Decoding menstrual hygiene in India: the strides that we have made, and the battles yet to be won
The use of hygienic methods of menstrual protection has seen a significant jump in recent years, enabled by the opening up of conversation on menstrual matters and a policy push to improve access. However, the Covid-19 lockdown experience and sustained high use of cloth serve a cautionary tale.
- The use of hygienic menstrual products has been rising steadily in India: 77.6% in 2019-21, up from 57.6% in 2015-16
- Improvement has been the sharpest among the poorest, the rural-urban gap in usage of hygienic product has narrowed by 12 percentage points
- Recent years have seen a marked shift in conversations, popular culture representation of menstruation. These have been accompanied by a policy push to enable improved access to period products
- However, cloth use remains prevalent across socio-economic categories, with nearly 50 percent of young women still reporting they have used cloth at some point during their periods
Over three-fourths of young women in India now use hygienic methods of protection during their menstrual periods, the latest round of the National Family Health Survey held in 2019-21 shows. This is a marked improvement from 2015-16, when 57.6 percent of young women reported using hygienic methods in the previous round of the same survey.
Sanitary napkins, locally prepared napkins, tampons, and menstrual cups are classified as hygienic methods. The data pertains to girls and women aged 15 to 24.
The improvement was particularly pronounced among the poorest in the country – among them, the use of hygienic products improved from 21.1 percent in the 2015-16 round to 53.6 percent. Households in the second-lowest income quintile also saw an improvement, from 41.3 percent to 71.1 percent. Those from marginalised communities, including scheduled tribe and scheduled caste households, also saw an improvement of more than 20 percentage points in the uptake of hygienic methods. The urban-rural gap has narrowed.
A shift in discourse and a policy push
In India, the progress recorded by NFHS for a practice that till very recently remained a taboo and out of mainstream popular and policy discourse is noteworthy, given that stigma and period poverty are widespread.
Films and popular culture have played an important part in pushing the envelope on a subject that has traditionally remained a hushed conversation for most women. Be it the 2018 Bollywood film Pad Man, Oscar-winning documentary Period. End of Sentence, or advertisements of sanitary pads using the colour red instead of blue, to conversations on menstrual pain and leave at workplace, recent years have seen a marked shift in the conversation. This has been accompanied by a market penetration of period products, as well as growth in availability of price-competitive brands (UNFPA and WaterAid, 2021).
Periods and associated health concerns even found mention in the Prime Minister’s independence day address in 2020, a significant development given the traditional silence on the matter.
This opening up of conversation has come alongside a policy push to improve access to period products.
Since 2011, the Indian government has been working to push the uptake of hygienic menstrual practices under its Menstrual Hygiene Scheme (MHS). Sanitary napkins are made available at highly subsidised costs under this scheme: initially at Rs. 4 per piece, and since 2019 at Re. 1 for a pad. These ‘Suvidha’ pads are available at the government’s Jan Aushadhi Kendras, and are also distributed by community health workers.
Over 22 lakh packs of Suvidha pads were sold across the country in the financial year 2018-19, and this number increased to 2.19 crore packs between April 2019 and January 2021, government data shows.
UNFPA and WaterAid (2021) estimate that the disposable sanitary pad market in India is worth more than 2,800 crore rupees, with a majority of the market share held by large multinational companies. In addition to the supply from private manufacturers, various states have come up with their own versions of the subsidised sanitary pads scheme under which they distribute pads either for free or at highly subsidised rates. Over Rs. 79 crore was sanctioned by the Centre for 2021-22 under the Menstrual Hygiene Scheme across 19 states that proposed such budgets, government data shows.
The twin initiatives by the Centre and states, along with improved availability of cost-effective products, have borne fruit. In 15 states, the share of young women who reported using hygienic methods of protection exceeded 90 percent. Similarly, between the two rounds of NFHS, the use of hygienic methods saw a sharp jump in several states. Odisha led them all registering a 34-percentage point improvement, followed by Rajasthan and West Bengal.
However, the story of progress isn’t yet complete.
Even as the budgets are approved, states often end up not exhausting them. Across the three financial years from 2017-18 to 2019-20, less than half of the funds allocated for sanitary napkin procurement were not spent, government data shows. While Odisha, Andhra Pradesh, Manipur spent their full budgets, Bihar, Telangana and West Bengal lagged behind. For several states, expenditure data was not mentioned.
According to the latest NFHS, in 11 states, the share of young women who reported using hygienic methods still remains below 80 percent, with Bihar, Madhya Pradesh, Meghalaya, Gujarat and Assam trailing at the bottom. While more and more young women are using hygienic methods, nearly half (49.6 percent) also reported using cloth during their periods. (Women could report multiple methods.)
Young women living in rural areas, from poorer households, and with little or no education were more likely to be using cloth pads, indicating the challenge of access. However, cloth use remained prevalent to some degree across all socio-economic backgrounds, suggesting there’s more to period choices than wealth, educational or social status.
Consider this: more than a fifth of the women from the wealthiest quintile reported having used cloth at some point. This share was as high as 35 percent among those with twelve or more years of schooling. On the other hand, 80 percent of women with no schooling reported using cloth. Among religious groups, Muslim women were most likely to be using cloth. Reported cloth usage was also high among women from marginalised caste and tribal communities.
Menstruation has been associated with stigma, which could involve women being shunned from common household spaces. The good news is that some of those taboos seem to be weakening. When it came to prevalence of hygiene practices and stigma, the NFHS found that most women do take a bath during their periods, and most (92 percent) did so in a bathroom that was also used by other members of the family. But it was not so everywhere. In West Bengal for instance, while nearly 99 percent women reported bathing during their periods, only 68 percent in rural areas of the state said they did so in a common bathroom. The pattern was somewhat similar in Odisha and Tripura, respectively with 69.3 percent and 73.3 percent women from rural areas saying they used a common bathroom.
A global evil
Even though more than a billion people menstruate around the globe, period poverty (the inability to access necessary sanitary materials), menstrual taboos and stigma are widespread in various parts of the world, WHO-UNICEF observed earlier this year.
Safe menstrual hygiene also remains out of reach for many. Data for these indicators remains limited, preventing a global comparison, but where available, it shows that menstruators in several countries do not have access to hygienic products and/or a private space to wash and change during their periods.
While the use of some menstrual material remains high in most countries where data is available, use of reusable material – such as cloth – varies by country. The use of reusable material, which can be unsafe, is more likely in rural areas compared to urban areas.
Health risks of poor menstrual hygiene
Disposable products are costlier and also pose a challenge of safe disposal. While reusable period products are more affordable, they pose a risk of infection, especially if they are not cleaned and dried properly.
In addition to being a significant disruptor of girls’ schooling, and causing them discomfort in general, lack of access to hygienic period products has also been associated with a range of serious health risks for women. A 2018 study based in Odisha found that women who were using absorbent pads during their periods were more likely to have Candida and Bacterial Vaginosis (a fungal and a bacterial infection, respectively) than women who were using disposable pads. (Torondel et al. 2018). Women using reusable absorbent pads were also more likely to have symptoms of urogenital disease than women using disposable pads, another study, also from Odisha, found in 2015 (Das et al. 2015) Poor menstrual hygiene practices such as using old cloth and disposal in the open can also be significant risk factors of cervical cancer (Singh, Rajput and Jaiswar, 2021).
Covid-19 was a reality check
Even as governments in India have introduced schemes for improving access to period products, policy blindness was evident when India imposed a stringent lockdown in March 2020 to control the spread of the coronavirus. In its list of what was “essential” and would remain available during the lockdown, the government ended up excluding sanitary pads and other period products. Only after a week, when shortages became conspicuous and the issue was raised, did the government correct its course.
However, the week of exclusion had created enough disruption for supply chains, which took a while to restore. With schools shut, mobility restricted, and services disrupted, and people staring at economic difficulties, the usage of hygienic period products suffered.
During the lockdown months, Indians spent less on purchasing period products, a working paper by Babbar and Dev (2021) estimated. Using data from the Centre for Monitoring Indian Economy (CMIE)’s Consumer Pyramids Household Survey (CPHS), the authors calculated a 27 percent reduction in the consumption of period products in “red zone” districts compared to “green zone” ones. In rural areas, this reduction was 33 percent.
Household expenditure on period products is fairly low as a share of total household expenditure, the paper observed. Yet, the lockdown pulled down the consumption of such products, a development that is often observed during times of crises, underscoring the need for more conversations, awareness, and sensitisation around a phenomenon that is experienced by such a large share of people.
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