Handbook of Adolescent Gynecology & ARSH (Adolescent Reproductive and Sexual Health) Swati Y Bhave, Ashwini Bhalerao Gandhi
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1Handbook of Adolescent Gynecology and ARSH (Adolescent Reproductive and Sexual Health)
2 3Handbook of Adolescent Gynecology and ARSH (Adolescent Reproductive and Sexual Health)
Editors Swati Y Bhave (Lele) MD DCH FCPS FIAP FAAP Senior Visiting Consultant Indraprastha Apollo Hospitals, New Delhi Member Technical Steering Committee CAH, WHO Geneva Member Technical Advisory Group Adolescent Health WHO SEARO Convener International Pediatric Association (IPA), Adolescent Interest Group Former Chairperson, IAP Adolescent Chapter Advisory Consultant “Expressions” India Ashwini Bhalerao-Gandhi MD DGO DFP FCPS DNB MICOG Consultant Gynecologist PD Hinduja National Hospital and Medical Research Centre, Mumbai. Ex-Associate Professor, TN Medical College and BYL Nair Hospital Chairperson of Adolescent Health Committee, FOGSI Foreword Naresh Dayal Secretary to Government of India Ministry of Health and Family Welfare Nirman Bhawan, New Delhi
4Published by
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Handbook of Adolescent Gynecology and ARSH
© 2007, Swati Y Bhave, Ashwini Bhalerao-Gandhi
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
This book has been published in good faith that the material provided by contributors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters to be settled under Delhi jurisdiction only.
First Edition:2007
9788184480139
Typeset at JPBMP typesetting unit
Printed at
5DEDICATED TO
Our respective spouses
Yashwant Bhave
and
Rajesh Gandhi
for their constant support and cooperation
for the effort required for this endeavor
Which we hope will benefit the millions of
adolescents who require RSH services 6
7Contributors 11FOREWORD
India today is a country of a large population of young people, with over 30 percent in the age group of 10-24. Based on the population projections by the Registrar General of India (1996) there are an estimated 300 million young people in the age group 10-24, whose need for sexual and reproductive health information and services remains very high.
In spite of a legal provision against child marriage, almost 50 percent girls remain at a risk of getting married before 18. Also, over 32 percent girls get married by age 15, however, as compared to this only 6 percent adolescent boys get married by that age (IIPS and ORC Macro, 2000).
There is also increasing evidence that the onset of sexual activity before marriage is starting at a younger age amongst men. More young men (ranging from 15-26%) report premarital sexual activity as compared to only (3-6%) young women reporting premarital sexual activity.
Young people are at high risk of negative sexual and reproductive health consequences like unwanted pregnancies, sexually transmitted infections and unsafe abortions. They start sexual activity without adequate knowledge of sexual and reproductive issues and seldom practice safe sex.
The adolescent fertility is very high with 20 percent girls giving births by age 17; 19 percent of the total fertility rates are contributed by girls aged 15-19 years. This early childbearing age contributes to high maternal morbidity and mortality. Many studies have also indicated the risk of closely spaced births in young women.
Between 1 and 10 percent of all abortion seekers are adolescents. 10-30 percent abortion seekers are young women. Most of these are married adolescents, at least 50 percent of unmarried women seeking abortions are adolescent and amongst these there are many below 15 years of age.
12The contraceptive use remains low among young married adolescent, 27 percent reporting an unmet need for contraception. Women in the age 15-24 years are more likely to discontinue use of contraceptives because of method failure and due to difficulty in access. The access to services and information depends on their marital status and gender.
The family welfare department, Government of India has introduced a strong adolescent reproductive and sexual service delivery component in the RCH II program. But it is equally important to strengthen the private sector awareness of ARSH has many youngsters will access service in this sector.
I am happy to know that clinicians, pediatricians, gynecologists, psychiatrists, surgeons, clinical psychologists, dermatologists and public health workers have come together to contribute to this Handbook on Adolescent Gynecology and ARSH issues. The topics included take a very holistic view of ARSH and will serve as a good resource material for those who wish to contribute to ARSH services. I congratulate Dr Swati Bhave on her initiative and hardwork.
Naresh Dayal
Secretary to the Govt of India
Ministry of Health and Family Welfare
Nirman Bhawan, New Delhi
13Preface
Dear readers,
It has given us a great sense of fulfillment to have come out with this Handbook of Adolescent Gynecology and ARSH (adolescent reproductive and sexual health issues)
Adolescent medicine is the field which is overlapped by many specialties. Adolescents are continued to visit to their family physicians and pediatricians for day-to-day problems and immunizations, to adult physicians for diseases, to a gynecologist for menstruation and pregnancy-related problems, to mental health professional, for their anxiety and depression, and so on. Hence, managing an adolescent is a teamwork; and hence this book is aptly contributed by pediatricians, gynecologists, mental health and public health professionals.
Though all aspects of adolescent health are important, the issues related to ARSH are not only vital for affected individual adolescents, but also have a great impact in the public health scenario of the nation. There are trained gynecologists available to look after adolescent girls but very few specialists for dealing with adolescent boys who are often neglected. Andrological problems of the adolescent males should not be forgotten in ARSH services
The national statistics show the importance and need of concentrating on delivering ARSH services in our country. The incidence of premarital sex is rising as shown by the surveys in different parts of the country. Adolescent sexual activity is generally impulsive unplanned; initiated without adequate knowledge of sexual and reproductive issues and seldom with the practices of safe sex. Hence we have a rising incidence of the various negative consequences like sexually transmitted diseases, unwanted teenage pregnancies and unsafe abortions. More than 50% of new cases of HIV/AIDS are in the age group of 15-24 years.
14Inspite of a legal provision against child marriage, we have a very high incidence of girls getting married before age of 18 yr. Once married they are pressurized to prove their fertility by producing a child in the very first year of marriage. They are not in a position to neither negotiate the number of births nor ensure good spacing inbetween. It is well proven that teen age pregnancy causes a high incidence of morbidity and mortality in both the mother and neonates. The incidence of abortions is high in both married and unmarried adolescents
Inspite of easy and free access to contraceptives both in the public and private set-up it has been seen that the use of contraceptives in married adolescents continue to be very low. Unmet need for contraception is reported in 27%. Unmarried adolescents cannot freely access ARSH services or supply on contraceptives without parental consent, which ofcourse is unlikely to be easily obtained.
The family welfare dept Government of India has aptly introduced a strong Adolescent Reproductive and Sexual Service delivery component in the RCH II and the NRHM (National Rural Health Mission).
But it is equally important to strengthen the private sector awareness of ARSH as many youngsters will access service in this sector. This book aims at increasing awareness of ARSH issues in the professionals of all the specialties dealing with adolescents, as ARSH is closely related with high risk behavior and mental health problems and substance abuse.
We are happy that this book has been published by M/s Jaypee Brothers Medical Publisher with whom we have had previous publications and we are sure it will reach many readers as our other books have.
We are specially honored that Mr Naresh Dayal, Secretary, Ministry of Health and Family Welfare, Government of India has graciously consented to write the Foreword.
Swati Y Bhave
Aswini Bhalerao-Gandhi 15
16Acknowledgements
→ To all our contributors who have added value to this book
→ Our families specially our spouses and children for putting up with the long hours dedication to this book, causing deprivation of family time
→ God Almighty for giving us motivation when at times we thought the task was impossible.
→ Mr Jitendar P Vij, CMD; Mr Tarun Duneja, Manager (Publishing) and all production staff especially Ms Mubeen Bano, Mr DC Gupta, Mr Alok Saxena and Mr Abhinay Kumar Nigam of M/s Jaypee Brothers Medical Publishers for the efforts put by them.
→ For photoes: We thank the following for permission to use their photographs for the cover of the book.
Photo 1: Adolescent girls: Pallavi Sovani, Niyati Sovani Surabhi Gokhale
Photo 2: Married couple: Prasad and Cresseide Taksal
Photo 3: Baby: Askshay Sagne
Photo 4: Joint family: Lata Sagne, Preetam Sagne, Mrs Asavari Sagne, Sharvari Sagne, Akshay Sagne.