Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis

Abstract

Objectives: To assess the status of menstrual hygiene management (MHM) among adolescent girls in India to determine unmet needs.

Design: Systematic review and meta-analysis. We searched PubMed, The Global Health Database, Google Scholar and references for studies published from 2000 to September 2015 on girls' MHM.

Setting: India.

Participants: Adolescent girls.

Outcome measures: Information on menarche awareness, type of absorbent used, disposal, hygiene, restrictions and school absenteeism was extracted from eligible materials; a quality score was applied. Meta-analysis was used to estimate pooled prevalence (PP), and meta-regression to examine the effect of setting, region and time.

Results: Data from 138 studies involving 193 subpopulations and 97,070 girls were extracted. In 88 studies, half of the girls reported being informed prior to menarche (PP 48%, 95% CI 43% to 53%, I(2) 98.6%). Commercial pad use was more common among urban (PP 67%, 57% to 76%, I(2) 99.3%, n=38) than rural girls (PP 32%, 25% to 38%, I(2) 98.6%, n=56, p<0.0001), with use increasing over time (p<0.0001). Inappropriate disposal was common (PP 23%, 16% to 31%, I(2) 99.0%, n=34). Menstruating girls experienced many restrictions, especially for religious activities (PP 0.77, 0.71 to 0.83, I(2) 99.1%, n=67). A quarter (PP 24%, 19% to 30%, I(2) 98.5%, n=64) reported missing school during periods. A lower prevalence of absenteeism was associated with higher commercial pad use in univariate (p=0.023) but not in multivariate analysis when adjusted for region (p=0.232, n=53). Approximately a third of girls changed their absorbents in school facilities (PP 37%, 29% to 46%, I(2) 97.8%, n=17). Half of the girls' homes had a toilet (PP 51%, 36% to 67%, I(2) 99.4%, n=21). The quality of studies imposed limitations on analyses and the interpretation of results (mean score 3 on a scale of 0-7).

Conclusions: Strengthening of MHM programmes in India is needed. Education on awareness, access to hygienic absorbents and disposal of MHM items need to be addressed.

Trial registration number: CRD42015019197.

Keywords: PREVENTIVE MEDICINE; PUBLIC HEALTH.

Figure 1

Elements important for menstrual hygiene management.

Figure 2

Flow chart of systematic review of MHM studies among adolescent girls in India. MHM, Menstrual Hygiene Management.

Figure 3

Bubble plot with a fitted meta-regression line of the log prevalence of commercial pad use by adolescent girls over time, 104 studies in India published between 2000 and 2015. Circles are sized according to the precision of each estimate with larger bubbles for more precise estimates. One study was excluded because of the large sample size (≈39 000), which led to distortion of all other information.

Figure 4

Bubble plot with fitted meta-regression line of the log prevalence of girls with religious restriction during menstruation over time, 67 studies in India published between 2000 and 2015. Circles are sized according to the precision of each estimate with larger bubbles for more precise estimates.

Figure 5

Tukey box plot of school absenteeism reported by adolescent girls during menstruation by region, 64 studies in India published between 2000 and 2015. The bottom and top of the box are the 25th centile and the 75th centile, and the band inside the box is the median. The lower whisker indicates the data between the 25th centile minus 1.5 times the difference between the 25th and 75th centiles, and the upper whisker indicates the data between the 75th centile plus 1.5 times the difference between the 25th and 75th centiles. The mean is indicated next or in the box plot, and the range of values is indicated under each region.

Figure 6

Bubble plot with fitted meta-regression line of the log prevalence of school absenteeism among adolescent girls and menstrual pad use, 53 studies in India published between 2000 and 2015. Circles are sized according to the precision of each estimate with larger bubbles for more precise estimates.