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Child Marriage and Reproductive Health Outcomes in South Asia
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Child Marriage and Reproductive Health Outcomes in South Asia

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This presentation provides an understanding of the role of child marriage on reproductive health outcomes using evidence from a multi-country study in South Asia.

This presentation provides an understanding of the role of child marriage on reproductive health outcomes using evidence from a multi-country study in South Asia.

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  • This research was supported by the US Government through the MEASURE Evaluation Population and Reproductive Health Award. I’d like to acknowledge my co-authors, Deepali Godha and Anastasia Gage of Tulane University.
  • Although substantial progress has been made in reducing the prevalence of child marriage (marriage before the age of 18 years), it remains a pervasive problem in South Asia and sub-Saharan Africa, with female children being disproportionately at risk. In India, which has been labeled one of the “hotspots” for child marriage, the proportion of girls aged 20-24 who married before the age of 18 years (the legal minimum age at marriage) declined from 54% in 1992-93 to 50% in 1998-1999 and 47% in 2005-2006. However, in 2005-2006, the prevalence of child marriage exceeded 55% in some eastern, northern, and southern states. Child marriage is increasingly recognized as a violation of human rights. Previous research has associated child or early marriage with a number of adverse health and social outcomes. Raj et al. found that child marriage was significantly associated with high fertility and poor fertility control among young Indian women. Women aged 20-24 who first married before the age of 18 were more likely than those who first married at older ages to have three or more births, a repeat childbirth in less than 24 months, multiple unwanted pregnancies, pregnancy termination, and sterilization. Other researchers have associated child marriage with increased exposure to HIV/AIDS, cross-generational sex, obstetric fistula, high maternal mortality and morbidity, and depression. These adverse outcomes have been attributed to a host of factors, including restricted access to education and health information, limited exercise of informed choices, greater power imbalances between spouses, limited mobility and social interaction, and limited access to health care among child brides compared with women who marry at older ages.
  • Despite the pervasiveness of child marriage and its potentially adverse consequences on reproductive health outcomes, there is relatively little empirical evidence available on this issue, which has hindered efforts to improve the targeting of adolescent health programs. Most studies to date have focused on India and little is known about the associations between child marriage and health outcomes in other countries. Empowering young adolescent girls is recognized as key to improving overall reproductive and child health outcomes and accelerating social and economic development in low- and middle-income countries.
  • For the purpose of this study, child marriage is defined as first marriage when the respondent is younger than 18 years of age. Age at first marriage consists of three categories: 18 years and older (reference group), 15 to 17 years (to capture marriage in middle adolescence), and 14 years of age and younger (to capture marriage in early adolescence and childhood). As opposed to the international age definitions of adolescence, the reference category of age at marriage at 18 years or older has been termed as “Married as adults”. Both descriptive and multivariate analyses are carried out separately for each country. Descriptive statistics include univariate statistics on the predictor and control variables and bivariate associations between age at marriage and the outcome variables. A series of logistic regression models are estimated to examine the association between various outcome variables and age at marriage. Results are presented as odds ratios with 95% confidence intervals. To examine the association between the number of antenatal visits and age at marriage, a Poisson regression model is estimated. The results from these models are presented as coefficients with 95% confidence intervals. No multi-collinearity was found among the predictor and control variables, with the highest variance inflation factor being 1.9. All analyses are conducted using STATA, version 10, and are weighted to account for survey design.
  • Efforts are needed to prevent child marriage, through more effective legal strategies and through education programs that involve community sensitization, awareness-raising and life-skills education. However, also, child brides are typically missed from school-based programs, and there needs to be a way to target girls already married.
  • Despite these contributions, the study has a number of limitations. First, the outcomes are self-reported and hence may be prone to bias due to social desirability and recall. This is particularly true for unwanted pregnancy, which may be under reported. Second, the data come from cross-sectional surveys, which makes it difficult to attribute causality. However, temporality can be assumed because marriage occurred prior to the assessed fertility-related behaviors. Third, in some models, high odds ratios and wide confidence intervals may be an indication of small cell sizes or small probabilities of the outcome among the sample. This particularly applies to the results for female sterilization in Nepal for young women who first married at age 14 or younger, and multiple unwanted pregnancies in Pakistan. Fourth, available data do not allow us to distinguish between natural and induced pregnancy termination, both of which can be associated with child marriage albeit for different reasons. While the former is related to lack of proper development of reproductive organs and functions in young age, the latter is probably a sequel to unwanted pregnancy owing to limited control and choice in family size and/or spacing and so is usually undertaken in a clandestine and unsafe manner. Either way pregnancy termination is a matter of grave concern because of its association with maternal morbidity and mortality. Finally, other important factors such as women’s empowerment and control over fertility and maternal health care utilization decisions are not included as explanatory factors in the models, due to their potential endogeneity.

Child Marriage and Reproductive Health Outcomes in South Asia Child Marriage and Reproductive Health Outcomes in South Asia Presentation Transcript

  • Understanding the role of child marriage on reproductive health outcomes: evidence from a multi-country study in South Asia Deepali Godha, David Hotchkiss, and Anastasia Gage Tulane University
  • Background
    • Child marriage remains a pervasive problem in South Asia and sub-Saharan Africa
    • Increasingly recognized as a violation of human rights
    • Previous research has associated child marriage with a number of adverse health and social outcomes
    • But most studies to date have focused on India – very little research in other countries
  • Purpose of study
    • To assess the association of child marriage and reproductive health outcomes in four South Asian countries after controlling for individual-, and household- level factors
    • Prevalence of child marriage in South Asia is high
      • Among currently married women 20 to 24 years of age, percent married prior to age 15 ranged from 10 percent in Nepal to 38 percent in Bangladesh.
  • Data
    • Most recent Demographic and Health Surveys in four countries
      • India (2005/6)
      • Bangladesh (2007)
      • Nepal (2006)
      • Pakistan (2006/7)
    • Sample: Ever-married women 20-24 years of age
      • Sample size ranged from 1,546 in Pakistan to 22,807 in India
  • Methods (1)
    • Dependent variables
      • Fertility
        • Early fertility – childbirth within the first year of marriage
        • Multiple unwanted pregnancies
        • Having had at least one pregnancy termination
        • Having had at least one unwanted pregnancy
      • Fertility control
        • Lack of fertility control prior to the first birth
        • Low lifetime fertility control – history of rapid repeat childbirth
      • Maternal health care utilization
  • Methods (2)
    • Independent variables
      • Age at marriage dummy variables
        • Married at 14 years of age or younger
        • Married at 15 to 17 years of age
      • Other individual- and household-characteristics
    • Statistical methods
      • Logistic regression models to examine the association between various outcome variables and age of marriage
      • Unit of analysis is individual woman
  • Descriptive results Percent of women married as children ranges from 50% to 77% Characteristic India Bangladesh Nepal Pakistan Total married 17 years of age or younger 58.9 77.2 62.5 50.3 - Married 15-17 years of age 41.6 39.3 50.0 36.3 - Married 14 years of age or younger 17.3 37.9 12.5 14.0 Husband older by 10 years of age or more 14.3 41.1 8.8 19.4 Primary or no education 54.5 46.7 64.6 78.4
  • Descriptive results Percent of women with various fertility and fertility control outcomes Characteristic India Bangladesh Nepal Pakistan Fertility Early fertility 19.9 19.2 16.5 18.7 Pregnancy termination 15.3 14.1 13.3 17.6 Unwanted pregnancy 15.2 19.8 24.0 13.9 Multiple unwanted pregnancy 3.1 1.7 3.1 4.0 Fertility control Lack of fertility control prior to 1 st birth 90.8 67.6 82.8 NA Low lifetime fertility control 23.0 14.8 21.5 30.8
  • Logistic regression results Odds ratios: comparison group is women married at 18 years and older Blue font indicates statistical significance (p<0.05) Characteristic India Nepal Married ≤ 14 Married 15-17 Married ≤ 14 Married 15-17 Fertility Early fertility 0.9 1.0 0.6 0.8 Pregnancy termination 1.6 1.4 2.3 2.3 Unwanted pregnancy 1.6 1.7 1.9 1.5 Multiple unwanted pregnancy 2.5 2.3 3.7 1.6 Fertility control Lack of fertility control prior to 1 st birth 1.7 1.3 2.2 2.5 Low lifetime fertility control 3.8 2.6 4.5 3.4
  • Logistic regression results Odds ratios: comparison group is women married at 18 years and older Blue font indicates statistical significance (p<0.05) Characteristic Bangladesh Pakistan Married ≤ 14 Married 15-17 Married ≤ 14 Married 15-17 Fertility Early fertility 1.0 0.9 Pregnancy termination 4.5 3.4 2.2 1.9 Unwanted pregnancy 1.1 1.2 2.9 3.8 Multiple unwanted pregnancy 4.7 4.1 24.2 18.2 Fertility control Lack of fertility control prior to 1 st birth 1.5 1.1 NA NA Low lifetime fertility control 5.9 3.7 8.3 5.7
  • Conclusions
    • In South Asia, child marriage is significantly associated with many negative fertility and fertility control outcomes (and maternal health care utilization)
    • Women married in early adolescence show a higher propensity towards most negative outcomes than women married in middle adolescence
    • Child marriage adds a layer of vulnerability to women that leads to poor fertility control and fertility related outcomes
  • Limitations
    • Outcomes are self-reported: may be prone to bias
    • Data are cross-sectional: difficult to attribute causality
    • High odds ratios and wide confidence intervals may be an indication of small cell sizes or small probabilities
    • Cannot distinguish between natural and induced pregnancy termination
    • MEASURE Evaluation PRH is a MEASURE project funded by
    • the United States Agency for International Development
    • (USAID) through Cooperative Agreement GHA-A-00-08-00003-
    • 00 and is implemented by the Carolina Population Center at
    • the University of North Carolina at Chapel Hill in partnership
    • with Futures Group International, Management Sciences for
    • Health, and Tulane University. Views expressed in this
    • presentation do not necessarily reflect the views of USAID or
    • the U.S. Government. MEASURE Evaluation PRH supports
    • improvements in monitoring and evaluation in population,
    • health and nutrition worldwide.