Many Indian women make do with little more than scraps of old cloth when menstruating, often risking their health, say aid workers trying to make clean and cheap sanitary napkins available.
Store-bought pads cost 60 rupees (1.5 dollars) for a packet of eight in a country where a fifth of the populations lives on 25 cents or less per day. Monthly purchases of cotton cloth are also out of the price range of many.
Millions of women in the billion-plus country are forced to get by with the little they have -- strips of old clothes, rags too dirty for household cleaning -- or nothing at all.
Some women sit at home for five days a month, and development workers say that ignoring this mundane need for a product Western women take for granted is taking a toll on the health and education of Indian women.
In the village of Rupaspur in northern Uttar Pradesh state, 260 kilometres (160 miles) from New Delhi, women talked about the discomfort of having each month to steal or salvage old cloth scraps.
Even worse, they recalled deaths from doing just that during post-pregnancy bleeding when the risk of infection is high.
"A neighbour delivered and when she had bleeding later she used cloth from an old blouse," said Shahnaz, who lives in the mostly Muslim village of 80 families. "But the blouse had a rusty hook. The doctors said she got tetanus," which led to her death.
Shahnaz, a mother of four in her early forties, has begun using cotton-cloth napkins provided by Delhi-based nonprofit Goonj (Echo).
The pads cost two or three rupees for a packet of six but are free for those who cannot pay. In Rupaspur and surrounding villages, about 600 women now use the handmade prewashed cotton pads.
The UN child welfare arm UNICEF says it found a combination of lack of proper school toilets, the onset of periods and lack of sanitary napkins was leading some girls to drop out.
Backed by officials in southern Tamil Nadu state, the group began working with women's village committees to help them buy machines to make sterile disposable napkins.
One of the first women they trained, Nagalakshmi, and her self-help group are doing brisk business in the pads which cost about 1.3 rupees each to make.
Both Goonj and UNICEF try to impart health information along the way.
"We're not looking to become a manufacturer of sanitary napkins," said Anshu Gupta, head of Goonj, which won a World Bank award for its project. "We want to start a movement so they do it themselves and we put in some good practices like drying cloths in sunlight and changing more frequently."
Women who use cloth strips give greater weight to the embarrassment of letting the fabric dry outside in plain view than to the risk posed by using damp fabric rife with fungal or other organisms, a doctor said.
"The knowledge is not there -- even in city slums. Everyone considers menses dirty so people don't discuss it. Because they don't discuss it these things go on," said obstetrician-gynecologist Pankaj Desai, president of the Federation of Obstetrics and Gynecology Societies of India.
"Normal menstrual blood is not infected. It is not dirty. But when it gets contaminated by these dirty cloths, organisms start growing" and there is the risk of infection.
Schools do not teach sex education in conservative India and parents are often too shy to talk to their children or lack information themselves.
One Rupaspur villager, a 30-year-old mother of five, says she had no idea what was happening to her when she got her first period.
"I thought something had cut me or bit me," said the woman, whose mother never raised the subject with her.
She kept bathing and worrying she was gravely ill until an older female friend told her she was menstruating and gave her a torn strip of a sari to use.
The women in Rupaspur say having proper pads has been a boon.
"If you're staying with your relatives, how are you going to ask for cloth or underwear?" said Shahnaz. "This gives you peace of mind. You can wear these and go anywhere."