DOI: 10.31038/AWHC.2020323

Abstract

The menstrual blood considered impure, dirty and contaminated in Jumla, a place of research for menstrual restriction and its impact on empowerment where the qualitative method, feminist ethnography employed, through three different methods: history/timeline, participant’s observation and In- Depth Interviews. The restriction during menstruation is very complex, vary from person to person, contradictory position between practice to practice within same person or family. The participant followed 29 types of restrictions related with food, touch and mobility during their menstruation. Because of these restrictions, girls and women deprived from access to food, water, shelter, mobility, hygiene, health, education. As a result, they felt isolated, inferior, disempower, deprivation from participation in school, social activities/celebrations and losing dignity. These situations contributed for compromising rights assured by the constitution of Nepal and considered as violation of human rights. Here, the restrictions during menstruation played a role to construct and shaped the power among girls and boys. As a result, the all aspects of the girls and women’s life affected and eventually they deprived from the empowerment.

Keywords

Menstruation, practice, restriction, women’s dignity, empowerment

Introduction

Globally, depending upon the areas of residence, school’s norms, parental guidance, media etc. few girls and women aware about the menstruation [1] where as many rural, tribal and even educated girls and women do not aware about the menstruation [2]. This kind of experience is very common in Nepali society even school going adolescent girls [3]. Nepalese community considered the menstrual blood as impure, dirty and contaminated that established by religious books, schools and informal institutions. As a result, girls and women are following multiple levels of restrictions during menstruation as common practice in Nepal. Among the development work, media in Nepal and beyond the word Chhaupadi is popular since MDGs (Millennium Development Goals) which as restriction during menstruation. The restriction during menstruation outlawed in Nepal since 2005 and there is law against any forms of discrimination, exploitation, violence during menstruation since 2018 (“Nepal Law Commission – NLC,” n.d.). There are schools of thought regarding the cause of practicing restrictions during menstruation. It has been in practice due to illiteracy, superstition and gender inequality revealed that the concept of impurity and poor menstrual hygiene impacted for Millennium Development Goal (MDG)-two on universal education and MDG -three on gender equality and women empowerment. Likewise, menstruation has multiplier effect for achieving the Sustainable Developmental Goals especially to goal five for gender equality.

Since the 2014, there are few studies started to take place in Nepal and globally that were most focused on hygiene. In Nepal, such studied conducted for the academic purpose as well as NGO’s intervention. Thus, the studies that encompass on consequences due to following the restrictions during menstruation is not available except some opinions in media and activism for instance for 2017, Jyoti Sanghera, a pioneer activist stated that the stigma during menstruation is violation of dignity including violation of several human rights [5]. The menstruation played a crucial role to bring equal position in holding power, participation in decision making at family and workplace [6].

In this connection, this study took place to provide the critical view on impacts of menstruation on empowerment of girls and women with following research questions:

i) What are restrictions practiced during menstruation?

ii) To what extent, the education affects by the menstrual practice?, and

iii) What are the impacts of menstrual restrictions on empowerment?

Methodology

This study employed the qualitative approach where applied postpositivist world view with feminist ethnography for the change at the life of women and society by questioning the policies and demands for social transformation [7]. Chandanath Municipality, Jumla district is the site for data collection due to accessible by bus, cost, time compare to others areas. More importantly, this community has been practicing restrictions during menstruation [8]. In order to avoid the reflexivity, the purpose and process explained with gate keepers. The participants for data collection identified as guided by the gate keepers till the saturation of data. The ethics maintained by securing the approval from National Health Research Council (August 2017) and obtained verbal and written consent. As suggested by the Elana D. Buch & Karen M. Staller, [9] primarily, the three types of methods: history taking/timeline, participants observation and In- Depth Interview employed in order to get rich data around menstrual practices. The interview guide, observational check list used for collection of data. The participants identified through gate keepers as well as snow ball methods specially to find the menstrual girls and women.

Life history/Timeline

The total four menstruating participants between 28-40 years identified. They all represented married and followed Hindu religion. Regards to caste two were from higher caste and the remaining belonged with Dalit and Chhetri respectively. Except one, all participants never ever been to school and three worked at home.

Participatory Observation (non- participant to participatory)

The six menstruating, married participants considered for participatory observation for three days. Out of six, two were never ever been to school, two were belonging with Dalit and rest of them belong with higher caste. And, three were working as health workers, two worked as house wife and one was student.

The place or location, clothing (during menstruation and after), physical gesture and sitting/sleeping, interactions (family and social), physical appearance, personal behaviours/emotions/feelings, key influencers, food/liquid intake, restrictions (private, public), mobility, used and management of sanitary materials, cleanliness observed [10].

Mass observation

Two mass activities; Teej celebration (Annual festival specific for women called red colour festival as well) and Temple observation observed.

In-Depth Interview with Key Informants

The total number of participants was 17 (Female -8, Male-9). All the female ranges from 14 to 80 years of age and have experienced of restrictions during menstruation. Regards to occupation, they belonged with teaching, health service provider, faith healers, journalist and housewife. Except three females, all were married. Regards to education, except one participant, all were educated. In terms of caste, only two participants were belonged with Dalit.

The data and informational triangulation through multimethod approach, probing questions as well as follow up visits during field visits. The field notes, videos, photos used to verify the information. The data started to analysis since the data collection. It was iterative process of collection of data and analysis. The data transcribed, coding, and generate themes. For ensuring the accuracy, the data corroboration with various sources of data. In order to ensure the grounded of data, logical inferences, appropriate themes, justified decisions and methods, credibility and biasness, the research process and analysis reviewed by peers and supervisors time and again as a form of eternal audit.

Results

Restrictions on Touch during Menstruation

Since menarche, participants were avoiding to touch various things by considering the menstrual blood impure. During menstruation, girls and women not eligible to touch places (foundation of house, house, kitchen, temple, toilet), person (male member, faith healers, seniors, priest,), things (tap, river, intercourse, book, cattle, clothes), and plants of vegetables and fruits.

Restrictions to Eat during Menstruation

Menstruators prohibited eating rice, vegetables, fruits, milk products, prasad, meat products, beans, sour foods during menstruation.

Restriction to Work/Mobility/Participation during menstruation

Menstruators restricted in mobility, cannot work inside the house, same road or place as seniors walk/work, around the temple, meetings and cultural celebrations.

Impact on Empowerment

The perceptions, practices and understanding around menstruation have been reflecting the impact on empowerment at individual, organizational and community level and overlapped each other [11]. The feminists considered the empowerment as mutually strengthening and intersecting the sub process where the problems identifying and deconstructing for action and critical reflection 12].

Due to restrictions, there is impact of education and health that overlapping each other and impacted to the lives of girls and women throughout the life. Girls and women do consider the menstruation as matter of shy, stigma, and taboo instead of biological process and pride. Simultaneously, their knowledge, attitudes, and practices pulled down the confidence of girls and women to see them as equal human being as boys or men.

Control of Body of Girls and Women during Menstruation

The imposed restrictions connote the lower status than boys. Those kinds of understanding started to build since age of fivenine years from their mothers, sisters, friends, other relatives and neighbourhood. This brings the `powerfulness’ for boys whereas the `powerlessness’ to the girls. Menstruation appeared as tool to construct the power since childhood. The boys possess the Power Over Decisions and girls resembles the Power over non-decisions according to the power theory [13] McCabe, n.d.).

Before menstruation, girls started to see themselves as humiliation and inferior than boys whereas boys are socializing the opposite direction. In addition, girls lost their dignity and peace of mind since childhood.

The isolation and exclusion from the home and regular activities, for five to seven days in a month has served the status of girls and women due to menstruation. Further, the living status gives the idea of menstrual girls and women are lesser than domestic animals.

Boys, teachers and girls know that the girls have menstruation from her absence of school during menstruation and drop off the class in between. Because menstruation considered as matter of shyness/ stigma/taboo. Such situation further amplifies the state of impurity for menstrual blood. Because of such understanding, girls cannot concentrate on class if they joining during menstruation. They lose their self-esteem, confidence within themselves and lose their dignity in the public. Participants shared that they felt like they are doing any act like crimes thus they felt so guilt while having menstruation and more shame and guilty if anyone knew without letting them directly.

“During my first menstruation, I missed the class for five days. I felt so embarrassed and powerlessness while joining the class next week. I was so flushed to see the faces of teachers and boys in class due to shame and feeling that I committed crime. Because they know automatically if any girl missed the class like this’’.

IDI_Healthworker_Female_5

Due to restrictions, menstruation considered as women’s private business thus girls and women feel humiliated and disempowered. Men never menstruate but they keep learning since about four to nine years old from their sisters, mothers, aunts, relatives and neighbourhood. Almost all of them agreed that they discussed about the menstruation among themselves (secretly). Boys gained the power that they never been menstruating means pure, higher, privileged than the girls. They started to see not only girls are inferior, low status but also started to learn to govern their ideas and body like do this and do not this since childhood to their sisters, friends and others.

As men grow by, their parents, faith healers, seniors are asked to follow the restrictions by limiting themselves because of state of impurity of women. There is a long list of` Do’ this and `Do not’ this regarding to menstruation. As a result, they strongly believed that menstruation is impure state, made by god and men should not contaminate with menstruating girls and women at all. Because men have posses’ superior position by god, men have outstanding power than women. Thus, men see themselves as governor, power holder wherever they are.

Feeling of Inferior

Regardless of caste, class, education and occupation, all female participants felt deeper level of humiliation, inferiority since they menstruate. One of the participants shared her first feeling from menarche was losing myself (aba ma sakiye -IDI_adolesent girl_17). The dehumanization and inferior complexity are deeper and stronger due to compromises the biological needs and social needs such as food, drink, shelter, sleep, security, mobility and isolation from the friends, family, affection, relationship. Participants verified themselves that the menstrual blood and menstruating women is really `impure’, `dirty’. Few close friends were visiting at shelter and often accompanied though they all confirmed that they are real `powerless’ creature in this world because their esteem needs such as self-esteem, achievement, mastery, independence, prestige etc. were heavily scrutinized. Meantime, they also so much confused with the imposed list of restrictions during menarche which were incompatible with learnings what they learned from formal education regards to purification process including cleansing with cow’s dung and urine, spray of golden water. They were depressed with lots of imposition including putting loads of responsibility to women followed by menarche.

Since the first day of menarche, participants experienced surprised, shocked, sad due to ignorance about menstruation, management of blood, the norms or lists of `Do’ and `Do not’ associated with menstruation. Continuously, they felt humiliation, disempower and lower than men. Due to inaccessibility with food, shelter, water, mobility, participation, they equally experienced humiliated, inferior and disempower. The purification process is mandatory and important even during the season of snowing and state of sick. However, all participants thought that the purification process also changed already.

“In the past, we used ash to wash for purity. Now we use soap, surf to wash cloths in river by slapping in stone. I, myself, use the shampoo for washing my hair, use tika on forehead. There are so many instructions for do and do not that make me sad, inferior and frustrated’’.

Timeline/History Talking_Female_3

All participants know that the menstrual girls and women are even not allowed to touch foundation of the house since childhood and often feel inferior to boys and men. Such feeling rises even more after their menarche. They feel themselves less recognized compared to male at family and community. They do not feel that they have any power or authority over the property of the family though they work so hard than boys and men. Participants shared that they often considered themselves as persons with less value. The restriction for not allowing to touch foundation of the house caused them disassociated with their own family and confirmed the feeling of inferior human being in this universe due to impure menstrual blood.

As like the restrictions, not allowing touching the foundation of the house, the restriction for entering into the house resembles the feeling of sad, sorrow, feeling of insecure, low confidence, low status than man. Because of the heavily compromised the biological needs such as food, air, shelter, hygiene, love affection, family etc. which are important for girls and women during menstruation.

Almost all participants including elders shared that they were so frustrated due to not allowing entering into the kitchen. They said that they have to be deprived from the getting food and water when they got hungry and thirsty. They tired up and losing their dignity while requesting and pleasing siblings/children/in laws. Most of the participants simply gave up them to please means they just waited whenever they gave. Few participants just went to bed without having food.

Because of the restriction to avoid touch with men members, girls and women lose their self -esteem, confidence and dignity as well as considered themselves as inferior and low status than men. In addition, participants also deprived from participation in activities related with learning, entertainment, social cohesion and development. Because the men are everywhere at home, school cultural gatherings and meetings at village council.

Due to the supremacy attitude and practice of seniors, the participants had `scared’ `irritating’ feeling towards seniors. They felt embarrassed, humiliation, inferior and often dehumanization’s from the comments passed by the senior. This culture is one of the pushing factors at family and community to engage in voluntary child marriage.

Feeling Isolated

The both deep ignorance and silence and emotional stress including sad, hopelessness, dying soon, crying, feeling isolated pushed participants towards disempowerment during menstruation and rest of the months.

Deprivation from Participation

The joining in a meeting is a form of participation of political process at community. The deprivation as well as the emotional and physical abuses both were double the reverse impact on empowerment. Once, they failed to exercise their rights here, they would fail to claim in municipality political process.

Losing the Dignity

The restriction for not touching the plants of vegetables and fruits promote the condition of deprivation of seasonal nutritious foods which is violation of right to food, right to dignity, right to mobility. Further, these situations created the emotional unwillingness which leads deep psychological trauma. The restriction for not touching the cattle leads disempowerment for girls. Few of them, expressed their anger and frustration against such restriction because they were responsible even during menstruation to cut grass, and graze them but not allow having it. They felt humiliation by considering the low status than the animals.

Restriction to touch toilet during menstruation negatively impacted to learning and health issues e.g. attacked by the wild animals, experienced sexual abuse including rape.

Touch has directly connection with right to dignity and right to participation or mobility or touch of the girls and women during menstruation that is assured by the constitution of Nepal (“Nepal Law Commission – NLC,” n.d.). They also deprived from safety, security, confidentiality, enough water to clean clothes and body etc.

Due to no access with clothes, adequate and nice clothes. These circumstances established the feeling of low status and humiliation among participants.

“I wanted to participate the festival at market with hiding my menstrual blood but I could not participate because my mother scolding that I should not use such new clothes during menstruation. If I were using these clothes during menstruation, I could not use these clothes in any programs for future due to concept of contamination with impure menstruation. The more I remember; I still feel more humiliation and anger though I am against of these naughty cultures’’.

IDI_Health Worker_Female_11

In the beginning, the female participants were spontaneously expressed their believes and practices regarding the reason of restrictions to have milk and milk products. Later, when they discussed deeply about their first feelings and impact, they appeared sad and unhappy. They said that this practice is visible form of discrimination towards girls and women and key reason of being weak. In earlier days of menstruation, they cried, they felt regret as being born girl, they fought with their parents and seniors and even they thought to end their life.

The restriction of not allowing to walk around temple also accelerating the disempowerment among female participants. Because of such practice, girls and women feel underprivileged and disadvantages than men. They feel humiliation, discrimination and anger towards the society, family then themselves due to unable to join in the public activities such as sports, group meetings, celebrations etc.

They had experienced of double victimization due to menstruation and also scolded by the neighbours while they were watching the celebration and meetings from distance. Often the religious or other activities were cancelled due to menstruation where menstrual women got blaming of all lost and reschedule.

“The status of menstruation is the foremost enemy and hateful thing for women. “Sometimes, I pushed myself and tried to join the cultural program but I had to stay and observe things from very distance. Sometimes, the women shouted even observing from distance. They became sad and angry if the menstrual woman is in front them. They believed that they were attacked by god and shaken (Paturne). People even do not allow to plant and gardening in the field at the beginning. The non- menstruating women start and then they allow menstrual women to enter in to field in farm. We are supposed to postpone the religious and cultural activities such as worships, weddings if the women menstruate at the house of hosting’’.

Life History//Timeline_Dalit Women _2

“I do not like to go anywhere because I often feel so weak and lazy and like to lie down.

At bed throughout the period. I often lose my appetite because of discomfort. My culture does not permit me to participate to any marriage ceremony and even religious activities. I am only allowed to go to field for work. Many times, I had to cancel my visits to religious activities with other family members after menstruation’’.

Almost all participants including men said that the menstrual women have rare chances of interactions with older and religious people. They can only interact with limited people such as daughters and female friends. The impact of menstrual restrictions, stigma has hit all aspects of life of girls and women in many ways. Because of restriction, they started to missed out the classes or poor attention on learning and education. Then they started to failing in subjects and eventually stop to go school. Some of them just trapped with early or child marriage because of dismissal of their dream on education and life. It is really complex to understand.

“I am 14 years old now studying at grade ten. It is only 5 minutes walking distance. I do not like to go school for 3-5 days during menstruation. I did marriage just six months before forcefully. My new role as married woman got much workload in the family and caused fail in English. Now, I am bit confused to continue my study or not’’.

Participants Observation__ Adolescent Girl_Dalit _6

Working in the field and collecting firewood or fodder is not a problem at all. But the problem is they have to work in pressure. They have to finish the work within bleeding days otherwise they cannot concentrate these works due to the work at inside the house. This is form of discrimination, violation of human right especially right to dignity, right to freedom, right to choose, right to food etc which is guaranteed by the constitution of Nepal.

Disempowerment due to Deprivation from Learning

Deprivation from learning and quality education, is a serious form of disempowerment. The level of chronic emotional unwillingness, deprivation from quality educational opportunities and trapped early or forced or voluntary marriage of girls, pushed further form of disempowerment.

“The situation was different in the past. In my case, I even, did not send my daughter to school after menstruation. She got marriage and sent to her husband’s house. The same situation applies to some of my relatives as well where daughters have to leave school after menstruation even at present. Now, situation seems changing gradually. Now, I myself prefer to send them to schools though few restrictions still exit in the society.”

IDI_Elder Women_12

The deprivation from touching the source of water supply means deprivation access to water supply. They disempowered from the perspective of health and dignity. The water for drinking and hygiene or clean both the basic need for humans. Participants expressed their frustration from this practice which is unavoidable at all.

‘`I have bitter experience when I got first menstruation in my life. I was not allowed to touch water for 15 days, though I got permission to stay inside my house and eat food without touching other members in the families. I was treated as beggar that made me so frustrated and angry. Even for bathing, I had to go to irrigation canal’’.

IDI_Healthworker_Female_11

Those girls and women who do not follow such restrictions, they have confidence to behave in front of all. Among the participants who represented dalit and Tibetan group, and were working at local hotel said that they never experienced discrimination and nobody asked them to follow restrictions during menstruation. They said they were serving food items to all people including even priests. They said that;

“We belong to dalit and Bhote caste people and work at this hotel for years. We do not make our menstruation period to public and do not follow any restriction as upper caste women follow. We do everything here from cooking food, serving to costumers, cleaning at kitchen, rooms and everywhere’’.

Informal Meeting_Feamle_Lama

During menstruation cycle, women are not allowed to work inside the house due to state of `impurity’ and `dirty’. This is very powerful instruction to dominate the status of girls and women since childhood even before having the menstruation. In Jumla, the kitchen is the primary level of parliamentary where the family members review their daily activities, share the common issues from neighbourhood and plan for next day and future but women in menstruation period have to miss the opportunity to participate among family members. The participants however, were found themselves as victims of social discrimination.

The youth participants said that during their menarche, even the girls from the educated families, were not allowed to go schools due to scare of contaminations. It even applied to those who were not at school. Such restriction not only hampered to their education but to their participation at household activities. The incidence of child marriage connected to menstruation however, was not perceived well. Regarding this, a female local politician said:

`I do not know why the practice of child marriage is rampant in my community. Though the Municipality is organizing various awareness raising activities, there is no impact yet’.

IDI_PoliticalLeader_Female

Discussion

Among 29 different restrictions, few are overlapped and interlinked with each other. These restrictions hit all aspects of the life of girls and women in many ways. As like restrictions, the impact also overlapped and interlinked each other.

There are various ways of defining empowerment, primarily focused on gaining power and used as key concept in almost all discipline [14]. Menstruation has significance role on life of girls and women from womb to tomb and all aspects of the life where they may or may not gain power.

First and foremost, menstruation associated practices constructed the power at an individual level of boy and girl and at institutional. Both girls and boys started to learn the menstruation since young childhood. Without knowing any logic, girls see themselves as like mother who have to work hard, dominated by the men members, powerless due to the state of impurity of menstrual blood. It has similarity with the believe of Rappaport (1987) where the empowerment as process of gaining mastery by people, organizations and Communities, happening at multiple levels [15]. Since childhood menstruating girls and women kept actively engage with their community and an understanding the socio-political dimension around them instead of having observations or self-perceptions regards to menstruation. In this vein, [11] emphasized that that psychological empowerment is more than self-perceptions.

As time passed by, girls started to cope with all consequences brings by menstruation. They do without any questioning, challenging even they do belief in such a deep way where they see logic against restrictions. They see these restrictions as part of culture, order from the god, who make and put everything in order. Consequently, they started to realize that the sexual abuse, domestic violence, rape, intimate partner violence, deprivation from opportunities etc. are all happening because of discrimination against girls and women due to their state of impurity. These are the form of violence but they do not have courage to speak due to deep feeling of powerlessness and hopelessness. Eventually, girls and women converted as victim. In alignment with this, the close tie was revealed between restrictions during menstruation and gender based violence including rape [16]. The state of powerlessness is constructed and learned by menstruating girls and women through the observation, past experience, ongoing practices, behaviour and thinking patterns before, and during the menstruation. Feminist believed that the powerlessness or oppression or deprivation is the outcome of both socio-economic and psychological factors [17]. Further, this study emphasised for understanding the material reality of oppression. In contrary this, powerlessness considered as more than lacking power including inability to cope with emotions, skills, knowledge, lack of self-esteem including lack of external supports [18].

Meantime, boys considered themselves more powerful, superior, privileged at home and community due to the state of purity or no menstruation throughout the life since god’s time. As time passed by, boys started to provoke with all consequences brings by menstruation. They denial to do, arguing even they do belief in such a deep way where they see logic against restrictions. They described these restrictions as part of culture, order from the god, who make and put everything in order. Consequently, they started to realize that the sexual abuse, domestic violence, rape, intimate partner violence, deprivation from opportunities etc. are all happening because of discrimination against girls and women. These are the form of violence but they do remained silence due to deep feeling of powerfulness and state of privileged. Eventually, boys converted as perpetrator.

In this vein, the Garg et al., [19] Johnston-Robledo & Chrisler [20] agreed that the segregation due to impurity and restriction regarding touch, the girls considered themselves inferior, negative feelings towards their body. As Rembeck et al., [21] believed the girls and boys self-esteemed and self-agency built since childhood where the family played a vital role for that and influenced by and from menstrual practice. In this vein, Johnston-Robledo & Chrisler, [20] argued that the lower status of women was determined by menstrual stigma and taboo in the family and community.

Figure 1. Menstrual Restrictions construct the power

Figure 2. Menstrual Restrictions and its Impact on Empowerment

Figure 3. Menstrual Restriction and its impact on empowerment

Menstruating girls and women lose their sense of and motivation to control, skills for decision making and problem solving and critical awareness on socio-political environment as impact of psychological disempowerment. In this vein [11] described as constructs; interpersonal, interactional and behavioural component under the homological framework of psychological empowerment. Additionally, limiting or exclusion due to menstruation also affects women legal rights and freedom of women in public sphere.

The impact of education and health are overlapping here. Girls and women have low self-esteem, feeling of inferior, humiliation, hopelessness, powerlessness because of compromising the needs and rights related with food, water, shelter, environment, education, health and eventually dignity [22]. Dignity is such a right which includes all rights and offers right to all aspects of life of girl, women and any individual. Poor education, poor health is the status of poor human right and status of disempowerment.

Conclusion

Girls and women lose the confidence for living as a dignified human kind due to imposing of varieties of restrictions during menstruation. They used to with this too. In this connection, stakeholders need to carryout the holistic approach to get rid off from the negative impact on the lives of girls and women due to restrictions due to menstruation. Because the above-mentioned figures showed that the impact is not in a single line (liner way). It has multiple connections and overlapping each other’s. The dignity and empowerment during menstruation could bring through combined efforts of different elements such as health, education, water, sanitation.

Limitations

This study confined with qualitative approach and employed in Chandanath Municipality, Jumla.

Conflict of Interest

No any conflict of interest. This has done for the sake of fulfilment of academic requirement as building block of my activism around menstruation.

Funding

There is no any funding for supporting of this study.

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DOI: 10.31038/AWHC.2020322

Background

The entire world was celebrating the New Year eve (December 31, 2019) but China officially informed to World Health Organization (WHO) about the unknown illness that later known as Corona Virus or COVID-19. The novel Corona virus labelled as pandemic by WHO in March 11, 2020 [1]. The impact of pandemic different to men and women and even more deeply and widely affected in the areas where countries are under conflict or post conflict or traditional [2]. In this response the variety of professional are working so hard around the clock where the 70% workforce (among 104 countries) represented by the women workers as a doctors, nurses, social workers, kitchen workers, security personnel and so on [3]. Each crisis situation intensifies the gender inequality and the COVID-19 further intensifies the affect against girls, women and menstruations [4]. This is supported by the idea of women are missing [5].

Roughly, half of this planet is occupied by the women no matter where they are. She could be anywhere but only visible as doctors, nurses or security personnel. Women are everywhere either at COVID-19 laboratory or kitchen of hospital or home or refugee camp or migrant workforce or conflict or anywhere. Indeed, women are everywhere but she is nowhere. The COVID-19 does not cease the menstruation of women regardless of women working in laboratory or patient at ICU or women under lockdown. Globally, the first time in a history that the demand of menstrual products as part of Personal Protection Equipment [6].

More importantly, the stigma, taboo and restrictions during menstruation is practicing across globe with variation on forms and severity. And globally, the menstruation as ignored and side silenced issue in development and human right till now. Furthermore, the dignity during menstruation or dignified menstruation is further unrecognized by the global community [7] . Paudel described the dignified menstruation as `as virtue of human being, each girl, women or menstruators deserved the dignity during menstruation. It is a state of free from any forms of abuse, discrimination, violence associated with menstruation no matter where the menstruator lives. In other words, there should not be difference between 25 and 5 days in a month, throughout the clock of 365 days because of menstruation’ [7].

Objective

The main objective is to assess the space for women amid COVID 19, Pandemic from the perspective of menstruation. The specific objectives are:

Objectives:

I. To understand the impacts of menstruation amidst COVID 19, Pandemic.

II. To examine the global policies and actions towards menstruation around the amid COVID 19 Pandemic, response.

Rational

The Secretary General Antonio Guterres constantly emphasised that the fighting the virus for all of humanity, with the most affected people: women, older person youth, low wages workers, small and medium enterprises, the informal sector and vulnerable groups. In a way, there is no visible need of menstruation and the other way round there is menstruation across all kinds of people.

Once the WHO confirmed the Pandemic for COVID-19, the global community starting from the UNs, governments, NGO and individuals are relentlessly are working for combating with amidst COVID-19 which is happening about a century after. In course of century development and human right discourse, world has been accomplished so many concerns related with women including for menstruation. The varieties of concepts around menstruation were emerged: in 2012, the UNICEF and WHO (Menstrual Health Management), in 2014, the UNSECO and Human Right Council, Water and Sanitation (Menstrual Hygiene Management) and in 2017 Nepal government (Dignified Menstruation). Additionally, the menstrual stigma, taboo, restrictions also discussed as factor for the construction and shape the power starting from childhood and it is a serious cause for provoking the gender-based violence [7].

Methodology

This quick review is under the qualitative, post-positivist world’s view. The data primarily secondary through the internet. The news, policy papers, statements etc. released by the various organizations and available in google during state of lockdown globally. Regards to timeline, it limits between the announcement as pandemic for Corona virus and till April 24, 2020 (total 44 days). However, the primary data also included through various webinar special focuses on menstrual health and hygiene and some observations of live press meets. In a way, the global perspectives assessed as provided by context.

Findings

1. Impacts of menstruation during response amidst COVID 19, Pandemic

Wuhan, an epicenter of The novel Corona virus of China and first city globally, where the front lines female workers were under physical and psychosocial pressure due to stigma and the government did not considered the menstrual products as essential supplies during COVID-19 response [8]. Likewise, the female front-line workers were talking birth controls for avoiding menstruation due to stigma and not supply of menstrual products [9] Jiajia, further shared the impact of menstrual taboo on urinary tract infections that associated with the discussion and supply of menstrual products.

In the same vein, the leading the way organization, WHO, to defeat against novel Corona virus in many ways but missing to acknowledge the needs and urgency of menstruation. It released a document in 18 March 2020 on mental and psychosocial consideration where it displayed message for general population, health workers, team leaders of health facilities, elder adults and people in isolation where the impacts of menstruation (before puberty, puberty, reproductive age, menopause) missed at all [10]. The WHO is also shown inconsistence on what it believes on menstruation (2012) and health’s definition since 1948.

2. Examine the global policies and actions towards menstruation around the amid COVID 19 Pandemic, response

Followed by the WHO’s confirmation of pandemic for novel Corona virus, the global organizations, networks, governments, NGOs, individuals who are working around women’s menstruation, peace, right, empowerment etc. are releasing the petitions, statements through online. This study attempted to examine to what extend these policies or documents reflects the needs and importance of holistic approach of dignified menstruation.

WHO is the leading organization for the COVID-19 responses globally, keeps releasing the resource materials for prevention of novel Corona virus, management of Corona positive patients, promotion of human right through various aspects etc. However, the WHO remained silent at all to response the direct and indirect needs arise from menstruation. Before the COVID-19, WHO recommended for gender transformative policies to address participation, inequalities, gender-based discrimination on pay, employment but not speak how menstruation plays in enabling work spaces [3].

For instance the seven points forwarded by the NGOWG to the security council with the demand for women’s right must be centre for response to COVID-19 [11] . This document is just reiteration of the documents, policies because these points do not visualize the specific actions directly what, where or how? The points number two (Require rights-based and age-, gender-, and disability-sensitive pandemic responses) and the point three (Prevent and respond to gender-based violence) are just coming through decades but not represent the need of menstruation and the role of menstruation in heighten the violence against girls, women and menstruators.

“Point 2: Require rights-based and age-, gender-, and disability sensitive pandemic responses: COVID-19 responses must be grounded in data disaggregated by gender, age, and disability and intersectional analysis that recognizes the gendered impact of the crisis. Point 3: Prevent and respond to gender-based violence: Take necessary measures to prevent, address, and document all forms of gender-based violence, particularly intimate partner violence and other forms of domestic violence’’.

The gender analysis is very common jargon but it does not provide a single clue to intervene the needs associated with menstruation e.g. status of menstruation or choice of menstrual products. Likewise, during COVID-19 response, the girls, women and menstruators are working as frontline workers or at refugee camps or migrant workers or disable or transgender to anyone under the lockdown characterized by quarantines at home or shelter, isolation, travel restrictions, social distancing, and curfews. In this condition, maintaining the stigma, taboo or restrictions is merely impossible thus the chances of increasing violence are high but not recognize at all. In addition, the menstruators are double victimization from the existing the stigma, taboo, restrictions during menstruation and the laws imposed by the governments for COVID-19, Pandemic response.

The almost all organizations and networks included UNs, Asia and Pacific Region; INGOs are primarily recommended for SRHR (Sexual and Reproductive Health Right). SRHR primarily focused on family planning, safe abortion, maternal and child health, adolescent health [12].

The dedicated organizations on menstruation are responding COVID-19 through producing the masks, hand sanitizers. Their surveys were floating over internet and listserv for assessing the supply chain and needs or menstrual products. Few are busy in infographic on importance of hygiene related info and only very few organizations working for promotion of dignified menstruation.

Discussion

The organizations which supposed to stand for dignity, equality, respect have already been working for many decades such as 72 years for Human Right Declaration and WHO (1948), 41 years for Convention on the Elimination of all Forms of Discrimination against Women (1979), 25 years for Beijing Declaration and Platform for Action (1995), 20 years of Security Council Resolution 1325 (2000) but the accounting of women as human being is always missing specially the menstruation. The veil of silence around menstruation play as vicious cycle for sexism and gender equality and 80% of participants of 2015 survey experienced disadvantaged position in society due to menstrual stigma [9].

Focus not for the biological need; menstruation

The entire focus of COVID-19 response fully directed as requirement of men’s protection like Personal Protection Equipment (PPE) and other essentials. It is observed that almost all global or national authorities showed the men members while conducting the press meets and highlighted their needs, demands, and challenges. They seemed so serious for the death and infections from novel Corona virus and focused on medical supplies, equipment and explorations for it. The official relief package also comprised the items except menstrual products. For instance, Government of Nepal relief package for wage labor included 30 Kgs rice, 3 Kgs pulse, 2 Kgs salt, 2 Liters cooking oil, 4 packed soap and 2 Kgs sugar [13]. It is clearly shown that both either ignorance or silence or taboos embedded within the minds of authorities. The menstrual products are not considered as either important logistics or relief packages among authorities or except small or focused organizations. Authorities even ignore to listen the demand of menstrual products and compelled to talking birth control pills [8]. The psychological trauma and hormonal impact on her body is inhuman condition indeed. The oral contraceptives could create the other impacts on her body such as increasing rates of amenorrhea over time, irregular and unscheduled bleeding [14].

Menstruation is nowhere and everywhere under SRHR

The history of sexual and reproductive health is already more than 25 years, fourth international conference on Population and Development in 1994 [15]. Despite having huge scope, it merely talks about the menstruation and its complexity and multifaceted nature on the life of girls, women and society as a whole [12]. The SRHR intervention package clearly showed the ignorance and silence around the need of menstruation (comprehensive sexuality education, counselling on modern contraceptives, Safe motherhood and neonatal health, safe abortion, HIV/STIs, SGBV, Reproductive cancers, infertility and sexual health and well-being). It is concluded that menstruation is very everywhere and menstruation is nowhere. The entire elements of comprehensive SRHR package have indiscernible relationship with menstruation but it is vague to understand the position of menstruation or no observable discussion at all. It is assumed that the ignorance and silence among SRHR actors including WHO even today.

Menstrual Hygiene and products are not demystifying the stigma, rumours and restrictions around menstruation

The menstrual hygiene and products are essential elements of the dignified menstruation which get more attention since 2014. However, the hygiene and products do not guarantee of the dignity of girl, women and menstruators at all. As like China, due to stigma, taboos and restrictions around menstruation, either the demands of menstrual hygiene and products heard or incorporate in to the essential logistics of COVID-19 response or distribute properly to the needy people. For sustained supply of menstrual hygiene and products, incorporate in to the policies and plans, the breaking silence, bursts the myths, rumours and restrictions, is urgent.

The female frontline workers do not represent the women who are vulnerable amid COVID-19

The half of the earth’s population scattered as poor, rural, refugee, migrant worker, women in informal sector, disability, sexual minority, women at isolation, quarantine, conflict and so on. They are living with travel restrictions, limited spacious rooms or tents or quarantine or camps or abusive partners or strange people. The resources for living such as food, toilets, water, soap, hand sanitizers, menstrual products are limited or could be unfilled. It is concluded that the almost all discussion do not account the women who are living except as front liners. They also menstruate about 3000 days in life and about seven years of reproductive life. They also have so many issues with before puberty, puberty and menopause.

Conclusion

Since 2014, menstruation gets more space in both development and non-development sector globally but the dedicated funds or programs yet to planned for achieve the 2030 agenda, `Leave no one behind’. The holistic approach of dignified menstruation could be the tool to address all issues related with menstruation including SRHR, human right and empowerment. Because of talking about dignity during menstruation allow to discuss about the stigmas, taboo, restrictions during menstruation that is supported by the Jiajia Li [9].

Globally the gender-based violence is increasing; 30 in France, 25% Argentina, 35% in Singapore [16]. The menstrual stigma, taboo and restrictions have significant role for the power construction thus the silence of the menstruation is a key underlying cause for increasing gender-based violence.

Recommendation

This COVID-19 is not only the challenge but also the opportunity to understand the complexity and multifaceted nature of menstruation before, during and after the crisis. In the twenty first century, the world has to learn and ready to shift for not only COVID-19 management but also shifting around peace, human right, and empowerment. The global community encourages leaving the blaming and naming around menstruation and having to move forward for the sake of planet as whole.

In specific manner, the following things need to consider in coming days:

• The disaggregated data has to have the menstruation and choice of products.

• The dignified menstruation and gender analysis policies and plan instead of gender analysis in silo. That guarantees the revision of logistic plan or essential supplies for crisis.

• The SRHR elements also need to revise to include the dignified menstruation

• The activities have to plan and implement by endorsing the indicators of dignified menstruations or beyond the infrastructure, hygiene or products.

• Without robust feeling of confidence and dignity, hard to report or fight back against gender-based violence. Thus, mainstreaming of dignified menstruation in to empowerment and human right would be the catalyst tool to prevent and response of the gender-based violence.

Delimitation of the study

This study delimited within 44 days of the emergency of COVID- 19, internet-based desk analysis.

Funding

This is no any funding or any assurance for the study.

References

1. Coronavirus confirmed as pandemic by World Health Organization [2020] BBC. [Crossref]
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4. Sitepu A and Saminarsih D [2020] COVID-19: Gender lens needed to fight pandemic. The Jakarta Post. [Crossref]
5. MISSING WOMEN: How to Ensure Beijing+25 Really Leaves No One Behind. (2020) International Rescue Committee. [Crossref]
6. United Nations. (n.d.). Gender equality in the time of COVID-19. THE DEPARTMENT OF GLOBAL COMMUNICATIONS [Crossref]
7. Paudel R (2020) Dignified Menstruation in a Global Discourse*An Unseen Topic in Human Rights? – 2020—COVID-19. [Crossref]
8. Zhou V (2020) Needs of Female Medical Workers Overlooked in Corona Virus Fight, advocate say. [Crossref]
9. Jiajia Li A (2020) How China’s coronavirus health care workers exposed the taboo on menstruation. South China Morning Post. How China’s coronavirus health care workers exposed the taboo on menstruation.
10. Mental health and psychosocial considerations during the COVID-19 outbreak (2020) World Health organization. [Crossref]
11. NGOWG (2020) Why Women’s Rights must be Central to the UN Security Council’s Response to COVID-19. [Crossref]
12. The COVID-19 Outbreak and Gender: Key Advocacy Points from Asia and the Pacific. (2020) Gender at Humanitarian Action Asia and Pacific Region. [Crossref]
13. Shrestha PM [2020] Rice, pulses, salt, oil, soap and sugar to be distributed to informal sector workers and destitute. [Crossref]
14. Hillard PA (2014) menstrual suppression: Current perspectives. Int J Womens Health. 6: 631–637. [Crossref]
15. Glasier A, Gülmezoglu AM, Schmid GP, Look and PFV (2006) Sexual and reproductive health: A matter of life and death. The Lancet Journal. [Crossref]
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DOI: 10.31038/AWHC.2020321

Abstract

Background: With the increase in fertility problems and delayed childbearing, demand for infertility treatments has been rising. Today, in vitro fertilization (IVF) is the most successful infertility treatment but it is costly. To meet rising demand for infertility treatment many markets have seen an increased entry of infertility clinics. Concerns have been raised of the effect of high per-treatment cost and rising competitive pressures on the outcomes of infertility treatments. The objective of this study is to examine the relationship between competitive pressures and prices charged by clinics for in vitro fertilization treatments as well as the effect of prices and competition on multiple gestations.
Method: This is a retrospective analysis of 2012-2014 clinic-level data in the United States. This study collects in vitro fertilization prices and combines the price data with the ART Fertility Clinic Success Rates Reports published by the Centersfor Disease Control and Prevention (CDC). The Herfindahl–Hirschman Index (HHI) is a widely-used measure of competition within a market. Regression analysis is used to estimate the relationship between HHI and price variables. The effect of prices and competitive pressures on multiple gestations is estimated.
Results: Multivariate regression results show that competitive pressures do decrease prices charged by IVF clinics (p-value<0.1). IVF refund programs that reimburse couples for multiple failures are more likely to be offered in more concentrated markets (p-value<0.05) and larger clinics (p-value<0.01). Lower prices translate into lower multiple rates for younger women (p-value<0.1). Controlling for prices, competitive pressures decrease multiple rates for younger women (below 35 years of age) but increase multiple rates for older women (above 40 years of age) (p-value<0.1).
Conclusions: Lower IVF prices translate into better quality as measured by the rates of multiples for younger women undergoing infertility treatments. Effect of competitive pressures on quality of care is ambiguous especially after we control for treatment cost. For older women such pressures may lead to more embryo transferred and higher rates of multiples. Further research is needed to identify the relationship between competition and quality of medical care in infertility and other markets.

Keywords

Infertility, in vitro fertilization, competition, econometrics

Background

Infertility and in vitro fertilization

About 11 percent of American women 15–44 years of age have difficulty getting pregnant or carrying a pregnancy to term [1]. Today, over 1.7 percent of all infants born in the United States every year are conceived using assisted reproductive technologies (ART) [1]. To meet this increased demand for ART, the number of infertility clinics in the United States has increased from 263 in 1995 when CDC started collecting ART success rate data to 459 in 2014. Today, in vitro fertilization (IVF) is the most successful infertility treatment but it is invasive and costly. IVF involves ovarian stimulation with prescription drugs with close monitoring by the reproductive endocrinologist to prevent overstimulation, ovarian retrieval (an outpatient surgery), fertilizing an egg with sperm outside of a woman’s body and then implanting it in her womb (another outpatient hospital procedure). Since IVF is a process, rather than a single procedure, costs include medications, laboratory tests, physician fees, hospital charges, anesthesia, and embryology lab fees. A full IVF cycle is priced at over $10,000 and a frozen embryo transfer at over $3,000 [2]. In addition, many couples have to go through several IVF cycles to achieve a live birth. CDC data indicates that only 32.98% of IVF cycles resulted in a live birth. High costs of IVF combined with relative low probability of success lead to more aggressive treatments and poor quality outcomes since patients’ immediate financial interests are best met by maximizing their pregnancy chances on each IVF cycle. Such financial incentives lead to patients transferring more than one embryo so as to limit the number of IVF treatments they undergo despite the health risks and long term costs associated with multiple gestations and births. Although IVF is a medical procedure that treats a medical problem of infertility, most private health insurers exclude it from coverage with only a quarter of insurers covering some infertility benefits [3]. To address costs, some states passed insurance mandates that require employers to cover – or offer to cover- infertility treatments. To date, few Americans have sufficient insurance to cover infertility treatments. While the Affordable Care Act extended insurance coverage to millions of uninsured Americans, IVF is not considered an “essential health benefit” under the Act and most insurers do not cover it outside of states where it is mandated.

Another factor that can address high costs of IVF is competitive pressures that lead to price competition among clinics. However, the effect of competition on IVF outcomes is ambiguous. While deciding on transferring another embryo, patients and clinics face short term benefits (higher probability of success and thus fewer IVF cycles) and long-term costs (higher probability of prematurity, C-section costs, other risks associated with higher risk pregnancy). On one hand, more competitive markets lead to lower prices which may allow patients to transfer fewer embryos per IVF cycle thus reducing multiple births. On the other hand, IVF clinics also compete for patients by advertising higher pregnancy rates and concerns have been raised that competitive pressures may lead clinics to transfer more embryos that may allow clinics to advertise higher success rates. This can lead to more multiple births.
This study examines the relationship between competitive pressures that infertility clinics face and health outcomes. We concentrate on one dimension of health outcomes: multiple gestations per ART birth. High costs of IVF procedure lead couples to transfer more embryos which leads to more multiple births (twins, triplets and high order multiples) per ART birth and thus poor quality health outcomes.

Health care providers in infertility markets compete along two dimensions: prices and quality. Due to lack of insurance coverage, price competition is more important in infertility settings relative to other areas of medical care that are better insured. This study attempts to use unique features of infertility market to distinguish between price and quality impacts of competitive pressures.

Competition and quality of health outcomes

Outside of infertility markets, the relationship between market competition and health care outcomes is ambiguous. While some studies show that hospital competition decreases mortality rates [4-7] others find higher mortality rates in competitive markets [8-9].

Empirical studies on mergers that result in accumulation of market power are similarly inconsistent.  For example, Ho and Hamilton show that mergers increase readmission rates but do not affect mortality rates while Hayford finds that hospital mergers are associated with increased treatment intensity and higher inpatient mortality rates [10,11].

Finally, Mutter, Wong and Goldfarb looked at 12 different dimensions of inpatient quality. They find that the effect of competition is not “unidirectional” with some quality measures showing improvements with greater market competition while others remain the same or even decrease [12].

Infertility treatment markets: The effect of competition

With more IVF clinics entering the market, many hypothesize that under competitive pressures doctors will pursue aggressive treatments so that the IVF clinics can advertise higher success rates. Some industry observers even propose limits on competition [13-15]. Few empirical results that exist however do not support these fears. Steiner measured competition as number of clinics in the area and found that competition did not affect pregnancy rates but decreased high order multiples (triplets and higher) [16]. Hamilton and McManus measured competition with a simple dummy variable (1=monopoly, 0-otherwise). They find that competition does not increase multiple birth rate [17]. Henne and Bundorf (2010) did not find a relationship between the number of competitors an infertility clinic has and embryo transfer decisions [10].

Infertility treatment markets: The effect of insurance mandates

Although previous literature does not exist on the effects of competition on prices of infertility treatments, several studies examined the effect of infertility mandates that make infertility treatments more affordable. Universal insurance mandates are associated with greater utilization of ART and other infertility treatments such as ovulation-inducing drugs and artificial insemination [17,19-21]. Schmidt finds that infertility mandates significantly increase first birth rates for older women [22]. The effect of insurance mandates on multiple gestations is ambiguous. On one hand, infertility mandates in New Jersey and Connecticut had no effecton embryo transfers and the rate of multiples [21]. On the other hand, a growing literature shows that infertility mandates improve outcomes of infertility treatments by decreasing treatment intensity and decreasing probability of multiple gestations per ART birth [17,19, 21]. However, Buckles estimates that state infertility mandates do not significantly affect multiple birth rates, they do increase triplet and higher-order births by 26% [24].

Previous literature on the cost and affordability of ART in the United States is limited but Chambers et al. using international data found that a decrease in a cost of an IVF cycle leads to fewer embryos transferred and higher use of single-embryo transfers. Affordability was measured as net cost of a standard IVF cycle relative to annual disposable income for thirty high and upper middle income countries [25].

Contribution to previous research

This study contributes to previous research on several fronts. First, we collect data on prices charged by IVF clinics to measure the effect of prices on multiple births. We also estimate the effect of the so-called money back programs that some IVF clinics offer. Second, we calculate Herfindahl–Hirschman Index (HHI) to measure market competition which shows more variance across markets in current data due to entry. Having both competition index and price data allows us to separate the effect of competition on prices from the effect of competition on quality. Finally, we are able to measure the effect of state insurance mandates while controlling for prices and competitive pressures.

Methods

Data sources

We use two waves 2012 and 2014of ART Fertility Clinic Success Rates Reports. The data is publicly available by Center of Disease Control and Prevention (CDC). The unit of analysis is a clinic performing ART (no patient level data is available). In this study we use data for non-donor fresh IVF cycles only. Thus, we excluded all cycles where an egg donor was used or frozen embryos were used.

All IVF cycles for each clinic were separated into three age groups since embryo transfer guidelines and IVF success rates vary by maternal age: women below 35 years of age, women between 35 and 40 years of age and women above 40 years of age. We use 2012-2014 ART Fertility Clinic Success Rates Report data to construct the following variables: number of IVF cycles by clinic (this variable captures the volume and the size of each clinic), multiple births by clinic and age group, percent of IVF cycles that underwent PGD (preimplantation genetic diagnosis) to test for genetic abnormalities for each IVF clinic, percent ICSI (intracytoplasmic sperm injection) cycles for each IVF clinic and society for assisted reproductive technologies (SART) membership which requires member compliance with strict embryo transfer guidelines.

Market area characteristics came from publicly available state and MSA-level data. Female labor force participation for years 2012 and 2014 was collected by the Bureau of Labor Statistics (BLS) at the state level. Percentage of educated women variable is based on National Center for Education Statistics report.  This data is collected at the state level and captures percent of women with at least a bachelor’s degree. MSA-level income per capita data came from the US Census Bureau. Data on state infertility mandates was obtained from the American Society for Reproductive Medicine. We also control for state-to-state differences in health care prices. We use annual average cost of living index for the health sector as reported by the Missouri Economic Research and Information Center (2015).

Competition index

We use Herfindahl–Hirschman Index (HHI) to measure market competition. The index is constructed based on total non-donor fresh IVF cycles performed for each clinic. Increases in the Herfindahl index generally indicate a decrease in competition and an increase of market power, whereas decreases indicate the opposite.  The index can vary from zero (perfect competition) to 10000 (Monopoly). We use metropolitan statistical area (MSA) as the relevant market for infertility clinics in our sample.

Price variables

State infertility mandates. Although previous studies used insurance coverage as a main price variable, currently few Americans have sufficient coverage for ART. By 2014fifteen states passed infertility mandates of which only eight states (Connecticut, Louisiana, Hawaii, Illinois, New Jersey, Massachusetts, Maryland, and Rhode Island) require all insurance plans to cover IVF. In addition, Arkansas, Montana and Ohio and West Virginia require some plans (all HMO’s or all non-HMO’s) to cover the costs IVF treatments. We use both definitions of the universal mandate to test the sensitivity of our results. It is important to note that even when insurance coverage is provided, the total value of the benefit may be capped at as low as $15,000 or the minimum number of cycles that must be covered may be as low as one [23].

In our definition of mandated infertility benefits, we do not include states like Texas that only require health insurance plants to offer infertility insurance since employers have the right to refuse such coverage. We also exclude states like California that require coverage of all infertility treatments except IVF.

IVF price measures. We supplement our analysis with price data from a health care price transparency website OkCopay. The price variable includes “one cycle of IVF procedure, using your own eggs, without monitoring” (http://www.okcopay.com/). In this study I used prices that included lab fees but not pharmaceutical prices. The data reflects cash prices, which is the charge before insurance.

In addition, many IVF clinics offer money back programs, (sometimes called IVF refund programs or IVF warranty programs) that allow a fixed fee for a number of IVF attempts and if the treatment is not successful, 80%-100% of money is refunded. Thus, couples that are successful on their first or second attempt most likely overpaid in comparison to traditional fee-for-service IVF.  But, this “overpayment” can be thought of as an “insurance premium” for money back, in the event the treatment is not successful. Data on refunds by clinics was collected from published sources (http://ivfrefund.com/about-ivf-refund.html) and verified with individual clinics. A dummy variable was created; it takes the value of 1 if a clinic offers a refund and zero otherwise.

Price data is only available for the 33.5% of clinics in the CDC sample while data on discounts is available for all 916 clinics in our sample.

Limited price information is an important limitation of this study since one might worry that the clinics that provide data to the transparency websites are systematically different from those that do not in a way that would boas the results. This is especially important since when price variable is included, all regressions are run on this selected sample of 307 clinics. To alleviate this concern we did look at the clinics with price information and did not find them to be different from clinics without price information. Separately we looked at markets where price data is available and markets where price data isnot available and did not find significant differences in market characteristics. These results increase our confidence that lack of data did not bias our empirical results.

Table 1 summarizes descriptive statistics. (Table 1)

Table 1. Descriptive statistics for selected variables

Descriptive statistics show that IVF clinics markets vary from unconcentrated (HHI<1500) to monopoly (HHI=10000) although an average clinic is located in a highly concentrated market (mean HHI of 4054). As of 2014, none of the markets can be classified as competitive (HHI< 100). Probability of multiple gestations varied from an average of 14.94% for women over 40 years of age to 29.50% for women under 35 years of age. Average price in our sample was $13,477 with 8.77% of clinics offering IVF refunds.

Empirical analysis

To test the effect of HHI on costs and quality of care, two empirical models are used. First, we estimate the effect of HHI on costs:

We use IVF clinic price variable and availability of refunds as our main measures of IVF costs (Costi) for clinic i. Coefficient β₁ captures the effect of competition in market m, coefficient β₂ captures cost of living (health component), β₃ captures the effect of state infertility mandates. In Clinic we control for characteristics of individual IVF clinics such as proportion of ICSI and PGD procedures performed as well as size of the clinic (measured by the volume of the IVF procedures). Variable Marketms is a vector of controls for variables that vary across MSA’s and states that might also affect costs. These include: median family income, population, female labor force participation rate, and percentage of women with at least a bachelor’s degree.  Economic theory predicts that more competitive markets should have lower prices. This relationship holds true in healthcare markets as well. Baker et al. showed that more competition among physician practices is related to lower prices for office visits [26]. Melnick et al. (1992) observed the same relationship in hospital markets: “greater hospital competition leads to lower prices” [27]. Given economic theory and previous empirical literature, we expect higher prices in more concentrated markets (positive β₁) and more IVF refunds in more competitive markets (negative β₁).

Second model estimates the effect of HHI on multiple gestations. We run the model with and without cost variables to gage the effect of the HHI on price and the effect of the HHI on quality competition. In this study, we concentrate on one important dimension of quality for IVF clinics: the rate of multiple births they produce. Multiple gestations are an important risk factor for preterm birth, with 11% of twins, 36% of triplets, and 67% of quadruplets and higher born very preterm (i.e. less than 32 weeks’ gestation), compared with less than 2% of singletons [28]. Preterm birth leads to increased risk for death, long-term neurological disabilities, and extended time in the hospital [29]. A recent study compared outcomes for women undergoing two IVF pregnancies with singletons and women undergoing one IVF twin pregnancy [30]. The neonatal and maternal outcomes were “dramatically” better for women undergoing two singleton pregnancies. IVF twins had higher rates of preterm births, low birth weight, respiratory complications, sepsis, and jaundice. Women delivering twins had higher rates of preeclampsia, preterm premature rupture of the membranes, and cesarean section. The authors proposed to decrease number of embryos transferred by IVF clinics to minimize the risks associated with multiple pregnancies. In our empirical model we use multiple rates per ART birth by maternal age for each clinic as a measure of quality [30].

where the dependent variable measures quality of health outcomes for age cohort a for clinic i. Coefficient β₁ captures the effect of market competition, coefficient β₂ captures costs of the procedure (prices charged by individual clinics and discounts offered by individual clinics), β₃ captures the effect of state infertility mandates.  Although state infertility mandates directly affect IVF costs we treat this policy variable separately.

Although we control for market characteristics at both MSA and the state level, one major concern is that there are likely to be unobservable characteristics that are correlated with both the independent and dependent variables that are driving the estimated coefficients in (2). Therefore, we also take advantage of the panel nature of the data and run (2) with fixed effects to better control for unobservable differences.

Results

IVF costs

We estimate Equation (1) to describe the effect of HHI on IVF prices and refunds offered. Results are presented in table 2. (Table 2)

Table 2. Costs of IVF

Notes: All continuous variables are in log form; Robust standard errors are in parentheses.* p<.10, ** p<0.05, *** p<0.01

Table 2 shows that more concentrated markets tend to have higher prices, as economic theory predicts. At the same time, IVF refund programs are more likely to be offered in more concentrated markets and in larger clinics. This result is robust to alternative specifications of the model. Health insurance mandates do not significantly affect prices. Other significant variables include regional factors. IVF costs in the northeast are significantly higher relative to Midwest and South. Also, clinics in the South and West are more likely to offer IVF refund relative to Northeast clinics. Prices tend to be higher in more populous areas and lower in areas with more educated women.

Multiple Gestations

The goal of the paper is to examine the effect of determinants of potentially dangerous outcomes from IVF treatments: multiple births. Table 3 presents results of Equation 2 estimates for multiple rates without fixed effects. (Table 3)

Table 3. Multiple births

Notes: Robust standard errors are in parentheses.* p<.10, ** p<0.05, *** p<0.01; All continuous dependent variables are in the log form

Results in Table 3 show that effect of competition on multiple gestations is ambiguous. On one hand, competition decreases multiples through lower prices and through quality competition for women under 35 years of age. Although price variable is not important for women above 35 years of age, younger women are more sensitive with higher prices leading to more multiples for this age group. Without price variables more concentrated markets result in more multiples. Once we control for cost variables, significance  of  HHI decreases although remains positive and significant at p<0.10. Overall for younger women both price and quality competition is important. For older women (over age of 40) the effect of price and other cost measures is not significant. Thus, for this age group the effect of competition is due to quality competition alone and more concentrated markets actually lead to more multiple gestations. For women between 35 and 40 years of age, regional variables and PGD procedures are more important at determining multiples rates than economic variables.

Table 4 presents equation (2) estimates with individual clinic fixed effects. (Table 4)

Table 4. Multiple births estimates with fixed effects

Notes: Robust standard errors are in parentheses.* p<.10, ** p<0.05, *** p<0.01; All continuous dependent variables are in the log form

Results in table 4 are consistent with results that were observed without fixed effects. Table 4 shows that IVF refund programs significantly decrease multiple gestations for younger women although do not seem to affect multiple rates for women over 35 years of age.

Table 5 below summarizes how HHI coefficient changes with and without price controls. (Table 5)

Table 5. Effect of competition

Table 5 finds that the effect of competitive pressures decreases when we control for prices in magnitude but remains significant for women below 35 years of age. For women over 40 years of age coefficient becomes negative and significant. Therefore, competitive pressures may affect quality differently for women of different age groups.

Overall results in tables 4 and 5 show that effect of competition changes with cost controls and may improve health outcomes for younger women but increase multiples for older women.

This study finds that health insurance mandates lead to fewer multiples (results omitted) but once we control for costs of the IVF, health insurance mandates are not statistically significant.

Discussion

Policy implications

The most important economic issues in the US IVF markets are: 1) barriers to access due to high prices and 2) health outcomes. Our empirical analysis confirms the existing consensus that competition lowers prices and lower prices translate into fewer multiples especially for younger women. Once we control for IVF costs, the effect of competition on multiple gestations is ambiguous and depends on the age of the patients.We also found fewer IVF discounts in more competitive markets. Thus, the overall effect of rising competitive pressures on health outcomes is not necessarily negative as previous literature suggests.

On one hand, competition policy is controversial in health care, compared to its use in other markets due to multiple market failures [31]. On the other hand, nothing about the unique features of health care industry suggests that market power is socially beneficial [32]. Despite expressed concerns that under competitive pressures doctors will be hard pressed to compete for patients by allowing more aggressive IVF treatments to boost clinic success rates, empirical results of this study show that this does not always hold true. At least for younger women, competitive pressures lead to fewer multiples by decreasing costs and through quality competition. Also, competitive pressures may be most helpful at improving access and equity when patients are faced with decreasing insurance funding for fertility treatments [33].

Patients searching for IVF clinics are faced with several factors they have to consider: price per cycle, success rate and multiple rate that clinics report. CDC and many IVF clinics make long-term consequences of IVF publicly available and patients are able to make comparisons of clinics by the multiples rates that they produce. This may be an important quality dimension that clinics use to attract prospective patients.

Limitations of the study

To separate the effect of competitive pressures on prices from its effect on quality, this study used the best available price data for IVF clinics to capture the cost of one fresh non-donor cycle of IVF procedure, without monitoring and pharmaceuticals. Unfortunately, this data was not available for all clinics. We did our best to verify and supplement the data but at this IVF prices with hospital and embryology lab charges are not attainable for many US clinics. Thus, low sample size is a problem. Our estimates of the effect of HHI on quality for the entire sample (without controlling for prices) show that competition leads to better quality for women under 40 and is not significant for older women. However, such estimates do not isolate the effect of prices from the effect of quality competition. As price data is becoming more available to consumers, future research is necessary to look at different ways in which competitive pressures affect prices and overall patient welfare.

This study uses only two years of available data. Although looking at a change in HHI over a longer time period may yield better results, price data is not available before 2012. As we accumulate price data to aid patients searching for health care providers, the effect of increasing over time competitive pressures that IVF clinics face can be estimated.

We use MSA as our definition of infertility market area. Since IVF is not an emergency procedure, many couples are able to search outside of their MSA area. Medical tourism allows an increasing number of Americans to cross international borders to obtain health care at a lower price and comparable quality. One may consider the entire world to be the market. In this study we assume that medical tourism is limited and most infertile couples search within their MSA.

Conclusions

This study found that lower IVF prices translate into better health outcomes as measured by the rates of multiples for women undergoing infertility treatments. Further research is needed to identify the relationship between competition and prices as well as competition and health care outcomes. With rising demand for infertility treatments, policy makers must consider the effect of ART funding on prices as well as the effect such funding has on quality and patients’ welfare in ART markets.

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