Abstract: More than one lakh women die in India every year due to pregnancy, most of them being married adolescents. India is still grappling with the effort of reducing maternal mortality as it records the highest number of maternal deaths (UNICEF 2009; Pachauri 2009). Our country is set to meet the United Nations Millennium Development Goal Five (MDG 5) to improve maternal health and achieve universal access to Reproductive Health (RH). Still we are not making any considerable efforts in addressing the RH concerns of adolescent girls.
Keywords: adolescent girls, maternal mortality rates, United Nations Millennium Development Goal Five (MDG 5), premarital sexual activities, young women, health services, early marriage, gender bias, gender norms, sexual behaviour, family planning, adolescent married girls
The beginning of adolescence- puberty marks the onset of an individual’s capability to reproduce. From this period on, RH and its relevance are felt. It is during this crucial beginning and later during adulthood that the stage is set for health beyond the reproductive years for both men and women. This can impact health of future generations. Adolescents constitute nearly 22 per cent of the population of India. Though the situation of young people in India has considerably improved, they experience significant constraints in making informed life choices (Registrar General, India 2001; Santhya and Jejeebhoy 2007). Despite laws (Child marriage restraint Act of 1978) advocating 18 years as the legal minimum age at marriage for females in India, as many as 45 percent of 20-24 year-old women were married by the age of 18 years (IIPS 2007). Statistics reveal that adolescent girls are facing unmet needs specifically in RH, and nutrition. This can be attributed largely to widespread gender discrimination and son preference. The latest Census of India 2011 reveals the most worrying and shocking trend shown in the drop in the sex ratio for children aged up to six years old, indicating a continued strong preference for sons. The child sex ratio for children from 0-6 years of age has dropped from 927 to a dismal 914 females as against 1000 males, the lowest since independence. The sex ratio (females: males) has crept up to 925:1000 but it is still below the national average of 940:1000. These findings are so disturbing that they could cast a shadow on the positive developments. Girls seem to have no place in India’s growth story. The gender bias yet again draws attention to a lingering societal flaw that economic growth is not being able to correct (Times of India 2011).
Gender Challenges Faced by Adolescent Girls
Adolescence is the phase when a boy’s world expands and a girl’s world contracts. The onset of puberty- menarche- marks the onset of a kaleidoscope of changes in a girl’s life- physical, physiological and psychological. It is also a time when girls face great educational and social challenges. In India, restrictions in dressing style, behaviours, social interactions and mobility start being imposed at this stage. A new set of rules are imposed on her that conform to social norms. A restriction on the mobility of girls is one aspect of the larger process of socialisation. This for girls begins in childhood and continues through adolescence. Public speculation can result, if girls have greater freedom, therefore restrictions are imposed by family to retain social status and honour. However, controlling the mobility of girls outside the home undermines their exposure to the outside world. Girls lose out in terms of educational opportunities and access to resources. These restrictions also limit the abilities of girls to develop key life skills and a sense of individual autonomy.
Several community-based programmes reveal a gender bias in terms of sexual behaviour and RH. It is accepted or even expected that boys indulge in premarital sexual activity, but is unacceptable for ‘respectable’ girls. Contraception is seen as a woman’s responsibility; but unmarried young women face problems in seeking contraception, or any other reproductive health service, for fear of being labeled ‘sexually active’ and therefore, promiscuous. Females are widely considered to be a social and financial liability and the dowry system is still prevalent. Social attitudes clearly favour cultural norms of premarital chastity in girls. Girls are taken out of school at an early age, usually soon after menarche. At times, such gender norms lead to many abuses such as sexual violence, including rape or domestic violence. There is some evidence indicating that adolescent abortion seekers often become pregnant as a result of rape or non-consensual sexual activity. Girls indulging in sexual activities may be a result of their inability to say no to older men because of a cultural tradition of respecting elders and men. In many cultures, the discrimination against girls and women that begins in infancy determines the trajectory of their lives.
One of the most common forms of discrimination in India especially in the northern states is ‘daughter neglect’ in terms of the biased allocation of food. This discrimination undermines adolescent girls’ nutrition and health. A study of school-going adolescents in Mumbai found haemoglobin values to be less than 8 gm (indicative of severe anaemia) in 16 percent of girls and only 2 percent of boys (Joshi et al 2005). This leads to considerable unmet needs of RH. The unmet needs of RH are also due to the lack of targeted health services for adolescents, widespread gender discrimination besides son-preference that prevail and limit adolescent girls’ access to health services. The persisting practice of early marriage and childbearing puts adolescent girls and their children at increased risk of adverse outcomes. The prevalence of early marriage is 44.5 percent in India overall and 52.5 per cent in rural areas (NFHS-3 2005-06). Child bearing at an early age is a major factor affecting Maternal Mortality Ratio (MMR). Abortion, haemorrhage, anaemia of pregnancy, mal-positioning of the child (foetal mal-presentation), sepsis and obstructed labour are some of the few major complications and causes of maternal deaths due to early childbearing. The UNFPA State of World’s Population 2010 reports that children are continuing to give birth to children, such as – in Nepal it is 101, in Bangladesh it is 72 and in India it is 68- out of every 1000 adolescent girls.
Risks involved in Sexual Behaviour
Young adolescent girls’ minds and bodies are not prepared to face the pressures of adulthood, and this puts them and their babies to huge health risks. Young women and men enter marriage with different pre-marital sexual experiences and risk profiles. Although available evidence suggests that fewer than 10 per cent of unmarried girls are sexually experienced, marriage, in contrast does not necessarily mark the initiation of sex for boys. Available evidence suggests that some 15- 30 percent of boys reported to have had premarital sex (Jejeebhoy and Sebastian 2004). Evidence from a community based study in Pune district, Maharashtra, shows for example that 16-18 percent of unmarried young men and 1-2 percent of unmarried young women report pre- marital sex. While the majority of sexually experienced unmarried women report having sex with a steady partner, a significant proportion of sexually experienced young men report sex with multiple partners, casual partners, commercial sex workers and older married women. Of the sexually experienced moreover, between one-fifth and one-quarter reported relations with more than one partner, compared to one in 20 sexually experienced young women. Condom use is reported by fewer than half of all sexually experienced young people in any pre-marital relationship (Alexander et al 2006). Such findings suggest the likelihood that many young men may already be having a sexually transmitted infection or may be HIV positive at marriage. In a study of 50 HIV positive males and their spouses / partners, 30 men reported becoming infected before marriage (Singh and Kumari 2000). This suggests the extent to which young men and women engage in risky sexual behaviours, along with the fact that social and economic disadvantage characterises girls who are married early, also suggests that married young women are at special risk of HIV.
Married adolescent girls face distinct risks of HIV. Several factors underlie these risks: married young women’s relative lack of awareness of HIV and safe sex practices, their low self-perception of risk, their lack of access to appropriate information programmes or reproductive health services, their lack of agency and unequal gender norms. Early marriage thus provides a particular path to and not a barrier against HIV transmission (Santhya and Jejeebhoy 2007). Married adolescents have limited decision-making power in their sexual relationships. They are often ignorant about the reproductive processes and may not realise that their concerns need professional attention.
To make matters worse, adolescent health care in rural India is limited. Programmes related to RH have been designed to be curative but not preventive. These programmes are not planned suitably for unmarried adolescents. Most public sector services target adult married women. A woman’s cervix is underdeveloped at puberty and this has greater chances of contracting HPV (human papillomavirus); HPV is transmitted through sexual contact. Unmarried adolescents often do not seek safe abortions for a number of reasons – fear that the services are not confidential; inability to pay the required fees; the prerequisite of parental / partner approval in some instances; or that health workers will react negatively and will be insensitive to their needs. Majority of the married adolescents in India are not using any contraception, many report a desire to delay the next birth or limit childbearing, but are not using a contraceptive. Studies have shown that use of contraception also increases the risk of reproductive health problems due to improper use and lack of knowledge about the contraception. The focus of the family planning programme has been on permanent methods aimed at older women. A small number of women do seek help when an unwanted conception outside marriage occurs.
Sexual and reproductive rights including prevention, control and management of Reproductive Tract Infections (RTIs) or Sexually Transmitted Diseases (STDs) form part of the RCH programme. But this component of the RCH programme has not been effectively implemented, coupled with the lack of responsible behaviour from women’s sexual partners, contributing to increasing incidence of these preventable diseases.
Since April 12th 2005, the National Rural Health Mission under its mission has included the Reproductive and Child Health-II (RCH) programme as a major component besides some of other programmes like the National Disease Control Programme and the Integrated Disease Surveillance programme (Sadgopal 2009). But none of these health programmes have so far focussed on a separate adolescents’ RH programme considering the vulnerability of poor young women and girls in terms of STDs and high-risk sexual behaviour in India.
How can we address the Reproductive Health concerns of Adolescent Girls?
The population policy of India is demographically driven instead of focussing on women’s empowerment and adolescents’ RH care, which is crucial at its stage. Available programmatic sexual and RH initiatives have focussed disproportionately on the unmarried and on premarital sexual activity. The policy is in contrast to the commitments it made at the International Conference on Population and Development (ICPD), Cairo, 1994, on achieving reproductive and sexual health and rights.
The achievement of MDG 5 by 2015 in India is crucial, due to existing gaps in achieving optimal adolescent RH and increasing maternal mortality. The first step is to provide adolescents with sexual information to bring about a change in behaviour. The important issues of health care arise in childhood and adolescence and should be continued as issues in reproductive years along with family planning, STDs, RTIs, adequate nutrition, care in pregnancy and concerns about cervical and breast cancer. Families and communities need to be sensitised on these issues.
We need to take up in-depth research in adolescents’ reproductive and sexual health in states across India where traditional features of culture are strongly practiced, especially those which hinder practicing of good RH and accessibility of health services. One way of identifying such areas is by looking at the RH indicators of the states. For instance, prevalence of early marriage in Rajasthan is 57.1 per cent (65.7 per cent in rural areas) and the median age for effective marriage is 15 years (NFHS-3 2005-06). A qualitative study that was conducted in Udaipur district, Rajasthan (Barua et al 2007), on 21 unmarried adolescent girls revealed that care and support in terms of diet, health and emotional care was received from parents, in contrast to the NFHS-3 findings that suggest that gender discrimination is highly prevalent in Rajasthan. It was revealed through the Rajasthan study that greater care and support that girls in the rural area received was most likely due to their Meena ethnicity. Many such tribal communities have progressive values that empower women and girls. This suggests that extent of care for adolescent girl varies. But findings of the Rajasthan study do not broadly apply to other communities where girls may be less valued. This suggests that similar studies on a wider scale could be carried out in the remaining part of Rajasthan.
In many cultures, adolescent girls and women are denied access to information on healthy and safe practices on sex, menstrual hygiene, family planning methods and in obtaining optimum RH care. Married and unmarried adolescents can practice proper RH and access health care facilities, even while observing ‘purdah.’ This is possible if their families are made aware of the recent RH problems which adolescents are facing and those which could have severe long term implications. This will sensitise the family to their RH problems and needs, and awaken family support.
Incorporating appropriate and affordable facilities, especially for adolescent girls, in the government health system is warranted. The Janani Suraksha Yojana (JSY) under the National Rural Health Mission has been initiated since 2005 for reducing maternal mortality and to increase institutional deliveries. Institutional deliveries need to be increased and ‘dai’ training is very important in areas where they can help the community to deliver in hygienic conditions at home, if institutional delivery is not possible. Accredited Social Health Activists (ASHAs) who bring the community closer to the health services should engage married and unmarried adolescents as major components of the RCH programme. At the time of training of ASHAs by the government, this should be highlighted.
Sexual activity and fertility among unmarried adolescents has to be addressed within a very different context and with different challenges. Any reproductive or sexual health problem should not be taken lightly. For example, adolescent girls whether married or unmarried, if suffering from any form of white discharge, should show themselves to a health specialist who would check them, and relate symptoms to any form of which could possibly be existing.
Persistent early childbearing is a public health concern. Efforts to delay marriage and increase age at the first birth should be made, along with expansion of schooling and provision of job training. Besides promoting norms of responsible parenthood family life education projects should focus on sexuality and gender relations. Therefore the content on sexual relations has to be in itself tailored, because failure to challenge existing sex roles and attitudes towards male and female sexuality simply reinforces prevailing imbalances of power in gender relations.
Programmes focussing on women’s empowerment should focus on reaching out to adolescents as well. For example, the garment industry in Bangladesh has extended the period before marriage by providing young women with the means to earn a living (UNFPA 2003). Women need to be empowered so that their health needs are also addressed. Health and nutrition services can be broadly tailored to meet the needs of the unmarried adolescent girls, and life-skill programmes for this group provide an opportunity to equip them with valuable skills for their future lives. These insights could encourage parents to allow their daughters to continue their education, delay their marriage, and develop life skills critical for their well-being in the future. For example, providing opportunities for girls to continue their education or earn money is another strategy for delaying marriage as well as expanding life skills and choices.
Intensive participatory training programmes that are rooted in social realities will help enable an understanding of women’s problems and needs. Programmes of health awareness for young married or unmarried women should work towards challenging existing gender norms. This is also important because their reproductive and sexual problems, could be attributed to sexual exploitation or to gender discriminatory practices such as families not allowing them to use contraceptives due to son preference. Women should be made to come together and discuss and understand the situation of women from a feministic perspective.
Sexual and reproductive health of adolescent girls should have a well defined approach today if India has to achieve the goals of women’s empowerment and gender equity.
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DR. HEENA K. BIJLI. Is Associate Professor, School of Continuing Education, IGNOU.