On 12 March, 2020, the World Health Organization (WHO) officially defined the COVID-19 outbreak as a global pandemic, when there were approximately 118,000 confirmed cases globally. In response, many countries have undertaken extreme measures to enforce social distancing and combat the spread of the virus. Bangladesh recorded the first confirmed case of COVID-19 on 8 March, 2020; till date the country has been 38,292 confirmed cases and 544 deaths. The Government of Bangladesh initiated a countrywide holiday from 26 March to 5 April, and then extended it up to 30 May to limit the spread of COVID-19.
Primary impacts of such outbreaks are the direct consequences on human health, while secondary impacts are those caused by the epidemic indirectly that go beyond the direct impact due to the measures taken to contain and control it (e.g. quarantines, travel restrictions, and social distancing which can be short or longer term) (1).
To date there is no evidence of the repercussions of COVID-19 on menstrual health directly, though stress, stigma, anxiety and malnutrition can impact reproductive health (1). However, the COVID-19 pandemic will have secondary impacts on girls’ and women’s ability to manage their menstruation, health and hygiene. The effects may differ based on the country context and ability to respond through good governance, proper health systems management and services. However, the low-and middle-income countries, including Bangladesh, and the poor population will be affected the most.
28 May marks Global Menstrual Hygiene or MH Day (the date was chosen because the length of bleeding - menstrual period is five days on average and menstrual cycles are an average of 28 days cycles). It was initiated by the German non-profit WASH United in 2013. The theme for Menstrual Hygiene Day 2020 is ‘It's Time for Action’ and with this in mind, icddr,b scientists have written a paper to act as a call for action to mitigate the impact of COVID-19 on menstrual hygiene management among women and girls in Bangladesh.
There are an estimated 54 million menstruating women and girls in Bangladesh. However, menstruation is a proscribed subject in Bangladesh, and managing menstruation in a confident, effective, comfortable and healthy way is difficult due to stigma, lack of products and facilities, gender inequality and discriminatory social norms. In emergencies like COVID-19, these deprivations can be exacerbated including shortfall of menstrual material supplies and unhygienic or unsafe management of menstruation.
COVID-19 will affect the menstrual hygiene management of women working in healthcare facilities (including doctors, nurses and janitors), readymade garments factories, patients visiting the healthcare facilities, the women and girls living in the urban slums and rural households, in prisons and in the Forcibly Displaced Myanmar National (FDMN) camps. There is a lack of research on the barriers these women are facing to manage their menstruation, making it more difficult to take protective measures.
This call for action summarises some important measures for consideration to ensure proper menstrual hygiene management among the women and girls in Bangladesh:
**Female healthcare workers, patients and janitors: **Provision of menstrual hygiene management (MHM) and water, sanitation and hygiene (WASH) facilities – including products, underwear, disposal systems, access to soaps, hand sanitisers and water – should be made in the hospitals so that doctors, nurses, patients and janitors can avail them and manage their menstruation, particularly during emergencies and with dignity. This can be a paid provision of sanitary pads in a private corner. Healthcare workers can be provided with additional Personal Protection Equipments (PPEs) to make it easier quickly changing of menstrual absorbents in every 4/6 hours to prevent staining the PPEs while putting on and removing the PPE (1). More research is required to understand the barriers they are facing and the solutions needed in the healthcare facilities.
**Women and girls in FDMN camps, prisons and hostels: **Sufficient supply of menstrual absorbents or MHM kits, provision of gender-segregated WASH facilities for the female prisoners, and availability of proper disposal and waste management systems. If required, budget needs to be allocated for safe and stress-free MHM among this group of women and girls.
**Women and girls in colleges and schools: **Though colleges and schools are closed, this is the right time for proper planning on how to support women and girls to manage their menstruation in the schools and colleges. This can include availability of menstrual absorbents and underwear, functional disposal systems, access to water and soap and MHM education. School boys also need to be educated to promote gender sensitivity and MHM friendly environment in schools and colleges.
**Women and girls in urban slums and rural communities: **Women and girls needs to be informed about the supply sources of products. The manufacturers of sanitary pads need to make such information available with contact numbers to make the products easily available for all those in need. Since most women and girls do not use underwear, these shall be kept available also. Where possible, use of clean and reusable cloth, cloth pads and alternatives like menstrual cups, tampons can be encouraged.
**Women at readymade garment factories:**Consider providing a private space for MHM with the availability of products, underwear and soap, either free or paid provision, and disposal systems. Women can also be encouraged to use their own do-it-yourself designs of reusable cloth pads if washing and drying is hygienically maintained.
**Marginalised women and girls: **We lack data on how the disabled and other marginalised women manage their menstruation, thus this call for action takes them into account, endeavoring to support the needs of this group with the best possible solutions. Further National Hygiene Surveys also need to consider including their MHM needs.
The Government of Bangladesh has taken many initiatives to mitigate the primary and secondary effects of COVID-19, including the provision of reliefs for poor people. To mitigate the impact on menstrual health and hygiene, the government can add sanitary pads and underwear with the relief packages to make their lives easier during this crisis situation. Where possible, from the corporate social responsibility point of view, free provision of sanitary pads can be considered by the largest manufacturers. Government can also consider tax removal, considering the emergency situation.
Over 80% of Bangladeshi women and girls use old cloth to manage their menstruation, which is not a problem unless the cloth is unhygienic (2). Rather trying to shift over 80% of menstruating women into an environment unfriendly and high cost method of using single use disposable pads, icddr,b is working on developing low-cost innovations for menstrual hygiene management solutions including reusable cloth pads, washer and dryer bags for reusable cloth pad, and jute cellulose-based sanitary pads in schools, urban slums and readymade garments factories. Considering current situation where there is a lack of supplies, many women and girls may use cloth. This call for action suggests use of cloth is not a problem. However, proper maintenance (e.g. washing them with soap and water, drying under sun, and storing in a safe place/closet) is required to prevent further infection and injuries. If needed, the scientists at icddr,b can be contacted to make reusable cloth pads for women and girls in need (on request). These reusable cloth pads have been distributed among urban and rural school girls in a pilot study; it demonstrated 83% uptake and 8% reduction in school absenteeism due to menstruation.
Finally, there is a need for MHM information availability not only for women and girls but for the public, particularly for men, to promote gender sensitivity and destigmatisation using online platforms, mobile messaging services, TV or radios. These initiatives are a starting point to allow women and girls to continue with their daily life without re-living the shame and stigma associated with their menstruation.
Written by Farhana Sultana (icddr,b), and reviewed by Dr Mahbubur Rahman (icddr,b), Erin Hunter (Sydney University, Australia) and Professor Stephen P. Luby (Stanford University, USA).
Mitigating the impacts of COVID-19 onmenstrual health and hygiene. Available at: https://www.unicef.org/media/68446/file/Mitigating-the-impacts-of-COVID19-on-menstrual-health-and-hygiene-Brief.pdf [Internet]. UNICEF 2020 [cited May 24, 2020].
Alam M, Halder A, Horng L. Bangladesh National Hygiene Baseline Survey Preliminary Report. Dhaka, Bangladesh2014. 2017.
[FS1]Farasha apa, this is as of 27 May.