The Impact of Periods
Promoting menstrual health is critical to women’s economic empowerment around the world.
This article appeared in the Fall 2017 issue of Stanford Social Innovation Review.
In April, the Financial Times ran an opinion piece by an unlikely pair: US first daughter Ivanka Trump and World Bank President Jim Yong Kim. The piece calls for greater access to capital, employment, and training for women, and for redistribution of care work so that women can take advantage of these opportunities. The common ground between Kim and Trump—the former known for a storied career in global health, the latter coming from the worlds of business and fashion—reflects the growing popularity of these ideas about reducing barriers to women’s economic participation, even among figures with such seemingly different worldviews. But many women and girls around the world face a much more basic barrier: They lack a way to manage their monthly menstrual cycle.
The challenge this poses for many women is clear in the story of Christine, now 43, from Nairobi, Kenya. Speaking to a program manager with Days for Girls, where one of us (Spelman) is chief operations officer, Christine recalled: “When I was 12 years old, I started to menstruate, and my mum had left me to stay with my grandmother. ... I had to cut my clothes to sew them together so as to get a pad. ... I could not go to school. ... I used leaves. It didn’t help...The teachers realized there was a problem. [A] male teacher saw a weak spot. So, [he and other men] gave me money for sex so as to get pads. Life was hard. Even my close relatives could rape me now. ... At 14 years old, I was pregnant and dropped out of school. I slept in the street. I was a street girl with a [child]. A lady took me in as a house girl (live-in maid). That’s when I met my husband and he took me to train in dressmaking.”
The onset of menstruation dramatically altered the course of Christine’s life. In places with limited or nonexistent access to appropriate and affordable menstrual-hygiene solutions—pads, tampons, or cups—menstruation prevents many women’s full and equal participation in social and economic activities. There are 1.5 billion women of reproductive age in the world, and 300 million live on less than $1.25 per day. This means they struggle to meet basic needs, including food, shelter, and water. And often, they also lack the means to cope with the monthly process of menstruation in a way that is dignified and healthful.
To be sure, a lack of menstrual-hygiene solutions does not cause sexual exploitation or persistent female poverty, or a society that systematically affords men more power and resources than it does women. But women are more vulnerable when they do not have access to appropriate, affordable menstrual-hygiene solutions.
This might seem like a “private” issue, but that perspective is misguided. Rather, menstrual-hygiene management has broad social and economic implications. When women and girls do not have access to pads, tampons, or cups, menstruation can impede their ability to attend class, pursue an education, or work without interruption on a monthly basis. Assuming that a school year spans nine months, girls without access to menstrual solutions can miss up to 45 days or 1.5 months of school each year. Women can miss up to 60 days or 2 months of work. Research from Kenya and India shows that women and girls who lack other options may use unsanitary materials including rags, ash, newspaper, and dried leaves to manage their monthly cycle. Although this practical response is understandable, it can expose women and girls to health risks that further prevent them from full participation in productive, public life.
A TWOFOLD ISSUE
Menstruation does not need to be a barrier to full educational and economic participation. Women and girls living in high-income economies, where access to menstruation solutions is a $15 billion industry, attend school and work with few, if any, interruptions. The problem for women and girls like Christine is twofold. Part of the issue is simple lack of access to stuff: pads, tampons, cups. The other part of the problem is the stigma associated with menstruation—something present in high- and low-income countries alike. Even though half of the population has, does, or will menstruate, and menstruation is directly linked to reproduction and the survival of the human race, this function of the female body still makes people squirm.
The historical roots of our hushing and blushing are well documented. Menstruating women have been ostracized by nearly every major religion, including Christianity, Judaism, Hinduism, Buddhism, and Islam. In biblical times, Abrahamic tradition associated monthly bleeding with witchcraft and sin. Fast-forward more than 2,000 years and we’re still stammering our way through conversations about a totally normal—and necessary—biological function.
While discomfort with menstruation in high-income countries may not prevent women and girls there from accessing the products they need, it has slowed the recognition of menstrual-hygiene management (MHM) as a development priority. It is because of this silence that women like Christine get left behind. Only in recent years has the development sphere started to recognize MHM as a necessary piece of any water, sanitation, and hygiene program. The literature examining the link between MHM and school attendance for girls has also just begun to grow.
Days for Girls (DfG) is one organization working to address the challenges that menstruation poses for low-income women and girls. The Bellingham, Wash.-based organization operates on three fronts: through provision of affordable hygiene kits, which are washable and last for two to three years; through health education; and through microbusiness and sewing training. Since 2008, DfG has distributed kits and provided health education to more than 650,000 women and girls in more than 100 countries. It has also provided training to more than 50,000 people at its centers in Uganda, Ghana, and Nepal. Together, these efforts help to destigmatize menstruation, both through the provision of stuff and through a curriculum that addresses stigma head-on with conversations around health, leadership, and safety.
DfG uses a hybrid system of volunteerism and social enterprise. Through the enterprise programs, local women earn income by making and selling kits. Meanwhile, volunteers distribute kits and help to meet hygiene needs in refugee and emergency settings, and in remote areas, where market-based solutions are not an option. Although DfG offers several long-lasting solutions, washable pads have proved the most viable, as they are adaptable to a wide range of environmental and cultural settings. After 28 design iterations based on feedback from thousands of women around the world, DfG has developed a kit that requires little water to wash, dries quickly, and camouflages stains well.
In 2015, Christine from Nairobi participated in Days for Girls University in Uganda, DfG’s two-week training program, which gives women instruction on how to sew their own kits, spread health education and awareness in their community, and run a local DfG enterprise. Christine later told a Days for Girls program manager: “I’m glad I went. My life was never the same. ... The ideas I got have really changed my perspective on girls and their needs. Now I have three [DfG] enterprises: Butere, Masai Mara, and Zariel Enterprise in Nairobi... I had no one to protect me from all this, but now as Zariel Enterprise I stand for girls.”
WOMEN’S EVERYDAY LIVES
Supporting menstrual hygiene management requires considering the daily realities of women’s circumstances: the resources at their disposal; the tasks for which they are responsible; and the opportunities and constraints they face in their households, neighborhoods, and communities. This means studying things that are not always very sexy and, to the contrary, can be quite mundane. Yet attention to this area can help tailor interventions to women’s needs and determine how to create policies that effect change on a larger scale.
Many organizations focused on MHM have emerged in recent years, including AFRIpads, MakaPads, and Huru International. And some prominent development groups now recognize MHM as a priority. Materials from the Global Partnership for Education link MHM to girls’ school attendance, and Grand Challenges Canada has invested CAD 1.8 million ($1.4 million) in MHM-focused social enterprises. However, funding levels are not yet commensurate with the level of need. To achieve the necessary support, we must get comfortable talking about the everyday (or every month) reality of menstruation. Here are three simple ways we can move toward these goals:
Use qualitative research methods to gather data on women and girls’ current MHM resources, strategies, and needs. Because the stigma around menstruation is high, people often will not speak about it unless asked outright. The experience of women like Christine can and should inform the design of appropriate and sustainable MHM solutions.
Integrate MHM into both water, sanitation, and hygiene (WASH) and education programs. Because menstruation is such a common barrier to education in many areas, provision of MHM products for girls in secondary school can be an important way to help them stay in class.
Talk about menstruation until it is destigmatized. In donor countries, campaigns such as Menstrual Hygiene Day bring menstruation into our public lives via social media. Funding initiatives such as Grand Challenges reward enterprises that work in the MHM sphere. In low-income contexts, where women like Christine face barriers to accessing MHM solutions, organizations can work with community leaders to identify ways to destigmatize menstruation through health education, youth leadership programs, or other methods.
Investing in MHM is an important step toward economic and social progress for women—as a reproductive-health issue, a WASH issue, and a means of reducing a common source of shame and barrier to education. It is also a simple and important way to recognize the inherent worth and dignity of every woman and girl.