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By Usha Rai
58% of girls in Maharashtra first conceive at 15-19 years. Following the success of an IHMP initiative which saw a three-fold increase in the use of contraceptives, delay in the median age of conception by a year, and a reduction in post-natal complications and reproductive tract infections, the Maharashtra government will reward villages that succeed in raising the age of marriage for girls
“What is masculinity? Who is a real man? Is it someone who marries a woman or a girl?” These are some of the questions being asked in a number of villages in rural Maharashtra where early marriage is the norm. The Maharashtra government has launched an important multi-pronged initiative in 10 most backward districts of the state to delay marriage and motherhood among young adolescent girls.
SATHI (Safe Adolescent Transition and Health Initiative), a pilot project being implemented in collaboration with the Institute of Health Management, Pachod (IHMP), is seeking to change social norms and attitudes by telling young men that marrying teenage girls is not a sign of mardaangi (manliness).
Though Maharashtra is considered one of the more advanced states in India, 49% of rural and 29% of urban girls are married before they reach the age of 18. This means a whopping 50 lakh adolescent girls in Maharashtra are married. A study conducted by IHMP showed that 58% of the girls first conceived when they were adolescents, at just 15-19 years of age. Instead of going to school or junior college and preparing for life, these adolescents became trapped in the cycle of procreation and responsibilities.
They suffered further trauma when their babies died within days or months of being born. Neonatal mortality was 54% when the mother was an adolescent; infant mortality was 76%. The study also revealed that 26% of the babies had a low birth weight.
Take the case of Rekha, from a village in Yavatmal district, who was just 15 years old when she got married. The life of this extremely bright girl, who excelled in athletics, changed dramatically after marriage. By the age of 19 she had two children and lived in a joint family. Pressured with housework and subjected to domestic violence, Rekha became anaemic and malnourished. As a result, both her babies had a low birth weight.
IHMP began its intervention, between 2003 and 2006, in 50 villages and 29 slums across 10 high-risk districts of Maharashtra. The objective was to improve the sexual and reproductive health of married adolescent girls and develop a model for rural areas.
IHMP’s strategy was to win the confidence of couples and instil in them a positive approach to reproductive health. The programme covered around 2,000 married pregnant adolescents. Surveillance involving the community led to early identification of pregnant girls. Couples were encouraged to avail of the healthcare and nutrition programmes, while peer educators went from village to village offering advice and support and gently probing men about their views on masculinity.
At the end of three years of intervention, the percentage of institutional deliveries went up from 61% to 64% in rural areas, and from 81% to 85% in urban areas. There was greater involvement from ANMs (auxiliary nurse midwives) in post-natal care and a significant reduction in post-natal complications like excessive bleeding, fever and pain in the lower abdomen. The rate of low birth weight babies dropped from 35% to 25% in rural areas, in three years, and from 27% to 18% in urban areas.
Dr Ashok Dyalchand, director of IHMP, explains that among the key outcomes of the pilot model was a three-fold increase in the use of contraceptives, delay in the median age of conception by a year, and a reduction in post-natal complications and reproductive tract infections (RTIs).
At a special one-day meeting held in Delhi recently, the Directorate of Health Services, Maharashtra, IHMP, Population Foundation of India and several donor organisations that have supported the research in Maharashtra focused on the need for special policy intervention for adolescent married girls. In fact, early marriage and early conception are common problems in most parts of the country. Therefore, a national policy for married adolescent girls is of paramount importance.
Dr Prakash Doke, Director, Health Services, Maharashtra, is confident that investing in married girls will pay rich dividends. In Maharashtra, girls have already embarked on an educational investment project called ‘How Red Are You’. Under the project, a column on haemoglobin count (to check for anaemia) has been added to the health cards of school children.
Also in the pipeline is a programme on the lines of the Nirmal Gram Puruskar (NGP) scheme. Under this scheme, villages that have achieved sanitation goals like zero open-defecation are given financial rewards. Similarly, the health department will reward villages that succeed in raising the age of marriage for girls. Doke hopes this will initiate healthy competition among villages to delay marriage.
Doke adds that for the first time, the state has the liberty to plan health programmes and avail of financial resources allocated by the National Rural Health Mission (NHRM). He points out that while ARSH (Adolescent Reproductive Sexual Health) is an important part of NRHM, it is considered a clinic-based approach to the problem. Secondly, its convergence with HIV/AIDS programmes is not taking place satisfactorily.
For ARSH programmes, the best approach is to go to schools and ‘capture’ students. This has been the approach for Maharashtra’s HIV/AIDS programme which has been dovetailed with the school life skills education course.
There is, however, the need to address the problem of out-of-school girls. In almost all states, except Kerala, the drop-out rate for girls is very high. Maharashtra has, in fact, several ‘mini Keralas’ like Sindhudurg district that boast excellent social indicators. But there are other areas that have dismal education levels. For example, Mumbai has a high education level among adolescents but the picture is the opposite just 100 km away, in tribal areas like Mokhla block in Thane. Ten per cent of Maharashtra’s population is tribal.
The SATHI programme is currently being implemented in the state’s most ‘backward’ districts of Parbhani, Hingoli, Jalna, Nanded, Beed, Gadchiroli, Dhule, Nandurbar, Yavatmal and Buldana through 20 primary health centres. In 2010, it will be reviewed and adopted in other districts too, says Doke.
What makes the SATHI programme replicable is that it requires no special health set-up. What is required, however, is assigning responsibility to a community-based link worker for monthly surveillance in order to identify the health needs of married adolescent girls.
There are several heart-warming stories that offer insights into the programme.
When Rattan Mausi, 56, a member of the village health committee, learnt that a young couple had approached a doctor for sex-selection, she threatened to report the man. She told the father-to-be that she would keep his wife with her unless he signed on an official stamp paper that he would not terminate the seven-month pregnancy. She even volunteered to adopt the baby girl.
The parents have since happily accepted the child.
Anjana, who was pressured into marriage when she was just 16, joined IHMP’s programme for married adolescent girls where she learnt about the dangers of early conception. She convinced her in-laws and her husband that her first pregnancy should be delayed. She also convinced her husband to use a condom until she could start on the oral pill. Anjana was on the pill for two years; she delivered a healthy baby only in 2006, when she was 19.
Rupali, 17, had been married for eight months. For several months, she complained of white discharge. A community health worker learnt of her problem in the course of a routine visit and, after taking her husband’s consent, referred her to a hospital for treatment. Rupali has been cured and, for the first time since her marriage, feels well.
While Maharashtra is determined to extend its special initiative for married adolescent girls throughout the state, it will be interesting to see how many other states start similar interventions to bring the smile back to the faces of adolescent girls.
Contact
Institute of Health Management, Pachod
Pachod
Aurangabad-431 121
Maharashtra
India Email:
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(Usha Rai is a senior development journalist based in Delhi)
InfoChange News & Features, October 2008
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