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PURPOSE: Marriage without meaningful consent persists in India, yet early marriage programs have rarely addressed consent, and research on the practice and its consequences for married life is limited. This study explores how consent in marriage decisions affects married life, specifically, agency, gender attitudes, spousal communication, contraception, and marital violence outcomes. METHODS: A subset of 1991 married girls and young women was drawn from a 2018 state-representative survey of adolescents and youth aged 15-21 years in Jharkhand. We compared outcomes between those in self-arranged marriages (n = 392), those in semi-arranged marriages who were acquainted with their husbands before marriage (n = 612), and those in fully parent-arranged marriages with no premarital contact (n = 995). Logistic regression analyses identify associations between marriage decision-making and outcomes of interest, controlling for confounding sociodemographic factors. RESULTS: Compared with girls whose marriages were self-arranged, those in both fully parent- and semi-arranged marriages were less likely, respectively, to make household decisions (odds ratios [OR], .37 and .60), hold egalitarian gender role attitudes (OR, .48 and .66), uphold girls' rights (OR, .41 and .48), communicate with their husbands (OR, .48 and .64), and practice contraception (OR, .51 and .67). Those in fully family-arranged marriages also had less freedom of movement (OR, .64) and were less likely to express self-efficacy (OR, .64). Marital violence was unrelated to marriage arrangements. CONCLUSIONS: Self-arranged marriage is associated with more positive outcomes than family-arranged ones, including semi-arranged ones, but marriage arrangements are unrelated with marital violence. Findings reaffirm the need to breakdown prevailing patriarchal norms and promote girls' right to meaningful, "free and full consent".

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Abortion service provision has changed noticeably in the recent past and medication abortion currently accounts for four-fifths of all induced abortions taking place in India. How these changes have modified abortion experiences among young women - a group known to be more disadvantaged than adult women - remains unanswered. This paper fills this gap and examines the experiences of married young abortion seekers, including pre-abortion decision-making, abortion seeking and experiences of the procedure, and post-abortion complications. Data were drawn from a community-based survey of 4952 married young women aged 15-24 years conducted in Uttar Pradesh and Rajasthan in 2015. The study focused on 166 young women who had an induced abortion in the two years before the survey, and used descriptive statistics to describe their abortion experiences. Seventy-four per cent of abortion seekers had relied on medication abortion and 47% had obtained it over the counter without a physician's prescription. Moreover, 90% accessed abortion services from private facilities, including drug sellers. A small proportion (4%) had undergone abortion in the second trimester of pregnancy. At the same time, 13% reported multiple abortion attempts; 17% underwent dilation and curettage; and 52% experienced self-reported complications, including 5% who experienced moderate to severe complications. The findings call for greater attention to providing contraceptive counselling and services to married young women, ensuring abortion services in public health facilities and exploring mechanisms to improve drug sellers' knowledge and practices in providing medication abortion.

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Although the importance of working with young men to transform traditional gender norms has been widely acknowledged, programmes for young men remain sparse in highly gender stratified settings such as India, and those that have been implemented have not reached those in rural areas and those out-of-school. Drawing on data from a cluster randomised controlled trial with panel surveys, of a gender-transformative life skills education and sports-coaching programme conducted among young men aged 13-21 who were members of youth clubs, this paper examines the extent to which it transformed the gender role attitudes of young men and instilled in them attitudes rejecting violence against women and girls. The intervention succeeded in changing gender role attitudes and notions of masculinity, attitudes about men's controlling behaviours over women/girls, attitudes about men's perpetration of violence on a woman/girl and perceptions about peer reactions to young men acting in gender-equitable ways. Effects were particularly significant among young men who attended regularly, underscoring the importance of regular attendance in such programmes.

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While there are a growing number of interventions and evaluations of programmes aimed at changing gender norms and violence against women and girls, there remains a dearth of documentation outlining the challenges faced in conducting these interventions and evaluations, particularly in traditional and low literacy settings. The Do Kadam Barabari Ki Ore (Two Steps Towards Equality) programme sought to understand what works to prevent violence against women and girls in Bihar, India. This paper draws insights from process evaluation data. It describes promising features and challenges of implementation, and characteristics which weaken the potential effects of complex, community based, social sector programmes that aim to change deeply entrenched gender power hierarchies. We drew on the Medical Research Council framework for process evaluation in analysing our process evaluation data, and focus on mechanisms of impact, and factors inhibiting programme success, including contextual and implementation challenges. The paper also outlines measures that may help overcome observed challenges and areas that require modifications and/or further investigation. The programme experienced several challenges. These included contextual issues, such as the lack of leadership skills of those delivering the intervention and the gap between expected responsibilities and activities of government platforms and reality. Implementation challenges were encountered in reaching men and boys, younger women and the community at large and ensuring their regular attendance; and in maintaining the fidelity of the intervention activities. Our insights call for an evidence-supported dialogue on these challenges and how best to anticipate and address them.

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CONTEXT: Although interventions such as the PRACHAR project in Bihar, India, have been associated with increased contraceptive knowledge and use in the short term, less is known about whether such gains are sustained years later. METHODS: Survey data, collected in 2013 from 2,846 married women aged 15-34, were used to compare contraceptive awareness and use between those who lived in areas where the PRACHAR project had been implemented in 2002-2009 and those who lived in matched comparison areas. Multivariate analyses assessed whether, after adjustment for covariates, outcomes differed between women in comparison and intervention areas, as well as between women directly exposed to the program and those who lived in intervention areas but had been only indirectly exposed. RESULTS: Compared with women in comparison areas, those in intervention areas were more likely to have method-specific knowledge of oral contraceptives, IUDs, condoms and the Standard Days Method (odds ratios, 1.4-1.7); to know that oral contraceptives and condoms are appropriate for delaying first pregnancy (2.3 for each) and IUDs and injectables are appropriate for spacing births (1.4 for each); to have ever used contraceptives (2.1) or be using a modern method (1.5); and to have initiated contraception within three months of their first birth (1.8). Levels of awareness and use were elevated not only among women directly exposed to the intervention but also, for many measures, among indirectly exposed women. CONCLUSIONS: The association of multipronged reproductive health programs like PRACHAR with contraceptive awareness and practices may last for years beyond the project's conclusion.

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This paper reviews the evidence on sexual and reproductive health and rights (SRHR) of adolescent girls in low-income and middle-income countries (LMIC) in light of the policy and programme commitments made at the International Conference on Population and Development (ICPD), analyses progress since 1994, and maps challenges in and opportunities for protecting their health and human rights. Findings indicate that many countries have yet to make significant progress in delaying marriage and childbearing, reducing unintended childbearing, narrowing gender disparities that put girls at risk of poor SRH outcomes, expanding health awareness or enabling access to SRH services. While governments have reaffirmed many commitments, policy development and programme implementation fall far short of realising these commitments. Future success requires increased political will and engagement of young people in the formulation and implementation of policies and programmes, along with increased investments to deliver at scale comprehensive sexuality education, health services that are approachable and not judgemental, safe spaces programmes, especially for vulnerable girls, and programmes that engage families and communities. Stronger policy-making and programming also require expanding the evidence on adolescent health and rights in LMICs for both younger and older adolescents, boys and girls, and relating to a range of key health matters affecting adolescents.

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In India, evidence is sparse regarding the demand for contraception to delay first pregnancy among married young people. Using data drawn from a study conducted in six Indian states among 9,572 women aged 15-24 who were married for five or fewer years, we explore the scope of this demand, the extent to which it has been satisfied, and, using logistic regression analyses, the factors correlated with contraceptive use to delay first pregnancy among those reporting demand. Findings confirm considerable demand for contraception to postpone first pregnancy (51 percent). Of those with demand, only 10 percent had practiced contraception. Contraception was more likely to have been practiced by educated women, those aware of family planning methods before they were married, those exposed to quality sexuality education, and those who participated in marriage-related decision making. Women who reported feeling pressure to prove their fertility were less likely to have practiced contraception.

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Intimate partner violence is pervasive in South Asia, yet married women's experiences regarding seeking help when faced with intimate partner violence and the health sector response remain largely unexplored. This commentary reviews the available published and unpublished literature and summarises what is known about the prevalence of marital violence against women and violence-related care-seeking experienced by women in this region. The commentary highlights that between one-fifth and one-half of married women are affected by violence perpetrated by their husband in South Asia, violence starts early in a marriage and the health consequences are wide ranging and long lasting. Yet, very few women seek support from the health sector, and the health system is not proactive in identifying and supporting women at risk. A greater commitment to making the health system responsive to women in distress is essential and should be undertaken with the same level of commitment given to prevention programmes.

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Evidence regarding the relationship between married women's autonomy and risk of marital violence remains mixed. Moreover, studies examining the contribution of specific aspects of women's autonomy in influencing the risk of marital violence using measures of autonomy that incorporate its dynamic nature are rare. We investigated the relationship between women's autonomy and their experience of marital violence in rural India using prospective data. We used data on 4,904 rural women drawn from two linked studies: the NFHS-2, conducted during 1998-1999 and a follow-up study for a subgroup of women carried out during 2002-2003. Three dimensions of autonomy were used: financial autonomy, freedom of movement, and household decision-making. Marital violence was measured as experience of physical violence in the year prior to the follow-up survey. Findings indicate the protective effects of financial autonomy and freedom of movement in reducing the risk of marital violence in the overall model. Furthermore, region-wise analysis revealed that in the more gender equitable settings of south India, financial autonomy exerted a protective influence on risk of marital violence. However, in the more gender-stratified settings of north India, none of the dimensions of autonomy were found to have any protective effect on women's risk of marital violence. Results argue for an increased focus on strategies aimed at improving women's financial status through livelihood skill-building opportunities, development of a strong savings orientation, and asset-building options.

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Evidence from India about young women's experience of physical and sexual violence within marriage and its sexual and reproductive health consequences is limited. Data, drawn from 12,220 married women ages 15-24 years old from six Indian states, were used to identify associations between the experience of violence and recent symptoms of gynaecological morbidity, using logistic regression analysis. Young women who had experienced physical, sexual, or both forms of violence in the 12 months preceding the interview were more likely than others to report symptoms of gynaecological morbidity (odds ratios, 1.8-2.1); associations were evident in all six states. However, associations were weak between those who had experienced violence earlier in marriage but not in the 12 months preceding the interview and those who had never experienced violence. Findings highlight the need for the health system to play a proactive role in recognising and responding to the needs of young women experiencing marital violence.

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Some of the commitments nations have made in international agreements, notably in the ICPD Programme of Action (1994) and the resolution of the UN Committee on Population & Development (2012), to young people include: realisation of the right to education and attainment of a secondary school education; delaying marriage beyond childhood and ensuring free and full choice in marriage-related decisions; exercise of the right to health, including access to friendly health services and counselling; access to health-promoting information, including on sexual and reproductive matters; acquisition of protective assets and agency, particularly among girls and young women, and promotion of gender equitable roles and attitudes; protection from gender-based violence; and socialisation in a supportive environment. These are crucial for a successful transition to adulthood with reference to sexual and reproductive health outcomes. This paper assesses the extent to which these commitments have been realised, drawing from available studies conducted in the 2000s in developing countries. It concludes that while some progress has been made in most of these aspects, developing countries have a long way to go before they can be said to be helping their young people achieve a successful sexual and reproductive health-related transition to adulthood.

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Many abortion seekers in India attempt to induce abortion on their own, by accessing oral medication/preparations from a chemist without a prescription or from an unauthorized provider, and present at registered facilities if these attempts fail. However, little is known about those whose efforts fail or the ways in which programmes and policies may address the needs of such women. This paper explores the experiences of women whose efforts failed, including their socio-demographic profile, the preparations they used, and the extent to which they experienced serious complications, delayed seeking care from an authorized provider, or delayed abortion until the second trimester of pregnancy. Data come from a larger study assessing the feasibility of the provision of medical abortion by non-physicians; a total of 3394 women who sought medical abortion from selected clinical settings in Bihar and Jharkhand between 2008 and 2010 constitute the sample. Prior to visiting the clinic, nearly a third of these women (31%) had made at least one unsuccessful attempt to terminate the unwanted pregnancy by using a range of oral medications/preparations available over-the-counter in medical shops. Logistic regression analysis suggests that educated women (OR 1.6-1.7), those from urban areas (OR 6.2) and those from Bihar (OR 1.6) were significantly more likely than women with no education, rural women and those from Jharkhand to have used such medication. Also notable is that the average gestational age of women who had made a previous attempt to terminate their pregnancy was almost identical to that of women who had not done so when they presented at the registered facility. These findings may inform policies and programmes that seek to identify and reduce the potential risks associated with unauthorized abortion-seeking practices, and highlight the need to fully inform women, chemists and providers about oral medications, what works and what does not, and how effective medication must be taken.

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CONTEXT: The availability of trained abortion providers is limited in India. Allowing ayurvedic physicians and nurses to perform medication abortions may improve women's access to the procedure, but it is unclear whether these clinicians can provide these services safely and effectively. METHODS: Allopathic physicians, ayurvedic physicians and nurses (10 of each), none of whom had experience in abortion provision, were trained to perform medication abortions. In 2008-2010, these providers performed medication abortions in five clinics in Bihar and Jharkhand for 1,225 women with a pregnancy of up to eight weeks' gestation. A two-sided equivalence design was used to test whether providers' assessments of client eligibility and completeness of abortion matched those of an experienced physician "verifier," and whether medication abortions performed by nurses and ayurvedic physicians were as safe and effective as those done by allopathic physicians. RESULTS: Failure rates were low (5-6%), and those for nurses and ayurvedic physicians were statistically equivalent to those for allopathic physicians. Provider assessments of client eligibility and completeness of abortion differed from those of the verifier in only a small proportion of cases (3-4% for eligibility and 4-5% for completeness); these proportions, and rates of loss to follow-up, were statistically equivalent among provider types. No serious complications were observed, and services by all three groups of providers were acceptable to women. CONCLUSION: Findings support amending existing laws to improve women's access to medication abortion by expanding the provider base to include ayurvedic physicians and nurses.

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While several studies have documented the prevalence of unprotected pre-marital sex among young people in India, little work has explored one of its likely consequences, unintended pregnancy and abortion. This paper examines the experiences of 26 unmarried young abortion-seekers (aged 15-24) interviewed in depth as part of a larger study of unmarried abortion-seekers at clinics run by an NGO in Bihar and Jharkhand. Findings reveal that recognition of the unintended pregnancy was delayed for many and many who suspected so further delayed acknowledging it. Once recognised, most confided in the partner and, for the most part, partners were supportive; a significant minority, including those who had experienced forced sex, did not have partner support and delayed the abortion until the second trimester of pregnancy. Family support was absent in most cases; where provided, it was largely to protect the family reputation. Finally, unsuccessful attempts to terminate the pregnancy were made by several young women, often with the help of partners or family member. Findings call for programmes for young women and men, their potential partners, parents and families and the health system that will collectively enable unmarried young women to obtain safe abortions in a supportive environment.

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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.

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CONTEXT: Little evidence is available from India concerning young people's 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.

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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.

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CONTEXT: Little evidence from India is available regarding the ways in which early marriage may compromise young women's 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.

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Studies suggest that the experiences of unmarried young women seeking abortion in India differ from those of their married counterparts, but the evidence is limited. Research was undertaken among nulliparous young women aged 15-24 who had abortions at the clinics of a leading NGO in Bihar and Jharkhand. Over a 14-month period in 2007-08, 246 married and 549 unmarried young abortion seekers were surveyed and 26 who were unmarried were interviewed in depth. Those who were unmarried were far more likely to report non-consensual sexual relations. As many as 25% of unmarried young women, compared to only 9% of married young women, had had a second trimester abortion. The unmarried were far more likely to report non-consensual sexual relations leading to pregnancy. They were also more likely to report such obstacles to timely abortion as failure to recognise the pregnancy promptly, exclusion from abortion-related decision-making, seeking confidentiality as paramount in selection of abortion facility, unsuccessful previous attempts to terminate the pregnancy, and lack of partner support. After controlling for background factors, findings suggest that unmarried young women who also experienced these obstacles were, compared to married young women, most likely to experience second trimester abortion. Programmes need to take steps to improve access to safe and timely abortion for unmarried young women.

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