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The Sexual %26 Reproductive Health Status of Young People in India -Challenges and Opportunities for Health Outcomes %28Brief-2_ Supported by UNFPA%29 |
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The Sexual & Reproductive Health
Status of Young People in India
Challenges and opportunities for healthy outcomes
Adolescent Health Days
Quarterly meetings conducted
at the village level to provide
preventive and promotive health
services and increase awareness
among adolescents, their families
and other key stakeholders about
issues and needs related to
adolescent health.
Adolescent Friendly
Health Centres (AFHCs)
Health clinics established by
the government to provide
preventive, promotive, curative
and referral services to young
people
Ante- and post-natal care
Ante-natal care is the care
provided by skilled healthcare
workers to pregnant women
and adolescent girls in order to
ensure better health conditions
for both mother and baby during
pregnancy. Post-natal care is
healthcare provided to women
and their newborns for the first
few months following childbirth.
Hygienic methods of
menstrual protection
Locally prepared napkins, sanitary
napkins, tampons or menstrual
cups.
Menstrual Hygiene
Management (MHM)
Access to menstrual hygiene
products during menstruation,
privacy to change the materials,
and access to facilities to dispose
of used menstrual management
materials.
Modern contraceptive
prevalence rate
Percentage of women who
use any modern contraceptive
method.
Young people and their unique sexual and
reproductive health (SRH) needs
YOUNG PEOPLE
‘Young people’ are collectively
defined as thosAedolienscetnht e Youth
10-19 years 15-24 years
age-group of 10 to 24 years1
YOUNG PEOPLE
Adolescence
10-19 years
Youth
15-24 years
YOUNG PEOPLE
India has an estimated
Adolescent
Youth
370 milli1o0-n19 yyeaorsung15p-2e4 yoeaprsle
– its largest number ever3
Young people comprise
nearly a quarter of
the world’s population2
193 million 177 million
Sexual and reproductive health (SRH) is an important component of young people’s
overall health and development, encompassing physical, emotional, mental and social
well-being4. This is the period of life with the most significant physical, intellectual and
emotional changes, also characterised by the onset of puberty, and sexual awareness
and maturation. Inequitable social norms and gendered attitudes differentially impact
the SRH outcomes for boys and girls.
Girls encounter conflicting messages about SRH, fertility and womanhood, and many
face stigma and taboos related to menstruation. Due to prevailing gender norms, many
girls are expected to take on household responsibilities in preparation for marriage,
and often miss or drop out of school. For boys on the other hand, puberty is seen
as the onset of masculinity, with increased exposure to risk-taking practices such as
substance use, violence and unsafe sex. They also begin to engage in paid work, with
the expectation of becoming breadwinners as adults5,6. As gender socialisation and
formation of habits begin in early adolescence, this time in life is critical for shaping
positive attitudes, behaviours, and SRH outcomes7.
SRH needs of young people range from age-appropriate information and awareness
about physical changes, sexual health and well-being, puberty and menstrual health
in early adolescence (10 – 14 years), to knowledge and counselling on contraceptive
methods and use, safe sexual practices and prevention of sexually transmitted
infections (STIs), and access to quality SRH services including family planning for
delaying and spacing births among older adolescents and young married people (15 –
24 years).
The sexual & reproductive health status of young people in India
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Modern methods of
contraception
Male and female sterilization,
injectables, intrauterine devices
(IUCDs/PPIUCDs), contraceptive
pills, emergency contraceptive
pills, implants, female and male
condoms, diaphragm, foam/
jelly, standard days method
(a calendar-based method of
avoiding sexual intercourse on
fixed days to prevent pregnancy),
and lactational amenorrhoea
method (LAM – temporary
infertility after giving birth, when
a woman is not menstruating and
is fully breastfeeding).
Modern reversible
methods of contraception
Pill, intrauterine devices,
injectables, male condom,
female condom, emergency
contraception, lactational
amenorrhoea method (LAM).
Peer educators
Adolescents from the community
selected and trained to sensitise
and inform peers about their
health and well-being.
Unmet need
Proportion of women in the
reproductive age (15 to 49
years) who want to stop or delay
childbearing, but are not using
any method of contraception.
NFHS
The National Family Health
Survey (NFHS) is a large-scale,
multi-round survey conducted
since 1992-93 in a representative
sample of households, women
and men throughout India.
The survey provides district,
state and national information
on fertility, infant and child
mortality, family planning,
maternal and child health,
reproductive health, nutrition,
anaemia, utilisation and quality
of health and family planning
services.
What is the status, knowledge and access to SRH
services among adolescents and youth in India?
India’s large segment of young people will drive the country’s trajectory of
population growth for the next two to three decades8. Many of them have or will
soon join the reproductive age group (15 to 49 years). Fulfilment of their SRH needs
will have a significant and long-term impact, not only on population growth, but also
overall economic and development outcomes.
Recognising the needs of this group and the health risks it is exposed to in the
course of transition to adulthood, the Government of India adopted the Adolescent
Reproductive and Sexual Health Strategy in 2005, and the subsequent Rashtriya
Kishor Swasthya Karyakram (RKSK) or national adolescent health programme in 2014.
In addition, the National Population Policy (2000), the National Youth Policy (2014),
Rashtriya Yuva Sashaktikaran Karyakram (RYSK – 2016), the National Health Policy
(2017), the School Health & Wellness Programme (2020), and several other policy
commitments as well as programme initiatives address the needs of adolescents
and youth.
Menstrual health
One of the most significant physical
manifestations of puberty for girls is the
onset of menstruation. The government
has addressed menstrual hygiene
management for adolescent girls through
outreach under RKSK, awareness
generation, and distribution of sanitary
napkins at subsidised rates under the
Menstrual Hygiene Scheme, through
Pradhan Mantri Bhartiya Janaushadhi
Pariyojana (PMBJP) stores, and several
state government schemes.
NFHS data shows that the use of
hygienic methods9 of menstrual health
management by 15 to 24 year-old women
increased by 20 percentage points
between 2015-16 and 2019-21 (Figure 1).
However, there are significant variations
in menstrual health management (MHM)
Figure 1
Percentage of women using hygienic method of protection*
during menstrual period, 2019-21
78
58
NFHS-4 NFHS-5
(2015-16) (2019-21)
Place of Residence
Rural
Urban
Schooling
No Schooling
< 5 years complete
≥ 12 years complete
Wealth Quintile
Lowest
Second
Highest
73
90
44
51
90
54
71
95
*Locally prepared napkins, sanitary napkins, tampons, and menstrual cups
For women in the age-group of 15 to 24 years who ever menstruated; Source: NFHS Rounds 4 & 5
Nine of 10 young women in urban areas use hygienic methods, as against
a little over seven of 10 in rural areas. Those with 12 or more years of
schooling are twice as likely to use hygienic methods compared to those
with no schooling. Young women in the lowest wealth quintile are 40
percentage points less likely to use hygienic methods compared to those
in the highest wealth quintile.
2
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Figure 2a
Sexual initiation and knowledge
Age at first sexual intercourse
(percentage of women & men)
15
years
18
years
1
10
6
39
Men
Women
For women & men 25 – 49 years old; Source NFHS-5
Figure 2b
The National Family Health Survey
(NFHS) found that on an average, women
reported their first sexual intercourse
at a younger age than men as they
marry much earlier than men (Figure
2a). Despite early sexual debut among
women, their knowledge and information
on contraception was lower than that
of men. Although overall knowledge of
contraceptive methods among older
adolescents (15 to 19 years) and youth
(20 to 24 years) was found to be nearly
universal, older adolescent girls had
lower knowledge of modern reversible
methods14 as compared to older
adolescent boys (Figure 2b).
Knowledge of modern reversible
methods, by percentage of adolescents
Girls
Boys
88
95
For women & men 15 – 19 years old; Source NFHS-5
that of young women across regions,
and based on the place of residence,
education and household income. Analysis
of NFHS-5 data shows that adolescent
girls with higher levels of education were
85 percent more likely to use a hygienic
method of protection than those with
no education (OR=1.0 vs OR=0.15). Girls
from the highest wealth quintile were
90 percent more likely to use hygienic
methods as compared to those from the
lowest quintile (OR=1.0 vs OR=0.09)10.
Contact with health care workers
and facilities
Family life education in school and through
community outreach with frontline
health workers and peer educators,
and counselling as well as health care
at Adolescent Friendly Health Centres
(AFHCs)15 are important programme
components for the health and well-being
of young people. NFHS-5 data shows that
contact of older adolescent girls (15 to 19
years old) and young women (20 to 24
years old) with health workers in three
months preceding the survey increased
between 2015-16 and 2019-21 (Figure 3).
However, the share of adolescent girls who
had contact with a health worker was half
Figure 3
Percentage of women who had contact
with any health worker* by age, 2019-21
Young girls also continue to face social
barriers due to myths and taboos related
to menstruation. Their movement often
gets restricted, in some cases as a result
of the social stigma, and in others due
to the unavailability of adequate water,
sanitation and hygiene facilities. Increase
in school absenteeism or dropouts
are seen among adolescent girls with
the onset of menstruation11,12. Health
emergencies such as the COVID-19
pandemic that necessitate shifting of
public health priorities exacerbate the
challenges faced by young girls, especially
from marginalised segments, in managing
their menstruation13.
15 - 19
years
15
21
20 - 24
years
35
42
NFHS-4 (2015-16)
NFHS-5 (2019-21)
*Auxiliary nurse midwife (ANM), lady health visitor (LHV),
Anganwadi worker (AWW), Accredited Social Health Activist
(ASHA), multipurpose worker (MPW), or other community
health worker
For women who had any contact with a health worker
in three months preceding the survey;
Source: NFHS Rounds 4 & 5
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A study among adolescents and youth
found low exposure to family life
education, and a negligible percentage
who had heard of AFHCs16. A rapid
programme review carried out by the
World Health Organization in 2016
found that although resources were
allocated for adolescent health, young
people continued to face geographical
barriers in accessing health centres. In
addition, there were gaps in training of
counsellors and monitoring of community
outreach initiatives such as Adolescent
Health Days and Peer Educators, and
interdepartmental convergence for
programme implementation was poor17.
Reproductive health practices among young women
and their socio-economic determinants
As adolescent girls grow older, critical events such as marriage and childbearing
change their life course, over which they often have limited decision-making
autonomy18,19. The transition depends on many interrelated factors, including
prevailing gender norms, their educational and socio-economic status, place of
residence, and the quality of reproductive health and family planning services they
have access to.
Premature entry into marital life and
childbearing
Early marriage among girls compounds
their vulnerability, as they are ill-equipped
physically, emotionally, socially and
economically to cope with the profound
changes in their lives. Overall, according
to data from NFHS-5, women marry
much earlier than men. Almost a quarter
of women (23%) in the 20 to 24 age-
group had married by 18 years, and 5
percent had married by 15 years. On
the other hand, just 3 percent 20- to
24-year-old men had married by the age
of 18 years, and almost none by the age
of 15. Although child marriage in India
has declined over the years, there are
significant differences in the levels by
region, place of residence, educational
and economic status.
Analysis of the NFHS-5 data shows that
girls with lower or no education were 12
to 15 times more likely to marry below
18 years as compared to those who had
received higher education20. The odds
of girls from the poorer wealth quintiles
marrying before the age of 18 were almost
50 percent higher than of those from the
richest wealth quintile. Girls from rural
areas were also more likely to marry before
18 years than those from urban areas.
Household poverty and insufficient
economic opportunities for girls have
been found to be a key driver for child
marriages21. The practice not only deprives
young girls of opportunities to fulfil
their educational and career aspirations
and be fully mature to take on marital
responsibilities, it also leads to early and
frequent childbearing due to limited
decision-making autonomy, and social
pressures to prove their fertility soon after
marriage.
Overall 7 percent teenage girls in the
age-group of 15 to 19 years began
childbearing, just a single percentage
point less than in 2015-16, and with
significant differentials based on
geographic location, educational levels
and socio-economic status (Figure 4).
Reproductive health and
contraception among young women
The use of modern contraceptive methods
by young married women has increased
significantly between 2015-16 and 2019-
21. However, it is well below the modern
contraceptive prevalence rate for currently
married women in the age-group of 15
to 49 years (Figure 5). 7 percent each of
married young women under the age
of 20 years, and those between 20 to 24
years, reported unplanned pregnancies
(those they wanted later – mistimed,
and those they did not want at all –
unwanted)22. In addition, the unmet
need of family planning among married
adolescents (15 to 19 years) and young
women (20 to 24 years) was almost
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double of the unmet need among all
married women (15 to 49 years) (Figure 6),
reflecting a gap in accessibility to this age
bracket.
Reproductive health outcomes are closely
related to interaction with frontline
health workers, especially information on
contraceptive methods, ante- and post-
Figure 4
Percentage of teenage girls who have begun childbearing, by background characteristics,
2019-21
Highest
Second
Lowest
Overall teenage
pregnancy
18
12 or more years complete
15
<5 years complete
7
8
No schooling
10
8
4
Rural
4
Urban
2
Urban
Rural
No
< 5 years
≥ 12 years
Lowest
Second
Highest
Schooling
complete
completed
Place of Residence
Schooling
For women in the age-group of 15 to 19 years; Source: NFHS-5
Wealth Quintile
Twice the share of girls living in rural areas began childbearing (8%) as compared to those from urban areas
(4%). More than four times as many girls with no schooling began childbearing (18%) compared to those who had
completed 12 years or more (4%). Similarly, girls from the poorest wealth quintile were five time more likely to
begin childbearing (10%) as compared to those from the richest wealth quintile (2%).
Figure 5
Percentage of currently married
women using any modern method of
contraception* by age, 2019-21
56
32
19
15 - 19 years 20 - 24 years 15 - 49 years
*Female sterilization, male sterilization, pill, intrauterine
devices, injectables, male condom, female condom,
emergency contraception, lactational amenorrhoea method
(LAM), and other modern methods
Source: NFHS-5
The sexual & reproductive health status of young people in India
Figure 6
Percentage of women with unmet
need for family planning by age,
2019-21
15 - 19 years
20 - 24 years
15 - 49 years 9
18
17
Source: NFHS-5
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natal care, and abortion services. Findings
of NFHS-5 show that health workers have
limited interaction with younger married
women, especially adolescents. While
about one in five (21%) currently married
adolescents (15 to 19 years old) not
using any family planning method were
contacted by health workers and informed
about contraceptives in three months prior
to the survey, nearly one in three (30%)
older currently married non-user women
in the age-group of 20 to 24 years had
similar interaction with health workers.
A longitudinal study with adolescents
and young people found that health
workers were less likely to meet married
adolescents and young women when
they did not have any children, thereby
losing the opportunity of counselling
young people who are beginning their
reproductive life. The study also found
that married girls who interacted with
health workers had higher chances
of using contraception and exercising
decision-making autonomy23.
Apart from compromising the freedom of
choice, childbearing at an early age can
also lead to adverse pregnancy outcomes
and heighten the risk of infant and child
mortality rates. NFHS-5 estimates show
that with the exception of 40- to 49-year-
old women, infant mortality rates are the
highest for young women who are less
than 20 years old at the time of birth. The
risk of mortality in the first five years of
birth among mothers less than 18 years
old was almost double of those who were
not in a high-risk category24. Early and
unintended pregnancy among adolescent
girls is not only associated with poor
health outcomes, and unfulfillment of
their educational and economic goals, but
also translates into a substantial burden
on the country’s economy and health
systems25.
The economic gains of investing in
comprehensive SRH for adolescent
girls
An estimation projects that providing
a comprehensive SRH package to all
adolescent girls in India who need these
services would cost a little over 11 rupees
per capita annually26. The projection
calculates that every additional 100 rupees
spent on contraceptive services above the
current level would save 252 rupees in the
cost of maternal, newborn and abortion-
related care by averting unintended
pregnancies.
Policy recommendations to address young people’s
sexual and reproductive health and well-being
Operationalising adolescent health and well-being education in schools
Adolescents and young people require timely and accurate information on their sexual
and reproductive health and well-being in order to have the knowledge and skills to
make responsible choices. Studies show that SRH education does not increase risky
behaviours27. India’s National Health Policy 2017, the draft National Youth Policy
2021, and the School Health & Wellness Programme being implemented under the
Government of India’s Ayushman Bharat recognise the importance of imparting age-
appropriate adolescent and sexual health education, beginning at the primary school
level.
However, despite programme commitments, there is unequal reach of age-appropriate
sexuality education for adolescents, and most awareness programmes focus on non-
taboo subjects such as menstrual health, nutrition, or reproductive health at an older
age28. At the same time, increased access to online communication often exposes young
people to misinformation, and reinforces harmful gender norms and attitudes towards
SRH. Information and education programmes on SRH for adolescents and youth need
to be operationalised as an integral part of school health programmes across the
country.
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School-based programmes are found to be most impactful when complemented with
community activities, including youth-friendly health services, training and engagement
with health providers to deliver those services, and involvement of parents, teachers,
and community leaders. Multi-component programmes are particularly important for
reaching marginalised young people, including those who are not in school29.
At the national level, joint initiatives through convergence between key ministries
such as Health & Family Welfare, Education, Women & Child Development, Youth &
Sports Affairs, and Skill Development & Entrepreneurship are necessary to address the
intersecting needs of India’s large and diverse young population.
Higher investments in social and behaviour change communication (SBCC)
strategies to address the social determinants of young people’s SRH
Investments in transmedia behaviour change communication strategies that address
the age-, gender- and location-specific needs of young people should be prioritised
in programme implementation plans. SBCC campaigns need to reflect the voices of
adolescents, sexual minorities, and adolescents with disabilities, and extend to families
and communities that are primary influencers, especially in adolescence.
Focusing on specific measures to retain adolescents in school
Apart from better information and behaviour change, secondary school education is
the most significant factor seen to be associated with better SRH outcomes, especially
for girls, including delaying marriage, sexual initiation and childbearing, and increase in
contraceptive use30.
Ensuring that girls have access to educational institutions with provision for
transportation, and adequate sanitation and hygiene facilities, would help retain them
in school31. Similarly, scholarships and livelihood opportunities linked to secondary
school and college education would help adolescents from socio-economically
underprivileged backgrounds to complete their education, and be better equipped to
handle their healthcare needs. Assuring higher education and workplace participation
for girls would also address the economic distress that leads poorer families to marry
them off at an early age.
Engaging men and boys in shifting regressive social norms
Regressive gender norms that perpetuate child marriage and early childbearing, and
toxic notions of masculinity need to be addressed through community-level SBCC
programmes, especially by engaging with men and boys and to promote gender
equality and more equitable norms. The key to gender norm change is to
provoke it and speed it up from within, acknowledging and forming alliances with those
men and boys who already believe in gender equality, and identifying the conditions
necessary to scale programs up in schools, the workplace, the health sector and other
spaces where millions can be reached.
Investing in adolescent- and youth-friendly SRH services and counselling
Young people continue to grapple with limited avenues for understanding their
physical, sexual and mental health issues and receiving services in a non-judgemental
atmosphere. Dedicated adolescent-friendly health clinics with trained counsellors and
health service providers that offer equitable, non-discriminatory SRH services while
maintaining privacy and confidentiality, need to be operationalised. At the same time,
India’s family planning programme needs to prioritise access to reversible spacing
methods of contraception for its young population, so that they can exercise their
reproductive health choices and reduce the unmet need for family planning.
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References
1World Health Organization
2World Population Dashboard 2022, UNFPA
3Census of India 2011. Population Projections for India and States,
2011 – 2036
4WHO. 2006a.Defining sexual health: Report of a technical consultation
on sexual health, 28–31 January 2002. Geneva, World Health
Organization
5UNESCO. International technical guidance on sexuality education. 2018
6Woog V and Kågesten A, The Sexual and Reproductive Health Needs
of Very Young Adolescents Aged 10–14 in Developing Countries: What
Does the Evidence Show? New York: Guttmacher Institute, 2017
7National-level data on the sexual and reproductive health of young
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8United Nations Department of Economic and Social Affairs, Population
Division (2022). World Population Prospects 2022: Summary of Results.
UN DESA/POP/2022/TR/NO. 3.
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cups
10UNFPA, 2022. Analytical Paper Series #2. Menstrual Hygiene among
Adolescent Girls: Key Insights from the NFHS-5 (2019-21)
112020 Elsevier Ltd. Improving menstrual hygiene among adolescent
girls in India. Patralekha Chatterjee
12Woog V and Kågesten A
13Population Foundation of India. Impact of Covid-19 on Young People.
2020
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emergency contraception, lactational amenorrhoea method (LAM) and
other modern methods
15Health clinics established by the government to provide preventive,
promotive, curative and referral services to young people
16Population Council, 2021. The significance of romantic relationships
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17Barua, A., Watson, K., Plesons, M. et al. Adolescent health
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27UNESCO, 2018
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31Banerji, Manjistha and Mathur, Kopal. 2021. Understanding school
attendance: The missing link in “Schooling for All”, 2021 Elsevier Ltd
Population Foundation of India is a national non-
government organisation (NGO), founded in 1970 by
JRD Tata, that promotes and advocates for the effective
formulation and implementation of gender-sensitive
population, health and development strategies and
policies. Working with the government and NGOs, it
addresses population issues within the larger discourse
of empowering women and men.
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United Nations Population Fund (UNFPA) is the lead
UN agency for delivering a world where every pregnancy
is wanted, every childbirth is safe, and every young
person’s potential is fulfilled.