Piloting alternative menstrual management in Imvepi refugee settlement

September 1, 2018

Viola Jackline, 20, is currently a pupil in Primary 5 in Imvepi Refugee Settlement. Viola is from Yei, South Sudan, and arrived in Uganda in March 2017 after two weeks of travel by foot with her grandmother and three siblings. She was only able to carry two bed sheets and two sets of clothes with her as she fled the violent conflict in her country. However, her grandmother was able to carry two saucepans, allowing her to cook some food along the way. With the bed sheets, Viola and her family were able to sleep in the bush in dark, camouflaged areas. Her long journey was coupled with thirst and hunger, verbal harassment from armed men, witnessing killings and escaping gunshots, and no means of bathing until she reached the Ugandan boarder.

Viola Jackline

Viola is one of 100 women and girls who participated in a menstrual hygiene management pilot that introduced menstrual cups, referred to as “Ruby Cups”, implemented by CARE and local partner WoMena in Imvepi settlement from April 2018. This pilot was funded by European Union Civil Protection and Humanitarian Aid (ECHO) and was rolled out in a consortium alongside Oxfam and CERFORD. CARE’s partner WoMena is a local organization dedicated to reproductive health, gender equality and menstrual management in Uganda. WoMena was responsible for training the participants on MHM and adequate use of the Cup, supervising and monitoring the trainers and participants.  At the end of the training that also covered Reproductive Health more broadly and particularly how to prevent HIV and other Sexually Transmitted Illnesses and avoid unwanted pregnancies that are so common under adolescent girls, each participant received a menstrual health hygiene kit along with one Ruby Cup.  Ruby cup is a healthier, more sustainable and eco-friendly alternative to pads and tampons. Made from 100% soft, medical grade silicone and reusable for up to 10 years, it is a low cost high impact intervention, particularly for extremely poor women and girls, particularly destitute refugees.

Like many women and girls in the settlement, it was challenging for Viola to find money to buy pads. She admitted to reverting to selling her food ration in order to buy a piece of cloth and a robe. She tore the robe and fitted it to hold the piece of cloth then fastened it around her waist. This wasn’t how Viola desired to manage her menstrual cycle as it was bulky and uncomfortable but it was her only option at the time. CARE has evidence from research that some girls ended up engaging in transactional sex to buy pads (Imvepi Inter Agency Assessment on Sex Trade, May 2017).  CARE also has data from gender analysis that adult women were beaten by their husbands after cutting blankets distributed in the NFI kits to manage their periods. 

There is also evidence that lack of menstrual hygiene solutions is a cause of absenteeism from school for many girls in Uganda from both refugee and Uganda communities, and also a cause for dropping out altogether. Female pupils are already under additional stress at school during their menstrual cycle due to being uncomfortable and not knowing what is happening with their bodies but the lack of solution too often means the beginning of a dangerous path out of school, quickly followed by teenage pregnancies, child marriage and other forms of exploitation and abuse. Boys will often tease girls when their uniforms show an outline of a pad, staining or, in Viola’s case, a piece of cloth which would enlarge her skirt. In fact, one of Viola’s friends in Imvepi, Jenet, dropped out of school due to boys bullying her about a stain on her uniform. Jenet was in Primary 7 when she left. Boys will also go through girls’ bags and make fun of the girls who have pads or cloth because they know she is on her menstrual cycle. This emotional abuse caused Viola to have low self-esteem, poor concentration and little interaction with her male peers.

Ruby Cup menstrual cup

Viola said she was excited when she was told that she is among the beneficiaries selected to pilot menstrual cups but, when she looked at the cup, she wondered how it would fit into her vagina. Despite her concerns, Viola attended scheduled training's, ready to learn and with an open mind. Targeted girls and women were trained on personal hygiene, the reproductive cycle, how to prevent STIs and HIV and early unwanted pregnancies and menstruation and menstrual management, and maintenance of the Ruby Cup. Training's were conducted by Trainers who were selected from refugees and host communities within Imvepi Refugee settlement.

After Viola received her training in April 2018, she was ready to use the ruby cup during her cycle in May. The first time she inserted the cup was not easy and she thought of giving up and reverting back to using a piece of cloth. However, she went to talk to her friend Nancy, who was also a refugee and a ruby cup beneficiary. Nancy assured her she should not be fearful and encouraged her to keep on trying to insert the cup based on the provided training guidance. The next month Viola attended a refresher training and this gave her confidence to try using the cup again. This time, insertion worked! She noticed immediately there was less odor and itching, and was much more comfortable than other methods she had used. She also did not have to look for money to buy cloth or pads, easing financial stress to her and her family.

While Viola was growing confident in using her Ruby Cup, family had some doubts. Because the menstrual cup is new in the settlements, some individuals thought this was a form of birth control or that it will cause bareness. Her peers were concerned it would stretch her vagina, break her virginity, and will lead to no one wanting to marry her. These perceptions are mostly caused by lack of awareness on the menstruation process as it is seen as a taboo that should not be talked about.  However, the pilot also included a community awareness component to help demystify these perceptions.  Also, as Viola candidly shared her experience and learnings with her family, misconceptions and fears in her social network would slowly fade away. A key concern for CARE was to test how much water the cups required.  This was particularly important as access to water is a challenge in certain refugee settlements.  Viola’s experience and that of the other women and girls in the pilot has however demonstrated that little water is required for disinfecting the cup. In fact, as little as 8 ounces is sufficient, a lot less than for cleaning reusable pads which majority of women and girls like Viola end up reverting to.

FGDs with ECHO Rep and ruby cup 

beneficiaries while  visiting to Imvepi Village 19

Under the community awareness component, CARE engaged 10 Role Model Men in the training of trainers on Ruby Cups.  This was done to ensure men in particular would understand the real purpose of the cups and to eliminate the risk of violence against women and girls adopting the cups. For young girls and women, men’s

attitudes towards menstrual management is all too often discouraging and sometimes violent. Men often times do not understand the menstruation process or what women and girls go through during their cycle. This can lead to violence, particularly as women are more likely to refuse having sex during their periods.  The trained men supported their wives, sisters, and friends who were beneficiaries of the project through understanding and advocating for both the girls and community members in the use of Ruby Cups and menstruation processes. Viola had several Role Model Men in her community, who helped her family understand the importance of supporting Viola during her cycle and in her efforts to adopt the Ruby Cup. “The Role Model Men talked to my grandmother about the Ruby Cup and its benefits. He also talked to her about her fears of me using the cup. He told her that it will not hurt me and after that she supports me.”

During the training, Viola said she learned many new things including her reproductive cycle, menstruation cycle length, anatomy, the ten steps of hand-washing for using the cup, how to clean and sterilize the cup, etc. In fact, this was the very first time Viola had ever been taught about these subjects…..  Viola explains how she feels more self-confident now. She now plays football, actively participates in youth meetings, and can walk long distances for food ration without having to worry about an odor coming from her cloth or a leak. She even feels capable of helping her peers to manage their menstruation more confidently. She is able to interact with boys and can be more attentive in class now that she does not have to worry about leaks or stains all the time when she has her periods!  Viola’s confidence has become noticeable to her friends as well. “Many of my friends, neighbors, and school mates admire the cup and requested to be included as beneficiaries.” Viola finds it hard to find the words to express her gratitude to CARE & WoMena for teaching her about menstrual management and for providing her with her cup. “I no longer have to look for money, I am comfortable, and I have confidence in school.”

Established in 1969, CARE Uganda targets the most vulnerable communities, with a special focus on women and girls, who are the most at risk of rights abuse and exploitation. CARE has been operating in West Nile, responding to the South Sudanese Refugee crisis since January 2014. To date, CARE has reached over 160,000 beneficiaries through interventions in Gender Based Violence (GBV), sexual reproductive health and livelihoods in Bidibidi, Rhino, Imvepi, Adjumani and Moyo.

Compiled By: Sophie Akongo

CARE Uganda, Psychosocial Support Counselor

Yumbe Sub Field Office, West Nile, Uganda

Edited By: Brandi Murley

Arua Field Office, West Nile, Uganda