Demographics

The study involved adolescent mothers, mothers aged 20–49 and fathers all who had children below 5 years. Adult women were on average 25, adult men 35 and adolescent women 18 years old (Table 1). Most women had primary education (60%), and none of the adolescent women had tertiary, although this could have been a reflection of their young age or interrupted education due to childbearing. More men completed secondary or tertiary education than women. All respondents were Christian. Adult women had a mean of 2.1 children, adult men 3.3 children and adolescent women 1.3 children. A majority of the inhabitants were involved in fishing, small scale entrepreneurship or subsistence farming as sources of livelihood. A small proportion of the residents were in formal employment such as teaching, nursing, civil service and other services. Poverty levels were high with most of the residents surviving on less than a dollar a day.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Participant demographics.

https://doi.org/10.1371/journal.pone.0229871.t001

Sources of information about menstruation

Respondents received most of their information through school, non governmental organizations (NGOs), family or friends. Friends were the most common source of information for women, who at times received accurate information from friends, more so than from school. Commonly, when a girl first started getting her menses, other girls told her that this meant she could now become pregnant. As is clear in the quote from the following woman, confusion mixed with underlying shame made it hard to reach out to friends for information and support:

I would want to hide it from her (my friend) because I feel embarrassed. It is just embarrassment because the first day I talked to her about it I did not know what was happening to me. I could hear us being taught but I did not think I had reached that age. So I was forced to ask her. She explained to me and told me I had attained that age and so every month I would have my periods and in case I missed my periods any month it would mean I had become pregnant. (Maria, 28, married woman, 2 children)

Women also mentioned talking with other women about menstruation, and its link to fertility, most frequently co-wives or sisters.

I normally ask her (co-wife) because she gets pregnant frequently hence make her have many children. I do ask her why she gets pregnant like almost immediately after delivery. And she tells me that immediately after delivery she gets her monthly period. I talk to her about such kinds of things and I tell her that after giving birth to my baby who is 8 years now, I stayed 4 years without getting my monthly periods (Mona, 25, married woman, 3 children)

Women who felt that they had not received information blamed lack of close female friends or relatives, for example, in the quote below where a woman lived with her grandmother and therefore did not have information until she learned about it in school.

The problem is that I grew up with my grandmother and she never told me anything about menstruation. At times a girl could soil her dress then I would ask to know what happened. But the school contributed a lot in teaching me about menstruation. (Akoth, 23, Married woman, 3 children)

A few men discussed how they learned about menstruation from their wives. A few described how, since they had been married at such a young age, they were already married when their wives first experienced menses and they told their husbands about it, so they learned of it then too. Other men mentioned male friends and elders as key sources of information.

I asked one of my friends if women experience menses and he told me that women must experience menses. Every month a woman must experience menses and a woman who is not experiencing menses could be having a problem, you need to take her for treatment. I then asked him that what problem could be there. He told me that women’s problem are so many, you may need to look for old men to come and tell you issues regarding marriage and how marriages are, that is how he left me. (John, 25, married man, 1 child)

One man discussed in detail the information that he had received in school, which was actually misinformation about the relationship between menstruation and pregnancy.

R: In school we were being taught during a subject called health science. We were told that when a woman is on her menses, a few days to end the menstrual cycle if she engages in sexual intercourse with a man then she can get pregnant… When she is about to clear her menses.

I: When she is about to clear her menses?

R: I mean if she clears today and tomorrow if she has sex then she can get pregnant

I: You were taught in health science that if a woman finished her menses immediately after that if she engages in sex then she can get pregnant?

R: Yes (Owiti, 55, married man, 5 children)

The adolescent mothers, who were mostly not married at the time they became pregnant, discussed talking to their boyfriends about menstruation as a way of planning when they would “visit” each other (in this population many of the boyfriends seemed to be working elsewhere, so the girls would visit them, and have sex, only at scheduled times).

I: Do you talk to him (boyfriend) about your monthly period?

R: We usually talk, in fact even when this one began and went on for one week, I told him my period had gone on for a whole week in the previous month and this month I had not got my period. He told me to just wait

I: You told me you use a calendar. Does your boyfriend help you track your period?

R: No, he lives far. We meet once in a while. But when I first started having my period he knew the dates; if I told him he would know. After delivery I hear your cycle can change

I: So how would he react when you would tell him about your menses before you delivered?

R: He would tell me when I know my period is close I should not visit him [laughter] because anything can happen

I: What did he mean by that?

R: We can get a baby (Sharon, Adolescent mother, age 18)

Another potential source of information about menstruation, especially the link between fertility and menstruation could have been at health facilities, or even at the time of antenatal care visits (ANC) or delivery. However, in our study while most women were asked about their LMP during their first ANC visit, they received no other related information, even why they were being asked that question. Younger women were more likely to go to their first ANC visit later in pregnancy, and they cited denial about being pregnant, fear of being scolded by staff or being attended to by male staff, and a general belief that people looked down upon them if they went to the health facility too early, as reasons not to go.

The reason why I feared (to go for ANC) when I was expecting my baby, is that there were male staff at the facility. I was imagining that I was going to find the same male staff there, so it was making me more worried. When I was expecting baby in 2007, I just remembered the male staff and it was not easy for me. But when I came I found there were some changes …The male staff were not there, there were sisters, and they were sisters that you can even share with them your ideas. (Auma, 21, married woman, 2 children)

I went (to the clinic) later when the pregnancy was 5 months…. I was afraid because I was going to a certain clinic in Kibera and they were very harsh…The clinic staff, they wanted the exact date when one conceived, which I did not know. And that is what made me fear. That is what made me take long I went after 3 months then stayed much longer before going back. (Awino, 24, married woman, 2 children)

Knowledge about the relationship between menstruation and pregnancy

Although most respondents knew there was a relationship between menstruation and pregnancy, accuracy of information was very poor. A few respondents did generally have the correct information, however, they were a little unsure and hesitant about the exact details. As one woman explained:

R: What I was taught in school or what I hear from my friends is that you can count your days like if your menses end today you can have sex like 3 days without using anything and you don’t get pregnant, I don’t know 3 or 6 days. There are some days after your menses that you cannot get pregnant, they are called safe days something of the sort. (Achieng, 31, married woman, 1 child)

Most respondents believed women could become pregnant during menstruation or in the few days before and after. Men especially held this belief, and described how they specifically avoided the days during their partner’s menstrual cycle, and perhaps the few days after that.

She always tells me when she is experiencing menstrual cycle. She tells me that “today I am experiencing menses and when I am experiencing the same you cannot have sex with me without protection unless you leave me to complete my days or you use a condom”. I also took note that when she is on her menses we don’t have sex, I leave her until she completes those her days after four days is when we start having sex with her. (Ojwang, 25, married man, 1 child)

Another man explained that he also believed women could become pregnant the few days before her menstruation, as well as during and after.

R: To get pregnant for a mother in that menstrual period, with my understanding it is before seeing that blood and after seeing that blood before seven days.

I: Can you come again?

R: It is that before the mother sees that blood, the blood will come and by that time it is still not bleeding and maybe you are having sex and it will find when that egg is mature and in that pregnancy maybe an outcome. Sometimes the woman has experienced periods and has completed the periods, but before seven days after ending the periods, she can also conceive at that time. (Odhiambo, 26, married man, 2 children)

Interestingly, men and women acknowledged some confusion about the relationship between the timing of menstruation and when a woman could get pregnant, discussing how they had heard different information from various sources. As seen in the quote below, some respondents, especially men, did use terms that were stigmatizing about menstruation, such as that a woman was “dirty.”

Some men are the ones who do say that if a woman is experiencing her menses that is the time he needs to have sex with her to make her pregnant and some are saying that when she is on her menses she is dirty, such that he cannot have sex with the woman. (Ojwang, 25, married man, 1 child)

Women also expressed fear and stigma about their menses, especially fear that it would occur while they were at school or other public settings.

R: I used to hear that people ‘dhi e dwe’ {Get monthly periods } and used to wonder what that is. When we were going to school some girls could have blood stains at the back of their dresses and that used to worry me a lot. There was a time when I had gone to visit my Aunt and it happened to me. This made me worry a lot but since that time I knew that it’s a stage that a girl must pass through.

I: You have said that whenever a girls dress would be stained at the back it would cause you a lot of worries.

R: Yes.

I: What was making you get so worried?

R: It was worrying because at times it could happen when you are in class and the boys would make fun of it so I used to imagine that the same thing would happen to me. (Mona, 25, married woman, 3 children)

Tracking of menstruation and support

Many women tried to track their menstruation, primarily calendars. Some men and women both said that they memorized the date. Some women specifically asked their partners to help them remember the date. Additionally, many women struggled with irregular periods and some stated that they did not know the date of their last menstrual period (LMP) when they became pregnant, highlighting the need for support for women in tracking their periods.

While most men were open to talking with their partners about menstruation, some men felt that tracking menstruation was a woman’s responsibility, as explained by this man below, who was using “safe days” with his partner.

I: How were you using safe days?

R: Safe days I think being a woman they know how to calculate this, they know the time they are safe.

I: So it is the woman who was calculating not you?

R: It is the woman,

I: So she was telling you this time no, this time it is okay to have sex?

R: Yes (Otieno, 35, married man, 5 children)

Some husbands discussed the importance of knowing about their wives’ menstruation so they could support their wives, for example, by buying pads. As the same respondent as the quote above said: “We talk, we discuss it because sometimes I take the responsibility of buying pads and if you cannot be discussing with her, then I don’t think you could be at a position to buy pads.” (Otieno, 35, married man, 5 children) One man even linked the importance of communicating about menstruation with the ability to plan pregnancies and know the date that the pregnancy occurred.

R: It is important if you are free with your wife talking to her, both of you are free with each other and she can tell you anything on her body and you can also tell her anything on your body, but I think it is important for one to know.

I: Why do you think it is important?

R: Because it is important when you know her timing when she is experiencing her menstrual cycle than when you don’t know. When you know time she is experiencing her menses, then you have sex and she get pregnant and you know that date she has gotten pregnant, you know there are women who are not even aware when they get pregnant and the pregnancy will come as a surprise to her until she is told by other women that are you pregnant and she will say that I am not pregnant. That is when you have a man who is “ma rikni” [proactive] you will hear him telling you that you know you are pregnant. (Ojwang, 25, married man, 1 child)

Aside from husbands who wanted to know about their wives’ periods in order to help buy them pads, much of the discussion about husbands wanting to know in order to know if they could have sex. One woman discussed that her husband thought she was using her period as an excuse and made her show him the evidence (blood) before believing her. A husband described needing to know because of superstitions about not having sex with other women during his wife’s menstrual period.

R: I should know that she is experiencing menstrual cycle, because according to us Luos it is a way of protecting one’s self, so I cannot move out anyhow.

I: How can you not move out anyhow?

R: I cannot meet and have sex with every woman, according to Luos it is a way of protection or “tieko kwer” [Cleansing a taboo]…

I: So you cannot have sex with any other woman?

R: Yes I will be waiting for my wife.

I: What happens if you have sex with another woman?

R: I can “roche”[Do something considered a taboo that can affect her reproductive health]

I: In what way?

R: She may then not give birth. (Obwogo, 25, married man, 1 child )

Women were interested in simple tools to track menstruation, and highlighted a need for privacy. Many women were interested in simple tools like a journal or calendar (on paper) that they could mark in, with some noting that illiterate women could potentially use that. Some women already used their phones, by setting an alarm (although other women felt that an alarm was a potential breach of privacy). Some had concerns of a phone because could easily be lost or stolen or that someone else could see phone, including children, who were seen as more technology savvy.

You know our kids nowadays they have become active especially on phones because they would want to know almost everything and they would want to know everything on the phone. So if you put it in a coded way then maybe the kid won’t understand it easily, but for the two of you, you will know the meaning of that sign or whatever you will be putting on the phone. (Otieno, 35, married man, 5 children)

Other respondents saw the benefit of a phone since it was something they already had and were using, and that it had the potential to provide other types of health related information as well. A few respondents even gave suggestions about how a phone could be used to help women, as described below.

Yes when you hear that alarm ringing in the phone and you see the picture of a moon indicating, it will act like a message, when you open that message you get all the information that you should be prepared like this, this is what the menstruation period says, you should act like this, you should be clean, pads it tells you like that. (Oguda, 26, married man, 2 children))

Overall, however, due to privacy concerns and lack of comfort, most female respondents felt that something like a calendar that they could mark more privately and more easily hide would be more beneficial to them. Additionally, few respondents had smart phones, and therefore even if there was a mobile option, it would have to be very simple. Notably, a few of the adolescent mothers worried that their parents would be suspicious of something unusual on their mobile phones, and therefore felt that it was not a safe option.