Access to menstrual hygiene products is a major challenge facing women and girls in developing countries and is an aspect of water, sanitation and hygiene that is often overlooked (Crofts et al., 2012). Lack of access to menstrual hygiene products can often mean that women and girls have considerable difficulty in going about their lives during menstruation and can be almost entirely restricted to the home, both due to practical reasons and the stigma frequently attached (APHRC, 2010). Multiple studies have found that girls in low-income settings miss or struggle at school during menstruation if it is not possible for them to effectively manage their menstrual hygiene (Boosey et al., 2014). In Ghana, it has been found that 95 per cent of girls sometimes miss school due to menstruation (House et al., 2012). Safe, accessible menstrual hygiene products have a considerable positive impact on women and girls’ occupational, social and educational capacity (APHRC, 2010).

A key barrier to access for girls is that facilities where menstrual hygiene products can be changed with dignity are frequently not provided in schools, or teachers may not grant students permission to use them (Scorgie et al., 2015). Women and girls who could afford to buy menstrual hygiene products may also be reluctant to do so from shops, which are often run by men, due to stigma (Millington et al., 2015). They may depend on their husband or father to provide them with funds to buy disposable pads, which may be withheld (House et al., 2012). The main menstrual hygiene products currently available are disposable pads, reusable pads and the menstrual cup. However, the cost of disposable pads often means that they are inaccessible to women and girls in resource poor settings (APHRC, 2010). It can also be challenging to ensure a consistent supply of disposable sanitary products in rural areas, particularly those affected by conflict (House et al., 2012).

Washable, reusable pads are therefore a preferable alternative for increasing access to menstrual hygiene products as they are sustainable, low cost and easily accepted by women and girls. Nevertheless, the stigma of menstruation means that women and girls can attempt to wash and dry reusable sanitary pads out of sight, which can result in them being washed with suboptimal frequency and dried in areas with poor ventilation, which can promote the growth of bacteria. The menstrual cup is the best option for women and girls in resource poor settings; though the initial cost is higher than that of reusable pads, it is far more cost effective over time as it lasts much longer (Millington et al., 2015). It is also quicker, easier and more discrete to wash and dry (APHRC, 2010). However, there can be psychological barriers to inserting the cup into the body (Hoffmann et al., 2014). Neither reusable pads nor menstrual cups are currently widely available in the developing world, though this is starting to change, which should be supported in order to increase access to menstrual hygiene products for women and girls.

The key methods to increase access to menstrual hygiene products are through improving their availability and affordability, and improving understanding of this topic in the community. To increase availability, various national and international initiatives have distributed free or subsidised menstrual hygiene products. However, while this approach can be used in the short term to quickly improve access to menstrual hygiene products in a community and is vital in humanitarian crises, in more stable development contexts it is not ideal as it creates dependency on external assistance. It is far more sustainable to work to ensure that an affordable and consistent supply of the reusable menstrual hygiene product(s) of choice is available (Millington et al., 2015), which can be done through private sector development by working with local suppliers and supporting the supply chain (Vatsalya, 2012), with investment to overcome key bottlenecks and technical assistance to produce an effective yet low cost product where required.

Once the supply side is in place, the demand side can be built through education. Targeted, culturally sensitive education – of men and boys as well as women and girls – works to decrease stigma and increase understanding of the usage, benefits and cost effectiveness of menstrual hygiene products such as reusable pads and menstrual cups (Lawan et al., 2010). Greater understanding also decreases the stigma that women and girls may feel regarding buying menstrual hygiene products from a shop, and increases the likelihood that men in charge of a family’s finances will provide menstrual hygiene products to their female family members. Improved awareness among teachers can make it easier for girls to change/empty menstrual hygiene products in schools, though support from donors may also be required to fund the creation of suitable toilet facilities in schools for this to take place (House et al., 2012).

By Tessa Hewitt, Liverpool School of Tropical Medicine