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.