Underwear, Poverty, and Implications for MHM Work

Written by Deborah Jordan Brooks (Project Director)

& Sophie B. (IMHER Research Assistant)

Edited by Jenny P. (IMHER Research Assistant)

The most common menstrual product solutions – sanitary pads – rely on the assumption that girls have underwear that they can wear during their periods. Additionally, menstrual education programs generally treat underwear as a given in their instructional materials.

While there seems to be little hard data on underwear usage and availability, our data suggests that about one-third of pad-focused organizations also donate underwear to girls, suggesting that some degree of importance is accorded to the issue by some groups doing MHM work.

IMHER will be returning to this issue from time to time.  In this post, we share what we have learned about the issue so far.

Why Lack of Underwear Might Matter

PHOTO CREDIT: Brand South Africa

Wearing underwear can be a choice for some women (see this article for pros and cons some have identified with the decision to “Go Commando,” which is slang in some countries for the decision to not wear underwear.)

Moreover, cultural practices can vary with respect to whether the wearing of underwear is seen as a requirement, or as a choice that is relatively discretionary. In turn, that may affect whether low-income families allocate limited funds towards the purchase of undergarments.

Some menstruators do not have a choice in the matter at all. For those who cannot afford underwear and/or for those whose families do not prioritize the provision of it to girls in their budgets, options for menstrual care tend to be limited.

Menstrual cups, menstrual underwear, and tampons provide clear solutions to this issue with respect to menstrual care, but they are still uncommon products in much of the world.  Without underwear, standard disposable and reusable pads will not work, and neither will the common practice of using absorbent cloth or loose cotton. Those options nearly always depend upon the use of underwear. 

How Common?

The prevalence of underwear availability and usage does not seem to have been clearly established.  Indeed, to our knowledge, it does not seem to have been firmly identified for even a single country, much less on a global or comparative scale.

As a rough indicator of lack of attention to this issue, within IMHER’s database of 730+ research studies pertaining to menstruation, fewer than 10 studies mention “underwear” in their abstracts.  None of those discuss the prevalence of underwear usage (most of the few mentions reference studies of infection rates.)

Snippets of existing information emerge from some studies of other MH issues.  For example:

PHOTO CREDIT: Liberty Writers Africa
  • This 2016 study published in Jamba (the Journal of Disaster Risk Studies) sampled from 211 schools for a survey conducted in the Masvingo district of Zimbabwe.  In that study, 10% of the girls reported that they had no underwear.
  • This 2014 unpublished study conducted by the Somali Red Crescent Society of refugees in Bwagiriza refugee camp in Burundi, which was comprised largely of Congolese refugees, found that only 7% of respondents “always had underwear available to use” during menstruation (see p. 6). 

There are surely more estimates of that nature buried within reports and other studies, both published and unpublished.  But from the little we have been able to locate on this issue so far, “buried” seems to be the operative term.

As such, there does not seem to be enough research about underwear accessibility and usage in different populations to clearly rule it out – or to rule it in – as a critical issue for MHM work.

Commercial Products

Several kinds of menstrual products – for example, menstrual cups, tampons, and menstrual underwear – do not require the use of underwear. 

  • TAMPONS:  Tampons are relatively rarely used in most of the world (see, for example, the Euromonitor chart in this fivethirtyeight.com article for tampon across many countries.) 
  • MENSTRUAL CUPS:  Menstrual cups show great promise as an environmentally-sensitive and low-cost (on an annual basis) menstrual solution for low-income populations. However, they are still probably best described as being in the “introduction” phase globally.
  • MENSTRUAL UNDERWEAR:  Menstrual underwear (or “period panties”) are not yet common as donation items for low-income populations.  That is likely due to their relatively high price (for example, Thinx panties tend to sell for $24-$39 dollars per pair, with several pairs needed.)  The need to provide different sizes to assure proper fit also presents additional complexities for distribution.  (For progress on this front, keep an eye on BeGirl which makes menstrual panties and donates a mix of those products and reusable pads to low-income girls).

As such, while promising with respect to the “no underwear” issue, the above options are most likely only making a dent in any need associated with it at this point in time. 

Meanwhile, the dominant menstrual product donation items – disposable and reusable pads – generally require attachment to underwear for use.

It is important to remember that it was not always the case that pads required underwear. Older women in many countries, including in the U.S. and parts of Europe, can recall a time when belted pads were the dominant form of menstrual care products on the commercial market. Pads that attach to underwear are a relatively new innovation in the history of menstrual care, rather than an inherent requirement for their use.

Local Workarounds

Necessity is the “mother of invention,” as they say. In some areas, women without underwear sometimes create homemade cloth belts, to which a crosspiece of absorbent cloth is attached (in Burundi, for example, this is an approach used by some women). 

While the homemade pads attached to the belts often lack a leak-proof barrier, cloth belt designs can avoid the need for underwear during menstruation while still acting as a viable, low-cost option for those who have underwear.

(If you happen have taken photos of homemade local pads with belts in the communities in which you work and are willing to share those, please send them to IMHER here.)

Recognition by Some MH Organizations

Lack of underwear has been recognized as a substantial enough issue that some pad-focused organizations donate underwear with pads, usually in “menstrual kits.” 

Based on IMHER’s database of product-focused organizations, providing underwear seems to be more of the exception than the rule.  Based on website descriptions by organizations of their own work, the IMHER student research team coded pad producers’ direct mentions of underwear donations.  We found that 33% of the organizations currently in our database that donate pads also donate underwear.  

This is a rough estimate, at best (for example, organizations may not always mention that they donate underwear, and we are adding organizations to the database on a regular basis.) But it suggests that a substantial number of organizations – but not a majority of them – seem to see the lack of underwear as a significant issue for the populations they serve.

Providing underwear may provide greater personal comfort to girls in need throughout the month, so it may be a worthy donation item in-and-of itself.  But it is not a costless addition to pad donations.  In effect, providing underwear in addition to pads will tend to mean that fewer kits can be donated, and that fewer menstruators can be reached. 

For example, in rural Tanzania, we have been given rough estimates that low-cost girls’ underwear typically costs about $.35 USD (+/-) per pair.  With three pairs as the minimum number that would permit sufficient drying between use, that adds roughly $1.05 USD to the cost of an average menstrual kit, with an extra pair or two preferable for daily, year-round use. A very rough estimate suggests that the inclusion of underwear could potentially raise the per-kit cost by 10-25% +/- depending on a wide range of factors.

When considered in conjunction with menstrual cup- and menstrual underwear-focused organizations, we find that 37% of MH product-donation organizations in our database address the no-underwear issue in some way, either directly (by providing underwear to at least some of the menstruators they serve) or indirectly (by distributing a product that does not require underwear).

One Solution – Choice: Femme International

One organization is addressing the no-underwear challenge by offering a choice of products to its recipients. 

Acknowledging that no single solution is an option for all women, Femme International allows users to choose between reusable pads and menstrual cups when receiving product donations. As a result, girls can select menstrual cups if they do not have underwear to which to attach pads.

IMHER will run a profile on Femme International’s innovation to integrate personal choice into their projects in the coming months, a model that is rare among NGOs doing MH work.

PHOTO CREDIT: Spiegel de

Innovative Pad Design: The MoonCatcher Project

Few pad-focused organizations offer underwear-free or underwear-optional designs. 

To date, we have only located one: The MoonCatcher Project, which produces and distributes reusable pads with a belted design. Read more about their design in a follow-up article by IMHER posted here.

Considering Options

It is not just pad-distributing organizations that may want to consider underwear usage issues: organizations that distribute menstrual cups and/or menstrual panties may have cause to follow this issue, too.  After all, the benefit side of cost/benefit calculations for any underwear-free menstrual care option will tend to look more favorable as the total cost of pad donations increases.

Overall, there seem to be far more questions than answers on this topic at this juncture. For the sake of idea generation, here is some initial “food for thought” regarding lack of underwear and its possible relationship to MHM work:

ASSESS & SHARE INFORMATION
  • Try to assess the prevalence of the “no underwear” issue with those you serve.  In addition to having informal discussions about the issue, consider adding two questions to any surveys you conduct: one that assesses whether girls typically choose wear underwear on a daily basis, and one that assesses whether they have underwear to wear during their periods (note: this may be sensitive information for girls to discuss, so it is critical that girls can be fully assured that their answers are anonymous).  After you have this information, try to get it out to other organizations doing MHM work in similar areas.
  • Consider sharing with IMHER any information on underwear prevalence that you have from current or past studies (published or unpublished).  Let us know here (in addition to results, please also tell us what you can about the population you were studying, i.e., location, income level, ages, etc.).
CONSIDER PAD DESIGN
  • Designing new versions of reusable pads for low-income populations?  Perhaps consider a belted version.  If the number of girls without underwear is significant in your area, consider developing and testing some belted pad designs (for some other design ideas, this Pinterest board shows some other examples of belt options for cloth pad designs.) In doing so, remember that peer adoption in school settings may facilitate product acceptance, perhaps especially with products that seem “different” than what other girls are typically using.  By that logic, testing this type of product with peer-groups of girls, rather than with individuals, may yield more realistic results.
  • Is it possible to modify local and homemade belts for use with pads provided by your organization?  If you are already committed to a pad design but learn that lack of underwear is an issue for a significant number of girls (without being able to provide underwear to them), consider whether there are local belt-based pad options that can be “hacked” (i.e. modified) to work with the pads you distribute.  Even just briefly describing and/or demonstrating possible solutions may allow more girls to feel included in your educational program, while potentially increasing usage rates of the pads being provided. 
CONSIDER EDUCATIONAL PROGRAMS
  • Does your menstrual education program assume that girls have underwear?  Do you only show photos of girls attaching pads to underwear?  Might it be possible to mention what girls without underwear can do for menstrual care? Can anything be tweaked or modified in future revisions to acknowledge how girls without underwear might need to approach menstrual care differently, and to allow them to feel fully included in the instruction your organization provides? 
  • Consider the benefits of acknowledging traditional methods of menstrual care in education programs.  As discussed in Chris Bobel’s book, The Managed Body, MH organizations and educational programs often present commercial products (or whatever product they happen to be distributing) as the only “good” option for menstrual care, while traditional options are treated as being inherently inferior.  The fact is that some menstruators  – whether due to comfort, pressure from home, replacement costs, cleaning requirements, or other reasons – will not make the switch to menstrual products that are being promoted, even sometimes when the products are free.  As such, addressing the hygienic care of traditional and homemade menstrual care options can be a useful and culturally-sensitive component of any menstrual education program.

What are your thoughts on this issue, based on the work that you do?  Comment below and/or tell IMHER about it here.