Menstrual hygiene management and social exclusion among women in Afghanistan: insights from a national survey

BACKGROUND: In Afghanistan, little is known about menstrual hygiene management (MHM) and the social isolation women experience during menstruation. Drawing on the nationally representative 2022-23 Afghanistan Multiple Indicator Cluster Survey (MICS), we quantified the prevalence of appropriate MHM and menstrual-related social exclusion and examined their sociodemographic drivers. METHODS: We conducted a cross-sectional analysis of 40,330 women aged 15-49 years who responded to questions on MHM, corresponding to those who had menstruated in the past year preceding the survey. "Appropriate MHM" was defined as the use of a sanitary pad, tampon, or clean cloth, plus access to a private space for changing or washing. "Social exclusion" captured any missed social activities, work, or schooling due to menstruation. Survey-weighted logistic regression models estimated adjusted odds ratios (AORs) for both outcomes, including interaction and stratified analyses by place of residence. RESULTS: Overall, 86.0% of women met criteria for appropriate MHM, yet 30.2% reported menstrual-related social exclusion. Provincial estimates of appropriate MHM varied widely (49.4% in Jawzjan to 98.5% in Khost), and social exclusion ranged from 2.7% (Ghor) to 79.0% (Faryab). After adjustment, women in rural areas (AOR: 1.91, 95%CI: 1.53-2.37), those with internet access (AOR: 1.50; 1.19-1.90), and those from the richest wealth quintile (AOR: 1.66; 1.22-2.26) had significantly higher odds of appropriate MHM. Never-married women had lower odds of appropriate MHM (AOR 0.86; 0.75-0.97). The odds of social exclusion were lower in women aged 18-24 (AOR: 0.87; 0.78-0.96), 25-34 (AOR: 0.79; 0.70-0.89), and 35-49 (AOR: 0.86; 0.76-0.98). However, mobile-phone ownership was associated with higher odds of social exclusion (AOR: 1.20; 1.08-1.33). A significant interaction by residence (p < 0.001) indicated that lack of adequate MHM was associated with higher odds of social exclusion among urban women (AOR: 1.46; 1.07-2.00), whereas in rural areas it was associated with lower odds (AOR: 0.68; 0.56-0.82). CONCLUSION: Although the majority of Afghan women report appropriate MHM, nearly one-third still experience social exclusion during menstruation. Policy efforts should prioritize low-tech, community-based approaches to address menstrual health challenges, particularly among unmarried and economically disadvantaged women, while considering digital platforms as complementary tools for subgroups with existing access.