Dr Tiziana Leone discusses her research on the relationship between menarche and socioeconomic development. She argues that age at menarche is such a fundamental determinant of women’s physiological development that it should be used as a key global health indicator.
This is the second blog in the 12 Days of Global Health series.
In 2020, I concentrated on the bookends of women’s reproductive health: menarche with Dr Laura Brown (UCL), menopause with Drs Brown and Gemmill (John Hopkins) and abortion and Zika using Google trends with Dr Clare Wenham and Professors Ernestina Coast and Sonia Corrêa. I also worked on a project that conceptualised deprivation through food insecurity and mental health in the Palestinian territory with a team at the University of Bizeit (Including Dr Weeam Hammoudeh and Prof Giacaman). However, in this blog I will focus on my research on menarche.
Menarche (first menstrual bleeding) serves as a critical marker of puberty, and the associated physiological, behavioural and social changes which collectively symbolise sexual maturation, adulthood and fertility. From the adoption of adult behaviours and the beginning of sexual life, to the shame and stigma which could lead to dropping out of school, the process and timing of puberty can have dramatic consequences in girls’ lives [1-4]. Timing and determinants of the age at menarche are key to understanding the potential linkages with health outcomes later on in life and also important because of the repercussions on sexual initiation and age at marriage and consequently fertility.
Age at menarche is such a fundamental determinant of women’s physiological development that it has been suggested in the literature that it should be used as a key global health indicator [5]. I have embarked on a hunt for menarche data that could identify trends and timings but also that could highlight where gaps in knowledge lie. Ultimately the stream of research coming from this work aims to identify life course patterns in reproductive histories starting from menarche till menopause. Along the way I will look at the impact that timing of menarche has on reproductive outcomes and ultimately on health later on in life (e.g.: ageing patterns). In order to do so we needed to map all available data and start looking systematically at the literature on timing.
Timing and determinants of the age at menarche are key to understanding the potential linkages with health outcomes later on in life and also important because of the repercussions on sexual initiation and age at marriage and consequently fertility.
Using 16 World Fertility Surveys and 28 Demographic and Health Surveys (DHS) from 27 countries, Dr Laura Brown and I analysed cohort trends and use fixed-effects models for DHS surveys to investigate socio-demographic and regional effects in the timing of age at menarche. To date no other study had put together all the DHS data on the topic. The trends of the mean age at menarche across time within and between countries show a declining or stalling path (Figure 1). Results of the determinants modelling show the relationship with wealth changes over time although not consistently across countries. We see a shift from poorer women having earlier menarche in earlier surveys to richer women having earlier menarche in most countries. The evidence is pointing towards a clear positive relationship between wealth and likelihood of early menarche. Future studies will need to look more in detail at how menarche can therefore be taken as a proxy for socio-economic development [5].
Beyond the results obtained in the statistical analysis, we exposed a dearth of information around timing of menarche in LMICs. The lack of studies around the DHS signifies the lack of interest or lack of knowledge that such data exist. Our informal discussions with experts in the field, showed an overall surprise firstly that menarche has not been included more systematically and secondly that where it has been included there is low interest in analysing it. We can only speculate that this might be derived from a lack of trust in the data and also a lack of forward thinking when approaching health in a life-course perspective.
The study we conducted demonstrated a gradual decline in the timing of menarche in LMIC which will also have implications for fast ageing settings. It shows a changing link to socio-economic status with further repercussions on the future health status of women. It highlights that the real issue is data availability over quality with many countries either not including or discontinuing collecting the information. There is a clear need to do more research on menarche in particular from the social science perspective and to make menarche a common variable in future health surveys.
References
- Coast, E., S.R. Lattof, and J. Strong, Puberty and menstruation knowledge among young adolescents in low- and middle-income countries: a scoping review. International Journal of Public Health, 2019. 64(2): p. 293-304.
- Dolan, C.S., et al., A blind spot in girls’ education: menarche and its webs of exclusion in Ghana. Journal of International Development, 2014. 26(5): p. 643-657.
- Biro, F.M., L.C. Greenspan, and M.P. Galvez, Puberty in Girls of the 21st Century. Journal of Pediatric and Adolescent Gynecology, 2012. 25(5): p. 289-294.
- Šaffa, G., et al., Is the timing of menarche correlated with mortality and fertility rates? PloS ONE, 2019. 14(4).
- Sommer, M., Sutherland, C. & Chandra-Mouli, V. Putting menarche and girls into the global population health agenda. Reproductive Health, 2015. 12, 24.
The views expressed in this post are those of the author(s) and in no way reflect those of the Global Health at LSE Blog or the London School of Economics and Political Science.
Photo: Group discussion UNICEF Ethiopia and visitors from Luxembourg with role model girls on FGM at Erubti Woreda, Afar Regional State. Credit: UNICEF Ethiopia/2017/Mersha. Licensed under creative commons (CC BY-NC-ND 2.0).
