NEW DELHI — One in four Indian women is married before 18, and 7.8 percent of women aged 15 to 19 are pregnant or mothers, according to the latest available 2015-16 National Family Health Survey-4 data.
While the percentage of women married before 18 decreased from 47.4 percent in 2005-06, according to NFHS-3 – and 16 percent 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 percent. While 2.7 percent of boys and eight percent 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 percent 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 percent, 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 U.N. agencies introduced an Adolescence Education Program in 2005. Adolescent health featured for the first time as a national program, 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 focused on "yoga and Indian cultural values."
The National AIDS Control Organization 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 Program, since several states that banned it earlier have begun implementing it, such as Kerala," said Dipika Srivastava, program coordinator at TARSHI, a New Delhi-based NGO working on sexuality.
However, even where the program 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 percent of unmarried adolescent boys and 6.3 percent of unmarried adolescent girls had premarital sex; and of them, 22 percent of boys and 28.5 percent of girls had premarital sex before 15 years, according to a 2016 report by the Population Council.
No more than 20.3 percent of unmarried boys and 8.2 percent of unmarried girls used a condom consistently, the study found. Among married girls aged 15-19 who cohabited with partners, only 11.2 percent ever used contraception within marriage and 45.2 percent 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 percent) of pregnant and adolescent mothers, there was a steady increase in the first pregnancy among adolescents (11.7, 12.4 and 14.4 percent). "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 immunization through anganwadi (day care center) workers, sexual and reproductive health is "completely neglected," Mehra said.
In October 2014, the government started the Rashtriya Kishor Swasthya Karyakram or National Adolescent Health Program, which, like adolescent-friendly health clinics, 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 percent of young men and eight percent 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 percent of young women sought services from the AFHCs.
The main reason 82-90 percent 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 sensitizing 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 percent to India's total fertility rate in 2012, and about 14 percent 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 and even HIV.
In the age group of 15-19, of those who had sexual intercourse, 10.5 of girls and 10.8 percent of boys reported having STI or symptoms of STI and 0.07 of girls and 0.01 percent 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 percent of India's AIDS burden despite accounting for 25 percent 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.
(In arrangement with IndiaSpend.org, a data-driven, non-profit, public interest journalism platform, with whom Swagata Yadavar is principal correspondent. The views expressed are those of IndiaSpend. Feedback at email@example.com)