Let's Talk About Periods

​Squirm-inducing facts of life like diarrhea, tapeworms, and other water, sanitation, and hygiene (WASH) ailments are part and parcel of one’s typical foray into health issues of the developing world, yet one hygiene-related phenomenon has received a surprising amount of attention from donors over the past decade: periods. With the countless number of euphemisms we’ve generated in the English language to refer to ladies’ “time of the month,” most people are inclined to politely veil the crimson tide’s existence. However, the circulation of a staggering 2005 World Bank estimate —that young women lacking access to feminine hygiene products in the developing world may be missing up to 20 percent of their education— seems to have caused a shift in that paradigm in recent international development discourse.

As the story goes, young women are missing up to one-fifth of their education because they lack access to modern sanitary products. Often left with soaked-through reusable pads, limited or no access to running water, or no menstrual hygiene management (MHM) resources at all, these girls face the difficult choice of braving school with stained clothing, using unhygienic and uncomfortable rags, or staying at home. This situation—further exacerbated in some contexts by cultural and religious taboos related to menstruation—is thought to lead to higher absenteeism, course failure, and, ultimately, dropout rates for young women in the developing world. In fact, some NGOs like Femme International have argued that periods are the “number one reason that girls miss school.”[1] Given that educational outcomes are tied to a wide variety of other indicators of social and economic progress, the effect of these estimates on development outcomes could be enormous if they are true.

As well-intentioned corporate philanthropists and nongovernmental organizations are wont to do, the release of these claims resulted in an outpouring of funds dedicated to financing eco-friendly sanitary products and providing MHM education to girls in the developing world. Campaigns such as the Procter & Gamble “Protecting Futures” program and commitments from prominent NGOs and the Clinton Global Initiative developed in earnest.[2] After all, the solution seemed so simple: if gender-based educational disparities are rooted in the fact that girls merely don’t have access to the proper MHM resources, then their provision could hypothetically be the silver bullet solution. 

Young girls in Ethiopia pose with their new reusable pads. Photo cred: BeGirl.org

The unfortunate reality is that there are rarely any such slam-dunks in international development, and this appears to be no exception. Although eliminating gender-based disparities in education outcomes has been a focus of aid donors since the advent of the Millennium Development Goals, a few notable actors have questioned whether the inaccessibility of appropriate sanitary products is the true culprit of absenteeism. Esther Duflo, Director of the Abdul Latif Jameel Poverty Action Lab (J-PAL), for example, has argued that absentee rates are the same for boys and girls in much of Africa, and that “What’s keeping children from school is the costs of attending”—not periods.[3]

To gauge whether the anecdotal evidence regarding female absenteeism was supported by investigative scrutiny, J-PAL affiliates designed an impact evaluation that distributed reusable menstrual cups to girls in the seventh and eighth grades in Chitwan, Nepal. The evaluation was designed to test whether menstruation indeed served as a barrier to female education, and whether the provision of modern sanitary products would increase attendance and school performance among girls.[4]

The results of the study indicated that the menstrual cup intervention did not have its intended impact: researchers found that girls only missed half a day of school per year, on average, due to their periods. While the intervention had some positive impacts—the girls in the treatment group overwhelmingly chose to use the cup and continued to do so over time—it was not shown to reduce the small amount of school missed due to menstruation, nor was it associated with an increase in test scores. Moreover, 44% of girls in the study reported that while the cup did help manage menstrual blood, they typically missed school because of the cramps they got while on their periods—not necessarily because of stains or embarrassment.[5] As the researchers concluded, “the underlying causes of low school attendance for girls are complex, and … the relatively easy solution of providing sanitary products may not result in the educational gains policymakers had hoped for.”[6]

Woman teaching young girls in the seventh and eighth grades how to use reusable menstrual cups. Photo cred: J-PAL

Randomized controlled trials (RCTs) such as this one are generally considered to be the gold standard for scientifically gauging the efficacy of interventions While anecdotal evidence is certainly valuable, RCTs are designed to examine the relationship between intervention and impact with greater accuracy. Nevertheless, it remains prudent to question the extent to which RCT findings should be universalized, particularly when they address complex cultural issues like periods. Menstrual taboos are pervasive throughout the world and interact with different social and spiritual norms depending on the cultural context. In western Nepal, for example, the tradition of Chhaupadi isolation requires women to live in a shed outside of the home for the duration of their periods. This raises a common question related to RCTs: to what degree might the findings of a study conducted in Nepal have cross-cultural applicability? Faith Macharia, the National Director of the Forum for African Women Educationalists in Kenya, has argued that they do not: “Girls will stay home rather than be embarrassed,” she said, citing studies conducted by her organization that support the period-absenteeism connection.[7] What, then, should one believe?

Social issues related to gender equity and female inclusion are complex and, unfortunately, are unlikely to be solved with a one-size-fits-all solution. This debate demonstrates that while social scientific evaluations like RCTs are undoubtedly useful, it is important to question their external validity: data certainly matters, but culture matters, too.
 
Sydney Taylor is a Master’s candidate in Global Policy Studies at the LBJ School of Public Affairs at The University of Texas at Austin.

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[1] “Menstruation, Development & Women’s Rights,” Femme International, 2013, http://www.femmeinternational.org/the-issue.html.
[2] Claudia H. Deutsch, “A Not-So-Simple Plan to Keep African Girls in School,” The New York Times, Nov. 12, 2007, http://www.nytimes.com/2007/11/12/giving/12GIRLS.html.
[3] Ibid.
[4] “Menstruation as a Barrier to Education?” Abdul Latif Jameel Poverty Action Lab, June 2011, https://www.povertyactionlab.org/sites/default/files/publications/Menstruation%20as%20a%20barrier%20to%20education.pdf.
[5] “Menstruation and Education in Nepal,” Abdul Latif Jameel Poverty Action Lab, 2011, https://www.povertyactionlab.org/evaluation/menstruation-and-education-nepal.
[6] “Menstruation as a Barrier to Education?” op. cit. 
[7] Deutsch, op. cit.