New Delhi: One in four Indian women (26.8%) is married before 18, and 7.8% 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% in 2005-06 (NFHS-3)--and 16% 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%. While 2.7% of boys and 8% 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% 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%, 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, IndiaSpend reported in November 2017.

That process begins with making more adolescents familiar with sexuality, but the opposite is happening.

Fewer states teach adolescent sex education than before

Spurred by concerns of HIV-AIDS, the Indian government in association with United Nations agencies introduced an adolescence-education programme (AEP) in 2005. Adolescent health featured for the first time as a national programme in 2006 under the National Adolescent Reproductive and Sexual Health Strategy (NARSHS), 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, reported on August 1, 2014. For instance, the website reported, 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’, reported, adding that in April 2009, a Rajya Sabha committee chaired by M Venkaiah Naidu--now Vice President of India and then member of Rajya Sabha (upper house of Parliament)--said the adolescent-education programme would “promote promiscuity of the worst kind, strike at the root of the cultural fabric, corrupt Indian youth and lead to the collapse of the education system and the decrease of virginity age [sic]”.

“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.

More teens are having sex, few use birth control

In Bihar, of more than 10,400 adolescents (15-19 years) surveyed, 14.1% of unmarried adolescent boys and 6.3% of unmarried adolescent girls had premarital sex; and of them, 22% boys and 28.5% girls had premarital sex before 15 years, according to a 2016 report by the Population Council, an advocacy.

No more than 20.3% of unmarried boys and 8.2% of unmarried girls used a condom consistently, the study found. Among married girls aged 15-19 who cohabited with partners, only 11.2% ever used contraception within marriage and 45.2% had an unmet need for spacing between children.

Similar results emerged in the advocacy’s survey in Uttar Pradesh (UP), where 17.2% of adolescent boys (15-19 years) and 6.2% of adolescent girls were found to be sexually active. UP and Bihar together account for 30% of India’s adolescent population of 253 million, enough to be the world’s fifth-most populous country.

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%) of pregnant and adolescent mothers, there was a steady increase in the first pregnancy among adolescents (11.7%, 12.4% and 14.4 %). “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.

Indian adolescents are sexually active

Multiple studies (here, here and here) have shown that Indian adolescents, like adolescents in most countries, are sexually active; yet, “services for unmarried adolescents are non-existent in India”, said Sunil 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.

The public-health system is not prepared to serve the sexual and reproductive needs of the adolescents, said a 2015 review in the Indian Journal of Psychiatry. Healthcare professionals often lack knowledge about sexual and reproductive needs, and since sex is itself a taboo subject, sexual histories of adolescents are usually not recorded.

“Incorrect information has the potential to create misunderstanding in the youth making them less likely to adopt healthy practices and attitudes toward sex enabling them to maintain lifelong sexual health,” said the journal review.

That isn’t likely to improve any time soon because government programmes for sexually active adolescents are not particularly popular.

The government has programmes, but almost no teens know

In October 2014, the government started the Rashtriya Kishor Swasthya Karyakram (RKSK) or National Adolescent Health Programme, which, like adolescent-friendly health clinics (AFHCs) set by under NARSHS, made village health clinics sensitive to adolescent needs--about 7,500 nationwide are so enabled, according to a health ministry source.

The ministry of health and family welfare has not made public any evaluation of these programmes. Independent studies reveal widespread ignorance.

No more than 5% of young men and 8% of young women in the studied villages were aware of AFHCs, even though their villages were located between 5-10 km away, said a 2014 study conducted by the Population Council in Maharashtra, Rajasthan and Jharkhand. No young man and 0.8% of young women sought services from the AFHCs.

The main reason 82-90% (these data are a range because questions asked covered three health problems) of 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 2014 study found.

No more than 1% of boys and girls aged 10-14 interviewed knew about RKSK and only 4-7% received health services and information from an accredited social health activist (ASHA) or anganwadi worker, according to this 2017 study.

However, with RKSK, the effort is now to engage adolescents through peer educators from their own villages 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” for adolescent sexual and reproductive needs, said Indrani Banerjee Bhattacharyya, assistant director, Quality Assurance, Child in Need Institute, a non-profit.

Lack of access to contraception, unintended pregnancies

Not accessing government health services either due to lack of awareness or embarrassment can have far-reaching effects.

Adolescent fertility rates contributed 17% to India’s total fertility rate--number of children a woman would bear in a lifetime--in 2012 and about 14% of births in women aged below 20 were unplanned, according to the aforementioned 2015 study in the Journal of Clinical and Diagnostic Research.

Half of India’s 48.5 million pregnancies were unintended, FactChecker reported in December 2017.

Amita Dhanu, director, Family Planning Association of India (FPA), a 68-year-old nonprofit, provided the example of 19-year-old Sana (name changed), who was in a relationship and was only aware of emergency contraceptive. So, whenever she had unprotected sex, she used only emergency contraceptives.

The consequences were that when Sana missed her periods once, she took an emergency contraceptive to induce an abortion. But she didn’t get her periods again and came to one of 39 FPA India clinics nationwide and was found to be pregnant--emergency contraceptives cannot induce abortions after pregnancy; she had had unprotected sex again. She was counselled about oral contraceptives and provided a safe abortion.

“Service providers and staff at these [FPA India] clinics are trained to address adolescent health issues,” said Dhanu. “The environment at the clinics is friendly and services are available at timings suitable to young people.”

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% of boys reported having STI or symptoms of STI and 0.07% of girls and 0.01% 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% of India’s AIDS burden despite accounting for 25% of its population.

It is obvious, said experts, that contraceptives are not adequately available.

The need for emergency contraceptives

Among contraceptives that are available for adolescents, intra-uterine devices and morning pills cannot be recommended, since they are meant for those with regular sexual activity.

The only 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), a nonprofit that tries to make contraceptive products affordable. 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.

Adolescents who do not know about contraceptives or have adequate access to them are likely to have early and unplanned pregnancies.

Early and unplanned adolescent pregnancies are highly prone for adverse pregnancy outcomes, such as eclampsia--seizures during pregnancy, low birth weight, early neonatal death and congenital malformation. Pregnant adolescents are also more likely to leave school, affecting their and their family’s future.

This article has been produced with the financial assistance of International Planned Parenthood Federation (IPPF). The content of this article is the sole responsibility of Family Planning Association (FPA), India, and IndiaSpend and under no circumstances can be regarded as reflecting the position of IPPF. FPA India operates through 44 branches and projects across 18 states to ensure access to sexual and reproductive Health services and information for all.

(Yadavar is a principal correspondent with IndiaSpend.)

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