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Sexual and Reproductive Health of Adolescents and Young People in India: The Missing Links During and Beyond a Pandemic

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• First Online: 09 April 2022

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• Sapna Kedia 3 ,
• Ravi Verma 3 &
• Purnima Mane 4  

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The authors discuss the impact of the pandemic on the sexual and reproductive health of adolescents and young people. Adolescents and young adults (AYA) are at low risk from COVID- 19, and hence, it may be assumed that their needs do not warrant immediate attention. However, it is important to understand how the pandemic may have affected their lives. Evidence from previous humanitarian disasters in India and elsewhere suggests that consequences for adolescents and young adults may be significant and multi-dimensional. The authors examine the impact (short- and long-term) of COVID on the sexual and reproductive needs and behaviors of AYA in India, particularly their intimate relationships, sexual violence, access to services, and impact on their mental health.

Programs for AYA should be responsive to their needs, feelings, and experiences and should treat them with the respect they deserve, acknowledging their potential to be part of the solution, so that their life conditions improve and the adverse impact of the pandemic is minimized. Programs must also address the needs of vulnerable AYA like migrants, those from the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, persons with special needs, HIV positive youth, and those who live in poverty. It is important to understand how gender impacts the sexual and reproductive health of AYA, particularly young girls and women, in terms of restriction of mobility, increase dependence on male partners/friends/relatives, gender-based violence, control of sexuality, and the lack of privacy and confidentiality. The responses to these needs by youth-based and youth-serving organizations and the government are summarized. Recommendations are made to address prevailing gaps from a sexual and reproductive health rights and justice perspective.

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Introduction.

The COVID-19 pandemic has by now affected the entire world. It has highlighted the existing gaps in equitable development and re-emphasized, in a manner that we could not imagine, the need to assess our privileges—in terms of access to education, health, housing, food security, transportation, and how we treat the environment. The stay at home and isolation requirements have impacted our basic human needs of connection, relationships, physical proximity, and intimacy. Over the last eight months, a lot has been said and written about the impact of the pandemic on our lives. COVID’s impact, however, varies depending upon one’s socioeconomic position. This is crucial to note because the effect of COVID on the most vulnerable sections of society and those whose human rights are least protected is likely to be more adverse and unique.

This chapter focuses on the impact of the pandemic on adolescents and young adults (AYA) aged 10–24, in India, with reference to their sexual and reproductive health (SRH). AYA are at low risk from COVID, and hence, their needs may not seem to warrant immediate attention. However, it is important to understand how the pandemic may have affected their lives. Evidence from previous humanitarian disasters in India and elsewhere suggests that consequences for adolescents and young adults may be significant and multi-dimensional [ 1 ].

A scan of the literature available on the impact of COVID on AYA in India presents a glaring gap of evidence on how the pandemic has affected their sexual and reproductive health (SRH). Most available evidence focuses on COVID’s impact on AYA’s education, overall health and well-being, access to livelihoods, loss of agency, and decision-making. Literature also shows COVID’s impact on AYA’s reproductive health. However, this is largely limited to disruption in services due to the lockdown imposed in India on March 24, 2020, which continued for months in different forms [ 2 ].

There is a noticeable silence around sexual health of AYA during the pandemic. This is an extension of course, of the silence prevalent pre-COVID. During pre-COVID times too, access to SRH information and services for adolescents, especially unmarried adolescents in India, has always been socially stigmatized and scrutinized, resulting in limited availability and accessibility of services for sexual and reproductive health and rights (SRHR) [ 3 ]. The reasons for this silence are known—the lack of acknowledgment of AYA as sexual beings, the stigma around adolescent sexuality and pre-marital sex, particularly in relation to unmarried adolescent girls, and the association of reproductive health with marriage and child birth [ 4 ]. Not surprisingly then, there is a lack of global estimates of the pandemic’s effect on AYA’s SRH outcomes due to the non-availability of meta-data on the SRH needs of the young, unmarried population, an invisibility largely due to stigma around pre-marital sexual activity. In India, the absence of SRH services from ‘essential’ health services during COVID amplifies this undocumented need [ 3 ].

While the immediate effects of the pandemic on AYA’s lives are visible in terms of impact on education, mobility, employment, and leisure, the pandemic’s other possible impacts on AYA’s SRH will gradually be understood. The pandemic may have medium- and long- term impacts on AYA’s basic rights and agency in terms of their health and safety [ 5 ]. It is important to note that the pandemic has put a break on many of the normative aspects of AYA’s development, a period ideally marked by increased independence and peer bonding [ 6 ]. This may affect the development trajectory of AYA.

Some AYA may have been forced to enter early marriages due to the pandemic; some may have had unintended pregnancies and difficulties in accessing abortions, and some may have experienced sexual violence during this period. In addition, adolescence is also a period marked by sexual awakening within the context of lack of knowledge and guidance on sexual matters from reliable sources, which is likely to be even more limited during the pandemic. It is thus important to understand the pandemic’s impact on the SRH of AYA so that timely and adequate responses may be developed and to ensure that a crucial aspect of their lives is not overlooked (Fig.  10.1 ).

Framework to understand the impact of COVID on adolescent and young adult’s sexual and reproductive health and rights

According to the current working definition, sexual health is

…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled [ 7 ].

Reproductive health (RH) implies that people are able to have a responsible, satisfying, and safe sex life and that they have the capability to have children and the freedom to decide if, when and how often to do so [ 8 ].

From the above perspective, sexual and reproductive health are key factors in shaping AYA’s physical and mental well-being, factors that are often overlooked in the context of a country like India. This chapter seeks to examine the impact (short- and long- term) of COVID on the SRH needs and behaviors of AYA, based on available evidence. The chapter also highlights crucial gaps in the existing evidence and builds a case for addressing them. The authors adopt the following framework in their analysis of COVID and its impact on adolescent and young adults SRHR.

Adolescents and Young People in India

As per the Census of India 2011, every fifth person in India is an adolescent (10–19 years) and every third, a young person (10–24 years). Adolescents constituted 21.7% of the total rural population and 19.2% of the total urban population in the Census in 2011. The youth population constituted about 18.9% of the total rural population and 19.7% of the population in urban areas. For the country as a whole, the percentage of male adolescents and youth is slightly higher than their female counterparts in both rural and urban areas. In 2011, the sex ratio among the adolescent population in rural areas was 901 and in urban areas was 892. In the case of the youth, the sex ratio in rural areas was 901 and in the urban areas was 910. Recently released data from the National Family Health Survey (NFHS)-5 (2019–2020) highlights that low sex ratio continues to be a major challenge in most Indian states. NFHS-5 also highlights the gender differentials across several indicators [ 9 ]. For example, the proportion of adolescent girls (15–19) who became pregnant before age 18 ranges between 10 and 15% with wide rural/urban and interstate variation. Similarly, the experience of gender-based violence (GBV) by youth (18–29) is about 4% with minor rural/urban variation. Anemia continues to be alarming among adolescents and young adult girls in comparison with their male counterparts. Child marriage rates are still high to the tune of almost 30% in some states with large interstate and rural/urban differentials.

AYA is not an homogenous group. AYA’s needs vary with their age, sex, stage of development, and life circumstances—in terms of access to quality education, life skills development, place of residence (rural/urban), opportunities for collective learning and sharing, and the socioeconomic conditions of their environment .

As per the United Nations Population Fund (UNFPA), AYA in India face several development challenges, including access to quality education, gainful employment, gender inequality, child marriage, absence of youth-friendly health services, and adolescent pregnancy. These challenges have been exacerbated due to COVID [ 10 ].

A few studies, conducted during the lockdown in India, have assessed the impact of COVID on adolescents and young people in India. The Population Foundation of India (PFI) conducted a rapid assessment of the impact of COVID-19 on youth in Bihar, Rajasthan, and Uttar Pradesh [ 11 ]. Quilt Al conducted a study on the impact of COVID on adolescent reproductive health, the DASRA Adolescent Collaborative collected experiences of civil society organizations working with adolescents, and the YP Foundation reached out to its adolescent and youth network spread across 25 states and six union territories of the country, to understand the impact of the pandemic on young lives [ 1 , 12 , 13 ]. Findings from these studies are representative of diverse communities of adolescents and young adults including informal laborers, gender and sexual minorities, young people belonging to different castes and tribal affiliations, sex workers, people living with HIV (PLHIV), substance users, and young people living in shelters and correctional homes.

These studies have highlighted the impact of COVID on AYA’s education, access to health services including sanitary pads, iron and folic acid (IFA) tablets, contraception, abortion services, nutrition, skilling and employment assistance, and mental health services. They also provide information on how the pandemic has impacted AYA of different genders. This chapter will present the sexual and reproductive health-related findings and recommendations from these studies and will highlight data gaps that need to be addressed.

Impact of COVID on AYA’s Sexual Relationships

COVID has resulted in restrictions on freedom, mobility, and socialization worldwide. This has created increased isolation. AYA have experienced increased restrictions on mobility, recreational activities, and access to support networks due to closure of schools, colleges, non-formal learning opportunities, and workplaces [ 1 ]. This has resulted in limited social engagement with their peers, guides, and mentors and in increased anxiety and loneliness [ 13 ].

Increased family time, especially in cases where AYA have been living away from home for some years, has led to greater surveillance from adults, lack of privacy, and increased likelihood of sexual abuse by family members. Personal and financial agency of adolescents and young people, especially the most vulnerable—unmarried young women, queer and trans youth, young migrants, young refugees, homeless young people, those in detention, and young people living in crowded areas such as townships or informal settlements—has been severely impeded. In a country like India where extensive parental authority is exercised over adolescents and young adults especially in the case of the unmarried, way into adulthood, one can only imagine the increase in the extent of control parents would exercise during COVID.

As said earlier, since AYA are a low-risk group for COVID, their needs are the least prioritized. It has been almost taken for granted that they would have unlimited ability to adapt to online classes, to engage in hobbies and activities to keep themselves busy, to engage with friends online and in general to stay out of adults’ way, and behave as the adults would want them to.

In all the literature around AYA in the pandemic, there is hardly any reference to or discussion of how the pandemic may have affected the romantic and sexual lives of AYA. As we already know, in India, in general there is very limited to no conversation around AYA’s romantic and sexual relationships and their sexual health. Therefore, one cannot expect anything different during the pandemic, especially when COVID-related health concerns are the only ones getting priority attention. As per DASRA [ 1 ], organizations working with AYA have often struggled with obtaining information about this aspect of AYA’s lives, and the constraints on meeting privately and in groups have further increased the challenge during the pandemic.

How are AYA engaging in intimate relationships during this time? How has the pandemic affected pre-marital sex, an open secret in India? Are AYA engaging in safe sex practices, keeping COVID precautions in mind? Who is providing them with this information and from where are they accessing it? Is sexual abuse a problem AYA are facing? These questions, particularly among unmarried AYA, are important but remain unanswered.

In the case of married AYA, there is evidence to show that some young married men are coercing their partners for sex, simply because the men are bored at home. The International Center for Research on Women (ICRW) and Vihara Innovation Fund’s rapid qualitative study to understand the impact of COVID on the family planning needs of women and men in Uttar Pradesh (UP) and Bihar showed that for some male respondents, sex was a way of releasing their stress and a distraction from their ongoing economic crisis. Female respondents of the study reported being frustrated because of the constant demands of sex by their husbands [ 14 ]. Cases of coercive sex and domestic violence might also be increasing as a result of this situation, but systematic attention has not been paid to explore this issue.

Added to these issues is the rise of digital connections in the context of sex. As per Quilt AI, in India, COVID will catalyze the digital revolution as the base of Internet users is expected to increase from 574 to 639 million by the end of 2020. Quilt AI’s study shows that more and more AYA have been spending time online, especially during the pandemic [ 12 ]. How are AYA accessing online spaces for personal connections? What about practices like online dating, sexting, virtual sex, and the associated safety-related issues? Quilt AI undertook a study to examine the impact of COVID on digital engagement on issues related to sexual and reproductive health (SRH), imparting skills to girls, and their employment. The study showed that there was an increase in searches for violent porn in towns/districts from February 2020. However, there was a gradual decline in cities. This is an important pointer toward AYA sexual behavior during the pandemic, particularly the use of online platforms for accessing porn that is violent in nature. This distinction between an increase in towns/districts and a decline in cities needs to be examined further in terms of the reasons and impact on AYA and their relationships.

It is important to recognize that the pandemic is likely to have impacted the relationships and sex lives of AYA about which little is known nor is it considered in policies and programs. Keeping in mind the social situations that might arise due to this pandemic, Banerjee and Rao explain that the probable impacts may be sexual abstinence, coercive sexual practices, non-compliance to precautions, disinterest in sex, unhealthy use of technology, interpersonal problems, rise in sexual disorders, and high-risk sexual behaviors [ 15 ]. This in turn may have impacted the already vulnerable gender dynamics, attitudes, and behaviors of AYA and their partners who may or may not be adolescents or young adults.

COVID and the Rise in Partner Violence

During COVID, adolescents and young adults, especially girls and women, may experience higher levels of violence, given the isolation and requirement to stay at home. In pre-COVID times, this population group tended to face high levels of domestic and intimate partner violence [ 1 ].

Globally, there has been increasing evidence of rising domestic violence since the lockdown, especially among women and young girls [ 16 ]. In India, it has been reported that calls seeking support against violence have been increasing since the lockdown [ 17 ]. The DASRA Adolescent Collaborative report on experiences of civil society organizations working with AYA highlights that many young people witnessed and experienced violence during the lockdown. This includes physical and sexual violence perpetrated by parents, siblings, boyfriends, and/or husbands [ 1 ]. Organizations reported to DASRA that they had been approached more often by girls in comparison with boys to report instances of physical and sexual violence [ 1 ].

Several organizations reported that many girls and young women they work with shared that their husband or boyfriend had forced them to have sex. International Council for Research on Women (ICRW) and Vihara’s study on family planning during COVID also highlighted instances of forced sex between young married couples. In studies by DASRA and YP Foundation, AYA reported that they feel unsafe at home, indicating that they may be living with their abusers. Organizations also reported continued trafficking of girls and boys during the pandemic, and in some areas, organizations reported an increase in the number of trafficking cases.

Further, limited information is available on the violence that AYA with lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) identities may be facing. The YP Foundation highlights that LGBTQA are at increased risk of gender dysphoria, and physical and psychological violence, which is likely to be further heightened during the pandemic. A few media reports have highlighted that there has been increased discrimination against sexual minorities during the pandemic, but it is likely to be hidden in the context of India where sexual minorities are discriminated against.

As mentioned previously, AYA have been spending more time online during the lockdown. Organizations reported that more incidents of cyber bullying and use of social media to spread morphed pictures and rumors especially about girls had come to their notice. The now infamous Boys Locker Room incident from a private school in Gurgaon, Haryana, India, where male classmates created an Instagram group and were casually discussing sexual violence and rape threats against their female classmates, is one such example.

The increase in sexual and gender-based violence emphasizes the need for information and support services, response mechanisms, and access to emergency contraception and other reproductive health services. It also emphasizes the need to study the causes and impact of these increasing instances because these affect AYAs’ interpersonal relationships, gender norms among them, sexual practices, and overall mental well-being in the short as well as in the long term. Going further, this highlights the importance of finding ways to address these problems during the pandemic and ensuring that the policy and program actions have an impact post-COVID as well.

Access to Sexual and Reproductive Health Services: Growing Gap for AYA During COVID

Global media reports and research studies have highlighted that routine reproductive health services and access to supplies have been interrupted due to COVID. The majority of public health facilities in India have been converted into COVID treatment centers or have shifted their focus to managing COVID care [ 11 ]. Further, smaller clinics including private ones have been shut or have found it challenging to ensure that related precautions are in place. Diversion of infrastructure, personnel, and financial resources to COVID-related care has resulted in a shortage of supplies and other challenges in delivering health services, including reproductive health care, which was already facing challenges [ 11 ]. This has resulted in extreme difficulties, particularly for women and girls, in accessing reproductive health services, especially in the rural areas of India where they are mostly dependent on the public health system [ 18 ]. Furthermore, it has rendered any form of sexual health services, already more inaccessible than reproductive health services, more remote for young people.

Given the current situation, health services for adolescents and young adults have been generally compromised. While government guidelines specify the need to provide adolescents counseling and services through the adolescent-friendly clinics established under the Rashtriya Kishore Swasthya Karyakram (RKSK) scheme, these clinics have largely been non-operational during COVID. It is particularly troubling that even in pre-COVID times, adolescents reported that they found it difficult to access these clinics [ 13 , 19 ].

In its study, DASRA explored the extent to which youth organizations faced challenges in accessing reproductive health and other healthcare services for the young. Findings from its report suggest that many youth-based organizations received feedback from young people about difficulties in accessing a range of services. Organizations reported that girls and boys had not received regular supplies of weekly iron and folic acid (IFA) tablets since the lockdown was imposed because these were dependent on schools and community health workers. Community health workers like accredited social health activists (ASHAs), anganwadi workers (AWWs), and auxiliary nurse midwives (ANMs) also confirmed this in the dialogue series organized by Women in Global Health India to amplify the voices of health workers during COVID between June–November 2020 [ 20 ].

A critical impact of COVID has been on access to sexual and reproductive health commodities and services for young people. Services like access to sanitary napkins, routine SRHR checkups, access to contraceptives, abortion services, and pregnancy-related care for adolescents and young adults were challenging even in pre-COVID times, given India’s cultural context and denial of AYA’s sexuality. During the COVID pandemic, several youth-based organizations reported that these challenges have increased [ 1 , 13 ].

Though young girls reported chronic shortages of sanitary napkins, their difficulties in accessing the napkins increased significantly during the lockdown. As per DASRA and YP Foundation, sexually experienced young people expressed difficulty in accessing contraceptive supplies. This may result in unintended pregnancies. Here it is important to note that there is underreporting among sexually experienced young people of unintended pregnancies. Most unmarried sexual relationships are clandestine given the social taboos and stigma associated with pre-marital sex [ 4 ]. Organizations also reported to DASRA and YP Foundation that pregnant girls had trouble in accessing ante-natal, delivery, and post-natal care when the lockdown was imposed. Some women and girls were compelled to deliver at home.

Furthermore, access to abortion services was severely impacted in general. ICRW’s study in 2018 on Male Engagement in Pre-marital Abortions in New Delhi highlighted that most pre-marital abortions are clandestine and AYA rely on their informal networks to gather information on abortion services [ 4 ]. These networks may have become difficult to access during COVID.

COVID and the lockdown have had an unprecedented impact on women and girls’ access to abortion. Several questions remain to be answered. What services are women and girls accessing to get abortions? Who is assisting them? How is this impacting their health and well-being? International Pregnancy Advisory Services (IPAS) estimates that in India, access to medical abortions, which is what most women and girls rely on, must have become very challenging during the lockdown and the COVID pandemic, due to lack of availability, lack of information, and lack of privacy and confidentiality. As per IPAS, 1.5 million medical abortions may have been compromised in the first three months of the lockdown period. This could be due to closure of outlets, disruption of the supply chain, and restriction in transport services, since AYA women or their partners generally avoid their neighborhood chemist shops and prefer a more distant outlet for buying medical abortion drugs due to the attached stigma [ 18 ]. Furthermore, accessing an abortion at an approved facility is challenging to begin with, particularly for abortion beyond 12 weeks. However, given the impact of COVID, as per IPAS, facility-based first or second trimester abortion may be the only option for a majority of the 1.85 million women, including adolescent girls and young adult women needing abortion services [ 18 ].

Restrictions on mobility and lack of transportation facilities during COVID-19 increased these challenges. It is important to note the unique vulnerabilities of AYA during the lockdown: limited autonomy and age-related vulnerability, wherein they are often not taken seriously, particularly in India, and the lack of adolescent-centric services to begin with may have pushed their sexual health practices and contraceptive needs further underground [ 3 ]. Also, it is crucial to recognize that data on AYA’s SRHR experiences remains limited, since these are not seen as priority issues to be monitored.

While researching for this chapter, the authors noted that the limited evidence that has been collected on AYA SRHR during COVID primarily focuses on their reproductive health. Information on AYAs’ sexual health and relationships remains very limited and, therefore, invisible and non-quantifiable. It is important to address this gap because we remain unaware of the impact on AYA, most of whom, anyway, lack the legitimacy or ability to openly seek SRH services.

Mental Health of AYA During COVID and Its Links to Sexual and Reproductive Health and Rights

COVID and the resulting isolation have impacted the mental health of human beings globally [ 21 , 22 ]. This includes AYA more so since they are not even recognized as a group having special needs, requiring attention. DASRA’s report highlights how AYA’s mental health was impacted during COVID in India. AYA are facing high levels of anxiety and stress related to COVID, school closures, lack of socialization, and violence at home. Further, due to lack of opportunities to meet their peers and other adults whom they trust, AYA are unable to share their anxieties. They do not know who to approach with their questions and thoughts. Sexual and reproductive health issues are likely to rank quite high among these concerns.

Youth organizations reported that some young people had approached them with fears about their intimate relationships, sexual violence, about their future, and had shown symptoms of anxiety and depression and a few had also expressed suicidal thoughts. They talked about the impact of the lack of space at home, isolation from their friends and partners, and the lack of intimacy with their partners. While organizations refer to mental health and well-being of AYA, they do not have information on how the lack of access to SRHR services and information is impacting their mental health. The limited data suggests the need to explore further into this aspect.

The need for mental health services and counseling in general is paramount, including for adolescents and young people, who are further isolated since they do not have any avenues to share and learn from each other, leave alone accessing services and counseling. The effect of a worldwide pandemic on AYA’s mental health can be devastating and cannot be overlooked [ 23 ]. The potential and lives of a whole generation of young people could be impacted.

Taking Stock of Responses to Adolescents’ and Young Adults’ Sexual and Reproductive Health and Rights During the Pandemic

The challenges presented above have been highlighted by youth collectives, youth-based and youth-serving organizations as seen in our review of the literature and conversations with some of these organizations. While recognizing the impact of the pandemic on AYA’s lives, these organizations also adapted their regular programs to respond to the unique needs of AYA during this time. They leveraged technology to reach AYA, trained and worked with their field staff and peer mentors to counsel adolescents remotely during the pandemic, and worked with community health workers and the public health system to address healthcare needs of adolescents.

As per DASRA, organizations leveraged digital tools like WhatsApp and Zoom, developed apps, quizzes, newsletters, and advertisements on television and radio, interactive voice response (IVR), and telephone systems to spread awareness about government-mandated information to dispel misconceptions and stigma, to learn about the feelings and experiences of AYA, and to run their SRHR programs. Some organizations adapted their sexuality education curricula to a digital mode (videos, audios, and animations) and are continuing their programs online. Organizations held creative sessions (poetry, painting, and movie screenings) to engage AYA on COVID and related issues, as well as other educational issues. Further, tele-services during the pandemic were used to provide counseling to AYA on SRHR, for example, where to access sanitary napkins and contraceptives, where young people can go for abortions, and on safe sex practices.

Organizations trained their staff to address the unique needs of AYA during this time, to connect with AYA, and understand their needs so that appropriate responses can be developed. They have also worked to provide women and girls access to sanitary napkins. Some delivered sanitary napkins to the homes of adolescent girls in rural areas and urban slums; others conducted online classes on how to make pads at home. They also helped pregnant women access ante-natal care, institutional delivery by arranging transportation, and post-natal care. They worked with community health workers to ensure that they could provide these services—IFA tablets, sanitary napkins, contraceptives, transportation for deliveries, and counseling—wherever possible. Organizations reported working with their youth leaders, peer mentors, and girl champions to reach out to AYA. For example, in the case of an unintended pregnancy, the peer mentors helped women and girls access timely abortion services.

Organizations responded to complaints of sexual violence by providing counseling through their field staff (mostly telephonic) and provided referrals to other facilities. In some cases, organizations went to the child protection committee and reported the case to the police and district or block authorities. Organizations also counseled parents about stopping early marriages, particularly of young girls, advised them to continue their education, and encouraged parents to create a space at home where adolescents could feel safe. All of these were vital before the pandemic but took on special impetus during the pandemic.

Some organizations created safe spaces to enable AYA to share their fears, anxieties, and uncertainties, both online and offline, through WhatsApp, TikTok, Instagram, and Facebook groups, and through telephonic platforms. Organizations are experimenting with online fellowship programs to build leadership and life skills. They are leveraging virtual training kits and tools developed by UNICEF and ChildLine India to check in with adolescents about their mental health. However, the issue of equitable access remains a big challenge. Many AYA do not have access or regular access to smart phones and the Internet. This is more challenging for girls and women, especially in rural areas, because the men and boys from the household control the smart phones available at home.

While all these efforts are commendable and responsive to local needs and contexts, a key gap remains—that of addressing the sexual health of AYA. Organizations have limited understanding of the sexual relationships of AYA. The challenges that they face in gathering this information increased significantly during COVID. Another gap is the issue of appropriate and gender-disaggregated data on SRHR of AYA. Organizations have not systematically collected data on how COVID has impacted AYA’s SRH. Data gathering has been sporadic and need based, which makes it difficult to capture realities accurately and to design programs to address SRH needs.

The Way Forward

The trend of not prioritizing adolescent and young adults’ sexual and reproductive health has continued during COVID. The recommendations for adolescents and young adults that SRHR experts have been making over the years remain valid and even more urgent—such as acknowledging adolescent sexuality, talking about sex from the perspective of pleasure as well as safety, ensuring sex education in schools and colleges, creating safe spaces where adolescents can share their fears, anxieties, feelings, experiences, gathering information from AYA to ensure that programs for them are responsive to their unique needs, creating peer groups of AYA, and building capacities of community health workers to respond to AYAs’ needs. In addition to continuing to persevere on earlier recommendations, the authors of this chapter would like to emphasize the following key recommendations.

First and foremost, the absence of young peoples’ voices from COVID response mechanisms set up by the government is unfortunate. It represents a dismissal of young people’s experiences and unique needs. In the task force set up by the government for COVID management, representatives from youth-based and youth-serving organizations need to be included. While the government, especially local functionaries, has benefitted from the assistance provided by youth-based organizations, their involvement in planning and developing strategies is limited and needs to be addressed.

Furthermore, while the needs of young people are deprioritized, young people from vulnerable groups—those that live in poverty, those with special needs, those from the lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) communities, and those that are disadvantaged because of their gender, caste, religion, and place of habitation—face greater challenges. Special focus should be given to the needs of young people from these groups, and their representatives should be a part of developing response mechanisms.

Gender is an obvious key factor in shaping young people’s experiences, and yet, this often goes unacknowledged. The gendered impact of the pandemic on young people’s lives, especially girls and women, needs to be central to the response. How has the pandemic fueled regressive gender norms, increased gender-based discrimination and violence against girls and women, and strengthened unequal power structures? This is a question that demands an answer because the pandemic will have long-term impacts on the lives of girls and women, especially those who have been married early, dropped out of school, experienced physical, economic, mental, and sexual violence, and been refused abortions. We cannot ignore or afford to sweep under the carpet, the long-term impact of the pandemic, in our current focus on immediate, short-term responses. For this purpose, timely and accurate data is required—data that captures the needs of various groups of AYA—unmarried and married, boys and girls, and so on—so that suitable and relevant responses can be developed.

We must adopt a human rights and social justice approach, something that is most overlooked with AYA, especially girls and women. This includes designating and planning sexual and reproductive health services for AYA, and re-allocating resources accordingly. For this, one must acknowledge adolescents’ and young adults’ sexuality as a reality. It is vital to integrate sexual well-being into the public health response for adolescents and young people.

Finally, COVID has shown the potential of technology in creating new opportunities for developing health content and disseminating it and delivering services. This must be extended to AYA’s sexual and reproductive health, which is currently limited. Also, the rise in digital sexual practices needs to be acknowledged; we cannot continue to ignore or look down on them. On the contrary, recognizing their value and reach, we must encourage safe digital sexual practices. As mentioned above, the digital divide in access to technology needs to be accounted for while developing tech-based solutions. However, despite digital inequalities, young people are more connected today than ever before, and therefore, these channels must be leveraged to their fullest potential, maintaining necessary caution. In all our efforts, we need to be sure that we are addressing the entire gamut of SRH without overlooking sexual health, as we have unfortunately tended to do.

Young people are a key resource and network, more so during a health emergency. This resource remains largely untapped. Peer group programs are particularly vital in this area. With the right training, young people can work with the health authorities to help respond to the pandemic. A healthy and empowered young population is an investment as we look beyond the pandemic.

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Kedia, S., Verma, R., Mane, P. (2022). Sexual and Reproductive Health of Adolescents and Young People in India: The Missing Links During and Beyond a Pandemic. In: Pachauri, S., Pachauri, A. (eds) Health Dimensions of COVID-19 in India and Beyond. Springer, Singapore. https://doi.org/10.1007/978-981-16-7385-6_10

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Adolescents’ reproductive health knowledge, choices and factors affecting reproductive health choices: a qualitative study in the West Gonja District in Northern region, Ghana

• Joseph Maaminu Kyilleh 1 ,
• Philip Teg-Nefaah Tabong 2 &
• Benson Boinkum Konlaan 3  

BMC International Health and Human Rights volume  18 , Article number:  6 ( 2018 ) Cite this article

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In Ghana, adolescents constitute about a quarter of the total population. These adolescents make reproductive health decisions and choices based on their knowledge and the availability of such choices. These reproductive health decisions and choices can either negatively or positively affect their lives. This study therefore explored adolescents’ reproductive health knowledge and choices, the type of choices they make and the factors that affect these choices.

This qualitative study adopted a narrative approach to qualitative enquiry. Eight focus group discussions ( N  = 80) were conducted among both in-school and out-of-school adolescents aged 10–19 years. The discussions were stratified by sex and studentship. In addition, nine in-depth interviews were conducted with various stakeholders in reproductive health services and community opinion leaders. Both the focus group discussions and in-depth interviews were recorded, transcribed and analysed using NVivo 11. Thematic analysis was employed in analysing data.

The study found that knowledge on reproductive health choices was low among respondents with majority of them relying on their peers for information on sexual and reproductive health. Having a sexual partner(s) and engaging in premarital sex was common and viewed as normal. Adolescents engaged in unprotected sexual practices as a way of testing their fertility, assurance of love, bait for marriage and for livelihood. Inserting herbs into the vagina, drinking concoctions and boiled pawpaw leaves were identified as local methods employed by adolescents to induce abortion. Reproductive health services were available in the community but received low utilization because of perceived negative attitude of health workers, confidentiality and social norms.

Conclusions

Adolescents in this study generally engaged in risky reproductive health choices that can negatively affect their reproductive health. Adolescents in this part of Ghana have challenges utilizing available reproductive health services because of socio-cultural and health system barriers.

Peer Review reports

Adolescence is a period of life during which individuals reach sexual maturity [ 1 ]. It is the period of transition from childhood to adulthood and it is often characterized by biological and psychosocial changes as well as sexual experimentation [ 2 ]. Globally, adolescents constitute about one billion of the world’s population, with 70% living in developing nations [ 3 ]. In sub-Saharan Africa, young people constitute about 33% of the 973.4 million population. The population of adolescents and young adults is expected to continue to increase over the next 35 years [ 4 , 5 ]. In sub-Saharan Africa, where a fourth of all adolescents are reported to have sexual experience, education on sexual and reproductive health are generally reported to be low [ 3 ]. In Ghana, the 2010 Population and Housing Census reported that the ratio of adolescents between 10 and 19 years to the total population is 1: 4.5; meaning this age group constitute about 22.4% of the national population [ 6 ]. In the northern region of Ghana, adolescents between 10 and 19 years are about 22.3% of the regional population and about 10.1% of the national adolescents’ population [ 7 ].

Evidence abound that adolescents experience very critical and life defining events, namely; first marriage, first sexual intercourse, and parenthood [ 8 ]. The downward trend in age at menarche from 15.5 years [ 9 ] to an average of 12–13 years in most developing countries [ 10 ] also means an increase in the interval between menarche and marriage. According to the Ghana National Population Council, the age at first marriage was 18.3 years for females and around 25 years for males in 1988, but this age has increased to around 21.4 years for females living in urban areas and 20.9 years for their counterparts in rural areas. For males, it increased to 26.1 years (urban residents) and 24.9 years for rural dwellers [ 11 ].

Adolescents’ knowledge and access to reproductive health services is important for their physical and psychosocial wellbeing. It has been found in an earlier study that the lack of knowledge about the consequences of unprotected premarital sex among adolescent females predisposed them to unwanted pregnancies, unsafe abortion and its complications, and sexually transmitted infections [ 12 ]. According to the 2014 Ghana Demographic and Health Survey (GDHS), about 14% of females aged 15–19 years had begun child bearing. Of these 14%; about 11% have had a life births and 3% were pregnant at the time of the survey [ 13 ]. Abstinence, use of condom, use of contraceptives, decision to keep a pregnancy, use of safe abortions services are some of the choices and reproductive health decisions adolescents make [ 14 ]. The International Conference on Population and Development (ICPD) which was held in Cairo in 1993 recognised the negative effects of risky sexual behaviour. Several countries including Ghana were implored to institute measures to ameliorate the situation [ 15 ]. Therefore, adolescent-friendly reproductive health services and comprehensive abortion care were instituted in Ghana to increase access to reproductive health and safe abortion services. This notwithstanding, many adolescents still encounter significant obstacles in accessing sexual and reproductive health services [ 16 ]. Knowledge on reproductive health services is essential to enable them make informed choices. The type of choices made by these young adults could either impact positively or negatively on their lives, their families and the society at large [ 15 ]. This study therefore explored adolescents’ knowledge about reproductive health and choices, what choices they make and the factors that affect those choices.

Study design

This study adopted a narrative approach to qualitative enquiry. Narrative research allows participants in a study to share their experiences in the community [ 17 ]. Since the researchers were interested in exploring the adolescents’ knowledge on reproductive health services and choices, factors affecting their reproductive health choices, and how these choices affects their lives, the narrative approach was deemed appropriate [ 18 ]. We conducted focus groups discussions with adolescents and individual interviews with stakeholders. In this study, we adopted the ecological model (Fig.  1 ). The ecological model provides a framework for understanding the multiple and interacting factors of adolescent sexual and reproductive health behaviour and their effects [ 19 , 20 ]. This framework posits that adolescent sexual and reproductive health behaviour and their choices are influenced by interpersonal, organisational, community and public policy factors. This model recognises that these factors (interpersonal, organisational, community and public policy) interact across different levels, focus on specific health behaviour and that interventions that address the multiple levels are more effective [ 21 ]. In the entire research process, steps were taken to adhere to the requirements of RATS guideline for conducting and reviewing a qualitative research [ 22 ].

Ecological model for adolescents’ reproductive health choices and factors influencing the choices [ 20 ]

The study was conducted in the West Gonja district of the Northern region of Ghana. The West Gonja district is one of the 26 districts in the region which lies within the savannah belt. The district has an estimated population of 46,803 with an annual growth rate of 2.9%. There are four major religious groups in the district, namely: Islam (about 70%), Catholics (10%), Protestants (8%) and Traditional Worshippers (12%) [ 23 ]. The 2011 and 2012 annual reports of the West Gonja District Health Directorate showed that the district recorded 13.7% and 14.4% of teenage pregnancies with 9.9% and 11.4% delivery rates respectively.

Selection of participants and data collection

The participants in this study were adolescents aged 10–19 years who lived in the West Gonja District at the time of the study. Both male and female in-school and out-of-school adolescents were recruited for the study. The communities were selected based on two criteria; high school dropout rates and teenage pregnancies. The researcher first collected the annual reports from the district and based on that communities were grouped into two; those with high teenage pregnancy and school dropout rates; and those with low teenage pregnancies and school dropout rates. From each category four communities were selected where the study was conducted. At the community level, school authorities were contacted for approval to recruit in-school adolescents. However, for the out-of-school participants, these were selected through the assistance of community leaders.

For stakeholders in adolescents’ sexual and reproductive health, a purposive sampling technique was used. In purposive sampling technique, researchers choose the sample based on who they think are appropriate for the study [ 24 ]. Hence, community opinion leaders and health workers who provide adolescent reproductive health services were selected.

Two main data collection strategies were employed in this study namely; focus group discussions (FGDs) and in-depth interviews (IDIs). Focus group discussion (FGD) refers to a qualitative data collection method where between 6 and 10 individuals with similar background or experiences are brought together to discuss a specific topic of interest with a researcher [ 25 ]. Thus, the use of focus group allows small number of participants to discuss a study topic led by a moderator using a discussion guide [ 26 ]. The focus discussion groups were homogenous for sex and studentship. The FGDs aimed at capturing the local context of sexual and reproductive health of the adolescents and, to enable the investigators get a true picture of the social reality. The FGD guide focused on individual, relationship, and community level factors that affect adolescents’ reproductive health knowledge and choices as required by the ecological framework used for this study. With the aid of an interview guide the investigators introduced the topic to the group and gave them leeway to express themselves. Their responses gave room for further probes. Participants’ responses were written in a field note book and recorded using a digital recorder as well.

Eight FGDs were conducted; four among in-school adolescents (2 males, 2 females) and four among adolescents who were out of school (2 males, 2 females). Each group comprised of 10 discussants making a total of 80 participants in all. Some of the adolescents were married whilst others were not married.

In-depth interviews using semi-structured topic guide were conducted with individuals who were engaged in reproductive health services in the district as well as opinion leaders in the community. This was done to elicit information on both community and the health service related factors that may inform the choices that adolescents make. In all nine IDIs were conducted among various stakeholders. The stakeholders were: one medical doctor, one public health nurse, two midwives, two community health nurses, two community opinion leaders (1 male, 1 female) and the programme manager of World Vision International, a non-governmental organisation engaged in child and adolescent educational programmes in the study area. The data collection was ended at the point of saturation as required in qualitative research [ 24 ]. The IDI topic guide covered areas such community and health system related factors, policies and strategies to ensure safe reproductive health practices among adolescents in line with the societal construct in the ecological model.

Data analysis

Data collected during the FGDs and IDIs were digitally recorded and transcribed verbatim. The field notes were converted into data documents. All transcripts were reviewed by an independent person who is an experienced qualitative researcher. In the review, the independent person listened to the recorded voices and compared the voices with the transcripts. Qualitative narrative data in English were then entered into a word processor (Microsoft Word) and imported into NVivo 11 for analysis.

Thematic analysis was employed in analysing the data. Thematic data analysis process involves data reduction, data display and data conclusion-drawing/verifying [ 27 ]. Line-by-line coding of the various transcripts were done as either free nodes or tree nodes. Queries (analysis in Nvivo) were performed to compare the coding against nodes and attributes to compare and contrast within-group and between-group responses and themes.

Knowledge on reproductive health services and choices

The results from the study revealed that both in-school and out-of-school adolescents had little or no understanding of adolescent reproductive health services and choices. However, some adolescents (15 in-school, and 6 out-of-school) were able to identify abstinence, use of condoms, and other contraceptives to prevent unplanned pregnancies. The following quotes illustrate the understanding of participants as to what reproductive health services are all about:

“Reproductive health services are the service that teach us how to protect ourselves from getting pregnant through the use of condom during sex…also use contraceptives though it is sometimes difficult for us to use contraceptive” (female, FGD, in-school).

“As adolescents, we have to make choices between not having sex until we are married, or if we cannot wait we have to use contraceptive methods that would prevent us from becoming pregnant” (Female, FGD, in-school).

Sources of reproductive health knowledge

FGDs respondents identified peers, parents, teachers, radio and television as the main sources of information on reproductive health. However, most of the adolescents especially those out of school relied mostly on their peers for information on reproductive health. The results showed that parents were an important source of information. For in-school adolescents, teachers emerged as another important source of information on reproductive health as it was unanimous among FGD participants. The following are quotes from some participants to illustrate these views:

“….the major sources of information are through our teachers and nurses. Most of us actually prefer getting our “filla” [information] from our friends and sometimes nurses” (female, FGD, in-school).

“…we get some information from the schools we attend. Sometimes too our parents give us some of the information we need in the form of a warning. I think most of the time when we discuss about it with friends we get to know more about the issues” (male, FGD, in-school).

“When we meet our friends who are more experienced they teach us how to protect ourselves from becoming pregnant. If you have a problem then you bring it out and people will advise you appropriately” (female, FGD, out-of-school).

The study also found that health workers generally believed that there was the need to provide adolescents with reproductive health information. Therefore health education sessions are organized in schools by trained nurses to talk to the students about sexual and reproductive health matters. This opinion is captured in the following statements:

“We have arranged with the schools so that from time to time we give them health talks on sexual and reproductive health” (Midwife-1, IDI).

“In one of the communities here, we noticed that teenage pregnancy was very common resulting in high school dropout rate among female adolescents. So we organised to go and educate them and also provide them with some contraceptives at the school, but the school authorities did not agree. When the community heard about it, they sent a delegation to warn us to desist from such acts. They said we wanted to encourage premarital sex. But you see, the teenagers were becoming pregnant and when you ask about the one responsible, you see it is usually an adult not a colleague teenager” (Public Health Nurse, IDI).

Views on having sexual partners and premarital sex

The findings of this study showed that having multiple sexual partners was considered a source of pride among both male and female participants. It emerged also that while the adolescent male had adolescent female as partners; majority of their counterparts (females) had adult males as partners. The following are quotes from the FGDs to buttress these points:

“As for boyfriends most of us have them, and some girls have sexual intercourse with their boyfriends. So teen pregnancies among the youth are uncountable around here” ( female, FGD, in-school).

“Abstinence among the youth is very difficult. Some people try to abstain from having intercourse, but they are usually described in derogatory terms such as; your penis is not good or manhood is not working” ( male, FGD, in-school).

“For us males, our sexual partners are our colleagues but for the females, their partners are mostly adults. So it is common to find a female having multiple partners because they will have one schoolmate as a boyfriend and an adult who will be providing her with material things and money” ( male, FGD, out-of-school).

Furthermore, both adolescents and stakeholders in this study perceive that sexual activities was rife among both in-school and out-of-school adolescents. The reasons adduced for adolescent engaging in sexual activities include: for sexual pleasure, to comply with his/her group norms, for gifts and also as an expression of love to their partners. Though adolescents in this study acknowledged that premarital sex is risky, it was equally generally believed to be worth the risk and therefore perceived to be indispensable. It also emerged that having sex with multiple partners by female adolescents was common especially sexual activities for gifts or favour from men. The following quotes support these points:

“Their expectations are that they will marry each other. Some expects to have fun and feel good as a girl or boy. Others expect support like money, gifts, clothing and other things from the boyfriend or the girlfriend. Some too expect trust from their girlfriends such that the girl should not have any other boy as a friend” (male, FGD, out-of-school).

“Yes the risk is there because one can get pregnant by having sex but we still do it. You can also get other sicknesses by having sex but what can we do? We have to do it to get what we want” (female, FGD, in-school).

“For us girls, it mostly for gifts from adults. Sometimes, there is nothing you can do about it because that adult is the one taking care of you so you risk losing him to another girl if you do not oblige. My first sex was with a man taking care of me. When I wanted to resist, he threatened to stop taking care of me and get another girl. So because of that I agreed” (female, FGD, in-school).

Interview with community opinion leaders revealed that this practice was really common and many female adolescents relied on it for their upkeep and also to take care of their education. Despite acknowledging this fact, opinion leaders we interviewed believed that advocating for the use of contraceptives was not the way to go. In their view, modern contraceptives can cause infertility among female users. To community opinion leaders, men who are not biological parents to adolescent females take care of their educational needs with the intention of marrying them in future. Also, a woman’s ability to beget children for the husband was perceived as a reward for the investment the man made in her education. So, with the belief that modern contraceptives could cause infertility, their use was seen as something that could lead to a loss in the man’s investment in the adolescent female. The following quotes illustrate these points:

“Premarital sex is very common in the community and for the girls, it is the adults that take them as their partner. Because of poverty, the girls have to rely on these adults for money and upkeep, so they take advantage of them” (Female, Opinion Leader, IDI).

“As for the contraceptives, the men will not agree because, it is believed that it can cause infertility in future. Men in this community take care of female adolescents to marry and have children with them in future. So, if the girl uses contraceptives and become infertile in future, it will mean the man has invested in vain. It is a serious problem, so some NGO is assisting the girls” (Male Opinion Leader, IDI).

The study also explored the use of condoms during such premarital sex since the use of female contraceptives were deemed inappropriate. Adolescents in this study believed most of them engage in unprotected sex. Condoms were believed to inhibit the pleasure in sex and since many engaged in sex for pleasure, the use of a condom was also regarded as impracticable. Another reason for the non-use of condom during sex was the inconvenience or challenges involved in getting one. Some adolescents were of the view that it was difficult going to buy condoms. This is because an adolescent who goes to buy a condom will be perceived as a “bad boy or girl” In their opinion, many of the drugstore sellers in the community know their parents. Therefore they were afraid the sellers may convey that information to their parents. The following quotes illustrate these points:

“Oh yes, condom is a waste of time and no feelings. Everything in life there is a risk and sex itself is a risk. The risk is there in having sex because most do not use condoms; some too have about two or more girlfriends and always have sex with all of them. Through that you can get any disease or even impregnate a girl that you may not even like to marry or have a child with” (male, FGD, out-of-school).

“Yes sometimes when you want to have sex you tell the boy to use condom. Some males agree and use but there are some males who will tell you that if you put a toffee with the wrapper in your mouth do you get the sweetness of the toffee?” ( female, FGD, out-of-school).

“You know, the condoms are sold at drug stores so when you want it, it is difficult to go there and buy especially us the girls. Yes, because of your age some say, you are too small to buy condoms” (female adolescent, FGD in-school).

“….Young people feel shy or afraid to buy condoms because the chemist shop owner may go and tell your parents that you have started using condoms or having sex” (male adolescent, FGD in-school).

Common strategies adopted to prevent pregnancy

This study explored what adolescents do to prevent getting pregnant. The results revealed that local remedies were available and widely used by community members. One of the strategies adopted by adolescents to prevent pregnancy is the use of a local herb called “yigewulso”. This herb is believed to have contraceptive effects. Other herbs also believed to have similar effects are used as emergency contraceptives after unprotected sex. This study also found that some adolescents believed that wearing of some local beads around the waist during sexual intercourse could prevent a pregnancy outcome. The following quotes serve to illustrate their views:

“We have this herb called “yigewulso” which is usually taken before sexual intercourse if you don’t want to get pregnant” (male, FGD, in-school).

“If you have sexual intercourse and you don’t want to be pregnant, you have to take “kaligutim” immediately. Normally, we buy it from the local chemist shop. It can be used either as an emergency contraceptive or when you miss your period” (Female, FGD, Out-school).

“In this community there is a belief that you can prevent getting yourself pregnant if you wear beads in your waist during sexual intercourse. This is why most girls wear beads around the waist before they have sex. Even women who are breastfeeding babies also wear beads to avoid pregnancy while the child is still young”. (IDI, Midwife-1).

These adolescents also reported that other techniques they employed to prevent pregnancy outcome was for the female to lie in the prone position or wash her vagina with soap and water immediately after sexual intercourse. These practices in their opinion would evacuate or kill the sperms in their vagina. They were also of the view that these practices were safe and produced no adverse effects. They had this to say:

“I was told by my friend that when you wash your vagina with soap and water and also lie on your stomach (prone position) immediately after sex, you won’t get pregnant. So, we do it to prevent pregnancy” (female, FGD, out-of-school).

“ ..Some of the traditional methods are better. If your girlfriend knows them and practice them there is no way she will get pregnant, and won’t have problems like those who use the modern contraceptive method” (male, FGD, out-of-school).

Unplanned pregnancies, abortions and sexually transmitted infections

Participants in this study were of the view that unplanned pregnancies were common among adolescents in the district. It emerged that some adolescents in this community believed that getting oneself pregnant was the guarantee or proof of one’s fertility. Male adolescents will also test their manhood by insisting on having unprotected sexual intercourse with the partner and hoping to be told she had “missed her period” (meaning she is pregnant). Sometimes the females may also prefer to have unprotected sexual intercourse in the hope of becoming pregnant as a bait for marriage as well as test for future fertility. The following quotes support these assertions:

“A lady became pregnant and she decides to abort it because she has nobody to take care of the baby. Another lady became pregnant for a guy she loved but her parents disapproved of their relationship because the boyfriend was not doing any work” (Female, FGD, out-of-school).

“Their knowledge level is little. This is because, data gathered in the district indicates high rate of teenage pregnancy and sexually transmitted infections” ( IDI, Midwife-2).

“In this community some of the girls try to get pregnant intentionally to show that they are fertile. Even a girl can tell the colleague you have been having sex with your boyfriend without ever becoming pregnant, it means either you or boyfriend is infertile” (IDI, Opinion Leader).

The results from this study also suggest that most of these unplanned pregnancies are aborted through unsafe practices using a combination of methods such as drinking concoctions of boiled pawpaw leaves, Nescafe, grinded bottles, alcoholic beverages and inserting herbs into the vagina. Participants in this study were of the view that these methods of terminating pregnancy are widely used in the community. The information gathered by this study suggest that some of the unsafe abortions have often resulted in fatal outcomes as illustrated by the following quotes:

“In fact we have plenty illegal abortion in this district particularly in Damongo town. For example one girl just died here last week. What we found out later was that she was given grinded bottles to drink. It is a very common practice” (IDI, Midwife).

“….A friend recently got pregnant and decided to abort using “Salaamalekum” leaves [herb] to do the abortion. Some also use some type of fruits, pawpaw leaves, Nescafe and sugar, alcoholic and non-alcoholic drinks as well as broken bottles to cause the abortion” ( female, FGD, out-of-school).

“I know a girl who was pregnant and the boyfriend bought malt and mixed it with grinded bottle and gave it to her and she drank, few hours after drinking that she bled and finally died” (female, FGD, in-school).

Participants in this study also indicated that sexually transmitted infections (STIs) were common in the community. They attributed this to the youth practicing unprotected sexual intercourse with multiple partners. In their opinion, there is risk in every activity. So it was normal to enjoy sexual intercourse and treat any STI that may arise. The following quotes illustrate these points:

“Sexually transmitted infections especially white (candidiasis) is very common among the females in the area. Often when they come they will just say…madam I have white and we have to test them for STIs” (IDI, Midwife-3).

“The STIs you are talking about is very common in this community because many of the youth have multiple partners which they call it “inter” and “exter” one in your school and one outside your school” (male, FGD, in-school).

“There is risk in everything we do, so it is better to enjoy yourself during sexual intercourse and if you get a disease, you treat it. I don’t ask the man to use condom, I don’t like it myself” (female, FGD, in-school).

Access to reproductive and sexual health services in the community

The findings of our study show that reproductive health services are generally available in the community. There are outreach services for the communities. These include; health education, counselling, and provision of contraceptive services. The study also found that adolescents were generally aware of some of these services and how to access them except for comprehensive abortion care. The following quotes illustrate these points:

“We have service-points for adolescent reproductive health service in this district where we provide education, counselling, contraceptive service and comprehensive abortion care to adolescent who visit us” (IDI, Public Health Nurse).

“There are outreach services for communities where there is no clinic or hospital to provide reproductive health service” (IDI, Midwife-2).

“The nurses have been coming to tell us that we can come to them for reproductive health service, so we know those services are available at the hospitals and clinics” (female, FGD, in-school).

The above notwithstanding, the results of this study show that there were some barriers to accessing these services. Four main sub-themes emerged in this respect, namely; sociocultural, attitude of service-providers, lack of privacy and confidentiality on the part of service providers and finally perceived adverse effects. The study found that the community generally perceived issues about sexual and reproductive health as only suitable for adults. Therefore, it was the general believe that it would be inappropriate to discuss such issues with adolescents. Though health workers were trained to provide these services to adolescents, there was the general believe and fear among adolescents that they may be scolded or described as “bad boys or girls” if they should go for such services. Some adolescents were also of the view that health care providers do not treat adolescents who seek for reproductive sexual health services well. The poor attitude of health providers towards adolescents deters the later from patronizing the available services.

Another barrier reported in this study was the lack of privacy. Adolescents who participated in this study were of the view that the service points did not provide enough privacy and confidentiality. In their opinion, the present environment does make it possible for people to see adolescents who seek such services as ‘spoilt children’ or may even conclude that you have come to do abortion or contraception. Another issue of confidentiality was the general believe that service providers sometimes tell parents of adolescents who seek such services that their ward was sexually active. The following quotes support these points:

“In this community, if an adolescent ask about sexual and reproductive issues, the person will be seen as a bad girl or boy. So we are afraid to go to the clinic and hospital for such services. Imagine a girl going to the hospital to do something and the information comes out that you went there to do abortion. People will say you are bad, and if you are not lucky, the information could spread to all over town the next day” (female, FGD, out-of-school).

“… Some of the nurses are not polite especially to us the young people. You go there with a problem then they will be shouting at you or even insulting you saying you are bad girl or boy. The authorities should punish or even sack such people, but you see, some of us do complain about these things but nothing happens to them” (Male, FGD, In-school).

Interviews with services providers revealed that the design of some of the service points makes it difficult to provide optimum privacy to clients. The study also found that some staff were not trained on adolescent friendly reproductive health services as illustrated:

“…The lack of privacy is due to how our facilities were designed. Many of our facilities in this district have no space provided for that. Lack of confidentiality from health personnel, as well as inadequate qualified personnel are serious challenges that we face on the daily basis” (IDI, Midwife-1).

“Our staff are not well trained as adolescent friendly reproductive health service providers. We are all using our previous knowledge from school which may not be enough and also the working experiences… everybody is committed in helping out to make the situation better. Inadequate staff numbers is also a big problem for us. The work is, actually too much for us” (IDI, Midwife-2).

“….Our consulting rooms are not safe. When a person comes with a sexually transmitted infection, they often not able tell us because some people may hear the conversation. They rather try to hide the truth from you and begin to tell you about other things, leaving you to guess the problem” (IDI, Public Health Nurse).

Stakeholders interviewed in this study noted that access to SRH information and services could reduce school dropout rate among females. However, stakeholders indicated that some health workers were uncomfortable providing adolescents with reproductive health services. In their view, availing condoms to adolescents may lead them to experiment with sex. Also, increasing access to comprehensive abortion services will encourage sexual activity among adolescents. Some stakeholders were of the view that some health workers have a negative attitude towards comprehensive abortion service because it conflicts with their religious beliefs. The following quotes illustrate these points:

“Allowing adolescent access to condom will encourage sexual practice among them. As for access to abortion, it means we will be encourage them to experiment with sex. After all when you become pregnant you can abort it at the hospital” (IDI, Opinion Leader).

“Some health workers are uncomfortable providing comprehensive abortion care to adolescents. They perceive abortion as something that is against their religious beliefs. So, it is even worse when they are to provide such a service to adolescent” (IDI, Public Health Nurse).

Knowledge on reproductive health and sources of information

The study found that both in-school and out-of-school adolescents in this part of Ghana did not have comprehensive knowledge on reproductive health issues and choices. The lack of knowledge makes them vulnerable to unsafe reproductive health behaviour and inappropriate choices. Some of these choices may have detrimental effects on their reproductive health and future. For example, a wrong choice can lead to unplanned pregnancy or STI infection [ 28 ]. In another study, it was found that lack of knowledge on reproductive health was associated with early initiation of coital relations and of unwanted pregnancies [ 29 ]. The effects of these unplanned pregnancies are multifarious with some capable of lasting for a lifetime. These potential human resource and future leaders end up as school dropouts due to unplanned pregnancy and other attendant complications. Additionally, a good number of adolescents who indulge in early sexual debut may contract HIV and other STIs [ 30 ]. These have social and economic implications for their households and the nation as whole as funds will be required to provide lifetime medication for people with HIV [ 31 ], and may even affect their line of generations yet unborn [ 32 ].

As we have shown, most out-of-school adolescents are reliant on their peers who are in-school and the mass media for information on reproductive health. These sources make them vulnerable to misinformation. In that case, they will be making decisions based on an incorrect information which can negatively affect them. Parents who could be the most appropriate source of information are inhibited by socio-cultural barriers that prevent them from discussing reproductive health issues with their children as has been reported by Owusu, Blankson & Abane [ 33 ] in the Central Region of Ghana. Similarly, studies in Nigeria and Uganda found that adolescents preferred parents as a source of information about sexual and reproductive health, however cultural sensitivity and social norms inhibited them [parents] from playing that role effectively [ 34 , 35 , 36 ]. Talking about sex is often frowned upon by both traditional and religious adherents in the Ghanaian society. This environment makes it difficult and sometimes impossible for adolescents to discuss sex and related issues with parents or adult family members [ 37 ]. The findings of this study underscore the need for innovative ways to expand access to reproductive health education and services to both in-school and out-of-school adolescents. School-based approaches which are linked to the community have been found to be effective in other countries [ 21 , 38 , 39 ]. These approaches could be adopted for Ghanaian adolescents as a community-related strategy (intervention) in the ecological model.

Views on having sexual partners and premarital sexual practices

The study found that having a sexual partner was a common practice among adolescents in the community, and is widely viewed as an acceptable practice. Among adolescents, this is done to conform to peer norms and a way of demonstrating that one had what it takes to be a woman or man. The act of engaging in sexual practice among adolescents has been widely reported across the sub-Saharan African region, with about 25% reporting having sexual contact before attaining 15 years of age [ 40 ].

This study also found that having multiple partners was a common practice. Similar findings were reported among adolescents in Tanzania [ 41 ]. Despite the fact that many adolescents reported having multiple partners, the use of condom was reportedly low during sexual encounters. This is a challenge to public health workers involved in sensitizing the population against risk of STIs and HIV among Ghanaians. The use of condom is one of the key strategies employed by the National AIDS Control Programme (NACP) to reduce the burden of HIV and STIs. Having sex with multiple partners without the use condom is one of the risk factors in HIV transmission and many studies have documented high prevalence of HIV infection among people with multiple partners [ 42 , 43 , 44 ].

The study found that transactional sex (sex for gift) was common in the community and many adolescents were engaging in this type of sexual acts with adults in the community. Female adolescents were engaged is this practice as a way of survival as a result of endemic poverty in the community [ 45 ]. This will require interventions at the community level to empower females. Also enforcing laws that protect the human right of females in the community and use of mass media approaches to create awareness about the existing laws and policies about adolescent sexual and reproductive health related issues may be essential in addressing transactional sexual practices. The policies and laws fall under the societal construct in the ecological model. Transactional sex has been found to be associated with having multiple partners as well as engaging in HIV-related risky behaviour [ 46 ]. An earlier study has found high prevalence of HIV infection among people engaged in transactional sex [ 47 ]. This high prevalence may not necessarily be due to the high level of exposure as a result of multiple partners [ 47 , 48 ] but it also creates a situation which makes it impossible for females especially to negotiate for the use of condom as found in this study. Therefore people engaged in HIV prevention must be concern about transactional sex.

Strategies against unplanned pregnancies, and abortions

From this study, it emerged that respondents believe that some local preparations and herbs are effective abortifacients. Such believes were widespread and well-known thereby resulting in low patronage for modern contraceptives. A study in southern Ghana reported similar believes where there was the widespread notion that ingestion of panacin and cafalgen (painkillers) before sex had some contraceptive effects [ 49 ]. Washing of the vagina and vulva with soap and water which is another local practice to avoid pregnancy after unprotected sex has implications on the reproductive health of adolescents. This practice can predispose adolescents to reproductive tract infections which can negatively affect their reproductive functions. Washing the vagina with soap is capable of destroying the normal flora of the vagina and vulva predisposing the female to vaginosis [ 50 ]. Vagina cleaning using soap and water has also been reported to increase HIV infection [ 50 , 51 ]. Health education to community should highlight the negative effects of these practices on the future reproductive health of adolescents.

It is however obvious in the study that these preparations believed to be abortifacients were ineffective as participants in this study indicated that the incidence of unplanned pregnancies was high even among people who had used these items to prevent pregnancy. The findings of this study further show that adolescents who become pregnant do not seek for safe abortion services but engage in unsafe abortion practices using grinded bottles, inserting herbs into the vagina and use of drinks that contain alcohol. These unsafe abortion practices have very serious implications on the health of adolescents as it can result in complications and death. Unsafe abortion is one of the leading preventable causes of maternal mortality across the world [ 52 , 53 , 54 , 55 ]. Increasing access to safe abortion and comprehensive abortion care were introduced to ameliorate the negative effects of unsafe abortion. Comprehensive abortion care have been found to have high impact in reducing maternal mortality [ 56 , 57 , 58 ]. Though Ghana has been implementing comprehensive abortion care in health facilities across all regions [ 59 ], the finding of this study reveals a lack of knowledge and awareness about comprehensive abortion care among adolescents as many still engaged in unsafe practices with detrimental effects on their health. More community sensitization should be done to create awareness on the existence of comprehensive abortion care service in health facilities in Ghana.

The study generally found that reproductive health services were available in the community. Also, efforts are being made to bring service close to the communities through outreach programme. However, these efforts were undermined by service-related barriers. Key amongst these was the attitude of health workers towards providing services to adolescents. The study reported there was widespread feeling of negative attitude of service providers towards adolescents, hence their refusal to patronize the services. The negative attitude was reported by both adolescents and stakeholders in this study. This negative attitude was due to community norms and beliefs of health workers concerning some services such as contraceptive use and safe abortion. This will require training of health workers on adolescent-friendly approaches to reproductive health services. Sensitization of community will also be required to increase acceptance. Adolescents’ reproductive health service programmes that target health workers to provide adolescent friendly facility-based services with the approval of community have been found to be more effective [ 39 ]. Lack of training has been found to negatively affect the quality of care provided to adolescents in an earlier study [ 60 ]. When the attitude of health service providers improves, it will lead to utilization of the services. A study in Kenya found a significant association between friendliness of service provider, and proximity to service provider and uptake of contraceptives [ 61 ].

Adolescents in this study were of the view that the designs of reproductive health service outlets did not provide enough privacy. This was therefore a barrier to uptake of such services in the community. Service outlets for adolescent reproductive health services should be designed to provide good privacy. This is because there are socio-cultural norms that prevent adolescent from using reproductive health services. Therefore, adolescents found utilizing reproductive health service risk been described in derogatory terms. This therefore call for measure to ensure strict privacy as that is the only way such services can be patronized by adolescents.

Limitation of the study

The main limitation of this study is that it was conducted in one rural district in Northern Ghana and the findings cannot be assumed to be the same in other settings. However, the study provides insight into areas to target for health promotion and interventions on adolescent reproductive health choices.

This study concludes that adolescents in this study generally engaged in risky reproductive health choices with potential of negatively affecting their reproductive health in future. Social and health systems barriers inhibited the utilization of existing reproductive health services. Advocates for reproductive health service providers need to develop better innovative ways to provide this important service to adolescent especially those who are out of school. Sexual and reproductive health promotional activities should target parents as a way of breaking the social barriers. Community sensitization and training of health workers is required to remove barriers and increase the utilization of reproductive health services.

Abbreviations

Focus group discussion

Ghana Demographic and Health Survey

Human Immunodeficiency Virus

International Conference on Population and Development

in-depth interview

National AIDS/STIs Control Programme

Sexual Transmitted Infections

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Acknowledgements

We wish to thank the district director of health services of the West Gonja District in Northern region and all the participants for their cooperation in this study.

The study was funded by the authors.

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Conceived and designed the experiments: JMK, BBK, PT-NT. Performed the experiments: JMK Analyzed the data: PT-NT, JMK, BBK. Contributed reagents/materials/analysis tools: JMK, PT-NT, BBK. Wrote the paper: PT-NT, JMK BBK. All authors read and approved the final manuscript

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Ethical approval was obtained from the ethical committee of the School of Medicine and Allied Health Science of the University for Development Studies. In addition, permission to conduct the study was solicited and obtained from the West Gonja District Health Directorate. A written informed consent was obtained from parents and guardians for those respondents < 18 years of age. In addition, an assent was also obtained from the minors before the interview. However, for respondents who were ≥18 year, informed consent was obtained from them as required in Ghana [ 62 ]. Participation in the study was voluntary and they were informed of their right to withdrawal from participation at any time during the interview. Data collected for this study were anonymized by de-linking personal information from the main data.

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Kyilleh, J.M., Tabong, P.TN. & Konlaan, B.B. Adolescents’ reproductive health knowledge, choices and factors affecting reproductive health choices: a qualitative study in the West Gonja District in Northern region, Ghana. BMC Int Health Hum Rights 18 , 6 (2018). https://doi.org/10.1186/s12914-018-0147-5

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Sexual and reproductive health in india.

• Shireen Jejeebhoy , Shireen Jejeebhoy Director, Aksha Centre for Equity and Wellbeing
• K. G. Santhya K. G. Santhya Senior Associate, Population Council
•  and  A. J. Francis Zavier A. J. Francis Zavier Senior Program Officer, Population Council
• https://doi.org/10.1093/acrefore/9780190632366.013.225
• Published online: 30 June 2020

India has demonstrated its commitment to improving the sexual and reproductive health of its population. Its policy and program environment has shifted from a narrow focus on family planning to a broader orientation that stresses sexual and reproductive health and the exercise of rights. Significant strides have been made. The total fertility rate is 2.2 (2015–2016) and has reached replacement level in 18 of its 29 states. The age structure places the country in the advantageous position of being able to reap the demographic dividend. Maternal, neonatal, and perinatal mortality have declined, child marriage has declined steeply, contraceptive use and skilled attendance at delivery have increased, and HIV prevalence estimates suggest that the situation is not as dire as assumed earlier.

Yet there is a long way to go. Notwithstanding impressive improvements, pregnancy-related outcomes, both in terms of maternal and neonatal mortality and morbidity, remain unacceptably high. Postpartum care eludes many women. Contraceptive practice patterns reflect a continued focus on female sterilization, limited use of male methods, limited use of non-terminal methods, and persisting unmet need. The overwhelming majority of abortions take place outside of legally sanctioned provider and facility structures. Over one-quarter of young women continues to marry in childhood. Comprehensive sexuality education reaches few adolescents, and in general, sexual and reproductive health promoting information needs are poorly met. Access to and quality of services, as well as the exercise of informed choice are far from optimal. Inequities are widespread, and certain geographies, as well as the poor, the rural, the young, and the socially excluded are notably disadvantaged. Moving forward and, in particular, achieving national goals and SDGs 3 and 5 require multi-pronged efforts to accelerate the pace of change in all of these dimensions of health and rights.

• sexual and reproductive health
• sexual and reproductive rights
• pregnancy and maternal health
• family planning and contraception
• induced abortion
• adolescent and youth health
• gynaecological morbidity and RTI and STI
• policies and programs

Introduction

Over the course of the 21st century , India has seen momentous and multi-dimensional changes in its population and sexual and reproductive health (SRH) situation. As of its 2011 census, India’s population was 1.21 billion, and its decadal growth rate had declined more sharply over the 2001–2011 decade than in earlier decades (Office of the Registrar General and Census Commissioner, India, 2013 ). The total fertility rate is now 2.2 and has reached replacement level in 18 of its 29 states (IIPS & ICF, 2017 ), and its age structure places the country in the advantageous position of being able to reap the demographic dividend (Kulkarni, 2014 ). The policy and program environment has shifted from a narrow focus on family planning to a broader orientation that stresses SRH and the exercise of reproductive rights. Sexual and reproductive health has improved in many ways. Yet, India may not meet several of the milestones set by Sustainable Development Goals (SDG) 3 and 5.

This article reviews what is known about India’s SRH situation and highlights remaining challenges that must be overcome to accelerate the pace of improvement in this situation.

A Brief Overview of Key Policies and Programs Addressing Sexual and Reproductive Health

There have been several policies, laws, and programs in the area of SRH that have been introduced over the course of the 21st century . Table 1 briefly describes selected key policies and programs and outline their prescriptions that are particularly relevant for SRH.

Table 1. Key Policies and Programs Addressing Sexual and Reproductive Health

Note: Many other policies, laws, and programs launched prior to 2010, relating to population, child marriage, AIDS, abortion, and more, are not described in the table.

In short, India has a plethora of policies, laws, and programs that are intended directly or indirectly to influence sexual and reproductive health and rights. Unfortunately, lacunae exist, and the limited reach and quality of program delivery, along with many demand side obstacles and limited allocation of resources, have thwarted the pace of improvement in India’s sexual and reproductive health situation. In many instances, goals have been set and strategies identified without adequate political commitment, and without a clear roadmap for action. Priorities tend to shift, and there is a risk that sexual and reproductive health and rights will be overshadowed by such currently stated priorities as health insurance, cleanliness, and open defecation free drives, the national nutrition mission, and even a recent resurgence of concerns about “population explosion” and the need to disincentivize those with more than two children.

The Sexual and Reproductive Health Situation

Maternal and newborn health, maternal mortality and morbidity.

The maternal mortality ratio has declined over the course of the 21st century , from 301 per 100,000 births in 2001–2003 to 130 by 2014–2016 (Office of the Registrar General, India, 2006 , 2018 ). While this ratio has declined impressively throughout the country over the 21st century , it must decline much further, to 70 by 2030 , if India is to meet its SDG3 commitment (Niti Aayog, 2018 ).

Figure 1. Maternal mortality ratio: India, EAG*, Assam, southern states, and other states (Office of the Registrar General, India, 2006 , 2011 , 2013 , 2018 , n.d. ).

Note : *Empowered Action Group (EAG), comprises eight lesser developed states (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttar Pradesh and Uttarakhand).

Data on causes of maternal death are unfortunately dated. Available data, from the early 2000s, suggest that common causes of maternal death are those seen in most low- and middle-income country settings (hemorrhage, sepsis, unsafe abortions, obstructed labor, and hypertensive disorders), and are largely preventable (Registrar General of India, 2006 ).

The real burden of maternal morbidity is poorly known, although it is accepted that for every maternal death, 20–30 others experience pregnancy-related morbidity (Firoz et al., 2013 ). Data on self-reported morbidity, although more unreliable than medical records, show that one in five women aged 15–49 who had delivered in the five years preceding the National Family Health Survey (NFHS)-4 had experienced massive vaginal bleeding and 15% reported the experience of very high fever within two months of their most recent delivery (IIPS & ICF, 2017 ). Estimates of morbidity using provider-assessed methods tend to be lower than those, such as the NFHS surveys, that rely on women’s own reports of morbidity. For example, Iyengar ( 2012 ) followed up in rural Rajasthan almost 5,000 women in their first week postpartum and measured morbidity using a structured checklist and found that 7% suffered from severe anemia, 4% with fever, and 5% from perineal conditions. Overall, 7.6% were assessed with a life-threatening condition (severe anemia, puerperal sepsis, severe hypertension, and secondary postpartum hemorrhage).

Perinatal and Neonatal Mortality and Morbidity

Both neonatal and perinatal mortality are, to a considerable extent, the result of inadequate or inappropriate care during pregnancy, childbirth, or the first critical hours after birth, and India has witnessed impressive declines in both. The neonatal mortality rate declined from 49 per 1,000 births for the five years preceding NFHS-1 in 1992–1993 to 30 per 1,000 births for the five years preceding NFHS-4 in 2015–2016 , and as of 2015–2016 , accounted for almost three-quarters of all infant deaths over this period (IIPS & ICF, 2017 ). A similar picture is evident for perinatal mortality which had reached 36 per 1,000 pregnancies of seven or more months duration in 2015–2016 , down from 48.5 per 1,000 such pregnancies in 2005–2006 (IIPS & ICF, 2017 ; IIPS & Macro International, 2007 ).

Table 2. Neonatal and Perinatal Mortality Rates, 1992–1993 to 2015–2016, India

Sources: IIPS ( 1995 ); IIPS & ORC Macro ( 2000 ); IIPS & Macro International ( 2007 ); IIPS & ICF ( 2017 ).

Major identifiable causes of neonatal mortality include neonatal infections (pneumonia, tetanus, sepsis, and diarrhea), prematurity, and birth asphyxia (Paul, Sachdev, Mavalankar, Ramachandran, & Kirkwood, 2011 ). Findings from the Million Death Survey over the 2000–2015 period show that while these conditions continued to be prominent in 2015 , there had been a sharp decline in each over the 2000–2015 period. The neonatal mortality rate from infections (mainly pneumonia and sepsis) fell from 11.9 per 1,000 live births in 2000 to 4.0 by 2015 , and from birth asphyxia and trauma fell from 9.0 to 2.2. In contrast, prematurity or low birth weight mortality rates rose from 12.3 to 14.3 deaths per 1,000 live births. While declines in mortality from infections and birth asphyxia or trauma fell in both rural and urban areas and in both poorer and wealthier states, prematurity or low birth weight mortality increased in rural areas and in poorer states but fell in urban areas and wealthier states, pointing to vast differences across states in modifiable factors such as antenatal care, education, and nutrition for example (Million Death Study Collaborators, 2017 ).

Maternal and Newborn Health Care Utilization

Pregnancy-related health care utilization increased modestly in the 1990s, and then steeply ever since (Table 3 ). Remarkable increases were noted in the 2005–2006 to 2015–2016 period, that is, in the period following the introduction of the safe motherhood initiative, namely the Janani Suraksha Yojana (JSY). The percentage of pregnant women who had availed of four or more antenatal check-ups increased from 37 in 2005–2006 to 51 by 2015–2016 , and those receiving two or more doses of tetanus toxoid increased from 76 to 84 in the same period. Care was more comprehensive, and by 2015–2016 , 88–93% of those who received antenatal services reported that they had been weighted, their blood pressure measured, a urine sample tested, and an abdominal examination conducted (compared to 58–72% in the 2000s). Institutional deliveries and skilled attendance at delivery increased enormously, from 39% to 79%, and 47% to 81%, respectively. While fewer women obtained postpartum care even in 2015–2016 , because of the increase in institutional delivery, a far larger percentage had done so in 2015–2016 than in the 2000s (from 41% to 69%). Finally, while far more women had been counseled about danger signals in 2015–2016 than in earlier years, percentages were far from universal.

Table 3. Pregnancy-Related Care: The Situation 1992–1993 to 2009

1 Sources: IIPS ( 1995 );

2 IIPS & ORC Macro ( 2000 );

3 IIPS & Macro International ( 2007 );

4 IIPS % ICF ( 2017 ); refers to women aged 15–49 with a birth in the three to five years preceding the survey.

Along with the spurt in institutional delivery, there has also been a significant shift from private to public sector deliveries following the introduction of the JSY program. While fewer than half of all institutional deliveries had taken place in public sector facilities in 1998–1999 and 2005–2006 , the situation had reversed by 2015–2016 , at which time about two-thirds of institutional deliveries were conducted in the public sector (IIPS & ICF, 2017 ; IIPS & Macro International, 2007 ).

Family Planning Practices and Unmet Need

Contraceptive use has been increasing in India. However, there continues to be substantial unmet need for contraception, particularly among the young, and the method mix remains skewed toward sterilization, and the shift toward non-terminal methods is not yet apparent.

Family Planning Use and Method Mix

Contraceptive use increased by some 15 percentage points from 1992–1993 to 2005–2006 , and has remained fairly steady at 54–56% over the subsequent decade (IIPS & ICF, 2017 ; IIPS & Macro International, 2007 ). Although efforts have been made to move the Indian family planning program away from its singular focus on sterilization to a more client-centric and rights-based approach that promotes informed choice and the use of non-terminal methods, contraceptive use patterns continue to be dominated by female sterilization. More than one-third of current contraceptive users in 2015–2016 had adopted sterilization, and sterilization accounted for three-quarters of all modern methods used (Table 4 ). Non-terminal method use remains limited, and has increased only modestly in the past 25 years—the percentage of women using oral contraceptives increased from 1% to 4%, those reporting condom use increased from 2% to 6%, and intra uterine device (IUD) use remained stagnant at 2%.

Table 4. Trends in Current Contraceptive Use, 1992–1993 to 2015–2016

Sources: IIPS ( 1995 ); IIPS & ICF ( 2017 ); IIPS & Macro International ( 2007 ); IIPS & ORC Macro ( 2000 ).

Use of male methods is limited. Together, male sterilization and condom use was reported by just 6% in 2015–2016 , and has remained stagnant since the mid-1990s.

Contraceptive prevalence continues to vary considerably by state. Percentages of women reporting any form of contraception in 2015–2016 ranged from 23% in Bihar to 70% in Andhra Pradesh. Although female sterilization continued to be the leading modern method used in every state, the method mix also varied considerably across states. In Andhra Pradesh, for example, just 1% of all women used a non-terminal modern method or a traditional method. In contrast, in West Bengal, 28% of all women used a non-terminal modern method and 13% used a traditional method. Among male methods, vasectomy was rarely reported (<2%) and condom use ranged from 1% in Tamil Nadu to 19% in Punjab. Differentials in contraceptive use patterns were evident with regard to various socio-demographic factors. Modern method use increased systematically from 36% among the poorest women to 53% among the wealthiest. It increased from 1% and 27% among those with no children or one living child to 67% among those with three children; at each parity, those without sons were far less likely than those with one or more sons to practice contraception. Moreover, contraceptive use ranged from 38% among Muslim women to 49% among Hindu women. Disparities by caste and women’s education were not observed.

The timing of contraceptive initiation reflects the method mix pattern. While about 40% of women had never practiced contraception, just 5% had initiated use prior to their first pregnancy. And, in keeping with the thrust on sterilization, another 40% had initiated contraception after having two surviving children (and 20% after three).

There is a clear divide in terms of public and private sector provision of contraceptive services. Sterilization services are largely provided in the public sector: 82% and 90%, respectively, of women who reported that they had undergone tubal ligation or that their husband had undergone vasectomy reported that the procedure had been conducted in the public sector. In contrast, the private or commercial sector played a much larger role in the provision of reversible contraceptive methods, such as condoms and oral pills (83% and 72%, respectively; IIPS & ICF, 2017 ).

Unmet Need for Family Planning

There is a substantial unmet need for contraception in India; as of 2015–2016 , 13% of women were not practicing contraception despite wishing to space or limit childbearing, and this proportion had remained unchanged since 2005–2006 (IIPS & ICF, 2017 ; IIPS & Macro International, 2007 ). Notably, the demand for spacing is limited, just 11% of women expressed a demand for spacing, while 55% expressed a demand for limiting childbearing, and while the majority of those with a demand for limiting had satisfied this demand (87%), far fewer—just 50%—of those with a demand for spacing their next pregnancy had done so.

Variation in unmet need levels was fairly narrow across such background characteristics as rural–urban residence, educational attainment levels, religion, caste, and wealth status. They were, in contrast, pronounced across age groups. Unmet need was most evident among young women: 22% of those aged 15–19 and 20–24 had an unmet need for contraception, compared with 19% of those aged 25–29 and 8–13% of those aged 30–39. As expected, unmet need among the young was overwhelmingly for spacing methods (16–20%). State-wise variation was also pronounced, with percentages of women with an unmet need for contraception ranging from 5–7% in Andhra Pradesh and Telangana in the south to 18–21% in Bihar and Jharkhand.

A pioneering national study of the incidence of abortion and unintended pregnancy estimates that a total of 15.6 million abortions are performed annually, that is, an abortion rate of 47 per 1,000 women aged 15–49 (Singh et al., 2018 ), far in excess of previous estimates, drawn on data from small samples (6.4 million, 26 abortions per 1,000 women; Duggal & Ramachandran, 2004 ).

The abortion scenario in India has undergone a significant shift over the course of the 21st century with the availability of medication abortion. There has been a radical shift from surgical methods of abortion to medication abortion. Estimates from 2015 suggest that the overwhelming majority of abortions (81% or almost 13 million) are achieved using medication abortion, compared to 14% through surgical intervention, and 5% using other methods (Singh et al., 2018 ).

Abortion-related deaths contributed to 8% of maternal deaths according to the somewhat dated data available (Montgomery et al., 2014 ; Registrar General of India, 2006 ). Using more recent data drawn from annual health surveys conducted in EAG states ( 2010–2013 ), Yokoe et al. ( 2019 ) noted that risk factors for abortion-related deaths included abortion in adolescence, rural residence, and belonging to socially excluded scheduled tribes.

Abortion-related complication data are not widely available. Findings from the national study found that, as of 2015 , the number of post-abortion complications due to induced abortion ranged from 51,000 in Assam to 1,100,000 in Uttar Pradesh, and the induced abortion complication treatment rate per 1,000 women aged 15–49 ranged from 4–7 in Assam, Gujarat, and Tamil Nadu, to 21 in Uttar Pradesh and 26 in Madhya Pradesh. That abortion has become much safer is evident from findings that the majority of women who sought care may have mistaken signals of the normal process of medication abortion, such as incomplete abortion from medication abortion or bleeding. Severe complications, many overlapping, are also estimated among treated patients: 4–16% for infection; 2–9% for physical injuries; 3–7% for sepsis; and 1–4% for shock (Singh et al., 2018 ).

Infertility and Surrogacy

Evidence on the prevalence of infertility in India is sparse, and in its absence, childlessness, or the percentage of women aged 40–49 who have never had a live birth is used as a proxy. According to the NFHS-4, 3% of currently married women aged 40–49 were childless (IIPS & ICF, 2017 ). Higher rates were observed in surveys that contained a specific module on infertility: the prevalence of current infertility was 5% (percentage who were childless and had difficulty conceiving for the first time); Patra and Unisa ( 2017 ) found it to be higher among the socially disadvantaged than among other women; and care-seeking was compromised for many. Consequences of infertility in terms of stigma, violence, and marital abandonment are often observed (Sama, 2018 ).

Despite this, infertility care and management are not a public health priority, with poor infrastructure and capacity in public sector facilities well documented (Chauhan et al., 2018 ). At the same time, there has been an increasing trend toward the use of such options as ART and surrogacy (Malhotra et al., 2003 ; Nadimpally & Venkatachalam, 2016 ). Efforts to regulate eligibility criteria for both clients and surrogates and to ensure that the rights of surrogates are protected are underway; the Surrogacy (Regulation) Bill 2019 was introduced in the lower house of the Indian Parliament, but is yet to be passed.

Sexually Transmitted Infections, Reproductive Tract Infections, and Other Gynecological Morbidities

Self-reported prevalence of sexually transmitted infections (STIs) and symptoms such as abnormal genital discharge and genital sores or ulcers in the 12 months preceding the interview stood at 11% and 8% among sexually experienced women and men aged 15–49 years, respectively, in 2015–2016 (IIPS & ICF, 2017 ). A similar proportion of women (11%) but fewer men (5%) had so reported a decade earlier (IIPS & Macro International, 2007 ). Percentages reporting an STI, genital discharge, or a sore or ulcer ranged from a low 5% or less in Andhra Pradesh, Telangana, Sikkim, and Dadra & Nagar Haveli, to over 20% in states such as Haryana, Jammu and Kashmir, Meghalaya, and Mizoram (IIPS & ICF, 2017 ).

Smaller studies, using clinical or lab-detected findings rather than self-reports, also report considerable reproductive tract infections (RTIs) and STIs. Vasireddy ( 2017 ) interviewed 520 randomly selected women in the slums of Guntur and found that the prevalence of infection using the syndromic approach was 33%, with the majority reporting vaginal discharge. Clinical confirmation noted that of those reporting a symptom, almost three in five (58%) were diagnosed with bacterial vaginosis, that adolescent girls were over-represented, as were the poor, the poorly educated, and the socially excluded (Vasireddy, 2017 ). Ghosh, Paul, Das, Bandyopadhyay, and Chakrabarti ( 2018 ) analyzed the cases of over 5,000 women attending an STI clinic in Odisha and noted that one-third were diagnosed with Trichomoniasis and bacterial vaginosis, respectively.

A strong and consistent association between RTIs and poor menstrual hygiene management practices is documented in a study of 558 women attending two hospitals in Odisha, among whom 62% were diagnosed with at least one infection, 41% with bacterial vaginosis, and 34% with candida infection. Torondel et al. ( 2018 ) showed that, even after adjustment for potentially confounding factors, women diagnosed with these two infections were more likely than others to report poor menstrual management practices such as use of reusable absorbent material, infrequent personal washing, and unhygienic drying and storage of materials.

Cervical cancer affects large numbers of Indian women. India is estimated to account for one-quarter of the worldwide burden of cervical cancers; an estimated 1 in 53 Indian women will experience cervical cancer during their lifetime. The high burden of cervical cancer has been attributed to such risk factors as poverty, early age at marriage, multiple sexual partners, multiple pregnancies, poor genital hygiene, malnutrition, and lack of awareness. Despite this high burden, there is no countrywide state-sponsored public health policy on prevention of cervical cancer screening or Human Papilloma Virus (HPV) vaccination (Bobdey, Jignasa, Jain, & Balasubramaniam, 2016 ).

Care-seeking for symptoms of infection and gynecological morbidity is limited. Moreover, public sector facilities are far less likely to be sought for treatment of STI symptoms than symptoms of other health problems. For example, Mitchell et al. ( 2011 ) found that while almost all women in rural areas of two districts of Andhra Pradesh sought antenatal services from the public sector (96%), few did so for STI symptoms (16%), and just 4% had sought STI-related services from a primary health center. Gawande, Srivastaba, and Kumar ( 2018 )’s findings in rural areas near Mumbai city corroborate: the prevalence of RTIs among ever married women was found to be 21%; yet, just 14% had sought treatment from a qualified provider. Jayapalan ( 2016 ) found that, of 85 STI-infected men and women in Kerala, 60% of men and 82% of women had sought appropriate treatment for their first point of contact, many had received inappropriate treatment at this point of contact, and many (30% of men and 37% of women) cited poor quality of care in the facility from which they had first sough care, notably the unavailability of medicine and lack of confidentiality and privacy.

HIV Scenario

An estimated 2.14 million Indians were HIV+ in 2017 , with overall rates declining to 0.22% from 0.31% in 2009 (NACO & ICMR-NIMS, 2018 ; NIMS & NACO, 2012 ). The NFHS found similar prevalence rates in 2015–2016 , with an overall rate of 0.24%, 0.23% for women and 0.25% for men (IIPS & ICF, 2017 ).

India’s National AIDS Control Organization (NACO) estimates suggest that the number of new infections has declined to 87,600 in 2017 from approximately 120,000 in 2009 . By 2017 , almost 97% of the total population living with HIV were aged 15 or older, with females comprising 42% of this group, compared to 39% in 2009 . HIV incidence per 1,000 uninfected population is estimated to have declined to 0.07 in 2017 . Regional variation is considerable, and by 2017 , incidence was considerably greater in northeastern states such as Mizoram, Nagaland, and Manipur (0.58–1.32) than previously high-incidence states such as Maharashtra and Tamil Nadu (0.05–0.09) and other states. The epidemic continues to be concentrated in high-risk populations, that is, sex workers, men who have sex with men, and injecting drug users (NACO & ICMR-NIMS, 2018 ).

Stigma and discrimination persist. The NFHS probed attitudes about an HIV+ person mixing with others in various situations (the school, the health facility, the workplace, and so on) and notes that positive attitudes on any one of seven situations were held by 60–80%, and on all attitudes by just 24% of women and 27% of men (IIPS & ICF, 2017 ).

Reproductive health choices have expanded for women living with HIV/AIDS. There has been a considerable increase in the coverage of HIV testing, antiretroviral therapy (ART), and prevention of parent-to-child transmission (PPTCT) services in last few years, and counseling and testing services are now available across the nation through more than 15,000 integrated counseling and testing centers and ART services are available in more than 400 centers across the country, and more than 38,000 HIV-infected women reported PPTCT services (Department of AIDS Control, 2013 , 2014 ). Rates of mother-to-child transmission have reduced, and more women are able to fulfill their fertility desires. Despite increased coverage of antiretroviral treatment, effective reproductive health care services do not always reach HIV-infected women, resulting, for example, in a high prevalence of unwanted pregnancies and induced abortions among them, and a low level of knowledge about prevention of mother to child transmission and safe pregnancy options (Darak, Hutter, Kulkarni, Kulkarni, & Janssen, 2016 ).

Gender-Based Violence

Notwithstanding laws that protect women from domestic violence, gender-based violence, notably marital violence, persist. Almost one-third of ever-married women (31%) had experienced physical or sexual violence perpetrated by their husband. Many of these women experienced injuries (25%), including 4% who suffered severe burns, 6% who had suffered deep wounds, and 8% who had experienced eye injuries, sprains, dislocations, and burns (IIPS & ICF, 2017 ). In addition, a significant and consistent association is observed between the experience of spousal violence and symptoms of RTIs/STIs (Jejeebhoy, Santhya, & Acharya, 2013 ), unintended pregnancy (Raushan, 2019 ), pregnancy-related care, and fetal and infant mortality (Jejeebhoy, Santhya, & Acharya, 2010 ).

Sexual and Reproductive Health of the Young

Almost one-third (30%) of India’s population (365 million in 2011 ) comprises young people aged 10–24 (Office of the Registrar General and Census Commissioner, India, 2014 ). Whether India realizes the advantage of its demographic dividend, whether it achieves the Sustainable Development Goals, and whether it achieves its national aspirations for development all depend on investments made in the health, education, and skilling of this cohort. Despite considerable advance, the achievement of a successful transition to adulthood eludes many young Indians.

Entry into Sexual Life Before Marriage

Despite strictly imposed norms proscribing pre-marital sexual relations and even social mixing between boys and girls exist, there is growing evidence of pre-marital onset of sexual activity in adolescence, particularly among boys and young men. A sub-national survey of youth in 2006–2007 showed, for example, that among those aged 15–19, 9% of unmarried boys and 3–4% of unmarried and married girls aged 15–19 had engaged in pre-marital sex (IIPS & Population Council, 2010 ). Subsequent state-representative studies in three states have found somewhat higher percentages a decade later: 14–20% among unmarried boys, 6–9% among unmarried girls, and 6–16% among married girls (Table 5 ).

Findings also confirm that while sexual relations overwhelmingly take place within a romantic partnership, non-consensual, exchange sex, and casual sex are not unknown. Because of stigma and fear of disclosure of sexual activity status, lack of information, and inaccessible facilities or judgmental providers, contraceptive practice among the unmarried is limited and inconsistent. Moreover, risky behaviors are reported by considerable minorities, including non-use or inconsistent use of condoms, multiple partner relations, forced sex (experienced by girls and perpetrated by boys), and unintended pregnancy (Table 5 ).

Table 5. Pre-Marital Sexual Relations Among the Young, Selected States, 2015–2018

Note: * among those who reported pre-marital sexual experiences.

1 Sources: Santhya et al. ( 2017a );

2 Santhya et al. ( 2017b );

3 Jejeebhoy et al. ( 2019 ).

Child Marriage and Lack of Free and Full Consent in Marriage-Related Decisions

Although India is committed to protecting adolescents from child marriage, and despite laws prohibiting marriage to young women before age 18 and to young men before age 21, many have married below these legally permissible ages. There has, however, been a precipitous decline in child marriage among girls over the 2005–2006 to 2015–2016 decade: among those aged 20–24, child marriage fell from 47% in 2005–2006 to 27% by 2015–2016 . Child marriage (below age 18) was rare for boys (4%), however, as of 2015–2016 , one-fifth of young men aged 25–29 had married below age 21 (IIPS & ICF, 2017 ; IIPS & Macro International, 2007 ). State-wise variation in child marriage among women is considerable. In 2015–2016 , child marriage prevalence ranged from 8–10% in Goa, Himachal Pradesh, Kerala, Punjab, and Jammu and Kashmir to 35–44% in Bihar, Jharkhand, Rajasthan, and West Bengal. Variation by socio-demographic characteristics was also observed, with urban and better educated young women, and those from economically well-off families far less likely to marry in childhood than other women (Kumar, 2019 ).

Evidence from India highlights that parents and extended family are typically involved in the screening of potential spouses for their children, and marriage is still perceived as a union between two families and not just between two individuals. Family-arranged marriage remains the norm. Self-arranged or love marriage in which young women and men select their spouse independently remain rare (Desai & Andrist, 2010 ; Jejeebhoy et al., 2019 ; Santhya et al., 2017a , 2017b ) and the practice of denying girls’ a real say in marriage-related decisions persists. State-level findings suggest that many married girls meet their husband for the first time on the wedding day (Bihar (77%), Uttar Pradesh (57%), and Jharkhand (48%); Jejeebhoy et al., 2019 ; Santhya et al., 2017a , 2017b ).

Child marriage is associated with a number of adverse marriage-related outcomes. Compared to those who had married in childhood, those who married after they were 18 were more likely to have been involved in planning their marriage, to reject wife beating, to have used contraceptives to delay their first pregnancy, and to have had their first birth in a health facility. They were less likely than women who had married early to have experienced physical or sexual violence in their marriage, or to have had a miscarriage or stillbirth (Santhya et al., 2010 ).

Early Childbearing

Childbearing in childhood and adolescence continues to be observed, although childbearing below age 15 is rare: 1% of women aged 20–24 had a first birth before age 15, 9% before they were 18, and 26% before they were 20. State-wise variation is wide; among young women aged 15–19, 8% had already begun childbearing nationally, ranging from 3% in some better developed states to as many as 19% in West Bengal (IIPS & ICF, 2017 ).

Neonatal and perinatal mortality are far higher, moreover, among neonates born to adolescent mothers than mothers aged 20–29 (39 and 27 neonatal deaths per 1,000 live births to women aged 15–19 and 20–29, respectively; 45 and 33 perinatal deaths per 1,000 births, respectively; IIPS & ICF, 2017 ).

Contraceptive use among the young is limited: just 10% of 15–19-year-olds had used a modern method, compared to 24% of 20–24-year-olds and 48% among all married women aged 15–49. Modern methods most likely to be used were the condom and oral pills (used by 4% each); notably 1% had already been sterilized (IIPS & ICF, 2017 ).

Individual-, Family-, and Community-Level Challenges

Several challenges operating at individual, family, and community levels continue to compromise India’s effort to realize SRH-related goals articulated within SDG 3. Issues such as lack of awareness of health-promoting behaviors, limited female agency, adherence to traditional notions of masculinity and femininity, inadequate male involvement, and limited spousal communication undermine SRH and rights of many.

Limited Awareness

Awareness of SRH-promoting behaviors, the need for SRH services, and women’s and men’s right to these services remain far from universal in India. Several parts of the country show low or moderate levels of awareness about best practices related to the care of women during pregnancy, delivery, the postpartum period, and of the newborns (Gupta, Shora, Verma, & Jan, 2015 ; Laishram, Thounaojam, Panmei, Mukhia, & Devi, 2013 ; Mangulikar, Howal, & Kagne, 2016 ; O’Neil, Naeve, & Ved, 2017 ; Patel et al., 2016 ; Santhya et al., 2017a , 2017b ). For example, Santhya et al. ( 2017a , 2017b ) showed that just 26–32% of unmarried girls, 28–32% of married girls, and 22–25% of unmarried boys, all aged 15–19 in two large states of India (Bihar and Uttar Pradesh), knew that a pregnant woman should have at least four antenatal check-ups. Awareness of danger signals is also limited (Chandhiok, Dhillon, Kambo, & Saxena, 2006 ; Goyal & Bhandari, 2008 ). Goyal and Bhandari ( 2008 ) studied delivery and postpartum morbidity in the Delhi slums and observed that, even among women experiencing excessive bleeding and high-grade fever, just 28% and 13%, respectively, recognized the condition as a severe morbidity. of 124 maternal deaths taking place across the country in 2012–2014 , Subha Sri and Khanna ( 2014 ) reported that lack of awareness to seek timely care was one of the key causes.

In the area of contraception, while awareness of at least one contraceptive method is virtually universal (99%) among currently married men and women, awareness of non-terminal is not universal. For example, just 69% and 48%, respectively, of currently married women and men were aware of IUCDs, condoms, and oral pills (IIPS & ICF, 2017 ). Moreover, the awareness percentage of specific methods increased only marginally over time: for example, awareness about condoms increased from 76% in 2005–2006 to 82% by 2015–2016 among currently married women. At the same time, awareness of emergency contraceptive pills increased dramatically: from 12% to 42% among currently married women, and 23% to 48% among currently married men. Furthermore, awareness of contraceptive methods tends to be superficial; among adolescents and youth, although awareness of contraceptive methods was almost universal, specific knowledge of at least one method was limited (IIPS & Population Council, 2010 ; Jejeebhoy et al., 2019 ; Santhya et al., 2017a , 2017b ).

Misconceptions about HIV transmission routes and means of protection against HIV are evident. A comparison of the levels of comprehensive awareness of HIV, that is, common misperceptions about transmission were rejected and the importance of consistent condom use and single-partner relations as means of avoiding infection were known, in 2005–2006 and 2015–2016 shows almost no change (17% to 21% among women and 33% to 32% among men; IIPS and ICF, 2017 ; IIPS and Macro International, 2007 ).

Limited awareness permeates the domain of rights and entitlements too. Women and the wider community lack awareness of women’s rights and the programs to which they are entitled. For example, they are poorly informed about the full range of services to which they are entitled under JSY (Santhya et al., 2011 ). Moreover, many women remain poorly informed about the legality of abortion and their rights under the Medical Termination of Pregnancy Act (Banerjee et al., 2013 ; Jejeebhoy et al., 2011a , 2011b ). For example, a community-based study found that while three quarters of rural women were aware that abortion is legal in at least one situation, about half believed that it is illegal in the case of unmarried women or contraceptive failure, and almost all women believed that women seeking abortion must obtain their husband’s consent (Jejeebhoy, Zavier & Kalyanwala, 2010 ). The perception that abortion is illegal in India has been partly fuelled by conflicting messages about the illegality of abortion following prenatal sex detection and the legality of abortions for other reasons (Nidadavolu & Bracken, 2006 ).

Limited Female Agency, Compromised Exercise of Reproductive Rights, and Wide Gender Power Imbalances

Within the age and gender-stratified family systems prevailing in India, women’s agency is hugely constrained. There is considerable evidence of the extent to which limited agency — in terms of decision-making, freedom of movement, control over economic resources, and experience of violence—has compromised health promoting behaviors and timely care-seeking (Bloom, Wypij, & Gupta 2001 ; Jejeebhoy & Santhya, 2014 ; Leon, Lundgren, Sinai, Sinha, & Jennings, 2014 ). Although women’s participation in decisions relating to their own health care has increased over time (62% in 2005–2006 to 75% in 2015–2016 ), women’s freedom to visit a health facility unescorted has remained unchanged (48% to 50%; IIPS & ICF, 2017 ; IIPS & Macro International, 2007 ). Likewise, while the proportion of women who have a savings account that they themselves use has tripled since 2005–2006 (15% to 53%), the proportion of women who have money that they can decide how to use had remained unchanged (45% to 42%).

Women’s limited agency is manifested in compromised exercise of reproductive rights too. A sub-national study of youth in India observed that 51% of young women expressed a desire to have postponed first pregnancy, but of those with demand, only 10% had practiced contraception (Jejeebhoy, Santhya, & Zavier, 2014 ). Also reflecting young women’s compromised exercise of reproductive rights were their reported reasons for not using a contraceptive despite a desire to postpone the first birth, as revealed in the recent stat-representative studies in Bihar, Uttar Pradesh, and Jharkhand: the leading reason, expressed by 18% of girls in Jharkhand, 20% of girls in Bihar, and 33% of girls in Uttar Pradesh was their husband’s objection to doing so, and 11–16% to other family members’ objections to doing so (Jejeebhoy et al., 2019 ; Santhya et al., 2017a , 2017b ). Similarly, about a fifth of women aged 15–49 who had a live birth in the five years preceding the survey who did not go for an institutional delivery cited objections from husband and other family members for doing so nationally (IIPS & ICF, 2017 ).

Gender power imbalances are evident in the persistence of marital violence. Women’s inability to refuse marital sex, even if they suspect their husband has engaged in extra-marital relations, and gendered attitudes that condone pre- and extra-marital sex for men but not women also have the potential to compromise women’s health. Several studies have noted that, as a result, many women, including the newly married, are at risk of acquiring infections from their husbands (Santhya & Jejeebhoy, 2007 ).

Limited Male Involvement and Traditional Notions of Masculinity

Men’s attitudes and behaviors influence not only their own SRH outcomes but also those of their wife or partner. Just 6% of couples practicing contraception were using a male method, even as recently as 2015–2016 . Condom use among men reporting high-risk behaviors has also been found to be limited: 41% of men who had engaged in high-risk sexual behaviors in the year preceding the interview used a condom at last high-risk sex and 48% of men who had engaged in paid sex in the year preceding the interview used a condom during their last paid sexual intercourse (IIPS & ICF, 2017 ). Furthermore, the percentage of men who perceive that contraception is women’s business rather than a man’s concern has increased from 22% to 37% and that women who use contraception may become promiscuous from 16% to 20% over the period 2005–2006 to 2015–2016 .

Male involvement in their wife’s pregnancy-related care has increased only marginally over time: of the men whose youngest living child was less than three years old at the time of the survey, and whose wife had received antenatal care, 79% had accompanied their wife for an antenatal check-up in 2015–2016 (increased from 74% in 2005–2006 ). Moreover, the leading reason provided by men whose wife did not receive antenatal care was the husband’s own objections, although the percentage so citing had declined over the decade (to 26% from 40%; IIPS & ICF, 2017 ; IIPS & Macro International, 2007 ).

Limited Spousal Communication

Spousal communication about sexual and reproductive matters is limited. Mishra and Ramanathan ( 2002 ) found that 45% of the husbands whose pregnant wives attended an antenatal clinic in Delhi reported that they had discussed family planning with their wives. Char, Saavala, and Kulmala ( 2009 ) observed that one-third of men in Madhya Pradesh who responded to a survey questionnaire and most of those participating in focus group discussions reported themselves to be the sole decision-makers about reproductive health. Limited communication is also evident among the young: the Youth Study found, for example, that just one-third (34%) of married men aged under 30 and half (54%) of married young women aged 15–24 had ever discussed contraception with their spouse (IIPS & Population Council, 2010 ). Where communication occurs, moreover, it is selective: a study of young men and women in Guntur district (Andhra Pradesh), and Dhar and Guna districts (Madhya Pradesh) found that topics discussed frequently included antenatal care-seeking but rarely included contraception (Santhya, Jejeebhoy, & Ghosh, 2008 ).

Spousal communication on reproductive illnesses, especially STIs, is also limited. Santhya and Dasvarma, ( 2002 ) showed that, in rural Tamil Nadu, only 37% and 20%, respectively, of married women and men with symptoms of possible RTIs had informed their spouse about their illness experience. Marfatia et al. ( 2000 ) also found that only 18% of married and unmarried men attending clinics in Gujarat had informed their wife or partner about their illness, while Mishra and Ramanathan ( 2002 ) highlighted that the same occurred for less than one-third of husbands of women attending antenatal clinics in Delhi, and Sahasrabuddhe et al. ( 2002 ) mentioned two-fifths of married males at a clinic in Maharashtra.

Program Challenges

Although many programmatic innovations have been implemented to improve reproductive health care delivery, gaps remain. Inadequate infrastructure and human resources, inadequate attention to provider capacity and training, poor quality of services, gaps in the delivery of a range of reproductive health services, and limited efforts to reach the most vulnerable and most in need have seriously compromised the pace of improvement in SRH outcomes.

Infrastructure and Human Resources

Limitations with regard to infrastructure and human resources play a key role in compromising access to and the quality of health services in general, including reproductive health services.

As far as infrastructure is concerned, as of March 2018 , there were a total of 158,417 sub-centers, 257,43 primary health centers (PHCs), and 5,624 community health centers (CHCs) in rural areas, and an estimated shortfall of 32,900 sub-centers, 6,430 PHCs, and 2,1185 CHCs in the country (MOHFW, 2018a ). Of those currently functional, just 7%, 12%, and 13%, respectively, of sub-centers, PHCs, and CHCs are functioning as per the Indian Public Health Standards.

Lack of human resources poses as severe a constraint to health service delivery as does the poor infrastructure. As of 2017 , there were 7.8 doctors and 21 nursing and midwifery personnel per 10,000 population in India (WHO, 2018 ). As of March 2018 , there was a shortage of 6% of auxiliary nurse midwives (ANMs) at sub-centers and PHCs, 14% of doctors at PHCs, and 82% of specialists at CHCs (MOHFW, 2018a ). Moreover, not all sanctioned posts have been filled—13% of posts of ANMs at sub-centers and PHCs, 25% of posts of doctors at PHCs, and 74% of posts of specialists at CHCs sanctioned were vacant.

These shortages in human resources are attributed to a number of factors, including difficulties in recruiting and retaining doctors and nurses in rural areas, especially in the high focus states, delays in sanctioning posts, and limited investment in building a cadre of midwives (MOHFW, 2011a ; Prakasamma, 2009 ). While the inclusion of contractual staff has significantly improved the availability of staff at health center level, contractual employment is fraught with problems, including delayed renewal of contracts, poor service conditions, high turnover, and disparities between contractual and permanent staff including in terms of salary (MOHFW, 2011a ).

Provider Capacity and Training

Significant measures have been taken, under the NRHM, to strengthen provider capacity. However, the reach of provider training has been variable, and provider awareness remains of concern. For example, awareness of health promoting behaviors was limited among many accredited social health activists (ASHAs) (MOHFW, 2011b ; Santhya, Jejeebhoy, & Zavier, 2011 ); an eight-state evaluation found that just 26% of ASHAs recognized foul-smelling vaginal discharge as a danger signal during the postpartum period and 34% knew that a newborn should not be bathed immediately (MOHFW, 2011c ). Medical officers at PHCs in selected districts of Maharashtra and Rajasthan were ill-informed about abortion-related issues: just half were aware that the consent of the husband or guardian is not required in order for an adult woman to undergo abortion (Jejeebhoy et al., 2011a , 2011b ).

Training does not always translate into enhanced knowledge or the practice of new skills. A study of some 96 ANMs in two districts in Rajasthan reports that 36% had conducted deliveries in the last three months; of those who had conducted deliveries, just 6% had always used the partograph while conducting the deliveries, and just 22% gave oxytocin injections always or sometimes during the third stage of labor (Santhya & Jejeebhoy, 2012 ).

Inequitable Reach of Services and Failure to Reach the Most Vulnerable

Findings from national level surveys have noted that despite some narrowing, there remain huge geographic and socio-demographic inequities in reproductive health indicators (e.g., infant mortality, child marriage, and early childbearing) and access to services (e.g., institutional delivery, contraception), by geography and socio-demographic characteristics. Figures 2 and 3 illustrate the change over time ( 2005–2006 and 2015–2016 ) in selected indicators between the most and the least disadvantaged across several socio-demographic characteristics. Findings underscore the country’s failure to reach the most marginalized, although improvement over time is seen.

As Figure 2 shows, neonatal mortality rates were considerably higher among adolescents (54/1,000, and 39/1,000, respectively, in 2005–2006 and 2015–2016 ) than among those aged 20–39 (34/1,000 and 27/1,000, respectively). Differences by education and household economic status were pronounced, but by religion and caste were relatively narrow by 2015–2016 (IIPS & ICF, 2017 ). Findings suggest that while levels of perinatal and neonatal mortality rates have declined among the least and the most disadvantaged, disparities have not narrowed or have narrowed marginally over the decade with respect to most indicators except educational attainment.

Figure 2. Neonatal mortality by socio-demographic characteristics, 2005–2006 and 2015–2016 (IIPS & ICF, 2017 ; IIPS & Macro International, 2007 ).

Note. ● = Most advantaged group; → = Most disadvantaged group.

The Constitution of India recognises and makes provision for special reservations for individuals belonging to socially disadvantaged castes and tribes in India, and classifies them as belonging to scheduled castes (SC) and scheduled tribes (ST).

Figure 3 shows corresponding patterns with regard to modern contraceptive use. There has been little change in either levels or patterns of modern contraceptive use. Disparities between the more and the less advantaged remain, for the most part, as wide in 2015–2016 as they were in 2005–2006 . However, the rural–urban disparity narrowed from 11 to 5 percentage points, and the disparity across household wealth quintiles narrowed from 23 to 17 percentage points.

Figure 3. Modern contraceptive method use at the time of interview by socio-demographic characteristics, 2005–2006 and 2015–2016 (IIPS & ICF, 2017 ; IIPS & Macro International, 2007 ).

Note. ● = Most disadvantaged group; → = Most advantaged group.

The reach of frontline workers also remains limited and inequitable: contact with a health worker (ANM, AWW, ASHA, MPW, and other) in the three months prior to the NFHS-4 interview was reported by just 24% of women. Unmarried women were about one-third as likely as currently married women (11% and 28%, respectively) to report a contact with a health worker (IIPS & ICF, 2017 ).

Poor Quality of Services

The poor quality of SRH services in the public sector has been widely observed, and such issues as lack of cleanliness, long waiting times, shortages of drugs, lack of visual and auditory privacy, demands for unauthorized payments, and absence of respectful treatment documented. For example, the most commonly reported reason for not using government health facilities is the poor quality of care (reported by 48% of households that do not generally use government facilities). Likewise, information provided tended to be skewed: the leading topic discussed was immunization, and even among pregnant women, such topics as delivery preparedness, complication readiness, and postpartum care were discussed with seven percent or less (IIPS & ICF, 2017 ).

The Ministry of Health and Family Welfare ( 2010a , 2011a ), the Planning Commission ( 2011 ), Santhya et al. ( 2011 ), and the United Nations Population Fund ( 2009 ) have also pointed to lacunae affecting the quality of services: a lack of supplies, skewed prioritization of responsibilities, delays in payments, and inadequate mentoring or supervision, for example.

The quality of services is also hampered by the uneven use of best practices. For example, the active management of the third stage of labor was practiced infrequently; instead, unmonitored intrapartum oxytocin has been observed even in hospital deliveries (Iyengar, Iyengar, Suhalka, & Dashora, 2009a ; Iyengar, Suhalka, & Agarwal, 2009b ; Sharan, Strobino, & Ahmed, 2005 ). Relatively few women in Rajasthan (29%) reported that all essential examinations had been performed at the time of hospital delivery (Santhya et al., 2011 ).

Concerns about the quality of care characterize HIV/AIDS/STI/RTI services as well. Health care providers are not always adept at communicating messages linking HIV and reproductive health: for example, about the prevention of sexually transmitted infections, unintended pregnancy and vertical transmission of HIV, promotion of a healthy sexual life, and relationships free from stigma and discrimination. They are also not necessarily well informed about HIV and sexual and reproductive health and rights, or have the skills to provide good quality care (Bharat & Mahendra, 2007 ).

Continued Unmet Need for Family Planning

A number of factors may be responsible for the program’s inability to satisfy the demand for family planning. Although the program is said to provide a cafeteria of contraceptive methods, choices offered are, in practice, limited. In fact, only seven methods are offered in the program: tubal ligation, vasectomy, oral contraceptives, IUCDs, condoms, injectable contraceptives, and emergency contraceptive pills (MOHFW, 2018b ). Methods that have aroused controversy, such as implants, are not available to women from the public health system.

Finally, although efforts to involve women in the selection of contraceptive methods or provide them information that could help them arrive at a decision for themselves have improved, client choice continues to be constrained. For example, in 2015–2006 , of women using modern contraceptives at the time of the interview and who had initiated use in the previous five years, 54% (an increase of 26 percentage points during the 2005–2006 to 2015–2016 decade) were informed about more than one method of contraception (IIPS & ICF, 2017 ). Also, far from universal was the experience of contraceptive counseling with regard to how the method works, what likely side effects are, and how side effects can be managed. Of women who were practicing contraception and had adopted a method in the previous five years, just 47% (an increase of 15 percentage points from 2005–2006 ) were informed about side effects or problems relating to the method they had adopted, and just 39% (an increase of 13 percentage points) were told what to do if they experienced side effects (IIPS & ICF, 2017 ).

Limitations in Meeting Women’s Need for Abortion Services

The NRHM Operational Guidelines stipulate that MVA and MA should be provided at PHC level for women up to eight and seven weeks of gestation, respectively, and these, along with second trimester abortion and management of post-abortion complications should be available at all facilities from the CHC level (those identified as first referral units) upward (MOHFW, 2010b ). These guidelines have not been realized, and abortion services are typically unavailable and inadequate in the public health system at levels below the District Hospital in most states. A recent sub-national study found that, among abortions provided in facilities, the public sector accounts for only one-quarter of facility-based abortion provision, largely because many public facilities do not offer abortion services. At the same time, also reflecting poor-quality services, relatively few abortions overall—fewer than one in four—are provided in health facilities, and almost three-quarters of all abortions are achieved using medication abortion drugs obtained directly from chemists and other unregistered persons, many without a prescription, rather than from health facilities (Moore et al., 2019 ; Singh et al., 2018 ). Among surgical abortions taking place in public sector facilities, moreover, between one-quarter and two-fifths continue to be performed using dilation and curettage or dilation and evacuation, indicating that these facilities are using methods that are outdated, and more likely to place women at risk of complications than other available methods (Singh et al., 2018 ). Notably, most PHCs and even some CHCs lacked trained staff, necessary certification, and/or the required equipment and supplies for providing safe abortions (Kalyanwala, Zavier, & Jejeebhoy, 2010 ). Finally, although medical abortion should be free in all public facilities, in several states, just 12–42% offered free medical abortion services, and 28–53% offered free first trimester surgical abortion (Moore et al., 2019 ).

Violations of women’s right are also evident. Inadequate provision of information to women about the law, including where and till which gestational age abortion is provided, poor quality of care, lack of confidentiality, and the frequent insistence by providers on concurrent family planning deter women from seeking abortion in public sector facilities (Stillman et al., 2014 ). Providers in almost all the facilities in the district-level study in Maharashtra and Rajasthan required the husband’s written consent, and many refused abortion to minors and the unmarried. Quality of care reported by women who had undergone abortion was indifferent, with relatively few women counseled about post-abortion contraception (Jejeebhoy et al., 2011a ; 2011b ; Jejeebhoy, Zavier, & Kalyanwala, 2010 ). Finally, the government of India’s strict measures to enforce the Pre-Conception and Pre-Natal Diagnostics Techniques (PCPNDT) Act of 2003 , which prohibits the misuse of prenatal diagnostic tests for the purpose of sex determination often denies women the right to access legal abortion. Many women themselves misperceive that abortion for any reason as illegal. And a number of qualified providers are reluctant to offer abortion services because they fear reprisals from authorities imposing restrictions on sex-selective abortions.

Limited Emphasis on Engaging Men in Reproductive Health

Health system biases persist against involving men in reproductive health. There has been, effectively, a bifurcation of services for men and women, with HIV/AIDS-related activities focused on men, and sexual and reproductive health services focused on women. The ASHA program and other periphery-level services overwhelmingly cater to women. Although efforts to engage men in the antenatal care of their wife have improved, substantial proportions of men are still not reached out. Of men whose youngest living child was aged under three years, only 37–51% reported that they had ever been informed by a health care worker about such specific signs of pregnancy complication as vaginal bleeding, convulsions, prolonged labor, severe abdominal pain, and high blood pressure (increased from 21–25% in 2005–2006 ), and 47% (increased from 37%) had been told what to do in case of complications (IIPS & ICF, 2017 ). Family planning services are also more focused on women than men, and couple counseling is rarely reported. Finally, efforts to include men in programs intended to change traditional notions of masculinity and build greater respect for women have been limited.

Gaps in the Implementation of Policies and Laws

India has a host of strong laws, policies, and programs that are intended to promote SRH and protect the rights of women, men, and young people to access appropriate services. Unfortunately, implementation of these laws and policies has been lax on several fronts. For example, child marriage persists and prosecution of violators is rare, despite a forward-thinking law prohibiting the practice. Abortions remain inaccessible despite a law that guarantees women’s right to access it. Unmet need for contraception is considerable, despite program commitments to ensure contraceptive choice is fulfilled. Efforts to raise awareness about rights under these laws, policies, and programs are limited, and people’s awareness of their sexual and reproductive rights is therefore compromised (see, for example, Jejeebhoy et al., 2011a , 2011b ; Santhya, 2019 ).

Moving Forward

India has demonstrated its commitment to improving the sexual and reproductive health of its population in many policies, laws, and programs. Significant strides have been made in many dimensions of sexual and reproductive health and rights. Yet there is a long way to go.

Moving forward requires multi-pronged efforts. Improvement is needed in the quality of infrastructure and equipment at public sector facilities, to an emphasis on capacity building of frontline and other providers, to ensuring that services are delivered in respectful ways that acknowledge client rights. Women, men, and adolescents must be made aware—through outreach work as well as, for the young, through schools and community groups—about health promoting practices as well as their right to access quality services. Above all, programs must target the most disadvantaged—the poor, the rural, the poorly educated, the young—in order that the vast inequities that persist are narrowed.

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Dissertations / Theses on the topic 'Reproductive health'

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Foy, Robbie. "Promoting effective reproductive health care." Thesis, University of Edinburgh, 2005. http://hdl.handle.net/1842/29108.

Tshiswaka-Kashalala, Gauthier. "Reproductive Health and Labour Outcomes." Thesis, University of Pretoria, 2014. http://hdl.handle.net/2263/45867.

Topelko, Katherine Mary. "The reproductive health of Guyanese women." Thesis, National Library of Canada = Bibliothèque nationale du Canada, 1998. http://www.collectionscanada.ca/obj/s4/f2/dsk2/tape17/PQDD_0006/MQ33514.pdf.

Ragúz, María. "Sexual and reproductive health and women development from a gender perspective: The role of men." Pontificia Universidad Católica del Perú, 2013. http://repositorio.pucp.edu.pe/index/handle/123456789/101096.

Cornish, Julie Ann. "Inflammatory bowel disease & female reproductive health." Thesis, Imperial College London, 2011. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.539280.

Islam, Mohammad Amirul. "Male involvement in reproductive health in Bangladesh." Thesis, University of Southampton, 2006. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.436920.

Sunil, Thankam Sukumaran. "Reproductive Health in Yemen: A Theoretical Approach." Thesis, University of North Texas, 2002. https://digital.library.unt.edu/ark:/67531/metadc3112/.

Goel, Hersh Vivek. "Adolescent's Reproductive Health Knowledge in Dehli, India." Thesis, The University of Arizona, 2010. http://hdl.handle.net/10150/146834.

Ozden, Asli. "Can Reproductive Health Program Empower Women? A Feminist Post-development Critique Of European Union Funded Reproductrive Health Program In Turkey." Master's thesis, METU, 2010. http://etd.lib.metu.edu.tr/upload/3/12612107/index.pdf.

Pacheco, Christy Lee. "Program Evaluation of a County Reproductive Health Program." Diss., The University of Arizona, 2012. http://hdl.handle.net/10150/228158.

Yalahow, Abdiasis. "Exploring the Reproductive Health Education of Health Service Professionals in Mogadishu, Somalia." Thesis, Université d'Ottawa / University of Ottawa, 2017. http://hdl.handle.net/10393/36709.

Gallipeau, Sherrie. "Altered Reproductive Function and Amphibian Declines." Thesis, University of California, Berkeley, 2014. http://pqdtopen.proquest.com/#viewpdf?dispub=3640434.

Agrochemical exposure is one of the factors that contributes to worldwide amphibian declines. Most studies that examine agrochemicals and amphibian declines focus on toxicity. However, declines are more likely caused by the sub-lethal effects of agrochemical exposure. Past emphases on the lethal effects of agrochemical exposure have overshadowed the contribution of decreased recruitment in amphibian declines. Additionally, studies that examine agrochemicals and reproductive function tend to focus on the effects of single chemical exposures instead of the effects of ecologically relevant mixtures. To address these issues, this dissertation examined the effects of ecologically relevant agrochemical exposures on the stress response and the reproductive endocrinology, morphology, and behaviors of male amphibians in the laboratory and the wild.

Chapter 1 provides a general review of the factors implicated in amphibian declines and provides an overview of the previous research conducted on the effects of agrochemical exposure on recruitment.

Chapter 2 is a field study that examined whether agricultural run-off alters the stress response and reproductive function of male bullfrogs ( Lithobates catesbeianus ). Bullfrogs were collected upstream and downstream of agricultural activity across three California river systems (Salinas, Sacramento and San Joaquin). Size, primary and secondary sex traits, sperm count, and corticosterone and testosterone levels were examined. Overall, bullfrogs living downstream of agricultural activity (i.e. exposure to agricultural run-off) were small and had elevated testosterone and corticosterone levels. In addition, downstream males from the Salinas and San Joaquin Rivers were also small in size and had elevated testosterone levels. However, only downstream males of the San Joaquin River had elevated corticosterone and exaggerated secondary sex traits. Together, these data suggest that living downstream of agriculture can alter size, hormone levels, and the expression of sexually dimorphic sex traits. Such changes to the reproductive endocrinology and morphology of male amphibians can be detrimental to the reproductive health and long-term reproductive success of amphibian populations.

In Chapter 3, I examined corticosterone, testosterone, and the reproductive clasping behaviors of adult male African clawed frogs (Xenopus laevis) exposed to field collected and simulated agricultural run-off. This experiment implemented a novel eco-relevant experimental design to mimic real-life agrochemical exposures. Male frogs were exposed to field water collected downstream (agricultural run-off) and upstream (negative control) of agricultural activity along the Salinas River, CA. In addition, a pesticide mixture containing the top agrochemicals used in the Monterey County was included to simulate agricultural run-off. Mating behavior was suppressed in males exposed to simulated agricultural run-off but enhanced in males exposed to field collected agricultural run-off. In addition, testosterone levels of clasping males were elevated in comparison to controls. Males immersed in simulated agricultural run-off had significantly lower testosterone levels than control males in 2010. These data suggest that agrochemical exposure (both field collected and simulated) can alter reproductive hormones and clasping behaviors. Altered sex hormones and behaviors in male amphibians may play a role in amphibian declines.

Lastly, this dissertation is summarized in Chapter 4. The applicability of this dissertation as a model for amphibian declines and other reproductive related human health concerns are also introduced.

Rokicki, Slawa. "Improving Reproductive Health: Assessing Determinants and Measuring Policy Impacts." Thesis, Harvard University, 2016. http://nrs.harvard.edu/urn-3:HUL.InstRepos:33493534.

Spring, Marline Ann. "Reproductive health and fertility of Hmong immigrants in Minnesota. /." ON-CAMPUS Access For University of Minnesota, Twin Cities Click on "Connect to Digital Dissertations", 2001. http://www.lib.umn.edu/articles/proquest.phtml.

Yakong, Vida Nyagre. "Rural Ghanaian women's experience of seeking reproductive health care." Thesis, University of British Columbia, 2008. http://hdl.handle.net/2429/3805.

Presern, Carole Bridget. "Reproductive health care in poor urban areas of Nepal." Thesis, University of London, 1996. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.243545.

Richiello, Isabella. "Women's experience of a sexual and reproductive health chatbot." Thesis, KTH, Medieteknik och interaktionsdesign, MID, 2018. http://urn.kb.se/resolve?urn=urn:nbn:se:kth:diva-231819.

Darbha, Subrahmanyam. "Reproductive Health Trends In Female Sex Workers In Madagascar." The Ohio State University, 2011. http://rave.ohiolink.edu/etdc/view?acc_num=osu1309360596.

Upton, Dannielle Heather. "Follicle stimulating hormone: ovarian reproductive function, health and aging." Thesis, The University of Sydney, 2016. http://hdl.handle.net/2123/15845.

Lui, Paraniala Silas Celebi. "Reproductive health problems faced by men in Solomon Islands." Thesis, Queensland University of Technology, 2016. https://eprints.qut.edu.au/101163/1/Paraniala%20Silas%20Celebi_Lui_Thesis.pdf.

Forsyth, Patricia Eileen. "Investigating the reproductive health knowledge, attitudes and practices among student nurses at a selected private nursing college in South Africa." University of the Western Cape, 2018. http://hdl.handle.net/11394/6865.

Kashyap, Sonya. "Assisted reproductive medicine: Systematic reviews and randomized controlled trials." Thesis, University of Ottawa (Canada), 2005. http://hdl.handle.net/10393/26940.

Ahmed, Misbah Uddin Pimonpan Isarabhakdi. "Married female adolescents' reproductive health behavior in Bangladesh : evidence from Demography and Health Survey /." Abstract, 2006. http://mulinet3.li.mahidol.ac.th/thesis/2549/cd393/4838752.pdf.

Bath, Louise E. "The reproductive health of women treated for cancer in childhood." Thesis, University of Edinburgh, 2005. http://hdl.handle.net/1842/24986.

Sheehy, Grace. "A Reproductive Health Needs Assessment in Peri-Urban Yangon, Myanmar." Thesis, Université d'Ottawa / University of Ottawa, 2015. http://hdl.handle.net/10393/32785.

Farragher, Tracey Marie. "Spatial epidemiology of indicators of male reproductive health in Scotland." Thesis, University of Edinburgh, 2005. http://hdl.handle.net/1842/29096.

Gupta, Vaibhav. "Reproductive and child health service delivery and utilization in India." CONNECT TO ELECTRONIC THESIS, 2007. http://dspace.wrlc.org/handle/1961/4164.

Begum, Farhana. "Women's reproductive illnesses and health seeking in a Bangladeshi village." Thesis, University of British Columbia, 2012. http://hdl.handle.net/2429/42492.

Schoeman, Jeanne. "Violence against women : impact on reproductive health and pregnancy outcome." Thesis, Stellenbosch : Stellenbosch University, 2003. http://hdl.handle.net/10019.1/53713.

Englund, Linnéa, and Evelina Persson. "Young women's sexual and reproductive health and rights in Ecuador." Thesis, Högskolan i Jönköping, Hälsohögskolan, 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:hj:diva-34734.

Mumtaz, Zubia. "Gender and reproductive health in Pakistan : a need for reconceptualisation." Thesis, London School of Hygiene and Tropical Medicine (University of London), 2003. http://researchonline.lshtm.ac.uk/4646513/.

Macleod, Catriona. "Public reproductive health and ‘unintended’ pregnancies: introducing the construct ‘supportability’." Oxford University Press, 2015. http://hdl.handle.net/10962/d1019881.

Milanes, Lilian. "Health care providers' perspectives on male involvement in their sexual and reproductive health care needs." Honors in the Major Thesis, University of Central Florida, 2012. http://digital.library.ucf.edu/cdm/ref/collection/ETH/id/590.

Hawkins, Kirstan. "Rights, health and power : a critical social analysis of the reproductive health and rights discourse." Thesis, Swansea University, 2002. https://cronfa.swan.ac.uk/Record/cronfa42673.

Graham, Elizabeth Miall Charlene. "An intensified pragmatism in repsonse [sic] to reproductive experiences and medicalization : a case study of Cape Breton women /." *McMaster only, 2003.

Liao, Rui Oratai Rauyajin. "Reproductive health rights a wareness of the rural-to-urban migrants in Yunnan, China /." Abstract, 2007. http://mulinet3.li.mahidol.ac.th/thesis/2550/cd400/4838031.pdf.

Jimmy-Gama, Dixon. "An assessment of the capacity of faculty-based youth friendly reproductive health services to promote sexual and reproductive health among unmarried adolescents : evidence from rural Malawi." Thesis, Queen Margaret University, 2009. https://eresearch.qmu.ac.uk/handle/20.500.12289/7456.

Olmo, Luisa. "Investigating smallholder cattle and buffalo reproductive health and management in Lao PDR to enhance reproductive efficiency and improve livelihoods." Thesis, The University of Sydney, 2020. https://hdl.handle.net/2123/21744.

Dahlbäck, Elisabeth. "Between opportunities and risks : adolescent sexual and reproductive health in Zambia /." Stockholm, 2006. http://diss.kib.ki.se/2006/91-7140-978-5/.

Nilses, Carin. "Health in Women of Reproductive Age : A Survey in Rural Zimbabwe." Doctoral thesis, Uppsala : Acta Universitatis Upsaliensis : Univ.-bibl. [distributör], 2000. http://publications.uu.se/theses/91-554-4893-3/.

Kirkham, Jacqueline. "Sexual and reproductive health in Romania and Moldova : contexts, actors, challenges." Thesis, University of Glasgow, 2011. http://theses.gla.ac.uk/2586/.

Chanchani, Devanshi. "Social inequality, reproductive health and child development : a Chhattisgarh village study." Thesis, University of East Anglia, 2015. https://ueaeprints.uea.ac.uk/53407/.

Nara, Ruth. "Understanding the Reproductive Health Needs of Displaced Congolese Women in Uganda." Thesis, Université d'Ottawa / University of Ottawa, 2018. http://hdl.handle.net/10393/38394.

Mpilambo, Jacques Elengemoke. "Reproductive health situation among youth in the Democratic Republic of Congo." Thesis, University of the Western Cape, 2015. http://hdl.handle.net/11394/5195.

Hoque, A. M. Mozibul Santhat Sermsri. "Sexual behaviour, contraceptive practice and reproductive health among Thai school adolescents /." Abstract, 1999. http://mulinet3.li.mahidol.ac.th/thesis/2542/42E-MozibulH.pdf.

Zerucelli, Rucell Jessica. "Obstetric violence & colonial conditioning in South Africa's reproductive health system." Thesis, University of Leeds, 2017. http://etheses.whiterose.ac.uk/20747/.

Nguyen, Quynh Anh. "Economic evaluation of adolescent reproductive health education interventions in Chilinh, Vietnam." Thesis, Queensland University of Technology, 2014. https://eprints.qut.edu.au/79547/1/Quynh%20Anh_Nguyen_Thesis.pdf.

Magnusson, Brianna. "Contextual Factors and Reproductive Control in U.S. Women." VCU Scholars Compass, 2011. http://scholarscompass.vcu.edu/etd/190.

Guo, Sufang Oratai Rauyajin. "Health service utilization of women with reproductive tract infections in rural China /." Abstract, 1999. http://mulinet3.li.mahidol.ac.th/thesis/2542/42E-GuoSufang.pdf.

Scotland, Graham. "Elicitation and application of preference values in economic evaluation : case studies in reproductive health." Thesis, University of Aberdeen, 2011. http://digitool.abdn.ac.uk:80/webclient/DeliveryManager?pid=186218.

• Open access
• Published: 19 July 2023

Effectiveness of school-based sexual and reproductive health education among adolescent girls in Urban areas of Odisha, India: a cluster randomized trial

• G. Alekhya 1 ,
• Swayam Pragyan Parida 1 ,
• Prajna Paramita Giri 1 ,
• Jasmina Begum 3 ,
• Suravi Patra 2 &
• Dinesh Prasad Sahu 4  

Reproductive Health volume  20 , Article number:  105 ( 2023 ) Cite this article

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A Correction to this article was published on 13 September 2023

This article has been updated

Various studies revealed that adolescent girls have limited knowledge pertaining to sexual and reproductive health (SRH). The current study assessed the effectiveness of SRH education among adolescent girls in urban areas of Odisha, India.

The study design was a cluster randomized trial, where the clusters composed of eight Odia (regional language) medium government girls’ high schools in Bhubaneswar, the capital city of the state of Odisha, India . For the selection of study participants, adolescent girls who were studying in the ninth and tenth standards were recruited from each school. Eight schools were randomized through restrictive randomization at a 1:1 ratio, with four schools each in the intervention and control arm. Baseline and end-line assessments were done using a pre-tested, semi-structured questionnaire. Following baseline assessment, an intervention was given with the help of handbooks developed by the study authors to the schools in the intervention arm. Outcomes included change in knowledge, attitude and practices pertaining to SRH.

In our study at baseline, there were a total of 790 students, where 469 (59.4%) students were in the intervention arm, and 321 (40.6%) students were in the control arm. At baseline, only 282 (60.1%) in the intervention arm and 171 (53.3%) in the control arm were aware that physical bodily changes due to puberty were normal. After the intervention, there was a statistically significant increase in knowledge in intervention group 367 (94.8%) (p-value < 0.001). Most students used sanitary pads as absorbent, 97.2% in the intervention group and 98.4% in the control group. However, after the intervention, the use of other absorbents reduced to zero in the intervention group with a statistically significant difference (p < 0.05). The number of students having awareness on different methods of contraception increased from 51 (10.9%) to 337 (87.1%) in the intervention arm (p < 0.001), and of those having awareness on STIs/RTIs increased from 177 (38.2%) to 371 (96.1%) in the intervention group (p < 0.001).

From our study, there is a significant proportional change in knowledge, attitude, and practices pertaining to SRH. Our study recommends policymakers and program managers for the implementation of comprehensive SRH in the regular school curriculum.

Trial registration CTRI/2021/01/030490, registered on January 15, 2021. Prospectively registered at https://ctri.nic.in/Clinicaltrials/login.php

Plain language summary

Adolescent girls lack adequate knowledge pertaining to sexual and reproductive health, for which they face various issues such as teenage pregnancy, unsafe abortions and sexually transmitted infections. Hence the authors conducted this study to assess the effectiveness of school-based sexual and reproductive health education among adolescent girls in Odisha state of India in terms of improving knowledge, attitude and practices pertaining to reproductive health. A total of eight vernacular (Odia language) medium schools were selected for the conduct of the study, and the schools were randomly assigned where four schools received SRH education, and the other four received no intervention. A baseline assessment pertaining to SRH was done among adolescent girls studying in ninth and tenth classes of all eight schools, and then education was given to the four schools in the intervention arm. Students were educated on topics such as puberty, menstrual health, pregnancy, contraception and STIs/RTIs with the help of handbooks prepared by the authors. After 3 months of providing education, an endline assessment was done for the adolescent girls in all eight schools. There was an increase in knowledge, attitude and practices pertaining to SRH among the students who received education when compared to those who didn’t. Hence our study recommends policymakers and program managers include SRH education in the regular school curriculum.

Peer Review reports

As per United Nations Children’s Fund (UNICEF), there are approximately 1.3 billion adolescents worldwide, with 90% of them living in developing countries. Among these, there are around 880 million adolescent girls [ 1 ]. Gender inequality has persisted in the communities marginalizing adolescent girls who are victims of pernicious social norms affecting their ability to make decisions regarding education, work, marriage and social relationships [ 2 ]. The United Nations Population Fund (UNFPA) defines Sexual and Reproductive health (SRH) as a state of complete physical, mental, and social well-being related to the reproductive system [ 3 ]. Literature shows that adolescent girls lack adequate knowledge on SRH, for which they face issues such as early pregnancy and childbirth, abortion, violence, unintended pregnancies, maternal mortality, reproductive tract infections (RTIs) and sexually transmitted diseases (STDs) [ 4 ]. Around twelve million girls aged 15–19 years and seven million girls under 15 years give birth each year in developing countries. Complications arising due to pregnancy and childbirth are the leading cause of death for girls aged 15–19 years globally [ 5 ]. Each year around 39,000 child marriages happen every day [ 6 ]. Available data suggest that adolescent mothers succumb to depression compared to non-pregnant peers and adult mothers [ 7 ]. The Sustainable Development Goal (SDG) 3.7 states that by the year 2030, there should be universal access to sexual and reproductive health care services, including family planning, education, and integration of reproductive health into national programs. Also, SDG 5 focuses on gender equality by empowering women and girls, but data suggests only 57% of women aged 15–49 years make informed decisions regarding sexual and reproductive health care [ 8 ]. International organizations such as the World health organization (WHO), United Nations Children’s Fund (UNICEF), and the Lancet Commission highlight the need to prioritize adolescents in achieving the SDGs [ 9 ].

India, with a population of 253 million, has the world’s largest adolescent population [ 10 ]. In 2014, the Government of India (GOI) launched the “Rashtriya Kishor Swasthya Karyakram (RKSK)” to provide services to adolescents, including SRH services [ 11 ]. However, studies have shown that service utilization remains poor, and adolescents are often unaware of these services [ 12 ]. In Odisha state, under the RKSK program, Adolescent friendly health clinics (AFHCs) are operational at Urban Primary Health Centers (PHC), with adolescent health counsellors providing clinical, counselling and outreach services to schools, colleges and youth clubs [ 13 ]. However, in a scoping review measuring adolescent-friendly health services in India, in Odisha state, community health workers had more knowledge about adolescent health programs than the teachers and the prevalence of SRH knowledge was low in the adolescent community [ 14 ]. As per the latest National family health survey-5 (NFHS-5), data shows that 6.8% of women aged 15–19 have begun childbearing, and 23.3% of women aged 20–24 married before the age of 18. In Odisha, a state in India, the prevalence of teenage pregnancy is 7.6%, and 20.5% of married women were below 18 years of age, similar to the national data [ 15 ]. These rates are far from the recommendations of the Lancet Commission on adolescent health, which states the prevalence of teenage pregnancy to be less than 1 per cent by the year 2030 [ 16 ]. SRH education in India has not been given much importance due to existing taboos. A report on sexuality education in India by Youth Coalition for Sexual and reproductive rights stated that higher secondary schools do not have SRH education in the curriculum; however, private schools had the liberty to choose for inclusion of SRH education in the curriculum, but no attempts have been made from public schools mainly vernacular government schools [ 17 ]. This report was made in accordance with the International Conference on Population and Development (ICPD), which states governments are obliged to provide comprehensive sexuality education for youth to make informed decisions [ 17 ]. But some Indian states, such as Maharashtra, Gujarat, Karnataka, Rajasthan, Kerala, Goa, Madhya Pradesh, and Chhattisgarh, have banned sex education [ 18 ]. Studies conducted across various states in India assessed the knowledge, attitude and practices (KAP) related to SRH among adolescent girls and showed poor awareness among adolescents [ 19 ]. While some interventional studies assessed SRH education among adolescent girls in India, most of them were non-randomized studies [ 20 , 21 ]. Only one randomized study compared conventional education delivered by nurses with peer education among school-going adolescent girls in Punjab state, which found that both approaches improved knowledge [ 22 ]. However, no studies assessed the effectiveness of a comprehensive SRH intervention package with a control arm.

Schools act as a platform for providing educational interventions, given the concentration of the adolescent population at schools and the ease of access to health promotion in poor communities without effective health systems [ 23 ]. The authors of the study aimed to assess the effectiveness of school-based comprehensive SRH education in improving knowledge, attitude, and practices related to puberty, menstrual health, pregnancy, contraception, and RTIs/STDs among adolescent girls studying in vernacular (Odia medium) secondary girls’ high schools in Odisha, India.

Study setting

The current study was conducted in Bhubaneswar, the capital city of Odisha state in India. Schools in India are broadly categorized into four types based on the enrollment of students: Lower primary school (classes 1 to 5), Upper primary school (classes 6th and 7th), High school (classes 8th, 9th and 10th), and Higher secondary school (class 11th and 12th). Each state in the country runs its own Department of Education. Schools in each state are of three kinds: government schools, privately owned schools, and schools that are provided grant-in-aid by the government [ 24 ]. After reviewing the syllabus, it was found that there was not much emphasis made on SRH in the state curriculum. Hence schools under the Odisha State Board of Education were selected to conduct the present study. The study was conducted among vernacular (Odia medium) girls’ high schools in Bhubaneswar city. For the conduct of the study, permission was obtained from District Education Officer (DEO), Khordha. There are a total of eight vernacular girls’ high schools in Bhubaneswar City, and all the schools were included in the study.

Study design and sampling strategy

The study design was a cluster randomized trial conducted from May 2020 to April 2022. During this period, there was an ongoing COVID-19 pandemic. The schools remained closed as per guidelines from the Government of Odisha (GOO). The schools conducted online classes using various virtual platforms such as Zoom meetings, Google Meet, and YouTube. Permission was taken to assess the students through online and offline modes when required and to give education to school students through both online and offline modes depending upon the school closure. Written informed consent was taken from parents of adolescent girls, and assent was sought from adolescent girls.

For sample size calculation, as per a study conducted in Gujarat in the year 2017, the proportion of participants having awareness about STIs varied between 23 and 29% [ 25 ]. Considering a total average of 26% as a baseline and assuming a 15% increase at end-line assessment, the sample size was calculated using nMaster software. The total sample size obtained was 345, with α at a significance level of 0.05 and the power of study being 91, and with design effect 2. Considering attrition of ten per cent, the calculated sample size was 380 per arm.

The sampling frame included all eight government girls’ high schools (GHS) in Bhubaneswar, Odisha. Schools were considered as clusters, and restrictive randomization was done to randomize eight schools at a ratio of 1:1, with four schools in each intervention and control arm. For the selection of study participants as per protocol, systematic random sampling was to be done among adolescent girls studying in ninth and tenth classes. However, due to the COVID-19 pandemic, all those who responded to the baseline questionnaire were included, and an amendment in protocol was done regarding the same and was approved by Institute Ethics Committee (IEC), AIIMS Bhubaneswar. Outcome variables included changes in KAP pertaining to domains such as puberty, menstrual health, pregnancy and contraception, STIs/RTIs, and HIV/AIDS.

Baseline assessment

A pre-tested semi-structured questionnaire was developed, which was adopted from the Illustrative questionnaire for interview surveys with young people, World Health Organization [ 26 ]. The questionnaire consists of components such as socio-demographic details of the students and KAP in domains such as puberty, menstrual health, pregnancy, contraception, STIs/RTIs, and HIV/AIDS. The questions on KAP related to various domains of SRH were prepared with reference to the International technical guidance on sexuality education by the UNESCO education sector [ 27 ]. The document includes a section on key concepts pertaining to different topics, including SRH, where learners should acquire knowledge, attitudes and skills based on these key concepts. The knowledge component focused on evaluating adolescent girls’ understanding of pubertal changes, including the concept of the menstrual cycle, the process of pregnancy, risks associated with teenage pregnancy, the concept of contraception and its various methods, as well as awareness of RTI/STIs, and HIV/AIDS. The attitude component aimed to gauge adolescent girls’ beliefs regarding pubertal changes, menstruation hygiene management, their opinions on sex education, and their perception of how an HIV-infected person should be treated. The practice component primarily examined menstrual hygiene practices. Due to the cultural context of the Indian setting, the authors made a decision not to include questions on contraceptive practices in the assessment. The questionnaire was developed in English and later translated into the local language (Odia) with the help of a professional translator. Also, a back translation of the questionnaire from Odia to English was done to test the accuracy of the translation. The questionnaire was pre-tested among 36 students who were not a part of the selected schools. The questionnaire for the baseline assessment of students was delivered to the students through online Google forms. The assessment was done in August–September 2021 during the second wave of the COVID-19 pandemic. Google forms were delivered in WhatsApp groups of seven selected schools after obtaining consent from the school principal and teachers at respective schools. Of eight schools, one was a residential school, where students who resided in rural areas lacked access to smartphones. In the month of August 2021, schools were re-opened, and assessment of the students at residential school was done through offline forms.

Intervention

A literature search was done for the preparation of an intervention package on SRH education. The intervention package consisted of handbooks covering the following topics.

Handbook Part 1—Adolescent health statistics, Female reproductive system, Puberty, and Menstrual Health

Handbook Part 2—Pregnancy, Contraception, STIs/RTIs, and HIV/AIDS

The principal investigator has done a literature search through various websites of WHO and UNICEF, which focused on adolescent health. The relevant documents were then downloaded. The content required as per need has been retrieved from the documents and has been included in handbooks. Also, various Indian documents and modules pertaining to adolescent health, textbooks of school, and Obstetrics and Gynaecology, were referred for handbook preparation. The handbooks were developed in the English language. Since the vernacular language is Odia, the handbooks were translated into Odia by a professional Odia translator. The translated handbooks were given to two medico-social workers (MSWs) separately to verify comprehension of the language. The intervention was given in the months of November and December 2021 for the schools in the intervention arm. Owing to the COVID-19 pandemic, schools were running only half—a day, and accordingly, intervention timing was fixed. The author (AG) visited all the four schools in the intervention arm to provide SRH education to school-going adolescent girls. In each school, the intervention included three sessions. Three sessions were done on 3 consecutive days in each school. Each session lasted for about 2 h. The intervention was given to adolescent girls studying in ninth and tenth classes separately. In the first session, education was given on topics such as the female reproductive system, puberty, and menstrual health with the help of the first part of the handbook. The second session included the topics of part 2 of the handbook, i.e., pregnancy, contraception, STIs/RTIs, and HIV/AIDS. The intervention included a PowerPoint presentation with the help of a projector, brainstorming sessions, and a discussion of case scenarios. The third session was an interactive session between the students and teachers, and various doubts were cleared.

Following the intervention, an endline assessment was conducted 3 months later among all eight schools using online Google forms. The assessment of each school was done on 8 different days between the months of February and March 2022. Once the endline assessment was completed, the same intervention was provided to students in the control arm. The flow of the study design is depicted in Fig.  1 .

CONSORT flow diagram

Data entry and statistical analysis

The recorded responses were exported to Microsoft (MS) Excel except in one school where data was collected through offline forms and entered manually into MS Excel. The data entry was done simultaneously on the same day of the collection of data by the principal investigator. Statistical analysis was done using International Business Machines (IBM)—Statistical Package for social sciences (SPSS) version 26. Descriptive data on socio-demographic details of students are presented in percentage or proportion. Quantitative variables such as the age of the students are expressed as mean and standard deviation. To assess the effectiveness of the intervention, the proportion of students in KAP of all domains was considered. The proportional change was measured among the intervention and control groups before and after the intervention by using the Chi-square test. With the cells having a count less than five, Fischer exact test was used. A p-value of < 0.05 was considered significant.

The baseline sample included a total of 790 students from eight government vernacular (Odia medium) girls’ high schools. Among 790 students, 469 (59%) were in the intervention arm, and 321 (41%) were in the control arm. The mean age of students in the intervention arm was 14.4 ± 0.92 years, whereas in the control arm was 14.4 years ± 0. 8 years. The majority of students’ parents, both mother and father, studied till high school (37% and 34.3% respectively), and occupations included mothers being homemakers (91%) and fathers either clerk/shopkeeper/worker (39.7%). There was no statistically significant difference in baseline characteristics between intervention and control groups (Table 1 ).

Table 2 shows KAP pertaining to puberty and menstrual health among intervention and control arms at baseline and 3 months endline. At baseline, only 282 (60.1%) in the intervention arm and 171 (53.3%) in the control arm were aware that physical bodily changes due to puberty were normal. After the intervention, there was a statistically significant increase in knowledge in the intervention arm to 94.8% (n = 367) (p < 0.01). At baseline, 297 (63.3%) in the intervention arm and 215 (67%) in the control arm considered menstruation as a good thing, and after the intervention, there was a statistically significant (p < 0.01) increase in knowledge in the intervention group, where 362 (93.5%) considered menstruation a good thing in comparison to the control arm 219 (72%). Most students used sanitary pads as absorbent, 97.2% in the intervention group and 98.4% in the control group. However, after the intervention, the use of other absorbents was reduced to zero in the intervention group (p < 0.05).

Table 3 shows KAP pertaining to pregnancy, contraception, RTIs/STIs and HIV/AIDS among intervention and control arms at baseline and 3 months endline. Only 78 (16.6%) in the intervention group and 67 (20.9%) in the control group were aware that pregnancy could occur with a single sexual act; however, after the intervention, it increased to 81.3% in the intervention arm and in the control arm it was 16.8% (p < 0.01). Awareness on contraception was only 134 (28.6%) in the intervention arm and 113 (35.2%) in the control arm. After the intervention, there was a statistically significant increase, where 360 (93%) in the intervention arm and 105 (34.5%) in control became aware that pregnancy could be prevented by using contraceptives. Awareness on different methods of contraception was 51 (10.9%) in the intervention arm and 39 (12.1%) in the control. After the intervention, the awareness increased, where 337 (87.1%) in the intervention arm became aware of different methods of contraception (p < 0.01). At baseline, 177 (38.2%) in the intervention arm and 116 (36.4%) in the control arm were aware of STIs/RTIs; after the intervention, awareness increased to 96.1% in the intervention arm, and 44.1% in the control group were aware (p < 0.01). Regarding awareness on HIV/AIDS at baseline, students in the control arm (50.2%) were more aware when compared to the intervention arm (42.6%) with statistical significance (p < 0.05). However, after the intervention, awareness increased to 95.6% in the intervention arm and in the control arm, only 44.1% were aware (p < 0.01).

The current study assessed the effectiveness of SRH education among vernacular school-going adolescent girls. At baseline assessment, adolescent school-going girls lacked adequate knowledge pertaining to SRH. However, post-intervention, there was a significant increase in KAP in the intervention arm when compared to the control arm. There are studies conducted across various countries to assess the effectiveness of SRH education among adolescent girls, with outcomes having an increase in knowledge pertaining to SRH [ 28 , 29 , 30 , 31 , 32 , 33 , 34 ]. In India, only one randomized trial was conducted assessing peer education and conventional educational strategies for improving SRH. However, both were effective, and peer education was found to be more cost-effective [ 22 ]. To our knowledge, this is the first cluster randomized trial in India to assess the effectiveness of SRH education among school-going adolescent girls.

In our study, the intervention was provided by a community physician, with the intervention delivered using PowerPoint presentations and handbooks. The KAP increased in all domains, such as puberty, menstrual health, pregnancy, contraception, RTIs/STIs and HIV/AIDS following the intervention. In our study at baseline, about 50–60% of adolescent girls were aware of pubertal changes, and forty per cent of students said they were not comfortable when puberty-related topics were discussed. After the intervention, awareness on puberty increased to 94.8%. Our finding was similar to an interventional study conducted in Kerala among school-going adolescent girls, where pubertal awareness increased from 32 to 83.9%, where intervention was delivered through interactive and quiz sessions [ 20 ]. Hence, there is a need for sensitizing students regarding pubertal changes, and training of schoolteachers would be helpful. In our study, 60% of adolescents felt restriction of activities during menstruation. However, it was reduced to 22% following the intervention, indicating that there are still myths about menstruation. The majority of students attended schools during menstruation; Our study finding could be due to the provision of sanitary napkins free of cost under the “Khushi scheme” by the government of Odisha [ 35 ]. It can be inferred that the provision of sanitary napkins facilitated the attendance of adolescent girls, which can be correlated with a study conducted in Gujarat, where the provision of sanitary napkins reduced absenteeism from 24 to 14% [ 21 ]. In our study, most of the students, both in the intervention and control arm, felt that menstrual hygiene should be taught in schools as vernacular government girls’ high schools did not provide education on menstrual hygiene management (MHM) when imparted priorly at an earlier age before attaining menarche will inculcate healthy menstrual hygiene practices among adolescent girls.

In our study at baseline, only 20–30% of adolescent girls were aware of pregnancy and contraception. However, after the intervention, knowledge on pregnancy, different contraception and emergency contraception methods increased to 90%. In an interventional study conducted in Gujarat, knowledge pertaining to contraception increased from 10 to 32% among adolescent boys and girls [ 25 ]. In the study done in Kerala, adolescent girls who were unaware of the prevention of pregnancy reduced from 63 to 13% [ 20 ]. The study done in Kerala was about a decade ago, but still, no efforts have been made to provide a comprehensive SRH curriculum. Our study noted that at baseline, students were more aware of HIV/AIDS as a disease but were not aware of RTIs/STIs. This finding may be due to HIV/AIDS being a more deadly disease than RTIs/STIs and awareness being provided on various platforms such as social media and celebrating World AIDS Day. Also, at baseline, awareness of HIV/AIDS was more in the control arm when compared to intervention, and this finding was statistically significant. This could be because one of the intervention schools was a residential school with students hailing from rural areas, whereas students from control schools were residing in urban areas. However, after the intervention, awareness of RTIs/STIs increased to 90%. Our study finding was similar to a randomized trial conducted in countries such as Zimbabwe among secondary school students, where awareness of RTIs/STDs increased from 20 to 96% [ 36 ] and in the study conducted in Gujarat state, awareness regarding STIs increased from 29 to 32% [ 25 ]. Hence, by imparting education on pregnancy and contraception, adolescent girls can make informed choices regarding their sexual health. Moreover, in the study, about two-thirds of students favoured sex education to be taught in school. As mentioned earlier, in India, various states have banned sex education, but evidence from various studies conducted in India showed parents, teachers, and students favoured sex education in school and to be provided by doctors [ 37 , 38 , 39 ]. Also, evidence reviews from various countries by UNESCO have stated that CSE should be a holistic strategy where young people shape their sexual and reproductive future [ 40 ]. From our study findings, the inclusion of comprehensive education in regular schools, mainly government vernacular schools, is the key recommendation, along with the training of teachers pertaining to SRH by community physicians.

The current study design was ideal for knowing the real effectiveness of an intervention package. Even though the study was conducted during the ongoing COVID-19 pandemic, the study achieved an adequate sample size. Other randomized studies had lesser sample sizes. The intervention package was comprehensive and included all the topics pertaining to SRH; hence intervention was effective in improving KAP among all domains in the intervention arm. Efforts were made by the authors of the study to include all the participants at the follow-up who were present at baseline through phone calls to students and informing parents and teachers regarding the importance of the study, which resulted in less attrition even though the study was conducted during COVID-19 pandemic. Our study demonstrated that schools act as an excellent platform for imparting SRH education.

A few limitations of our study include, the study was conducted only among adolescent girls studying in vernacular (Odia) medium schools. From various study findings, it was observed that adolescent boys had more knowledge of SRH when compared to girls; the former could not be assessed in our study. Our follow-up period was 3 months; hence there is a need for long-term follow-up in further studies. The effectiveness of intervention can be compared between urban and rural areas and in all types of schools, such as private and English medium schools. Our study did not assess the contraceptive practices among adolescent girls; where only the knowledge component was assessed. The gap between the awareness and utilization of contraceptive methods needs to be assessed. Also, the study did not assess sexual activity following intervention which recommends further studies to assess contraceptive usage, sexual activity, and incidence of teenage pregnancies. There are no randomized trials conducted which assessed these domains in an Indian setting owing to cultural taboos. Hence, there is a need for further evidence to strengthen the interventions pertaining to adolescent SRH.

Scale-up assessment: considering the seven key categories for scaling up in the sense of global health, an assessment of the current strategy was done [ 41 ]. The National Health Policy of India (NHP), 2017 clearly envisages the provision of sexual health education to adolescents [ 42 ]. Thus, the current strategy of implementing comprehensive SRH education in schools has a national focus, scale neutral, with a well-defined scaling strategy for a targeted group of adolescents in any geographic region. The intervention package developed was in accordance with recommendations provided by WHO on comprehensive sexuality education and addresses a significant and persistent problem that is currently high on the agenda of NHP of India. The current strategy resulted in KAP in all domains of SRH with a large effect size when compared to any other study conducted in the Indian state. Each section of the module was prepared after a robust review of the literature, making it both country and state specific to meet the need of adolescent girls. The study was funded by the Indian Council of medical research and the MAMTA Institute for Mother and Child, implicating support for change.

The intervention was delivered through schools, which are already established educational institutions. Training teachers and frontline workers to deliver SRH education could potentially be integrated into existing educational programs. Thus, the model can be implemented with existing educational institutional mechanisms, infrastructure, and human resources, including field functionaries of the health department, NGOs and other private stakeholders engaged in implementing health programs at the micro level, indicating a great fit between intervention and any adopting organization. The intervention provided is a collaborative approach with permission obtained from school mass education. National health programs, namely Ayushmann Bharat [ 43 ], envisage outreach visits to schools by healthcare workers to provide counselling services to adolescents. The intervention can be integrated through and scaled out through current programs such as Ayushman Bharat, RKSK, state-owned programs, and various international organizations working on adolescent health with adequate and sustainable funding, a strong network, trained manpower and microlevel institution mechanisms.

Adolescent girls face various issues pertaining to sexual and reproductive health in day-to-day life. Our study assessed the effectiveness of school-based SRH education among school-going adolescent girls in urban areas of Odisha, India. The study showed a significant increase in knowledge, attitude, and practices pertaining to SRH among students in the intervention arm compared to the control arm. The study has generated evidence that schools can act as a platform for providing SRH education to adolescents, which is an immediate need of the hour in shaping healthy young people for the future. Based on the evidence, policymakers and the Department of School Mass Education should include comprehensive SRH education in the regular school curriculum for adolescents’ health and well-being.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Change history

13 september 2023.

A Correction to this paper has been published: https://doi.org/10.1186/s12978-023-01668-y

Abbreviations

Sexual and Reproductive Health

World Health Organization

United Nations Children’s Fund

Comprehensive sexuality education

United Nations Population Fund

National family health survey

Government of India

Rashtriya Kishore Swasthya Karyakram

Adolescent friendly health Clinics

Sexually Transmitted Infections

Reproductive Tract Infections

Human immunodeficiency virus/acquired immunodeficiency syndrome

Knowledge, Attitude, and Practices

Government of Odisha

District Education Officer

Institute Ethics Committee

Government Girls’ High School

Medico-Social Workers

Microsoft; IBM: International Business Machines

Statistical package for social sciences

Menstrual hygiene management

National Health Policy

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Acknowledgements

Not applicable.

The study is funded by an ICMR grant [No 3/2/June-2020/PG-Thesis-HRD (15)] and MAMTA fellowship ID: 2020 21/MD/006 health institute for Mother and Child, New Delhi. Funding was used for the preparation of handbook materials, assessment forms, travel to the schools, stationaries, and refreshments for school students.

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Department of Community Medicine and Family Medicine, AIIMS Bhubaneswar, 3rd Floor, Academic Block, Bhubaneswar, Odisha, 751019, India

G. Alekhya, Swayam Pragyan Parida & Prajna Paramita Giri

Department of Obstetrics and Gynaecology, AIIMS Bhubaneswar, Bhubaneswar, Odisha, India

Suravi Patra

Department of Psychiatry, AIIMS Bhubaneswar, Bhubaneswar, Odisha, India

Jasmina Begum

WHO NTEP, Bhubaneswar, Odisha, India

Dinesh Prasad Sahu

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Contributions

SPP, PPG, JB, and SP conceptualized the study. Data collection was done by AG. AG and DPS prepared the handbook materials for intervention under the guidance of SPP, PPG, JB, and SP. AG and DPS conducted and analyzed the study under the supervision of SPP, PPG, JB, and SP. AG wrote the manuscript with inputs from SPP, PPG, JB, SP, and DPS. All authors approved the final manuscript.

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Correspondence to Swayam Pragyan Parida .

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Ethical clearance was obtained from Institute Ethics Committee (IEC), AIIMS Bhubaneswar, with reference number IEC/AIIMS BBSR/PG Thesis/2020-21/51. Permission was obtained from the District Education Officer (DEO), Khordha, for the conduct of the study. Informed verbal consent was taken from the principal and school teachers. Assent from the students and written informed consent from their parents were taken.

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Alekhya, G., Parida, S.P., Giri, P.P. et al. Effectiveness of school-based sexual and reproductive health education among adolescent girls in Urban areas of Odisha, India: a cluster randomized trial. Reprod Health 20 , 105 (2023). https://doi.org/10.1186/s12978-023-01643-7

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DOI : https://doi.org/10.1186/s12978-023-01643-7

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• Adolescence
• Adolescent girls
• Sexual and reproductive health
• Adolescent sexual and reproductive health
• School health
• Health education
• Randomized trials

Reproductive Health

ISSN: 1742-4755

• General enquiries: [email protected]

[Laser enucleation of the prostate (HOLEP and THULEP): a comparative effectiveness analysis in treating recurrent prostatic hyperplasia]

Affiliations.

• 1 I.M. Sechenov First MSMU of Minzdrav of Russia, Moscow, Russia.
• 2 Research Institute for Uronephrology and Human Reproductive Health, Moscow, Russia.
• PMID: 28952693

Introduction: The estimated recurrence rate of benign prostatic hyperplasia (BPH) after transurethral resection of the prostate is about 5 to 15%. Laser enucleation of the prostate results in a much lower recurrence rate (not exceeding 1-1.5%). At the same time, laser enucleation of the prostate is still not widely used for recurrent prostatic hyperplasia since it believed to be technically difficult in cases.

Aim: To describe the distinctive features of thulium and holmium laser enucleations of the prostate in the management of recurrent BPH and show that the technical difficulties are not an obstacle to the wide application of this technique.

Materials and methods: This was a retrospective study comprising 676 patients aged 54 to 87 years with clinically pronounced infravesical obstruction due to prostatic hyperplasia (IPSS>20, Qmax<10). All patients were divided into four groups. Groups 1 (n=489) and 3 (n=153) underwent holmium (HoLEP) and thulium (ThuLEP) laser enucleations of the prostate, respectively. Groups 2 (n=23) and 4 (n=11) included patients with BPH recurrence after HoLEP (group 2) and ThuLEP (group 4). All patients underwent diagnostic evaluation at baseline and at 6 months after surgery.

Results: The mean ThuLEP operating time was shorter than that of HoLEP (p=0.02). The mean duration of repeat and primary ThuLEP and HoLEP did not differ statistically significantly (p>0.05). There was no difference in the length of hospitalization and catheterization between the four groups (p>0.05). At six months after surgery, a statistically significant improvement in I-PSS, Qmax, QoL, and RUV was observed in all groups compared with preoperative values (p>0.05)).

Conclusion: We found that the technical difficulties of the re-operation, such as the difficult separation of adenomatous tissue from the prostate capsule, the multinodular nature of the adenoma, increased tissue density are easy to overcome and do not confer a significant complexity. In turn, better completeness of resection, low complication and recurrence rates and the possibility of surgery, even in elderly patients with multiple comorbidities - these features allow us to conclude that laser enucleation of the prostate is not only an effective treatment for infravesical obstruction due to benign prostatic hyperplasia, but is also a method of choice in the treatment of patients with recurrent BPH.

Keywords: HoLEP; ThuLEP; infravesical obstruction; laser enucleation; monopolar enucleation; removal of prostatic adenoma.

Publication types

• Comparative Study
• Aged, 80 and over
• Lasers, Solid-State / therapeutic use*
• Middle Aged
• Prostate / surgery*
• Prostatic Hyperplasia / surgery*
• Retrospective Studies
• Treatment Outcome

Unpacking 5 truths about equality in sexual and reproductive health and rights today

• 16 April 2024

UNITED NATIONS, New York – Over the past 30 years, global commitments to sexual and reproductive health and rights have made remarkable advances: Maternal death rates have dropped by almost a third, the number of women using modern contraception has doubled and more than 160 countries have passed laws against domestic violence.

A new report by UNFPA, the United Nations sexual and reproductive health agency, traces the path that led to this progress and empowered millions with increased freedom and autonomy. But it also lays bare how little these improvements have affected the world’s poorest and most marginalized, for whom rights and choices remain largely out of reach.

These disparate realities are driven by inequality and discrimination, often hidden within our health systems and economic, social and political institutions. Achieving equity, then, requires exposing inequalities so that inclusive solutions can be imagined and implemented.

Below, read about where and how inequality shows up in our societies, lifting some communities up while pushing others behind – and about what can be done to counteract it and ensure a peaceful, prosperous future for all.

1. Inequalities in sexual and reproductive health and rights are everywhere .

In Ashgabat, Turkmenistan, Alia* and her husband were told that it was “undesirable” for them to have a baby. The reason? They were both blind.

Women and girls with disabilities often face discrimination when it comes to sexual and reproductive health, limited access to services and exclusion from comprehensive sexuality education. Some are even forcibly sterilized.

The particular challenges Alia and other women with disabilities face during pregnancy and childbirth reinforce one of the report’s main themes: That access to health and rights vary greatly from one region, country and person to another.

Disability status represents just one facet of identity that affects the right to health. Geography is another, with women in Africa around 130 times more likely to die from pregnancy complications than women in Europe. And as for women and girls from ethnic minorities, disparities in health-care access were found in all countries surveyed for UNFPA’s report.

2. Progress on sexual and reproductive health for all is stalling, and by many counts, unravelling.

For nearly 20 years, the global annual reduction in maternal deaths has been zero – meaning there has been no progress. Meanwhile, one quarter of women today report not being able to say no to sex with their husband or partner.

This means that despite investments, advocacy and rafts of legislation, women’s ability to exercise decision-making over their own bodies is diminishing. And while barriers to health have fallen quickly for the most privileged, they are standing firm for the most disadvantaged.

“Even in better-off countries, maternal death rates are higher among communities that continue to confront racial and other prejudices in everyday life,” UNFPA Executive Director Dr. Natalia Kanem said in her World Health Day statement . “We can and must do better.”

3. Sexual and reproductive health and rights are being politicized – and opinions polarized.

As half the world goes to the polls this year, many leaders have decided to base their political strategies on sowing division.

Anxieties over migration as well as low- and high-fertility rates are being weaponized by some policymakers to strike down sexual and reproductive health and rights agreements. Meanwhile others are making their legal systems less equitable by decriminalizing female genital mutilation or restricting the rights of LGBTQIA+ people, for instance.

Harmful stereotypes about women, girls and people with diverse sexual orientations and gender identities are too often peddled to justify gender inequality and homophobia, with dangerous consequences. As Efram*, a refugee from Syria who was struggling to access sexual health care in a new country, explained to UNFPA: “I can’t tell anyone that I’m gay because of the stigma. We are not recognized, and we don’t have any kind of rights”.

4.But there is hope: Where inequalities exist, community leaders are helping to bridge gaps in services.

Gender inequality, racial discrimination and misinformation are deeply embedded in many health systems: UNFPA research has found that in the Americas, Afrodescendent women are more likely to die during childbirth due in part to racist abuse in the health sector.

For these reasons and others – including cost and distance to facilities – Afrodescendent women may avoid going to hospitals for health care. “It wasn’t the environment I wanted,” Shirley Maturana Obregón from Colombia told UNFPA about her birth plan.

Instead, she delivered with a partera, a traditional birth attendant and practitioner of knowledge ancestral to Colombia’s Afrodescendent community.

Parteras provide culturally sensitive care among Colombian communities that remain largely disconnected from the country’s formal health system – and for whom getting to a doctor can require expensive travel across hazardous, conflict-affected terrain.

Ms. Maturana Obregón said her delivery with a partera was beautiful and unforgettable; she later became a traditional birth attendant herself. “We are there, making women’s dreams come true,” she said.

5. Progress is achievable, but we must reject division and embrace collaboration.

UNFPA’s report shows above all that we cannot divide and conquer on our way to ensuring universal health and rights. Rather, we must find political consensus, tailor solutions to communities and mobilize urgent funding to achieve our aims.

Grassroots leaders are essential to this work: Sarah Sy Savané, who advocates against female genital mutilation and child marriage in Côte d’Ivoire, says programmes aimed at eliminating harmful practices are designed by people working in the communities they target. “Safe spaces, husbands’ clubs and other interventions are making a real difference, shining a light where young girls thought they had no rights,” she told UNFPA.

Initiatives like these have tangible impacts, but they need more support. Spending an additional $79 billion in low- and middle-income countries by 2030 would avert 400 million unplanned pregnancies, save 1 million lives and generate $660 billion in economic benefits. Training more midwives could also prevent about 40 per cent of maternal and neonatal deaths and over a quarter of stillbirths. 

Funding saves lives, while a lack of investment endangers them.

The truth is that inequality is everywhere we look – and once its devastating consequences have been revealed, they cannot be unseen. As UNFPA Executive Director Dr. Natalia Kanem said, “We have every reason to act – for human rights, for gender equality, for justice and for the world’s bottom line.

There is only one way to achieve a future of dignity and rights for all: By working together.”

Related topics

• Sexual & reproductive health
• Maternal health
• Comprehensive sexuality education

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Senior Spotlight: Reflections from the Class of 2024

April 29, 2024.

These 20 seniors took a moment before graduation to share what their Bass Connections experiences have meant to them. They’re among nearly 1,000 Duke undergraduates who participate in Bass Connections each year along with 200 graduate and professional students and 350 faculty and staff members.

For some undergraduates, taking part in collaborative, interdisciplinary research confirmed their interests; for others, the experience opened up new pathways. Numerous students found ways to take their research further through related honors theses and other opportunities while at Duke, and have identified career interests to pursue through post-graduation employment and further education.

Congratulations to all our graduating seniors!

Martha Deja

Neuroscience.

Eye Tracking: Objective Assessment for Mild Traumatic Brain Injury in Youth Athletes (2021-2024)

“Bass Connections has taught me so much about the research process, the importance of stepping up and pursuing your own passions by your own volition, and how to collaborate within a team community and further life’s important questions. From Dr. Luck, my mentor, I have learned how to lead a project with various moving pieces, how to delegate and how to foster my own sense of strength and self.”

After graduation, Deja will be working at a boutique healthcare consulting firm in Boston. She plans to apply to medical school.

Math and Computer Science

Measuring Urban Heat Islands and Their Causes in Durham (Data+ 2023)

“The thing I loved about Data+ the most is that we are able to apply what we have learned in class to a real-world challenge so that we can actually make a societal impact. It is such a well-structured program that I was able to get all the resources, guidance and funding that I needed to carry out the research. And the collaborative environment led our team to publish a paper in Scientific Reports. It is no doubt my best academic experience at Duke.”

Ge will be pursuing a master’s degree in management science and engineering at Stanford University.

Biomedical Engineering

Novel Therapies for Treating Cervical Cancer in Peru (2022-2023);  Duke and the Evolution of Higher Education (2023-2024)

“My experiences through Bass Connections allowed me to explore my unique interests that both converged and diverged with my primary academic major studies. I really enjoyed conducting oral history interviews with professors to better understand the evolution of teaching at Duke over the years and learning about the importance of stakeholders analysis in regulatory approval of novel therapies. Working on diverse teams revealed the importance of understanding different perspectives on a specific topic and sharpened my teamwork and organization skills. The collaborative and interdisciplinary research experiences from Bass Connections provide a strong foundation for my future work.”

After graduation, Guan will pursue a master of public health in chronic disease epidemiology at Yale University.

Trisha Gupta

Economics and global health.

Policy Surveillance of Financing for Universal Health Coverage (2021-2022)

“I loved my Bass Connections project! I was involved with the project my sophomore year and it made me realize my passion for the intersection between data and healthcare. I really loved being able to work alongside faculty and students across disciplines. I also enjoyed learning more about developing countries and the implementation of universal healthcare schemes worldwide.”

After graduation, Gupta will be working as a digital operations and marketing analyst for RVO Health in Charlotte.

Literature 

Big Data for Reproductive Health (2021-2022); Developing Nursing Resources for LGBTQ+ Older Adult Care Using Human-Centered Design (2022-2023); Mental Health and the Justice System in Durham County  (2023-2024)

“Bass Connections has given me invaluable research experience in the social sciences that I wasn’t able to get directly through my coursework. I relied heavily on this experience when applying to social work programs, and I hope it will provide the foundation for eventual doctoral study in social work or a related discipline.”

After graduation, Hart will be pursuing a master’s degree in social work.

Kaylin Hernandez

Public policy.

Strengthening Partnerships Between Durham Schools and Local Universities (2022-2024)

“Participating on this Bass Connections team solidified my passion for education equity and my desire to learn about how we can improve our U.S. PK-12 education system. I’ve loved working on this team, creating an anti-racist curriculum for college student volunteers, and engaging in site visits in Los Angeles, Philadelphia, and New York to learn about the University-Assisted Community Schools model in practice! I’ll always draw back on these past two years on the team, and I’m excited to contribute to our education system as a future educator and/or education lawyer.”

Hernandez plans to take a gap year researching education policy and working in K-12 public schools before heading back to school to obtain a master’s degree in education.

Computer Science

Implementing Electronic Symptom Screening for Telehealth Visits (2020-2021); Bioremediation of Plastic Pollution to Conserve Marine Biodiversity (2021-2024)

Related Thesis: Stutzering Up a Storm: In-Vitro Experimental Validation of Bioinformatics Techniques and Identification of Pseudomonas stutzeri as a Plastic Polymer Degrader

“Bass Connections has been immense during my time at Duke … [The program] allowed me to blend my STEM work and background to understand the humanity behind it all whether that was the emotional impacts of telehealth on cancer patients or the environmental and policy impacts of plastic-eating bacteria. The biggest things I learned were patience and persistence  – through Bass Connections I experienced challenges that forced me to find solutions I might have given up on before.”

Hong will pursue a career in software engineering after graduation.

Sophie Johnson

North Carolina Early Childhood Action Plan: Evidence-Based Policy Solutions (2021-2022); The Seat of Fascism: Narratives of Repression and Resistance in North Carolina (Story+ 2021)

“Participating in Bass Connections helped me discover what kind of policy I wanted to go into! It ignited my passion for early childhood education, something I have spent the past two years focusing on. I was able to build up my skills as a researcher and collaborate with community members and stakeholders. I was also able to help publish a policy brief! Spending a full year on a small team allowed me to really engage in the work I was doing and contribute substantially. Through Story+ I was also able to dive into archival research, something I value immensely as a history minor.”

Smith will take a gap year to work in early childhood policy before applying to law school to study education law.

Brendan Kelleher

Alcohol Use Behavioral Phenotyping Test for Global Populations (2021-2024)

“[Through Bass Connections], I have gained invaluable experience in the realms of computer programming, behavioral science and global health. The overall flexibility and diversity of ideas in my project have allowed me to delve into these various fields and find the topics that excite me the most while working towards an end product with real-world implications … The project’s flexible format also helped grow my leadership skills, as I was able to step up and take on new responsibilities, whether it was communicating our subteam’s work with the overall team or working with outside partners to troubleshoot our app when necessary. Overall, Bass Connections has shown me that you truly do not have to narrow the breadth of your passions to conduct research and create meaningful change in the world.”

Julia Leeman

Neuroscience and music.

Performing Embodied Communities: New Paths for Cultural Institutions  (2021-2022);  Auditory Imagery of Speech and Nonspeech Sounds (Data+ 2023)

Related Thesis: Event-Related Potential Differences in Auditory Imagery of Speech Compared to Nonspeech

“As a part of the Performing Embodied Communities team, I conducted a case study of Music & Memory, an organization that provides personalized music to older adults with dementia. This was a very personal project for me, as I had become fascinated by the connection between music and the brain through singing with my great grandmother who had dementia. This experience inspired me to find ways to combine my interests in science and the arts. After this experience, I began to work with Dr. Tobias Overath, studying the perception and imagination of speech and non-speech sounds, which led me to start a Data+ team and complete a senior thesis in neuroscience. In the fall, I will begin pursuing my Ph.D. through the Psychology & Neuroscience program at Duke!”

Leeman will begin her Ph.D. in psychology and neuroscience at Duke in the fall.

Yuxi (Jaden) Long

Creating Artificial Worlds with AI to Improve Energy Access Data  (2021-2022)

“My Bass Connections project exposed me to one of the fundamental difficulties in machine learning, data sparsity. Knowledge of this difficulty eventually inspired an original research project in my senior year. Furthermore, my Bass connections team has helped me gain experience in teamwork and collaboration in large-scale research projects.”

In the fall, Long will begin his Ph.D. at the Tri-Institutional Computational Biology & Medicine program in New York.

Alejandra Mella-Velazquez

Program ii: hispanic health behaviors and disparities.

Information, Perceptions and Health Behavior (2021-2022)

Related Thesis: Disparities in Care-Seeking Frequency and Decision Preference Among Hispanics Compared to Asians and Blacks and Across SES

“Bass Connections has truly been one of the most memorable experiences I’ve had at Duke … It introduced me to the immense opportunities that exist through interdisciplinary research. I was fortunate enough to have two amazing advisors, Cheryl Lin and Pikuei Tu, who have gone above and beyond as mentors for me.They have taught me everything that I know about research, and we have collaborated on many projects beyond our initial Bass Connections project. I learned about the endless opportunities that exist in research and how easily interconnected it can be to different disciplines and career pathways. Research shouldn’t be thought of as an individual activity but rather as an opportunity to engage with others and appreciate the diversity that brings people together with a common goal.”

In the fall, Mella-Velazquez will be attending the University of North Carolina’s Adams School of Dentistry.

Kishen Mitra

Eye Tracking: Objective Assessment for Mild Traumatic Brain Injury in Youth Athletes  (2021-2022)

“Overall, having an opportunity to make a direct impact on my local community through this Bass Connections project has led me to become an aspiring physician, pursuing a career at the intersection of engineering and medicine. While I have had an ongoing passion for product development, Bass Connections has allowed me to gain an appreciation for the translational value of research and the satisfaction that comes from serving others.” Mitra (center) working on a prototype in his first-year Engineering Design and Communication course (Photo: Jared Lazarus)

McKenna Paulik

Psychology and global health.

Optimizing a Community Health Program for Hypertension Control in Nepal (2022-2023)

“Bass Connections provided me with the opportunity to participate in a global health initiative based in Nepal, a country where I had the privilege of spending my gap year. This experience served as a meaningful intersection, enabling me to both contribute to a community that held personal significance and apply the skills I had acquired in the classroom. The collaborative nature of working within interdisciplinary teams, comprising both graduate and undergraduate students from various parts of the world, was undeniably the highlight of my Duke experience. Bass Connections has deepened my proficiency in collaboration, communication, writing and research, all of which I believe will be instrumental in shaping my future career endeavors.”

After graduation, Paulik will work as a research coordinator at the University of Chicago Medical Center. Her work will focus on building grassroots community health initiatives aimed at reducing healthcare inequities.

Alfredo Sanchez

Mechanical engineering.

Energy and the Environment: Design and Innovation (2021-2022)

“Through Bass Connections, I was able to engineer a portable wind turbine that can be used to charge your phone while backpacking, sailing or hiking. The experience helped me understand the power of harnessing wind energy, and how to use technical skills, like 3-D printing, to develop a consumer product. The variety in topics and scopes of my and my peers’ projects showed me that there are many different paths to a career in the climate space.”

Sanchez was recently awarded a Fulbright scholarship to travel to Taiwan for a year and teach English. In Taiwan, he will also learn Mandarin, practice tai chi and study the country’s energy systems.

Public Policy Studies

Celebrating Latinx Culture with a Spanish Reading Program (2021-2022)

Related Thesis: Mind the Gap: A Comparative Analysis of Adolescent Mental Health, Social Determinants of Health and Medicaid Policy in North Carolina

“Looking back on my experience with Bass Connections, I feel especially grateful for the opportunities to work directly with members of the Durham community on a cause I feel passionate about. As an undergraduate researcher, I helped construct the reading curriculum and later conducted its sessions with families myself. I also saw the research process through by helping analyze the study’s findings. This hands-on, comprehensive research experience inspired me to pursue other research in the Sanford School, both through personal and other collaborative projects. Additionally, it has sustained my interest in working towards improving social sectors such as education and healthcare in my career.”

After graduation, Smith will be a state and local government solutions associate at KPMG.

Sophie Smith

Program ii: sexual, reproductive and maternal health.

Promoting Psychological Adjustment and Pelvic Health Among Female Cancer Survivors (2021-2022)

Related Thesis: Examining Reproductive Justice: The Impact of Shackling on Incarcerated Pregnant Women

“Through Bass Connections, I acquired invaluable experience in research methodologies, such as qualitative coding using NVivo, and received unparalleled mentorship and friendship from my peers. This experience not only influenced the creation of my own Program II major but also shaped my decision to pursue work as a health and benefits consultant.”

After graduation, Smith will be joining Mercer Heath as a health and benefits consultant.

Keri Tomechko

Program ii: maternal health and developmental biology.

Community for Antepartum Patients (CAP): Establishing an Inpatient Model for Group Prenatal Care at Duke (2022-2023)

Related Thesis: Effects of Physical Activity Patterns and Barriers During Pregnancy on Health Outcomes for Women in High-income Countries

“Through education, discussion, reflection and immersion, my Bass Connections experience provided me with a much deeper understanding of the key factors that shape maternal health and pregnancy. The unparalleled opportunity to directly interact and communicate with antepartum patients helped me to develop a deeper understanding of the most common challenges and conditions that inpatient antepartum women face. The experience helped me find and fuel my academic niche and drove me to design and petition for my own major. My Program II, titled Maternal Health & Developmental Biology, has given me a greater appreciation of the intricacy of human physiology while reinforcing the incontestable role that external factors play in shaping health. I completed a senior thesis/capstone related to the subject, and I could picture myself continuing down a related path in my career.”

Tomechko will be starting medical school in the fall.

Neuroscience and German

Language, Music and Dementia  (2021-2024)

“Bass Connections was a program that had caught my eye back when I was a high schooler applying to Duke, and it was a dream come true to join the Language, Music and Dementia team with Dr. Andrews! I knew I wanted to be a neuroscience major and pursue medicine, but I wanted to continue cultivating my passions for music (as a musician myself) and language-learning (I grew up speaking English and Mandarin and have been studying German). It was so rewarding to join a research project where I could combine those interests and learn about how these fields inform each other, all in the name of improving human health. I have found Bass Connections and what it stands for to be the hallmark of my meaningful Duke education.”

Finnie Zhao

Economics and environmental sciences & policy.

Empowering Youth Civic Action on Plastic Pollution (2021-2022); Exploring Links Among Ecological, Social and Personal Resilience (2022-2023)

Related Thesis: A Just Pathway Toward Resilience: Building Local Communities’ Adaptive Capacity through State-Level Funding Program

“Having participated in two Bass Connections projects, I have enjoyed the unparalleled community and research experiences I found on both project teams. These two projects … provided me with different perspectives and methodologies in dealing with environmental issues. Both allowed me to experience the integration of research, service and engagement, from designing civic engagement curricula for secondary school students to studying coastal ecosystems and resilience through literature review to creating an environmental resilience toolkit for community-based practitioners.”

In the fall, Zhao will begin her Ph.D. in environmental policy at Duke.

• See highlights from the  2024 Fortin Foundation Bass Connections Showcase .
• Explore  additional reflections from students  about their Bass Connections experiences.
• Check out the winners of this year’s  Bass Connections Award For Outstanding Mentorship  and Student Research Awards .

Moscow Pullman OB/GYN

Preventative health.

For patients who are considering having children, regular obstetric care should begin before a woman becomes pregnant. At Moscow Pullman OB/GYN, we believe that by monitoring a woman’s overall health, we’re able to help her plan in advance for a healthy pregnancy and baby. Additionally, our health care experts provide preventive care guidelines and advice that help our patients remain healthy in areas such as diet, nutrition, and sexually transmitted diseases.

After taking your medical history and completing a physical examination, your Moscow Pullman OB/GYN doctor will discuss the results with you and answer any questions you might have. During this visit, our patients often ask us about such topics as:

• Cancer signs
• Breast self-exams
• Menopause symptoms and treatment options
• Sexuality/sex drive
• Types of birth control
• Having a baby
• Disorders that can be inherited
• Infertility
• Vitamins and supplements

Should your Moscow Pullman OB/GYN lab results happen to show anything unusual, our health care professionals will discuss the results and any implications to your future good health.

1205 SE Professional Mall Blvd #102

Pullman, WA 99163

(509) 332-7511

( 509) 334-4712

623 South Main #5

Moscow, ID 83843

(208) 883-0813

 (208) 882-8319