Girl-child marriage and its association with morbidity and mortality of children under 5 years of age in a nationally-representative sample of Pakistan

The legal and medical consequences of child marriage

The Marriage and Civil Partnership (Minimum Age) Act 2022 came into force in England on 27 February 2023 and made both registered and unregistered marriages involving people under 18 illegal in England and Wales. This means that such marriages which take place outside England and Wales will not be recognised and those who organised them, including parents, will have committed a criminal offence.This review considers issues related to families where such marriages have happened, including their impact on the health of the victim and any resulting children. It touches on religious and societal issues and the need for targeted and appropriate education.

"Can't live willingly": A thematic synthesis of qualitative evidence exploring how early marriage and early pregnancy affect experiences of pregnancy in South Asia

In South Asia, early marriage has been associated with a range of adverse outcomes during pregnancy and infancy. This may partly be explained by early marriage leading to a younger maternal age, however it remains unclear which other factors are involved. This review aimed to synthesise the qualitative evidence on experiences of pregnancy following early marriage or early pregnancy in South Asia, to inform our understanding of the mechanisms between early marriage and adverse pregnancy outcomes. We searched MEDLINE, EMBASE, Scopus, Global Index Medicus, CINAHL, PsycINFO, Web of Science, and grey literature on 29/11/2022 to identify papers on experiences of pregnancy among those who married or became pregnant early in South Asia (PROSPERO registration number: CRD42022304336, funded by an MRC doctoral training grant). Seventy-nine papers from six countries were included after screening. We appraised study quality using an adapted version of the Critical Appraisal Skills Programme tool for qualitative research. Reporting of reflexivity and theoretical underpinnings was poor. We synthesised findings thematically, presenting themes alongside illustrative quotes. We categorised poor pregnancy experiences into: care-seeking challenges, mental health difficulties, and poor nutritional status. We identified eight inter-connected themes: restrictive social hierarchies within households, earning social position, disrupted education, social isolation, increased likelihood of and vulnerability to abuse, shaming of pregnant women, normalisation of risk among younger women, and burdensome workloads. Socioeconomic position and caste/ethnic group also intersected with early marriage to shape experiences during pregnancy. While we found differences between regions, the heterogeneity of the included studies limits our ability to draw conclusions across regions. Pregnancy experiences are largely determined by social hierarchies and the quality of relationships within and outside of the household. These factors limit the potential for individual factors, such as education and empowerment, to improve experiences of pregnancy for girls married early.

Nurturing care among adolescent mothers

Many studies show the impact of adolescent mothers on child development. To prevent the impact of adolescent pregnancy, nurturing care is needed to support optimal children's development. This study aims to identify comprehensive nurturing care among adolescent mothers. This study used secondary data in the integration of the 2018 National Socioeconomic Survey and Basic Health Survey. To measure nurturing care, 5 components were used: health, adequate nutrition, security and safety, responsive caregiving, and opportunities for early learning with latent class analysis. The results of the analysis showed that 62% of adolescent mothers provided uncompleted nurturing care. About 21% of adolescent mothers need assistance in improving nurturing care related to adequate nutrition and learning opportunities, and 17% need assistance to improve health, nutrition, responsive caregiving, and opportunities for early learning. Adolescent mothers are in need of comprehensive nurturing care for their children. Practice is needed in order to enhance nurturing care initiatives, particularly for teenage mothers.

Child marriage and its association with partner controlling behaviour against adolescent girls and young women in sub-Saharan Africa

BACKGROUND

Child marriage and partner controlling behaviours are culturally seated phenomena in sub-Saharan Africa (SSA). Child marriage refers to any legal or customary union involving a boy or girl below the age of 18. Partner controlling behaviour on the other hand refers to a situation where a sexual partner consistently tries to control their spouse's behaviours, movements, and social contacts with other people. This study examined the association between child marriage and partner controlling behaviour among adolescent girls and young women (AGYW) in SSA.

METHODS

We extracted data from the most recent Demographic and Health Surveys of 26 countries in SSA. Countries whose surveys were conducted from 2010 to 2020 were included in the study. A total of 26,970 AGYW (15-24 years) were included in the study. We used a multilevel mixed-effect binary logistic regression analysis to examine the association between child marriage and partner controlling behaviour.

RESULTS

The average prevalence of child marriage was 55.40% (95% CI: 48.83-61.97). This proportion ranged from 19.62% (95% CI: 16.71-22.53) in South Africa to 85.10% (95% CI: 83.14-87.06) in Chad. The proportion of AGYW who had experienced partner controlling behaviour was 68.36% (95% CI: 64.40-72.33), and this ranged from 38.40% (95% CI: 35.55-41.25) in Burundi to 88.18% (95% CI: 83.80-92.56) in Gabon. AGYW who married as child brides were more likely [aOR = 1.31; 95% CI = 1.21, 1.43] to experience partner controlling behaviour compared to those who did not marry as child brides. AGYW in Western [aOR = 1.51; 95% CI = 1.33, 1.71] and Eastern [aOR = 1.31; 95% CI = 1.13, 1.50] part of SSA were more likely to experience partner controlling behaviour compared to those in Central Africa.

CONCLUSIONS

Our study has shown that there is a significant association between child marriage and the likelihood of experiencing partner controlling behaviour in SSA. Effective policies and interventions are, therefore, needed to prevent child marriage and raise AGYW's awareness of its implication on victims of partner controlling behaviours.

Patterns in age at first marriage and its determinants in India: A historical perspective of last 30 years (1992-2021)

Reproductive health and well-being of a woman are associated with factors such as menarche, first marriage, first sex, first birth, and menopause. The beginning of these events also brings about significant changes in women's lives. Despite marrying early being acknowledged as a detrimental and discriminatory socio-cultural global practice, a huge proportion of girls are being married at an early age, often detrimental to maternal and child health. Adding to the current national debate for the revision of the minimum age at marriage for girls from 18 to 21 years it becomes important to understand the past scenario and current situation of age at marriage in India. In this study, first five rounds of the National Family Health Survey (NFHS) have been used as a data source. Cox Proportional Hazard Model, Multiple Classification Analysis (MCA), Kaplan Meier Curve, Life table survival analysis, hierarchical clustered heat map, Multivariate Decomposition Analysis (MDA), and geospatial mapping were used to fulfill the objective of the study. The results showed that almost 65.9% of women got married before reaching the age of 18 years in the year 1992-93 which reduced to 23.2% among women aged 20-24 years in 2019-21. Region, respondent's level of education, caste, religion, wealth, and mass media exposure were significantly associated with the age at first marriage. The hazard of age at marriage declined significantly with higher educational attainment [higher education- AHR:0.37; CI:0.36 to 0.37], improving household wealth [richest wealth- AHR:0.91; CI:0.90 to 0.91], and mass media exposure [AHR:0.96; CI:0.95 to 0.96]. Since, the age at marriage has a substantial impact on fertility pattern and has a strong association with maternal & child health, policies regarding improving the age at marriage and better enforcement of the concerned laws are required to meet the SDG targets.

From little girls to adult women: Changes in age at marriage in Scheduled Castes from Madhya Pradesh and Uttar Pradesh, India

BACKGROUND

Research confirms the negative relationship between early marriage and mothers' and children's health outcomes. This is why studies of the changes in age at marriage are an important task from the point of view of the health status and well-being of a mother and her offspring, especially in groups represented by extremely disadvantaged social strata in India. The results of such studies may influence the future family planning policy in the country.

OBJECTIVES

This study aims to investigate the trend of age at marriage among the Scheduled Castes (SCs) women from two Indian states: Madhya Pradesh and Uttar Pradesh relative to the level of education and also to socioeconomic changes in the states. These states manifest the highest proportion of girls getting married below the age of 18 years-far above the proportion observed in entire India.

METHODS

Women from Scheduled Caste, N = 1,612, aged 25-65, born in 1950-1990 were investigated. A modern semiparametric regression approach was used. To capture the relationship between age at marriage and year of birth, categories of women's level of education (illiterate; primary: 1st-5th standards; middle school: 6th-8th standards; high school: 9th-10th standards; higher secondary: 11th-12th standards), and categories of the profession (women working in the agricultural sector or the non-agricultural sector), flexible framework of the Generalized Additive Model (GAM) was applied.

RESULTS

A significant impact of the cohort defined by the year of birth (<0.001), and women's education (<0.001) on age at marriage was noted, while the influence of women's occupation was not significant (p = 0.642). Mean age at marriage differed significantly with different education level. Women who graduated from primary school married 0.631 years later on average than illiterate ones, while those who graduated from middle schools, high schools (9th-10th standards) and higher secondary schools married significantly later than illiterate ones by 1.454 years and 2.463 years, respectively. Age at marriage increased over time: from slightly above 15 years in the cohort of illiterate women born in 1950 to almost 19 years in quite well-educated women born in 1990. The average age at marriage estimated for four education levels in 1990 ranged between 16.39 years (95%CI: 15.29-17.50) in the group of illiterate women and 18.86 years (95%CI: 17.76-19.95) in women graduated from high and higher secondary schools.

CONCLUSION

The rise of age at marriage can be partly explained by the increase of females enrolled in schools, the alleviation of poverty, and the implementation of social programs for women.

The association of child marriage with morbidities and mortality among children under 5 years in Afghanistan: findings from a national survey

BACKGROUND

There is still a gap in knowledge of the impact that child marriage could have on the mortality and morbidity of children in Afghanistan. This study used the data from the latest Afghanistan demographic health survey conducted in 2015 (ADHS) to address this gap and advance the current knowledge.

METHODS

A secondary analysis of the 2015 ADHS, including the births in the past 5 years to ever-married women aged 15-24 years old, was carried out. Logistic regression analyses were employed to examine the association of child marriage (< 18y) with morbidities (diarrhea, acute respiratory infection, and fever in the last 2 weeks), mortality (neonatal, infant, child), and size at birth among the children under 5 born to women aged 15-24 years, before and after adjusting for the effect of sociodemographic and structural inequalities.

RESULTS

Approximately two-thirds of births in the past 5 years belong to 15-24 years old mothers who married at ages < 18. The majority of them were born to mothers residing in rural areas (75.67%) with no education (51.68%) from poor households (39.39%). As compared to the births to women married at ages ≥ 18, there was a significantly higher likelihood of neonatal mortality among births to women married at ages < 18 (crude OR = 2.30, 95% CI: 1.52-3.49 & adjusted OR = 1.94, 95% CI: 1.25-3.01) and higher infant mortality among the births to the women married at ages ≤ 14y (crude OR = 1.94, 95% CI: 1.06-3.53). However, it disappeared for neonatal mortality after adjustment for adequacy of antenatal care (ANC) and infant mortality after adjustment for sociodemographic inequalities.

CONCLUSION

Although the births to women married as a child (< 18) were more likely to die at an early age, this association disappeared after adjustment for the adequacy of ANC. Given the unavoidable practice of child marriage in Afghanistan, this finding emphasizes the importance of providing adequate ANC for young brides to prevent child mortality. In addition, strong global advocacy is required to empower and support young Afghan women in negotiating their reproductive and maternity rights with their partners by reducing social and gender-based inequalities.

Is there any association between undesired children and health status of under-five children? Analysis of a nationally representative sample from Bangladesh

BACKGROUND

Child health, especially childhood mortality, is one of the critical indicators of human development. No child mortality is desirable, but it is still high in Bangladesh. We aimed to assess the effect of the child's desired status on childhood morbidity and mortality in Bangladesh.

METHODS

We used the data from the nationally representative cross-sectional Bangladesh Demographic and Health Survey (BDHS) 2017-18 and restricted the analyses to children born in the past five years preceding the survey. We estimated the undesired status (excess in boy, girl, both, and parity) by subtracting an ideal number of children from the total live birth. We measured childhood mortality (perinatal, early neonatal, neonatal, post-neonatal, infant, child, and under-five mortality), morbidity (fever, diarrhea, cough, and acute respiratory infectious-ARI), nutritional problems (stunting, wasting, underweight, and low birth weight), and treatments (postnatal care, treatment for fever, diarrhea/cough, and vitamin A supplementation). Finally, we utilized the chi-square test and multilevel mixed-effects logistic regression analyses.

RESULTS

The prevalence of undesired children was 19.2%, 21.5%, 3.7%, and 25.4% for boys, girls, both boys and girls, and parity, respectively. Age, education, residence, division, and wealth index were significantly associated with undesired children. The prevalence of under-five mortality was 3.3% among desired children, almost double (5.4%) among undesired children. The likelihood of under-five mortality was [adjusted odds ratio (aOR): 2.05, p ≤ 0.001] higher among undesired children. Despite lower under-five mortality among higher socioeconomic status, the relative contribution of undesired children to under-fiver mortality was substantial. The undesired girl children were associated with an increased likelihood of moderately wasting (aOR: 1.28, p = 0.072), severely underweight (aOR: 1.41, p = 0.066), and low birth weight (aOR: 1.50, p ≤ 0.05). Moreover, the undesired children were 19% (p ≤ 0.05) more likely to be infected with fever. The undesired children had lower treatment for diarrhea and fever/cough and were less likely to get vitamin A supplementation (aOR: 0.71, p ≤ 0.001).

CONCLUSIONS

The share of childhood morbidity, mortality, and malnutrition were higher among undesired children. Every child should be wanted, and no unwanted pregnancies are desirable; thereby, the government should reemphasize the proper use of family planning methods to reduce child mortality and malnutrition.

Associations between early marriage and preterm delivery: Evidence from lowland Nepal

OBJECTIVES

Preterm delivery (<37 weeks gestation) is the largest cause of child mortality worldwide. Marriage and pregnancy during adolescence have been associated with an increased risk of preterm delivery. We investigate independent associations of age at marriage and age at first pregnancy with preterm delivery in a cohort of women from rural lowland Nepal.

METHODS

We analyzed data from 17 974 women in the Low Birth Weight South Asia Trial. Logistic regression models tested associations of age at marriage and age at first pregnancy with preterm delivery, for primigravida (n = 6 243) and multigravida (n = 11 731) women. Models were adjusted for maternal education, maternal caste, and household asset score.

RESULTS

Ninety percent of participants had married at <18 years and 58% had their first pregnancy at <18 years. 20% of participants delivered preterm. Primigravida participants married at ≤14 years had higher odds of preterm delivery than those married ≥18 years, when adjusting for study design (adjusted odds ratio (aOR) 1.45, 95% CI: 1.15-1.83), confounders (aOR 1.28: 1.01-1.62) and confounders + age at pregnancy (aOR 1.29: 1.00-1.68). Associations were insignificant for multigravida women. No significant associations were observed between age at first pregnancy and preterm delivery.

DISCUSSION

In this population, early marriage, rather than pregnancy, is a risk factor for preterm delivery. We hypothesize that psychological stress, a driver of preterm delivery which is increased among those marrying young, rather than physiological immaturity, drives this association. Further research into the psychological consequences of child marriage in Nepal is needed.

Child marriage and its association with morbidity and mortality of under-5 years old children in Bangladesh

INTRODUCTION

Child marriage is a significant social and health concern in many low- and middle-income countries (LMICs). This harmful practice violates children's rights and continues to be widespread across developing nations like Bangladesh. This study investigated the mortality trend among Bangladeshi children and the impact of child marriage on under-5 children morbidity and mortality in Bangladesh.

METHODS AND MATERIALS

A sample of 8,321 children under-5 years old was analyzed using bivariate and multivariate statistical techniques collected from the recent 2017-18 BDHS data. Chi-square test and logistic regression (unadjusted and adjusted) were used to determine the influence of covariates on the target variable.

RESULTS

Results revealed that child mortality was significantly higher among children whose mothers married at an early age than their counterparts. Although the general trend in the prevalence of different childhood mortality in Bangladesh was declining gradually from 1993 to 2018, it was still high in 2018. Also, marriage after 18 years lessens likelihood of diarrhea (adjusted OR = 0.93; 95% CI: 0.76-1.16) and cough (adjusted OR = 0.91; 95% CI: 0.78-1.17) among children. Furthermore, findings reveal that likelihood of different child mortality is higher among early married women.

CONCLUSION

Immediate intervention through rigorous enforcement of policies and different programs to raise the age at marriage and by lessening socioeconomic disparities can combat the prevalence of high morbidity and mortality of under-5 years old children. Findings from this study will be helpful to accelerate strategies for achieving the Sustainable Development Goals (SDGs) related to child and maternal health by 2030.

Effects of Gender Role Beliefs on Social Connectivity and Marital Safety: Findings From a Cross-Sectional Study Among Married Adolescent Girls in India

PURPOSE

The purpose of the study was to examine associations of gender role beliefs with marital safety as well as social and digital connectivity among married adolescent girls in India.

METHODS

We analyzed cross-sectional survey data from married adolescent girls from rural Bihar and Uttar Pradesh, India in 2015-2016 (N = 4,893). Gender role belief items assessed participants' beliefs regarding appropriateness of female marital choice and economic decision-making, male childcare responsibility, and marital violence. The outcomes were time with friends (social connection), freedom of movement, mobile phone ownership and internet access (digital connection), and safety from marital violence (marital safety). Adjusted regression models examined associations between gender role beliefs and outcomes, caste/religion beliefs related to segregation, and demographics.

RESULTS

Beliefs supportive of female marital choice (adjusted odds ratio [AOR] 1.38, 95% confidence interval [CI] 1.00-1.88, p = .048) and female economic decision-making (AOR 1.43, 95% CI 1.03-1.99, p = .03) were associated with social connection. Beliefs supportive of female marital choice (AOR 1.88, 95% CI 1.31-2.71, p = .001), female economic decision-making (AOR 1.67, 95% CI 1.03-2.72, p = .04), and male childcare responsibilities (AOR 1.42, 95% CI 1.05-1.94, p = .03) were associated with freedom of movement. Belief supporting female marital choice was associated with mobile phone ownership (AOR 1.23, 95% CI 1.01-1.50, p = .04), and belief supporting male childcare responsibility was associated with internet access (AOR 1.76, 95% CI 1.11-2.77, p = .02). Beliefs supportive of female marital choice (AOR .73, 95% CI .59-.89, p = .003), male childcare responsibility (AOR 1.26, 95% CI 1.03-1.54, p = .02), and unacceptability of marital violence (AOR 1.72, 95% CI 1.38-2.15, p < .001) were associated with safety from marital violence.

CONCLUSIONS

Progressive gender role beliefs regarding female choice, control, and safety in marriage are associated with greater connectivity and safety for married adolescent girls in India. Future studies that can longitudinally assess these associations are warranted.

Epidemiologic View and Spatial Analysis of the Mortality of Children under 5 Years of Age in Isfahan Province in 2011-2016

Background

Children's mortality rate reflects the health level of the community. Therefore, accurate mapping of child mortality is one of the most important ways to reduce this rate. The purpose of this study was to investigate the mortality rate of children under 5 in Isfahan province in 2011-2016.

Methods

In this analytical cross-sectional study, all mortalities of children under 5 of Isfahan province related to Child Death Care System Program during 2011-2016 were studied. Mortality rate of children was calculated. Relationship between variables [demographic characteristics, place of death (urban/rural), and underlying cause of death] and child mortality was analyzed using Chi-square test. Mortality rate in the cities of Isfahan province was plotted on a geographical map.

Results

Whole number of mortalities of children under 5 was 5247 cases. Most of the mortalities (60.1%) were occurred in neonatal. Mortality rate was higher in boys than girls (12.6 vs. 11.1 per 1000 live births) (P < 0.001); "mortality rate in non-Iranians who live in Iran was more than that of Iranians (21.4 vs. 11.5 per 1000 live birth) (P < 0.001) and rural areas more than urban areas (15.2 vs. 11.4 per thousand live births) (P < 0.001)." Certain conditions originating in the perinatal period were reported as the greatest causes of death (45.9%). Congenital malformations (27.4%) and external causes of morbidity and mortality (6.7%) were the second and third causes of death. Fereidun Shahr had the highest U5MR and Khansar had the lowest U5MR.

Conclusions

Considering the major contribution of neonatal to the death of children under 5 and also the most important causes of death, interventions such as preventing early delivery, genetic counseling in high-risk couples, and parent training for accident prevention can play an effective role in reducing child mortality.

Maternal age at birth and neonatal mortality: Associations from 67 low-income and middle-income countries

BACKGROUND

Both young and advanced maternal age have been associated with higher risks of neonatal mortality, but most studies are from high-income countries and the evidence from low- and middle-income countries (LMICs) is scarce.

OBJECTIVE

To investigate the association between maternal age at delivery and neonatal mortality in LMICs.

METHODS

This is a cross-sectional study using data from 159 Demographic and Health Surveys in 67 LMICs between 2000 and 2018. Maternal age at the time of the birth was the exposure variable, and neonatal mortality was the outcome. Multivariable logistic regression model taking into consideration complex survey design was performed with adjustments for maternal education level, paternal education level, rural/urban residence, country, and survey year. Subgroup analyses were performed by time of death, sex, the country's World Bank income classification, the World Health Organization region, and survey year.

RESULTS

A total of 1 395 746 mother-neonate pairs were included. Overall, compared with neonates born to mothers aged 25-29 years, those born to younger mothers aged 20-24, 16-19 and 12-15 years were at an increased risk of mortality (adjusted odds ratio [OR] 1.24, 95% confidence interval [CI] 1.17, 1.30; OR 1.81, 95% CI 1.71, 1.93; OR 2.29, 95% CI 1.96, 2.67, respectively). Neonates born to mothers aged 30-34, 35-39, 40-44, and ≥45 years were also at an increased risk of mortality (OR 1.09, 95% CI 1.03, 1.15; OR 1.30, 95% CI 1.21, 1.39; OR 1.50, 95% CI 1.38, 1.64; OR 1.84, 95% CI 1.54, 2.20, respectively). The results were consistent across most subgroup analyses.

CONCLUSIONS

Neonates born to younger (<25 years) and older mothers (≥30 years) are at increased risk of neonatal death in LMICs.

Application of machine learning to understand child marriage in India

BACKGROUND

Prior research documents that India has the greatest number of girls married as minors of any nation in the world, increasing social and health risks for both these young wives and their children. While the prevalence of child marriage has declined in the nation, more work is needed to accelerate this decline and the negative consequences of the practice. Expanded targets for intervention require greater identification of these targets. Machine learning can offer insight into identification of novel factors associated with child marriage that can serve as targets for intervention.

METHODS

We applied machine learning methods to retrospective cross-sectional survey data from India on demographics and health, the nationally-representative National Family Health Survey, conducted in 2015-16. We analyzed data using a traditional regression model, with child marriage as the dependent variable, and 4000+ variables from the survey as the independent variables. We also used three commonly used machine learning algorithms- Least Absolute Shrinkage and Selection Operator (lasso) or L-1 regularized logistic regression models; L2 regularized logistic regression or ridge models; and neural network models. Finally, we developed and applied a novel and rigorous approach involving expert qualitative review and coding of variables generated from an iterative series of regularized models to assess thematically key variable groupings associated with child marriage.

FINDINGS

Analyses revealed that regularized logistic and neural network applications demonstrated better accuracy and lower error rates than traditional logistic regression, with a greater number of features and variables generated. Regularized models highlight higher fertility and contraception, longer duration of marriage, geographic, and socioeconomic vulnerabilities as key correlates; findings shown in prior research. However, our novel method involving expert qualitative coding of variables generated from iterative regularized models and resultant thematic generation offered clarity on variables not focused upon in prior research, specifically non-utilization of health system benefits related to nutrition for mothers and infants.

INTERPRETATION

Machine learning appears to be a valid means of identifying key correlates of child marriage in India and, via our innovative iterative thematic approach, can be useful to identify novel variables associated with this outcome. Findings related to low nutritional service uptake also demonstrate the need for more focus on public health outreach for nutritional programs tailored to this population.

Maternal Age at Marriage and Adverse Pregnancy Outcomes: Findings from the India Human Development Survey, 2011-2012

STUDY OBJECTIVE

This study aimed to examine the association between maternal age at marriage and selected pregnancy outcomes: stillbirth, miscarriage, and complications during pregnancy, labor, and postpartum period.

DESIGN

Cross-sectional study.

SETTING

India.

PARTICIPANTS

A total of 35,253 ever-married women aged 15-49 years from the second round of the India Human Development Survey were used to examine the association between maternal age at marriage and stillbirth and miscarriage. Moreover, 14,229 ever-married women who gave birth since January 2005 were used to assess the effect of maternal age at marriage on pregnancy, labor, and postpartum complications.

INTERVENTIONS

Cross-tabulation, Pearson's χ² test, and binary logistic regression were performed for the analyses of the study data.

MAIN OUTCOME MEASURES

Stillbirth, miscarriage, and complications during pregnancy, labor, and postpartum period.

RESULTS

Bivariate association showed significant differences in women's pregnancy outcomes according to their age at marriage. Multivariate logistic regression analyses revealed that after controlling for relevant demographic characteristics, the likelihood of stillbirth (adjusted odds ratio [AOR], 1.12; P < .05), miscarriage (AOR, 1.15; P < .01), pregnancy complications (AOR, 1.24; P < .01), and postnatal complications (AOR, 1.32; P < .01) were significantly higher among the women who married at 14 years or younger than those married at the age of 18 years or later. However, the current study did not show any significant association between the women who married at 15-17 years and the pregnancy outcomes except for postnatal complications (AOR, 1.12; P < .05) in adjusted analyses.

CONCLUSION

This study showed that early maternal age at marriage substantially increases the risk of adverse pregnancy outcomes, which suggests strengthening of existing laws and policies to increase age at marriage of girls, and effort should be made to improve health status of married adolescents.

Under-Five Child Mortality and Morbidity Associated with Consanguineous Child Marriage in Pakistan: Retrospective Analysis using Pakistan Demographic and Health Surveys, 1990-91, 2006-07, 2012-13

Objective To assess the combined effect of consanguineous and child marriages (CCM) on children health, which has not previously been explored, either globally or locally. Methods We analyzed secondary data from a series of cross-sectional, nationally representative Pakistan Demographic and Health Surveys 1990-91, 2006-07, and 2012-13. A total of 5406 mothers with 10,164 children were included in the analysis. Child health was assessed by variables such as history of diarrhea, acute respiratory infection (ARI), ARI with fever, Under-5 child mortality (U5CM) and small-size birth (SSB). Associations among variables were assessed by calculating unadjusted Odd Ratios (OR) and adjusted OR (AOR). Results A majority (n = 6,247, 61%) of the births were to mothers having CCM as compare to non-CCM (3917, 39%). There was a significant association between CCM and U5CM during 1990-91 (AOR 1.24, 95% CI 1.03-1.49) and 2006-07 (AOR 1.25, 95% CI 1.05-1.51), and infant mortality in 1990-91 (AOR 1.39, 95% CI 1.05-1.85) and 2006-07 (AOR 1.61, 95% CI 1.17-2.21). A significant association was also found between CCM and SSB infants in the period 2006-07 (AOR 1.19, 95% CI 1.01-1.42) and 2012-13 (AOR 1.22, 95% CI 1.02-1.46). We noted no effect of CCM on diarrhea, ARI, and ARI with fever. Conclusion CCM increases the likelihood of U5CM, infant mortality and SSB infants. Further quantitative and qualitative research should be conducted to assess the effects of environmental, congenital and genetic factors on the health of children born to mothers in CCM.

Circumstances leading to intimate partner violence against women married as children: a qualitative study in Urban Slums of Lahore, Pakistan

BACKGROUND

Child marriage (<18 years) is prevalent in Pakistan which is associated with negative health outcomes including intimate partner violence (IPV). Our aim is to describe the types and circumstances of IPV against women who were married as children in urban slums of Lahore, Pakistan.

METHODS

Women of reproductive age (15-49 years) who were married prior to 18 years, for at least 5 years were recruited from most populous slum areas of Lahore, Pakistan. Themes for the interview guide were developed using published literature and everyday observations of the researchers. Interviews were conducted by trained interviewers in Urdu language and were translated into English. The interviews were tape-recorded, transcribed, analyzed and categorized into themes.

RESULTS

All 19 participants were married between 11 and 17 years. Most respondents were uneducated, poor and were working as housemaids. Majority of participants experienced verbal abuse, and threatened, attempted and completed physical violence by their husbands. A sizeable number of women reported unwanted sexual encounters by their husbands. Family affairs particularly issues with in-laws, poor house management, lack of proper care of children, bringing insufficient dowry, financial problems, an act against the will of husband, and inability to give birth to a male child were some of the reasons narrated by the participants which led to IPV against women.

CONCLUSIONS

Women married as children are vulnerable to IPV. Concerted efforts are needed from all sectors of society including academia, public health experts, policy makers and civil society to end the child marriage practice in Pakistan.

Child marriage and its associations with controlling behaviors and spousal violence against adolescent and young women in Pakistan

PURPOSE

Child marriage (before 18 years) is widely prevalent in Pakistan, and disproportionately affects young girls in rural, low-income, and poorly educated households. Our study aims to determine the associations between child marriage and controlling behaviors (CB) and spousal violence by husbands against adolescent and young women in Pakistan beyond those attributed to social vulnerabilities.

METHODS

We analyzed data from the Pakistan Demographic and Health Survey, 2012-2013, of currently married women aged 15-24 years who had participated in the domestic violence module (n = 589, 22.5% [589/2,615] of the subsample aged 15-24 years) to identify differences in CB and spousal violence experiences between early (<18 years) and adult (≥18 years) ages at marriage. Associations between child marriage and CB and spousal violence by husband were assessed by calculating adjusted odds ratios (AOR) using logistic regression models after controlling for demographics, social equity indicators (education, wealth index, and rural residence), spousal age gap, and husband's education.

RESULTS

Overall, 47.8% of currently married women aged 15-24 years in Pakistan were married before the age of 18 years. About one third of women aged 15-24 years in Pakistan reported experiencing CB (31.8%) and spousal violence (31.1%) by their husbands. Compared with adult marriage, child marriage was significantly associated with CB (AOR = 1.50; 95% confidence interval [CI], 1.042-2.157), any form of spousal violence (physical or emotional) (AOR = 2.03; 95% CI, 1.392-2.969), emotional violence (AOR = 1.86; 95% CI, 1.254-2.767), and physical violence (AOR = 2.44; 95% CI, 1.582-3.760), including severe physical violence (AOR = 2.57; 95% CI, 1.122-5.872).

CONCLUSIONS

Effective interventions are needed to prevent child marriages and raise awareness about their negative consequences, with special reference to spousal violence.

Knowledge and attitude towards child marriage practice among women married as children-a qualitative study in urban slums of Lahore, Pakistan

Background

Child marriage (<18 years) is prevalent in Pakistan which is associated with negative health outcomes. Our aim is to describe women’s knowledge and attitude towards child marriage practice who themselves were married as children.

Methods

Women of reproductive age (15–49 years) who were married prior to 18 years, for at least 5 years and had at least one child birth were recruited from most populous slum areas of Lahore, Pakistan. Themes for the interview were developed using published literature and everyday observations of the researchers. Interviews were conducted by trained interviewers in Urdu language and were translated into English. The interviews were tape-recorded, transcribed, analyzed and categorized into themes.

Results

Nineteen of 20 participants who agreed to participate were married between 11–17 years. Most respondents were uneducated, poor and were working as housemaids. The majority participants were unaware of the negative health outcomes of child marriages. They appeared satisfied by the decision of their parents of marrying them before 18 years, and even condemned banning child marriages in Pakistan. Strong influence of culture and community perceptions, varying interpretation of religion, and protecting family honor are some of the reasons that were narrated by the participants, which seems playing a role in continuation of child marriage practice in Pakistan.

Conclusion

Raising awareness of the negative health outcomes of child marriage, implementing and enforcing strict laws against child marriage practice, promoting civil, sexual and reproductive health rights for women, can help eliminate child marriages in Pakistan.