Acceptability, usage, and efficacy of menstrual cups: A cross-sectional study among the women of Kochi municipal corporation in Kerala

INTRODUCTION

Menstruation is a normal physiological process that occurs in girls at an average age of 13 years for the first time, and continues every month for almost three decades. It is considered one of the signs of the onset of puberty among them, and is treated as a special stage in a girl’s life cycle, when they experience a transition from childhood to womanhood. But this natural and extremely important biological process does not receive its due importance because of cultural taboos and social stigmas, making it a challenge for girls and women to manage their periods hygienically.¹ Among the different issues related to menstruation, such as insufficient nutrient intake, improper support for pain and cramps management, lack of emotional support systems,² one crosscutting theme is that of the choice of a good menstrual hygiene product that is safe, affordable, and accessible. In low-income countries, girls and women face substantial barriers to ensure adequate menstrual management services and facilities.³ It has been observed that the use of poor-quality materials has been shown to predispose women to an increased risk of urogenital infections, including bacterial vaginosis.^4-6

As per the 2015-2016 National Family Health Survey report (NFHS-4), of 336 million menstruating girls and women in India, about 121 million (roughly 36 percent) girls and women are using locally or commercially produced disposable sanitary napkins (DSNs).⁷ The report surveyed the percentage of young women aged 15–24 years who used hygienic methods like locally prepared napkins, sanitary napkins, or tampons during their menstrual period.⁸ It was found that 42% use sanitary napkins, 62% use cloth, and 16% use locally prepared napkins. In addition, the survey findings indicate that only 48% of rural women used a hygiene product compared to 78% of urban women.⁹

In this scenario, our country generates 12.30 billion sanitary napkin wastes that amount to >9,000 tons every year. Sanitary pads, when thrown in open fields, end up in landfill grounds with a lot of infectious microbes.^10,11 The plastic used in sanitary napkins is non-biodegradable, and is not only harmful for health, but also has negative consequences on the environment. Waste handlers separate out soiled napkins from recyclable items by hand, exposing themselves to micro-organisms like E. coli, Salmonella, Staphylococcus, HIV, and pathogens that cause hepatitis, tetanus, and other serious health conditions.^12,13 Thus, used sanitary napkins pose environmental and public health risks and add considerably to the solid waste management of the country.

During the COVID-19 pandemic, challenges for menstruating women had become more serious. Restrictions in movement and disrupted access to menstrual hygiene materials pose additional challenges in managing menstruation for women who constitute the majority of front-line healthcare workers, female patients in healthcare facilities, women in communities, women in shared facilities like hostels, prisons, camps, etc. Moreover, the demand is high in places where natural resources like water and other facilities are scarce, ensuring the reproductive health and hygiene of women and girls across socio-geographic areas. In this context, the need for an alternative safe, affordable, convenient, and hygienic menstrual product that does not cause public health risk is imperative and can contribute considerably to the health and well-being of women and society at large.

In view of the above, a study was conducted in Kochi Municipal Corporation through the flagship project “Thinkal” to analyze the level of awareness and acceptance towards menstrual cups (M-Cups). It is a community-based cross-sectional study to explore the level of readiness of the beneficiaries to adopt M-Cups as a hygienic sanitary product.

METHODS

The M-Cup supplied through this project is made of medical-grade, platinum-cured silicone and reusable for up to 10 years, and was used for our study purposes. The tapered shape allows for increased comfort in insertion, and the matte finish gives better grip for removal, to first time users. The air holes near the rim help to release the suction while removing the cup without pain or discomfort. The M-Cups were provided in non-dyed cotton cloth pouches, which double up as a storing pouch, along with a clear instruction manual in Malayalam and English, and a pamphlet with contact details of a 24-hour helpline and distribution center. The study intends to measure the level of acceptability of the M-Cups and the problems, if any, the beneficiaries have faced during their usage. The study was undertaken among women belonging to the age group of 21- 52. The study used quantitative and qualitative methods to collect data. Simple Random Sampling was the methodology that was adopted for the study, where data was collected from 750 beneficiaries from the sample frame of 5000 beneficiaries of the Thinkal Project.

Out of 750 beneficiaries who were contacted, 704 beneficiaries shared all information about various aspects of the study. The data collected from 704 beneficiaries were coded and analyzed using Excel and SPSS software (Version 18).

RESULTS AND DISCUSSION

The distribution and awareness sessions of M-cups were implemented by HMA through ASHA workers, local specific groups (SHGs, NGOs, etc.), and facilitated by public health centers and local self-government bodies. Medical professionals of HMA provided guidance about the usage of M-Cups to the beneficiaries and also to Anganwadi and Kudumbasree workers, as they acted as peer educators for personal guidance at the community level. Theme-based awareness camps and training programmes were organized for the beneficiaries in sub-areas. The training programmes focused on awareness creation and the dissemination of information regarding the usage of M-Cups, solving the issues faced by the beneficiaries. Counseling services were also offered to the beneficiaries to clarify their doubts about the usage. The majority of the beneficiaries received information related to M-cup through the training programmes that were conducted in aganvadies, kudumbasree units, ayalkootams, and camps conducted in the colleges and panchayaths. Among the beneficiaries from whom data was collected majority of the respondents belong to the age of 31–35 [Figure 1]. It was found that around 48% of the respondents were graduates, whereas 51% were non-graduates [Figure 2]. It was also observed that the majority of them were Housewives (55%), and others were either working with a private organization or self-employed (29%, 13%) [Figure 3]

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Figure 1: Age group of the respondents (N = 704).

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Figure 2: Educational Background of the respondents (N=704)..

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Figure 3: Employment Status of the respondents (N = 704).

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Out of the study population of 704 (100%), 596 (84.6%) have accepted M-Cup and initiated its usage as a menstrual hygiene management product. Therefore, the 596 respondents will be referred to as M-Cup users and 108 respondents as Non Users.

From Table 1, it can be inferred that beneficiaries belonging to the age group of 25–35 were more confident to use M-Cups (94.44%, 92.1%), whereas respondents belonging to the age group 41–45 were found to be least confident (64.9%). However, from the correlation, it was found that there is a significant negative correlation between age and M-Cup usage (r = -0.164, p <0.05), which shows that there is no relationship between age and M-Cup usage, which further depicts that adaptability and ease of use do not affect the age of respondents.

From Figures 4 and 5, it can be found that there is no correlation between educational level or occupation and the M-Cup usage shown by the respondents. From all the above correlations between demographic variables and M-Cup usage, it is clear that demographic variables such as age, occupation, employment status, etc., do not possess a direct relation to the usage of M-cups. Various other social support factors might be influencing the confidence and usage among the respondents, which need to be further explored in future studies.

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Figure 4: Relationship between educational level and menstrual cup usage of the respondents (N=704).

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Figure 5: Occupation and menstrual cup usage of the respondents (N = 704).

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The study also focused on the factors that affect the usage of M-Cups. Figure 6 depicts that users were having the fear that they may get a urinary infection or M-Cups may get stuck in the vagina, but even after having this fear, they were using the M-Cup because of the support provided by the counselors. In the case of non-users, the major fear that hindered them from using M-Cup was that it may get stuck in the vagina (70), other reasons why the respondents were not comfortable using it in the public toilet (35), were even scared of getting some secondary infection (24), urinary infection (2), and fear of leakage (2). Some participants were worried about the size, shape, and texture of the M-Cup and were unsure of how to insert the M-Cup into their vagina. During the case study and personal interview, one of the respondents described that she always used to have a frequent tendency to urinate whenever she used M-Cups. After analyzing the major factors restricting the beneficiaries from using the M-Cup, further analysis was done to identify the major factors encouraging the usage.

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Figure 6: Fear hindering the usage of M-Cup; Users (N=596), Non Users (N=108).

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From the feedback and data obtained from the study [Table 2], it was found that the majority of the respondents described the M-Cup as a menstrual hygiene management product that is easy and convenient to use; they also highlighted that it is very comfortable to use a M-Cup while moving out.

The impact was analyzed using a bipolar scale where the beneficiaries were directly asked about the impact of M-Cup on their day-to-day work involvement [Table 3].

About 99% of the beneficiaries have reported improvement in their day-to-day work involvement. The majority of the respondents, 86.36% (608), would like to continue/initiate the usage of M-Cups. Around 47% of the non-users did not have the confidence to use the M-Cup. Therefore acceptability and usage of M-Cups could be improved by providing awareness sessions, thereby conducting one-to-one counseling modules to deal with the fears about the cup. Beneficiaries belonging to the age group 25–35 were more confident to use, being aware of its multifold advantages. 68% of the users liked M-Cup because it is reusable, and this aspect was perceived as the major advantage of M-Cup. The largest section (86%) of the respondents believe that menstrual Hygiene management is important, and also 84.6% has accepted the M-cup and have initiated its usage as an efficient menstrual hygiene management compared to sanitary pads, as the majority (97%) of the respondents used disposable plastic pads before they received M-cups. From the feedback received from the respondents who were reluctant to shift to M-Cup, fear was one of the major reasons for their willingness to use it for the first time. Later, the same was found to be improved through the awareness sessions and doubt clearance sessions rendered to the beneficiaries.

CONCLUSION

The current study reveals that the majority of the beneficiaries have accepted M-cup as an effective method for managing menstrual health and hygiene. The acceptance level of M-Cups was high among the disposable pad users, as they found M-Cups convenient and economical, which enhanced their freedom to carry out day-to-day tasks. Effective training eliminates doubts regarding the usage and fear, along with the social stigma associated with an insertion device like the M-cup.