Access to Pads: Five Takeaways from Menstrual Hygiene Management (MHM) Research with Adolescent Girls and Young Women in India and Ethiopia

Menstruation is a monthly challenge for billions of women and girls worldwide. On any given day, more than 300 million girls are menstruating.* With support from the Bill and Melinda Gates Foundation, PSI sought a deeper understanding of access to menstrual hygiene management (MHM) products for girls and young women, including the roles of the commercial market and global health community. Qualitative and quantitative research was conducted over 2017-2018 in two states in India and four cities in Ethiopia.

Below are 5 takeaways from our research.

  1. More women and girls are using commercial pads than we expected.*

In India, 58% of women and girls age 15-24 report using hygienic* products. ​In Ethiopia, 86% of girls in urban areas and 49% of girls in rural areas report using sanitary pads. 87% of women in Kenya and 65% of women in Uganda​ report using sanitary pads as their main menstrual hygiene material. ​

We wanted to understand why, so we started our project by asking them. In both India and Ethiopia, the drive to use sanitary pads was strikingly similar. Firstly, girls use commercial sanitary pads because they have a fear of stains caused by visible leaks, and the commercial products provide greater security against this. Secondly, commercial sanitary pads give girls the confidence and security to leave the house during menstruation, enabling increased mobility.

  1. Women and girls are willing to pay for product features they value.

We hypothesized that price would be the most important feature, but consistently both rural and urban adolescent girls and young women (AGYW) prioritized better quality over price when selecting products.* Specifically, there were strong preferences for products that stick well to underwear during activity, have high levels of absorbency and length to manage heavier flow, and include wipes, likely for ease for cleaning where access to WASH facilities is limited. On average, AGYW were also willing to pay for these better attributes.

However, affordability was a barrier for a larger proportion of girls from rural areas, in the lower wealth quintiles, and among those who had no experience with commercial disposable pads. We found that the barriers AGYW face in accessing their preferred MHM products are counteracted by mixed-use strategy. With a small supply of sanitary pads, many AGYW are saving pads for when at school or work, and using homemade or improvised cloth at home. We also found that exclusive pad use was clearly correlated to the higher wealth quintile.

  1. The commercial sector should be treated as a partner to achieve quality and scale.

We strongly believe that supporting the growth and development of the commercial sector is key to meeting the MHM needs of AGYW. Girls prefer commercial pads, and the commercial sector has capacity to produce, distribute and market products at a scale. MHM markets in India and Ethiopia have been growing impressively, at around 13% CAGR. If per capita consumption follows a similar pattern to the US and China as incomes increase (increasing pads used per year from 9 in Ethiopia and 13 in India to around 250+ units per WRA) the markets could potentially grow to 7-9 Billion pads a year in Ethiopia and 100-120 Billion pads a year in India.*

However, the incentives for manufacturers to target rural areas is limited as the costs required to serve these areas are generally higher. Governments and stakeholders should explore new partnership models to overcome market barriers and incentivize large scale manufacturers to serve rural markets.  This could include incentivizing production in areas with large unmet need, integrating MHM programming with main stream curriculum in schools, and incentivizing the use of locally sourced absorbents to reduce costs and dependency on imports.

  1. Sexual and reproductive health (SRH) should own the MHM agenda.

There has been increasing movement on MHM, but uncertainty remains among stakeholders of how to engage it or who owns the agenda. Based on the reproductive life cycle approach, menstrual health presents a first engagement point for adolescent girls on their sexual and reproductive health. We believe SRH teams and initiatives should take ownership of MHM as key element of strategy and programming.

In addition to this, MHM should be included as part of adolescent health and gender equity programs. Donors could invest in research and pilots to identify and optimize linkages between menstrual health and funded development priorities such as family planning, gender equity, and adolescent health. For example, can engagement in MHM — as a non-sexual early entry point for discussion between girls, their influencers, and health workers — result in greater uptake of safe SRH practices and family planning? Increased evidence of these linkages could unlock funding from large development institutions that might not otherwise invest in MHM.

  1. Access to products is not enough. Support girl’s entire MHM journey.

Although access to preferred products is fundamental to MHM, our research and others* have shown that access alone is not enough. Girls need help navigating the entire MHM journey, and we recommend stakeholders consider MHM strategy holistically when thinking about how to coordinate programs and leverage resources. This approach would recognize that access is one step in the individual journey to meet a health need at the center of a complex system of influencers, motivators, and barriers.

Initiatives in adolescent health, gender, and SRH that aim to shift social norms or improve knowledge and awareness will be key to tackling barriers at various steps in the menstrual health journey. MHM messaging and referrals could be integrated into each of these. As consumption of sanitary pads increases across the globe, processing of waste will become a greater challenge. All Water, Sanitation and Hygiene  programs should plan for this increasing disposal of MHM waste.


Learn more about PSI’s menstrual hygiene management landscaping research and its surprising insights here:

Expanding Access to Menstrual Hygiene Products in India

Expanding Access to Menstrual Hygiene Products in Ethiopia

*All citations can be found in the these briefs


Banner image © PSI/Manprit Shergill and Gurmeet Sapal

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