Epidemiology of menstrual-related absenteeism in 44 low and middle-income countries

BackgroundMenstrual-related absenteeism from work, school, or social activities is an important functional indicator of poor menstrual health that disrupts women and girls daily lives and exacerbates gender inequality. We sought to estimate the prevalence and factors contributing to menstrual-related absenteeism across low- and middle-income countries (LMICs). MethodsWe analysed cross-sectional data from 47 nationally representative Multiple Indicator Cluster Surveys from 2017-2023 comprising 3,193,042 individuals from 555,869 households across 44 countries. The outcome of interest was menstrual-related absenteeism from work, school, or social activities during the respondents last menstrual period. Independent factors included womens age, household wealth index, use of menstrual materials (e.g. pads, tampons, or cloth), availability of a private place to wash at home during menstruation, and contraceptive use (hormonal and other). Univariable and multivariable associations between each factor and menstrual-related absenteeism were obtained using log binomial models. Prevalences and associations were pooled by geographical region and across all surveys using a random effects meta-analysis. FindingsWe included 673,380 women and girls aged 15-49 years in this analysis. The pooled global prevalence of menstrual-related absenteeism was 15{middle dot}0% [95% CI: 12{middle dot}7-17{middle dot}3], with the highest prevalence in South Asia (19{middle dot}7% [11{middle dot}6-27{middle dot}8]) and West and Central Africa (18{middle dot}5% [13{middle dot}5-23{middle dot}5]). After pooling data across surveys, girls aged 15-19 years were found to endure a higher prevalence of menstrual-related absenteeism compared to older age-groups. There was no association between menstrual-related absenteeism and household wealth or the use of menstrual materials. In contrast, having a private place to wash at home was associated with an increased prevalence of menstrual-related absenteeism (global adjusted Prevalence Ratio [PR]: 1{middle dot}25 [1{middle dot}05-1{middle dot}48]). Menstrual-related absenteeism was less prevalent in women and girls using contraception (global adjusted PR any contraception vs no contraception: 0{middle dot}86 [0{middle dot}82-0{middle dot}90]), including those using hormonal contraception (global adjusted PR hormonal contraception vs non-hormonal or no contraception: 0{middle dot}85 [0{middle dot}78-0{middle dot}93]). InterpretationMenstrual-related absenteeism is prevalent, especially in Asia and Africa, and particularly in adolescent girls. The age-independent protective effect of hormonal contraception suggests symptoms such as heavy menstrual bleeding or pain drive absenteeism. Improving access to private wash facilities outside the home and medical solutions for menstrual symptoms may reduce menstrual-related absenteeism, but further prospective research is urgently needed. FundingNational Health and Medical Research Council, Australia. Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSMenstrual health is a historically understudied topic, with limited knowledge on the epidemiology of menstrual health issues and contributing factors. One consequence of poor menstrual health is menstrual-related absenteeism from school, work, or social activities, which can interfere with womens quality of life and contribute to gender inequality. We searched PubMed, PsychINFO, Embase, and Medline for articles investigating menstrual-related absenteeism across low- and middle-income countries (LMICs) from data inception to April 2023, without language restrictions. Numerous qualitative studies have investigated womens experience of menstrual health in LMICs, but there was a lack of epidemiological studies which are needed to understand the breadth of this issue. Studies were similarly focussed on single countries, and often on particular sub-populations such as adolescents and girls attending school. A global perspective on menstrual health is therefore lacking, requiring studies representative of the entire population of menstruating women. Additionally, many of the quantitative studies available were descriptive only, with no investigation of the associations between menstrual-related absenteeism and contributing factors. Where investigative studies were available, menstrual hygiene management was often the focus of analyses, with limited investigation of other factors which may contribute to menstrual health. Added value of this studyIn this study, we extracted data from 47 nationally representative Multiple Indicator Cluster Surveys from 44 different LMICs. Data on menstrual-related absenteeism was available for more than 673 000 women and girls aged 15-49 years of age, who were included in our study. This study broadens epidemiological knowledge surrounding menstrual health by estimating the prevalence of and investigating the factors relating to menstrual-related absenteeism including age, wealth, use of sanitary products, availability of private wash facilities at home, and contraception use, across a diverse array of countries. Our study was therefore able to compare the importance of these factors and identify priorities for future menstrual health research and interventions. Additionally, the standardised nature of MICS surveys allowed for comparisons between survey populations, facilitating a more global understanding of the menstrual health problem. Implications of all the available evidenceOur work identified menstrual-related absenteeism as a common health concern for women and girls in LMICs, particularly in South Asia and parts of sub-Saharan Africa. Adolescents and young women were at the highest risk of menstrual-related absenteeism, hereby identifying this population as a key priority for future menstrual health programs and research. Our results suggest that private out-of-home sanitation facilities are lacking in LMICs, which has been cited in previous literature. However, more research is needed to determine what improvements are required to better facilitate menstrual health and hygiene. Additionally, our results identified hormonal contraception to be protective against menstrual-related absenteeism, which we hypothesize is due to improved menstrual symptoms. Future work is needed to better understand the importance of menstrual symptoms for women and girls quality of life, and the efficacy of different treatments for these symptoms.