Improving menstrual hygiene in low-income settings requires more than just access to products—it demands tackling stigma and restrictive social norms that threaten women's health and economic opportunity.
Editor's note: This episode of VoxDevTalks is also available on Spotify, Apple Podcasts, and YouTube.
In this episode of VoxDevTalks, Silvia Castro and Kristina Czura discuss their research on menstrual health in Bangladesh. Together, they explore the intersection of economics, social norms, and gender inequality, with a specific focus on how stigma and limited access to hygienic menstrual products affect women’s education, health, and participation in the workforce.
Castro and Czura demonstrate that menstrual hygiene is not only a public health concern but also an economic one. Their work underscores how entrenched cultural taboos and inadequate access to information and products reduce women’s dignity, productivity, and opportunities for advancement.
Lack of hygienic menstrual practices threaten health, dignity and opportunity
Accurate data on menstrual health remains scarce, but the World Bank estimates that 500 million women worldwide lack access to adequate menstrual hygiene facilities - a lower bound approximation of the issue. In Bangladesh, despite the increasing availability of disposable sanitary pads, adoption remains low with only 29% of adolescent women using pads. The majority of women rely on repurposed cloth that is often unsuitable and potentially unhygienic.
“These materials are not designed for menstruation so they often have poor absorption capacity, they can leak easily, and they require careful cleaning and drying to remain hygienic.” Castro
This leads to a cascade of negative outcomes, including reproductive tract infections, missed school or work, and profound embarrassment.
“Girls bleed through their clothes while in class, and this is quite common. These incidents can cause shame, embarrassment, can lead to missed class time or even school dropout.” Castro
Social stigma and cultural taboos reinforce poor menstrual practices
Menstruation carries a weight of cultural stigma and misinformation in many societies, perpetuating harmful practices. Czura highlights that in many cultures, menstrual blood is perceived as “something dangerous or unclean” or even “a punishment for sins.” These ideas have real consequences, including the normalisation of suffering and avoidance of treatment for medical conditions such as anaemia.
Even when women know the correct hygiene practices, social norms often prevent them from acting accordingly. For instance, while 97% of women in one study understood that menstrual cloths should be washed with soap, very few did so publicly due to shame.
“Only 8-9% actually dry them outside… Those practices would be seen as shameful... considered as socially inappropriate.” Czura
Economic research on menstrual health as a labour market issue
While menstrual health research has traditionally belonged to public health and gender studies, economists are beginning to examine its implications for opportunity and inequality.
“It’s now becoming clearer that this is not just a health issue or a gender studies issue, it’s also an economic one. As economists, we’re starting to see that menstrual health is tightly linked to gender inequality in both schooling and the workplace.” Castro
Economists bring valuable tools to the table, such as rigorous impact evaluation and the ability to quantify outcomes such as productivity loss or school absenteeism.
“If a girl misses school every month or a woman avoids certain jobs because of inadequate sanitation or fear of stigma, that’s a constraint on human capital and productivity.” Castro
Information campaigns can shift norms—not all practices change
In their first study, Castro and Czura delivered hour-long group information sessions to artisan women in rural Bangladesh. These covered the biological basics of menstruation and practical hygiene techniques. The sessions led to a measurable shift in social norms:
“After the sessions, the belief that drying cloth outside is inappropriate dropped dramatically.” Castro
Crucially, some of these effects persisted for two years.
“Two years later, many women still report that it's socially appropriate to dry cloth in the sun outside, they also describe feeling less ashamed, and we observe an increase in self-reported hygienic practices.” Castro
However, the intervention had limits. Norms around cloth washing did not change significantly, likely because menstrual blood is still seen as impure.
“Changing social norms might require more than just facts. They might need a deeper cultural change.” Castro
Sanitary product access improves health, but not always productivity
In a second study conducted in Bangladeshi garment factories, researchers examined whether free sanitary pads and information sessions could improve menstrual practices and labour outcomes. Four groups were compared: information-only, product-only, both, and a control.
Providing free pads increased usage by 23%, and information sessions significantly improved how cloths were dried. However, there were no noticeable gains in earnings or reductions in absenteeism.
“We do find sizable effects on self-reported health... but we don’t find anything on absent days or earnings.” Czura
Several factors may explain this. The improvements in health may not have been large enough to shift labour outcomes, and the work environment—where wages are docked for missed days—may already limit discretionary absence. Nevertheless, as Czura states: “These improvements in female health are important on their own.”
Breaking the silence: Addressing the stigma of buying menstrual products
In another study, Castro explores the social cost of buying menstrual products, particularly from male shopkeepers.
“Menstruation is still treated as something shameful and private in most countries… Buying pads means admitting, oftentimes in public, that you are on your period.” Castro
The intervention involved women-only discussion groups that encouraged participants to share personal experiences. The results were compelling: women in the treatment group were willing to pay 25% more for sanitary pads and were 14% more likely to collect a new product - antibacterial menstrual underwear - from a male-run factory store.
“What changed was the social cost… The model answer flips to ‘it’s socially appropriate’.” Castro
The findings underscore that normalising menstruation in peer settings can reduce stigma and increase product adoption.
A growing global research agenda to inform policy and inclusion
Castro and Czura are expanding their work beyond Bangladesh. Collaborations with Oxfam are underway in humanitarian settings like the Central African Republic, Mali, and Somaliland, with further studies being conducted in Nepal to explore how stigma affects schoolchildren and their teachers.
“All projects are centred on understanding and breaking down barriers to menstrual health management.” Castro
Their hope is that such interdisciplinary research will continue to influence policy, particularly that on workplace inclusion and school retention. The challenge is urgent:
“This issue is invisible to many people, in particular those in power, who are still predominantly male.” Czura
To make a difference, the team is combining rigorous evidence with storytelling and partnerships.
“If we can combine that with academic research and the evidence base... then it becomes much harder to look away and to ignore these facts.” Czura
Towards inclusive policy change
The episode makes a powerful case for menstrual health being an economic issue as much as a public health one. Addressing it requires cross-disciplinary collaboration and open conversation—not just among women, but also with men, policymakers, employers, and educators. Indeed, if this research shows anything, it’s that changing the narrative around menstruation begins with breaking the silence.
References
Castro, S and C Mang (2024), “Breaking the silence – Group discussions and the adoption of menstrual health technologies,” Journal of Development Economics, 169: 103264.
Castro, S and K Czura (2025), “Cultural taboos and misinformation about menstrual health management in rural Bangladesh,” World Development, 188: 106871.
Czura, K, A Menzel, and M Miotto (2024), “Improved menstrual health and the workplace: An RCT with female Bangladeshi garment workers,” Journal of Development Economics, 166: 103174.