Ongoing Debates in MHM

Issues with no consensus for which messages often tend to be mixed.

Written by: Deborah Jordan Brooks, Ph.D.

QUESTION: Does increasing access to menstrual products increase school attendance and/or improve school performance?

ANSWER:  To the surprise of many, this is still an unsettled question. 

Many researchers have concluded that definitive conclusions on this matter will have to wait until considerably more research has been conducted. In particular, there need to be findings from more experimental studies with randomized assignment of subjects, conducted in a greater array of countries and socioeconomic settings, with a greater array of menstrual products as the treatment conditions (see, for example, Hennegan & Mongomery 2016.)

But does uncertainty on that front mean that addressing menstrual hygiene in the developing world is somehow unimportant?  No.  We can’t yet conclude that there is a relationship, but we similarly do not know enough yet to conclude that there is not a relationship.  We just don’t know yet.  Moreover, there are still many good reasons to make the lives of low-income girls and women more dignified and more empowering anyway.  Go here for more analysis by IMHER of this issue.

QUESTION:  Does increasing access to menstrual products improve workplace attendance and/or salaries in adult women?

ANSWER:  This is an unsettled question.  There has been even less work done around the effects of menstrual products on workplace productivity than on education. It is not nearly enough research to draw any conclusions – even just suggestive ones – on this matter.

QUESTION:  When forced to choose, what should be the top priority:  affordable access to products, lack of menstrual education, or something else entirely?

ANSWER:  When choices have to be made about where limited resources should go, this tends to turn into an area of active debate among those working on menstrual hygiene issues. 

Those focusing on education tend to lean towards thinking that education should be the first priority, while those focusing on products tend to lean towards advocating product access as the core issue to solve.  Still others point towards menstrual stigma and taboos at being the root of the problem more than products or education, per se (see, for example, Chris Bobel’s book, “The Managed Body: Developing Girls and Menstrual Health in the Global South” for more on this.) 

This debate may never be fully resolved, because a compelling case can be made for each priority. 

However, everyone I have met so far who works within the global MHM community seems to agree that that all three issues are each important goals that would help to improve the lives of girls and women the world over.  Any disagreements seem to emerge primarily over resource allocation and the order of priorities, rather than the need for improvement on all of those fronts.

QUESTION: Is it better for organizations to sell menstrual products or to donate them to users?

ANSWER:  The bottom line is that “it depends.” 

Building local economies and the business experience of local leaders – most of whom are women themselves – can be empowering for all concerned, where viable. 

However, in many cases, non-profit organizations are donating products where product sales are not especially promising, often due to high levels of poverty.  Additionally, non-profits can often distribute reusable products (usually washable pads or menstrual cups) that can require considerable education in a community before entrepreneurs are likely to be able to turn a profit by selling them.  As such, in most cases, non-profit and for-profit work tends to be complementary rather than competitive. 

Moreover, they can be hard to separate entirely anyway:  many for-profit organizations have non-profit arms that donate products and/or conduct educational programs, while non-profit organizations are increasingly setting up social enterprise projects, for local women to sew pads and the like. Go here for more discussion of this issue.

QUESTION:  In situations where lowering menstrual product costs might come at the expense of the environment, what should be the priority?

ANSWER:  This is an active debate, with few clear answers.

On the disposable products front, standard (non-compostable, non-biodegradable) disposable sanitary pads tend to be convenient for users, while being relatively inexpensive to buy for a given month.  A key problem, however, is that standard disposable pads tend to have negative environmental consequences, especially in low-income communities where waste-management issues tend to be a major challenge (see, for example, this 2018 research paper on the topic of MHM and waste management.)

Compostable or biodegradable disposable pads offer a compelling solution, as they minimize environmental harm without compromising user convenience. However, their production costs – while dropping considerably over time – tend to still be somewhat higher than the production costs of their less environmentally-friendly siblings.  Moreover, at any price point, it is an unsettled question as to whether 100% biodegradable pads will be able to offer the same level of comfort and effectiveness as the best standard disposable pads on the market.

Reusable pads and menstrual cups offer promise.  The long-term cost of most reusable menstrual products is nearly always substantially lower than the purchase of either type of disposable over the same duration of time, while also usually providing environmental benefits.  The key challenge to reusable products tends to be that their greater up-front costs can be formidable to those in poverty; as such, reusable products are not always viable to sell in the lowest-income areas.  Limited access to water for washing can sometimes be a problem (although some workarounds for menstrual cups — i.e., water bottles, etc. – have been used with some success.) 

Additionally, convincing users that washable pads are an appealing product that can be cleaned effectively can often require substantial marketing and education costs.  Access to water for cleaning washable pads can be a challenge in some homes as well.

QUESTION:  Should menstrual products be made in the lowest-cost location possible, or should they always be made locally, even if that makes them more expensive?

ANSWER:  This is an interesting debate, with few clear answers.

Where products can be made to the same quality standards and at the same price locally as abroad, most would agree that local production is the best option, as it can help to alleviate community poverty.  It is also important to note that some producers have managed to produce high-quality menstrual products while producing pads locally, at a competitive price, with production facilities that can financially empower local communities (see, for example, AFRIpads, which has its primary production facility in Uganda.)

However, local production is rarely without at least some trade-offs that can sometimes make it harder to keep up with the competition.  Suppliers based elsewhere (often China or India) can often undercut local production based on price and/or quality.  Off-shore sourcing can also allow local organizations and entrepreneurs to focus more on product distribution than on building and managing expensive production facilities and staffs of their own.

One thing that nearly everyone involved in menstrual hygiene can agree on is that menstruators everywhere deserve to have more product choice, and that many low-income communities around the world need to offer more options. 

QUESTION:  Is it always the case that commercially-made products are superior to traditional absorbent methods?

ANSWER:  According to Chris Bobel in The Managed Body, traditional menstrual care is often caricatured or described inaccurately; she argues that rather than mud, leaves, sand, and other uncomfortable absorbents that nearly all women who cannot afford pads (and some who do) use repurposed cloth, i.e., old clothes and bedding.  Studies  generally find that most girls and women want access to more sanitary product options than repurposed cloth.  However, it is also the case that at least some menstruators – even if cost constraints were to be removed – would not want a change from traditional absorbency methods.  As such, it is inaccurate to characterize all women in poverty as wanting alternatives.  Moreover, it is also the case that research has not proven that regular cloth is unsanitary or unsafe as a menstrual absorbent (more research is needed.)   Bobel argues that those points are too often overlooked by many of those working in the MHM space.  For more on this question, see more discussion here.

QUESTION:  If I were to read just one source on this topic, what should it be?

ANSWER:  Now THAT is a contentious question if there ever was one! 

Forced to choose one, we would recommend this report by Tellier and Hytel of WoMena (a report commissioned for the May 2018 UNFPA ESARO Conference held in Johannesburg) as the most recent and comprehensive “meaty” compilation of current information on the topic. 

However, we would recommend some additional sources, as well (along with too many others to list.)

This short NPR article from February 2019 puts a good deal of information into clear context, and efficiently cuts through some of the hype that prevails on this topic.  This short article helps to make it clear that there is still a great deal of important work to be done, both on the ground and in terms of further research.

For those interested in state of the academic research on the effects of menstrual health product access on education and psychosocial outcomes, read Hennegan & Mongomery’s 2016 article, “Do Menstrual Hygiene Management Interventions Improve Education and Psychosocial Outcomes for Women and Girls in Low and Middle Income Countries? A Systematic Review.”

Chris Bobel’s book (The Managed Body) is a provocative read, with a more comprehensive look at global menstrual health work as an industry and as a movement than any other to date.  However, it is sufficiently expensive to buy at $80+ USD that many working in the MHM field will unfortunately not have access to that book.  As such, we will try to reference and cite her book and ideas where relevant on IMHER.