Breaking the Silence on Menstrual Hygiene Advocacy Workshop Report

Breaking the Silence on Menstrual Hygiene Advocacy Workshop Report 30 May 2017 Addis Ababa, Ethiopia Report prepared by Kalkidan Gugsa, WASH C4D Specialist, UNICEF Ethiopia

Contents Contents 1 Executive Summary 2 MHM Day Objective 2 Icebreaker 3 Speeches 3 Opening keynote address 3 Launching of National MHM Guideline 4 Girls Portrait Gallery 5 Student Experiences 5 Sheno Primary School, Oromia 6 Bole Addis Primary School, Addis Ababa 6 National MHM KAP Assessment Results 7 Panel Discussion 10 OneWASH National Programme Linked to MHM 10 Menstrual Education 10 Products and Infrastructure 11 Convergence 12 Role of Men and Boys in MHM Awareness 12 MHM programme impact 12 Conclusion 12 Reference Documents 13

Executive Summary In 2012, WaterAid and partners developed a resource for improving menstrual hygiene around the world, entitled Menstrual Hygiene Matters. The team also highlighted the need for a menstrual hygiene management (MHM) knowledge-attitude-practice (KAP) assessment in countries that have significant disparities in gender inequality. This baseline has now been conducted in Ethiopia and the data presented at this meeting. The ministries of Health, Education, Water and Women and Children s Affairs in collaboration with UNICEF, WaterAid, World Vision, SPLASH and SNV brought together different stakeholders like corporations, NGOs, government representatives, faith-based organizations and bilateral agencies, beneficiaries and health experts to build a strong collective voice to advocate for holistic action on MHM. The culmination of these efforts were presented in the National MHM Guideline on MHM Day, 30 May, in Addis Ababa. Government media agencies and non-government officials also promoted the day and highlighted the effects of poor MHM to reinforce the message, launch the guideline and show how the respective institutions benefit from it. UNICEF Ethiopia s Water, Sanitation and Hygiene (WASH) programme recognizes that MHM is an important aspect of eliminating inequalities in access to WASH services and that MHM contributes to reducing early marriage by improving girls school attendance, performance and school completion. UNICEF, in coordination with the Ministry of Health, commissioned detailed baseline surveys to learn about the challenges girls and women face due to poor MHM and also to guide the design of UNICEF s MHM programme. Accordingly, below are some highlights of the baseline findings: Over half of girls in Ethiopia have never received any information about menstrual hygiene. Less than half of the girls in the county are taught about menstrual hygiene in school. Over 1/3 of girls say they wait until they get home from school to change sanitary materials. Four out of five (80 per cent) said there is never use soap in school. Over half of girls (56 per cent) said there is no water availability at school toilets 11 per cent of girls in Ethiopia miss school because of menstruation. Pain, discomfort and teasing stop girls from coming to school. The majority (63 per cent) of adolescent girls never talk about or discuss menstruation with another person. Only 22 per cent of women said they talked with their daughter before she started menstruating. 69 per cent of girls say they don t discuss menstruation because of shame. MHM Day Objective The ministries of Health, Education, Water and Women and Children s Affairs, along with their partners commemorated the global MHM day on 30 May 2017 with the theme Let s Break the Silence about Menstruation. Menstrual Hygiene Day is intended to be an open platform for partners across all sectors to engage in awareness and advocacy and knowledge-sharing around the importance of MHM. 2

The overarching objective of the event was to support government and funding agencies, corporations and NGOs to increase effective outcomes of their work on MHM. Discussions were designed to gather critical inputs from all stakeholders on policy, funding and monitoring and evaluation on MHM programmes in Ethiopia. The event examined MHM programme areas with a goal to provide inputs on: 1. How MHM education should be comprehensive 2. Social taboos surrounding menstruation 3. Boys/Men involvement on MHM 4. Sanitary material options 5. MHM and the OneWASH National Programme (OWNP) 6. The convergence of pertinent sectors on MHM implementation 7. MHM and its impact on gender equality 8. Child marriage and MHM 9. Quality sanitary pad production assurance mechanisms in the country Menstrual Hygiene Management Day event participants UNICEF/2017/Tadesse Icebreaker Adolescent groups of boys and girls presented an edutainment song with a clear message of how boys teased girls during menstruation in particular when clothes were stained with menstrual blood. The play was showcased as a potential tool in the school communities and the significance of boys involvement and supportive role to come forth and speak on the importance of breaking the silence around menstruation and empowering girls to manage their menstruation in a safe, hygienic and dignified manner. The play was performed by adolescent girls associated with SPLASH NGO working on school sanitation and hygiene interventions. Speeches Keynote speeches were given by MHM focal people from the various ministries and reflected the critical aspects of the event. These included: Opening keynote address Dr. Hassen Mohamed Advisor to State Minister of Health Dr. Zufan Abera Damtew Director, Health Extension and Primary Health Service Directorate 3

Jane Bevan UNICEF Rural WASH Manager Tsige Tadele Advisor to State Minister of Women and Children s Affairs Critical aspects of MHM were highlighted, including the launching of the National MHM Guideline and how menstruation affects the lives of millions of women and girls and impacts their education and health. Dr. Hassen and Dr. Zufan, during speech UNICEF/2017/Tadesse Launching of National MHM Guideline The launching of the MHM Guideline was one of the key events undertaken during the day. The Federal Ministry of Health with partners of UNICEF, WaterAid and SNV developed the guideline with the purpose of providing a comprehensive resource on menstrual hygiene that supports the development of context-specific information for improved practices for women and girls at institutions, in the community, workplace and emergency contexts. The guideline is useful for professionals who are concerned with improving the lives of girls and women, in particular for WASH sector professionals, as well as those from other sectors, including health, sexual and reproductive health and rights, education, community development, protection and gender sectors. The National MHM Guideline also covers why menstrual hygiene is important for all, what should be done at household, community, subnational, national and international levels, as well as men and boys involvement in menstrual hygiene, menstrual sanitary protection materials and disposable options, MHM WASH facilities, working with schools, in emergency, and research, monitoring and advocacy. 4

Launching of the National MHM Guideline UNICEF/2017/Tadesse Girls Portrait Gallery The portrait gallery highlighted girls portraits when they were talking about their first experience of menstruation. Also in the portrait gallery were various MHM product options, including multiple types of washable cloth pads, disposable pads, commercial sanitary napkins as well as behaviour change communication materials used to initiate the conversation around MHM in communities. Portrait and materials exhibition at the MHM Day event in Addis Ababa, Ethiopia. UNICEF/2017/Tadesse Student Experiences UNICEF, in partnership with World Vision, has been implementing a comprehensive MHM intervention in four regions, targeting both schools and communities. Participants from those schools, were also present at the MHM Day event. In total, three girls, a boy and a female teacher participated. Below are testimony highlights from the school participants. 5

Sheno Primary School, Oromia Girls discussed their fear of being teased and humiliated if there was a visible bloodstain on their clothes. They also mentioned being bullied by boys and parents who said that they are no longer virgins because they were menstruating and punished by parents who blame them for being raped. This teasing and bullying caused girls to isolate themselves: the girl who menstruates stays in a corner of the classroom or stayed at her desk till all classmates had gone because she doesn t want to be bothered by anyone. We have seen many challenges because of not knowing how to manage menstruation in an hygienic manner, but due to this project we have seen results like, boys being supportive of us on managing menstruation and ourselves being able to manage without fear and shame. Another student, Daniel, admitted that he did not know much about menstruation and thought it only a matter for girls and women to discuss. The MHM education in the school helped me to know more and how to be supportive of girls. I am a member of the MHM club to motivate my peers, particularly boys. Boys make fun of girls if they know she is menstruating, they see it as something ugly and icky. However, this is due to a lack of knowledge and guidance from home, said Sisay Adugna, a teacher at Sheno. Sisay also highlighted that long before this project started, she advised girls how to manage menstruation, but due to the negative feedback she received from school management, she was forced to resign. Despite the great importance that menarche represents in the life of a young girl, many girls and boys were in the dark about puberty, menstruation and reproductive health. Now things have changed thanks to this project, said Sisay. Now we do not need to hide to guide our students about menstruating and managing it in a dignified manner. She concluded by saying, Education on these topics is crucial to guide girls and boys through the physical, social and emotional changes they experience during adolescence and to help them make sound decisions regarding their health. Bole Addis Primary School, Addis Ababa One female student emphasized that even though Addis Ababa is the capital city, it does not mean that schools there are privileged with fulfilled WASH infrastructure. She underlined the importance of investment in urban town schools to alleviate the challenges in MHM WASH facilities. She also highlighted her first experience was not difficult as she was supported by her mother and sister but pointed out her friend's devastating experience while managing menstruation. I used to give sanitary pads to my friend when she could not afford them. She would use old rags tightened with a rubber band to avoid dislodging them. 6

Students (L to R): Daniel Worku, Hiwot Werka and Simret Hailu, from Sheno Primary School in Oromia; and Zinebech Daniel from Bole Primary School in Addis Ababa share their experiences about menstruation during the Menstrual Hygiene Day event. On the right, teacher Sisay Adugna from Sheno on 30 May 30 2017 in Addis Ababa, Ethiopia. UNICEF/2017/Tadesse National MHM KAP Assessment Results Jane Bevan from UNICEF presented the key findings of the National MHM KAP results. The major findings are presented in the executive summary and below are informative graphs from the presentation. 80 70 60 50 40 30 20 10 0 Urban Rural pastoralist Rural non-pastoralist Total Figure 1. Sources of information about MHM 7

Figure 2. Percentage of girls missing some days of school due to menstruation 90 80 70 60 50 40 30 20 10 0 Afar Oromia Gambella SNNP Shocked and frightened I thought I was sick I took it easy as already informed Other Figure 3. Experience with menarche (first menstruation) 100 90 80 70 60 50 40 30 20 10 0 Disposable sanitary pads Reusable sanitary pads Reusable pieces of cloth Disposable pieces of cloth/rage Urban Rural pastoralist Rural non-pastoralist Total Figure 4. Options for pads 8

0.6 0.5 0.4 0.3 0.2 0.1 0 Teasing from other students Too much pain Lack of water in school Lack of separate toilets for girls Oromia Afar Gambella SNNPR Lack of supplies Parents asked me to stay at home Other Figure 5. Reasons for missing school Social taboos around Menstruation Few people in rural areas associate girls bleeding with sex and if she has her period without getting married, society suspects her of having sex before marriage [Tigray- KAP] Almost one third of girls say their mothers think first menses is a sign of sexual activity. [Amhara]. One of the boys started to shout pointing his finger at a girl in grade six after observing a drop of blood on her uniform. Immediately, almost all the boys in the field surrounded her teasing and laughing at her... Later on I heard that she left the school because of the incident and decided to quit her education. Whenever I think of that day, I always regret because I was one of the boys who was teasing and shouting at her because I have no knowledge and awareness about menstruation. [Schoolboy in SNNPR] If, for example, there is a pond in the surroundings and if a menstruating female goes around it, it may dry. Further, if she snips pieces from some such plants as buckthorn, that we grow at home, it is believed that the plants may 9

Panel Discussion Participants of the panel discussion included: Dr. Zufan Abera Director of Directorate PHC and HEP, MOH Metsehate Ayenekulu PSI Advisor on Adolescent Health Bethlehem Mengistu Country Director WaterAid Kidist Alemu Child Protection Specialist, UNICEF Ellen Alem Gender Adviser, UNICEF Panel discussion, from L to R: Dr. Zufan, Metsehate Ayenekulu, Bethlehem Mengistu, Kidist Alemu, Ellen Alem UNICEF/2017/ Tadesse OneWASH National Programme Linked to MHM The focus of WASH has traditionally been on hardware, namely the construction of WASH facilities and typically MHM has been largely neglected from wider WASH interventions. There was a gap in research on MHM and previous efforts focused on advocacy, however now we have global and national evidence to advocate for it and must make MHM an integral part of WASH. Menstrual Education There is an opportunity to integrate puberty education into all programmes related to hygiene, sanitation, women s reproductive health and school education. Puberty education can be effectively leveraged as a platform for MHM education as it would target menarche in a girl s reproductive life cycle. Within the Government framework, this can be achieved through convergence at the policy level of OWNP signatory ministries to train last mile government functionaries for awareness generation. For example, health care providers such as HEWs, teachers and community- 10

level sanitation and hygiene committees can be trained to impart MHM information and skills, particularly to reach out of school children. There is also a need to start reproductive health education earlier in schools so that adolescent girls are well informed on menstrual health management as they enter puberty. MHM conversations with mothers have a lasting impact on girls and shapes their perception of menstruation. Un-informed mothers are likely to perpetuate the culture of silence through generations. This can be developed into an opportunity for sustained and positive intergenerational impact on MHM, if mothers are made aware of the biological and management aspects of menstruation. Sensitized mothers, being a key source of information on MHM, can effectively turn this into a positive experience for their daughters and also sensitize sons on the issue. There is a need to develop more creative, effective and interactive learning menstrual education tools which help participants break the stigma on menstruation and have effective conversations about it. Finally, there is a need to provide a comprehensive intervention rather than fragmented activities. Talking about menstruation should focus on holistic approaches of MHM facilities, disposable mechanisms, and education breaking social taboos, boys and men s involvement and most importantly working on the supply chain for sanitary pad production. Products and Infrastructure There is lack of information on disposal mechanisms of used products as well as lack of dissemination of existing approaches to disposal of menstrual waste products in communities. Thus, safe disposal and infrastructure should be made part of any campaign that advocates for widespread use of sanitary napkins. Menstrual hygiene is largely ignored in latrine design and construction, particularly in schools. In the absence of a safe and private place to manage their periods, girls often make their own unhygienic arrangements or miss school altogether. Currently the Ministry of Education with development partners is revising the WASH construction manual with inclusive MHM designs. There is limited awareness about how to wash and dry cloths used for traditional sanitary napkins until they are completely sanitized for further use. Also, there is very little privacy in and around homes to wash and dry these cloths. Standards of health and safety for all sanitary napkins should be mandatory. The Ministry of Health with UNICEF is working with the Ethiopian Standards Authority to set standards both for disposable and reusable sanitary pads in the country. Toilets in schools and institutions are often non-existent or non-functional. This makes it difficult to take the MHM agenda forward. Access to water for washing purposes during menstruation is a challenge in most schools/homes. Disposal of commercial sanitary napkins is a problematic issue. 11

Convergence Lack of coordination and convergence between various Government ministries/ departments have led to gaps in gender sensitivity training and sensitization around menstruation health. There is a need for OWNP signatory ministries including Ministry of Women and Children s Affairs to be part of this convergence issue. Role of Men and Boys in MHM Awareness Men are an important focus group and must be involved in creating a better MHM environment. Men are decision makers in households as well as in the health, education and sanitation sectors. Many school principals and teachers are also men who must learn to effectively engage with female students on menstruation issues. Hence, engaging males in MHM conversations at all levels from community to policymaking is essential to addressing gender inequity. Equally important is also to engage boys in the school environment, which will help to avoid teasing of girls and be supportive of the whole MHM process. MHM programme impact There are components of various MHM programmes that have been effective in achieving desired outcomes of access, awareness and availability. On a regular basis, it is important to identify such components that contribute to successful programme outcomes. These include indicators that capture progress in dealing with stigma related to menstruation, related levels of awareness, adoption and use of sanitation and hygiene infrastructure and menstrual management products, correctness and consistency of information available to the target community about MHM. Conclusion MHM is an integral part WASH. There is a need for a holistic approach to MHM programmes with specific objectives related to awareness and breaking social taboos, peer-to-peer support and infrastructure access (WASH/MHM and disposal). Monitoring and evaluating the impact of MHM programmes is essential for identifying components that may be replicated to scale. Programme design needs to take into account appropriateness and availability of product material, infrastructure (water, sanitation, etc.) and disposal mechanisms, as they are closely related to MHM. Further research is needed on safe options for MHM, including various product options as well as traditional management methods to ensure environmentally safe disposal of menstrual waste. Finally, the event concluded with voices from the panellists and participants: MHM should be looked at from a gender lens; discussions on menstruation can be an introduction to wider debates to establish reproductive rights of women including age of marriage, time of first childbirth, birth spacing etc. and thus can have far reaching effect on women s rights. Given this, there is definite space for collaboration across different Government ministries and departments. Women and men need to be able to speak about menstruation. It is very important for improvement of MHM to include boys in the discussion as well. 12

Reference Documents 1. Menstrual Hygiene Management in Ethiopia an Inter-sectoral Issue: Policy and Implementation Guideline. July 2016 2. Menstrual Hygiene Management in Ethiopia: National Baseline Report from Six Regions of Ethiopia. UNICEF WASH. May 2017 13