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Sexual and Reproductive Health among Youth in Bihar and Jharkhand: An Overview

Young women in India are less likely than young men to be aware of sexual and reproductive health matters or be able to negotiate safe/wanted sex with spouses and partners. This special issue explores the sexual and reproductive health situation among youth in Bihar and Jharkhand, two states that are rarely studied from this perspective.

REPRODUCTIVE HEALTH AMONG YOUTH IN BIHAR AND JHARKHANDdecember 1, 2007 Economic & Political Weekly34Sexual and Reproductive Health among Youth in Bihar and Jharkhand: An OverviewShireen J JejeebhoyThe sexual and reproductive health situation in India has undergone major changes over the last decade or so. For one, the policy and programme environment has under-gone a significant shift from a narrow target-oriented family planning approach to a broader orientation that stresses sexual and reproductive health and the exercise of reproductive rights more generally. Second, there have been considerable changes in the sexual and reproductive health scenario. Some changes have been positive, such as declining infant mortality, increased access to skilled attendance at delivery and declining unmet need for contraception. Others are extremely disturbing, such as stagnat-ing levels of maternal mortality, the spread of sexually transmit-ted infections notably human immunodeficiency virus (HIV), misuse of prenatal diagnostic techniques for sex selection, the persistence of wide gender imbalances and the compromised ex-ercise of reproductive rights by large segments of the population, notably women. Third, the past decade has also seen a growing concern about the unique sexual and reproductive health needs of the young, a group whose needs remain, however, poorly understood and served. In short, despite the strides made on several fronts, the sexual and reproductive health situation in India continues to be characterised by considerable ill-health and lack of informed choice.Available evidence on sexual and reproductive health in India suggests significant state-wise heterogeneity in levels and pat-terns of access to services and in socio-cultural, gender and health system determinants. States such as Bihar and Jharkhand (carved out of Bihar in 2000) lag behind other states on most in-dicators of sexual and reproductive health for which data are available. Compared to India as a whole, women in Bihar and Jharkhand marry early, are less likely to practise contraception and less likely to have access to pregnancy-related care; factors that exacerbate women’s and young people’s vulnerability. Bihar and JharkhandOver the 1990s, several studies have addressed various aspects of sexual and reproductive health in India in-depth; however, few have focused on the states of Bihar and Jharkhand. While lessons learned from evidence obtained from other settings can be extra-polated to Bihar and Jharkhand, the dearth of evidence focused specifically on these states has meant that neither the levels nor the patterns of various aspects of sexual and reproductive health, nor the contextual and socio-cultural factors impeding sexual and reproductive health have been understood in-depth. Cor-respondingly, strategies and actions to enhance sexual and Young women in India are less likely than young men to be aware of sexual and reproductive health matters or be able to negotiate safe/wanted sex with spouses and partners. This special issue explores the sexual and reproductive health situation among youth in Bihar andJharkhand, two states that are rarely studied from this perspective.The research into these articles was supported through a competitive grants programme coordinated by the Population Council. We are grateful to the Packard Foundation for supporting the programme and to Lester Coutinho and Don Lauro for their constructive inputs and insights. We would also like to record our appreciation to the Technical Guidance Group and a number of peer reviewers who shaped the programme and provided critical peer review of earlier drafts of the articles: DineshAgarwal, J K Banthia, Bela Ganatra, Shiva Halli, Arvind Pandey, Pertti J Pelto, Radhika Ramasubban and Leela Visaria. Deepika Ganju provided technical and copy editing of the entire series. Population Council staff members guiding this programme of work included R Acharya, S Kalyanwala, K G Santhya and K Saxena.Shireen J Jejeebhoy ( is senior associate at the Population Council.
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200735reproductive health in the 21st century in these states remain generic and uninformed by the special needs of women and men in these settings. This series of papers represents an effort to build the evidence on various aspects of the sexual and reproductive health situa-tion in Bihar and Jharkhand. Two studies highlight the sexual risk behaviour of different groups of youth: rural migrants and school- and college-going youth, respectively. One addresses pregnancy-related experiences and the needs of married tribal adolescents and two address the pregnancy-related experiences of women with regard, specifically, to delivery and abortion. Certain cross-cutting issues – gender double standards and power imbalances, exercise of informed choice, male involve-ment, quality of care and services, for example – are highlighted within the discussion of each study as appropriate. All five stud-ies focus on limited geographic areas of these states; two studies have drawn their data from in-depth interviews and three have used a combination of qualitative and quantitative methods.Insights from each of these studies are presented in this special issue. While these studies have by no means addressed all of the gaps in our understanding of the sexual and reproductive health situation and needs of these states, they have taken a small step in uncovering evidence in two broad areas of sexual and repro-ductive health, namely, the situation and needs of youth on the one hand, and pregnancy and abortion practices on the other.This overview briefly describes, from available evidence, the sexual and reproductive health situation in Bihar and Jharkhand, and India more generally, for comparative purposes. It then sum-marises the findings of the five studies and their implications for policy and programmes. SettingThe states of Bihar and Jharkhand are characterised by a large rural population, high dependence on agriculture and wide-spread poverty with significant proportions living below the pov-erty line [National Sample Survey Organisation 2007]. Some cur-rent demographic and reproductive health indicators drawn largely from the recent National Family Health Survey (NFHS-3) [International Institute for Population Sciences 2007a; 2007b; 2007c] and, where information remains disaggregated, from the 1998-99 round of the NFHS-2are presented in the table [IIPS and ORC Macro 2000], which clearly reflect the extent to which the situation in Bihar and Jharkhand lags behind that of India in many areas, including, in many instances, with regard to the situation of women.As can be seen from the table, literacy rates, both of the gener-al population, and women aged 15-49 in particular, are far lower in Bihar and Jharkhand than in India on average. Two indicators suggesting socio-economic conditions are presented in the table – type of house and ownership of television – which also reveal that the situation in Bihar and Jharkhand is far below the all-India average: 20 and 28 per cent of the population of Bihar and Jharkhand, respectively, reside in a ‘pucca’ house, compared to the all-India average of 41 per cent; and only 18 and 27 per cent of households in Bihar and Jharkhand own a television, compared to the national average of 44 per cent. Availabilityofhealthcare facilities are also skewed: fewer than one in three rural women inthese states live in a village with a primary health centre or sub-centre (compared to 45 per cent all-India); and fewer than two in five live in villages with a middle school or a post office (all-India 45 per cent and 43 per cent respectively) [IIPS andORC Macro 2000]. Among demographic indicators, as the table shows, both in-fant mortality rates and fertility rates are considerably higher in Biharand Jharkhand than in India on average; correspondingly, household size is somewhat larger on average in these states than Table: Selected Demographic and Sexual and Reproductive Health Indicators Socio-economic and Demographic Indicators IndiaBiharJharkhandPopulation, 2001 (‘000s) 1 10,28,610 82,99926,946Sex ratio, 2001 (females/1,000 males)1 933 919 941Population aged 6+ that is literate , 2005-062 67.6 54.158.6Women aged 15-49 who are literate, 2005-06 2 59.0 38.041.0Child sex ratio, 2001 (0-6 years)1 927 938 966% residing in a pucca house, 2005-06 2 41.4 20.1 28.1% households owning a television, 2005-06 2 44.2 18.227.1% population living below the poverty line3 27.5 41.4 40.3Infant mortality rate (estimated 2005) 2 57 62 69Total fertility rate, 2005-062 2.68 4.003.31Mean household size , 2005-06 2 4.8 5.4 5.4Sexual and reproductive health indicatorsContraceptive use dynamics Contraceptive prevalence rate, 2005-06 2 56.3 34.135.7 Currently married women with an unmet need for contraception, 2005-06(%)2 13.2 23.123.7Youth Women aged 20-24 married by 18 years, 2005-06 (%)2 44.5 60.361.2 Women aged 15-19 already mothers or pregnant, 2005-06 (%)2 16.0 25.027.5 Men aged 25-29 married by 21 years, 2005-06 (%)2 29.3 43.047.1Maternal healthcare Maternal mortality ratio (per 100,000 live births), 1997-20034 398 531* Pregnant women anaemic,2005-06 (%)2 56.2 60.268.4 Mothers who had at least three antenatal care visits for last birth,2005-06(%)2 50.7 16.936.1 Skilled attendance at delivery, 2005-06 (%)2 48.3 30.928.7 Institutionaldeliveries, 2005-06 (%)2 41.0 22.019.2 Mothers who received skilled post-natal care within 2 days of delivery , 2005-06 (%)2 36.4 15.317.0Induced abortion Estimated number of abortions performed annually (million)6 6.7 NA Estimated number of abortions at approved centres performed annually(million)7 0.6 NA Induced abortions per 100 live births8, 9 3.4-14.0 NA Maternal deaths resulting from unsafe abortion, 1998 (%) 5 8 NA Prevalence range for sex-selective abortions (%) (community-basedstudies)9-12 3-17 NAHIV knowledge Women who have heard of HIV/AIDS, 2005-06 (%)2 57.0 35.228.9 Men who have heard of HIV/AIDS, 2005-06 (%)2 80.0 70.052.8 Women aware that consistent condom use can reduce chances of HIV transmission, 2005-06 (%)2 34.7 22.421.8 Men aware that consistent condom use can reduce chances of HIV transmission, 2005-06 (%)2 68.1 58.446.7Women’s autonomy and experience of spousal violence 37.0 Involved in decisions relating to own health,1998-99 (%)13 51.6 47.666.8 Involved in decisions relating to purchase of jewellery,1998-99 (%)13 52.6 42.9 65.4 Can visit market without permission,1998-99 (%)13 31.6 21.739.0 Can visit friends/relatives without permission,1998-99 (%)13 24.4 20.535.9 Have access to money,1998-99 (%)13 59.6 66.764.5 Ever married women who have experienced spousal violence, 2005-06 (%)2 37.1 59.0NA: datanot available. *Data for Bihar and Jharkhand. Sources: 1 Registrar General, India (RGI) 2001; 2 International Institute for Population Sciences (IIPS) 2007a; 2007b; 2007c; 3 National Sample Survey Organisation (NSSO), 2007; 4 National AIDS Control Organisation (NACO) and United Nations International Children’s Emergency Fund (UNICEF) 2002; 5 RGI 2006; 6 Chhabra and Nuna 1994; 7 Khan et al 1999; 8 Ganatra 2000; 9 Malhotra et al 2003; 10Elul et al 2003; 11Ganatra et al 2000; 12Khanna 1997; 13 IIPS and ORC MACRO 2000.
REPRODUCTIVE HEALTHdecember 1, 2007 Economic & Political Weekly36respectively; in comparison, only 42 and 35 per cent, respectively, of girls did so. Infant and child mortality rates are considerably higher for females than for males, suggesting differentials in childcare and feeding practices. As seen earlier, marriage and childbearing occur among females in adolescence, exposing them to sex and pregnancy before they are physically or emotion-ally prepared. In most of the country, including in Bihar and Jharkhand, females have limited autonomy and face considerable constraints on decision-making, mobility and access to resources. Women are far less empowered to have a say in their own lives than are men; for example, findings fromNFHS-2 suggest that only about half of all women were involved in decisions relating to their own health or to the purchase of such items as jewellery; only one-third were permitted to go to the market and one quar-ter to visit a friend or relative without seeking permission; and only about three-fifths had access to any money. The situation in Bihar and Jharkhand is largely similar, although, as the table suggests, women in Jharkhand appear to have significantly more autonomy than do those in Bihar or those in India on average [IIPSand Macro 2000]. More recent evidence presented in the table reconfirms that large proportions of women report experiencing domestic vio-lence perpetrated by their husbands: 37 per cent in Jharkhand and India on average and almost three in five of those in Bihar. Finally, as the table shows, women are considerably less likely to be aware of modes of transmission and prevention of HIV than are men in all settings. Synthesising this evidence, we may infer that young women are less likely to be aware of sexual and repro-ductive health matters more generally, less likely to make deci-sions pertaining to their own lives and health, less likely to seek care for reproductive matters and less likely to be able to negoti-ate safe or wanted sex with spouses and partners than are men. Vulnerabilities of Youth As noted earlier, young people are a vulnerable group that face significant risks related to sexual and reproductive health as a result of unsafe behaviours, poor awareness of health-related matters, gender disparities and practices such as early marriage.Young people are a heterogeneous group; their needs differ by such factors as age, sex, marital status, education and employ-ment status. Three studies in this issue focus on different groups of youth. Two address the sexual risk behaviours of migrant young men from rural Palamu, Jharkhand and school- and college-going youth (both female and male) in Patna, Bihar. A third addresses pregnancy-related experiences of married ado-lescent girls in a tribal setting in Lohardaga, Jharkhand and is discussed along with other studies focused on pregnancy-related issues. Findings underscore the extent to which these different groups are indeed vulnerable and the need to tailor programmes to encompass their varied needs. That migrant men engage in risky sexual behaviour is widely acknowledged [Brockerhoff and Biddlecom 1999; Gras et al 2001; Wolffers et al 2002]. The study by Dhapola and colleagues ex-plores the extent of vulnerability experienced by unmarried young rural-rural and rural-urban migrants aged up to 24 years from Palamu, a poor rural district, with scarce economic in India. Contraceptive prevalence rates are, correspondingly, much lower, and a much larger proportion of women in Bihar and Jharkhand report an unmet need for contraception than in India. Available evidence on youth highlights their vulnerability. Marriage continues to take place before the minimum legal age for both young women and men: while 45 per cent of women aged 20-24 were married by age 18 in India as a whole, more than three in five were married by this age in Bihar and Jharkhand; and while 16 per cent of men aged 25-29 were married by age 21 in India on an average, about one in four young men from these states were married by this age. While state-level data on per-centages reporting the experience of premarital sexual relations are not available to date, studies have suggested that in India as a whole, some 15-30 per cent of young men and under 10 per cent of young women have engaged in premarital sex [Jejeebhoy and Sebastian 2004] and we may assume that percentages in Bihar and Jharkhand are similar. What we do know is that of those youth who report casual sexual relations, while about one quar-ter of both men and women aged 15-19 report consistent condom use in India as a whole, corresponding percentages in Bihar and Jharkhand (jointly) are much lower: 10 per cent of young men and under 1 per cent of young women[NACO andUNICEF2002]. Maternal HealthcareAvailable indicators on maternal health and care suggest likewise that the situation in Bihar and Jharkhand is considerably worse than that in India in general. The maternal mortality ratio in these states is 531 per 1,00,000 live births compared to 398 nationally. Pregnancy-related care, correspondingly, reaches far fewer women in Bihar and Jharkhand than in India on average, including antenatal, delivery-related and post-partum care. For example, while half of all women in India on average have received the recommended three antenatal care visits, only 36 and 17 per cent in Jharkhand and Bihar, respectively, report at least three visits. Likewise, fewer than one-third of women were delivered by a skilled attendant in Bihar and Jharkhand compared to almost half in India as a whole. Disparities in institutional de-livery are equally wide. Finally, among those who did not deliver institutionally, few receive post-partum care in the two days fol-lowing delivery: 36 per cent in India on the whole and 15-17 per cent in Bihar and Jharkhand (for details, see the table).Data on induced abortion are sparse and come from studies conducted in small geographic settings. Data available at the na-tional level indicate that some eight per cent of all maternal deaths are the result of unsafe abortions[RGI 2006]. Small stud-ies suggest moreover that between 3 and 14 per cent of women interviewed have experienced induced abortion, the majority outside of approved centres. Unfortunately, there are no studies thus far that elucidate the levels or patterns of abortion in Bihar and Jharkhand. As noted earlier, available indicators for these states reveal wide gender disparities. Schooling data suggest that girls are far less likely than boys to be literate or attend school in adolescence. Findings from NFHS-2 suggest, for example, that 58 and 64 per cent of boys aged 15-17 attended school in Bihar and Jharkhand,
REPRODUCTIVE HEALTHEconomic & Political Weekly december 1, 200737opportunities. Findings suggest that in comparison to similarly aged young men who had never left their areas of origin, migrant young men were poorly informed about HIV and the role of con-doms in preventing its spread, a finding attributed to the gener-ally poorer educational attainment levels of young migrants. At the same time, migrant young men were more likely to have ex-perienced sexual relations than non-migrants (30 per cent vs 15 per cent). Finally, among the sexually experienced, condoms were never consistently used and multiple partner relations were reported by about one-third of young men, irrespective of migration status. While these findings reiterate those of other studies that high-light the vulnerability of migrants, they also suggest that among migrant young men, sex is more likely to take place not in their areas of destination but in their areas of origin – both before and especially during regular visits home. Typically, partners are girl-friends and relatives and not sex workers as often hypothesised. Authors suggest that in this poorly developed setting, migration affords young men considerable social status and migrant young men have substantially more resources at their disposal than do non-migrant youth. Indeed, it is this enhanced status and these additional financial resources that appear to enable them greater access to girlfriends and relatives when they return to their areas of origin. Similar findings are also noted in studies ofyouth in sub-Saharan Africa and Nepal [Chirwa 1997; Poudel et al 2004]. Findings of this study suggest that programmes for migrants that focus on their sexual networks in their places of destination and on sex worker contacts may not reach or be relevant to young migrants; what is needed in addition are programmes that also reach youth in their areas of origin, that focus on interventions to empower them with information and services about sexual and reproductive health, and more specifically for protection fromHIV. Adolescents and Sexual RelationsSchool- and college-going adolescent girls and boys in urban Patna also report experiences of physical intimacy and, to a lesser extent, sexual intercourse. Patkarand colleagues’ survey of youth in ClassesIX andXI in a range of government and private schools reports that over one quarter of boys and over one-tenth of girls reported the experience of any physical intimacy; some 10 per cent and 1 per cent respectively reported having engaged in sexu-al relations. Awareness of HIV, while not comprehensive, was more complete than awareness of other sexual and reproductive matters such as contraception, menstruation and pregnancy. Interestingly, significant minorities of school- and college-going adolescents in Patna have been exposed to pornographic materi-als, in the form of blue films and a pornographic television chan-nel aired from Russia. The study also explored the individual, family and peer level factors that may underlie awareness of sexual and reproductive health and physical and sexual experiences. Findings suggest that selected factors at all three levels are significantly associated with awareness of sexual matters among girls; among boys in contrast, family and household level factors are not associated. Among boys, exposure to blue films appears positively associatedwith awareness of sexual matters, raising questions about whether or not the information provided in these is always accurate. Family level factors play a key role in determining whether or not adolescent boys engage in physical or sexual relations; mater-nal education, perhaps suggestive of communication on sexual matters, appears to inhibit such experiences among boys. As ex-pected, exposure to pornographic films is significantly associated with physical or sexual experience among boys. What is notable is the extent to which parental supervision influences young peo-ple’s behaviour. While among girls, the extent of supervision is only weakly associated with physical intimacy indicators, find-ings highlight that boys reporting somewhat strict and very strict parental supervision are significantly less likely to report sexual relations. Findings underscore the important role played by maternal education and parental supervision of adolescents, and the need to engage parents more directly in offering adolescent children a supportive environment in which to discuss sexual matters. Pregnancy-andAbortion-RelatedCareAside from the study of pregnancy-related experiences of mar-ried tribal adolescents in Jharkhand, two studies in this issue have explored in-depth women’s pregnancy-related experiences from different perspectives: one examines childbirth-related practices and care and the second sheds light on abortion-relatedexperiences. All three highlight the lack of access to appropriate care.Despite the fact that many adolescents in Jharkhand experi-ence their first pregnancies in adolescence, little is known about patterns of maternal healthcare seeking or the factors underlying maternal healthcare seeking among married adolescent girls. Evidence is even more lacking in the case of such disadvantaged groups as tribal adolescent girls. The third study sheds light on the pregnancy-related situation of married tribal adolescents in Lohardaga district, Jharkhand, using data from a cross-sectional survey. Findings suggest that the majority of young women (59 per cent) received some antenatal services (check-ups, iron and folic acid tablets or immunisation). However, only 12 per cent of these women received all of these services; most received no more than immunisation and the provision of iron and folic acid supplements. Far fewer (under 10 per cent) delivered in an insti-tution, were delivered by a trained attendant (24 per cent) or received a post-partum check-up (15 per cent). In contrast, nearly three-fifths of young mothers reported that their babies had been immunised. While healthcare seeking in this tribal setting is limited in general, multivariate analyses reveal a clear link between young women’s levels of education and their pregnancy-related practices and experiences. In addition, young women who reported auto-nomy in terms of household decision-making and access to moneywere indeed more likely than other women to have re-ceived appropriate pregnancy-related care, even after such factors as household economic status and women’s education were controlled. Other key factors included peer or social support
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