Menstrual Cups - a cost-effective gem?

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 in the world, 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 50/50². The worst of the two 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 year³, 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…

1. Financial Burden of buying period products⁴

2. Health problems caused by unsanitary products

3. Educational time lost

4. Struggle to work and do household tasks during periods

5. Anxiety and reduced wellbeing

6. Environmental cost of disposing pads⁵

The Menstrual cup

Might solve these challenges⁶. 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? 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, in partnership with Pad & Prejudice

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.

1) 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.

2) 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.

3) 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 area⁷
5. I will assume the average Asan cup lifespan is 7.5 years⁸.
6. I’ll convert everything as best as possible 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 $1.50⁹ a month in Uganda. With pads costing 18$ 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 Nepal¹⁰ and Kenya¹¹ 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.

2) Health benefits - Bacterial Vaginosis (BV)

There is decent evidence that cups reduce discomfort from BV, 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 BV. This protective effect 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 DALY improvement of 0.0008 DALYs per cup. Due to low cup cost and a 7 year time horizon this small benefit might still be meaningful at about $10,000 per DALY averted. As irritation and itching are major BV symptoms, this benefit might be better captured in wellbeing improvement.

3. 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.

Improved wellbeing 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 surveys¹², but the other hand some studies didn’t show improvement in mental health scores¹³.

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 which comes through is from money saved, but this might just be a reflection of the lack of evidence. Here’s the final calculation…

One $7 cup = Dollar 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 is likely to be an overestimate of cost-effectiveness.

Great potential - Let’s do Wellbeing research

Menstrual cups are a 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.

1. 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.

2. https://www.wjgnet.com/2308-3840/full/v11/i5/196.htm?utm_source=chatgpt.com

3. Cheaper in Asia, more expensive in Africa

4. For those buying pads only. Those buying no products at all don’t spend extra money.

5. Not tackled here

6. We’re not going to discuss how it works here, check out this video series for more info!

7. Asan cup sell to low income countries for $5, and I’m leaving a buffer for distribution

8. Ira from Asan thinks 10 years of uptake is a reasonable assumption, I think 5 is realistic, so I’ll split the difference

9. https://www.monitor.co.ug/uganda/special-reports/period-poverty-the-cost-of-menstruating-in-rural-uganda-4665298

10. https://www.povertyactionlab.org/sites/default/files/research-paper/99%20Menstruation%2C%20Sanitary%20Products%2C%20School%20Attendance.pdf

11. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00438-8/fulltext

12. https://www.researchgate.net/publication/272357220_Adolescent_schoolgirls'_experiences_of_menstrual_cups_and_pads_in_rural_western_Kenya_A_qualitative_study

13. https://pmc.ncbi.nlm.nih.gov/articles/PMC12041187/