Evidence, not assumptions, need to be a driving factor in any program demanding funding and claiming impact.
The Menstrual Hygiene Management (MHM) has emerged as an area of interest in relation to maintaining adolescent girls’ school attendance, with the ultimate goal of reducing dropout rates and supporting adolescent girls to achieve better educational outcomes.
Evidence, not assumptions, need to be a driving factor in any program demanding funding and claiming impact. Tweet This Quote
Despite this interest, there is a dearth of evidence in support of any causal relationship between menstruation and girls’ school attendance. Many advocacy campaigns, interventions, and pitches for investment are based on the assumption that distribution of sanitary products will lead to improved school attendance, performance, progression, and better outcomes for girls.
But, with larger and larger amounts of funding and resources being put into MHM efforts, it’s increasingly important to make sure that the various approaches are backed by real impact data.
There is a dearth of evidence in support of any causal relationship between menstruation and girls’ school attendance. Tweet This Quote
I have become particularly interested in the evidence around menstruation and schooling outcomes for adolescent girls during my recent work in East Africa with startups. Through my work, I’ve met with almost every local player in the market, and have heard the arguments that sanitary pads reduce adolescent girls’ absenteeism, keeping girls in school, and thus improving schooling outcomes. I’m seeing a couple of problems with these claims that need to be addressed in order for us to make real progress.
There is a weak understanding of what counts as evidence amongst many MHM businesses. One business has claimed that provision of their sanitary pads in schools lead to a 75 percent decrease in school absenteeism amongst adolescent girls. When I enquired what absenteeism was before (the baseline), in order to understand the magnitude of the reduction, they were not able to provide data on this. This was important because if girls were only missing on average 0.2 days of school per month, a reduction of 75 percent only meant that girls were attending, on average, an additional 1.5 hours per month. Not much of an impact in anyone’s books.
There is a weak understanding of what counts as evidence amongst many MHM businesses. Tweet This Quote
A number of businesses make claims that they can “ensure girls stay in school” based on anecdotal evidence, either of what they saw their sisters or other female relatives experience, or tales from the field. While these stories are no doubt true, and legitimate, this is not evidence.
Others use statistics, claiming that “65 percent of girls in East Africa could win back up to six weeks of school each year if given affordable, dignified means to manage their periods.” Still others claim that this amount is two months of school every year. One company claimes: “Hundreds of thousands of young girls… miss school on a regular basis because they don’t have access to safe and affordable sanitary pads.” In chasing down the data to substantiate these claims I, and others, have been given small-scale qualitative studies and poorly designed quantitative studies—or we have just hit back holes and stone walls.
And even if the evidence for MHM interventions did show evidence of an increase in .5, or 1 or more days of school per month, if this cannot be linked to better school performance, likelihood of re-enrolling the following year, likelihood to transition to secondary school, and higher literacy levels, then I question whether this could be considered impact worth investing in.
Fortunately, some MHM businesses I have spoken with also understand this evidentiary problem, and they are in the process of designing more robust quantitative research to better understand the relationship between MHM and schooling outcomes. This is exactly what we need going forward.
But what is the state of the evidence at present?
What is the evidence?
This leads me to the second—killer—problem. Sanitary pad companies are over-claiming impacts on the basis of poor, limited or no data. Here is what four independent studies from Kenya, Zambia, Malawi and Nepal say.
The Adolescent Girls Empowerment Programme in Zambia collected data from 5,241 girls in 2013 for a baseline study1. Among those girls who reported having missed days of school in the past year, the reasons given (with multiple responses possible) were:
- Student sick/ill: 54%
- Other: 29% (the majority of which had to do with financial issues, lack of money for books, fees, uniforms)
- Household responsibilities: 15%
- Uniform dirty: 8%
- Rather do something else: 5%
- Funeral/bereavement: 5%
- Menstruation: 1%
In Kenya, baseline data from a study in Kilifi2 that surveyed 2,500 girls recorded reasons for girls missing school (over a 3 month period) in number of days missed as:
- Sickness: 2.6 days
- Lack of school fees/materials: 1.7 days
- Death/sickness of family/friend: .93 days
- Menstruation: .45 days
- Housework: .25 days
- Care for family: .19 days
So, menstruation does not appear to be a major cause of girls missing school in either Zambia or in Kenya. In Zambia, illness, poverty, and household responsibilities are all far more important. In Kenya, sickness, poverty and family care and responsibilities were far more important. While some claim that “sickness” might also cover the effects of menstruation, studies that allow multiple responses, as the above do, minimize this risk.
For those who reported missing school due to menstruation in the Kilifi study, the reason given was:
- In pain: 70%
- Nothing to manage period: 45%
- Scared to have accident at school: 20%
- Embarrassed: 12%
- Scared to be teased: 12%
- No private place at school to manage period: 4%
So, even for those who were missing school due to menstruation, not having anything to manage their periods was not the most important driver—pain was. And, taken together, being scared about being embarrassed should others find out about their periods (reasons three through five), taken together account for 44 percent of reasons, and are therefore just as important as having nothing to manage their periods (at 45 percent). This suggests a need not only for girls to have greater ability to manage their periods (which would reduce this fear), but also approaches that build girls’ confidence, and boys’ understanding and support for girls.
Menstruation does not appear to be a major cause of girls missing school in either Zambia or in Kenya. Tweet This Quote
The Malawi Schooling and Adolescent Study (MSAS)3 is a school-based survey of 1,675 students between 14 and 16 years old sampled from 59 primary schools and their catchment areas in two rural districts in southern Malawi. This longitudinal study on adolescence and school quality found that, “although one-third of female students reported missing at least one day of school during their previous menstrual period, menstruation accounts only for a small proportion of all female absenteeism and does not create a gender gap in absenteeism.”
So, menstruation is not one of the main reasons for absenteeism, and does not disproportionately disadvantage girls over boys in regards to absenteeism.
Menstruation is not one of the main reasons for absenteeism, and does not disproportionately disadvantage girls over boys in regards to absenteeism. Tweet This Quote
In Nepal, an RCT (Randomized Controlled Trial)4 found no effect of the use of menstrual cups on absenteeism amongst girls who used the menstrual cups regularly during their periods. Girls in the study were randomly allocated a menstrual cup for use during their monthly period and were followed for fifteen months to measure the effects of having modern sanitary products on schooling. The study found that, while girls were three percentage points less likely to attend school on days of their period, there was no significant effect of being allocated a menstrual cup on school attendance.
There were also no effects on test scores, self-reported measures of self-esteem or gynecological health. They conclude that these results suggest that policy claims that barriers to girls’ schooling and activities during menstrual periods due to lack of modern sanitary protection may not be warranted. We need to be really cautious with the finding, as what Oster and Thornton appear to have been testing is impact of better menstruation technology on school performance, not whether access to any menstruation management product improves school performance (98 percent of all the girls in the study were already using some form of menstrual management).
Girls deserve access to menstrual hygiene information and products as a human right. Tweet This Quote
So, even with a better way to manage their periods, girls are not attending more. This supports the findings from Zambia and Kenya above that girls miss school for a number of different reasons that are generally more important than menstruation.
The best evidence comes from a recent systematic review on menstrual hygiene management by Sumpter and Torondel.5 Not only did they highlight a plethora of methodological problems with the studies that they reviewed, but after looking at the 11 studies that were investigating the relationship between menstrual hygiene products and psychosocial outcomes including education, they concluded that “there was no quantitative evidence that improvements in [menstrual] management methods reduce school absenteeism.”
The reasons why girls miss school and drop out of school are complex, and require multi-pronged contextual solutions underpinned by robust evidence. Tweet This Quote
I want to finish by stating that I absolutely think that girls deserve access to menstrual hygiene information and products as a human right. But, if you are looking for a silver bullet that will reduce absenteeism, keep girls in school longer and lead to better schooling outcomes, the current state of the evidence suggests that menstrual pads are not that bullet.
In fact, it is unlikely that a silver bullet exists at all. The reasons why girls miss school and drop out of school are complex, and require multi-pronged contextual solutions underpinned by robust evidence. I suggest that in an environment of scare resources, and lots of competing claims for these resources, investors need to demand better evidence, and social impact ventures need to do more to supply this. I’ll be looking forward to reading more about the impact of MHM products on schooling outcomes from those companies who are committed to exploring this issue through robust research and evaluation.
1 Unpublished data. For more information on study see: http://www.popcouncil.org/research/adolescent-girls-empowerment-program
2 Unpublished data. For more information see: http://www.popcouncil.org/research/building-an-evidence-base-to-delay-marriage-in-sub-saharan-africa
3 Monica Grant, Cynthia Lloyd and Barbara Mensch. “Menstruation and School Absenteeism: Evidence from Rural Malawi”. Comparative Education Review. Vol. 57, No. 2 (May 2013), pp. 260-284
4 Oster, E and Thornton, T. Menstruation and Education in Nepal NBER Working Paper No. 14853, April 2009.
5 Sumpter C, Torondel B (2013) A Systematic Review of the Health and Social Effects of Menstrual Hygiene Management. PLoS ONE 8(4): e62004. doi:10.1371/journal.pone.0062004
Last updated: August 10, 2015