5.3 ADOLESCENT BIRTH RATE    (per 1000 women):

a.    1998: 51.0^[19]

b.    2005: 45.9^[20]

c.    2007:

The adolescent birth rate measures the annual number of births to women 15 to 19 years of age per 1,000 women in that age group. It represents the risk of childbearing among adolescent women 15 to 19 years of age. It is also referred to as the age-specific fertility rate for women aged 15-19^[21].

The adolescent birth rate declined from 51.0 in 1998 to 45.9 in 2005 in India.

According to the National Family Health Survey -3 (2005-06), early marriages and teenage pregnancies are not a rarity in India. Among young women age 15-19, 16 percent have already begun childbearing. Young women in rural areas are more than twice as likely to be mothers as young women in urban areas. In Jharkhand, West Bengal, and Bihar, at least one in four teenage women have begun childbearing.

Teenage fertility and pregnancies are a major health concern because teenage mothers and their children are at high risk of reproductive morbidity and mortality. Early childbearing  also impedes the overall development of teenage girls and their access to education and labour force participation.

Critical indicators to comprehensively monitor adolescent birth rate would look at the median age at marriage, the legal age at marriage and access to sex and sexuality education

5.3.1 Median age at marriage

The median age for marriage for women aged (25-49) in India is 17.2 years.  According to NFHS-3 data, “men get married more than six years later, at a median age of 23.4 years. Almost half (46%) of women age 18-29 years got married before the legal minimum age of 18. Women and men living in urban areas and those with higher levels of education marry later than their rural and less educated counterparts.”

5.3.2 Legal age of marriage 

The legal age of marriage in India is 18 for women and 21 for men.

Arranged marriages are very much prevalent in India. Conventionally, in India the normative framework of the right to marry does not reflect women’s autonomy and decision making in the realm of relationships per se and, more specifically in terms of marriage, the different dimensions of the right to choose if, when, and whom to marry. Digression from this leads to sanctions and violations by the family and the community reinforcing the pressures with regards to marriage whether child marriage, early marriage, practices of forced marriage (forcing a person to marry per se or marry a person of the family’s choice, denying a person’s right to marry of her own free will, a person of her own choice), adultery, and bigamy.^[22] There is an overall agreement that this practice was essentially a way of uniting and maintaining the differences between the rich and the poor, as well as those between the various different castes. Recently, the Indian government has come up with an innovative approach - offering people cash incentives for marrying into a lower caste.^[23]  

India, according to the CEDAW shadow report, still operates against a “backdrop of feudalistic and patriarchal cultural norms and institutions, regardless of law, child marriages are still being practiced.”^[24]  

5.3.3 Sex and sexuality education

Sex education is defined as the basic education about reproductive processes, puberty and sexual behaviour. Sex education may include other information, for example about contraception, protection from sexually transmitted infections and parenthood.^[25] Sexuality education is defined as education about all matters relating to sexuality and its expression. Sexuality education covers the same topics as sex education but also includes issues such as relationships, attitudes towards sexuality, sexual roles, gender relations and the social pressures to be sexually active, and it provides information about SRH services. It may also include training in communication and decision-making skills.^[26] 

Sex education is called the Adolescence Education Programme (AEP) in India. The curriculum was developed by the National AIDS Control Programme, and was rejected by several state governments including those of Madhya Pradesh, Chhattisgarh, Rajasthan, Uttar Pradesh, Kerala and Karnataka, with the chief ministers writing to the Ministry of Human Resources Development accusing it of corrupting the morals of the young. The module was revised but, in turn, was rejected by 33 NGOs from across the country, including youth groups, sexual rights groups, women's groups and groups working with child sexual abuse. In a joint statement, they declared: "The thrust of the… curriculum is abstinence. It is silent even about the biological aspects of reproduction. The lesson on conception, whilst addressing internal biological mechanisms, omits any description of intercourse. Sexual intercourse is shrouded in the euphemism 'intimate physical relationships.' Without the knowledge of what does cause conception, the curriculum will fail in one of its own objectives -- that of addressing teenage pregnancy.”^[27]  

5.3.4 Access to reproductive health services for adolescents within the public health system

In India, there is limited access for youth to SRH services and socio-cultural norms constrain unmarried adolescents from seeking these services. Thus contraceptives remain out of their reach. Social stigma prevents unmarried girls and their family members from seeking services related to abortion. Providers are often judgemental and lack counselling skills.^[28] However, the National Youth Policy talks about the inclusion of information on reproductive health as part of the curriculum and of setting up clinics in rural areas to address the health needs of adolescents, and of access to antenatal, postnatal and natal health services.^[29] 

Voices from the ground:

    Videos:

a.    This video highlights the plight of many young women in India: how they are pressured to marry and have children at very young ages. This video focuses on teaching these young women about reproductive health.  Watch it here 

b.    This video shows how forced weddings are frequent in the western Indian state of Rajasthan, with the brides sometimes as young as five. It's been an illegal practice since 2006, but families struggling to feed their children see little alternative. Watch the video

 News/MagazineArticles:

a.    “According to official figures, over 68% girls in the state (Rajasthan) are married by the age of 18.” This article explores the topic of teen pregnancies, and why they occur. Read it here 

b.    “Though child marriages have been strongly prevalent in India the results of which are girls becoming mothers in their teens. In addition to that, the spate of incidents of rape on minors and the rising levels of promiscuity among teenagers are also a cause of great concern as they lead to teenage or say adolescent pregnancies.” Read more 

c.    This story is written by a young woman who was pregnant as a teen, pointing out that teen pregnancy can happen to anyone, even the ‘good’ girls. Read it here

d.    This is a cross-sectional study on the effect of maternal child marriage on Morbidity and Mortality of Children under 5 in India. Read it here

e.    Upheld and sanctioned by traditional customs, child marriage is still significantly practiced across India. The 205th Law Commission Report cites significant statistics on the scale of child marriages in India. This report maps the trajectory of legal reforms when it comes to child marriages in India.  Read it here 

f.     This article focuses on how forced marriages are forcing unwilling women to take

drastic measures, a woman in India had a sex change operation so she would not be forced to marry someone she didn’t want. Read it here 

5.4 CONTRACEPTIVE PREVALENCE RATE(Current contraceptive use among married women 15-49 yrs old any method%):

a.    2001: 46.9^[30]

b.    2006: 56.3^[31]

c.    2007:

CPR in India went from 46.9 in 2001 to 56.3 in 2006.

Critical indicators to comprehensively monitor contraceptive prevalence rate would include looking at range of methods available including access to modern methods and provision of informed choice.

5.4.1 Range of contraceptive methods available.

Beyond the numbers for CPR it is essential to look at access to a range of contraceptive services.

Permanent methods of contraception are highly used: female sterilization accounts for a whopping two-thirds - 66.25% of all methods!! A preponderence of one method often demonstrates provider bias/ service provision bias. In comparison, male sterilization forms a mere 1.77% of all methods.

In countries that strongly implement population control policies, such as India, permanent methods are favoured. Targets for permanent methods are women.

5.4.2 Provision of informed choice service provision. 

Informed choice of family planning methods is an important rights indicator. However it has not been commonly regarded as an important aspect of the service provided with the contraception method. Informed choice includes: information on the full range of methods including traditional and male methods; information on side-effects of all methods and the appropriate course of action; and information on the efficacy of each of the methods^.[32]

In India, information on the full range of methods was not commonly disseminated - “less than 30 % were ever informed about other types of family planning methods,” ^[33]

In India, information on side-effects and appropriate courses or action was given to few users - “only about one-third of modern contraceptive users were informed about the side effects or problems of their method, and only one-quarter were told what to do about side effects.” ^[34] 

However, it was noted that “IUD users were most likely to be provided with each of the three types of information and users of female sterilization were least likely to be provided with this information.” ^[35]  

Informed choice, in India is noted as being consistently higher in urban areas, and is somewhat more common in private than in public medical facilities.^[36]  

5.5 UNMET NEED FOR CONTRACEPTION:

a.    2003: 21.1^[37]

b.    2006: 6.6^[38]

c.    2007:

Unmet need reduced from 21.1% in 2003 to 6.6% in 2006.

Younger women (age 15-24) have a greater unmet need for spacing than for limiting. Rural women have higher unmet need than urban women for both spacing and limiting. Unmet need for both spacing and limiting decreases with an increase in wealth quintiles.^[39] 

Women with lower education or are uneducated, who are poor, who live in remote areas and rural areas face the greatest challenge in controlling their own fertility. Socio-economic inequities are closely inter-linked with higher rates of unintended births and it is important to ensure access to contraception to all groups of women.^[40]

The accepted definition of “[u]nmet need for contraception is the percentage of fertile, married women of reproductive age who do not want to become pregnant and are not using contraception.”^[41] The concept of unmet need is an important one because it assesses the ‘need’ for contraception based on whether and when a woman wants a child or another one rather than focusing on government limits on family size. The limitation, currently, is that the DHS calculates unmet need based on a sample of married, heterosexual women and not single, unmarried women and this does not accurately capture the extent of unmet need in a country. Another limitation is that it assumes all users as having their need ‘met’ including women with infertility and secondary infertility. But many women may be using a contraceptive method not of their choice due to provider bias or government policy as earlier discussed and this constitutes an ‘unmet need’ too. It is also important to keep in mind that contraception is primarily focused on pregnancy prevention. There is also an urgent unmet need for disease/infection prevention which is not being considered.^[42] 

Critical indicators to comprehensively monitor unmet need would take into account differences between total and wanted fertility rates and reasons for non-use of contraception.

5.5.1 Total and Wanted Fertility Rates

     Wanted fertility rates compared to Total Fertility Rates

a.    Total Fertility Rate (2005): 2.68^[43]

b.    Wanted Fertility Rate (2005): 1.9^[44]

c.    % difference: 41%^[45]

It is important to look at Wanted Fertility Rates and Total Fertility Rates to also establish unmet need. In the NFHS 2005-6, the TFR was 2.68 and the WFR was actually 1.9; this means women were having 41% more children than they actually wanted and this constitutes an unmet need.^[46]

5.5.2 Reasons for non-use of contraception

One of the most common reasons given by married women with an unmet need for not using contraception is associated with the supply of methods and services and within this category, concerns about the side effects, health consequences and inconvenience of methods were the most prominent reasons. The prevalence of these concerns is particularly high in South Asia.^[47]

Apart from the fertility-related reasons, method-related reasons and health concerns, a major reason for non-use of contraception in India is ‘fatalism’ (5.9%) i.e. fertility is still seen as something ‘fate’ deals out rather than a matter of exercising choice. In addition, opposition to use (both own and spousal) constitute 5.5% and religious prohibition constitutes 5.0% all of which are not being considered in discussing unmet need^.[48]

5.6 ANTENATAL CARE COVERAGE 

a.    At least one visit (%):

Ø  2000: 61.8^[49]

Ø  2006: 74.2^[50]

Ø  After 2005: 90.9^[51]

b.    At least four visits(%):

Ø  1999: 29.5^[52]

Ø  2006: 37.0^[53]

Ø  2007:

Voices from the ground:

Fact Sheet:

The District Level Household and Facility survey is one of the largest ever demographic and health surveys carried out in India, with 

sample size of about seven lakhs households covering all the districts of the country. This fact sheet  presents information on the key

indicators and trends for the state of Assam. Read it here