The country needs to recognise the wrongs and affirm the rights for advancing women’s sexual and reproductive health
Young women (15-24 years) constitute 11 per cent of India’s population, out of whom 41 per cent have faced sexual violence, 27 per cent are married before the legal age and 7.8 per cent (15-19 years) become mothers or are pregnant. The data on access to information on contraceptives reveals that only 17.7 per cent were informed about family planning by health workers and just 6.9 per cent women in Bihar and 11.6 per cent in Uttar Pradesh (UP) reported using contraceptives within marriage.
The policy level commitments on health, education and gender parity often look in absolute terms of changing certain societal norms through cash transfer based schemes, number of girls reported to be married before the legal age of marriage, status of body mass index and nutrition and sometimes enrollment in school and skill development among women. While evidence in these parameters are significant, this skewed approach to gender equality leaves out a range of issues, including prevalence of sexual violence and status of accessible sexual and reproductive health services. Stigma and fear attached to young women’s sexuality act as a major barrier in achieving gender equality. Young girls are marginalised within the larger constituency of youth and remain an invisible group to be addressed by the stakeholders including families, service providers and policymakers. This denial takes them farther from exercising their human rights, forcing them to maintain the disbalanced status-quo and thus impacting their lives, homes, education and career potential. This manifests itself in five key aspects of their lives — sexual health, early, forced marriage and early, forced pregnancy, domestic violence, education, economic opportunities and income. Restrictive sexual norms limit their access to information on menstruation, consent, violence and stigma-free relationships, right to abortion, resulting in them feeling dis-empowerment.
Globally women’s reproductive and sexual health choices have stirred debates between conservative, protectionist and patriarchal groups and rights-based feminist and public health movements. Even with a five-decade old law in India, the Medical Termination of Pregnancy Act in 1971 continues to face challenges in implementation due to the stigma, bias, lack of awareness and lack of provision of trained service providers. This widens the gap between access to health and choice for women. Evidence shows that unsafe abortion continues to be the third-leading reason of maternal mortality in India. The Lancet Global Health Report estimates 48.1 million pregnancies with a rate of 144·7 pregnancies per 1.000 women aged 15-49 years, and a rate of 70·1 unintended pregnancies per 1.000 women aged 15-49 years.
At a public health centre in Delhi, a 25-year-old woman shares her experience of being denied service on account of her marital status. She was asked by the doctor to come only after marriage and if really needed. Similar findings through audits conducted in Varanasi and Delhi have highlighted the lack of accessible, affordable and youth-friendly services on sexual and reproductive health. Additionally, there is an inherent problem with the language that the country’s legal system adopts which further increases the marginalisation of young people who might not conform to the heteronormative gender and sexual identities. Another legal barrier is the convolution that has emerged post the implementation of the Protection of Children from Sexual Offences (POCSO) Act, 2012. While it has been significant in increasing accountability of a range of stakeholders on responding to child sexual abuse, the mandatory reporting system has added to the confusion, reduced intent for uptake of additional responsibility and delays from service providers, thus preventing young women from accessing confidential and safe abortion and reproductive health services.
The lack of accessible and compulsory sex education across settings also compounds the problem as it prevents young people from making informed choices. In the case of suspension of Adult Education Programmes, the objections raised by teachers, parents and some policy makers on the grounds of protecting Indian culture and upholding morality, took precedence over the rights of young people as guaranteed in Article 14, Article 15 and Article 21. This has made conversations pertaining to body, sexuality and sexual and reproductive health more suppressed. As a result, unplanned pregnancies, unwanted sexual relationships, sexually transmitted infections, early marriage and violence are then endemic in young women’s narratives. Several studies mapping the quality of sexual and reproductive health and rights services on various parameters have repeatedly pointed out that young people face stigma because of the mindset that adolescent sexual behavior is not “allowed”. In the case of unmarried women, the provider service bias has less impact on seeking information on menstruation hygiene management but it aggravates in situations where information on contraception and abortion is sought. The cyclic form of violence then forces young women towards harmful health practices that impacts their physical and mental health. The problem at large, therefore, emerges from attitude and availability of trained service providers, lack of supplies and commodities, lack of privacy and confidentiality and overall lack of continuum of care thereby adversely impacting young women’s informed decision making capacities on matters of their sexual and reproductive health.
As a way forward, it is important that we work towards bringing societal transformation as well as strengthening of Government programmes and policies. Cultural understanding of family’s honour as daughters’ responsibility needs to be challenged to bring about a shift in the status quo. It is important to promote a culture where unmarried young women are not judged by any service provider for asking questions around menstruation, sex and relationships and where teachers are sensitive and trained to understand how sexual health and rights contribute to young women’s overall well-being. Young women’s aspiration of realising positive and affirmative sexual well-being should reflect in the cultural attitude and behaviour of parents, teachers and health service providers.
Service providers and all health facilities have a greater role to play in providing comprehensive and quality abortion service care including post-abortion contraception and upholding the dignity and choice of women. Interventions are needed to provide women with accurate information on self-administered drugs along with provision for follow-up care. Research is needed to test interventions that improve knowledge and practice in providing medication abortion and the Government needs to prioritise improving policies and practice to increase access to comprehensive abortion care and quality contraceptive services that prevent unintended pregnancy. Across Government departments, a robust accountability mechanism needs to be reinstated for effective implementation of Government- sponsored programmes focussing on adolescent girls and young women. It should be the Government’s mandate to monitor and audit these programmes through committees led by girls and young women, to voice the community’s issues. Hope the voice of women is heard as we celebrate International Day for Elimination of Violence against women today.
(The writer is Pratigya Campaign Advisory Group member.)