Millions of girls and women avoid school and work while they are menstruating because of stigma and inadequate hygiene, yet too little research has been done to assess the effectiveness of programmes designed to address the problem, says an Oxford University study.

Programmes to support menstruating women vary wildly, with no comprehensive review of what works best or why. As a result, governments, international organisations and local charities may be investing funds and resources in programmes that could be more efficient, according to the paper published on Wednesday in the journal Plos One.

“Interventions such as the provision of sanitary products or education around puberty may be simple strategies that can increase girls’ attendance at school and reduce the stigma surrounding periods,” said senior author Paul Montgomery of Oxford University’s Centre for Evidence-Based Intervention. “Such programmes may be a cost-effective way to target gender inequalities, but we need proper evidence that can measure their effectiveness.”

If women and girls cannot manage their monthly cycles with ease and comfort, there can be major consequences: poor menstruation care is a significant barrier to development and gender equality, can induce shame and anxiety in women, and results in poor attendance at school and work.

Less than half of girls in lower- and middle-income countries have access to basics such as sanitary towels or tampons, soap and water, or facilities to change, clean or dispose of hygiene products, data shows, while nearly a quarter of girls in India drop out of school after they begin menstruating.

The cost of hygiene products – as well as access to toilets – are major barriers too, the study says.

Commercial absorbents such as sanitary napkins are often expensive and hard to find in many areas, forcing women to use inadequate – and sometimes dangerous – alternatives. In India, 70% of women can’t afford sanitary napkins, forcing many to use husk sand, unsanitised cloth or sand to trap the blood instead, resulting in extremely high rates of infection.



Open pit toilets and ones without doors or locks can make a girl feel threatened and indicate to others when she is menstruating, causing embarrassment.

Positive interventions can work: school attendance improved by 9% in Ghana after girls were provided with absorbents. But, to date, only eight such trials have been performed worldwide, and only three tested the value of providing sanitary products. Another issue, say authors, is that most research focuses on girls, not adult women, even though they are still affected.

“Women are expected to suffer in silence, and menstruation is not acknowledged in reports or development documents. What we need is a situation where all women and girls are able to manage their menstruation with comfort and dignity,” said the study’s lead author, Julie Hennegan.

• This article was amended on 11 February 2016 to clarify there could be major consequences if women were not able to manage their monthly cycles well.