TLDR: Menstrual cups cost a few dollars and have great potential to improve lives in low-income settings. High quality Wellbeing research might tell us if they’re a big bet worth making.
Every Month
Periods are a challenge to manage anywhere, but in low income rural areas, women must overcome huge physical, social and financial barriers. Every month. Most women in this tricky situation manage their periods in one of two ways.[1]
1. Reused cloths/rags, not made for purpose
2. Pads - Disposable or reusable
These aren’t great options, and in low income countries women are split between them about 50/50[2]. The worst is reusable cloths which are unsanitary, reduce productivity and contribute to a monthly cycle of worry. On the other hand disposable pads cost between $20 and $50 dollars a year[3], too expensive for those living on dollars a day. Reusable pads are cheaper, but carry similar hygiene problems of cloths.
And the scale of period poverty is massive. My best guess is that between 500 million and 1 billion women don’t buy any period products at all.
The Period Poverty Burden
There are huge financial, education and healthcare gaps between high and low income countries. Period poverty is almost a caricature of these disparities. With such a wide range of challenges that contribute to period poverty, it can be hard to isolate which is even most important (we’ll get to that). These include…
- Financial Burden of buying period products[4]
- Health problems caused by unsanitary products
- Educational time lost
- Struggle to work and do household tasks during periods
- Anxiety and reduced wellbeing
- Environmental cost of disposing pads[5]
The Menstrual cup
Might solve these challenges[6]. They’re a one-shot buy which can last over 10 years. Hard physical labour becomes easier, and cups might prevent health problems. Are they just better in every way (Pareto improvement)? These features plus the environmental benefits have led to gradual uptake in high-income countries. About 10-20% of women in high income countries use cups, yet most people in low-income countries have never heard of them. Even among the middle classes cups are but a whisper. 15 of our OneDay Health nurses are trying Asan Cups at the moment - only one had ever heard of them before.
Women in Janakipuram, Uttar Pradesh receive Asan cups
Cups as a “Leapfrog” Tech?
In low-income countries, some technology has been passed over and “leapfrogged” in favour of newer, better options. In East Africa cellphones leapfrogged landlines, saving billions on infrastructure. Mobile money leapfrogged banks. The menstrual cup could leapfrog older “worse” period products. If cups really are much better, and there is a concerted drive to promote and distribute cups, we may have the opportunity to skip straight from rags to cups.
Asan Cups
Asan wants to transform the period poverty landscape for women in low income countries. Their founder Ira was inspired after seeing a domestic worker in India miss work due to period poverty, then designed the Asan cup as a Harvard grad student. Asan sells their high quality cups in high income countries for about $30, then donates cups or sells them at low cost in low income settings. Over the last 5 years they have distributed 100,000 cups through non-profit partners and factories, most in rural India. Through this process they’ve learned a lot about what drives successful cup uptake. Here are 3 key insights.
- Cup quality is key. If a cup leaks or causes discomfort then women will ditch it, even if the cup was cheap. Adoption depends on a well engineered product that’s easy to use.
- Peer networks are powerful. When trusted friends and community members use cups, word of mouth can spur a snowball effect. Social proof matters more than marketing.
- Schools might seem like a good place to distribute cups, but have far lower uptake than community distribution. The special relationship between mothers and daughters can make all the difference.
Challenges
Mass cup distribution and uptake isn’t easy. A number of moral objections and practical challenges stand in the way.
1. Are we removing womens’ choice? Womens’ rights campaigners can balk at a one-size-fits-all menstrual solution because of the understandable stance that all women should have the right to choose whatever method they prefer. Powerful foreigners deciding what’s best for poor women can also seem paternalistic or even neocolonial.
2. Behaviour change: Is always tough. A seachange would be needed and cultural barriers dismantled for cup user to proliferate. Here in Uganda there’s a common, understandable aversion to putting any external object inside the vagina. That said, we’re encouraged by our initial nurse trial where almost all nurses who tried cups liked them so much they’re sticking with it.
3. Cleaning the cups: Can be difficult where water is scarce or dirty.
Are Cups Cost-Effective? - A rough estimate
(This gets into the weeds, feel free to skip)
I’m going to do this suuuuuuper loose BOTEC with these assumptions
1. I’ll compare Menstrual Cups to disposable pads
2. I assume context of rural Uganda, the context I know best
3. Financial benefit DALY equivalents will be taken from GiveWell
4. I’ll will use $7 as the cost for buying and distributing one ASAN cup in a rural area[7]
5. I will assume the average Asan cup lifespan is 7.5 years[8].
6. I’ll convert everything to DALY equivalents.
1) Money Saved. One cup costs about $7 to buy and distribute and can last over 10 years, which I’ll discount to 7.5. Disposable pads cost about $1.50[9] a month in Uganda. With pads costing 18$ a year, menstrual cups might save a woman 135$ over 7.5 years. If we (mis)use GiveWell’s estimate that a 2.3x doubling of consumption is equivalent to 1 DALY, and estimate Uganda’s average GDP per capita of $987 a year that’s
135 / (987x2.3) = 0.059 DALY equivalents averted per cup
2) School days - none gained from cups?
To my surprise, large robust RCTs in Nepal[10] and Kenya[11] showed no increase in school attendance for any period product use. Women are less likely to attend school during their period and menstrual cup advocates who swear black and blue that menstrual cups helps kids stay in school, but alas the best evidence shows no signal
I’m counting this one out for now, but watch this space, but more research will be incoming…
3) Health benefits - Bacterial Vaginosis
There is decent evidence that cups reduce discomfort from Bacterial vaginosis, but no clear evidence of reduction of UTIs or STIs. This analysis doesn’t take into account the increased risk of HIV transmission for women with bacterial vaginosis. This protective effect of cups could increase the DALYs prevented by 10x-100x in high HIV prevalence settings.
Cups vs pads/cloth Claude translated a 10-20% reduction in bacterial vaginosis to a small DALY improvement of 0.0008 DALYs per cup. Due to low cup cost and a 7 year time horizon this still might be non-negligible at about $10,000 per DALY. As irritation and itching are major symptoms, this benefit might be better captured in wellbeing improvement.
4) Improved Wellbeing?
“… for the beneficiaries, the single biggest perceived benefit seemed to be immeasurable
… Although the economic and environmental impacts are immense, our focus groups revealed reduction in anxiety and stress relating to periods.” - Asan Cup survey from rural Kanartaka, India.
Wellbeing improvement might be largest benefit of menstrual cups, but this hasn’t been studied much. Women report a wide range of wellbeing improvements in qualitative studies and surveys[12], but the other hand some studies didn’t show improvement in mental health scores.[13]
Cups might improve wellbeing through a range of mechanisms which include
1. Enabling more activities (digging, playing, running) during periods
2. Reduced financial stress around monthly financial and practical burdens
3. Overall increased freedom and empowerment
Loose DALY calculation
So in the end, the only large benefit in our estimate comes from money saved, but this might just be a reflection of the lack of evidence. Here’s the final calculation…
One $7 cup = $ DALY (0.059) + Health DALY (+0.0008) + Wellbys?
= 0.0598 DALYs averted per cup distributed
= 1 DALY averted per $120 spent on cups + ???Wellbys
As a sense check, this would mean 1 DALY averted per about 18 cups distributed, which sounds a bit on the high side to me but not-ridiculous. This is a very low quality, early stage BOTEC, and likely to be an overestimate of cost-effectiveness.
Great potential - Let’s do Wellbeing research
Menstrual cups are a tractable, neglected and scalable intervention which have great potential to improve lives. The missing piece is whether the benefit of distributing a cup is large enough to be worth the (low) cost. As benefits cut across financial, physical and psychological realms, cup distribution could be a great candidate for a high quality study which assessed wellbeing benefits. I’m a bit surprised this hasn’t been done already.
With a concerted effort, it might be possible to move towards menstrual cups as a “norm” in low income countries over the next 20 years. They could even be adopted faster in low income countries than high income countries, just like mobile money and solar panels. But at risk of being really boring, we really do need more research….
To finish, a shameless plug for Asan Cup - Ira and her team really care about period poverty for the poorest women. If you’re in the market for a cup, consider buying an Asan. By all accounts their cup is awesome, and you’ll also help women worse off than you get super-cheap cups.
Conflict of interest: Well soon pilot distribution of Asan cups through our remote OneDay Health centers. Asan is a for-profit company so this is on one level free publicity for them.
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Tampons are far too expensive for most women, and used by a surprisingly small fraction of poor rural women. In larger towns and cities though, more women do use tampons.
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https://www.wjgnet.com/2308-3840/full/v11/i5/196.htm?utm_source=chatgpt.com
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Cheaper in Asia, more expensive in Africa
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For those buying pads only. Those buying no products at all don’t spend extra money.
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Not tackled here
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We’re not going to discuss how it works here, check out this video series for more info!
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Asan cup sell to low income countries for $5, and I’m leaving a buffer for distribution
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Ira from Asan thinks 10 years of uptake is a reasonable assumption, I think 5 is realistic, so I’ll split the difference
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Nick, thank you for studying this and for sharing your findings. I do think there's probably something to this space.
That said, I think you know probably more than anyone in EA how good people in poverty are at saving money. Don't you think it's unlikely that there is an option available that could save tens of dollars a year, which people are not taking advantage of on their own initiative? I doubt that achieving sufficient capital is the issue (as for example with a tin roof) if we're talking about a $7, or even $2 product.
Maybe another way of framing this is, why do you think that this is a market failure / why do you think the free market is not addressing this on its own?
I would be very curious to know if Living Goods has looked at this; I know that at one point at least they used to sell reusable pads. It seems like an obvious fit to me, and a much lower risk one than distribution for free.
I can't speak to this product in particular but my experience at One Acre Fund in Tanzania was that it's often just really hard to physically distribute products to rural Africa without super high costs or damage. The practicalities of distribution are hard to solve, which I guess is more what Nick is looking to do here. Once you find a way to get the product in front of users and it saves them money, they'll often buy it, I agree that it might not need to be given for free (not withstanding another practical note: if you need to charge, that also generates a bunch of logistics!)
Do you think Living Goods is well positioned to deal with those practicalities? If not, why not?
One note that I don't think anyone has brought up (though I might have missed something): I think each person reached would mostly get either the health benefits or the cost benefits, not both, since people currently buying pads are already using a sanitary option and people using rags/cloths aren't spending money on products.
<< Cleaning the cups: Can be difficult where water is scarce or dirty>>
This seems quite important? How would you plan on solving this problem otherwise it could lead to more infections and could potentially create more harm than good.
As someone that uses these products I do believe it requires quite alot of maintenance to ensure they are sterile every month once using them and that you can wash them out a few times a day, so Im curious on how you think this would work in countries with lower access to water who may not be able to steralise them?
As far as I can tell (both from searching manually and via Claude), none of the RCTs of menstrual cups in low-resource settings have had severe adverse events (see for example https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00438-8/fulltext, https://bmjopen.bmj.com/content/7/4/e015429). That's enough to give some confidence that adverse events are rare, but not enough to really understand what the true rate is (it seems like all studies together cover at most 10000 person-years of menstrual cup usage in low-resource settings, and my understanding is that among e.g. tampon users in high-income countries, rates of toxic shock syndrome are something like 1-3 per 100000 person-years of usage, with risks for menstrual cup users thought to be broadly similar but less certain due to smaller sample sizes). Also, the RCTs have generally involved some kind of hygiene education, which I'm not sure Nick's $7.5 accounts for.
If the rate of severe complications was 1 per 10000 person-years of menstrual cup usage (which seems at the higher end of what could be theoretically compatible with the evidence we have so far) and women still wanted to use the cups when informed of the risks, that actually wouldn't change Nick's BOTEC very much (say an average severe adverse event led to a 15 DALY loss, we have 0.0598-15*7.5/10000 = 0.04855 DALY/Cup). Accounting for cup hygiene education costs might be the more meaningful change to the BOTEC, but I don't think it would change things by more than 50%. That would leave menstrual cups still looking like a potentially promising intervention.
So overall after looking at this, I don't think that the infection risk concern is a slam-dunk reason against menstrual cups as an intervention. But it seems like if future wellbeing-focused research returned promising results, it would be prudent to fund a big trial that tried hard to monitor for severe adverse events before going to large-scale implementation.
Seconding this. I've heard both "you could die from toxic shock syndrome if you don't clean your cup properly" and also there are something like 5 known cases and no deaths of TSS from menstrual cups. Getting the right balance of education would be important: conveying that cleaning the cup is needed, but it's apparently unlikely to cause a serious problem with typical use.
Thanks @Julia_Wise🔸 and @MHR🔸 for the fantastic responses. I talked to a couple of people involved in cup distribution in low income countries, and their take was that if water is good enough to wash clothes and bodies, it should be good enough to wash cups. I'm not sure if this is evidence based though.
So in some very remote places with highly dirty/infected water it could be a problem, but those situations would be rare. Like others say there's sparse to no evidence that washing cups with unclean water has caused problems with cups.
Minor point, but how would this not be evidence-based? It might not be quantitative evidence, but "the opinions of people involved in cup distribution in low-income countries" should count as evidence of some kind, no?
Yes that's correct it is still evidence for sure, just what might be considered "lower level" evidence.
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Thanks Ligea that's great to hear and and impressive price for sure!
Interesting idea. I know One Acre Fund had a (possibly just pilot) program distributing Afripads in Kenya (https://www.afripadsfoundation.org/the-challenge/). I happen to be chatting with old colleagues from the Kenya program soon, will share any lessons + connect you if useful.
Yes that s great point. I probably should have included a section about reusable pads as that has been the predominant solution tried out so far by NGOs in recent times. Both through local community manufacturing and larger scale commercial operations like Afripads.
Adoption is likely easier than cups but I suspect reusable pads might be inferior on price, comfort and perhaps hygiene depending on washing techniques
Nice, agreed. I could totally see cups being superior, I mostly was thinking of OAF from the perspective of having shareable lessons on e.g. marketing, impact measurement, stuff that might make ODH's work a little easier. Will share what I hear!
I think this is a great idea and write up! I ran similar calculations and had come to similar conclusions in the past thinking it would potentially be a good solution for those experiencing extreme poverty in the US and other high-income settings at the very least. Although, as everyone has pretty much mentioned, they still depend on practical access to private toilets, clean water, soap, and adequate time to wash and reinsert during the day, and UNICEF and WHO both note that many schools globally still lack the privacy and hygiene conditions needed for dignified menstrual management just in general, so it perhaps makes school use workarounds important to iron out?