Period Poverty: A Neglected Public Health Issue
Article information
Abstract
Period poverty is a global community health dilemma that has long been overlooked. This condition is described as having insufficient access to menstrual products, education, and sanitation facilities. Briefly, period poverty means that millions of women are subjected to injustice and inequity due to menstruation. This review aimed to explore the definition, challenges, and effects of period poverty on the community, especially among women at their productive ages. In addition, suggestions to minimize the impact of period poverty are discussed. A search strategy was applied using the keywords “period poverty,” “period equity,” “period poverty,” and “menstrual hygiene” in Google Scholar, ScienceDirect, SpringerLink, MEDLINE, and PubMed electronic databases, journals, and articles on relevant topics. Trained researchers conducted a keyword search from January 2021 to June 2022. Based on the reviewed studies, it has been proven that many countries are still affected by the period stigma and taboo, inadequate exposure to menstrual health and its management, lack of education about menstruation, and shortage of access to menstrual products and facilities. The next step is to reduce and slowly eliminate the period poverty issue by conducting more research to increase clinical evidence and future references. This narrative review could inform policymakers of the magnitude of the burden related to this issue and guide them to develop effective strategies to minimize the impact of poverty, especially during the challenging years of the post-coronavirus disease 2019 era.
INTRODUCTION
Period poverty is a word that sounds cliché yet is unfamiliar. How far and how many people know this word correctly? How many people are aware and understand this issue? During the coronavirus disease 2019 (COVID-19) pandemic, period poverty has become an important public health issue because many people have started to lose their jobs and have income problems owing to the long quarantine and closing of many businesses [1,2]. A study conducted in the United States reported that the COVID-19 pandemic exacerbated period poverty, through the low accessibility and unaffordability of products. It was found that 30% of the respondents had difficulty accessing menstrual products because of the compulsory home quarantine, 29% struggled to purchase menstrual products, and 18.5% struggled to afford any menstrual products during the pandemic. Among these factors, women with small children were more likely to have difficulty accessing menstrual products during the pandemic. Consequently, those who indicated challenges in accessing period supplies were more likely to report absenteeism [3]. Another study in France found that women experiencing period poverty also had significant mental issues, such as depression and anxiety. Almost half (49.4%) of the women who had experienced period poverty reported at least one psychological symptom compared with those without any experience of period poverty [4].
COVID-19 has resulted in a significant burden on women, especially among low-income groups, because of the need for food, heating, and lighting being prioritized during the pandemic, leaving women improvising with materials or wearing products for longer than desired. Consequently, women lack the resources necessary to manage their menses well, which negatively affects their health [5]. When they were required to manage and use money only for essentials and important needs, menstrual products were not included in the list of essentials. Women needed to find other ways to use sanitary pads during their periods. All of this happened because they needed to use the money for other important things and the pad was not counted as one of the essentials that they need to buy. The question here is whether menstrual products are included as essential things in life. Alternatively, is it never on the list? Because menstruation, or the period itself, involves only one sex, it is understandable for some people not to consider menstrual products as one of the most important things in life. However, people live with both sexes; males are surrounded by females, and every family has a mother; therefore, it is important to have a mindset that menstrual products are essential.
Period poverty can be defined as the lack of access to safe and hygienic menstrual products during monthly periods and inaccessibility to basic sanitation services or facilities as well as menstrual hygiene education [6]. Period poverty affects not only middle-/low-income and humanitarian crisis countries but also developed countries, as evidenced by the fact that 10% of girls in the United Kingdom have been unable to purchase menstrual products, 15% have struggled to access them, and 19% have switched to less appropriate products because of high costs [7,8]. Many negative consequences can occur if this issue is not seriously addressed. Many women are neglected and persecuted because of a lack of attention from others, especially decision-makers and policymakers. Hence, all challenges, effects, and solutions to period poverty have been discussed in this study.
Before further discussing period poverty, menstruation is briefly explained. Menstruation is a healthy biological process that occurs in women of reproductive age in which the uterus sheds blood and tissue through the vagina in a monthly cycle [9]. Different women have different cycles; commonly, the cycle is approximately 28 days. Menarche is defined as the first menstrual cycle, and menstruation continues until the end of fertility, which is called menopause. Briefly, menstruation occurs after hormonal changes (estrogen and progesterone) that stimulate the uterus to either shrink the tissue or continue thickening the wall based on egg fertilization and ovulation [2]. Good management of menstruation can determine menstrual health. Menstrual health is a key factor that has been affected by period poverty. Menstrual health has been defined, from a more comprehensive point of view, as follows: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, concerning the menstrual cycle.” [10,11]
This review highlights three main issues, including the following: (1) to describe the definition of period poverty; (2) to determine the challenges and effects of period poverty on the population; and (3) to suggest solutions to period poverty.
CHALLENGES AND EFFECTS OF PERIOD POVERTY
There are many challenges that women need to overcome because of period poverty. Every challenge affects women. This study discusses the challenges and effects of period poverty in terms of three aspects: health challenges, economic problems, and education.
Health challenges involve physical health and mental health. Women who have their menstrual cycle monthly need to have good and safe hygiene products and health facilities to visit if required. The lack of access to harmless and hygienic products has caused women to use other unsafe products. Many countries still have problems creating a safe place for women to manage their menstrual products comfortably and with dignity. Not all schools or workplaces provide clean toilets and water. This has caused women to wear menstrual products for a long period of time, which can affect their health. The prolonged use of menstrual products, such as pads, tampons, or menstrual cups, increases the risk of infections such as urinary tract infection and bacterial vaginosis. Based on a study conducted in Odisha, India (2015), women who used disposable pads were less likely to exhibit symptoms or be diagnosed with bacterial vaginosis or urinary tract infection than those who used reusable pads [12]. In addition to infection, the risks of skin irritation, vaginal itching, and white or green discharge were also noted [12,13]. When there was no other way to access safe and hygienic menstrual products, women tended to choose pregnancy to avoid menses because they could afford to buy such products [13,14]. This solution poses a high risk of maternal complications after delivery because of poor pregnancy spacing [5,13,14].
In addition, women feel shame about menstruation, and the stigma about periods prevents them from talking about this topic. Some cultures have a stigma toward menstruation, which is being associated with uncleanliness and a disgusting matter in that they need to be isolated from others by sleeping and living separately from their family members throughout their menses. This taboo still occurs in modern life, such as in Nepal [15]. The society continues to believe in dangerous, incorrect ideas, for example, using tampons causes women to lose their virginity, or handling food while menstruating causes it to spoil the food. Social stigma on menstruation remains even in more advanced nations: in the United States, 58% of women are ashamed of having a period, and 51% of men believe that it is improper to discuss periods at work [1,16]. Because of this uneducated tradition, stigma, and taboo, women are reluctant to talk about their periods. They feel uncomfortable asking others about menstrual products when they are having problems obtaining them [17]. They choose to hide their periods by asking for emergency leave or absence from work and school. This is supported by the 2014 United Nations Educational, Scientific and Cultural Organization report that one of every 10 menstruating adolescents miss school during their menstrual cycle due to insufficient accessibility to menstrual products and resources [18]. They may also develop stress, social isolation, depression, and anxiety because of stigma about periods, inadequate toilets, and privacy measures, along with poor clean water, sanitation, and hygienic menstrual products, making it difficult to manage their periods harmlessly.
From an educational perspective, the challenges are the lack of knowledge about correct hygiene practices and inadequate access to the right information. Women with less education regarding menstrual hygiene also tended to develop urinary tract infections [12]. The lack of education about menstruation is the main factor that causes negative opinions to arise, even though it is a normal and healthy cycle in the life of women. Teen girls have nowhere to depend on if they have any inquiries about their menses. The lack of education may affect their actions and timing of meeting doctors. They never know when to seek help if they have dysmenorrhea, menorrhagia, or an abnormal discharge. In fact, of the 19 billion women who menstruate, approximately 500 million are unable to achieve good menstrual health [19,20]. The lack of knowledge about menses is focused not only on women but also on men. Men also need to be aware of the period to reduce taboos, especially in certain cultures. Knowledge about menses can also increase awareness and precautions among partners. Women’s health is a vital element to consider before starting a family. Thus, partners should be aware of each other’s health.
In terms of economic challenges due to humanitarian crises, natural disasters, and COVID-19, the availability of menstrual products has deteriorated. Moreover, although living in developed countries, typically, low-income women have difficulty affording menstrual products. Higher-income women with personal hygiene spaces at home are more protected against bacterial vaginosis than lower-income women with a lack of sanitary facilities [12]. Consequently, women are turning to other methods of managing their periods. Based on Malaysia’s National Population and Development Board, there is evidence that lower-income women may have used coconut husks or newspapers for their periods [21]. Furthermore, a tax known as the tampon tax is levied on menstrual products. Consequently, the cost of menstrual products has increased. Women who could not afford to acquire period management equipment are burdened more by this charge. This can be proven by a study on menstrual products in the United States, which shows that the tampon tax exacerbates period poverty and has a detrimental impact on women’s quality of life by decreasing the accessibility of menstrual products [22].
SOLUTION TO PERIOD POVERTY
Several solutions can be suggested. Some of these suggestions may have been implemented, whereas others may not. Solutions that have already been implemented need to be scaled up and strengthened until there is a better judgment toward menses and solutions to period poverty.
First, policymakers should reduce or abolish taxes on menstrual products. Every country needs to eliminate the period tax to justify women and provide them with reasonable prices for menstrual products. Several states, such as the United States, Kenya, Canada, Australia, India, Colombia, Malaysia, Nicaragua, Jamaica, Nigeria, Uganda, Lebanon, Trinidad, and Tobago, have reduced or eliminated taxes on period goods [8]. In addition, the American Medical Association has urged for the items to be exempt from all sales taxes and for the Internal Revenue Service to recognize menstrual products to be “healthcare necessities.” [23,24] Hoping for another country to join in eradicating the tampon tax by making menstrual products more accessible for a better quality of life.
Second, the government, in collaboration with a nongovernment organization (NGO), needs to provide free menstrual products in public places, such as public lavatories, schools, and workplaces, for easier accessibility. For example, in July 2019, the Malaysian NGO MyCorps Alumni launched the Bunga Pads initiative, a program that provides sanitary pads to low-income female students. The founder, Fitriyati Bakri, initiated this after visiting Bangladesh and witnessed the struggles of local women in accessing menstrual products. Later, she taught them how to make reusable pads and brought the idea back to Malaysia to save lower-income communities [20]. Free menstrual products have also been distributed to anyone who wants them in Scotland since the law was enacted in 2021 [25]. In Victoria, Australia, all public schools were provided with free sanitary pads in 2019 [26,27]. Moreover, authorities need to improve the waste management system that is used for the disposal of menstrual materials and ensure that adequate water sources, sanitation facilities, and changing bathing spaces are provided. This step is required to provide privacy and protection to women when managing their menstruation [19,28,29].
Third, policymakers, NGOs, and society should promote menstrual health information through social media, ads, posters, or print media. Regardless of sex, the community should be aware of how critical this issue is when seeking knowledge about period poverty. This is not only about women but also about human rights; thus, everyone needs to know about it [2]. Normalizing discussions about menstruation and encouraging women to talk and seek help when they are in need will also reduce stigma and taboos about period poverty [30]. Then, healthcare workers also need to pay more attention to this issue, as it can influence women’s trust in them and how they manage women with menstrual problems [2,30].
Finally, researchers should collect more data, details, facts, statistics, and information regarding menstrual health and period poverty [2]. These studies may change society’s perceptions of period poverty. More studies are required to raise awareness and provide an eyeopener for policymakers and the general public regarding how to address the issue of period poverty.
RELIGIOUS PERSPECTIVES (ISLAM) UPON PERIOD POVERTY
Before the emergence of Islam, women’s self-esteem was neglected and undervalued. Women were considered slaves or servants who could be treated whatever they wanted. The fulfillment of masculine lust has shackled women. However, after the emergence of Islam, women’s dignity has increased. Women are no longer despised, and Islam encourages followers to care for and respect them. Islam protects women from all forms of human depravity. An example in Islam is from the Prophet Muhammad (PBUH) in Hadith, narrated by Aisha r.a in Sahih Bukhari 297:
“The Prophet used to lean on my lap and recite Qur’an while I was in menses.” [31]
This demonstrates that women should be treated and cherished. Menses do not create barriers between husbands and wives living together because the period itself is not an unpleasant or filthy event. Another hadith that can be evidenced in how Islam raised women’s pride is Aisha r.a’s narration in Sahih Bukhari 299:
“Abu Huraira reported: While the Messenger of Allah was in the mosque, he said: O ‘A’isha, get me that garment. She said: I am menstruating. Upon this, he remarked: Your menstruation is not in your hand, and she, therefore, got him that.” [32]
This creative narrative demonstrates how the Prophet (PBUH) opposed any stigma around women in their period, instead encouraging others to consider them as normal people rather than dirty or chastised human beings.
The Prophet Muhammad (PBUH) stated that menstruation has never been associated with shame or impurities. Every Muslim should follow the Prophet’s (PBUH) attitude to raise awareness of period poverty and eventually work to solve this issue. We believe that other religions have also highlighted the issues of menstruation among women and their health. As a community, we should minimize the impact of period poverty by reducing stigma [33].
Several policies have been implemented to address the issue of period poverty in Islamic countries, such as Malaysia, Iran, and Lebanon. Among others, the subsidization of sanitary products, such as menstrual pads and menstrual cups, has been initiated to reduce the financial burden, especially for those with lower socioeconomic backgrounds. When this policy was implemented, it helped minimize out-of-pocket expenditures on sanitary products and make them more affordable [34,35].
In addition, various sectors, such as schools, universities, and companies, are encouraged to provide their employees with free menstrual pads to reduce the impact of period poverty among workers and teenagers in schools. In Malaysia, the government provides monthly assistance with feminine hygiene kits for teenagers from low-income families. Free sanitary pads were distributed across various government offices. Currently, a specific Ministry of Health budget is allocated for this effort to make it sustainable to bid on this issue in Malaysia [34]. In Lebanon, a national fund was established for menstrual products that aimed to provide women with free access to sanitary pads each month to minimize the burden related to poverty [35].
In addition to these two policies, the government has allocated a huge amount from the national budget to educate and empower women through awareness campaigns and address the stigma, taboos, and shame associated with menstruation and period poverty. The main aim of this effort was to remove all misconceptions related to menstruation and open up conversations about period poverty issues. This was significant in Malaysia, Iran, and Lebanon [34-36].
In addition, the Lebanese Government has worked to provide incentives to companies willing to venture into building facilities and innovations in sanitary pads at cheaper prices. All these efforts encourage more companies and industries to work hand in hand with the government to address this issue and minimize its impact on our population [35].
CONCLUSION
Period poverty is not about privilege or sex issues but about human rights. Women have the right to use safe menstrual products during their monthly menses. They have the right to a safe and private place to manage their menses, as well as clean water sources and facilities. Anyone needs to have good knowledge about menses to understand the difficulty that a woman has to go through every month. Knowledge of menses can also help avoid negative stigma about menstrual periods. As long as people have a mindset that menstrual products are not a priority, women will always be discriminated against, and it will not be easy for them to purchase menstrual tools, seek help when they are in need, and learn correct knowledge about menstrual health. In fact, many fundamental rights, such as poverty, education, health, water and sanitation, and gender equality, have inspired the development framework of the United Nations Sustainable Development Objectives; hence, tackling menstrual health and period poverty issues are vital to achieving these goals by 2030.
Notes
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.