In A Pandemic Year, Menstrual Health In India Was Forced To Take A Back Seat

On March 25, 2020, with COVID-19 cases on the rise around the world, the government of India announced its first lockdown. ‘Lockdown 1.0’ effectively barred any movement within and from outside India’s borders. Various sectors – right from the unorganised workforce to small-scale and large-scale industries/services – came to a standstill, resulting in some obvious, yet largely unaccounted for, repercussions.

Among such repercussions was the serious lack of accounting for the menstrual health and hygiene of a population of more than 366 million Indians. It should be noted that the number cited is exclusive of the population of menstruating individuals who do not identify as women, but as gender non-binary and trans folks.

In many ways, the pandemic has laid bare the systemic gaps and social prejudices that exist in India. This is particularly true for the heavily hushed subject of menstruation. The climate associated with it has made it challenging to effectively deal with the interconnections of menstrual health and the daily livelihood of menstruating individuals.

In this article, we explore the ripple effects caused by the lacuna in menstrual policies and programmes specifically related to the implementation of emergency interventions in India.

Disrupted Product Supply Chain

“Because of the sudden lockdown, I didn’t have time to buy anything. For a month, the anganwadi didi gave us pads, but after that, I had to switch to using a cloth. I also do not have a toilet at home and use the community toilet. Due to the virus, I am afraid to use it,” said Rekha*, a 30-year-old woman from Madhya Pradesh, sharing the effect the lockdown had on her menstrual experience.

According to statistics, nearly half of India’s population does not have a toilet at home. While there has been an increase in toilet construction, as part of the Swachh Bharat Mission, most of these toilets go unused.

The infrastructure within which a menstruator is situated and their lifestyle, has a major influence over the period product they use. It is clear that the unhygienic condition of the community toilet had influenced Rekha’s decision in choosing disposable napkins. Evaluating the mechanics of washing and drying a cloth which is used to absorb blood in an area that is frequented and prone to infections is a reality for every woman in the same circumstance as Rekha.

In response to COVID-19, the government issued a directive listing essentials that needed to continue production to sustain distribution during the lockdown. This list did not include menstrual products, leading to most manufacturing units, especially sanitary napkin industries, shutting down production. After public outcry, the government clarified that sanitary napkins and other menstrual hygiene products are essential products. However, India continues to face a sanitary napkin crisis.

Other than private manufacturers, schemes like the Menstrual Hygiene Scheme (Ministry of Health and Family Welfare), under which rural adolescent girls, between the ages of 10 to 19, can access sanitary pads at a subsidised rate of Re 1, continue to stand uninterrupted. However, there are no records of the availability of these pads during the lockdown.

Under the Kishori Shakti Yojna (Ministry of Women and Child Development), government schools are also made a critical part of the supply chain for schoolgirls. Girls in the age group of 11 to 18 can exercise this scheme. But as government schools remain shut during the lockdown, millions of young girls are left feeling anxious. “Several government school teachers have said that they have been receiving distress calls from their students,” reads a Hindustan Times article.

It is important to note that the schemes mentioned above are decentralised and extend to all states within India, however, some state governments have yet to put these schemes to effect.

Added to this, the most trusted distributor in the chain, the ASHA workers, were also severely hit by a shortage in the supply of napkins during the lockdown. “I have distributed whatever pads I had at my centre (anganwadi) to women and girls in my community. But I really don’t know how they will manage in the coming days,” an ASHA worker told Boondh.

Although government schemes exist, they do so with gaps and lack adaptability to emergencies and proactive circumstantial planning, a shortfall that painfully impacts menstrual experience and overall health of millions. Stakeholders, policymakers, executives of the government machinery must comply at least with the basic minimum of WASH needs.

According to SPHERE Standards, a movement started by humanitarian professionals who seek to improve the quality of humanitarian interventions, especially during emergencies and disasters, WASH policies need to have a three-fold approach. The document that references COVID-specific WASH action states:

“… there are three important overarching factors: Firstly, people should be seen as human beings, not just cases. Human dignity is paramount. Secondly, community engagement is crucial. And thirdly, focusing on preventing the spread of the Coronavirus should not make us forget affected people’s other needs, nor the long-term needs of the wider population.”

Inaccessibility To Menstrual Healthcare And Emergencies

“I have been bleeding irregularly for three months now. The gynaecologist near me still hasn’t opened up her clinic. I was also supposed to get an ultrasound done, but I do not know what to do. I can’t go to the lab,” said Sapna, a 25-year-old woman from Madhya Pradesh.

Menstruators who live with disorders like Premenstrual dysphoric disorder (PMDD), Amenorrhea, Polycystic ovary syndrome
(PCOS) etc struggled with access to healthcare as most private clinics remain shut. The absence of PPE kits and the inability to abide by social distancing measures at small clinics makes accessing medical services all the more challenging. While these dilemmas are faced by big private hospital chains as well, some hospitals continue to accept admission but restrict it to COVID-19 patients. This left non COVID-19 patients and people with other medical emergencies mostly stranded with a thin silver lining: online consultations.

Teleconsultations in India saw a 500% spike during the lockdown period with over 80% being first time users. It is also interesting to note that one in three consultations that were referred to were gynaecology related, and period concerns were one of the top queries. As an Indian Express article stated, “Unanticipated irregularity in periods” and “how expectant mothers can have a safe pregnancy” were two of the most common health issues raised online. Other top queries included “period problems, pregnancy complications during coronavirus, birth control techniques, and miscarriage.”

However, this option has its own drawback.

“I wanted to see a gynaecologist for abrupt bleeding changes. I instead saw closed shutters with a notice stuck on it which read, ‘In light of the current pandemic, the doctor won’t be seeing any patients until further notice’. I had to find a doctor virtually. This wasn’t very fruitful because the medicines prescribed were not available in the nearby medical store and weren’t getting delivered as well,” said Lenna*, a 22-year-old gender studies student from Dwarka, Delhi, who lives with PCOD.

The major drawbacks of online consultations is affordability and accessibility. Practo, the teleconsultation service platform that has been growing “at an average of over 100% week-on-week”, is a platform that is based in English, and charges a minimum Rs 100.

While this might seem reasonable to some, a large section of our country relies on government welfare schemes and services as they cannot pay such fees for consultations.

Invisibilisation Of Marginalised Communities

The narrative around menstruation has largely been dominated by cis-able-bodied women. It is important to be critical of homogenising menstruation. Especially during a time of emergency or severe distress, it becomes all the more important to take a more community/individual specific approach when it comes to policy measures.

Abha*, who comes from Ahirwar, a small district in Chhattisgarh, told Boondh that there were organisations who did distribute pads as a part of their relief measure, but their community was overlooked as they belong to a lower caste. To be able to obtain some pads for her 15-year-old daughter, Abha moved to a nearby community where her caste was not a deterrent.

This is one instance where casteist prejudice affects accessibility to not only the product but also menstrual health by extension.

One section of our society that is absent from any of the governmental menstrual policies is the trans community. The transgender community, including trans women, trans men, non-binary, gender non-conforming persons and others whose socio-cultural identities remain in the sidelines.

“Lobo noticed a drop in her earnings as the number of women travelling by local trains began to reduce for a week before the lockdown. But she could rely on the vegetable vendors in Dadar to provide her with free groceries. ‘But now I can’t go there or if I do, the police would chase us away,’ says Lobo, who stays alone in a rented room in a slum area in Bandra (West),” reads an anecdote from an article in The Hindu.

Although the government has included disposable pads to the essential commodities list, for a major part of the Bahujan community and trans community, menstrual products still remain a luxury. Interventions by civil society and crowdsourcing are the only support that reaches the community.

Gaps In The Approach To Menstrual Policies

Menstruation, in the popular discourse, is instantly linked to products, especially sanitary napkins. This is a deeply flawed approach and adopting it into policy making severely restricts the scope of socio-cultural and scientific interventions in this space.

The biggest misconception that is reflected in the polices is the generalisation of the demographic which menstruates, thereby losing out on the needs of diverse menstruators.

This is problematic because menstruation is a very personal experience and each person has a different relationship with their menstrual experience. How one navigates this must be facilitated by policies, and not hindered by them. If we push products, for example, non-biodegradable sanitary napkins, to varied demographics without studying a particular socio-economic status or the infrastructure within which they are located, it would be a disservice to that population.

While studying these demographics, it is important to not go in with broad stroke assumptions as well. During a study conducted to find out why women refrain from using menstrual cups, it was found that rural women were more interested in understanding it and trying it out while women in urban setups worried “about the discomfiture cups or tampons might cause because they involve vaginal insertion”.

Apart from this, one cannot completely write off the mental blocks that have been facilitated by our culture. Policy interventions that do not address an issue at its root do not address the issue at all.

The ‘sanitary napkin’ crisis is not necessarily a menstrual crisis. But again, this largely depends on how innovatively the government can turn this into an opportunity to introduce more sustainable and cheaper options like cloth pads, menstrual cups, or even period panties. Period panties at subsidised rates – just imagine!

Another key issue about interventions is the lack of concerted action. The improvement of menstrual health directly contributes to sexual and reproductive health as well, and unless there is a direct body accountable for the development in this area, the cascading effects (disease, gender-based violence etc) of ill development will continue.

To put it plainly, the redressal for issues that concern menstrual health and hygiene must come from a single body or a group of stakeholders who can be held accountable for different aspects based on their definitive roles and responsibilities. Currently, funds that address MHH in India are dispersed to multiple larger ministries like the Ministry of Health and Family Welfare, Ministry of Women and Child Development, Ministry of Human Resource Development, Ministry of Drinking Water and Sanitation, and the Ministry for Textiles. Therefore, the subject of menstruation is at the receiving end of a lot of ambiguity, ill-guided responses, initiatives, and reactions.

Lastly, setting up state and district level guidelines on menstrual health and hygiene would be the best alternative to carrying out schemes/guidelines advised by the Centre. A decentralised approach will naturally allow for more socio-culturally and socioeconomically informed decision-making. The research backed guidelines will also provide a concentrated and detailed database that can be used as a reference for larger studies that aim to look at patterns for improved state and national-level interventions.

*Names have been changed for privacy

With inputs from Sakshi Shrivastava, Naina Ojha and Bharti Kannan

This article was first published here.