Adolescent Care Seeking for Family Planning in Madhya Pradesh and Odisha, India: A Low Equilibrium Trap?.

1. September 2017
This publication was produced for review by the United States Agency for International Development.
It was prepared by Dr. Y.P. Gupta, Naveen Roy and Priya Emmart of Avenir Health for the Health Finance and
Governance Project.
ADOLESCENT CARE SEEKING FOR
FAMILY PLANNING IN MADHYA PRADESH
AND ODISHA, INDIA:
A LOW EQUILIBRIUM TRAP?

2. The Health Finance and Governance Project
USAID’s Health Finance and Governance (HFG) project will help to improve health in developing countries by
expanding people’s access to health care. Led by Abt Associates, the project team will work with partner countries
to increase their domestic resources for health, manage those precious resources more effectively, and make wise
purchasing decisions. As a result, this five-year, $209 million global project will increase the use of both primary
and priority health services, including HIV/AIDS, tuberculosis, malaria, and reproductive health services. Designed
to fundamentally strengthen health systems, HFG will support countries as they navigate the economic transitions
needed to achieve universal health care.
September 2017
Cooperative Agreement No: AID-OAA-A-12-00080
Submitted to: Scott Stewart, AOR
Office of Health Systems
Bureau for Global Health
Recommended Citation: Gupta, Y.P., Naveen Roy, and Priya Emmart. September 2017. Adolescent Care
Seeking for Family Planning in Madhya Pradesh and Odisha, India: A Low Equilibrium Trap?. Bethesda, MD: Health
Finance and Governance Project, Abt Associates Inc.
Abt Associates Inc. | 4550 Montgomery Avenue, Suite 800 North | Bethesda, Maryland 20814
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| Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D)
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3. ADOLESCENT CARE SEEKING FOR
FAMILY PLANNING IN MADHYA
PRADESH AND ODISHA, INDIA:
A LOW EQUILIBRIUM TRAP?
DISCLAIMER
The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency
for International Development (USAID) or the United States Government.

5. i
CONTENTS
Acronyms.................................................................................................................. v
Acknowledgments................................................................................................. vii
Definitions of Key Terms....................................................................................... ix
Executive Summary ............................................................................................... xi
1. Background ........................................................................................................17
1.1 The Rationale for Intervention in Adolescent Health.............................................17
1.1.1 The context of intervention in India..............................................................17
1.1.2 Organization of NHM at the state level.......................................................18
1.1.3 Health indicators and access in the two states ..........................................18
1.2 Study Objectives................................................................................................................19
2. Methods ..............................................................................................................21
2.1 Sample Districts .................................................................................................................21
2.2 Sampling Methodology .....................................................................................................21
2.3 Ethical Considerations......................................................................................................22
3. Results.................................................................................................................23
3.1 Demand for Services.........................................................................................................23
3.1.1 Variation within states: Girls in HFG districts versus all Girls and
MWRA.........................................................................................................................23
3.1.2 Married versus unmarried girls, endowments, and constraints.............24
3.1.3 Decision-making on family size and contraceptive use and marriage ..26
3.1.4 Methods awareness and use............................................................................26
3.1.5 Future use of contraception ............................................................................28
3.1.6 Client satisfaction with community health services ..................................29
3.2 Supply of Services..............................................................................................................30
3.3 Sources of Contraception among Married Girls ......................................................31
3.3.1 Role of CLWs (ASHAs, ANMs, and AWWs).............................................33
3.3.2 Role of public facility providers and managers ...........................................40
3.3.3 Role of the private sector in family planning...............................................42
3.3.4 Recommendations from providers on improving adolescent
outcomes.....................................................................................................................42
4. Discussion...........................................................................................................45
4.1 The Demand for Services................................................................................................45
4.2 The Supply of Adolescent Services...............................................................................47
4.2.1 Incentives drive low supply of services.........................................................48
4.2.2 Providers do not offer a standard benefits package..................................49
4.2.3 Supply of services comes with high costs for girls ....................................50
4.2.4 Supply of services constrained by provider efficacy..................................51
4.2.5 Supply of services is low, despite reports of high need...........................52
4.2.6 Supply, unmarried girls, and education .........................................................52
4.3 Conclusions.........................................................................................................................53

6. ii
4.4 Recommendations.............................................................................................................54
4.4.1 Both States............................................................................................................54
4.4.2 Madhya Pradesh...................................................................................................55
4.4.3 Odisha....................................................................................................................55
Annex A: Sampling................................................................................................57
Annex B: Field Data Collection ...........................................................................59
Annex C: Listing of Villages Sampled .................................................................61
Annex D: IDI Provider Perspectives ...................................................................67
Annex E: References .............................................................................................75
List of Tables
Table 1: Sample Size by State, Household Survey.......................................................................22
Table 2: Sample Size, In-Depth Interviews and Focus Groups................................................22
Table 3: Family Planning and Education Outcomes: Married Girls versus All MWRA.....24
Table 4a: Education and Empowerment Characteristics, by Marital Status and State......24
Table 4b: Barriers to Health-Seeking at Facilities, by Marital Status and State...................25
Table 5: Method Awareness, by Marital Status and State.........................................................27
Table 6: Client Satisfication with CLWs, by Type of CLW and Study District ..................29
Table 7a: Services Provided by ASHAs, from the Client Perspective ...................................33
Table 7b: Services Provided by AWWs, from the Client Perspective..................................34
Table 7c(i): General Contraceptive Information & Service Provision and Constraints
Reported by CLWs ..................................................................................................................34
Table 7c(ii): Contraceptive Information & Services Provided in Madhya Pradesh, as
reported by CLWs....................................................................................................................36
Table 7c(iii): Information and Contraceptive Services Provided in Odisha, as
reported by CLWs...................................................................................................................37
Table 8: Information Given on Methods Provided by CLW after Recent Birth,
by State .........................................................................................................................................40
Table D1: Responses of CLWs on Contact with Adolescents and Services Provided ....67
Table D2: Responses of CLWs on Providing General Contraceptive Services .................68
Table D3: Responses of CLWs on Services/Information Provided, by Method and
Marital Status...............................................................................................................................69
Table D4: Responses of CLWs on Other Services Provided to Adolescents....................70
Table D5: Responses of CLWs on Unmarried Adolescents: Sexual Activity and
Need for Services ......................................................................................................................71
Table D6: Responses of CLWs on Type of Methods They Would Promote,
by Marital Status........................................................................................................................71
Table D7: Reasons Why CLWs would Promote the Methods They Selected,
Unmarried Girls .........................................................................................................................72
Table D8: Reasons Why CLWs would Promote the Methods They Selected,
Married Girls...............................................................................................................................72
Table D9: Responses of Facility Providers on Unmarried Adolescents Sexual Activity,
Service Need...............................................................................................................................73
Table D10: Responses of Public Facility Providerrs on Type of Methods They Would
Promote, by Marital Status......................................................................................................73
Table D11: Responses of Medical Providers on levels and seriousness of abortions
by state..........................................................................................................................................74
Table D12: Reasons Why Public Facility Providers would Promote Selected
Methods, All Girls......................................................................................................................74

7. iii
List of Figures
Figure 1: Method Prevalence, Married Girls, by State ...............................................................28
Figure 2: Source of Method Reported by Girls, by Provider Type and State .....................32
Figure 3: Comparision of Within-State Variation by Provider Type: Proportion of
CLWs Reporting Service Provision to Married and Unmarried Girls........................38

9. v
ACRONYMS
AHC Adolescent-Friendly Health Clinic
ANM Auxiliary Nurse Midwife
ASHA Accredited Social Health Activist
AWC Anganwadi Centre
AWW Anganwadi Worker
CCT Conditional Cash Transfer
CHC Community Health Centre
CLW Community Level Worker
CPR Contraceptive Prevalence Rate
ECP Emergency Contraceptive Pill
FGD Focus Group Discussion
GOI Government of India
HFG Health Financing Governance Project
ICDS Integrated Child Development Scheme
IDI In-Depth Interview
IEC Information, Education and Communication
IFA Iron/Folic Acid
IRB Institutional Review Board
IUCD Intra-Uterine Contraceptive Device
JSY Janani Suraksha Yojana
LAM Lactational Amenorrhea Method
MA Married Adolescent
MO Medical Officer
MOHFW Ministry of Health and Family Welfare
MP Madhya Pradesh
MPW Multipurpose Worker (male)
MWRA Married Women of Reproductive Age
NFHS National Family Health Survey (Demographic and Health Survey)
NHM National Health Mission
OCP Oral Contraceptive Pill

10. vi
PHC Primary Health Centre
PIP Program Implementation Plan
PPIUCD Post-Partum Intra-Uterine Contraceptive Device
PPS Probability Proportionate to Size
PTK Pregnancy Test Kit
RKSK Rashtriya Kishor Swasthya Karyakram
RMP Rural Medical Practitioner
SC Scheduled Caste
SDM Standard Days Method
ST Scheduled Tribe
TT Tetanus Toxoid
UA Unmarried Adolescent
VHND Village Health Nutrition Day
YFHC Youth-Friendly Health Clinic

11. vii
ACKNOWLEDGMENTS
The authors of this report would like to thank Dr. S.K. Sikdar, Deputy Commissioner, In-charge, Family
Planning Division, Ministry of Health and Family Welfare, Government of India; Nirman Bhavan, New
Delhi, for proposing the study, and the guidance and support he provided to the study in the two
National Health Mission (NHM) states. In addition, we are especially grateful to Dr. B.S. Ohri, Director
Family Welfare, NHM, Madhya Pradesh; the Chief Medical and Health Officers of the Raisen and
Tikamgarh districts in Madhya Pradesh; Dr. Binod Kumar Mishra, Director Family Welfare, Government
of Odisha; and the Chief District Medical Officer cum-District Mission Director in Odisha’s Rayagada
and Koraput districts. We are especially grateful to all the health staff of these districts for their time
and perspectives on improving adolescent services for family planning. In addition, we thank the
Chairman and all members of Research and Ethics Committee, Directorate of Health Services, Odisha,
and the Chairman and other members of Sigma Institutional Review Board, New Delhi, for approval of
the study and for granting permission to conduct the study in the two states.
Last but not least, we wish to acknowledge the willingness of all the adolescents and their partners for
their participation, and sharing their knowledge and experience in negotiating the complex web of
services for family planning in their districts.

13. ix
DEFINITIONS OF KEY TERMS
Accredited Social Health Activist (ASHA)
A cadre of health volunteer, ASHAs are usually women ages 25-45 years, resident in the village they
work in, and have undergone at least eight years of formal education. ASHAs are entitled to receive
incentives for their work under the National Health Mission for tasks related to skilled delivery, pre-
conception, and antenatal care and family planning.
Anganwadi Worker (AWW)
AWWs are frontline workers who are responsible for the implementation of the Integrated Child
Development Scheme at the community level. They usually are women aged 18-35 years and must have
completed at least a 10th grade education. They receive an honorarium of Rs. 5,000 per month but are
not salaried. They run the community-level Anganwadi centers and together with the ASHA are
responsible for implementing the National Health Mission’s Village Health Nutrition Days to improve
access to maternal, newborn, and child health and nutrition at the community level.
Auxiliary Nurse Midwives (ANM)
The first-level salaried providers in the health system, ANMs are women who have completed a two-
year diploma in auxiliary nursing and midwifery and oversee a staff at the sub-center health clinic.
Community-Level Workers (CLW)
For the purpose of this study, CLWs are defined as frontline health workers who work and interact
with adolescents at the community level: ASHAs, AWWs, and ANMs, and Multi-purpose Workers.
National Health Mission (NHM)
The NHM is an initiative launched by the Government of India to achieve universal access to “Equitable,
Quality and Affordable” health care. It is the major source of financing to states to improve well-being
especially for women and children with the broad purpose of addressing the social determinants of
health, reducing the disease burden, and providing financial protection for households. In 2014, the
government launched the Rashtriya Kishor Swasthya Karyakram (RKSK) under the NHM, to improve the
well-being and productivity of adolescents.

15. xi
EXECUTIVE SUMMARY
The governments of Madhya Pradesh and Odisha states through National Health Mission (NHM)
programs are interested in understanding the levels of care seeking for family planning among
adolescents and synergies with the Rashtriya Kishor Swasthya Karyakram (RKSK) strategies in their states.
The USAID-funded Health Financing and Governance (HFG) project conducted an investigation in select
districts in these states, where it plans to implement adolescent programs. The study was conducted in
Tikamgarh and Raisen districts in Madhya Pradesh and in Rayagada and Koraput districts in Odisha. The
study employed both a cross-sectional survey design and qualitative methods to explore care seeking
from the client, extended network, and provider perspectives. Adolescent girls, both married and
unmarried, were randomly selected in these districts to participate in a survey on their knowledge of,
access to, and use of family planning. Data from the survey were supplemented with focus group
discussions with married and unmarried adolescent girls, husbands of adolescent girls, and adolescent
boys. Data from the provider perspective were obtained from in-depth interviews with community-level
workers and public facility and private sector providers at the sub-centers, community health centers,
and district hospitals serving the study districts.
This report presents the findings of the investigation from both the adolescent and provider
perspectives on the use of family planning services in the context of health systems and service delivery.
Findings are grouped by the extent to which they offer opportunities, and have evidence of success in
improving adolescent outcomes, within the existing health system. The recommendations address the
principal finding that adolescent care seeking for family planning is in a low equilibrium trap1 where the
demand for services is low and their supply is equally low, and fragmented. Adolescent girls have a low
demand for contraceptive services in these districts, largely as a function of social norms relating to
fertility, to socioeconomic circumstance, and limited accurate knowledge of the safety and range of
available methods of to prevent pregnancy. Low demand fuels a cycle of disinterest in service provision
that is buttressed by distorted incentives to providers, provider inefficacy related to adolescent health
issues, lack of funded mechanisms to approach adolescents with quality services, and poor governance of
supply systems. As in economic growth, unless there is a substantive shift in either the forces of demand
or supply, it is unlikely that service use will shift to a higher level of equilibrium.
1 An equilibrium trap is an economic concept describing a state of stable equilibrium that is achieved at low levels of per
capita income resulting in zero economic growth (Nelson, 1956).It has been applied in sectors including health to describe
the low provision of good quality services and low demand for them in employment, as low employer demand for higher
level skills and low supply of higher level skills in response to the low demand (Wilson, 2003).This emphasis on the
balance between demand and supply is being applied here to describe the low demand for good quality services on
contraception which is being balanced by the low supply of good quality services.

16. xii
A limited but immediate opportunity to expand access to
contraception under NHM
The study found higher levels of awareness and use of maternal and child health services by married girls
in the sample districts compared to their use of modern methods and low levels of knowledge of the
pregnancy risk in the post-partum period. Over 80 percent of married adolescents in Madhya Pradesh
had used health facilities or camps in the last 12 months for maternal and child health services. Almost
half of them had also visited an Anganwadi Centre (AWC) for health services. More than two-thirds of
married adolescents in Odisha had visited an AWC for health services and two-fifths had also used
health facilities or camps in the last 12 months for maternal and child health services. In contrast, fewer
than 10 percent of married adolescent girls in Odisha and about a quarter in Madhya Pradesh use
modern methods of contraception. Over two-thirds of married adolescent girls who do not want
another pregnancy believe that not menstruating or breastfeeding alone will protect them from
pregnancy. Recent global evidence suggests that only a quarter of women who use lactational
amenorrhea use it correctly to protect against pregnancy (Fabic, 2013). The discrepancy between health
service and contraceptive use offers an immediate opportunity to expand post-partum family planning
among married adolescents, since existing incentives for providers and systems are aligned to bring
young mothers to deliver in facilities. Resourcing sub-centers, primary health centers (PHCs), and
community health centers (CHCs) with trained providers and methods including post-partum intra-
uterine contraceptive device (PPIUCD), the progestin-only pill ( POP), and expanding knowledge and
use of Lactational Amenorrhea Method (LAM), can reduce the risks and costs of teenage pregnancies
and poor spacing in these populations.
Strengthening facilities and preparing providers to deliver
post-partum family planning to adolescents is the biggest
barrier to this opportunity. Adolescents uniformly report
that lack of providers, in particular female providers, and lack
of supplies to be “big” problems in their determination to
obtain care. Incentives to community and facility providers
do not link maternal health with post-partum services; these
latter are relatively poorly compensated for. Ensuring
accurate use of LAM by improving provider and client knowledge will be equally important to protect
against unintended pregnancy in the six months post-partum. Very few providers at any level report
discussing “breastfeeding” as a contraceptive. Social norms relating to “proving fertility” are the second
barrier: in general, most of the literature shows opportunities to delay the second child, rather than the
first pregnancy, and hence the target population for this intervention is most likely to be adolescent girls
already pregnant or those with one child. This study found that two-thirds of married adolescent girls
are in this category.
“Aurat ko method se dar lagta hai
ke method ke estamal se kanhi
bad me bachha paida na ho”
Women are afraid that if they use a method they
may have not be able to have a child later

17. xiii
Existing elements under NHM can be leveraged to improve
demand
There is a low level of demand for modern contraception among adolescents in both states. Only
slightly over a quarter of married adolescents in each state plan to use a method in the next 12 months.
This study finds that existing elements of the NHM to improve demand are either non-functional or
poorly functioning, including peer educators, community provision of services, and adolescent-friendly
health clinics (AFHCs).
Peer educators are a main element for improving demand for health services under RKSK, but were not
in evidence in either state. Most adolescents identify “friends” as their primary source of information on
family planning. Peer educators have been shown to be effective primarily for information sharing and
reducing stigma but there is no evidence that they are effective in changing reproductive health practices
or outcomes (Chandra-Mouli et al., 2015). Recent evidence from India suggests that if peer educators
are selected based on the social networks of adolescents, they are likely to be more successful than
traditional providers in providing information (Bhatia, 2015), and it is certainly peer educators on whom
adolescents currently depend for information in the study districts. This study found “shyness” to be
pervasive among adolescents, and it makes them reluctant to even discuss anything to do with
contraception. Addressing the stigma associated with such forbidden knowledge will be critical to
expanding demand. Peer educators could be leveraged to improve accurate knowledge of modern
methods and combat the misinformation on sexual activity, contraception, and abortion that is
pervasive. They could also be used to reduce stigma associated with delaying marriage and spacing births
(Kim and Free, 2008; Michielson et al., 2012; Swartz et al., 2012). State program implementation plans
(PIPs) in both Odisha and Madhya Pradesh have funds allocated to expand investments in pilot districts
for the peer education component of RKSK (MOHFW, 2017-18). The states will assess evidence of
impact as well as strategies to deliver impact on health behaviors. However, none of HFG districts is
included in the planned pilots.
Adolescents engage with Anganwadi workers (AWWs) more frequently than with accredited social
health activists (ASHAs) on nutrition and menstrual hygiene. At a minimum, efforts at planned
opportunism can take better advantage of where adolescents go for any service and whom they speak
to – combining the peer, community, chemist, and facility provider networks.
Adolescent meetings, which are meant to be held monthly and to include all community-level workers
(CLW) including ASHAs, AWWs, and auxiliary nurse midwives (ANMs) do not occur with the
frequency nor cover all the content intended. Intensity and regularity of provision of messages is critical
in behavioral interventions. Providers in the study districts uniformly agree that coordinated meetings
would be very useful. Devising ways to include married adolescents will be critical as they largely do not
participate.
There are no AFHCs in the Madhya Pradesh study districts but they do exist in Odisha. Clinics at the
PHC and hospital levels in Madhya Pradesh report providing adolescent-specific services. However,
there is no evidence that such clinics improve outcomes of disadvantaged youth or increase use of
services by them (Chandra-Mouli et al., 2015). Reprogramming funds allocated to this sub-category for
these districts into investments that improve existing facility and provider readiness are potentially more
useful as these adolescents do use public facilities. This would include resourcing facilities adequately,
improving communication skills of current facility and community providers, and supervising peer
educators and CLWs to improve outcomes. Providers in Madhya Pradesh at these facilities restrict
offering a range of methods and information to unmarried and married clients. Thus, improving provider
knowledge and efficacy is a critical part of resourcing facilities.

18. xiv
Near-term opportunities to improve supply through better
governance
This study finds that there is poor governance of health services for adolescents in the HFG districts.
Both near- and medium-term opportunities exist for improvements in leadership, management,
financing, and monitoring.
To improve governance in the near term, better prioritization with accurate baseline information will be
a good start. In-depth interviews with CLWs and facility providers show that they are operating without
a clear understanding of health burdens of their adolescent populations and have widely differing
understanding of health burdens in their districts. District Level Action Plans (DHAPs) are a critical
instrument of the NHM and should be used to appropriately resource for adolescent health needs. HFG
districts should invest in improving district-level oversight and management through regular supervision,
human resources, and commodity resourcing. This can only be done if districts prioritize using pooled
data from CLWs, and private and public providers on the level of health need and health-seeking
behavior among adolescents. This study found that adolescents find supply-related problems to be
significant. Supply-side constraints range from stock-outs of methods and lack of female providers to
being able to give only poor-quality advice or none at all. Health facility providers and, to an extent,
chemists report stock-outs of regular and emergency contraceptive pills and condoms. Partnering with
the private sector, especially pharmacies and NGOs to expand options for adolescents to discreetly
obtain information and contraception has been shown to be useful in other settings. Pharmacies in the
study districts are particularly interested in partnering with CLWs. The private medical sector is not
accredited in Odisha but is already providing services. All providers report that NGOs have a
comparative advantage in delivering sensitive sexual and reproductive health information. These avenues
can be explored through DHAPs since social costs of seeking services in the community will take time
to alter.
All above recommendations can be folded into existing mechanisms of health service delivery and policy
– ASHAs, DHAPs, and using existing data obtained from baseline assessments conducted for the RKSK.
These recommendations will allow for better prioritization of service provision and be more cost-
effective than the current practice of widely dispersed but limited dosage of interventions.
Medium-term opportunities to improve outcomes
In the medium term, governance improvements need to focus on the way health services for women are
currently incentivized. Current incentives to CLWs and workload mean that they prefer maternal and
child over adolescent health and prefer female sterilization over other methods. Until these method-
specific incentives change, it will be difficult to alter the practice and effort of CLWs relating to birth
spacing. Multiple studies of the effectiveness of ASHAs show that current incentives reflect the priorities
of the health system and are implemented as such in their practice. There are no incentives for demand
generation, and only marginal incentives for improving knowledge through community meetings or
providing information to excluded groups like unmarried girls and adolescent boys. Given the multiple
roles played by ASHAs and the lack of a formal salary, they rightly prioritize interventions that are highly
incentivized.

19. xv
In the medium term, exploring the flexibility of states in reprogramming incentives to reward ASHAs for
their work in demand generation and community mobilization will be important. This will mean a
willingness to tolerate changes in current indicators of success “Expected Levels of Achievement for
sterilization acceptors and IUCD acceptors”(NIHFW, 2014), changing communication about unmarried
sexual activity, supporting ASHAs with facilities that are better resourced and that offer more dignified
care to adolescents.
Improving provider capacity to deliver services tailored for adolescents is needed but will also take time.
Adolescents who use family planning are bypassing community providers, especially in Madhya Pradesh
This study found indirect evidence of CLW inefficacy in delivering services, including services to
adolescent boys. Building capacity of providers to become more informed and agile in discussing sexual
activity in the face of strong community disapproval will be critical, if we expect clients to seek services
from CLWs. This finding is similar to findings from previous research in India (Jejeebhoy and Santhya,
2014). Translating capacity into improved quality service will require that the incentives are right.
Identifying effective interventions for unmarried adolescents is clearly needed. Interventions targeting in-
and out-of-school unmarried adolescents with programs that show evidence of impact on delaying
marriage and teenage pregnancy are needed. In the study districts, a quarter of unmarried adolescent
girls and slightly over 10 percent of married adolescent girls interviewed had completed secondary
schooling with the largest proportion of both dropping out of school between the 6th and 10th grade.
Hence, HFG districts in these states should consider interventions for adolescent girls in and out of
school. An analysis of multiple approaches to delaying marriage and improving education outcomes finds
limited high-quality evidence especially in South Asia (Buchman et al., 2016). The same analysis finds,
however, that modest direct financial incentives to girls are the most cost-effective way to avert early
marriage. In addition to marriage effects, providing incentives conditional on marriage rather than
education was found to significantly reduce teenage childbearing and improve education outcomes for
girls in school (Buchman et al., 2016). Conditional cash transfer (CCT) schemes are well established in
Madhya Pradesh but were launched only recently in Odisha. Evaluations of these schemes show
significant implementation gaps and have multiple conditions (Shekar, 2012). HFG districts should
evaluate access to and improvements in targeting by these schemes to address the burden of early
marriage and short spacing in these districts. In addition to cash transfers, there is evidence from India
that comprehensive reproductive health education has an impact on improving adolescent outcomes
(Daniel, 2012).
Summary recommendations
1. In the near term:
a. Focus on proven interventions for expanding use where there is most opportunity. These
include (a) post-partum family planning and (b) commodity and provider supply
improvements in existing facilities.
b. Ensure consistency and intensity in providing services through existing mechanisms including
CLW, facilities, and peer educators.
c. Exploit higher use of nutrition services through AWCs to provide accurate sexual and
reproductive health information.
d. Target peer education investments on improving accurate knowledge about methods and
abortion as well as reducing stigma associated with the use of contraception post-marriage
and among unmarried adolescents who are sexually active.

20. xvi
e. Engage in expanding partnerships with the private sector, including pharmacies, to improve
the discreet purchase of contraceptives, since social costs of community purchase may be
high and improving availability and quality of CLW service will take time.
2. In the medium term:
a. Improve the coherence of incentives being offered to CLWs such that adolescent
preferences and needs in family planning are addressed, including post-coital methods and
birth spacing methods.
b. Improve the targeting and direct transfer of financial incentives conditional on marriage to
unmarried adolescents and their families. Evaluate the potential for comprehensive sex
education programs.
c. Invest in improving skills in communication and knowledge of providers to improve use of
public health services.
State-specific recommendations
1. Madhya Pradesh:
a. Identify if selection issues related to caste and social status are a constraint on adolescent
uptake of services. Examine if Madhya Pradesh can learn and adapt lessons from Odisha on
selection processes for ASHAs, training, and governance.
b. Evaluate levels of unintended pregnancy and abortions given reported high levels of Standard
Days Method (SDM) and effectiveness without “correct” use (Marston and Church, 2016).
c. Exploit near universal access to mobile phones among adolescents to evaluate delivery of
accurate information, including LAM and SDM, given high levels of SDM use.
2. Odisha
a. Build on existing linkages between ASHAs, ANMs, and adolescents to expand awareness and
use of PPIUCDs and LAM.
b. Leverage state PIPS to invest in peer educators to optimize selection criteria and target
services toward accurate information and stigma reduction.
c. Examine if CCTs conditional on marriage can be incorporated into new CCT initiatives in
Odisha given higher levels of school completion and lower levels of early marriage.

21. 17
1. BACKGROUND
1.1 The Rationale for Intervention in Adolescent Health
One-sixth of the world’s population, some 1.2 billion people, are adolescents, defined as 10-19 years of
age (United Nations, 2017). The majority of these adolescents live in developing countries. Transforming
adolescents into productive, healthy adults is a critical part of ensuring demographic dividends to
economic growth. A major challenge to this is the high prevalence of teenage pregnancy and early
marriage. Choices relating to sexual activity and marriage made during adolescence have a long-lasting
impact on the health of women and children, on demographics, and on labor force participation of
women in developing economies.
India is one of the countries where prevalence of early marriage and childbearing is high, with 40
percent of girls age 18-22 years having been married before the age of 18, and nearly one in five girls in
this cohort having had a child before the age of 18 (Wodon et al., 2017). These proportions matter in
India, where, according to the 2011 census, over 253 million people, one out of five, are adolescents
(Ministry of Home Affairs, GOI2011). It is well established that the costs of early marriage and
childbearing are high in terms of their impact on maternal mortality and child survival. Children born to
adolescent mothers in developing countries are known to have a 50 percent higher risk of being
stillborn compared to those whose mothers are over 20 years of age (WHO, 2014). Low birth weight is
more common with its attendant long-term impacts among infants born to adolescent mothers (WHO,
2014). Maternal health issues are the leading cause of death for those 15-19 years of age (WHO, 2017),
another cost of early childbearing. Iron-deficiency anaemia is a leading cause of disability adjusted life
years lost among all adolescent girls (WHO, 2017). India has the highest prevalence of iron-deficiency
anaemia and adolescent mothers face higher risks to their own health and their newborns, due to their
own iron needs for growth in addition to the specific needs relating to pregnancy and breastfeeding
(Aguayo et al., 2013). There is new evidence of the economic benefits of ending early marriage and
associated childbearing, with welfare gains from population growth being the most acute, in the order of
more than $566 billion dollars globally by 2030 (Wodon et al., 2017).
1.1.1 The context of intervention in India
The Government of India (GOI) has invested substantially in reproductive health programs through the
National Health Mission (NHM), including services for adolescents (MOHFW, 2012). More recently, the
Ministry of Health and Family Welfare (MOHFW) launched the Rashtriya Kishor Swasthya Karyakram
(RKSK) initiative to shift service provision from a curative to a holistic model for adolescents in India
(MOHFW, 2014). The RKSK brings together services in nutrition, sexual and reproductive health, and
mental health and substance abuse to manage a healthy transition from youth to adulthood (MOHFW.
2014). The primary mechanism to deliver this holistic package are community-level workers (CLWs) –
Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), Anganwadi workers
(AWWs), peer educators, and a band of pure volunteers Nehru Yuva Kendra Sangathan (NYKS).
Adolescent-friendly health clinics (AFHCs) represent the facility-level contribution to the initiative.
Overall governance of the RKSK is established through nodal officers at the state and district levels
funded through a line item in the Adolescent Health component of the Program Implementation Plans
(PIP) within the NHM and coordinated with funding for adolescents’ programs that are being
implemented by other, non-health departments (MOHFW, 2014).

22. 18
Given the intended scale and delivery modality of RKSK, the government has sought information on
existing provision and challenges for this population in India. Prior studies on adolescents and health
have demonstrated that the supply of services is fragmented (Joshi et al., 2017; Jejeebhoy et al., 2014;
Gupta et al., 2012), with CLW having limited interaction with adolescents and less engagement on sexual
as opposed to maternal health and hygiene services. In addition, studies have also shown that provider
engagement is gendered (Jejeebhoy et al., 2014): CLWs provide information largely to adolescent girls
only and prefer that adolescent boys approach male doctors at the sub-center or higher level. Male
providers at the facilities also follow this gendered approach.
There is limited, micro-level data, on how current knowledge and health-seeking behavior among
adolescents varies across and within states by married and unmarried women. Variations in micro-level
data can be exploited to improve program planning and implementation both at the scale of the NHM
and smaller projects. The HFG project is investing in interventions to improve the sexual and
reproductive health outcomes among adolescent girls in Madhya Pradesh and Odisha. To support future
investments by the GOI and inform the interventions of the HFG project, this report provides an
assessment of these states, in particular of knowledge, preferences, and barriers faced by young women
who navigate the health systems for their sexual and reproductive health needs.
1.1.2 Organization of NHM at the state level
The NHM’s objectives are delivered through the State Health Society in each state and funded through
the state’s PIPs. NHM services are delivered through the public health systems in the state, which
include health facilities and CLWs. Adolescents seeking family planning services encounter CLWs
starting at the village level, with ASHAs and AWWs, as well as ANMs and Multi-purpose Workers
(MPWs) at the sub-center level, who serve a cluster of villages. MOHFW policy and guidelines mandate
population coverage of 1,000 people per ASHA (slightly less in hilly areas), 3,000-5,000 per ANM at the
sub-center level, 20,000-30,000 at the PHC level, and 80,000-1.2 million at the CHC level. ASHAs and
AWWs work on an outcome-based incentive system and are not salaried, whereas ANMs are salaried.
1.1.3 Health indicators and access in the two states
According to the National Family Health Survey (NFHS4) (IIPS and Macro International, 2016) early
marriage and teen pregnancy are on the decline in both study states. In 2006, prevalence of early
marriage in Madhya Pradesh was 53 percent but declined to 30 percent by 2016. In Odisha, early
marriage declined from 37.2 percent in 2006 to 21.3 percent in 2014. Similar levels of teen pregnancy
prevail in both states (NFHS4). Thirty percent of women 20-24 years of age were married before age 18
years in Madhya Pradesh and 7.3 percent of girls 15-19 years were pregnant at the time of NFHS4. The
HFG districts in Odisha belong to the southern belt or KBK+,2 which are known to have higher levels of
poverty and higher proportions of socially disadvantaged groups including scheduled casts (SCs) and
scheduled tribes (STs) than the rest of the state. One of the districts, Nabarangpur, has the highest level
of poverty in the state. Geographical access to health facilities in these districts is made more difficult by
hilly terrain and poor roads. State investments target these districts with mobile health clinics, incentives
to increase the supply of medical providers, and investments in the health infrastructure (MOHFW,
2017-18). In Odisha, unlike most states, there is a heavy reliance on the public sector for health services.
The latest round of the National Sample Survey (NSS) indicates that while nationally 72 percent of rural
health services were delivered by the private sector, the opposite occurred in Odisha, where 76 percent
2 KBK+ districts refer to the old districts of Koraput, Balangir, and Kalahandi, which were broken up into eight districts in
1992; according to the Planning Commission of India, they are the most backward districts of Odisha

23. 19
of all rural health services were delivered by the public sector (MOSPI, 2014). The HFG districts in
Madhya Pradesh are also disadvantaged with historical “structural inequalities” driven by differences in
land ownership, size of holdings, and caste. Almost a third of the population in both Tikamgarh and
Raisen belong to socially excluded communities including SCs and STs compared to the state average of
25 percent (Ministry of Home Affairs, 2011). Tikamgarh was among the worst performing districts
identified in the Annual Health Survey Bulletin 2012-2013, performing poorly in terms of skilled delivery
(31.5% against a statewide average of 66%), full antenatal care coverage (10.3% versus 16%), and full
immunization coverage (31.5% versus 66.4%), while Raisen showed lowest district levels of
contraceptive use and highest levels of unmet need (Ministry of Home Affairs, 2011).
1.2 Study Objectives
The overall study objective is to assess care-seeking behavior related to family planning and
contraception use including Pregnancy Test Kits (PTKs), emergency contraceptive pills (ECPs), oral
contraceptive pills (OCPs)/condoms/others, etc. among unmarried and married adolescents in selected
districts of Madhya Pradesh and Odisha.
The specific objectives of the study are:
 To study the sources of knowledge, products, and services about various contraception including
PTKs, ECPs, OCPs/condoms, etc., among both married and unmarried adolescents;
 To explore barriers in seeking information, products, or services on family planning by adolescent
groups from ASHAs, ANMs, and other private and public service providers; and
 To develop recommendations to inform strategy designed to improve access to family planning
services/products by adolescents under the NHM.

25. 21
2. METHODS
2.1 Sample Districts
This assessment was conducted in Madhya Pradesh and Odisha, the focus states of the HFG project.
Purposeful sampling was used to select districts. These districts were selected based on discussions with
USAID and where the HFG project plans to operate. HFG plans to operate in Nabarangapur, Koraput,
Kalahandi, and Rayagada districts in Odisha and in 17 districts in Madhya Pradesh identified by the
project as high-focus districts. For Madhya Pradesh, an additional step of classification was used given the
number of planned districts: districts with low contraceptive prevalence rates (CPRs) (range 10.4% to
49.1%, n=10)) and districts with high CPRs (50.7% to 66.9%; n=7). Two districts, Tikamgarh and Raisen,
were randomly selected from the high and the low CPR districts, respectively. Rayagada and Koraput
districts were randomly selected from the four HFG priority districts in Odisha.
2.2 Sampling Methodology
The assessment employed a mixed methods approach. A household survey of adolescent girls aged 15-
19 years was conducted in the sample districts as were focus group discussions (FGDs) and in-depth
interviews (IDIs) with key populations. These include:
 Separate FGDs with unmarried and married adolescent girls;
 FGDs with boys aged 15-19 years and husbands of married adolescent girls;
 IDIs with community providers: ASHAs, ANMs, AWWs, local chemists/pharmacists/rural medical
practitioners (RMPs); and
 IDIs: Block and district health officials and private health providers.
A multistage sampling procedure using probability proportionate to size (PPS) with 30 clusters were
selected in the first stage. At the second stage, a listing of households with married and unmarried
adolescents was done to develop two sampling frames of unmarried and married adolescent households
in each village. At the third stage, from each sampling frame of married and unmarried adolescent
households, 11 (10% extra for refusal) households with married and 11 households with unmarried
adolescent were selected (total of 22 households) using systematic (circular) sampling. A total of 1,060
adolescent girls from each state were required for the study to meet the minimum sample size required
for 95 percent confidence bounds and a design effect of 1.5. Further details on sampling can be found in
Annex A. Of the total married and unmarried adolescent girls planned for this sample, over 100 percent
of the required sample was surveyed (Table 1). The number of participants by focus group is shown in
Table 2. FGDs were done in villages other than those surveyed except those of husbands of married
adolescent girls. All tools were pre-tested in two villages of Tikamgarh district (Madhya Pradesh) and
were translated and published bilingually, in English-Hindi and English-Oriya.

26. 22
Table 1: Sample Size by State, Household Survey
Sample Size Madhya Pradesh Odisha Total (both states)
Married 649 626 1275
Unmarried 607 613 1220
Total 1256 1239 2495
Note: Attempted to obtain 50% married and 50% unmarried in each state
Table 2: Sample Size, In-Depth Interviews and Focus Groups
Participant Type
Madhya Pradesh Odisha Totals
Number of
participants
(# x Groups/IDIs)
Number of
participants
(# x Groups/IDIs)
Number of
participants
In-depth Interviews
AWW 30 (15x2) 30 (15x2) 60
ASHA 30 (15x2) 30 (15x2) 60
ANM 12 (6x2) 12 (6x2) 24
PMP/RMP 8 (4x2) 8 (4x2) 16
Pharmacist/Chemist 8 (4x2) 8 (4x2) 16
CHC/PHC 6 (3x2) 6 (3x2) 12
District Hospital 2 (1) 2 (1) 4
Focus Group Discussions
Unmarried adolescent girls 4 (2x2) 4 (2x2) 8
Unmarried adolescent boys 4 (2x2) 4 (2x2) 8
Married adolescent girls 4 (2x2) 4 (2x2) 8
Husbands of married adolescent girls 4 (2x2) 4 (2x2) 8
2.3 Ethical Considerations
The protocol, tools for data collection, and other relevant documents were reviewed and approved by
the Sigma Institutional Review Board (IRB), New Delhi. Given the sensitive nature of this survey, the
options of written consent and witnessed verbal consent were carefully considered. In India, it is normal
practice to obtain verbal consent, because respondents generally are reluctant to sign a consent form
even if they agree to participate in a study. To respect this norm, verbal consent was obtained from
participants. To maintain confidentiality, the questionnaire for adolescent girls excludes the name of
household head as well as the name of the respondent, but retains the code from the house listing on
the questionnaire. The protocol was also approved by Ethics and Research Committee in Odisha,
without which the study could not have been started in its selected districts. To gain consent, HFG
presented the protocol to committee members in a meeting on May 5, 2017, in Bhubaneswar.
Additional details on confidentiality and informed consent are given in Annex A. Annex B provides
details on the process of field data collection, recruitment and training of data collectors, quality
assurance, and data entry and analysis. Tabulated results obtained from the survey, IDIs, and FGDs are
available separately in the Addendum Report. Annex C provides the list of villages where this study was
conducted in Madhya Pradesh and Odisha. Since the documents were approved by the Sigma IRB,
approval of Abt’s IRB was not required.

27. 23
3. RESULTS
3.1 Demand for Services
This section describes characteristics of the sample population relating to the demand for family
planning, incorporating socioeconomic endowments, empowerment, engagement with providers, and
preferences of adolescent girls. All results on levels and sources of contraceptive use are limited to
survey responses from married adolescent girls as unmarried girls were not asked about their own
contraceptive use.
3.1.1 Variation within states: Girls in HFG districts versus all girls and
MWRA
Table 3 uses the most recent demographic (NFHS4) data to compare family planning and education
outcomes for married Girls of the sampled populations versus all married women of reproductive age
(MWRA) (15-45 years) by state. Levels of modern method use among the sampled married girls are
significantly lower in both states than among MWRA in each state. In Madhya Pradesh, modern
contraceptive use among surveyed married girls is nearly half that of all MWRA in the state, while in
Odisha the CPR is one-sixth of the rate among all MWRA. These differences indicate that either district
or age characteristics, or both, are driving lower use of family planning services. Traditional method use
is similar among sampled adolescents and all MWRA in Madhya Pradesh, but much lower among
sampled girls than among all MWRA in Odisha. These differences are more difficult to interpret. Finally
modern method use in the sample population in Madhya Pradesh is nearly three times that of Odisha,
largely driven by the use of Standard Days Method (SDM), which represents 42 percent of the modern
method mix. This is an interesting finding, since levels of SDM use in this sample population are much
higher than those observed in other studies (Marston and Church, 2016; Wright et al., 2015).
Besides comparison of contraceptive use, preliminary data from NFHS4 allow comparison of some of
the factors that influence contraceptive use among girls, including age of childbearing and educational
achievement. Of some concern is the disparity in levels of childbearing between 15-19 years in sampled
populations versus girls of the same age group in both states (NFHS4). Early childbearing is 10 times
higher among all girls in the selected districts compared with adolescent girls in the general MWRA
populations in the two states. School completion rates are significantly lower in this sample compared
with the state overall, in both states. In the selected districts, school completion rates are half that of all
MWRA in Madhya Pradesh and a third of all MWRA in Odisha. Differences of such magnitude argue for
differential programming in HFG districts to address lower educational capital and fewer opportunities
to delay childbearing.

28. 24
Table 3: Family Planning and Education Outcomes: Married Girls versus All MWRA
Sample MP
Married Girls (MG)
NFHS4 MP
MWRA
Sample Odisha
Married Girls (MG)
NFHS4 Odisha
MWRA
Use of modern methods 29% 49.6% 7.34% 45.4%
Use of traditional methods 2.4% 2.6% 1.79% 11.9%
Already mother or pregnant
at time of survey
(aged 15-19)
69.4% 7.3% 60.7% 7.6%
Proportion completing
10+ years of schooling
12.2% 23.2% 10.6% 26.7%
Source: NFHS4 Fact Sheets MP, NFHS4 Fact Sheet Odisha
Note: MG=married adolescent, UG=unmarried girls
3.1.2 Married versus unmarried girls, endowments, and constraints
Girls in sample districts are not different just from all MWRA, but also differ by residence and marital
status in terms of endowments and constraints. In both states, the overwhelming majority of girls belong
to groups that suffer from social exclusion including SCs and STs of “Other Backward” classes (91.4% in
Madhya Pradesh and 98.7% in Odisha). Early marriage and childbearing are common in both states. Most
adolescent girls aged 18-19 years (87.3% Madhya Pradesh and 82.4%, Odisha) and over 10 percent of 15-
17 year olds are married (12.7% in Madhya Pradesh and 17.6% in Odisha). Nearly half of the adolescent
girls in the sample districts had at least one child (46.2% in Madhya Pradesh and 47.5% in Odisha) at the
time of survey.
Low levels of school achievement also are common. Illiteracy, however, is four times higher among the
sampled married Odisha girls (38.7%) than among their Madhya Pradesh counterparts (11.2%) and twice
as high for unmarried adolescent girls. A high proportion of adolescent girls work outside the home in
Odisha, primarily as migrant labor (26.6%, MW and 25.1 UW) or farm labor (9.2% MW, and 7.7% UW).
Working outside the home is uncommon in Madhya Pradesh, especially for married adolescent girls
(Table 4a). Most adolescent girls in the sample districts live in households where the incomes range
from less than Rs. 5,000 to Rs. 10,000 per month.
Table 4a: Education and Empowerment Characteristics, by Marital Status and State
MP
Married
MP
Unmarried
Odisha
Married
Odisha
Unmarried
Secondary school completion 7.1% 20.2% 6.4% 19.3%
Works outside home 8.2% 57.2% 38% 76%
Current student 2.3% 52.7% 0.3% 42%
Respondent alone decides about taking up job/working 8.1% 23.3% 3.3% 9.6%
Respondent alone decides about contraceptive use 3.1% 10.9% 0.3% 1.4%
Respondent alone decides how much children should
study
1.3% 5.9% 1.3% 8%
Respondent alone decides how much girl child should
study
1.3% 7.9% 7.7% 7.8%
Respondent alone decides age at which girl child should
be married
0.7% 3.7% 11.1% 10.2%

29. 25
In both states, unmarried adolescent girls differ from their married counterparts in regard to educational
outcomes, and mixed patterns emerge on empowerment. Neither marrieds nor unmarried are much
empowered in the sense of being able to take decisions independently. However, residence and marital
status matter: married girls in Madhya Pradesh report higher levels of independent decision-making than
do their counterparts in Odisha. Surprisingly, unmarried adolescent girls in both states report much
higher levels of independent decision-making than their married counterparts: 10.9 percent of unmarried
adolescent girls in Madhya Pradesh versus 3.1 percent of married ones, and 1.4 percent of unmarried
ones versus 0.3 percent of married ones in Odisha alone decide about contraceptive use.
Married and unmarried adolescent girls in each state report significant barriers to health seeking and
very similar levels of constraint (Table 4b). Supply-side barriers are seen as bigger problems in general
than self-empowerment to obtain services. That is, concerns about availability of providers, including
female providers, availability of drugs, distance to facilities, and need for transport are reported by a
higher proportion of girls than needing permission or having someone accompany them.
Table 4b: Barriers to Health-Seeking at Facilities, by Marital Status and State
In case of sickness or desire for
medical advice/treatment,
proportion reporting: Big problem
MP
Married
MP
Unmarried
Odisha
Married
Odisha
Unmarried
Getting permission to go 27.5% 22.3% 23.2% 19.2%
Getting money 34.1% 28.7% 56.4% 55.0
Distance to health facility 47.1% 40.5% 30.5% 31.6%
Need for transport 42.7% 35.6% 27.6% 28.1%
Finding someone to go with 31.1% 26.2% 12.1% 8.8%
Concern that there may not be a female
provider
53.4% 45.1% 41.3% 41.7%
Concern that there may not be any
provider
48.3% 43.9% 47.0% 44.6%
Concern that there may not be any drugs 35.3% 33.0% 43.4% 38.5%
In general, there are few differences between married and unmarried adolescent girls when it comes to
economic endowments or household characteristics. In the sections that follow, additional results are
described on health seeking and barriers faced by girls at the community and facility levels. These results
capture information and service provision at the community level, as well as at the facility level from the
client and provider perspectives.
Access to media and mobile phones is high in both states. In Madhya Pradesh, mobile phone access is
near universal (97% MW and 96.1% UW) and over three-quarters have access to television (81.5% MW
and 84.4% UW). In Odisha, access to television is higher among unmarried adolescent girls (78% UA
versus 65% MA), but access to mobile phones is similar in the two groups (59% UA versus 55% MA).
Girls’ access to the internet is limited overall, but unmarried adolescent girls have more access in both
states (8% UA versus 1% MA in Odisha and 15% UA versus 6% MA in Madhya Pradesh).

30. 26
3.1.3 Decision-making on family size and contraceptive use and
marriage
Survey data show that a majority of married adolescent girls jointly decide with husbands on
contraceptive use (75% Madhya Pradesh and 48% Odisha). A higher proportion of girls in Madhya
Pradesh, married and unmarried, make this decision on their own (3.1% MW and 10.9% UW), compared
with their counterparts in Odisha (0.3% MW and 1.4% UW). Over 40 percent of adolescent girls in
Odisha report that husbands alone decide on contraceptive use. FGDs with husbands, however, reveal
discordance in decision-making and preferences. Husbands report that wives are the ones who drive
non-use, but this is a function of wanting to prove fertility or ability to bear children. The FGDs suggest
that spoken or unspoken expectations by in-laws strongly reduce an adolescent girl’s ability to make
decisions on fertility and contraceptive use. The differences between survey responses and FGDs are
significant and further exploration is needed to interpret these differences. Provider perspectives on
decision-making reinforce the view that “family pressure to complete fertility” is an important driver of
non-use among married girls.
The majority of married adolescent girls in Odisha say they make decisions on family size jointly with
their husbands (73%), but a substantial minority reports that others, particularly husbands, make the
decision for them (27%). Similar proportions are reported in Madhya Pradesh (77% joint decision-
making). There is evidence from the survey of shifts in empowerment with marriage, on decisions
relating to contraceptive and family size. Few unmarried adolescent girls in either state report making
such decisions on their own, and identify parents making these decisions for them. The majority of
married adolescent girls report joint decision-making on the age at which a girl should marry, for their
offspring (50% in Madhya Pradesh and 48% in Odisha).
3.1.4 Methods awareness and use
Knowledge of female sterilization is nearly universal among married girls in Madhya Pradesh, and in both
states, this is the most well-known method (Table 5). Knowledge of methods beyond sterilization varies
by state, with a higher proportion of girls in Madhya Pradesh, both married and unmarried, aware of
almost all methods except OCPs compared with adolescent girls in Odisha. For example, more than a
third of married adolescent girls in Madhya Pradesh are aware of intra-uterine contraceptive device
(IUCDs) and nearly three-quarters are aware of male condoms but only a fifth are aware of IUCDs and
a third know about male condoms as methods in Odisha. Knowledge of the pregnancy test kits much
higher in Odisha, with 86 percent of married adolescent girls and 75 percent of unmarried adolescent
girls reporting awareness of the kit. Comparatively, 74 percent of married and 57 percent of unmarried
adolescent girls in Madhya Pradesh are aware of the same.
FGDs in both states with married and unmarried adolescent women, husbands, and adolescent boys
revealed large misconceptions about all methods except sterilization, relating to fertility effects,
infection, and strong association between using modern methods and illness, especially “weakness.”
FGDs also revealed misconceptions about ECPs and their impact on fertility, and an association between
having an abortion and becoming infertile. These misconceptions are not limited to ECPs but also carry
over to the use of the OCP and abortions. Common concerns relate to weight gain and disruption of
the menstrual cycle, ill-effects on the uterus, nausea, and “weakness.” Most respondents also believe
that abortions are “sinful.” ECPs are the least known method after Lactational Amenorrhea Method
(LAM) among married adolescent girls and after LAM and PPIUCDs among unmarried adolescent girls in
Madhya Pradesh. ECPs are better known among unmarried adolescent girls in Madhya Pradesh,
compared to their cohort in Odisha. Knowledge of ECPs among unmarried in Odisha is 3.8 percent, less
than knowledge of commonly available spacing methods including condoms and OCPs.

31. 27
Table 5: Method Awareness, by Marital Status and State
MP
% Married Girls
MP
% Unmarried
Girls
Odisha
% Married Girls
Odisha
% Unmarried
Girls
Female sterilization 91.4 85.4 76.3 51.9
Male sterilization 27.7 20.6 8.2 6.2
Male condom/ Nirodh 70.7 41.1 33.8 21.2
OCP 57.0 42.2 65.6 36.1
IUCD 36.6 18.3 19.7 6.4
PPIUCD 12.0 3.5 3.4 0.5
ECP 6.4 13.1 5.1 3.8
Injectables 58.2 42.4 3.1 2.1
LAM 1.5 0.3 2.3 0.0
SDM/cycle beads 41.7 3.5 1.1 0.0
PTK 79.4 57.4 85.5 74.5
The moderate level of method awareness in both states does not translate into method prevalence as
seen below in Figure 1. Slightly more than a quarter of married adolescent girls in Madhya Pradesh (29%)
and less than 10 percent of married adolescent girls in Odisha (7.3%) use modern methods. In Madhya
Pradesh, the dominant modern method is the SDM (13.2%), followed by condoms (10.5%). All other
modern methods show marginal levels of use, with less than 2 percent of married girls using PPIUCDs
(1.8%), followed by OCPs (1.3%), LAM (0.98%), and IUCDs (0.8%); injectables represent the smallest
share (0.3%).
Traditional method use is low in Madhya Pradesh: Less than 2 percent (1.5%) of adolescent girls use the
rhythm method, followed by withdrawal and “other” traditional methods (0.3% and 0.3%). None of the
married girls use ECPs. In Odisha, most modern method users use oral contraceptives (4.2%). Nearly 1
percent of married girls use injectables, followed by equal proportions of IUCD (0.81%) and male
condoms (0.81%). Only 0.3% of married adolescent girls use PPIUCDs and equal proportions report
using ECPs and LAM (0.16% and 0.16%). Traditional method use is slightly lower in Odisha with 1.8
percent reporting use of rhythm, withdrawal, and “other traditional methods.” It should be noted that
questions relating to use of contraception were only asked of married girls.

32. 28
Figure 1: Method Prevalence, Married Girls, by State
3.1.5 Future use of contraception
Adolescent married girls in general are unlikely to plan to use contraception to prevent pregnancy in the
near future. Most married adolescent girls in Madhya Pradesh either do not plan to use a method (34%)
in the next 12 months or don’t know (37%) if they will use a method in that period. In Odisha, 60
percent of married girls do not plan to use a method in the next 12 months and 13 percent do not know if
they plan to use a method. Among those who were not pregnant at the time of survey in Madhya
Pradesh, 60 percent did not plan to use because they wanted another child, compared to 70 percent in
Odisha. Another 25 percent of this group in Madhya Pradesh and 18 percent in Odisha felt that lack of
menstruation and breastfeeding would confer protection against pregnancy. Since the length of
protection was not asked, it is difficult to interpret if girls are using LAM.
0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0%
IUCD
PPIUCD
Injectables
Oral Contraceptive Pill (OCP)
Male Condom/ Nirodh
ECP
Standard days/cycle beads
LAM
Rhythm method
Withdrawal
Other traditional method
Odisha MP
MethodsthatcanbeprovidedbyCLW

33. 29
3.1.6 Client satisfaction with community health services
Adolescent girls, boys, and husbands of married adolescent girls were asked during FGDs to rate their
level of satisfaction with community health service provision as either “Satisfied,” “Ok,” or “Low.” Table
6 describes satisfaction disaggregated by type of CLW in the study districts. There was a higher level of
satisfaction with ASHAs in Odisha than in Madhya Pradesh. In both states, ASHAs generally rate better
than ANMs and AWWs. Most respondents in Odisha rate ANM services as “low,” while there is a
mixed pattern in Madhya Pradesh. AWWs are generally rated as being satisfactory or “ok” in both
states.
Table 6: Client Satisfication with CLWs, by Type of CLW and Study District
ASHA ANM AWW
Satisfied Ok Low Satisfied Ok Low Satisfied Ok Low
Tikamgarh (MP)
Married Girls  - -  - -  - -
Husbands  - -  - - -  -
Unmarried Girls -     -   -
Unmarried Boys -  - -     -
Raisen (MP)
Married Girls   -  - -  - -
Husbands  - -   - -  -
Unmarried Girls   -  -   - 
Unmarried Boys - -  - -  - - 
Koraput (Odisha)
Married Girls  - -  - -  - -
Husbands  - - - -  -  -
Unmarried Girls  - - - -   - -
Unmarried Boys  - - - - - - - -
Rayaguda (Odisha)
Married Girls  - - - -   - -
Husbands   - -   -  -
Unmarried Girls  - - - -  -  -
Unmarried Boys  - - - -  -  -
Reasons for satisfaction with ASHAs in Rayagada district, Odisha, include organizing community
meetings, distributing pills, and condoms and “convincing people” about contraceptive use. Married
adolescent girls in the same district identified ASHAs as reliable providers and praised them for
providing services irrespective of “caste feelings.” In Raisen district, Madhya Pradesh, ASHAs are praised
for distributing IFA tablets and “calling the children for immunization.” Unmarried adolescent girls in
Raisen who rated their ASHA as “ok” commented on her ability to call an ambulance when needed and
to distribute medicines.

34. 30
From the Hindi word “Angan” meaning
courtyard, a place for social gatherings.
AWWs are women responsible for
implementing the Integrated Child
Development Services (ICDS) at the
community level, targeting nutrition of
children under six years and their mothers.
AWWs work out of small facilities providing
food, supplements, and health education,
and making home visits.
Source: Ministry of Women and
Child Development, GOI
ANGANWADI WORKERS
ANMs are likely to be given a satisfactory rating in Madhya Pradesh and to be rated as “low” in Odisha.
Reasons for dissatisfaction with ANMs in Odisha included comments such as “she only instructed the
ASHA to do work” and “did not do any discussion.” In Rayagada district, unmarried adolescent girls
rated ANMs as “low” as they “do[es] not have any role in service provision.” Unmarried adolescent
boys also reported that they felt that the ANM “gets all her work done” by ASHAs and AWWs. ANMs
were also criticized for their irregular visits. In Madhya
Pradesh’s Tikamgarh district, those who rated ANMs as
“low” reported not being aware of her existence.
Few AWWs received a low rating. In Tikamgarh district,
some respondents complained that the AWWs do not
provide them with “all the information.” Those who rated
AWWs as “low” reported only visiting them for nutrition
supplements. AWWs are seen as providing services but
“not moving in the village like ASHAs.” Husbands of
married adolescent girls also rated ANMs as “low”
because they did not provide services but were seen to
merely instruct ASHAs.
Respondents were also asked about satisfaction with
private doctors. In general, the primary criticism of
private doctors is the cost of services, or that they are
unaffordable, while most reported that they provide good
services. Unmarried adolescent boys in Odisha also
commented that “they explain well” and the
contraceptives provided are of “good quality.”
3.2 Supply of Services
This section examines the sources of information and contraceptive services from both the provider and
client perspectives and the overall context of delivering services to girls.
Adolescent girls in the selected districts theoretically have a range of options to obtain health
information and services. Of these, CLWs represent the most directly resourced mechanism for
delivering adolescent care. CLWs include ASHAs and AWWs. These CLWs together with peer
educators are responsible for delivering the targeted program for girls, the RKSK, along with an
expanded range of clinical services at the facility level. Besides CLWs, girls can seek services at the sub-
center, the first point of facility-level care, community-level facilities that are staffed by female ANMs and
a male MPW. Beyond the sub-center are PHCs, headed by a Medical Officer and supported by a
paramedical health care provider and other staff. Chemists or drug shops and private health clinics
represent another option for services, but they are smaller in scale in both states. Finally, health
information is also available via television, radio, newspapers, and the internet.
Given that the RKSK is the primary program for delivering services to all girls, this study examined levels
of implementation from both the adolescent and provider perspectives. In general, CLWs report
delivering services through adolescent groups, or peer groups, more robustly in Odisha than in Madhya
Pradesh. However, there is disagreement between ASHAs and AWWs on the presence of adolescent
groups. In Madhya Pradesh, less than half of ASHAs reported the formation of such groups in villages,
while all AWWs (100 percent) reported their formation. In Odisha, there was greater alignment
between ASHAs and AWWs on the issue. ASHAs in both states reported contacting married and
unmarried adolescent girls through these groups as well as through home visits, Village Health Nutrition

35. 31
Days (VHNDs), and at AWCs. However, CLWs do not seek out adolescent girls; rather, they wait for
these adolescent girls to seek services through their participation in group meetings, when they seek
supplementary nutrition, during Iron/Folic Acid (IFA) distribution, and during home visits. None of the
CLWs directly reported organizing an Adolescent Health Day, one RKSK element, although they do
organize VHNDs. Eight out of 10 married girls in Madhya Pradesh did not know if their AWC held
adolescent meetings and less than 2 percent have attended such a meeting. More girls in Odisha are
aware of these meetings (38% MW; 62% UW) but very few married adolescent girls (7.3%) have actually
attended compared with unmarried adolescent girls, at least two-fifths (39%) of whom have attended.
On the facility side, creation of AFHCs is another element of the RKSK. None of the CHCs/PHCs
covered in Madhya Pradesh have AFHCs but five out of six CHC/PHCs and both district hospitals in
Odisha do. Facility-level informants reported that the AFHCs in Odisha provide counselling, treatment
for adolescent health problems, information about care during pregnancy, childbirth, and immunizations,
and contraceptives, and “minimum age after which adolescent should go for child bearing,” including a supply
of contraceptives.
As noted, CLWs come in contact with married girls primarily when the latter come to the AWC for
supplementary nutrition, when they seek antenatal care with the ANM, and when they attend VHNDs.
Of the 30 AWWs interviewed in each state, only seven in Madhya Pradesh and none in Odisha had met
a married adolescent in her home. Unmarried adolescent girls are also largely encountered when they
come for adolescent meetings, for nutrition, and for IFA tablets. However, most AWWs in Madhya
Pradesh report meeting unmarried adolescent girls at home. Unlike ASHAs, AWWs in Madhya Pradesh
report girls being unavailable at home as an important secondary barrier, while those in Odisha identify
their own work burden as a barrier. Strikingly few ASHAs or AWWs identify home visits as a strategy
for demand generation. ANMs, whom girls report seeing the least, report interacting with girls primarily
during the VHND or when adolescent girls visit the AWC for supplementary nutrition. ASHAs in
Odisha are far more secure in their capacity to interact directly with girls, compared with ASHAs in
Madhya Pradesh. ASHAs and AWWs consistently report low levels of unmarried sexual activity and
abortions among unmarried adolescent girls in both states. ANMs, however, report high levels of
unmarried sexual activity and abortions in this population. Responses of ANMs do not track closely with
ASHAs and AWWs when it comes to knowledge about sexual activity, and the burden of unintended
pregnancies in the community. ANMs share concerns of high levels of unmarried sexual activity and
abortions among unmarried with medical providers at the facility. Unlike ASHAs and AWWs, ANMs are
like medical providers, ranking abortion as a very serious problem in their districts.
3.3 Sources of Contraception among Married Girls
Figure 2 shows the proportion of girls reporting their source for each method, with some girls reporting
more than one source for a method. The most important source for short-term methods are medical
stores and government facilities. Sourcing short-term methods from the private sector and government
facilities is more costly than sourcing them at the community level, where they are free. Especially in
Madhya Pradesh, CLWs provide a small share of these methods; only 4 percent identified CLWs as a
source for OCPs (ANM 2% and ASHAs 2%), 6 percent identified pharmacies, 2 percent identified
government facilities, and 1 percent identified private clinics. Also in Madhya Pradesh, pharmacies and
stores combined are a prominent source (62 percent: pharmacies at 54% and general stores at 8%) of
male condoms for girls. Government facilities are the second most popular source for condoms (18%),
and CLWs are a far third (8%: ANMs 4% and ASHAs, 4%).

36. 32
Figure 2: Source of Method Reported by Girls, by Provider Type and State
CLWs provide a greater share of short-term methods in Odisha, competing equally with facilities and
chemists to provide OCPs. In Odisha, 27 percent of girls identified CLWs a source of OCPs (ANMs 8%
and ASHAs 19%), 22 percent identified pharmacies, 19 percent identified government facilities, and 2
percent identified private clinics.
In contrast, government facilities are the dominant providers of long-acting and permanent methods
although these methods are rarely used by the sample population. Private facilities provide a small share
of post-partum and IUCD methods in both states. Injectables are virtually unused, with only 1 percent
reporting in Madhya Pradesh and all reporting private clinics as the source. Per regulations, only the
private sector provides injectables, but this is changing and injectables will soon be rolled out in the
primary health care system up to the sub-center level (MOHFW, 2016). For IUCDs, government
facilities dominate, with 5 percent of girls identifying government clinics as a source in Madhya Pradesh
and 4 percent in Odisha and 1 percent identifying ANMs as a source for IUCDs.
2
18
19 2 8 2 19
1
1
1
12
1
2 6
54
22
0 20 40 60 80 100 120
PPIUCD
IUCD
OCP*
Injectables
Male Condom/ Nirodh*
MP Odisha MP Odisha MP Odisha
MP Odisha MP Odisha MP Odisha

37. 33
3.3.1 Role of CLWs (ASHAs, ANMs, and AWWs)
This section first looks at how girls perceive availability and content of services and then discusses CLW
reports of service provision and perceptions.
In general, adolescent girls in both states report that CLWs provide low levels of family planning
information and services. Although ASHAs are the frontline workers for family planning and maternal
and child health services under the NHM, only a small minority of married and unmarried adolescent
girls in Madhya Pradesh (6.6% and 4.5%) were aware that ASHAs provide contraceptives (Table 7a). A
slightly larger proportion of adolescent girls in Odisha were aware of community-level provision of
methods (19% married and 10% unmarried). In contrast, an overwhelming majority of adolescent girls in
both states know ASHAs in their role as accompaniers to delivery centers for pregnant adolescent girls.
Girls in Odisha have a broader understanding of the multiple tasks performed by ASHAs, while those in
Madhya Pradesh have a higher awareness of a few tasks like home visits and child immunization. During
FGDs, girls in Madhya Pradesh said that information on family planning should be sought from husbands,
family, and friends, and did not mention CLW.
Table 7a: Services Provided by ASHAs, from the Client Perspective
Topics discussed by ASHAs MP
Married
MP
Unmarried
Odisha
Married
Odisha
Unmarried
Young child health 63.7% 28.2% 62.1% 2.3%
Maternal health 54.4% 11.7% 64.2% 5.4
Personal hygiene during menstruation 18.3% 30.4% 12.4% 60.2%
Adolescent’s health 7.1% 17.2% 7.9% 68.3%
Family planning 12.3% 4.9% 23.9% 5.4%
Ideal family size 2.2% 1% 0.3% 1.4%
Other topic 0% 0% 0% 4.5%
No discussion with adolescent 12.83% 36.9% 0% 0.5%
What girls know about the role of ASHAs depends on whether they have interacted with an ASHA.
Almost a quarter of married adolescent girls in Madhya Pradesh (22%) and over a third of them in
Odisha (35%) have never met an ASHA. Unmarried adolescent girls are less familiar with ASHAs: nearly
half (44%) of them in Madhya Pradesh, and two-thirds of them in Odisha have never met an ASHA.
Among those who have met an ASHA, intensity of interaction varies by marital status and state.
Between a quarter of married adolescent girls in Madhya Pradesh and over a third in Odisha have not
had a home visit by an ASHA in the last three months. Slightly less than half of unmarried adolescent
girls in Madhya Pradesh and nearly two-thirds in Odisha have not had a home visit by an ASHA in the
last three months. The majority who have had a visit in that period had between one to two visits.
Adolescent girls were also asked questions about their interaction with AWWs, who are the frontline
workers for the Integrated Child Development Scheme (ICDS), run Kishori programs for girls at the
village AWC, and hold adolescent meetings within the ICDS programs. In Madhya Pradesh, half of
surveyed unmarried and married adolescent girls had never visited an AWC (49% and 53%). In Odisha,
nearly two-thirds of married girls and slightly more than half of unmarried girls have visited AWCs (69%
and 57%). Adolescent health is the primary topic of discussion, but it appears to be disconnected from
sexual health, since no married and less than 2 percent unmarried adolescent girls report hearing about
family planning in Madhya Pradesh, while 8 percent of married and 1 percent of unmarried girls report
the same in Odisha (Table 7b).

38. 34
Table 7b: Services Provided by AWWs, from the Client Perspective
Topics discussed by AWWs MP
Married %
MP
Unmarried
Odisha
Married
Odisha
Unmarried
Personal hygiene during menstruation 14.3% 58.2% 0% 57%
Adolescent’s health 42.9% 10.9% 0% 10.5%
Told about cleanliness/Maintaining
personal hygiene
14.3% 5.5% 75% 0%
Benefits of IFA tablets 0% 1.8% 16.7% 26.7%
Young child health 14.3% 0% 0% 0%
Maternal health 0% 5.5% 0% 1.2%
Family planning 0% 1.8% 8.3% 1.2%
Balanced diet/Food & nutrition 0% 1.8% 0% 5.8%
Age of marriage/Child marriage 0% 1.8% 0% 4.6%
Rangoli and Mehndi 0% 1.8% 0% 0%
Sewing 0% 1.8% 0% 0%
Sports activity 0% 1.8% 0% 0%
To understand service availability and provision, this study conducted IDIs with CLWs. CLWs were
asked to describe what they actually provide and also what they would provide to capture preferences.
They were also asked to discuss levels of unintended pregnancies through prevalence of abortions and
their perspective on challenges they faced to provide services. The study found that CLWs report
providing a lot more services than girls report receiving. However, this does not mean that all methods
are provided by all CLWs based on what they are permitted to provide. The data show that there is no
consistency across providers across and within states in what they say they are providing or would
provide (Tables 7c (i-iii).
Table 7c(i): General Contraceptive Information and
Service Provision and Constraints Reported by CLWs
Type of information and services
provided on contraception
according to CLWs
Multiple responses
ASHA (n=30) AWW (n=30) ANM (n=12)
MP Odisha MP Odisha MP Odisha
Provide any contraceptive services to
adolescent girls
30 24 30 24 11 11
Not able to provide information to newly
married, 15-19
1 0 0 0 0 0
No girls in area are married 0 3 0 0 0 0
No discussion about method with
unmarried girls
0 4 0 6 0 0
No contraceptive advice/Don't know 20 2 1 2 1 0

39. 35
Fewer CLWs in Odisha than in Madhya Pradesh report providing services to girls. Fewer ASHAs and
AWWs in Odisha have discussed contraception with unmarried adolescent girls, and a few ASHAs claim
that they have no married adolescent girls in their districts. Since this study found and interviewed
married adolescent girls in the districts, and since AWWs and ANMs do not report their absence, this
response is puzzling. Equally contradictory, is that CLWs in Madhya Pradesh report that they do not
know or have no contraceptive advice to provide girls, even when they say they do provide any
contraceptive services to girls.
Tables 7c (ii) and (iii) present within-provider variation on methods provided, along with contraceptive
advice, by marital status and by state. The results show large within provider variation in both states on
the content of contraceptive services and methods.
In Madhya Pradesh, most method provision is reported
by ASHAs and most of this is to married adolescent girls
in the form of condoms and OCPs, and advice/referral
on sterilization and IUCDs. ANMs provide the least
amount of services. AWWs and ASHAs provide an equal
amount of services to unmarried adolescent girls but this
includes AWWs reporting information on sterilization
for unmarried girls. While about a third of AWWs and
ASHAs report advising married girls on sterilization,
neither provides services on all spacing methods. Only a
quarter of ANMs report providing all methods and about
the same percentage provide “information” on whatever
services the girls need.
For post-partum services, there is both variation in, but also an overall lack of services. Only three
ASHAs report providing information on PPIUCDs; none of the AWWs, and none of the ANMs who are
permitted to provide the service, provides information. Only one ASHA has informed girls on
“breastfeeding” as a contraceptive, and none of the other providers have done so. Information on SDM,
the most popular method reported by girls in M.P., was only provided by one ASHA. Finally, seven
AWWs report providing advice on injectables, although this method is not available in the public sector
in the study districts (Table 7cii).
Table 7 ciii describes the range of method and information provision on fertility regulation in Odisha.
Most method provision is reported by AWWs closely followed by ASHAs. Among methods these two
CLWs can provide, the majority report providing OCPs followed by condoms to married adolescent
girls. The majority of ANMs but very few ASHAs and AWWs offer ECPs to married girls, even though
ECPs are meant to be supplied by ASHAs and AWWs as well. Only one AWW reports advising on
injectables, although this method is available in the private sector in the study districts in Odisha. For
methods ASHAs and AWWs can refer but not provide, the most common method referred are IUCDs
followed by information on sterilization. ANMs rarely provide information or services on these two
methods to married girls. None of the CLWs provided information on LAM or breastfeeding as a
contraceptive in the immediate post-partum period. As in Madhya Pradesh, CLWs in Odisha offer very
little services during the postpartum period. Only one ASHA reported providing information on
PPIUCDs to married girls and three ANMs to unmarried girls, which is not expected. CLWs in Odisha
are also consistent in not providing a choice in methods: none reports providing information on “all
methods” or “all spacing methods” or “information, whatever they need.”
ASHAs and AWWs can directly
provide condoms, OCPs, ECPs and
pills for medical abortion. For
sterlization, PPIUCD and IUCD,
and more recently, injectables, they
are required to provide information
and referrals. They may not
provide the service themselves.
ANMs can directly provide all
services except sterilization services

40. 36
For unmarried adolescent girls in Odisha, condoms are the method most often provided, with ANMs
providing the smallest proportion of condoms among all CLWs. OCPs are the next most common
method but offered by substantially fewer providers. Only half or less of information and advice that is
provided to married adolescent girls is provided to unmarried adolescent girls. Given differences in
sexual activity this may be appropriate. However, the range of methods provided to unmarried
adolescent girls is even more limited than the limited range provided to married adolescent girls. By
state, the study found that unmarried adolescent girls in Odisha are exposed to more methods than are
unmarried adolescent girls in Madhya Pradesh. Proportionally, ANMs provide the least amount of
service even for methods which they are by guidelines permitted to provide (Figure 3). In both states,
there is a pattern of within-provider variation, but the differences are less striking than in Odisha when
it comes to married girls and more striking when it comes to unmarried girls, with ANMs in Odisha
providing more services to unmarried girls compared with those in M.P. Taken together, however,
responses from ANMs, AWWs, and ASHAs show inconsistent, inadequate, and potentially improper
provision of services. Additional details about knowledge of services, content provided by CLWs,
knowledge of abortions among girls, and ways to prevent abortion and promote contraceptive use are
shown in Annex D,
Table 7c(ii): Contraceptive Information and
Services Provided in Madhya Pradesh, as reported by CLWs
Information and Services provided on
contraception and abortion
ASHA (n=30) AWW (n=30) ANM (n=12)
MA UA MA UA MA UA
Direct provision by all
CLWs permitted;
abortion pills but not
clinical abortion by
ASHAs and AWWs
Condom 30 10 22 7 3 5
OCP (Mala-N) 27 3 19 5 3 3
ECP 5 4 1 0 0 2
Safe Period/SDM 1 0 0 0 0 0
Breastfeeding 1 0 0 0 0 0
Abortion 0 1 0 0 0 0
Spacing Methods all 0 0 0 0 3 1
Only ANMs can directly
provide other CLWs
may counsel and refer
Cu-T/IUCD 17 1 16 2 0 0
PPIUCD 3 0 0 0 0 0
CLWs counsel and refer
for these methods: no
direct provision
Female Sterilization 8 0 9 4 0 0
Injectables 1 0 7 0 0 0
Male Sterilization 0 0 0 0 0 0
Information about
contraception and sex
provided to adolescent
girls
All methods 0 0 0 0 0 0
Provide information
whatever they need
0 0 0 0 2 3
Don't do sex regularly 0 0 0 0 0 0
Don’t do sex without
contraception/after 2 child,
use contraceptives or do
operation
0 0 0 0 0 0
Don’t have sex before
marriage
0 0 0 0 0 0
Note: ASHAs and AWWs cannot provide Female Sterilization, IUCD, PPIUCD or Injectables. Those reporting services are reporting information and referrals to
the next level. ANMs can provide PPIUCD, IUCD but not sterilization.

41. 37
Table 7c(iii): Information and Contraceptive Services Provided in Odisha, as reported by CLWs
Information and Services provided on
contraception and abortion
ASHA (n=30) AWW (n=30) ANM (n=12)
MA UA MA UA MA UA
Direct provision by all
CLWs permitted;
abortion pills but not
clinical abortion by ASHAs
and AWWs
Condom 20 16 22 12 6 11
OCP (Mala-N) 25 8 27 7 8 6
ECP 2 0 3 1 9 7
Safe Period/SDM 0 0 0 0 0 1
Breastfeeding 0 0 0 0 0 0
Abortion 0 0 0 0 0 0
Spacing methods all 0 0 0 0 0 0
Only ANMs can directly
provide other CLWs may
counsel and refer
Cu-T/IUCD 23 0 25 0 7 0
PPIUCD 1 0 0 0 0 3
CLWs counsel and refer
for these methods: no
direct provision
Female sterilization 13 0 15 4 4 0
Injectables 0 0 1 0 0 0
Male sterilization 1 0 0 0 0 0
Information about
contraception and sex
provided to adolescent
girls
All methods 0 0 0 0 0 1
Provide information
whatever they need
0 0 0 0 0 0
Don't do sex regularly 0 0 0 0 2 0
Don’t do sex without
contraception/after 2
children, use contraceptives
or do operation
0 0 0 0 8 6
Don’t have sex before
marriage
0 0 0 0 1 0
Note: ASHAs and AWWs cannot provide Female Sterilization, IUCD, PPIUCD or Injectables. Those reporting services are reporting information and referrals to the next level.
ANMs can provide PPIUCD, IUCD but not sterilization.

42. 38
Figure 3: Comparision of Within-State Variation by Provider Type:
Proportion of CLWs Reporting Service Provision to Married and Unmarried Girls
CLWs were also asked about services other than contraception that they provide to girls. Even within
this category there is wide variation across and within states. In general, most of the services provided
relate to information on “maintaining personal hygiene during menstruation.” Even though this is the
most common service, only two-thirds of AWWs, and a tenth of ASHAs and ANMs in Madhya Pradesh
provide it. In Odisha, two-thirds of ASHAs and AWWs provide this service; none of the ANMs does.
Slightly more than a quarter of ASHAs and AWWs in Madhya Pradesh and slightly more than a sixth in
Odisha provided IFA tablets to girls, which is the second most provided service. Other services that are
marginally provided include “maintaining cleanliness,” the tetanus toxoid (TT) injection, information on
nutrition, and least often about early marriage. Additional details on services provided to girls are shown
in Annex D.
Besides services provided, CLWs discussed services they would provide, to help understand to some
extent whether it is provider preferences that are driving the limited and varied services. The study
found that more CLWs would provide contraceptives, especially to unmarried adolescent girls,
compared to those who report providing services. Half the ASHAs, two-thirds of AWWs, and all ANMs
interviewed in Madhya Pradesh report that unmarried adolescent girls are sexually active and similar
proportions would be willing to provide unmarried adolescent girls with services. However, when it
comes to methods, these ASHAs, AWWs, and ANMs in Madhya Pradesh would mostly offer the same
range of methods: condoms and OCPs to unmarried adolescent girls. A few more CLWs would be
willing to offer OCPs and ECPs compared to what they generally provide in both states. For married
adolescent girls, the range of methods is greater, but the main methods, condoms, OCPs, and IUCDs,
remain the same. For married adolescent girls, fewer AWWs and ANMs in Madhya Pradesh would offer
condoms, but a similar proportion of ASHAs would do so. For OCPs, similar proportions of ASHAs and
AWWs providing these would offer them, while ANMs who provide none would also offer none to this
population. The same proportions of provided and would offer also hold for female sterilization. Only
0.0
0.2
0.4
0.6
0.8
1.0
1.2
Madhya Pradesh
ASHA MG ASHA UG AWW MG
AWW UG ANM MG ANM UG
0.0
0.2
0.4
0.6
0.8
1.0
1.2
Odisha
ASHA MG ASHA UG AWW MG
AWW UG ANM MG ANM UG

43. 39
ECPs are a method that would be offered at slightly higher proportions by CLWs to married adolescent
girls. In Odisha, fewer CLWs than in Madhya Pradesh would be willing to offer condoms and OCPs to
married women, and nearly double would offer female sterilization to married adolescent girls. More
would offer ECPs, especially ANMs, where thrice the number would offer these to married adolescent
girls. Fewer would offer PPIUCDs to married adolescent girls.
CLWs were also asked about their understanding of the prevalence of abortion as a proxy for
unintended pregnancies among girls. ASHAs and AWWs concur on the level of prevalence for both
unmarried and married adolescent girls in both states. One-fifth of ASHAs in Madhya Pradesh and none
in Odisha told the study that unmarried adolescent girls in their districts have abortions, compared to
AWW estimates of slightly over one-fifth among unmarried in Madhya Pradesh and just one in Odisha.
For married adolescent girls, four-fifths of ASHAs in Madhya Pradesh, and one-fifth in Odisha felt this
was taking place, and similar proportions of AWWs report the same. Over half of ASHAs and AWWs
in both states believe that abortions in their districts were either not a serious issue or not common.
ANMs had very different perspectives on the prevalence and seriousness of abortions in their districts.
Nearly all ANMs in Madhya Pradesh and half in Odisha believed these were common among unmarried
adolescent girls. All ANMs in Madhya Pradesh and a sixth of ANMs in Odisha reported abortions among
married adolescent girls. All ANMs consider the levels of abortion a “very serious” issue in their
districts.
There is a clear disconnect between what adolescent
girls in Madhya Pradesh believe CLWs can/do provide
versus what CLW report providing. ASHAs and ANMs in
M.P. are identified as a source for OCPs by less than 10
percent of married adolescent girls. In Odisha, almost
half of married adolescent girls (45%) and less than 15
percent of unmarried adolescent girls identify ANMs as a
source for OCPs. Based on NHM protocol, we should
expect that adolescent girls know that ASHAs and ANMs
provide such methods, while AWWs, with their ICDS
focus, are less likely to work as directly in family planning.
Beyond contraception advice and provision, there are low levels of knowledge among girls in Madhya
Pradesh on the PTK. Only 8 percent of married girls and less than 5 percent of unmarried adolescent
girls in Madhya Pradesh are aware that ASHAs have PTKs, and even lower proportions believe they can
access these from AWWs (4.6% MW; 2.4% UW). The CLW system appears to be more robust in
terms of sexual health in Odisha. Sixty percent of married and half of unmarried adolescent girls are
aware that ASHAs are a source of these kits. AWWs here perform better as well, with 18 percent of
married adolescent girls and 14 percent of unmarried adolescent girls identifying them as a source for
kits. ANMs uniformly identify themselves as a source of supply in Odisha, but not in Madhya Pradesh. In
Madhya Pradesh, only a small proportion of the 12 ANMs interviewed identify providing contraceptives
to those who “demand” them (Annex D, Table D3).
The paucity of information and service provision by CLWs is validated by survey responses of married
adolescent girls in both states (Table 8). ASHAs and AWWs find that difficulty having direct access to
girls and “shyness” in discussing contraception by clients are important barriers to providing services. In
Odisha, most AWWs did not report any difficulty approaching girls, but an almost equal number in both
states report that they do not believe that they can engage unmarried girls.
ASHAs and ANMs do poorly on post-partum family planning. Over three-quarters of married
adolescent girls in Madhya Pradesh (80%) and over half of married adolescent girls in Odisha (55%)
report that CLW did not inform them about family planning after their present pregnancy or delivery.
Over three-quarters of married girls
in Madhya Pradesh and over half
of married girls in Odisha report
that CLWs did not inform them
about family planning during their
current pregnancy or recent
childbirth.