Period poverty in India: an analysis of the National Family Health Survey-5

INTRODUCTION

The World Health Organisation’s Partnership for Maternal, Newborn, & Child Health has defined period poverty as a “lack of knowledge of menstruation and an inability to access necessary sanitary materials” [1]. Difficulty caused by period poverty leads to absenteeism from school among girls and from work among women, and forces them to stay at home. This situation hinders their educational and economic opportunities [2]. Glo­bally, most menstruating women experience social, physical, and mental issues imposed by period poverty. Furthermore, menstruation has a social stigma and taboo associated with it. These make life of menstruating women even harder [2, 3]. The stigma, however, is global phenomena, but it is highly prevalent in low-middle income countries [2]. Poor water, sanitation, and hygiene facilities make the condition worse for menstruating females and schoolgirls [4, 5]. Period poverty is prevalent globally, and it affects mostly menstruating women from poor socio-economic conditions [6, 7]. Menstruation is, however, a natural phenomenon, experienced by most women in reproductive age. Women who cannot afford to buy products during their period time tend to use unhygienic products to manage menstruation [8]. This puts them at risk of developing reproductive and other related health problems. The purchase of period products creates an enormous economic burden on poor families [9]. Due to this, many menstruating women from poor families avoid buying period products and will prefer to use unhygienic products to manage menstruation.
India is a low-middle income country, which has a significant number of poor people living in rural areas [10], where limited access to healthcare facilities, inadequate sanitation, lack of awareness, poverty, and poor health infrastructure are prominent [11]. However, caste affiliation in India has historically been a marker of one’s social status within a hierarchical social structure. The Indian caste system plays a significant role in determining a person’s socio-economic position [12]. In this system, historically marginalised groups such as the “untouchable” castes are classified as scheduled castes (SC), while indigenous groups are categorised as scheduled tribes (ST). Disadvantaged castes fall under the other backward classes (OBC) category, and the forward castes (FC), also known as unreserved (UR) or general (GEN) caste, represent the higher castes [12].
According to the Global Multidimensional Poverty Index, 5 out of every 6 multidimensionally poor indivi­duals in India belong to SC, ST, or OBC households [13]. Another study highlights that SC and ST groups have higher mortality rates compared to higher castes [14]. Additio­nally, scheduled castes and tribes are more likely to consume tobacco or alcohol compared to other castes, while lower castes are more prone to stunting or wasting [14].
Many studies suggest that women from disadvantaged populations, e.g. poor, scheduled tribes and schedule castes, living in rural areas, Muslim, and illiterate, are significantly affected by period poverty [6, 7]. However, there are limited country level data on socioeconomic factors contributing to period poverty in menstruating women for policy change. To address this gap in the research, we aimed to study how socioeconomic factors are responsible for the poor management of menstruation in women who menstruate. Therefore, we aimed to use data of the Natio­nal Family and Health Survey (NFHS)-5 on menstruation to understand the socioeconomic factors associated with period poverty in India. We hope that this data will help in changing the policy of menstrual health protection in India, targeting the affected women, which will eventually ameliorate the condition of period poverty in India.

MATERIAL AND METHODS

STUDY DESIGN, SETTING, AND PARTICIPANTS

We used the secondary data collected from the National Family Health Survey-5 (NFHS-5). This survey was completed under the stewardship of the Ministry of Health and Family Welfare (MoHFW), Government of India. MoHFW designated the International Institute for Population Sciences (IIPS), Mumbai, India as the nodal agency for conducting the all the rounds of NFHS-5 from the period 2019-2021. The I.C.F. and U.S.A provided technical assistance to this survey through demographic and health surveys (DHS) Program. NFHS-5 was performed on a large scale across India, providing a representative sample of all Indian households. The survey was completed in 2 phases, from 17 June 2019 to 30 April 2021. The survey collected data from a total of 636,699 households, 724,115 women, and 101,839 men across all 36 states and union territories in India. NFHS-5 was intended to provide up-to-date and reliable information on population and health, nutrition, women’s anaemia status, family planning, women’s fertility behaviour based on birth interval, birth order, and age at marriage, maternal healthcare services, child immunisation services, nutritional status, breastfeeding practices, childhood morbidity, and mortality [15].
The United Nations defines period poverty as a lack of knowledge of menstruation hygiene and an inability to access necessary sanitary products [1]. However, for this study, use of cloth material instead of other sanitary products (sanitary napkins, locally prepared napkins, tampons, and menstrual cups) during menstruation was considered as an indicator of period poverty because no data on knowledge of menstrual hygiene management were available in NFHS-5 data. We analysed the data of 241,104 menstruating women/girls aged 15-25 years, who took part in the NFHS-5. The NFHS-5 collected data from women of all ages. However, it did not cover the menstruating information of all women in the reproductive age group. Consequently, the data of menstruating women aged < 15 years and > 26 years was not available for analysis and reporting.

SAMPLING AND DATA COLLECTION

Stratified 2-stage sampling was used in the NFHS-5. Strata were formed based on urban and rural areas. Each rural stratum was further sub-stratified based on population of scheduled castes and scheduled tribes (SC/ST). The sampling frame was obtained from the census of 2011 for the selection of Primary Stage Units (PSUs). In rural areas PSUs were villages, while in urban areas census enumeration blocks (CEBs) were taken as PSUs [15].

DATA EXTRACTION AND CODING

Data extraction was done from the website of the Demographic and Health Survey (DHS) program website (https://dhsprogram.com/Data/) [16]. Access to download the dataset was provided after a formal request by the study’s author. Data were extracted in .dta file format in Stata software (version 17) (Lakeway Drive, College Station, Texas, USA). Data analysis was done after carefully identifying the most appropriate variables from the dataset. Data extraction and data analysis was completed from March to April 2024.

STATISTICAL ANALYSIS

Continuous variables were reported as mean ± SD, and categorical variable were reported as number, percentage, and 95% confidence interval (95% CI). Prevalence was reported as number, percentage, 95% CI, and standard error. There were 2 outcomes viz. the use of hygienic methods and the use of cloth material during menstrual cycle. Bivariate logistic regression analysis was used to find the factors significantly associated with the outcomes. Multivariable logistic regression analysis was also performed to obtain the adjusted odds ratio to control the effect of background characteristics of respondents, i.e. age, residence, schooling, religion, caste/tribe, and wealth quintile. Results of logistic regression analysis were reported as odds ratio (95% CI) and p-value. The cut-off for statistical significance was p < 0.05. Stata (version 17) (Lakeway Drive, College Station, Texas, USA) was used for statistical analysis.

RESULTS

CHARACTERISTICS OF THE STUDY PARTICIPANTS

We included the data of 241,104 menstruating women aged 15-25 years in the analysis. The mean (SD) age of these women was 19.4 (2.9) years. The majority (77.4%) of study participants were from rural areas, and only 32.1% of them had completed their education beyond intermediate level. About 75.2% study participants were Hindu. Most participants belonged to OBCs (39.0%) and a significant proportion (67.1%) were either from the middle or lowest wealth quintiles. Period poverty was present in 125,107 (51.9%) study participants (Table 1).

DEMOGRAPHIC PREVALENCE OF PERIOD POVERTY

States in central India, North India, and the Northeast region exhibited a significant prevalence of period poverty, while the utilisation of hygienic methods was more prominent in southern India (Figure 1). The highest prevalence of period poverty was observed in Uttar Pradesh (71.4%), followed by Bihar (69.0%), Assam (68.9%), Chhattisgarh (68.9%), Manipur (68.0%), Madhya Pradesh (67.7%), and Meghalaya (66.0%). In contrast, the Andaman and Nicobar Islands (8.5%), Chandigarh (10.5%), and Tamil Nadu (11.8%) displayed a lower prevalence of period poverty (Figure 2).

FACTORS ASSOCIATED WITH PERIOD POVERTY AND HYGIENIC METHOD

Multivariable logistic regression analysis revealed that for menstruating women aged 20-25 years, with AOR [95% CI, p-value] = 1.25 [(1.23-1.27), < 0.001], those from rural areas 1.56 [(1.52-1.60), < 0.001], illite­rate women 3.33 [(3.18-3.48), < 0.001], Muslim women 1.14 [(0.85-1.53), 0.381], from other backward classes 1.23 [(1.20-1.27), < 0.001], and from the lowest wealth quintile 5.27 [(5.08-5.47), < 0.001] had higher odds of facing period poverty during their menstruation (Table 2). In contrast, women in the 15-19 year age group with an AOR of 1.22 [(1.20-1.25), < 0.001]; those from urban areas had 1.48 [(1.44-1.53), < 0.001]; those who had completed 12 or more years of schooling 5.49 [(5.26-5.72), < 0.001], those from other religions 2.44 [(2.20-2.70), < 0.001], belonging to unreserved caste 1.29 [(1.24-1.35), < 0.001], and from highest wealth quintile 7.00 [(6.61-7.40), < 0.001] had higher odds of using more hygienic methods during menstruation (Table 3).

DISCUSSION

This study highlights a clear social gradient in the use of hygienic methods and cloth material during menstruation among Indian women, revealing significant disparities between women across different socioeconomic and sociocultural groups. Menstruating women living in urban areas, rich, educated, and belonging to high castes or Sikh communities have better access to hygienic menstrual methods compared to those in rural areas, illiterate, poor, or those belonging to scheduled tribes and Muslim communities. These inequalities reveal a broader trend of socioeconomic and health inequality in India, where factors like caste, religion, wealth, and education determine access to essential health services. However, attributing period poverty solely to a lack of resources, knowledge, or power oversimplifies the issue. Cultural practices, regional disparities, and structural issues such as poor menstrual health knowledge, poverty, unemployment, inflation, illiteracy, and inaccessibility of clean drinking water and sanitation facilities also play significant roles in limiting access to menstrual hygiene products.
Period poverty is a multifaceted issue, shaped by both socioeconomic and sociocultural factors. In countries like India, period poverty is largely driven by socioeconomic disparities, including low income, limited education, inadequate access to sanitary products and facilities, and rural-urban divide [17]. A similar pattern has been observed in our study.
In contrast, in higher-income countries like the United States, period poverty is primarily a socioeconomic issue, affecting low-income and homeless populations in large urban areas [2, 18]. Although the problem is more commonly associated with lower-income nations, it also persists in wealthier countries, impacting marginalised communities [19]. However, in countries like India and Nepal, period poverty is not solely an economic issue; it is compounded by deeply entrenched sociocultural practices such as “period exile” or menstrual seclusion, where menstruating women are isolated due to cultural taboos [20-22]. These women face a “double burden” of both socioeconomic hardship and sociocultural discrimination, making their experience of period poverty more severe and complex. Thus, while period poverty exists globally, the intersection of socioeconomic and sociocultural factors makes it a more pervasive and layered issue in low-income countries.
The regional disparity in menstrual hygiene practices is also evident in our study. States like Uttar Pradesh and Bihar showed a higher prevalence of period poverty compared to regions like the Andaman and Nicobar Islands and Tamil Nadu. This geographic divide mirrors broader patterns of multi-dimensional poverty in these states [23]. Multidimensional poverty, which encompasses more than just income, includes a range of deprivations such as poor health, malnutrition, lack of access to clean water or electricity, and limited educational opportunities [23]. Moreover, these states with higher levels of multidimensional poverty are also lagging behind in achieving the targeted 17 sustainable development goals (SDGs) at national level in India [24, 25]. Of all 17 SDGs, goal 1 (no poverty), goal 2 (good health, and well-being), and goal 6 (drinking water and sanitation) are directly related to menstrual health factors, such as access to sanitary products, clean water, and adequate sanitation, that are crucial for managing menstruation safely and hygienically, and the failure of Indian states to meet these SDG targets exacerbates the issue of period poverty and further entrenches health and social inequalities for women living in these regions [24, 25].
Logistic regression analysis suggests that comparatively the women aged 20-25 years had 1.25-fold higher odds of using cloth material, possibly due to the fact that many in this age group have completed or discontinued their education, are married, or have taken on greater economic and familial responsibilities [6, 7, 26]. These factors may limit their ability to access or afford menstrual hygiene products, contributing to period poverty. We also noticed that rural women faced more period poverty. This could be due to their inability to buy period products and/or the scarcity of period product in rural areas. A similar pattern has been documented in many studies [6, 7, 27, 28]. We also observed an association between illiteracy among women and period poverty. It is a well-known fact that illiterate women may not be as aware about menstrual hygiene as educated women. Education plays a critical role. Evidence suggests that illiterate women face the problem of period poverty [6, 7].
As is evident from our study, religion, caste, and wealth also play a significant role in menstrual hygiene management. Our study observed the major issue of period poverty among Muslim women. This may be due to challenges related to the affordability, availability, and accessibility of period products by Muslim women. Lower socio-economic status probably contributes to these difficulties. One study suggests that Muslim women are disproportionately affected by period poverty, largely due to their disadvantaged socio-economic conditions [7]. Caste-based social hierarchies, which have long been a source of discrimination and inequality in India, continue to shape access to resources, education, and health services. Women from lower castes and economically disadvantaged groups face multiple layers of marginalisation, making it more difficult for them to afford or access menstrual products [6, 7, 27, 28]. Our study also observed caste-wise gap, in which women belonging to the OBC category faced greater period poverty compared to high-caste women. Another major finding of this study is that women who were from the lowest wealth quintile had suffered significantly from period poverty. It is obvious that poor women cannot afford to buy period products because they have barely enough for sustenance. Studies have consistently shown that poor women are less likely to use hygienic menstrual products because they prioritise other basic needs such as food and shelter [6, 7, 26, 27]. This economic constraint is a major driver of period poverty, as poor women are forced to make difficult trade-offs between their health and other survival needs.
At the same time, the study points to a contrasting reality for women, who are wealthy, educated, residing in urban areas, and belong to higher caste by virtue of their birth, socioeconomic status, and access to resources, are better positioned to manage their menstrual hygiene. These groups of women are more likely to have better quality of life, improved menstrual health, and a stress-free menstrual period caused by less period poverty. They were also less likely to face absenteeism from work or school/college due to menstrual health issues, giving them greater economic and educational opportunities. They may not need much pressure or support to maintain their menstrual health because they are already at the forefront in doing so. Moreover, this socioeconomic disparity highlights the broader theme of health equity, defined by the World Health Organisation [29] as the absence of unfair and avoidable differences in health among different population groups.
The study has certain limitations: First, this study only captured information about the use of cloth mate­rial among women ≤ 25 years old, excluding older women who may also face significant menstrual health challenges, and no data was available about their knowledge on menstrual hygiene management. Hence, it does not give the true picture of period poverty faced by all menstruating women of India. Second, this study also does not give information on some of the contextual factors, e.g. environmental factors that may be causing period poverty in differently divided social groups in India. Third, the study does not provide details on the sociocultural factors related to period poverty. Nonetheless, period poverty has been found to be a big problem in this study, which needs attention from policy makers and those in governance. We strongly feel that we need more details on how mensuration and its management are influenced by diverse cultural and contextual factors in India. Future studies are warranted that could give a better and deeper understanding of period poverty.

CONCLUSIONS

Based on our study, menstruating women (20-25 years old), those from rural areas, belonging to the other backward class, Muslim community, and the lowest wealth quintile need most attention while devising policies for mitigating period poverty in India. India has already eliminated taxes on menstrual products to make it more accessible to marginalised populations, but there are more important yet neglected issues such as menstrual stigma and taboos, and insufficient menstrual education, unavailability of clean water and sanitation facilities at schools, workplaces, and public toilets, which have to be addressed to mitigate the problem of period poverty in India. In addition, proper disposal facilities of sanitary products should also be ensured.
National and international voluntary organisations should also play crucial roles in combating these issues related to period poverty in India. They should collaborate to ensure that menstrual products are available for free in public facilities, such as schools, workplaces, and public lavatories, which should be scaled up to improve access, especially for women and girls from marginalised communities in India. It is also crucial to promote menstrual health education through social media campaigns, public ads, and educational programs. Normalising discussions about menstruation and educating the community, regardless of gender, about the issue of period poverty will help in breaking stigmas and taboos. Healthcare workers should also be trained to address menstrual health issues sensitively to build trust with girls and women. Authorities need to ensure wash facilities, which includes adequate water sources, sanitation facilities, and menstrual waste management systems for the disposal of menstrual products. Providing private spaces where women can manage their menstruation with dignity is essential for improving their overall health and well-being, which will ensure their safety. Researchers should collect more data on the extent and impact of period poverty, including social, cultural, economic, and environmental factors. This information will help policymakers to design more effective interventions and raise awareness about the issue of period poverty, ultimately changing societal attitudes and perceptions towards menstrual practices and fostering long-term solutions.

ACKNOWLEDGEMENT

We are sincerely thankful to the Demographic and Health Survey (DHS) for sharing the data with us. We acknowledge the support of the scientific and technical staff of the ICMR – Regional Medical Research Centre, Gorakhpur, in the study.
This study uses a publicly available, de-identified dataset that contains no personally identifiable information about the survey participants. Therefore, no ethical approval was required. The NFHS-5 data used in this research is publicly accessible through the Demographic and Health Surveys (DHS) website at https://dhsprogram.com/data/available-datasets.cfm and can be accessed by submitting a formal request to the DHS.

DISCLOSURE

The authors report no conflict of interest.

References