Learning from perimenopausal women
Dr Amita Bhakta, Freelance consultant
Hygiene has come to the forefront of conversation during the COVID-19 crisis. Each time we tune into a news piece on the television, or read a newspaper, we are reminded of the importance of handwashing with soap. Handwashing is, of course, the first line of defence against COVID-19, though this advice is difficult to follow where water and sanitation services are lacking. But in reality, hygiene is about more than handwashing alone. We should not be thinking just about hand hygiene, but bodily hygiene. In communities across the global South where shared water, sanitation and hygiene (WASH) facilities are the norm, and implementing social distancing measures is not so simple, it is important to re-evaluate our understandings of hygiene, and what this means for a new ‘normal’.
The concept of hygiene provokes us to think of a sense of cleanliness. Hygiene is fundamentally about keeping yourself and your surroundings clean, in order to prevent the spread of disease. Discussions on COVID-19 focus on managing the spread of bodily fluids through coughing and sneezing, by washing our hands. However, our bodies are permeable in other ways too. Our bodies leak sweat and urine every day; women and girls of reproductive age also face the challenge of managing the leaks of menstrual blood. After all, periods don’t stop for pandemics. There are some members of society who are trying to manage all of these leaks collectively in their homes as countries go into lockdown, from whom we can learn some vital lessons on the importance of maintaining good bodily hygiene as well as hand hygiene, as we seek to combat COVID-19 and for the long term future. I recently completed research exploring the WASH needs of older women in urban Ghana who are going through the perimenopause, which until now, have received little attention from a hygiene perspective. The perimenopause, often called the change, is the time in a woman’s life when she approaches the menopause, when menstrual periods permanently cease. It occurs on average between the ages of 47 and 51 years. The symptoms of the perimenopause are largely marked by erratic leaks of bodily fluids. Menstrual periods can be very heavy and women can lose up to 6 tablespoons (80ml) of blood. The leakage of urine can become more difficult to control due to incontinence. Women also face copious levels of sweating, exacerbated by hot flushes (sensations of heat spreading from the chest and up to the face). All of these symptoms require women to consider other aspects of hygiene besides handwashing on an everyday basis which are all too often neglected by the WASH sector: the need to bathe, and to wash clothes.
Experiencing very heavy menstrual periods, urinary incontinence and frequently sweating can leave perimenopausal women feeling dirty and unclean. Heavy bleeding can confine perimenopausal women to the vicinity of the home, going out only to use community toilet facilities where they try to use the little water available to them to wash away the stains of menstrual blood on latrine slabs. Menstrual cloths, commonly used by women on low incomes in Ghana and across the global South, fail to adequately absorb the large volume of blood lost. It is not enough for perimenopausal women to use menstrual materials or incontinence products to maintain good hygiene. Women bathe several times a day to cleanse themselves of the stains and smells of blood, sweat and urine left upon their bodies. These leaks spread onto their clothes, leaving embarrassing stains which means more changes in clothing and a significant increase in laundry. Perimenopausal women need to cleanse themselves and maintain good bodily hygiene due to the sudden onset of symptoms, day or night, which is made all the more challenging when 24-hour access to water supply and sanitation facilities is not guaranteed.
If the WASH sector strives to leave no-one behind, it must be recognised than women are still going through the perimenopause during the COVID-19 pandemic. In the communities where I worked in Accra and Kumasi, the majority of people, including the perimenopausal women in my study, used shared community toilet facilities and water points to meet their every day hygiene needs. Perimenopausal women relied on community toilet facilities to change their heavily soiled menstrual cloths and to urinate on a very frequent basis. Being able to bathe and wash more frequently requires more water to be collected from water points daily. Looking at hygiene from the perspective of perimenopausal women in Ghana, to manage their various bodily leaks emphasises the critical importance of social distancing. Water points, especially in humanitarian contexts, need to be spread out with significant distances between them, to reduce long queues and the risk of catching COVID-19, particularly for people who rely on them regularly for good bodily hygiene such as perimenopausal women.
There are lessons to be learned here from perimenopausal women for what the WASH sector should be recognising as ‘hygiene’ in COVID-19 and beyond. It is not only the hands of the people in low- and middle-income countries which need to be kept clean where WASH services are lacking, nor is it just about meeting women and girls’ menstrual hygiene needs. Hygiene encompasses entire bodies. As we encourage social distancing measures, it is critical for us to consider the different uses of water for keeping bodies clean, clothes clean, and the spaces in which people wash clean. The new normal for the WASH sector requires a re-examination of the infrastructure needed for overall bodily hygiene. Inclusive design in bathhouses and spaces for washing clothes deserve greater attention in the longer term. Let the COVID-19 crisis be a time for the WASH sector to renew our understandings of hygiene, in order to provide sustainable water and sanitation for every body to be kept clean.