Rawan Raad | AMNA

Menstrual Hygiene: a Culture of Silence

Menstrual hygiene is a concern for women globally. In Sudan, the lack of knowledge and awareness surrounding menstruation, especially in rural and conflict areas, along with social, cultural, and religious restrictions, makes it difficult for women and girls to take proper care of their hygiene during their monthly cycle. This can result in many challenges at home, school, and the workplace. Menstrual hygiene is important for the well-being of women and girls. In order to ensure menstrual hygiene for women and girls, it is important for women and girls to be able to manage their periods safely without shame or stigma, but with dignity and confidence.

According to a UNESCO report surveying several countries in sub-Saharan Africa, one out of every 10 girls misses school during menstruation. A Ugandan study found that nearly two-thirds of schoolgirls in rural areas miss school at least once a month due to menstruation. Similarly, in Ethiopia, more than half of the adolescent school girls remain absent during menstruation.

In Sudan, the situation is similar to some extent. Women and girls from low socioeconomic backgrounds, especially those in rural and conflict areas, suffer from unhygienic menstrual practices. The lack of sanitary products as well as accessibility to safe and hygienic places to manage their periods leads girls to miss school and to feel unsafe and self-conscious.

“I share a little torn towel with my 11-year-old daughter during our menstruation because buying actual sanitary pads from the shops is very expensive and not available. Family hygiene kits are crucial for us. In the past I used to feel bad each time I had my monthly period, I didn’t feel comfortable using unhygienic rugs they are not comfortable, nor are they effective, and they can lead to very serious health concerns, with free disposable sanitary pads provided, I can safely manage my health, I can now openly talk about menstruation and the sanitary pads. I feel confident and empowered.”
Leila Mustafa, who lives in a camp in East Darfur and received family hygiene kits from UNICEF.

Poor menstrual hygiene management practices can be attributed to three main factors: lack of knowledge, lack of access, and lack of acceptance.

Lack of knowledge:

Despite the scarcity of data, different studies indicate that less than 40% of adolescent girls are unaware of menstruation until they encounter their first period. This leads to girls being too ashamed and afraid to seek medical advice. The lack of knowledge surrounding menstruation leads to misconceptions, taboos, and negative societal attitudes and perceptions.

Lack of access:

Many girls and women cannot afford sanitary products, so they resort to rags, cloths, papers, layering underwear, and other highly unhygienic methods to manage their menstruation. Several countries, such as Kenya and Rwanda, have removed taxes from menstrual products. Counties such as Zimbabwe have used local resources to sustainably manufacture sanitary products for women.

According to UNICEF, globally, 2.3 billion people live without basic sanitation services. In developing countries, only 27% of people have adequate hand washing facilities at home. Not being able to use these facilities makes it harder for women and young girls to manage their periods in a safe and dignified manner.

Lack of acceptance:

In various cultural settings, the topic of menstruation has been surrounded by silence. While anthropological literature documents that various cultures have historically embraced menarche as the passage to adulthood, menstrual blood itself along with its management has been stigmatized and perceived as a taboo. Menstruation and menstrual practices are often obscured by taboos and socio-cultural barriers rendering adolescent girls oblivious of medical facts and hygienic practices which can lead to negative health implications.

We asked women and girls about their reactions when they first encountered their periods, most of them expressed how stressed and scared they were. The lack of knowledge about menstrual hygiene and the stigmatization of menstruation forced many girls to suffer in silence. Some didn’t even tell their mothers. The girls shared with us how they suffered from infections and lack of confidence:

“I did not understand what I was going through. At first, I thought that I was injured somewhere and was searching for the source of bleeding. I was not comfortable with asking my mother or any other person to buy me sanitary pads, so I used other materials to manage my period, without knowing the negative effects of using unhygienic products.”

“I was shocked and frightened. I thought that I did something bad and my body is punishing me. I ran to my mother but she shut me at first because I was talking in front of my brother. I felt ashamed, shy, and bad about myself.”

“I searched for various ways to provide the products used during the menstrual cycle secretly without anyone’s help. During that period, I was not able to use medical cotton properly, which caused me a state of tension during my menstruation.”

Period Poverty:

Period poverty is a global issue affecting women and girls who do not have either access to safe and hygienic sanitary products or knowledge on menstruation often due to financial issues. Period poverty does not only refer to those who have no access to sanitary products, it also refers to women and girls who have limited access to sanitary products which leads to prolonged use of the products which can cause infections.

Period poverty has a great role in poor menstrual hygiene which leads to reproductive and urinary tract infections. Additionally, period poverty stops women from reaching their full potential by missing out on opportunities important for their growth. It also forces girls to miss days of school which impacts their school performance.

“Meeting the hygiene needs of all adolescent girls is a fundamental issue of human rights, dignity, and public health.”
Sanjay Wijesekera, former UNICEF Chief of Water, Sanitation, and Hygiene

Menstrual Hygiene in Humanitarian Situations

As of 2017, more than 26 million menstruating girls and women have been displaced as a result of conflict and disasters while many more have been affected without being displaced. Menstrual hygiene is almost always overlooked and not effectively addressed in post-conflict and disaster settings. Conflicts and disasters can leave women and girls without access to clean and proper sanitation facilities, privacy needed to proceed with their menstruation management methods, and access to safe sanitation products and material to manage their menstruation. This could be due to the lack of availability of these products or the lack of funds to purchase them. As a result, women and girls are forced to use improvised methods to manage their periods, including torn pieces of clothing, filthy rags, and other unhygienic methods.

Such alternative methods are often ineffective, uncomfortable, and unhygienic. They can lead to dangerous infections and other health complications which can cause women and girls to feel isolated during their period. In the aftermath of an earthquake in Nepal, women and girls were left with no option but to depend on the use of locally available resources as adsorbents during menstruation. Menstrual hygiene products and kits were not addressed as essential humanitarian needs by humanitarian agencies.

Tackling menstrual hygiene management during emergencies needs a multi-faceted approach and interventions ranging from providing proper and private sanitation facilities, protection, reproductive health education to community support.

Health complications:

Menstruating women and girls have developed their approach to cope with menstruation based on their knowledge, available resources and economic and sociocultural statuses. As a result of these limitations, women often manage menstruation with practices and methods that are unhygienic. Such methods can lead to serious health complications. Certain practices are more likely to increase the risk of reproductive tract infections which can increase susceptibility to cervical cancer. Using unclean rags, especially if they are inserted into the vagina, can facilitate the growth of unwanted bacteria in the cervix and the uterine cavity which could lead to infection. Prolonged use of the same pad will also increase the risk of infection and skin irritation that can result in dermatitis. Douching (forcing liquid into the vagina) upsets the normal balance of yeast in the vagina and makes infection more likely. Also, unsafe disposal of used sanitary materials has the risk of infecting others, especially with diseases such as Hepatitis B. The lack of hand-washing after changing sanitary materials can also facilitate the spread of infections.

Why it isn’t addressed often

Despite its importance, menstrual hygiene management doesn’t receive enough attention in developing countries. Since the global health priorities in Sexual and Reproductive Health was aimed at reducing maternal morbidity and mortality and the HIV epidemic, the main focus in developing countries was towards adolescent girls because of their increased vulnerability to unwanted pregnancy and infection with HIV and other sexually transmitted infections.

Many in the education sector perceived menstruation as less important than the shortage of resources for textbooks, classrooms, and other essentials, and believed that the onset and management of menses was a private matter, to be taken care of within the family. The low number of women in leadership and decision making positions hindered the efforts to effectively advocate forcefully about a topic as taboo as menstruation and the importance of Menstrual Hygiene Management (MHM).

What can we do?

Menarche remains one of the biggest taboos. A study conducted by the International Women’s Health Coalition found that there are about 5,000 euphemisms used to refer to menstruation in 10 different languages which can indicate the general attitude the follow the word. Breaking such taboos and publicly addressing the needs of menstruating females is the first step we can take to educate and try to eliminate period poverty. The current initiatives in Sudan to provide pads and menstrual products in the areas that were affected by floods as part of the humanitarian response can be highlighted as an excellent step to address and bring light to the hidden emergency menstruating females go through.

To work more on raising awareness and knowledge among local communities to end the menarche stigma through public advocacy.
To advocate for policy changes to make menstrual products more accessible through evidence-based advocacy to decision-makers.
To work on the implementations of proper sanitary facilities in marginalized communities.
To raise awareness on the importance of the inclusion of menstrual hygiene health and management in education and health programs to build knowledge for girls and boys, and work on engaging parents and community leaders.
To further research and collect data on menstrual hygiene effects on women’s health and rights.

Resources:

https://www.wvi.org/publications?field_topics_target_id%5B761%5D=761

https://www.unicef.org/wash/files/UNICEF-Guide-menstrual-hygiene-materials-2019.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2784630/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5482567/

https://www.worldbank.org/en/news/feature/2019/05/24/menstrual-hygiene-day-2019

https://www.globalcitizen.org/en/content/period-poverty-everything-you-need-to-know/

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-6360-2

https://web.archive.org/web/20191030213257/https://www.actionaid.org.uk/about-us/what-we-do/womens-economic-empowerment/period-poverty

https://www.downtoearth.org.in/news/waste/amp/menstrual-hygiene-in-africa-no-pad-or-no-way-to-dispose-it-63788 https://www.globalcitizen.org/en/content/period-poverty-everything-you-need-to-know/

https://sswm.info/sites/default/files/reference_attachments/MOMA%20n.y.%20Menstrual%20hygiene%20management%20in%20Africa.pdf

Illegal Abortion: The Tragedy of Unwanted Pregnancy

Introduction:

The World Health Organization (WHO) defines unsafe abortion as “the termination of an unwanted pregnancy by persons lacking the necessary skills, or in an environment lacking minimal medical standards, or both”. According to WHO, unsafe abortions are found to end 47,000 lives annually while 3 out of four of them occur in Africa and Latin America. Unsafe abortions occurfrequently in developing countries with restrictive abortion laws and limited access to health care facilities.

Unsafe abortion and illegal abortion- Are they the same thing?

The environment in which an abortion takes place and whether the performer of the abortion is a licensed professional determines the safety of the procedure. An illegal abortion refers to when the law prohibits women from undergoing abortions unless certain conditions apply. Those conditions vary across countries and legal frameworks.However, restictions and conditions hinder the anonymity of abortions for women which compels them to resort to unsafe abortions as their situations do not meet legal requirements. In the MENA region, only Tunisia and Turkey have legalized abortion under all grounds in the first trimester. However, most countries in the region still entertain punitive and restrictive safe abortion laws. We will be exploring Sudan’s legal status in the matter particularly in this piece.

Unsafe Abortion in Sudan:

Unsafe abortion and limited access to safe abortion health services can be attributed to two main factors: cultural and legal restrictions.

Cultural Restrictions:

In Sudan, gender roles are highly regarded and abided by. Women who choose to defy their reproductive role and undertake abortion are not only considered disgraceful, but are accused of rejecting God’s blessings upon them.

Despite the scarcity of data in Sudan, existing research indicates a high rate of unintended pregnancy which is a major reason behind why women and girls seek unsafe abortion. Unintended pregnancy is highly rampant due to factors associated with lack of awareness regarding contraception, lack of understanding for family planning, as well as systemic barriers to the different methods of contraception. The stigmatization of contraception is due to the culture’s entrenchment to gender roles and women’s tendency to produce offspring. Such an environemnt leaves women with no choice but to subject themselves to unsafe methods of abortion.

Abortion is a clear indication of misconduct. Added to that, in Muslim communities, having children is regarded as the most noble thing to do, so even the feeling of not wanting a child is a huge mistake. Part of women’s value, and in fact the most important part for women, is to be fertile and give birth to as many possible children, and women who even think of having space between deliveries is questioned. A woman’s femininity is measured by her ability to give birth to children.
(interview, 2017)

The idea of unintended pregnancy is frequently associated with fornication and adultery. Fornication is the act of sexual intercourse outside a marriage contract. Adultery is sex outside of marriage whilst an individual is married. Fornication and adultery are widely believed to be forbidden in Islam and are punishable by 100 lashes. Thirty years of Islamist rule in Sudan has criminalized pregnancy outside marriage and labelled it as a blasphemous form of pregnancy. The use of the terms unintended pregnancy and illegal pregnancy interchangeably is key in contributing to the increase of Sudanese women and girls seeking unsafe abortions. Society’s demonization of women who seek an abortion has produced the notion that every woman seeking one has committed fornication or adultery and is exploring ways to avoid ostracisation. While this is the case for many, the explicit connection made between abortion and illegal pregnancy has created an appalling image on abortion which disregardes other situations such as unwanted pregnancies in a marriage and pregnancy as a result of rape.

Legal restrictions:

In Sudan, the abortion law only protects women whose lives are endangered due to the pregnancy and women who are pregnant as a result of incest or rape.

A person who intentionally causes a woman to miscarry is not guilty of an offence where (a) the miscarriage is necessary to save the mother’s life; (b) the pregnancy is the result of rape which has occurred not more than 90 days before the pregnant woman has desired to have the abortion; or (c) it is proved that the quick unborn child has died in the mother’s womb. If the pregnancy is of less than 90 days’ duration, the person who performs the illegal abortion is subject to up to three years’ imprisonment and/or payment of a fine. If the pregnancy is of more than 90 days’ duration, the penalty is increased to up to five years’ imprisonment and payment of a fine. In both cases, the person may be subject to the payment of compensation.

While Sudan is the first country in the MENA region to legalize abortion in the case of rape, this legal text remains restrictive. Not only does it exclude unintended pregnancies in and outside of marriage, but it is highly unresponsive to the cultural and legal context of rape and sexual abuse.

The 1991 law reform to include rape came in resonse to the attention Darfur received after the documentation of sexual violence cases. However, after the ICC issued an arrest warrant for Omar Elbashir, the government expelled many of the humanitarian organizations who were leading the documentation of incidents as well as the distribution of post-rape kits in conflict areas such as Darfur. Nevertheless, this law reform was originally made on a gendered basis. Abortion was only legalized to preserve the honor of the women who have been raped and to sustain their future chances of marriage rather than a way of preserving their rights and dignity.

The gendered basis of the law reform is translated in how rape survivors don’t often entertain this right due to the faulty legal definition of rape. In order for a woman to access abortion services, she must first prove that she has been raped, a procedure which has been accounted to be futile, discriminatory and incriminating. In article 149 of Sudan’s Criminal Code of 1991, rape is categorized as adultery without consent which is criminalized in Sudan. Proving that sexual intercourse took place forcibly requires the victims to reach out to the police and attain what is called Form 8. Form 8 is given by the police after the victim provides proof of being exposed to sexual abuse.Only after receiving the form can a woman access safe abortion at a healthcare institution. Documenting form 8 is the role of the police. Because this form is the sole means of evidence for physical injuries and bruises in Sudanese courts (except for when the victim is a child) if injuries are not documented, the survivor may face incrimination for fornication or adultery.

With such aggravating conditions set in place to prove the occurrence of rape, many are discouraged. Those who do prove their rape often become subject to a prolonged trial process that is unlikely to end before the 90 days limit in which the abortion is legally permitted.

Available data:

Considering the aforementioned cultural and legal restrictions for abortion in Sudan, it is no surprise that available data on this issue is scarce. However, according to Women Deliver “An estimated 25.1 million unsafe abortions take place [globally] each year. Every year, approximately 6.9 million women in developing countries are treated for complications from unsafe abortions, and complications from unsafe abortions cause at least 22,800 deaths each year.”

A study conducted in Khartoum reveals that 96.7% of women seeking abortion services do so for the treatment of post-abortion complications or after undergoing an incomplete abortion. This prevails how bureaucratic barriers and the culture of health worker are causing women and girls to seek unsafe abortions. Moreover, unsafe abortions lead to the hospitlization of of women and often times leaves them in critical conditions.

Demographics- can we identify certain groups:

Most existing content does not associate unsafe abortions with certain age groups, ethnicities or social classes. However, it does identify variances in the way unsafe abortion takes place in relation to people with different identities.

Unsafe abortion can be described as a class issue. Many women from the upper and middle-class have access to private clinics or connect with networks of doctors who are willing to help terminate their pregnancy. Some women are also able to access the black market or web to purchase medications that aren’t available in Sudan such as misoprostol. While women in lower socioeconomic statuses are left with no choice but to seek traditional and dangerous methods of abortion such as drinking herbs, ingesting various drugs and poisons, and inserting objects such as metals and wood into the uterus leading to critical complications that can cause death.

“I would see 16 cases of failed abortions on a given day. I would insert my hand and pull out syringes or leaves, unsanitary items that were inserted by midwives to induce a miscarriage,”
Nabil, a Sudanese doctor told IPS.

General lack of access to reproductive healthcare is more evident in conflict areas in Sudan where not only are the healthcare systems insufficient, but where sexual abuse and rape is pervasive. The use of rape as a weapon of war in Darfur was what led the Islamist Sudanese government in 1991 to legalize abortion in the occurence of rape.

In 2016, interviews conducted by Human rights watch researchers in rebel-held South Kordofan explored accessibility to reproductive health in the area. The researchers spoke to witnesses and victims of sexual abuse, local rebel authorities, and humanitarian aid workers.

*In the* *photograph above,* Mukuma Hamad, a volunteer health worker, holds a container of folic acid, the only assistance she can give pregnant women who visit the lone health clinic in Hadara village, in rebel-controlled Southern Kordofan.

Most of the women interviewed did not know what condoms were and were unaware of any other kind of contraceptive. Local aid workers informed the researchers that condoms are not available in the market despite the increase in gonorrhea, syphilis and Hepatitis b cases. Women are unable to protect themselves against sexually transmitted diseases, nor are they able to control their fertility.

Dr. Abdelahadi Ibrahim, a Sudanese Obstetrics and Gynaecology specialist, faced a 6 year jail sentence after being arrested for conducting safe abortions for women and girls. Dr. Ibrahim explained in an interview that he has carried out approximately 10,000 abortions during his 7 years of operation. He elaborated that 90% of the cases were university students, while the remaining 10% included the wives of migrant husbands and other kinds of cases. He believed that he was able to save 10,000 Sudanese families from the kind of instability an unintended pregnancy can cause, taking note that those families are not from planet “Mars”.

Displacement also plays a major factor. Current estimates suggest that women who are displaced due to conflicts are more vulnerable to sexual abuse which contributes to unintended pregnancy and unsafe abortion.

Seeking a safe abortion in Sudan- Bureaucratic barriers

In addition to the emotional trauma women and girls experience due to social stigmas and legal consequences, bureaucratic barriers also contribute in making this situation more burdensome.

According to the roadmap for reducing maternal and newborn mortality rates in Sudan, misoprostol is authorised to be used by mid-level health providers. In the contrary, this isn’t the case on the ground. The fear of health providers to use the materials in order to carry out illegal abortions caused for the implementation of strict procedures that are designed to prevent the “misuse” of the medication.

The Roadmap is not implemented. Decision makers are influenced by religious ideas and think that if midwives accessed the drugs they can use it for aborting unmarried girls and that would spread immorality. They are more concerned with morality than the lives of women.
Women’s rights activist (interview, 2019)

An interview-based article explored the criminalization of abortion and looked into the policing of maternity wards. It highlighted the high level of security put in place at the entrances of those institutions especially in public hospitals. Any unescorted pregnant woman is a suspect of an illegal pregnancy.

“Are you married? Where is your husband? If you enter a maternity ward alone, you are a suspect”
(interview, 2018).

Ideally, only a woman with Form 8 should be able to access a safe abortion service. However, whether she’s able to be admitted into the hospital depends on the present doctors’ moral judgement. Some choose to abide to their professional ethics in maintaining the patient’s privacy, disregard Form 8 and treat the case as a miscarriage. However, others choose to report them to the police. Such an act highlights health institutions’ common misuse of their authority especially when legitimized by law enforcement. Healthcare institutions and legal authorities often brutalize women who seek safe abortions. This takes place in the shape of derogatory remarks that are used to describe women pregnant outside of marriage.

Security staff and police treat women badly, as if they are the judges, even before presenting her case to the legal system. One time, a woman pregnant with twins was kept handcuffed the whole time, and she was discharged directly to the prison because of illegal pregnancy.
(interview, 2018)

Seeking abortion unofficially- who can women reach?

The accessibility to safe methods of abortion in unofficial means carries a classist nature. However, even the existing networks led by healthcare and social workers who work on providing abortion pills have a confined reach out. The measures they take to ensure their safety means that women and girls can only reach them if they are aware such a network exists. This leaves many girls resorting to midwives who perform the procedure in unsafe conditions which later causes them post abortion complications. The problem with midwives does not only stop at health complications but also personal mistreatment of the girls they interact with.

“I know a girl who was circumcised by a midwife after an abortion and was told that this is to stop her from having sex again, it is clear that midwives could punish you or take advantage of your situation,”
Ali (A sudanese woman who has undergone an abortion unofficially)

What can we do?

In the light of Sudan’s current transition, there’s a glimmer of hope regarding women related legislation and women’s statuses. We have recently witnessed positive law reforms being made by the Ministry of Justice on issues such as FGM and a mother’s agency in her children’s mobility. However, there is no doubt that abortion is a notion that is extremely stigmatized,so the direction of this conversation remains undetermined.

The absence of legislation does not mean unsafe abortions are not taking place. Reflecting on what the context is telling us, certain action points can be made:

To work on increasing acceptance of safe abortion amongs local communities, policy makers, and health workers.
To further collect and share statistics
Research data on the consequences of unsafe abortion to women’s health and rights.
To strengthen individuals’ knowledge on family planning and the use of contraception through the implementation of comprehensive sexuality and reproduction education which can significantly lower the rate of unintended pregnancy.
Improve access to affordable contraceptive methods.