CHAPTER 2: LITERATURE REVIEW
2.1 M ENSTRUAL PREPAREDNESS
2.1.3 Menstrual preparedness in sub-Saharan Africa
A study carried out in Ethiopia, South Sudan, Uganda, Tanzania and Zimbabwe investigating the menstrual hygiene management of schoolgirls revealed that “few girls in any of the countries are prepared for menstruation before it occurs, so that menarche is a distressing experience of fear, pain and shame” (SNV, 2014:10). In a study in Nigeria, out of 187 post-menarcheal girls, 10% had no knowledge of what menstruation is or its significance (Abioye-Kuteyi, 2000). A further 40% had incorrect information about menstruation. This means that more than half of the menstruating girls in this study were not prepared for menstruation in terms of knowledge, even though they may know how to manage their periods materially (Abioye-Kuteyi, 2000). According to Umeora and Egwuatu (2008b), the topic of menstruation is a source of discomfort among Igbo women in Nigeria. They note the reluctance of Igbo mothers in preparing daughters for ménarche and the cycles of menstruation that would follow (Umeora & Egwuatu, 2008b).
The Southern Ndebele have a female initiation ceremony known as iqhude or ukuthombisa. It takes place when a Ndebele girl reaches puberty and starts before the first full moon.8 The word ukuthombisa in Southern Ndebele is commensurable with the Northern Ndebele word for reaching ménarche (ukuthomba).
The Ndebele iqhude ceremony is not unlike the Xhosa intonjane which is “a female rite of passage performed at menarche” (Padmanabhanunni et al., 2018:705). It signified “the transition from childhood to adulthood and eligibility for marriage owing to the girl having reached biological sexual maturity”
(Padmanabhanunni et al., 2018:705). The ritual consisted of eight days in which they would be secluded from men and boys and, at this time, “Girls are also provided with information regarding sexual and reproductive health and how to manage menstruation”. The initiates ranged between 11-16 years (Padmanabhanunni et al., 2018). The practice of intonjane was opposed by missionaries, so girls are initiated variably in modern South Africa, particularly in the Eastern Cape province – a homeland to the Xhosa people. Though acknowledged as a transition into adult status, the Northern Ndebele do not have a formal initiation rite associated with ménarche.
In a study carried out in the Vhembe district of Limpopo province in South Africa, it was found that among the Vha-Venda, only 27% of 273 girls had no knowledge of menstruation at ménarche, while another 27%
“reported knowledge of the physical changes that relate to menarche” (Ramathuba, 2015:4). Of the 73%
who claimed to have knowledge on menstruation, only 27% of these girls understood the physical changes that came with ménarche (Ramathuba, 2015:4). For these Vha-Venda girls, Vho-Makhadzi (like Ndebele girls’ babakazi) is the paternal aunt who prepared girls for menstruation; shaping and helping manage menstrual practices at a household level (Ramathuba, 2015). Menstrual preparation vis-à-vis understanding the physiology of menstruation when once ménarche is reached, the body becomes reproductively capable is integral to serves as a link curbing early unintended pregnancy.
In Zambia, similarly, “there is a lack of understanding among girls around the biological purpose of menstruation” (Sinden et al., 2015:49). As a result, many girls in Zambia do not know or understand what is happening to them when they begin menstruating (Sinden et al., 2015). UNESCO (2018) notes that in the Zambian rural areas in particular, there are especially high rates of early unintended pregnancy, revealing a connection between menstrual knowledge and early unintended pregnancy. Miiro et al. (2018) state that in Uganda parents found it difficult to have open dialogue about menstruation and MHM with their daughters because of cultural norms. Unsurprisingly, Ugandan girls report that insufficient knowledge on menstruation and its management prior to reaching ménarche triggered anxiety about ménarche (Miiro
8 https://southafrica.co.za/ndebele-initiation-and-rites-of-passage.html
et al., 2018). Grant et al. (2013) explain that female students in rural Malawi may feel poorly prepared to deal with menstruation because they lack information. A glimpse into early unintended pregnancy is captured in the Demographic Health Survey Data for adolescent girls aged 15-19 years. In Zambia and Uganda along with Tanzania and Malawi the proportion is high at over 25% (UNESCO, 2018:xii).
Zimbabwe is not far behind with the 2015 ZDHS revealing an early childbearing rate for adolescent girls aged 15-19 years of 21.6% (ZIMSTAT & ICF International, 2016). The unintended pregnancy rate for the same cohort is 37.6%. The survey reports that 37.8% of girls aged 15-19 years in primary school compared with 17.3% of girls aged 15-19 years had their first birth (UNESCO, 2018). This suggests that girls with lower educational outcomes (primary school repeaters or pupils whose yearly progression from one grade to another has been impeded for external factors), are at increased risk of falling pregnant in Zimbabwe.
This crystallises the need to address the transition rate crisis and grade succession for Zimbabwean girls.
The proportion of rural girls (27.2%) having the first birth between 15-19 years is more than double that of urban girls (10.3%) in Zimbabwe (UNESCO, 2018). Consequently, UNESCO has recommended focusing on rural communities where early unintended pregnancy rates are highest. I have highlighted the consequences of exclusion of girls from school as a factor compromising gender parity in education (see page 21). UNESCO has spoken of the need to “strengthen re-entry monitoring framework” for girls following early unintended pregnancy in Eastern and Southern Africa (UNESCO, 2018:xix).
This dissertation frames menstrual preparedness as girls having both the prior knowledge of what to expect of menstruation and the ability to manage menstruation, as well as how prepared society is to fully educate girls on the nature and implications of ménarche and menstruation – before ménarche is reached. It creates a link between menstrual preparation and early unintended pregnancy, a crisis that is also touching the village of Sikelela. Therefore, menstrual preparedness is not just information about menstruation at the time of the first period. McMahon et al. (2011) raise an important aspect of menstrual preparedness from their research in Kenya. They suggest that teaching girls how to track their periods is a menstrual preparation strategy that could lessen fear and anxiety around starting one’s period while at school and better equip them to cope with menstruation. School is a terrain that makes girls especially nervous about menstruation.
This is because this private issue of menstruation must be negotiated in the public space of school (Fingerson, 2005b). Prendergast points to another layer of menstrual preparedness that complicates our understanding of the problem when she explains that:
Interwoven through all of this [i.e., managing menstruation in school], girls also acquire informal social knowledge about menstruation: how it is viewed and dealt
with in the world, to whom and how she must speak about it, and the practical arrangements that must be made so that rules and etiquette as to its visibility and management are not contravened. Using appropriate strategies for managing menstruation, they must negotiate their time, the adult world telling them when to go to the bathroom, and their menstrual supplies (Prendergast, 2000:108).
The above is what I describe an ecosystem of ‘growing up’. As I mentioned on page 29, the practical aspects of menstrual preparedness include access to use sanitary wear and knowledge on how to use sanitary wear.
Ménarche is a gateway into knowledge about MHM (Sommer, 2010a; Yücel et al., 2018) and an introduction into the tacit code of conduct governed by a code of “menstrual etiquette” (Laws, 1990). This menstrual etiquette dictates the concealment of menstruation and menstrual products. It is like a prism in which light is absorbed from the outside world but is refracted internally, and this light represents societal views on menstruation. Without proficiency in the vernaculars of menstruation and the literacy on how to read this social script of menstrual etiquette, girls are doomed to (albeit unintentionally) commit contraventions as they blunder unknowingly through this ecosystem.
This section of the chapter has reviewed the related literature on menstruation and menstrual preparedness globally. It has outlined the problem of poor menstrual preparedness and the dangers that may arise out of poor menstrual preparedness, for example: early unintended pregnancy; STIs (including HIV/AIDS);
unhygienic MHM practices that can lead to RTIs; stress, anxiety, and the inability to manage the problems accompanying menstruation, e.g., dysmenorrhea. It builds on the introductory chapter by highlighting some of the reasons for poor menstrual preparedness. It has texturised our understanding of menstrual preparedness and its different dimensions -: from knowledge on the physiology of menstruation, to the ability to navigate the world of menstrual etiquette; to tracking one’s cycle and being physically and emotionally prepared through knowledge of MHMMMs and how to use them. Menstrual preparedness also consists of knowing who to turn to information and emotional support around the changes that accompany the passage into ménarche.