Anaba et al. BMC Women’s Health (2022) 22:92 https://doi.org/10.1186/s12905-022-01670-9 RESEARCH Open Access Use of reusable menstrual management materials and associated factors among women of reproductive age in Ghana: analysis of the 2017/18 Multiple Indicator Cluster Survey Emmanuel Anongeba Anaba1 , Emilia Asuquo Udofia2 , Adom Manu1* , Anita Anima Daniels3 and Richmond Aryeetey1 Abstract Background: The use of unsafe materials to collect menstrual blood predisposes women and girls to infections. There is a paucity of literature on the utilization of reusable menstrual materials in sub-Saharan Africa. This study examined factors associated with the use of reusable menstrual management materials among women of reproduc- tive age in Ghana. Findings from this study can inform menstrual health programmes and reproductive health policy to address menstrual hygiene and specific areas of emphasis. Methods: We analysed secondary data from the 2017/18 Ghana Multiple Indicator Cluster Survey. Descriptive statistics were employed to compute frequencies and percentages, while Chi-square and complex sample Binomial Logistic Regression was conducted to identify factors associated with the use of reusable menstrual materials. Results: Half (52%) of the respondents were below 30 years old; mean (± sd) = 30.7(9.0). Thirteen percent used reusable materials to collect menstrual blood during their last period. Women aged 45–49 years (AOR = 5.34; 95% CI 3.47–8.19) were 5 times more likely to manage menstruation with reusable materials compared with those aged 15–19 years (p < 0.05). Women classified in the middle wealth quintile (AOR = 0.66; 95% CI 0.50–0.88) were 34% less likely to use reusable materials to collect menstrual blood compared with women in the poorest wealth quintile (p < 0.05). Also, women who were exposed to television (AOR = 0.78; 95% CI 0.61–0.99) had less odds of using reusable materials compared with women who were not exposed to television (p < 0.05). Conclusion: This study showed that the use of reusable menstrual materials was influenced by socio-demographic factors, economic factors and exposure to mass media. Therefore, policies and programmes aimed at promoting men- strual health should focus on less privileged women. The mass media presents an opportunity for communicating menstrual hygiene. Keywords: Reusable menstrual materials, Women in reproductive age, Ghana, Sanitary pad Background Menstruation is a normal biological process that marks *Correspondence: amanu@ug.edu.gh the beginning of the reproductive age. Globally, 1.8 bil- 1 Department of Population, Family and Reproductive Health, School lion women of reproductive age menstruate every month of Public Health, College of Health Sciences, University of Ghana, Accra, [1]. Promoting optimal hygiene during menstruation is Ghana Full list of author information is available at the end of the article crucial for preventing menstruation-related infections. © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom- mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Anaba et al. BMC Women’s Health (2022) 22:92 Page 2 of 10 Unfortunately, about 500 million women and girls lack very low in Ghana [18]. This suggests that a majority of access to menstrual hygiene facilities, including safe and women who use reusable menstrual materials may be clean menstrual management materials (MMMs) [2]. using reusable cloth/pads. There are two main types of MMMs: disposable materials There is limited empirical evidence for the correlates (including tampon and disposable sanitary pad) and reus- of using reusable menstrual materials. Prior studies in able materials (including reusable pad, cloth, and men- Ghana focused on assessing knowledge, attitudes and strual cup) [3]. Disposable menstrual materials are mostly menstrual hygiene practices among school girls [17, 18]. considered clean by women. Reusable materials can also For instance, [18] revealed that the majority of school be classified as clean if they are cleaned with soap, dried girls in northern Ghana involved in unhygienic menstrual in sunlight, and stored in a clean place [4, 5]. However, practices, such as using unsafe materials (i.e. old cloth, effective management of reusable menstrual materi- pieces of mattress and cotton) to collect menstrual blood. als, especially reusable cloth/pads, remains a challenge The correlates of good menstrual hygiene practices for many women [6]. Reusable pads/cloths are often not included age of respondent, staying with both parents, appropriately cleaned and stored under hygienic condi- access to funds and adequate knowledge about men- tions [7]. Mostly, menstruators dry them indoors or keep struation. In addition, [17] demonstrated that maternal them in the toilet room, due to socio-cultural beliefs and education, late adolescence (15–19  years) and exposure norms surrounding menstruation [8]. Also, the cleaning to radio and television were protective factors against of reusable menstrual materials requires water and soap, poor menstrual knowledge among school girls in north- which may not always be available [9]. These challenges ern Ghana. None of the existing studies explored the cor- may predispose users to reproductive tract infections and relates of reusable menstrual materials among women of complications. reproductive age. Further, the use of menstrual materials Evidence on the safety of reusable menstrual materials is influenced by context-specific factors, such as cultural is mixed. Some studies have reported that reusable men- beliefs, availability and socio-economic factors [20, 21]. strual materials are associated with reproductive tract Hence generalizing findings from other countries would infections [10–12]. However, other studies have demon- be inappropriate. This is the maiden study in Ghana to strated that reusable menstrual management materials examine the use of reusable menstrual materials among are safe, reliable and accepted by menstruators [13, 14]. women of reproductive age using nationally representa- Reusable menstrual materials are more cost-effective and tive data. Findings from this study can inform menstrual environmentally friendly compared with single-used pads health programmes and reproductive health policy to [7]. Women and adolescents in low-income countries address menstrual hygiene and specific areas of empha- prefer reusable pads because they are culturally accept- sis. The objective of this study was to identify factors able, user-friendly, affordable, clean, effective, and acces- associated with the use of reusable menstrual materials sible [11, 15, 16]. There is a preference for reusable pads, among women of reproductive age in Ghana. especially among women in rural settings [5]; however, young women preferred disposable sanitary products. Methods Adolescent girls felt that it was old fashioned to collect Study location, design and source of data menstrual blood with reusable materials [9]. Ghana is one of the countries in West Africa and shares In Ghana, adolescent girls use reusable materials to boundaries with Togo to the east, Cote d’Ivoire to the manage menstruation [17]. A considerable proportion west, Burkina Faso to the north and the Gulf of Guinea to (including 44% and 54.2%) of schoolgirls in northern the south. Ghana has a total population of about 30.8 mil- Ghana use reusable cloth pads to manage menstrua- lion with the majority being females (50.7%) [22]. Women tion due to lack of access to menstrual hygiene facilities, and girls in Ghana face several menstruation-related including safe and clean sanitary products. Many girls in challenges, including lack of access to safe menstrual rural and poor households lack access to disposable sani- materials, water, sanitation and hygiene facilities, hence tary pads and resort to unsafe materials to collect men- they are predisposed to infections and school absentee- strual blood [17]. Adolescent girls use old cloth, panty ism [18, 23]. This study analysed secondary data from liners, pieces of mattress or cotton to collect menstrual the 2017/18 Multiple Indicator Cluster Survey (MICS). blood [18]. Girls lack access to disposable pads due to The 2017/2018 MICS was the sixth round of MICS in financial constraints, unavailability and stigma. Most Ghana, nationally representative and the most recent. girls do not have income for purchasing disposable sani- Unlike previous MICS, this survey employed Computer- tary pads [17]. In addition, menstruators dry reusable Assisted Personal Interviewing (CAPI) to collect data menstrual materials indoors or under the shade [19]. from the participants. Participants were recruited across Moreover, awareness and uptake of menstrual cups are the previous ten administrative regions in the country, A naba et al. BMC Women’s Health (2022) 22:92 Page 3 of 10 employing a two-stage sampling technique. The first adjusted for the complex nature of the survey (clustering, stage of the recruitment process involved the selection of stratification and sampling weight) by employing the ‘svy’ 660 clusters from the 2010 Population and Housing Cen- Stata command. All statistical significance was reported sus sampling list proportional to size. Secondly, 13,202 at the 0.05 significance level, while the odds ratios and households (including 6163 from urban areas and 6864 their 95% confidence intervals were used to examine the from rural areas) were selected from the clusters using strength of association. a systematic random sampling technique. This study focused on women of reproductive age, hence we ana- Results lysed data from the women file. After dropping missing Descriptive statistics values and adjusting for the complex nature of the sur- The results showed that 21% of the participants were aged vey, we obtained a weighted sample size of 10,861 women 15–19 years, 15% were between the ages of 30–34 years aged 15–49  years. The 2017/18 MICS report indicated and 8% were between the ages of 45–49  years. The that verbal consent was obtained from all participants mean age was 30.7 years and a standard deviation of 9.0. before questionnaires were administered. Informed con- (Table 1). Exactly 41% of the participants had completed sent was obtained from parents or legal guardians of par- junior high education, while 17% had pre-primary/no ticipants below 18 years (minors). Moreover, participants education. About 16% of the women were classified in were assured of voluntary participation, confidentiality, the poorest wealth quintile and 24% in the richest wealth anonymity of information, and free will to withdraw from quintile. The majority (55%) of the participants were cur- the interview at any point. Data analysed in this study rently married, and 36% had never married. Fifty-two per was obtained from UNICEF through a formal request. cent of the participants resided in urban areas, 25% were from the Ashanti Region, and 9% had disabilities. The Measurement majority (89%) of the women did not read a newspaper, The dependent variable in this study was the use of reus- 31% did not listen to a radio, and 46% watched televi- able menstrual management materials. This was a direct sion almost every week. The prevalence of using reusable follow-up question to materials used during the last men- menstrual materials was 13% and 87% used disposable struation (were the materials reusable?). This item was menstrual materials. originally coded as (Yes = 1, No = 2, and don’t know = 8). Before the analysis, the outcome was re-coded as ‘Yes’ = 1 Association between participants’ characteristics and ‘No’ = 0. Responses indicating ‘don’t know’ and and usage of reusable materials ‘non-response’ were deleted from the dataset. The inde- A higher proportion (29%) of women aged 45–49  years pendent variables identified were socio-demographic used reusable menstrual materials compared with characteristics, disability status, and exposure to the mass women aged 15–19  years (6%) (p < 0.05). Also, the use media. The following socio-demographic variables were of reusable materials was significantly associated with included in analyses: age of respondent, educational sta- educational status (p < 0.05). Thirty-eight per cent of the tus, household wealth index, marital status, type of place women with no education used reusable materials, while of residence, and region. Disability status was coded as only 2% of the women with higher education used reus- ‘has functional difficulties’ = 1 and ‘has no functional dif- able materials. A considerable proportion of women in ficulties’ = 2. Exposure to mass media was assessed using the poorest (29%) wealth quintile managed menstruation three items: frequency of reading a newspaper, listening with reusable materials. Significant associations were to a radio, and watching television. Details about the cod- found between marital status, disability, and the use of ing of the independent variables are provided elsewhere reusable materials (p < 0.05). Four in ten women in the [24]. Northern region used reusable materials to collect men- strual blood. A substantial proportion of women who Statistical analysis had less exposure to mass media, including newspaper We employed univariate, bivariate, and multivariable (14%), radio (18%) and television (24%), preferred reus- analyses. At the univariate level, descriptive statistics able materials (p < 0.05) (Table 2). were computed using frequency and percentages and summarized in tables. At the bivariate level, the Chi- Predictors of use of reusable menstrual materials square test was used to examine the association between among women of reproductive age the dependent and independent variables. Binomial In the unadjusted analysis, all participant characteristics Logistic Regression was used to identify significant pre- and exposure to mass media were statistically significant dictors of the outcome variable. All the statistical tests predictors of using reusable menstrual materials. For were embedded in Stata/SE version 16. Further, we instance, women aged 45–49 years (COR = 6.13; 95% CI Anaba et al. BMC Women’s Health (2022) 22:92 Page 4 of 10 Table 1 Participants’ characteristics Table 1 (continued) Characteristic Frequency Percentage Characteristic Frequency Percentage Age (years) At least once a week 2672 21 15–19 2697 21 Almost every week 3779 30 20–24 2023 16 Frequency of watching television 25–29 1892 15 Not at all 3173 25 30–34 1836 15 Less than once a week 1478 12 35–39 1678 13 At least once a week 2187 17 40–44 1462 12 Almost every week 5744 46 45–49 993 8 Reusable menstrual material Education level completed Yes 1614 13 Pre-primary/no education 2156 17 No 10,907 87 Primary 2092 17 Junior high 5158 41 Senior high 2402 19 Higher 774 6 4.66–8.06) were six times more likely to manage men- Wealth index categories ses with reusable materials compared with women aged Poorest 1973 16 15–19 years. Also, women who had at least primary edu- Second 2287 18 cation (COR = 0.31; 95% CI 0.24–0.39) were 69% less likely to use reusable materials compared with those with Middle 2551 20 pre-primary or no education (Table  3). In the adjusted Fourth 2713 22 analysis (Table  3), women who were between the ages Richest 3058 24 of 45–49  years (AOR = 5.34; 95% CI 3.47–8.19) were 5 Marital status times more likely to manage menstruation with reusable Currently married 6884 55 materials compared with those aged 15–19  years. Also, Formerly married 1190 9 women who had attained at least primary school educa- Never married 4508 36 tion (AOR = 0.50; 95% CI 0.38–0.66) were 50% less likely Area of residence to use reusable materials compared with women who Urban 6508 52 had pre-primary/no education. Also, wealth index was Rural 6074 48 a significant predictor of using reusable materials. For Region instance, women classified in the middle wealth quintile Western 1275 10 (AOR = 0.66; 95% CI 0.50–0.88) were 34% less likely to Central 1255 10 use reusable materials to collect menstrual blood com- Greater Accra 1677 13 pared with women in the poorest wealth quintile. Fur- Volta 905 7 ther, women who had never married were less likely to Eastern 1520 12 use reusable materials compared with those who were Ashanti 3101 25 currently married (AOR = 0.70; 95% CI 0.52–0.93). Brong-Ahafo 1138 9 Women who were exposed to mass media had less odds Northern 1086 9 of using reusable materials compared with women who Upper East 359 3 were not exposed to mass media. Also, women with dis- Upper West 265 2 abilities (AOR = 1.36; 95% CI 1.06–1.76) had higher odds Disability status of managing menstruation with reusable materials com- Has functional difficulty 974 9 pared with their counterparts. The goodness of fit test Has no functional difficulty 9887 91 (Hosmer–Lemeshow Test) showed that the model was Frequency of reading newspaper well fitted (p = 0.78) (Table 3). Not at all 11,000 89 Less than once a week 796 6 At least once a week 559 4 Discussion Almost every week 166 1 The prevalence of reusable menstrual management mate- Frequency of listening to a radio rials was 13%. This implies that most Ghanaian women of Not at all 3918 31 reproductive age use disposable menstrual hygiene man- Less than once a week 2213 18 agement materials. Although Ghana has no established benchmarks regarding reusable menstrual materials, A naba et al. BMC Women’s Health (2022) 22:92 Page 5 of 10 Table 2 Cross-tabulation of participant characteristics and use Table 2 (continued) of reusable pads Characteristic Menstrual material reusable Characteristic Menstrual material reusable Total (n) Yes (%) No (%) Chi-square Total (n) Yes (%) No (%) Chi-square Frequency of listening to a radio Age groups (years) Not at all 3918 18 82 23.32* 15–19 2697 6 94 62.07* Less than once a week 2213 12 88 20–24 2023 6 94 At least once a week 2672 10 90 25–29 1892 9 91 Almost every week 3779 10 90 30–34 1836 12 88 Frequency of watching television 35–39 1678 17 83 Not at all 3173 24 76 80.68* 40–44 1462 24 76 Less than once a week 1478 17 83 45–49 993 29 71 At least once a week 2187 11 89 Education completed Almost every week 5744 6 94 Pre-primary/no education 2156 38 62 204.94* * p Value < 0.05 Primary 2092 16 84 Junior high 5158 7 93 this prevalence is commendable when juxtaposed with Senior high 2402 3 97 the findings of previous studies. For instance, prior stud- Higher 774 2 98 ies revealed that 34–54% of adolescent girls in northern Wealth index Ghana use reusable cloth to manage menstruation. Not- Poorest 1973 29 71 113.92* withstanding, the prevalence found in this study is higher Second 2287 21 79 than the prevalence of reusable menstrual materials Middle 2551 13 87 among university students in Ghana (9.2%) [25]. The dis- Fourth 2713 5 95 parities in the findings may be attributed to differences Richest 3058 3 97 in study locations and populations. This study analysed Marital status nationally representative data among women of repro- Currently married 6884 18 82 97.22* ductive age, while prior studies focused on specific geo- Formerly married 1190 15 85 graphical locations or social class. Never married 4508 5 95 In addition, existing studies elsewhere have reported Area of residence higher prevalence of reusable menstrual materials. For Urban 6508 8 92 93.84* instance, a study in Nepal revealed that 66.7% and 76.1% Rural 6074 18 82 of women used reusable sanitary cloth before and after Region an earthquake respectively [26]. In India, the preva- Western 1275 13 87 59.91* lence of reusable menstrual materials ranged from 42 to Central 1255 13 87 51.2% among women of reproductive age [27–29]. On Greater Accra 1677 6 94 the contrary, a study in Kolkata, India reported that 6.5% Volta 905 28 72 of women in reproductive age use reusable menstrual Eastern 1520 7 93 materials [30]. Also, studies have reported that 4.8% and Ashanti 3101 3 97 1.4% of high school girls in Ethiopia and Benin use reus- Brong-Ahafo 1138 13 87 able menstrual materials respectively [31, 32]. To the best Northern 1086 44 56 of the authors’ knowledge, this is the maiden study to Upper East 359 15 85 report a prevalence of 13% for reusable menstrual mate- Upper West 265 24 76 rials among women of reproductive age. The differences Disability status in these findings may be attributed to differences in con- Has functional difficulty 974 22 78 33.69* textual and socio-demographic factors. Evidence shows Has no functional difficulty 9887 13 87 that decisions on the type of menstrual materials to use Frequency of reading newspaper are influenced by availability, cost and cultural beliefs Not at all 11,000 14 86 5.39* surrounding menstrual materials [20, 21]. Also, young Less than once a week 796 3 97 women(10–24  years) have negative attitudes toward At least once a week 559 3 97 reusable menstrual materials [9]. Almost every week 166 2 98 Age was a significant predictor of using reusable men- strual materials. This finding is supported by a previous Anaba et al. BMC Women’s Health (2022) 22:92 Page 6 of 10 Table 3 Binary Logistic Regression analysis of predictors of usage of reusable menstrual materials Characteristic Crude analysis OR (95% CI) Adjusted analysis OR (95% CI) Age groups (years) 15–19 1(ref ) 1(ref ) 20–24 0.92(0.68–1.26) 1.05(0.72–1.52) 25–29 1.58(1.18–2.12)* 1.45(0.95–2.20) 30–34 2.16(1.63–2.87)* 2.08(1.35–3.21)* 35–39 3.22(2.44–4.26)* 2.39(1.57–3.65)* 40–44 4.76(3.67–6.19)* 4.35(2.82–6.72)* 45–49 6.13(4.66–8.06)* 5.34(3.47–8.19)* Education levels completed Pre-primary or no education 1 (ref ) 1(ref ) Primary 0.31(0.24–0.39)* 0.50(0.38–0.66)* Junior high 0.12(0.10–0.15)* 0.33(0.25–0.43)* Senior high 0.04(0.03–0.06)* 0.24(0.16–0.34)* Higher 0.02(0.01–0.05)* 0.18(0.09–0.35)* Wealth index Poorest 1 (ref ) 1(ref ) Second 0.65(0.51–0.84)* 1.01(0.77–1.32) Middle 0.35(0.27–0.45)* 0.66(0.50–0.88)* Fourth 0.13(0.10–0.18)* 0.32(0.23–0.44)* Richest 0.06(0.04–0.09)* 0.19(0.12–0.29)* Marital status Currently married 1 (ref ) 1(ref ) Formerly married 0.79(0.63–1.00)* 0.86(0.69–1.08) Never married 0.24(0.19–0.30)* 0.70(0.52–0.93)* Area of residence Urban 1 (ref ) 1(ref ) Rural 2.76(2.23–3.42)* 1.05(0.83–1.33) Region Greater Accra 1 (ref ) 1(ref ) Western 2.22(1.47–3.36)* 1.21(0.74–1.98) Central 2.36(1.54–3.63)* 1.38(0.84–2.28) Volta 6.08(3.85–9.60)* 2.58(1.62–4.11)* Eastern 1.20(0.75–1.92) 0.52(0.30–0.88)* Ashanti 0.41(0.24–0.70)* 0.19(0.11–0.32)* Brong-Ahafo 2.23(1.47–3.37)* 0.88(0.53–1.45) Northern 11.86(7.85–17.90)* 2.98(1.82–4.87)* Upper East 2.62(1.70–4.03)* 0.56(0.32–0.99)* Upper West 4.82(3.27–7.09)* 1.07(0.65–1.77) Disability status Has no functional difficulty 1 (ref ) 1(ref ) Has functional difficulty 1.84(1.49–2.27)* 1.36(1.06–1.76)* Frequency of reading newspaper Not at all 1 (ref ) 1(ref ) Less than once a week 0.21(0.12–0.36)* 1.02(0.58–1.79) At least once a week 0.20(0.10–0.37)* 1.03(0.48–2.20) Almost every week 0.05(0.00–0.40)* 0.43(0.06–2.97) Frequency of listening to a radio Not at all 1 (ref ) 1(ref ) A naba et al. BMC Women’s Health (2022) 22:92 Page 7 of 10 Table 3 (continued) Characteristic Crude analysis OR (95% CI) Adjusted analysis OR (95% CI) Less than once a week 0.67(0.53–0.83)* 1.00(0.79–1.27) At least once a week 0.47(0.38–0.59)* 0.97(0.76–1.24) Almost every week 0.50(0.41–0.61)* 1.00(0.81–1.25) Frequency of watching television Not at all 1 (ref ) 1(ref ) Less than once a week 0.67(0.52–0.87)* 1.18(0.89–1.57) At least once a week 0.40(0.32–0.51)* 0.86(0.65–1.13) Almost every week 0.21(0.17–0.26)* 0.78(0.61–0.99)* Population size: 10,860.982 Number of observations: 10,861 Number of strata: 20 Number of primary sampling units: 660 Design df: 640 F (36, 605): 21.87 Prob: < 0.0001 McKelvey and Zavoina’s R-sqaure: 0.40 CI confidence interval, OR odd ratio *p Value < 0.05; ref (reference category) study in India, where adult women preferred reusable women. This finding is expected because well educated materials and young women preferred disposable sani- women are more likely to be employed and can there- tary products [33]. Adolescent girls in Malawi perceived fore afford disposable pads. Moreover, educated women reusable materials as ‘old fashion’, hence preferred single- are literate and can access health information regarding use pads [9]. A plausible explanation is that adult women sanitary products. The use of reusable menstrual mate- may be more familiar with reusable pads compared with rials was common among women in the poor wealth disposable pads [33]. In addition, women in rural areas index. Understandably, women of low economic status were more likely to use reusable menstrual materials may not be able to afford commercial sanitary pads. compared with those in urban settings. Prior studies Previous studies in Ghana have reported that financial have shown that women in remote areas preferred reus- constraint was a major barrier to accessing disposable able pads, while those in urban areas preferred commer- sanitary products among adolescent girls in school [17, cial sanitary pads [5]. Women in rural communities are 18]. more likely to be unemployed or engaged in menial jobs, It was also revealed that women with disabilities pre- hence may have little disposable income to buy com- ferred reusable materials compared with those without mercial sanitary pads. Besides cost, disposable pads may disabilities. Women with disabilities are less likely to be not always be available in rural areas compared to urban employed and may not be able to afford disposable pads areas. There is evidence to show that menstruators prefer every month. Women who were exposed to mass media reusable pads because they are cost-effective and avail- had less odds of using reusable menstrual materials. In able [7, 9]. Ghana, commercial sanitary products are advertised on Further, it was revealed in this study that women television, radio and in newspapers. Therefore, women who were currently married or in a union had higher who are exposed to the mass media may be influenced odds of using reusable materials compared with those by these advertisements. Also, women in the Northern who were never married or in a union. This finding is and Volta Regions were two times more likely to use not surprising because never-married women are more reusable materials compared with women in the West- likely to be adolescent or young women, while married ern Region. This finding may be explained by the high women are more likely to be adult women. As indi- incidence of poverty in the Northern and Volta regions cated earlier, adult women prefer reusable menstrual compared with the Western Region [34]. Therefore, materials to disposable pads [33]. We also found that women from these geographical regions may not be less educated women were more likely to use reusable able to afford commercial sanitary pads compared with menstrual materials compared with highly educated their counterparts. Anaba et al. BMC Women’s Health (2022) 22:92 Page 8 of 10 Implications for policy, practice and research Limitations and strengths of the study These findings have implications for menstrual health This is a primal study in Ghana which investigates men- policy, programming and research. strual hygiene behaviours among women of reproduc- Reusable materials can breed infections when they are tive age using nationally representative data, hence the not well cleaned and stored [12]. Since most menstrua- findings of this study can be generalized to the study tors in Ghana dry their reusable materials indoors or population. Also, we employed appropriate statistical under the shade; instead of drying them in the sunlight analysis, such as weighting to adjust for oversampling [23], they may be at a higher risk of infections, including and under-sampling. Moreover, the data analysed in candidiasis, bacterial vaginosis and urogenital infections. this study was from the most recent MICS. Another These infections are risk factors for HIV, adverse preg- major strength of this study is the good response nancy outcomes and Human Papillomavirus Infection rate (99.8%). In addition, this study provides relevant [35]. Untreated infections can lead to prenatal infection, empirical information on menstrual hygiene manage- infecundity, toxic shock syndrome, ectopic pregnancy ment practices of Ghanaian women of reproductive and low birth weight [36]. age. Stakeholders, including the Ministry of Health and It is therefore crucial for the Ghana Health Services to Ministry of Gender, Children and Social Protection educate the public about good menstrual hygiene prac- and non-governmental organizations, can leverage this tices. Stakeholders can leverage the mass media to dis- information to inform reproductive health policies and seminate menstrual health information. In addition, the programmes which would contribute to promoting the Ghana Education Service should intensify efforts towards health and wellbeing of women and girls. menstrual health education by providing skilled-based However, this study has some limitations, includ- education regarding the management of reusable men- ing the study design. The cross-sectional survey nature strual materials as well as educating girls about safe reus- of the study cannot establish a causal relationship able menstrual materials. There is also a need for social between the independent and dependent variables; and behavioral change communication programmes to hence the findings must be interpreted with caution. help reduce the stigma and shame associated with dry- Also, we acknowledge that the prevalence of reus- ing reusable menstrual materials in the sunlight. These able menstrual management materials may be under- efforts will help reduce the unhygienic management of reported or over-reported. Further, data collection was reusable materials and infections among users. based on self-report, hence there were possibilities of In addition, it is necessary to promote access to dis- recall bias and social desirability bias. Also, the 2017/18 posable sanitary pads since it is safe and easy to use [4]. Ghana Multiple Indicator Cluster Survey did not col- Currently, in Ghana, disposable sanitary pads attracts an lect data on the types of reusable menstrual materials import tax of 20% and a value-added tax of 12.5% [37]. used by women, management of reusable menstrual There has been little commitment on the part of the materials and health status of women who use reusa- Government of Ghana regarding implementing policies ble menstrual materials. This information is useful for that will make disposable sanitary pads affordable. Other menstrual health education and should be collected in Africa countries, including Kenya, Ethiopia and Tanza- future surveys. nia, have either reduced or eliminated taxes on sanitary products to make it affordable [38]. This study reiter- ates that it is necessary for the Government of Ghana to Conclusions reduce taxes on sanitary pads to make it affordable and This study has demonstrated that a minority of Ghana- accessible to women and girls. ian women of reproductive age use reusable menstrual This study sets the pace for future research on the materials. Age, lower education, low economic status, lit- subject matter to help inform policy and programmes. tle exposure to mass media, being married, residing in a Currently, little is known about the types of reusable rural area, and geographical region were the significant menstrual materials patronized by women in Ghana as determinants of using reusable menstrual materials. The well as the health status of women who manage period findings of this study provide relevant information for with reusable materials. Also, future studies should menstrual health policy and programming. Clean and explore the acceptability of safer and easy to clean reus- safe reusable menstrual materials should be available for able menstrual materials, such as the menstrual cup. women to make their preferred option. Reusable men- Moreover, there is a paucity of literature on the socio- strual materials should be accessible through outlets and cultural correlates of reusable menstrual materials and information regarding use disseminated through mass the experiences of women who use reusable menstrual media. materials. A naba et al. BMC Women’s Health (2022) 22:92 Page 9 of 10 Abbreviations 5. Kaur R, Kaur K, Kaur R. Menstrual hygiene, management, and waste MICS: Multiple Indicator Cluster Survey; MMM: Menstrual management mate- disposal: practices and challenges faced by girls/women of developing rials; UNICEF: United Nations International Children’s Emergency Fund; CAPI: countries. J Environ Public Health. 2018; 2018. Computer assisted personal interviewing. 6. Hennegan J, Dolan C, Steinfield L, Montgomery P. A qualitative understanding of the effects of reusable sanitary pads and puberty Acknowledgements education: implications for future research and practice. Reprod Health. Emmanuel Anongeba Anaba is receiving funding as a PhD candidate from 2017;14(1):1–12. the HRP Alliance, part of the UNDP-UNFPA-UNICEF-WHO-World Bank Special 7. Hennegan J, Dolan C, Wu M, Scott L, Montgomery P. Schoolgirls’ experi- Programme of Research, Development and Research Training in Human ence and appraisal of menstrual absorbents in rural Uganda: a cross-sec- Reproduction (HRP), a cosponsored programme executed by the World Health tional evaluation of reusable sanitary pads. Reprod Health. 2016;13(1):143. Organization (WHO), to complete his studies. 8. Shah SP, Nair R, Shah PP, Modi DK, Desai SA, Desai L. Improving quality of life with new menstrual hygiene practices among adolescent tribal girls Authors’ contributions in rural Gujarat, India. Reprod Health Matters. 2013;21(41):205–13. EAA: Conceptualization, data curation, formal analysis, writing of original draft, 9. Kambala C, Chinangwa A, Chipeta E, Torondel B, Morse T. Acceptability of review and editing. AAD: Conceptualization, writing of original draft, review menstrual products interventions for menstrual hygiene management and editing. RNOA: Supervision, reviewing and editing. AM: conceptualization, among women and girls in Malawi. Reprod Health. 2020;17(1):1–12. supervision, writing of original draft, reviewing and editing. EAU: Supervision, 10. Das P, Baker KK, Dutta A, Swain T, Sahoo S, Das BS, Panda B, Nayak A, reviewing and editing. All authors read and approved the final manuscript. Bara M, Bilung B. Menstrual hygiene practices, WASH access and the risk of urogenital infection in women from Odisha, India. PLoS ONE. Funding 2015;10(6):e0130777. The author did not receive any funding for this study. 11. Hennegan J, Dolan C, Wu M, Scott L, Montgomery P. Schoolgirls’ experience and appraisal of menstrual absorbents in rural Uganda: a Availability of data and materials cross-sectional evaluation of reusable sanitary pads. Reprod Health. The data used in this study is owned by UNICEF, therefore, the authors cannot 2016;13(1):1–12. share the data. Interested persons can contact UNICEF for the data (contact 12. Torondel B, Sinha S, Mohanty JR, Swain T, Sahoo P, Panda B, Nayak A, Bara via accra@unicef.org). The authors confirm they did not have any special M, Bilung B, Cumming O. Association between unhygienic menstrual access or privileges to the data that other researchers would not have. management practices and prevalence of lower reproductive tract infec- tions: a hospital-based cross-sectional study in Odisha, India. BMC Infect Dis. 2018;18(1):473. Declarations 13. Juma J, Nyothach E, Laserson KF, Oduor C, Arita L, Ouma C, Oruko K, Omoto J, Mason L, Alexander KT. Examining the safety of menstrual Ethics approval and consent to participate cups among rural primary school girls in western Kenya: observational The Ghana Health Service Ethics Review Committee approved the protocols studies nested in a randomised controlled feasibility study. BMJ Open. for the 2017/18 MICS. Informed consent was obtained from all adult partici- 2017;7(4):e015429. pants and informed assent from minors. A formal request to use the raw data 14. Phillips-Howard PA, Nyothach E, Ter Kuile FO, Omoto J, Wang D, Zeh C, was made to UNICEF through their website (https:// mics. unicef.o rg/s urve Onyango C, Mason L, Alexander KT, Odhiambo FO. Menstrual cups and ys). Permission to use the raw data was granted by UNICEF. The study was sanitary pads to reduce school attrition, and sexually transmitted and performed in accordance with relevant regulations and guidelines. Data used reproductive tract infections: a cluster randomised controlled feasibility in this study were anonymised before use. study in rural Western Kenya. BMJ Open. 2016;6(11):e013229. 15. Tilley E, Bieri S, Kohler P. Sanitation in developing countries: a review Consent for publication through a gender lens. J Water Sanit Hyg Dev. 2013;3(3):298–314. Not applicable. 16. Sommer M. Menstrual hygiene management in humanitarian emergen- cies: gaps and recommendations. Waterlines. 2012;31:83–104. Competing interests 17. Mohammed S, Larsen-Reindorf RE. Menstrual knowledge, sociocultural The authors declare that they have no competing interests. restrictions, and barriers to menstrual hygiene management in Ghana: evidence from a multi-method survey among adolescent schoolgirls and Author details schoolboys. PLoS ONE. 2020;15(10):e0241106. 1 Department of Population, Family and Reproductive Health, School of Public 18. 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