Adding It Up: Investing in the Sexual and Reproductive Health of Adolescents in India

India has made important gains in improving the sexual and reproductive health of women and young people. These advances include the expansion of the contraceptive method mix under the National Family Planning Programme, efforts to strengthen the contraceptive supply chain, and the 2014 launch of the Rashtriya Kishor Swasthya Karyakram (National Adolescent Health Programme), which prioritizes healthy development during adolescence.^1,2

Critical gaps in meeting adolescent sexual and reproductive health needs remain. As a result of lack of accurate information, provider bias and other barriers, many adolescents have limited agency to protect and foster their own sexual and reproductive health,^3–5 and obtaining comprehensive abortion care can be particularly challenging.^4,6,7 Difficulties related to obtaining information and services are compounded for adolescents who are marginalized on the basis of their sexuality, gender expression or marital status.^8–10 Gaps in access to comprehensive sexual and reproductive health care must be addressed for all adolescents, so they can exercise their rights to bodily autonomy and lead healthy lives.^11–14

The Adding It Up project estimates the need for, impact of and costs associated with increased investment in essential sexual and reproductive health services, including contraceptive care, maternal and newborn health care, and abortion-related care. These estimates demonstrate the immense potential benefits of investments to ensure that young women can decide whether and when to have children and can experience safe pregnancy and delivery. The estimates presented here pertain to adolescent women^* aged 15–19 in India in 2019.^†

Unless otherwise noted, the estimates in this report come from Sully E et al., Adding It Up: Investing in Sexual and Reproductive Health 2019, New York: Guttmacher Institute, 2020, and its accompanying methodology, which contains sources and methodological details. Some of the key data sources for this report include the United Nations (UN) Population Division’s World Population Prospects 2019, for population data; the UN Population Division’s Estimates and Projections of Family Planning Indicators 2020, for unmet need and current contraceptive use data; the Indian National Family Health Survey (NFHS-4), for data on subgroup and state-specific service coverage and need; and the Sample Registration System from the Office of the Registrar General, India, for numbers of maternal deaths. Unless otherwise noted, the data in this report come from calculations based on these sources.

Need for contraceptive services

In India, many women become sexually active, marry and start childbearing between the ages of 15 and 19. Many adolescent women—3.4 million—want to avoid pregnancy. This includes 3.2 million married women and 195,000 sexually active unmarried women.^‡

• Among adolescent women wanting to avoid a pregnancy, only about one million (29%) are using modern contraceptive methods (Figure 1).

• About half (48%) of adolescent women and their partners who use modern methods rely on male condoms. Forty percent use other short-acting methods including 37% who use the oral contraceptive pill and 3% who rely on either injectables, lactational amenorrhea or female condoms. These methods are predominantly obtained from the private sector.¹⁵ Eight percent of adolescent women using modern methods use permanent female sterilization, and 4% use long-acting reversible methods.
• More than two million adolescent women wanting to avoid a pregnancy (71%) do not use a modern contraceptive method and are therefore categorized as having an unmet need for modern contraception. The majority of these adolescents use no method at all, while about 10% of them use withdrawal as their primary form of contraception.
• Among women wanting to avoid a pregnancy, the proportion who have an unmet need for modern methods is much higher for adolescents (71%) than for all women in India of reproductive age (27%).
• The level of unmet need for modern contraception varies across groups of adolescent women wanting to avoid a pregnancy. For instance, unmet need affects 63% of adolescents from the richest households and 77% of those from the poorest households (Figure 2). Unmet need is also elevated among adolescent women in rural areas, those who have not begun childbearing and those younger than 18.

• Of the 60 million adolescent women in India, two million each year experience a pregnancy. The majority of these pregnancies (63%) are unintended, meaning they occur too soon or are not wanted at all. Adolescent women with an unmet need for modern contraception account for nine out of every 10 unintended pregnancies among 15–19-year-olds.

Need for maternal and newborn health care

Although relatively high proportions of adolescent women giving birth do so in a health facility (85%; Figure 3) and deliver with a skilled birth attendant (86%), there are still many adolescents whose needs for pregnancy-related health care are not being met, and these gaps vary according to women’s characteristics.

• Forty-eight percent of adolescent women who experience major medical complications related to pregnancy or delivery do not receive necessary treatment.
• Only 52% of adolescents giving birth receive the recommended minimum of four antenatal care visits.^§ This proportion is much lower among adolescents giving birth who have no education (30%) than among those who have more than a secondary education (56%), and it is lower among rural adolescent women (48%) than among those in urban areas (64%).
• Among adolescents giving birth, the proportion delivering in a health facility is lower for women from the poorest households (72%) than for those from the wealthiest households (96%).
• Sixty percent of adolescent women giving birth receive a postnatal checkup within 24 hours of delivery. This proportion is lower among rural adolescent women (44%) than among married adolescents (60%).

Abortion-related care

• Of the two million pregnancies that occur among adolescents in India each year, 53% of them end in abortion, resulting in 930,000 abortions annually.^**
• An estimated 78% of abortions among adolescents are unsafe (either less safe or least safe). Abortions categorized as least safe are those most likely to result in complications.
• Of the 450,000 adolescent women per year who need postabortion care for complications following an unsafe abortion, 42% of them (190,000) do not receive it.
• Full provision of both safe abortion care and postabortion care should include counseling on and provision of contraceptives.¹⁸

Impact

• Adolescent women who want to avoid pregnancy need contraceptive services that allow them to make informed choices about their bodies, protect their health and avoid unintended pregnancies, unsafe abortions and maternal death. These services must include nonjudgmental contraceptive counseling, provision of the full spectrum of contraceptive options, and full information about correct method use, potential side effects and management of side effects.
• If all adolescent women in India who want to avoid a pregnancy were using modern contraceptives and all pregnant adolescents were to receive care at the standards recommended by the World Health Organization (WHO), the impacts would be dramatic: Unintended pregnancies and unsafe abortions would decline by 66% (Table 1).
• Further, if all abortions that are currently unsafe were provided safely, and if all needs for contraceptive and postabortion care were met, abortion-related deaths would decline by 97%.

Costs

• The annual combined cost of providing current levels of contraceptive, maternal, newborn and abortion-related care for adolescent women in India is estimated at ₹1,073 crore, or US$147 million^†† (Figure 4).

• This total includes ₹67 crore (US$9 million) for contraceptive services, ₹654 crore (US$89 million) for maternal and newborn health care, and ₹353 crore (US$48 million) for abortion-related care. Annual direct costs^‡‡ are ₹553 crore (US$75 million) and annual programs and systems (indirect) costs are ₹521 crore (US$71 million).
• A comprehensive package of sexual and reproductive health care that would meet all adolescent women’s needs for modern contraceptive services (including contraceptive counseling), maternal and newborn health care, and abortion-related care, would cost ₹1,561 crore (US$213 million) annually.
• This comprehensive package would actually cost less than increased investment in maternal and newborn health care alone. Because investing in contraception averts unintended pregnancies, every additional ₹100 spent on contraceptive services above the current level would save ₹252 (or US$2.52 saved for every US$1 spent) in the cost of maternal, newborn and abortion-related care.
• In addition, providing full access to comprehensive safe abortion care would reduce the incidence of abortion-related complications and, therefore, the cost of postabortion care. The overall costs associated with abortion-related care would decrease by ₹297 crore (US$41 million) to ₹56 crore (US$8 million) annually.
• In addition to immediate cost savings and improvements in health, increased investment in sexual and reproductive health would also achieve far-reaching long-term benefits to households and society at large. For example, the Population Foundation of India estimated that 15 years’ worth of appropriate public investment in modern contraceptive care could save households one-fifth of their out-of-pocket expenditures on child health care costs, and cause India’s per capita gross domestic product to rise by 13%.¹⁹

Recommendations

Targeted investment in the sexual and reproductive health of adolescents in India is vital to reducing unintended pregnancies, unsafe abortions, unplanned births and maternal deaths, as well as to ensuring the bodily autonomy and well-being of the country’s young people. In addition to full investment, a rights-based policy framework is needed to prevent reproductive coercion and ensure equity in access to services. The following shifts in policies, programs and practices will be required in order to meet health goals set at state and global levels.

Help adolescents make informed decisions by providing them with high-quality, inclusive, accessible and nonjudgmental contraceptive counseling services.

• Health workers must provide adolescents with accurate, nonbiased information.
• All health workers must be trained in how to provide adolescent-friendly services, including how to provide respectful, nonjudgmental care for young people, regardless of their marital status or gender. Value clarification exercises that expose underlying judgments and beliefs around adolescent sexual health may help health workers provide adolescents with the same quality of care they offer older women.
• Information on contraception needs to be provided to unmarried adolescent women and men through multiple channels, so that their first point of contact with the health system is not for maternity care.
• Contraceptive counseling for adolescents must include information about a range of contraceptive methods, as well as each method's effectiveness, potential side effects and cost; assistance in choosing a method that matches their childbearing goals (including information about the use of temporary methods for preventing, delaying or spacing births); STI prevention strategies; and information on emergency contraception and abortion services for adolescents whose primary method has failed.

Diversify efforts to disseminate information and provide sexual and reproductive health care.

• Private-sector channels must be strengthened to ensure high-quality and comprehensive care, particularly for contraceptive services focused on spacing births, as adolescents tend to seek this care from providers outside of the public sector.¹⁵
• Social marketing and digital solutions, including social media campaigns, must be leveraged to reach young people unable to obtain care through traditional channels.
• Adolescent women must be provided with information, commodities and support according to WHO guidance for self-care in sexual and reproductive health. Sexual and reproductive health services must reach adolescents who desire to self-administer methods of contraception, such as oral contraceptives and injectables, as well as medication abortion.

Strengthen national laws and policies to protect the rights of adolescents to sexual and reproductive health care.

• Comprehensive, stigma-free contraceptive and abortion services must be accessible for all adolescents.
• Age-appropriate comprehensive sexuality education that affirms young people’s rights, including their right to pleasure, must be offered through community- and school-based programs. These programs should provide information on fertility awareness, pregnancy and contraceptive options.
• Government family planning programs, such as Mission Parivaar Vikaas, should broaden their language so that messages about preventing unintended pregnancy apply to all people, regardless of their marital status.
• The high rates of child marriage found in some states must be addressed through increased education about the harmful social norms and practices that perpetuate early marriage, and by enforcing the legal age of marriage. This type of multipronged approach is necessary to ensure girls’ physical safety and reproductive autonomy.
• Young people must be meaningfully engaged in conceptualizing, designing, implementing, monitoring and evaluating programs and policies that affect them, in accordance with guidance from WHO's Global Accelerated Action for the Health of Adolescents (AA-HA!).

Lastly, adolescent sexual and reproductive health must be prioritized amidst the spread of COVID-19 to avoid disruption of awareness efforts and service delivery, which could widen existing gaps in health outcomes and access to care.