A Missed Opportunity: Prioritizing the Development of a Healthy Market Ecosystem for Equitable Menstrual Health Within the International Conference on Population and Development Programme of Action

MENSTRUAL HEALTH: A MISSING LINK TO ACCELERATE THE INTERNATIONAL CONFERENCE ON POPULATION AND DEVELOPMENT PROGRAMME OF ACTION

In 1994, the International Conference on Population and Development (ICPD) placed sexual and reproductive health and rights (SRHR) at the forefront of the global agenda. From Cairo, 179 governments pledged support for the bold Programme of Action, calling upon the global community to accelerate efforts to support family planning (FP) and maternal health and to recognize the innate linkages between women’s reproductive health (RH) and economic empowerment and participation.¹ In the years since, the ICPD Programme of Action has seen various iterations, adaptations, and new calls to action as new evidence emerges, demographic trends shift, efforts stall, and new sociopolitical trends take center stage. Despite new commitments made under its many iterations—the original 1994 Programme of Action, 20th Anniversary Edition, and the Nairobi Summit commitments from 2019— an important commitment that is intricately linked with outcomes related to SRHR, education, and women’s economic participation and gender equity has always been absent: menstrual health (Box 1).^2–5

Yet, menstrual health, in its comprehensive definition for policy and practice, plays a critical role in delivering on the bold ICPD Programme of Action.⁵ Sidelined by pervasive stigma and taboo and coupled with a lack of data, menstrual health was long siloed away from broader sexual and reproductive health (SRH) and gender equity. Only in the last 15 years has menstrual health started to receive global attention as a catalyst for RH, education, economic, and gender equity outcomes, following incredible efforts by passionate advocates across the globe and catalytic funding and research.⁵ During the 2019 Nairobi Summit on ICPD25, several global advocacy organizations, including The Case for Her and WASH United, pushed for menstrual health’s inclusion in the renewed ICPD commitments, and there were a few isolated examples of country governments adopting menstrual health commitments (e.g., South Africa).^6,7 Now, it’s time for menstrual health to have a place in the official ICPD Programme of Action as we look ahead to the next 30 years. Activists, advocates, and leaders from the Global South have been instrumental in the progress to date and will continue to be important in leading the charge.⁸

While quantitative data around menstrual health access and linkages to gender equity, economic advancement, education, and health outcomes is still limited—in large part due to the lack of investment in data generation—there is a growing body of qualitative evidence from the Global South that documents the status of poor menstrual health and alludes to these linkages.^9,10 There are also efforts to generate good quality quantitative data to understand these linkages further.¹¹ First and foremost, menstrual health access is an issue of gender equity, dignity, and human rights for those who menstruate. Throughout this article, we use the term “those who menstruate” instead of women and girls to emphasize the important intersection of gender and recognize the complexities of gender identity with menstruation.

Approximately 26% of the global population are women of reproductive age. Every day, an estimated 300 million of these women are menstruating.¹² Lack of information, products, services, and facilities for the management of menstruation and related issues contribute to reduced participation at school and work, poor RH outcomes, and increased risk of gender-based violence (GBV).

Globally, 100 million girls of high school age are out of school.¹³ In 2018, global women’s labor force participation at 48.5% was still 26.5 percentage points below their male counterparts.¹⁴ The proportion of adolescent girls and young women who are not in education, employment, or training is twice as high for female youth compared to males in low- and middle-income countries (LMICs).¹⁵ Access to safe, affordable, and quality menstrual products when needed, water and sanitation facilities, knowledge of pain management strategies, and a supportive ecosystem are needed to ensure engagement at school and workplaces. These gaps lead to distraction, disengagement, and absenteeism from school and work for those who menstruate.^16,17 In low-income contexts, where education and economic participation for girls and women is not a priority, this sets the stage for school dropouts and skewed labor force participation.¹⁸

Menstruation also marks the beginning of the reproductive cycle, inextricably linking menstrual health to broader SRH outcomes. Menstrual health conversations can improve health-seeking behaviors and symptomatic identification of reproductive tract and sexually transmitted infections, menstrual disorders (endometriosis, fibroids, and cysts), identification pipeline for cervical cancer, and appropriate and continued use of cycle-based and hormonal contraceptive methods. Menstrual health awareness can also be used to strengthen self-care for maternal health, including managing postnatal bleeding, expected changes in the menstrual cycle, and symptomatic identification of infections and managing perimenopause and menopause, including preventing and managing cardiovascular, musculoskeletal, mental, and noncommunicable disease health issues.^19,20

Thirty-five percent of women globally experience GBV, and 200 million women have experienced female genital mutilation.²¹ Stigmatization of menstruation is associated with and cumulatively leads to the lack of psychosocial agency over hygiene and reproductive practices of those who menstruate and also has far-reaching impacts on factors like age of marriage and first childbirth.²² Cumulatively, this lack of agency, starting with prepubertal gender norms, increases the vulnerability of those who menstruate over the reproductive life course. The stigma and silence around menstruation lend themselves to poor body literacy and loss of psychosocial agency, which, in contexts where harmful practices like female genital mutilation and other forms of GBV are prevalent, can make those who menstruate more vulnerable to these practices.^22–24 Addressing gaps in access to information, products, services, and facilities for menstrual health is a critical step toward addressing these cross-sectoral outcomes.

While those working in the field of menstrual health are starting to take note of these linkages, practical approaches for achieving these outcomes are still extremely limited.^19,20,25 An underexplored pathway for influencing these intersections is the development of a healthy and well-functioning market for menstrual health products and services. Such a market keeps those who menstruate as the focus and aims to offer choice and agency in information, products, and services through the democracy of the market.

A PATHWAY FORWARD FOR MENSTRUAL HEALTH THROUGH A HEALTHY MARKET ECOSYSTEM

A healthy market for menstrual health products, services, and facilities can ensure that those who menstruate have (1) access to unbiased and comprehensive information about them; (2) proximal availability to them as part of a supportive ecosystem; and (3) psychosocial agency to negotiate for and access them when needed, across their reproductive life course for the management of menstrual bleeding, pain, disorders, and other issues (Box 2).

Accelerating access to menstrual health for influencing cross-sectoral outcomes will require dedicated investment and coordinated efforts across sectors to address systemic barriers to the development of these markets. The emphasis on leveraging market-based approaches to realize the bold ambition of the ICPD Programme of Action and expand the quality and range of RH services is also well-established. In fact, the ICPD Programme of Action highlights the important role of market-based approaches in ensuring the realization of the reproductive rights and RH agenda, highlighting the important opportunity to engage the private sector, develop cost-recovery strategies, and leverage the market to improve accessibility.² To develop a healthy market ecosystem for menstrual health, the following different investment areas should be explored.

CALLING ON THE GLOBAL COMMUNITY TO PRIORITIZE MENSTRUAL HEALTH

Now that the global community has celebrated 30 years of ICPD, it is time to ensure that menstrual health is not only included in the ICPD agenda but also prioritized and funded. To achieve the ICPD Programme of Action, menstrual health is a necessary ingredient and a prerequisite for achieving gender equity, educational advancement, economic empowerment, SRHR and eliminating GBV, discrimination, and bias. By investing in the development of healthy markets for menstrual health, we will not only ensure that those who menstruate worldwide have access to the information, products, and services that they need to manage their menstruation but also ensure that that access remains equitable and sustainable. Let us not miss another opportunity to elevate menstrual health in the global agenda.