Over the past two years, FIFA's Women’s Football Division has been dedicated to addressing crucial challenges in women's health within the realm of sports, with a vision to elevate women's participation, education, and performance to new horizons. In August 2023, in collaboration with leading experts from around the globe, the FIFA Women’s Health, Wellbeing, and Performance project was unveiled. One of the experts involved is Dr Nonhlanhla Mkumbuzi. During the recent COSAFA Women’s Championship in South Africa, she spoke to FIFA.com/Inside about one of her current research projects.

I trained as a physiotherapist and specialised in exercise physiology at the University of Zimbabwe. I then went on to do my PhD at the University of Cape Town in exercise science and sports medicine. My area of expertise is female athlete’s health - specifically the intersection between the biology of female athletes and the socio-economic, religious, and cultural contexts that they live in.

We know we have a shortage of research on women and girls in sport globally, and that research has mostly been conducted on women and girls from high income countries. What we are saying is this is a problem. We don't know what's happening in women, so we don't know what their needs are. We are again taking stuff and copying and pasting it from men. We hope that by doing more research on African women and girls in sport and hopefully across other underrepresented regions, people sitting in positions of power 10/15 years from now can make truly well-informed decisions. I think it's a bit like Neil Armstrong. It's a tiny little step. We hope that somewhere we have a giant leap forward with other people taking on the same type of research. In our case it is a small contribution that we hope can lead to more research, and collectively lead to the creation of a bigger research database.

We have one conducted one study every year since 2020, centred on injury surveillance. What kind of injuries and illnesses do we get? How many? How are they managed? Doing such research allows us to be able to understand the characteristics of injury in our context. We are trying to implement injury surveillance data (similar to UEFA’s club study of the last 20 years) and then we can observe trends. What are the most common injuries that we face in our environment? Once we understand this, we can then design preventative measures and try to mitigate those injuries. Specific to our setting, and specific to the injuries our female players face. In 2020, our study focused on the menstrual cycle and the experiences of female African players. We read so much about how one’s menstrual cycle affects performance. Data from Australia, the UK, but not so much from Africa. We wanted to find out what the players’ experience was.

Interestingly I don't think in any of that data, you've ever read that players in Switzerland for example don’t have sanitary pads. Our data however shows that 35% of African players sometimes use old rags. Not having a dollar to buy a packet of sanitary pads is a real issue. Previously we had conducted a study on the menstrual cycle and attitudes towards the menstrual cycle too. Again, because we needed to start talking about this with teams and to normalise it. We need to train according to a menstrual cycle. Which phase you are in? Before we can go to that step of developing programs about the menstrual cycle, we want to find out what our players, our coaches and referees know. Less than 20% knew the hormones of the cycle and on only half of the medical personnel knew. If you are letting someone manage female players but they don't know the hormones of what it is that makes them women, that means we need to do something, and that is education.

This year, we also wanted to find out if the football environment is menstrual cycle friendly. If the environment doesn't have a toilet for a player to change their used tampon, or water for them to wash, or a disposal bin, these are all things that affect thirty other people around a squad. We're asking players: do you have water to wash your hands? Do you have a toilet with a door with a lock? Do you have privacy? Do you have safety when you're changing? All those things, FIFA can do something about, and at a MA level, MAs can do something. This is a conversation that can also help with future sponsors. Do you want to sponsor a women's team? Well, players need bathrooms, they need bins to throw away their used sanitary pads. How do we know? Because we asked them, and they told us that they don't have them.

I think we are headed in the right direction. I recently came from Kenya where I was conducting a physio workshop. I would use that as a perfect example of female athlete health being safeguarded. Here was a Federation and the women's football division making the conscious effort that they are going to train physiotherapists and train the people who take care of athletes. Making a conscious effort of prepping and capacitating their medics; the people who look after female athletes, with education. I think that was very commendable.

• 95% of players experience daily menstrual cycle symptoms. • 1 in 3 players have adjusted training due to symptoms. • 66% feel symptoms affect their performance. • 90% of players do not communicate menstrual cycle issues with coaches. • 41% of players have encountered heavy bleeding. • 85% perceive insufficient menstrual cycle knowledge. • 42-47.1% of athletes use hormonal contraception, and 45% use analgesics for menstrual symptoms. Source: FIFA Women’s Health, Wellbeing, and Performance Project