Cloth sanitary napkins are shown to village women in Rupaspur, around 60 kms from Agra. Many Indian women make do with little more than scraps of old cloth when menstruating, often risking their health, say aid workers trying to make clean and cheap sanitary napkins available.
Sushma Devi, a mother of three in Northern India, stores her "moon cup" on the window sill of the mud-brick veranda that shelters the family goats.
In a village where few have indoor toilets and the Hindi word for her genitals is a profanity, 30-year-old Sushma struggles to talk about how she manages her period and the changes brought by the bell-shaped device she inserts in her vagina to collect menstrual blood.
"It's a thing from hell," she says of the malleable, silicone cup, which she received from a Massachusetts Institute of Technology research group. "I have to keep it far from the house, from where I pray."
Across the world's largest democracy, where a decade of economic growth nearing 8 percent a year has tripled per-capita income, millions of women are held back by shame around their most basic sanitary needs.
Teenage girls and young women are encouraged to go to school and enter the workforce, yet have little access to the infrastructure and products -- separate bathrooms, sanitary pads -- that will help them succeed. Taboos around sexual health reflect a level of discomfort with the female body that affects women's contribution to the economy and marks India as the third-worst nation in Asia for gender inequality.
"When our periods start, it becomes much harder," explains Sushma, who wears a faded floral-patterned sari with silver toe rings and colorful glass bangles jangling on her arms. She was 15 years old when her mother showed her how to use fabric torn from discarded saris to handle her monthly period.
Until a team of researchers from MIT's Abdul Latif Jameel Poverty Action Lab taught her how to use the menstrual cup, which she washes and re-uses, she'd sneak out at night to bury her soiled rags in the dirt.
For Sushma and many others in India, puberty didn't just mark the process of becoming a woman. It brought a source of humiliation and an obstacle to learning.
"Many girls, when they get their period, say it means the end for them," says Lizette Burgers, who headed Unicef's water, sanitation and hygiene program in India from 2004 to 2011. "It's taboo to talk about it."
Persistent differences in women's health, education and economic participation can only become detrimental to India's growth, the World Economic Forum said in an October report on the global gender gap. Giving women more opportunities could boost the country's economic growth rate by about 4 percentage points, Lakshmi Puri, the assistant secretary-general of UN Women, estimated in 2011, according to a report from the Center for Strategic and International Studies in Washington.
India ranked equal to Congo on the United Nations Development Program's gender inequality index for 2012. Female participation in the labor force was 29 percent in 2011, 2 percentage points below Sudan and less than half of China's 68 percent, according to World Bank data. Only 65 percent of women can read or write, compared with 82 percent of men, according to India's census data for the same year.
The vulnerability of women attracted international attention last December when a female medical student was gang-raped aboard a bus in New Delhi one evening. Her death sparked nationwide demonstrations calling for a government and police crackdown on sex crimes.
Sushma says she was never molested when she left the house at night to bury her rags, though she knows women who were and she felt exposed and fearful.
"I've always struggled to understand why there is such little attention on this issue that impacts dignity, education, health and women's involvement in the workplace," says Virginia Roaf, an adviser to the United Nations Special Rapporteur on the right to water and sanitation.
Of the 355 million reproductive-age women in India, only 12 percent use absorbent pads or another sanitary method to stem the blood flow during their periods, a report by AC Nielsen and Plan India found in 2010. The rest tend to rely on old fabric, husks, dried leaves and grass, ash, sand or newspapers.
Menstrual cups, designed to be re-used and collect rather than absorb blood, have been around since the 1930s. Brand names and manufacturers include Diva International Inc., maker of the DivaCup; Mooncup Ltd., the U.K. company that was first to make the device with silicone; and Mumbai-based MediAceso Healthcare Pvt., supplier of the device Sushma uses.
The consequences aren't just economic. There's a public health toll. India accounts for 27 percent of the world's cervical cancer deaths, according to World Health Organization data. The incidence rate there is almost twice the global average, and doctors studying the disease say poor menstrual hygiene is partly to blame.
The homespun solutions raise the risk of vaginal infections that can suppress the reproductive tract's natural defenses. A weaker immune response can compromise the body's ability to fight the sexually transmitted human papillomavirus, the microbial cause of most cervical cancers, says Robert Tindle, an emeritus professor of immunology at the University of Queensland in Brisbane who has studied HPV.
There isn't good data to show the role menstrual hygiene plays in the prevalence of cervical cancer in India, according to Rajesh Dikshit, chief of epidemiology at Mumbai's Tata Memorial Hospital, India's biggest cancer treatment center. Some analysis points to a link by way of clean water access, he says.
"Where there is no water in India, there are very high rates of cervical cancer," Dikshit says. "Where you have water, you don't have the cervical cancer."
Kimberly-Clark Corp. (KMB), Procter & Gamble (PG) Co. and other makers of feminine hygiene products are working to wrench open a market that could be worth billions. Things are moving slowly.
Sales of sanitary protection products in India reached $236 million last year and that number will probably only swell to $442 million by 2017, according to London-based researcher Euromonitor International. That compares with a projection of $13.2 billion that year for China, which according to the United Nations has 42 million more women.
Procter & Gamble, the maker of Whisper sanitary pads, found by working with local schools to educate girls and their mothers about feminine hygiene and biology that they were "busting myths and cultural superstitions," says Shweta Shukla, a spokeswoman based in Mumbai. Kimberly-Clark is also conducting awareness programs for school-age girls to help them understand the changes the body undergoes at puberty.
"Women asking for more comfortable desks is one thing," says Clarissa Brocklehurst, a water and sanitation consultant in Ottawa who headed Unicef's water, sanitation and hygiene division in New York until June 2011. "Being forced to speak out about an issue that everyone gets a bit shy and cringing about is another."
Companies tend to focus on schools because that's where the exclusion begins. At least one in five girls drop out when periods begin, according to research by AC Nielsen and Plan India, a New Delhi-based non-profit organization. Those who persist typically miss five days of school each month due to inadequate menstrual protection.
"The schools they study in, the spaces they play or relax in, the markets, farms and offices they work in, do not design facilities with this simple and recurrent biological need in mind," Chris Williams, executive director of the Geneva-based Water Supply and Sanitation Collaborative Council, wrote in a May note.
Procter & Gamble's Shukla says the Cincinnati-based company has worked to bring sanitary napkins "out of the closet" by showing actual pads in advertising instead of relying on euphemisms, and encouraging retailers to move the packs from the back of the store to the front.
Besides Procter & Gamble and Kimberly-Clark, India's health ministry is working to bolster awareness by selling pads at a subsidized rate of 6 rupees per pack of six to adolescent girls under the brand name Freedays.
There is also research into cheaper products better suited to developing countries. New York-based Sustainable Health Enterprises has developed technology to make a sanitary pad with cheap local materials such as banana stem fibers as the absorbent core.
And the research team from MIT's Abdul Latif Jameel Poverty Action Lab last year introduced the moon cup -- a device used by a handful of environmentally conscious women in the U.S. and Europe -- to Bihar, where 54 percent of the population lives below the poverty line, more than in any other Indian state.
The lab dispatched 50 field staffers to a district called Jehananbad, an expanse of green paddy and wheat fields dotted with tiny mud-hut villages outside Bihar's capital, in SUVs to reach villages so remote many weren't connected by roads.
The workers often had to walk the final 3 to 4 kilometers (2-2.5 miles) of dusty terrain to meet the research team's goal of introducing the cup to almost 200 women. More than 40 percent of the women approached had never seen a sanitary absorbent.
"Going to these villages is like going back in time," says Vivian Hoffmann, an economist and the lead researcher on the project investigating whether the menstrual cup can become a viable alternative to pads and rags for rural women. "There's a real gap in the literature when it comes to this population. So if we're going to find an impact from menstrual hygiene anywhere, we're going to find the impact here."
Menstruating women can't perform religious rituals, touch idols, pray, visit temples, cook, serve food and touch drinking water in many traditional Hindu homes because they're considered impure. Sushma, who says the cup has improved her life and stoked envy from other women, will still cook but not pray.
A few households in rural Uttar Pradesh, the state just west of Bihar, have a separate area for menstruating women to sleep, according to a report from Unicef.
Sushma isn't ready to ditch the taboos she grew up with. While she says she will discuss these issues with other women, and has showed them her cup, she goes out of her way to keep her husband and sons in the dark.
"We absolutely don't talk about it with men," she says, protectively cupping the head of her 6-year-old son. "It is dirty. Why should they know about it?"