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

Background: Menstrual-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). Methods: We 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. Findings: We included 673,380 women and girls aged 15-49 years in this analysis. The pooled global prevalence of menstrual-related absenteeism was 15.0% [95% CI: 12.7-17.3], with the highest prevalence in South Asia (19.7% [11.6-27.8]) and West and Central Africa (18.5% [13.5-23.5]). 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]: 1.25 [1.05-1.48]). Menstrual-related absenteeism was less prevalent in women and girls using contraception (global adjusted PR any contraception vs no contraception: 0.86 [0.82-0.90]), including those using hormonal contraception (global adjusted PR hormonal contraception vs non-hormonal or no contraception: 0.85 [0.78-0.93]). Interpretation: Menstrual-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. Funding: National Health and Medical Research Council, Australia. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was made possible through the Victorian State Government Operational Support Program and the Australian Government NHMRC IRIISS. S-RP is funded by the Australian National Health and Medical Research Council (NHMRC) Fellowship GNT2009047. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: MICS study datasets are available upon request to the MICS programme for legitimate research purposes (available at: https://mics.unicef.org/surveys). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present work are contained in the manuscript.