Emma Kelly (pseudonym), a registered nurse from the U.S., resides in India, where she began The Pad Project in 2013. The Pad Project is a women's health program used to educate women on their monthly menstrual cycles and provide sustainable hygienic kits to promote menstrual health. This unique health education program also integrates stories from the gospel to illustrate Christ's love and caring commitment toward women and women's health. When asked what inspired this program, Emma Kelly recounted,
While visiting a friend who worked with homeless and poverty stricken women in India, I noticed a woman wearing a red sari, the traditional dress in India. The woman was the last to stand among the group, and as she stood I watched her smear a pool of blood on the floor with her foot so it could dry before anyone noticed. I recognized the woman had her period. I had never thought that women in India would have different hygienic practices than I do. As I researched ways to help, I realized many women could not afford disposable pads. They use what supplies they have: ash from the fire wrapped in a cloth, old torn rags, the hairs from the outside of a coconut, shredded newspapers. The really poor allow the blood to flow down their legs, wiping it with their petticoats from their saris, as it... as it drips down their bodies. (personal communication, July 9, 2015)
THE PAD PROJECT
Menstrual hygiene management (MHM) and issues associated with menstruation are rarely openly discussed with girls or women in India, leading to burden and stress (Juyal, Kandpal, Semwal, & Negi, 2012). Only 7% of women use sanitary napkins (Fernandez, as cited in Jothy & Kalaiselvi, 2012). Emma designed the Pad Project in India to combine group education on menstruation and personal hygiene with Scripture to communicate God's love for women. Each woman attending a Pad Project session receives a sustainable kit as a gift, another example of Christian love. The kit contains six washable, reusable reusable pads, two panty liners, underwear, a washcloth, two safety pins, a bar of soap, and a bar of laundry detergent. Contents are carefully wrapped in a modest folding clutch, lined with waterproof material that contains separate sections for clean and soiled pads.
The group educational session works best with 10 or fewer women, ages 10 to 38. The presentation begins with a discussion of the terminology women use worldwide to describe their monthly menstrual cycles. The facilitator asks, “What do you call your cycle?” and “What have you heard it called?” Next, a simple overview of female reproductive physiology is given to answer questions such as, “Why do I bleed every month?” An illustrated guide increases understanding, as the presentation moves through the phases of a woman's cycle. Additional questions are posed to encourage dialogue and establish trust between the group members. (Table 1).
The presentation then transitions into the story of God's creation. The story in Genesis is presented first because it is important for the women to understand that God made everything for a good purpose. This approach is used to emphasize that God specifically made woman in his own image for a purpose that is good (Genesis 2:20-25). The story ends with the account of the first disobedience of God (Genesis 3) and Adam and Eve's feelings of shame and being unclean. The phrase from Scripture “they knew they were unclean” is used because it is true, and it explicitly sets up the problem theme, “Jesus makes us clean,” an important concept shared in the second story.
An overview of how to use the washable pads is then provided, complete with pictorials and a step-by-step process for pinning or snapping the pad in place. The women are taught how to remove, clean, and dry the pads, with a warning not to share pads. Another phase of education focuses on the importance of washing the body to remove blood and includes practical tips such as, it is acceptable to bathe and participate in normal daily activities during menstruation.
JESUS' COMPASSION FOR WOMEN
The crux of the gospel is then presented with the story of Jesus and his compassion for the woman with the bleeding problem. The facilitator tells the story, crafted from Mark 5:
The first man and woman had children, and their children had children, and their children had children. But everyone was still separated from God. They were unclean. Finally, God sent his Son to make us clean and to bring us back to him. His Son's name was Jesus. One time, Jesus was with a crowd of people. A woman was there. She had been bleeding for 12 years. The doctors couldn't heal her. She heard about Jesus so she came to see him. She thought, “I will touch his robe. Then I will be healed.” She came up behind him and touched the hem of his robe. Immediately, her bleeding stopped! Jesus knew someone had touched him. He asked, “Who touched me?” The woman was frightened. She came to Jesus and fell on her knees in front of him. She told him what she had done. Jesus said, “Daughter, your belief in me has healed you. Go in peace.” (personal communication, July 9, 2015)
In India and other countries, women understand that her bleeding made the woman religiously unclean. The audience may initially think that Jesus became unclean when the woman touched him. Through the story and the discussion, they understand that not only did he not become unclean, Jesus made the woman clean. The power of God's miracle is emphasized.
The last stage of the presentation addresses practical strategies to reduce menstrual cramps and premenstrual syndrome. Signs, symptoms, prevention, and treatment of a yeast infection are covered.
The final biblical account presented is Luke 7:36-50, the woman washing Jesus' feet:
A religious leader asked Jesus to come to his house for a meal. Jesus came and sat down. There was an immoral and unclean woman in town. She heard that Jesus was at the religious leader's house. She came to the house with a jar of expensive perfume. She knelt at his feet. She was crying because she was so thankful. Her tears fell on Jesus' feet. She wiped Jesus' feet with her hair and poured perfume on them. She kissed his feet to show respect. The religious leader was surprised that Jesus allowed this because this woman was unclean. Jesus knew his thoughts. Jesus said to the leader, “This woman loves me so much because she was very unclean and disobedient. But I have forgiven her.” Jesus said to the woman, “Your sins are forgiven because you have believed in me. Go in peace.” (personal communication, July 9, 2015)
When asked how she started, Emma explained she originally tested the project with women in such poverty they were compelled to beg on the streets. Emma was able to use their feedback to change the pad design to be longer and thinner, and added a tab to the end to pin it in place. When asked about obstacles, Emma replied:
One aspect I did not anticipate almost ruined the project in the final months of development. I was explaining to a group of ladies in a slum how to dry their pads in the sun. They had been intently listening and were excited to use underwear for the first time and to have pads to catch their blood. But when I told them to hang their pads to dry, they told me they would not use the pads if they had to do that. I almost panicked! The issue of modesty is worldwide; no one wants anyone to see their pads or know they have their period. I quickly offered a solution: lay the pads out wherever you choose, but cover them with your thin duppata (scarf) so that no one can see what is underneath. They agreed this method would work. (personal communication, July 9, 2015)
The importance of women's health is a high-profile global health topic; however, there is little focus on the impact appropriate MHM can have (Jothy & Kalaiselvi, 2012). The cultural pressure to shroud menstruation in secrecy, combined with inadequate supplies in many low- and middle-income countries (LMICs), manifests at times as severe restrictions on activity and social isolation (Guya, Mayo, & Kimwag, 2014).
Although Emma's Pad Project conveys a Christian worldview, there are many international pad project initiatives. Globally, approximately 52% of the female population is between the age of menarche and menopause. Although the age of onset varies, most will begin between 8 and 16 years, with an average age of 13 years. For a typical woman with onset of menopause starting at 50 years old, this equals approximately 1,400 lifetime menstrual days (Sumpter & Torondel, 2013). In many countries, menstruation is considered to be dirty, impure, and rarely mentioned (Kaundal & Thakur, 2014). Although a normal and important part of life, menses also is associated with negative attributes. Religious beliefs, social norms, and myths are deeply embedded in many cultures (Bhartiya, 2013; Dunnavant & Roberts, 2013; House, Mahon, & Cavill, 2012). Examples of these beliefs are highlighted in Table 2. Some cultural beliefs on menstruation are associated with evil spirits and shame. In Tanzania, some believe that if someone sees your menstrual pad, you will be cursed (Guya et al., 2014). In Bangladesh, some women bury their menstrual pad to keep evil spirits from using it (House et al.).
The Pad Project is needed because the lack of basic supplies for menstruation keeps girls from attending school (Grant, Lloyd, & Mensch, 2013; Shahidul & Karim, 2015). Monthly missed days of education are a reason adolescents drop out of school (Guya et al., 2014; King, Dewey, & Borish, 2015). When young girls miss school because of menstruation, they may become embarrassed, get behind, and drop out of school early. As studies have linked maternal education more closely with child survival than poverty, this has the potential to negatively affect the country (Sartorius & Sartorius, 2014).
For girls and women to manage menstruation hygiene, they must have access to a private place to change their sanitary pads, clean water to wash their hands and sanitary pads, and a place to dry or dispose of used materials (House et al., 2012). The lack of MHM creates a barrier to girls continuing their education in LMICs. Schools frequently do not have private bathrooms, making managing menstruation difficult for both female teachers and students. It is essential to overcome the barriers to educate and empower girls and women in LMICs. Educating children is essential for economic development; educating girls is considered one of the best ways to improve the health and economy of LMICs (Betteridge, 2013). The factors that keep girls from school also keep women from working outside of the home (Chin, 2014). Women often do not have a seat at the table where decision-making and program development occurs. Even at the household level, often women do not have control over access to a private bathroom or money to purchase menstrual products. Globally, women have learned how to manage their menses, though how they do this varies. Because of these restrictions, many women manage with unhygienic and inconvenient methods, especially in poorer areas (Sumpter & Torondel, 2013).
Recently, there has been growing attention to this problem. Governments, nongovernmental organizations [NGOs], and private sectors are working together to address this global issue across Africa and Asia. Several projects have been implemented to deliver sustainable, reusable, locally produced, or low-cost products to women in LMICs. Programs geared to educate girls and women to make their own pad kits include Afripads, Water Hyacinth Sanitary Pad Project, Pads4Girls, The Pad Project, Empowering African Dreams, and EcoFeeme (Sumpter & Torondel, 2013).
Menstrual hygiene is essential to the dignity and welfare of women (Eco Femme, 2013; Government of India National Rural Health Mission, 2015; Sumpter & Torondel, 2013). Women-to-women education about how their bodies work is a strong point in the Pad Project. In cultures where it is taboo to speak about menses, creating an environment of trust and open conversation about menstruation can cultivate a richer, deeper bond. Implementing simple changes to address dysmenorrhea and other issues has significant value. Girls and women benefit from an increased understanding of basic concepts of health. Many young girls do not understand what is happening when they begin menstruation; mothers often are not comfortable talking about it or may not understand it themselves (Shrivastava & Shrivastava, 2013). Boys and men know even less and need education and knowledge to better understand and support their mothers, sisters, and wives (House et al., 2012).
WHAT DOES THE FUTURE HOLD?
When Emma was asked what the project means to her as a Christian nurse, her answer was insightful:
To utilize my nursing skills and see God moving because of the project is humbling. Churches in the U.S. have come alongside to make pads and kits. Sewing groups, church groups, and nursing students have embraced the heart of this project: to meet a practical need and share the gospel. In a world where you are viewed as unclean when you are bleeding, the Bible is well-understood; the bleeding woman was not to be touched or to touch anyone without making that person unclean. Women in South Asia understand this, and they understand how humiliated they feel when someone is made unclean because they touched something. Providing a health-need solution and filling a spiritual need is something nurses understand well. People are more than a body; they are soul and spirit, and all need healing. (personal communication, July 9, 2015)
An intangible and yet empowering component of the Pad Project is equipping women to approach this normal monthly event with dignity. The beauty of the ministry is the myriad rewards from such a simple idea. Sharing the gospel stands alone. To share the gospel is a profound Christian outreach that clearly conveys our faith, shows value and esteem for all people, and is a rich gift to share. Many women have experienced God's abiding love through this project in South Asia, and Christian fellowship groups have been established.
Emma speaks of the growth of the project since its inception:
This project was not written for others. It was something I wanted to do to combine ministry and health.... I'm sure if I had known that women all over the world would utilize this, I would have been terrified. As I began to share the project, and as my husband encouraged me, we began to see how this met a need that wasn't being met. This project has grown because of God's plan. Women have come to know Christ, groups have started, and women in other countries tell me of conversations they were able to have because they offered women something so helpful to their lives. This project started with 30 kits, and I can't even begin to count how many thousands of kits have been given out. Each kit [represents] a life, and each kit has sown a gospel seed. (personal communication, July 9, 2015)
When asked, “Where do you think God will take this project next? How will he continue to use you?” Emma explains the Pad Project is gaining momentum. She anticipates as women desire to have a helpful way to connect with other women and meet a need, they will utilize the Pad Project. Future projects include safe birth kits and modules on newborn care.
Emma shared a favorite quote from a woman who sews pads in a Vietnamese church in California. When asked, “Why are you sewing for the ladies in South Asia?” she replied, “I remember!” This woman recalled what it was like not to have supplies to use when menstruating. Emma shares that the project is well accepted because:
All women deal with this issue. This isn't something you have to wonder about. A woman is either about to start her period, is well into her reproductive age or ending that stage. If she has had issues, she will remember; some have struggles, some do not, but one thing that unites all women: we bleed, and we need a Savior! (personal communication, July 9, 2015)
HOW CAN NURSES HELP?
One significant contribution nurses and others can make is to be culturally sensitive to the differences in menstrual hygienic practices that women from various ethnic backgrounds may have. Women who perceive they are unclean during menstruation may miss appointments or avoid social functions, even with close friends. In some countries, education is not a guarantee that women understand the menstrual process. Nurses should establish and maintain trusting relationships when caring for women so that open dialogue may occur.
The Pad Project may be used as a tool to establish relationships with groups of women during health mission trips. Nurses can engage groups in their communities to make pads and collect other supplies to initiate the project for mission trips. A pattern for sewing a washable pad is illustrated in Figure 1 (see Figure, Supplemental Digital Content 1, http://links.lww.com/NCF-JCN/A51). People of all ages can come together for the purpose of helping women have a tangible way to care for themselves monthly.
It is clear that Emma Kelly has made an impact on the neighborhood women of her Indian city and beyond. The Pad Project is a way to share not only about menstrual health, but about how much Christ loves us. This beautiful message for women—conveyed in nations where women are not necessarily held in the high esteem—is delivered every time the Pad Project is shared by one nurse who has found a way to make a difference in her world.