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Waterlines Vol. 35 No. 3 July 2016
Global attention on improving the integration of menstrual hygiene management (MHM)
into humanitarian response is growing. However, there continues to be a lack of consensus
on how best to approach MHM inclusion within response activities. This global review
assessed the landscape of MHM practice, policy, and research within the field of humanitarian response. This included an analysis of the limited existing documentation and
research on MHM in emergencies and global key informant interviews (n=29) conducted
with humanitarian actors from relevant sectors (water, sanitation, and hygiene; women’s
protection; child protection; health; education; non-food items; camp management).
The findings indicate that despite a growing dialogue around MHM in emergencies,
there remains a lack of clarity on the key components for a complete MHM response, the
responsible sectoral actors to implement MHM activities, and the most effective interventions to adapt in emergency contexts, and insufficient guidance on monitoring and
Assessment. There is a critical need for improved technical guidance and documentation
on how to integrate MHM into existing programming and monitoring systems and to
ensure adequate coordination and communication about MHM across relevant sectors.
There is also a need for improved evidence on effective MHM approaches, the development
of MHM-specific indicators, improved consultation with girls and women in crisis-afflicted
areas, and the documentation of practical learning. It is only through improving the
resources available and enhancing this evidence base that MHM can be perceived as an
integral and routine component of any humanitarian response.
What is the scope for addressing
menstrual hygiene management in
complex humanitarian emergencies?
A global review
MARNI SOMMER, MARGARET L. SCHMITT,
DAVID CLATWORTHY, GINA BRAMUCCI,
ERIN WHEELER, and RUWAN RATNAYAKE
Marni Sommer (marni.sommer@gmail.com) is Associate Professor of Sociomedical Sciences and
Margaret L. Schmitt is Program Manager in Sociomedical Sciences at the Columbia University,
Mailman School of Public Health, New York; David Clatworthy is Environmental Health Technical
Advisor, Gina Bramucci is Women’s Protection and Empowerment Senior Technical Advisor,
Erin Wheeler is Family Planning and Post-abortion Care Technical Advisor, and Ruwan Ratnayake
is Epidemiology Technical Advisor at the International Rescue Committee, New York.
This work was supported by the Research for Health in Humanitarian Crises (R2HC) programme
managed by Enhancing Learning and Research for Humanitarian Helpance (ELRHA)
[SCUK – Accountable Grant No. 12964]. The R2HC programme (www.elrha.org/work/r2hc) aims
to improve health outcomes by strengthening the evidence base for public health interventions in
humanitarian crises. The £8 m programme is funded equally by the Wellcome Trust and
UK Department for International Development.
© Practical Action Publishing, 2016, www.practicalactionpublishing.org
http://dx.doi.org/10.3362/1756-3488.2016.024, ISSN: 0262-8104 (print) 1756-3488 (online)
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246 M. SOMMER et al.
July 2016 Waterlines Vol. 35 No. 3
Keywords: menstrual hygiene management, emergencies
Massive population displacement has become a reality across much of the world,
with an estimated 60 million people currently displaced by war, conflict, or
disaster (UNHCR, 2015). With nearly half of the displaced comprising girls and
women (UNHCR, 2015), there has been a growing impetus within the humanitarian response community to better address the gender-specific needs of displaced
populations. This includes increasing efforts by many international relief organizations to mainstream gender priorities through targeted policy, programming,
and research (Gasseer et al., 2004; Kovacs and Tatham, 2009; Mazurana et al.,
2011). A critical gender issue that has yet to be adequately prioritized is that
of meeting the menstrual hygiene management (MHM) needs of adolescent
girls and women. Girls and women across low-income contexts face numerous
challenges managing their menstruation safely, hygienically, and with dignity
including physical access to latrines during menstruation, dedicated places of
disposal for materials, and being able to manage menses without shame and
repercussions (House et al., 2012; Mahon and Fernandes, 2010; Sebastian et al.,
2013). In emergencies, they face additional challenges. Girls and women who
flee their homes may not be able to carry adequate supplies of materials (cloths,
pads, underwear) to manage monthly bleeding. They may prioritize children, the
elderly, and other family members’ needs over their own body-related needs. They
may be on the move, or living in crowded, unsafe environments that lack access
to private and safe water and toilet facilities (especially at night) for changing
menstrual materials and washing themselves (Parker et al., 2014; Sommer, 2012;
IFRC, 2013; Hayden, 2012). They may lack mechanisms for privately disposing of
used materials, or for discreetly washing and drying reusable menstrual materials.
All of these factors increase women and girls’ exposure to risk of sexual violence
and exploitation in humanitarian settings (Sommer et al., 2014; Gosling et al.,
2011; Davoren, 2012).
The range of challenges girls and women face may differ if an emergency is
acute or protracted, urban or rural, or if they find themselves on the move, living
in camps, host communities, or informal settlements. Girls and women from
different cultures will also have unique menstrual beliefs that influence how
they manage menstruation, including strongly held taboos around disposal of
menstrual waste (e.g. burying versus burning, or disposing of waste in a secret
manner) (Hayden, 2012; Sommer, 2012; Sommer et al., 2013; Kjellén et al., 2011)
and methods for washing and drying used menstrual materials (de Lange et al.,
2014; Nawaz et al., 2006). They may, for example, prefer to manage menstruation in
private bathing spaces instead of toilets. The varying socioeconomic backgrounds
of the changing displaced global population may influence preferences for
menstrual material distributions. As with other interventions in emergencies,
the type of emergency (e.g. natural disasters, acute conflict) will determine the
types of MHM response needed (Sphere Project, 2011). Programming must take
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MENSTRUAL HYGIENE MANAGEMENT IN EMERGENCIES 247
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such vulnerability into account. Each humanitarian response scenario generates
contextual considerations with regard to MHM across a range of sectors, such
as water, sanitation, and hygiene (WASH), women and child protection, health,
shelter, and education. Understanding what responses can be deployed across
the diverse range of existing emergencies, what adaptations are essential, and the
most effective interventions to apply is vital. This includes the need for ongoing
coordination between the relevant sectors responsible for assuring an effective
MHM response is delivered.
In 2012 a global desktop review was conducted to assess the inclusion of
MHM within humanitarian response (Sommer, 2012). Given the limited peerreviewed and grey literature on the topic, key informant interviews with a range
of humanitarian experts were also conducted. The review identified several
MHM-related gaps in the humanitarian sector. In general, there was a lack of
uniform guidance for MHM inclusion, including key programmatic considerations and attention to timing (phase introduction). Existing guidance materials
that mentioned MHM were limited in scope and primarily concentrated within
WASH. There was minimal Assessment of MHM-related programming, especially
examining beneficiary experiences, or the range of sectoral inputs needed for
an effective response. Systematic documentation of practical learning was
lacking, despite many key informants articulating experiences addressing MHM
in emergencies and internal dialogues among organizations on how to improve
future MHM responses.
Since the 2012 review, the management of menstruation in emergencies appears to
have gained traction as an area worth analysing and improving upon. This is evidenced
by the engagement of key players in developing resource documents (WaterAid/SHARE
and Menstrual Hygiene Matters) and conducting operational research (International
Federation of the Red Cross). Therefore, an updated review was undertaken. The main
objectives were to assess the current state of documentation on MHM in emergencies,
including the existence of clear guidelines on implementation and monitoring of a
holistic MHM response in an emergency context; and to assess cross-sectoral perspectives on the definition of an MHM response, its prioritization in various emergency
contexts, and existing gaps in addressing the MHM needs of adolescent girls and
women in emergencies.
The review defined a ‘holistic MHM response’ (see Figure 1) as including the
provision of safe, private, and hygienic water and sanitation facilities for changing
menstrual materials and bathing, easy access to water inside or near toilets, supplies
(e.g. laundry soap, separate basin) for washing and drying menstrual materials
discreetly, disposal systems through waste management, and access to practical
information on MHM, for adolescent girls in particular. There may also be unique
needs for the health sector, such as post-partum women needing additional pads
for managing heavy bleeding, or for the child protection or education sectors,
such as sensitized staff or teachers being supportive of adolescent girls’ menstrualrelated needs.
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248 M. SOMMER et al.
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Methods
The global assessment incorporated three components, two of which will be
described in this paper: (1) a literature review, and (2) key informant interviews
with a broad range of humanitarian experts from relevant sectors and organizations.
Formative research in two differing emergency contexts (internally displaced people
(IDP) camps in Myanmar and informal settlements of Syrian refugees in Lebanon)
was also conducted and will be reported in a future publication.
Literature review
The review included a systematic search of the literature, and outreach to humanitarian experts around the world to capture the range of existing documentation.
First, a systematic web-based search was conducted of the peer-reviewed and grey
literature. Key databases searched included PubMed, Google Scholar, the Sustainable
Sanitation Alliance, and Reliefweb. Search terms included ‘menstrual hygiene in
emergencies’, ‘menstruation and refugee camps’, ‘WASH and menstrual hygiene’,
‘gender and sanitation’, and ‘menstruation and crisis’. The aim was to identify
peer-reviewed and grey literature on aspects of implementation, relevant guidance
Component 1 includes: Component 2 includes:
• Appropriate menstrual
materials (pads, cloths,
underwear) provided.
• Additional supportive
materials for storage,
washing and drying.
• Demonstration on how to
use MHM materials.
Continuous consultation with girls
and women on their MHM
experiences and challenges
during the design and implementation of all three components.
• Safe and private water
and sanitation facilities
equipped for changing,
washing and drying
menstrual materials.
• Convenient and private
disposal mechanisms for
menstrual waste.
• Waste management
systems in place for
menstrual waste.
Component 3 includes:
• Basic menstrual health
education (especially for
pubescent girls).
• Basic menstrual hygiene
promotion and education.
1. Access to
MHM
supportive
materials
3. Access to
menstrual health &
hygiene education
2. Access to
MHM
supportive
infrastructure
Figure 1 Three essential components of a holistic MHM humanitarian response
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MENSTRUAL HYGIENE MANAGEMENT IN EMERGENCIES 249
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documents, published reports, training materials, and relevant accepted global
emergency standards (e.g. Sphere Project). To avoid missing relevant studies, the
search was not limited to emergency contexts. We included material that was in
the English language and directed at low and middle-income countries, and we did
not have any restriction on time periods.
Given that organizations may not make internal documents publicly available,
and that new guidelines and internal studies may never be published in peerreviewed journals, we communicated directly with individuals and organizations
involved in humanitarian response to request additional documentation. We also
asked for recommendations of humanitarian response experts from a diverse range
of sectors and organizations who could serve as global key informants.
A flyer that described the effort to gather the existing guidance and evidence
on MHM was shared through blog posts, relevant meetings, and conferences. We
requested feedback from interested individuals over a five-month period.
Global key informants with humanitarian practitioners
Key informant interviews (KII) were conducted with a range of cross-sectoral
humanitarian experts (e.g. practitioners, donors, policy makers). A key informant
guide was developed for use over Skype, phone, in-person, or, in situations when
experts were unable to participate due to limited internet connectivity (i.e. those
engaged in an emergency response), written responses were submitted. Key informants were sampled purposively; maximum variation sampling was used to
ensure at least two individuals were sourced from each sector (WASH, women’s
protection, child protection, health, education, camp coordination, and camp
management). Key topics that we aimed to discuss included the frequency and
rationale for inclusion of an MHM response, timing and content of MHM intervention components in differing humanitarian contexts (e.g. post-disaster versus
post-conflict, rural versus urban, IDPs versus refugees), challenges experienced in
delivery and coordination, sector-specific aspects, identified best practices, and
recommendations for key guidance to include in the MHM in emergencies toolkit
under development.
Informed consent was obtained from all participants. The KIIs were conducted in
English by the Columbia University Principal Investigator (PI, MS) and one member
of the research team (MSc). The names of KIIs and organizations are anonymized as
informants were not asked to respond on behalf of their respective organizations.
The study obtained ethical approval from the Columbia University Medical
Center and the International Rescue Committee (IRC) institutional review boards.
Analysis
Transcripts from the qualitative assessment were reviewed and key themes were
identified by two researchers using deductive content analysis methodology (Elo and
Kyngäs, 2008). The data were systematically reviewed to identify predominant
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250 M. SOMMER et al.
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themes arising. The documentation gathered from the desk review was collated and
analysed in terms of the type of resource (e.g. research, programmatic guidance, case
study), sectoral relevance, accessibility, and significance (new source of evidence,
best practices, or lesson learned).
Results
Direct emails were sent to 176 individuals with a 95 per cent response rate; 29 total
KIIs were conducted across 18 global organizations and agencies. A number of
thematic areas emerged from the review, including: 1) different understandings
of what an ‘MHM response’ includes; 2) insufficient MHM technical guidance for
practitioners; 3) minimal evidence on effective MHM interventions in emergencies;
4) challenges in cross-sectoral coordination and leadership in MHM emergency
responses; and 5) the need for improved monitoring and Assessment.
Differing understandings of an ‘MHM response’
There exists relatively widespread recognition of the importance of including
MHM in humanitarian response activities across agencies; however, the timing
and inclusion of response activities appears to vary. A significant finding was
the differing interpretation of what a ‘standard’ MHM response should include,
including varying interpretations of the responsibility of each sector. Part of
this may be attributed to the ways in which the humanitarian community may
already be addressing interventions of critical importance to MHM, such as
gender-segregated toilets and the provision of flashlights, which also contribute to
other humanitarian aims (e.g. safety, dignity) and so are viewed as part of broader
programming led by specific sectors (e.g. WASH, protection). As a result, there is
often a lack of clarity around which actor should lead or take primary responsibility. There was a general lack of consensus of key components of an MHM
response beyond the distribution of hygiene or dignity kits, without mention of
other key components (e.g. bathing facilities, toilets with easy access to water,
washing and drying of reusable materials, endpoint disposal systems, the provision
of MHM guidance to girls).
One identified challenge is that many organizations distribute their own kits,
with the timing of delivery and contents varying within a given emergency. This
was reported to occasionally cause resentments between beneficiaries and gaps
in access to supplies (especially sanitary pads). In addition, the rapid decision
to prioritize the provision of materials may sometimes be done without consideration of local menstrual practices (e.g. preference of disposable versus reusable
pads) or the broader ‘lifecycle’ for menstrual waste, including disposal systems,
the impact on toilet lifespan of improper disposal, the privacy-related needs for
washing and drying of reusable pads, and waste management. As one WASH adviser
explained, ‘there is often a flood of [menstrual hygiene] materials at the start and
no way to deal with disposal. I think that has fallen off the radar’. This focus on
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prioritizing the distribution of materials may result in some emergency responses
not addressing the spectrum of MHM components. Differences in MHM response
measures were identified across categories of emergency (e.g. natural disasters versus
active conflict). As one WASH adviser conveyed:
If it’s a disaster like a drought, you probably won’t see hygiene or dignity
kits. It is assumed that while they may be lacking food or water, the rest of
their lives had not shifted as much, they are still at home. (WASH adviser,
government agency)
The MHM products distributed are also impacted, as one WASH expert explained,
‘during a flood, you will think more about materials you can wash than ones you
dispose’, taking into account the limitations (e.g. disposal) for that type of disaster.
The state of the emergency (acute versus protracted) can also influence the provision
of MHM supplies. Several actors explained how it is often assumed that after the
initial acute phase of an emergency, girls and women should be able to access local
markets or return to using their traditional methods. However, a few respondents
suggested that more recent events of sustained active conflict, such as in Syria and
Iraq, have required prolonged MHM Helpance.
The review also identified differing perspectives on the prioritization of MHM
interventions. Decisions on what to implement and when appear to be influenced by a number of factors, such as the gender of programme staff, especially
senior leadership, with females generally perceived to more rapidly prioritize
MHM interventions. As one NGO’s senior health adviser noted, ‘The reason
why it hasn’t been taken up is the lack of understanding and the lack of senior
women in roles and program design. If you look at WASH programming, it’s
male dominated’.
In addition, perceived cultural taboos around discussing MHM with beneficiaries may impact the comfort of staff in responding to beneficiary MHM needs.
Respondents identified challenges for both male and female staff in discussing issues
related to MHM, and viewed this as a barrier to MHM inclusion in programming.
Differing views in relation to acute emergencies also appear to exist, with some
experts articulating MHM as ‘not a life-saving intervention’ of relevance in an acute
response. These varied perspectives for MHM inclusion at the onset of an emergency
were conveyed by both a WASH and a health practitioner:
I don’t think it’s a lack of means or capacity of people – it’s just that you need
to change the mind-set of an entire sector. Even after 10 years, we have been
saying we need to segregate latrines between men and women and you go to
the field, and it never happens. (WASH sector, UN agency)
It is pressing for women but it is not pressing for survival of people. It’s not
water and it’s not sanitation. It’s part of sanitation but it’s not general health or
food or infectious disease or vaccinations. (Health sector, NGO)
Despite these differing views, there was generally consensus that attention to
MHM is growing at all phases of a given response, from pre-positioning of supplies
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252 M. SOMMER et al.
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(i.e. pads, underwear, soap), to responses in acute and protracted scenarios.
However, the absence of a recommended package of interventions for an MHM
response across a range of emergency scenarios, and the lack of clearly defined
minimum standards for MHM, is likely contributing to differing understandings
of an ‘MHM response’.
Insufficient MHM technical guidance for practitioners
There have been minimal additions to the limited MHM technical guidance
available since 2012. Existing guidelines for assessment and response, and
documentation of MHM interventions, are generally disseminated internally
within organizations, or mentioned only briefly within sector-owned or other
broader humanitarian guidance publications (see Table 1). Overall there exists a
lack of clear and specific guidance on appropriate timing for introducing MHM
interventions, on recommendations of culturally adapted and effective interventions, and designation of sectoral responsibility for leadership of a coordinated
response. There also exists limited consensus on which MHM guidance resources
to prioritize.
Across humanitarian response, the Sphere Project continues to be the most
widely cited and internationally recognized set of standards (Sphere Project, 2011).
The latest edition makes specific references to MHM within the context of WASH.
Chapters 2 and 3 define a set of minimum standards on MHM within WASH,
including key actions (discreet provision of appropriate materials and disposal
mechanisms) and guidance notes for hygiene promotion, water supply, excreta
disposal, and solid waste management. Although a significant improvement, these
references are limited to WASH, lack specificity on process and timing, and do not
address broader cross-sectoral responsibilities.
In terms of sector-owned guidance documents, MHM (or MHM-related interventions, such as the building of gender-segregated latrines or the provision of dignity
kits) is present, to varying degrees, within 10 sector guidelines. These include
institutional guidance recommendations, such as UNICEF’s Immediate Response
WASH and Dignity Kits and Family Hygiene and Dignity Kits, and broader inter-agency
manuals, such as the Guidelines for Integrating Gender-based Violence Interventions into
Humanitarian Response. The latter, a robust cross-sectoral resource for reducing risks
to women and girls, includes many interventions relevant to MHM, and discusses
MHM most specifically within the WASH chapter. Other sectors, such as child
protection and education, and camp coordination and management, articulated
the need for incorporation of attention to MHM in the next updating of their global
guidelines for emergencies (see Table 1).
The most comprehensive resource available is Menstrual Hygiene Matters, published
in 2012 by WaterAid/SHARE. Although this resource is focused primarily on the
development sector, it contains a chapter dedicated solely to MHM in emergencies.
Much of the other guidance throughout the document is relevant, especially
to protracted emergency contexts, including content on MHM in schools, the
household, and workplace environments (House et al., 2012).
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MENSTRUAL HYGIENE MANAGEMENT IN EMERGENCIES 253
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Table 1 MHM content in key guidelines for humanitarian response
Title MHM content identified Last revision
The Sphere Handbook Distribution: Provision of culturally
appropriate MHM materials
Infrastructure: Provision of gendersegregated toilets, access to water
source, and support for the disposal,
washing, and drying of MHM materials
(WASH sector)
Sphere Project (2011)
(new edition under way)
Inter-agency Field Manual
on Reproductive Health in
Humanitarian Settings
Distribution: Provision of culturally
appropriate sanitary materials
Infrastructure: Ensure for gendersegregated toilets
Inter-Agency Working
Group on Reproductive
Health in Crises (2010)
(new edition under way)
Minimum Initial Service
Package for Reproductive
Health in Crisis Situations
Distribution: Provision of culturally
appropriate sanitary materials
Quick (2011)
Adolescent Sexual and
Reproductive Health
Toolkit for Humanitarian
Settings
Distribution: Provision of culturally
appropriate sanitary materials to
adolescent girls (including distributions
through teachers at schools)
UNFPA and Save the
Children (2009)
INEE Minimum
Standards for Education:
Preparedness, Response,
Recovery – A Commitment
to Access, Quality and
Accountability
Distribution: Provision of culturally
appropriate sanitary materials to
adolescent girls
Education: Ensure that adolescent girls
receive education on menstruation and
teachers are sensitized
Infrastructure: Provision of gendersegregated toilets and nearby water
source (INEE Gender Task Team, n.d.)
INEE (2010)
Camp Management
Toolkit
Distribution: Provision of culturally
appropriate sanitary materials
Bentzen et al. (2015)
Guidelines for Integrating
Gender-based Violence
Interventions into
Humanitarian Response
Distribution: Provision of culturally
appropriate sanitary materials
(WASH sector)
Education: Ensure that adolescent girls
receive education on menstruation
(education sector)
IASC (2015)
The Minimum Standards
for Child Protection in
Humanitarian Action
No current MHM references identified
during this review exercise
Child Protection
Working Group (2012)
Médecins Sans Frontières (MSF) developed a relevant water and sanitation
assessment tool that addresses MHM along with other gender concerns. The Gender and
Sanitation Tool for Displaced Populations provides step-by-step guidance for addressing
gender concerns, including specific MHM and proxy measures, throughout the
design and development of water and sanitation facilities (MSF, 2015). This includes
developing contextually appropriate toilets and bathing spaces that better support
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254 M. SOMMER et al.
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the menstrual needs of girls and women through improving measures related to
safety (gender segregation, doors), privacy (locks), and comfort (nearby water source)
(de Lange et al., 2014).
A small literature of inter-agency and/or institutional technical guidance briefs
is also available. The majority are concentrated in the WASH sector. For example,
the WASH cluster in Myanmar in 2014 developed an internally disseminated brief
focused on the contextual needs of MHM within the Kachin and Rahkine emergency
response activities. The brief includes guidance on culture and MHM supportive
interventions for the local context (i.e. providing disposable pads, waste bins, and
education focused on deterring girls and women from disposing of pads directly in
the latrines) (IRC-Myanmar, 2014).
Minimal evidence on effective MHM interventions in emergencies
There continues to exist minimal literature and, more importantly, limited rigorous
evidence in the scientific, peer-reviewed literature on MHM interventions in
emergencies. Conducting research during emergencies is challenging, due to the
volatile nature of many crisis-affected areas, the perceived vulnerability of displaced
populations, and heightened political tensions. These sensitivities influence the
process of conducting research, including the methods used, evidence produced,
and the obtainment of ethical clearances (Ford et al., 2009). Two studies exist which
included both qualitative and observational methodological approaches. A qualitative study explored the MHM challenges faced by girls and women in an IDP
camp in northeast Uganda. This assessment, which compared findings with those
of girls and women living in the host community, indicated that IDPs experienced
greater challenges in accessing MHM supplies, appropriate water and sanitation
facilities, and menstruation education. These challenges were found to have a
negative impact on women and girls’ dignity and mobility (Parker et al., 2014).
Another relevant article published in 2014 included an Assessment of MSF’s Gender
and Sanitation Tool for Displaced Populations in IDP camps in South Sudan (described
earlier) (MSF WatSan Working Group, 2015). The study examined the feasibility
of the tool, satisfaction of users, and its effects. Initial findings revealed women’s
discomfort with the proposed design of facilities for washing menstrual cloths,
resulting in the use of shower stalls as a more appropriate solution. In addition, an
Assessment comparing the intervention group (those engaged with the tool) and
a control group found a 25 per cent increase in usage of toilet and water facilities
among those consulted using the prescribed tool (de Lange et al., 2014).
Operational research that was not published in a peer-reviewed journal was
also found. The International Federation of Red Cross and Red Crescent Societies
(IFRC) piloted menstrual hygiene kits for 2,000 Congolese refugees living in
Burundi. The Assessment demonstrated concrete improvement in knowledge,
hygiene practices, and perceptions of dignity following the distribution of MHM
kits. Findings also provided valuable learning on the appropriate design of
menstrual hygiene kits for this context, including the type of washing container,
preferences for reusable pads, and the need for both washing and bathing soap
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MENSTRUAL HYGIENE MANAGEMENT IN EMERGENCIES 255
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(IFRC, 2013). Another MSF-related study is a Master’s thesis that describes an
Assessment conducted on gender and WASH (with a primary focus on MHM) in
MSF health facilities for displaced Burmese and host communities in southeast
Bangladesh. This included a desk review and qualitative appraisal with staff and
beneficiaries. Findings indicated difficulties for women accessing menstrual
materials, their preferences for washing menstrual materials in shower facilities,
and health staff’s low knowledge of MHM. The learning was used to develop
guidelines for better integrating MHM within health facility operations and an
MHM monitoring tool (Mena, 2015).
Challenges in cross-sectoral coordination and leadership on MHM in emergencies
A key challenge remains a lack of consensus on a recommended sector lead for
assuring that a holistic MHM response is delivered. The majority of respondents
indicated the crucial role of the WASH sector, given its responsibility for water,
sanitation, and disposal (all of great relevance to MHM), and its role in the distribution of hygiene kits in many contexts. Many respondents also articulated the
importance of the women’s protection sector, given its experience, expertise, and
comfort working with girls and women on sensitive topics. There was generally
consensus that WASH and women’s protection should be collaborating on MHM,
and that the decision about ‘who takes the lead’ may vary depending on a given
emergency context. There was a strong consensus on the importance of one sector
taking the lead so that MHM and its various components do not fall through the
cracks, missing out on the staffing and funding required for a complete response.
There was also articulated a need for clearer delineation of each sector’s role in
supporting an MHM response. For example, the education sector may be collaborating with WASH to design the sanitation facilities in schools, but may also need
to focus on the distribution of MHM materials and software (MHM information,
sensitized teachers). Similarly, the health sector may need to focus on the provision
of private, safe latrines near health facilities for girls and women who seek out
providers, and for those managing heavy menstrual bleeding related to the postpartum period or other reproductive health issues. Other examples emerged from
Sierra Leone and Nepal, where girls and women reportedly had preferences for
household latrines for MHM (an issue for the shelter sector); from Liberia and
Guinea, where girls felt at heightened risk for sexual violence or rape while using
toilets (UNHCR and Save the Children-UK, 2002) (an issue for protection and
WASH); and from Pakistan and Haiti, where gaps in menstrual hygiene knowledge
and education were identified, illustrated by the use of sanitary pads for other
household purposes beyond MHM (an issue for the WASH, non-food items (NFIs),
and education sectors).
In general, the review findings suggested that the WASH sector should take the
lead for MHM response in close collaboration with women’s protection, child
protection, education, health, NFIs, camp coordination and camp management,
with the NFIs and shelter sectors playing important but subsidiary roles. The failure
to coordinate may lead to piecemeal programming, or inadequate attention to the
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256 M. SOMMER et al.
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multiple components needed for a successful MHM response (e.g. adequate lighting
for night-time latrine use). One WASH adviser warned of these coordination
challenges, explaining: ‘We have people [sectors] looking at MHM in just their angle
and nothing else. It makes them blind in many ways when you only look at one
thing and don’t see it as a holistic matter’ (WASH adviser, UN agency).
Respondents indicated that improved coordination was likely contingent on the
heightened visibility of MHM as an issue across sectors, especially within the cluster
system.
The need for improved monitoring and Assessment
The review identified a lack of adequate monitoring and Assessment (M&E) of
MHM interventions, with three main issues emerging. First, emergency responders
are already overwhelmed with the number of indicators they need to collect on
other key response aspects, so there is a hesitancy to introduce more indicators
that may be burdensome to staff. As one WASH adviser explained:
There is a tendency to have indicator overload. It is a bit like that for solid waste
disposal, with all these wonderful indicators, but no one collects the data. At
our level, if I can get one indicator on water and one on sanitation and one on
hygiene, I am considering myself very lucky … anything more than that, the
quality is challenging. (WASH adviser, UN agency)
Second, there are a number of proxy indicators that likely capture relevant MHM
content (e.g. gender-segregated latrines, distribution of hygiene kits) and may not
be articulated as ‘MHM’ indicators but are nevertheless very relevant. Third, there
do not exist recommended (and tested) global indicators for capturing the multiple
components of a complete MHM response. The Inter-Agency Standing Committee’s
Gender-Based Violence Guidelines provide one indicator related to coverage of
materials distribution, but in other cases where indicators are discussed, notably
Sphere, the focus is on what to measure, rather than how to measure. However,
in reviewing the available lists of any non-crisis indicators, including those from
WaterAid (2015), Save the Children (2015), and Plan International (Roose and
Rankin, 2015) which focus on the development sector, there is a lack of sufficient information on how to correctly measure quantitative indicators without
an intensive population-based survey, or how to integrate these indicators within
existing population-based surveys. Guidance on appropriate qualitative methods to
assess monitoring needs is also lacking.
Across the global KIIs, the majority of emergency experts indicated that few or
no indicators are currently being collected specific to MHM. Individual organizations or agencies may have their own internal indicators; however, there
is a clear need to better integrate MHM into existing M&E systems to ensure
that more rigorous and systematic monitoring occurs. Some existing examples
of monitoring and measurement include post-distribution monitoring surveys
and focus group discussions. These methods did not appear to be widespread
in use, and tools were frequently described as being ad hoc or only internally
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MENSTRUAL HYGIENE MANAGEMENT IN EMERGENCIES 257
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available to organizations. As this practical learning is essential for improving
MHM implementation and addressing the needs of girls and women in ongoing
and future responses, it is critical that the monitoring of MHM is more uniformly
adopted, including improved access to measurement tools and collective sharing
of lessons learned.
Discussion
The MHM in emergencies global review was useful in identifying the progress being
made in attention to MHM in a range of emergency response scenarios and global
dialogues, and the continuing gaps in addressing MHM in emergencies. The latter
includes the absence of clear guidance and standards, best practices for implementation of MHM-related interventions, recommended coordination for key components, and the generation of evidence for improved beneficiary outcomes. The key
differences identified since the 2012 review included an overall increase in attention
and programming targeting MHM during emergencies, improved global dialogue
on the topic (as illustrated by the wider range of organizations and experts familiar
with MHM), and, lastly, a growth in the analysis on what appropriate MHM supplies
should be provided in a given context (IFRC, 2013). The review also highlighted
some particular areas in need of focus from the humanitarian community.
First, much of the programing and learning being generated is focused on
addressing MHM within camp settings, with populations that are easier to target
with MHM distributions and infrastructure improvements. However, there are
increasing numbers of displaced populations in states of sustained movement,
living in host communities, in urban contexts, in areas of active conflict, or in
environmentally challenging settings (e.g. limited water availability) (Burkle et al.,
2014). These dissimilar environments require MHM responses to be adaptive and
able to accommodate a range of considerations, such as differing preferences for
menstrual management materials or differing levels of safety around latrine usage.
As an example, while the inherent MHM needs for girls and women may be the
same, the MHM experiences and challenges of migrants journeying across mainland
Europe may vastly differ from those living in urban Kenya. There is an urgent need
for improved guidance that better supports responders in managing MHM across a
greater range of contexts.
Second, there is a clear need for improved consensus and clarity on sectoral
responses, including a system for identifying the ‘MHM lead’ sector within a given
emergency. The overall recommendation is for WASH to lead in close coordination
with women’s protection, and other sectors serving subsidiary but important roles.
This will require engagement with the cluster systems, inter-agency working groups,
and other approaches to not only enhance global and local dialogue on MHM in
responses, but also to define these roles. A complete MHM response is contingent
on effective collaboration between multiple sectors and established partnerships.
In addition, it is recommended that as well as the MHM in emergencies toolkit
currently under development, that MHM be incorporated into sector-owned guidance
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258 M. SOMMER et al.
July 2016 Waterlines Vol. 35 No. 3
documents to enhance the ownership of MHM response activities within sectors
beyond WASH (R2HC, 2015). This may require MHM advocates within each sector to
articulate the need to include MHM (as a new addition or as expanded content) into
sector responses in future guideline revisions.
Third, there is a need for attention to the MHM needs of specific (and sometimes
difficult to reach) populations. This was made evident by the dearth of programming
targeting the MHM needs of adolescent girls in many contexts. Prior to, during, and
following a crisis, adolescent girls are at a heightened risk of abuse, neglect, and rape
(Robles, 2014). At the same time, broader children or women’s protection responses
often fail to reach adolescent girls or to find safe, functional, tailored entry points for
girls to access information and Helpance (Robles et al., 2015). In many protracted
emergencies, there may be a breakdown of traditional familial networks and education
systems, which are important for sharing information about menarche with girls.
A few examples were identified through the women’s protection and health sectors
of targeted outreach to adolescent girls on MHM, including health education, the
provision of girl-tailored dignity kits (IRC Adolescent Girls Initiative, 2015), and the
provision of sanitary materials through schools (Bishop et al., 2014; Parker et al.,
2014). However, these activities were not widespread, lacked coordination across
sectors (especially crucial linkages with WASH actors), were rarely documented, and
often overlooked the needs of the rapidly increasing population of out-of-school
adolescent girls living in crisis (Alam et al., 2016). Another overlooked population
is that of vulnerable girls and women, which can include those who are very poor,
very young, orphaned, or with physical or mental disabilities. This population may
have limited access and movement within communities, making it more difficult to
identify them and address their specific needs. Specific considerations for vulnerable
girls and women include ensuring access to MHM supplies (beyond traditional distributions), educating care-takers, and the design of water and sanitation infrastructure
to meet their specific needs.
In order to ensure MHM interventions reach all women and girls, all sectoral
actors must also recognize the role that men and boys can play, either as supporters
or as barriers. In a household, for example, the male head of family may often be the
primary individual registered for aid and, even when women and girls are explicitly
targeted, may control and make decisions about household goods and resources.
This can impact women and girls’ privacy and access to appropriate menstrual
supplies. Research and experience have shown that men may not be aware of girls’
and women’s basic MHM needs, including sanitary pads, within their households
(Pillitteri, 2011). Improving their understanding and ability to support women and
girls may help increase women and girls’ ability to manage their own menstrual
needs. Currently there remains a lack of consensus on the best approach and
timing for male engagement on MHM within a given emergency response, and this
may vary widely depending on context. There is a need for Assessment of various
approaches. Relevant learning on male engagement with MHM may also be gleaned
from the development sector (Plan International, 2015; Mahon et al., 2015) and
from strategies employed for tackling other traditional female-focused approaches,
such as reproductive health (White et al., 2003).
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MENSTRUAL HYGIENE MANAGEMENT IN EMERGENCIES 259
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Fourth, there is an urgent need for practical learning and evidence on basic
solutions for integrating MHM into existing emergency response interventions,
particularly in the WASH sector. For example, although there are some Assessments
of the types of sanitary kit most acceptable to girls and women under way, along
with interest in identifying more sustainable methods (e.g. reusable pads), there
continues to be limited examination of improved water, sanitation, and disposal
approaches in relation to MHM in emergencies. The use of various pads (disposable
or reusable) will only be successful if enabling environments support their actual
usage. This includes identifying improved, culturally appropriate approaches for
discreetly and privately washing and drying these products, and improved designs
for gender-supportive toilet and washing facilities, disposal mechanisms for
menstrual waste (e.g. covered dustbins), and methods for waste management (e.g.
incinerators or safe burying mechanisms). More practical examples of successful
MHM interventions are also needed, such as strategies for sensitively distributing
and demonstrating MHM supplies and educating girls and women in a range
of sociocultural contexts, and examples (including curricula and trainings) for
improving staff (especially males) comfort and confidence in addressing MHM. It
is essential that the learning from Assessments of such activities is documented and
disseminated to improve the limited existing body of MHM knowledge. Lastly, there
may be some variance between girls’ and women’s reported preferences (e.g. water
inside toilet stalls) and the standards deemed feasible by water and sanitation actors
in a humanitarian response.
Finally, this review identified a compelling argument for the need to expand
the breadth of M&E methods and strategies for assessing MHM in emergencies. It
is important for this research to occur in a range of locations and during various
phases of an emergency. One area requiring further investigation is the impact
of cash Helpance programming on MHM. As international response organizations are increasingly adopting cash Helpance and voucher programmes (Harvey,
2005), including to address WASH and hygiene-related needs, there is little understanding of how that impacts the MHM needs of girls and women. To generate
evidence of the effectiveness of a particular MHM approach, randomized or quasirandomized studies using well-defined and measurable outcomes relevant to social
functioning are necessary. The latter will be difficult but important to do well, but
lessons from other domains such as mental health in crises could be applied to
develop relevant outcome measures for MHM (Sumpter and Torondel, 2013; Lahiri
et al., 2016). Proxy outcomes, such as measuring use of WASH services by women
and girls, may be sufficient for achieving an understanding of whether specific
needs are being met in crisis settings.
As research and learning is conducted, it is important for this information
to be disseminated more widely. Although this review identified the existence
of significant valuable knowledge on MHM, it was found to frequently remain
within institutions, rather than being published or more widely disseminated.
Tremendous workloads, shifting priorities, and lack of forums for sharing this
type of informal information are all very legitimate reasons why this occurs.
The MHM in Emergencies Toolkit (R2HC, 2015) currently under development will
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260 M. SOMMER et al.
July 2016 Waterlines Vol. 35 No. 3
aim to synthesize much of the practical learning, tools, and guidance captured
during this global review. The toolkit will seek to address many of the gaps
identified, including standardizing the elements of a complete MHM response,
providing practical tools for research and monitoring, and simplifying directions
for assessment and response. In addition, the integration of MHM into existing
sectors’ key guidance documents as they are revised in the coming years would
serve to greatly enhance the quality and frequency of attention to this critical
issue for adolescent girls and women.
Limitations
Although this review attempted to be as systematic and comprehensive as possible,
there are some important limitations to note. First, given the common practice of
including MHM within internal rather than external publications of organizations,
it is very possible that additional documents on MHM learning were missed. As
well, documentation from national and sub-national organizations may have been
missed. Second, as many of the global key informants were recruited based on their
familiarity with the topic of MHM in emergencies, participants may have been more
likely than others to advocate for the importance of this topic.
Conclusion
If the field of humanitarian response is to improve standards and safety for girls and
women affected by emergencies, their MHM needs can no longer be overlooked.
This review indicates an urgent need for guidance on the components of a holistic
MHM response in emergencies, including effective approaches to implementation,
monitoring, and Assessment of this work across a range of contexts. The review also
reveals the need for a defined articulation of a sectoral lead for MHM, linked to
recommendations for improved cross-sectoral work and coordination. This can
only occur through strategic buy-in, leadership, and prioritization of MHM within
organizations, sectors, and funding agencies. MHM should be integrated into
existing emergency responses, and not delayed through a perception that its implementation can wait for later phases of humanitarian response or that it exists as a
separate area of programming, disconnected from ongoing WASH, protection, and
other efforts. Only recognition of and movement towards cross-sectoral action on
MHM in emergencies will ensure that humanitarian action more comprehensively
meets the needs of women and girls.
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