NEW DELHI – One in four Indian women is married before 18, and 7.8 % ofwomen aged 15 to 19 are pregnant or mothers, according to the latestavailable 2015-16 National Family Health Survey (NFHS)-4 data.

While the percentage of women married before 18 decreased from 47.4 % in2005-06 (NFHS-3) — and 16 % of women aged 15 to 19 who were mothers adecade ago — the use of contraceptives in married women aged 15-49 yearsdropped from 56.3 to 53.5 %. While 2.7 % of boys and 8 % of girls reportedtheir sexual debut before the age of 15 in 2005-06, the latest comparativedata have not been released.Yet, social and policy barriers do not allow the sexual and reproductiveneeds of adolescents (10 to 19 years) to be addressed because many of thosewho have sex are unmarried and below the age of consent, said Sunil Mehra,Executive Director of MAMTA, a Delhi-based non-profit working on adolescentand reproductive health issues.

As a result, 33.6 % of India’s population is born of adolescentpregnancies; delaying the onset of child-bearing could reduce India’sprojected 2050 population of 1.7 billion by 25.1 %, according to a 2013United Nation Population Fund review.

India has 253 million adolescents, more than any other country andequivalent to the combined populations of Japan, Germany and Spain, but thecountry 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 UNagencies introduced an adolescence-education programme (AEP) in 2005.Adolescent health featured for the first time as a national programme whichincluded health clinics that offered preventive, promotive, curative andreferral services for adolescents (10-19 years) and youth (19-24 years).

Within two years of inception, the AEP was banned in 12 states, includingMaharashtra, Karnataka, Kerala and Uttar Pradesh. For instance, MadhyaPradesh Chief Minister Shivraj Singh Chouhan said the illustrations weretoo graphic; he wanted adolescent education focussed on “yoga and Indiancultural values”.

The National Aids Control Organisation (NACO) removed contentiousillustration and words considered explicit, such as ‘intercourse’,‘condoms’ and ‘masturbate’.

“It is difficult to say how many states are implementing the AdolescenceEducation Programme, since several states that banned it earlier have begunimplementing it, such as Kerala,” said Dipika Srivastava, ProgrammeCoordinator at TARSHI, a New Delhi-based NGO working on sexuality.

However, even where the programme is being implemented, the quality ofimplementation is open to question, she said. “Given that sexualityeducation 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 % ofunmarried adolescent boys and 6.3 % of unmarried adolescent girls hadpremarital sex; and of them, 22 % boys and 28.5 % girls had premarital sexbefore 15 years, according to a 2016 report by the Population Council.

No more than 20.3 % of unmarried boys and 8.2 % of unmarried girls used acondom consistently, the study found. Among married girls aged 15-19 whocohabited with partners, only 11.2 % ever used contraception withinmarriage and 45.2 % 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 %) ofpregnant and adolescent mothers, there was a steady increase in the firstpregnancy among adolescents (11.7, 12.4 and 14.4 %). “Early marriage andlow contraceptive use are the reasons behind this trend,” said a 2015review in Journal of Clinical and Diagnostic Research.

What is clear, said experts, is that Indian adolescents are more sexuallyactive than ever – yet, “services for unmarried adolescents arenon-existent in India”, said Mehra.

Reproductive health services include counselling on menstrual disorders,menstrual hygiene, use of sanitary napkins, use of contraceptives, sexualconcerns, sexual abuse and gender violence.

While there has been a recent uptake in activities around menstrual hygieneand iron folic supplements through schools and immunisation throughanganwadi (day care centre) workers, sexual and reproductive health is“completely neglected”, Mehra said.

In October 2014, the government started the Rashtriya Kishor SwasthyaKaryakram (RKSK) or National Adolescent Health Programme, which, likeadolescent-friendly health clinics (AFHCs), made village health clinicssensitive 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 5% ofyoung men and 8% of young women in the studied villages were aware ofAFHCs, said a 2014 study conducted by the Population Council inMaharashtra, Rajasthan and Jharkhand. No young man and 0.8 % of young womensought services from the AFHCs.

The main reason 82-90 % why adolescents did not seek help was because theythought their problems were not serious enough; the second-most commonreason was because they were too embarrassed, the study found.

However, with RKSK, the effort is now to engage adolescents through peereducators who would speak about various life skills, including nutrition,mental health, non-communicable diseases, gender and sexual andreproductive health, while sensitising ASHAs, auxiliary nurse midwives,anganwadi workers, counsellors and medical officers to offer“non-judgemental services”, said Indrani Banerjee Bhattacharyya, AssistantDirector, Quality Assurance, Child in Need Institute.

Adolescent fertility rates contributed 17 % to India’s total fertility ratein 2012, and about 14 % of births in women aged below 20 were unplanned,according to the 2015 study in the Journal of Clinical and DiagnosticResearch.

Without sex education and counselling, adolescents are also at a high riskof acquiring sexually transmitted infections (STI) and even HIV. In the agegroup 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 and0.01 % of boys were found to be HIV positive, according to the 2005-06National Family Health Survey. Youngsters between 15-24 years contribute to31 % of India’s AIDS burden despite accounting for 25 % of its population.

It is obvious, said experts, that contraceptives are not adequatelyavailable. And among contraceptives, the only real option is a condom,“yet, it means girls have to rely on their male partners for protectionwhich is not ideal,” said Vivek Malhotra, Director, Population HealthServices (India). Emergency contraceptives as an alternative should be madeaffordable and widely available, he said.

Today, emergency contraceptives are available as commercial products, overthe counter, but they are priced too high to be accessible for adolescents,said experts. If not in schools, emergency contraceptives should beavailable in colleges and sold at an affordable rate by the government,they said. – Agencies