International Women’s Day marks 67 days since the beginning of 2022. That is seven days more than the average number of school days a girl in Laos misses every year due to period poverty.
Period poverty — inadequate access to menstrual hygiene tools and education — is estimated to affect as many as 1 in 10 menstruating girls and women worldwide, according to a report by the United Nations.
The issue is particularly rife in patriarchal societies such as Laos, where periods are considered a taboo subject. Anything concerning the female reproductive system is discussed only in hush-hush tones, and information about menstruation is mostly limited to old wives’ tales, such as the belief that girls must not eat spiced mango while on their period.
A 2016 survey by Lotus Educational Fund, an international NGO that supports the schooling of girls in southern Laos’ rural Champhone district, revealed that 70 per cent of women and girls in the district’s poorest villages did not know why they bled every month.
Many girls also admitted to skipping work or school when menstruating due to a lack of sanitary resources or knowledge of how to look after themselves.
“Girls told us that they were too embarrassed to attend school when they were menstruating because they had no sanitary pads,” Lotus co-founder Dianne Gamage told Nikkei Asia. “One girl even told me that she wore two sinhs (traditional Lao female dress) on the days of her period, for fear of bleeding through the fabric.”
But despite the prevalence of period poverty, and its potential impact on girls’ education, improving menstrual health is rarely at the top of governments’ to-do lists, said Trine Angeline Sig, managing director of RealRelief, a Danish-based company that has been designing sustainable aid products for developing countries since 2013.
“I have so many stories from entering high-level offices and meeting ministers,” Sig told Nikkei Asia. “And when you talk to them about combating malaria, or distributing mosquito nets, etc, they will listen and they think it’s fantastic. But the minute you bring up sanitary products, the meeting is suddenly over and they don’t have time. Menstruation is so stigmatised in so many countries, and men don’t want to be involved.”
Yan Li, a professor of digital transformation at ESSEC Asia-Pacific in Singapore, told Nikkei that women’s health has historically been sidelined not only by governments but by the medical industry itself. “Women’s healthcare is treated as niche,” Li said, “even though we make up half of the population. Many drug trials don’t even test on female subjects, so women can easily be overdosed by accident.”
According to an often-quoted study published in the British Journal of Clinical Pharmacology in 2018, only 22 per cent of subjects in Phase 1 drug trials are female.
Out with the old, in with the tech
In the absence of sufficient representation in mainstream healthcare, entrepreneurs across Asia are turning to a new force to address women’s health concerns: femtech.
Coined in the US in 2016, “femtech” refers to any software, product or service that uses technology to improve women’s health.
Early femtech came in the form of sustainable sanitary products for tackling period poverty, such as the 3,200 sanitary kits produced and distributed in Laos by Lotus in 2016. The kits contained reusable pads, underwear and detergent, and were produced by girls enrolled in Lotus’ education programme.
As technology has evolved, so has femtech. In 2018, RealRelief won the Danish Design Award for its Safepad, a reusable sanitary towel made with a unique antimicrobial fabric that kills any bacteria within 30 seconds.
RealRelief’s Sig explained that antimicrobial technology is necessary because many girls in Asia’s poorest regions do not have access to clean water. “With Safepad,” Sig said, “even if you wash it in a contaminated lake or river, the fabric kills any harmful bacteria, so you don’t have to worry about infections.”
Safepad is currently distributed in 10 countries across Africa and Asia, including Laos and Bangladesh. RealRelief’s latest challenge has been getting the product to girls in Afghanistan, which has been experiencing a humanitarian crisis following the withdrawal of US troops last year, and where the UNHCR estimates that 80 per cent of the 700,000 people displaced by conflict in 2021 are women and children.
When the Taliban took over the country in August, Safepad’s production centre in Kabul was immediately forced to shut down.
But after several months of cautious talks with the Taliban, Safepad was given permission to resume production, provided the 12 local women employed to assemble the pads are accompanied to and from work by male guardians.
“I have to say,” Sig said, “I didn’t expect them to let us continue, but I was so happy for the women because they really look forward to coming to work every day . . . For them, it’s freedom.”
Asia’s femtech boom
The last couple of years have seen a boom in investment in femtech worldwide. Analytical information agency FemTech Analytics counted 1,323 femtech companies globally last year, 41 of which were in south-east Asia, with 1,292 investors.
“The massive digitisation of healthcare, partially driven by the Covid-19 pandemic, has given a much-needed boost to the femtech industry. More and more technologies aimed at improving women’s health are being designed,” said Kate Batz, director of FemTech Analytics, in an interview with Nikkei.
Asia is home to just 14 per cent of the world’s femtech companies, but is set to make the most of the boom. FemTech Analytics predicts that by 2026 the Asia-Pacific region will be seeing the world’s fastest growth in women’s health apps.
This growth will be fuelled by “greater awareness and openness about female health topics, changing perceptions about women’s health issues and more capital accessibility for female founders” in the region, Batz said.
One such app is Oky, launched in 2019 by Unicef, that was designed in collaboration with girls in Indonesia and Mongolia. It helps teach girls aged 10 to 19 about menstruation, with a cycle tracker and diary function, and lists local resources for reproductive health and sexual violence support.
Oky, now available globally, also has readout functionality for users with low literacy or visual impairments. Unicef plans to expand the app’s localised language content to eight countries this year, based on a franchise model.
But Gerda Binder, who leads the Oky team at Unicef’s East Asia and Pacific regional office, said there is a need for more interest and investment from big businesses if expansion goals are to be achieved. “There’s a huge untapped [well of] corporate contribution,” she said.
Covid’s impact on female health
Asia’s need for more femtech innovation has been highlighted by the Covid-19 pandemic; menstrual health is the tip of the iceberg.
Sarah Knibbs, the officer-in-charge of UN Women Asia and the Pacific, told Nikkei the pandemic had disproportionately affected the region’s women.
“Even before the pandemic, women on average were doing three times as much unpaid care work as men,” Knibbs said. “During the pandemic, there has been a huge increase in the burden of care work, due to closures of child care, elderly care and schools.”
The increased strain on women has affected their capacity to address pre-existing health concerns. “If you’re tied down with child care or social norms that make it difficult to leave the home,” Knibbs said, “you may not be able to access the healthcare, including vaccines, you need for yourself.”
MyAva, an Indian femtech start-up, hopes technology is the key to getting women the healthcare they need under pandemic conditions.
The MyAva app streamlines the monitoring and treatment of polycystic ovary syndrome (PCOS) by giving women access to centres that employ gynaecologists, nutritionists and fitness coaches, all in one place.
Among women aged 15 to 44 around the world, 1 in 10 is thought to suffer from PCOS, a hormonal condition whereby small follicles form on the inside of the ovaries. Symptoms include weight gain, irregular periods and facial hair.
Research suggests that PCOS disproportionately affects Asian women. According to a nationwide survey conducted in 2021 by OZiva, a plant-based nutrition and wellness brand, the syndrome affects 1 in 5 Indian women.
Divya (a pseudonym) lives in New Delhi. The 17-year-old suffers from PCOS. “Her condition has worsened” during the pandemic, Divya’s mother told Nikkei Asia. “Due to fear of catching Covid-19, I haven’t been taking my daughter to the gynaecologist regularly,” said the mother, visibly worried. “Before the pandemic, I never missed an appointment.”
Even before Covid hit, getting treated for PCOS in India was a challenge. Like menstruation, the condition is traditionally seen as taboo and not talked about with male family members, the decision makers in most households.
Despite the syndrome’s prevalence in India, OZiva’s survey revealed that 25 per cent of India’s female population did not know anything about PCOS, while 65 per cent were unaware of the symptoms.
Evelyn Immanuel, a biomedical engineer who has PCOS herself, founded MyAva in 2020 to “provide a holistic approach to the management of PCOS”.
The app has about 50 doctors, 25 nutritionists and 12 fitness coaches on board as consultants. Its subscription plans, which range from a duration of three to 12 months, cost anywhere from 2,500 to 18,000 rupees ($33 to $239).
UN Women’s Knibbs thinks technological approaches such as MyAva hold great potential for advancing women’s health. “One of the benefits of [femtech] is it can create an environment where women can seek help on an issue that they have difficulty talking about, or in situations where it’s difficult for them to leave the house,” she told Nikkei.
But there are concerns about the viability of femtech in societies where women have limited access to technology, or lack the financial means to pay for subscriptions. Neither Divya nor her mother had ever heard of femtech as a PCOS treatment option.
“In south Asia, the digital gender gap is enormous,” Knibbs said, explaining that “58 per cent fewer women than men have access to mobile internet services, and 28 per cent fewer women than men own mobile phones” in the region.
The situation concerns Pushpendra Singh, a professor at the Indraprastha Institute of Information Technology Delhi. Singh is involved in a project that uses mobile learning platforms to educate women in rural India about healthcare.
“The way many femtech apps have been developed means they are targeting themselves at women in urban areas,” Singh told Nikkei. “If [an app] requires users to pay, that user has to be from a higher economic background. If we want to reach rural women, we have to fundamentally change the way apps are being developed.”
The project Singh works on uses WhatsApp to provide free or low-cost medical consultations to women in India’s poorest regions, focusing on female-specific health concerns such as pregnancy and post-partum. His hope is to provide “informational support” to women, increasing awareness of female health issues and mobilising communities towards better health planning.
Femtech’s role in family planning
Demand for motherhood- and fertility-related femtech, which comprises 38 per cent of the world’s femtech market, shot up during the pandemic.
Maternal care and family planning were the first services to be scaled back or axed when hospitals were forced to redirect resources to the Covid response. A recent UN report found that 1 in 3 women in Pakistan have been unable to access the antenatal or postnatal care they needed during the pandemic.
In the Philippines, community health centres paused sexual and reproductive health programmes to focus on Covid, according to the University of the Philippines Center for Women’s and Gender Studies.
Jessica de Mesa, a registered nurse, saw a “big first-mover advantage” in providing Filipino women with health services and medical contraception, sold online and delivered discreetly. The Philippines already has health tech companies and specialised women’s clinics, so de Mesa and co-founder Abetina Valenzuela started Kindred to combine the two.
Kindred’s 12 staff and 21 doctors have served around 900 patients in their first five months. As soon as a new customer signs on, the company foresees lifetime demand, from menarche (a girl’s first period) to motherhood to menopause.
Anna, Kindred’s contraception arm, sells six different drugs for medical contraception, as well as emergency birth control. Monthly packages range from 500 to 1,000 pesos ($9.75 to $19.50). Virtual consultations with doctors on Kindred start at 850 pesos, with additional packages for fertility and sexual healthcare.
Instagram has been the main sales channel for Anna. Kindred customers, which de Mesa describes as upper-middle-income women in the urban workforce, prefer to engage with Anna via direct messages on the platform.
The start-up plans to open its first physical clinic this year and keep raising funds; it has already won an initial investment from Pulse 63, a venture capital focusing on healthcare.
“Kindred’s success will set the stage for other femtech start-ups,” de Mesa believes.
Femtech for men?
The appetite for femtech is growing in Vietnam, too. The capitalist class is taking cues from the ruling Communist party, which talks up equality across classes and among genders. Its efforts include requiring menstruation breaks at work and female-friendly labour laws.
Ngoc Nguyen, a coder from the Mekong Delta, can trace her life as a start-up CEO back to a little black dot on an ultrasound that appeared when she was pregnant in 2016. That dot turned out to be no cause for concern, but the early scare launched her on an obsessive bid to scour the web, books and her network to learn more about pregnancy.
Her research gave birth to Momby, a parenthood app. On Momby, users press one button to make an obstetrician appointment, another to ask questions to a chatbot and yet another for tips on breastfeeding.
“Parents have told us that when they don’t know who to ask [about pregnancy-related concerns] they can come to us,” Nguyen told Nikkei. Working with seven doctors, Momby combats “information overload” by giving parents verifiable facts in Vietnamese.
Vietnam takes a progressive line on reproductive rights, from abortion access to parental leave. The country of 99mn outperforms the region on maternal mortality, with 43 deaths per 100,000 live births, compared to 69 on average in Asia, according to the World Bank.
But as is the case in much of the region, strains on the family unit tend to come from society, including a preference for sons, an ageing population and the traditional belief that child care is a woman’s responsibility.
Momby’s aim is to appeal to fathers as well as mothers, to make pregnancy and parenthood more collaborative. The app includes a diary of what to expect at each stage of pregnancy and childhood development, a feature popular with both mothers and fathers.
Momby contains specific content directed at fathers, such as information about morning sickness and perinatal depression that their partners may encounter — and how they can help.
“I felt really happy when we got feedback like that,” the founder said, noting that 20 per cent of users are men.
The menace that is menopause
As Asia slowly emerges from the pandemic, an unlikely new kid on the femtech block is gaining attention: menopause care.
Menopause — the period during which a woman’s ovaries stop producing eggs, usually between the ages of 45 and 60 — affects 100 per cent of menstruating women and brings with it symptoms such as hot flushes, night sweats and headaches.
As lifespans get longer, the North American Menopause Society estimates that 1.1bn women — 12 per cent of the world’s population — will be experiencing menopause by 2025. This figure is becoming increasingly hard to ignore in Asia, home to some of the world’s most rapidly ageing populations. In Japan, for instance, over 29 per cent of the population is over 65.
But Susan Davis, director of the Women’s Health Research Program at Monash University’s School of Public Health and Preventive Medicine, Australia, told Nikkei that research into the impact of menopause on women’s health is slow and underfunded.
“There’s so much we don’t know,” Davis said. “No one is interested in investing money in mid-life women’s healthcare. Younger women’s health is far more attractive because they can have children, so people are more emotionally invested in that.”
What little research has been done suggests menopause could be seriously affecting women’s mental wellbeing. “Our studies found that the impact [of menopause] on women’s psychological wellbeing is equivalent to the impact of having chronic back pain,” Davis told Nikkei.
And “it’s not just about hot flushes”, Davis went on. “Menopause also impacts your bone health and cardio-metabolic health. When oestrogen levels drop, bone mass drops, which is why so many women get osteoporosis after menopause.” There is also research to suggest menopause increases women’s risk of contracting diabetes, heart disease and cancer.
Treatment options for menopause are limited. Hormone replacement therapy (HRT), which replenishes some of the hormones a woman’s body loses during menopause, is the most common approach, but “we still have doctors all over the world who don’t know how to prescribe HRT”, Davis said. “And what works for one woman, might not work for another. We need more information.”
Menopause femtech in Japan
In Japan, female entrepreneurs tired of waiting for advances in menopause care are turning to femtech.
Akiyo Takamoto, founder of femtech start-up Yorisol, decided it was time to take matters into her own hands after struggling to find information and support when she started experiencing menopausal symptoms a few years ago.
“Previous generations used to just put up with the burden of things like menstruation and menopause,” Takamoto said, “and there are still a lot of women in Japan who think that gaman (perseverance) is the right way to deal with these issues.”
Launched in April 2020, Yorisol uses artificial intelligence to facilitate communication between female users experiencing menopause and their male partners. “I often got into fights with my husband because I felt he didn’t understand my symptoms or thought I was complaining too much,” Takamoto said. “There’s a big gap in communication between men and women when it comes to menopause.”
By adding Yorisol as a contact on the popular messaging app Line, female users can log their daily symptoms and feelings, prompted by questions from an AI-powered bot. The bot then forwards these responses to the user’s partner, with suggestions of how they might relieve their wife’s or girlfriend’s symptoms that day.
“My aim,” Takamoto said, “is to create a new culture where men and women can navigate menopause together.” She added: “Japan still views menopause as a women’s problem above all else. But it impacts men’s lives, too.”
Takamoto told Nikkei that the lack of awareness about menopause in Japan, among both men and women, is leading to communication problems and even divorce for many couples. On top of the chat function, Yorisol provides a monthly couple’s counselling service.
Streamlining menopause care
But the societal impact of menopause extends outside of the home. Research suggests that untreated menopause symptoms negatively impact women’s performance at work.
A survey conducted in January by the Japan Society of Endometriosis found that 66.3 per cent of Japanese women going through menopause felt their productivity at work drop by at least 30 per cent on days when they were experiencing symptoms.
Davis, the Monash University professor, told Nikkei that companies have a responsibility to help their female employees find appropriate menopause treatment.
“Workplaces should be providing special leave for women who need to visit the doctor and get menopause care,” Davis said. “Turning up the aircon in the office because some women are having hot flushes is not enough.” Menopause leave is not currently a legal requirement in any country.
EloCare, a Singapore-based wearable technology start-up, believes the key to reducing menopause’s impact on women’s productivity is to streamline their access to effective treatment.
“Menopause affects every woman differently,” Mabel Yen Ngoc Nguyen, the start-up’s CEO, told Nikkei. “Many women do not understand their own symptoms, so it can take multiple trips to the doctor to even get diagnosed with menopause, let alone be prescribed appropriate treatment.”
Mabel, who holds a doctorate in biomedical engineering, co-founded EloCare with Fandi Peng in 2020 after noticing a gap in Singapore’s femtech market. “I’ve always been interested in femtech and realised that no one [in the industry] was talking about menopause,” Mabel said. According to FemTech Analytics, only 6 per cent of the world’s femtech companies specialise in menopause.
EloCare is developing a wearable product that monitors a woman’s body temperature, blood pressure and other variables to provide “personalised data treatment for menopause”, Mabel said. The aim is that users will be able to monitor their hot flushes and other symptoms, then see a doctor armed with data about their condition, in the hope of receiving a more accurate diagnosis and appropriate treatment.
Through EloCare, Mabel hopes to help women better understand their own symptoms and provide valuable data to researchers and doctors in the menopause field — data that was not available when EloCare started out. “The reason our prototype is taking so long is that there was no research to base it on,” Mabel said. “We had to do it all from scratch.”
Mabel sees Asia’s female healthcare landscape evolving. “More and more women are demanding solutions to menopause symptoms,” she said. “And investors are getting more and more interested in femtech. Male investors might not understand why it’s important, but they can see femtech is trendy, so I think investment will only increase.”
Dylan Loh in Singapore and Gwen Robinson in Bangkok also contributed to this story
A version of this article was first published by Nikkei Asia on March 2 2022. ©2022 Nikkei Inc. All rights reserved