Would everyone prefer commercial pads if given the choice?

There are very few issues on which all people agree.  Unsurprisingly, sanitary product options are not an exception.  Given a choice, any group of women anywhere in the world seem to have a wide range of preferences for different types of menstrual products.

To watch any menstrual product ad on television or to read most websites focused on menstrual products one would be led to think that using regular cloth, rather than commercial products, is an inherently horrible experience.

Most women would in dire economic straights would prefer to have other options.  Yet given the choice, some studies have shown that at least some women would prefer to keep using traditional methods, such as cloth.  This seems to be counter to the assumption of many working in this space, and it should be kept in mind for educational materials and product advertising strategies.

Misplaced hype about leaves and mud

In her book, The Managed Body, Chris Bobel deconstructs the commonly-promoted notion that women in poverty are forced to resort to extreme measures such as the use of dried leaves, ashes, newspapers, husk, sand, and mud to absorb  their menstrual blood.

After researching the matter, Bobel concludes that repurposed cloth (usually old clothes or old bedding) is far-and-away the dominant traditional method in use worldwide by those not using commercial products, and that claims of the use of clearly uncomfortable and/or unhygienic methods are effectively “click bait,” or unsubstantiated hype used to draw undue attention and concern.  Raw materials sold primarily for absorption (i.e., cotton wool, falalin, etc.) are also traditional options available to those with a some discretionary money to spend on menstrual care.

Bobel does very important work in demonstrating that the most prevalent traditional methods tend to get dismissed as viable options too easily by many of those who run MHM organizations, and by those who donate to them.  However, her implication that the focus of MHM work should not be on product provision but on education instead, implicitly seems to rest on an assumption that repurposed cloth should be a sufficient method for low-income women.  That is a more controversial claim.  Surveys and qualitative studies suggest that many (but also not all) users feel that repurposed cloths tend to be uncomfortable (especially due to unpredictable movement, or due to uncomfortable changes in their composition over multiple uses), leak-prone, and/or odor producing in ways that they find to be unpleasant.

Voting with their feet

Beyond the words of women, there is also suggestive evidence that users tend to vote with their feet and move away from repurposed cloth once pricing allows.  Consider, for example, the case of urban India, where the availability and price of affordable disposable pads has dropped considerably in recent years.  Studies are now finding that a majority of menstruators living in urban slum areas now use disposable pads (see Garikipati & Boudot (2017), which stands in stark contrast to the vastly lower numbers cited in during the previous decade (see, for example, Baridalyne and Reddaiah who reported a rate of under three percent for resettlement colonies in Delhi in 2004, and Garg et al. who reported a rate of 28% in Delhi slums in 2001; of course, those are different areas, and there are a number of other factors in play, too, including a significant push by the Indian government to encourage sanitary pad use through both education and product subsidies.  As with much of the data surrounding MHM, it is hard to demonstrate a clear causal connection.)

Not all women want commercial pads

Despite a preference by many or most for options beyond repurposed cloth, it is critical to point out there are also generally a fair proportion of women who would prefer to use some form of traditional methods, even were price to not be a motivating factor.  The preferences of these women should not be forgotten by anyone working on MHM issues, yet often seem to be.

Why would any woman not want the convenience of disposable sanitary pads, if given the option?  This is a question that women from economically privileged backgrounds often struggle to understand.  Beyond long-term environmental considerations – a luxury that few people living in poverty have the luxury to prioritize – disposal issues can be complicated in developing countries, both from a logistics standpoint (where do used pads go in places where there is no trash collection?) and from a traditional beliefs standpoint (i.e., common taboos and beliefs that the blood from used menstrual pads can be used for destructive black magic and/or can wreak havoc if ever encountered by certain animals.)  The comfort of disposable pads in hot, humid environments is also a matter of personal preference (i.e., heat-related rashes for some women with disposable pads, for example, can be at deterrent to use.)

A recent study by Garikipati & Boudot (2017) conducted in Indian urban slums found that the majority of women were already using disposable sanitary pads all the time (56%) or part of the time (8%).  Of the 36% who used repurposed cloth exclusively, 43% preferred that method even if cost were not an issue.  And of the 57% of respondents open to change, there was much greater interest in high-quality washable pads (94%) than in disposable pads (52%).  Calculated another way, 74% of women in those areas were already using disposable pads, or would be open to using if they could afford them.  But 15% preferred repurposed cloth above other options, even if the costs were the same.  And another 19% of Indian women use repurposed cloth and would like to have access to high-quality washable pads (with just just over half of them open to the use of disposable pads, as well.) 

As in any society, women had different preferences for how to approach self-care.  That should not be surprising.  But it often seems to be forgotten in the dialogue around these issues.

Slightly modifying traditional options may yield big gains

An earlier study by Shah et al. (2013) of low-income rural Indian girls also showed a strong preference for alternative methods to standard repurposed cloth, while also showing the value of education specifically around traditional methods. 

The vast majority of the girls (90%) used standard repurposed cloth prior to the onset of the study.  The girls in the student then had the option of buying subsidized versions of two alternative methods for three months each (most, but not all, tried both.)  One option tried by many was standard disposable sanitary pads; only 32% of girls ended up choosing those as their first choice method at the conclusion of the study. 

The second method tried by most the girls was an alternative traditional method of menstrual management – falalin cloth – an option that almost half of the girls (46%) did not know was available for menstrual purposes in their local marketplace, and only 8% of the girls in the study used as their primary method prior to the start of the study(this may be due to low levels of discussion about menstruation in families; only 40% of the girls in the study had been told about menstruation before the onset of menses.)  

By the end of the study, the falalin cloth was the strongly preferred first choice for the vast majority of girls (68%), while no study participant preferred standard repurposed cloth over those other options.  Girls concluded that the relatively modest cost of the falatin cloth was justified over (essentially free) repurposed cloth in terms of greater comfort, ease of washing, and lower embarrassment (its red color masked stains.)   Waste issues for disposable sanitary pads (location and traditional beliefs about dangers from disposing of products with menstrual blood on them) and lesser comfort were cited at reasons for preferring the traditional falalin cloth option over disposable pads.  In contrast to standard repurposed cloth, girls said that regular reusable cloth would get rough and uncomfortable after a few washings, while retaining stains, in a manner that falalin did not.

As with most MHM-related topics, it would be helpful to have a good deal more research on these issues from across different countries and cultural contexts.

Questionable safety claims

So this shows that some women prefer traditional methods of cloth (re)use, but is it as safe as commercial methods? 

There are prevalent claims for the idea that repurposed cloth leads to infections and adverse health outcomes; however, there is little research evidence at this point to support that conclusion.   Cloth pad use has been too rarely studied to draw conclusions on the matter (and in the rare occasion when it is studied, it is often lumped in with any/all traditional methods of menstrual management, such that cloth use cannot be specifically isolated). 

In in Chris Bobel’s book, The Managed Body, see the section “Claim One: Girls Are Getting Sick” (pp. 137-145) for an excellent review of the weak state of the literature in backing up claims of adverse outcomes from the use of repurposed cloth; the evidence to date is very sparse and weak, at best.

Can education support, rather than undermine, traditional options?

Given the suggestive evidence above, women who prefer to use repurposed cloth would seem to deserve to be supported and educated in continuing with that choice, without undue pressure — ideally with education about how to best care for the type of cloth that predominates in a given area. 

The challenge is that much of the messaging by product-providing organizations, both commercial and non-profit, tends to state or imply that traditional methods are inherently “less than” whatever commercialized or professionally-packaged product they are providing.  Even when a profit-motive is not involved, with their understandable enthusiasm about the exciting menstrual product projects they are bringing to the many women who want them, even the most well-meaning organizations can easily fall into this trap of contributing towards stigma against the traditional methods — methods that will continue to be preferred and used by at least some women after their usually-brief intervention is complete.

More education around prevalent local methods of menstrual hygiene management — and less implicit negative judgement about cloth pad use in both education programming and advertisements along the way — would undoubtedly be beneficial for the many women who may chose to avoid commercial products, either due to need or personal preference.

Keeping a focus on cultural sensitivity and individual preferences

Cultural sensitivity is key in this arena; however, that can be hard to maintain when most of the people working in MHM organizations and in academia grew up in circumstances far removed from those of the girls and women they serve (even when not in terms of country and region, nearly always in terms of family income level; an important point also noted by Bobel in her book.) 

Moreover, a world where women from all backgrounds have the ability to make their own informed choices would seem to be central to the empowerment of women, and most of those working in the MHM space can probably agree on that as a shared value for the progress of women with respect to their menstrual health.