Ongoing Debates:

Menstrual Products & School Attendance

By Deborah Jordan Brooks, Ph.D.

Many people working issues pertaining to menstrual health feel strongly that lack of access to menstrual supplies leads to increased school absences and ultimately to higher dropout rates by girls in developing countries. 

Anecdotal evidence of a negative effect on schooling abounds. Girls and women in the developing world themselves often poignantly describe how lack of effective menstrual products – especially menstrual blood stains, and fear of experiencing them at school – caused them to miss time at school, and report that their happiness and academic performance often suffered accordingly (see, for example, our database on video storytelling about MHM)

Personal accounts cannot be dismissed.  A relationship is clearly felt by many of those without access to high-quality sanitary products.

Additionally, some non-experimental research – especially studies that involve surveys, focus groups, and observational studies – seems to conclude that lack of high-quality menstrual hygiene products keeps girls home from school (see, for example, Muthaa & Njue 2015 and Crofts & Fisher 2012.)

In a report written for the 2018 Menstrual Health Management Symposium in Johannesburg, Tellier & Hyttel take stock of the literature on product availability and school attendance. Even with many references to survey and observational studies, they still keep their conclusions about an effect relatively measured:

“In summary, there has been substantial focus on MHM in adolescence and the effect on school attendance but results have until recently been curiously inconclusive, possibly related to the heterogeneity of methods, with many small scale qualitative studies and testimonies and few randomized controlled trials. Recent studies are, however, beginning to give more clear indications of a negative effect. There is little research on quality of school engagement and its effect on educational outcomes, and very little on higher level education, health and work performance, throughout the life-cycle.”

Tellier & Hyttel, 2018. WoMena Report for the Menstrual Health Management Symposium.

A Need for More Randomized, Controlled Experiments

While personal stories and opinion surveys tell us about the felt experience of girls and women, the challenge is that those methods cannot necessarily tell us definitely that there is an empirical relationship between menstrual product access and school attendance. 

A good deal of research on surveys has shown that people are not always reliable assessors of their own behavior (see, for example, Breener & DeLamater, 2016.)   Furthermore, specific to menstrual research, it can be especially difficult for girls to separate out menstrual product availability from menstrual pain and/or bathroom quality/privacy as a cause for an unwillingness to go to school.

Most researchers would agree that, to have a good answer to this kind of question, there would need to a critical mass of findings from high-quality experiments that have been conducted across a broad array of school settings. The process of getting there has only just begun.

In 2016, Hennegan & Montgomery conducted a meta-analysis of all studies to date that examined the effects of menstrual education or menstrual product distribution on school attendance. They imposed a reasonable standard of causality for studies to be included: experiments had to be individually and cluster randomized controlled trials, non-randomized controlled trials, or controlled pre-post studies. Cross-sectional studies and pre-post designs without a control group were ineligible.

With those criteria, a grand total of five studies of the effects of educational interventions and just two studies of the effects of menstrual products were deemed eligible for analysis.

• Wilson, Emily, et al. 2014 In a non-randomized cluster control trial, they found a 68.8% reduction in absenteeism after girls in Kenya were trained to make pads. The author wisely calls the findings “preliminary results” due to the small number of clusters in their study, and refrains from drawing strong conclusions accordingly.

• Oster, Emily and Thornton, Rebecca. 2011 (or see an earlier version of it here ).  These economists make strong claims that the provision of menstruation products does not reduce school attendance.  Those conclusions are based on experiment involving menstrual cups distributed to a random array of girls and their mothers in four schools and 100 girls in one district of Nepal.

Put another way, only two published findings published through 2016 can establish causality on this topic. And their findings point in different directions.

To be clear, the researchers mentioned above did not do anything wrong; indeed, partly by keeping their scope narrow, they were able to show a relationship with reference to the specific thing they studied. That is what good research studies do.

The issue is that findings — robust findings, at least, the ones that make for responsible, strong claims — tend to come from the triangulation of findings across many different types of studies, conducted by different people in different places, while converging across a given answer. However, this field is still a long way away from that point.

There are many questions left at this point. Would disposable or reusable pads instead of menstrual cups have had a different effect on the behavior of girls in Nepal? Would menstrual cups have a different effect on girls in Kenya, rather than homemade pads, and what about girls in Pakistan or the Philippines or Burundi or elsewhere? Did the type of homemade products most commonly used in a given area as an alternative to commercial products affect the results? Might an urban versus rural setting have produced different findings? And so on.

Referencing the findings on both the effects of product availability and menstrual education on school attendance and other related variables, Hennegan and Montgomery conclude:

“There is insufficient evidence to establish the effectiveness of menstruation management interventions, although current results are promising. Eight trials have been conducted, but a high risk of bias was found and clinical heterogeneity precluded synthesis of most results. Whilst trials provided some indication of positive results, further research is needed to establish the role of menstruation hygiene management in education performance, employment and other psychosocial outcomes.”

Julie Hennegan & Paul Montgomery 2016

Little Support, but Big Claims Persist

Definitive findings should wait. Yet strong claims on these fronts continue to be made.  The conventional wisdom that better menstrual product access will keep girls in school is still very much in play.

Many organizations feel pressure to amp up those claims on their websites and in their brochures.  After all, the anecdotal and self-reported evidence is reasonably strong. And donors tend to prefer cost-effective interventions that can make a big difference in a short period of time. The idea of “keeping girls in school” by donating pads or menstrual cups is tempting. Moreover, it doesn’t help to have big stakes when trying to keep an overworked and often underpaid staff motivated to do good work, either.

(For an interesting analysis of issues such as those discussed above, see Chris Bobel’s 2019 book, The Managed Body.)

Meanwhile, based on the same body of research, at least some development economists have concluded that product availability does not matter for low-income women.

“Females of our species have been menstruating for a long time, and by and large, they figured out how to deal with it.  Hence, on average, the impact of menarche on schooling is very small and hard to detect. 

Senior-level development economist at a major U.S. university, in an email message to Deborah Brooks.

In short, the unsettled state of the research on these issues may lead to a tendency to pick and choose from preferred findings in order to support prior beliefs.

Waiting for Answers

One of the bigger challenges associated with overstating the evidence is that opportunities to explore the other benefits of providing low-income girls and women with menstrual supplies may be being missed.

Regardless of whether lack of high-quality supplies keeps girls home from school, increasing empowerment while reducing worry associated with menstruation is an important goal in its own right.  Allowing girls to use any extra money they have to buy lunch, rather than pads, seems like an important goal.  Normalizing menstruation through education in order to allow people to talk about these issues with more comfort seems like an important goal.  Increasing choice for girls and women about how they want to care for their bodies seems like an important goal.  And so on.

While the jury is still out on whether improving access to high-quality menstrual hygiene products will improve school completion and success rates for low-income girls on average, it is certainly not going to hurt attendance, and it may (or may not) have positive effects on under-studied outcomes, like school performance, graduation rates, workforce entry, and/or psychosocial outcomes, like happiness or efficacy.

Moreover, the education that typically goes along with pad distribution may help girls to better manage their menstrual pain, which may itself help to produce the desired effect of keeping girls in school.

In other words, while the field awaits more definitive findings regarding any connections between menstrual hygiene practices and school attendance, opportunities to explore the many other potentially important relationships in play should not be missed.