African Population And Health Research Centre (APHRC) (2010) Experiences and Problems with Menstruation among Poor Women and School Girls in Nairobi, Kenya. Akoth, S.A (2004). 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Weigaard, Julie.(2013).Helping girls go through periods with dignity, Stellan consultant.


INTRODUCTION
Globally, there are approximately 1.8 billion young people living in the world and the majority live in the developing countries. About 900 million are adolescent girls and young women.
The statistics show that approximately 113 million adolescent girls live in India, of this 54% are unaware of menstruation before they have their first menarche, 77% do not know that the uterus is the source of bleeding and 45% believe that menstruation is normal. Menstruation is a natural process though it is linked with misconception and practices and is still regarded as unclean and dirty. The way an adolescent girl reacts to menarche depends on the awareness and the knowledge given and this can have a lasting impact on her response to the event of the menstruation. This is further complicated with the lack of facilities affecting the girls in developing countries. Notably in India alone, 63 million girls lack the adequate menstrual health facilities. According to , such facilities should consist of clean menstrual management material that absorbs menstrual blood, privacy, use of soap and water for washing hands and having unlimited access to facilities to dispose of used material. It should be done with dignity and without discomfort or fear. However, he acknowledges that there is absence of guidance, facilities and materials for school girls to manage their menstruation in low and middle income countries.
Research has shown that poor menstrual health contributes to inequity, increasing exposure to transactional sex to obtain sanitary items, this has long term consequences such as girls dropping out of school and early pregnancies. This greatly affects the future of the girl child a factor prevalent in the marginalized countries (Sommer et al 2016, House et al 2012. In the Sub Saharan Africa one in ten girls misses school during their menstruation period , accounting to approximately 20% yearly, many girls drop out altogether (UNICEF and WHO 2013 ). In addition, approximately 17 million girls are out of school, most of whom end their formal education after reaching puberty. According to UNICE, of the 121 million school age children that are not in school, the majority 65 million are girls. The magnitude of the numbers can mask the uniquely personal nature of the challenge many girls face in attaining education.
In Ghana, it is estimated that 11.5million women lack hygiene/sanitation management that adequately separate waste from the human contact. In Ethiopia, like in many parts of the developing world, Menstrual Hygiene Management is one of the critical challenges adolescent girls face while they are in school (Tsegaye,2011). A study conducted in four districts in southern Ethiopia revealed that the school environment is not conducive especially for Menstrual Hygiene Management. The study showed that girls use unhygienic rags during menstrual period and have little knowledge on how to keep personal hygiene during menstruation. The study also revealed that menstruation is seen as a taboo by communities and school teachers. Parents do not provide information and guidance on Menstrual Hygiene Management which leave school girls without assistance on how to manage their menstruation hygienically. The same study disclosed that 70% of adolescent school girls miss 2-3 school days each month, which in turn has a significant impact on their school performance.
Studies have consistently revealed that girls attending school in several remote rural areas stayed at home the entire length of their periods due to fear of soiling themselves in the presence of others. They used discarded cloth, which they felt offered insufficient protection on the long walks to school, which in turn prompted them to stay at home (Linda 2009). As mentioned earlier, In Kenya, 1 million girls miss over six weeks of school in a year due to lack of access to affordable sanitary pads. The Girl Child Network conducted a need assessment on gender equity and equality following the introduction of Free Primary Education (FPE) the study revealed that a girl who is absent from school due to menstruation is likely to lose 13 learning days equivalent to two weeks. This has an impact on the transition to the next class, the self esteem of the girl and the academic performance (Girl Child Network 2003) The foregoing discussion shows glaring challenges the adolescent girls face in the developing countries. The discussions below focuses on the Kenyan context, highlighting the challenges and the innovative ways of dealing with menstrual health. The challenges are grouped into three , the socioeconomic, sociocultural and inadequate knowledge on menstrual health.

SOCIOECONOMIC FACTORS
One of the greatest challenges facing Kenya and other developing countries is poverty. Kenya has a population of 44million people, 42% live below poverty line. Nearly one in two people in This simply shows that many girls cannot afford to pay for hygienic absorbing material, pain relieving medicine and the adequate disposal of used materials. In some rural areas girls use rags and leaves as an alternative to sanitary pads, ( Lukalo 2010).Notably, certain qualities that those living in the developed countries such as the United States of America consider basic such as healthcare, education, clean water and sanitation are luxuries for those living in Kenya. Lack of these essential facilities puts the adolescent girl in a precarious position. The cost of sanitary wear and towels is beyond the reach of many girls who are living in poverty, most of them end up missing school. According to UNICEF, one in ten school girls in Africa miss class frequently or drop out completely out of school due to their periods and they substitute pads or tampons for less safe and less absorbent materials such as rags, newspapers or bark, WHO and UNICEF (2013). Citizen Kenya, (2013) showed that Girls in Marigat, Baringo county Kenya, do not afford sanitary towels, it was one of the districts that had not benefitted from free sanitary towels programme rolled out by the ministry of Education in Kenya. The girls missed school during their menses and opted to use goat skins, chicken feathers, soil and even leaves during their menses . Valentine Atieno a 13 year old girl narrated that before she was introduced to Ruby cup she was using rags and newspapers during her periods, as her mother could not afford sanitary pads. She usually stayed at home during menstruation because she was afraid of the too frequent leaks that made boys and other girls in school laugh at her (Weigaard, Julie, 2013). A study carried out by FAWE on sexual maturation in Kenyan, Ghana, Uganda, Zimbabwe found out that menstrual materials used by girls during menstruation depended on the family's socio-economic status. The study showed that girls who were fortunate to access cloth reportedly did not have enough of it, thus resulting in sharing of the menstrual cloth with other girls. The absorptive capacity of the product determined how secure the girl felt and the level of mental concentration in class work ( FAWE 2003) .
Reportedly, the girls who used 'Always' pads only worried about the period pains and cramps while those who used rags or cloth constantly worried about potential "accident" of soiling their clothes. The physical and mental discomfort forces the girls to stay away from school during the duration of the menses. Studies show that most girls from poor backgrounds are forced to stay away from school during menstruation period while boys continue learning, a situation that creates a margin gap in performance between the two genders, they cannot compete well with the boys, their self esteem is affected among other inhibitions (Matovu, 2011). Poor sanitation facilities is another factor that is a hidden barrier to girls' education. According to UNICEF (2008) the child-friendly schools, which provided privacy and hygiene facilities for girls through separate toilets for boys and girls as well as water and wash areas, tended to attract and retain students at a comparatively higher rate, especially the girls. This is because separate toilets not only provide privacy but also encouraged girls who are menstruating to attend and remain in school where they are able to attend to their feminine hygiene needs and manage their period discreetly (Muchemi, 2007). Studies have shown that many schools in Kenya do not have lockable toilets, access to flowing water for washing hands. Estimates on access to private , improved sanitation in Kenya shows 31% of urban population and 39% of rural population , slightly over 21 million people still use unsanitary or unshared latrines. Approximately 18% of rural populations in the country still practice open defecation, WHO , UNICEF (2015). An assessment of existing WASH facilities in schools in rural Kenya shows that only 60% have acess to water for hand washing and 2% had soap. While 84% of schools had gender separated toilets , 77% did not have locks, This puts the girls in a disadvantaged situation. Kelly( 2014), Mason (2013). Studies show that the Arid and Semi Arid communities are the most marginalized due to poor sanitation , many of them drop out of the formal education system due to lack of basic facilities in schools such as toilets and sanitary facilities. Notably, the number of girls enrolled in upper primary progressively decreases towards upper classes . In addition, the girls lacked adequate options for safe and private disposal of menstrual waste in the rural areas, only 1% of girls are able to dispose their menstrual waste in a safe environment , Kelly, (2014) . (Mbatia, 2003:53,Akoth (2004 and Odhiambo (2004). Studies have consistently shown that menstruation causes discomfort and high incidences of pain for majority of women. It can cause shifts mood, depression, vomiting, pyrexia, endometriosis, hemorrhage, migraines, anemia and fibroids (Donimirski, 2013). It is reported that more than 10% of young women on their menstruation are incapacitated for up to three days due menstrual discomfort, (Pullon.et al., 1998). The burden of dysmenorrhea is greater than any other gynecological complains. Though mild and moderate cases of dysmenorrhoea could be treated by reassurance and Paracetamol, it is acknowledged that the effect of menstrual disorder and discomfort on a woman's life could be so severe as to confine the woman to bed ( El-Gilany et al 2005), Patel et al (2006) Davis et.al (2001 ).

SOCIO-CULTURAL FACTORS
Studies show that girls who are on their menstruation are being restricted in some activities for fear that they may contaminate others, menstrual blood is considered dirty and harmful. In most African communities, menstruating girls are not allowed to be in the kitchen, to cook, to wash dishes, to participate in games. Some are not even allowed to enter into their parents' bedroom. This enhances stigma and the girls perceive menstruation as shameful and harmful, (Kotoh 2008). Quite striking is the restricted control which many women and girls have over their own mobility and behavior during menstruation including myths, misconceptions, superstitions and taboos concerning menstrual blood and menstrual hygiene. Compounded with early marriages in some cultures forces many girls to stay away from school when they start menstruating, either permanently or temporarily (UNICEF,2005;GAPS & FAWE,1999). The girls are therefore deprived their right to health and education. Various studies show that girls fear to wash themselves adequately in school, clean their reusable sanitary pads due to a fear of harassment and cultural inappropriateness. To make matters worse the boys tease and laugh at the girls especially when they spoil their clothes due to leakage. The cultural restrictions affect the psychological wellbeing of the girl as well as the possibility of using different types of menstrual devices such as the menstrual cup seen as culturally inappropriate. .

INADEQUATE KNOWLEDGE AND UNDERSTANDING ON MENSTRUAL HEALTH
The family is the primary agent of socialization, the parents have a responsibility of teaching their children about their sexuality but studies have shown that it is a taboo to discuss matters concerning sex in some cultures. This this leads to lack of understanding and inadequate knowledge on menstruation. Besides many young girls don't even know about menstruation before their first period and have nobody to discuss with about this important change in their bodies. "The sexual and disgust connotations of menstruation make it a taboo subject for girls to raise, even with their mothers (Sompter & Torondel, 2013). Additionally, those who know or found out have a poor physiological understanding of menstruation. There is also a culture of silence around menstruation leading to the menstrual process being viewed as a women weakness. Pre-menstrual awareness to girls is very important (UNICEF,2007). Menstruation is a biological inevitability in human nature, therefore preparing women and girls on how to respond to menstruation issues without demeaning their dignity is an educational imperative. Over decades, women including those in Africa settings and elsewhere have been taught that having periods is shameful and this narrative has got to change (UNICEF, 2007. The need to have good Menstrual Hygiene Management awareness is the key in preparing the girls for menstruation. According to (Tsegayo et al., 2011) there is need for government to sensitize people about the social and cultural constructions of menarche to make it better experience for girls. Psychological and physical barriers have to be handled in order to lessen their impact on girls schooling, and the existing social structures have to be strengthened so as to create a better learning environment for girls. Further the possibility of forming girls clubs which constantly monitor the sanitation infrastructure would be a great action towards gender parity in schooling. Menstrual studies should be integrated in puberty studies in the science classes to reduce shocks and discomforts associated with menarche. Similar to findings by Bharadwaj (2004), poor Menstrual Hygiene Management emanates from the beliefs and attitudes within schools and the community and is worsened by other factors like poverty and lack of supporting infrastructure. The Menstrual Hygiene Management approaches have to deal with the physical, emotional and cultural aspects in order to have meaningful impact and this can well be done if its spearheaded by Government as a key stakeholder, (Ten, 2007).

INNOVATIVE WAYS OF DEALING WITH MENSTRUAL HEALTH
However, all is not lost, more and more organizations have come up with innovative solutions to help the adolescent girls deal with menstruation in a more dignified manner. The use of menstrual cups is one of the innovations that help keep the girls in school. Femme International provides school girls with menstrual cups, the menstrual cups collect blood and are emptied when it is removed. It can last upto 12 hours, the cup is made of silicone and can last for ten years. African Population and Health Research Centre carried out a study on the suitability of the menstrual cup among the adolescent girls in Kenya. It was found out that women would engage in activities more freely, it was cost effective. The problem of purchasing the pads on a monthly basis was no longer a challenge and that the focus shifted from the burden of costs to that of cleaning and sterilizing it. In addition, the menstrual cups use less water for cleaning as compared to reusable pads. It also reduces the temptation to solicit funds from transactional sex in order to have funds to purchase the pads ( Steward, K, et al 2009). However, studies have also established that the menstrual cup is faced with challenges of limited access to water, participants in the study found it problematic to change when there was no water , they preffer to stay with the cup the whole day so that they could change at home. It was also found out that the toilets are not lockable hence lacking privacy and security. In the slums of Korogocho they could not access the toilets at night, forcing them to change in the house and retain the waste for disposal the next morning in the sewage point ( APRHC (2010). It is important to have some privacy when changing the cup. Sometimes, changing it needs extra care and caution which means one can take long in the washrooms.
It is worth noting that the menstrual cup is an alternative technology that helps women deal with menstruation in a dignified way, but water and sanitation need to be strengthened. When using the cup one needs to maintain a high standard of hygiene especially during insertion, removal and general cleaning. As discussed earlier, the infrastructure in most schools need to be strengthened, most of the toilets are not lockable, lack water for washing hands and this poses a health risk. A study done in Kenya on menstrual cup showed it reduced chances of embarrassment on the girls because it minimized the risk of soiling the clothes. It also reduced the burden of purchasing the pads every month. However, it faced challenges due to limited access to water, toilets, privacy and security. It was also found to be culturally unacceptable (Mwita, 2013).
The Period Panties For Girls is another innovation which is designed for empowerment and purpose. The drive behind it is BeGirl . It also designs the reusable period panties and pads for girls. Be Girl is working to close the gap in education that comes about when girls miss school or drop out. It designs and produces the Flexipad which can be filled with safe and absorbent materials washed and then dried up indoors in less than one hour. Their products are comfortable, environmentally friendly and leads to 70% reduction in water used for washing in one year.

Another important innovation is the Sustainable Health Enterprise (SHE) based in Rwanda.
It is a locally owned enterprise which manufactures affordable, ecofriendly menstrual pads. It is made from local, absorbent and affordable banana fibre. Apart from distribution, they train community health workers on how to provide education to both boys and girls about puberty and menstrual hygiene.SHE's first advocacy campaign 'Breaking the Silence' brought the taboo of Menstruation to national attention as a result, the government of Rwanda included in its 2001 budget to procure sanitary pads for schools. The ministry of Education further pledged to support Menstrual Health Management as part of the national school health and nutrition plan. SHE also invests in a scalable franchise model employing women entrepreneurs to manufacture and distribute affordable, eco -friendly menstrual pad by sourcing local, inexpensive material ( banana fibres). SHE has also created a new market, creating jobs all across the value chain, from the banana farmer through the pad assembler to the pad distributer. Rwanda like any developing country, is faced with poverty. SHE notes that in Rwanda, it is estimated that 36% of the girls who miss school do so because the pads are too expensive. The rags they use combined with lack of accessible safe water supply are unhygienic and potentially harmful. SHE therefore with its market based approach is responding to the demand and strengthening capacity in Rwanda to improve access, quality and affordability of disposable sanitary pads. A commendable innovation indeed which can be replicated in other parts of Africa.
AFRIpads is a social business in Uganda that specializes in the local manufacture and global supply of cost effective reusable pads. It also contributes to the development of a Ugandan rural industry that empowers its 90% female staff with productive employment. AFRIpad is also a recipient partner for a number of buy-one' give-one programme with sustainable business enterprise in Canada, U.S and Australia. The Menstrual man is another innovation which is unique because it involves man, It is invented in India by Arunachalam Murugantham who was shocked by how his wife was managing her monthly period. He purposed to create a more affordable sanitary pad, he even wore the pad himself mimicking menstruation with goat blood to test his designs. In India only 12%of women use commercial products due to their prohibitive costs. He developed a low cost method to produce pads using pulverized wood fibre and build the model machine, a simple machine to be operated and maintained in India villages. After developing the model, he began to distribute to the villages, each machine employs ten women and can produce upto 250 pads . The women make and sell to the customers, as they give them information on how to use the pads.
Another innovation is by Zana Africa Foundation. It produces and sells low cost high quality sanitary pads that are made for the African female. According to Zana Africa four of every five East African Girl do not have consistent access to sanitary pads and the girls rely on hygienic materials such as raqs and leaves. ZanaAfrica uses local agricultural resources to produce affordable pads. They reach women and girls in small towns and remote areas. Two brands are being produced, the Safi pads that target women and the Nia pads that are distributed to girls for free through organizations. Besides producing affordable pads, they also give health education to both boys and girls. The above innovations and others which may not have been brought out go a long way in helping the marginalized adolescent girl go through menstruation in a dignified manner. Research has shown that some of these interventions have helped girls stay in School. In a study in Ghana 120 girls between the ages of 12 and 18 were enrolled in a non-randomized trial of sanitary pad provision with education. Girls either received puberty education alone, puberty education and sanitary pads, or nothing (the control group). After three months, providing pads with education significantly improved attendance among participants, and after five months, puberty education alone improved attendance to a similar level. The total improvement through pads with education intervention after five months was a 9% increase in attendance. While this study is small-scale, it indicates that puberty education even if unaccompanied by menstrual Health materials can have an impact on education, (Montgomery,P et al (2012).
Regrettably these interventions are constrained to scale up due to lack of resources. On the other hand, reusable pads come with its own challenges. Oftentimes reusable pads can cause significant health problems when not cleaned properly. Social stigma and taboos inhibit the girls from washing the pads , they even feel embarrassed when drying , this poses a risk of reusing the pads when still damp causing reproductive infections and illness. The resilient nature of the adolescent girls in marginalized communities is commendable. The Kenyan government through the ministry of Education is trying its best to meet the girl child in school. The overall goal of the Ministry of Education in Kenya is to provide equal access to education for both boys and girls irrespective of their Socio-economic Status. The issue of gender equality and equity is in line with the Constitution of Kenya 2010 and the Basic Education Act 2013 and Kenya Vision 2030. In Kenya, it is estimated that 2.6 million girls require support to obtain menstrual hygiene materials. Approximately 300,000 of them owing to cultural practices particularly in arid and semiarid regions, would require both sanitary towels and underwear at an estimated cost of 2.6 billion. To address this problem, the Ministry of Education initiated the School's National Sanitary Towels Programme with the objective of keeping the girl in School and increasing their access, participation and performance in Education. The Sanitary Towels Programme has the following components: • Provision of Sanitary towels to school girls • Training of teachers on hygienic usage and disposal of sanitary towels • Monitoring and evaluation.
The programme has been in place since 2010. However, the programme is still faced with challenges, the cost of sanitary towels remains high. Lack of underpants to support use of sanitary towels. The persistent cultural practices that hinder girls from pursuing education such as Female Genital Cutting (FGC), early marriages and early pregnancies. The programme is faced with poor coordination, and lack of accountability so that all the needy girls do not have access to the sanitary pads provided by the government.
The teachers, however, need to be encouraged to be actively involved in the coordination and monitoring of the programme for its effectiveness. Studies shows that there is limited evidence of approaches to teachers' engagement and professional development that effectively address the specific demands of life skills education delivery that is beyond knowledge content (UNICEF, 2012). According to UNICEF effective delivery is dependent on participatory approaches and learning methodologies. Notably, delivery of Life skills education has often been donor driven. This, however, should be linked to governments in order to ensure acceptability and sustainability. The paper recommends consistent creation of awareness on the existence and importance of innovative ways of dealing with menstrual health, that is, the provision of affordable sanitary pads to the girls so as to keep them in school. Collaborations and Networking between various countries in Africa and beyond should be strengthened.This enhances replication of innovations in other countries as long as it is culturally acceptable. In my view, SHE enterprises in Rwanda seems a sustainable option and should be replicated in Kenya.
The infrastructure should be a priority in the marginalized communities. The schools should be equipped with clean and safe water and hand washing facilities. Adequate sanitation facilities such as lockable and clean toilets should be provided. In other words, a healthy social environment which values respect and human dignity should be promoted. Linkages and Partnerships with the development partners and the NGO's should be encouraged and strengthened. These agencies not only help to demystify and reduce the taboos around menstruation but they also support the governments in developing countries with funding. There should be dialogue between the various stakeholders in society, the girls, the mothers' teachers and the peers which include the boys. This will help the girls to appreciate menstruation as a natural process and discuss any challenges that come with it in an open way. On the other hand the mothers and the teachers should be encouraged to be more understanding to the girl child and support them without condition during menstruation.
Investing in research is encouraged to unearth more innovative ways of dealing with menstrual health. The governments should provide funding to the existing foundations such as Zana Africa in Kenya towards producing more affordable sanitary products and education on menstruation. This will strengthen the capacity of the foundation to reach more girls and women among the marginalized communities in Kenya. Since 2011, with the help of Zana Africa, the Kenyan government has allocated more money to distribute free pads to school girls. But this programme has not always been implemented well. Sometimes pads are not enough and the supplies run out quite fast. This requires close monitoring, accountability and transparency for better implementation. Finally, a multipronged approach that encompasses government institutions, communities, parents, teachers and development partners should be adopted. The stakeholders' should play a critical role in ensuring that the innovative ways become sustainable. In conclusion, it is important to note that menstruation is here to stays since it is a natural process. Children are born every day. Therefore, the governments should come up with sustainable inbuild mechanisms that deal with this process. Ultimately, governments are responsible for the health of their citizens, this includes menstrual health.