Introduction

Maternal mortality rates remain high in low- and middle-income countries, where 94 percent of all cases are recorded.^[1],^[2] In India, maternal mortality ratio stands at 113 per 100,000 live births;^[3] the government is aiming to reduce the incidence to below 70 by 2030.^[4] Experts agree that the promotion of sexual and reproductive health (SRH) is among the keys to addressing this massive challenge. However, women—especially those with disability and those caught in conflict or disasters—^[5], ^[6] and transgender and non-binary people continue to face massive challenges in accessing sexual and reproductive healthcare.^[7]

Achieving global targets on SRH, in turn, greatly depends on a collective commitment to improve menstrual health and hygiene (MHH). Using evidence from India and other developing countries, this brief argues that without improving MHH, the world stands farther from realising SRH.^[a] There is a need to make SRH programming gender-transformative, first by recognising the link between MHH and SRH.  The task is urgent, given the economic case to sexual and reproductive health: i.e., promoting SRH helps improve a country’s economic, educational and development outcomes.^[8],[9],[10]

The stark reality is that individuals who menstruate lack adequate access to information and services around SRH^[11] and are unable to exercise their SRH rights throughout their life cycle.^[12] Among the factors for this lack of access are poor economic and educational outcomes. Multiple studies in different developing countries have shown that those with fewer number of schooling years tend to experience early sexual initiation and early marriage, have higher fertility rates, and suffer poor maternal outcomes.^[13],^[14]

A crucial aspect of sexual and reproductive health is menstrual health and hygiene.^[15] However, multiple barriers hinder the promotion of menstrual health and hygiene; these include socio-cultural norms that regard menstruation as taboo,^[16],[17] and biological and medical issues such as urinary tract infections, and abnormal urinary bleeding that can be caused by fibroids.^[18],^[19],^[20],^[21],^[22]These issues diminish the agency of menstruating individuals in making decisions related to sex, relationships, family planning, and contraceptive use. This sets them back into the vicious circle of poor SRH.^[23]

In India, taboos and myths hinder the optimal use of the more than 8,000 Adolescents-Friendly Health Clinics (AFHCs) set up by the government across the country.^[24] Menstruation-related challenges are seen in schools, work places, and communities where menstruating individuals cannot safely manage their needs with privacy and dignity.^[25],^[26] In certain communities, restrictive social norms do not allow menstruating individuals to pray, bathe, sleep in the same bed as others, or make food.^[27],^[28] Raising awareness about the menstrual cycle should therefore be among the priorities of communities and policymakers.^[29]

The challenges are compounded for older women, who could face issues of post-menopausal bleeding that directly impacts their sexual health.^[30] There is a need for more stringent data monitoring in this aspect, especially in developing countries.^[31]

Integrated attention to the links between MHH and SRH can advance the mutual goals of both sectors, improving the health and well-being of individuals who menstruate throughout their life cycle.

Global Outlook

Despite strong evidence that one of the anchors of sexual and reproductive health is menstrual health, governments, policymakers, and NGOs rarely include menstrual health in their SRH agendas. Although SRH was the focus of both the World Population Day and Gender Equality Forum in 2021, little attention has been paid, if at all, to menstrual health.^[32],^[33] Even the seminal 2018 Guttmacher-Lancet’s report^[34] on SRH mentions menstrual health only once in its 43 pages. Early studies also suggest that during the production of COVID-19 vaccines, menstrual health was not taken into account while conducting the pilot studies on understanding the efficacy of the vaccine.^[35]

The education aspect is also lacking. A study of education policy documents across 21 developing countries found little attention to menstrual health.^[36] Of those countries that appeared to have MHH in their health and education agenda in the last decade, the focus was on the distribution of disposable sanitary pads, largely for schoolgirls; they tended to ignore the other issues related to menstrual health and hygiene—including safety, disposal, right to dignity—and providing choices to people who menstruate.^[37]

The gaps in targets for promoting menstrual health must be filled, if the global community is to achieve the Sustainable Development Goals on health and well-being, education, and gender equality.^[38] The UN High-Level Meeting (UNHLM), 2023 Action Plan, which underlines the need to “leave no one behind” in global goals on universal health care, must bring menstrual health and hygiene to the forefront of the SRH agenda.

A Framework for India

This brief offers the following recommendations for mainstreaming menstrual health and hygiene in sexual health conversations in India.

1. Conversations around menstruation could be started in schools and local communities by including menstrual health and hygiene in sessions on reproductive health.^[39],^[40],^[41],^[42] These sessions should seek to dispel the common myths and taboos surrounding menstruation, and include discussions that will guide those who menstruate through challenges such as family planning and serious infections.^[43],[44]In 2007, the Indian government introduced the Adolescent Education Program to promote discussions around sexual education, including MHH. The initiative received backlash from teachers and parents, however, who objected to the programme’s objectives and said the material was “very graphic” and “not suitable for Indian audiences.”^[45]Much of the work being done around menstrual health has historically been limited to environmental factors—i.e., providing access to Water, Sanitation and Hygiene (WASH) facilities, and sanitary pads. Sociocultural issues, however, are equally important and should be given adequate attention by stakeholders.

2. Governments, NGOs, and other stakeholders must focus on improving their existing programs to expand the knowledge of those who menstruate by providing them with information about various period products, their use, and their environmental impacts.^[46],^[47],^[48] Such interventions will help boost the agency of individuals who menstruate and enable them to make informed decisions on their menstrual health.

3. Programmes should be initiated that will focus on distributing disposable sanitary pads to girls and women, and not only those who are in school.^[49] There is a need to provide choices for those who menstruate by empowering them with information on period products.^[50] As the discourse on menstruation is now shifting toward sustainable menstruation, it is crucial to equip individuals who menstruate with knowledge about the potential harm of the period products they use.^[51]

4. Organising sensitisation workshops for gatekeepers such as teachers, healthcare workers, and women in local communities would go a long way in helping young people who menstruate. Recent studies^[52],^[53] suggest that mothers, teachers, and healthcare workers are the first sources of information for adolescent girls about menstruation in India. It is therefore critical to provide MHH sessions to these cohorts and build their capacity on practical and scientific expertise to support those who menstruate.

5. Adolescent boys, and men, need to be involved in the conversation around MHH to create supportive spaces.^[54],^[55] These conversations will help them understand the importance of MHH and prompt changes in societal norms, including removing the stigma around menstruation.

6. Workplace policies for individuals who menstruate should be laid out, including the provision of adequate WASH facilities.^[56],^[57]
7. Conversations around menstruation need to include trans and non-binary individuals. Menstruation is a variable concept, such that many women do not menstruate, while some transmen, non-binary individuals, and people with masculine gender identities do.^[58],^[59],^[60] However, academic literature and mainstream media coverage that discuss issues around menstruation continue to view them from the lens of the cisgender female, which has further perpetuated shame and silence around menstruation in trans communities. The feminisation of menstruation has led to the exclusion of transgender and non-binary people from the discourse.^[61]As per 2011 Census data, around 0.5 million individuals self-identify as third gender^[b] in India.^[62] There is a need to engage communities and educate them about the LGBTQIA+ population and enhance their SRH knowledge by looking at the menstrual health discourse with the core principle of inclusivity.

8. There is a need to evaluate the COVID-19 vaccine’s potential effects, if any, on menstrual health. According to first-person anecdotes shared on social media, there have been people who menstruate who experienced unusually heavy periods and changes in menstrual cycles after receiving the COVID-19 vaccines.^[63] Scientists in current, exploratory studies caution, however, against making a direct link as menstrual cycles are affected by many factors, with or without any kind of vaccine.^[64]
9. Small-scale reports have documented poor MHH infrastructure and resources, including lack of WASH facilities and lack of access to period products.^{[65],[66],[67],[68],[69],[70]} There is a need to strengthen the public health responses that improve MHH infrastructure and resources, especially in LMICs. Another alternative could be engaging with the multi-sector stakeholders who can work in improving MHH infrastructure and WASH facilities. 

Conclusion

Global and national agendas on sexual and reproductive health continue to give little attention to its link with menstrual health. Achieving SRH goals, including those contained in the Sustainable Development Goals, would depend on a universal commitment to promoting menstrual health of those who menstruate.

It is crucial to integrate MHH into all SRH aspects to create gender-transformative policies that challenge societal norms and view the subject of menstruation and menstrual health guided by the core principle of inclusivity. Integrated attention to the links between MHH and SRH can advance the mutual goals of both sectors, and improve the health and well-being of individuals who menstruate, throughout their entire life cycle.

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Karan Babbar is Assistant Professor at Jindal Global Business School, OP Jindal Global University. He works on issues at the intersection of education, health, and gender.

Sivakami is Professor at the School of Health Systems Studies, Tata Institute of Social Sciences. She works in the areas of Demography, Gender and Health.

Endnotes

^[a] This brief defines MHH as the process of adequately and safely managing menstrual needs by using a clean menstrual management material to absorb the menstrual blood in a private place; using soap and water for cleaning the body; having access to disposal facilities; receiving adequate social support and resources to manage pain. MHH also includes understanding the menstrual cycle and managing it in a dignified and comfortable way in a socio-cultural environment without discomfort, fear, or worry^. See: Elizabeth R MacRae et al., “’It’s like a burden on the head’: Redefining adequate menstrual hygiene management throughout women’s varied life stages in Odisha, India.” PloS one 14, no. 8 (2019): e0220114.

^[b] The Supreme Court of India formally recognised the third gender in India in April 2014. There is no formal definition of third gender, however, individuals who do not identify as men or women are commonly referred to as transgender and hijras.

^[1] World Health Organization, “Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division,” (2019).

^[2] World Health Organization, “Maternal mortality”, WHO. www.who.int.

^[3] Office of the Registrar General & Census Commissioner, India (ORGI), (2022).

^[4] Kerean Watts, “Maternal mortality ratio in decline,” Health Issues India, (2019).

^[5] Penelope A Phillips-Howard, “What’s the bleeding problem: menstrual health and living with a disability,” The Lancet Regional Health–Western Pacific no. 19 (2022).

^[6] Margaret L Schmitt et al., “Innovative strategies for providing menstruation-supportive water, sanitation and hygiene (WASH) facilities: learning from refugee camps in Cox’s bazar, Bangladesh,” Conflict and Health 15, no. 1 (2021): 1-12.

^[7] S. E. Frank, “Queering menstruation: trans and non-binary identity and body politics“, Sociological Inquiry 90, no. 2 (2021), 371-404.

^[8] Stephanie R. Psaki et al., “Causal effects of education on sexual and reproductive health in low and middle-income countries: A systematic review and meta-analysis,” SSM-Population Health 8, (2019): 100386.

^[9] Marni Sommer et al., “How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals,” Global Health Action 14, no. 1 (2021): 1920315.

^[10] Karan Babbar and Pritha Dev, “Modelling the impact of ovulatory cycle knowledge on the number of children and age of women at first birth,” IIM A Working Papers, (2021).

^[11] Inga T. Winkler et al., “The politics, promises, and perils of data: Evidence-driven policy and practice for menstrual health,” Women’s Reproductive Health 7, no. 4 (2020): 227-243.

^[12] Kathleen Chau, “Technical brief on the integration of menstrual health into sexual and reproductive health and rights policies and programmes” (2021).

^[13] Alaka Malwade Basu, “Why does education lead to lower fertility? A critical review of some of the possibilities,” World Development 30, no.10 (2002): 1779-1790.

^[14] Robert A. LeVine et al., “Literacy and mothering: How women’s schooling changes the lives of the world’s children,” Oxford University Press (2011).

^[15] Sommer et al., “How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals”

^[16] Suneela Garg and Tanu Anand, “Menstruation-related myths in India: Strategies for combating it,” Journal of Family Medicine and Primary Care 4, no. 2 (2015): 184.

^[17] Mary M. Olson et al., “The persistent power of stigma: A critical review of policy initiatives to break the menstrual silence and advance menstrual literacy,” PLOS Global Public Health 2, no. 7 (2022), e0000070.

^[18] Penelope A. Phillips-Howard et al., “Inclusion of menstrual health in sexual and reproductive health and rights,” The Lancet Child & Adolescent Health 2, no. 8 (2018): e18.

^[19] Priyanka Negi, Aprajita Mishra, and Pramesh Lakhera, “Menstrual abnormalities and their association with lifestyle pattern in adolescent girls of Garhwal, India,” Journal of Family Medicine and Primary Care 7, no. 4 (2018): 804.

^[20] Lucy Whitaker and Hilary OD Critchley, “Abnormal uterine bleeding,” Best Practice & Research Clinical Obstetrics & Gynaecology 34, (2016): 54-65. t al.,

^[21] Negi, Mishra, and Lakhera, “Menstrual abnormalities and their association with lifestyle pattern in adolescent girls of Garhwal, India”

^[22] Whitaker and Critchley, “Abnormal uterine bleeding”

^[23] Chau, “Technical brief on the integration of menstrual health into sexual and reproductive health and rights policies and programmes”

^[24] Andrea J. Hoopes et al., “Measuring adolescent friendly health services in India: A scoping review of evaluations,” Reproductive Health 13, no.137 (2016).

^[25] Cristina Espinosa-Heywood and Karki Richa, “Breaking taboos: Menstruation, female subordination and reproductive health – The case of India,” (2019). Insights Anthropology:111–20.

^[26] Emily Wilson et al., “Dismantling menstrual taboos to overcome gender inequality,” The Lancet Child & Adolescent Health 2, no. 8 (2018): e17.

^[27] Karan Babbar, “Taboos and Myths as a mediator of the Relationship between Menstrual Practices and Menstrual Health,” European Journal of Public Health 31, no. Supplement_3 (2021): ckab165-552.

^[28] Karan Babbar et al., “Menstrual health is a public health and human rights issue,” The Lancet Public Health 7, no. 1 (2022): e10-e11.

^[29] Babbar, “Taboos and myths as a mediator of the relationship between menstrual practices and menstrual health”

^[30] Chau, “Technical brief on the integration of menstrual health into sexual and reproductive health and rights policies and programmes”

^[31] Chau, “Technical brief on the integration of menstrual health into sexual and reproductive health and rights policies and programmes”

^[32] World Population Day, United Nations, July 11, 2021,

^[33] Generation Equality Forum. Paris | Generation Equality Forum. Gender Equality Forum 2021.

^[34] Ann M Starrs et al., “Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission,” The Lancet 391, no. 10140 (2018): 2642-2692.

^[35] Jennifer Couzin Frankel, “Thousands report unusual menstruation patterns after COVID-19 vaccination,” Science, July 15, 2022.

^[36] Marni Sommer et al., “Attention to menstrual hygiene management in schools: An analysis of education policy documents in low-and middle-income countries,” International Journal of Educational Development 57 (2017): 73-82.

^[37] Sommer et al., “Attention to menstrual hygiene management in schools: An analysis of education policy documents in low-and middle-income countries”

^[38] Sommer et al., “How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals”

^[39] Karan Babbar, Deepika Saluja, and Muthusamy Sivakami, “How socio-demographic and mass media factors affect sanitary item usage among women in rural and urban India,” Waterlines 40, no. 3 (2021): 160-178.

^[40] Alejandra Almeida-Velasco and Muthusamy Sivakami, “Menstrual hygiene management and reproductive tract infections: a comparison between rural and urban India,” Waterlines 38, no. 2 (2019): 94-112.

^[41] Srinivas Goli et al., “Geographical disparity and socio-demographic correlates of menstrual absorbent use in India: A cross-sectional study of girls aged 15–24 years,” Children and Youth Services Review 117 (2020): 105283.

^[42] Enu Anand, Jayakant Singh, and Sayeed Unisa, “Menstrual hygiene practices and its association with reproductive tract infections and abnormal vaginal discharge among women in India,“ Sexual & Reproductive Healthcare 6, no. 4 (2015): 249-254.

^[43] Anand, Singh and Unisa, “Menstrual hygiene practices and its association with reproductive tract infections and abnormal vaginal discharge among women in India”

^[44] Babbar and Dev, “Modelling the impact of ovulatory cycle knowledge on the number of children and age of women at first birth”

^[45] Dhruv Krishna, “Sex education: Still a taboo in India?,” Times of India (2020).

^[46] Babbar, Saluja and Sivakami, “How socio-demographic and mass media factors affect sanitary item usage among women in rural and urban India”

^[47] Goli et al., “Geographical disparity and socio-demographic correlates of menstrual absorbent use in India: A cross-sectional study of girls aged 15–24 years”

^[48] Anand, Singh, and Unisa, “Menstrual hygiene practices and its association with reproductive tract infections and abnormal vaginal discharge among women in India”

^[49] Karan Babbar and Pritha Dev, “COVID-19 and period products usage among menstruating women in urban and rural India,” IIMA Working Papers (2021).

^[50] Alejandra Almeida-Velasco and Muthusamy Sivakami, “Menstrual hygiene management and reproductive tract infections: a comparison between rural and urban India.” Waterlines 38, no. 2 (2019): 94-112.

^[51] Goli et al., “Geographical disparity and socio-demographic correlates of menstrual absorbent use in India: A cross-sectional study of girls aged 15–24 years”

^[52] Anna Maria van Eijk et al., “Menstrual hygiene management among adolescent girls in India: a systematic review and meta-analysis. BMJ Open 6, no.3 (2016): e010290.“

^[53] Shantanu Sharma et al., “Menstrual hygiene preparedness among schools in India: A systematic review and meta-analysis of system-and policy-level actions.” International Journal of Environmental Research and Public Health 17, no. 2 (2020): 647.

^[54] Linda Mason et al., “‘We do not know’: a qualitative study exploring boys’ perceptions of menstruation in India,” Reproductive Health 14, no. 1 (2017): 1-9.

^[55] Therese Mahon, Anjali Tripathy, and Neelam Singh, “Putting the men into menstruation: the role of men and boys in community menstrual hygiene management,” Waterlines, (2015): 7-14.

^[56] Rachel B Levitt and Jessica L. Barnack-Tavlaris, “Addressing menstruation in the workplace: the menstrual leave debate,” The Palgrave Handbook of Critical Menstruation Studies (2020): 561-575.

^[57] Marni Sommer et al., “Managing menstruation in the workplace: an overlooked issue in low-and middle-income countries,” International Journal for Equity in Health 15, no. 1 (2016): 1-5.

^[58] A. J. Lowik, “Just because I don’t bleed, doesn’t mean I don’t go through it: Expanding knowledge on trans and non-binary menstruators,” International Journal of Transgender Health 22, no. 1-2 (2020): 113-125.

^[59] Joan C. Chrisler et al., “Queer periods: attitudes toward and experiences with menstruation in the masculine of centre and transgender community,” Culture, Health & Sexuality 18, no. 11 (2016): 1238-1250.

^[60] Babbar et al., “Menstrual health is a public health and human rights issue”

^[61] Nalini Kaushik and Karan Babbar, “Re-imagining menstruation under the lens of new normal,” Gender & Covid-19 (2021).

^[62] Registrar General of India (2011)., Census of India, Provisional Population Totals, New Delhi: Government of India, 409-413.

^[63] Kate Clancy (@KateClancy), “A colleague told me she has heard from others that their periods were heavy post-vax. I’m curious whether other menstruators have noticed changes too? I’m a week and a half out from dose 1 of Moderna, got my period maybe a day or so early, and am gushing like I’m in my 20s again” Twitter Thread, Feb 25, 2021.

^[64] Gemma C Sharp, Abigail Fraser, Gemma Sawyer, Gabriella Kountourides, Kayleigh E Easey, Gemma Ford, Zuzanna Olszewska et al., “The COVID-19 pandemic and the menstrual cycle: research gaps and opportunities,” International Journal of Epidemiology 51, no. 3 (2022): 691-700.

^[65] Prachi Sharma, “Implications Of A Lack Of Gender Lens In India’s Vaccine Roll-Out Policy,” Feminism In India, Nov 18, 2021.

^[66] “Introduction: Periods Don’t Stop for Pandemics,” PLAN International (2020).

^[67] Sommer et al., “Menstrual Product Insecurity Resulting From COVID-19‒Related Income Loss, United States, 2020,” American Journal of Public Health 112, no. 4 (2022): 675-684.

^[68] Jacqueline Coombe, Helen Bittleston, and Jane S. Hocking, “Access to period products during the first nation-wide lockdown in Australia: Results from an online survey,” Women & Health 62, no. 4 (2022): 287-292.

^[69] Karan Babbar, Niharika Rustagi, and Pritha Dev. “How COVID‐19 lockdown has impacted the sanitary pads distribution among adolescent girls and women in India.” Journal of Social Issues (2022). DOI: 10.1111/JOSI.12533.

^[70] Karan Babbar and Pritha Dev, “COVID-19 and period products usage among menstruating women in urban and rural India,” IIMA Working Papers (2021).

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