Research Article: Women’s and girls’ experiences of menstruation in low- and middle-income countries: A systematic review and qualitative metasynthesis

Date Published: May 16, 2019

Publisher: Public Library of Science

Author(s): Julie Hennegan, Alexandra K. Shannon, Jennifer Rubli, Kellogg J. Schwab, G. J. Melendez-Torres, Jenny E Myers

Abstract: BackgroundAttention to women’s and girls’ menstrual needs is critical for global health and gender equality. The importance of this neglected experience has been elucidated by a growing body of qualitative research, which we systematically reviewed and synthesised.Methods and findingsWe undertook systematic searching to identify qualitative studies of women’s and girls’ experiences of menstruation in low- and middle-income countries (LMICs). Of 6,892 citations screened, 76 studies reported in 87 citations were included. Studies captured the experiences of over 6,000 participants from 35 countries. This included 45 studies from sub-Saharan Africa (with the greatest number of studies from Kenya [n = 7], Uganda [n = 6], and Ethiopia [n = 5]), 21 from South Asia (including India [n = 12] and Nepal [n = 5]), 8 from East Asia and the Pacific, 5 from Latin America and the Caribbean, 5 from the Middle East and North Africa, and 1 study from Europe and Central Asia. Through synthesis, we identified overarching themes and their relationships to develop a directional model of menstrual experience. This model maps distal and proximal antecedents of menstrual experience through to the impacts of this experience on health and well-being. The sociocultural context, including menstrual stigma and gender norms, influenced experiences by limiting knowledge about menstruation, limiting social support, and shaping internalised and externally enforced behavioural expectations. Resource limitations underlay inadequate physical infrastructure to support menstruation, as well as an economic environment restricting access to affordable menstrual materials. Menstrual experience included multiple themes: menstrual practices, perceptions of practices and environments, confidence, shame and distress, and containment of bleeding and odour. These components of experience were interlinked and contributed to negative impacts on women’s and girls’ lives. Impacts included harms to physical and psychological health as well as education and social engagement. Our review is limited by the available studies. Study quality was varied, with 18 studies rated as high, 35 medium, and 23 low trustworthiness. Sampling and analysis tended to be untrustworthy in lower-quality studies. Studies focused on the experiences of adolescent girls were most strongly represented, and we achieved early saturation for this group. Reflecting the focus of menstrual health research globally, there was an absence of studies focused on adult women and those from certain geographical areas.ConclusionsThrough synthesis of extant qualitative studies of menstrual experience, we highlight consistent challenges and developed an integrated model of menstrual experience. This model hypothesises directional pathways that could be tested by future studies and may serve as a framework for program and policy development by highlighting critical antecedents and pathways through which interventions could improve women’s and girls’ health and well-being.Review protocol registrationThe review protocol registration is PROSPERO: CRD42018089581.

Partial Text: Each day, more than 300 million women are menstruating [1]. There is increasing recognition that this natural process is experienced negatively and presents a barrier to health and gender equality in low- and middle-income contexts [2]. A growing body of qualitative research has been critical to highlighting this issue. Early studies focused on adolescent girls reported that menstruation was experienced with discomfort and fear [3–5]. Access to clean, reliable materials to absorb menses, supportive sanitation infrastructure, and biological and pragmatic information about menstruation were highlighted as core challenges [6, 7]. Studies suggested that these challenges negatively impacted school participation [4, 8, 9], health, and well-being [10, 11, 12, 13]. Fewer studies of adult women have highlighted that they too lack resources and support [14, 15], which may contribute to stress and absence from employment [16, 17].

The review protocol is registered on PROSPERO: CRD42018089581 and is reported according to PRISMA guidance (S1 PRISMA Checklist).

The review flowchart is presented in Fig 1.

This systematic review had 2 overarching objectives: (1) to synthesise extant qualitative studies of women’s and girls’ menstrual experience in LMICs and (2) to integrate findings across studies to develop a directional model of menstrual experience to advance problem theory in menstrual health research. Despite different settings and populations, the narratives and lived experiences that emerged reflected consistent themes, with manifestations that differed by context. Mapping relationships between themes highlighted the multidimensional nature of menstrual experience. The integrated model produced illustrates pathways through which distal and proximal antecedents influence menstrual experience and ultimately result in impacts on physical and psychological health, education, employment, and social participation.



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