SLU Study: Menstrual Hygiene Needs Unmet for Low-Income St. Louis Women

01/10/2019

ST. LOUIS – While access to menstrual hygiene products has been garnering attention in the developing world, low-income women and girls in a major U.S. metropolitan area also struggle to afford period supplies and often resort to making do with cloth, rags, paper towels, or even children’s diapers during their monthly cycles.

In one of the first needs assessments of its kind, Anne Sebert Kuhlmann, Ph.D., MPH, associate professor of behavioral science and health education at Saint Louis University’s College for Public Health and Social Justice and her team, have documented the challenges, from affordability to transportation, that low-income people with periods face in accessing basic sanitary supplies. Their findings are published ahead of print and are slated for publication in the February issue of Obstetrics & Gynecology.

Kuhlmann’s study found that nearly two-thirds of the women her team surveyed and interviewed were unable to afford menstrual hygiene supplies like pads or tampons at some point during the previous year, and 21 percent of women lacked supplies on a monthly basis. Nearly half – 46 percent – of those surveyed could not afford to buy both food and period-related products during the past year.

While lack of access to menstrual hygiene products can result in negative health issues including infection and poor quality-of-life, Kuhlmann points to the need for broader education and policy shifts surrounding menstruation and women’s health.

“Adequate menstrual hygiene management is not a luxury,” Kuhlmann and her co-authors conclude in the study. “It is a basic need for all women and should be regarded as a basic woman’s right. Our failure to meet these biological needs for all women in the United States is an affront to their dignity and barrier to their full participation in the social and economic life of our country.”

Uncovering a "Global" Health Issue Close to Home

As part of her research on reproductive health and global health programming, Kuhlmann has worked with women and girls in Ethiopia on menstrual health initiatives as a board member of Dignity Period, a St. Louis-based non-profit organization dedicated to helping girls stay in school by providing them with the education and supplies they need to manage menstruation.

Kuhlmann’s experiences in Ethiopia led her to examine how low-income people with periods in St. Louis, a large U.S.  metropolitan area accessed menstrual hygiene supplies and educational resources. The needs assessment was funded by a grant from St. Louis’s Incarnate Word Foundation in 2017.

“Global health issues are local health issues,” Kuhlmann said. “Few people are talking about this in the U.S.. This is about changing a cultural narrative. Most women in society can identify with having to ‘make do’ with toilet paper or tissue for a few hours when they are caught off guard by the start of their menstrual flow or run out of products. But, for the women who participated in this needs assessment, they are often forced to ‘make do’ all day, for their entire cycle, and often every month.”

The Impact of an Unspoken Need

Between July 2017 and March 2018, the study team surveyed 183 women between the ages of 18 and 69 who were drawn from 10 participating St. Louis community organizations that provide services to low-income people. Most of the women had begun menstruating between the ages of 12 and 13, and have spent decades coping with period product insecurity.

Lack of access to menstrual hygiene products meant that 36 percent of the surveyed women who reported being employed part or full-time had missed one or more days of work per month due to their periods.

The women reported that a key challenge in accessing period products stems from the products’ high cost and their inability to apply government benefits toward their purchase. Funds from Women, Infants, and Children Program (WIC) or Supplemental Nutrition Assistance Program (SNAP) can’t be used to buy period products. In Missouri, among other states, the supplies are taxed in a higher sales tax bracket, even though the supplies are necessities for many women and girls.

According to Kuhlmann’s findings, taxing period products at the full sales tax rate adds quickly to the “economic cost of being a woman.” While the area’s sales tax rates vary, if a woman buys a 36-count pack of overnight Maxi Pads with Wings for $9.27, she would pay between $0.71 and $1.08 per pack in sales tax for her menstrual hygiene products. That cost is nearly 10 percent of the item’s price. If the pack were charged at the lower food sales tax rate, the cost per pack would drop significantly, saving a woman over the course the year and her menstruating lifetime.

“This may not seem like a lot,” Kuhlmann explained, “but for someone who may be struggling to earn enough money for basic necessities, an extra pack of liners every year would be tremendously helpful. Furthermore, this is a financial burden that only affects women with periods.”

Women who lived in households with a daughter who was also menstruating reported “making do” with alternate, jury-rigged period supplies so they could buy period products for their daughters to use.

“The cost of buying menstrual hygiene products for multiple women in a household accumulates quickly and can add to the struggles women have in coping with the realities – bleeding, cramps, and other symptoms – of their menstrual cycles,” Kuhlmann said.

In open-ended survey questions, the women also described struggling to manage heavy bleeding days during their periods with products made available to them; problems accessing products due to limited public transportation options; and concerns about their safety while accessing public bathrooms during their monthly cycles.

Adequate menstrual hygiene management is not a luxury. It is a basic need for all women and should be regarded as a basic woman’s right."

Anne Sebert Kuhlmann, Ph.D.

Some of those surveyed reported that, as a last resort when they had no money or place to get period products, they stole them or went to hospital emergency rooms to receive pads intended for post-partum women.

The team also surveyed 18 St. Louis non-profit organizations about what menstrual hygiene products they offered to their clients. Thirteen of those organizations provided period products to their clients, but nine reported that those supplies were only available intermittently.

“It’s easier to get diapers than period products in St. Louis,” Kuhlmann said. “Women buy disposable products when they can, but are often forced to rely on donations and/or to create make-shift pads and tampons for themselves, mostly out of toilet paper, tissue, or paper towels but also out of their kids’ diapers, old socks, ripped T-shirts or rags. When women with limited incomes are forced to make choices about their own needs versus those of their children, they often prioritize their children’s needs. They will purchase diapers first and then get menstrual hygiene products for themselves if money remains.”

Research Lights a Path Forward to Action

In order to address the needs identified by the study, Kuhlmann, together with Ellen Barnidge, Ph.D., MPH, associate professor of behavioral science and health education, and Enbal Shacham, Ph.D., associate professor of behavioral science and health education, are conducting a “women’s resources audit” in the City of St. Louis, examining product availability, cost and overall access. Kuhlmann plans to expand her research to menstrual hygiene education access for pre-teens and teenagers with periods in school settings, and will begin work investigating the menstrual hygiene needs of immigrants and refugees in the St. Louis area.

Kuhlmann’s research is also informing efforts underway locally through the soon-to-launch St. Louis Alliance for Period Supplies. The alliance would link partnering organizations to distribute menstrual hygiene products in a model similar to that employed by the alliance’s coordinating member, the St. Louis Diaper Bank. The alliance would develop and maintain a distribution network for a variety of menstrual hygiene supply types and absorbencies in order to keep supplies on-hand for low-income women to access regularly.

On Saint Louis University’s campus, a newly-launched SLU Project Period spearheaded by undergraduates Shanaya Shah and George Tharp is also underway to provide college students access to menstrual hygiene resources. Kuhlmann’s study involved SLU doctoral student Eleanor Peters Bergquist, alumna Djenie Danjoint, master’s students Jackie Decoster and Abby Waters as well as undergraduate students Binu Kolenchery and  Brenna Steichen as data entry assistants and student researchers.

The study also calls for the creation of a community resources directory, follow-up with hospitals and health care providers, increased menstrual hygiene education and advocacy efforts to address tax rate, transportation and bathroom access issues identified by the survey participants.

“This must change,” Kuhlmann and study authors note. “We urge women’s health care providers and their professional organizations to advocate for such policy changes.”

Other authors, and their affiliation when the paper was written include Eleanor Peters Bergquist, MA, MSPH, Saint Louis University College for Public Health and Social Justice; Djenie Danjoint, MPH, Saint Louis University College for Public Health and Social Justice ; and L. Lewis Wall, M.D., D. Phil., Washington University.

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The Saint Louis University College for Public Health and Social Justice is the only academic unit of its kind, studying social, environmental and physical influences that together determine the health and well-being of people and communities. It also is the only accredited school or college of public health among nearly 250 Catholic institutions of higher education in the United States.

Guided by a mission of social justice and focused on finding innovative and collaborative solutions for complex health problems, the College offers nationally recognized programs in public health, social work, health administration, applied behavior analysis, and criminology and criminal justice.

Story by Amelia Flood, University Marketing and Communications