1. Introduction

“Menstrual health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity, in relation to the menstrual cycle” [1]. The World Health organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) Joint Monitoring Programme (JMP) emphasize the need for “clean menstrual management material to absorb or collect menstrual blood, that can be changed in privacy as often as necessary, using soap and water for washing the body as required, and having access to safe and convenient facilities to dispose of used menstrual management materials” [2]. The broader concept of menstrual health encompasses knowledge of self-care and the menstrual cycle, access to menstrual care services, the ability to make informed decisions about personal care, diagnosis and treatment of any menstrual-related discomfort, and a respectful environment for this natural process [3].

Ensuring optimal menstrual hygiene management is critical to sexual and reproductive health and is a fundamental human right [4]. This right entails the provision of clean materials for managing the menstrual flow and facilities for washing and disposing of used products, as well as privacy and the ability to change products as needed during the menstruation period [5]. UN Women also emphasizes the importance of sanitation that respects human dignity and caters to the unique needs of women and girls [6]. Access to proper sanitation facilities and menstrual hygiene management resources can significantly impact the physical and mental well-being of menstruators, particularly in low-income settings. Therefore, menstrual hygiene management must be prioritized to ensure that everyone has access to the resources they need to manage their menstruation safely and with dignity [7].

Unfortunately, out of the 1.9 billion menstruating women and girls, around 500 million do not have adequate facilities for menstrual hygiene management worldwide [8]. In low- and middle-income countries (LMICs), inadequate access to safe and clean water, sanitation facilities, hand hygiene facilities, puberty education, and inappropriate waste disposal systems exacerbate public health challenges [9]. This results in limited menstrual hygiene management and restricted access to hygiene materials, further reducing the quality of life for menstruating individuals and placing a substantial burden on the healthcare sector [10].

There are two main types of menstrual materials: single-use materials (including tampons and disposable sanitary pads) and reusable materials (including cloth, washable sanitary pads, and menstrual cups) [11]. Women and girls’ preferences for menstrual products vary depending on personal preference, economic status, cultural beliefs, and local market availability [12]. While it is likely that moist reusable pads may increase reproductive tract infections (RTIs) risk, reusable menstrual cups do not have these same challenges and have been shown to reduce RTIs risk overall [13, 14]. The wide variety of improvised materials encompasses a range of options, extending from reused cloth such as old clothes and rags to clean newly acquired clothes. The utilization of old clothes among women has the potential to increase susceptibility to infections and provoke allergic reactions in the sensitive skin surrounding the genital area [15]. However, women and girls in LMICs face difficulties washing and changing reusable menstrual materials, which increases the risk of RTIs [16, 17]. Adequate menstrual product options can enable girls and women to continue with their daily activities, work, or education without the fear of menstrual blood leakage [18].

Girls and women face various obstacles when attempting to find the most suitable menstrual products. These obstacles include lack of information, prejudice, cultural norms, lack of means, location, safety fears, and limited availability [18]. The evidence on the use of reusable menstrual materials is varied. Some studies suggesting that reuse may be associated with urinary tract infections (UTIs) and poor hygiene-related health conditions [16]. However, other studies argue that, when used appropriately, reusable products can be both environmentally sustainable and as effective as any other product [12, 19]. Emerging research is also exploring the effectiveness of menstrual cups in comparison to other menstrual products, with some findings suggesting that they may offer certain advantages in reducing the risk of reproductive tract infections (RTIs) [18]. However, more research is needed to draw definitive conclusions.

The JMP Progress reports, such as the one titled "Progress on household drinking water, sanitation, and hygiene 2000–2020: Five years into the SDGs," have provided an evaluation of the utilization of reusable menstrual materials on a country-specific basis [20]. However, the existing body of empirical research on the correlates of utilizing reusable menstrual materials, particularly in relation to sociodemographic and socioeconomic factors, remains limited. Additionally, the association between the use of such materials and a country’s Gross Domestic Product (GDP) lacks substantial empirical evidence. Therefore, this research endeavor aimed to evaluate the extent to which reusable menstrual materials are utilized in LMICs, while also identifying individual and country-level factors that may be linked to the use of reusable menstrual materials.

2. Methods

2.3. Sample information

Our study includes 42 surveys, with a total of 471364 responses to the " use of reusable menstrual materials" question. We excluded 1036 responses due to missing values, missing weights, no response, or unknown response. Our final sample size was 470328, which we weighted using MICS-supplied weights, resulting in a sample size of 1653850 (rural = 554869, urban = 1098981) (The MICS surveys never define the urban-rural in a surveyed country. The urban-rural definition is country-specific; they may vary from country to country. Some are population size based, some are infrastructure based); Table 1 provides further details.

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Table 1. Sample characteristics.

https://doi.org/10.1371/journal.pone.0310451.t001

3. Results

This study analyzed data from 38 LMICs, including a total of 1653850 samples from 42 recent nationally representative surveys, with 1098981 from urban areas and 554869 from rural areas. All surveys were conducted between 2017 and 2019 (see Table 1).

The prevalence rates for the overall use of reusable menstrual materials, as well as for rural and urban areas, were 12.1% (95% CI: 12.1–12.2), 23.9% (95% CI: 23.8–24.0), and 6.2% (6.2–6.2), respectively. Sao Tome and Principe had the highest prevalence of use of reusable menstrual materials at 97.2% (95% CI: 96.5–97.9), followed by Chad at 84.6% (95% CI: 84.1–85.2), Madagascar at 77.9% (95% CI: 77.1–78.6), and Malawi at 70.4% (95% CI: 69.7–71.1). Serbia had the lowest overall frequency at 0.5% (95% CI: 0.3–0.8). The prevalence of use of reusable menstrual materials in urban areas was highest in Sao Tome and Principe at 97.7% (95% CI: 96.8–98.4), followed by Madagascar at 59.6% (95% CI: 58.1–61.2), Chad at 59.2% (95% CI: 57.6–60.8), Guinea Bissau at 57.7% (95% CI: 52.8–62.5), Nepal at 56.8% (95% CI: 55.7–57.8), Malawi at 53.6% (95% CI: 52.1–55.2), Bangladesh at 52.2% (95% CI: 51.3–53.0), and The Gambia at 51.6% (95% CI: 50.6–52.7). The lowest prevalence rate in urban areas was recorded in Serbia at 0.6% (95% CI: 0.3–1.0). On the other hand, Sao Tome and Principe had the highest rural prevalence of 96.5% (95% CI: 95.0–97.6), followed by Chad at 91.4% (95% CI: 90.9–91.8) and Sierra Leone at 90.8 (95% CI: 90.1–91.5). Serbia (0.5%) and Turkmenistan (0.5%) had the lowest prevalence rates of use of reusable menstrual materials in rural areas (see Table 2).

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Table 2. Prevalence of the use of reusable menstrual materials among surveys.

https://doi.org/10.1371/journal.pone.0310451.t002

For both overall and urban areas, the categories with the highest prevalence of use of reusable menstrual material were those who were younger, had less education and were currently married. Never-married women and girls from rural areas had a higher prevalence. Those who were poor and lived in rural areas, as well as those who were rich and lived in urban areas, had the highest prevalence. The prevalence was also higher among women and girls who were from lower- and lower-middle-income countries, lived in South Asia, West and Central Africa, and Eastern, and Southern Africa. Furthermore, this trend was observed among women who lacked access to private washing facilities for their menstrual materials [See Table 3 and S1–S3 Tables].

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Table 3. Prevalence of the use of reusable menstrual materials among features.

https://doi.org/10.1371/journal.pone.0310451.t003

The prevalence of reusable menstrual materials was significantly associated with all independent variables examined, regardless of region (all p < 0.001). Specifically, younger women, those with lower education levels, and individuals from poorer economic backgrounds exhibited significantly higher prevalence rates of reusable menstrual materials in rural areas compared to urban areas. Furthermore, it was found that women who were currently married and had access to private washing spaces demonstrated a significantly higher prevalence rate of utilizing reusable options. [See S4 Table].

Use of reusable menstrual materials was higher in women aged 40–44 years than in women aged 45–49 years in overall (AOR = 1.25, 95% CI: 1.21–1.29), rural (AOR = 1.16, 95% CI: 1.11–1.21), and urban (AOR = 1.37, 95% CI: 1.31–1.43) areas [See Fig 1 and S5 Table]. Women and girls with primary or no education were more likely than women and girls with higher education to use reusable menstrual materials in urban (AOR = 1.84, 95% CI: 1.79–1.90), rural (AOR = 3.03, 95% CI: 2.90–3.16), and overall areas (AOR = 1.96, 95% CI: 1.91–2.00). Furthermore, formerly married (divorced, separated, or the death of a spouse or partner) women and girls in rural areas (AOR = 1.47, 95% CI: 1.41–1.55), urban areas (AOR = 1.04, 95% CI: 1.0–1.07), and overall areas (AOR = 1.19, 95% CI: 1.15–1.22) were more likely to use of reusable menstrual materials than unmarried women and girls. In comparison to the richest, poor women and girls had higher use of reusable menstrual materials in urban (AOR = 2.86, 95%CI: 2.75–2.97), rural (AOR = 4.54, 95%CI: 4.34–4.74), and overall (AOR = 5.06, 95%CI: 4.94–5.18) locations.

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Fig 1. Adjusted odds ratios of the use of reusable menstrual materials among features by area (rural, urban, and overall).

Note: Adjusted for age, education, marital status, wealth index quintile, and availability of private places for washing menstrual materials, region, and country’s economy.

https://doi.org/10.1371/journal.pone.0310451.g001

South Asian women and girls were more likely to use reusable menstrual materials in urban (AOR = 64.94, 95% CI: 59.88–70.43), rural (AOR = 84.92, 95% CI: 79.18–91.08), and overall (AOR = 72.63, 95% CI: 68.91–76.54) areas, followed by Eastern and Southern Africa, West, and Central Africa, and Latin America and Caribbean. Low-income countries were more likely than upper-middle-income countries to use reusable menstrual materials in urban areas (AOR = 3.58, 95% CI: 3.27–3.93), rural areas (AOR = 26.90, 95% CI: 24.81–29.17), and overall areas (AOR = 11.10, 95% CI: 10.45–11.79). More crucially, women and girls who had a private washing place were more likely to use reusable menstrual materials in urban areas (AOR = 1.08, 95% CI: 1.03–1.13), rural areas (AOR = 1.09, 95% CI: 1.04–1.13), and overall areas (AOR = 1.09, 95% CI: 1.06–1.13) than those do not have private washing facility.

In the overall area’s linear regression model, the percentage of use of reusable menstrual materials decreases when the GDP per capita increases (β = -68.88, p-<0.001). Similar to the overall area, the prevalence of use of reusable menstrual materials decreases when GDP per capita increases both in rural (β = -61.97, p-<0.001<0.001), and urban areas (β = -77.06, p-<0.001) [see Fig 2].

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Fig 2. Linear regression of the use of reusable menstrual materials percentages according to their GDP per capita by area (rural, urban, and overall).

https://doi.org/10.1371/journal.pone.0310451.g002

4. Discussion

This study analyzed data from 42 nationally representative surveys in 38 LMICs to better understand the prevalence of the use of reusable menstrual material in both urban and rural areas. Out of a total of 1653850 samples, the pooled prevalence of the use of reusable menstrual materials was 12.1%. In this study, the prevalence of using reusable menstruation materials varied greatly by country, ranging from 0.5% in Serbia to 97.2% in Sao Tome and Principe. A study conducted in Nepal demonstrated that a significant proportion of women, specifically 66.7% before the earthquake and 76.1% after the earthquake, utilized reusable sanitary cloth [23]. Our findings in Nepal support this, with a similar prevalence of 62.8%. In the Indian context, it is worth noting that the utilization of reusable menstrual materials among women of reproductive age varied between 42% to 51.2% according to multiple studies [16, 24, 25]. However varying evidence is presented around these prevalence estimates as another research study conducted in Kolkata, India revealed that a notable proportion of women in the reproductive age group, specifically 6.5%, opt for the utilization of reusable menstrual materials [26]. However, because our analysis did not include India, these findings add context but are not directly comparable to our dataset. Similarly, studies from Ethiopia and Benin found lower prevalence rates among high school females (4.8% and 1.4%, respectively), but our study, which focused on MICS surveys, excluded data from these countries. The variations observed in these results can be attributed to disparities in the contextual and socio-demographic variables, the accessibility and affordability of menstrual products, and the influence of cultural norms and beliefs pertaining to menstrual materials [27, 28].

Interestingly, the prevalence of the use of reusable menstrual materials was much higher in rural areas, at 23.9%, compared to urban areas, where it was only 6.2%. The authors suggest that this may be due to a lack of access to single-use products, which are more commonly used in urban areas. However, this should not be taken as an indication that reusable products are inherently inferior; rather, it highlights the differences in accessibility and choice due to economic and geographic factors. Reusable cloth pads are often used in rural areas, largely due to their affordability, as many women and girls face financial barriers to purchasing single-use products [29]. Additionally, lower levels of education in rural areas may limit awareness about the range of available menstrual products and their proper usage [12]. This study highlights the importance of increasing access to a variety of menstrual products including both affordable, single-use options and high-quality reusable materials, especially in rural areas, as well as to provide education on menstrual hygiene management to empower informed choices.

Furthermore, the findings of this study revealed that women who were currently married or in committed relationships were more likely to use reusable materials compared to those who had never been married or in a committed relationship. This aligns with existing research, which indicates that never-married women often include a higher proportion of adolescents or young women, whereas married women are more representative of the adult female population. Previous research has shown that adult females tend to prefer reusable menstrual materials over disposable pads [30].

Moreover, our research also identified a significant difference in the usage of reusable menstrual materials based on the level of education. Specifically, use of reusable menstrual products was higher in women with lower educational attainment. This aligns with the expected trend, as women with higher education often have better information and knowledge about various menstrual products, have greater employment opportunities and purchasing power, enabling them to afford disposable sanitary pads. Women with a lower level of education in LMICs may have limited financial resources, and reusable options may be the more economical option over time. Nevertheless, it is crucial to acknowledge that reusable products are frequently selected for their long-term cost-effectiveness and environmental benefits, which are significant factors for many women, irrespective of their educational background. Consequently, it is crucial to disseminate comprehensive reproductive health education that enables women to make informed decisions based on their individual circumstances and preferences.

Notably, the utilization of reusable menstrual materials was observed to be more prevalent among women from lower socioeconomic strata. This trend may be influenced by financial constraints, which can limit access to commercially available sanitary pads. However, the decision to utilize reusable products should not be perceived as inferior or problematic; rather, it is a reflection of personal preference and economic realities. In LMICs, particularly in rural regions, access to a variety of menstruation products, including disposables, can be limited. Due to a lack of nearby stores or pricing concerns, women from lower socioeconomic backgrounds may have restricted access to disposable pads. Previous research in Ghana has highlighted that financial limitations represent a significant obstacle for adolescent girls in obtaining disposable sanitary products while attending school [31, 32]. This emphasizes the need of addressing disparities in menstrual hygiene management, particularly in low-income settings, where limited access to affordable and safe menstrual products can affect the health and well-being of women and girls.

Interestingly, reusable menstrual products were found to be most commonly used by women from both low-income rural areas and high-income urban areas. In rural areas, lower-income women may face challenges in accessing disposable menstrual products. As a result, they often turn to reusable options as a more affordable and accessible alternative. On the other hand, in wealthier urban areas, the widespread use of reusable products may be attributed to a greater understanding of menstrual health, a focus on environmental sustainability, and the easy access to high-quality reusable products. Members of this group may also be more informed about the advantages of utilizing reusable materials, such as long-term cost-effectiveness and decreased environmental impact. These contrasting patterns highlight the complexity of menstrual product use and underscore the importance of tailoring educational and policy interventions to address the specific needs and circumstances of different socioeconomic groups.

Access to safe and affordable menstrual products is crucial for menstruating individuals, but unfortunately, many worldwide lack the means to obtain them reliably. Reusable menstrual products, such as menstrual underwear, cloth pads, and menstrual cups, can cost between $15 and $40 per pair [33], $9 to $40 per napkin [18], and $25 or more per cup [34], respectively, depending on their location. While the initial cost may be high, reusable products can be used for two to six years for menstrual underwear and five to ten years for cloth pads, which significantly lowers the cost per menstrual cycle compared to disposable products. However, challenges with washing, drying, and changing reusable products have been reported frequently [18, 35, 36], and carrying used products and washing away menstrual blood can be seen as unpleasant and require privacy, time, water, soap, and equipment [18]. These necessities are often lacking in LMICs compared to high-income countries, where washing machines are prevalent [18]. Moreover, improper handling of reusable products can lead to infections. Therefore, it is essential to ensure that menstruating individuals have access to clean water and sanitation facilities to stay clean, comfortable, confident, informed, and free of infection, particularly in developing countries where access to these necessities is limited.

Disposing of menstrual waste can be a challenge for users, sanitation infrastructure, and the environment, with both safe and unsafe methods being used. Some commonly used methods, such as pit latrines, toilets, garbage, incineration/open burning, burying, and open dumping into ponds and fields, are rudimentary, unregulated, and potentially harmful. However, they may be the only available option for some users [37–39]. Non-biodegradable materials used in disposable sanitary pads can also be detrimental to the environment [37]. Studies in France, India, and the United States have shown that disposable pads score higher in terms of negative environmental effects than reusable pads [40]. Tampons, which contain at least 6% plastic, and menstrual pads, which contain 90% plastic, contribute to air pollution and global warming due to the large volumes of greenhouse gases released during their production [41]. Therefore, setting performance and quality criteria for reusable and biodegradable menstrual products is crucial for both women’s and girls’ health and waste reduction, as well as the environment. Safer and environmentally friendly options such as bamboo, banana, and water hyacinth fibers should be made available to women and girls at an affordable cost [12]. However, norms and regulations for menstrual products are lacking in several countries, making it essential to conduct performance research to establish high-quality standards for these products. This will ensure safe use and have significant implications for disposal and waste handling [42].

The use of reusable menstrual materials varies across regions, with South Asian women and girls using them the most, followed by those in Eastern and Southern Africa. In Central African countries, the Caribbean, and Latin America, reuse is not as widespread due to inconsistent access to menstrual materials and inadequate cleaning options for reusable menstrual products [43]. Management of menstrual products is a critical global issue beyond the physical and psychosocial impact that menstrual waste can have on young girls. Challenges in menstrual waste management, access to reusable materials [44], shame and stigma around discussing menstruation, and a lack of private cleaning and care spaces for women and girls make menstrual health a public and human rights issue globally. To promote healthy and dignified living for girls and women, men and boys must be included in discussions to break barriers and taboos around menstruation. Education and awareness on financial planning for menstrual products or safe ways to reuse materials through routine cleaning with soap and water can help address these issues [45].

It is important to acknowledge and address the inherent limitations present in our study. Initially, it is important to note that this study represents the most extensive investigation undertaken thus far on this specific topic. Furthermore, it is important to note that the utilization of MICS data limited our ability to conduct subnational analyses. This restriction may have obscured potential disparities in the use of reusable menstrual materials prevalence at the district level. The data utilized does not distinguish between reusable cloths and dirty rags, nor does it indicate respondents’ preferences for various products. Moreover, certain variables present in their questionnaire were regrettably absent from the dataset provided for our analysis. As a consequence, specific variables that could potentially influence the use of reusable menstrual materials were not taken into account. The overall prevalence estimate, fails to consider the differential population sizes across countries. Instead, these estimates assume an equal population size for each country. In conclusion, it is important to note that our binary-coded functional difficulties variable solely encompasses the challenges that have been incorporated into the dataset. However, it is crucial to acknowledge that this may not encompass the entirety of the use of all reusable menstrual materials (for example, menstrual cups).

5. Conclusions

The findings of this study highlight the widespread use of reusable menstrual materials in LMICs, specifically among women from lower socioeconomic status, with limited education, and living in rural regions. The practice is more prevalent in countries with lower GDP per capita, indicating a potential link to economic development. To address the widespread use of reusable menstrual materials among vulnerable populations in LMICs, policymakers should prioritize investments in sanitation infrastructure, particularly private washing spaces. In addition, it is crucial to promote reusable products through subsidies, awareness campaigns, and local production support. This study highlights the importance of implementing comprehensive educational interventions for menstrual health, which involve enhancing access to affordable menstrual products, improving sanitation facilities, and educating on menstrual hygiene management. It is essential to consider continuous research and data collection on the long-term impacts of both reusable and disposable menstrual products when making policy decisions. Future studies should aim to incorporate subnational data, examining specific preferences for menstrual products, and exploring the larger socio-cultural aspects that influence menstrual health management in diverse settings.

Supporting information

Acknowledgments

We express our gratitude to the UNICEF MICS team for granting us access to the dataset.