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Why acknowledging and addressing ‘Period Poverty’ is essential for overall women health?

Bobby Luthra Sinha and Deepali Sudhindhra

Menstrual Hygiene and Challenges: Fact-Check on India

Menstrual Health and Hygiene: Around 1.8 billion people menstruate every month worldwide, meaning at a given point each day, 800 million women and girls menstruate, comprising 26% of the global population, according to National Centre for Biotechnology Information (2023). Given the high prevalence of period poverty, how safe and secure are women while handling this cyclical, fundamental and embodied phenomenon? Period poverty is defined as a lack of access to menstrual hygiene products and facilities, education, waste management or a combination of these.

An estimated 500 million people worldwide experience period poverty, which in many cases implies that they cannot go to school, work regularly or participate in daily life. Improper water, sanitation, hygiene and care services within school campuses cause female students and teachers to miss schools during periods. Period poverty causes physical, mental, and emotional challenges causing people to experience shame. Additionally, stigma and debilitating attitude on periods prevents individuals from talking about it.

Does India have period poverty?

An estimated 355 million Indian women and girls must find ways to cope with monthly menstrual hygiene. Most of these women either have no access to toilets or make do with unclean lavatory facilities. In remote and rural places, most women  wait until night-time before using public toilets or fields which exposes them to various forms of physical attacks, whether from humans or animals. Molestation, insect-bites, snakebites, thorn bush-injuries are some of the many challenges that women undergo while venturing out at the night to change their menstrual materials.

Data from Joint Monitoring Programmes of WHO and UNICEF as well as World Bank indicates that around 91 million urban Indians lack basic hand washing facilities at home.  In terms of facilities, regular supply of clean water and functional toilets are essential for managing hygiene during periods. India fares better than least developing countries where only 27% of the population has a handwashing facility with water and soap at home. In India, approximately 60% of households (mostly urban) have water and handwashing facilities at home.

A study by UNICEF (2014) found that between 43% to 88% of Indian girls use and reuse washed cotton cloths. A report published by Dasra Foundation in 2014 reveals that 70% mothers of adolescent girls considered menstruation as ‘dirty’.  71% of adolescent girls came to know of menstruation only during their first period while only half of them considered menstruation as normal. According to National Family Health Survey (NFHS 2014-16 of India) 43% of Indian women did not have access to sanitary pads. An independent study by Times of India (2018) showed that 82% of women did not know about sanitary pad and its purpose. Only 18% of those who were aware of sanitary pads knew how to use and dispose them correctly.

Inadequate MHM practices have been associated with adverse health outcomes

Worldwide studies indicate how conditions of inadequate MHM expose women to various kinds of physical and mental health challenges.  For instance, adolescent girls in rural Gambian (Africa) schools found that heavy menstrual bleeding predisposed them to depressive symptoms. Extreme menstrual pain and cramps, accessing sanitary pads in unclean toilets coupled with less access to a functional water source at school were associated with urogenital infections (UTIs) symptoms. Reports for India are indicative of similar issues wherein lack of privacy and sanitation in school toilets may aggravate the chances of UTI symptoms as well as lead to full blown infections.

In India, menstrual hygiene management is a significant challenge, particularly in rural areas. According to the 2011 census, 89% of the rural population in India lives in households that lack toilets. More recently, under the Swach Bharat Mission households have acquired toilets structures but these may not be adequately functional.  This absence of proper sanitation presents public health challenges and affects Indian women disproportionately. A survey among Maharashtra’s cane cutters identified a widening blind spot in women’s health: the unchecked rise of hysterectomies. Half of the women reportedly go through hysterectomies before they turn 35, as per National Family Health Survey-5 data (2020).  The highest percentage of hysterectomies (51.8%) occurs to treat excessive menstrual irregularities such as pain and heavy bleeding.

A report by FSG states that 70% of the cases of reproductive diseases in India are due to poor menstrual hygiene. Using unhygienic materials during menstruation can lead to several health problems ranging from Reproductive Tract Infections (RTIs) and Urinary Tract Infection (UTIs) to cervical cancer. While commercially available sanitary napkins provide a possible alternative, a Forbes-India study (2018-2019) concluded that only 12% of Indian girls and women use sanitary pads during menstruation. 88% of women in India use alternatives like rags, ash, hay, or sand.

Resource and Practice gaps in MHM

Some of the main obstacles, from a public health perspective, in ensuring a smooth MHM in India include stigma and culture of silence at the social level. In terms of sanitation products and services, dearth of access to sanitary napkins, menstrual absorbents and information about menstrual hygiene materials is a huge gap.

Moreover, absence of support from family and community keeps the issue side-lined. Clean and functional toilets for girls and women are hard to find in rural India and public places. A majority of rural women in India employ clothes and rags for feminine hygiene. These materials might predispose women to reproductive tract infections since it may be difficult for them to keep their used napkins clean and free of harmful bacteria. Lack of disposal mechanisms of used sanitary pads and cloths further compound the issue.

In remote areas of districts such as Odisha’s Malkangiri and Kalahandi, women have to go far away from home to fetch water and lack sufficient resources to clean the menstrual materials or maintain menstrual hygiene.  In Bihar and Chhattisgarh, MHM suffers owing to presence of contaminated water.  Washing reusable feminine products with unclean water and inability to dry them in sunlight (read in the open) thereafter, owing to cultural taboos associated with menstruation jeopardise menstrual hygiene.

Listening to Voices of Women is Fundamental for MHM throughout the World

The ability of girls and women to exercise the power of their voice in terms of opinion and choice to make themselves be heard brings best solutions to problems that women are privy to. Menstruation in this sense is an embodied experience, as women and girls undergo it every month. A worldwide survey from 2020 found that when women were asked what services their country should provide concerning menstruation, almost half said menstrual materials should be provided free.

Data given below illustrates the percentage of women worldwide who shared their preference over select services that their country should provide w.r.t to their menstrual needs:

National Menstrual Hygiene Policy, 2023, India

National Menstrual Hygiene Policy (2023) draft, currently under review by the Indian government, aims to address the challenges associated with menstruation in India and promote menstrual hygiene as a natural and normal part of life. The draft does justice to India’s commitment to achieving the Sustainable Development Goals (SDGs).

SDG 3 on good health and well-being, Goal 4 on quality education, Goal 5 on gender equality, and Goal 6 on clean water and sanitation have a crucial significance for MHM. There is no direct mention of any goal or indicator of menstrual health and hygiene in the UN SDGs. Nevertheless, it is well recognized that poor MHM practices will adversely affect the initiatives and performances of the countries toward achieving a number of important developmental goals (SDGs 3, 4, 5, 6, 8, and 12).

In short, National Menstrual Hygiene Policy (2023) draft of India recognizes menstruation as a natural bodily process for all who menstruate, including girls and women of reproductive age. It addresses the long-standing challenges associated with menstruation in India.

Way Forward: Place Menstrual Hygiene needs at Par with National Public Health goals

Studies have found that lack of MHM infrastructure and resources at home, in villages and in schools in rural areas leads to significant absences (almost 4 to 5 days a month) of adolescent girls from their classes. Menarche is symbolic of a girl attaining youth, coming of age and acquiring a milestone in reproductive health.

At the same time, owing to the patriarchal gaze that adolescents face, many families in remote and resource -scarce areas understand the onset of puberty and menarche (start of periods) as a challenging phase for young girls. Therefore, National Menstrual Hygiene Policy needs to increase awareness and outreach drives. Affordable and accessible menstrual products alongside broader efforts to expand information and knowledge on adolescence and menstrual health can safeguard the progress of young girls in a hygienic and dignified manner.

Ensuring safety and security of menstruating women of all ages in India also requires the breaking of the silence on this hushed up topic.  Working towards ending taboos, myths, and mental stigma associated with menstruation can thus benefit communities.  MHM is the integral part of Swachh Bharat Mission guidelines. The Ministry of Health and Family welfare fulfils MHM requirements by distributing sanitary pads but only to adolescent girls. Moreover, this distribution is not homogenous or regular and is ridden with many lacunae.

Under-preparedness to distribute menstrual materials during disasters such as floods or natural calamities or reaching remote tribal zones is a daunting anomaly in the public health sector. Streamlining distribution in normal times and  also, continuing  basic amenities such as the availability of soap and water in schools and toilets would go a long way in protecting women against infectious diseases and disorders during disaster times.

A holistic approach towards relieving menstruating women of their woes would require the public health policy to have more than a Water, Sanitation and Hygiene (WASH) focus. Research work among girls and women; community -based awareness drives; free and fair distribution of products and services can remedy period poverty to bring a gender-based wellbeing in India.

Dr. Bobby Luthra Sinha is the Deputy Director at the Centre for Asian African and Latin American Studies (CAALAS), ISS, Delhi and Head of Research at Un Paso Mas, LLP, Delhi.  

Deepali Sudhindra Data Analyst and Researcher in health currently working in SATHI, Pune, Maharashtra.

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