Menstrual health education: reflections from the field

Mar 13, 2019 | Education, Pad for pad.


Eco Femme Pad for Pad facilitator and trainer Nikethana, shares her reflections on giving menstrual health education sessions to girls and women around India.

I have been working as a part of Eco Femme’s Pad for Pad programme for more than 2 years now as a facilitator and trainer in menstrual health education. I facilitate sessions that are held primarily in and around the local Auroville area, with the primary language being Tamil. I also travel around India to train partners to be able to hold these education sessions and also do remote phone trainings.  As part of this programme, a big part of my journey has been in understanding, living and questioning the ethics of this work. I write this article to reflect on some questions that are constantly alive for me through my own experience in the field.


The biology of menstruation and the menstrual cycle

A key part of any adolescent menstrual education programme focuses around the biology of menstruation –

  • what is puberty?
  • How does menstruation happen?
  • How can girls ensure hygiene in their personal care in this time?


Chris Bobel (1) describes the main stream MHM (Menstrual Hygiene Management) work as having emerged from the ‘male-dominated and technically oriented’ WASH (Water, Sanitation and Hygiene) development sector. This form of discourse reduces menstruation to something to be ‘managed’, focuses around hygiene/personal care, and boxes the process to its technical, biological aspects – thereby abstracting it from the girl’s own bodies and lived experiences, isolating menstruation from the entire cyclical process.

“A question that we at Eco Femme always ask, is how can a menstrual education session focus less on biology and more on the lived experience of girls and women?”

In conversations with Kathy (Walkling, the co-founder of Eco Femme), and others, emerges the importance of holding sessions with small numbers of girls, a focus on quality rather than quantity. We also generally split the education into two sessions of 1.5 hours, each held over a two week period in order to be able to hold this space.

We focus the discussions/activities through exercises that bring the concept of menstruation back to the girls’ own body – for example, in asking them to locate and feel their own uterus, in vocalising loudly and proudly all the parts of the female reproductive system in their own language, in having discussions around first period experiences, in exploring how they recognise the onset of their periods (through changes in their body and emotions) and connecting all this to the menstrual cycle and also wider cycles in nature.

Every time I locate and feel my own uterus along with the girls, it is a reminder to come back to my own body.

Girls at a session, looking at a knitted uterus – one of our teaching tools

Menstrual cycle literacy is a key part of the education work. In the Pad for Pad education programme, a key exercise with the girls involves helping them learn how to mark the dates on the calendar, to calculate the length of their cycle and then predict their potential ovulation and menstruation dates – of course emphasizing that this is a rough prediction and discussing how the cycle can change.

We discuss why the tracking could be important – for fertility and contraception, to understand their cycle and to recognise problems when they arise. We discuss the relationship between strong emotions/stress and the menstrual cycle – a reminder that our psychological health can be intrinsically linked to the physical.

Harishini demonstrating the phases of the menstrual cycle

After 2 years, I am still learning cycle literacy for myself, unlearning years of distancing myself from my own cycle. The question of how to teach it better is there, how to inspire more girls to track their cycle and connect to their own bodies. That involves connecting with my body deeper too – authenticity is key to this. Some girls get it instantly, when an adult gives them permission and reasons to observe their own body, to reconnect. This brings me some joy in an area where it is easy to question what impact one actually has.

Using a knitted uterus as a teaching tool

The sad reality is, after 2 or 3 short hours of the session, the girls still return to a world where the social messages and taboos encourage them to distance themselves from their body and to fear its potential.

A fun part of the session for me focuses on exercises for reproductive health/pain relief. When discussing health and how to deal with pain during menstruation, I usually show the girls a few yoga exercises that help strengthen and/or relax the area around the uterus. I also show them a move I have learned through the Aviva method (2), that helps with menstrual cramps and clots. This part of the session has seemed to me to be increasingly key to focus again on the body and to empower with concrete tools along with dialogue. Along with teaching the move is the reminder to observe the body, to understand its’ limits and the effects of the various positions.


Culture and taboos:

The taboos surrounding menstruation and well and truly alive in Tamil Nadu. I speak mainly of this state of India as it is where I have the most direct experience.

In the Tamil language, menstruation is still strongly described as “theetu” or curse.

Whether in the rural or urban context, I hear menstrual blood constantly described as dirty and impure, which I recognize as the language used in my own childhood growing up in Coimbatore, Tamil Nadu. This resonates with what I hear from many women around India too, particularly those that practice Hinduism. There is generally much silence, shame and embarrassment at the start of most sessions.

I constantly hear stories of:

  • girls and women still sleeping separately from their family during this time,
  • eating on specific utensils in order to not contaminate the others,
  • not feeding animals when menstruating for fear of bringing a curse on themselves and their family,
  • not touching plants because they fear killing them,
  • not drying cloth outside in fear of snakes moving over the cloth and thereby cursing them with infertility

…and so many more. As described in our menstrual health education guide, ‘over many generations, a culture of silence can be passed down and intensified, creating a lack of accurate information about menstruation’.

Eco Femme Menstrual Health Education Program – Facilitators Guide

Eco Femme’s approach has been sensitive, recognizing the multiple ways that girls and women can navigate these beliefs and practices. In our menstrual health education guide it says ‘the same cultural practice may be experienced differently by different women; for example while some women may feel confined by the ritual of not entering the kitchen during menstruation, others may enjoy it because it means they get the chance to rest rather than cook’. As facilitators, we are encouraged to be sensitive to these nuances, taking on only beliefs and practices that could cause harm – for example, the belief that a cloth used to catch menstrual flow should be dried somewhere where no one can see – often under the bed or stuffed into the thatch roof. Such practices could result in a young girl or woman using a damp and unhygienic cloth that may leads to infection.

I constantly battle with myself on how far to push. If I have time, I play with the girls the game of ‘Chinese whispers’ in which players form a line, and the first player comes up with a message and whispers it to the ear of the second person in the line and this person whispers it to the next player and so on until the final player repeats out loud what they have just heard. It usually gets a good laugh! In most cases, the message has changed by the time it reaches the end. I reflect with the girls what that means, especially if it is information orally passed down through generations. To frame taboos as silly superstition removes reason and rationale from their existence. It helps to trace their history and why they might have existed in some form.

“I ask the girls to reflect what these taboos and cultural practices mean for them, whether they allow them to make safe decisions for themselves, how relevant they are in this time, emphasising the importance of making their own choices as they grow into women. That is all one can do in this short time.”

As a facilitator, even as I sometimes feel powerless to change the context of the worlds and narratives they return back to, recognising of course that these narratives are changing, even if it feels slow, I hope that at least for one or two of the girls, a seed of honest critical reflection has been planted, guiding their choices as they move into adulthood, whatever they may be.


Menstrual products:

In Tamil Nadu, and particularly in the local village area, my observations on the field have been that the vast majority of the girls I encounter have switched to using disposables, some from the big commercial DSN companies and many from the government distributed cheaper, more locally made disposables. My observations are in line with the recent data. According to the National Family Health Survey taken in India in 2015-16, 57.6% women (15 – 24y/o) use hygienic menstrual absorbents during their period, with 45% of women and girls using commercial pads. Access differs widely across states, in Tamil Nadu – the survey indicates that 90% of the women have shifted to disposables (3).

Chris Bobel shares that the core message of the MHM sector is to ‘Give a girl a {disposable} pad and change her world. MHM discourse so consistently situates the pad as the key that unlocks girls’ potential (and saves them from a tragic life)’. In Eco Femme’s recent article written by Kathy and Lauren critiquing this messaging, they write:

‘the topic of menstruation isn’t necessarily about having access to a sanitary napkin.  When it comes to solutions, we need to recognise that there is no one-size-fits-all. It has to be context specific – and we don’t have the knowledge, or right, to decide for others.  And in some ways, the product you offer as a solution is symbolic too. For example, if you don’t disclose what the ingredients are then there is still limited education which inhibits dialogue, choice and cultural change’.

This captures in essence the ethics of our work.

Product analysis and informed choice is key to our education sessions. In a Pad for Pad session normally, I go through 5 different menstrual absorbents:

  • the disposable sanitary napkin
  • cloth
  • the Eco Femme cloth pad
  • tampon
  • menstrual cup

We critically look at all of them, how they are made and what they are made from, functionality, health and safety, cost, disposal and environmental impact, ease of use etc. We look at advertising and its’ impacts on our choices of products, breaking down how disposables become an aspirational product. I make sure that the girls have a safe space to ask questions about the products, to allow them to touch and feel and interact with every product. It is important to emphasize that this is not to force them to choose any product but to make informed choices when they do. I tell them that some of the products may not be available in the markets right now, but if they did have access they would know what they were. We also look at what is inside the cloth pad, to show them that it is also easy to make at home if they do not want to depend on our product.

At the end of the session, I normally ask them to choose two absorbents – with first and second preference. The class allows for difference in opinions in what the girls would like to use. I feel it is very important here to remain objective and non-judgmental when choices are made. I gently probe to understand and get the girls to reason as to why they have chosen a particular product.  I usually share my own story of making the switch to cloth pads and cups at this point. After going through product care, I offer the girls the choice of taking a set of cloth pads if they wish to. Most do.

This video shows how we conduct menstrual product analysis in real time


Other questions:

What are our ethics as facilitators? We are in a position of power, where our words are believed as fact.

I feel it is very important for facilitators to be armed with the most accurate information and a healthy dose of humility – so many times I am asked questions about menstruation that I do not have answers to. I usually tell the girls that I am not a medical professional and do not not have answers. I ask them to check with a medical professional – with a heavy heart – as I reflect on the inadequacies of the health system in India.

Other questions rise related to the closely related topic of sex. On the field we are constantly juggling maintaining long term relationships with schools with the struggles of censoring ourselves in fear of offending the cultural sensitivities of the teachers and parents and losing access to the girls. While retaining integrity regarding certain compromises we will not make to the curriculum such as the connection to reproduction and menstruation, it still becomes a carefully worded dance to find a description of sex that avoids all references to male genitalia and the actual act, abstracting it to the egg and the sperm and fertilisation in order to explain pregnancy.

Change trickles in slowly, as we are now at the beginnings of experimentation with menstrual and sex education in our local community schools with mixed gender groups, recognising the importance of including boys and men in the conversation too.

As the journey continues in this vastly complex area of menstrual education, I want to conclude by stating that working with Eco Femme has been a real privilege, I am grateful that I continue to be given the opportunity to learn and embody these values, to raise questions and try new ways to pass the message on.


Facilitator toolkit – everything you need to educate.


By Nikethana Venkatesan

(1) Chris Bobel, author of the recently released book ‘The Managed Body:Developing Girls and Menstrual Health in the Global South’ 2018 critiquing the growing social movement to support menstruating girls in the Global South.

(2) Aviva Method is a physical exercise system that aims to stimulate the related glands for optimal reproductive hormone secretion. The name of the method is given by its developer, Aviva Gabriella Steiner, a Hungarian origin Israeli ballet dancer and PE teacher.