Displaced girls and women face a range of gendered challenges living in humanitarian contexts, including issues related to managing their menstruation safely, privately, and with dignity. Specific barriers identified across contexts include a lack of access to menstrual materials and supplies, safe and private toilets, and menstrual health information. Despite growing efforts by humanitarian organizations to address the menstruation-related needs of displaced populations, key aspects related to the maintenance of menstrual materials, including disposal and laundering, continue to be overlooked. This qualitative assessment was conducted in Northeast Nigeria with female Internally Displaced Persons aged 15–49 years (n = 70) and humanitarian response staff (n = 11). Findings indicate inconsistent access to menstrual materials and supplies, including items required for the routine cleaning of reusable menstrual materials. Additionally, many respondents highlighted insufficient access to menstruation-supportive toilets, including a lack of disposal options and poor lighting. Challenges with being able to discreetly launder reusable menstrual materials was problematic, leading some to adopt coping strategies such as constructing makeshift washrooms. Moving forward, more attention should be directed towards ensuring that the full spectrum of menstrual-related needs of girls and women are addressed, including improved water, sanitation and hygiene (WASH) facility design and programming that considers the practical implications of menstrual material maintenance.
Menstruation programming often overlooks the practical tasks related to the maintenance of menstrual materials, including disposal and laundering.
Displaced girls and women experience inconsistent access to menstrual maintenance supplies like soap and water.
Insufficient menstruation-supportive toilets may lack gender segregation, lighting, and disposal options, which can cause anxiety and discomfort for users.
Of the 29 million people forcibly displaced across Africa due to conflict and political repression, 72% are internally displaced within their own countries (Africa Center for Strategic Studies 2021). This includes the over 2.5 million Internally Displaced Persons (IDPs) living in northern Nigeria (Africa Center for Strategic Studies 2021). Women and adolescent girl IDPs in camps and informal settlements face many gendered challenges in relation to their ability to manage their monthly menstruation comfortably, privately, and with dignity (VanLeeuwen & Torondel 2018b). Key barriers include inadequate access to menstrual materials (e.g., pads and cloth), menstruation information, and female-friendly toilets; the latter referring to appropriately designed sanitation facilities for the changing and disposing of menstrual materials (Schmitt et al. 2018; VanLeeuwen & Torondel 2018b). Insufficient supplies of menstrual materials can pose daily challenges, including heightened risks for stained clothing, emanating odors, or chafing from damp materials, especially when walking long distances, attending school, or conducting farm work (Akongo 2018; Majed & Touma 2020). Menstrual stains on clothing, in particular, may also heighten experiences of embarrassment and the likelihood of peer teasing (Benshaul-Tolonen et al. 2020). Water, sanitation, and hygiene (WASH) facilities in displacement camps often lack sufficient locks, doors, lighting, and effective gender segregation (VanLeeuwen & Torondel 2018b). Poor access to female-friendly facilities is also associated with girls and women experiencing shame (Massey 2011), anxiety (Bisung & Elliott 2016), and a heightened risk for gender-based violence (Corburn & Hildebrand 2015).
In recent years, the humanitarian field has demonstrated a growing commitment towards addressing the menstrual hygiene management (MHM) needs of displaced girls and women. This includes a rise in guidelines, research, and programming addressing MHM issues in emergencies (Sommer et al. 2018; VanLeeuwen & Torondel 2018b; Farrington 2019; IFRC 2021). Existing guidance highlights the need to focus on three main MHM priorities: (1) menstrual materials and supplies; (2) menstrual health and hygiene (MHH) education; and (3) MHM-supportive WASH facilities (Sommer et al. 2018). Although MHM-supportive WASH facilities are often still inadequately provided, reports suggest an improved distribution of menstrual materials and supplies (e.g., soap and buckets) (IFRC 2021). Reusable menstrual materials have gained popularity in emergencies, given their sustainability benefits (VanLeeuwen & Torondel 2018b). Finally, the provision of MHH education has been increasingly incorporated into emergencies, often in combination with material distributions (Giles-Hansen et al. 2019).
With increased and more regular distributions of menstrual materials, girls and women must conduct the practical tasks necessary for taking care of them (see Figure 1). This includes both the ability to launder reusable menstrual materials and underwear, and to dispose of used menstrual waste (disposable and reusable items, in time). Girls and women also require hygienic storage solutions for stowing reusable menstrual materials in between changings or menstrual cycles. Widespread, ongoing menstrual stigma complicates these activities. For those laundering reusable materials, extra efforts are undertaken to ensure no one sees them washing or drying their used menstrual materials; such as the widely documented practice of hiding menstrual materials underneath clothing or ‘kangas’ while on drying lines (Robinson & Barrington 2021). Menstrual disposal creates complexity, given strong cultural beliefs around menstrual blood. In some contexts, girls and women have disclosed fears about risks of infertility or diseases from the burning of menstrual waste (Umeora & Egwuatu 2008) or worries about witchcraft if these materials are seen or taken by others (Downing et al. 2020). Menstrual disposal solutions, however, are rarely integrated into female-friendly toilets in emergencies. An absence of disposal options leads many girls and women to discard used menstrual products through burying, burning, or dropping them directly into toilets (Schmitt et al. 2017, 2021; Elledge et al. 2018). Informal disposal practices can create environmental hazards or reduce toilet capacity, including clogged pipes and difficulties emptying cesspits and septic tanks (Elledge et al. 2018).
|FGDs .||7 FGDs conducted .|
|Total FGDs||70 women and girls|
|KIIs with staff||11 key informants|
|Infrastructure visits||3 camps|
|FGDs .||7 FGDs conducted .|
|Total FGDs||70 women and girls|
|KIIs with staff||11 key informants|
|Infrastructure visits||3 camps|
This paper shares learning from a project focused on generating evidence for menstrual material maintenance-related difficulties found in emergencies. The aim was to fill an identified gap in the MHM response literature and guidance around menstrual disposal and laundering of reusable menstrual materials (Sommer et al. 2016). Assessments were conducted in three emergency settings: Nigeria, Jordan, and Bangladesh (Schmitt et al. 2021), with this paper highlighting learning from IDP camps in Northeast Nigeria around the need for improved evidence on the menstrual disposal and laundering practices of displaced girls and women.
A qualitative assessment was conducted in IDP camps within and near Maiduguri, Borno State, Nigeria, in 2019. The aim was to examine how displaced girls and women were managing their MHM needs, with an emphasis on menstrual disposal and laundering practices and challenges. The research also explored to what extent humanitarian responders were addressing MHM. The assessment captured learning directly from female IDPs and response staff, including international and local non-governmental organization (NGO) workers across management levels.
Over 2.5 million Nigerians have been displaced in Northeast Nigeria due to Boko Haram and the Islamic State in West Africa (Africa Center for Strategic Studies 2021). While many of the displaced now live in IDP camps supported by humanitarian actors, larger numbers live outside the formal camp structures in small informal settlements or in host communities. Research activities took place in the Bakassi, Konduga, and Teacher's Village (TV) camps located in or nearby Maiduguri, the capital and largest city of Borno State. Bakassi and Konduga Camps included tent and semi-permanent shelter structures served by communal tap stands, and blocks of communal toilets and bathing spaces. TV Camp consisted of makeshift shelters and homes built inside existing infrastructure from an incomplete Teacher's College dormitory. Some of the IDPs had lived in the camps for several years, while others had arrived in recent weeks. Sanitation access, as reported by UN monitoring data, varied by camp, ranging from approximately 14 persons per latrine stall in Bakassi camp (OCHA 2020) to more than 100 persons per latrine stall in TV camp (OCHA 2019). Intermittent violence in the region created a transient dynamic in the camps, as some displaced families would periodically return to their homes (Africa Center for Strategic Studies 2021).
Research design and methods
The qualitative assessment included a global desk review and three types of data collection methods: (1) key informant interviews (KIIs) with the NGO and the UN Agency Staff, (2) focus group discussions (FGDs) with IDP adolescent girls and women, and (3) direct observations of WASH infrastructure.
Sample and recruitment
The sample (see Table 1) included a range of cross-sectoral humanitarian staff (male and female) and IDP girls and women. Key informants (n = 11) were sampled purposively, with a focus on WASH and protection actors involved in designing and implementing MHM programming. The sample for the FGDs included adolescent girls and women between the ages of 15 and 49 years to capture those who are most likely menstruating. The FGDs were stratified into three age groups (15–18; 19–25; and 26–49 years) to increase the comfort and participation of girls and women. Purposive sampling was utilized to identify girls and women living in a diversity of camp contexts (e.g., newer and older tents, informal housing), with NGOs operating in the camps facilitating the recruitment.
The findings discussed in this paper are drawn from data collected across three different sources:
KIIs: Semi-structured interview guides were utilized with international and local NGOs, UN agencies, and private sector staff (e.g., desludging operators) from various sectors (WASH, Reproductive Health, Shelter). The guide sought to capture perspectives on strategies and challenges with providing an MHM response in the camps in and surrounding Maiduguri, with a particular focus on issues related to menstrual waste disposal and laundering.
FGDs: Semi-structured FGD guides examined girls’ and women's experiences with managing their menstruation in the camps and challenges with WASH facilities and the laundering and disposal of menstrual materials.
Direct observations of WASH infrastructure: The research team also conducted a series of environmental observations of formal and informal WASH facilities, which included taking photos and documenting various hardware and software design aspects.
Data collection occurred over a 2-week period in April 2019. The research team included two female staff from BLINDED and one male staff from BLINDED. FGDs were conducted in confidential settings with a local female translator who was trained on the importance of confidentiality. FGDs were conducted in Hausa with the two female research staff and the translator present. KIIs were conducted in English with all or some research staff (male and females) present. To ensure the comfort of participants, FGDs were not tape-recorded. Prior to commencing data collection, all FGD participants provided oral informed consent, and KII participants provided written consent. Careful notetaking was conducted by two team members, including capturing both verbal and non-verbal reactions to create FGD and KII transcripts. All KIIs were conducted in program offices and worksites in and around Maiduguri.
All study procedures were approved by the Columbia University Medical Center Institutional Review Board and the National Health Ethics Committee of Nigeria.
A three-person research team reviewed all qualitative transcripts (KII and FGDs). The data were then analyzed using Malterud's ‘systematic text condensation,’ an explorative and descriptive thematic analysis method (Malterud 2012). Key themes identified were then shared with the larger research team for further validation, discussion, and consensus.
Three key thematic areas emerged from the analysis, including (1) inadequate access to menstrual materials and supplies; (2) insufficient MHM-supportive toilets and disposal options; and (3) menstrual-related laundering issues and coping strategies.
Inadequate access to menstrual materials and supplies
Adolescent girls and women indicated using three types of menstrual materials after displacement: pieces of cloth, disposable menstrual pads, and reusable menstrual pads. The latter two were generally acquired from NGO distributions, which had become a source of materials dependency. Prior to displacement, most girls and women indicated using cloth as their primary menstrual material. Many girls and women indicated high levels of acceptance of both disposable and reusable menstrual pads as they provided improved protection from bloodstains when compared to cloth. As one adolescent girl described: ‘the piece of cloth, if you are not careful, it will even fall off if you are playing rough… but the reusable pad is secure once you use the bottom fastener.’ Both reusable and disposable pads were directly attached to underwear, which ensured they were less likely to shift when girls and women were active throughout the day. The usefulness of these pads, however, was reliant on the availability of underwear, which was not always provided alongside menstrual materials. One adolescent girl described this predicament: ‘many of us had to buy underwear [in order to use the pads] … but we didn't have enough money.’ Such findings underscore the importance of consulting girls and women prior to distributions to identify their full range of MHM needs.
The majority of NGOs were distributing reusable pads. However, both the number of pads provided and the distribution schedule were described as challenging by some IDPs. Variance in blood flow was one reason, as some girls and women experienced heavier bleeding. One IDP woman described her own challenges with reusable pads: ‘it is not enough … you need to change at regular intervals depending on your flow … so three [reusable pads] is just not enough.’ Given that each reusable pad needed to be washed and dried prior to reuse, many girls and women indicated lacking sufficient time to complete these tasks between wears, especially during the rainy season. In response, girls and women supplemented reusable pads with pieces of cloth.
The consequences of insufficient menstrual protection, which were heightened for those using cloth, included girls’ and women's anxiety around the potential staining of clothing or poor odors. Both occurrences were described as embarrassing and stressful, as such events disclosed their menstrual status to others. Some women described that the ramifications of such a disclosure would mean being forbidden to cook or socialize: ‘if a woman cannot take care of herself well enough … if she lets stains be seen, then they won't let her handle the cooking utensils.’ Many women described the increased shame that they experienced if males became aware of their menstruating status.
Numerous respondents noted challenges related to maintaining menstrual materials, given the unreliable access to MHM-supportive supplies such as soap or laundry detergent. Both items were provided during NGO distributions but were described as inconsistently available. As a result, some girls and women described washing or soaking their pads solely in water, scrubbing out as much blood as possible. This often proved inadequate, however, as one woman explained: ‘the smell is sometimes still there … but there is no alternative.’ Other women described trying alternative approaches such as using salt water or ash. Some adolescent girls, frustrated by the odors, described throwing away their reusable pads in the event of soap shortages. One adolescent girl explained this predicament: ‘sometimes in school, there is not even enough water for drinking or even washing your body … so then I will just throw [the reusable pad] out.’ Without access to supportive supplies or other necessities, like water, the usefulness of reusable products was diminished.
Not all respondents preferred reusable pads, highlighting the importance of menstrual material choice. Differences in preference were especially apparent among adolescent girls, who were more likely to prefer disposables. Their reasons included the challenges encountered with storing a used reusable pad when having to change outside the home. As one adolescent girl described:
‘ … you will travel out and go to places that are not to your home and cannot start washing your pad while there … so disposable pads would be better because you can just throw it away …’
In addition, many girls lacked leakproof bags for storing used menstrual pads during the day and feared that storing a used pad in their bag put them at risk for emitting bad odors. Additional criticisms about reusables included discomfort with washing pads or that they were less absorbent than disposable options. One adolescent girl explained this aversion, ‘some of us don't want washable pads; we don't like washing the blood out, especially if we have a heavy flow.’ Another adolescent girl described the problems encountered around odors with reusable pads: ‘I don't like washing blood with my hands or the smell of handling it for a long time.’ Despite these concerns, some girls indicated resignation, including the need to readjust their preferences due to the limitations of their situation. One girl described the rationale for her shifting preferences, ‘we don't get used to something we cannot afford.’ Reusable pads were still perceived as providing better protection from stains than pieces of cloth, a quality valued by most adolescent girls.
Insufficient MHM-supportive toilets and disposal options
Adolescent girls and women described inadequate access to supportive or female-friendly toilets for conducting MHM-related maintenance tasks, such as changing and menstrual disposal. Most girls and women indicated that toilets, whether at school or shared by households, were their primary location for changing during the day, given the lack of privacy within their shelters. Typically, girls and women change menstrual materials 3–5 times daily, based on their individual blood flow. Girls and women indicated reliance on communal latrine blocks, which served multiple households. This included separate blocks designated for females and males, although adherence to segregation rules was rarely followed. One woman described her frustration:
‘… the toilets are all the same and used by males and females at the same time … it would be better if gender segregated, but that is not possible because of the population size and because it is hard to control men …’
A WASH manager also observed this challenge, describing how despite clear signage and sensitization sessions, ‘men will see this one [toilet] is neat, or this one is clean, they just think they can use it.’ Several female IDPs felt resigned to the lack of gender segregation, despite it making them uncomfortable and increasing their worries about intruders. One woman described this anxiety: ‘sometimes, when you are using it [the toilet], someone may come in and open it … some of the locks are broken.’ Numerous respondents also indicated feeling rushed while using toilets, which was especially stressful while managing their period.
Nighttime was described as introducing additional challenges, largely due to the lack of lighting in the camps, including at the latrines. Given the unique security concerns of these IDP camps, NGOs were unable to provide overhead lighting. As one WASH manager described: ‘the military is concerned that if we put in lights, it will make it easier for insurgents to watch the movement within the camp.’ This resulted in girls and women being reliant on personal light sources, e.g., flashlights or cellphones, to guide their way to and inside the toilets. Some participants described challenges of trying to balance their cellphone lights while using the toilet, an even more difficult task when changing menstrual materials. While some NGOs provided battery-operated flashlights, the girls and women reported that these required battery replacements, which were not always affordable.
Adolescent respondents reported that school toilets were unsatisfactory for period management. Girls cited a lack of gender-segregated toilets and poor water access as particular challenges. One adolescent girl described how the lack of water made toilet use uncomfortable while menstruating as she could not properly clean the toilet stall:
‘… the only thing that you can do is to go home and change because at school there is not enough water, so you have to leave the toilet untidy, and someone could come and see it …’
This discomfort with managing periods in school had the unfortunate consequence of some girls leaving school to change their pads, negatively impacting class attendance. Girls also described their schools’ failure to enforce gender segregation of toilets, which exacerbated their discomfort and heightened the likelihood of disclosing their menstruating status.
A reported lack of accommodation for disposal was an additional inadequacy related to communal toilets. Many girls and women threw used menstrual waste directly into the latrine pits, as this was considered convenient and discreet. Disposal directly into pit latrines, however, had come under scrutiny within one camp. Local desludging companies responsible for emptying and transporting latrine waste had asked community elders to dissuade girls and women from these disposal practices, citing that pads and cloths, often wrapped in nylon bags, were creating desludging issues. Guidance on alternative disposal approaches, however, was not provided. One woman shared how, ‘they didn't tell us anything … so burying it [the menstrual waste] was our idea … as to not to dispose of the pads in the toilet … but to bury.’ Women from all three camps indicated preferences for burying menstrual waste as an alternative to disposing into the latrines, with some noting they had buried prior to displacement.
NGO staff confirmed that disposal into latrines created challenges with desludging, particularly with items such as diapers, pieces of cloth, or plastic bags filled with used menstrual materials. The NGO staff noted that they had shifted to using desludging equipment with a wider pipe and had conducted community sensitization discouraging product disposal into latrines, steps which seemed to reduce blockage. Notably, the desludging actors interviewed indicated that while larger menstrual cloths could cause issues, individual disposable pads were not as problematic. As one desludging contractor explained, ‘the pads [disposable] are soft and can easily evacuate … the cloth can get blocked.’ Desludging actors did advocate for more NGO initiatives sensitizing people against disposing of anything down the toilet beyond urination and defecation to improve desludging efforts and the operational capacity of toilets. Additional benefits to reducing menstrual waste in latrine pits were that it might slow down pit filling rates and thus reduce desludging requirements.
The importance of consultation with girls and women around disposal was reinforced from discussions about acceptable disposable methods. The possible approaches discussed included covered waste bins located inside toilet stalls, a common strategy in many high-income country contexts. Most respondents expressed discomfort with this idea, citing fears that children or males would see their menstrual waste. One woman explained her fears: ‘the problem with doing it this way [bins] is that some children are so stubborn, they will move into the toilet with you and see it … which is not good.’ In addition, some respondents indicated fears of supernatural occurrences: ‘there is some type of spiritual belief that if you dispose of it like that [in bins] … you might attract evil spirits.’ Burning was also not positively viewed, as respondents worried about fumes and potential risks to their health. Such findings highlight the complexities of menstrual waste, which can shape the acceptability and feasibility of menstrual disposal approaches and highlights the importance of consultation and monitoring.
Menstrual-related laundering challenges and coping strategies
Most girls and women indicated using communal bathing facilities for the washing of reusable menstrual materials and underwear. The bathing facilities in the camps included blocks of five stalls with floor drains leading to a soakaway pit (drainage pit). The benefits of washing menstrual materials in the bathing facilities included their relative privacy and the convenience of being able to pour the bloody water directly into the drain. This reduced the potential for others to view the bloody water and risk menstrual disclosure.
Although the bathing blocks were intended to be gender-segregated, this was rarely the case. As a result, girls and women using these spaces worried about possible intruders, especially boys and men. Additionally, some respondents cited that there were often queues at these facilities, particularly at specific times of the day. One adolescent girl explained her anxiety while washing pads in the bathing facility when there were others waiting outside: ‘I am never comfortable washing my pads in the bathing room as oftentimes people will be knocking saying please be fast … so I always feel rushed.’ Many IDPs also noted that the soakaway pits, located directly behind the bathing facilities, often filled up from overuse. One woman frustratedly described this occurrence in relation to inadequate facility operations and maintenance: ‘the soakaway pit is always full … it would be better if drained at regular intervals as there are so many people and it fills up so quickly … it needs to be drained more often.’ This sometimes resulted in standing water inside the bathing stalls, making these spaces challenging to use.
To provide a private laundering space, one NGO constructed a multi-purpose WASH facility that included an area for doing laundry as well as bathing spaces, all situated behind privacy screens. These new WASH facilities, however, were rarely used by girls and women. A WASH program officer described his observations about low usage of the WASH facilities, explaining:
‘… I'm not sure if they appreciate those things to be there … and just to avoid people's views about them spending a lot of time in that particular area … they prefer it to be open so people can see …’
Staff indicated that the privacy screens and walls surrounding the WASH facility had inadvertently made girls and women more uncomfortable as they worried about neighbors’ assumptions if they spent considerable time there. The facility was also located a distance from the water point, making it inefficient and arduous for women to use. As a result, NGO staff described how many women continued washing their clothes near the water point rather than in the new facility. However, given existing menstrual taboos, it is unlikely that women would feel comfortable washing their menstrual materials in public.
The drying of menstrual materials, which necessitates privacy, also arose as a key challenge to using communal laundering spaces. Many participants worried about theft of menstrual materials if left inside the bathing spaces or hung outdoors without supervision. As one adolescent girl described: ‘I dry it in one corner of the room where I can see it from far away, so no one steals it.’ Most respondents indicated drying materials inside their shelters given the increased privacy and security. The use of a piece of cloth or other clothing to cover the pads while drying them inside was common, as it provided an additional layer of privacy. This practice, however, was stressful for some girls and women, as one woman explained: ‘I am not comfortable [drying at home] at all because I fear someone might come and see the pads.’ A few women also described drying their menstrual materials on their shelter roof at night, which required them to get up at early hours to retrieve them prior to others waking up.
Consulting women about their ideal locations for laundering menstrual materials proved insightful. Most indicated desires for small personal washrooms attached to their existing shelters. Some participants indicated they would never feel comfortable washing menstrual materials in a public or communal space, even if gender-segregated. Notably, NGO staff and several women described how some camp households had constructed ad hoc washroom structures attached to their shelters, using random supplies such as straw mats or leftover building materials. These unroofed structures enabled women more privacy for drying items in the sunlight, which many respondents explained was important. However, camp management staff viewed the ad hoc washrooms cautiously, highlighting that these informal spaces lacked proper drainage and could lead to greywater or runoff issues within the camp. Similarly, if the makeshift washrooms were used as informal latrines, a common practice during the night, it could lead to fecal contamination, posing health risks.
The findings from this qualitative assessment with IDP girls and women living in Northeast Nigeria highlight the need for emergency responders to consider the full range of maintenance tasks required to use disposable and reusable menstrual materials as intended. This includes consistent access to MHM-supportive supplies, such as soap, water, and underwear, as the absence or shortages of these supplies can hinder the usefulness of reusable materials. Toilets also require more female-friendly features, including gender segregation, lighting for nighttime usage, and attention to menstrual disposal. Finally, given the growth in distribution of reusable menstrual materials, more attention is needed on how to provide laundering facilities that better support the maintenance requirements of these sensitive items.
Distributions focused on menstrual materials and other household needs were inconsistent, resulting in unreliable access to menstrual supplies. This is particularly important when distributions prioritize reusables, as findings from other displacement contexts highlight that inconsistent access to soap may lead to the premature disposal of reusable materials (Sommer et al. 2018; Majed & Touma 2020). Consultation with beneficiaries is useful for identifying which types of soap are preferred for removing bloodstains (e.g., laundry detergent versus bar soap) as this can impact the usability and acceptability of reusable materials over time. Considerations should also be made for episodes of water scarcity, a common occurrence in many emergencies. In post-disaster Vanuatu, for example, displaced women expressed feeling pressure to not waste water on cleaning blood from clothing or materials (Downing et al. 2020). To account for episodes of water scarcity, some NGOs provide mixed-material MHM kits, with both disposable and reusable menstrual materials, for girls and women living in drought-prone regions, such as Somalia (Robinson & Obrecht 2016).
Our assessment noted the increased popularity of distributing reusable menstrual materials, as similarly documented in other recent humanitarian contexts (Kuncio 2018; VanLeeuwen & Torondel 2018b; Giles-Hansen et al. 2019). Despite the current lack of evidence, the COVID-19 pandemic and its requirement for household isolation may have further validated the usefulness of reusable menstrual products. Although most humanitarian menstrual material distributions in recent years have included cloths, and disposable and/or reusable pads, there has also been increased attention to alternative reusable products, including menstrual cups and period underwear. For example, one NGO piloted the distribution of menstrual underwear with refugee women in camps in Greece. Notably, this pilot found many of the same laundering challenges seen in the Nigerian context, including insufficient access to water and soap coupled with drying difficulties, which were especially problematic in Greece's colder winter months (VanLeeuwen & Torondel 2018a). Menstrual cup distributions in emergencies have occurred with Sudanese refugees in Ugandan camps (Akongo 2018). Like menstrual pads, additional MHM-supportive supplies are required to facilitate the hygienic usage of menstrual cups, such as a metal container for boiling water and disinfecting the cup (Akongo 2018). Despite growing evidence suggesting the feasibility of menstrual cup use in low-resource settings (van Eijk et al. 2019), more research is needed examining their appropriateness in emergencies, especially in water-scarce contexts.
Ensuring access to female-friendly toilets continues to be a major challenge in many emergencies (VanLeeuwen & Torondel 2018b). Our study found that Nigerian IDP girls and women were often uncomfortable using toilets, especially given the lack of gender segregation. This is common across emergencies (VanLeeuwen & Torondel 2018b) and can result in incidents of harassment, ‘peeping,’ and even sexual assault (Oxfam International & WEDC 2018). WASH actors need to better prioritize the unique sanitation and safety needs of girls and women when designing WASH facilities. This includes directly consulting girls and women during the design and planning phases of female WASH facilities; an approach that has been increasingly identified in some humanitarian responses (Farrington 2019; Downing et al. 2020; IFRC 2021). Improved engagement with male community members may also help to mitigate these gendered toilet concerns (Farrington 2019; Schmitt et al. 2021).
A lack of lighting for nighttime access to toilets was also identified as a serious concern for many of the girls and women in this study. This issue proved to be especially challenging for camp authorities to address in the Nigerian context, given the unique security issues. Discomfort and fears around insufficient lighting in or around communal toilet facilities is a common predicament in camps and informal settlements (Oxfam International & WEDC 2018; Farrington 2019; Majed & Touma 2020). Many organizations are trying to address this issue through the construction of large overhead lighting (Oxfam International & WEDC 2018; IFRC 2021) or the distribution of personal light sources (Giles-Hansen et al. 2019). The latter, however, is inconsistent in many emergencies, requiring women to adopt strategies such as only visiting the toilet in groups, using personal light sources or constructing informal household toilets (Schmitt et al. 2017).
This assessment found a lack of attention to menstrual disposal, despite concerns over the role of menstrual waste in hastening latrine filling rates and potentially creating desludging issues. These represent common challenges across humanitarian contexts, and the consequences can differ depending on the environment and the types of toilets being constructed. For example, menstrual disposal may be a more urgent issue in emergencies with pour-flush toilet models, such as camps in Myanmar and Bangladesh, as this waste can cause immediate clogging and render toilets unusable (Schmitt et al. 2017, 2021). Humanitarian actors in both contexts have piloted menstrual disposal and waste management strategies to attempt to address these problems (IFRC 2021). In Myanmar, WASH actors are testing the use of locally constructed incinerators placed near female toilet blocks (Milonova 2020), while in Bangladeshi camps, NGO actors have installed menstrual disposal chutes inside communal and hospital female toilets to help mitigate the taboos associated with menstrual waste being seen by others (Schmitt et al. 2021). Preliminary research suggested, however, that the communal disposal chutes were not being adequately utilized by Rohingya girls and women (IFRC 2021). Further research is needed to better understand the barriers to utilization and acceptability.
Our findings indicated some challenges for desludging actors in managing menstrual waste dropped directly into latrine pits, with the most serious concerns being disposed pieces of cloths and the practice of putting reusable materials into plastic bags. More understanding on the impact of menstrual waste on desludging practices and latrine pit filling rates over time could prove useful to sanitation engineers. This study also highlighted that when girls and women were asked to modify their disposal behaviors, they were not always provided with alternative solutions. Appropriate education is needed to support these behavior changes, including signage that clearly indicates alternative disposal options.
Finally, this scoping highlighted the specific laundering facility challenges that emerge in humanitarian contexts. Many girls and women indicated discomfort with the idea of washing sensitive menstrual materials in communal spaces, given the pervasive stigma around menstrual blood. Valuable learning can be gathered from other emergencies, given the commonality of these issues across contexts. One NGO operating in the Rohingya camps in Cox's Bazar sought to address this problem by designing communal laundering blocks inside Women's Protection Centers that used design measures to enhance women's privacy. This included the placement of shower curtains separating the laundry stalls, which allowed women to pull the curtain around them for privacy when washing more sensitive items like pads or underwear (Schmitt et al. 2021).
There are some limitations to note. First, this research was conducted during a 2.5-week window. Given the limited timeframe, the researchers were unable to observe how beneficiaries interacted with WASH facilities over time. Second, as the researchers were dependent on Hausa translators for communication with displaced girls and women, it is possible that there have been some miscommunications or deviations from the original message during translation of the FGDs.
This study on the menstrual maintenance, disposal, and laundering practices and needs of displaced girls and women living in Northeast Nigeria yields important learning for designing and implementing MHM programming in emergencies. Three key recommendations for future emergency practice include the following: (1) humanitarian actors need to consider the full range of actions required of displaced girls and women for the maintenance of both reusable and disposable menstrual materials; (2) there is a need for improved innovation to the design and operation of female-friendly WASH facilities, including increased attention on how to address gender segregation, lighting and menstrual disposal needs; and (3) all solutions should be designed and delivered through continuous consultation and monitoring with girls and women to ensure their gendered needs are more effectively met.
This work was supported by the United States Agency for International Development's Office of Foreign Disaster Assistance (Grant # 720FDA18GR00049) and the Osprey Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. We want to thank all Nigerian adolescent girls and women living in displacement camps who were willing to openly discuss this sensitive topic and share with us their personal insights. We also thank the humanitarian staff from numerous organizations and the desludging contractors who took the time to share with us their expertise on this subject.
DATA AVAILABILITY STATEMENT
Data cannot be made publicly available; readers should contact the corresponding author for details.
CONFLICT OF INTEREST
The authors declare there is no conflict.