Abortion among married young women: findings from a community-based study in Rajasthan and Uttar Pradesh, India.

Abortion service provision has changed noticeably in the recent past and medication abortion currently accounts for four-fifths of all induced abortions taking place in India. How these changes have modified abortion experiences among young women - a group known to be more disadvantaged than adult women - remains unanswered. This paper fills this gap and examines the experiences of married young abortion seekers, including pre-abortion decision-making, abortion seeking and experiences of the procedure, and post-abortion complications. Data were drawn from a community-based survey of 4952 married young women aged 15-24 years conducted in Uttar Pradesh and Rajasthan in 2015. The study focused on 166 young women who had an induced abortion in the two years before the survey, and used descriptive statistics to describe their abortion experiences. Seventy-four per cent of abortion seekers had relied on medication abortion and 47% had obtained it over the counter without a physician's prescription. Moreover, 90% accessed abortion services from private facilities, including drug sellers. A small proportion (4%) had undergone abortion in the second trimester of pregnancy. At the same time, 13% reported multiple abortion attempts; 17% underwent dilation and curettage; and 52% experienced self-reported complications, including 5% who experienced moderate to severe complications. The findings call for greater attention to providing contraceptive counselling and services to married young women, ensuring abortion services in public health facilities and exploring mechanisms to improve drug sellers' knowledge and practices in providing medication abortion.

Transforming the attitudes of young men about gender roles and the acceptability of violence against women, Bihar.

Although the importance of working with young men to transform traditional gender norms has been widely acknowledged, programmes for young men remain sparse in highly gender stratified settings such as India, and those that have been implemented have not reached those in rural areas and those out-of-school. Drawing on data from a cluster randomised controlled trial with panel surveys, of a gender-transformative life skills education and sports-coaching programme conducted among young men aged 13-21 who were members of youth clubs, this paper examines the extent to which it transformed the gender role attitudes of young men and instilled in them attitudes rejecting violence against women and girls. The intervention succeeded in changing gender role attitudes and notions of masculinity, attitudes about men's controlling behaviours over women/girls, attitudes about men's perpetration of violence on a woman/girl and perceptions about peer reactions to young men acting in gender-equitable ways. Effects were particularly significant among young men who attended regularly, underscoring the importance of regular attendance in such programmes.

Preventing violence against women and girls in Bihar: challenges for implementation and evaluation.

While there are a growing number of interventions and evaluations of programmes aimed at changing gender norms and violence against women and girls, there remains a dearth of documentation outlining the challenges faced in conducting these interventions and evaluations, particularly in traditional and low literacy settings. The Do Kadam Barabari Ki Ore (Two Steps Towards Equality) programme sought to understand what works to prevent violence against women and girls in Bihar, India. This paper draws insights from process evaluation data. It describes promising features and challenges of implementation, and characteristics which weaken the potential effects of complex, community based, social sector programmes that aim to change deeply entrenched gender power hierarchies. We drew on the Medical Research Council framework for process evaluation in analysing our process evaluation data, and focus on mechanisms of impact, and factors inhibiting programme success, including contextual and implementation challenges. The paper also outlines measures that may help overcome observed challenges and areas that require modifications and/or further investigation. The programme experienced several challenges. These included contextual issues, such as the lack of leadership skills of those delivering the intervention and the gap between expected responsibilities and activities of government platforms and reality. Implementation challenges were encountered in reaching men and boys, younger women and the community at large and ensuring their regular attendance; and in maintaining the fidelity of the intervention activities. Our insights call for an evidence-supported dialogue on these challenges and how best to anticipate and address them.

Meeting the commitments of the ICPD Programme of Action to young people.

Some of the commitments nations have made in international agreements, notably in the ICPD Programme of Action (1994) and the resolution of the UN Committee on Population & Development (2012), to young people include: realisation of the right to education and attainment of a secondary school education; delaying marriage beyond childhood and ensuring free and full choice in marriage-related decisions; exercise of the right to health, including access to friendly health services and counselling; access to health-promoting information, including on sexual and reproductive matters; acquisition of protective assets and agency, particularly among girls and young women, and promotion of gender equitable roles and attitudes; protection from gender-based violence; and socialisation in a supportive environment. These are crucial for a successful transition to adulthood with reference to sexual and reproductive health outcomes. This paper assesses the extent to which these commitments have been realised, drawing from available studies conducted in the 2000s in developing countries. It concludes that while some progress has been made in most of these aspects, developing countries have a long way to go before they can be said to be helping their young people achieve a successful sexual and reproductive health-related transition to adulthood.

Unsuccessful prior attempts to terminate pregnancy among women seeking first trimester abortion at registered facilities in Bihar and Jharkhand, India.

Many abortion seekers in India attempt to induce abortion on their own, by accessing oral medication/preparations from a chemist without a prescription or from an unauthorized provider, and present at registered facilities if these attempts fail. However, little is known about those whose efforts fail or the ways in which programmes and policies may address the needs of such women. This paper explores the experiences of women whose efforts failed, including their socio-demographic profile, the preparations they used, and the extent to which they experienced serious complications, delayed seeking care from an authorized provider, or delayed abortion until the second trimester of pregnancy. Data come from a larger study assessing the feasibility of the provision of medical abortion by non-physicians; a total of 3394 women who sought medical abortion from selected clinical settings in Bihar and Jharkhand between 2008 and 2010 constitute the sample. Prior to visiting the clinic, nearly a third of these women (31%) had made at least one unsuccessful attempt to terminate the unwanted pregnancy by using a range of oral medications/preparations available over-the-counter in medical shops. Logistic regression analysis suggests that educated women (OR 1.6-1.7), those from urban areas (OR 6.2) and those from Bihar (OR 1.6) were significantly more likely than women with no education, rural women and those from Jharkhand to have used such medication. Also notable is that the average gestational age of women who had made a previous attempt to terminate their pregnancy was almost identical to that of women who had not done so when they presented at the registered facility. These findings may inform policies and programmes that seek to identify and reduce the potential risks associated with unauthorized abortion-seeking practices, and highlight the need to fully inform women, chemists and providers about oral medications, what works and what does not, and how effective medication must be taken.

Experiences of unmarried young abortion-seekers in Bihar and Jharkhand, India.

While several studies have documented the prevalence of unprotected pre-marital sex among young people in India, little work has explored one of its likely consequences, unintended pregnancy and abortion. This paper examines the experiences of 26 unmarried young abortion-seekers (aged 15-24) interviewed in depth as part of a larger study of unmarried abortion-seekers at clinics run by an NGO in Bihar and Jharkhand. Findings reveal that recognition of the unintended pregnancy was delayed for many and many who suspected so further delayed acknowledging it. Once recognised, most confided in the partner and, for the most part, partners were supportive; a significant minority, including those who had experienced forced sex, did not have partner support and delayed the abortion until the second trimester of pregnancy. Family support was absent in most cases; where provided, it was largely to protect the family reputation. Finally, unsuccessful attempts to terminate the pregnancy were made by several young women, often with the help of partners or family member. Findings call for programmes for young women and men, their potential partners, parents and families and the health system that will collectively enable unmarried young women to obtain safe abortions in a supportive environment.

Marriage Without Meaningful Consent and Compromised Agency in Married Life: Evidence From Married Girls in Jharkhand, India.

PURPOSE: Marriage without meaningful consent persists in India, yet early marriage programs have rarely addressed consent, and research on the practice and its consequences for married life is limited. This study explores how consent in marriage decisions affects married life, specifically, agency, gender attitudes, spousal communication, contraception, and marital violence outcomes. METHODS: A subset of 1991 married girls and young women was drawn from a 2018 state-representative survey of adolescents and youth aged 15-21 years in Jharkhand. We compared outcomes between those in self-arranged marriages (n = 392), those in semi-arranged marriages who were acquainted with their husbands before marriage (n = 612), and those in fully parent-arranged marriages with no premarital contact (n = 995). Logistic regression analyses identify associations between marriage decision-making and outcomes of interest, controlling for confounding sociodemographic factors. RESULTS: Compared with girls whose marriages were self-arranged, those in both fully parent- and semi-arranged marriages were less likely, respectively, to make household decisions (odds ratios [OR], .37 and .60), hold egalitarian gender role attitudes (OR, .48 and .66), uphold girls' rights (OR, .41 and .48), communicate with their husbands (OR, .48 and .64), and practice contraception (OR, .51 and .67). Those in fully family-arranged marriages also had less freedom of movement (OR, .64) and were less likely to express self-efficacy (OR, .64). Marital violence was unrelated to marriage arrangements. CONCLUSIONS: Self-arranged marriage is associated with more positive outcomes than family-arranged ones, including semi-arranged ones, but marriage arrangements are unrelated with marital violence. Findings reaffirm the need to breakdown prevailing patriarchal norms and promote girls' right to meaningful, "free and full consent".

Timing of first sex before marriage and its correlates: evidence from India.

While several studies have documented the extent of pre-marital sexual experience among young people in India, little work has been done to explore the factors that are correlated with the timing of pre-marital sexual initiation. This paper examines age at initiation of pre-marital sex, circumstances in which first sex was experienced, nature of first sexual experience and correlates of age at initiation of pre-marital sex. Life table estimates suggest that pre-marital sexual initiation occurred in adolescence for 1 in 20 young women and 1 in 10 young men. For the majority of these young people, their first sex was with an opposite-sex romantic partner. First sex, moreover, was unprotected for the majority and forced for sizeable proportion of young women. A number of individual, family-, peer- and community-level factors were correlated with age at first pre-marital sex. Moreover, considerable gender differences were apparent in the correlates of age at first pre-marital sex, with peer- and parent-level factors found more often to be significant for young women than men.

Experience seeking abortion among unmarried young women in Bihar and Jharkhand, India: delays and disadvantages.

Studies suggest that the experiences of unmarried young women seeking abortion in India differ from those of their married counterparts, but the evidence is limited. Research was undertaken among nulliparous young women aged 15-24 who had abortions at the clinics of a leading NGO in Bihar and Jharkhand. Over a 14-month period in 2007-08, 246 married and 549 unmarried young abortion seekers were surveyed and 26 who were unmarried were interviewed in depth. Those who were unmarried were far more likely to report non-consensual sexual relations. As many as 25% of unmarried young women, compared to only 9% of married young women, had had a second trimester abortion. The unmarried were far more likely to report non-consensual sexual relations leading to pregnancy. They were also more likely to report such obstacles to timely abortion as failure to recognise the pregnancy promptly, exclusion from abortion-related decision-making, seeking confidentiality as paramount in selection of abortion facility, unsuccessful previous attempts to terminate the pregnancy, and lack of partner support. After controlling for background factors, findings suggest that unmarried young women who also experienced these obstacles were, compared to married young women, most likely to experience second trimester abortion. Programmes need to take steps to improve access to safe and timely abortion for unmarried young women.

Participation in civil society and political life among young people in Maharashtra: Findings from the Youth in India - Situation and Needs study.

Youth participation in civil society and political life is increasingly recognised to be an important development objective. Nonetheless, research that sheds light on the extent to which youth participate in these arenas, and the factors that facilitate or inhibit such participation remain limited in most developing countries including India. Drawing on data from a representative survey of young people in the state of Maharashtra, India, this paper explores the extent of and the factors associated with youth participation in civil society, their adherence to pro-social values, and their participation in political processes. Findings suggest that for many youth, particularly for young women, opportunities to engage in civil society and political life are limited, and that pro-social values are not uniformly observed. Findings underline the importance of education, agency and close parental interaction in facilitating youth participation in civil society and political life and their expression of pro-social values.

Correlates of premarital relationships among unmarried youth in Pune district, Maharashtra, India.

CONTEXT: Although premarital partnerships-whether or not they involve sex-are widely discouraged in India, some youth do form such partnerships. It is important to know more about the nature of and the factors associated with these relationships. METHODS: Data are drawn from a community-based study of 15-24-year-olds in urban slum and rural settings in Pune District, Maharashtra. Multivariate analyses were conducted to identify associations between youths' individual, peer and family factors and their experience of romantic relationships and physical intimacy, including intercourse. RESULTS: Among young men, 17-24% had had a romantic relationship, 20-26% had engaged in some form of physical intimacy and 16-18% had had sex; the proportions among young women were 5-8%, 4-6% and 1-2%, respectively. Exposure to alcohol, drugs or pornographic films and having more frequent interaction with peers were positively associated with romantic and sexual relationships for both young women and young men. Educational attainment was negatively associated with both types of relationships for young women, but only with sexual relationships for young men. Closeness to parents was negatively associated with relationships only for young women. Young women whose father beat their mother were more likely than other young women to form romantic partnerships, and those beaten by their family had an elevated risk of entering romantic and sexual partnerships. Youth who reported strict parental supervision were no less likely than others to enter relationships. CONCLUSIONS: Program interventions should ensure that youth are fully informed and equipped to make safe choices and negotiate wanted outcomes, while positively influencing their peer networks; encourage closer interaction between parents and children; and be tailored to the different circumstances and experiences of young women and men.

Romance and sex: pre-marital partnership formation among young women and men, Pune district, India.

Using qualitative and survey data in a rural and an urban slum setting in Pune district, India, this paper describes patterns of pre-marital romantic partnerships among young people aged 15-24, in spite of norms that discourage opposite-sex interaction before marriage. 25-40% of young men and 14-17% of young women reported opposite-sex friends. Most young people devised strategies to interact with others, largely from the same neighbourhood. There were wide gender differences with regard to making or receiving romantic proposals, having a romantic partner and experiencing hand-holding, kissing and sexual relations. For those who engaged in sexual relations, the time from the onset of the partnership to having sexual relations was short. Sex most often took place without protection or communication, and for a disturbing minority of young women only after persuasion or without consent. Among those who were unmarried, a large percentage had expected to marry their romantic partner, but for a third of young women and half of young men the relationship had been discontinued. Partnership formation often leads to physical intimacy, but intimacy should be wanted, informed and safe. Findings call for programmes that inform youth in non-threatening, non-judgmental and confidential ways, respect their sexual rights and equip them to make safe choices and negotiate wanted outcomes.

Sexual and reproductive health and rights of adolescent girls: evidence from low- and middle-income countries.

This paper reviews the evidence on sexual and reproductive health and rights (SRHR) of adolescent girls in low-income and middle-income countries (LMIC) in light of the policy and programme commitments made at the International Conference on Population and Development (ICPD), analyses progress since 1994, and maps challenges in and opportunities for protecting their health and human rights. Findings indicate that many countries have yet to make significant progress in delaying marriage and childbearing, reducing unintended childbearing, narrowing gender disparities that put girls at risk of poor SRH outcomes, expanding health awareness or enabling access to SRH services. While governments have reaffirmed many commitments, policy development and programme implementation fall far short of realising these commitments. Future success requires increased political will and engagement of young people in the formulation and implementation of policies and programmes, along with increased investments to deliver at scale comprehensive sexuality education, health services that are approachable and not judgemental, safe spaces programmes, especially for vulnerable girls, and programmes that engage families and communities. Stronger policy-making and programming also require expanding the evidence on adolescent health and rights in LMICs for both younger and older adolescents, boys and girls, and relating to a range of key health matters affecting adolescents.

Meeting Contraceptive Needs: Long-Term Associations of the PRACHAR Project with Married Women's Awareness and Behavior in Bihar.

CONTEXT: Although interventions such as the PRACHAR project in Bihar, India, have been associated with increased contraceptive knowledge and use in the short term, less is known about whether such gains are sustained years later. METHODS: Survey data, collected in 2013 from 2,846 married women aged 15-34, were used to compare contraceptive awareness and use between those who lived in areas where the PRACHAR project had been implemented in 2002-2009 and those who lived in matched comparison areas. Multivariate analyses assessed whether, after adjustment for covariates, outcomes differed between women in comparison and intervention areas, as well as between women directly exposed to the program and those who lived in intervention areas but had been only indirectly exposed. RESULTS: Compared with women in comparison areas, those in intervention areas were more likely to have method-specific knowledge of oral contraceptives, IUDs, condoms and the Standard Days Method (odds ratios, 1.4-1.7); to know that oral contraceptives and condoms are appropriate for delaying first pregnancy (2.3 for each) and IUDs and injectables are appropriate for spacing births (1.4 for each); to have ever used contraceptives (2.1) or be using a modern method (1.5); and to have initiated contraception within three months of their first birth (1.8). Levels of awareness and use were elevated not only among women directly exposed to the intervention but also, for many measures, among indirectly exposed women. CONCLUSIONS: The association of multipronged reproductive health programs like PRACHAR with contraceptive awareness and practices may last for years beyond the project's conclusion.

Violence against women in South Asia: the need for the active engagement of the health sector.

Intimate partner violence is pervasive in South Asia, yet married women's experiences regarding seeking help when faced with intimate partner violence and the health sector response remain largely unexplored. This commentary reviews the available published and unpublished literature and summarises what is known about the prevalence of marital violence against women and violence-related care-seeking experienced by women in this region. The commentary highlights that between one-fifth and one-half of married women are affected by violence perpetrated by their husband in South Asia, violence starts early in a marriage and the health consequences are wide ranging and long lasting. Yet, very few women seek support from the health sector, and the health system is not proactive in identifying and supporting women at risk. A greater commitment to making the health system responsive to women in distress is essential and should be undertaken with the same level of commitment given to prevention programmes.

Women's autonomy and experience of physical violence within marriage in rural India: evidence from a prospective study.

Evidence regarding the relationship between married women's autonomy and risk of marital violence remains mixed. Moreover, studies examining the contribution of specific aspects of women's autonomy in influencing the risk of marital violence using measures of autonomy that incorporate its dynamic nature are rare. We investigated the relationship between women's autonomy and their experience of marital violence in rural India using prospective data. We used data on 4,904 rural women drawn from two linked studies: the NFHS-2, conducted during 1998-1999 and a follow-up study for a subgroup of women carried out during 2002-2003. Three dimensions of autonomy were used: financial autonomy, freedom of movement, and household decision-making. Marital violence was measured as experience of physical violence in the year prior to the follow-up survey. Findings indicate the protective effects of financial autonomy and freedom of movement in reducing the risk of marital violence in the overall model. Furthermore, region-wise analysis revealed that in the more gender equitable settings of south India, financial autonomy exerted a protective influence on risk of marital violence. However, in the more gender-stratified settings of north India, none of the dimensions of autonomy were found to have any protective effect on women's risk of marital violence. Results argue for an increased focus on strategies aimed at improving women's financial status through livelihood skill-building opportunities, development of a strong savings orientation, and asset-building options.

Demand for contraception to delay first pregnancy among young married women in India.

In India, evidence is sparse regarding the demand for contraception to delay first pregnancy among married young people. Using data drawn from a study conducted in six Indian states among 9,572 women aged 15-24 who were married for five or fewer years, we explore the scope of this demand, the extent to which it has been satisfied, and, using logistic regression analyses, the factors correlated with contraceptive use to delay first pregnancy among those reporting demand. Findings confirm considerable demand for contraception to postpone first pregnancy (51 percent). Of those with demand, only 10 percent had practiced contraception. Contraception was more likely to have been practiced by educated women, those aware of family planning methods before they were married, those exposed to quality sexuality education, and those who participated in marriage-related decision making. Women who reported feeling pressure to prove their fertility were less likely to have practiced contraception.

Adolescents' perceptions of health from disadvantaged urban communities: findings from the WAVE study.

The Well-being of Adolescents in Vulnerable Environments (WAVE) is a global study of young people living in disadvantaged urban communities from Baltimore, MD, Johannesburg, South Africa, Shanghai, China, New Delhi, India and Ibadan, Nigeria. WAVE was launched in the summer of 2011 to: 1) explore adolescents' perceived health and their top health challenges; and 2) describe the factors that adolescents perceive to be related to their health and health care utilization. Researchers in each site conducted in-depth interviews among adolescents; community mapping and focus groups among adolescents; a Photovoice methodology, in which adolescents were trained in photography and took photos of the meaning of 'health' in their communities; and key informant interviews among adults who work with young people. A total 529 participants from across the sites were included in the analysis. Findings from the study showed that gender played a large role with regards to what adolescents considered as their top health challenges. Among females, sexual and reproductive health problems were primary health challenges, whereas among males, tobacco, drug, and alcohol consumption was of highest concern, which often resulted into acts of violence. Personal safety was also a top concern among males and females from Baltimore and Johannesburg, and among females in New Delhi and Ibadan. Factors perceived to influence health the most were the physical environment, which was characterized by inadequate sanitation and over-crowded buildings, and the social environment, which varied in influence by gender and site. Regardless of the study site, adolescents did not consider physical health as a top priority and very few felt the need to seek health care services. This study highlights the need to focus on underlying structural and social factors for promoting health and well-being among adolescents in disadvantaged urban environments.

The association between social support and mental health among vulnerable adolescents in five cities: findings from the study of the well-being of adolescents in vulnerable environments.

PURPOSE: Globally, adolescents are at risk of depression, traumatic stress, and suicide, especially those living in vulnerable environments. This article examines the mental health of 15- to 19-year-old youth in five cities and identifies the social support correlates of mental health. METHODS: A total of 2,393 adolescents aged 15-19 years in economically distressed neighborhoods in Baltimore, MD; New Delhi, India; Ibadan, Nigeria; Johannesburg, South Africa; and Shanghai, China were recruited in 2013 via respondent-driven sampling to participate in a survey using an audio computer-assisted self-interview. Weighted logistic regression and general linear models were used to explore the associations between mental health and social supports. RESULTS: The highest levels of depression and posttraumatic stress symptoms were displayed in Johannesburg among females (44.6% and 67.0%, respectively), whereas the lowest were among New Delhi females and males (13.0% and 16.3%, respectively). The prevalence of suicidal ideation ranged from 7.9% (New Delhi female adolescents) to 39.6% (Johannesburg female adolescents); the 12-month prevalence of suicide attempts ranged from 1.8% (New Delhi females) to 18.3% (Ibadan males). Elevated perceptions of having a caring female adult in the home and feeling connected to their neighborhoods were positively associated with adolescents' levels of hope across the sites while negatively associated with depression and posttraumatic stress symptoms with some variation across sites and gender. CONCLUSIONS: Adolescents living in the very economically distressed areas studied register high levels of depression and posttraumatic stress. Improving social supports in families and neighborhoods may alleviate distress and foster hope. In particular, strengthening supports from female caretakers to their adolescents at home may improve the outlooks of their daughters.