Sanitary Pads and School Attendance: What the Conditions Actually Are

Over the next week, I would like to outline some of the issues with sanitary pads in the developing world context for the purpose of informing some of the discussion now going on among providers and policy-makers. In this post, I will focus on describing the conditions that face girls in rural areas. I am speaking from close experience in sub-Saharan Africa, but my research in Bangladesh suggests the same conditions are found in south Asia and, likely, in poor nations everywhere. In subsequent posts, I will discuss the potential performance of various forms of disposable and cloth alternatives.

What the girls use now is cloth. They use whatever they can find, often cutting up old clothes, but sometimes taking “found” cloth, even from the public rubbish. We have heard horror stories of girls using animal skin and leaves, but all the direct reports we have heard have been of cloth usage, if sanitary pads (or sometimes toilet paper) are not in use.

Because the girls are using whatever becomes available, the cloth is often not particularly absorbent, not particularly clean, and not particularly quick to dry when washed. But nearly always, cloth is scarce. So, what that means is that they only have a few pieces to use, maybe one or two. Some households are so poor that the girls must share their cloth with sisters or their mother.

When the girl has used the first piece of cloth, she washes it. While the first cloth dries, she switches to the second piece, and then to the third if she has it. These girls wash with water that is sometimes not clean because there is no plumbing and water may be retrieved from a source in which humans and even animals are bathing or, sometimes, defecating. The girls often have very little soap, if any. Perhaps most importantly, they have no private space in which to dry the cloth once it is washed.

Health care workers and teachers tell them they must dry the cloth in the sun and preferably iron it, before putting it back on. They know what they are supposed to do. It is not a matter of “educating” them. But as a practical matter, they are embarrassed to hang the cloth out in the sun and they have no iron. So, they hang the cloth to dry in a dark, often dirty place with little air circulation because that helps keep the matter of their menstruation private.

By the time they have worked through the third cloth, however, the first cloth is often not dry. So, they put it on damp. This continues through the rest of their period because they simply do not have enough cloth to wait for each piece to dry before wearing it again. Remember that the cloth may still be, from a modern health perspective, dirty. So, there is a personal health question surrounding the use of cloth when the means for keeping it clean are not available.

Often, the cloth begins to smell in a way so distinctive that everyone in the community knows what it comes from. So, their privacy is broken by the scent, even if they have hidden the cloth from view. Maintaining privacy about menstruation is very important. This is because menstruating girls are often seen as “fair game” for sexual predators and the natural candidates for early marriage. Male members of our team have even been told by men in west Africa that the sight of a menstrual cloth hanging to dry is an erotic stimulus.

In our experience, the single most frequent answer when we ask why a girl left school is “unwanted pregnancy.” This occurs because, once the girl is known to be menstruating, her family often cuts her off economically, expecting that she will find “a boyfriend” to support her. Then they are surprised and outraged when she turns up pregnant! But it also happens because sexual predators, once they find out she is “ripe,” will push themselves on a young girl. Sexual abuse of teenage girls is an everyday occurrence in such settings. So, again, keeping privacy is important.

Whatever cloth is used needs to be absorbent enough to rely on when the girl walks to school (sometimes as long as a two hour walk). Most cloth available, even in products currently being designed for this purpose, will not be absorbent enough to pass this test. Even if the cloth were adequate, once the girl arrives, most schools have no private toilet space for girls to change in or water with which to wash. Many schools we have visited have no separate facilities for boys and girls. Many had no doors on them. So, needing to change a cloth at school presents a big obstacle .

So, it is crucial to understand that providing girls with cloth for their periods will not, by itself, help to solve the challenge of keeping girls in school. They need enough cloth to use while washed items dry. They need soap. They need private space, at home and at school. These are infrastructural demands that will be expensive and take a long time to build.

So, why was this not a problem for their mothers? We often get this question, too. First, let me assure you that it is a problem for their mothers, even now. The mothers don’t want to hang their cloth out in clear view to dry, either, and they, too, have a problem going out of the house to work if they must rely on cloth. Second, let me point out that the rate of education among previous generations shows clearly that the mothers and grandmothers were not faced with the challenge of going to school–walking a long way with the cloth, sitting for hours in a mixed sex environment. We have talked to grandmothers who were married off after their first period and never had another one because they were constantly pregnant after that. It was a different world and an environment we are trying to change. Third, menstruation is a taboo in every culture in the world. No woman is going to walk up to an international aid representative and announce, unprompted, that what she really needs is a sanitary pad. Since most such representatives are male, they never thought of it on their own. For all these reasons, the problem is only now coming to public attention.

In the next posts, I will talk about the relative pros and cons of disposables and cloth solutions. I will address performance and cleanliness, but also the affordability and environmental implications.


  • Thank you for reporting on this vastly under reported issue.

    One alternative that I’ve seen a bit of discussion on lately is the silicone or rubber menstruation cup. I’ve read that the Diva cup is the longest lasting. If hygiene issues (private areas to dump it, handwashing stations and the ability to sterilize it in boiling water) could be addressed, it would handily circumvents the drying cloth and absorbency issues. It also avoids the serious issues that come with disposables, including the lack of a place to put used supplies that won’t attract animals, attract unwanted male attention and allow girls the privacy they need.

    I, myself, am a big fan of the Diva Cup.

    • Dear April,

      Thank you for being concerned about this important problem. It does seem, from the perspective of many in the West that the menstrual cup would be a good solution for girls in Africa. However, they do not have easy access to clean water nor usually soap. Boiling is something that takes a good bit of work (collecting wood, setting the fire) and has to be done in front of others. We have also found that menstrual materials that are not disposable are often shared. So, really, menstrual cups are not a good idea in this situation. If we are worried about the rubbish, it would be better to try and convince our sisters who live in places with lots of privacy, lots of hot water and soap, to use menstrual cups or cloth pads. It is still a puzzle to me why all the waste of the West should come to rest on the shoulders of poor girls in Africa.

      • Linda,
        Thanks for the explanation. It’s clear that the West and Africa are very different contexts, however April did not say anything about rubbish except as it relates to privacy and safety for the user.
        From what you have described elsewhere on this website on the risks of using cloth, and from my own experience in using a cup for over 10 years also while camping (I have also used cloth, pads and tampons), if I or my daughter had to live in the conditions you described in Africa I would still choose a cup if given the choice, purely on the basis of personal costs and benefits.

        • Dear Rose,

          Your personal choice would, of course, be your own. Our concerns, as people who are introducing new objects into such communities, is that they can and will be used safely. Since we are in some sense responsible, we need to be careful to know what the likely health outcomes would be and act accordingly.

          I dare say if you went on a camping trip, you would take some soap and could use it to clean your cup. Unfortunately, the girls we work with are seldom able to have soap, which means that their cups would be cleaned with water only–and the water would be unlikely to be clean. Further, we have found that some women will share cloth, even for this intimate use, and we feel that sharing a cup–particularly one that is not clean–poses a public health problem. So, I question whether, if you and daughter were truly in these conditions (not on a Western camping trip, but truly without clean water and soap, living in a setting where infection is frequent), it would be commensurate with your “personal costs and benefits” in the way it is at home.

          Thanks for writing,

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