The impact of pre-menarcheal training on menstrual
practices and hygiene of Nigerian school girls
Aniebue1&, Patricia Nonyelum Aniebue 2,
Theophilus Ogochukwu Nwankwo1
1Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Enugu Nigeria
Community Medicine, University of Nigeria Teaching Hospital, Enugu Nigeria
DR. UU Aniebue, Department of
Obstetrics/Gynecology, University of Nigeria Teaching Hospital, Enugu, Nigeria - Phone 2348037113342
the cyclical shedding of the inner lining of the uterus, the endometrium, under
the control of hormones of the hypothalamo-pituitary axis. Menarche, or
the onset of menstruation, is a landmark feature of female puberty and signals
reproductive maturity. Anxiety, fear, confusion, and even depression are
frequently reported experiences of menarche [1, 2].
While the anatomy
of the genital tract and physiology of menstruation are taught in school in Nigeria, the practical management of menstruation has often been regarded as inappropriate
for public discussion . Myths, superstitious
beliefs, and cultural taboos substitute appropriate information in the growing
education is a vital aspect of health education. It is known that attitudes to
menstruation and menstrual practices developed at menarche may persist
throughout life . The study of the menstrual practices
of adolescent girls unveils health issues that affect their adjustment to
reproductive life and provides the basis for formulating health education
strategies relevant for this crucial period in reproductive life.
The objectives of
this study were to ascertain the prevalence of pre-menarcheal training among
school girls surveyed in Enugu State, Nigeria and to determine whether hygiene
and menstrual practices were influenced by pre-menarcheal training.
The survey was administered to consenting
post-menarcheal adolescent school girls in Enugu, Nigeria, between March and May
2006. Adolescent girls were defined as those aged 10 and 19 years . Enugu, the capital of Enugu State (southeastern Nigeria), is mostly inhabited by Christians. There are 46 secondary schools in the
metropolis comprising of 26 co-educational schools, 12 girls schools and 8 boys
schools. At the time of the study, the total student enrolment was 50,822
consisting of 22,089 males and 28,733 females .
Permission to carry out the survey was obtained from relevant school
authorities. The study was also approved by the Ethical Committee at the University of Nigeria Teaching Hospital, Enugu, Nigeria.
Sample size was
determined using a standard formula Z2pq/d2 (Where Z =
confidence limit of 95% or 1.96, p = prevalence, q= 1 – p and d = sampling
Using a prevalence of 40% for deficiency in knowledge about menstruation from a
previous study among Nigerian school girls and a sampling error of 5%, the
minimum required sample size was 369 . However, a sample of 500 students was
selected to accommodate refusals or non-response.
A local adaptation
of the geographical stratification method was used to select the location of
the schools studied [9,10]. Residential areas were stratified into upper, middle and
lower classes based on the predominant type of residential building in each area:
detached bungalows and storey building for upper class, flats for middle class,
and single room houses of multiple-occupation for the lower class. One
female school from each stratum was randomly selected and surveyed. The
school in the lower class area had 1,931 (all females) students, that in the
middle class area had 3,744 (all females) students, and the school in the upper
class area had 1,614 (960 girls) students.
The classes in
each school were serially numbered and six classes randomly selected using a
table of random numbers. Equal numbers of questionnaires were distributed to
the selected classes. A brief explanation of the study was done before
administering the questionnaires and girls who were pre-menarcheal were
informed of their ineligibility for the survey. In each class, consecutive
consenting post-menarcheal girls were surveyed beginning from the extreme right
hand corner of the first row until the required number was obtained. The survey
was carried out during the classes’ free period but within school hours.
completed the self-administered, pre-tested, semi-structured English
questionnaire in a classroom setting proctored by medical students. The
questionnaire had sections on personal data, family background, pre-menarcheal
training, age at menarche, attitude to menstruation and menstrual hygiene
training was ranked into “Yes” or “No” and the main outcome measures were the
menstrual and hygiene practices of the girls. The other variables studied were
(1) Pre-menarcheal training: Respondents were only qualified as having been
trained if they responded affirmatively to each of the following questions: (a)
Being told about and made to expect the first menstrual bleeding. (b) Having
been instructed on how to collect menstrual blood. (c) Having been instructed
on how to dispose of the material used to collect menstrual blood. Each
question in this segment had a yes or no response. Those who were trained were
ranked as “Yes” while those who were deemed untrained as “No”. (2)
Menstrual and hygiene practices: Methods used for collection of menstrual
blood, frequency of changing the absorbent, method of disposal of the
absorbent, and the effect of menses on family, social life, and occupation. (3)
Menstrual information: Any oral and written materials related to menstruation
and menstrual practices. (4) Menarcheal experience: The feeling of preparedness
or otherwise at the time of the first menstrual experience. (5) Menstrual pain:
Cyclical lower abdominal pain around the time of menstrual bleeding. (6)
Attitude to menstruation: Respondents’ feeling towards the expectation of a
menstrual period. It was graded as undesirable (the preference to exist without
menses), unprepared (onset of menses usually takes her by surprise) and
satisfactory (menses regarded as an acceptable, natural phenomenon that should
be expected). (7) Relationship with mother: The extent of closeness to the
mother. Relationship with mother was graded as not close, ordinary, close, and
Data entry and
statistical analysis were done using SPSS (Statistical Package of Social
Sciences) Version 10. Chi square tests were used to assess associations between
categorical variables and statistical significance was considered present if
the p-value was 0.05 or less. Pearson product moment correlation was used to
test for correlation between the educational attainments of the parents and
menstrual knowledge of respondents.
Out of 500
questionnaires, 495 were properly filled yielding a response rate of 99%. The
general characteristics of respondents, educational attainment of their parents
and the proportion who received pre-menarcheal training are shown in table 1. The mean age of the
students was 14.9 ± 1.7 years and most (98.6%) were Christians. Among the
respondents, 52.9% were in senior secondary school and 47.1% were in junior
secondary school. Pre-menarcheal training was received by 273 (55.2%)
students and the rest (44.8%) had no preparation prior to menarche.
Mothers’ and fathers’ highest level of educational attainment were
significantly correlated (r = 0.7, P < 0.001). Their mean age at menarche
was 12.7+ 1.3 years.
The social and
other factors influencing the availability of pre-menarcheal training are shown
in table 2. The level of educational
attainment of both parents and the sources of information about menstruation
were significantly associated with pre-menarcheal training. Girls whose parents
received tertiary education and those whose mothers were their main source of
information were most likely to have had pre-menarcheal training
menarcheal experience, adverse effect of menstruation on schooling and
social life, use of unhygienic material as menstrual absorbent and unacceptable
methods of disposal for menstrual absorbents were more common in girls who did
not have pre-menarcheal training than those who did (table 3). More girls who had no training
disposed of their menstrual absorbents in farms and road side or by recycled
them by washing than those who were trained. Girls who did not have
pre-menarcheal training also reported more number of severe cases of menstrual
pains than those trained. The subsequent menses following menarche were
better anticipated and more often reported as satisfactory; changing menstrual
absorbent at least thrice daily was more common among those who were trained
than those who were not but the differences were not significant.
In many societies,
including Nigeria, menstruation is regarded as very private and is seldom
discussed in public or taught openly [1,2].
More than a third (44.8%) of the respondents in this study had no form of
preparation for menarche. This is comparable to 40% previously reported
in Ile-Ife Western Nigeria . In Saudi Arabia, ignorance about proper
menstrual practices was found in two-fifths of the adolescent surveyed in
gynaecological and medical clinics in Riyadh, the capital city . The rate of deficient menstrual training in this study
was much lower than the 84% rate observed in a cross sectional study of 250
women aged 15 – 49 years in New Delhi, India, but higher than 25% reported
among 250 high school students in Tehran, Iran [12, 13].
followed by other relatives (13.2%) were the main source of menstrual
information in this study. In a related study in Egypt, 92.2% of the girls
accessed menstrual information primarily from the mass media .
In our study, pre-menarcheal training was significantly related to the
educational attainment of the respondent’s parents. This corroborates the
finding in a study in western Nigerian which showed that parental education was
positively associated with girls’ menstrual knowledge .
The educational attainment of parents is expected to influence the economic
strength of the family and individuals’ social exposure hence reducing the
negative impact of harmful local practices.
relationship with their mothers was not significantly related to pre-menarcheal
training. It may hence be speculated that inadequate training of mothers,
negligence or reluctance to communicate appropriate menstrual information
determines the prevalence of inadequate pre-menarcheal training. Some
studies highlight the effectiveness of formal education on female students in
relation to health issues [14, 15, 16]. Unfortunately, only 8.8% of the girls in this study
received menstrual information from health workers and school teachers.
Organized health education complements family life education received at home
and serves to correct inappropriate information while stimulating peer
dissemination of health information .
of inadequate pre-menarcheal training are multiple. Menarche was
described by almost a third (29.9%) of the respondents as
frightful. Another 106 (21.4%) girls described their experience as
confusing. It has been postulated that the experience at menarche provides the
framework for the girl’s latter attitude to menstruation, her body image, and
general health behavior . Sixty five percent of the
respondents who had satisfactory menarcheal experiences had received
pre-menarcheal training. Menstrual pain, which is a common reason for
gynaecological consultation , is experienced by many
women in the early years of their menstrual life . The
occurrence of severe menstrual pain and inappropriate menstrual hygiene
practices were more common in respondents without pre-menarcheal training than
those who had. Training probably modifies perception rather than
obliterates menstrual pain. Poor menstrual hygiene practices are known risk
factors for genital infections in women and were assessed in this study in
terms of sanitary protection method, frequency of changing the menstrual
absorbent, and the means of disposal of the absorbent .
Most girls (69%) used sanitary pads. The use of cloth and tissue paper pads,
however, was more common among girls who had no pre-menarcheal training.
Soft sterile pad absorbent changed every four hour regardless of the amount of
staining, in the absence of menorrhagia, ensures comfort and prevents the
development of offensive odour . Over half of the
respondents changed their menstrual absorbent 3 or more times a day and there
was no difference by pre-menarcheal training.
limitation of this study was recall bias. In addition, the use of geographical
stratification of cities is not fully validated because of the broad variation
in the construction of cities and factors that determine domicile. The outcome
of social classification based on geographical stratification cannot be
generalized for all cities and its use in this study was limited to the selection
of the school and not for any form of social classification of individual
Due to wide social
and cultural diversity it must be admitted that generalization of the outcome
of this study may be limited. It is hoped that future studies would examine the
impact of ethnicity, religion and socio- economic diversity on pre-menarcheal
training and menstrual practices. Mothers need to be surveyed in order to
identify obstacles faced when preparing their daughters for menarche.
The absence of
pre-menarcheal training resulted in inappropriate menstrual experiences and
poorer menstrual hygiene practices. The contributions of the health sector,
mass media and the formal educational sector in pre-menarcheal training were
poor. The media has the important role of promoting the use of sanitary pads
and instructions on menstrual health could be incorporated into health
education sessions in family planning and antenatal clinics. Women’s
associations and professional organizations related to women’s health care
should promote public discussion of menstrual health issues through seminars,
workshops and conferences. These non-governmental organizations may similarly
help in the provision and distribution of sanitary pads at subsidized rates. Although
not directly studied in this survey, it is expected that inclusion of
pre-menarcheal training in early secondary school curriculum would enable
teachers to address the practical aspects of the management of menses in formal
classes. Menstrual health instructions should contain practical
discussions on how girls should look after themselves during menses in order to
maintain appropriate menstrual and hygiene practices. The issuance of these
instructions is best started before menarche. Finally, proper menstrual
waste disposal facilities should be provided in schools. It is recommended that
toilets be equipped with waste disposal containers and incinerators for
sanitary pads. The absence of these conveniences may be at the root of
school absenteeism associated with menstruation.
they have no conflicts of interest.
contributed in the designed, analysis and preparation of the manuscript.
Characteristics of the 495 secondary school girls surveyed
Factors influencing pre-menarcheal menstrual training
Influence of pre-menarcheal menstrual training on attitude to menstruation and
menstrual and hygiene practices
We hereby acknowledge Awkadigwe F.I, Okoro
P.I , Onyia U for their assistance in distributing the questionnaires
used for this study.
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