DEBATE – Products vs. Other Factors
By Deborah Jordan Brooks (Associate Professor, Dartmouth College)
(Last Updated: 1 August 2018)
BOTTOM LINE: There are important reasons for researchers, governments, and donors to identify the highest impact interventions. Product producers, arguably as much or more than anyone, can improve their businesses by having more knowledge about these matters. In the meantime, there are a number of small ways that MH product and education innovators can work to address the broader range of factors, without compromising their core goals.
I have yet to hear that anyone is against having expanded menstrual product options in communities around the world. Most people who have spent any time thinking about MHM seem to agree that such advances are all to the good.
However, the language around MHM sometimes seems to take menstrual product production to task for getting disproportionate focus among the broader range of challenges pertaining to menstrual health.
That perspective – a common one among researchers, in particular – is reflected to some extent in comments made by Inga Winkler, a lecture in human rights in the political science department of Columbia University:
“There is this emphasis on pads. Generally, the development sector wants quick fixes and it seems to easy to give pads to girls, and then have a solution to the problem. But the reality is so much more complex, and without addressing that, we will not see real change. I don’t want to belittle it. I would not want to be without any materials when I menstruate, but there is so much more…: the social stress, the stigma that relates to it – and that is really one of the key points” (from https://www.devex.com/news/menstrual-health-while-excluded-from-sdgs-gains-spotlight-at-un-political-forum-93137)
Similarly, Chris Bobel, a professor of gender studies at the University of Massachusetts wrote the following, in her high-profile 2018 New York Times Op Ed, “Menstrual Pads Can’t Fix Prejudice”:
“In the last decade, the difficulties women and girls across the globe face during menstruation have inspired a raft of grass-roots campaigns…Why, then, after years studying these efforts, do I feel ambivalent? Because too many of them have opted to focus on providing women with new products, failing to substantively fight the core problem surrounding menstruation: cultural stigma.” (from https://www.nytimes.com/2018/03/31/opinion/sunday/menstrual-periods-prejudice.html )
That perspective – one that was also prevalent among speakers at the 2018 UNFPA Conference in Johannesburg – seems to be that additional sanitary supplies probably can’t hurt, and may very well help. However, the extent of their benefit relative to other solutions is still mostly unproven. Moreover, products are ultimately only one piece of a very complicated puzzle, anyway.
What is a menstrual innovator focused largely on increasing product availability supposed to make of that kind of thinking? Should they feel that their contributions are being challenged by it, or should such questions be enthusiastically engaged?
A case for why these questions are worth asking
In practice, for someone committed to addressing sanitary supply issues, the question of whether focusing on products is the best possible avenue to improving health, education, and life quality outcomes is largely moot. They see that there are supply issues, that local women are dissatisfied by the options they have, and that have committed to addressing them.
In that case, whether other issues also exist is also irrelevant, to some extent. No one of us can solve every problem in the world, or probably even make significant inroads on more than a couple. They have seen a problem that they feel they can progress in addressing. As long as they have found an avenue that feels like they are making a difference on it, and as long as it is creating no harm along the way, the question of whether it happened to be the single most important problem to take on is not of primary concern. After all, the world benefits from people taking on all kinds of problems, rather than just the single most important one.
But there are people and institutions working on MH issues who do need to try to understand the role of sanitary product availability, relative to other possible factors. In particular, governments, researchers, and donors may reasonably want to know, given specific set of financial and organizational resources, whether investing in greater menstrual product availability offers the most “bang for the buck” out of the range of possible solutions at hand?
The case I am making here is that the questioning of the focus on products is a healthy one, even – perhaps especially – for organizations and entrepreneurs that are already committed to working on products specifically.
Besides contributing to knowledge about menstrual health and hygiene experiences – a goal shared by virtually everyone working in this sector – enhanced understanding of the non-product issues around MHM can help to identify hurdles that innovators regularly face (i.e., slow product adoption, unexpected usage patterns, marketing challenges, etc.) Knowledge is power, as they say.
Additionally, proof that sanitary product availability is still in remarkably short supply, which can make your job harder to do than it should be. Confounded by study design limitations (i.e., the limitations of self-reports regarding motivation and behavior, poor school attendance records kept by schools, confounds presented by pain versus product availability, questionable compliance with product usage, etc.), there has been a good deal of work on how access to products can affect outcomes like school attendance, with little by way of firm conclusions. Most sanitary product producers want to make credible claims that their products can help to produce tangible benefits, like keeping girls in school. But until researchers establish relationships of that nature, such claims are questionable.
Put another way, I am making the case that a focus on these-product areas stands to increase the potential markets for menstrual products. Even though the questions tend to be couched in “either/or” language that sometimes might seem to set products in “competition” with these other areas of need, research on these matters can help you to achieve your own goals.
Beyond sanitary products: Other “Hardware issues”
In this realm, issues are often separated into “hardware” issues – i.e., the “things” that can be provided to solve a problem – versus “software” issues – i.e., the thinking, educational curricula, cultural practices, and governmental role in addressing a problem.
Beyond sanitary products themselves, what are some of the other key “hardware”-based issues that constitute other factors that can affect the menstruation-related issues for girls in the developing world?
- Providing beneficial companion products
Menstrual hygiene product producers tend to focus on blood-holding or absorbing solutions. However, that often ignores part of the supply challenge for girls.
Panties/underwear are not worn in all cultures, and can be especially infrequent where poverty rates are high. When such conditions are in place, providing pads – whether disposable or reusable – without making underwear available to which to attach them is likely to result in a mostly failed in effort. Menstrual cup distribution can help to minimize the need for underwear supplies, and absorbent menstrual panties can theoretically eliminate the need for extra underwear (however, absorbent panties do not seem to be yet at a price point where the costs are viable for purchase by low-income women.) However, the most prevalent MHM solutions – i.e., pads – nearly always require girls to have underwear, without addressing that need directly.
Another hole in the landscape of menstrual hygiene provisions is sometimes the challenge of how to dry reusable cloth pads in a manner that is viable in practice. In many countries, it is either socially unacceptable or deeply embarrassing to leave sanitary products out to dry, where they can be seen by others. However, many reusable cloth pads benefit from sun drying, while a minority of others benefit from it. In practice, many pads are tried in unhygienic ways due to these considerations (i.e., drying pads under bunkbeds in school dormitories, etc.)
Some drying options do exist; however, they tend to require attention to the options by producers that are not always in place. Some producers of washable pads have innovated ways to allow them to be dried while shielding them from view (for example, some have workarounds; for example, Afripads can be dried outdoors under another cloth, whereby shielding them from view.) There has also been innovation regarding drying systems for reusable pads (https://www.fastcompany.com/3050139/an-innovative-solution-to-menstrual-hygiene-in-developing-countries ), although those options so not seem to have taken off, likely due to added cost and distribution challenges.
In short, those kinds of companion products – i.e., things created to compensate for deficiencies in actual usage patterns – tend to get less attention than pad distribution efforts, thereby potentially compromising the market reach and usability of some of the core products being distributed by MH innovators.
- Improving school bathroom design
The WASH sector has drawn attention to many key aspects of bathroom design. Some studies have found that approximately one-third of schools around the world lack adequate sanitary facilities, broadly defined (McGinnis et al. 2017, as discussed in the UNFPA 2018 Johannesburg Conference review paper by Teller and Woman), and that percentage that would clearly be much higher if limited to an investigation of the just the developing world.
Common design issues in bathrooms that limit potential for menstrual hygiene include:
- Working toilets, with working drains
- Lack of privacy for the bathroom and/or for individual stalls (bathrooms or stalls sometimes lack roofs or full walls; girls facilities are sometimes not even shielded entirely from bathrooms used by boys)
- Safety (bathrooms are sometimes built and/or located in areas where girls do not feel safe using them)
- Lack of running water (with lack of running warm water even more rare)
- Lack of wash basins (with clean water running into them)
- Lack of changing areas, ideally separate from the often-unsanitary toilet area.
Additionally, some specific cultural beliefs – i.e., a common belief that one’s menstrual blood should never be seen by others, including other women (e.g., Malawi) – can add to bathroom design challenges that will promote proper self and proper menstrual product care.
Bathrooms which are lacking can tend to lead to multiple adverse outcomes pertaining to menstruation: i.e., the wearing of a given product to a point that is unsafe; leakage as the maximum usage time is exceeded; lack of genital cleaning; and an inability to change clothes after menstrual leakage has occurred. Moreover, poor bathroom design and safety concerns can lead to negative heath outcomes in a broader sense: potentially compromising their safety, potentially causing children to refrain from using the toilet when needed, and less hand-washing.
Thus, many school bathrooms need to be rebuilt and outfitted, to provide girls with minimally safe and hygienic places in which girls can address engage MHM and regular self-care needs. That tends to be an expensive proposition.
WASH-related programs have been making inroads in this area. However, need for school bathroom improvement greatly exceeds current capacity. And MHM is a component of relatively few WASH programs (FSG 2016, as cited on p. 25 of the UNFPA 2018 Johannesburg Conference Review Paper.), which means that even newly improved bathrooms do not always provide the optimal privacy and washing options for menstrual hygiene management.
To the extent that school bathroom design has benefitted from WASH interventions at the primary and secondary school levels, there has been relatively less focus on bathrooms in tertiary education settings, workplaces, and homes, many of which lack the basic components required for MHM-sensitive bathrooms. (see p. 34 of the UNFPA 2018 Johannesburg Conference Review Paper.)
Moreover, even the best design bathroom will fall short if it doesn’t have the necessary cleaning supplies, while keeping the bathrooms clean.
- Stocking school bathrooms with necessary supplies
Even a well-designed school bathroom (more on that below) will fall short for girls if it lacks basic cleaning supplies. At a minimum, girls need access to soap, water, toilet paper, hand drying towels or dryers, and a trash receptacles. Additionally, bathrooms need to be cleaned regularly (i.e., regular washdowns with disinfection products; regular disposal of trash; clogged drains fixed in a timely manner; etc.) Regardless of design, many schools lack these basic supplies, making hygienic personal care a challenge for girls when away from home.
As just one example, only 2% of bathrooms in schools in rural Kenya had soap present (Alexander et al 2014, as discussed in the UNFPA 2018 Johannesburg Conference review paper by Teller and Woman.)
Without basic cleaning supplies, there can sometimes be workarounds for at least some aspects of menstrual hygiene (i.e., water bottles are often provided to girls with menstrual cups to facilitate quick cleaning in a toilet stall; waterproof/odor-proof cases for reusable pads to be brought home; etc.)
But overall cleanliness can be enhanced dramatically by figuring out how to get basic hygiene supplies to schools, often at fairly modest cost overall. Moreover, community health can be improved dramatically by instituting handwashing supplies and practices for both girls and boys, so all kids and all communities in need can tend to benefit from interventions of this nature.
While provide soap and other cleaning supplies is typically (but not always) outside of the scope of products distributed with pads and/or cups, MHM educators should at a minimum embrace any opportunity that can allow for emphasis on the part of effective bathroom washing and basic supply provisions in schools, workplaces, and homes.
- Making accessible proven solutions to menstrual pain.
Dysmenorrhea, or pain associated with menstruation, is a frequent complaint of adolescent girls, and is regularly undertreated. (See DeSanctis 2017, as cited on p. 11 of the UNFPA 2018 Johannesburg Conference Review Paper.)
Indeed, some of the fuzziness around findings regarding linkages between school attendance and MHM product available may be due to the often-underspecified role of under-treated menstrual pain in many studies: is insufficient product available at the root of reports of school absences, or was menstrual pain, instead, driving some of those decisions and/or recollections about attendance? Those factors can be hard to separate, and we seem to know little about the independent role of each as a result at this juncture.
Many girls do not have access to forms of pain relief that are standard in the developing world (i.e., Ibuprophen.) In low-income areas, this is sometimes a “hardware” issue: how to make pain relief tablets available to girls, at a price they feel like they can afford.
Sometimes iburprophen usage most more into “software” territory, when the issue is skepticism about its effectiveness relative to traditional methods of pain relief. There are a variety of different menstrual pain treatments used in various countries, some of which may be more effective than others. At various points I have seen mild tensions emerge over the elevation of commercial pain solutions like Ibuprophen over traditional methods, and such discussions require cultural awareness and sensitivity. Regardless, there has been little efficacy testing of the various options that could help to inform women, educators, and medical professionals to identify the best options available locally.
Regardless of pain reliever availability, cultural practices that discourage discussion of menstruation among family members can also serve to keep girls in the dark about potential pain relief options. It is also the case that many girls regularly report that they are told that they need to simply toughen up and deal with the pain, without treatment.
At this point, no one can conclude that pain management is more, or less, important than product availability. We just do not know. However, it is clear that girls and women would like to have more access to both, and that their sense of what is best for them should be a target outcome in its own right.
Puberty education can potentially improve awareness and usage of both pain relief options and menstrual products. All product products, distributors, and educators should look for opportunities to increase dialogue around menstrual pain, and its range of culturally-acceptable remedies. To ignore either product availability or pain management for periods is to ignore part of the problem, and to miss an opportunity to give girls and women needed option. So for those of you on the ground, educating about these issues, remember to address pain relief, in addition to the product-related work that you do.
Beyond sanitary products: “Software” issues
Beyond sanitary products themselves, what are the “software”-based solutions that can affect the menstruation-related issues for girls in the developing world?
- Improving puberty education
It surprise basically no one involved in MHM work that there are many places where menstruation and hygienic practices are rarely discussed in schools or in homes, and where problematic practices abound. Products and puberty education are clearly not at odds with one another; indeed, many product producers/distributors tend to be involved in puberty education as either a primary or secondary aspect of their work.
Products provided without education may be limited in their effects where puberty education and communication is sparse. For one thing, without education, non-hygienic practices may be the norm, resulting in a range of negative consequences (i.e., compromised medical outcomes, psychological distress, etc.) Moreover, from a practical perspective for producers, if hygiene is not prioritized, then the added value and expense associated with commercial products may not be recognized, thereby limiting markets and likely spending thresholds for commercial products.
It is easy enough to accept that product usage tends to require education, especially in areas where it has been lacking. And MH donor organizations and entrepreneurs often help to fill those critical educational gaps left by resource-strapped governments, schools, and cultural practices in homes.
- Reducing cultural shame around menstruation.
In her 2018 New York Times op ed mentioned earlier, Chris Bobel implicitly questions the flow of donor and governmental money to product-based solutions rather than to education. And she does question whether, what she refers to as the “better living through more consumption” model of providing pads will produce the needed cultural change. She does so partly on the bases that, many countries that have had ample product availability for decades still have cultures of shame around menstruation that hurt women. In other words, products alone will improve the culture to empower girls regarding their periods; culture needs to be fixed on its own. (see https://www.nytimes.com/2018/03/31/opinion/sunday/menstrual-periods-prejudice.html)
As with many scholars, Bobel also makes it clear that she believes that, all else equal, more and better menstrual products are good for women. She just isn’t sure that it is the most important to be solved, and she questions the degree to which they will be effective until better education is in place, and until periods are treated as normal rather than shameful.
This is yet another case where even most menstrual producers probably do not disagree with this reasoning as much as the “either/or” language would suggest. Many MH innovators would agree with Bobel that more education and less shame around periods would be a very critical improvement that would allow their own efforts to go farther. From an MH entrepreneur’s position, these ideas seem to be complementary rather than in competition with one another at their core.
- More highly prioritizing the needs of girls within families.
Part of the challenge for menstrual hygiene entrepreneurs is that disposable money sometimes exists in some low-income families, but the menstrual needs of girls and women rarely rank highly enough to be able to access that money, as least until family income levels hit an unusually comfortable level.
Some of the reason is poverty, pure and simple, where comfort and sanitation tend to understandably rank below food, water, fuel, and shelter on a family’s list of priorities. But part of the reason is likely silence and shame around menstruation, such that the unmet needs of girls are too rarely articulated and/or listened to in the rare case when the needs are expresses. And part of the reason is likely that – even in cases where the needs of female family members are expressed and heard – their needs, in many cultures, tend to rank below the needs of males in the family.
Such distinctions can perhaps most clearly be seen most clearly in male versus female educational achievement rates in different countries. Similar decision-making dynamics likely track down to smaller family decision making processes.
While surveys of girls’ preferences basically all reveal that they would like to have better access to affordable sanitary products, we actually have very little information about whether girls themselves would actually allocate that disposable income to menstrual health needs, versus other needs or wants. Fortunately, a new study with an innovative and unusually ridorous experimental design intends to study this very dynamic (DISCUSS PENNY’S NEW STUDY HERE)
However, even that study looks at what happens when girls are specifically given disposable income of their own. In most cases, such money flows not directly to girls, but through families, where girls have to negotiate to have their needs address. Logic suggests that such dynamics may increase the prevalence of transactional sex by girls, as it can give them a source of discretionary income outside of the confines of family allocation decisions (for a discussion of the possible relationship between MHM and transactional sex, see pp. 10-11 of the UNFPA 2018 Johannesburg Conference Review Paper.)
The status of girls and women in family financial decisions is a hugely complex “software” issue that tends to be deeply embedded within cultures and family norms. It is also a dynamic that can play out in developed countries, although with more benefits to distribute, and usually fewer disparities between boys and girls as a result. This is likely a major problem that limits the market for commercial sanitary products, but it is never going to be easy to overcome. Increasing focus on menstruation, menstrual hygiene, and on the importance of girls staying in school is a potentially important way in which those in the MHM world can contribute to progress on this front.
- Poverty reduction
Poverty clearly resides at the center of nearly everything pertaining to MHM deficiencies.
Poverty is clearly core of most of the above “hardware” issues pertaining to “things” that could potentially make menstrual hygiene easier and more effective for women. Products do not tend to be developed and/or made available when local markets, schools, and households cannot afford them. People in high-poverty communities typically have to learn to “make due” will less out of necessity, even if the costs of those compromises are high, making it challenging to sell products, sometimes even when incomes increase.
Poverty also contributes to some of the field’s challenges on the “software” fronts (i.e., education, culture etc.) Schools and teachers tend to be stretched extremely thin with respect to core educational subjects, much less “extra” topics such as health and puberty education. Low levels of education in societies, and among women in particular, can limit exposure to information that can potentially change cultural practices, and can limit willingness to try non-traditional practices.
More generally, girls and women tend to fare poorly where poverty levels are high. That is not to say that girls and women fare as well as their male counterparts almost anywhere in the world. But where resources are scarce, females tend to be on the frontlines of privation even more than their male peers.
I suspect that every entrepreneur and donor organization in the world would love to alleviate poverty worldwide, were that to be possible. However, while poverty contributes mightily to the challenges faced by menstruators in the developing world, none of us will hold our breaths waiting for dramatic change on that front in the short term.
Instead, MHM innovators tend to do important work by alleviating poverty to a small degree and/or minimizing its negative effects as much as possible. Many do so by filling holes in short-term sanitary product availability, creating jobs, working to keep girls in school to increase their earning and societal power, educating girls to delay marriage and parenthood to a sustainable time in their lives. Moreover, in many cases, by themselves becoming role models to showcase how local women can become organizational leaders while creating financial security for themselves and their own families.
Such contributions cannot, in their own right, alleviate global poverty, of course. But MHM innovators tend to do important work in chipping away at poverty and at some of its more frequently-occurring challenges faced by girls and women.
- Pushing politicians and institutions to address menstruation as an important issue.
While most who study MHM would agree that governments could be doing far more to improve the healthcare of girls and women, and to minimize menstrual health challenges faced by them, improvements in terms of political engagement on these issues tend to benefit those who work on menstrual hygiene products.
Most obviously, menstrual activists have been making strides in countries around the world in terms of minimizing taxes placed upon menstrual health products.
But there are other things that governments can do. For example, XXX.
Moreover, governments play a role in health and safety regulations for products. That type of intervention can be positive or negative, depending on XYZ.
But against, products vs. government intervention would be a “false dichotomy.” In most respects, one does not come at the expense of the other. Government involvement tends to help producers.
The bottom line on asking whether products matter
Some of the language used in this realm can seem to call the focus by donors and entrepreneurs on menstrual hygiene supply provision into question. But the case it made here that asking such questions tends to further the interests of those working on menstrual health products.
For a few large organizations or governmental bodies, with a focus across different issues, real decisions about allocations of money or time sometimes do need to be made (i.e., do we focus on providing pads to students or puberty educational resources to teachers? Do we focus on providing pads, building bathroom facilities, or on making sure that bathrooms have soap, water, and garbage receptacles?) For those decisions, such information can be invaluable. Moreover, even some organizations strictly in the MHM realm have choices to make on the products vs. education front. It may sometimes be the case that a focus on issues in the “software” realm might be the best use of their energies, because those more complicated issues too often do seem to get neglected in favor of “quicker fix” hardware interventions.
But for innovators who are already working to provide sanitary products to girls, whether by donation or for profit, these questions typically do not, and probably should not, affect your mission. Affordable, convenient, comfortable hygiene options are wanted by most women, and those too often do not exist in low income communities in the developing world. Those who are asking these broader question are mostly pushing the question of what might also need to be addressed, rather than fundamentally questioning whether more options would be better. None of them want there to be fewer options for women, or expect their work to produce those outcomes. Instead, answers to those questions may help to provide a range of positive effects; for example, better educating women about menstrual hygiene options, and providing them with facilities where products can be more hygienically used. And that strikes me as a win/win for everyone.