Teenagers are thirsting for information about themselves and the changes that puberty brings to their bodies. It is time to pay greater attention to their voices and needs
It was late at night when Seema Kumari, an accredited social health activist working in Bihar’s Sitamarhi district, heard the news. The 16-year-old daughter-in-law of her neighbour had given birth at home earlier than expected. Despite the late hour, she rushed to their house to see if she could be of any help. Unfortunately, the infant, weak and born prematurely, did not survive. In Sitamarhi, 106 newborn babies die for every 1,000 live births according to the Government’s statistics. Early marriage further exacerbates the vulnerability of adolescents. According to the fourth National Family Health Survey (NFHS-4), in Sitamarhi, 50.5 per cent of the women aged between 20-24 years had been married off before the age of 18 and 11.7 per cent of girls/women aged 15-19 years were already mothers or pregnant at the time of the survey in 2015-16.
Although she was deeply saddened by their loss, Kumari took the opportunity to convince the mother-in-law that she would not insist on another grandchild until her teenaged daughter-in-law had recovered physically and mentally. In fact, Kumari extracted a promise that they would wait for at least three years before trying for another baby. By this time not only would Pinky turn 19 and be better prepared for motherhood, it would also reduce the risk of infant mortality. Over the next three years, Kumari kept an eye on the family. It meant daily visits, talking to the mother-in-law and constantly reminding her of the promise. She also provided reproductive and sexual health information and aids to Pinky so that she could plan her family and delay motherhood till she was ready for it. In January this year, Kumari’s hard work bore fruit when Pinky gave birth to a healthy girl at the local primary health centre.
Women like Kumari are among the many frontline health workers who are making a difference between life and death for mothers and babies. Pinky was fortunate that Kumari was able to persuade her conservative marital family that there was a need to wait before the next pregnancy. The likelihood of girls aged between 10-14 dying during pregnancy and childbirth is five times higher than for women aged between 20- 24. An estimated 6,000 adolescent mothers die every year in India. The underlying reasons are early marriage coupled with a lack of sexual and reproductive health information. It was to disrupt the vicious circle of having too many children, too quickly and provide adolescents with appropriate information on reproductive and sexual health that the Rashtriya Kishor Swasthya Karyakram (RKSK) was launched by the Government in 2014.
Although the RKSK prioritised sexual and reproductive health as one of its six strategic areas of adolescent well-being, talking about this sensitive issue remains a taboo. In Bihar, entrenched patriarchy has made RKSK even more critical as adolescents, especially girls, are forced to remain invisible and refrain from being seen or heard. It becomes difficult for them to confide in their parents. Hence, they desperately need someone they can turn to for advice. But there is a shortage of trained, skilled human resource who can be their friend and guide.
Many girls on the brink of puberty know little about menstruation as no one prepares them for it when they reach puberty. In fact, menstruation comes as a shock for many and affects their mental health as they are unable to grapple with this major change in their bodies.
There is also an acute shortage of medical counsellors as well as women doctors. Though the biology textbook has a chapter on reproductive health, most teachers in rural areas skip it. This trend was more prevalent in co-educational schools where the teacher was too embarrassed to teach this important chapter to a class full of boys and girls.
Eighteen-year-old Fatima, who travels 20 kilometres daily to a college from Sherghati block of Gaya District, admitted that she wanted to know more about sexual and reproductive health. Fatima said the only information she had gleaned on this subject was from television programmes but that was not enough. Neither was it comprehensive. Under the RKSK, peer educators and Adolescent Friendly Health Clinics (AFHCs) are supposed to bridge this information gap. For a population of 1,000 people, there are supposed to be four peer educators, two boys and two girls. The Accredited Social Health Activists (ASHAs), panchayats and local Non-Government Organisations are part of the group to select and train the peer educators or “Sathiyas” as they are called. It is their responsibility to remove all doubts and fears of the adolescents by bringing them to the AFHCs.
Unfortunately, in many villages of rural Bihar, such clinics remain on paper. During a social audit conducted to assess the ground realities, it was found that even where they did exist, the absence of qualified service providers including counsellors mandated under the RKSK, made these clinics mostly non-functional.
One such AFHC is at the Belsand Primary Health Centre in Sitamarhi. The signage on the board outside mentions the services the clinic offers. The dilapidated board and the faded writing is the first sign of the clinic’s present state of health. The clinic doubles up as an Outpatient Department since there is no other room. Adolescents prefer not to come to this clinic primarily because there is an acute shortage of staff and privacy. Apart from a lack of a counsellor dedicated solely for adolescents, the Auxilliary Nurse Midwife (ANM) was on contract from the sub-centre!
The clinic was supposed to have seven doctors but it had only two. The lack of a woman doctor meant that few abortions were conducted there. According to ANM Rakhee Kumar, the lack of a woman doctor was the reason why very few came to seek abortion services at the clinic. The fact that parents and girls preferred to visit quacks for abortions underlines just how vital functioning AFHCs are for adolescents to access sexual and reproductive information and safe abortion services. Sadly, girls visit trained healthcare workers only when abortions are botched up by the quacks. And sometimes it is too late to help them.
When mothers are well-informed there are better chances that adolescents, both girls and boys, will better understand the changes their bodies are undergoing. In turn, well-informed teenagers are able to help their friends cope with their problems.
The three daughters of Anganwadi Worker (AWW) Anita Devi are different from their friends. They understand the importance of education and the pitfalls of early marriage. They have accurate information on puberty and its related changes. They have taken on the responsibility of sharing this knowledge with their friends.
Adolescents between 10-19 years comprise 22 per cent of Bihar’s population. The RKSK strategy was to provide a continuum of care for the health and development of adolescents. Also, envisioned was a convergence model of service delivery by involving ANMs, ASHAs, AWWs and volunteers of the Nehru Yuva Kendra Sangathan.
Several Union Ministries were to provide various components for adolescent development through special programmes like the Integrated Child Development Services. Adolescent health programme managers at the State and district level were to oversee the initiative based on project implementation plans.
Further, at the community level the intervention was to be through peer educators, holding quarterly Adolescent Health Day meetings, providing weekly iron and folic acid supplements and through a Menstrual Hygiene Management scheme. The facility-based intervention was through setting up and strengthening of AFHCs.
Despite such good intentions, the Government has failed in implementation due to the lack of convergence among the various departments and lack of trained service providers and supplies. There is an urgent need to empower frontline health workers like ASHAs, ANMs and AWWs in understanding the voices, aspirations and potential of adolescents and providing accurate information. Adolescents are thirsting for information about themselves and the changes that puberty brings to their bodies and way of thinking. It is time to pay greater attention to their voices and give them the power of information.
(The writer is a senior journalist. The views expressed are personal)