Sexual, Reproductive Health Narrative In India: Will 2024 Turn Tables?

Anecdotal experiences in capacity building through Nari Adhikar Kendra, established by Transform Rural India (TRI), revealed poor standards of menstrual hygiene among adolescents and women, a lack of affordability and accessibility to materials, and unavailability of functional toilets within homes and in schools impacting menstrual health. Discussions in Tapal, Uttar Pradesh, exposed reproductive health issues: menstrual irregularities and uterine prolapse resulting from strenuous fieldwork, worsened by the lack of undergarments and safe menstrual hygiene practices. TRI, with a multi-dimensional approach to addressing deprivation and vulnerability, has developed a strategy for engaging in awareness building, impacting the system for access, and advocating to fill in policy gaps on the gender dimensions of reproductive health.

In India, discussions around sexual and reproductive health have been integral to family planning policies since the inception of the five-year plans. In the first five-year plans, the focus was on women as mothers and caregivers, leading to an emphasis on family planning and reproductive health. Furthermore, reproductive health has been central to all five-year plans, including programs for adolescent girls under women and child development. The National Rural Livelihood Mission (NRLM) flagship program involves nine crore women in self-help groups. Despite mobilization efforts, sexual and reproductive health remains taboo, with sparse discussions and adolescent awareness programs veiled in shame and secrecy.

Practices and beliefs related to menstruation

Menstruation is revered in certain regions like Assam and Kerala and celebrated in festivals such as Ambubachi Mela and Thripputhu Aaraatt in Chengannur Mahadev Kshetram. However, in many parts of India, it instils fear in adolescents due to notions of impurity. This fear restricts their access to nutritious diets, as there is a belief that certain foods may lead to hormonal changes and illicit relationships. Menstrual irregularities are a major health issue, with anaemia levels at 58.5% for women and 60% for adolescent girls, according to NFHS-5. Some women still tend to use clothing without sufficient hygiene practices, and often, the poorest women in rural areas do not have access to cotton and hygienic clothing."

Global practices around menstruation

Male surgeons documented menstruation pre-Christ, but their accounts exclude women's voices and non-binary menstruators. The Egyptians used wool fused with herbs as a pessary, or vaginal insertion, to control menstrual flow. The subject of menstruation remained a problematic topic in the Middle Ages under the powerful influence and growing power of the Church. Even Hinduism, Islam, and Judaism had taboos surrounding menstruation, and women were labelled unclean and impure and were bound by cultural rituals. Different cultures used various clothing, with the term 'on the rag' originating from cloth rags in medieval Europe. Women sought remedies for cramps, while those deviating from societal norms, especially in science and philosophy, were shunned and even prosecuted and publicly burnt as witches.

Since the Vedic Ages, Indian society confined women during menstruation, believing their touch to be contaminating. In 1850, Europeans started using sanitary aprons and belts, and the first pad was invented in 1888 but not sold until 1920. India produces 12.3 million disposable pads annually with inadequate menstrual waste management. Sanitary products end up in open landfills, posing threats to the environment and the health of healthcare workers (Blood Safia, August 4, 2020).

Menstrual leave and international provisions

Internationally, menstruation and issues surrounding it have been considered by a few countries that have developed policies around it. In March 2021, Spain became the first to legalize menstrual leave, allowing female workers four paid days annually for painful symptoms. Since 2003, Indonesia has granted two days of paid menstrual leave per month, though it's discretionary. Japan's law, dating back to 1947, allows companies to grant menstrual leave without mandatory pay. South Korea permits one unpaid menstrual leave day monthly, and in Taiwan, the Act of Gender Equality in Employment allocates three paid menstrual leave days per year for women.

Menstrual practices, access, and hygiene

Globally, 25% of women lack the resources to manage menstruation, posing acute challenges in low-income countries. In these regions, 61% lack access to menstrual products, and 55% of adolescent girls have limited knowledge before their first period. Poor sanitation conditions further exacerbate these gaps, with 1.8 billion women lacking access to adequate sanitation services, and over 1.1 billion lacking basic handwashing facilities at home. In low-income countries, an estimated 61% of women lack access to safe menstrual products, with figures of 42% in Sub-Saharan Africa and 48% in South Asia. Consequently, women and girls often use makeshift products like cloth, rags, or cotton wool.

The Draft National Menstrual Hygiene Policy, 2023, recognizes menstruation as a natural process, aligning with SDGs on health, education, gender equality, and sanitation. NFHS-5 reports a rise in hygienic protection use among women aged 15-24 from 58% to 78%. The policy emphasizes access, affordability, equity, and inclusivity for all menstruating individuals. Education focuses on raising awareness, while safe facilities aim to provide dignified menstrual hygiene management. To achieve this, clean, private, well-maintained toilets, washing facilities, and disposal systems are needed in schools, workplaces, public spaces, and communities.

An environmental sustainability perspective in menstrual hygiene helps develop eco-friendly products and proper disposal methods to minimize pollution. Collaboration with various departments ensures safe and hygienic menstruation practices.

The comprehensive policy should be implemented by bringing together various stakeholders, including agencies of regenerative development, CSOs, market players, and community-based organisations. This collaborative effort aims to destigmatize menstruation, dispel notions of pollution, and ensure that hygienic measures are accessible and available to all, irrespective of social and economic structures and disparities.

Authored by Seema Bhaskaran, Lead for Gender at Transform Rural India (TRI), a solution designer for regenerative development.