'We avoid drinking water to avoid going to the washroom'

In ill-fitting PPEs for hours drenched in sweat, women health workers face another battle during their menstrual cycle

Among the many issues faced by frontline female COVID-19 warriors, a predominant one, but one that many shy from speaking about, is that of menstrual hygiene. Most have to work in 8 to 12 hours shifts while wearing PPE kits in wards and ICUs, and in many places, are forced to use unhygienic common toilets as they don't have separate ones. A major concern is that of disposal of sanitary pads and the fear of damaging the PPE kit.

Many female frontline staffers, whom this paper spoke to admitted the problem and added that apart from psychological and hormonal changes, some are suffering from urinary tract infections, bacterial and fungal problems and in worst cases, even toxic shock syndrome - a rare bacterial infection that can cause death.

A UNICEF brief, as well as a policy brief from United Nations in April 2020, discussed mitigating the impacts of COVID-19 on menstrual health and hygiene. The report clearly mentions that female health workers could develop stress, anxiety, and malnutrition. "The United Nations and UNICEF recommend that female health workers be provided with sufficient quantity of menstrual hygiene materials (approximate 20 to 30 pieces per month) and that female health care workers be allowed breaks every four hours. The menstrual pads should be made of high absorbency materials. Females should have access to separate washrooms and should also be provided pain killers, if needed," explained Dr Wiqar Shaikh, senior allergy and asthma specialist. He added that a study from the USA published in the journal Fertility and Sterility in August 2020, noted that menstruation increases a female's susceptibility and vulnerability to COVID-19.

A file picture of a doctor at a top city hospital, wearing a PPE and other protective gear

Dr Shraddha Maheshwari, neurosurgeon, has been vocal on the issue. She said, "World over, more than 70 per cent of the healthcare workforce is formed by women. Most of these have been frontline healthcare workers during this pandemic. Besides performing their duties, these women face additional challenges of managing their menstruation. This not only affects their own health, hygiene and dignity, but also affects the overall ability of Health System to deliver. Every day we talk about gender equality, let's at least start by being gender sensitive. During this pandemic, the government of India declared sanitary napkins into the group of essential commodities, but menstrual health and hygiene among healthcare workers is yet to be prioritised,"

Dr Maheshwari added, "Most of the government-run hospitals are not air-conditioned. During menstruation, the temperature of females is generally higher than normal and wearing a PPE kit makes them more vulnerable to sweat, adding to the discomfort of periods. Given that there is 6 to 8 hours of continuous duty wearing a PPE kit, most health healthcare workers do not drink adequate water and hold onto their urge to urinate. A woman who is menstruating does not get to change her pad as often as needed. All this not only hampers her hygiene and health, but also causes loss of confidence and decreased work performance."

"A simple solution to these problems could be providing a break in between duties to women who are menstruating. They can also be provided with adequate PPE kits so that they could change them as and when needed. They should also get facilities such as clean bathrooms which have sanitary pad vending machines as well as sanitary napkin disposal machines. Instead of having a schedule with fixed work and leave days, consideration should be given to women to take leave as per their requirement, especially during their periods." Dr Maheshwari suggested.

Staff nurses, working in COVID-19 wards and ICUs in civic run-COVID centres and private hospitals in Central and South Mumbai, said the biggest concern was about unhygienic washrooms. A staff nurse said, "Earlier the PPE kit was of a plastic-like fabric. Once we wore it, within few minutes, we would be drenched, Imagine wearing it and working for 6 to 8 hours. And during menstruation, it is more difficult and challenging. We avoid having water to skip going to the washroom while on duty."

"Earlier, some nurses had attempted to inform the superior incharge of assigning duty about the issue, but she ignored it stating we are professionals and here for patient care, we can't give such excuses. In the ICU, it is more challenging, especially when the period is heavy, and we are completely drenched in sweat in the PPE kit, making us more irritable and helpless," she said.

Jibin TC, president of United Nurses Association, which has 23,000 nurses in Maharashtra and 5.50 lakh across the country as its members, acknowledged that menstrual hygiene was a major concern, for front line nursing and class 4 female staff, especially those on COVID-19 duty.

Jibin said, "We have been trying to address this issue (menstrual hygiene) at both state and central government level, but unfortunately, our plea has not been acknowledged so far. We must understand that nearly 70 per cent of the covid pandemic frontline staffers are women, and we cannot ignore their basic problems. The irony is that there is never a representative from the nursing community in any government-formed committee or task force."

He added, "I was approached by a staff nurse from a private hospital with an issue. She had applied for leave due to menstrual cramps, but the reporting matron, asked her to report to duty after taking a painkiller as they were already short staffed, as some nurses were under quarantine. Some staff nurses are also popping tablets to delay their menstrual cycle so that it doesn't clash with their duty days."

Jibin added that many hospitals are not hiring new people in place of old staff, who either resigned or their contract period was over. "In some nursing homes and private hospitals, due to lockdown and no regular patients coming, the number of staff has been brought down, putting additional burden on existing staff. We request the state and central government to take cognizance of these issues, and help us have our representation in order to raise our concerns."

Adding to the issue, Dr Shaikh explained that when managing patients, maintaining personal hygiene is extremely important, particularly, when menstruating. "During menstruation, the female body temperature is elevated and therefore, there is exaggerated sweating. In a PPE kit with a dry mouth and excessive thirst, those who are menstruating may have the urge to pass urine. The urine and menstrual fluid could leak into their PPE kits, causing a urinary tract infection and/or a fungal infection. If these conditions are not adequately treated or prevented, they could lead to toxic shock syndrome, caused by bacterial toxins. In this the woman will develop high fever, low blood pressure, vomiting, and skin rash with an overall risk of death. It is therefore mandatory that all female front line workers be provided adult diapers. During menstruation, along with the diaper, they should be provided extra large (XL) sanitary pads."

He also said the problems of menopausal female frontline health workers, who tend to have more psychological issues, hormonal disturbances, diabetes, hypertension, cardiac issues, cannot be ignored and require sufficient care and support.

Dr Shaikh added, "Most of the civic and government-run hospital's washrooms are in a pathetic condition, and could spread any infection, which includes COVID-19, as they are not cleaned regularly, and the front line female staff don't have a better option.'

Dr Shaikh concluded stating, "We are so insensitive about our own female front line workers, that we have overlooked their basic concerns and need, and unfortunately, even the state COVID task force has failed them miserably by not having any female expert on it. She who could have highlighted the issues of female frontline staff."

Dr Subhash Hira, professor of Global Health at the University of Washington-Seattle, USA and health advisor to several UN, Indian and African health agencies said, "The process of wearing a PPE suit normally takes 45 minutes, and it would take another 45 minutes to remove it, if a female health worker went on duty, unprepared for menstruation. Such a situation has been faced by many female workers during the past months. Worse still, the sanitary pads are not best suited for wearing with PPE suits. Instead, they require tampons that can soak menstrual fluid for 6-8 hours at a go."

Dr Deepti Dongaonkar, a gynaecologist and former dean of Nagpur, Latur and Miraj Government Medical Colleges said, "It is indeed a very important issue that concerns the vast women frontline warriors working in pandemic care, and not following menstrual hygiene on duty will only expose them from mild to serious health issues, and impact their work efficiency. They may also go through psychological and hormonal stress."

Dongaonkar added, "It is still considered to be a taboo, to openly talk about menstrual issues, but the reporting supervisory staff should be notified about the dates in advance, so that they can delegate lighter duties, on those days to the concerned woman, so that she does not go through unwanted physical and psychological distress, during her period."

She added, apart from reducing the shift hours, it is important that in government and civic-run hospitals, one toilet should be reserved for women staffers, and it should be well-maintained and cleaned. Special waste disposal dustbins should be placed in it so that women can change pads. Similar arrangements should be made for resident doctors. In female COVID wards, sanitary pads should be made available, at nominal rates in vending machines for the patients and staff, if required in emergency. Also wards and ICU should have mood elevators, like light music or light instrumental music, which could help staff experiencing menopause.

Dr Shivangi Pawar, consulting psychotherapist, said, "Stress certainly affects the menstrual cycle. To put it simply, our stress hormones, adrenaline and cortisol, fight with our period hormones oestrogen and progesterone for resources and priority. If we are too stressed, our menstrual health will suffer giving rise to numerous issues like PMS, dysmenorrhoea or painful periods, amenorrhea or absence of periods, etc. The physical and mental exhaustion is taking a toll on the health of women caregivers. If they are constantly in a 'fight or flight mode,' it is going to be harder for them to do their job."

Dr Pawar's tips to hospitals to help women healthcare workers

Provide them with facilities like separate and hygienic washrooms, menstrual cups and sanitary napkins and the sanitary pad disposal machines

Implementation of crisis communications - be clear and optimistic.

Communicate with them frequently and encourage them to share their problems with the management.

Understand that during menstruation they are more stressed and sad. Approximately 85 per cent of women who menstruate, experience symptoms of premature menstrual syndrome, which significantly reduces occupational productivity.

Arrange shift changes whenever required.

Did you know

. August 2020: Zomato introduces 10 days period leave for women employees

. Bihar is the only state in India which has been providing two days of special leave every month to its female employees since 1992

. Ninong Ering, a member of Lok Sabha from Arunachal Pradesh, moved a Private Member's Bill, 'The Menstruation Benefit Bill, 2017'

. Japan, South Korea, Indonesia and Taiwan provide menstrual leave to their female employees every month

'Given that there is 6 to 8 hours of continuous duty wearing a PPE kit, most health healthcare workers do not drink adequate water and hold onto their urge to urinate. She does not get to change her pad as often as needed. All this not only hampers her hygiene and health, but also causes loss of confidence and decreased work performance'
Dr Shraddha Maheshwari, neurosurgeon

'A staff nurse from a private hospital told me she had applied for leave due to menstrual cramps, but she was asked to report to duty after taking a painkiller as they were already short staffed, as some nurses were under quarantine. Some staff nurses are also popping tablets to delay their menstrual cycle'
Jibin TC, United Nurses Association

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