Pakistan: Menstrual Hygiene Management (MHM) Research Project

MHM Held Conference: January 2019

March 01, 2019

Dr. Rubina Mumtaz

Trainers of TOT Workshop L-R: Alisa Jones of WSSCC Asia Regional Office, Virginia Kamow of WSSCC Pakistan Office , Afshan of RMF Pakistan, Sumera Javed of HANDS Islamabad and Deepa Shakia of ERM, Nepal.

Trainers of TOT Workshop L-R: Alisa Jones of WSSCC Asia Regional Office, Virginia Kamow of WSSCC Pakistan Office , Afshan of RMF Pakistan, Sumera Javed of HANDS Islamabad and Deepa Shakia of ERM, Nepal.


RMF’s Presence

In early 2015, Dr. Marni Sommer of Columbia University, in collaboration with Real Medicine Foundation and with funding from Grow N Know Inc (G&K), launched a research study to explore how the onset of menstruation and puberty influences Pakistani girls’ school-going experiences, including school retention. The other key goal of the study was to develop the Pakistan Girls’ Puberty Book in line with G&K’s model of similar puberty books in low and middle-income countries, with the aim of promoting young women’s health and education during pubertal transitions. This project is an adaptation of a similar research methodology previously used in studies conducted in Tanzania, Ghana, Ethiopia, and Cambodia, which also developed context-specific, culturally sensitive girls’ puberty books; all above studies were conducted by the same principal investigator.

Starting in December 2016, RMF began building upon previous, successful studies in Punjab and Balochistan (conducted in collaboration with Columbia University) by extending our research to the province of Sindh. This Menstrual Hygiene Management (MHM) research study was funded by UNICEF, following the same research methodology as our previous studies, and collected data in Sindh to ensure that the diverse social and cultural norms and practices of Pakistan were included in the Pakistan Girls’ Puberty Book. Our MHM research study came to a successful close by February 2017. The key outcome of the study findings was the development of the Pakistan Girls’ Puberty Book, which was a natural next step to UNICEF’s research and interventions in Menstrual Health Management in Pakistan.

Afshan instructing participants on use of Puberty Book as an advocacy tool for MHM

Afshan instructing participants on use of Puberty Book as an advocacy tool for MHM

Program Progress

Puberty Book Submission Status

The Pakistan Girls’ Puberty Book, developed by RMF Pakistan, University of Columbia, and UNICEF, has been submitted to the Provincial Ministries of Education of all four provinces—Punjab, Sindh, Khyber Pukhthunkhwa (KPK), and Baluchistan—with the request to incorporate it into their secondary school curricula as a supplementary reader. The province of Sindh was the first to formally accept this request in October 2018. The process of modifying the Pakistan Girls’ Puberty Book, now referred to as the Girls’ Book in Sindh, into a more culturally sensitive format and then translating it into Sindhi language is underway. This modification is being carried out as a collaboration between UNICEF, RMF Pakistan, and STEDA (Sindh Teachers Education Development Authority).

National Level TOT Seminar, January 2019

Meanwhile, the National MHM Working Group took the first step towards introducing MHM as an awareness and health education strategy at a health facility level by holding a week-long National Level TOT (Training of Master Trainers) seminar. This took place on January 23–29, 2019 at Serena Hotel, Islamabad and was hosted by the chair of the MHM group, the Water Supply and Sanitation Collaborative Council (WSSCC). MHM Working Group members carried out development of MHM guidelines for primary health workers based on national information on MHM and best practices at a global scale. Members of the MHM Working Group brainstormed until consensus was achieved regarding each talking point. UNICEF compiled the newly developed guidelines into a formalized training handbook, which was translated into Urdu and handed over to the participants.

  • The seven-day National Level TOT workshop was inaugurated with a High-Level Policy Dialogue on Menstrual Health & Hygiene Management.
  • The participants were mostly LHVs (Lady Health Visitors) who work in primary and secondary level hospital facilities and come into direct contact with female patients of all ages; some participants were representatives of local community organizations that are implementing MHM, health care services, and/or educational services in their project profiles. Participants originated from all parts of the country.
  • Our Pakistan Girls’ Puberty Book was selected as advocacy tool to be distributed to the trainers at the TOT workshop. Instruction on appropriate use of the book was delivered by Afshan of RMF Pakistan on January 28, 2019. This was accompanied by a live demonstration session at a local healthcare facility.

1. To describe local cultural understandings and meanings of menarche in urban and rural Pakistan through the use of ethnographic observations, interviews and participatory activities with adolescent young women and the adults who play key roles in the lives of school-aged young women.
2. To explore, through comparative case studies of young women’s lives, the ways in which local cultural meanings about menarche and menstruation interact with sanitary technology, school design, and peer group relations, to create intolerable menstrual-related stigma that leads to young women dropping out of school.
3. To utilize adolescent young women’s own recommendations for improving the pubertal and menstrual management related guidance adolescent girls receive through the development of a girls’ puberty book in Pakistan.

The intersections between menarche and education in Pakistan are still poorly understood. Nonetheless, existing reports suggest the dominance of male students in middle and high schools, and the absence of other “girl friendly” supports in the schooling environment are causes, e.g. water is rarely available in rural schools in Pakistan, with 75% of hand pumps and 28% of latrines being non-functional. Furthermore, female students lack separate, private latrines, and they often are attacked, sexually harassed, or shamed when waiting to use lavatory services, posing yet another barrier to school attendance. Female students may also have difficulty accessing sanitary materials owing to their high cost, especially if male family members make most major household purchases, as is the case in the majority of households in Pakistan. Given that menarche may be jeopardizing young women’s schooling and health in Pakistan, it is both timely and important to better understand the relationship between menstruation, education, and health for young Pakistani women, and to improve pubertal transitions.