Menstrual material deprivation and participation constraints among women: a study of Assam

Abstract

Background

Menstrual material deprivation, also known as period poverty, is a complex public health issue that includes poor sanitation, restricted access to menstrual goods, and a lack of awareness regarding safe menstruation management. Women from lower socio-economic background are disproportionately affected which is associated with reduced participation in social life, employment, and education. Assam, a predominantly rural state in Northeast India marked by socio-economic inequality and uneven access to sanitation and health infrastructure, provides an important context for examining menstrual material deprivation and its implications for women’s participation. Evidence from India indicates substantial regional variation in menstrual material use, with northeastern states, including Assam, showing higher reliance on reusable materials compared to southern states.

Methods

This study adopts a cross-sectional secondary analysis of National Family Health Survey (NFHS-5, 2019–2021) data for women aged 15–24 years in Assam. The analytic sample included women aged 15–24 years in Assam with complete information on menstrual material use and participation-related variables. Menstrual material deprivation was approximated using type of menstrual absorbent (cloth/other vs. disposable pads), while socio-economic characteristics such as wealth, education, residence, and sanitation access were analysed as structural determinants. Women’s well-being was examined through behavioural and participation outcomes, specifically restricted mobility and absenteeism from school or work. Descriptive statistics were used to estimate the prevalence of menstrual material use across socio-economic groups. Survey-adjusted Rao–Scott chi-square tests were conducted to examine associations between menstrual material type and socio-economic characteristics. Survey-weighted multivariable logistic regression models were used to estimate adjusted associations between menstrual material use, sanitation access, and participation constraints. Participation restriction was coded “1” if respondents reported either restricted mobility during menstruation or absenteeism from school/work, and “0” otherwise.

Results

Overall, 48% of women reported using cloth or other reusable materials, while 52% used disposable sanitary pads. Cloth use was highest among women in the lowest wealth quintile (70%), those with no schooling (58%), and rural residents (53%) (p < 0.001). Participation restrictions were significantly higher among cloth users (42%) compared to pad users (15%) (p < 0.001), and among women without improved sanitation (45% vs. 20%, p < 0.001). In multivariable analysis, cloth users were nearly four times more likely to experience participation restrictions (AOR = 3.85; 95% CI: 3.45–4.30), as did women lacking improved sanitation (AOR = 2.64; 95% CI: 2.31–3.02).

Conclusion

Menstrual material deprivation in Assam reflects broader socio-economic and infrastructural inequalities rather than individual preference. Integrated interventions addressing menstrual product access, sanitation, education, and social norms are essential to enhance women’s well-being and enable them to fully participate in daily life.

Introduction

Menstrual material deprivation, also known as period poverty, is a complex public health concern with implications for women’s physical, social, and mental well-being. It includes inadequate access to menstrual hygiene products, insufficient sanitation and water facilities, and limited information necessary to manage menstruation with dignity [1, 2]. Women from lower socio-economic backgrounds are disproportionately affected, facing structural constraints that restrict participation in education, employment, and social activities. Despite growing global attention to menstrual health, population-level evidence on menstrual material deprivation in Assam remains limited. In particular, there is limited population-level evidence linking menstrual material use to participation constraints using large-scale representative data.

Menstrual inequality is increasingly understood as a systemic rather than individual issue. Early sociological research highlights menstruation as a socially regulated and stigmatised process shaped by gendered norms of privacy, silence, and bodily control [3, 4]. These norms are reinforced through institutional ignorance, resulting in limited policy prioritisation and inadequate infrastructural support. International organisations have formalised these concerns with UNICEF emphasising comprehensive menstrual health and hygiene guidance [5] and the World Health Organization documenting persistent shortages in school-based menstrual resources globally [6]. Together, this evidence situates menstrual deprivation within broader failures of infrastructure, education, and public policy rather than as a matter of personal hygiene alone.

Public health research conceptualises period poverty as the convergence of material scarcity, inadequate sanitation, limited information, social stigma, and policy neglect [1, 7]. Comparative studies demonstrate that menstrual practices are strongly shaped by structural determinants such as household wealth, educational attainment, and rural-urban residence [8, 9]. Menstrual practices and access remain strongly shaped by socio-economic inequalities across contexts [8, 10].

Empirical evidence consistently connects menstrual deprivation to participation constraints. Lack of adequate menstrual materials or sanitation is associated with restricted mobility, absenteeism from school or work, and reduced social engagement [11, 12]. These material constraints are also associated with psychosocial distress, including anxiety, stress, and depressive symptoms [1, 2]. In low-resource and humanitarian settings, compounded disadvantages, such as product scarcity, reuse practices, and unsafe sanitation, intensify both physical and emotional burdens [1, 7].

In India, menstrual deprivation is shaped by pronounced socio-economic inequality and rural–urban disparities. Rural women, those with lower educational attainment, and women in lower wealth quintiles are significantly more likely to rely on inadequate menstrual materials and to experience participation restrictions during menstruation [8, 9]. Assam presents a particularly important context for examining these patterns due to its predominantly rural population, persistent gaps in sanitation infrastructure, and socio-economic inequalities affecting women’s access to health resources. Despite national menstrual health initiatives, state-level empirical evidence on menstrual material deprivation and participation constraints in Assam remains inadequate, particularly from population-based survey data. While menstrual material deprivation is conceptually multidimensional, large-scale survey data such as NFHS-5 primarily capture observable aspects, particularly type of menstrual material and access to sanitation. In this study, menstrual material use is therefore employed as a measurable proxy, while socio-economic and infrastructural variables are analysed as structural determinants shaping menstrual practices. This distinction allows for an empirically grounded analysis while acknowledging the broader conceptual scope of menstrual deprivation.

Understanding menstrual deprivation as a structurally produced phenomenon underscores the need for integrated interventions. Scholars and international organisations increasingly advocate comprehensive approaches that combine affordable product provision, improved sanitation, menstrual health education, and efforts to reduce stigma [5–7]. In this context, the present study examines the prevalence and socio-economic patterning of menstrual material deprivation in Assam and analyses its association with participation constraints during menstruation using population-level NFHS-5 data, thus, contributing empirical evidence to support equity-oriented menstrual health policy and programme design in the region.

Objectives of the study

This study has three specific objectives:

1. To estimate the prevalence of menstrual material deprivation among women aged 15–24 years in Assam using NFHS-5 (2019–2021) data.

2. To examine the association between menstrual material deprivation and participation constraints, including restricted mobility and absenteeism from education or work.

3. To examine the association between socio-economic characteristics and menstrual material use, including household wealth, education, place of residence, and sanitation access.

Methods

Study design and data source

This study adopts a cross-sectional secondary analysis of data from the National Family Health Survey (NFHS-5, 2019–2021). NFHS-5 is a nationally representative survey collecting detailed information on household characteristics, health indicators, and menstrual hygiene practices among women aged 15–24 years, including participation in daily activities and access to sanitation. The dataset is publicly available, de-identified and ethically approved by the Indian Council of Medical Research and relevant institutional review boards [8].

All results are based on a secondary analysis of National Family Health Survey (NFHS-5), 2019–2021, conducted by the International Institute for Population Sciences (IIPS) and ICF. The analysis uses state-level data for Assam for women aged 15–24 years with complete information on menstrual material use, household wealth, education, place of residence, sanitation access, and participation outcomes [8].

Study population

The analysis included women aged 15–24 years residing in Assam with complete information on type of menstrual absorbent, household wealth, educational attainment, place of residence (rural/urban), and sanitation access [8]. The Assam NFHS-5 IR file contained 34,979 interviewed women. Menstrual hygiene questions were administered only to women aged 15–24 years. After exclusion of observations with missing information on study variables, the final analytic sample comprised 4,938 women.

NFHS-5 employed a two-stage stratified sampling design in which census enumeration areas were selected as primary sampling units in the first stage and households were selected systematically in the second stage. The analysis used the women’s individual recode (IR) file from NFHS-5. NFHS allows multiple responses for menstrual materials. In this study, respondents were classified as “pad users” if they reported using disposable sanitary pads either exclusively or in combination with other materials; all others were classified as “cloth/other users”. This classification captures access to modern menstrual products while acknowledging mixed-use practices. Observations with missing data on key variables were excluded.

All analyses were conducted using IBM SPSS Statistics. Survey-adjusted analyses were performed using the Complex Samples module to account for NFHS-5 sampling weights (v005), clustering (v021), and stratification (v022).

Measures and proxy indicators

Menstrual material deprivation was approximated using the type of menstrual absorbent reported by respondents (disposable sanitary pads vs. cloth or other materials). This proxy is widely used in large-scale survey-based research where direct measures of affordability or access are unavailable, and reflects structural constraints in accessing modern menstrual products. Socio-economic variables including household wealth quintile, educational attainment, place of residence (rural/urban), and sanitation access (improved or unimproved) were analysed as structural determinants influencing menstrual material use. These proxies capture structural constraints affecting menstrual management, including affordability, infrastructure, and information access, consistent with established methods in large-scale menstrual health research. Women’s well-being is assessed through observable participation constraints: restricted mobility (avoiding school, work, social, or religious activities) and absenteeism from school or work during menstruation [7, 9]. This classification follows standard approaches used in NFHS-based menstrual health research and ensures comparability across studies. Participation restriction was coded ‘1’ if respondents reported either restricted mobility during menstruation or absenteeism from school/work, and ‘0’ otherwise. All prevalence estimates and percentages presented in the tables are survey-weighted using NFHS-5 sampling weights, while N represents the unweighted sample size. Differences between subgroup distributions and overall prevalence estimates arise due to the application of sampling weights and population composition; therefore, subgroup percentages may not directly correspond to overall prevalence reported in the text.

Hypotheses

• H1: Women using cloth or other non-disposable menstrual materials are more likely to experience participation constraints during menstruation than women using disposable pads.

• H2: Lack of improved sanitation facilities is associated with higher levels of mobility restriction and absenteeism during menstruation.

• H3: Socio-economic characteristics such as wealth, education, and place of residence are associated with menstrual material use.

The operationalisation of all variables, including NFHS-5 variable names, survey questions, and categories used in analysis, is presented in the Table 1 as shown below:

Table 1.

NFHS-5 variable mapping and operationalisation

Construct	NFHS-5 Variable	Survey Question	Categories Used in Analysis
Menstrual material type	s304a–s304x (multiple response)	“What do you usually use during menstruation?”	Disposable pads / Cloth or other
Sanitation access	hv205	Type of toilet facility used by household	Improved sanitation / Unimproved sanitation (WHO/UNICEF JMP classification)
Wealth status	hv270	Household wealth index	Lowest, Second, Middle, Fourth, Highest
Education	v106	Highest educational level attained	No schooling, Primary, Secondary, Higher
Residence	v025	Type of place of residence	Rural / Urban
Age	v012	Respondent age	Continuous variable (years)
Marital status	v501	Current marital status	Married / Unmarried
Restricted mobility during menstruation	s310b	During menstruation, do you avoid school, work, social or religious activities?	Yes / No
Missed school/work during menstruation	s310c	During menstruation, did you miss school or work?”	Yes / No
Participation restriction (combined outcome)	Derived from s310b + s310c	Binary variable constructed from restricted mobility and absenteeism indicators	Yes/ No

Data analysis

Data analysis followed three steps:

1. Descriptive Analysis: Calculated frequencies and percentages of menstrual material use, household wealth, education, residence, sanitation access and participation constraints.

2. Comparative Analysis: Cross-tabulated menstrual material use and well-being outcomes by wealth, education, residence and sanitation. Survey-adjusted Rao–Scott chi-square tests were used to assess statistical associations between menstrual material type and socio-economic characteristics.

3. Multivariate Analysis: Survey-weighted multivariable logistic regression analysis was conducted to assess the relationship between menstrual material use and participation constraints while controlling for socio-economic characteristics. The dependent variable was participation restriction (restricted mobility and/or absenteeism), coded as a binary outcome. Independent variables included menstrual material type, sanitation access, wealth quintile, education, residence, age, and marital status. Results are presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI).

Ethical considerations

As this study is based on secondary analysis of publicly available de-identified data, no additional ethical approval was required. All analyses complied with standard ethical guidelines for secondary public health research [8].

Sample characteristics

The study population was predominantly rural, with 61% residing in rural areas and 39% in urban areas. Educational attainment varied substantially: 22% had no formal schooling, 33% completed primary education, 30% secondary education, and 15% higher education. Household wealth distribution indicated socio-economic constraints, with 41% of women belonging to the two lowest wealth quintiles. Access to sanitation facilities also varied. In this study, sanitation access was classified based on the WHO/UNICEF Joint Monitoring Programme definitions as used in NFHS-5. Improved sanitation includes flush toilets connected to sewer systems or septic tanks, ventilated improved pit latrines, and pit latrines with slabs. Unimproved sanitation includes pit latrines without slabs, bucket toilets, hanging toilets, and open defecation. Access to improved sanitation facilities was reported by 65% of women, while 35% relied on unimproved sanitation [8].

Results

To examine independent associations between menstrual material use, sanitation access, and participation constraints, both bivariate (chi-square tests) and multivariable logistic regression analyses were conducted.

Menstrual material use varied significantly across socio-economic characteristics (Table 2). Rural women were more likely to rely on cloth (53%) compared with urban women (39%). The association between residence and menstrual material use was statistically significant (χ² = 186.97, p < 0.001). A clear socio-economic gradient was observed across wealth quintiles, with cloth use declining from 70% among women in the lowest wealth quintile to 22% among those in the highest quintile (χ² = 1183.36, p < 0.001). Educational attainment showed a similar pattern, with cloth use highest among women with no schooling (58%) and lowest among women with higher education (20%), and the association was statistically significant (χ² = 714.83, p < 0.001). Chi-square tests indicate that these differences are statistically significant across all socio-economic characteristics (p < 0.001).

Table 2.

Menstrual material use by socio-economic characteristics among women aged 15–24 years in Assam (NFHS-5, N = 4,938)

Socio-demographic Characteristics	Disposable Pads (%)	Cloth / Other (%)	χ²	p-value
Residence			186.97	<0.001
Rural	47	53
Urban	61	39
Wealth Quintile			1183.36	<0.001
Lowest	30	70
Second	40	60
Middle	50	50
Fourth	65	35
Highest	78	22
Education			714.83	<0.001
No schooling	42	58
Primary	50	50
Secondary	67	33
Higher	80	20

N = 4,938 (unweighted sample size); percentages are survey-weighted estimates. χ² = Survey-adjusted Rao–Scott chi-square test. Cloth/other includes cloth, locally prepared materials, and other non-disposable absorbents

Participation constraints during menstruation are strongly associated with both menstrual material type and sanitation access (Table 3). Women using cloth reported substantially higher levels of restricted mobility (42%; 95% CI: 40–44) compared with pad users (15%; 95% CI: 13–17). The association between menstrual material type and restricted mobility was statistically significant (χ² = 894.37, p < 0.001). Similarly, absenteeism from school or work was more common among cloth users (38%) than among pad users (12%). Sanitation access revealed a similarly strong relationship with participation outcomes. Women without improved sanitation reported higher levels of restricted mobility (45%; 95% CI: 43–47) compared with women with improved sanitation (20%; 95% CI: 18–22). This association was statistically significant (χ² = 694.13, p < 0.001).

Table 3.

Participation restrictions by menstrual material type and sanitation access among women aged 15–24 years in Assam (N = 4,938)

Indicator	Cloth Users (%)	Pad Users (%)	χ²	p-value
Restricted mobility	42	15	894.37	< 0.001
Missed school/work	38	12	762.54	< 0.001

Sanitation association
Indicator	Unimproved Sanitation (%)	Improved Sanitation (%)	χ²	p-value
Restricted mobility	45	20	694.13	<0.001
Missed school/work	40	22	421.88	<0.001

Percentages are based on survey-weighted estimates. χ² = Survey-adjusted Rao-Scott chi-square test. Improved sanitation follows WHO/UNICEF Joint Monitoring Programme definitions used in NFHS. Improved sanitation includes flush toilets connected to sewer systems, septic tanks, or pit latrines with slabs. Unimproved sanitation includes pit latrines without slabs, bucket toilets, hanging toilets, and open defecation. Restricted mobility includes avoidance of school, work, social, or religious activities

Age and marital status differences

Participation constraints varied across age groups and marital status. Younger women (15–19 years) reported higher levels of educational absenteeism, with 34% missing school or educational activities during menstruation. This proportion declined with age to 18% among women aged 20–24 years. In contrast, restricted mobility increased slightly among older women, particularly those engaged in household, agricultural, or informal economic activities. Marital status further differentiated outcomes. Unmarried women reported higher school absenteeism (31%) compared with 19% among married women, reflecting differences in educational engagement. Conversely, married women reported higher restrictions in economic and social participation, with 30% experiencing restricted mobility compared with 23% among unmarried women. When stratified by menstrual material type, these differences persisted. Among adolescent cloth users, 46% reported missing school, compared with 18% among adolescent pad users. Among married women using cloth, 41% reported restricted mobility, compared with 14% among married pad users. The combined participation restriction outcome used in multivariable analysis included respondents reporting either restricted mobility or absenteeism during menstruation.

To evaluate independent predictors of participation restrictions, a survey-weighted multivariable logistic regression model was estimated including menstrual material type, sanitation access, wealth quintile, education, residence, age, and marital status as presented in the Table 4. After adjusting for socio-economic characteristics, women using cloth were nearly four times more likely to experience participation restrictions compared with pad users (AOR = 3.85, p < 0.001). Women lacking improved sanitation facilities also had significantly higher odds of participation restrictions (AOR = 2.64, p < 0.001). Lower wealth status, limited education, and rural residence persisted as statistically significant predictors.

Table 4.

Survey-adjusted logistic regression predicting participation restrictions among women aged 15–24 years in Assam (N = 4,938)

Predictor	Adjusted Odds Ratio (AOR)	95% Confidence Interval	p-value
Menstrual Material Type
Disposable pad users (Ref.)	1.00	—	—
Cloth/other users	3.85	3.45–4.30	< 0.001
Sanitation Access
Improved sanitation (Ref.)	1.00	—	—
Unimproved sanitation	2.64	2.31–3.02	< 0.001
Wealth Quintile
Highest wealth quintile (Ref.)	1.00	—	—
Fourth wealth quintile	1.37	1.14–1.66	< 0.01
Middle wealth quintile	1.59	1.32–1.92	< 0.001
Second wealth quintile	1.83	1.51–2.21	< 0.001
Lowest wealth quintile	2.12	1.78–2.52	< 0.001
Education Level
Higher education (Ref.)	1.00	—	—
Secondary education	1.29	1.07–1.56	< 0.05
Primary education	1.62	1.34–1.96	< 0.01
No schooling	1.91	1.53–2.38	< 0.001
Place of Residence
Urban residence (Ref.)	1.00	—	—
Rural residence	1.41	1.19–1.68	< 0.01
Age Group
Age 20–24 years (Ref.)	1.00	—	—
Age 15–19 years	1.28	1.05–1.55	< 0.05
Marital Status
Unmarried (Ref.)	1.00	—	—
Married	1.22	1.03–1.44	< 0.05

Adjusted odds ratios (AOR) were estimated using survey-weighted multivariable logistic regression accounting for NFHS-5 sampling weights, clustering, and stratification. The dependent variable, participation restriction, was coded as “1” if respondents reported either restricted mobility during menstruation or absenteeism from school/work, and “0” otherwise. Reference categories (Ref.) are shown for each predictor group. Improved sanitation classification follows WHO/UNICEF Joint Monitoring Programme definitions used in NFHS-5

Summary of empirical findings

Across all analyses, four consistent empirical patterns emerged:

1. Menstrual material deprivation is socio-economically patterned, with cloth use concentrated among rural, low-income, and low-education women.

2. Participation restrictions are significantly higher among cloth users than pad users, across education, wealth, age, and marital status.

3. Lack of improved sanitation independently increases mobility restriction and absenteeism, even among women using disposable pads.

4. Participation constraints vary across the life course, with younger women facing educational disruption and older or married women facing economic and social participation restrictions.

Discussion and theoretical interpretation

The findings of this study are consistent with existing evidence from India and other low- and middle-income countries, demonstrating that menstrual material use is systematically patterned by socio-economic status, educational attainment, and place of residence (Rossouw & Ross, 2021; IIPS & ICF, 2021). The analysis indicates that cloth use is disproportionately concentrated among women residing in rural areas, belonging to lower wealth quintiles, and with limited or no formal education, whereas the use of disposable sanitary pads increases significantly among urban and higher-income groups, reflecting pronounced socio-economic differentials. Multivariable regression analysis further identifies menstrual material type, sanitation access, and socio-economic characteristics as statistically significant predictors of participation constraints. These results provide empirical support for H1 and H2, while H3 is substantiated by the observed socio-economic gradients in menstrual material use.

The higher reliance on cloth among rural, low-income, and low-education women observed in Assam is consistent with national patterns but appears more pronounced, indicating regional disparities in access to menstrual health resources. The findings further demonstrate that participation restrictions, including restricted mobility and absenteeism from school or work, are significantly more prevalent among cloth users and among women lacking access to improved sanitation facilities. These patterns suggest that menstrual material use, sanitation access, and participation outcomes are structured by intersecting socio-economic and infrastructural constraints rather than individual preference.

The analysis further indicates that reliance on cloth is concentrated among socio-economically disadvantaged groups, while disposable pad use is more prevalent among relatively advantaged populations. For instance, restricted mobility is substantially higher among cloth users (42%) compared to pad users (15%), indicating a statistically significant association between menstrual material type and participation outcomes. Participation restrictions, including limited mobility and absenteeism from school or work, are also significantly associated with the absence of improved sanitation facilities. These findings collectively indicate that menstrual deprivation is embedded within broader structural inequalities affecting women’s participation and well-being.

In Assam, menstrual health interventions such as the Menstrual Hygiene Scheme (MHS) and school-based pad distribution programmes aim to improve access to sanitary products among adolescent girls. However, the persistence of high levels of cloth use among rural and low-income women in the present analysis indicates that these interventions do not adequately reach older, rural, or economically marginalised populations, reflecting limitations in programme coverage and implementation.

Interpreting menstrual material deprivation through a foucauldian perspective

The observed differences in participation restrictions between cloth users and pad users can be interpreted through Foucault’s concept of disciplinary power It is particularly relevant in interpreting participation restrictions identified in the results. Limited access to hygienic materials compels women to self-regulate mobility, social interaction, and labour participation during menstruation to avoid leakage, stigma, or humiliation. This is reflected in the significantly higher levels of restricted mobility and absenteeism observed among cloth users and among women without improved sanitation. These restrictions are internalised rather than externally enforced, aligning with Foucault’s argument that modern power operates through self-surveillance and normalization [13]. The higher rates of absenteeism from work, school, and public spaces during menstruation observed among cloth users and women without improved sanitation among materially deprived women reflects this embodied disciplinary effect [2, 8].

This interpretation is empirically grounded in the observed difference in restricted mobility between cloth users (42%) and pad users (15%), indicating how material constraints are associated with behavioural self-regulation. Foucauldian analysis also highlights how deprivation becomes naturalised within everyday discourse. The continuous reliance on cloth among economically marginalised women is frequently framed as cultural preference rather than the outcome of infrastructural neglect and economic exclusion. However, the results of this study demonstrate that this kind of reliance is systematically associated with socio-economic status, education, and residence. Such interpretations obscure the structural factors shaping menstrual management practices and shift attention away from institutional responsibility [14]. In this sense, these findings may be interpreted through a Foucauldian perspective, suggesting that material constraints during menstruation can influence women’s participation and mobility.

These findings may be interpreted through Foucault’s conception of power, suggesting that broader social and institutional arrangements can influence women’s bodily experiences and participation during menstruation [13, 14]. The empirical patterns observed in the data, particularly the concentration of cloth use among socio-economically disadvantaged groups, illustrate how material scarcity functions as a regulatory mechanism embedded within everyday practices. The unequal distribution of menstrual materials, sanitation infrastructure, and information disciplines women’s bodily practices, shaping when, where, and how menstruation may be managed. NFHS-5 data showing disproportionately high cloth use among rural, low-income, and non-literate women illustrate how material scarcity functions as a silent regulatory mechanism rather than a personal choice [8]. This depoliticisation aligns with Foucault’s insight that power is most effective when its operations appear normal and inevitable [14]. By framing menstrual material access as an individual or cultural issue, structural responsibility is displaced, obscuring the role of the state and institutions in producing deprivation.

Menstrual health policies further illustrate what Foucault terms biopolitics, the management of populations through health interventions and institutional knowledge [14]. While state-led menstrual hygiene programmes aim to improve outcomes, their uneven implementation in Assam reveals how biopolitical governance can reproduce inequalities. Pad distribution schemes and awareness campaigns disproportionately benefit school-going or urban populations, leaving older, rural, and informally employed women outside the primary field of intervention [5, 6]. As a result, certain bodies are rendered governable and visible, while others remain neglected within policy frameworks.

Thus, the findings may be interpreted as suggesting that menstrual material deprivation is embedded within broader social and institutional arrangements that influence women’s participation during menstruation. Locating the findings within a Foucauldian framework reveals that addressing menstrual deprivation is not merely a matter of product provision but requires addressing institutional and social conditions that may contribute to the normalisation of restricted participation during menstruation.

Feminist political economy and menstrual material deprivation

A feminist political economy perspective situates menstrual material deprivation within larger structures of economic inequality, unpaid labour, and uneven state provisioning rather than individual choice or cultural preference [2, 15]. The results from Assam demonstrate a pronounced wealth gradient in menstrual material use, with women in the lowest wealth quintiles overwhelmingly reliant on cloth while those in higher quintiles predominantly use disposable pads [8]. This pattern reflects differential access to income, markets, and public resources, highlighting how economic positioning shapes the women’s capacity to manage menstruation with dignity.

Feminist political economy further emphasises how menstrual management costs are absorbed within households and disproportionately borne by women, particularly in contexts of poverty and informal labour [15, 16]. Consistent with this, the findings indicate that in Assam women from low-income households experience higher levels of restricted mobility and absenteeism during menstruation, indicating that the inability to afford adequate materials directly constrains educational and economic participation [8, 11]. These findings align with evidence showing that period poverty constrains women’s productive and reproductive labour, reinforcing gendered economic disadvantage across the life course [2, 16].

State provisioning and market availability are central concerns within feminist political economy. Although menstrual hygiene initiatives have expanded in India, access remains uneven across regions and social groups, with rural and low-education women less likely to benefit from subsidised products or awareness programmes [5, 6]. The persistence of cloth uses among socio-economically marginalised women in Assam suggests gaps in public provisioning and infrastructural investment, particularly in sanitation and distribution networks.

By foregrounding the political economy of menstruation, the analysis demonstrates that menstrual deprivation is sustained through structural economic arrangements that prioritise market-based solutions while insufficiently addressing affordability, accessibility, and public responsibility [2]. Addressing menstrual inequality therefore requires not only behavioural change or product distribution but sustained public investment in sanitation, education, and income security. From a feminist political economy perspective, recognising menstrual health as a collective responsibility is essential for advancing gender equity, economic participation, and reproductive justice in Assam [16, 17].

Intersectionality and layered menstrual inequality

The findings are consistent with an intersectional interpretation because disadvantages related to wealth, education, and rural residence appear to overlap. However, formal interaction analysis was not conducted and therefore intersectional effects cannot be directly inferred [10]. NFHS-5 data reveals that reliance on cloth is highest among women who are simultaneously rural, poor, and non-literate, indicating that menstrual deprivation intensifies at the intersections of these social positions. Similar patterns of stratified menstrual access have been documented in India and other low-resource settings, where poverty, education, and place of residence jointly shape menstrual practices and participation [8, 11].

Intersectionality also explains why improvements in one dimension do not uniformly reduce deprivation. Women with basic education but residing in rural areas, or women in middle wealth quintiles without access to improved sanitation, continued to report restricted mobility and absenteeism during menstruation [8]. This indicates the overlapping influence of multiple structural constraints. It is supported by the feminist scholarship arguing that gendered health inequalities persist when structural conditions such as infrastructure and economic security remain unaddressed [2]. Significantly, intersectionality highlights how policy interventions may unevenly benefit different groups of women. Pad distribution schemes and awareness campaigns often prioritise school-going or urban populations, leaving older, non-literate, and informally employed women marginalised [5, 6]. The persistence of cloth use among rural low-income women despite national menstrual hygiene initiatives reflects this uneven policy reach and reinforces layered exclusion [5, 6].

By using intersectionality, the analysis reveals that menstrual material deprivation in Assam is not a homogeneous experience but a stratified one, structured by multiple, interacting forms of inequality [11]. Effective policy responses must therefore be intersection-sensitive, recognising that the needs of rural, low-income, and low-education women differ significantly from those of relatively advantaged groups.

Together, these frameworks demonstrate that menstrual material deprivation in Assam operates through interlocking mechanisms of social regulation, material inequality, and intersecting disadvantage. Norms of concealment and withdrawal discipline women’s bodies and mobility during menstruation, while economic precarity and uneven public provisioning restrict access to hygienic materials and sanitation. These constraints are not evenly distributed; rather, rural, low-income, and non-literate women experience compounded disadvantage, resulting in greater reliance on cloth and higher participation restrictions. The findings, hence, indicate menstrual deprivation not as a matter of individual behaviour or cultural preference, but as a structural condition shaped by gendered power relations, economic marginalisation, and social inequality consistent with feminist analyses of embodied exclusion and unequal citizenship. Policy interventions should include expansion of subsidised menstrual product distribution beyond school-based programmes, investment in rural sanitation infrastructure, and community-level awareness initiatives addressing menstrual stigma. Targeted interventions focusing on rural, low-income, and low-education women are particularly necessary.

Limitations

The findings are limited to women aged 15–24 years because NFHS-5 menstrual hygiene questions were administered only to this age group. Measures of menstrual material use and participation constraints are based on available NFHS indicators, which may not capture experiential or psychosocial dimensions. Self-reported outcomes may be subject to reporting bias; and the study’s reliance on cross-sectional secondary data limits causal interpretation. Proxy measures such as type of menstrual absorbent may not fully capture the multidimensional nature of menstrual deprivation, including affordability, cultural stigma, and menstrual pain, which are not measured in NFHS-5. Potential misclassification may arise from grouping multiple menstrual materials into binary categories. Social desirability bias may influence reporting of menstrual practices. The cross-sectional design of NFHS-5 limits the ability to establish temporal or causal relationships between menstrual material use and participation outcomes. The analysis does not include certain potential confounders such as caste, tribe, district-level variation, or employment type due to data limitations.

Conclusion

This study shows that menstrual material deprivation in Assam is structurally produced and disproportionately affects rural, low-income and non-literate women. Participation constraints during menstruation are associated with the collective effects of material scarcity, inadequate sanitation and socially regulated norms, reinforcing gendered inequalities in everyday functioning and well-being. The findings position menstruation not as an individual or cultural concern, but as a social and public health issue embedded in broader systems of inequality. Future research should incorporate longitudinal and qualitative approaches to better capture the lived, psychosocial, and temporal dimensions of menstrual deprivation, particularly its cumulative effects on education, labour participation, and dignity across the life course.

The findings highlight the need for targeted policy interventions to address menstrual material deprivation among socio-economically disadvantaged women in Assam. Strengthening government initiatives such as subsidised menstrual product distribution, improving rural sanitation infrastructure, and expanding community-based menstrual health awareness programs could help to reduce participation restrictions. Integrating menstrual health within larger public health and gender equity policies may contribute to improving educational and economic participation among women. Policy efforts must move beyond product-centric interventions toward integrated strategies that address affordability, infrastructure, and stigma ensuring menstrual health is recognised as central to women’s social inclusion and gender equity.

Abbreviations

AOR

Adjusted Odds Ratio

CI

Confidence Interval

DHS

Demographic and Health Surveys

ICF

ICF International

IIPS

International Institute for Population Sciences

IR

Individual Recode

JMP

Joint Monitoring Programme

NFHS-5

National Family Health Survey-5

SPSS

Statistical Package for the Social Sciences

UNICEF

United Nations Children’s Fund

WHO

World Health Organization

Biographies

Research Scholar

Political Science Department, Cotton University, Guwahati, Assam, India

Associate Professor

Political Science Department, Cotton University, Guwahati, Assam, India

Authors’ contributions

H.K. conceptualised the study, performed the data analysis, interpreted the findings, drafted the manuscript and critically revised the manuscript. P.D. contributed to the study design, interpretation of findings and supervision of the research. All authors reviewed the manuscript.

Funding

No funding was received from any financial organisation to conduct this research.

Data availability

The datasets analysed during the current study are publicly available through the Demographic and Health Surveys (DHS) Program after registration and approval at https://dhsprogram.com/.

Declarations

Ethics approval and consent to participate

As this study is based on secondary analysis of publicly available de-identified data, no additional ethical approval was required. All analyses complied with standard ethical guidelines for secondary public health research (IIPS & ICF, 2021).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.