The measure of a country's standing in terms of health can be gauged comprehensively by the parameters related to women's health. As much as the progress India has made since its independence, women's menstrual health continues to be riddled with taboos and reduced accessibility to period products. These are some of the findings of a study titled "COVID-19 and period products usage among menstruating women in Urban and Rural India" conducted by IIM Ahmedabad's professor Pritha Dev and Karan Babbar, a student. On the occasion of World Menstrual Hygiene Day on May 28, EdexLive got the opportunity to discuss their study and its implications on Indian society. How did the pandemic affect menstrual hygiene in the country? How can we battle the taboos and pave our way forward to complete menstrual hygiene across the nation? We found out in this tête-à-tête. Here are the excerpts:
Can you give a brief insight into the relevant factors whose interplay is essential to understanding menstrual hygiene issues in India?
Menstrual hygiene issues are a combination of the personal, interpersonal, environmental and socio-cultural contexts in India. In India, the socio-cultural context shrouds menstruation in taboos and shame, which derive from patriarchal norms. Menstruating women in India face restrictions in what they can do, touch and eat. Using the Consumer Pyramids Household Survey (CPHS) data collected by the Centre for Monitoring the Indian Economy (CMIE) and using expenditure on sanitary products by households for the year 2020, we find that in Jan 2020 around 60% of the households in our sample do not report any expenditure on sanitary products and this figure approaches 65% when considering rural areas only. Restricting attention to households that do spend on sanitary products, we find that an average household spends Rs 80.5 in Jan 2020, which constitutes a mere 0.6% of their total expenditure on average. Period poverty is a sad reality for most women in India and the pandemic has just exacerbated this.
The exclusion of period products in the initial list of essential items during the lockdown showcases that India still has a long way to go before realising mass awareness of women's health. How do you think governments and public perception can be changed?
There is an urgent need for government action and formulation of policy to sensitise the public regarding menstruation. Without this intervention, the concerns related to menstruation remain under a cloud of taboo, shame and silence. The government had taken some good steps with the scheme of pad distribution. The Ministry of Health and Family Welfare launched the Menstrual Hygiene Scheme to promote menstrual health and hygiene among the adolescent girls in the age group of 10 to 19 as a part of their Adolescent Reproductive Sexual Health (ARSH) to ensure good health and hygiene for the girls. The objective of this scheme was three-fold — to increase menstrual awareness among adolescent girls, to increase access and usage of sanitary pads to adolescent girls and to ensure safe disposal of sanitary pads to promote a friendly environment. More needs to be done to ensure everyone has access to menstrual products that they need and to ensure that public places have adequate WASH (water, sanitation and hygiene) facilities. Additionally, government programmes need to pay strong attention to awareness programmes, which work toward destigmatizing menstruation. Such programmes need to work with both adolescents and adults to have the largest impact possible.
Research on women's health is often very exclusive in nature with respect to how many people it informs. How do you feel this can be rectified so that more people become aware of societal shortcomings?
It is true that most of the research on women’s health is published in academic journals or outlets which are not accessed by the public. The only way of ensuring a transference to the public is via public awareness programmes, which work towards sensitising without being didactic.
Period products being considered essential items has a lot to do with people's perception. Where do you think is the gap that is hindering people's acceptance of the issue? Why do a majority of households still choose to avoid using them? (Since your research states that only around 37 per cent of households spent on period products from October 2019 to May 2020)
Menstruation is accompanied by multiple taboos and myths, situated in patriarchy. Women have been trained to hide their periods and period products. Since there is an unwillingness to recognise and openly talk about periods and period products, the issue of them being an important element in women’s health gets sidelined. The omission of period products from the list of essential products is an omission due to their invisibility, especially in the perception of men who are often at the helm of such decision making and women who are used to the silence around menstruation.
What can be the government's role moving forward? How can it get more people inclined to spend on their menstrual health? Or is it something the government should be more proactive about?
The concerns around women’s reproductive and menstrual health stem from widespread stigma and lack of knowledge. The government already does have programmes under which adolescent girls have access to free and subsidised menstrual products. Better menstrual health is a lot more than expenditure on menstrual products and it is intricately linked with knowledge levels of the individual and attitudes of society. Government should focus on increasing access to menstrual products via direct provision as well as ensuring better commercial supply chains, enhancing WASH facilities in public places, increasing the knowledge around reproductive health and running campaigns to break taboos around menstruation.
Is there a need for a differentiated strategy across geographies of urban and rural spaces to improve menstrual health?
According to NFHS-4 data, around 49% and 76% of the girls and women in the rural and urban areas use period products. Babbar, Saluja & Sivakami (2021) have shown that the factors affecting period product usage are similar in both urban and rural areas. However, the taboos and myths are much larger in the rural areas, as compared to urban areas, which created shame and secrecy around the topic. Additionally, ease of access to period products is also lower for all products in rural areas. Thus, the policymakers need to ensure that they go beyond distributing sanitary pads and complement it with educational programmes for enhancing community engagement, as well as bringing behavioural change towards better MHM (expand).
What further research are you planning to conduct in this area?
Almost 1 billion sanitary pads are used and disposed of every year. With the climate change conversations going around it is essential to move towards sustainable menstruation. However, in India, merely 2% of girls and women aged 15-24 use tampons or menstrual cups in India (NFHS-5, 2019-21). Thus, it is important to improve the uptake of sustainable menstrual products in India. We plan to conduct randomised control trials to improve the uptake of sustainable period products in India. We also plan to use the recently released NFHS-5 to conduct more in-depth studies around the period product usage and inform the policy.
What can be done to improve education around menstrual health, especially when girls face issues in schools?
One of the big issues around menstrual health is the associated taboos and myths, which create secrecy and shame around the topic. This coupled with the lack of sex education are the factors behind the poor menstrual health of the individuals who menstruate. Thus, to start with, we need to ensure sex education sessions in the middle schools as most of them attain/start attaining puberty by then. These sessions should (a) go beyond focusing on the scientific terms and include the practical guidance required to improve menstrual cycle knowledge and (b) educate them about the various period products, the environmental concerns with regard to the sanitary pads and other disposable period products and give them the agency to choose the period products of their choice.
Can you take us through your research and the challenges that you faced along the way?
We conducted a research study on menstrual hygiene that broadly focuses on the impact of the government-mandated lockdown across various zones on the period product consumption for menstruating women in India. The research paper used a combination of temporal (lockdown versus pre-lockdown) and spatial (government-mandated classification of districts into red, orange, and green zones) variation, which helps the researchers to exploit the lockdown as a natural experiment across 510 districts of India. As a part of this study, the researchers used household expenditure data from CMIE's CPHS data. They used the expenditure of households on sanitary products for all of 2020 where the months of April to May 2020 coincide with the national lockdown period. They use the expenditure data along with data on district-level classification into red, orange, and green zones.
Results: The results showed a reduction of 27% in period product consumption in red zone districts compared to the green zone districts. When restricting attention to rural districts only, this reduction was 33%. Further implications from the study highlighted a reduction in consumption in both the intensive and extensive margin. Comparing red and green districts, the research found a reduction in the number of households with any expenditure on period products as well as a reduction in the amount spent by households.
The results showed that households with menstruating women in rural areas were more likely to choose to not spend at all on period products and also to spend less on period products during the lockdown. It also highlighted a negative effect of the lockdown on the period product usage in India overall and especially in rural areas. There is a need to keep public policy focused on period products and menstrual hygiene and to understand the differential impact on period products of travel restrictions.
Challenges: We have used the secondary data from CMIE to conduct this study, hence, no challenges were faced in collecting the data. We just want to highlight that we could not find the data on trans and non-binary individuals who menstruate. Via this platform, we would like to urge the policymakers and data collection agencies to collect the data on trans and non-binary individuals.
Were there any observable trends regarding the menstrual hygiene of girls in your study? How can the issue be addressed specifically with respect to non-schooled girls whose awareness is critical?
As discussed above, NFHS-4 survey (2015-16) highlights that 49% and 76% of the girls and women use period products in rural and urban areas. These numbers improved to 72% and 89% for rural and urban areas in 2019-21 (NFHS-5 Data). We do not have a sub-sample of non-schooled girls to specifically answer this question. If we restrict our data to the girls with no education/0 years of schooling from NFHS-4 and NFHS-5 data, then, the % of women using period products has increased from 19.9% to 43.5%.
It is essential to conduct community-level interventions for the increase in the period product usage among the non-schooled girls. It is also essential to tell them about the various period products and give them the agency to choose a period product of their choice.
