Poverty And Adolescent Girl Health
By
Adolescence in girls has been recognized as a special period in their life cycle that requires specific and special attention. There are direct linkages between poverty and adolescent girls' health and vast majority of poor girls caught in this vicious circle are the young mother to be of the 21st century, deprived of their basic rights to health, education, development and independence. Health and nutritional needs of adolescent girls are mostly ignored. There is enough evidence to indicate that fewer resources are invested in their health care - very few receive medical care and those who receive are taken to local and less qualified doctors.
Studies conducted in three metropolitan cities - Bombay, Calcutta, and Madras, indicate that a significantly higher proportion of girls compared to boys fall into grade II and III malnutrition. The cumulative effect of poverty, under nourishment and neglect is reflected by their poor body size/ growth and narrow pelvis as they grow into adolescence, making child bearing a risk. Girls between 13-18 years of age show lower percentage of iron, and with the onset of menarche become highly susceptible to anaemia. A majority of girls from poor families, with the onset of adolescence are 12-15 cm shorter than their well to do peers.
With such health conditions, a large number of girls from poor households are pushed into early marriages, which are consummated almost immediately after menarche of the 4.5 million marriages that takes place in India every year. Three million marriages involve girls in the 15-19 years age group (Glimpses of Girlhood in India). Girls bearing their first baby between the ages of 14-18 are at obstetric risk and the subsequent result is low birth weight babies and perinatal complications, common among teenaged girls. The upsurge of female deaths in the age group of 15-19 years bears testimony to the high mortality rate of women.
Adolescent girl's health covers mortality, morbidity, nutritional status and reproductive health and linked to these are environmental degradations, violence and occupational hazards, all of which have implications for adolescent girl health. The health of adolescent girl is intricately related to the socio-economic status of the households to which they belong and their age and kinship status within the households. Given the predominantly patriarchal setup, girls get a lesser share in the household distribution of health, goods and services compared to men and boys. There is data to show that in a situation of extreme food and scarcity, the adverse effect on the nutritional status of girls is greater than on boys. Girls in the 13 to 16 years of age group consume less food than boys. However, in the intra-household distribution of labour, adolescent girls get the major share of economic, procreative and family responsibilities. Due to the competing demands on their time and energy as well as their socialization, girls tend to neglect their health. The lesser access to food coupled with neglect invariably leads to a poor nutritional status and a state of ill health for most of the adolescent girls' health.
Adolescent girls' health plays an important role in determining the health of future population, because adolescent girls' health has an intergenerational effect. The cumulative impact of the low health situation of girls is reflected in the high MMR, the incidence of low birth weight babies, high prenatal mortality and foetal wastage and consequent high fertility rates.
The MMR for India is high and maternal death constituted 1.1% of the total reported death in 1990. Further, it is estimated that 15% of deaths in the reproductive age group (15-44 years) are maternal deaths. The specific cause of maternal death shows that bleeding and anaemia are the two major causes of death followed by abortion and toxemia. Severe anaemia is one of the important reasons for abortion, premature births and low birth and low birth weight of babies.
It has been observed that many Indian girls enter motherhood without adequate precaution for it. It results in high wastage of human resources, increasing rate of maternal mortality, infant and child mortality. The most relevant cause behind these problems is ignorance of mother, inadequate preparation of adolescent girls for safe motherhood and various undesirable practices prevalent in Indian society. Furthermore, 20 percent of women in the world become pregnant before attaining 20 years of age. This figure is much higher in a country like India. The incidence of teenage pregnancy, which is very high in India, is responsible for high infant and maternal mortality (NIPCCD, 1992-93).
Approximately 138 million of India's population is between the age of 15-25 years. About 50% adolescent girls get married at below the age of 20 in U.P, M.P, Bihar and Rajasthan, which contribute to 40 percent of India's population. It is rather unfortunate, but true that in the majority of girl children in India, there is no period of "Adolescence" as they shift from childhood to adulthood and soon become a pregnant adult.
However, these potential mothers and future homemakers continue to face the constraints of nutritional inadequacy - which is associated with high maternal mortality and morbidity. This is significantly higher in the States where early marriage of the girl child is the norm. The Government of India NFHS survey in 1992-93 revealed the maternal mortality rate in the country as 420 deaths per 100,000 live births.
As malnutrition among the child population in the country is widely prevalent, it follows that a moderate to severe degree of malnutrition would persist among girl child too. As a consequence, the malnutrition persists throughout adolescence and in pregnancy. As a result, the growth and development of unborn child is affected, giving rise to low birth weight. About 30 % of the total births in the country constitute low birth weights and this in turn leads to high infant and child mortality and morbidity. According to the NNMB data (National Nutrition Monitoring Bureau), a very high proportion of girls are at obstetric risk as they enter the 14th-15th year of life with a height less than 145 cm and weight less than 38 Kg.
The collaborative study done in Hyderabad, New Delhi, Calcutta and Madras showed that amongst girls between 6-14 years of age, the prevalence of anaemia was 63.8%, 65.7%, and 98.7% respectively. A study in rural area showed that 65.5 % parent of adolescent girls never spoke about the physical changes during puberty, like menarche, with their daughters.
On the other hand, adolescent girl's conditions of work in the informal sector are oppressive and exploitative, because of low wages, long hours of work, lack of provision for holidays and maternity leave. These lead to malnutrition, anaemia, morbidity and poor occupational health. The exposure of sexual exploitation is also common in the informal sector. In the urban context, majority of migrants live in squatter settlements on construction sites and disease prone areas, with lack of water supply, sewerage, garbage removal or electricity facilities. Medical care, access to education and the public distribution system are inadequate or absent. Adolescent girls are thus a vulnerable group exposed to the deteriorating urban environment, rapid urbanization, lack of employment opportunities, loss of employment, consumption of alcohol, effects of films on crime and sexual deviance, widespread circulation of pornographic literature, precipitate violence on women and adolescent girl. These processes have profound effects on their physical and mental well being. However research efforts in the area of adolescent girls' mental health, in general, and the effect of violence in particular are scanny.
In recent years urban population has been growing at a very high rate due to various factors of socio-economic hardships resulting in migration of rural poor to urban areas in search of employment and livelihood. The increase in urban slum is quite evident, gradually creating serious health problems. The existing urban health services are under pressure and services in the slum areas being most vulnerable and inadequate. There are multiple agencies providing health services in urban areas, but poor coordination among them results in duplication and inefficiency in services. Poor sanitary conditions in urban slums continue to create favourable conditions for disease transmission and health hazards for not only the slum population but for the entire population.
These prevailing conditions are causes of poor sanitation and other problems that have direct and indirect negative influences on adolescent girls' health. Problem of sanitation in the country and its implication for families, particularly the adolescent girls living in urban poor settlement, is frightening. Surveys (MICS- Multi Indicator Cluster Survey, 1995-96, urban slums, UNICEF; and the NFHS 1992-93) in nine States indicate that between 29-71 percent people use open spaces for defecation. Access to toilets among those urban poor generally living in legal slum settlements is just below 40 percent.
Government Initiative, Programme and Policies:
The adolescent age group differs in different set ups, according to WHO and UNICEF the adolescent age group is from 12-18 years. Due to menarche starting at a much earlier age, even at the age of 10-11 years, for all practical purposes, these girls should also be included in the programmes meant for adolescents. Concern has been expressed at the attitude towards menarche (onset of menstruation) and the myths and misconceptions associated with menstruation. The need for sensitively addressing the question of menstrual hygiene, the physiology and anatomy for developing a healthy understanding of the body and its functions; for example, menstruation as a part of growing up is very important.
Adolescent girl scheme is a special intervention for girls between 11-18 years of age to meet the special needs in nutrition, education and skill development. This scheme is extended to 3.91 lakh adolescent girls through 507 selected ICDS blocks in the country. Adolescent health is an important thrust of the new RCH programme.
Realising the situation of the girl child, The Heads of the Government of the SAARC Region met at Male in 1990 and declared 1991-2000 AD as 'SAARC Decade for Girl Child'. In fulfilment of this commitment, the Government of India has formulated a National Plan of Action (NPA) for the SAARC Decade of the Girl Child (1991-2000 AD) with a major theme of 'Survival, Protection, and Development' to attend to her gender specific needs and requirements to the fullest possible extent. This was a conscious effort to ensure equitable rights, opportunities, benefits and status to the girl child who faces discrimination much before her birth and throughout her life.
The NPA for the Girl Child broadly envisages three gender specific goals for the Decade (1991-2000) - which are akin to those of World Declaration on the Survival, Protection and Development of children in 1990 and the Male Declaration of SAARC. These are:
· Survival and Protection of girl child and safe motherhood,
· Overall development of the girl child, and
· Special protection for vulnerable girl children in difficult circumstances and belonging to special groups.
State Governments have formulated State Plans of Action for Girl Child appropriate to the condition prevailing in each State. So far, Governments of Karnataka, Madhya Pradesh, Tamil Nadu and Goa have formulated the State Plan of Action for Girl Child.
Conclusion:
The adolescent girls constitute an area that is not well researched and there is need to investigate how laws and official policies influence their reproductive health. The world's population between 10 and 19 years of age is more than 1 billion and to help meet their sexual and reproductive health needs, better data are needed about the proportion of youth who are sexually active at different ages and about their patterns of sexual behaviour. Situational analyses are required to provide these data, and there is also a need for research to identify a set of indicators that can be used to measure the sexual and reproductive health of adolescent girl health.
There is also not enough information about the context in which adolescent sexual activity occurs. Social situations have a strong influence on adolescent sexual behaviour. Many young people need support in delaying sexual intercourse; others need to know how to protect themselves from pregnancy and infection, while others require comprehensive services (including maternal health care). But little research has been carried out into how adolescents view their sexuality and how their views differ from those of adults. What are the best ways to help young people disclose their problems and what barriers to communication exist? Research should also investigate how laws and official policies influence adolescent reproductive health.
Besides the efforts and independent initiatives taken by different Government and NGOs, till recently adolescent girls health has not received any attention. Adolescent girls need to be considered as a special target group by schemes and development programmes. They need a package of services/ facilities, which will enhance their capacity for advancement and enable them to become capable citizens.
References:
1. The Girl Child and the Family, S. Anandalakshamy, 1994. Department of Women and
Child development, Ministry of HRD, GOI.
2. Glimpses of Girlhood in India, UNICEF, 1994.
3. National Nutrition Monitoring Bureau.
4. Situation of Girls and Women in Delhi, NCERT and TINNARI, January 1997.
Anant Kumar
Rehabilitation Psychologist and Research Scholar
Centre of Social Medicine and Community Health,
School of Social Sciences,
Jawaharlal Nehru University,
New Delhi - 110067.
pandeyanant@yahoo.co.uk)
