Menstrual Hygiene Management and Women’s Economic Empowerment

Women and girls all over the world experience challenges in managing their periods, especially those who live and work in environments that do not support adequate menstrual hygiene management (MHM). Adequate MHM is defined by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and leading scholars as occurring when women and girls have: (i) awareness, information, and self-confidence regarding menstrual hygiene; (ii) access to safe, hygienic, and absorbent materials or products and supplies; (iii) access to safe and clean facilities that are equipped with water and soap to bathe oneself and clean or dispose of materials; and (iv) a supporting environment that allows women and girls to manage their periods without fear of stigma or embarrassment (Patkar, 2011; Sommer & Caruso, 2015; Sommer, Chandraratna, Cavill, Mahon, & Phillips-Howard, 2016; WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation, 2015). To date, MHM research has focused predominately on school-age girls (Phillips-Howard et al., 2016; Sommer, Figueroa, Kwauk, Jones, & Fyles, 2017; van Eijk et al., 2016) and on displaced populations (Schmitt et al., 2017; Sommer, Schmitt, Clatworthy, Bramucci, Wheeler, & Ratnayake, 2016; VanLeeuwen & Torondel, 2018b, 2018a) with much less attention on women and their experiences in the workplace. Yet the challenges experienced by working women may have critical implications for their health and general well-being, as well as for economic outcomes such as work attendance, performance, earnings, and advancement.

To better understand the experiences of working women globally, USAID’s Water, Sanitation, and Hygiene Partnerships and Learning for Sustainability (WASHPaLS) project conducted a review of the limited evidence on the adequacy of MHM in the workplace to identify the cost-effectiveness, sustainability, and scalability of approaches to improve conditions. This report presents the findings of the review and describes some of the challenges experienced by working women and provides guidance for future investments. Findings and recommendations are drawn from three complementary lines of inquiry: (i) a systematic review of the peer-reviewed literature; (ii) a comprehensive search of the gray literature; and (iii) key informant interviews with experts in the areas of MHM, gender, and water, sanitation, and hygiene. Interviewing working women was beyond the scope of this desk-based review. The systematic review identified 11 relevant articles (plus one additional article published after the search was completed). The review of gray literature led to the inclusion of 55 documents, and the team interviewed 20 key informants representing international donors, non-profit organizations, and academia.

Observational studies, principally of working women in low- and middle-income countries (LMICs), found that women working in the formal and informal sectors experienced significant challenges in managing their periods, with the situation exacerbated by employment in certain occupations, such as construction and domestic work (Rajaraman, Travasso, & Heymann, 2013). Conditions in formal
workplaces may be better than those in informal settings like marketplaces (Rajaraman et al., 2013; Speak Up Africa, 2017); however, women working in factories or offices continue to face significant challenges and barriers to adequate MHM such as toilets that may be of mixed gender, unclean, or unsafe; lack access to water; or be generally unsuitable for managing menstruation (Speak Up Africa, 2017; Taylor, 2011). These studies also examined the relationship between menstruation and absenteeism, finding higher absenteeism among menstruating women in Senegal (Speak Up Africa, 2017) and more robust, causal evidence attributing absenteeism to menstruation (or poor MHM) from four economic studies in Burkina Faso, Italy, and the United States (Herrmann & Rockoff, 2013; Ichino & Moretti, 2009; Krenz & Strulik, 2018; Rockoff & Herrmann, 2010).

The review identified very few interventions or programs that focused specifically on workplace MHM and even fewer that were evaluated. One such intervention, menstrual leave legislation, accommodates the needs of menstruating women; however, providing women paid leave does not entirely address their sanitation or hygiene needs, the social norms relating to menstruation, or the menstruation-related
stigma that women experience in the workplace. Another example of a workplace MHM intervention comes from the HERproject, implemented by Business for Social Responsibility. The HERproject consists of a package of interventions that includes MHM education and the provision of subsidized sanitary pads to factory workers within the context of a broader health program (Yeager, 2011). An evaluation of the HERproject identified quantifiable reductions in absenteeism and staff turnover relating to improved MHM, leading to returns on investment of 4:1 in Egypt and 3:1 in Bangladesh (BSR, 2010; Yeager, 2011). Qualitative evidence also suggests improvements in worker-supervisor relationships, increased knowledge of MHM, and greater sense of agency due to increased knowledge about MHM and other health topics (BSR, 2010; Yeager, 2011). Other ongoing programs such as SNV’s Working with Women II and Gap Inc.’s Personal Advancement and Career Enhancement Program, implemented as part of the Women + Water Global Development Alliance, may offer similar insights in the future. Additional documents identified in the review include manuals from organizations such as CARE Canada that provided guidance (rather than mandatory policies) on meeting the MHM needs of women in the

The link between poor MHM and economic outcomes for women is plausible given the economic impacts of poor sanitation and preliminary evidence noted above. However, there is a need for greater evidence on the poor MHM conditions experienced by women in both informal and formal workplaces and how these conditions may affect women’s working experiences and economic outcomes. To date, only evaluation data from the HERproject and economic studies (principally in developed countries) establish the link between improved MHM and better economic outcomes for women (Herrmann & Rockoff, 2013; Ichino & Moretti, 2009; Krenz & Strulik, 2018; Rockoff & Herrmann, 2010), with minimal evidence regarding women’s economic empowerment. More research, using both qualitative and quantitative methods and employing longer-term studies, is also needed to further validate the effects of inadequate MHM on women’s health and, relatedly, on their economic empowerment (Geertz, Iyer, Kasen, Mazzola, & Peterson, 2016).

A conceptual model illustrates the impacts of inadequate MHM on women and businesses. Additional research, guided by the priorities noted in this report, is needed to establish the relationship more robustly between MHM and women’s economic empowerment in LMICs.

The team’s recommendations for future interventions include:

• Gather more information on the menstrual experiences of working women (e.g., what are their needs, how do they manage their periods, and what are the limitations they experience?).
• Evaluate interventions in both formal and informal work settings.
• Integrate MHM programming with sexual and reproductive health initiatives.
• Shift focus from hardware interventions that target toilets, facilities, and MHM products to those that address social norms and workplace culture relating to menstruation.
• Generate more data through use of MHM-specific indicators.
• Increase government attention and investment in MHM research and programming

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