Constrained Choices? Menstrual Health and Hygiene Needs Among Adolescents in Mumbai Slums

Abstract

Menstruation, an essential and healthy biological function, is cloaked in a culture of silence. Sociocultural norms at the family and community level play a pivotal role in shaping how young unmarried women understand and manage their monthly period. Less is known about how unmarried young women living in low-income urban areas in India seek help for their menstrual needs. This qualitative study seeks to understand how young unmarried women (aged 15–24) living in a slum settlement understand menstruation and perceive menstrual problems, and identifies factors that influence their help-seeking behaviour for menstrual needs and problems. It also proposes recommendations for national health programmes addressing menstrual health and hygiene.

The findings echo previous research findings emphasising young unmarried women’s low levels of awareness and misconceptions about menstruation. These girls perceived menstrual problems as a key concern, as it significantly interfered with their daily routine and caused emotional distress. Young women’s ability and willingness to seek help to address menstrual needs is influenced by a culture of silence that surrounds menstruation, excessive scrutiny and blaming by the community, and restrictions on their mobility and interactions with peers. The findings underscore the role of mothers as gatekeepers who greatly influence young women’s perceptions of menstruation and menstrual problems and their ability to seek help.

Existing interventions need to be expanded to address young women’s need for emotional and social support, and to involve significant gatekeepers such as mothers in promoting the health and well-being of young unmarried women in slum communities. Intervention strategies should be expanded to enhance the capacity of mothers to recognise, understand and address their teenage daughters’ needs for information, emotional support and access to essential clinical and social services.

Keywords

Adolescent girls mothers of adolescents slums menstruation

Introduction

Menstruation, an essential and healthy biological function, is cloaked in a culture of silence. Knowledge, attitudes, practices and the sociocultural milieu in which young women live affect their access to menstrual information, products, facilities and support. Along with access to healthcare and social policy, this shapes the ways in which girls and women understand and manage their monthly periods, with substantial implications for their physical, emotional and social well-being. Menarche, the onset of menstruation, typically occurs in India between the ages of 12 and 14 years, its timing is associated with socio-economic and nutritional factors (Bagga & Kulkarni, 2000; Dahiya & Rathi, 2010; Dambhare, Wagh, & Dhule, 2012; Diaz, Laufer, & Breech, 2006; Graham, Larsen, & Xu, 1999; Rokade & Mane, 2008; Thakre et al., 2011). In general, Indian girls start menstruating at a younger age than ever before, a finding consistent with global trends (Bagga & Kulkarni, 2000; Dahiya & Rathi, 2010; Dambhare et al., 2012; Dasgupta & Sarkar, 2008; Diaz et al., 2006; Graham et al., 1999; Nemade, Anjenaya, & Gujar, 2009).¹ Some evidence suggests that girls living in urban India may attain menarche at a slightly younger age than their rural counterparts (Dambhare et al., 2012).

Adolescent girls’ understanding of menstruation is characterised by overwhelmingly poor knowledge and erroneous beliefs about how and why it occur (Dasgupta & Sarkar, 2008; Garg, Sharma, & Sahay, 2001; Jogdand & Yerpude, 2011; Khanna, Goyal, & Bhawsar, 2005; Kumar & Srivastava, 2011; Narayan, Srinivasa, Pelto, & Veerammal, 2001; Nemade et al., 2009). Girls may have little knowledge of menstruation prior to menarche, although recent studies suggest that this may be changing (Jogdand & Yerpude, 2011; Kumar & Srivastava, 2011). Awareness of menstruation prior to its onset does not necessarily imply that girls know how to manage it as sociocultural norms shape their understanding and management of their periods (Jogdand & Yerpude, 2011; Kumar & Srivastava, 2011). Menstrual blood is often considered dirty, impure or polluting, and this deeply entrenched belief determines girls’ choice of menstrual absorbents, hygiene practices and observance of social, religious and dietary restrictions (Dasgupta & Sarkar, 2008; Deo & Ghattargi, 2005; Garg et al., 2001; Narayan et al., 2001; Nemade et al., 2009; Omidvar & Begum, 2010). Paradoxically, while girls and women are aware of and often follow these restrictions, they remain unaware of what menstruation is and why it occurs (Khanna et al., 2005; Narayan et al., 2001; Nemade et al., 2009). Girls typically learn about menstruation from their mothers, older sisters and friends, with mothers being a primary source of information (Dasgupta & Sarkar, 2008; Deo & Ghattargi, 2005; Jogdand & Yerpude, 2011; Kamath, Ghosh, Lena, & Chandrasekaran, 2013; Omidvar & Begum, 2010; Shanbhag et al., 2012; Tewari & Taneja, 2003). At or after menarche (rather than before it), they are usually told by their mothers how to manage their menstrual flow using absorbent materials and about the taboos they must observe.

Menstrual problems are among the health problems most commonly mentioned by adolescent girls and women in both urban and rural areas (Bhalchandra, Soundra, & Rajam, 1993; Dasgupta & Sarkar, 2008; Kanani, Latha, & Shah, 1994; Kumar, Verma, & Mittal, 1998; Tewari & Taneja, 2003). One-fifth of the unmarried women aged 15–24 years in urban Maharashtra reported menstrual problems (IIPS and Population Council, 2010). Among adolescent girls attending a Mumbai school, 15 per cent experienced irregular periods and 44 per cent had dysmenorrhoea (painful menstruation) (Joshi et al., 2006). Two-thirds of adolescent girls in a Delhi slum experienced dysmenorrhoea and premenstrual symptoms (Sharma, Malhotra, Taneja, & Saha, 2008).

In response to the growing evidence on the menstrual health and hygiene needs of young women, the Ministry of Health and Family Welfare, Government of India, launched the menstrual hygiene scheme under the National Rural Health Mission (NRHM) in 2010 to promote menstrual hygiene among adolescent girls aged 10–19 years. The initiative aims to bridge some of the gaps identified in the literature, including limited understanding of menstruation, and to increase the use of high-quality sanitary napkins and ensure their safe disposal after use. In 2014, the ministry announced a new adolescent health strategy, the Rashtriya Kishor Swasthya Karyakram (RKSK), to bolster the adolescent health component of the NRHM. The RKSK strategy identifies menstrual hygiene as a priority, suggests that adolescent health clinics treat menstrual disorders and proposes convergence with the menstrual hygiene scheme for health information and distribution of sanitary napkins. In 2015, the Ministry of Drinking Water and Sanitation presented the national guidelines for menstrual hygiene management (MHM) in schools, proposing a comprehensive, inter-sectoral approach to MHM programming in rural schools. These notable government initiatives centre on adolescent girls and address their influencers, such as teachers, only through training to build their capacity. Mothers, who are often the primary source of information, are left out of most programmes.

A notable gap is the lack of attention to urban adolescents. Unlike the primarily rural menstrual hygiene scheme, the RKSK intends to reach both rural and urban adolescents. However, the programme strategy is yet to articulate how the urban components will be operationalised and which urban adolescents will benefit. Attention to menstrual needs of young urban women is critical in the light of growing urbanisation in India. An estimated one-third of the population lives in cities, and by 2050 almost half of the Indians will be urban. India’s leading industrial state, Maharashtra, has among the largest number of urban residents—over 50 million—and the Mumbai Metropolitan Region accounts for a quarter of the state’s total population (Office of the Registrar General and Census Commissioner, 2001). As the country’s financial centre, Mumbai attracts migrants in search of better economic prospects, although natural growth also contributes to its increasing population. Urban migration and population growth have not been matched by effective policies or adequate investments in the city’s infrastructure.

The paucity of formal low-income housing in Mumbai and other major cities in India has led to the growth of densely populated informal settlements (slums) marked by poor-quality housing, poor availability of and access to civic amenities and an insecure tenure (Chandrasekhar, 2005; Davis, 2006; World Health Organization [WHO], 2007). Some research suggests that the characteristics of these urban neighbourhoods adversely affect the health, safety and well-being of their residents, especially women and children (Chandrasekhar, 2005; Karn & Harada, 2002; Unger & Riley, 2007; WHO, 2007). The health problems of poor urban communities are aggravated by the lack of access to basic healthcare that is widely available in cities (Sclar, Garau, & Carolini, 2005). While women living in urban areas may have better sexual and reproductive health (SRH) indicators than their rural counterparts on average, evidence suggests that the inferior health outcomes of poor urban women may be comparable with those of rural women. We know that poor married women living in deprived urban communities do have poor SRH and that unfavourable gender norms, financial constraints and limited access to health facilities further undermine their health and their ability to seek help (Ramasubban & Rishyasringa, 2008).

In Maharashtra, more girls go to school and get married older, but SRH problems and unhealthy practices often begin in adolescence and continue into adulthood (International Institute of Population Sciences [IIPS], 2007; Ramasubban & Rishyasringa, 2008). Urban, low-income communities may therefore pose risks for young unmarried women, with detrimental effects on their health in ways that are yet to be fully understood. Young women aged 15–24 years comprise one-fifth of the urban female population (IIPS, 2007; Municipal Corporation of Greater Mumbai, 2009; Ramasubban & Rishyasringa, 2008). With approximately 55 per cent of Mumbai’s population living in informal settlements, the city is considered to be the ‘global capital of slum dwelling’, and understanding the factors that shape young women’s experience of a healthy physiological phenomenon such as menstruation, as well as their response to menstrual problems, will inform government health programmes to better meet their health needs (Davis, 2006).

This qualitative study had three objectives: (a) to understand how young unmarried women (aged 15–24 years) living in an informal urban settlement understand menstruation and perceive menstrual problems, (b) to identify the factors that influence their help-seeking behaviour for menstrual needs and problems and (c) to propose recommendations for national health programmes addressing menstrual health and hygiene.

Methodology

The study site was a non-notified (that is, unrecognised by the Greater Mumbai Municipal Corporation) informal settlement in Dharavi, an agglomeration of over 90 localities in central Mumbai. The study area, henceforth referred to as RG Nagar, was about 25 years old and had a heterogeneous population of approximately 45,000 migrants from all over India. Dharavi’s residents considered it one of the poorest and most deprived neighbourhoods. Being a relatively recent settlement, R. G. Nagar lacked many of the civic amenities and infrastructure found in older neighbourhoods. The community had access to piped water, but toilet blocks were few and constructed as recently as 2010–2011. Municipal garbage bins were available at only three locations on the main road outside the area. Open and partially covered drains lined the narrow lanes, flanked by one-room tenements. The R. G. Nagar was built on the land reclaimed from the marshlands of Mahim Creek, one of the channels into which Mumbai’s sewage drained. During the monsoon season, sewage and garbage often overflowed into the community’s space.

We used qualitative methods of data collection to study how young women living in R. G. Nagar experienced menstruation and sought help for their health problems. Study participants, recruited purposively, included unmarried women aged 15–24 years living in R. G. Nagar, as well as their mothers. Two types of young unmarried women were included: school-going girls and out-of-school young women who were engaged in housework or part-time work from their homes. The average age was 17.4 years, and 38 per cent were enrolled in schools at the time of data collection. Some mothers were employed as domestic workers, a few ran their own small business in the slum and others were housewives who occasionally engaged in piecework. Three focus-group discussions (FGDs) with young unmarried women and three with mothers were conducted using a semi-structured topic guide. To encourage participation from all members and to generate a rich discussion, each FGD had at least six members and no more than 12. The FGDs informed the development of questions for subsequent in-depth interviews (IDIs). The FGDs with young unmarried women elicited local terminology and perceptions of SRH, identified potential sources of help and provided some insight into the help-seeking process. Participatory learning and action tools such as body mapping and calendar methods were used to facilitate discussion around sensitive topics. The FGDs were not used to probe individual attributes, personal experiences and behaviours. The FGDs with mothers initiated discussions on their perceptions of the menstrual needs of young women, of the need for help and sources of help available and of the family’s role in seeking help.

Semi-structured IDIs were conducted with 26 young unmarried women and 10 mothers. The interview guide for young women covered the following topics: daily routine or schedule, perceptions of sexual and reproductive health needs, perceived sources of help, factors that influenced seeking help and the process and experience of seeking help. Prompts included pubertal changes, menstruation, reproductive tract symptoms, sexual harassment, relationships, premarital sex, pregnancy and abortion. The IDI guide for mothers included questions on their perceptions of the sexual and reproductive health needs of young women (with a focus on menstrual needs), their perception of how young women address these needs, sources of help available and mothers’ role in helping their daughters. rior to the interview, a short questionnaire was used to collect demographic information (age, native language, state of origin, educational and employment status, number of years in R. G. Nagar and family size and composition) from all participants.

The FGDs and IDIs were conducted in Hindi and audio-recorded, transcribed and translated into English. Detailed field notes were also taken. The transcription was done by the author using Microsoft Word 2008 (Microsoft Corporation), and each transcript was assigned an alphanumeric code to maintain anonymity. Transcripts were transferred to NVivo version 8 (QSR International) for analysis. A conceptual framework provided themes and codes for detailed content analysis. Attribute, structured and descriptive codings were applied to the data, as well as domain and taxonomic codes and pattern coding techniques. Analytic memos were maintained.

Our underlying assumption was that help-seeking behaviour is not an individual process but results from interactions within and across individual, familial, community and structural forces. Factors external to the individual exert a subtle, indirect or strong influence at each step of the help-seeking continuum, from a young woman’s understanding of menstruation to the act of seeking and receiving help. The conceptual framework, informed by models of health and help-seeking developed by Kleinman (1980) and Barker (2007), explores how help-seeking for menstruation is influenced by individual, family and practitioner’s beliefs, perceptions and experiences of health and illness and how these processes are influenced by the sociocultural milieu in which health is experienced (refer Figure 1; Barker, 2007; Kleinman, 1980). The focus on help-seeking behaviour reflects attention to the various health-related needs of young women, including normal developmental changes (e.g., puberty), health problems and personal stress. The framework also enables exploration of the types of help or support young woman can take to meet their needs: instrumental support (e.g., clinical services), information (such as health information or education), affiliative support (like youth groups) and emotional support (from family and peers).

Figure 1.

Source: The author.

The study was approved by the Boston University Medical Centre Institutional Review Board and the multi-institutional ethics committee of the Anusandhan Trust, Mumbai. The study protocol detailed the steps to be taken to minimise potential risks to study participants, especially since many respondents were younger than 18 years, and the study addressed sensitive SRH issues. Consent was sought from parents of all the girls who agreed to participate. Interviews and FGDs were conducted in the community, at a location which the participants identified as safe. Young women were given a participant information sheet (in Hindi) which provided information about organisations they could contact if they needed health information, healthcare services or counselling.

Results

Menstrual needs emerged as a key reproductive health issue for unmarried young women in R. G. Nagar.

Menarche

For both adolescent girls and their mothers, menarche was a defining moment and one that was often associated with anxiety. Participants spoke of it in colloquial terms meaning mature and grown-up that implied sexual maturation: a worrying development for mothers, especially in a slum environment. Most of the girls attained menarche at 12–13 years and believed that later menarche indicated a deformity, an inability to become a mother later or an inadequacy as a woman. In contrast, mothers believed that girls who attained menarche at 12–13 years were too young to menstruate, saying that they had reached menarche at an older age (15–16 years), when they were physically stronger and emotionally more mature. Mothers attributed early menarche to the consumption of food contaminated by chemicals, excessive medicines, exposure to sexual stimuli through popular Bollywood films and in the community and relationships with young men. These forces created heat in the body, resulting in early menarche.

When girls eat fruits and vegetables that are ripened well before their time using chemicals, they will also ripen before they should. (Seema,² a housewife)

At menarche, mothers, older sisters and friends told girls how to manage menstrual blood, but often hesitated to provide more detailed information or lacked the knowledge to do so. Girls were often told that all women menstruate to eliminate bad or dirty blood from the body. For many living in the slum, the experience of menarche was governed by secrecy, mainly to suppress information on a girl’s sexual maturity. This supported a culture of silence around menstruation that soon became the norm for most girls. Mothers typically told their daughters about food taboos and restrictions related to menstruation and something about personal hygiene and using menstrual absorbents. The underlying message was to conceal menstruation, primarily to protect girls from unwanted attention from young men in the area. In some cases, mothers firmly told their daughters not to tell anyone that they had started menstruating and that they must go about their day as if nothing had changed. Families belonging to communities that traditionally celebrated menarche in their villages often abandoned these practices in the city as they believed that they would draw unwanted attention to their teenage daughters.

The day my daughter got her period, I told her, ‘You go on with your work as if nothing has happened.’ No one should come to know that she has started menstruating. I told her to continue doing the housework, speaking to her friends, having fun with her friends—doing all the things she did before so that no one will come to know that she has her period. I want people to see her as happy, healthy, and active. If she looks like she has menstrual cramps, everyone will know she has started menstruating. I don’t want that—it is too much stress for me. (Rekha, a mother)

In keeping with their concerns about early menarche and about cultural norms that dictated when and what girls should be told about menstruation, many mothers did not prepare their daughters, believing that they were too young and would only understand the processes when they actually experienced them. A few mothers, especially of school-going girls, believed that they should be prepared. The reason for this appeared to be the need to conceal a girl’s menstrual status, an important consideration among school-going girls who spent a considerable amount of time outside the home. With more mothers employed full-time and more girls going to school, mothers may have wanted their daughters to be prepared so that they could manage and therefore conceal menstruation when it occurred. These mothers, however, did not want to provide the information themselves, preferring older daughters or teachers to do so. The discomfort around discussing menstruation with mothers was also highlighted by girls. They rarely asked them questions and quickly realised that conversations about menstruation were considered inappropriate.

Our girls are young and have not experienced anything in life. Why tell them about periods? Girls do not have a uterus when they are young. The body starts making the uterus only after they get their first period. So whatever information you give them before they are mature, it is all lost. Their body doesn’t even have those parts, parts are still developing. How much will they understand? (Babita, a self-employed mother)

Managing Menstruation

Girls and mothers were guided by their beliefs about causation, which in turn informed the way in which they managed menstruation. Both believed that it was a normal, healthy, and necessary phenomenon, especially since bad blood was being expelled from the body.

I think periods are good for the body, so a girl should get her periods. If she doesn’t, then her body will swell up. (Sonu, an out-of-school girl, 15 years)

I do think it is very important for a girl to get her periods regularly. A woman is only complete when she gets her period. It is healthy. If a girl does not get her period, it means that her body is lacking in something. It means that there is some problem in the girl – she is inadequate in some way. (Jayanti, a mother)

Girls and mothers knew little about the menstrual cycle. Girls were often confused about where menstrual blood came from and had scant knowledge of the reproductive system. Many mothers lacked information and their understanding of menstruation may have influenced their daughters’ conception of it.

Girls’ use of menstrual absorbents was guided by what they perceived to be secure, comfortable and easy to manage in slums. On attaining menarche, mothers, sisters and friends told a girl whether to use commercially available sanitary pads or homemade cloth pads, often based on their own experiences and beliefs and on the ease of disposal. Equal numbers of girls used cloth and sanitary pads and a few used both. School-going girls were more likely to use sanitary pads, while those at home were more likely to use cloth. The need to conceal menstrual status influenced the choice of menstrual absorbent. Some preferred to use cloth as they found the disposal of sanitary pads inconvenient, embarrassing and unseemly. The lack of garbage disposal facilities in most areas made the disposal of sanitary napkins challenging and increased the chances that people would come to know about a girl’s menstrual status.

I don’t think it is easy to use pads in this slum. You have to throw used pads in the gutter outside the house. And when we do that, everyone will come to know that we have our period. People will shout that pads are being thrown in the gutter for everyone to see. So my mother—she says it is best to use cloth. Cloth stays with you. If someone sees our used pad—we have committed a sin! People will abuse you. (Karishma, an out-of-school girl, 15 years)

Girls who used cloth found it more comfortable and secure than sanitary pads, less likely to cause genital irritation and rashes and more cost-effective. Girls changed menstrual cloths 2 or 3 times a day, whereas they had to use fresh pads 4–6 times a day, believing that cloth gets less soiled than pads. Cloth was more cost-effective than pads as girls typically used old cotton sarees given to them by their mothers or grandmothers. Cloth users were aware that they should use cotton, preferably soft. While most of them washed and reused cloths, a few wrapped them in paper and disposed of them in the gutter or dustbin after a single use as they found menstrual blood dirty and were uncomfortable washing them.

Girls’ menstrual hygiene practices highlighted two issues of concern. They were aware that improper use of cloth, particularly using the same cloth for a long time or not washing it properly, could lead to infections. Those who reused cloth washed it with soap and disinfectants such as Dettol and phenyl. Second, because of the need to conceal menstruation, girls dried menstrual cloth under their other clothes, out of sight of (male) family members and passers-by. Lack of privacy and space in homes made it hard to wash and dry cloth properly.

I wash the cloth at home when no one is there. That is when I can wash it. I dry it under my other clothes. And I change cloth at home behind the curtain. (Anu, an out-of-school girl, 16 years)

Users of branded sanitary pads found them more secure (less chance of slippage and staining), more convenient to use when travelling, working, or going to school, and easier to carry. The overwhelming advantage, particularly for school-going girls, was the ease of use. Many sanitary pad users, however, found it difficult to change and dispose pads in their homes, public toilets or garbage disposal areas. Cramped living spaces and the lack of privacy to maintain menstrual hygiene were a concern.

Menstrual Problems

Unmarried girls identified menstrual problems as a key health issue. Menstruation was problematic or bothersome because of its frequency and duration, the amount of menstrual flow, painful symptoms and the extent to which it interfered with daily life. The most common problems were its frequency and pain. Regular, monthly menses were considered essential for good health, a perception consonant with the belief that menstruation rids the body of impure blood. Consequently, irregular periods caused significant stress in girls as they feared they might fall sick.

Even though my mother and my friends told me not to worry, I was scared. I have heard that if you do not get your period, the blood in your body goes bad, and the body begins to ache. (Priya, an out-of-school girl, 16 years)

An irregular menstruation was defined as a period that occurred much earlier than expected or twice in a month, a period that was delayed by a couple of months or the absence of periods for ≥ months. Girls found it difficult to manage irregular menstruation as it was unpredictable and had unpleasant and embarrassing consequences. Reasons for delayed periods, suggested by both girls and mothers, were distinctly different from reasons for frequent periods. Frequent periods were caused by eating sour food items, personal stress and hot weather, all of which increase body heat. Lack of blood and weakness might cause delayed periods. Additionally, manual labour, being overweight and pregnancy were offered as possible explanations for the absence of menstruation. Delayed or late menstruation appeared to be a more common and recurrent complaint than frequent menstruation. Girls were most concerned when they did not menstruate because of what it implied— a pregnancy due to premarital sex.

I think everyone is worried about their periods. But I think that those who do not get their periods at all are the most stressed … People are quick to misinterpret why a girl is not menstruating … they think she is pregnant. (Heena, an out-of-school girl, 15 years)

Girls believed that in a normal period, menstrual flow was heaviest on the first and second days and tapered off towards the end of the cycle. They worried when they had an exceptionally heavy or fast period, when they had very light periods or when menstrual flow was erratic. Some linked menstrual flow to the frequency of periods. For instance, if a girl menstruated twice a month the flow would be scanty, and if she menstruated once in 2 months she would experience heavy bleeding. Girls said that heavy periods were more common than scanty periods which were often caused, they believed, by delayed periods, personal and academic stress and strenuous housework.

Girls were most bothered by the discomfort they experienced before or during the period. They and their mothers believed that discomfort and pain were common and a normal aspect of menstruation, arising from their perception of menstrual blood as dirty. Despite their belief that discomfort was expected, girls were bothered by its persistence and the disruption it caused to their daily routine. The most common symptoms reported were severe menstrual cramps, lower back pain, pain in the legs and arms, fatigue and lethargy (in that order). Less common symptoms included body ache, headache, pain in the breasts, acne, loss of appetite and irritability.

About three to four days before the period starts, legs and lower back start to hurt. Then four days later, the period starts. We have some discomfort, some pain on the first two days, then it becomes okay… Lower part of stomach: that is what hurts a lot during periods. It is pain from the inside—feels like the stomach is being pulled inside. (Gayatri, a school-going girl, 16 years)

Girls’ perceptions of the severity of symptoms were influenced by their intensity: how long the symptoms lasted, the particular combination of symptoms and the extent to which they interfered with daily functioning. Subtle differences were noted in the symptoms reported by girls who were at school and girls who were not. The former were more likely to report severe menstrual pain, rarely mentioning any other accompanying symptom. Girls who did not go to school usually reported more than one symptom, the most common being menstrual cramps and lower back pain, followed by menstrual cramps and pain in the arms and legs. It appears that girls who were not at school were more bothered by a combination of symptoms than by one severe symptom, while school-going girls were bothered mostly by menstrual cramps. Many mothers and girls attributed menstrual pain to the removal of bad blood from the body and excessive pain to weakness, consumption of certain foods (raw rice and spicy food), strenuous housework, irregular menstruation and overall poor health.

During menstruation, dirty blood is thrown out of the body. Some people experience little discomfort, others experience a lot—but everyone, everyone has some degree of pain in their stomach or back. (Lalita, an employed mother)

Tension Related to Menstruation

For girls, menstruation caused tension or stress for two reasons: its sociocultural implications in the community and its impact on their daily life. Menstruation signalled sexual maturity and had different implications for girls and mothers. For girls, it was associated with limited, supervised interactions and restricted mobility. Mothers worried that their daughters would be attracted to and start relationships with young men in the area and the threats this posed to their marriage prospects.

When we grow up, our parents tell us to stay away from boys. Things really change after we start menstruating—we are not allowed to go out much; we are expected to stay at home; we are not allowed to spend much time with friends. Parents want to know where we are at all times. (Kavita, an FGD participant, girls group)

When a girl starts menstruating, a mother starts worrying about her wedding. And, of course, mothers and fathers worry about keeping their daughters safe… We need to look after our daughters a lot more…. After she starts menstruating, then we have to watch where she is going, how long she has been away, who she is with, how long she talks to this person. (Savitri, an employed mother)

Tension could also result from a girl’s perceived inability to manage menstruation or continue with her daily tasks and schedule at home or in school.

I tolerate the pain. What else can I do? If I stay home from school, they mark me absent… this is not a good enough reason to take leave…. I get very stressed. Because I have bad cramps, I have to go to the toilet repeatedly. And the teacher in school doesn’t let you go to the toilet in the middle of class, and this is very difficult for us girls who need to go to the toilet when we have our periods. This really stresses me out. (Rina, a school-going girl, 15 years)

Perceiving the Need for Help

When a girl experienced a menstrual problem, her assessment of its severity, probable cause and prevalence, as well as her mother’s perceptions, influenced her decision to seek help. Because menstrual blood is believed to be dirty, girls and mothers believed that the discomfort and pain was expected and should be borne. The perceived high prevalence of menstrual cramps also believed to be normal and did not require any particular remedy. The pressure to conceal menstruation further affected whether a girl sought help.

I don’t want to make a mountain of a molehill, so I think to myself, let the pain continue. I just sit quietly. Crying will not make the pain go away, telling my mother will not make the pain go away. I just have to go through it. (Divya, a school-going girl, 15 years)

There is never any need to go to the doctor for menstrual problems. Some pain during periods is normal. But if a girl creates such a fuss and cannot deal with period pain, what will she do when she gives birth? (Rama, a mother)

Girls and mothers considered seeking medical treatment only if the girl’s menstrual condition caused discomfort and pain so severe that it disrupted her daily routine and work, if it persisted or recurred or if the mother was worried about the long-term adverse consequences. Some mothers sought prompt treatment for their daughters’ reproductive health problems for two reasons: to deal with a condition that might later become more severe, and therefore more difficult and expensive to treat, and to circumvent any problem that might affect her ability to conceive after marriage. Alternatively, some mothers waited to see if the problem recurred before they decided to seek medical care. One mother believed that the doctor might not be able to diagnose the underlying condition unless the girl consulted him when it was serious. When girls believed that they knew the cause of the menstrual problem, they were less likely to seek help for it. For them, the solution lay not in seeking medical care but in changing the behaviour or situation that caused the problem. In some cases, girls believed that nothing could be done to address the problem. For instance, girls who broke menstrual food taboos would experience problems, while those who followed them would experience relief. Since menstrual problems were caused by weakness, lack of blood in the body and stress, they would pass when a girl got stronger, consumed nutritious food, had more blood or when a stressful event was over. Some mothers felt that menstrual problems were hereditary and that a girl should seek help if she experienced problems which her mother did not have.

Perceived Sources of Support

Mothers were gatekeepers who decided if, when and what type of information, support or treatment their daughters needed and assessed the appropriateness of the information and help that others might provide. Friends often played a more critical role than mothers, siblings, schools or organisations in extending much-needed emotional support. Friends were seen as a more stable and constant source of support than older sisters who moved away after marriage. Friends were more sympathetic and accepting than mothers, and many girls hesitated to share their personal feelings with their mothers for fear of adverse consequences in terms of restricted mobility and interactions.

Girls talk to their friends. They have limited conversations with their mother even if they have a good relationship, but they can tell their friends everything—all the details. (Nisha, a school-going girl, 16 years)

Girls shared their personal and family issues with friends, such as disagreements with parents or siblings, financial problems at home and the pressure to get married. In turn, friends were empathetic and offered advice on how to resolve issues. Discussions about reproductive health issues, however, tended to be superficial. For instance, girls simply told each other that they were menstruating or that they could not engage in certain activities like going to the temple. During FGD sessions and interactions with girls, we noted that while girls were generally very friendly, affectionate and comfortable with each other, they appeared to be more restrained and self-conscious when talking about reproductive health needs. They rarely spoke about themselves in a group setting, preferring instead to talk about reproductive health issues faced by other girls they knew. During individual interviews, girls said that they were indeed cautious about what they said to their friends for the fear of being gossiped about. A few even questioned their friends’ ability to provide them with information on menstruation because of their own limited knowledge.

Scrutinised Interactions

Mothers were aware that friends were a source of information on reproductive health issues and viewed friendships as potentially threatening. As gatekeepers, they constantly screened and restricted their daughters’ interactions with peers and others in the community. Girls’ hectic daily schedules and their mothers’ concerns about the social environment made it hard for them to spend much time with their friends. According to some girls, parents worried that friends—especially those of poor character—adversely influenced their behaviour and reputation and that girls talked about inappropriate topics such as young men and romantic relationships. Mothers firmly believed that their concerns were well-founded, saying that they had the foresight their daughters lacked, but regretted they could not watch them all the time.

I know that when girls get together they gossip and talk about useless things. I just do not like that. So I tell my girls, ‘You sit, you talk—but you sit with your sister and talk, you sit with me and talk, you sit with your best friend and talk.’ But I cannot let them sit with any friend because I know they will just gossip. (Nidhi, an FGD participant, mothers’ group)

Neighbours and other people too scrutinised girls’ interactions and passed judgements on their upbringing and lack of parental control. Despite a heterogeneous population in terms of caste, class and state of origin, parents were concerned that community gossip affected their daughters’ reputation and marriage prospects, making them even more determined to limit their daughters’ interactions with friends. Paradoxically, while girls valued friendships and leaned on their friends for emotional support, they sometimes worried about their friends’ gossiping or speaking ill of them. It appears that girls were often torn between wanting to confide in their friends and being afraid that their privacy would be violated. Some girls said that they evaluated their friends by the criterion of whom they could trust.

My friends ‘ group—I tell them maybe 50 per cent of personal things… You see, I am still trying to figure out their mentality, their attitude, and whether they will share what I tell them with others. (Monica, a school-going girl, 20 years)

Girls did not ask questions or seek clarification on sensitive issues for the fear that their friends might judge them and that this might reduce their ability to seek help from or provide help to their friends.

Perceptions of Appropriateness

Discomfort with SRH issues and perceptions of what was appropriate may have affected girls’ willingness to seek, provide and receive relevant information, as well as support for their needs. Appropriateness may be understood in terms of the content of the information provided, who provided it, support or treatment and the age of the girl receiving the information. Mothers had mixed feelings about schools providing their daughters with information on SRH. They appreciated the candid manner in which it was imparted but were uncomfortable with the level of detailing their daughters get before marriage. Echoing their mothers, some girls found the information provided in schools inappropriate. They saw asking questions and receiving information about SRH from a friend or an older woman such as their mothers, teachers or NGO workers as embarrassing and even disrespectful.

I really think it’s important that schools provide girls with information so openly…. I think openness and honesty about these issues are very important …. But my problem with these sessions is that they tell girls about sex and pregnancy before marriage. Girls should learn about these things only after marriage…. I feel odd that my daughter was given this information in such an open manner. This is not correct! (Pratibha, an employed mother)

The teacher was showing us how babies are made. I didn’t like that she was showing us these things so openly. So I told her that it was not right for her to be so open about these things. (Kiran, an out-of-school girl, 20 years)

Choosing a Healthcare Provider

If girls decided to seek treatment from healthcare providers, they had the option of going to private providers who operated from small local clinics or to government health facilities. Their choice was guided by their perceptions of the availability, accessibility, acceptability and quality of care. Residents typically sought treatment from local private healthcare providers for minor ailments such as cough, cold, headache, fever and stomach disorders. They were more likely to use government healthcare services—those are 30 minutes’ walk away—for serious ailments that required hospitalisation or surgery, as well as for antenatal care and delivery. If girls sought treatment for menstrual problems, they preferred private providers to the local government health facilities. The perceived proximity of private healthcare facilities was particularly advantageous when they required immediate assistance.

The government hospitals are too far. If a girl has severe period pain, she cannot waste time going to the government hospital. We will go to the private doctor nearby. (Bhanu, a mother)

Girls, both in and out of school, found the evening consultation hours at private clinics more convenient than the morning timings of out-patient departments (OPD) at government health facilities. These hours were also convenient for working mothers who accompanied their daughters, as they came home from work late in the evening. Government health facilities were inconvenient for another reason: clients often had to make repeated visits. Girls and their mothers found this difficult, given their school and work schedules and their household responsibilities and the distance of the facility from their area and the associated travel costs.

Mothers were more likely to take their daughters to healthcare facilities with which they were familiar and comfortable. Some preferred government hospitals as they were acquainted with the doctors and procedures there. Others favoured their private family doctor. The government health facilities were undoubtedly more affordable than private clinics in terms of consultation fees, diagnostic tests and medicines, but this advantage are offset by the costs associated with the repeated visits and missed schooldays or workdays. Private healthcare providers tended to be more expensive, yet girls consulted them believing that they would get better quality treatment. They felt uncomfortable and self-conscious in government facilities due to long waits and consultation rooms where clients lacked privacy, and in private clinics they disliked waiting rooms that opened onto the main road.

Both girls and mothers said that private healthcare providers offered prompt and good quality treatment and recommended tablets or injections based on clients’ preference and their ability to pay. Perhaps most valuable, especially for mothers, was the relationship that private providers established with their clients. Family doctors were familiar with people’s health problems, as well as the family’s situation, particularly its financial condition. Many girls and mothers mentioned that private healthcare providers spoke well with their clients, fully explaining the condition or ailment and the treatment to be taken. One mother said that providers who had been operating in the area for a number of years understood their living conditions and offered advice accordingly.

The most significant hurdle that girls faced in seeking healthcare for menstrual problems was the scarcity of female healthcare providers. All the private healthcare providers around the study site and most of them in the wider surrounding area were male. Female providers were available but were few and often located at a distance. Girls expressed inhibition when talking to a male provider and were particularly uncomfortable when he examined them or administered an injection. Many mothers shared this discomfort. Girls acknowledged that both male and female providers were well-trained and possessed the same medical knowledge and skills, but they could not share their personal health problems with a male provider in the same way they could with a female provider. For both girls and mothers, a female healthcare provider was more likely to understand a reproductive health problem.

I like lady doctors. I can talk to them openly about my body and not be embarrassed. I can talk about my chest area or my genitals and not be embarrassed. They can understand what the problem is because they are women, too. (Swati, a school-going girl, 16 years)

Discussion

The culture of silence surrounding menstruation shapes how young unmarried women living in urban, informal and low-income neighbourhoods experience their monthly periods and seek information, emotional support or treatment. Stress or tension was common among these young women yet rarely recognised and addressed. This tension was exacerbated by unsupportive responses from mothers and the larger community. Lacking information about the reproductive system and menstruation, young women erroneously believed that menstruation was the expulsion of impure blood from the body, a belief that affected how they managed it and responded to the related problems. Girls were often ill-prepared, because their mothers believed that they were too young and inexperienced to deal with the information before menarche. Girls neither asked for nor received much information about menstruation, apart from how to manage menstrual flow and the attendant dietary, religious and social restrictions. Through their own beliefs and behaviour, mothers communicated that menstruation was an event that should be concealed.

Silence and embarrassment or shame related to menstruation is found in other South Asian and African countries, as well as among adolescents in developed nations, and influences their attitudes and behaviours (Ali & Rizvi, 2010; Dixon-Mueller & Wasserheit, 1991; Guterman, Mehta, & Gibbs, 2007; Nwankwo, Aniebue, & Aniebue, 2010; Simes & Berg, 2001). The pivotal role of mothers in perpetuating this culture of silence was a key finding. While they believed that they were protecting their daughters, they limited their daughters’ understanding of menstruation and mediated their access to the information, support and services they needed to protect and promote their health and to help each other. The inability to seek and receive accurate and comprehensive information, emotional support and social and clinical services has implications for a girl’s menstrual health in terms of her ability to manage regular menstruation, maintain personal and menstrual hygiene to protect herself from infections and seek appropriate help treating menstrual problems in a timely manner.

Young women’s practices suggested that they were aware of the importance of menstrual hygiene, yet they placed themselves at the risk for reproductive tract infections through suboptimal behaviours. The risk is potentially exacerbated by the physical and social environment: cramped living spaces, lack of privacy and poor access to toilet and garbage disposal facilities affected their ability to practise personal and menstrual hygiene (Poureslami & Osati-Ashtiani, 2002). In addition to the immediate health effects of poor menstrual hygiene, Koenig et al. suggest that unsafe practices during adolescence might persist into adulthood, placing adult women at increased risk of reproductive tract infections and sequelae such as pelvic inflammatory disease, adverse pregnancy outcomes and even infertility (Keonig, Jejeebhoy, Singh, & Sridhar, 1998).

Erroneous beliefs about menstruation extended to menstrual problems, the most common being the irregularity and pain. Misconceptions about causation and the severity of symptoms influenced whether and from where girls sought help. Mothers’ perceptions that menstrual discomfort and pain were normal might have affected girls’ perceptions of the need for an intervention. In general, mothers felt the need to seek help when they believed the condition would adversely affect their daughters’ future fertility. Menstrual problems, while not being life-threatening, have important social and health implications for young women. The unpredictability of irregular menstruation and heavy bleeding are difficult to manage and can cause embarrassment, leading girls to miss school or discontinue education, especially when they lack access to adequate sanitary protection and toilet facilities (Ali & Rizvi, 2010; Sommer, 2010). Dysmenorrhoea or painful menstruation can interfere with daily work and productivity, and in some cases it might be a sign of an underlying pathology such as endometriosis or pelvic infection. Studies in Pakistan and Africa report that girls missed school and even discontinued their education because of debilitating menstrual pain (Ali & Rizvi, 2010; Sommer, 2010). Amenorrhoea (the absence of menstruation) and irregular menstruation with heavy bleeding may be symptomatic of an underlying disorder like polycystic ovarian syndrome (PCOS; Nidhi, Padmalatha, Nagarathna, & Amritanshu, 2011). Undiagnosed and untreated PCOS can exacerbate anaemia and lead to infertility, diabetes, hypertension, heart diseases and endometrial cancer in adult women (Nidhi et al., 2011). Irregular menstruation may also be symptomatic of uterine fibroids and RTIs (Reproductive tract infections).

Girls turned primarily to their mothers and also to their friends for information and support and consulted local private healthcare providers for menstrual problems. However, their ability to get help was restricted: they had limited opportunities to spend time with their friends, and when they were able to share their problems they worried that their friends would judge them or break their trust; girls and their mothers had strong ideas about the appropriateness of the kind of information and assistance needed and sources of help available. Moreover, the availability and accessibility of female healthcare providers was a significant barrier to accessing treatment. A girl’s experiences of interacting and receiving help, relief from symptoms and favourable health outcomes may in turn shape her beliefs about menstruation and her perceptions of causation and severity, sources of help and barriers and facilitators to seeking remedies. These findings are in line with the research on sexual and reproductive health morbidity in married Indian women and suggest that the culture of silence around menstruation persists into adulthood, affecting women’s sexual and reproductive health in the long run. Ramasubban and Rishyasringa (2008) found that married women living in a Mumbai slum sought treatment for menstrual problems, abnormal vaginal discharge, lower back pain and weakness only when they experienced multiple problems simultaneously or when they interfered with their daily chores or work. Their decision to seek treatment, like the girls and mothers in the present study, was also influenced by ‘culturally prevailing notions of normalcy and pathology’ (Ramasubban & Rishyasringa, 2008, p. 232). Unfavourable gender norms, stigma related to the problem, family support (particularly from husbands and mothers-in-law), financial constraints and limited access to health facilities compound their reluctance to seek help (Barua & Kurz, 2001; Garg et al., 2001; Ramasubban & Rishyasringa, 2008).

A limitation of this study was the use of purposive sampling to recruit participants, especially unmarried young women. Only those who were willing and able to participate were included, and young women who had little freedom of movement and whose interactions with outsiders were limited by parents were unable to participate. Their narratives may have provided further insights into how they address their SRH needs, given the severe constraints they experience. The lack of a clinical diagnosis of menstrual problems identified by girls makes it difficult to ascertain the need for a clinical or medical intervention to address them. The study would also have benefitted from key informant interviews with government officials to better understand how their initiatives can respond to the menstrual health needs of girls living in underserved urban areas.

Conclusion

Findings highlight the role of mothers as gatekeepers who influence their daughter’s perceptions of menstruation and girls’ ability to seek help, with narratives of each participant group pointing to the pivotal role these women played in their daughters’ lives. The NGO staff stated that one of the programmatic challenges they faced was convincing mothers to allow their daughters to participate in NGO programmes and activities on health promotion. Likewise, healthcare providers said that a mother had a say in whether her daughter should seek treatment for her menstrual problem and adhered to the prescribed treatment regimen. In addition, mothers themselves had partial and incorrect knowledge about menstruation, held strong beliefs about preparing daughters for puberty, providing them with information about SRH issues (such as menstruation, sex and pregnancy), giving them access to sources that can provide such information and seeking treatment for menstrual problems. For these reasons, intervention efforts are needed that involve mothers in improving the sexual and reproductive health of girls living in slums.

These findings underscore the need for multilevel and multipronged interventions that respond to the culturally based concepts of health, illness and help seeking. Health interventions reaching adolescents and young women need to strengthen components related to health education, healthcare services, community outreach and infrastructure concerning menstruation or menstrual hygiene. Concurrently, interventions must have a component that is directed at influencers or gatekeepers such as mothers, healthcare providers and the wider community to create an environment that engenders healthy attitudes and practices related to menstruation. Here, influencers/gatekeepers should not be seen only as those who can provide information to girls but also as groups that require education and support themselves to overcome the deep set social norms on menstruation. Health education or promotion activities with girls and their mothers must provide information on the reproductive health system, why and how menstruation occurs, how to maintain menstrual hygiene, the use of hygienic cloth or sanitary napkins and common menstrual problems. These activities can also facilitate critical reflection on the underlying sociocultural norms that shape women’s experiences of menstruation and how harmful norms may be challenged and changed at home and in the community. At the household and community levels, community-wide and mass media activities can contest inequitable norms and foster supportive attitudes and healthy practices related to menstruation, especially among mothers. Equipped with information on how to manage their periods, girls need infrastructure that will enable them to maintain menstrual hygiene. Access to water, safe toilet facilities and viable disposal mechanisms will help them. Finally, sensitisation of male and female healthcare providers who treat menstrual problems is critical. Healthcare providers need to be informed of the clinical aspects of common menstrual problems among girls and equipped with skills to elicit sensitive information from clients about their experiences and problems. The RKSK is an ideal platform to reach adolescents, their mothers and healthcare providers, given its focus on empowered as well as strengthened healthcare services for young people.

Footnotes

Acknowledgements

The author would like to thank Dr William Dejung (Boston University), Dr David Osrin (University College London), all staff at SNEHA Mumbai and residents of R. G. Nagar in Dharavi.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author received no financial support for the research, authorship and/or publication of this article.

Notes

References

Ali

T. S.

, & Rizvi

S. N.

(2010). Menstrual knowledge and practices of female adolescents in urban Karachi, Pakistan. Journal of Adolescence, 33(4), 531–541.

Bagga

, & Kulkarni

(2000). Age at menarche and secular trend in Maharashtrian (Indian) girls. Acta Biologica Szegediensis, 44(1–4), 53–57.

Barker

(2007). Adolescents, social support and help-seeking behavior: An international literature review and program consultation with recommendations for action (WHO Discussion Papers on Adolescence). Geneva: WHO.

Barua

, & Kurz

(2001). Reproductive health-seeking by married adolescent girls in Maharashtra, India. Reproductive Health Matters, 9(17), 53–62.

Bhalchandra

, Soundra

, & Rajam

(1993). Gynecological problems in adolescents. Journal of Obstetrics and Gynecology India, 43, 599–604.

Chandrasekhar

(2005). Growth of slums, availability of infrastructure and demographic outcomes in slums: Evidence from India. Population Association of America Annual Meeting. Silver Spring, MD: Population Association of America.

Dahiya

, & Rathi

V. K.

(2010). Relationship between age at menarche and early-life nutritional status in India. British Journal of Sports Medicine, 44(Suppl. 1), 143.

Dambhare

, Wagh

, & Dhule

(2012). Age at menarche and menstrual cycle pattern among school adolescent girls in Central India. Global Journal of Health Science, 4(1), 105–111.

Dasgupta

, & Sarkar

(2008). Menstrual hygiene: How hygienic is the adolescent girl? Indian Journal of Community Medicine, 33(2), 77–80.

10.

Davis

(2006). Planet of slums. London and New York, NY: Verso.

11.

Deo

, & Ghattargi

(2005). Perceptions and practices regarding menstruation: A comparative study in urban and rural adolescent girls. Indian Journal of Community Medicine, 30(1), 33–34.

12.

Diaz

, Laufer

, & Breech

(2006). Menstruation in girls and adolescents: Using the menstrual cycle as a vital sign. Pediatrics, 118(5), 2245–2250.

13.

Dixon-Mueller

, & Wasserheit

(1991). The culture of silence: Reproductive tract infections among women in the Third World. New York, NY: International Women’s Health Coalition.

14.

Garg

, Sharma

, & Sahay

(2001). Socio-cultural aspects of menstruation in an urban slum in Delhi, India. Reproductive Health Matters, 9(17), 16–25.

15.

Graham

, Larsen

, & Xu

(1999). Secular trend in age at menarche in China: A case study of two rural counties in Anhui Province. Journal of Biosocial Science, 31(2), 257–267.

16.

Guterman

, Mehta

, & Gibbs

(2007). Menstrual taboos among major religions. The Internet Journal of World Health and Societal Politics, 5(2), 1–7.

17.

International Institute of Population Sciences (IIPS) (2007). National family health survey (NFHS-3), 2005–06. Mumbai: International Institute of Population Sciences.

18.

International Institute of Population Sciences (IIPS) (2010). Youth in India: Situation and Needs 2006–2007. Mumbai: IIPS.

19.

Jogdand

, & Yerpude

(2011). A community-based study on menstrual hygiene among adolescent girls. Indian Journal of Maternal and Child Health, 13(3), 2–6.

20.

Joshi

B. N.

, Chauhan

S. L.

, Donde

U. M.

, Tryambake

V. H.

, Gaikwad

N. S.

, & Bhadoria

(2006). Reproductive health problems and help seeking behavior among adolescents in urban India. Indian Journal of Pediatrics, 73(6), 509–513.

21.

Kamath

, Ghosh

, Lena

, & Chandrasekaran

(2013). A study on knowledge and practices regarding menstrual hygiene among rural and urban adolescent girls in Udupi Taluk, Manipal, India. Global Journal of Medicine and Public Health, 2(4), 1–9.

22.

Kanani

, Latha

, & Shah

(1994). Applications of qualitative methodologies to investigate perceptions of women and health practitioners regarding women’s health disorders in a Baroda slum. In Gittelsohn

, Bentley

M. E.

, Pelto

P. J.

, Nag

, Pachauri

, Harrison

A. D.

, & Landman

L. T.

(Eds.), Listening to women talk about their health: Issues and evidence from India (pp. 116–130). New Delhi: Har-Anand Publications.

23.

Karn

S. K.

, & Harada

(2002). Field survey on water supply, sanitation and associated health impacts in urban poor communities: A case from Mumbai City, India. Water Science & Technology, 46(11), 269–275.

24.

Keonig

, Jejeebhoy

, Singh

, & Sridhar

(1998). Investigating women’s gynaecological morbidity in India: Not just another KAP survey. Reproductive Health Matters, 6(11), 84–97.

25.

Khanna

, Goyal

, & Bhawsar

(2005). Menstrual practices and reproductive problems. Journal of Health Management, 7(1), 91–107.

26.

Kleinman

(1980). Patients and healers in the context of culture: An exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley, CA: University of California Press.

27.

Kumar

, & Srivastava

(2011). Cultural and social practices regarding menstruation among adolescent girls. Social Work in Public Health, 26(6), 594–604.

28.

Kumar

, Verma

, & Mittal

(1998). Gynecological disorders in girls less than 20 years of age. Journal of Obstetrics and Gynecology India, 48(1), 61–63.

29.

Municipal Corporation of Greater Mumbai (2009). Mumbai human development report 2009. Oxford: Oxford University Press.

30.

Narayan

, Srinivasa

D. K.

, Pelto

P. J.

, & Veerammal

(2001). Puberty rituals, reproductive knowledge and health of adolescent schoolgirls in South India. Asia Pacific Population Journal, 16(2), 225–238.

31.

Nemade

, Anjenaya

, & Gujar

(2009). Impact of health education on knowledge and practices about menstruation among adolescent school girls of Kalamboli, Navi-Mumbai. Health and Population: Perspectives and Issues, 32(4), 167–175.

32.

Nidhi

, Padmalatha

, Nagarathna

, & Amritanshu

(2011). Prevalence of polycystic ovarian syndrome in Indian adolescents. Journal of Pediatric and Adolescent Gynecology, 24(4), 223–227. doi: 10.1016/j.jpag.2011.03.002.

33.

Nwankwo

T. O.

, Aniebue

U. U.

, & Aniebue

P. N.

(2010). Menstrual disorders in adolescent school girls in Enugu, Nigeria. Journal of Pediatric and Adolescent Gynecology, 23(6), 358–363. doi: 10.1016/j.jpag.2010.04.001.

34.

Office of the Registrar General and Census Commissioner (2001). A-series tables: General population tables. New Delhi: Office of the Registrar General and Census Commissioner, Government of India. Retrieved from http://www.censusindia.gov.in/Census_Data_2001/Census_data_finder/A_Series/Urban_population.htm

35.

Omidvar

, & Begum

(2010). Factors influencing hygienic practices during menses among girls from south India: A cross sectional study. International Journal of Collaborative Research on Internal Medicine & Public Health, 2(12), 411–423.

36.

Poureslami

, & Osati-Ashtiani

(2002). Attitudes of female adolescents about dysmenorrhea and menstrual hygiene in Tehran suburbs. Archives of Iranian Medicine, 5(4), 219–224.

37.

Ramasubban

, & Rishyasringa

N. S.

(2008). Treatment-seeking for gynecological problems by women in Mumbai slums. In Koenig

, Cleland

& Jejeebhoy

S. J.

(Eds.), Reproductive health in India: New evidence (pp. 227–251). New Delhi: Rawat Publications.

38.

Rokade

, & Mane

(2008). A study of age at menarche, the secular trend and factors associated with it. The Internet Journal of Biological Anthropology, 3(2), 1–7.

39.

Sclar

E. D.

, Garau

, & Carolini

(2005). The 21st century health challenge of slums and cities. Lancet, 365(9462), 901–903.

40.

Shanbhag

, Shilpa

, D’Souza

, Josephine

, Singh

, & Goud

B. R.

(2012). Perceptions regarding menstruation and Practices during menstrual cycles among high school going adolescent girls in resource limited settings around Bangalore city, Karnataka, India. International Journal of Collaborative Research on Internal Medicine & Public Health, 4(7), 1353–1362.

41.

Sharma

, Malhotra

, Taneja

D. K.

, & Saha

(2008). Problems related to menstruation amongst adolescent girls. Indian Journal of Pediatrics, 75(2), 125–129.

42.

Simes

M. R.

, & Berg

D. H.

(2001). Surreptitious learning: Menarche and menstrual product advertisements. Health Care for Women International, 22(5), 455–469. doi: 10.1080/073993301317094281.

43.

Sommer

(2010). Putting menstrual hygiene management on to the school water and sanitation agenda. Waterlines, 29(4), 268–278.

44.

Tewari

, & Taneja

(2003). Reproductive health education: Experiences of Parivar Sewa Sanstha in communicating with youth in India. In Bott

, Jejeebhoy

, Shah

& Puri

(Eds.), Towards adulthood: Exploring the sexual and reproductive health of adolescents in South Asia (pp. 174–177). Geneva: World Health Organization.

45.

Thakre

S. B.

, Thakre

S. S.

, Reddy

, Rathi

, Pathak

, & Ughade

(2011). Menstrual hygiene: Knowledge and practice among adolescent school girls of Saoner, Nagpur district. Journal of Clinical and Diagnostic Research, 5(5), 1027–1033.

46.

Unger

, & Riley

L. W.

(2007). Slum health: From understanding to action. PLoS Medicine, 4(10), 1561–1566.

47.

World Health Organization (WHO) (2007). Our cities, our health, our future: Acting on social determinants for health equity in urban settings. Report to the WHO Commission on Social Determinants of Health from the Knowledge Network on Urban Settings. Kobe: WHO Kobe Centre.