Preventing teenage pregnancy in India to end the cycle of undernutrition
Authors: Nandita Bhan
Journal: The Lancet Child & Adolescent Health (2019)

India's large adolescent population of more than 243 million1Central Statistics OfficeYouth in India. Ministry of Statistics and Programme Implementation, Government of India, 2017http://mospi.nic.in/sites/default/files/publication_reports/Youth_in_India-2017.pdfDate accessed: April 9, 2019Google Scholar presents both an unprecedented opportunity and challenge. Although these adolescents hold the promise of achieving India's economic potential, a growing body of work shows persisting challenges to adolescent health and development, including nutrition deficits, exclusion from livelihood choice, social engagement and health services, and unequal gender norms inside and outside the home.2Jejeebhoy SJ Adolescent sexual and reproductive behavior: a review of the evidence from India.Social Sci Med. 1998; 46: 1275-1290Crossref PubMed Scopus (104) Google Scholar, 3India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; 3: E478-89Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 4Petroni S Patel V Patton G Why is suicide the leading killer of older adolescent girls?.Lancet. 2015; 386: 2031-2032Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 5Venkaiah K Damayanti K Nayak M Vijayaraghavan K Diet and nutritional status of rural adolescents in India.Eur J Clin Nutr. 2002; 56: 1119-1125Crossref PubMed Scopus (106) Google Scholar, 6Achyut P Bhatia N Singh A et al.Building support for gender equality among young adolescents in school: findings from Mumbai, India. International Center for Research on Women.https://www.icrw.org/publications/building-support-for-gender-equality-among-young-adolescents-in-school/Date: 2011Date accessed: April 9, 2019Google Scholar Adding to this body of work, a new study by Phuong Nguyen and colleagues7Nguyen PH Scott S Neupane S Tran LM Menon P Social, biological, and programmatic factors link adolescent pregnancy to early childhood undernutrition: a path analysis of India's 2016 National Family and Health Survey.Lancet Child Adolesc Health. 2019; (published online May 15.)http://dx.doi.org/10.1016/S2352-4642(19)30110-5Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar presents evidence on the health costs of teenage pregnancy in India, which can be lifelong and intergenerational, that affect the lives of a large number of girls. To gauge the importance of this study, we need to consider the high burden of undernutrition in India, particularly the triple burden of stunting, wasting, and underweight among children and high rates of anaemia among women and girls, which is a concern nationally as well as globally. Although undernutrition indicators in India have improved in the past decade,8International Institute for Population SciencesICFNational Family Health Survey (NFHS-4) 2015–16. International Institute for Population Sciences, Mumbai2017https://dhsprogram.com/pubs/pdf/FR339/FR339.pdfDate accessed: April 8, 2019Google Scholar progress is slow, and malnutrition remains a barrier to the health and growth of young people as well as a determinant of maternal and child morbidity and mortality. Nguyen and colleagues7Nguyen PH Scott S Neupane S Tran LM Menon P Social, biological, and programmatic factors link adolescent pregnancy to early childhood undernutrition: a path analysis of India's 2016 National Family and Health Survey.Lancet Child Adolesc Health. 2019; (published online May 15.)http://dx.doi.org/10.1016/S2352-4642(19)30110-5Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar analysed data on 60 096 primiparous women aged 15–49 years who gave birth between 2010–16 from the fourth National Family Health Survey (NFHS-4) 2015–16.8International Institute for Population SciencesICFNational Family Health Survey (NFHS-4) 2015–16. International Institute for Population Sciences, Mumbai2017https://dhsprogram.com/pubs/pdf/FR339/FR339.pdfDate accessed: April 8, 2019Google Scholar They examined whether first pregnancy in adolescence (10–19 years of age) was associated with higher child undernutrition compared with first pregnancy after adolescence, and if so, whether biological, social, and programmatic factors explain this intergenerational risk. The five hypothesised mechanisms—maternal nutritional status, education and bargaining power, access to health services, child feeding practices, and living conditions—were examined using structural equation modelling. Issues related to temporality, bidirectionality of associations, and recall bias are a concern given the cross-sectional nature of data. Despite this concern, the study provides evidence that teenage pregnancy was associated with higher undernutrition risks and that children born to teenage mothers were 0·25 SD shorter for their age and 5 percentage points more likely to be stunted compared with those born to adult mothers. As many as 25% of adolescents in the survey gave birth, and teenage mothers were more vulnerable and disenfranchised compared with older first time mothers—they married younger, were poorer, undernourished themselves, reported lower agency, and were excluded from health services. Although this study provides evidence for a vicious cycle of undernutrition, issues related to unequal gender norms and girls' lack of agency in making choices regarding marriage, family planning, or general health cannot be ignored. In India, 26·8% of girls (17·5% in urban and 31·5% in rural areas) were married before 18 years of age in 2015–16, and the states of Bihar (42·5%), West Bengal (41·6%), Jharkhand (37·9%), and Uttar Pradesh (21·1%) reported high prevalence of child marriage.8International Institute for Population SciencesICFNational Family Health Survey (NFHS-4) 2015–16. International Institute for Population Sciences, Mumbai2017https://dhsprogram.com/pubs/pdf/FR339/FR339.pdfDate accessed: April 8, 2019Google Scholar Early marriage of girls infringes on their social and health rights and, as gender researchers have shown, often leads to school dropout, fewer livelihood options, lower bargaining power within households concerning their autonomy or say in family planning, social isolation, and domestic violence.9Parsons J Edmeades J Kes A Petroni S Sexton M Wodon Q Economic impacts of child marriage: a review of the literature.Rev Faith Int Aff. 2015; 13: 12-22Crossref Scopus (132) Google Scholar, 10Malhotra A Warner A McGonagle A Lee-Rife S Solutions to end child marriage—what the evidence shows. International Center for Research on Women, 2011https://www.icrw.org/publications/solutions-to-end-child-marriage/Date accessed: April 9, 2019Google Scholar, 11Raj A When the mother is a child: the impact of child marriage on the health and human rights of girls.Arch Dis Child. 2010; 95: 931-935Crossref PubMed Scopus (183) Google Scholar Married adolescent girls are also less likely to use contraceptives, and poor birth spacing increases risks for low birthweight among offspring, with long term effects on morbidity and mortality.12Ghule M Raj A Palaye P et al.Barriers to use contraceptive methods among rural young married couples in Maharashtra, India: qualitative findings.Asian J Res Soc Sci Humanit. 2015; 5: 18-33PubMed Google Scholar High suicide rates among young women, particularly married girls in India as reported by one study,3India State-Level Disease Burden Initiative Suicide CollaboratorsGender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016.Lancet Public Health. 2018; 3: E478-89Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar might also be symptomatic of larger social factors related to unfair circumstances or norms and absence of social support from a partner or social network. Investments in research on adolescents need to consider the specific vulnerabilities of married adolescent girls, who are harder to reach due to their lower autonomy and mobility, and school-based adolescent programmes need to be supplemented with community outreach. Adolescence is a crucial life stage, marking the transition from childhood to adulthood.13Dahl RE Allen NB Wilbrecht L Suleiman AB Importance of investing in adolescence from a developmental science perspective.Nature. 2018; 554: 441-450Crossref PubMed Scopus (351) Google Scholar The adolescent health programmes in India (eg, Rashtriya Kishor Swasthya Karyakram) have brought adolescent issues into the mainstream to some extent.14National Health MissionAdolescent health (RKSK). National Health Mission, Ministry of Health & Family Welfare, Government of India, 2014Google Scholar Developmental and programmatic factors related to adolescent health, as also outlined in the study (mechanistic factors account for an 11 percentage point increase in prevalence of child stunting), need more scrutiny from a gender equity perspective.15Chandra-Mouli V Plesons M Amin A Addressing harmful and unequal gender norms in early adolescence.Nat Hum Behav. 2018; 2: 239-240Crossref PubMed Scopus (6) Google Scholar This study should prompt a moment of reflection, because it renews focus on understanding the inequalities faced by women and girls at home, school, and work. Identifying interventions16Svanemyr J Chandra-Mouli V Raj A Travers E Sundaram L Research priorities on ending child marriage and supporting married girls.Reprod Health. 2015; 12: 80Crossref PubMed Scopus (56) Google Scholar for child marriage that draw from rigorous science on its multilevel determinants and adding robust measures of gender empowerment to adolescent health programmes can enable policies to end child and early marriage in India and can help break the cycle of vulnerability and undernutrition faced by girls in India. I declare no competing interests. Social, biological, and programmatic factors linking adolescent pregnancy and early childhood undernutrition: a path analysis of India's 2016 National Family and Health SurveyChildren born to adolescent mothers are at risk of being undernourished. Adolescent pregnancy is related to child undernutrition through poor maternal nutritional status, lower education, less health service access, poor complementary feeding practices, and poor living conditions. Policies and programmes to delay pregnancy and promote women's rights could help break the intergenerational cycle of undernutrition through many routes. Full-Text PDF Open Access