Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The topic of MHM has been largely neglected, and studies like this is of great importance. The material and analysis is original and interesting. The value of this study is also found in its perspective from "below", the experiences of the girls. 

There is one question relating to the Findings: on line 321 and line 384 there are mentions of a girls that experienced shaming and embarassment concerning a blood stain on her cloths. Is this the same girl, the same participant? This must be clarified. 

For those of us who do not know the MAS program, it would be helpful to have a little more information about the program and its activities concerning menstruation. I am curious if there is some kind of outreach from  the program centres to, for example, schools or educational authorities? 

I would also prefer to have 1 or 2 more headlines in part 4.3 and in the discussion. 

Author Response

Reviewer 1

1. Emphasize that the topic and perspective of the study are important given that MHM has been largely neglected.
1. Response: We agree that it is important to foreground the significance of the topic and our perspective. In the Introduction, we now explicitly emphasize both the neglect of menstrual health and the importance of our focus on married adolescents. On p. 2, we write: “The research problem addressed in this study, therefore, is not simply that menstrual inequity exists, but that we still know too little about how menstruation operates as an everyday mechanism of constraint in the lives of married adolescent girls in northern Nigeria, and how girls interpret, negotiate, and respond to those constraints. By centering these processes, this study moves beyond documenting menstrual disadvantage as a static condition and instead examines menstruation as a lived social process embedded in gendered, marital, economic, and community power structures.”
2. In the Background (p. 4), we also note that existing LMIC scholarship “has tended to foreground in‑school, unmarried girls and aggregate categories of ‘adolescents’ or ‘women,’ leaving gaps in knowledge about how menstrual disadvantage is produced and lived in the specific context of marriage during adolescence.”
2. Highlight that the material and analysis are original and interesting and that the perspective “from below” (girls’ experiences) is a key strength.
1. Response: We have strengthened statements about the originality and “from below” perspective in both the Introduction and Discussion. In the Introduction (end of p. 2), we now state: “Drawing from research conducted by the Centre for Girls’ Education (CGE) Married Adolescent Safe Spaces (MAS) program…we foreground married girls’ own narratives of how menstruation shapes and is shaped by mobility, schooling, stigma, secrecy, and the individualized burden of menstrual self‑management.”
2. In the Discussion opening (p. 26), we explicitly tie this perspective to our contribution: “Through this interconnected lens of understanding, the girls’ lived narratives extend prior work on period poverty by showing how menstrual management becomes embedded in broader systems of societal control over married adolescents’ lives.”
3. Clarify in the Findings whether the girl who experienced shaming and embarrassment due to a blood stain on her clothes (mentioned in two locations) is the same participant or different participants.
1. Response: We clarified that these are two distinct cases and signaled this explicitly in the Findings. In the subsection “Menstruation as a Catalyst of Constraint” (pp. 16-17), the paragraph now reads: “Two distinct cases in the data reveal how humiliation at school precipitated girls’ withdrawal. In the first case, one girl… ‘I totally stopped attending school while menstruating because it has cost me an embarrassment that I am not sure I can ever forget.’ … In a separate account, another girl explained that severe menstrual pain combined with teachers’ disbelief… ‘Ever since that incident, I stopped attending school whenever I am menstruating…’”
2. We also added the following to make the analytic point clear: “Together, these cases show that experiences of menstrual staining and pain become consequential turning points after which girls reconfigure their relationship to schooling.”
4. Provide more background on the MAS program, including more information about its activities concerning menstruation.
1. Response: We expanded the Background section “Programmatic responses: safe spaces and menstrual interventions” to include more detail on MAS. On p. 7, we now describe: “The CGE Married Adolescent Safe Spaces (MAS) program… targets married girls aged 14–20… with twice‑weekly clubs focusing on literacy, SRH (including birth spacing…), self‑advocacy, and livelihoods… While MAS program briefs report increased contraception use… rigorous evidence on impacts specific to girls’ menstrual experiences remains limited. In particular, there is little qualitative research that documents how participation in married‑girl safe spaces shapes the concrete ways girls understand, manage, and talk about menstruation…”
2. We further explain in the Findings and Discussion sections how MAS sessions included menstrual education (e.g., teaching cycle tracking and hygiene) (pp. 24-25, 29-30).
5. Indicate whether there is outreach from MAS program centers to schools or educational authorities.
1. Response: While MAS is primarily community‑based, we clarified the program’s positioning relative to schools in the Background and Methods. On p. 7 we describe MAS as implemented “in several rural communities in Kaduna State… with clubs held in community settings rather than schools.”
2. In the Methods (p. 11), we note that data collection occurred “in the safe spaces, the girls’ homes, and around the community,” and in the Findings we show how teachers and school staff engaged with menstruation but were institutionally separate from MAS (pp. 16–17). Because MAS does not currently have formal outreach to school authorities within this dataset, we chose to clarify the locus of the program rather than imply outreach that is not present.
6. Add one or two more sub-headings in section 4.3 and in the Discussion to improve structure and readability.
1. Response: We added the Discussion subheading “Safe Spaces as Relational Sites of Support” (p. 30) to more explicitly highlight the practical and policy implications of the MAS intervention.

Reviewer 2 Report

Comments and Suggestions for Authors

Do provide some more details about the MAS program - the goals of the program, how widespread it is, how many participants, whether state or donor funded, etc. Also, the study does not mention the number of participants surveyed and their ages. 

Author Response

Reviewer 2

1. Provide more details about the MAS program, including its goals, how widespread it is, how many participants it has, and whether it is state-funded or donor-funded.
1. Response: We added detail about MAS’s scope, goals, and funding in the Background and Methods sections. On p. 7, we now write: “The CGE Married Adolescent Safe Spaces (MAS) program… targets married girls aged 14–20, who are often the most isolated, with twice‑weekly clubs focusing on literacy, SRH (including birth spacing…), self‑advocacy, and livelihoods (Perlman et al., 2016).”
2. In the front end and Methods sections, we note that the project is funded by the Centre for Girls Education (Funding statement and p. 9) and implemented “across several rural communities in Kaduna State, Nigeria” (p. 10). We also specify that MAS is implemented by a Nigerian women‑led civil society organization rather than a state program (p. 11).
2. State the number of participants included in the study and their ages.
1. We added explicit sample and age‑range details in the Methods. On p. 10 we now state: “Participants in this study were married adolescent girls enrolled in MAS safe space clubs. Across the research period, the team engaged with approximately 300 married girls between the ages of 14 and 20 years (early-late adolescence), who were purposively selected based on their active participation in MAS sessions and residence in participating rural communities.”

Reviewer 3 Report

Comments and Suggestions for Authors

Attached

Comments for author File: Comments.pdf

Comments on the Quality of English Language

The paper is a well-written and enjoyable read. Some sentences might need to be shortened and/or simplified. Some interview excerpts might be better off indented for better formatting and readability. 

Author Response

Reviewer 3

1. Clearly define the research problem underlying the study, not only the social problem of menstrual inequity. State clearly what specific research problem the paper addresses so that the contribution highlighted in the discussion is already situated at the outset.
   1. Response: Thank you for your close reading of our manuscript. Your feedback was incredibly helpful in enhancing our paper’s argument and impact. We substantially revised the Introduction to define and foreground the research problem. On p. 2 we now write: “The research problem addressed in this study, therefore, is not simply that menstrual inequity exists, but that we still know too little about how menstruation operates as an everyday mechanism of constraint in the lives of married adolescent girls in northern Nigeria, and how girls interpret, negotiate, and respond to those constraints.”
   2. We also close the Introduction by linking this research problem to the guiding research question (p. 3): “We qualitatively explored the following research question… How do married adolescent girls in northern Nigeria experience and navigate menstruation as a source of everyday life constraint, and what do these experiences reveal about the gendered social, material, and relational conditions that shape menstrual inequity?”
   3. The Discussion opening (p. 25) then explicitly returns to this problem and confirms that it has been addressed.
2. More explicitly position the study’s unique contribution to extend the boundaries of critical menstruation studies. Engage more critically with existing scholarship instead of only presenting it logically; clarify how the study builds on or challenges prior work.
   1. Response: The Background section now critically situates the study relative to existing work. For example, pp. 4–6 we state: “Taken together, this scholarship has established menstrual inequity as a pervasive social problem in LMICs, yet it has tended to foreground in‑school, unmarried girls…” and “However, most of this evidence focuses on school‑enrolled adolescents… offering relatively limited insight into how menstrual inequities are experienced by married adolescent girls…”
   2. In the “Programmatic responses” subsection (p. 7), we contrast MAS with prior safe‑space evaluations and identify the gap: “While MAS program briefs report increased contraception use… rigorous evidence on impacts specific to girls’ menstrual experiences remains limited… In particular, there is little qualitative research that documents how participation in married‑girl safe spaces shapes the concrete ways girls understand, manage, and talk about menstruation…”
   3. The Discussion (pp. 26–27) now systematically situates each theme in relation to scholarship; for instance: “This analytic theme aligns with previous scholarship… The present study significantly contributes to this broader literature by demonstrating that menstruation itself functions as a symbolic and practical marker…” (p. 26) and “Our study deepens existing menstrual health research by showing that silence itself is a gendered social practice…” (p. 28).
   4. These revisions make the contribution to critical menstruation studies explicit and consistently tie findings back to the defined research problem.
3. Explain how the marital status of adolescent girls (and related socio-spatial, sociocultural, economic, and power implications) shapes their menstrual experiences and inequities. Clarify the unique features of the chosen study population (married adolescent girls) and show how this yields distinctive insights beyond existing LMIC menstruation literature.
   1. Response: We expanded the Introduction and Background sections to highlight the specificities of married adolescent girls. On p. 1: “In particular, less attention has been devoted to married adolescent girls in rural northern Nigeria, whose experiences of menstruation are shaped not only by poverty and inadequate menstrual resources, but also by early marriage, gendered expectations of fertility, restricted mobility, family surveillance, and unequal household power relations.”
   2. The “Gender, marriage, and adolescence in northern Nigeria” subsection (p. 6) now explains how menstruation intersects with norms of seclusion, fertility expectations, and surveillance, explicitly stating: “For married adolescent girls, menstruation therefore carries layered meanings… Yet, despite the centrality of menstruation to normative expectations of marriage and motherhood, few studies explicitly examine how these gendered, marital, and religious dynamics shape girls’ day‑to‑day menstrual practices, feelings of safety and dignity, or access to support.”
   3. The Findings and Discussion sections now repeatedly return to marriage as a key axis of constraint, thereby clarifying why this population offers distinctive insights.
4. Use the term “theoretical framework” rather than “conceptual framework,” as this is a more accurate description of the lenses employed.
   1. Response: Clarify the unique features of the chosen study population (married adolescent girls) and show how this yields distinctive insights beyond existing LMIC menstruation literature.
5. Draw the theoretical framework (Intersectionality, Socioecological Theory, Menstrual Health and Rights Framework) back into the discussion of findings to elevate the analysis beyond the immediate context. Use the theoretical framework more explicitly to theorize menstrual health and wellness in broader global and disciplinary discourse.
   1. Response: The Theoretical Frameworks section (pp. 8–10) now previews how each framework is used analytically, and the Discussion explicitly revisits these frames. For example, in Theoretical Frameworks we add: “In our analyses, we drew on this intersectional social ecological lens to interpret how girls’ narratives… reveal the multi‑level production of menstrual constraint across bodies, relationships, and institutions.” (pp. 8-9)
   2. In the Discussion, we explicitly connect findings to these frameworks, such as: “Viewed through an intersectional social ecological lens, this finding shows how bodies, households, schools, and community norms work together to construct menarche into a hinge between childhood and tightly controlled married womanhood.” (p. 27) and “Here, our use of menstrual health and rights frameworks makes visible how girls’ efforts to ‘make do’ are a response to systemic denial of the conditions required for safe, dignified menstrual management…” (p. 29).
6. Provide fuller methodological details, including sample details (for example, number of participants), data collection period, and age range of participants. Specify the age range of participants.
   1. Response: Sample and age details were added to Methods (p. 10): “Across the research period, the team engaged with approximately 300 married girls between the ages of 14 and 20 years (early-late adolescence), who were purposively selected based on their active participation in MAS sessions and residence in participating rural communities.”
   2. The data collection period is clearly stated (“between 2020 and 2024,” p. 10).
7. Clarify the specific research questions that guided data collection and analysis related to menstruation, beyond the general themes of “safe space dynamics, girls’ lives and their wellbeing.”
   1. The research question is explicitly stated at the end of the Introduction (p. 3) and the Findings opening (p. 14) now notes that the analysis presents “three interrelated themes that illuminate how menstruation operates as an everyday mechanism of constraint in marriage,” thus linking the analytic themes back to the research question. The Data Analysis section (p. 14) explains that we first created “an analytic corpus” from all menstruation‑related segments and then derived overarching themes via thematic analysis.
   2. The Methods RQ and analytic focus on menstruation are clarified in Data Analysis (p. 14): “For this study, we first identified all segments of data in which married adolescent girls or mentors discussed menstruation, menstrual management, bleeding‑related stigma, mobility restrictions, or program sessions focused on menstruation. These segments were compiled into an analytic corpus that formed the basis for the menstrual experiences analysis.
8. Unpack what is meant by “safe space(s)” and describe this concept and its implementation more clearly.
   1. Response: The Background’s programmatic subsection (pp. 6–7) now describes MAS’s purpose, content, and implementation. We clarify that MAS consists of twice‑weekly clubs for married girls focusing on literacy, SRH (including menstrual hygiene), self‑advocacy, and livelihoods, implemented in rural Kaduna communities.
9. Elaborate what “participant observation” entailed in practice with respect to adolescents’ menstrual management. Specify what was actually observed regarding menstrual management and how such observations were organized and analyzed. Clarify how participant observation was possible given that menstrual management is private, secretive, and stigmatized; explain what aspects were accessible and how this was navigated. Address the apparent mismatch between the description of “participant observation” and conventional definitions involving social integration, objective observation, structured analysis, and participation in ethnographic research.
   1. Response: We greatly expanded the description of participant observation in Methods. On p. 11 we now write: “Participant observation consisted of researchers regularly attending MAS sessions; observing interactions among girls, mentors, and community members; and recording detailed field notes on how menstruation was discussed, managed, and responded to in everyday settings. Because menstrual management is largely a private practice, observations focused not on intimate bodily acts but on public and semi‑public dimensions of menstrual life, including girls’ mobility, school attendance, participation in religious and social activities, and discussions of menstrual pain, staining, or product use, alongside the material environments (e.g., WASH facilities, household spaces) that shaped these practices.”
   2. This clarifies what was observed, how, and why, and situates our use of “participant observation” in a transparent and methodologically grounded way.
   3. We added detail on integration and settings in Methods (p. 11): “The Nigerian research team spent at least two days in the field visiting the communities and collecting field note data through observations and conversations that occurred in the safe spaces, the girls’ homes, and around the community. The researchers had lived in the communities for several months as part of a previous study and had developed strong rapport with the rural communities and the girls and their mentors.”
10. Give more detail on procedures to safeguard participants’ well-being, especially considering intersecting vulnerabilities such as age, socioeconomic dependence, menstrual trauma, and adolescent marital status. Explain how consent procedures were navigated for married adolescent participants and justify the use of verbal consent, including whether this was approved by the relevant IRB or ethics committee.
    1. Response: We strengthened the ethics description in Methods (pp. 10–11): “For girls under 18, verbal assent was obtained in addition to verbal consent from a parent, guardian, or husband… The use of verbal rather than written consent was approved by the ethics committee because of low literacy levels, concerns about the confidentiality of written signatures in small communities, and the cultural sensitivity of discussing reproductive health and menstruation.”
11. Describe counselling referral, debriefing, and distress protocols used, if any, during data collection.
    1. Response: We also added explicit protection and referral procedures: “To protect participants’ wellbeing during data collection, researchers avoided pressing for details about traumatic menstrual experiences, paused or redirected conversations if girls showed signs of distress, and offered information on available counselling or referral pathways through CGE programming and local health facilities. Field notes were de‑identified… and stored on password‑protected devices.” (p. 12)
12. Expand the section on positionality to include how researcher identities, power dynamics with adolescent participants, and personal attributes or biases may have shaped data collection and analysis. Move beyond conceptualizing positionality only positively (rapport, professionalism, extended presence) by addressing how complexities and potential constraints on participants’ expression were handled. Clearly discuss reflexivity, rather than only listing research-centered activities such as dialogue, memo-writing, and iterative checking of themes; show how reflexive practices centered participants and shaped interpretation. Add detail on positionality and reflexivity to strengthen trustworthiness and enhance the paper’s credibility.
    1. Response: The Positionality and Reflexivity section (pp. 12–14) has been substantially revised. We now explicitly discuss potential constraints and mitigation: “At the same time, the team’s internal roles and shared commitment to MAS may have made some girls reluctant to voice negative views… To mitigate these dynamics, researchers emphasized the voluntary nature of participation, invited both positive and critical reflections on MAS, and conducted some conversations outside of formal safe space meetings…” (p. 13)
    2. We also clarify how reflexivity shaped analytic interpretation: “Throughout fieldwork and analysis, the team engaged in reflexive dialogue, memo‑writing, and iterative checking of emergent themes… Reflexive discussions explicitly considered how researchers’ identities (e.g., staff members, outsiders, older adults, or former residents) might shape which girls felt comfortable participating, what they chose to disclose, and how stories about menstruation, marriage, and MAS were interpreted.” (p. 14)
    3. These additions directly address your concerns about power dynamics, bias, and trustworthiness.
13. Explicitly articulate the research questions and link them to the data analysis and findings.
    1. Please see our response to point #7.
14. Indicate what themes emerged from the data and/or literature in the data analysis section, not only the procedures followed.
    1. Please see our response to point #7.
15. Situate the findings clearly within a defined research problem, not just a social problem, recognizing that a social problem is not synonymous with a research problem.
    1. Please see our responses to points #1 and #7.
16. More clearly position the data and findings within scholarship and in relation to scientific shortcomings or limitations in the field.
    1. Please see our responses to points #1, #2, and #7.
17. Indent interview excerpts for improved readability.
    1. Response: We reformatted key quotations in the Findings so that the longer excerpts read as clearly separated blocks rather than dense paragraphs. For instance, in “Menstruation as a Catalyst of Constraint” (pp. 15–16), extended quotes now begin on new lines and are visually separated from analytic sentences, improving readability in line with this suggestion.
18. Shorten or simplify some long, winding sentences, particularly in the Introduction and Background sections.
    1. Response: We revised long sentences throughout the Introduction, Background, and Discussion sections. For example, in the Background on p. 5, a previously long sentence is now split and simplified: “Collectively, these findings underscore that menstrual inequities in Nigeria are widespread and shaped by structural, socioeconomic, and cultural barriers that restrict girls’ access to products, information, and supportive environments.”

 

19. Discuss research findings alongside the theoretical framework in the Discussion section.
    1. Response: The Discussion now explicitly engages the theoretical framework throughout. For instance, on p. 25 we write: “Viewed through an intersectional social ecological lens, this finding shows how bodies, households, schools, and community norms work together to construct menarche into a hinge between childhood and tightly controlled married womanhood.”
    2. Later we interpret self‑management and resilience via the menstrual health and rights lens: “Here, our use of menstrual health and rights frameworks makes visible how girls’ efforts to ‘make do’ are a response to systemic denial of the conditions required for safe, dignified menstrual management… rather than evidence that current structures are adequate.” (p. 27)
    3. These additions ensure that the Discussion consistently integrates the theoretical lenses rather than treating them as background only.
20. Provide more detail and justification for using verbal consent, including whether it was explicitly approved by the relevant IRB.
    1. Response: Please see our response to point #10.