Menstruation, Education, and Economies: How Empowering Schoolgirls Can Impact the Developing World

Author: Jacquelyn Easterwood, 2017

“Menstruation hygiene management (MHM) remains an unfavorable conversation for many young girls globally…”

Photo from Pixabay under Creative Commons.

Menstruation hygiene management (MHM) remains an unfavorable conversation for many young girls globally. It continues to be discussed only in hushed tones and behind closed doors. As a result, girls are taught to hide their hygiene products from boys at school and are perceived as weak when they struggle with dysmenorrhea. A study done in Iran showed that 15 percent of the surveyed girls are so hindered by dysmenorrhea that they miss between 1 and 7 days of school each month (Bharadwaj et al. 11). The information on MHM is limited, and studies done on MHM education are sparse (Sommer et al. 3); however, issues surrounding menstruation are negatively affecting the potential of young women globally and the potential success of local economies.

Every day around 200 million girls in low-resource communities around the globe manage their menses in a way that is unhygienic and stigmatizing (Crofts and Fisher 3). While girls growing up in the Global North may experience the same physical discomforts with dysmenorrhea, they don’t typically struggle to find sanitary products or the privacy needed to properly handle their menses. Many girls around the world find themselves without access to proper sanitary materials or clean water needed to wash their blood-soaked rags (Crofts and Fisher 3). Additionally, girls are confronted with inadequate bathroom facilities that often do not have the proper equipment to wash themselves or private rooms in which to change their menstrual products (Garg et al. 771). While there are clear WASH (water, sanitation and hygiene) restrictions that girls face in developing countries, many of them are also subjected to burdening cultural stigmas that have an adverse psychosocial effect on their lives and stifle their potential to succeed socially as well as educationally (Crofts and Fisher 3).

The normalization of menstruation, the accessibility of low-cost feminine hygiene products, and improvements in the WASH sector could potentially decrease menses-associated shame, increase school attendance, and encourage lifetime success for females. Additionally, investing in menstrual hygiene management and the education of young girls could positively impact the economy. T. Paul Shultz credits the education of girls and women as influencing “their health, longevity, and welfare and that of their children, and perhaps other members of their family” (710). This paper aims to outline the struggles associated with menstruation in developing countries, particularly as they relate to schoolgirls (girls of primary-secondary school age were the focus of this research) and their educational and social success. Additionally, this research aims to address why it is economically imperative that the global community takes an interest in minimizing the limitations associated with menstruation because of their effects on girls’ access to education in the developing world.

Cultural Stigmatization

The stigmas surrounding menstruation in different cultures and religions can have a deep impact on the overall mindset of young girls. Almost all religions classify menstruation as “unclean,” causing girls to feel dirty, ashamed, and embarrassed over a natural and unavoidable process (Bhartiya 523). In India, a study done by the Indian Council for Medical Research revealed that around 70 percent of mothers believe the process of menstruation is “polluting” (Garg et al. 768). Consequently, a survey conducted by Aru Bhartiya (526) determined that 41 percent of adolescent girls did not know anything about their period before their menarche (first menstrual cycle). Considering the plasticity of young girls, ignorance regarding menarche can result in a lifetime of fear and self-shame directed towards their inevitable cycle. Both familial and societal shame can make menstruation distressful and cause self-consciousness, especially when the average age of menarche is just 13 years old (Garg et al. 767-768).

Cultural and religious views of menstruation are slowly progressing with time and advancements in human rights, but the marks of traditional reproach linger in some parts of the world. In traditional Hindu faith, menstruating girls are “ritually dangerous” and are prohibited from touching food or plants, as it may spoil or die simply from physical contact (Garg et al. 768). Confirming the negative effects that menstruation has on education, Garg et al. reported that over 15 percent of girls surveyed do not attend school while they are menstruating causing girls to fall behind in their studies (768). Menstruating girls must also refrain from worship or entering the temple, as the impurity of menstruation has no place in the sacred temple (Bharadwaj et al. 8). Additionally, Bharadwaj et al. mention that they cannot touch male family members, engage in sex, attend events, or even cook while they are menstruating (768). In some households, menstruating girls must stay in a separate section of the house and use a different door than the rest of the family members when exiting or entering the home (Bhartiya 525).

Due to the perceived impurity of menstruation and resultant prohibition of touch, Hinduism goes as far as shunning menstruating girls to ‘menstrual huts,’ as referenced in Nepal (Bhartiya 525). During a female’s menses, these structures are specifically designated for sleeping, following a tradition known as “chaupadi.” Though this has been illegalized in Nepal, the practice is still prevalent in many areas of the country (525). Bhartiya mentions that these huts expose girls to a variety of unnecessary dangers such as wild animals, sicknesses, and sexual assault from men who are aware that they are alone in the huts (525). These types of huts can also be found in some Russian Orthodox households (524), and according to Bharadwaj et al., they are also used in parts of Africa (8). This tradition not only adds to the shame, disgust, and fear that girls already feel towards their menses, but also exposes them to additional risk of injury, psychological damage, and even death.

Similar to Hinduism, Bharadwaj et al. state that Islamic law does not allow menstruating girls to worship or have sex. Females are not permitted to touch the Quran if it is written in Arabic because it is a holy translation; however, they are permitted to read translated texts (9). Additionally, they can only be considered “clean” again after a ritual bath takes place (Bhartiya 524). Of course, Hinduism and Islam are not the only two religions that have restrictions for girls who are menstruating. Most religions practiced traditionally have similar limitations to Hinduism and Islam, including Christianity (Bhartiya 523-525). In addition to the stigmatization girls experience, they often lack access to the products they need to properly combat their menses.

Access to Proper Menstrual Hygiene Materials

Schoolgirls in developing countries do not have sufficient access to the same commercial sanitary products or sufficient WASH facilities that girls growing up in Western cultures may have which limits their ability to succeed in school. Montgomery et al.’s pilot-study in Ghana showed the importance of proper sanitary products in relation to education. Their surveys showcase that schoolgirls without access to sanitary pads missed an average of 3 to 5 days of school. On the long walk to school they would tend to bleed through their makeshift products, which would encourage them to stay at home to avoid the embarrassment of leakage (4). Unlike girls in developed countries, girls in low-resource communities are unable to go to the nurse’s office for menstrual hygiene products (MHP) when they unexpectedly start their periods at school (Sommer 522). Instead, girls who cannot afford imported products are left to use old rags or cloths and, sometimes, even leaves (Crofts and Fisher 6). In Uganda, a 10-pack of pads costs more than the daily income of some families (4). Not surprisingly, parents often choose to not spend funds on sanitary products for their daughters because they are too expensive, leading to the reliance on using dangerous makeshift supplies (Bhartiya 10).

Appropriately combating menses at school in low-resource countries can prove challenging. Girls often lack the privacy and washing facilities they need to approach their periods with dignity. School latrines in low-resource communities are typically co-ed and lack appropriate supplies for dealing with menses such as soap and water (“Girls” 3). In most villages in India, there is no piped water supply, making sufficient menstrual hygiene management nearly impossible (Garg et al. 768). These latrine doors often do not lock properly, and the latrines themselves do not usually have a proper disposal system for girls (Crofts and Fisher 3). Additionally, the lack of soap and water in the latrines means that girls are unable to properly wash blood from their hands or school uniforms (Sommer 527). Sommer mentions that because schoolgirls are often harassed by boys who suspect them of menstruating, many of them wear the same pad or absorbent material the entire day to remain free of suspicion. This limits their class experience as they have to sit uncomfortably for the entirety of the day, instead of in classroom activities and learning while the trepidation of leakage looms over them (526). Likewise, girls are apprehensive to participate in sports and extracurricular activities for fear that the folded toilet paper or cloth they are using in lieu of sanitary pads may fall onto the ground and cause even more embarrassment and shame (Crofts and Fisher 11). The desperation for commercial sanitary products and WASH facilities limits schoolgirls’ ability to focus in the classroom while also limiting the opportunity to maximize their learning potential. There is even evidence to suggest that girls participate in transactional sex for money to buy these commercial products when they cannot afford them (Phillips-Howard et al. 1-2).

Menstrual Health and Education

While the global community stresses the important of education, there is a lack of research in menstrual hygiene management as it relates to education even when menses proves to be a noteworthy conversation in the health and livelihood of young girls (Sommer 523). Marni Sommer indicates the importance of MHM research in sub-Saharan Africa noting that although 57 percent of girls are enrolled in primary school, only 17 percent are enrolled in secondary school (521). Sommer surveyed girls in Kilimanjaro in northeastern Tanzania and asked what they would include in a class specifically tailored to sexual and reproductive health. One group replied with a particularly noteworthy suggestion:

We are advising the government to include a topic which has things to do with girls growing up – about menstruation and how to use pads. They should be taught…not to have love relationships because they will be in danger of getting different kinds of diseases and pregnancy. There should be people to teach them how to clean themselves. We are insisting…that there should be people who go to different schools and teach them about growing up things, how they should manage when they are in their “days” and they are at school and when they have cramps (527).

The above quote should serve as a realistic suggestion for what the international community and local governments can do to bring menses and puberty to light and encourage girls to stay in school. Firstly, normalizing the discussions about menses. Montgomery et al. deduced from their findings in Ghana that when girls are provided with proper information regarding menses they are better equipped to handle their periods, which may encourage consistent school attendance (6). Girls need guidance so they can understand the changes that their bodies are undergoing in addition to how to deal with those changes (Sommer 528). The mainstreaming of menstruation and female sexual health has the potential to decrease the body shaming epidemic plaguing the self-images of girls everywhere (Garg et al. 768).

International Community Involvement

Governments in developing countries can make substantial economic gains by advancing girls’ education and investing in possible solutions to the issues brought about by menstruation. The Sustainable Development Goals (SDGs) established in 2015 by the United Nations to combat global issues do not specifically mention menstrual hygiene management; however, the targets have a strong focus on girls’ health and education. MHM applies to several of the SDGs including “Education for All,” gender equality, and the promotion of good health (“Girls” 3). Fortunately, over the last few years the international community has begun to recognize the need for MHM research, education, materials, and facilities in developing countries across the globe. “MHM in Ten” was established in 2014 and was hosted by UNICEF and Columbia University in New York City (Sommer et al. 1). This established five key priorities to be achieved by 2024 which promote the ability of schoolgirls to manage their menses with dignity and cleanliness in low and middle-income countries (LMICs). The meeting brought together representatives from a wide range of sectors from water, sanitation, and hygiene NGOs to UNESCO (2).

The participants in “MHM in Ten” recognized the higher dropout rate of female adolescents as it relates to the management of their menses, and agreed on allocating funding for more research in this area of health and education (Sommer et al. 2). “MHM in Ten” promotes the collaboration of the education and WASH sectors to address inadequate facilities on school campuses which make combating menses challenging and psychologically detrimental (3). The first priority stresses the need for more national-level research, and determining the most cost-effective way to pursue strong evidence collection regarding MHM (4). Sommer et al. mention that the second priority emphasizes the need to implement guidelines that governments must meet within their school systems, while the third calls for increased advocacy and the mainstreaming of MHM even where it is culturally taboo. The fourth priority mentions the need to allocate budgetary and monetary responsibility to certain entities. Finally, the fifth priority is the total integration of MHM into the education systems’ budgets, plans, services, etc. (4-5).

Further Suggestions for Change

Normalization

The normalization of menstruation needs to become a priority for the global community. While too many premenarchal girls lack information, women also need to be aware that menstruation is natural, not only for their own sake but for the sake of their future daughters so that they do not have to experience the limitations of shame. Proper information regarding menstruation is also necessary in preventing adolescent pregnancies (Phillips-Howard et al. 2). WASH NGOs should train staff members to educate women in developing communities about proper menstrual hygiene practice. Further, advertisements and pamphlets are efficient catalysts for change and could be utilized more in the mainstreaming of menstruation in developing nations and even in Western culture (Bhartiya 526). Female celebrities are also effective in influencing young girls, and should take part in normalizing menstruation around the globe (Garg et al. 773).

As previously mentioned, menstrual hygiene products are often displayed out of sight, making it more difficult for women to find the products they need. Additionally, societal perceptions further limit women from using the materials properly even when they already have them, perpetuating unhealthy and even deadly habits. An example is a Hindu myth that says if a man sees a female’s stained rags he could go blind (Garg et al. 768). Garg et al. mention that this mentality (and these myths) encourages girls in developing countries to dry their reusable makeshift pads indoors instead of outside in the sun. This method of drying is insufficient and leads to the spread of bacteria and infection in girls’ genitals (768). A study done in Uganda found that just 3 percent of girls dried their reusable pads and cloths in the sunlight (Crofts and Fisher 14). Deficient management of menstrual hygiene can increase the risk of Reproductive Tract Infections or RTIs (Garg 768). RTIs, if left untreated, can lead to fetal wastage, prenatal infection, infertility, and even death (768). However, without proper hygiene products and knowledge, these girls are left with little choice. Good MHM is described by UNICEF and the World Health Organization as “when girls and women use clean material to absorb or collect menstrual blood; can change this material in private; and have access to soap, water and disposal facilities for used materials” (“Girls” 2). These are the standards that the global community should strive to achieve.

Funding and Research Improvements

Additionally, the funding for menstrual hygiene management research needs to be prioritized within the education and WASH sectors. Large-scale studies should be performed in various communities to understand the precise effect that menstruation has on the post-menarchal schoolgirl (Phillips-Howard et al. 5). Expanding the knowledge of MHM in developing countries will better equip the international community to proceed with interventional measures (2). Teachers need to be trained on how to effectively teach girls and boys what puberty entails, and must prioritize curriculum (Garg et al. 772). For example, cities in India frequently skip the chapter on puberty and assign it as homework for the student to read on their own (770), and teachers are not often very understanding of the girls’ situations. Oftentimes girls leave school when they’re feeling ill from menstruation since they have no one at school to assist them (Sommer 526).

In addition to proper teacher training and research, schools’ WASH facilities desperately need to be improved in order to keep girls in school. Poor sanitation requirements are affecting the ability of girls to reach their maximum potential in developing countries. “Gender-unfriendly” infrastructure in schools does not provide a safe environment for girls to combat their menses with dignity (Garg et al. 772). Oftentimes schools do not adequately adhere to sanitation standards, leaving large populations of girls unenrolled (Bharadwaj et al. 5). UNICEF estimated that 1 in 10 African schoolgirls skip school or drop out entirely due to sanitation conditions of the schools they attend (Garg et al. 771). Likewise, 43 percent of surveyed girls in a community in Uganda did not feel comfortable changing their pads at school due to a lack of privacy within the latrines, which often do not have the ability to effectively lock (Crofts and Fisher 13).

Fixing the locks and providing cleaning supplies in latrines could greatly improve the comfort of managing menses at school which has the potential to raise attendance rates and lower the female dropout rates (Sommer 527). An out-of-sight area for proper disposal of menstrual materials, such as an area to properly burn them, would not only encourage the changing of pads, but would improve the condition of the latrines and environment. Girls tend to throw their used materials in the pit of the latrine or onto the ground when faced with no other option which also increases the levels of pollution in the communities (Bharadwaj et al. 5-6, 10). Latrines that are secure and stocked with cleaning supplies and disposal capabilities for menstrual hygiene materials are clearly crucial to the dignity and rights of girls in low-income communities (Croft 18).

The affordability and availability of low-cost hygiene products in developing countries needs to be addressed as well. The previously mentioned 2012 pilot study in Ghana utilized three different test groups to determine if the availability of proper sanitary pads would affect school attendance (Montgomery et al. 1). The first group was given sanitary pads and proper education on menses, puberty, proper hygiene, and how pregnancy occurs (3). The second was provided with proper education but not sanitary pads, and the third was a control group receiving no education or products (1). The most immediate results came from the first group of girls who were well-equipped for their cycles. Their attendance improved within three months, and the attendance of the second group caught up with the first after just five months proving that proper education and access to MHP supplies can positively impact girls’ school performance (4).

Further research should be conducted to determine the rate in which the accessibility of low-cost sanitary pads and generalized information about puberty is effective in the long-term at increasing the attendance of girls in primary and secondary schools. Crofts and Fisher mention that a potentially sustainable solution to the lack of affordable sanitary pads in developing countries could be the training of local women to make menstrual kits. While the women benefit monetarily from such a program, girls also benefit from the availability of menstrual supplies (Crofts and Fisher 16). Perhaps these women could also be relied on to provide information about menses to curious adolescents when requested.

Garg et al. found through their study of menstruation in India that only around 10 percent of girls were using sanitary pads during menstruation, and that over 70 percent were using reused cloth pieces to manage their periods (769). Additionally, Water Aid Mission in Nepal reported that 41 percent of girls were not well-informed regarding sanitary pads and 38 percent of girls simply could not afford them (769). Luckily the Indian government approved a plan to provide subsidized sanitary pads to girls in rural parts of the country, providing around 15 million girls (ages 10-19) with a new-found level of dignity every month (769). The program also aimed to provide information to girls regarding their bodies and has yielded remarkably positive results. Garg et al. reports that the use of legitimate sanitary pads increased to 25 percent, and the use of makeshift, dirty products decreased (770). Another important success recorded from this subsidization plan was that a significant number of girls reported that they are more aware and knowledgeable about their menstrual cycle and health (Garg et al. 770). Girls in Tanzania also reported that they would be grateful if their government would supply them with sanitary pads in schools (Sommer 527). While low-resource governments in developing nations may be reluctant to prioritize the potential of young girls in their countries, it is important to note the benefits that investing in girls has on the local economy (Chaaban and Cunningham 3).

Economic Potential

Supporting girls to achieve their potential is not only a humanitarian necessity, but it is also economically wise. Even though girls represent half of the population of children in developing countries, they contribute less to the economy than they potentially can (Chaaban and Cunningham 1). Education is key to improving female human capital and empowering women and girls. Rekha Mehra describes female empowerment in terms of development as including “the expansion of choices for women and an increase in women’s ability to exercise choice. For example, improvements in women’s access to economic opportunities such as credit and employment expand choices, while health services and education improve women’s capabilities to take advantage of those choices” (138). Essentially, a fair opportunity at an education means that girls can grow into socially and economically competent women in their adult lives. Similarly, investing in girls’ educational success in developing nations has proven to have a greater return on investment over investing in boys (Schultz 695). According to Chaaban and Cunningham, in Thailand, Ghana, and Côte d’Ivoire, returns on secondary education of girls were 15-25 percent higher than boys (2).

By prioritizing proper menstrual hygiene management as a valuable sector of girls’ sexual and reproductive health (SRH) and as a crucial component of advancing their overall rights, governments can encourage girls to stay in school longer and achieve their maximum potential. If governments start taking girls’ education more seriously, there is opportunity for a significant increase in economic growth (Chaaban and Cunningham 3). Women make up a significant number of the agricultural workforce, and there is evidence that shows how women are becoming more involved in formal and reportable wage earning positions as education becomes prioritized in the global community (Mehra 136). Typically, women have held more informal positions than men most likely due to the higher rate of female illiteracy and lack of job skills as a result of deprioritizing female education in parts of the world (144).

As mentioned above, there are generally more girls enrolled in primary schools rather than secondary schools (Sommer 521). There are several factors that could contribute to girls dropping out of school between the primary and secondary levels. These include: child marriage, adolescent pregnancy, and inadequate sanitation standards as previously mentioned (Garg et al. 771). In the developing world, one quarter of adolescent girls are not enrolled in school, and one quarter to one half of girls become mothers before the age of 18 (Chaaban and Cunningham 2). This can cost girls in terms of a “share of gross domestic” up to 30 percent over a lifetime (1). It is important to delay early pregnancies for the safety, health, and potential of young girls. If governments end debilitating traditions, such as child marriage, and focus their efforts on improving girls’ health and education, they will produce healthier and more societally productive women and families (3). This reform should also include girls’ SRH and menstrual hygiene management in schools. Shultz mentions that intervention in girls’ education also directly impacts the future children of their households because as mothers, the educated girls are more likely to stress the importance of education in their own families (727). Additionally, the women of the family are more likely to focus their income on food, healthcare, and the education system which encourages an increase in economic growth for the community in which they live as well as improves the overall welfare of the family (Schultz 715, Mehra 143).

If governments in developing countries invest in girls’ SRH and MHM, the rate of unwanted fertility is likely to decrease as girls become more informed and more educated (Schultz 716, Revenga and Shetty 41). Poor menstrual hygiene management has a negative effect on girls’ ability to learn and receive the education they have the basic right to enjoy (Sommer 526). As improvements are being made in girls’ education, the number of women in the labor force is increasing while fertility rates are lowering (Revenga and Shetty 41). However, even more improvements could potentially be made in girls’ education if more extensive reports are done on MHM in developing countries. The education sector needs to increase its involvement with WASH regarding the sexual health of adolescent girls to keep them enrolled in secondary school and consequently assist in benefitting the growing economies of the developing world (Sommer et al. 3). A study done by Chaaban and Cunningham in a series of African and Asian countries reports that there is a 5-15 percent increase in earnings for women who successfully completed secondary school as adolescents (2). They also report that GDP (gross domestic product) could increase by 1.2 percent in a single year if the education gap between girls and boys is closed (Chaaban and Cunningham 1). T. Paul Schultz brought to light a study done within African countries that inferred the “average social returns to investment in primary, secondary and higher education” were 27 percent per year (717). Girls who are unfairly restrained from meeting their potential are unable to contribute to the economy as substantially as they could had they received the proper healthcare and education they deserve (Chaaban and Cunningham 4). Therefore, improvements in SRH and sanitation in schools must be prioritized.

Conclusion

This research has stressed the need to recognize and address the unsanitary and dangerous environment in which girls live during each month of their menses. There is a societal stigma surrounding the natural process of menses, even in Western cultures where body shaming and period shaming is common amongst adolescents (Garg et al. 768). In developing countries where the schooling of girls is essentially deemed as wasteful, their struggles to obtain a satisfactory education are magnified when they are menstruating. Schools are not equipped with the proper WASH facilities to permit girls to manage their menses with dignity, nor are they staffed with teaching professionals that are comfortable with discussing the topic (Sommer et al. 3). The probability of girls dropping out of primary- secondary school due to poor sanitation situations also negatively affects economies and the welfare of their future families (Chaaban and Cunningham 4). Additionally, specific cultural beliefs classify menstruating girls as dirty and polluting, making the normalization of menses a challenge. Although menstruation itself is not a process that females can control, girls’ mothers even tend to think it is a shameful time of the month (Garg et al. 768).

Thankfully, for girls in LMICs across the globe, the issues associate with menstrual hygiene management are coming to light. This can be seen with “MHM in Ten,” and the recent involvement of the education sector in menstrual health (Sommer et al. 3). It is crucial to the advancement of girls’ rights and their overall empowerment in society to address an issue that is negatively affecting their potential in the global economy. If we are to break poverty traps, women need to be given the opportunity to make their own choices and prosper through fairness in education and health so they may contribute to their economies (Mehra 140). Additional research should be done on a larger scale to appropriately measure the effects of unsatisfactory MHM on the potential of girls (Phillips-Howard et al. 2). Government entities and NGOs should stress the importance of innovative and sustainable ways to combat the issues associated with MHM that have been expressed here. Training women to make low-cost sanitary products could be an effective way to grow the economy while also promoting good MHM (Crofts and Fisher 16).

The education of young girls has been overlooked for too long around the world. While the Millennium Development Goals of 2000 and the Sustainable Development Goals of 2015 focus on the empowerment of girls, they do not specifically mention the struggles that menstruating schoolgirls face (“Girls” 3). If the international community plans to properly address the potential of young girls, then the conversation about periods can no longer be a hushed one.

Works Cited

Bharadwaj, Sowmyaa, and Archana Patkar. “Menstrual hygiene and management in developing countries: Taking stock.” Mumbai: Junction Social (2004).

Bhartiya, Aru. “Menstruation, religion and society.” International Journal of Social Science and Humanity 3.6 (2013): 523.

Chaaban, J. and Cunningham, W. (2011) Life Expectancy: Measuring the Economic Gain of Investing in Girls: The girl Effect Dividend. World Bank, Washington DC. http://dx.doi.org/10.1596/1813-9450-5753

Crofts, T. and Fischer, J., 2012. Menstrual hygiene in Ugandan schools: an investigation of low-cost sanitary pads. Journal of Water, Sanitation and Hygiene for Development, 2 (1), pp. 50 – 58. http://washdev.iwaponline.com/content/2/1/50

Garg, Rajesh, Shobha Goyal, and Sanjeev Gupta. “India moves towards menstrual hygiene: subsidized sanitary napkins for rural adolescent girls—issues and challenges.” Maternal and child health journal 16.4 (2012): 767-774.

“Girls’ and Women’s Right to Menstrual Health: Evidence and Opportunities.” PATH. N.p., 01 Feb. 2016. Web. 11 Apr. 2017.

Mehra, Rekha. “Women, empowerment, and economic development.” The Annals of the American Academy of Political and Social Science 554.1 (1997): 136-149.

Montgomery P, Ryus CR, Dolan CS, Dopson S, Scott LM (2012) Sanitary Pad Interventions for Girls’ Education in Ghana: A Pilot Study. PLoS ONE 7(10): e48274. doi:10.1371/journal.pone.0048274

Phillips-Howard, Penelope A et al., “Menstrual hygiene management among adolescent schoolgirls in low-and middle-income countries: research priorities.” Global health action 9 (2016).

Revenga, Ana, and Sudhir Shetty. International Monetary Fund. “Empowering Women Is Smart Economics-Closing gender gaps benefits countries as a whole, not just women and girls.” Finance and Development-English Edition 49.1 (2012): 40.

Schultz, T. Paul. “Investments in the Schooling and Health of Women and Men: Quantities and Returns.” The Journal of Human Resources, vol. 28, no. 4, 1993, pp. 694–734.

Sommer M, Caruso BA, Sahin M, Calderon T, Cavill S, Mahon T, et al. (2016) A Time for Global Action: Addressing Girls’ Menstrual Hygiene Management Needs in Schools. PLoS Med 13(2): e1001962. https://doi.org/10.1371/journal.pmed.1001962

Sommer, M. “Where the education system and women’s bodies collide: The social and health impact of girls’ experiences of menstruation and schooling in Tanzania.” Journal of adolescence 33.4 (2010): 521-529.