Acceptability and feasibility of using vaginal menstrual cups among schoolgirls in rural Nepal: a qualitative pilot study

Abstract

Introduction
Menstrual hygiene management can be challenging in low-income settings and among school-aged girls due to traditional beliefs, lack of knowledge and information on best hygienic practices, and limited access to appropriate and affordable menstrual hygiene products. An alternative method for menstrual hygiene management, instead of sanitary pads or tampons, is the vaginal menstrual cup. As evidence on the use of menstrual cups is relatively limited, this study aimed to explore the acceptability and feasibility of using vaginal menstrual cups among school-aged girls in Thokarpa, Sindupalchowk, Nepal.

Methods
This is an exploratory study based on four focus group discussions with a purposive sample of 28 schoolgirls between 13 and 19 years of age who were provided with vaginal menstrual cups in Thokarpa, Sindupalchowk, Nepal. The data were collected between February and March 2019, i.e. approximately three months after the distribution of the menstrual cup. Participants were included in the study if they had started their menstruation and never given birth. Conventional content analysis was applied.

Results
Most participants perceived the menstrual cup positively. Not missing a single class in school due to problems related to menstrual hygiene management was described as a major benefit. The participants found using the menstrual cup easy and convenient, and described economic and environmental advantages of using it. Cleaning the menstrual cup did not cause any problems, according to the participants. Discomforts mentioned by the participants were: pain when inserting the menstrual cup, feeling the menstrual cup sticking out of the vagina, feeling a constant urge to urinate and leakage. Concerns were related to the size, shape and texture of the menstrual cup, and that it may “get stuck” in the vagina, while relatives were said to be concerned about the use of the menstrual cup leading to reduced fertility or losing virginity.

Conclusion
The use of vaginal menstrual cups for menstrual hygiene management among schoolgirls in Thokarpa, Sindupalchowk, Nepal, appears feasible and acceptable, as it involves practical, economic and environmental advantages. However, the scale-up of menstrual cups will require resolving described concerns and discomforts and fostering peer and family support.

Full text

Pokhreletal. Reprod Health (2021) 18:20
https://doi.org/10.1186/s12978-020-01036-0
RESEARCH
Acceptability andfeasibility ofusing vaginal
menstrual cups amongschoolgirls inrural
Nepal: aqualitative pilot study
Diksha Pokhrel1, Sabina Bhattarai1, Malin Emgård2,3, Michael von Schickfus2,3, Birger C. Forsberg4
and Olivia Biermann3,4*
Abstract
Introduction: Menstrual hygiene management can be challenging in low-income settings and among school-aged
girls due to traditional beliefs, lack of knowledge and information on best hygienic practices, and limited access to
appropriate and affordable menstrual hygiene products. An alternative method for menstrual hygiene manage-
ment, instead of sanitary pads or tampons, is the vaginal menstrual cup. As evidence on the use of menstrual cups is
relatively limited, this study aimed to explore the acceptability and feasibility of using vaginal menstrual cups among
school-aged girls in Thokarpa, Sindupalchowk, Nepal.
Methods: This is an exploratory study based on four focus group discussions with a purposive sample of 28 school-
girls between 13 and 19 years of age who were provided with vaginal menstrual cups in Thokarpa, Sindupalchowk,
Nepal. The data were collected between February and March 2019, i.e. approximately three months after the distribu-
tion of the menstrual cup. Participants were included in the study if they had started their menstruation and never
given birth. Conventional content analysis was applied.
Results: Most participants perceived the menstrual cup positively. Not missing a single class in school due to prob-
lems related to menstrual hygiene management was described as a major benefit. The participants found using the
menstrual cup easy and convenient, and described economic and environmental advantages of using it. Cleaning the
menstrual cup did not cause any problems, according to the participants. Discomforts mentioned by the participants
were: pain when inserting the menstrual cup, feeling the menstrual cup sticking out of the vagina, feeling a constant
urge to urinate and leakage. Concerns were related to the size, shape and texture of the menstrual cup, and that it
may “get stuck” in the vagina, while relatives were said to be concerned about the use of the menstrual cup leading to
reduced fertility or losing virginity.
Conclusion: The use of vaginal menstrual cups for menstrual hygiene management among schoolgirls in Thokarpa,
Sindupalchowk, Nepal, appears feasible and acceptable, as it involves practical, economic and environmental advan-
tages. However, the scale-up of menstrual cups will require resolving described concerns and discomforts and foster-
ing peer and family support.
Keywords: Menstrual hygiene management, Menstrual cup, School-aged girls, Rural Nepal
© The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco
mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Introduction
Menstrual hygiene management can be challenging
inresource poor settings, such as Nepal, due to tradi-
tional practices and beliefs [1–3], lack of knowledge [4,
Open Access
*Correspondence: olivia.biermann@ki.se
4 Department of Global Public Health, Karolinska Institutet, Stockholm,
Sweden
Full list of author information is available at the end of the article
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 2 of 10
Pokhreletal. Reprod Health (2021) 18:20
5] and information [3] on best hygienic practices, lack
of infrastructure such as access to soap and water [6],
as well as limited access to appropriate and affordable
hygienic products [2, 7]. e use of unhygienic clothes
to replace pads or tampons may cause restriction in
movement, skin irritation, concerns about leaking and
odor [8, 9], and increase the risk of urogenital infections
[10, 11]. In Nepal, many families impose restrictions on
menstruating girls and women, which may vary based
on religion, social group and education level [12]. e
severest restriction is "Chhaupadi", meaning the isola-
tion of menstruating women in small huts made of mud
and stones with no doors or windows, which is still prac-
ticed in the Far-Western Development Region of Nepal
[13]. A study conducted in the Central Development
Region, where this study was conducted, showed that in
the aftermath of the 2015 earthquake, menstrual hygiene
management was rated as the sixth highest overall need
by study participants (after food, shelter, water, clothes
and information about family members)[14, 15]. om-
son and colleagues [16] emphasized the need to reframe
menstrual hygiene management as a question of rights as
opposed to hygiene, acknowledging that a wide range of
issues linked to menstruation beyond hygiene, e.g. secu-
rity, stigma, safety, taboo and policy ownership.
Problems with menstrual hygiene management may
be particularly prevalent in school-aged girls. Accord-
ing to a report from the United Nations Children’s Fund,
UNICEF, 18.4% of schools in Nepal did not have a toi-
let in 2018, while others lacked sex-segregated facili-
ties, adequate water supply or disposal systems, which
would allow for appropriate menstruation management
[17]. Girls are therefore more likely to miss school [17,
18] and, in some parts of Nepal, are not allowed to go to
school during their menstruation [17]. Studies conducted
across sub-Saharan Africa have furthermore shown that
discomfort during menstruation led to school absentee-
ism and drop-outs in adolescent girls [19–21]. A recent
study from Ethiopia demonstrated that the provision of
menstrual education and menstrual hygiene kits helped
improve school attendance by girls [22].
A method for menstrual hygiene management, alter-
native to sanitary pads and tampons, is the menstrual
cup. e menstrual cup is a bell-shaped device made of
high-grade medical silicon, which is inserted into the
vagina during menstruation. e device should be boiled
once per month and can be used for 5–10years. It col-
lects more blood than the standard sanitary pads and
is environmentally friendly with few known side effects
[23–25]. e use of menstrual cups has been studied in
countries of all income-levels [23, 24, 26–31]. In stud-
ies conducted in high-income countries, the menstrual
cup was perceived as satisfactory, e.g. due to comfort,
less leakage, less odor and less frequent need to change
compared to tampons and sanitary pads [23, 24, 26].
Different studies conducted in low- and middle-income
countries have reported the acceptability of menstrual
cups among girls and women [27–31]. For instance, a
study from South Africa showed that girls and women
rated menstrual cups as significantly better for comfort,
quality, menstrual blood collection and appearance [28].
Studies reported that girls embraced the use of menstrual
cups, while the uptake was slow, requiring peer support
and mentoring [29, 31]. A study from Nepal showed that
peers influence learning on how to use the menstrual cup
but found less evidence that peers impact an individu-
al’s desire to use it [29]. e latter study did not analyze
the acceptability and feasibility of menstrual cup usein
depth. A recent systematic review and meta-analysis on
the use, acceptability, safety and availability of menstrual
cups stated that menstrual cups were a safe option for
menstruation management [32].
e setting of this study is okarpa, a village of
approximately 8000 inhabitants in Sindupalchowk,
Nepal. It is located approximately 3h travel northeast of
Kathmandu. Despite its relative proximity to the capital,
it is less developed, poverty is widespread and access to
health care limited. e main sources of income are agri-
culture and/or work in the capital by a family member.
Currently, a health post provides care for minor health
needs, while a larger health facility is being constructed
and expected to be running in 2021. ere are five pri-
mary schools and two secondary schools in the village.
ere is one main water source in okarpa provid-
ing clean fresh water. Families use the water source to
carry water to their homes. Yet, tap water is available in
the selected school. To the best of our knowledge, evi-
denceon the use of menstrual cups in Nepal isscarce.
A gap of context-specific evidence remains with regards
to the acceptability and feasibility of using menstrual
cups for menstrual hygiene management among school-
girls in okarpa, Sindupalchowk, Nepal. is evidence
is needed to inform local decision-making, but even to
inform interventions in similar contexts across low- and
middle-income countries worldwide.
Methods
is study aimed to explore the acceptability and feasibil-
ity of using vaginal menstrual cups for menstrual hygiene
management among school-aged girls in okarpa, Sin-
dupalchowk, Nepal. It is an exploratory study based on
four focus group discussions (FGDs) with a purposive
sample of 28 schoolgirls between 13 and 19 years of
age who were provided with vaginal menstrual cups in
okarpa.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 3 of 10
Pokhreletal. Reprod Health (2021) 18:20
Preparatory phase
In November 2018, one of the researchers (ME) met
with local stakeholders to discuss the possibility of
piloting menstrual cups in okarpa. e stakehold-
ers included the Chairman of the Village Development
Committee, the coordinator for health projects, the
director of one of the secondary schools, politicians,
teachers, health and social workers, as well as mem-
bers of a women’s group. During the meetings, the
menstrual cup, its potential benefits and risks, as well
as the required conditions for its use were explained
and discussed. Preconditions for the useof menstrual
cups were: interest among key stakeholders, cultural
acceptability, availability of fresh water and possibility
to boil the cup. e local stakeholders discussed and
confirmed that the required conditions were met in
okarpa and they welcomed and supported the con-
duct of the pilot study.
Selection ofparticipants
irty girls were sampled purposively to participate in
the study. Local stakeholders supported the sampling;
while 10 girls were invited to participate by a local wom-
en’s group, 20 girls were invited by the coordinator for the
health projects and the school principal in collaboration
with a female teacher. e girls were from classes eight
(age group 13–14years), nine (age group 15–16years)
and eleven (age group 17–19years). ey were included
in the study if they were interested in participating, and
if they had started their menstruation and never given
birth. Girls from classes 10 and 12 were not included as
their final exams would take place within a few months,
after which they would move away from okarpa to
pursue work opportunities; a follow-up of these girls
would have therefore not been possible. All participants
could speak and understand the Nepali language. Based
on recommendations by the Chairman of the Village
Development Committee and the coordinator for health
projects, the selected 30 girls represented most of the
different social groups present in the village. Each FGD
included a mix of different social groups.
Together with the teacher, a nurse, one of the research-
ers (ME) and an interpreter, a 3-h interactive health edu-
cation class in Nepali language was organized in late
November 2018. Topics covered included the anatomy of
the female reproductive organs, the menstrual cycle and
the menstrual cup. In addition, the girls were given infor-
mation about the planned pilot study after three months
to evaluate the acceptability and feasibility of using the
menstrual cups. e girls were informed that their par-
ticipation was voluntary and that their (or parents’) con-
sent would be needed. ey were also informed that they
could stop using the menstrual cup at any time and leave
the study without any repercussions or implications for
them or their families.
Each girl was provided, free of charge, with a men-
strual cup (size “mini”; diameter 37mm/1.46 in.), a bar
of soap and a user manual in Nepali language. e men-
strual cups had been purchased from MonthlyCup (Indu-
medic, Munka-Ljungby, Sweden) at a reduced rate of 14.5
USD per piece. InduMedic Polymer AB follows quality
assurance number ISO 9001:2015/ISO 9001-00006082,
issued by LRQA Sverige AB for Lloyd’s Register Qual-
ity Assurance Ltd, 1 December2016. e MonthlyCup’s
user manual was translated into Nepali by a professional
translator. Costs for menstrual cups manufactured in
Nepal currently range between 7 and 18 USD per piece.
ey can be purchased in shops selling women’s acces-
sories and online stores.
e group of girls, together with the coordinator for
health projects, chose two girls from different grades and
social groups to serve as contact persons for the group
and to follow up twice with each of the girls during the
upcoming three months. e girls should turn to the
two contact persons for the group for follow-ups, and to
inform the nurse and health worker in case of medical
questions or issues. e coordinator for health projects,
the nurse and the researcher kept in contact via email
during the three months test period.
Data collection
Between February and March 2019, a female resident
doctor from the Department of Community Medicine at
Kathmandu Medical College (DP) conducted four FGDs
with 28 out of the 30 schoolgirls who had received men-
strual cups in okarpa, after seeking informed consent
from the girls (or their parents). Two girls did not partici-
pate in the FGDs due to lack of time or interest.
e FGDs were divided by school grade (Table 1).
Table1 shows the constellation of FGDs by number of
users and non-users of the menstrual cup; the non-users
had not yet used the menstrual cup after having been
provided with it. With permission by the school’s direc-
tor, FGDs 1–3 were convened after the end of a school
day in one of the school’s privatemeeting rooms. FGD
4 was organized during a second visit to okarpa, as
some girls were not present and/or had not yet obtained
informed consent from their parents during the first visit.
FGD 4 took place in a private room in the public library,
close by the school. e discussions lasted from 15 and
45min.
e FGDs were based on an interview guide developed
by the authors (Appendix 1). All FGDs were conducted in
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 4 of 10
Pokhreletal. Reprod Health (2021) 18:20
Nepali, audio-recorded, transcribed and translated into
English by the first author (DP).
Data analysis
e data analysis was done by DP with guidance from
OB. e analysis was based on the full database, and the
coding process was done manually. All data were ana-
lyzed using conventional content analysis; meaning units
were identified, condensed and abstracted inductively to
create codes that were combined into categories based on
the manifest content of the transcripts [33]. DP identi-
fied themes inductively and discussed them with OB. SB
and ME validated the findings and checked the results of
the analysis to enhance credibility. e concept of infor-
mation power guided the data analysis [34]. Information
power implies that the more information (relevant to the
study) a sample holds, the fewer participants would be
needed [34]. As such, we found the sample to hold high
information power, given that it provided relevant infor-
mation and we judged themes to be repeated towards
the end of the FGDs. In the presentation of the results,
selected quotations are presented to reflect common
answers from the respondents. We also highlight differ-
ences in the responses.
Results
We identified two overarching themes in the data (1)
practical, economic and environmental advantages of
using the menstrual cup and (2) discomfort and concerns
related to the menstrual cup, which we describe in the
following section.
Before using themenstrual cup
e participants explained their menstrual hygiene man-
agement practices before using the menstrual cup. Due to
the unavailability and/or high costs of menstrual hygiene
products in local stores, the participants illustrated how
they would make pads out of fabrics (e.g. from old sarees).
ese homemade pads would be unhygienic, get soaked
quickly and require frequent changing or washing. e
participants explained how they would feel embarrassed
using homemade pads, as they would be visible through
their clothes and leave blood stains. Furthermore, they
described feeling uncomfortable as the homemade pads
would slide out of place while walking and be difficult
to handle when using public toilets. Some participants
had to use public taps for washing their pads, which also
made them feel uneasy, in particular when men and boys
would be passing by: "While washing the pads [in public
taps], the water and lather get all red with blood and it’s a
big trouble what to tell the guys while throwing the water.
We feel embarrassed." (FGD 1) Moreover, drying a home-
made pad in the sun was thought to be shameful due to
the risk that a male family member might catch sight of
it: "We should not dry the pads in the sun and it’s also
believed to be shameful in front of the male members of
the house, especially the father figures." (FGD 1) One par-
ticipant expressed the belief that "if someone sees the pad
you’ve used, they might curse you with bad spirits which
will harm you." (FGD 1)
Practical, economic andenvironmental advantages
ofusing themenstrual cup
Most participants perceived the menstrual cup positively.
Not missing a single class in school due to problems
related to menstrual hygiene management was described
by the participants as a major benefit. One participant
stated:" I have never missed a class due to periods after
I started using the [menstrual] cup." (FGD 4) Another
participant described the practicality of using a men-
strual cup as opposed to homemade pads: "I didn’t wash
my used homemade pads for a very long time because I
felt disgusted. ere are small shelves inside my toilet
where I used to store them which irritated my mom so
much that she would always scold me for that habit. But,
after I started using the menstrual cup, there would be no
used pads in the shelves which made my mom so relieved
that she actually thought that the menstrual cup was
invented exclusively for me." (FGD 1)
e participants found using the menstrual cup easy
and convenient. One participant said: "It is so easy that
I even forget that I’m on my period. Once, I entered the
kitchen while I was on my period and got a bad scolding
from my mom. We are not allowed to enter the kitchen
Table 1 Characteristics ofFGD participants
FGD number School grade Age group (in years) Constellation oftheFGD Duration
(in min)
1 11 17–19 7 users, 1 non-user 45
2 9 15–16 5 users, 4 non-users 20
3 8 13–14 2 users, 6 non-users 25
4 9 (n = 1) and 11 (n = 2) 15–19 3 users 15
Total 17 users, 11 non-users 105
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 5 of 10
Pokhreletal. Reprod Health (2021) 18:20
during our periods, that’s our culture." (FGD 1) In addi-
tion, the participants described the menstrual cup as
convenient to use when outdoors, as they would not have
to be concerned about changing, washing or disposing a
homemade pad or a sanitary pad: "Once, while I visited
my relative, she showed me a big plastic bag on the corner
of the bathroom to dispose my sanitary pad. It felt disgust-
ing that the used sanitary pads were kept in the bathroom
for so long. Moreover, it’s uncomfortable talking about
sanitary pads with a male relative." (FGD 1) Further-
more, the participants did not have to worry about leav-
ing stains of blood on toilet seats or their own clothes:
"e problem of embarrassment among friends when the
drops of blood were left in the toilet is solved. So, for me
at least, the [menstrual] cup has been very, very helpful."
(FGD 1).
e participants described economic and environ-
mental advantages of using the menstrual cup. Buying
sanitary pads used to be an economic burden to the par-
ticipants, with a cost of approximately NPR 100 (USD
0.8) for eight pads. Moreover, sanitary pads would some-
times be unavailable in the local store, requiring the girls
to buy them from a market located a 1.5-h bus ride away.
One girl described how, since using the menstrual cup,
she could use the money she would spend on sanitary
pads otherwise: "Buying sanitary pads every month used
to be very expensive for us. We use that money for buy-
ing ourselves lunch now." (FGD 1) In terms of the envi-
ronment, a participant highlighted the menstrual cup as
being “good for the environment” (FGD 1), as itis reusable,
while pads or tampons would need to be discarded.
Cleaning the menstrual cup did not cause any prob-
lems, according to the participants. One participant
stated: "Changing and washing the cup is not a problem
as such because we usually do that in the toilet of our
own home. Moreover, it also doesn’t take as much effort
and water as homemade pads do." (FGD 2) Boiling the
menstrual cup was no problem either, girls highlighted,
as they were allowed to boil the menstrual cup over the
regular fire of their kitchen using a dedicated pot: "We
are allowed to boil our cups in our own kitchen over the
same fire but we do have to use a separate pot." (FGD 4)
Moreover, participants elaborated that taking a small
bottle of water along with them when leaving their home
was enough for washing the menstrual cup in instances
when water was unavailable.
e participants stressed the benefits of the menstrual
cup for girls and women and recommended it to their
friends. One participant believed that every woman in
their village would benefit from using a menstrual cup,
especially because they have to work hard in the fields,
even during their menstruation: "I feel like this is best for
teenage girls and also to women who do so much of work
during their periods because this [using the menstrual
cup] is so easy." (FGD 4) e girls also recommended
and promoted the use of menstrual cup among their
friends: "I’ve told my friends that since a cup can be used
for fiveyears, it’s worth the money and they seemed inter-
ested." (FGD 1)
Discomfort andconcerns
Discomforts mentioned by the participants were: pain
when inserting the menstrual cup, feeling the menstrual
cup sticking out of the vagina, feeling a constant urge to
urinate and leakage (especially during nighttime). One
participant described discomforts when the menstrual
cup was not properly inserted: "If it [the menstrual cup]
is not kept fully inside or is a bit down, I feel like some-
thing is pricking me. And also, when it’s inside, I feel an
urge to urinate very frequently." (FGD 3) e feeling of
pain at insertion may be a reason for non-use, as one girl
explained: "I did not use the menstrual cup after I tried it
once because it was too painful to insert even when I did
it with the method taught, carefully." (FGD 1) In FGD 2,
one participant using the menstrual cup showed her sup-
port towards a non-user: "e first time was hard for us
too, but it gets easier later on. Once it [the menstrual cup]
gets completely inside [the vagina], you won’t feel a thing."
(FGD 2).
Concerns were related to the characteristics of the
menstrual cup and that it may “get stuck” in the vagina,
while relatives were said to have mentioned concerns
about the use of the menstrual cup leading to reduced
fertility or losing virginity. Some participants were wor-
ried about the size, shape and texture of the menstrual
cup and were unsure how to insert it into their vaginas:
"It [the menstrual cup] was very hard in texture." (FGD
1) Meanwhile, other participants were relieved on see-
ing the menstrual cup: "I thought it would be very big
and hard to insert. But, after I got one for myself, it was
smaller and softer than I had imagined it to be. It could
also be folded so easily." (FGD 2) Many participants were
concerned that the menstrual cup might leak. One girl
expressed her fear of not being able to take out the men-
strual cup: "Once, I thought that the cup got lost inside my
vagina although they had taught us that the vagina is a
closed space. I tried pushing it out of my vagina using all
of my strength and only then I could feel the tip of the cup.
at was such a relief." (FGD 1) Along the same lines, a
participant described how her parents were hesitant and
advised their daughters to use the cup only after receiv-
ing feedback from the other participants: "My mom said
to try it [the menstrual cup] once, but carefully, as it might
get stuck inside my vagina." (FGD 4)
Another concern said to have been mentioned by par-
ticipants’ family members included reducing fertility and
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 6 of 10
Pokhreletal. Reprod Health (2021) 18:20
losing virginity by using the menstrual cup. One partici-
pant said: "My parents fear that it might do some harm
to my uterus." (FGD 3) One participant’s family mem-
ber was said to have expressed her concern as follows:
“You shouldn’t be using such things. We’re married and
have babies, but it may be difficult to conceive [a child]
for you, if you use such kind of thing [a menstrual cup]."
(FGD 1) Another relative was said to be concerned the
girl may lose her virginity by using the menstrual cup
which would be perceived negatively, as a girl is expected
to remain a virgin until getting married. At the same
time, the participants highlighted the importance of sup-
port from their families: “Everybody was very supportive
including our parents. e only reason of not using it [the
menstrual cup] was because we could not get it inside [the
vagina]." (FGD 2).
Discussion
is was a qualitative study exploring the acceptability
and feasibility of using vaginal menstrual cups for men-
strual hygiene management among school-aged girls in
okarpa, Sindupalchowk, Nepal. e results revealed
the perceived practical, economic and environmental
advantages of using the menstrual cup, as well as the dis-
comfort and concerns related to its use. Menstrual cups
appear feasible and acceptable for menstrual hygiene
management in the described target group and setting,
while it will be paramount to resolve mentioned concerns
and discomfort and fostering peer and family support. In
the following, we compare our findings on (1) how girls
managed their menstruation before using the menstrual
cup, (2) perceived advantages of using menstrual cups, as
well as (3) discomfort and/or concerns with the available
literature in the field.
As poverty inhibits menstrual hygiene manage-
ment, the situation before using the menstrual cup was
described similarly across low-income settings compared
to how the participants described it in okarpa. Due to
limited resources, girls would use homemade pads but
perceive them as “bulky” and uncomfortable due to leak-
age and odor [27]. Parents would observe their daugh-
ters suffering from itching, irritation and redness due to
the use of homemade pads [30]. Moreover, other studies
also portrayed taboos related to menstruation which lead
to fear [8, 9]. McMahon and colleagues [9] elaborated
how girls became self-conscious during their menstrua-
tion, wearing a sweater around their waist, dark-colored
or multiple layers of clothes, or asking friends to walk
closely behind them to avoid others seeing blood stains
on their clothes. is fear was said to potentially lead to
decreased concentration while at school [8].
Advantages of using menstrual cups have been
described similarly in other studies, while existing
evidence sheds light on additional benefits linked to
menstrual cup use. Firstly, the ease and convenience
of using menstrual cup has also been documented in
other studies conducted in low- and middle-income
countries [8, 9, 18]. A study from Kenya described the
pleasure girls felt being active and confident that the
cup would remain insitu; the menstrual cup resulted in
less (if any) leakage, would not drop and once inserted
properly was more comfortable than pads [8]. Secondly,
in line with our results, studies conducted across sub-
Saharan Africa have shown that the use of menstrual
cups could prevent physical and social discomfort dur-
ing menstruation and related school absenteeism and
drop-outs [19–21]. One study highlighted that the
cost of menstruation-related absenteeism would make
it difficult for girls to catch up during examinations,
ultimately leading to school dropouts [19]. irdly,
the economic advantage and cost effectiveness as well
as a positive environmental impact of menstrual cup
use has also been highlighted by previous work [35].
In addition to our results, studies conducted in Kenya
[30], South Africa [28] and the United Kingdom [24]
have found no increased infection risk associated with
menstrual cup usage. A decrease in candidiasis and
bacterial vaginosis by using menstrual cups was also
reported by a study implemented in Kenya which com-
pared menstrual cups, sanitary pads and using cloth
pads or other makeshift materials [36].
Discomfort and/or concerns were similarly described
in the existing literature, while our study also shed light
on certain aspects which have not been previously
described in the literature, such as perceiving the men-
strual cup to be sticking out of the vagina, feeling an urge
to urinate, and the concern that the menstrual cup may
“get stuck” in the vagina. Firstly, discomforts mentioned
by the participants such as pain when inserting the men-
strual cup and leakage have been comparably described
in the literature [26, 30]. Secondly, concerns regarding
reducing fertility and losing virginity, which participants’
relatives brought up, have been similarly described by
other studies from Zimbabwe [27] and Kenya [30]. In
contrast to our results, other studies have reported that
the menstrual cup was perceived as messy and ill-fitting
[26, 30], and that it may get lost or damaged [25, 26]. Per-
ceptions that we have not seen described by other studies
included feelings of discomfort by perceiving the men-
strual cup to be sticking out of the vagina as well as by
feeling an urge to urinate, and the concern that the men-
strual cup may “get stuck” in the vagina. Importantly, the
participants in this study elaborated on the significance
of support from peers and family members, as well as the
nurse and teacher who acted as contact persons within
the project. e relevance of peer support has further
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 7 of 10
Pokhreletal. Reprod Health (2021) 18:20
been acknowledged by studies done in Nepal [29] and
Uganda [37], as such support helped in successful adop-
tion of the menstrual cup by schoolgirls.
Strengths andlimitations
Strengths of this pilot study include that schoolgirls
from different age and social groups were involved, aim-
ing to reflect a broad range of perspectives on the use
of menstrual cups for menstrual hygiene management.
e participants showed trust in the interviewer, as they
seemed to speak openly about their experiences in using
or not using the menstrual cup and discuss the topic in
an engaged manner with other FGD participants. e
diverse groups and way of communication increased
the study’s trustworthiness, including its confirmability
and transferability [38]. ough our sample may be lim-
ited, the congruence between our data and earlier stud-
ies suggest that our study gave a good insight into the
experiences of using menstrual cups in the community
studied. Moreover, we believe that our findings are a val-
uable contribution to the literature and can inform future
research and guide the local planning and implementa-
tion of programmes on menstrual hygiene management
and beyond. For instance, our findings could inform a
larger discussion on water, sanitation, hygiene efforts,
as well as human rights, gender and inequality. Rigor-
ous preparation had foregone the implementation of this
pilot, including stakeholder engagement, preparation of
information materials in Nepali language, the appoint-
ment of local contact persons for the participating girls
and the organization of a health education session. We
see this preparation as a strength of our study and as a
recommendation for any study or programme imple-
menting innovations such as menstrual cups.
Limitations of this study included that we conducted
the interviews only about three months after hav-
ing introduced the menstrual cups to the participat-
ing schoolgirls. e FGD results might have been more
nuanced and grounded, given the girls’ “learning curve”
in using the menstrual cup, had we conducted this study
at a later stage. Such a “learning curve” had previously
been described by Van Eijk and colleagues [32]. Yet, this
early follow-up provided us with the opportunity to har-
ness the girls’ early impressions of using the menstrual
cups, which are meaningful for the future implementa-
tion. Another limitation of this study was that 11 of the
28 participants (39%) had not actually used the menstrual
cup in the test period. However, we think that this pro-
vided an excellent opportunity to explore reasons for
non-use which, according to the participants, was solely
related to the menstrual cup being difficult to insert into
the vagina. In addition to that, some girls may not have
had their menstruation during the 3-months test period,
given that teenagers’ menstruation may still be irregular.
e participants did mention negative aspects (concerns
and discomfort) with regards to using the menstrual cup,
but did not report on any major problems related to its
use; rather than assuming that problems did not exist,
we acknowledge that the participants may have felt shy
to report problems. Shyness may also be reflected in the
short duration of one of the FGDs (15min).We did not
systematically conduct analyses by age or social group
(while the FGDs included schoolgirls of different social
groups, they were divided by age group), but we have
highlighted the FGD number along each quote that we
mentioned in the results to provide contextual under-
standing. Finally, we acknowledge that making menstrual
cups available in low-income settings at an affordable
price today will require subsidies by governments or
organizations to cover the costs fully or partly. e non-
governmental organization that supported the provision
of menstrual cups as part of this study continued to pro-
vide 50 additional menstrual cups for NPR 300 (USD 2.4)
per piece (equivalent of approx. 24 sanitary pads) in the
local pharmacy of okarpa to test the demand among
the local population. e price had been agreed upon
with local stakeholders involved in this pilot study.
Future research
Future research should explore the feasibility and accept-
ability, potential benefits and risks, as well as barriers and
facilitators of using menstrual cups in more depth. More-
over, the topic should be explored from the perspectives
of a variety of stakeholders, including boys, men, parents,
relatives, teachers and health care providers. Other stake-
holders’ points of view could shed light on additional bar-
riers and facilitators for menstrual cup use and menstrual
hygiene management more broadly, and help identify
ways in which menstrual cups could be a strategic oppor-
tunity to improve intersectional inequalities, gender
equity as well as equity within families, schools and com-
munities. Potential benefits which would be worth inves-
tigating include: saving water, as washing menstrual cups
requires less water than washing home-made pads (even
in the case of water shortages, the girls would still be able
to use menstrual cups, e.g. if they brought a bottle of
water to school for washing the menstrual cup); reducing
waste, as menstrual cups could be used for up to 10years
(depending on the manufacturer); and saving costs due to
not having to buy menstrual hygiene products in the first
place.
Conclusion
This study provides context-specific evidence about
the use of vaginal menstrual cups for menstrual
hygiene management among schoolgirls in Thokarpa,
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 8 of 10
Pokhreletal. Reprod Health (2021) 18:20
Sindupalchowk, Nepal, appears feasible and accepta-
ble, as it involves practical, economic and environmen-
tal advantages. However, the scale-up of menstrual
cups will require resolving described concerns and
discomfort and fostering peer and family support. As
such, this study offers local evidence that can inform
local decision-making and contribute to setting a
research agenda for the use of menstrual cups in low-
and middle-income countries.
Abbreviations
FGD: Focus group discussion; UNICEF: United Nations Children’s Fund.
Acknowledgements
We would like to thank all the schoolgirls who participated in the FGDs and
their parents who allowed them to do so. We thank local stakeholders for
their support of this project: Netra Karki, Chairman of the Village Develop-
ment Committee; Shankar KC, coordinator for health projects; Bishnu Prasad
Neupane, principal at the Bhag Bhairab secondary school; Laxmi Marahata,
teacher at the Bhag Bhairab secondary school; Saraswati Shahi Thakuri, nurse;
and the “Mahila” women’s group. We furthermore wish to thank Kabita Lama
and Astha Palilchey Rai, interpreters; as well as Sunita Subba, translator.
Authors’ contributions
OB, ME and MS conceived the study. OB developed the interview guides,
which SB, ME and MS provided feedback on. ME conducted preparatory
activities including the engagement of local stakeholders and the health
education class. DP conducted all FGDs, transcribed and translated the data.
DP coded the data, which SB, ME and OB provided feedback on. DP, SB and
OB developed a first draft of the manuscript which all authors reviewed and
contributed to. DP and OP finalized the manuscript, which all authors read
and approved.
Funding
The authors declare that this study has no funding support.
Availability of data and materials
The data underlying this study are not publicly available owing to the duty to
protect participants’ confidentiality as outlined in the informed consent proto-
col. Versions of the transcripts that have been modified to protect confidenti-
ality are available from the corresponding author upon reasonable request.
Ethics approval and consent to participate
Ethics approval was obtained from the Kathmandu Medical College Public Ltd.
Institutional Review Committee Sinamangal (affiliated to Ethical Review Board,
Nepal Health Research Council) (Ref: 150320191). Written informed consent
was obtained from the participants or from their parents (in case of partici-
pants under the age of 18 years) before the start of each FGD. The anonymity
and confidentiality of the participants were ensured by removing all identifiers
except the school grades in the presentation of the results.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests. MonthlyCup
(Indumedic, Munka-Ljungby, Sweden), the company that manufactured the
menstrual cups used in the pilot study, had no role in study design, data
collection, data analysis, data interpreting or writing of the report. None of
the researchers has had any commercial interest in the product. Some of the
co-authors of this study (ME, MvS and OB) had a role in the community as
representatives of a non-governmental organization involved in health care
provision and public health promotion in Thokarpa, Sindupalchowk, Nepal.
Author details
1 Kathmandu Medical College, Kathmandu, Nepal. 2 Linköping University
Hospital, Linköping, Sweden. 3 Foundation Human Nature, Nidda, Germany.
4 Department of Global Public Health, Karolinska Institutet, Stockholm,
Sweden.
Appendix1: Interview guide forfocus group
discussions
1 What comes to your mind when you think about
menstruation in general?
(a) How would you usually feel when you have
your menstruation?
(b) How would you usually manage the menstrual
bleeding?
2 ink back a few months/years ago: How would the
days during your menstruation typically look like?
(a) Would your menstrual affect your daily activi-
ties? How?
(b) How would you manage the bleeding?
3 When you first heard about the menstrual cup, what
did you think about it?
(a) What was your expectation from using the
menstrual cup?
(i) Did you expect any benefits? Which?
(ii) Did you expect any risks? Which?
(b) What were your friends’ expectation from
using the menstrual cup?
4 What did you think about the health education ses-
sion where the menstrual cups were explained to
you?
(a) Was there any other topic you would have liked
to learn about?
5 How did you find the instruction manual for using
the menstrual cups that you were provided with?
(a) Was the information understandable?
6 Have you used the menstrual cup?
(a) If yes, during how many menstrual cycles have
you used it? (continue with question 7)
(b) If no, why not?
(i) Could you describe why you decided to/
why you were not able to use it?
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 9 of 10
Pokhreletal. Reprod Health (2021) 18:20
(ii) Anything (like lack of information) that, for
instance, education of the parents could overcome?
(continue with question 10)
7 How was your experience in using the menstrual
cup?
(a) How did you feel about using it?
8 How easy was it to use the menstrual cup?
(a) How easy or difficult was it to change the cup?
(b) Where would you usually change the cup?
(c) How easy or difficult was it to wash the cup?
(d) Where would you usually wash the cup?
9 How was your friends’ experience in using the men-
strual cup?
10 What were the advantages of using the menstrual
cup?
11 What were the disadvantages of using the menstrual
cup?
12 What did your family think of you using the men-
strual cup?
13 Has using the menstrual cup affected your everyday
life?
(a) Has your motivation to go to school during
your period changed using the menstrual cup
compared to before?
14 Do you plan to continue using the menstrual cup?
(a) Would there be any other products you would
prefer to use during your menstruation?
(b) Have you talked about this with the other girls,
your teachers or health workers?
15 Would you recommend the menstrual cup to others?
(a) To who?
16 Do you have any other comments?
Received: 25 August 2020 Accepted: 2 November 2020
References
1. Oche O, Umar S, Gana J, Ango T. Menstrual health: the unmet needs of
adolescent girls in Sokoto, Nigeria. Sci Res Essays. 2012;7(3):410–8.
2. Adinma ED, Adinma JI. Perceptions and practices on menstrua-
tion amongst Nigerian secondary school girls. Afr J Reprod Health.
2008;12(1):74–83.
3. Shrestha N, Dangal G, Khanal G, Bhandari TR. Knowledge of menstrual
hygiene management among adolescent girls: what does evidence
show? Nepal J Obstet Gynecol. 2020;15(30):9–17.
4. Yadav RN, Joshi S, Poudel R, Pandeya P. Knowledge, attitude, and practice
on menstrual hygiene management among school adolescents. J Nepal
Health Res Counc. 2018;15(3):212–6.
5. Adhikari P, Kadel B, Dhungel SI, Mandal A. Knowledge and practice
regarding menstrual hygiene in rural adolescent girls of Nepal. Kath-
mandu Univ Med J (KUMJ). 2007;5(3):382–6.
6. Thapa B, Powell J, Yi J, McGee J, Landis J, Rein L, Kim S, Shrestha S,
Karmacharya B. Adolescent health risk and behavior survey: a school
based survey in central Nepal. Kathmandu Univ Med J (KUMJ).
2017;15(60):301–7.
7. Crichton J, Okal J, Kabiru CW, Zulu EM. Emotional and psychosocial
aspects of menstrual poverty in resource-poor settings: a qualitative
study of the experiences of adolescent girls in an informal settlement in
Nairobi. Health Care Women Int. 2013;34(10):891–916.
8. Mason L, Nyothach E, Alexander K, Odhiambo FO, Eleveld A, Vulule J, et al.
We keep it secret so no one should know—a qualitative study to explore
young schoolgirls attitudes and experiences with menstruation in rural
western Kenya. PLoS ONE. 2013;8:e79132.
9. McMahon SA, Winch PJ, Caruso BA, Obure AF, Ogutu EA, Ochari IA, et al.
The girl with her period is the one to hang her head - reflections on men-
strual management among schoolgirls in rural Kenya. BMC Int Health
Hum Rights. 2011;11:7.
10. Das P, Baker KK, Dutta A, Swain T, Sahoo S, Das BS, et al. Menstrual hygiene
practices, WASH access and the risk of urogenital infection in women
from Odisha, India. PLoS ONE. 2015;10:e0130777.
11. Phillips-Howard PA, Nyothach E, TerKuile FO, Omoto J, Wang D, Zeh
C, et al. Menstrual cups and sanitary pads to reduce school attrition,
and sexually transmitted and reproductive tract infections: a cluster
randomised controlled feasibility study in rural western Kenya. BMJ Open.
2016;6:e013229.
12. Mukherjee A, Lama M, Khakurel U, Jha AN, Ajose F, Acharya S, Tymes-
Wilbekin K, Sommer M, Jolly PE, Lhaki P, Shrestha S. Perception and
practices of menstruation restrictions among urban adolescent girls and
women in Nepal: a cross-sectional survey. Reprod Health. 2020;17(1):81.
13. Kadariya S, Aro AR. Chhaupadi practice in Nepal—analysis of ethical
aspects. Medicolegal Bioethics. 2015;5:53–8.
14. Budhathoki SS, Bhattachan M, Castro-Sánchez E, Sagtani RA, Rayamajhi
RB, Rai P, Sharma G. Menstrual hygiene management among women
and adolescent girls in the aftermath of the earthquake in Nepal. BMC
Womens Health. 2018;18(1):33.
15. Budhathoki SS, Bhattachan M, Pokharel PK, Bhadra M, van Teijlingen E.
Reusable sanitary towels: promoting menstrual hygiene in post-earth-
quake Nepal. J Fam Plan Reprod Health Care. 2017;43(2):157–9.
16. Thomson J, Amery F, Channon M, Puri M. What’s missing in MHM? Mov-
ing beyond hygiene in menstrual hygiene management. Sex Reprod
Health Matters. 2019;27(1):1684231.
17. UNICEF Nepal Country Office. Analysis of menstrual hygiene practices in
Nepal. The role of WASH in Schools Programme for Girls Education. Nepal:
UNICEF; 2018.
18. Brocklehurst C, Bartram J. Swimming upstream: why sanitation, hygiene
and water are so important to mothers and their daughters. Bull World
Health Organ. 2010;88(7):482.
19. Boosey R, Prestwich G, Deave T. Menstrual hygiene management
amongst schoolgirls in the Rukungiri district of Uganda and the impact
on their education: a cross-sectional study. Pan Afr Med J. 2014;19:253.
20. Sommer M, Sahin M. Overcoming the taboo: advancing the global
agenda for menstrual hygiene management for schoolgirls. Am J Public
Health. 2013;103(9):1556–9.
21. Sommer M. Where the education system and women’s bodies collide:
the social and health impact of girls’ experiences of menstruation and
schooling in Tanzania. J Adolesc. 2010;33(4):521–9.
22. Belay S, Kuhlmann AKS, Wall LL. Girls’ attendance at school after a men-
strual hygiene intervention in northern Ethiopia. Int J Gynaecol Obstet.
2020;149(3):287–91.
23. Howard C, Rose CL, Trouton K, Stamm H, Marentette D, Kirkpatrick N,
Karalic S, Fernandez R, Paget J. FLOW (finding lasting options for women)
multicentre randomized controlled trial comparing tampons with men-
strual cups. Can Fam Physician. 2011;57:e208–15.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 10 of 10
Pokhreletal. Reprod Health (2021) 18:20
•
fast, convenient online submission
•
thorough peer review by experienced researchers in your field
•
rapid publication on acceptance
•
support for research data, including large and complex data types
•
gold Open Access which fosters wider collaboration and increased citations
maximum visibility for your research: over 100M website views per year
•
At BMC, research is always in progress.
Learn more biomedcentral.com/submissions
Ready to submit your research
Ready to submit your research
? Choose BMC and benefit from:
? Choose BMC and benefit from:
24. Stewart K, Greer R, Powell M. Women’s experience of using the Mooncup.
J Obstet Gynaecol. 2010;30:285–7.
25. Juma J, Nyothach E, Laserson KF, Oduor C, Arita L, Ouma C, et al. Examin-
ing the safety of menstrual cups among rural primary school girls in
western Kenya: observational studies nested in a randomised controlled
feasibility study. BMJ Open. 2017;7:e015429.
26. North B, Oldham M. Preclinical, clinical, and over-the-counter postmarket-
ing experience with a new vaginal cup: menstrual collection. J Women’s
Health. 2011;20(2):303–11.
27. Averbach S, Sahin-Hodoglugil N, Musara P, Chipato T, van der Straten A.
Duet for menstrual protection: a feasibility study in Zimbabwe. Contra-
ception. 2009;79:463–8.
28. Beksinska ME, Smit J, Greener R, Todd CS, Lee ML, Maphumulo V, Hoff-
mann V. Acceptability and performance of the menstrual cup in South
Africa: a randomized crossover trial comparing the menstrual cup to
tampons or sanitary pads. J Women’s Health. 2015;24:151–8.
29. Oster E, Thornton R. Determinants of technology adoption: peer effects
in menstrual cup up-take. J Eur Econ Assoc. 2012;10:1263–93.
30. Mason L, Laserson K, Oruko K, Nyothach E, Alexander K, Odhiambo F,
et al. Adolescent schoolgirls’ experiences of menstrual cups and pads in
rural western Kenya: a qualitative study. Waterlines. 2015;34:15–30.
31. Van Eijk AM, Laserson KF, Nyothach E, Oruko K, Omoto J, Mason L, et al.
Use of menstrual cups among schoolgirls: longitudinal observations
nested in a randomised controlled feasibility study in rural western
Kenya. Reproductive Health. 2018;15:139.
32. Van Eijk AM, Zulaika G, Lenchner M, Mason L, Sivakami M, Nyothach
E, et al. Menstrual cup use, leakage, acceptability, safety, and
availability: a systematic review and meta-analysis. Lancet Public Health.
2019;4(8):e376–93.
33. Graneheim UH, Lundman B. Qualitative content analysis in nursing
research: concepts, procedures and measures to achieve trustworthiness.
Nurse Educ Today. 2004;24(2):105–12.
34. Malterud K, Siersma VD, Guassora AD. Sample size in qualitative
interview studies: guided by information power. Qual Health Res.
2016;26(13):1753–60.
35. Hyttel M, Thomsen CF, Luff B, Storrusten H, Nyakato VN, Tellier M. Drivers
and challenges to use of menstrual cups among schoolgirls in rural
Uganda: a qualitative study. Waterlines. 2017;36:109–24.
36. Phillips-Howard PA, Caruso B, Torondel B, Zulaika G, Sahin M, Sommer M.
Menstrual hygiene management among adolescent schoolgirls in low-
and middle-income countries: research priorities. Glob Health Action.
2016;9:33032.
37. Oster E, Thornton R. Menstruation, sanitary products and school attend-
ance: evidence from a randomized evaluation. Am Econ J Appl Econ.
2011;3:91–100.
38. Lincoln G, Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park: Sage
Publications; 1985.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in pub-
lished maps and institutional affiliations.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com