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The right to an informed choice: Dr Supriya Garikipati on how India can make menstrual health available for its girls and women

Pushkar, India, November 28, 2012: Beautiful Indian girls and women at Pushkar fair, in the Indian Rajasthan state

When it comes to menstrual health, India’s girls and women face extreme challenges ranging from lack of accessibility to menstrual hygiene products to stigma. In particular, there is the lack of ability to exercise their right to an informed choice. Health Issues India talks to expert Dr Supriya Garikipati about the situation surrounding menstrual health in India and how the country can deliver for its girls and women a future where an informed choice is possible and menstrual hygiene can be pursued in a safe, sustainable, and affordable way.

  • Thank you for taking the time to speak with us, Dr Garikipati. To begin with, could you provide an insight into the challenges facing India’s girls and women when it comes to their menstrual health and hygiene?

Women in India face steep challenges when it comes to their menstrual health and hygiene. Foremost among these is a supreme lack of awareness. In fact, in the menstrual value chain, creating awareness on menstrual issues is the very first identifiable role for public policy: bursting the social myths that regard menses as “impure”, and creating a gender equitable culture where these issues can be freely discussed. Also to impart awareness among women on product choice, correct use and waste disposal is critical. Unfortunately public policy has failed women on all these fronts. Women in India are effectively denied an environment where they can discuss menstrual issues with peers and elders. The singular policy focus on disposable pads also effectively denies women the right to informed choice. These awareness issues are exacerbated when combined with lack of access to the range of menstrual products and lack of access to right WASH and disposal facilities. We find a public policy push for small and medium size incinerators – with little concern for whether releasing toxin in the air we breathe is the right approach to disposing menstrual waste. So yes, I would say that a supreme lack of awareness and knowledge on these issues is our biggest challenge. 

  • Could you give an insight into the work you carry out in this field?

We started work in this area some three years back – inspired by a visit to a slum on another project. I remember watching sanitary pads floating in the open sewers next to people’s dwellings. This started a series of discussion, application to ODA funding and our first project in slums in Hyderabad that opened our eyes to how effectively the public policy push for disposable pads had percolated down to even the most marginalised communities in urban India. We found that nearly eighty percent of women in slums used pads as their primary menstrual care. This was quite different to earlier reports on pad usage emerging from India. We then followed this up with a RCT (randomised controlled trial) to understand acceptability for reusable, sustainable menstrual products (re-usable cloth and compostable pad). This study clearly demonstrates that India’s invasive ‘disposable pad culture’ poses a challenge to the adoption of more sustainable alternatives and disposal practices. Significantly, we find that awareness of menstrual materials other than disposable pads is negligible among women. Most interestingly, we find that the group exposed to non-pad options were the most open to alternatives at end-line. Our results also suggest that promoting sustainable menstrual products will require innovations focussed on convenience to end-users alongside evidenced-based, policy-driven messaging, at a minimum to support awareness of alternative choices.  We have now received further ODA funding to study the acceptability of menstrual cups as an alternative among various segments of women in India. This work is ongoing. In summary, I can say that we started by examining the impact of India’s MHM policy and now we are pushing the boundaries of that policy for inclusion of informed choice. 

Schoolgirls walking in Delhi.
  • During our prior correspondence, you mentioned a particular project you have been involved in this field related to informed choice when it comes to menstrual health management. Could you explain more about the project to our readers?

Yes, this is the impact element of our work. The motto of my department at the University of Liverpool is ‘Learning to Make a Difference’ and this imbibes a culture of using research to make a difference to the society around us. I am deeply influenced by this motto. Using some of my research findings, we started working with partners like WaterAid, Unicef and Menstrual Health Alliance of India on the idea of informed choice. We find that India’s MHM policy (like elsewhere) focusses quite heavily on promotion of disposable pads only – this has come at a cost. So much so that many women have no knowledge of the existence of other products like antimicrobial cloth pads, compostable pads and menstrual cups that could provide far more sustainable menstrual care – both financially and environmentally speaking. We are collectively trying to change this narrative. So far we have held several events, made some policy briefs and also looking at translating some of the information into regional languages. Our message is simple – women must have the right to informed choice and the least public policy can do is to support awareness of alternative choices.

This is a disturbing trend indeed. An organisation that we work with, MARI, has observed that in some villages in Andhra and Telangana the incidence of hysterectomies are extremely high – close to 100 percent and some as young as 23 years of age. Once a woman has conceived the desired number of children, apparently the medical practitioner recommends hysterectomy as a way of killing two birds with one stone – alleviate any minor gynaecological complaints and rid women of the stigma of menstruation. The incentive comes from this surgery being extremely lucrative for private practices.  Women opt for this without realising the full implications of the intervention. We have cases of serious domestic violence and spread of prostitution in these areas – but as yet no study looks at the full picture of what seems to be a devastating phenomenon.    

Copyright: belchonock / 123RF Stock Photo
Menstrual pads.
  • To what extent are girls and women informed about their periods, and what can be done to raise awareness among populations where knowledge is scant?

Lack of awareness is certainly a most major issue, as I have said before. Things are getting better, especially in pockets, particularly in the more progressive states like Kerala and Andhra Pradesh. While parents and older siblings have a role to play, this is largely a role for public policy. Educational materials used in schools needs to be made more accessible and sessions on menstruation and fertility need to be carried out in a utilitarian way where girls and boys are encouraged to question and discuss issues with peers. Gender segregated sessions have been seen to be more effective in encouraging young people engage with these issues. Importantly until these issues are part of the assessed curriculum, schools and students are likely to treat these issues as a burdensome inclusion to their already demanding syllabuses. We need to experiment with creative ways for those populations who are not in formal education. MHM events in villages; street plays; story telling; media advertising; mobile education units; celebrity involvement are all worthy ideas.  

  • Attitudes to menstrual health in India often stigmatise girls and women. Are sufficient efforts underway within Indian culture and society to challenge this stigma and educate individuals about the realities of menstruation?

I must say that things are improving. We have come a long way from when menstruating women were not allowed to touch drinking water but a lot still needs doing. The recent incidents at Shabrimala have demonstrated the deep and complex nature of the social interlinkages that stigmatise menstrual women. This is a tough uphill struggle. We have many good stakeholders engaged in these efforts – the Menstrual Health Alliance India – is a unique national forum that has brought together many organisations working on this issue to give them a common voice and purpose. We work to give voice to girls and women who have been denied this voice so far and we also work to influence policy makers to shift the narrative on menstrual hygiene management. So a lot of work is being done – but it is a long road ahead. 

  • A mere 57.6 percent of girls and women in India aged 15-24 use a modern form of menstrual protection. What do you think the main reasons are for this?

Poverty and lack of awareness are the two main reasons for why young girls tend to use traditional forms of menstrual protection. However, it is important not to stigmatise all traditional materials. For instance, cloth – if used correctly, is a perfectly good menstrual material. The big plus of cloth is that it is inexpensive and good for the environment too. But a policy focus on disposable pads is has resulted in embedding the perception that cloth is an inferior menstrual material. We have created an invasive pad culture that poses a challenge to sustainability, but importantly also to women’s right to informed choice. The focus needs to shift on creating awareness on the correct use of cloth. Frequent change of cloth, thorough soap washing and sufficient drying time in direct sunlight are what needs to be taught rather than stigmatising cloth. Indeed today we have in a market several variants over home-made cloth pads that provide girls with the convenience, comfort and security of disposable pads. 

  • To what extent would you consider affordability a challenge, in terms of girls and women being able to access safe, modern forms of menstrual protection?

This is an issue indeed. In our studies, willingness to pay for modern menstrual protection among cloth users is around twenty rupees per cycle. This does not buy a pack of quality sanitary pads and women are not aware of or do not want to consider other options – like menstrual cups. These do cost a fair bit – a reasonably good cup can cost 250 rupees or more – but these can last up to ten years or even more. These have been proven to be safe in several global trials. We have large amounts of state subsidies committed to disposable pads – perhaps some of these could be diverted to menstrual cups. We find that the Government of Kerala has already pioneered one such initiative – Thinkal cups – perhaps more states can follows. We have initiated an acceptability and safety study for cups in India. Watch the space. 

Some research has indicated that menstrual cups show similar or improved leakage rates compared to other menstrual hygiene products. Image credit: gaelx [CC BY-SA 2.0 (]
  • We have reported recently on menstrual cups being a potentially viable alternative to other forms of menstrual protection such as pads and sanitary napkins – particularly that cups are potentially more affordable and more environmentally friendly. However, the research we cited noted that the quality of research in the field is frequently low. How do we incentivise high-quality, comprehensive research into menstrual protection and the potential benefits of alternatives to the more commonly used forms of protection?

Research funding is a real hurdle. Many of the cup studies are not well resourced and this is an issue. If a project is inadequately funded – this typically impacts on quality of people that can be hired and time that can be committed on projects. I think public-private partnerships might be a viable way forward – for instance, diverting some of the CSR money into meaningful research might help. Government and research institutions need to work together to find creative solutions to fund research that is meaningful for public policy.

  • How do we ensure that such research engages populations in all regions, not only high-income nations in the West?

A lot of the research funding originating in the west is already conditional on engaging with higher educational and research institutions in the southern countries. But for a more comprehensive stake in cutting edge research, countries like India need to have their own independent research agendas that serves their needs. We also need to improve the profile of interdisciplinary research – that is where most of the innovative work comes from. Especially for issues like menstrual hygiene which intersects with a number of areas.  

  • To what extent does menstrual stigma and the resultant effects on hygiene and health threaten the overall social development and wellbeing of girls and women?

There are around two billion girls and women of the menstruating age worldwide of whom 1.7 billion live in low and middle-income countries (LMICs). Their menstrual health intersects with several Sustainable Development Goals, such as SDG3 (good health); SGD4 (quality education); SDG5 (gender equality); SDG6 (universal WASH); SDG9 (jobs and the economy), and SDG10 (reducing inequities). And before SDGs it was MDGs. The effects of poor MHM on girls and women is identified as a neglected component of public health systems in LMICs. In fact this is what lead to its inclusion in the mandate of WHO, UNICEF, UNFPA, UNDP, and other development agencies. And if we are seeing any progress in this area – its is partly because of the setting of this global agenda. 

  • Do you have anything else you wish to add?

My central message would be to focus on menstrual awareness. Removing the stigma around menstruation and giving women the right to informed choice would win half the battle. Of course there are other important considerations for public policy like access to appropriate WASH facilities and waste management – but without awareness, these are like weapons without the warriors. 

Dr Garikipati is an Associate Professor in Gender and Development at the University of Liverpool. Her doctoral work was at Cambridge, UK, after which she worked in various positions at Cambridge and the Open University before joining Liverpool. Her research interests are mainly in examining the impact of public policy interventions on women’s livelihoods and wellbeing with a focus on sustainability. She has worked extensively on development finance, rural labour markets, reproductive health and urban resilience in India. Her work has been supported by funding from DFID, British Academy, Newton Trust and ODA and published in several high ranking development journals. She recently completed a project on acceptability of sustainable menstrual hygiene products amongst urban users in India and has started work on acceptability of menstrual cups in India in collaboration with LSTM. Dr Garikipati also collaborates with practitioners to ensure that her research work has real world impact. She has co-produced several policy briefs with WaterAid, UNICEF on menstrual issues.

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