Improving Reproductive Health of Married and Unmarried Youth in India

"More than half the population in India is younger than 25, and many adolescents, particularly unmarried girls, suffer serious reproductive health problems but face significant constraints in receiving care and treatment. Between 60 percent and 70
percent of adolescent girls are anemic. Early marriage - which increases girls' risk of
health complications related to early childbearing among other problems - also is pervasive in India....Both married and unmarried youth in India also suffer from reproductive tract infections. Because of the shame and stigma associated with such infections, young people frequently do not seek treatment, which can cause more serious health problems, including infertility."

This 85-page report shares the results and lessons learned from 6 studies carried out by the International Center for Research on Women (ICRW) and partners as part of a 10-year (1996-2006) initiative funded by the Rockefeller Foundation in an effort to improve the reproductive health of young people in India. The core insight to emerge from this research is that programmes seeking to break the silence around adolescent sexual and reproductive health must work with communities, including parents, in-laws, spouses, elders and other people who make decisions about young people's lives. That is, community involvement was found to be key in tackling early marriage, girls' poor nutrition, and reproductive tract infections (RTIs) - precisely because their participation is crucial in changing the social norms which underlie gender constraints (the main obstacle to youth accessing the information and services they need). Involving boys and men emerged as another important strategy.

Specifically, in an effort to fill in gaps about how to design and evaluate programmes to empower youth and improve their reproductive health, ICRW collaborated with 5 India-based organisations: Christian Medical College, Vellore (CMC); Foundation for Research in Health Systems (FRHS); KEM Hospital Research Centre; Institute of Health Management, Pachod (IHMP); and Swaasthya. The various interventions worked with both married and unmarried boys and girls ranging in age from 12 to 30, as well as their families and communities. These interventions included: interactive reproductive and sexual health education for unmarried girls; life skills courses for unmarried girls; nutrition behaviour change and communication for unmarried girls to reduce iron-deficiency anaemia; involving men, families, and communities to advocate for young women's reproductive health; sexuality counseling for young couples; improving couple communication; changing provider attitudes; and testing models to provide clinical diagnostic and treatment facilities of RTIs for young married women and their partners.

Findings from the research indicate that girls' vulnerability to reproductive and other health problems, including poor nutrition and anaemia, stem from beliefs about their social roles, which often are reinforced by family and community. These unequal gender-based norms can be a serious constraint, particularly for young women with respect to reproductive health. Social norms also influence the lives of boys and young men. The research studies show effective ways to change social norms so that adolescents and communities better understand these health problems and the services available to them, and youth are empowered to make their own health care decisions (see, especially, Chapters 3, 4, and 5 of this report). Among the findings:

• Life skills programmes can increase the age at marriage for girls.
• Life skills and adolescent development models can increase girls' confidence and their perception of their ability to make decisions about marriage and childbearing.
• An integrated health care programme with reproductive health education, clinical referrals, and sexuality counseling can be used in a rural community. However, the extent to which youth will access and benefit from each programme element may vary.
• Village-level female health aides can be trained to undertake speculum exams and are able to reach, examine and treat a larger proportion of young rural married women than a conventional doctor, even if the doctor is a woman.
• Community mobilisation is associated with higher levels of some reproductive health knowledge and use of services for many, but not all, health issues.
• Community involvement and mobilisation is effective in creating a supportive environment for youth reproductive health and changing attitudes among key decision makers who influence young people's environments.

Specifically, by involving communities within their own setting, change can happen fairly quickly, in this case in 3 years or less. Key results include:

• Girls' age at marriage in the rural Maharashtra study increased by one year, from 16 to 17.
• The percent of unmarried girls who ate 3 or more meals per day increased from 2.9% to 27.7% in the Pune city slum intervention.
• Young married women's knowledge and use of services for a wide variety of reproductive concerns, including RTIs, increased in the rural Maharashtra study.
• Overall prevalence of RTIs in the study communities of rural Tamil Nadu decreased by half between 1997 and 2006.
• Unmarried girls in the rural Maharashtra and Delhi slum programmes experienced greater self-confidence and improved ability to negotiate key decisions - such as staying in school and when to get married - with parents and other important people in their lives.

In an effort to link research to policy, ICRW and its partners disseminated core messages based on this research to government officials throughout India, several of whom have replicated and adapted some of the reproductive health programmes.