Behind closed doors: Cost of underage pregnancies in India

Earlier this week, a 14-year-old girl gave birth to a baby in a district hospital of Uttarakhand, a media outlet reported. It was also brought to light that the girl was married and the case got registered under the Protection of Children from Sexual Offences Act (POCSO).

In another incident, the Supreme Court allowed a teenager to terminate her 30-week pregnancy in February this year.

Karnataka recently directed private hospitals to mandatorily report cases of minor pregnancies under the POCSO Act, whether married or unmarried.

Teenage pregnancies continue to pose serious risk for the mother and the child. Also, they become legally challenging for doctors to navigate. 

While there is a marginal decline in the percentage of adolescent pregnancies, the fifth edition of the National Family Health Survey (NFHS-5) found about 6.8 percent of women between ages 15 and 19 who were mothers or pregnant at the time of the survey.

Among the states with the highest percentage of teenage pregnancies were: Tripura, West Bengal, Andhra Pradesh, Assam and Bihar.

The prevalence of non-adult pregnancies is predominantly more in the rural regions of the country, the findings suggested.

High risk pregnancies

Teenage pregnancies are far more complicated than adult pregnancies, said experts.

Speaking to DH, Dr Archana Dhawan Bajaj, a gynaecologist and IVF expert at Nurture IVF Clinic said: “Many teenage pregnancies don’t start with a plan. They happen at a time when one is least expecting them. Many of them are not ready to be mothers. As opposed to adult pregnancies, teenage ones often come with shame, secrecy and poor care. One has to figure out a lot of complexities associated with them.”

Teenage mothers have increased chances of high-risk pregnancies, said the expert.

Such mothers are at a higher risk of suffering from anemia, being underweight or giving birth to premature babies. They are also more likely to have hypertensive emergencies, having an elevated blood pressure resulting in complications and organ damage, and obstructed labour due to an under-developed pelvis. 

As per multiple studies, the pelvic canal of a teenager female undergoes a gradual growth and is comparatively smaller than an adult female. 

Also, closer to onset of menstruation, the reproductive cycle is not as finely regulated as that of a grown woman.

Factors like consent, sexually transmitted diseases and mental preparedness also become important to consider, said another expert.

Speaking to DH,  Dr Vaishali Sharma, a senior gynecologist and fertility expert (AIIMS) said: “When a minor is involved, one has to be extra cautious around infections like HIV, hepatitis B and C and their mental preparedness for becoming a parent. Also, gestational age (days, weeks or months into pregnancy) also becomes pertinent. If any of these factors are a concern, one also needs to counsel them on whether it is safe for the pregnancy to progress or not.”

Such pregnancies also require an active involvement of the patient's guardians who are involved in decision making.

Legality of teenage pregnancies in India

Teenage pregnancy is intertwined within the framework of the POCSO Act which protects children (under 18 years of age) from sexual offences.

Any sexual activity with a child below 18 years of age is punishable by the law. It is equally relevant if both the sexual partners are minor.

The legal enforcement of the law protects all children regardless of their marital status.

Healthcare workers who are presented with cases of adolescent pregnancies become legally bound to report it to the authorities. However, they also tend to the clinical needs of the underaged patient.

As per the Section 19 of the POCSO Act, it becomes mandatory for the person to report it to the police on knowing that a punishable offence has been committed.

Moreover, a minor alone is not allowed to make the decision to go ahead with the pregnancy or to abort it. 

One has to notify the authorities and involve the guardians. These cases often become an institutional decision, said Dr Sharma.

In cases where the patient and guardians decide to abort the baby, gestational age becomes important, said the expert.

As per the law, the number of medical practitioners that need to provide their opinion as to whether the reason for abortion is in alignment with the Medical Termination of Pregnancy Act (MTP) solely depends on the gestational age of the pregnancy.

If the gestational age is between 0 to 20 weeks, one registered medical professional can make the decision, between 20 to 24 weeks, two registered medical professionals are needed to do the same and beyond 24 weeks, the medical board decides its propriety. 

The bureaucratic framework to progress with a teenage pregnancy makes it far more complex and often navigate. 

Two bodies growing at the same time

Unlike an adult giving birth to a baby, teenage pregnancies are like two people growing at the same time.

Most experts believe a female body is still developing in early adolescent years, both physically and mentally.

“They require different treatment protocols than those used for routine pregnancies. Healthcare providers often need to intervene at an earlier stage than they would with adult pregnancies and must be vigilant throughout the entire nine months. A lot of teenage moms are still growing, which means their bodies are supporting two developing systems at the same time. Getting enough iron, calcium, and protein has to be made sure. Supplementation is often more aggressive, and dietary counselling is a big part of every visit,” said Dr Bajaj.

Teenage pregnancies often bring with them emotional and psychological problems, such as fear, shame, a lack of support, or even denial at first, added the expert.

Hence, counseling becomes a crucial part of the procedure.

Caught between careful reporting of the pregnancy to the concerned authorities and an age appropriate clinical treatment, healthcare providers have to also protect the privacy of the patient as instructed by the law, said Dr Sharma.