22/10/2017 11:05 AM IST | Updated 22/10/2017 11:08 AM IST

Why India Ranks As One Of The Highest In The Number Of Reported Adolescent Pregnancies

Adolescent sexual and reproductive health: a reality check (Part 1)

Ajay Verma / Reuters
Image used for representational purposes only.

"How old are you? What is your age?" I asked Babita (name changed), a young girl breastfeeding her two-month-old daughter.

"What do you mean by age?", her sunken eyes looked puzzled.

Realising we don't share the same references to time, I reword my question, "How many years ago did you start menstruating?"

"Two-three years ago," she tells us.

She is approximately 15-16 years old, I surmise.

During the interview, Babita told me that she was married off a year after she started menstruating. At the time of interview, she was staying with her mother as her husband had gone to Punjab for six months to work as an agricultural labourer. There are no functional schools in her village since the headmaster seldom shows up, so she stopped going to school early on. Added to this was the fact that she had to help her parents by cutting dhaan (paddy) in the field all day. To escape that drudgery, she agreed to get married. Why did she conceive a child so soon after marriage, I ask? "Baanj bulayenge warna sab" (otherwise they will call me infertile)," she exclaims!

This is a typical example of my conversations with young girls I had met in Araria, Bihar during field work for a formative study on adolescent reproductive and sexual health (ARSH). For this population, child marriage and early pregnancy are a stark reality; according to NFHS-4 survey (2015-16), 26.8 percent of women in India between the ages of 20 and 24 years are married before they turn 18 years old.

For rural Bihar, this number is more alarming – 2 out of 5 women aged 20-24 years were married before 18 years of age (NFHS-4). Similarly, 42.6 percent of men aged 25-29 years in rural Bihar were married before they turned 21 years.

Adolescent pregnancy remains underreported in India

It is important to point out here that these numbers do not reflect ground realities. Even though NFHS survey questionnaires undergo extensive pre-testing, they do not account for two things: the cognitive and conceptual gaps in understanding and reporting age in rural areas, and the impact of messaging and government's Information Education and Communication (IEC) material on mis-reporting or over-reporting one's age. Young boy and girls, especially when under-age, and their parents, either fear adverse consequences if they have been exposed to messaging on child marriage or fester false hopes of receiving benefits during survey exercises.

Babita's mother for example vehemently insisted that her daughter got married when she turned 18 years old, which our probing and triangulation of information revealed was not true. Adolescents as well as their parents frequently misreported their age either because they did not know their actual age and miscalculated years, or because they knew they cannot report being married if they are less than 18 or 21 years old. For similar reasons, the data on adolescent pregnancy also remains underreported in India, indicating a need to re-look standardised data collection practices.

ARSH Status Quo and Unmet Needs

Around 12.8 percent of women aged 15-19 years in rural Bihar were already mothers or were pregnant at the time of the NFHS-4 survey, which in real terms is a significant number. India in fact ranks as one of the highest in the number of reported adolescent pregnancies – the actual numbers are probably higher.

Yet, awareness and use of contraceptive methods as well as sexual rights remain limited in rural India. Babita, who upon some probing acknowledged that while she has heard about some contraceptive methods, argued that she will not use Copper-T or oral pills for delaying her next pregnancy as, it will "make her infertile". Such myths and misconceptions associated with IUD, pills and condoms are a commonplace in rural areas and are a significant reason behind lack of uptake of contraceptive methods in spite of rudimentary awareness. This is compounded by limited use of male-dependent methods, high discontinuation rates, and lack of support from family as well as service providers.

Studies show that the unmet need for contraceptives, especially for spacing pregnancies, in rural Bihar is as high as 21% (NFHS-4). The use of short-term contraceptives among adolescent women to delay pregnancy is even lower as they are expected to establish their fertility right after marriage to avoid stigmatization by the society.

Consequently, female sterilisation after bearing a few children has become the most widely accepted contraceptive method. "do ladka hone ke baad operation karvaungi" (I will undergo an operation after delivering two sons)," Babita told us when we asked her how will she prevent pregnancy after she has had the number of children she wants. The success of female sterilisation is explained by the penetration of Accredited Social Health Workers (ASHAs) in rural areas under the National Rural Health Mission, an increase in number of institutional deliveries, and the compensation offered in public health facilities for sterilisation.

Unmarried adolescents are simply discouraged from seeking reproductive and sexual healthcare and their problems are dismissed as trivial.

However, our field experience suggests that the problem with sterilisation is that it is viewed as a permanent contraception method which is adopted only after the couple has had multiple children, preferably sons. The onus of this adversely falls on women and their health who are in turn pushed towards early pregnancy and consecutive child births.

This social pressure on adolescent and young women is coupled by lack of alternative life choices, limited mobility and lack of control over their own sexual and reproductive rights. Further, while married adolescents still enjoy certain social legitimacy while accessing reproductive health services, unmarried adolescents are simply discouraged from seeking reproductive and sexual healthcare and their problems are dismissed as trivial.

This is bolstered by the population control and family centric approach in our policy environment which primarily focuses on improving access to contraceptives for married couples, and an overall development of the 'family'. Such a discourse fails to take into account the overall quality of life that young women in rural areas are leading, the social costs associated with delaying or limiting pregnancies and the lack of decision making power in the hands of women.

The movie Parched (2015), set in the landscape of rural Rajasthan about four women navigating the patriarchal society, drives home this point really well. When Lajjo, a young woman in an abusive marriage fails to conceive due to her husband's impotency, she is mocked for infertility, and when Janki, a child bride, chops off her hair to stop her marriage, she is forced into it nonetheless. The movie ends on a positive note: the three characters escape their village in search for a better life. But it leaves a crucial question unanswered, what is the life that awaits them?

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