Period poverty and the cycle of neglect

Every so often, an Indian firm announces that female employees will soon have the option of ‘period leave’, amounting to 10 days off every year. Debates erupt in workplaces, homes and newsrooms on whether this is a move towards inclusion or towards the ‘ghettoisation’ of women.

Miles away, in a school in Shivamogga, a 12-year-old girl is shocked and embarrassed when her first period stains her uniform in the middle of the school day. The jeers of her classmates ring in her ears, and in the months to come, she begins to stay home the week of her period. Another reason behind her reluctance — the toilets at her school are yet to get running water.

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Journeying even further, to a village in Odisha, where residents have recently gained access to sanitary pads. The women here hesitate to use them, as they have no means of disposing the pads safely. Dumping them without care carries the risk of contaminating the village’s key water sources.

The experiences of women across India with regard to menstruation exist across a spectrum. Sadly, the one thing menstruators — young and old, urban and rural — have in common, is the stigma they are subject to on account of this normal biological process.

The stigma translates into several effects beyond the emotional, leaving women to grapple with serious complications. Research shows that reproductive tract infections are about 70 per cent more common among women with poor menstrual hygiene practices.

A report by NGO Dasra and USAID revealed that 23 million girls in India drop out of school annually due to a lack of proper menstrual hygiene management facilities.

According to the most recent National Family Health Survey (2020-21), more than 30 per cent of women between the ages of 15 and 24 do not use hygienic methods of protection during their menstrual period. Hygienic methods include “locally prepared napkins, sanitary napkins, tampons, and menstrual cups.”

The data shows a 20 per cent increase in the use of hygienic methods in the last seven years. Still, only 14 states report more than 90 per cent of women using hygienic methods of menstrual hygiene management (MHM).

There is also a wide variance across states, ranging from 58 per cent to 99 per cent of women using hygienic methods.

The data uncovers a stark disparity between rural and urban regions. For instance, while nearly 82 per cent of women in urban Madhya Pradesh use hygienic MHM methods, the percentage of women in rural areas with this privilege is only 54.4 per cent.

The gap is glaringly evident in several other states, including Gujarat (urban - 77.6 per cent, rural - 58.6 per cent), Assam (urban - 82.9 per cent, rural - 63.8 per cent) and Meghalaya (urban - 85 per cent, rural - 59 per cent).

These numbers, and the realities behind them, reveal that with approximately 33 crore menstruating women, India is still plagued by astounding levels of ‘period poverty’. Defined as a lack of access to menstrual products, information, and infrastructure for hygiene and waste management, period poverty denies women a basic right to safe menstrual hygiene management.

The issue is further aggravated by stigma. Centred around a core idea of ‘impurity’, there are several superstitions surrounding menstruation. Practices range from barring entry to places of worship, kitchens and even homes when a woman is on her period.

A 2018 study by UNICEF found that 70 per cent of Indian mothers believed menstruation was ‘dirty’. This attitude, passed on to adolescents, leads to more misconceptions, with research finding that only about half of the adolescent girl population believes that menstruation is normal.

Shame reinforces this misconception. “Girls are not allowed to touch others. They are made to eat separately, not allowed to enter the kitchen. This is so humiliating, but such beliefs are deep-rooted in our mindsets and influence our behaviours,” says Dr Sania Siddiqui, a medical professional who started the Humjoli Foundation in Pune to raise awareness on menstrual health and hygiene.

When the number and length of women’s periods are totalled, it is estimated that a woman cumulatively spends about seven years of her life on her period. Yet, there is a wide discrepancy in access and availability of core necessities for menstrual health and hygiene management. “Accessibility, affordability and availability are all compromised, especially in rural areas,” says Dr Siddiqui.

Ground realities

Exacerbated in rural areas, the lack of access to safe MHM affects women’s education, livelihoods, mental and physical health, and is sorely detrimental to their overall quality of life.

“In most households in our village, women use cloth during their period, as pads are expensive,” says M Geethamma, an ASHA worker from Ballari.

While reusables can be a sustainable choice, due to the cost of clean cloth, women end up using old rags, explains Dr Siddiqui.

“I use leftover cloth from dress materials and other old clothes,” says Kaveramma, who works as pourakarmika in Bengaluru.

“I wash and dry the cloth indoors at night, and wake up at 4 am to take it down before the men in my house wake up. I have been doing this for over 30 years now,” she says.

This is a common occurrence, as many women feel ashamed to dry the cloth out in the sun. But this is required to clean it properly, says a social worker from Bagalkot. Limited access to running water and functional toilets makes hygiene even more of a challenge.

As a result, when not properly washed, dried and maintained, the use of cloth in menstrual hygiene leads to reproductive tract infections, urinary tract infections, rashes, and posits higher risks of ovarian cancer.

The results can be devastating, as in the case of 18-year-old Jahnavi* from a slum in East Delhi. In 2019, she suffered an infection and visited a doctor when the pain became unbearable. Medical examination detected severe infection inside her vaginal tract and uterus. She was using old cloth to manage her period, including material from an old blouse. Contact of the hook with her vulva had led to the infection. She had to eventually undergo surgery.

Several years ago, in a similar case, a woman died of tetanus because of a rusted hook.

Period products like sanitary napkins are out of reach for many women. Beyond being an expensive option, sanitary napkins account for a recurring expense and therefore, it is only in high-income rural households that they are commonly used. The sale of subsidised options at Re 1 per pad has helped, but remains an incomplete solution.

As the purchasing power often lies in the hands of the male members of the family, “women hesitate to ask them to buy pads. As a result, they manage with what they have, or change pads less frequently, which takes a toll on their health,” says Rikita Narula, projects head at Sachhi Saheli, a Delhi-based NGO.

Pads are not practically viable, in some contexts. “Women who work long days outdoors without access to toilets report that they have developed rashes, itching and infections, due to long hours of exposure, and not changing the pad as often as needed,” says Dr Meenakshi Bharath, a gynaecologist and sustainable menstruation advocate in Bengaluru.

Awareness

The hesitation to talk about menstrual needs and processes is clear in the lack of knowledge that young girls have about their own anatomy. Research shows that less than half of teen girls in India are aware of periods pre-menarche.

Change is slow due to the deep-rooted negative perceptions. Most girls miss a minimum of a week of school each month during their period.

Rhema* (14), for example, was missing 10 days of school due to her period. When social workers investigated further, they found that Rhema was taking five days when she got her period. However, she also had to stay home for five more days during her mother’s period, as her mother would not be able to enter the kitchen and cook during that time.

For the young girls who overcome these setbacks and make it to school, the scenario is only marginally better. Under the National Health Mission’s Menstrual Hygiene Scheme, pads are distributed free of cost for girls between the ages of 11 and 19. Pads are also given out at Anganwadis and Primary Health Centres to girls who have dropped out. A Karnataka state-run menstrual hygiene programme also provides free sanitary napkins to girls.

While the distribution of free period products came as a welcome move, the supply has since stopped in several districts.

“Since the pandemic, for the past three years, we are not getting the pads from the government for distribution,” says Geethamma. “Girls constantly ask us about when the supply will restart. Many are struggling to buy pads and have switched back to cloth,” she adds.

Officials in the Department of Health in Karnataka explain that supply was interrupted due to failures in the tendering process. “The most recent tender was successful and now government approval is awaited to award the work,” says Randeep D, Commissioner, Health and Family Welfare.

Even when supply remains undisrupted, the standardised system fails to account for women’s unique health needs. “Some girls report getting their period for more than a week. Others have short cycles, getting their period more often than once a month,” says Annapurna K, an ASHA worker from Shivamogga.

With girls receiving a total of 10 pads per month, they are either forced to use them sparingly and face the health consequences, or struggle to buy them on their own.

It is not just sanitary napkins that are in short supply. In Maharashtra’s Khed taluk, volunteers from Humjoli Foundation were distributing sanitary napkins. On receiving information on how to use pads, a mother of four explained that in her household, the five menstruators only had two pairs of undergarments between them.

Whoever was on their period would use the undergarments, she said. “So where do I put all these pads you are giving me?” she asked. The foundation has since been distributing hygiene ‘kits’, complete with pads, undergarments, disposal bags and soap.

A menstrual health and hygiene management programme that hinges on the distribution of sanitary napkins barely touches the surface of meeting women’s basic needs.

While the government scheme also includes information and education programmes, activists are calling for a greater focus on the development of facilities.

“The need is not just for material to manage menstruation, but also infrastructure — running water, facilities for disposal and menstrual health awareness. These are equally as important,” says Rikita. These mechanisms are absent or non-functional in most schools.

Safe disposal is a major concern across the board — in schools and homes, and in cities and villages alike. Disposal methods range from burning the waste outside homes or dumping it in toilets or landfills.

According to the Menstrual Health Alliance India, over 12.3 billion pads are disposed of every year in the country. This would mean an annual menstrual waste generation of around 1,13,000 tonnes.

The solutions

Sustainable menstruation activists point towards menstrual cups and reusable cloth pads as viable solutions.

“No cash, no rash, no trash,” quips Dr Meenakshi, emphasising that reusables could also address issues of access. “Period poverty in India is manufactured poverty. We are teaching women that disposable products are the only option,” she says.

However, menstrual cups have been practical solutions for women, as is evident during floods and natural disasters, when running water and waste management systems are disrupted.

Further, while disposables require a consistent expenditure, reusables require a larger initial investment, but prove more cost-friendly over time. “The average menstrual cup costs around Rs 600. It can be used for 10 years,” she explains.

Cloth pads can also last three to four years. With new designs that look like an ordinary piece of cloth, the problem of drying the pads out in public is also addressed.

In Karnataka, the government has introduced a pilot intervention to distribute menstrual cups in Chamarajanagar and Dakshina Kannada districts. “Preliminary feedback from users is encouraging and this will help us plan for expansion activities,” says Randeep.

Comprehensive policy

Effective policy needs to be focused on sustainable menstrual management, that does not leave women dependent on the government for supply.

The system of distributing sanitary napkins varies across administrations, says Rikita. “Women need a lifetime supply of pads – until the age of menopause, and no government is promising or providing that. The policy and practice could change, leaving women who depend on the supply at a loss,” she says.

Schemes and plans need to be inclusive. While the Menstrual Hygiene Scheme outlines the distribution of pads and menstrual education to adolescents, there is little to no mention of older women and their needs in policy and research.

Finally, a sound menstrual policy also requires a holistic approach that makes a range of options available to women — be it cups, sanitary napkins, reusable pads or tampons. “What women need is the knowledge of all options available to them, and the right to make an informed choice. They need to know the pros and cons, and decide for themselves,” says Rikita.

(*names have been changed)