About a quarter of India’s population bleeds for an average of five days every month for a large part of their lives. This is a simple biological fact of life. But is this simple act of managing menstruation – hygienically and with dignity – a reality for women in India?
As the world celebrates the ninth Menstrual Hygiene Day on May 28, we took stock of menstrual hygiene management among young married women in India. We focused on the use of menstrual products like sanitary napkins and tampons and explored if their use varied by location.
A holistic approach to hygienic menstrual practices includes women’s access to soap, water, private toilets and bathing facilities as well as the availability of sanitary menstrual management materials. Additionally, they should have access to all essential information linked to their menstrual cycle and how to manage it with dignity and confidence.
India has made great strides in ensuring wide access to toilets and water over the past few years. According to the fifth National Family Health Survey (NFHS-5), almost 80% of sampled households had access to a toilet on their premises, 89% had a hand washing place in their homes, and 72% had a water source.
While the objective of attaining complete sanitation coverage is ongoing, the substantial progress made in this area cannot be overlooked. The story around sanitary menstrual products, however, is less encouraging than progress in ensuring wider access to toilets and water.
About 47% of married women between the ages of 15 and 24 exclusively use sanitary methods (locally-prepared pads, sanitary napkins, menstrual cups, or tampons) to manage their periods, while 23% exclusively use cloth.
It is striking that despite using sanitary menstrual products, nearly 29% of the sample does not use them exclusively. Therefore, over 50% of married women aged between 15 and 24 are still partially or wholly reliant on cloth to manage their periods.
Figure 1: State Wise Usage of sanitary menstrual products. The left panel depicts the proportion of women who exclusively use sanitary menstrual products, and the right panel depicts state wise variation in usage of any sanitary menstrual product. Source: NFHS-5
There is substantial state-wise variation in the usage of sanitary menstrual products (Figure 1). The use of only sanitary menstrual products among married women between 15 and 24 years of age is less than 30% in Uttar Pradesh and Bihar, while less than 60% of the respondents in Madhya Pradesh and Bihar use any sanitary menstrual products.
A possible explanation for this might be differences in socioeconomic indicators across states. However, we find that utilization of sanitary menstrual products is not correlated with typical economic and social development measures.
For instance, Gujarat is the fourth most prosperous state in the country by aggregate GDP and is usually among the top five big states by per-capita GDP. However, it is in the same category as Chhattisgarh and Jharkhand if we consider the usage of sanitary menstrual products.
Even in Kerala, which has the highest score on the Gender Development Index in India, only about 59% of the sample uses only sanitary menstrual products. The utilization of sanitary menstrual products is the highest in Tamil Nadu, where 88% of the sample uses only sanitary menstrual products, and 98% of the sample uses them in combination with cloth.
To further unpack if sanitary menstrual product use varied by the accident of location, we explored if it varies by the rurality of the location of the woman’s residence. We found that the exclusive use of sanitary menstrual products is higher in urban areas (~67%) than in rural areas (~42%). Is the difference in wealth across rural and urban areas the reason for these location-based differences?
Figure 2: Rural-urban gap in exclusive usage of sanitary menstrual products, by wealth categories.
At first glance, the answer seems to be no. The urban-rural gap in the exclusive usage of sanitary menstrual products is persistent across the wealth spectrum (Figure 2). In fact, this gap is the widest for the richest one-fifth of households, and exclusive usage of sanitary menstrual products among the richest households in urban areas is 14% more than among those in rural areas.
Then, does the difference in education levels among women in rural and urban areas drive the urban-rural gap when it comes to using sanitary menstrual products?
Figure 3: Rural-urban gap in exclusive usage of sanitary menstrual products, by educational attainment.
Even the average education differences across rural and urban areas do not seem to mediate the gap in urban-rural sanitary menstrual product usage. While 32% of the sample without any education still exclusively uses sanitary menstrual products, only 17% of the rural sample does so. The gap is the widest among women with secondary education, where the exclusive sanitary menstrual product usage is more than 50% higher among the urban sample than the rural sample (Figure 3).
Finally, we asked if the urban-rural gap in sanitary menstrual product utilisation is due to differences in the level of autonomy women across urban and rural areas have.
We created an index of autonomy that includes women’s role in the intra-household decision-making, their ability to go out in their community alone, their access to modes of communication such as a mobile phone, and whether their names are also on the land and home ownership documents.
Figure 4: Rural-urban gap in exclusive usage of sanitary menstrual products, by women’s autonomy.
The urban-rural difference in sanitary menstrual product usage is also not explained by a potential difference in women’s autonomy within their homes and communities.
Even among the women in the highest autonomy group, there is a substantial urban-rural gap in sanitary menstrual product usage (Figure 4). While 70% of the women in urban areas in the highest autonomy group exclusively use sanitary menstrual products, this number is only 45% among women in rural areas.
As noted above, the difference in the exclusive use of sanitary menstrual products across urban and rural areas cannot be explained by wealth, education attainment or women’s empowerment as defined by the autonomy index.
Therefore, it is unlikely that this gap is due to the difference in the composition of women residing in these areas, and more likely due to differences between urban and rural areas. A plausible explanation for the gap is simply the lack of access to sanitary menstrual products in more remote areas. Clearly, there is a role for deliberate policy action to improve the availability of sanitary menstrual hygiene management products in relatively remote areas.
The Menstrual Hygiene Scheme, launched by the Ministry of Health and Family Welfare, distributes sanitary napkins to adolescent girls at subsidised rates. Many state governments have also launched their schemes to distribute sanitary napkins to adolescent girls and women in below poverty line (BPL) households, at low or no cost.
However, there have been instances of sub par quality of menstrual products provided under these schemes. One such instance is of Maharashtra’s Asmita Yojana, where sanitary napkins were found to be unfit for use because of their lack of absorbent capacity and small size. Moreover, during pandemic induced lockdowns, women in rural areas were forced to resort to cloth usage since the lockdowns brought the distribution of these napkins to a halt.
Menstruating with dignity and hygiene is fundamentally important for women to fully participate in society and the economy. Not being able to use sanitary menstrual products simply because of the accident of one’s location is a denial of their basic right.
As we mark the 75th year of independence on this Menstrual Hygiene Day, we need to look at future policy design to target uptake of sanitary menstrual hygiene products while we celebrate how far we’ve come on making some aspects of menstrual hygiene management available through deliberate policy action.
Madhulika Khanna is an independent researcher and Shreya Bhattacharya is Senior Research Analyst, Digital Inclusion and Governance Lab, Global Research Institute, William & Mary.