Better protected

An extra from Blood speaks

How can sanitary pads be made more widely available in low-income countries? 

Like many inventors, Arunachalam Muruganantham first tested his creation on himself. In his case, this involved wearing a sanitary pad for a week and simulating a period by means of a bottle of goat blood. The workshop employee from Tamil Nadu, India, had noticed that his wife was having to choose between buying food and buying sanitary pads (also known as napkins or towels), so he developed a low-cost machine for making the pads – then refused to patent it. There are now over 600 of his machines operating across India and beyond, producing low-cost cellulose pads. 

Muruganantham’s wife is not alone in her stark choice. A survey by Plan India/AC Nielsen reports that only 12 per cent of girls and women in India have access to decent sanitary protection while menstruating. This is in comparison, say Plan India, to the 100 per cent of women in Singapore and Japan and the 88 per cent of women in Indonesia who have access to commercial sanitary pads. What of the ones who don’t? There are widespread and alarming anecdotes from across Asia and Africa of girls resorting to selling sexual favours to buy pads.

Of course, pads are not the only solution to the health problems caused by poor menstrual hygiene. But tampons fall foul of insertion taboos, so are unsuitable for unmarried girls or women who are supposed to remain ‘intact’.

Menstrual cups (reusable vessels of silicon or rubber that are inserted into the vagina) are touted as a low-cost, sustainable solution but require privacy and access to clean water, often in short supply. Their adoption might also be hampered by insertion taboos. So initiatives aiming to reach wide numbers of girls and women focus on the sanitary pad.

In 2012, I visited a school in Maharashtra, India. In one classroom, a group of girls was being educated in menstrual hygiene, and the unspeakable – to them – mysteries of their menstrual cycles. Next door was a group of boys being taught about periods by their male teacher. I joined the boys and, as they’d never seen one, showed them a sanitary pad I had in my bag. That’s probably more that most of their peers get to see. But things may change, as initiatives to provide free or subsidised sanitary pads are growing.

In 2010, the government of India announced the Menstrual Hygiene Scheme, as part of its National Rural Health Mission, to provide highly subsidised sanitary pads to rural girls living below the poverty line. State governments – including Himachal Pradesh, Delhi, Tamil Nadu and Bihar – have followed suit with similar initiatives, though the scope and budgets vary, as does the success. In 2012, medical officers in Varanasi reported receiving no funds to implement the scheme.

In Kenya, meanwhile, where an estimated 2.7 million girls require sanitary protection, the government in 2011 allocated almost $4m to provide free sanitary napkins for schoolgirls, although one local TV channel reported in 2013 that the budget had been slashed, and girls were resorting to using feathers, goat skin and soil instead. 

Elsewhere, field workers have found girls and women using newspaper, straw, ash or sand to absorb menstrual blood. Why shouldn’t they? Because it’s unhygienic and dangerous. Cloth need not be if it is clean and properly dried in sunlight, but shame leads girls and women to dry washed cloths under beds, out of sight, in damp conditions. Bacterial infections of the urinary and reproductive tracts ensue. In factories in Dhaka, Bangladesh, welfare officers told me that most women using chemically treated cloth from the factory floor had had chronic vaginal discharge and infections (which disappeared when they switched to pads).

But because academics and scientists have been slow to explore the health impacts of poor menstrual hygiene, studies are still scanty, sample sizes small, and conclusions difficult to draw. A recent survey of existing research literature on the health impacts of menstruation found that methodologies varied greatly and “overall quality was low”.

Evidence to support the link between poor menstrual hygiene management and health (including secondary infertility, reproductive and urinary tract infections, and anaemia) is “weak and contradictory”. Although it’s known that reproductive tract infections are common in lower-income countries, “the proportion of this burden that can be attributed to poor menstrual hygiene management… is unknown”. 

Improving access to sanitary pads is not the only challenge: how used ones are to be disposed of remains unclear. Research by the University of Maryland’s Dr Vivian Hoffman in Bihar, India, found that 60 per cent of women disposed of their sanitary napkins or cloths in the open.

Other disposal options are also problematic: commercial sanitary pads – which deliberately contain highly absorbent polymers – can block sewer systems. “Menstrual waste blockages can block a city sewer system for a whole day,” Madeleine Fogde of the Stockholm Environment Institute told a UN meeting on menstrual hygiene. Pads can block suction hoses used to empty latrines. Or girls may be too embarrassed to use dedicated latrines with disposal bins.

Muruganantham closed a 2012 TED talk on his work by saying how he wants to make India a country where 100 per cent of women use sanitary pads. While the provision of hygienic, affordable pads is undoubtedly much needed, we must also ensure that there are safe, sustainable ways of disposing of them.