One in four Indian women is married before 18, and 7.8 per cent of women aged 15 to 19 are pregnant or mothers, according to the latest available 2015-16 National Family Health Survey (NFHS)-4 data.
While the percentage of women married before 18 decreased from 47.4 per cent in 2005-06 (NFHS-3) — and 16 per cent of women aged 15 to 19 who were mothers a decade ago — the use of contraceptives in married women aged 15-49 years dropped from 56.3 to 53.5 per cent. While 2.7 per cent of boys and eight per cent of girls reported their sexual debut before the age of 15 in 2005-06, the latest comparative data have not been released. Yet, social and policy barriers do not allow the sexual and reproductive needs of adolescents (10 to 19 years) to be addressed because many of those who have sex are unmarried and below the age of consent, said Sunil Mehra, Executive Director of MAMTA, a Delhi-based non-profit working on adolescent and reproductive health issues.
As a result, 33.6 per cent of India’s population is born of adolescent pregnancies; delaying the onset of child-bearing could reduce India’s projected 2050 population of 1.7 billion by 25.1 per cent, according to a 2013 United Nation Population Fund review.
India has 253 million adolescents, more than any other country and equivalent to the combined populations of Japan, Germany and Spain, but the country is not doing enough to ensure that they become productive adults. That process begins with making more adolescents familiar with sexuality, but the opposite is happening. Spurred by concerns of HIV-AIDS, the government in association with UN agencies introduced an adolescence-education programme (AEP) in 2005. Adolescent health featured for the first time as a national programme which included health clinics that offered preventive, promotive, curative and referral services for adolescents (10-19 years) and youth (19-24 years).
Within two years of inception, the AEP was banned in 12 states, including Maharashtra, Karnataka, Kerala and Uttar Pradesh. For instance, Madhya Pradesh Chief Minister Shivraj Singh Chouhan said the illustrations were too graphic; he wanted adolescent education focussed on “yoga and Indian cultural values”. The National Aids Control Organisation (NACO) removed contentious illustration and words considered explicit, such as ‘intercourse’, ‘condoms’ and ‘masturbate’.
“It is difficult to say how many states are implementing the Adolescence Education Programme, since several states that banned it earlier have begun implementing it, such as Kerala,” said Dipika Srivastava, Programme Coordinator at TARSHI, a New Delhi-based NGO working on sexuality. However, even where the programme is being implemented, the quality of implementation is open to question, she said. “Given that sexuality education addresses long-held attitudes and cultural or moral norms, effective implementation is key to making sure young people get accurate, non-judgmental information related to sexuality,” said Srivastava.
In Bihar, of more than 10,400 adolescents (15-19 years) surveyed, 14.1 per cent of unmarried adolescent boys and 6.3 per cent of unmarried adolescent girls had premarital sex; and of them, 22 per cent boys and 28.5 per cent girls had premarital sex before 15 years, according to a 2016 report by the Population Council. No more than 20.3 per cent of unmarried boys and 8.2 per cent of unmarried girls used a condom consistently, the study found. Among married girls aged 15-19 who cohabited with partners, only 11.2 per cent ever used contraception within marriage and 45.2 per cent had an unmet need for spacing between children.
Nationally, while the three national health surveys (1992-93, 1998-99, 2005-06) reported an almost equal proportion (59.1, 59.8 and 58.2 per cent) of pregnant and adolescent mothers, there was a steady increase in the first pregnancy among adolescents (11.7, 12.4 and 14.4 per cent). “Early marriage and low contraceptive use are the reasons behind this trend,” said a 2015 review in Journal of Clinical and Diagnostic Research. What is clear, said experts, is that Indian adolescents are more sexually active than ever — yet, “services for unmarried adolescents are non-existent in India”, said Mehra. Reproductive health services include counselling on menstrual disorders, menstrual hygiene, use of sanitary napkins, use of contraceptives, sexual concerns, sexual abuse and gender violence.
While there has been a recent uptake in activities around menstrual hygiene and iron folic supplements through schools and immunisation through anganwadi (day care centre) workers, sexual and reproductive health is “completely neglected”, Mehra said. In October 2014, the government started the Rashtriya Kishor Swasthya Karyakram (RKSK) or National Adolescent Health Programme, which, like adolescent-friendly health clinics (AFHCs), made village health clinics sensitive to adolescent needs — about 7,500 nationwide are so enabled, according to a Health Ministry source.
Yet, independent studies reveal widespread ignorance. No more than five per cent of young men and eight per cent of young women in the studied villages were aware of AFHCs, said a 2014 study conducted by the Population Council in Maharashtra, Rajasthan and Jharkhand. No young man and 0.8 per cent of young women sought services from the AFHCs.
The main reason 82-90 per cent why adolescents did not seek help was because they thought their problems were not serious enough; the second-most common reason was because they were too embarrassed, the study found. However, with RKSK, the effort is now to engage adolescents through peer educators who would speak about various life skills, including nutrition, mental health, non-communicable diseases, gender and sexual and reproductive health, while sensitising ASHAs, auxiliary nurse midwives, anganwadi workers, counsellors and medical officers to offer “non-judgemental services”, said Indrani Banerjee Bhattacharyya, Assistant Director, Quality Assurance, Child in Need Institute.
Adolescent fertility rates contributed 17 per cent to India’s total fertility rate in 2012, and about 14 per cent of births in women aged below 20 were unplanned, according to the 2015 study in the Journal of Clinical and Diagnostic Research. Without sex education and counselling, adolescents are also at a high risk of acquiring sexually transmitted infections (STI) and even HIV.
In the age group of 15-19, of those who had sexual intercourse, 10.5 of girls and 10.8 per cent of boys reported having STI or symptoms of STI and 0.07 of girls and 0.01 per cent of boys were found to be HIV positive, according to the 2005-06 National Family Health Survey. Youngsters between 15-24 years contribute to 31 per cent of India’s AIDS burden despite accounting for 25 per cent of its population. It is obvious, said experts, that contraceptives are not adequately available. And among contraceptives, the only real option is a condom, “yet, it means girls have to rely on their male partners for protection which is not ideal,” said Vivek Malhotra, Director, Population Health Services (India). Emergency contraceptives as an alternative should be made affordable and widely available, he said.
Today, emergency contraceptives are available as commercial products, over the counter, but they are priced too high to be accessible for adolescents, said experts. If not in schools, emergency contraceptives should be available in colleges and sold at an affordable rate by the government, they said.