Karan Babbar on Access to Reproductive Health

This episode is the eighth in a miniseries of weekly short episodes featuring young scholars entering the academic job market who discuss their latest research. In this episode, Shruti and Karan Babbar talk about his job market paper, “COVID-19 and Period Products Usage Among Menstruating Women in Urban and Rural India.” They discuss access to feminine hygiene products, effects of the pandemic on women’s health, how reproductive knowledge is transmitted, and much more. Babbar is a Ph.D. scholar at the Indian Institute of Management Ahmedabad. His research interests include education, public health, gender and intersectionality.

SHRUTI RAJAGOPALAN: Welcome to Ideas of India, a podcast where we examine academic ideas that can propel India forward. My name is Shruti Rajagopalan, and this is the 2021 job market series, where I speak with young scholars entering the academic job market about their latest research on India. I spoke with Karan Babbar, Ph.D. candidate in economics at Indian Institute of Management Ahmedabad. He has a bachelor’s in technology from Maharishi Dayanand University.

We talked about his job market paper titled “COVID-19 and Period Products Usage Among Menstruating Women in Urban and Rural India.” We talked about women’s access to healthcare and sanitary products during the COVID lockdown, and access to knowledge, in particular ovulatory cycle knowledge and its impact on unplanned pregnancies, and much more.

For a full transcript of this conversation, including helpful links of all the references mentioned, click the link in the show notes or visit mercatus.org/podcasts.

Hi, Karan, welcome to the show.

KARAN BABBAR: Hi, Shruti. Thank you for having me here. I’m super pumped up to talk about my research to a wider audience. And yes, can’t wait to get started.

Women’s Access to Healthcare

RAJAGOPALAN: Great. You basically work on women’s health, specifically gender-related consumption in healthcare and hygiene consumption, and also LGBTQ issues. Can you give us the basic landscape of women’s access to healthcare and sanitary products in India? Because we do understand that it’s limited, but I don’t think we understand the magnitude of the problem.

BABBAR: Correct. Thank you for the question. NFHS-4 data has shown that sanitary item usage—so they look at commercial products; menstrual cups are something that has not been included as part of that. We have local and commercial sanitary napkins and tampons, and around 57% of women use sanitary items.

In rural and urban areas, it’s around 49% in the rural areas and 76% in the urban areas. There are many state-level variations. For example, it’s as low as 12% in Bihar to as high as 91% in Chandigarh or 97% in Lakshadweep and 89% in Kerala.

Another important aspect that I look at is ovulatory cycle knowledge (OCK). Ovulatory cycle knowledge is the information around pregnancy. NFHS-4 data has shown that around 17% of women have ovulatory cycle knowledge in India. That’s a really, really low number. These numbers are around 16% in rural areas and around 19% in urban areas.

Now, again, the state-level variations are really different. It’s as low as 8% in Andhra Pradesh to as high as 61% and 66% in Punjab and Chandigarh. Other than Punjab and Chandigarh, the second-highest state would be Kerala, which stands at 36%. There’s a lot of state-level variations, which clearly shows that OCK is definitely one of the most taboo topics in India when we talk about sexual and reproductive health.

RAJAGOPALAN: Thank you for that. I want to dive straight into your paper, which is specifically talking about sanitary hygiene and menstrual products and access, in particular during the COVID lockdown of 2020 and 2021.

In this sense, the pandemic has these additional unintended consequences through the lockdowns in that they exacerbate gender inequality, in particular health and hygiene. That has both short-term and long-term effects. Can you tell us exactly the nature of the problem that has been exacerbated because of these lockdowns?

Sanitary Products During the Pandemic

BABBAR: Sure. Before starting with this, I would like to also talk about why we really did this research. The pandemic and the lockdowns have severely impacted period products. There were many commentary pieces, many small surveys which were clumped with larger topics on health. Then there were reports, which were based on very small numbers, that came out. However, these used to give us valuable insights, but these were extremely small. We needed something that could provide us a nationwide picture when we talk about period product prices.

Now when you look at the literature, there’s a lot of work around school girls. However, the unschooled—or the non-schooled girls—and women who are greater than 18 years old, these were never the focus of the researchers. So our paper also focuses on girls and women from age 10 to age 55. We have a larger composition in terms of the girls whom we are using in our study. Our paper uses a combination of temporal and spatial variation.

By temporal variation, I mean lockdown versus pre-lockdown, and by spatial variation, I mean that there was a government-mandated classification of districts into red, orange and green zones. This helped us in exploiting the lockdown as a national experiment in 510 districts of India. In terms of zones, we have data for Ministry of Home Affairs 2020; red, green and orange districts; and later on, period products were taken from CMIE (Center for Monitoring the Indian Economy).

Now, we have seen two things. Firstly, we have seen the period product consumption and then we have also seen the total product consumption. And both these measures of consumption were taken care of, since we have used RBI [Reserve Bank of India] estimates of inflation, so all the expenditure numbers were appropriate. In terms of results, what we have found is that period products reduced by almost four times in red zones as compared to green zones, whereas it has reduced almost two times in orange zones as compared to red zones.

This is broadly what we found, and then going forward in terms of implications, one big alternate that can be used is to improve the existing distribution system. Right now, we have ASHA [Association for Social and Health Advancement] workers and we have local shopkeepers who would be selling the sanitary napkins. However, with the lockdown, firstly, sanitary items never made it to the essentials list in the first go, which created a lot of delay. And obviously there was a little dip in terms of sanitary items. Hence it’s very important that the existing distribution mechanism needs to be enhanced.

We need divisional administrators or district administrators who need to gather and release the period products. They can tie up with ASHA workers or other frontline health workers, local NGOs, SHGs, and they can distribute such pathways which can further be distributed to the other people in the communities, especially during the emergencies. Because sanitary items are a very important part of women’s health, and that needs to be taken care of as much as the other essential items.

RAJAGOPALAN: One of the interesting things that I’m learning from this is that sanitary products were not even included in the essential list items.

BABBAR: They were not included in the first go. One week later, they were added into the sanitary items list. There was a big backlash from women and the local NGOs, and it created a stir, and they were finally added after a week. But then that little delay of a week has definitely created a larger delay in terms of production of sanitary items, because now everyone is allowed only 50% consumption. Let’s say even if there were 10 people initially who were making sanitary pads in terms of production, now only five can produce them. There was an initial delay, and then there was another production delay. All these things created a lot of delay.

Supply of and Demand for Sanitary Products

RAJAGOPALAN: It’s so interesting that it seems like it is men making policies for men, and there seems to be just a conversation missing about what is an essential household item. And this is particularly so in India—where India is just such a young country, so one would imagine that you would expect most women to be in the reproductive age and requiring these products. It’s kind of astounding to me that we have just completely forgotten about hundreds of millions of women. This is not a small group that we’re talking about. From your paper, that was the part that sort of struck me the most.

I have a couple of follow-up questions on sanitary products in particular. Overall, we know that consumption dipped during the lockdown. This is not just true for sanitary products. It’s true across the board. We know that it also bounced back, for the most part, as the lockdowns started easing. How were sanitary products affected worse than regular consumption because of the lockdown?

BABBAR: Actually, this is a very interesting question. What we did—we checked the data on gloves, syringes, ORS [oral rehydration salts] and other antibodies. There was a small decrease in April and May, but there was a colossal dip when we talk about sanitary pads. That clearly shows that these items, which are transferred to various distribution channels—so definitely there is some kind of distribution mechanism that is being maintained. However, maybe sanitary pads were not on the priority list by the government and other policymakers, and that was the reason why we found that there was a lot of product dip around it.

RAJAGOPALAN: Could there be a demand-side dip? In the sense that I know that sanitary pad usage is pretty low in India overall. Women use a lot of substitutes like rags and other kinds of homemade products. Could it be that because they’re not going out to work and they don’t need to be out and about, so to speak, they are substituting away from these slightly expensive products more for home use products given that they are confined?

BABBAR: Actually, this could be a good question, good argument, but remember, we are using difference in difference. These are the same women who were using sanitary products before the lockdown and the same women who are using sanitary products after the lockdown.

RAJAGOPALAN: They shouldn’t, right? Because during the lockdown, you’re not leaving the house. If there is a time to substitute away from these goods, then maybe that’s the time to do it?

BABBAR: Another thing, so—

RAJAGOPALAN: I don’t mean they’re substituting away from them overall—just during the lockdown.

BABBAR: Definitely.

RAJAGOPALAN: Does consumption reduce, for instance? People bought less footwear because they’re not leaving the house very much, or people bought fewer clothes because they’re not leaving the house. They’re sitting in their yoga pants, right? This is the very Western world—people have been talking about how formal clothing consumption has dipped. Could there be a similar demand-side effect only during the lockdown for sanitary products, which is not a supply explanation? I guess that’s my question.

BABBAR: Sure. Actually, again, this is very interesting because I also conducted a small survey to understand the menstrual health of the women during the lockdown. In my survey, I couldn’t find any such thing. Definitely there was one thing that I appreciated. A lot of women—a small percentage of women—moved to using menstrual cups. You are at home and you are relaxed, so if you’re trying a new product, you are comfortable in your own zone. That happened, definitely, but it was a very, very small dip. And that dip can’t account for the four or four and a half times of items that we have seen.

Secondly, I agree that the growth might be a little low since everyone was at home, but the essential products were being delivered by Amazon and Flipkart and many other companies. That was always there. That was something that people have used. Obviously I haven’t talked about it in this paper because this is completely different from what I have done in the research, but these were few of the examples that I have seen.

I’m also going to talk about black marketing that I also see as one of the responses. There were a lot of women who have reported black marketing of period products. Women said that they went to the shopkeeper to buy the sanitary items, and then they were—so let’s say the item is for 70 rupees; they had to pay 350 rupees for that, just because they are saying that this is an essential product. And if I can quote the exact thing, they said in Hindi that, “Madam, yeh toh zaroorat ki cheez hai. Aapko isko abhi use karna hai, aur lockdown mein kuch bhi nahi banraha hai.” This is very important, and this is very essential. For the listeners who don’t understand Hindi, what I’ve said is that “During the lockdown, we don’t have the sanitary production going on, and that’s the reason why everything has been costly. And this is an essential item, so you should buy it at this amount.”

Long-Term Implications for Women’s Health

RAJAGOPALAN: Yes, demand was incredibly inelastic at that point, right? When you need a pad, you absolutely need a pad, so you end up paying 350 rupees for it if that’s what the requirement is when there’s a shortage. When we think about sanitary products and this kind of shock, this lockdown or pandemic-related shock, it’s a very short-run issue, and it bounces back relatively quickly. Are there any long-run implications?

BABBAR: Yes, there are. Again, if you talk to doctors during the same time, there was a dramatic increase in reproductive and urinary tract infections. Infections increased to a multifold region Second, there was this black marketing. I’m not talking only in terms of women’s health, but what were the larger-level issues.

Another thing that came out from my survey was that around 22% of women have missed their periods, 15% have got two periods within the same month, approximately 75% women have reported changes in menstrual pain and blood flow and 60% have reported change in the menstrual cycle. These are very long-term implications that we are talking about, and definitely, it had a big impact.

Knowledge of Reproductive Health

RAJAGOPALAN: If you don’t mind, I want to also discuss another one of your very interesting papers, which is now about access to knowledge, more than just access to goods and services. This is about the information on ovulation cycles. I haven’t thought about this too much because, as you can imagine, I had a very privileged education.

I have learnt all this in schools and at home. To me, the idea that women might be lacking knowledge in correct ovulation cycles and therefore it leads to more unplanned pregnancies is surprising. But as you laid out, it is a more common phenomenon in India than one would imagine. It has some really serious long-term implications. Can you just tell us a little bit about what is happening with information and education of women about their personal health and reproductive health, in particular ovulation cycles?

BABBAR: Sure. Around 85 million women worldwide face unplanned pregnancy, and 15% of these cases are in India. Since you talked a lot about school education, definitely school education has been designed to talk about ovulation cycles. However, these sexual and reproductive health sessions are overly relied on, and they broadly talk about the science concepts, but they do not talk about the practical guidance. Due to the lack of this formal education, most of the women or most of the girls get the ovulatory cycle knowledge basically from their mothers or from other elderly figures in the home and the state.

Now, if we talk in terms of research, most of the researchers worldwide have focused on understanding the link between unplanned pregnancies and usage of contraceptives. They’ve also talked about unplanned pregnancies and socio-economic factors. One of the critical factors that they really need to talk about is knowledge of ovulation, but to the best of my abilities, I couldn’t find more than one or two papers which talked about it, and none in the Asian context.

They were broadly talking about the determinants of OCK and the research objective. Even in schools when we talk about—teachers either skip this topic, or it is something that is rarely talked about. And hence, it is very important that we start talking about ovulatory cycle knowledge and how it links to the other fertility outcomes. As a part of this study, we have made two broad contributions.

Firstly, we have tried to see the prevalence and correlates of OCK. OCK is very much endogenous for fertility outcomes, and we found that ovulatory cycle knowledge is definitely linked to education levels. In the case where I’m well educated, I will have a good ovulatory cycle knowledge. And hence, my age at first birth and—my number of children would be less, and my age at first birth will be a little higher. That’s why we have used an intergenerational knowledge transfer from elder women and from mothers as an IV (Instrumental Variable) to measure the ovulatory cycle outcomes.

Our instrument works since the knowledge held by older women in the district cannot directly impact the fertility decision of the women, except they can have an impact on their ovulatory cycle knowledge. And hence, we feel that our instrument worked very well.

RAJAGOPALAN: Can you tell me a little bit about this transmission mechanism? To me, it seems like you’re saying that because they don’t have good science and schooling, which actually describes the process in detail, a lot of how they learn this is through their informal networks: women, their friends, elderly women, maybe the midwives, the anganwadis that are in a particular community and so on and so forth. That’s the information transmission mechanism that is taking place, right?

Could it be that some of this informal knowledge transmission is now being substituted away because people are relying more and more on contraception to prevent unplanned pregnancies? And because of this, this overall culture of intergenerational transfer of knowledge or women talking about these ideas has overall reduced because now there are alternatives to it in the form of condoms and birth control and so on?

BABBAR: That’s a very interesting thing, but at the same time, we also need to understand that in India it’s such a taboo that I don’t see girls or women walking in the shop and asking for condoms or asking for contraceptives. They would need someone else for that. I don’t think it could be working that way in India as of now, just because it’s such a big tabooed topic. And if we can focus on ovulatory cycle or if we can focus on ovulation, it would work very well.

In terms of results, first we talked about the determinants of ovulatory cycle knowledge. We found area of living, in terms of rural or urban area, age groups, religion, caste, education level, wealth index and mass media as the important factors which determine the ovulatory cycle knowledge.

Then we also checked for the intergenerational transfer of ovulatory cycle knowledge. When we talk about the socio-demographic coders like area of living, age groups, et cetera, when we talk about these things, the odds ratio lies somewhere between zero to two. When I talk about intergenerational transfer of ovulatory cycle knowledge, it had almost 143 times impact on the final ovulatory cycle knowledge. That had a big, big impact. That really identified that IV variable as a really good one.

Then we controlled for endogeneity by using the intergenerational transfer as IV, and we found that OCK increases age at first birth and reduces the number of children. That was something that we found in our study.

Homophobic and Gender-Based Bullying

RAJAGOPALAN: That makes sense, right? The people get to know their ovulatory cycles better, and then they’re able to better plan their sexual decisions and their pregnancies and so on.

Karan, what else are you working on right now?

BABBAR: I conducted another survey during the pandemic to understand how homophobic bullying and gender-based bullying is creating issues for the mental health of those coming from the LGBTQIA community. That is another thing that we are working on.

Broadly, we are working on two papers right now. In the first paper, we are talking about the coming-out stories of the LGBTQIA community to the parents and families. It’s a qualitative study, and it’s a work-in-progress paper. In the other paper, we are trying to understand how homophobic bullying affects depression. We have developed a moderated mediation model, where we show that gender-based bullying mediates the link between homophobic bullying and depression. And again, the link between gender-based bullying and depression is moderated by the self-concept.

People who have higher levels of self-concept and who are being gender-based bullied are more likely to be in a depressed state. This is broadly what we have found out. That’s about it.

RAJAGOPALAN: Is this specific to the pandemic or the lockdown? Did that exacerbate these problems the way you find with women’s menstrual products and access, or was it just the convenient time for you to do the survey?

BABBAR: Actually, we conducted the survey sometime in October, so it was not exactly in the lockdown. I don’t think that the lockdown has exacerbated these situations, but these might be very underrepresented situations right now, just because since the pandemic is there and most of people are doing work from home. A lot of bullying comes not from the people who are at home, but from people who are outside. Now, since everyone is inside, these might be underreported results. But again, one of the very important research studies done in India.

RAJAGOPALAN: Yes, it’s interesting. On the one hand, the pandemic and work-from-home situations and a decrease in economic and outside activity can reduce the kind of bullying one might face.

BABBAR: Yes.

RAJAGOPALAN: On the other hand, it might also closet more people, right? Because a very large part of the problem in the LGBTQ community in India is coming out to families themselves, and so being at home—it’s this tradeoff between one kind of mental health problem versus another kind of mental health problem. You’re absolutely right. It’s an incredibly underrepresented topic in India, and the numbers are so large in India that it’s worth studying the community stand-alone as a question of mental health.

On a happier note, what have you been up to during the pandemic?

Pandemic Activities

BABBAR: I started writing last year during the pandemic. I’ve written various media articles. That is one thing that I’ve started doing, because there are a lot of issues that I actually think about that I should be talking about, I would say. After that, any topic that I felt that should be out there in the market or I should have an opinion about it, I have talked about it.

Recently, there was a TikTok ban in India last year in May, right? Everyone was saying they have done really well by banning TikTok, but we were coming from the other side. We said that TikTok actually created a good market for a lot of people. For example, someone who is coming from a rural area—he’s extremely talented or she’s extremely talented, so TikTok provided them a platform where they can show their talent and they can reach out to a wider audience. It is like killing the voices of those people that has been really awful. That is one thing that I have done.

Then, last year, there was this National Education Policy that came out. I was actually hoping that National Education Policy is coming out after like almost 28 years, and we would be getting something really great. But when National Policy came out, we realized that there was no mention about menstruation, which is one of the very important topics. At one end, the policy was saying that girls are an underrepresented group. We need to do things where we can bring girls back to school. At the same time, there was no talk about menstruation.

Girls almost miss around 23% of their school time just because of menstruation. Hence, it’s one of the very, very big topics that needs to be really talked about. It was missing out from National Education Policy. That was, again, another thing that we talked about, why it’s really, really important that we need to come together as a society and really talk about menstruation.

Lastly, I’m also vocalizing for men to talk about sexual and reproductive health, especially menstruation and ovulation. If you’ll see, there is not a lot of work around sexual and reproductive health. It’s because we, as men, don’t talk about it. Any topic that men talk about gets the dominant discourse in society. Just for this product domain to be coming out, we really need to talk about menstruation.

Lastly, there is no mention of LGBTQIA in the discourse around menstruation. When we talk about menstruation, it’s just about women. There’s nothing about the LGBTQIA community. We really need to include trans and non-binary in the discourse of menstruation, so these are some of the things—

RAJAGOPALAN: Absolutely.

BABBAR: These were some of the things that I really felt that we should be talking about. I wrote a lot of popular pieces around these articles.

RAJAGOPALAN: Well, I’m really looking forward to reading that. I’ve only read your research so far, so I’ll definitely look up some of the popular pieces, and we’ll link to them. Finally, the most important question: During the pandemic, what have you been binge-watching?

BABBAR: I’ve watched a lot of web series, a lot of movies. I’m a movie buff. Before the Ph.D., I used to watch movie almost every Friday, but then the Ph.D. happened and then the pandemic happened. I have recently started watching movies. It was required for me to start living again. That has really helped me.

RAJAGOPALAN: Do you have any recommendations?

BABBAR: I have talked a lot about sex education. I would recommend everyone watch “Sex Education.”

RAJAGOPALAN: [laughs] That’s, I think, a great recommendation. It marries your personal interests and your research interests really well. Thank you so much for doing this, Karan. It was a pleasure to speak with you.

BABBAR: Same here, Shruti. It was really nice, and I look forward to talking with you again.