Adolescent Pregnancy In India: A Critical Review Of The Contributing Structural Determinants And The Impact Of Government Health Programs

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By Megna Srinivasan

 

Introduction 

The World Health Organization defines adolescent pregnancy (AP) as “pregnancy in young women aged 10–19 years”.¹ Although the global adolescent birth rate has decreased by 23.2 births per 1000 women over the past two decades, low- and middle-income countries (LMICs) still have around 21 million adolescent pregnancies annually.¹ According to Sustainable Development Goals 3.1 & 3.7, reducing adolescent fertility is an essential step in meeting sexual and reproductive health targets of global significance.2 

 

The Burdens of Adolescent Pregnancy 

In LMICs, the leading cause of mortality amongst adolescent girls is pregnancy and childbirth-related complications.3 AP is associated with unsafe abortion, pregnancy-induced hypertension, puerperal endometriosis, and eclampsia.4 Babies born to adolescent mothers are more likely to be premature and have low birth weight, congenital anomalies, neonatal issues, and a higher risk of being stillborn or dying within the first 7 days of life.4 As adolescent mothers are “more likely to leave school for childcare compared to other females,” they are less likely to be financially independent with limited education and employable skills. Financial strain, social stigma, and a lack of community support culminate in higher suicidality among young mothers.3 

 

Adolescent Pregnancy in India 

According to a 2010 UNFPA report, India had the highest number of women who had a live birth by 18 years of age.5 In 2017, estimates from the 4th National Family Health Survey (NFHS-4) cite that there were 11.8 million adolescent pregnancies in India.6 With 253 million adolescents aged 10-19, India has the largest adolescent population in the world.6 However, Indian adolescent reproductive health needs are poorly understood.7 The proportion of adolescent maternal deaths to total maternal deaths remains high, around 10 percent, despite substantial improvements in maternal mortality in India over the last two decades.8 Considering this, it is important to unpack the issue of AP in India. The purpose of this paper is to understand the social determinants of adolescent pregnancy in India and evaluate if current government health programs are effective.  

 

Methodology 

I conducted this review using the PubMed, BruKnow Search, The Lance, and BMJ Global Health databases. Keywords of the search included “adolescent pregnancy”, “teenage pregnancy”, “maternal mortality” and “India”. I sorted results by the relevancy feature and selected articles depending on publishing date and how specific they were to India, adolescents, pregnancy, and maternal mortality. I conducted backward citation searches where the references in the identified papers were scanned for more relevant articles. This paper also seeks to evaluate interventions. I conducted an additional search using specific keywords like “National Health Mission” or “Adolescent Education Program” to find intervention-specific literature. Finally, 11 papers were chosen to evaluate, along with 8 supplementary papers, and 5 web pages. It is important to note that these search strategies limited results to studies written in English. 

 

Determinants of Adolescent Pregnancy 

Structural determinants of health are the societal, economic, and political contexts that produce health. The following section of this paper will look into the cultural and socioeconomic determinants of AP in India. Although this paper separates determinants into categories and discusses them in terms of their independent contribution to AP, it is important to note that socioeconomic and cultural determinants are highly intersectional. 

 

Cultural Determinants 

 

i) Early Marriages & Age-Based Hypergamy

In The Prohibition of Child Marriage Act of 2006, India raised the minimum age of marriage to 18 years for females. However, 47 percent of all marriages in India in 2013 were between adolescents under 18.9 AP is socially condoned within marriages.10 Along with early marriages, there is a cultural norm of age-based hypergamy (ie. age-gap marriages). It is believed that husbands should be older than their wives. The spousal age gap between men and women in India is around 5 years. This pattern has remained stable over decades, with some regions experiencing an increase in spousal age gaps.10 

Shri et al.’s (2023) study depicts how entrenched marital values contribute to adolescent pregnancies in two highly affected Indian states, Uttar Pradesh and Bihar. Using data from the Population Council’s “Understanding the Lives of Adolescents and Young Adults” (UDAYA) survey, the study sampled 4897 married adolescent girls between the ages of 15 to 19. The study found that “adolescents who married before the age of 18 years were 1.79 times more likely to experience pregnancy and 3.21 times more likely to experience motherhood”. Adolescents with a spousal age gap of 5 to 10 years were “52 percent more likely to be pregnant”, with the odds of pregnancy and motherhood rising with a greater spousal age gap.6 The study establishes the strong relationship between early marriage, age-hypergamy, and AP with a large sample size from both rural and urban localities. There are a few limitations to the study. Firstly, the study does not look at data on adolescents aged 10-14. Additionally, the study looks only at two states where adolescent pregnancies are particularly concentrated. Whilst this allows the researchers to account for confounding factors, it calls into question whether we can generalize the results to the rest of the Indian subcontinent. 

 

ii) Caste & Religious Systems

While legally discontinued, the caste system exerts a lingering influence on Indian society and is a notable determinant of health outcomes. In India, “socially backward classes” are socioeconomically marginalized populations that encompass groups like scheduled castes (SC), scheduled tribes (ST), and other backward castes (OBC).12 Beyond economic poverty, these communities grapple with cultural and geographical marginalization. In India, religion is intertwined with the caste system. 40.7 percent of the Muslim community is categorized as part of the ‘other backward castes’ (OBC) and 43 percent of Muslims live below the official poverty line, with a lower average literacy rate.12 

Shukla et al.’s study explores the predictors of AP among girls in Maharashtra, India (2023). Maharashtra is a relevant state to analyze the intersection of caste and religion on AP as 55.2 percent of the population belongs to lower castes (SC/ST/OBC) and 11.2 percent of the population is Muslim. With a sample of 3049 girls aged 13–18 from urban and rural areas, the study employed a mixed-methods approach. The researchers analyzed the sample’s vulnerability to AP by considering household characteristics, behavioral aspects, societal factors, and the COVID-19 pandemic. The study found a significant association between being lower caste and experiencing AP. Conversely, the study found a significant association between being non-Muslim and experiencing AP. Although caste and religion align in the context of cultural marginalization, the study displayed that the two factors can influence AP outcomes differently.13 This study is one of the first of its kind to account for the COVID-19 pandemic. However, the research is limited because the authors did not conduct interviews with high socioeconomic-status families, who tend to be from higher castes, to make a robust comparison. 

 

iii) Sexual Violence and Sex Work 

There is evidence that the state of sexual violence and sex work in India is a determinant of adolescent pregnancies. The NFHS-4 reveals that the “prevalence of sexual intimate partner violence is significantly higher when the age of marriage is under 19 years”.14 The Ministry of Health & Family Welfare Government of India (MoHFW), found that “31 percent of ever-married female adolescents aged 15–19 reported having experienced physical, sexual or emotional violence perpetrated by their spouse” in the third round of NFHS.14 Furthermore, a 1998 study on adolescent sexual behaviors in India cites that “almost 25 percent of rape victims are reportedly aged under 16 and 20 percent of all sex workers are adolescents”.7 Forced sexual activity, sexual violence, and sex work can lead to unwanted adolescent pregnancies. The literature on sexual violence, sex work, and Indian adolescent health outcomes is sparse. More research is needed to inform policy decisions on how to reach sexually marginalized adolescent groups in India. 

 

3.2 Socioeconomic Determinants 

 

i) Sexual & Reproductive Health (SRH) Education

A literature review by Panda et al. (2023) examined 40 studies on perception, practices, and understanding related to teenage pregnancy among adolescent girls in India. The paper reveals the importance of sexual and reproductive health (SRH) knowledge on improved adolescent fertility outcomes. In India, it is taboo to discuss reproductive health, pregnancy, and conception-related information with adolescents in school. Safe sex information among Indian adolescents primarily comes from friends or media, and to a lesser extent, parents, health workers, and school teachers. Inadequate education and access to contraceptives resulted in insufficient contraceptive knowledge and use. This trend was prominent among married adolescent women. Limited understanding of pregnancy, intercourse, and abortion led to unwanted pregnancies, sexual health complications, and delays in abortion.16 Whilst this paper does not consider SRH knowledge amongst adolescent men, it is equally important to understand when it comes to AP. 

Kumar et al.’s paper on adolescent students in Chandigarh helps to reconcile the gap in understanding of male SRH knowledge and build upon the body of evidence from Panda et al.’s paper (2017). By surveying a sample composed of 57.2 percent males and 42.9 percent females from eight government schools and four private schools, the study explores the state of SRH knowledge amongst adolescents. Awareness of condoms, oral contraceptives, and emergency contraceptive methods was 83.4 percent, 67.1 percent, and 65.3 percent respectively. A majority of students sampled have an awareness of contraception, but “69.4 percent of respondents displayed the need for more sex education in schools” .17 

Saha et al. (2022) found that SRH knowledge is linked to years of education in school. Girls with higher education were more knowledgeable about “sexual intercourse, pregnancy, contraceptive methods, and HIV/AIDS when compared with illiterate girls”.18 This study presents the impact of social media on SRH knowledge in India. The study collected data from participants of the UDAYA survey and cross-referenced information on social media usage and pregnancy status. Although only 28 percent of participants had access to social media channels, “social media was associated with knowledge of sexual intercourse, pregnancy, contraception, and HIV/AIDS”. Social media access was also found to be higher amongst female adolescents who were from educated, wealthy, and urban communities. The authors recommend that education interventions involving social media should be conscious of differential access to technology in India.18 

 

ii) Socioeconomic Status (SES)

A study by Nguyen et al. (2019) collated data from 14,107 adolescent mothers in India’s NFHS-4 to uncover the relationship between AP and socioeconomic status (SES). Rates of women who gave birth during adolescence were more prevalent in households characterized by lower SES. The findings suggest that AP perpetuates cycles of intergenerational poverty, where women who gave birth during adolescence were less likely to have paid jobs or have agency over household money.19 The study presents the limitation of cross-sectional design, where it is hard to disentangle whether AP leads to reduced SES or if pre-existing SES conditions contributed to AP. Nevertheless, the study was bolstered by its strict consideration of teenage mothers who have only had one birth, which helped the authors avoid biases on other explanatory factors like birth spacing. 

 

iii) Rural vs. Urban Living 

Bhakat and Kumar conducted a comprehensive analysis of all five rounds of the NFHS, aiming to elucidate more factors that contribute to AP in India.20 Their findings reveal that women residing in rural areas exhibit a higher probability of AP than their urban counterparts. The study describes rural areas as more “pronatalist”, or encouraging the practice of having children, which drives elevated rates of adolescent pregnancies in rural areas. The article emphasizes the imperative of educating parents and communities in rural regions about the burden of AP.20 Due to the study’s use of all NFHS data, it was unable to capture data on young girls aged 10-14. This compounds evidence of a systematic research gap on AP in younger girls. 

 

Government Interventions Addressing Adolescent Pregnancy 

One of the three main programmatic components of India’s National Health Mission is Reproductive, Maternal, Neonatal, Child, and Adolescent Health, or RMNCH+A. The main National Adolescent Health Programme, Rashtriya Kishor Swasthya Karyakram (RKSK) lies under RMNCH+A. RKSK was remodeled in 2014 from the previous program called Adolescent Sexual & Reproductive Health Strategy (ARSH) (2005-2014).21 While these programs tend to focus broadly on adolescent health, components of the programs are intended to improve SRH and AP. The next section of this paper will evaluate the implementation of RKSK and ARSH. 

 

ARSH and RKSK: Implementation Challenges 

Established in 2005, ARSH marked India’s inaugural adolescent health program, offering a spectrum of SRH services for adolescents, adopting a clinic-based approach, and emphasizing the establishment of adolescent-friendly health centers (AFHCs) within existing public health facilities.22 Barua et al. (2020) conducted a rapid program review comparing ARSH and the new RKSK program, aiming to identify lessons learned. The study, encompassing semi-structured interviews with 70 stakeholders at national, state, and local levels, field visits, and reviews of third-party studies, policy documents, and reports from MoHFW, assessed both programs in governance, implementation, monitoring, and linkages. 

ARSH faced challenges in program planning, resource deployment, and integration into the broader health system. Limited adolescent involvement in AFHC governance and a narrow focus on SRH were noted. Cultural resistance and insufficient community-level follow-up hindered progress, keeping ARSH in “project mode” until its termination in 2014.22 The RKSK Program, a departure from ARSH’s clinic-centric approach, embraced community-based interventions engaging adolescents in schools, families, and communities.23 Although RKSK improved resource planning and program organization, challenges in vacant positions, budget, and coordination persisted. Despite expanding AFHCs across healthcare levels, adolescent involvement and accessibility remained problematic. RKSK introduced community counseling services, adolescent health days, and peer education but encountered difficulties in implementation and monitoring. Both programs faced challenges in linkages, such as partnerships and interdepartmental collaboration. The research concludes that RKSK has learned from ARSH by adopting better programmatic approaches, yet challenges persist in all domains.22 

A study in Gujarat’s Sabarkantha district24 delves into RKSK’s implementation. The RKSK provides three main services to adolescents in Sabarkantha: weekly iron-folic acid supplementation (WIFS), AFHCs, and menstrual hygiene assistance. Utilizing a cross-sectional mixed-methods approach, the study involved interviews with health personnel and adolescents and a desk review of reports. While RKSK excelled in services like WIFS, weaknesses were identified in counseling and education services at AFHCs, particularly at secondary and tertiary levels. Peer educators faced challenges in finding educational materials, and discussions primarily focused on contraception during sessions. The study highlighted a lack of promotion for follow-up sessions and identified privacy concerns hindering open sexual health conversations. Stakeholders expressed the need for refresher training and greater awareness about RKSK among adolescents, potentially involving non-governmental organizations.24

 

Solutions: Using Community-Based Interventions for Adolescent Pregnancy in India 

A scoping systematic review by Pattathil & Roy (2023) sheds light on ways to make adolescent sexual health programs more successful. The researchers express how SRH education has been notoriously hard to establish in India with the example of the national Adolescent Education Program (AEP). The AEP sought to teach adolescents “culturally relevant information regarding sexual health, gender, sexuality, communication skills, and relationships”. Unfortunately, after mass outrage on teaching youth about sexuality, the AEP was banned in five states with highly variable implementation, monitoring, and follow-up. The paper’s findings establish that the most successful programs are those that are created to be socially condoned. The study stresses the importance of involving parents, community members, local experts, and organizations in program design and implementation to garner lasting support and engagement. The authors emphasize the significance of addressing program participation barriers, such as the stigma and discrimination youth may face if they openly discuss SRH issues.25 The study acknowledges its limitations such as its limited capacity to effectively compare programs and populations across India’s diverse settings. 

The success of community-based initiatives is evidenced in a study conducted by Mehra et al. (2018). The researchers implemented Youth Information Centers (YICs) where students were taught an adapted AEP course in Uttar Pradesh and Bihar. They engaged the community by enlisting “local young people, parents, religious leaders, opinion makers, and elected members from local governance” to discuss issues surrounding adolescent pregnancy. The intervention involved training peer educators, who conducted meetings at the family, community, and government levels to address early marriage, education retention, and AP. The study concluded that significant improvements in school retention, delaying early marriages, and first pregnancy were seen upon using YICs.9 This study serves to show the effectiveness of community-based interventions for AP in India. 

 

Discussion: Summary and Critique 

The literature presents the key cultural and socioeconomic determinants that drive AP in India, including a culture of early marriages, belonging to socially backward castes or tribes, being non-Muslim, a lack of SRH education and social media access, lower SES, and residing in rural areas.9 These key determinants have been observed to influence the level of maternal healthcare services utilized by pregnant adolescents, thereby also playing a crucial role in determining the postnatal outcomes and maternal mortality of adolescents.26 

There are notable gaps in the literature. There is a need to explore how experiences of sexual harm contribute to AP in India to inform better policy decisions. Most of the literature focuses on youth aged 15-19. It is important to understand more about AP in younger demographics (10-14), as it may be driven by different determinants. There is an insufficient consideration of male adolescents in the literature. Including male adolescents in research and SRH intervention efforts like their female counterparts is important to addressing and understanding the issue. 

Existing studies often rely on the same surveys for data, primarily the NFHS19,20 and, to a lesser extent, the UDAYA survey.6,18 Although the NFHS in India is a strong source of data over time, supplementing NFHS data with other independent surveys would provide a less biased understanding of the issue of AP. The UDAYA survey focuses on two states, Uttar Pradesh and Bihar, so finding similar information from other states would help the literature become nationally representative. Additionally, most of these studies are cross-sectional. Cross-sectional studies offer the advantage of providing a cost-effective method to identify current trends in a population. However, they do not allow researchers to establish causation. Longitudinal studies, although more resource-intensive, should be conducted on AP in India to explore the causal and long-term effects of these key determinants. 

National Health Programs that are concerned with adolescent sexual health, like the RKSK, have been strengthened over time by learning from prior programs like ARSH. Given that SRH education is an important determinant of AP, counseling and education services offered via AFHCs in the RKSK program are the most relevant interventions for preventing AP. It seems like there should be a restructuring of how AFHCs are conducted to offer adolescents more privacy in discussing their sexual health questions. This will allow educators to effectively counsel adolescents on matters influencing AP, like sexual behavior, contraceptives, school retention, and early marriage. Interestingly, it seems like the Indian government has placed less of a priority on adolescent SRH by remodeling RKSK to include action on broader adolescent health issues such as “nutrition, injuries, violence, non-communicable diseases, mental health, and substance misuse”.23 Research should be conducted into whether expanding the scope of the RKSK has diminished the government’s focus on adolescent SRH and AP. 

 

Conclusions and Future 

This paper aimed to understand the factors that contributed to AP in India and how effective government public health interventions have been. Key determinants, rooted in cultural and socioeconomic factors, include early marriages, age-based hypergamy, caste and religious systems, sexual violence, sex work, limited SRH education, lower SES, and rural-urban disparities. The state of AP in India, marked by a large adolescent population and substantial teenage pregnancies, necessitates urgent and effective interventions. This paper critically evaluated the evolution from ARSH to RKSK under the National Health Mission. Persistent challenges in education and counseling services make current government programs ineffective in tackling adolescent pregnancy. Community-based interventions, such as Youth Information Centers, have emerged as effective strategies, displaying the importance of culturally sensitive programs involving local stakeholders. While progress has been made, there is a need for continued research and policy refinement. Future research should focus on addressing literature gaps, such as the relationship between sexual harm experiences and AP. Future government efforts should offer local partners and community members a larger role in the facilitation of larger systematic health programs.

 

References 

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Megna Srinivasan