Lack of information on and access to hygienic practices adversely affects girls and women, especially from marginalized castes and tribes.
Only 37% women across India reported experiencing hygienic menstruation, which includes the proper use of safe materials to absorb blood according to the National Family Health Survey (NFHS), 2015-2016. Unhygienic menstrual hygiene practices such as changing an absorbent outside a toilet facility, washing only once a day, and storing reusable cloths in a toilet can have severe and long-lasting consequences. Such practices are said to be the fifth biggest killer of women globally. For example, a study on women in Odisha found a strong link between reproductive tract infections and poor menstrual hygiene.
Along with Manas Pradhan and Sunita Patel, we analysed this NFHS data to investigate the factors crucial in hindering access to menstrual products. We found that one of the decisive factors is the material condition of Indian women. Uneven distribution of wealth and resources determined by the hierarchies of caste and class severely affect women’s health. Across the country, Scheduled Castes (SC) / Scheduled Tribes (ST) / Other Backward Classes (OBC) women were most vulnerable to harmful menstrual practices. This is unsurprising given that women from these communities have historically been engaged in back-breaking labour that provides for little rest and safety.
Our study is the first to use national data to measure exclusive use of disposable absorbents and analyse the demographic and socioeconomic factors involved. Our findings call for an urgent need to develop resource-based strategies to address these persisting health risks.
A HEALTH WORKER SPEAKS
Rural women, like those living in Beed (a district in Maharashtra) were far more likely to reuse cloth or rags while on their period. One in three (33%) general caste women in the countryside were able to use safe disposable methods. In contrast, only 19% of rural women from Scheduled Tribes reported the same.
Siddhu Tai (name changed) works as an Auxiliary Nurse Midwife (ANM) in a village in Beed. She notes the lack of freedom and mobility girls have in her village as an important deterrent to healthy sanitary habits.
“If a girl gets her period at night, she can’t come by herself to our house and collect pads. So, we have to slyly go and give them packets. But that’s not always possible”, she said.
Another issue is the actual process of disposal. There is no mechanized wastage facility in Siddhu Tai’s village. She tells girls to either bury pads in a pit or burn them.
“But these girls can’t even burn their pads in private. How can they get rid of the waste without their brothers or father seeing?”, she said.
Government health centres charge a nominal price for providing sanitary pads. In Siddhu Tai’s village, the subsidized cost for these was Rs. 6 per pad, of which Rs. 5 went to the Primary Health Centre (PHC) and Rs. 1 to the health worker in charge of distributing it.
If a person’s menstrual cycle runs for 6 days, this adds up to Rs. 36 per month, assuming they only use one pad per day. More realistically, this cost can go up to Rs. 60 if they have to change pads. Many girls are told by their mothers that this is too expensive. It is cheaper to rewash and reuse ‘dadi ki sooti’ (‘grandmother’s cotton cloth’, a vernacular way of saying old personal cloth).
Our analysis also showed that more women relied on unsafe practices in their marital homes than in their natal homes. There is far more shame and embarrassment around the topic in spaces with few or no trusted confidantes.
What Data Show
While 71% of the richest women from general castes experienced safe periods, this number dropped to 12% in the poorest quintile according to data from NFHS-5. A large proportion of women from Scheduled Tribes did not respond positively regardless of their wealth status; only 9% of the poorest ST women had any access to disposable absorbents. This was also true for 10% of women in the poorest SC families and 8% of the poorest OBC households. These numbers are abysmally low.
Meeting with health workers like Siddhu Tai who openly discuss menstrual hygiene significantly increased women’s chances of experiencing safe periods. Health workers include Auxiliary Nurse Midwife (ANMs), Accredited Social Health Activist (ASHAs), Anganwadi Worker (AWWs), Multi-Purpose Worker (MPWs), and others.
However, 32% of women surveyed nationally had met with a health worker but did not discuss menstrual hygiene. Another 39% of women said they had not met a health worker at all.
Education played a crucial role, across the board, in cultivating positive health practices. If anyone in a home had attained 10 or more years of education, the respondent was far more likely to use disposable absorbents. For all castes, at least 50% of women who had been educated (for over 12 years) used pads, as compared to those who received no education.
A study in Uttar Pradesh found that the availability of affordable commercial menstrual hygiene products remains extremely low. The study revealed that the majority of products available in the market appear to be expensive packs of fewer than 10 pads, priced between 29 and 90 rupees.
According to the 2021 edition of The State of Food Security and Nutrition in the World jointly released by five UN organisations, undernourishment increased in India from 13.8% in 2018 to 15.3% in 2020. A recent study conducted by Basic HealthCare Services, a non-profit organization located in Udaipur, revealed that 97% of high migration tribal communities in Rajasthan mentioned lack of money as the impediment to buying sufficient food for their households. Spending Rs 90 for a menstrual hygiene product, then, would rank far below in a family’s expenditure priority.
Siddhu Tai also points out the unseen effects of migration when it comes to women’s health. Several families in her village seasonally migrate to places like Satara within Maharashtra as sugarcane harvesters.
“Periods come at any time. Suppose they are working in the fields when they start bleeding, where are they supposed to go and find a pad? They are in the farm from approximately 2 AM in the night to 4-5 PM in the afternoon. It’s very difficult in the middle of all this to go look for and change into a pad. Using their ‘dadi ki sooti’ is easier”, said Siddhu Tai.
Being away from one’s own home and constantly engaging in back-breaking work for half the year leaves little room for anyone, man or woman, to even think about their own health let alone do anything to secure it. Siddhu Tai believes that political leaders should commit to finding alternative work for people who are forced to seasonally migrate.
“Sometimes pad availability is scarce in our own village whenever there is no supply from the government. Then how can we be asked to depend on pads in unknown villages we are guests in? Male labourers don’t arrive alone. They come with their wife and possibly daughters. No one cares about them. Neither employers nor the government think about the needs of women migrant workers.”
A 2015 report found that schools in several states like Maharashtra and Chhattisgarh did not have any arrangements for menstruating students. In order to reach all girls, governments must substantially increase investment in free or affordable public education. They must also ensure that public education centres are equipped to cater to the needs of students. Unfortunately, the Union Budget for the education sector continues to remain lower than the recommended level of 6% of India’s GDP.
Free distribution of sanitary napkins in schools may go a long way in promoting healthy practices and reducing absenteeism of young female students when they are on their periods. Rural schools in particular need to not only be conduits of information but also provide infrastructural support in the form of free sanitary napkins, proper waste disposal facilities, etc.
For improving the health of girls and women, it is imperative to make sanitary napkins free and accessible to all through scheme workers such as ASHAs, ANMs, etc. This would also then necessitate a serious shift in how health workers are compensated.
Cultural reasons cannot explain all the gaps in Indian women’s personal practices. At a time when health and safety are at the centre of public discourse, we must remember to address looming gender and caste inequities in our healthcare systems. Women from deprived castes and tribal communities are disproportionately forced into unsafe conditions. Public health must centre the health of all women.
This piece was first published on the Syaahi collective.