Tryggare flickor på skolbänken tack vare menskoppar
Runt en fjärdedel av flickorna i Nepal missar fortfarande upp till en fjärdedel av sin skolgång pga mensen. Orsakerna är inte bara kulturella och religiösa skäl utan även praktiska. Delar av Nepal har ett mycket strikt och traditionsbundet sätt att förhålla sig till en kvinnas menstruation med en stor mängd förbud och förhållningsregler för kvinnan att anpassa sig till. I sin striktaste form tillåts tex inte en menstruerande kvinna att sova inomhus, gå in i köket eller äta tillsammans med andra, inte äta salt, dricka vatten från samma brunn som någon annan eller röra vid någon man, då kvinnan anses som oren. Samma omfattande förhållningsregler gäller när en kvinna är nyförlöst.
Dessa typer av regler finns i många modifikationer, generellt i mildare form i städerna medan de är vanligare och striktare på landsbygden och i bergen. Flickor i delar av Nepal är inte tillåtna att gå till skolan när de har sin mens. Men även i de många regioner som inte praktiserar den mest strikta kulturen finns risk att flickorna inte tar sig till skolan under mensen av praktiska skäl.
På landsbygden används ofta hemgjorda mensskydd av gamla kläder, då tillgången till alternativ som bindor är mycket begränsad. Kostnaden för engångsbindor är hög och det kan vara svårt för en kvinna att hävda sitt behov av bra skydd när vardagsekonomin är knapp. Hemgjorda skydd är svåra att hålla på plats, klumpiga och läcker. Det behövs bra tillgång till vatten för att rengöra dem och infektioner är vanligt. För kvinnor som arbetar med fysiskt tunga arbeten ute på fältet hela dagarna kan mensen utgöra ett uppenbart praktiskt problem.
En femtedel av Nepals skolor saknar fortfarande toalett, det kan vara ont om vatten i skolan och utan fungerande sophantering. Otillräcklig kunskap om hygien förekommer och utebliven skolgång pga mens är därför vanligt, inte minst av praktiska skäl.
Varför behövs menskoppar i Nepal?
Sedan ett par år har det börjat anas ett ökat intresse för menskoppen som ett alternativt mensskydd i Nepal, inte minst utifrån användbarheten i avlägsna områden med mycket begränsad tillgång till alternativ. Ekonomiska och miljömässiga skäl lyfts också fram. Det skrivs om menskoppen i media och har lovprisats av bollywoodstjärnor på Youtube. Information har dock generellt svårt att nå ut till landsbygden där behovet kan vara än större än i städerna.
En menskopp är tillverkad av silikon och kan användas under 5-10 år, beroende på kvalitet och tillverkare. Menskoppen, som finns i olika storlekar, har inte visat sig ha någon ökad infektionsrisk, har få biverkningar och genererar inga sopor. Vanligen räcker det att man tar och ut och sköljer av den 2-3 gånger per dygn.
Studier om för- och nackdelar med menskoppar
2019 publicerades en stor litteraturstudie (1) men i övrigt finns förhållandevis få vetenskapliga artiklar skrivna om menskoppar. Vi valde att i samarbete mellan Karolinska Institutet och Kathmandu Medical College göra en egen mindre studie i ämnet, i ett område på landsbygden där problemen kring mensen till största delen är praktiska. Syftet var att se om det på ett relativt enkelt och billigt sätt går att förbättra skolflickors situation under mensen och att samtidigt öka kunskapsnivån.
Innan studiestart diskuterades ämnet ingående med byns manliga beslutsfattare, liksom med en grupp av kvinnor med tungt inflytande i byn. Efter att ha fått dessa båda gruppers godkännande och uppmuntran påbörjades studien. De svenskproducerade menskoppar som vi använder oss av sponsras av företaget MonthlyCup (www.menskopp.se) och av den svensk- tysk- engelska INGOn Foundation Human Nature (www.f-h-n.org), en vänorganisation till Sverige- Nepalföreningen. En annan svensk organisation som aktivt och framgångsrikt arbetar med menskoppar i Nepal är Care Mahila.
Studien omfattande trettio skolflickor från byn Thokarpa i Sindhupalchowk, etiskt tillstånd införskaffades liksom skriftligt medgivande från föräldrarna. Flickorna fick tillsammans med sin menskopp tre timmars utbildning och en nepalesisk manual i text och bild. Uppföljning skedde efter fyra månader genom gruppintervjuer genomförda av en nepalesisk läkarkollega.
Utbildning och informationsspridning har stor betydelse för projektet.
Studien publicerades 2021 (2) och kom även att refereras till i en betydande nepalesisk dagstidning. Resultaten var huvudsakligen positiva, vilka flickorna beskrev som: 1) inte missat en enda dag i skolan pga mensen 2) enkelt och praktiskt 3) ekonomiska och miljömässiga fördelar 4) lätt att tvätta, behövs inte så mycket vatten. Svårigheter och utmaningar bestod i 1) obehagligt till en början, viss inlärningstid 2) rädsla för att den ska fastna 3) familjemedlemmar (enstaka) oroat sig för oskuld och fruktbarhet.
Menskoppen har i det här området mottagits långt mer positivt än vi förväntat, inte minst av föräldrarna, och även männen har varit engagerade och motiverade till en bättre vardag för flickor och kvinnor. Även vuxna kvinnor i Thokarpa har provat och mer finns att läsa i bloggen www.sverigenepal.se/bygga-vardcentral. Vi planerar nästa uppföljning i Thokarpa i november.
Mer forskning behövs, men vår studie stödjer uppfattningen att menskoppen kan vara ett användbart alternativ i låg- och medelinkomstland och där det är ont om vatten. Vi kan också konstatera att det är viktigt med förberedelse, utbildning och stöd från kompisar och familj för bra resultat.
Styrkta av resultaten i den här studien har jag och studiens huvudförfattare dr Diksha Pokhrel, med stöd av FHN, valt att fortsätta att arbeta med information kring och introduktion av menskoppar. Vi inledde i våras ett samarbete med The Family Planning Association of Nepal (FPAN) i Palpa. FPAN, som finns representerat i 37 distrikt, är en statlig organisation och den största som arbetar med familjeplanering och sexuell och reproduktiv hälsa i Nepal. Ett samarbete med en riksomfattande organisation som FPAN har förutsättningar att på ett effektivt sätt kunna sprida information till flickor och kvinnor i avlägsna delar av landet och projektet är sanktionerat av FPANs huvudkontor i Kathmandu.
Arbetet vi nu påbörjat avser att utbilda FPANs community- och healthworkers samt ungdomsgrupper, som i sin tur kommer att ansvara för utbildning och information till traktens flickor och kvinnor. Utbildning är fundamentet i det här arbetet. I samband med denna överlämnas menskoppar till intresserade. Vi planerar en uppföljning på plats i Palpa i november och enligt de preliminära uppgifter vi hittills fått har mottagandet varit positivt och efterfrågan redan stor. Förutom att fortsatt rikta sig till Palpas skolflickor, planerar FPAN att som nästa steg bidra med menskoppar till kvinnor som arbetar inom den lokala textilindustrin.
Hur kan jag bidra?
Sverige- Nepalföreningens visade intresse för detta arbete betyder mycket för fortsättningen. Vi köper våra menskoppar för 150 kr/st (sponsrat med halva priset av MonthlyCup). Finns intresse att bidra kan detta göras genom Swish till Sverige-Nepalföreningen 123 633 58 30 eller insättning på föreningens plusgiro 649 52 42–7. Märk bidraget med ”menskopp”.
Det är svårt att inse vidden av och betydelsen det har för flickor att inte behöva missa en fjärdedel av sin skolgång. Vikten av att vuxna kvinnor på ett anständigt vis kan arbeta och hantera sin vardag under mensen kan inte nog understrykas. Att bidra med en menskopp är att vara en del av att på sikt bygga upp och stärka kvinnors och flickors möjligheter och rättigheter i Nepal.
Referenser:
- Van Eijk et al. 2019: Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis. Lancet Publ. Health; 4(8):e376–93
- Pokhrel et al. 2021: Acceptability and feasibility of using vaginal menstrual cups among schoolgirls in rural Nepal: a qualitative pilot study, BMC Repr. Health vol.18, no.20
Text och foto: Malin Emgård
(Alla personer på bilderna har gett sitt medgivande till publicering)
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Senaste nytt från Project Menskoppar
Interview with Mr. Soba Kanta Neupane, Branch Manager of FPAN, Palpa Branch and Head of the FHN - FPAN Menstrual Cup Collaboration, held in Tansen, Palpa, Nepal in November 2024
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What inspired you to focus on menstrual health/cups?
I have been working in the field of sexual reproduction health and rights, based on the WHO and the ICPD Cairo convention of 1994, so when I was heading to the FPAN Family Planning Association of Nepal in 1998, I was especially connecting with the young people in schools and the community with projects on sexual and reproductive health and education, that is RHSE (Reproductive Health and Sexual Education). Working with young people and women in the community, we had some projects with support from the European Union, together with support from the International Brand Family Federation in Nepal. We were working among the young people in schools and out of schools too. We worked for environmental issues as well with the support of the government of Finland. Later, with the support of Australian Head (?) we were working for the needy access of reproductive health services among the marginalized people with poor social acceptability and in underserved communities.
Secondly, there is a practice (in Nepal) of a very stigmatizing and taboo situation during the menstruation among young girls and women. This is called “chhaupadi”. It’s like a “non- touch condition”. It’s like a seen (the whole society knows and maintain) condition among the women during their bleeding times. During this time, they don’t have access to proper nutritional food, to have good clothes and rooms and environment during their periods. So, these all factors are the motivating factors to work with something new to make it more comfortable for the young women. When we go back and think about the time of 20 years back, gradually it’s improving, but there are still problems in many different communities in Nepal and especially in Palpa and other communities as well. Where there are marginalized communities also living there, there is problem during their periods. They don’t have access to education. There is gap (meaning that the girls may not be able – or would not be allowed, depending on how strict their community is – to go to school during their period) during their periods because of lack of proper sanitary management or menstrual health management system.
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What milestones have been achieved so far?
The main thing that we’ve achieved is…, let me explain. There is a minimal access of disposable sanitary pads among the young girls and women in the urban and semiurban areas of the Nepalese community (in rural areas there are none). But there is also a gap due to the financial status and other things, affecting the availability of menstrual management products. There is a gap in access to those materials. There is availability by the government centers (lately handing out disposable pads in governmental schools), but that is limited only for young girls in the schools, only those who are studying in ordinary schools. And there are some other very bureaucratic procedures that are making problems to get the sanitary products to gain the girls. These kinds of problems, like easy access of toilets, disposable systems (garbage bins) and water for the sanitation, are still there. But the situation has improved a little bit with the support of the menstrual cup. It is a very good replacement for sanitary pads and other things because of environmental and other benefits comparing to other products. What else is used in Nepal is sanitary pads (especially in rural areas but (decreasing) in urban areas too, usually homemade pads), but we don’t have access to other products like cups or tampons.
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What is your motivation to keep going and keep developing the program/project?
The motivation to work with the menstrual cup and for menstrual hygiene management is mainly when we were working with young girls with disabilities, especially among the girls in schools with visual impairment or blindness. They had a challenging menstrual hygiene management and when they received the menstrual cups it was much easier for their management. Key motivations are working for the young women and other women who are working in the community or in the field areas and cannot buy disposable sanitary pads. This (the cup) will be very supportive for their menstrual management as well as the product management. Instead of pads or other things, cups will be very much easier and good for them.
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What do you think can become a challenge in the future (regarding menstrual health and the project)?
There will not be many challenges, but it will be an opportunity to do work especially for menstrual health and of course for the menstrual cup program in Nepal. Because there are more opportunities and the demands in utilizing the menstrual cup are increasing gradually into the communities. It is spreading into a larger community wherever we are working. Then other communities are also interested in the menstrual cups. The government is also supportive about the menstrual management, and they are also adopting in (participating in) the Menstrual Hygiene Day celebrations. They are also making progress among young people in schools and colleges like debate competitions on menstrual hygiene or on other conditions among young girls. These things have been initiated since last year with the support of and collaboration with FPAN. So, there will not be many more challenges, but I think it’s a good opportunity. What is challenging for us is the continuous supply of cups. There are not enough local producers of menstrual cups so we will need to buy them imported from other countries. So that will be something challenging for the future. Otherwise, the interest is gradually increasing, and I can see some work opportunities here as well here.
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For our donors as a repetition: what challenge do women and girls in Nepal face regarding menstruation and menstrual health?
There are still challenges for women, especially in the rural communities for those who are working 15-20 hours a day for food, shelter and their children. There are poor hygiene and sanitation conditions in the village areas of the communities in Nepal. Secondly, the numbers of working women and educated women are increasing but they are busy (meaning working very hard at their job and in the household as well), and they could not afford all the sanitary products. So, these are the key challenges. And third one is that there is still this prevalence of stigma situation gap about young girls and other women. They are not allowed to do all the various work (meaning many cultural restrictions in their daily lives while menstruating) and must do all the non-touch techniques during their menstrual periods. This stigma is there in many communities of Nepal, from the national headquarters and the capital and the rural communities as well. So, there are so many other things remaining in working with menstrual hygiene management. Of course, the menstrual cup is a very good environmental friendly product with increasing acceptance and is becoming a popular method for menstrual management.
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How do local communities/schools/etc react to the topic of menstrual cups? Do you encounter any biases or misconceptions?
Yes, there are some biases and some misconceptions towards the menstrual cups. The main biases are in the schools among the parents and the teachers and the male involvement, because the knowledge about menstruation management in the communities is very poor. There are some other biases for the menstrual cup because they still have some hesitations to insert something into there (the vagina), because it’s not easy for the Nepalese people to insert a foreign body, this is a little bit difficult. Some of the communities are denying using the cups for their young girls because they should not have something inserted into their vaginal canal, so there are some of the biases. But the young girls who are already using the cups are teaching their friends very well about the usage of the cups. Other women and parents are also encouraging because it’s very useful.
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What is the benefit of a menstrual cup over single use sanitary products (we all know the answer but just to make it clear)?
It’s easy to use, easy to detach and store the product to manage menstrual bleedings. The usable characteristic of this cup is also that it’s cost effective because it’s potentially to be used for a very long time. The cup is very useful as a reusable menstrual management product, it’s environmental friendly and very easy to carry and very easy to clean, with little amount of water only, and reuse from one menstrual period to another. So, it has been very popular. Only thing is some hesitations for the girls to insert it for the first time. Some girls says that it brings some discomfort when inserting it for the first few times and that it may cause some minor pain in the beginning.
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How has life changed for the women and girls who have started using menstrual cups? Is there any story or feedback from participants that particularly stand out or show how much the project has improved their lives?
Of course, I can share the success story or the successful case studies on the use of the menstrual cups. There are so many villagers where the young girls were participating during the visit from Sweden like Marie didi’s and the other teams to the FPAN office, where they also shared their very good experience. And some of the young women and older women were also participating using the cup. They were also very satisfied because it is useful for the working women, for the sportsmen (?) and for travelling as well and it’s very easy to discharge the blood and they can easily clean with a little amount of water and then use again after cleaning. So, these are the very good things with the cup.
Secondly, the menstrual cup is lifechanging for menstrual management because of by using the cups they don’t have any disturbances for their classes (meaning missing classes or days in school due to their period). Especially among the school going and university going young girls. They can use this very easily and go to the washroom and clean and use very easily. So it’s being easy and friendly for the education. Secondly, it’s very friendly for the working women, those working in the remote area into the fields, like digging in the fields or doing something for their cattle. So, this is being very easy for these women as well.
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How high do you estimate the demand (of more workshops/cups)?
This is a very much appreciated program by the young people, girls and adult women with the benefits of the menstrual cup. And wherever we visit the schools, doing classes for the menstrual hygiene management, there are presentation by our nurses and other staff, like me and young people, from FPAN. When we are visiting schools the teachers, those teaching health education, are very positive because the cup is a very good alternative for the menstrual hygiene management. This (education classes/ workshops) is a part of the sexual education and very important topics and part of the reproductive and sexual components for the young girls. This (education classes/ workshops) is very good for understanding their body and to understand about the reproductive system, the hormonal changes, physical and emotional and other social and mental changes during the adolescent period. This is very good to talk about during the menstrual management and hygiene education classes, that we are conducting in the communities. The older women are very happy as well and they realize that these are very good classes, and these have become very popular. Many young girls have clubs, even in schools. Women groups, like different forestry- or property fusion groups, are also inviting us to please arrange time for them and menstrual hygiene management and reproductive health classes. They are asking if we could please manage to bring some menstrual cups, since the demand is getting quite high and it is very interesting, they say, and they are feeling very proud and satisfied by this program.
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Do you encounter difficulties or resistances?
Although we are working with different communities, very rigid (meaning conservative) and some quite liberal communities for discussions on reproductive health, and menstrual hygiene and changes, we are not facing any challenges or difficulties or barriers of denial of the situations, talking about menstrual hygiene management or in discussions about the menstrual cup. Additionally, we got the opportunity to participate and do collaboration with the management of the rural municipality as well. And the rural municipalities were also participating in the menstrual hygiene management and campaigning programs. The mayor of the municipality was also participating in our programs. The district level and other high-level officers and bureaucrats were also participating in this program. So, there has not really been any barriers or difficulties, but it has been quite easy and the demand is high in the communities.
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Are there any cultural/traditional/religious factors that make it difficult to implement the project in certain areas?
Initially we were also very worried about the discussions about the menstrual cups. But people find it very easy. When discussing about different religious and other cultural barriers there are no problems. We can share and we can discuss about these things. Menstrual hygiene topics has been very difficult to discuss in the communities, and still there are some problems, but while we are working with the schools and teachers, young girls and women groups, this is the way to discuss these things easily in the community. They may say things behind their closed windows, inside their home or something, but formally they can’t deny or do anything bothering for us. The demand is high, and many young girls form different types of cultural and religious communities are now users of the menstrual cups. Many different casts, religions, race and people from different financial and geographical conditions, from the rural to the urban areas, everywhere they are using.
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What are your long term hopes for the women and girls involved in this project?
I’m very much optimistic about this program because the demand is being good and many of the governments and health sector workers are also including the topic of menstrual cups now. In the initial phases they were not very easy or open to discuss this topic. In those days, about 5-6 years ago or more, the people only knew about the use of sanitary pads. Reusable pads, I mean the locally made pads (meaning homemade cloth pads) or disposable pads. The government is also distributing menstrual pads now, disposable sanitary pads, but only for the girls studying in the schools. But the rest of the girls will not have the benefit of these pads.
In the future and for the long time, planning for the menstrual hygiene management programs and the menstrual cups, we should do many things for this. While the demand is increasing in the community, the supply problem needs to be addressed. The education classes should also be continuing in the communities. So, for the planning of the future, minimum at least five to ten years we should do something to continue. Additionally for the second phase of this program, maybe after two or three years, the middle phase of this program, we should have some advocacy programs among the local governments and maybe with the media for the national level advocacy and the dissemination of the user uptake of this program. And third one is, we are also thinking, from the national level; the university, the lecturers, the PhDs scholars are also interested to do research and additional studies on this program in Palpa and we are collaborating for this. So, for the future plan this program will be very effective.
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What have you personally learned through the project? And are there any experiences that you want to share with the donors of FHN for the next newsletter?
Yes, of course, I want to share something with the donors and other communities. In the community of young people and adult women, everybody is comparing with other global communities and know that the women and the young girls are still behind in the Nepalese community. So, it will be very nice to have an opportunity to share the efforts that we are making for the menstrual cup and the menstrual hygiene management. Gathering of young women and other people in the communities for the menstrual hygiene management, especially in the restricted communities, is the first thing. Secondly, there are still so many problems regarding the sexuality and reproductive health management. Like discussing about the menstrual hygiene and discussing about the changes over the years, from the beginning of “non-touching times” stigma situation of the menstrual hygiene (chhaupadi) to talking about today’s use of menstrual cups and reusable (modern, not homemade) sanitary pads. Many things are challenging in our community. Still we are working very well and the communities are transforming very well and positive in a supporting manner. So, these things need to be shared with our donors, physically, virtually or maybe through one of the reports, this is very important.
My personal experience and learning by working with this program is that the people in the community are very positive to adopt new things. They are searching for options and they are supportive to transformations. They are positive about new things that they realize are good for their health. The male involvement to protect the women’s reproductive health and the male involvement for the menstrual management is also being very good. Compared to previous days, in the communities we have visited with our menstrual hygiene management education programs with supply of cups, it has been received very positive. Young people are transformative and especially males are also very positive in the communities. So, these are the very good things.
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If you could share a message with others interested in advocating for menstrual health, what would it be?
My personal learning and my personal experience is that the women and girls are interested in new things that are good for their health. They are feeling very good and satisfied and dignified in life with the use of menstrual cups and menstrual management products. For the dignified life of women, self-respectful lives and a self-confident life and to enhance and improve their day-to-day lives. In living standard for women, the first thing is menstrual hygiene management. Because this is the leading cause of many kinds of depriving problems, tensions in life and sexual problems for women. After management of these things everything will improve, and the dignified life of women will also be increased. This is my experience of learning of this program.
I would like to thank Foundation Human Nature, Sweden-Nepal Society and obviously Dr. Malin and Marie Schön from Sweden, those who make it happen in Palpa. Especially among the communities that are poor, marginalized and socially excluded communities and some of the indigenous people and some of the women with disabilities. Still we have challenges to cover the larger community, as the demand is high for the cups and other types of sanitary products which can be reused for a longer time. Additionally, the information and education program with mobilization of nursing staff and young people is also very effective. We hope to be able to continue and expand this program for the next few years, after being accepted and encouraged by the local government, making continuous support to rural communities, along with support to larger groups benefitting from this service.