Rajib Acharya

Associations between Early Marriage and Young Women's Marital and Reproductive Health Outcomes: Evidence from India

CONTEXT Little evidence from India is available regarding the ways in which early marriage may compromise young womens lives and their reproductive health and choices. METHODS Data from 8,314 married women aged 20-24 living in five Indian states, obtained from a subnationally representative study of transitions experienced by youth, were used to compare marital, reproductive and other outcomes between young women who had married before age 18 and those who had married later. Logistic regression analyses were conducted to identify associations between timing of marriage and the outcomes of interest. RESULTS Young women who had married at age 18 or older were more likely than those who had married before age 18 to have been involved in planning their marriage (odds ratio, 1.4), to reject wife beating (1.2), to have used contraceptives to delay their first pregnancy (1.4) and to have had their first birth in a health facility (1.4). They were less likely than women who had married early to have experienced physical violence (0.6) or sexual violence (0.7) in their marriage or to have had a miscarriage or stillbirth (0.6). CONCLUSIONS Findings underscore the need to build support among youth and their families for delaying marriage, to enforce existing laws on the minimum age at marriage and to encourage school, health and other authorities to support young women in negotiating with their parents to delay marriage.

Do current measurement approaches underestimate levels of unwanted childbearing? Evidence from rural India

The validity of estimates of unintended childbearing has often been questioned, especially given their almost exclusive reliance on responses to survey questions that ask women to recall their intentions about past pregnancies. An opportunity to compare prospective and retrospective descriptions of intendedness was provided by a follow-up survey in four Indian states in 2002–2003 of rural woman originally interviewed in the 1998–99 National Family Health Survey-2. The results demonstrate a pronounced tendency for births prospectively classified as unwanted to be retrospectively described as having been wanted or mistimed. The main reason seems to be either that mothers adapt to the reality of a new birth or are reluctant to describe an existing child as having initially been unwanted. Our findings suggest that retrospective accounts of the wantedness of a birth, such as those obtained by current Demographic and Health Surveys, may lead to significant underestimates of true levels of unwanted childbearing.

Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India.

BACKGROUND Although legal, access to safe abortion remains limited in India. Given positive experiences of task-shifting from other developing countries, there is a need to explore the feasibility of expanding the manual vacuum aspiration (MVA) provider base to include nurses in India. STUDY DESIGN A prospective, two-sided equivalence study was undertaken in five facilities of a non-government organisation in Bihar and Jharkhand to explore whether efficacy and safety rates associated with MVA provided by newly trained nurses were equivalent to those provided by physicians. Eight hundred and ninety-seven consenting women with gestation ages of ≤ 10 weeks were recruited. RESULTS Nurses were as skilled as physicians in assessing gestation age and completed abortion status, performing MVA and obtaining patient compliance. Overall failure and complication rates were low and equivalent between the two provider types, and both provider types were equally acceptable to women who underwent the procedure (98%). CONCLUSION Findings of the study make a compelling case for amending existing laws to expand the MVA provider base in order to increase access to safe abortion in India.

Timing of first sex before marriage and its correlates: evidence from India

While several studies have documented the extent of pre-marital sexual experience among young people in India, little work has been done to explore the factors that are correlated with the timing of pre-marital sexual initiation. This paper examines age at initiation of pre-marital sex, circumstances in which first sex was experienced, nature of first sexual experience and correlates of age at initiation of pre-marital sex. Life table estimates suggest that pre-marital sexual initiation occurred in adolescence for 1 in 20 young women and 1 in 10 young men. For the majority of these young people, their first sex was with an opposite-sex romantic partner. First sex, moreover, was unprotected for the majority and forced for sizeable proportion of young women. A number of individual, family-, peer- and community-level factors were correlated with age at first pre-marital sex. Moreover, considerable gender differences were apparent in the correlates of age at first pre-marital sex, with peer- and parent-level factors found more often to be significant for young women than men.

Respondent-Driven Sampling for an Adolescent Health Study in Vulnerable Urban Settings: A Multi-Country Study

The global adolescent population is larger than ever before and is rapidly urbanizing. Global surveillance systems to monitor youth health typically use household- and school-based recruitment methods. These systems risk not reaching the most marginalized youth made vulnerable by conditions of migration, civil conflict, and other forms of individual and structural vulnerability. We describe the methodology of the Well-Being of Adolescents in Vulnerable Environments survey, which used respondent-driven sampling (RDS) to recruit male and female youth aged 15-19 years and living in economically distressed urban settings in Baltimore, MD; Johannesburg, South Africa; Ibadan, Nigeria; New Delhi, India; and Shanghai, China (migrant youth only) for a cross-sectional study. We describe a shared recruitment and survey administration protocol across the five sites, present recruitment parameters, and illustrate challenges and necessary adaptations for use of RDS with youth in disadvantaged urban settings. We describe the reach of RDS into populations of youth who may be missed by traditional household- and school-based sampling. Across all sites, an estimated 9.6% were unstably housed; among those enrolled in school, absenteeism was pervasive with 29% having missed over 6 days of school in the past month. Overall findings confirm the feasibility, efficiency, and utility of RDS in quickly reaching diverse samples of youth, including those both in and out of school and those unstably housed, and provide direction for optimizing RDS methods with this population. In our rapidly urbanizing global landscape with an unprecedented youth population, RDS may serve as a valuable tool in complementing existing household- and school-based methods for health-related surveillance that can guide policy.

Adoption and continuation of contraception following medical or surgical abortion in Bihar and Jharkhand, India

This study was carried out to explore whether the rates of postabortion adoption of a contraceptive method, and continuation of contraception over 6 months, differ among women undergoing medical abortion (MA) or surgical abortion by manual vacuum aspiration (MVA).

Knowledge attitudes and practices of certified providers of medical abortion: evidence from Bihar and Maharashtra India.

To explore Indian abortion providers’ knowledge of medical abortion (MA), their personal experiences and practices of providing medical abortion, and their attitudes toward providing MA to eligible women who were poor, uneducated, and/or from rural areas.

How adolescents perceive their communities: a qualitative study that explores the relationship between health and the physical environment

BackgroundThe Well-Being of Adolescents in Vulnerable Environments (WAVE) study was conducted among adolescents aged 15-19 years in Baltimore, Ibadan, Johannesburg, New Delhi, and Shanghai to examine perceived factors related to their health. A preliminary analysis of the data, unexpectedly, revealed that the influence of the physical environment on adolescent health was a dominant theme across every site examined. To explore this further, this paper analyzed the specific components of the physical environment that were perceived to influence health, and how they contributed to various health outcomes across sites.MethodsResearchers in each site conducted in-depth interviews among adolescents; community mapping and focus groups among adolescents; a Photovoice methodology, in which adolescents were trained in photography and took photos of the meaning of ‘health’ in their communities; and key informant interviews among adults who work with young people. A total 529 participants from across the sites were included in the analysis.ResultsFindings showed that while there was surprising uniformity in how adolescents characterized their physical environment, perceived health outcomes related to the physical environment varied by site and gender. In Baltimore and Johannesburg, vacant homes and the lack of recreation facilities were perceived to impact on sexual and reproductive health problems for girls, while among boys they contributed to drugs and violence. In Shanghai, New Delhi, and Ibadan, garbage and trash observed in their communities were perceived to have a higher impact on infectious and chronic diseases.ConclusionsAs the world continues to urbanize, our study points to a strong need to examine how the physical aspects of a living environment contribute to the health of adolescents. Specific aspects, such as housing, safety, garbage, and recreational spaces must all be examined as possible pathways for making improvements to health of adolescents, particularly among those living in poor urban environments.

MARRIAGE-RELATED DECISION-MAKING AND YOUNG WOMEN'S MARITAL RELATIONS AND AGENCY

There is little research that has explored how marriage arrangements, i.e., family-arranged, semi-arranged marriages with some say in spouse selection and self-arranged marriages, affect young womens married life in settings traditionally characterised by arranged marriage. Using data from 13,912 married young women aged 15–24 in India, we explore associations between marriage arrangements and young womens marital relations and agency. Logistic regression analysis shows that women experiencing semi- and self-arranged marriages were more likely than those in family-arranged marriages to communicate and interact with their husband (OR, 1.3–2.8), and exhibit agency in their life (OR, 1.2–2.3); those in semi-arranged marriages were less likely to experience marital violence. These associations were, however, stronger and more consistent among women from southern and western states than in northern and eastern states. Findings call for expanding the discourse on marriage to ensure young peoples right to free and full consent in spouse selection.

Condom use before marriage and its correlates: evidence from India.

CONTEXT Little evidence is available from India concerning young peoples use of condoms in premarital relationships. METHODS Data from a subnationally representative study of Indian youth conducted in 2006-2008 were used to assess condom use in premarital relationships. Analyses used survey data from 2,408 married or unmarried youth aged 15-24 who had had premarital sex, and qualitative data from 271 such youth who completed in-depth interviews. Logistic regression was used to identify characteristics associated with four measures of condom use (ever-use, consistent use, use at first sex and use at last sex). RESULTS Only 7% of young women and 27% of young men who had had premarital sex had ever used condoms. Among both sexes, discomfort with approaching a provider or pharmacist for condoms was inversely correlated with most measures of condom use (odds ratios, 0.5), while having peers who had had premarital sex was generally positively correlated (1.6-2.9). Females who had had premarital sex only with nonromantic partners were less likely than those with only romantic partners to have used a condom at last sex (0.2), while males were generally more likely to use condoms with nonromantic than romantic partners (1.5-1.6). Among men, education level, age at sexual initiation and neighborhood economic status were positively associated with use. CONCLUSION Programs that encourage condom use are needed. Service delivery structures should be modified to enable youth to obtain condoms easily and privately.