Menstrual hygiene management can be challenging in low-income settings and among school-aged girls due to traditional beliefs, lack of knowledge and information on best hygienic practices, and limited access to appropriate and affordable menstrual hygiene products. An alternative method for menstrual hygiene management, instead of sanitary pads or tampons, is the vaginal menstrual cup. As evidence on the use of menstrual cups is relatively limited, this study aimed to explore the acceptability and feasibility of using vaginal menstrual cups among school-aged girls in Thokarpa, Sindupalchowk, Nepal.
Article From BMC
Authors Diksha Pokhrel, Sabina Bhattarai, Malin Emgård, Michael von Schickfus, Birger C. Forsberg & Olivia Biermann 16 June 2021
This is an exploratory study based on four focus group discussions with a purposive sample of 28 schoolgirls between 13 and 19 years of age who were provided with vaginal menstrual cups in Thokarpa, Sindupalchowk, Nepal. The data were collected between February and March 2019, i.e. approximately three months after the distribution of the menstrual cup. Participants were included in the study if they had started their menstruation and never given birth. Conventional content analysis was applied.
Most participants perceived the menstrual cup positively. Not missing a single class in school due to problems related to menstrual hygiene management was described as a major benefit. The participants found using the menstrual cup easy and convenient, and described economic and environmental advantages of using it. Cleaning the menstrual cup did not cause any problems, according to the participants. Discomforts mentioned by the participants were: pain when inserting the menstrual cup, feeling the menstrual cup sticking out of the vagina, feeling a constant urge to urinate and leakage. Concerns were related to the size, shape and texture of the menstrual cup, and that it may “get stuck” in the vagina, while relatives were said to be concerned about the use of the menstrual cup leading to reduced fertility or losing virginity.
The use of vaginal menstrual cups for menstrual hygiene management among schoolgirls in Thokarpa, Sindupalchowk, Nepal, appears feasible and acceptable, as it involves practical, economic and environmental advantages. However, the scale-up of menstrual cups will require resolving described concerns and discomforts and fostering peer and family support.
Menstrual hygiene management can be challenging in resource poor settings, such as Nepal, due to traditional practices and beliefs [1,2,3], lack of knowledge [4, 5] and information  on best hygienic practices, lack of infrastructure such as access to soap and water , as well as limited access to appropriate and affordable hygienic products [2, 7]. The use of unhygienic clothes to replace pads or tampons may cause restriction in movement, skin irritation, concerns about leaking and odor [8, 9], and increase the risk of urogenital infections [10, 11]. In Nepal, many families impose restrictions on menstruating girls and women, which may vary based on religion, social group and education level . The severest restriction is "Chhaupadi", meaning the isolation of menstruating women in small huts made of mud and stones with no doors or windows, which is still practiced in the Far-Western Development Region of Nepal . A study conducted in the Central Development Region, where this study was conducted, showed that in the aftermath of the 2015 earthquake, menstrual hygiene management was rated as the sixth highest overall need by study participants (after food, shelter, water, clothes and information about family members) [14, 15]. Thomson and colleagues  emphasized the need to reframe menstrual hygiene management as a question of rights as opposed to hygiene, acknowledging that a wide range of issues linked to menstruation beyond hygiene, e.g. security, stigma, safety, taboo and policy ownership.
Problems with menstrual hygiene management may be particularly prevalent in school-aged girls. According to a report from the United Nations Children’s Fund, UNICEF, 18.4% of schools in Nepal did not have a toilet in 2018, while others lacked sex-segregated facilities, adequate water supply or disposal systems, which would allow for appropriate menstruation management . Girls are therefore more likely to miss school [17, 18] and, in some parts of Nepal, are not allowed to go to school during their menstruation . Studies conducted across sub-Saharan Africa have furthermore shown that discomfort during menstruation led to school absenteeism and drop-outs in adolescent girls [19,20,21]. A recent study from Ethiopia demonstrated that the provision of menstrual education and menstrual hygiene kits helped improve school attendance by girls .
A method for menstrual hygiene management, alternative to sanitary pads and tampons, is the menstrual cup. The menstrual cup is a bell-shaped device made of high-grade medical silicon, which is inserted into the vagina during menstruation. The device should be boiled once per month and can be used for 5–10 years. It collects more blood than the standard sanitary pads and is environmentally friendly with few known side effects [23,24,25]. The use of menstrual cups has been studied in countries of all income-levels [23, 24, 26,27,28,29,30,31]. In studies conducted in high-income countries, the menstrual cup was perceived as satisfactory, e.g. due to comfort, less leakage, less odor and less frequent need to change compared to tampons and sanitary pads [23, 24, 26]. Different studies conducted in low- and middle-income countries have reported the acceptability of menstrual cups among girls and women [27,28,29,30,31]. For instance, a study from South Africa showed that girls and women rated menstrual cups as significantly better for comfort, quality, menstrual blood collection and appearance . Studies reported that girls embraced the use of menstrual cups, while the uptake was slow, requiring peer support and mentoring [29, 31]. A study from Nepal showed that peers influence learning on how to use the menstrual cup but found less evidence that peers impact an individual’s desire to use it . The latter study did not analyze the acceptability and feasibility of menstrual cup use in depth. A recent systematic review and meta-analysis on the use, acceptability, safety and availability of menstrual cups stated that menstrual cups were a safe option for menstruation management .
The setting of this study is Thokarpa, a village of approximately 8000 inhabitants in Sindupalchowk, Nepal. It is located approximately 3 h travel northeast of Kathmandu. Despite its relative proximity to the capital, it is less developed, poverty is widespread and access to health care limited. The main sources of income are agriculture and/or work in the capital by a family member. Currently, a health post provides care for minor health needs, while a larger health facility is being constructed and expected to be running in 2021. There are five primary schools and two secondary schools in the village. There is one main water source in Thokarpa providing clean fresh water. Families use the water source to carry water to their homes. Yet, tap water is available in the selected school. To the best of our knowledge, evidence on the use of menstrual cups in Nepal is scarce.
A gap of context-specific evidence remains with regards to the acceptability and feasibility of using menstrual cups for menstrual hygiene management among schoolgirls in Thokarpa, Sindupalchowk, Nepal. This evidence is needed to inform local decision-making, but even to inform interventions in similar contexts across low- and middle-income countries worldwide.
This study aimed to explore the acceptability and feasibility of using vaginal menstrual cups for menstrual hygiene management among school-aged girls in Thokarpa, Sindupalchowk, Nepal. It is an exploratory study based on four focus group discussions (FGDs) with a purposive sample of 28 schoolgirls between 13 and 19 years of age who were provided with vaginal menstrual cups in Thokarpa.