We found that nearly one in three (31%) female students in sub-Saharan Africa missed school for at least a day during menstruation. The current finding is slightly higher than the findings of a systematic review conducted in India where nearly a quarter (24%) of school girls missed school during menstruation [50]. The observed variations might be attributed to the better access to absorbent materials in India [50] compared to the situations in sub-Saharan Africa [23].
It is worrisome that menstruation not only affected school attendance but also girls’ concentration [41, 42, 44, 46], academic performance [18, 44], and participation in sports [21, 22, 42, 44]. There are similar study findings where the academic performance and school concentration of the majority of female students are affected during menstruation [51]. Similarly, a study conducted in Oman showed that class concentration, academic performance, and sports activities were limited during menstruation [9]. This could be explained by the pain experienced during menstruation [9, 52] or the unmet need for menstrual hygiene materials in sub-Saharan Africa [5]. It could also be attributed to poor menstruation perceptions and unacceptable menstrual practices that pose restrictions of movement [10, 53]. Female students may also refrain from daily activities due to depression associated with dysmenorrhoea [54].
Different sociodemographic factors such as age [43], religion [43] and ethnicity [43, 49] were associated with school absenteeism during menstruation. The effects of religion and ethnicity on school attendance are not surprising as menstruating girls often experience religion-related restrictions from several daily activities [50, 55]. Adolescent girls seldom discuss issues pertaining to menstruation [10] as this is usually considered a social taboo [56] that might restrict them from participating in several events. Although the effect of age on school absenteeism during menstruation is not well explored, the family’s sociodemographic variables such as the mother’s educational status were associated with school absenteeism [55]. Rural residence [18] and longer walking distance from schools [38, 45] were also reported as reasons for menstruation-related school absenteeism. This might be explained by the fact that female students who walk long distances while menstruating may feel discomfort and worry about unexpected blood leaks.
Moreover, negative perceptions of female students about their menstruation were found to be a major reason for school absenteeism. Shame [16, 18, 21, 41, 46], fear of attending classes [16, 18, 21, 40, 41, 46] and embarrassment [16, 21, 41, 43, 45] were the major reasons caused female students to miss school during menstruation. These findings are in line with the findings of similar systematic reviews [50, 57]. A lack of water supply in many schools to maintain personal hygiene, fear of bad smell [39] and a lack of hygienic materials [43] during menstruation may deter girls from going to school. Consistent reports are available that most female students experienced difficulties engaging in class, due to fear of smell and leakage, and subsequent teasing of menstruation [39]. This could be explained by a shortage of water supply to maintain personal hygiene [58] or a lack of knowledge about menstrual hygiene management [59]. Fear of unexpected blood leaks [18, 39, 41, 45, 47, 49] was mainly reported across studies as a reason for missing school during menstruation. This might be attributed to a shortage of sanitary pads which can effectively absorb and prevent blood leakage if persistently used [23].
Poor menstruation hygiene management in schools in sub-Saharan African countries was reported as one of the reasons for school absenteeism during menstruation. Many schools lack private areas for changing pads [18, 38, 40, 41, 43, 46, 48, 49] and water supply [18, 38, 45, 48] so maintaining personal hygiene was difficult [38, 40, 45, 47]. There was also a shortage of separate bathrooms and toilets for female students [18, 47] so it was difficult for female students to change sanitary pads in a way that ensured dignity. Likewise, results of a systematic review in sub-Saharan Africa [23] and other developing countries such as India [50] and Indonesia [60] showed that most female students prefer to stay at home during menstruation due to poor menstruation hygiene management in school.
Shortage of sanitary pads [16, 18, 38, 39, 41, 43, 45, 48, 49] and lack of sanitary disposal system [18, 40, 41, 45, 49] were reported across studies to cause school absenteeism during menstruation. This could be explained by the unmet need for menstrual health in schools for female students [5]. Similarly, a study conducted in six sub-Saharan African countries revealed that only 1% of rural schools in Ethiopia and Mozambique and 23% of rural schools in Rwanda had improved sanitary facilities. Fewer than 20% of rural schools in the six countries studied have at least four of the five recommended menstrual hygiene services (water at facility, separate-sex facilities, presence of a door, lock on the door, pit or bin for disposal) [61].
Dysmenorrhea was the main factor that interfered with school attendance [8, 18, 22, 37–44, 46, 48, 49]. Consistent with another systematic review conducted in India [50], our review showed that many girls who experienced dysmenorrhea missed classes. This might be explained by the fact that pain interferes with regular daily activities including schooling. Heavy blood flow [38, 43], blood flow for more than three days (2, 4) and irregular cycle [8] were also reported across studies as reasons for school absenteeism during menstruation. In developing countries girls hardly get sufficient sanitary pads [5, 62] that they prefer to stay at home due to fear of leakage. Abnormally heavy bleeding or blood flow for long days are serious health problems to cause school absenteeism [63, 64].
Stigma and discrimination during menstruation [16, 38, 43] and humiliation [18] were also persistently reported to cause school absenteeism during menstruation. Menstruation is usually considered a source of social stigma for women even in developed nations [65]. This indicates that there is a long history of menstrual taboos across all cultures where women face social exclusions [39]. Menstruating students often prefer to stay at home due to teasing and humiliation [41, 45, 46, 49]. This could be explained by the poor hygienic practice during menstruation due to shortage of water and poor Menstrual Hygiene Management in most schools [23, 50, 60, 66]. Therefore, students who are menstruating might feel that they are dirty and they could have a bad odour sitting beside their male fellow students [40].
The culture of most communities poses restrictions on females during menstruation. Parents often instruct their daughters to stay at home during menstruation [45, 49]. Sometimes, menstruation is considered as an “evil” that should be kept secret and menstruating females should stay far away from people [16, 45, 48]. This might be due to a lack of health education resources available to people about menstruation. Yet the menstrual cycle is often not discussed in public because of cultural discomfort, social customs or simply lack of information about the topic [39, 57, 59, 67–69]. These cultural beliefs also affected several female students in different African countries [53]. This might be explained in such a way that menstruation is a topic that people are usually uncomfortable talking about and is often kept secret [65].
This systematic review had several strengths. We used broader inclusion criteria to capture a wider range of school absenteeism during menstruation in sub-Saharan Africa. We also searched for articles from six online databases so as not to miss studies on the topic of interest. Furthermore, the PRISMA guideline was strictly followed, and articles were comprehensively assessed for quality. Methodologically, we included articles conducted with quantitative, qualitative, and mixed-methods study designs, rather than a homogeneous source; hence, wider findings were represented. On the other hand, the study has the following limitations. First, the study methods used in all the included articles were cross-sectional design. Therefore, this review shows the prevalence of school absenteeism only at a single point in time and it is impossible to infer causal relationships between the dependent and independent variables. Studies included in this review were only those papers published in the English language, thus may introduce language bias. We limited the search to databases of published literature and lacked inclusion of grey literature including government reports that representativeness might be affected. Furthermore, there was a lack of similar studies making our findings difficult to interpret.