Child marriage and intimate partner violence: a comparative study of 34 countries

Measuring social norms related to child marriage among married women and men in Niger

BACKGROUND

Child marriage remains prevalent in the Sahel region. Pervasive norms regarding child marriage, and sexual behavior persist. We explored norms from multiple perspectives to strengthen interventions aimed at delaying age at marriage.

METHODS

This study analyzed a cross-sectional household survey conducted in Niger in 2022 with women aged 15-49 (n = 2,726) and a subset of their male household members aged 15-59 (n = 1,136). Separate logistic regression models assessed factors associated with three descriptive (e.g., perception of what others do) and injunctive (e.g., perception of a group's approval or disapproval) normative outcomes related to practices that support marriage as soon as a girl reaches puberty and beliefs related to premarital sex.

RESULTS

Our study found a greater proportion of men described early marriage as protective from the fear of socially induced ruined marital prospects for women (70% vs. 64%), while women expressed its protection from being harassed (62% compared to 42%). The injunctive norm outcome that "my neighbors think that one should marry off one's daughter as soon as she reaches puberty" was significantly associated with the belief that child marriage was protective for females among women (OR = 4.49; 95% CI 3.13. 5.50) and men (OR = 8.21; 95% CI 5.88, 11.45).

CONCLUSIONS

Programs addressing child marriage should consider both male and female perspectives to address differences and foster an environment where communities and families shift norms to delay early marriage.

Path Analysis of Adverse Childhood Experiences, Early Marriage, Early Pregnancy, and Exposure to Intimate Partner Violence Among Young Women in Honduras

Purpose

The pathways by which adverse childhood experiences (ACEs) are associated with early marriage and early pregnancy are poorly understood. Early marriage and early pregnancy may be risk factors for adulthood intimate partner violence (IPV). The aim of this study was to assess the relationships among ACEs, early marriage, early pregnancy, and IPV among women in Honduras.

Method

We used weighted data from 1,436 women aged 18-24 years from the nationally representative 2017 Honduras Violence Against Children and Youth Survey. We used path analysis to estimate relationships and accounted for sample design, non-response, and within-country clustering.

Results

We found that ACEs had differential relationships with outcomes of interest. For example, witnessing violence in the community was directly associated with increased probability of early pregnancy (10 percentage points (PP); 95% CI: 0.04, 0.15) and IPV (6 PP; 95% CI: 0.01, 0.10), while emotional violence was not directly or indirectly associated with any outcome. Early marriage and early pregnancy had no direct or indirect effect on IPV, but the total effect of early marriage on IPV was significant.

Conclusions

Understanding the relationship between ACEs, early marriage, early pregnancy, and IPV may help inform prevention efforts. For example, programs aiming to reduce early pregnancy may consider addressing sexual violence experienced in childhood.

Contraceptive use and discontinuation among women aged 15-24 years in Kenya

Introduction

The 15-24-year-old age group of young women make up about 15% of the population of 47 million Kenyans which comes to 7 million. Addressing the reproductive health goals of this cohort is thus a policy priority because of the high potential they pose for unintended pregnancy through incorrect and intermittent use of contraception.

Objective

The study sought to present evidence on contraceptive use among women aged 15-24 in Kenya between 2012 and 2014 using Kenya Demographic and Health Survey (KDHS) 2014 Contraceptive calendar data and make recommendations on enhancing the correct and consistent use of contraception.

Methodology

The data used was obtained from the Choices and Challenges tool developed by Population Reference Bureau (PRB) and visualized innovatively using Sankey Diagrams that show contraceptive use/non-use, continuation, switching/discontinuation, and pregnancy.

Results

The use of contraceptives went up by about 30% during the study period while the use of modern methods went up by 83%. The uptake of Long-Acting Reversible Contraception (LARC) went up by 87% while that of Short Acting Methods (SAM) went up by 70% but the progress was clouded by discontinuation rates of 35% with side effects being the leading reason for the abandonment of contraception.

Conclusion

For Kenya to achieve transformative results in ending the unmet need for contraception and preventable maternal deaths, it is critical to sustaining the current gains in contraceptive prevalence rate (CPR) by promoting the retention of youth users and encouraging new users.

Consortium for violence prevention research, leadership training, and implementation for excellence (CONVERGE): a protocol to train science leaders in gender-based-violence and violence-against-children research for impact

Background

Gender-based violence (GBV) and violence against children (VAC) are two prevalent and highly interconnected global health challenges, yet data and research capacities to study these forms of violence and to generate evidence-based policies and programs remain limited. To address critical shortages in research capacity in Vietnam and to establish a model for other Low- and Middle-Income Countries (LMICs), we are establishing CONVERGE-the Consortium for Violence Prevention Research, Implementation, and Leadership Training for Excellence.

Methods

Based on a needs assessment with partners in Vietnam, CONVERGE will provide a comprehensive research training program supporting 15 long-term, postdoctoral trainees with multi-disciplinary research training in GBV and VAC. We also will offer in-country trainings and short-courses to 40 short-term mid-career academic trainees and 60 short-term practitioner/stakeholder trainees over 5  years to build productive GBV and VAC academic, scientific, and practitioner networks. The CONVERGE training program has four components: (1) 14 h of virtual/in-person annual mentorship training to prepare research mentors and to create a pipeline of future mentors in Vietnam; (2) a one-month intensive research training for long-term postdoctoral fellows at Emory University; (3) a structured 17-month, in-country mentored research project for long-term trainees that results in a peer-reviewed manuscript and a subsequent grant submission; and, (4) week-long in-country intensive translational trainings on implementation science, advanced topics in leadership, and advanced topics in science dissemination. Opportunities for on-going virtual training and professional networking will be provided for CONVERGE trainees and mentors in Vietnam with other trainees and mentors of D43s focused on injury/violence prevention, D43s housed at Emory, and D43s with other institutions in Southeast Asia. To assess the reach, implementation, fidelity, and effectiveness of these four components, we will implement a rigorous, mixed-methods, multi-level evaluation strategy using process and outcome measures. Findings from the evaluation will be used to refine program components for future trainee and mentor cohorts and to assess long-term program impact.

Discussion

Led by Emory University in the US and Hanoi Medical University in Vietnam, CONVERGE represents leading institutions and experts from around the world, with a goal of providing mentorship opportunities for early-career scientists with an interest in violence prevention.

Child marriage and perinatal health in Ecuador, 2015-2020

This study sought to estimate the prevalence and distribution of newborns to mothers under age 18 in Ecuador and the association between perinatal indicators and maternal marital status. Newborn records obtained from Ecuador's Instituto Nacional de Estadísticas y Censos (INEC) between 2015 and 2020 were used to assess the joint association between maternal age groups (10-15, 16-17, 18-19, and 20-24 years) and marital status (married, common-law, and single) with low birthweight, preterm birth, and inadequate prenatal care. The prevalence of newborns to mothers under age 18 was 9.3% overall, but declined over the study period, drastically among married mothers. The association between marital status and perinatal indicators depended on maternal age. The more favorable outcomes observed among married mothers aged 20-24 years (compared to their single counterparts) weaken or disappear among mothers under age 18. Mothers in stable unions exhibited outcomes in between those of married and single mothers.

Cross-National Associations between Age at Marriage and Intimate Partner Violence among Young Women: An Analysis of Demographic and Health Surveys from 48 Countries

We estimated the associations between age at first marriage and recent intimate partner violence (IPV) among women young women aged 20-24 years using data from demographic and health surveys (DHS) conducted at 48 low- and middle-income countries (LMICs). We fitted a multilevel logistic regression model controlling for sociodemographic covariates. Our pooled analyses revealed that age at marriage is strongly associated with past year IPV in a non-linear way, with steep reductions in violence when young women marry after age 15 and a continued decline in IPV for every year marriage is delayed up to age 24. The risk of physical IPV was 3.3 times higher among women married at age 15 (24.4%, 95% CI 19.7; 29.2%) compared to young women married at age 24 (7.5%, 95% CI 5.8; 9.2%). For sexual IPV, girls married at 15 had 2.2 times higher risk compared to those married at 24 (7.5%, 95% CI 5.6; 9.5% vs. 3.4%, 95% CI 2.7; 4.2%, respectively). For psychological IPV, the relative risk was 3.4 for the same comparison (married at 15: 20.1%, 95% CI 14.6; married at 24: 25.5% vs. 6.0%, 95% CI 3.4; 8.6%). Country specific analyses showed that, age at marriage was negatively associated with physical and psychological IPV in nearly half of the countries (n/48) and with sexual IPV in ten countries. Our findings underscore the importance of integrating violence prevention and response interventions into efforts to prevent child marriage, as well as the health, educations and social services young women access.

Correlates of co-occurring physical child punishment and physical intimate partner violence in Colombia, Mexico and Peru

Background

Violent discipline of children and intimate partner violence (IPV) against women are global public health and human rights problems. To address calls for more evidence on intersections, this study aimed to expand knowledge about correlates of physical child punishment, physical IPV against women and their co-occurrence (both) in the same household. 

Methods

Using national, population-based survey datasets from Colombia, Mexico and Peru, multinomial logistic regressions examined correlates of three mutually exclusive patterns of violence in the household: physical child punishment (only), physical IPV ever (only) and co-occurrence (both), each compared with no violence, after adjusting for other factors. Logistic regression was used to analyse odds ratios of physical child punishment in households affected by IPV past year and before past year compared with never, after adjusting for other factors.

Results

In all countries, adjusted odds ratios (aOR) of co-occurrence were significantly higher among women with lower education, more than one child, a child aged 2–5, a partner who tried to socially isolate her, and a history of childhood violence (caregiver violence and/or IPV exposure). They were significantly lower among women who reported collaborative partnerships (joint decision-making and/or shared chores). Co-occurrence was also significantly correlated with a history of child marriage/early motherhood in Colombia and Mexico, partner’s excess drinking in Mexico and Peru, agreement that physical child punishment was necessary in Peru and partner’s history of childhood violence in Colombia and Mexico. Evidence of shared risk factors was strongest for social isolation and caregiver histories of childhood violence and of shared protective factors for collaborative partnership dynamics. In all countries, associations between physical child punishment and physical IPV remained significant after adjusting for other factors, suggesting that correlations could not be explained by shared risk factors alone.

Conclusions

These findings are consistent with several theories relevant for violence prevention: 1) more collaborative, gender equitable partnerships may protect both children and women from violence; 2) violence between intimate partners may ‘spill over’ into violence against children (as correlations could not be explained by shared risk factors alone); and 3) there appears to be strong evidence of intergenerational transmission of violence.

Child Marriage in South Asia: A Systematic Review

Background: Child marriage is a serious public health issue with dire implications at the individual and societal level. Almost half of all child marriages globally originate from South Asia. The aim of this study is to identify consistent factors associated with and resulting from child marriage in South Asia through a review of available evidence. Methods: This systematic review adhered to the 2015 Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. Six computerized bibliographic databases, namely PsycINFO, CINAHL, EMBASE, Ovid Medline, PUBMED, and Scopus were searched. Retrieved studies were exported to EndNote and screened for eligibility using pre-determined criteria. The quality of the included studies was rated using 14 quality appraisal criteria derived from the National Institutes of Health (NIH) Tool. Results: A total of 520 articles were retrieved from six databases. Of these, 13 articles met the eligibility criteria and were included in this study. Factors consistently associated with child marriage in South Asia were rural residence, low level of education, poor economic background, low exposure to mass media and religion (Hindu and Muslim in particular countries). Maternal health care factors resulting from child marriage included: low utilization of antenatal care services, low institutional delivery, and low delivery assistance by a skilled birth attendant. Conclusions: Child marriage results from an interplay of economic and social forces. Therefore, to address the complex nature of child marriage, efforts targeting improvement in education, employment, exposure to health information via mass media, and gender egalitarianism are required. This systematic review was registered with PROSPERO [CRD42020190410].

The Psychosocial Impacts of Intimate Partner Violence against Women in LMIC Contexts: Toward a Holistic Approach

Work on the mental health impacts of intimate partner violence in low-and middle-income countries has focused primarily on clinical disorders such as post-traumatic stress disorder, depression, and substance abuse. This paper analyzes how non-clinical, psychosocial impacts from everyday stressors, particularly economic hardships and concern over one's children, cause extensive suffering and damage women survivors' well-being, influencing the development and expression of clinical disorders. Using a social ecological framework, the paper analyzes how psychosocial impacts arise at multiple levels, including societal levels where social norms often devalue women and privilege men, and how the stressor accumulation increases the harm caused by intimate partner violence (IPV) against women (IPVAW). Drawing on survivors' narratives and studies from diverse low and middle income country (LMIC) settings, including armed conflict and natural disaster settings, the paper underscores the importance of understanding both clinical impacts and the non-clinical, psychosocial impacts, which interact with and complement one another. Recognizing the interplay also between IPVAW and other forms of violence against girls and women, the paper calls for a more comprehensive approach to understanding and addressing the impacts of IPVAW. Recognizing the enormous variety within and across countries that are considered to be LMIC settings, the paper cautions against universalized approaches to understanding the effects of IPVAW and helping to support survivors.

Child Marriage and Problems Accessing Healthcare in Adulthood: Evidence from India

The association between child marriage and the access to or utilization of maternal and antenatal healthcare has been widely studied. However, little is known about child brides' access to healthcare for illnesses later in life. Using data on 496,283 married women aged 18 to 49 years from the India National Family and Health Survey 2015-2016, we developed an 11-point composite score (ranging from 0 to 10) outlining the extent of problems accessing healthcare, as follows: (i) no/little problem (score 0 to 2), (ii) some problems (score 3 to 6), and (iii) big problems (score 7 to 10). The differences between child brides and their peers married as adults were assessed by the relative risk ratios obtained from multinomial logistic regressions. The adjusted risk of having "some problems" and "big problems" accessing healthcare relative to "no/little problem" for child brides was found to be 1.22 (95% CI: 1.20-1.25) and 1.26 (95% CI: 1.22-1.29) times that of those married as adults, respectively. These findings highlight the disproportionate barriers to healthcare access faced by women married as children compared to women married as adults and the need for further research to inform policies regarding effective public health interventions to improve healthcare access.

Child Marriage Acceptability Index (CMAI) as an essential indicator: an investigation in South and Central Sulawesi, Indonesia

Background

Child marriage remains an important social issue in Indonesia. Child marriages were reported from 14.67% in 2008 to 10.82% in 2019. However, 22 out of 34 provinces in Indonesia still had high child marriage rates above the national average in 2019. This study aims to assess child marriage acceptability in the two locations in Indonesia by gender inequality, financial security, education rates, legal frameworks, dowry, and sexual and gender-based violence (SGBV).

Methods

This study used a quantitative approach with a cross-sectional study design. A total of 1000 respondents consisting of 500 households in Bone District, South Sulawesi and 500 households in Palu, Sigi, and Donggala District in Central Sulawesi participated in the study. Data analyses were conducted based on the Child Marriage Acceptability Index (CMAI) using the bivariate correlation, ANOVA (analysis of variance), and logistic regression.

Results

This study found several significant factors that contributed to child marriage acceptance in Central and South Sulawesi: household financial security (p = 0.016), dowry (p < 0.001) and legal frameworks (p = 0.017) based on ANOVA analysis. After conducting a bivariate correlation, dowry (p < 0.001) and sexual and gender-based violence (p < 0.001) remain significant factors. Dowry (p < 0.001), with expected B = 0.122, and sexual and gender-based violence (p < 0.001, with expected B = 0.064) remains significant after the linear regression analysis.

Conclusions

Dowry practice and sexual and gender-based violence were the most significant factors contributing to child marriage acceptance in Central and South Sulawesi. There is a need to conduct interventions to prevent child marriage, including providing sexual and reproductive health education.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41256-022-00252-4.

Child Marriage, Reproductive Outcomes, and Service Utilization among Young Afghan Women: Findings from a Nationally Representative Survey in Afghanistan

This study explored the prevalence of child marriage and its association with reproductive outcomes and service utilization among young women in Afghanistan. We conducted a secondary analysis of data from the 2015 Afghanistan Demographic and Health Survey (DHS), focusing on women aged 20-24 years old based on the United Nations' recommendation on child marriage study. Multivariate logistic models examined the association between child marriage, reproductive outcomes, and service utilization. An estimated 52% of the Afghan women aged 20-24 married at ages less than 18 years. Poverty and illiteracy were associated with the higher likelihood of early marriage. There was a significant negative relationship between child marriage and history of rapid repeat childbirth, delivery by skilled personnel, and institutional delivery. In both adjusted and unadjusted models, women married at age ≤14 were more likely to experience terminated or unintended pregnancy, inadequate ANC, unmet need for family planning, and fistula; while, for those married at age 15-17 years, only terminated or unintended pregnancy remained significant. Strict international law enforcement and advocacy are needed in the current situation of Afghanistan to increase young women's education, promote their civil rights, and improve their autonomy and role in decision-making concerning their fertility preferences and reproductive health.

Are Child Domestic Workers Worse Off than Their Peers? Comparing Children in Domestic Work, Child Marriage, and Kinship Care with Biological Children of Household Heads: Evidence from Zimbabwe

Child domestic work is a hidden form of child labour driven by poverty and social norms. However, little is known about the situations of child domestic workers. This study aims to describe and analyse gender-specific working conditions, health, and educational outcomes among hidden child domestic workers (CDWs) living in third-party homes relative to married children, biological children, and other children in kinship care. Data from the 2019 Zimbabwe Multiple Indicator Cluster Survey (MICS) were analysed. Descriptive statistics and bivariable logistic regression were used to describe frequency and estimated prevalence. Directed Acyclic Graphs (DAGs) were used to identify exposures and inform the selection of covariates. Multivariable logistic regression models were fitted to estimate the effect of each exposure variable. The prevalence of CDWs was 1.5% and CDWs were mainly girls and living in much wealthier households with more educated household heads while married girls were living in much poorer households. When compared among girls themselves, being a CDW was significantly associated with having a functional disability, while married girls were more frequently engaged in hazardous working conditions. We provide the first intersectional analysis comparing work, violence, and health outcomes among CDWs, married children and other children. Child protection measures are needed to safeguard children in domestic work and marriages.

Child marriage and risky health behaviors: an analysis of tobacco use among early adult and early middle-aged women in India

BACKGROUND

Though the harmful impacts of child marriage have been evaluated across several domains, evidence on the relationship between child marriage and health behaviors over the life course is limited. In this paper, we examined whether getting married as a child is associated with one of the most common risky health behaviors, tobacco use, in adulthood.

METHODS

Using nationally representative data from India, we compared the odds in favor of tobacco use among early adult (age 22-34) and early middle-aged (age 35-44) women who were married before age 18 with that of those who were married as youths (age 18-21). We estimated univariate and multivariable logistic regressions to obtain odds ratios in favor of any tobacco-use and relative risk ratios in favor of mutually exclusive types of tobacco use (smoking-only, smokeless-only, and dual-use). We also explored the intensive margin of the relationship by assessing if the odds of tobacco use in adulthood were affected by how early (13 or less, 14-15, or 16-17) a child bride was married.

RESULTS

We find that the adjusted odds of tobacco use for those who were married as a child were 1.3 and 1.2 times that of those who were married as a youth among early adult and early middle-aged women, respectively. The younger was the child bride when married, the higher were the odds of tobacco use as an adult. The relative risks of different types of tobacco use were also higher for child brides than their peers.

CONCLUSIONS

These results are the first evidence of the association between child marriage and a major risky health behavior, tobacco use, over the life course. These findings will inform policies to strengthen child marriage prevention efforts and targeted tobacco control initiatives in the low-and-middle income countries.

Sexual violence as a predictor of unintended pregnancy among married women of India: evidence from the fourth round of the National Family Health Survey (2015-16)

BACKGROUND

Sexual Intimate Partner Violence (IPV) is a public health problem globally, with about one in three women experiencing sexual IPV ever in their lifetime. Unintended pregnancy is one of the consequences of sexual IPV and has its repercussions that can span generations. The present study was conducted to estimate the prevalence of sexual intimate partner violence (IPV) and assess the association between sexual IPV and unintended childbirth in India among married women aged 15-49 years.

METHODS

The National Family Health Survey-India (NFHS-4) fourth-round dataset was used for the present study. Pregnancies intention was the primary outcome variable, and the main predictor variable was self-reported sexual IPV in the past 12 months. Women's current age, age at marriage, education and occupation, place of residence, wealth quintile, parity, religion, caste, region, mass media exposure, and husband's education were other control variables. Weighted analysis depicted the prevalence of unintended pregnancies and their association with different socio-demographic variables. Binary logistic regression was done in two steps respecting a hierarchical approach for potential confounders.

RESULTS

Approximately 6.4% of study participants had ever experienced sexual IPV in India. Prevalence of sexual IPV was significantly higher when the age of marriage was < 19 years, among uneducated, in the lowest wealth index quintile, belonging to scheduled caste, having multiparity, and not having mass media exposure. About 12.1% of pregnancies were considered unintended by the respondents, and 22.9% of women who ever had a history of sexual IPV considered the last pregnancy to be unintentional. Women who experienced sexual IPV were in younger age groups, having parity ≥1, and bigger families had significantly higher odds of having an unintended pregnancy compared to their reference groups.

CONCLUSIONS

We observed that sexual IPV has a significant role in unintended pregnancies. Effective counseling means should be rolled out for victims of sexual IPV as it is a taboo subject. The significant factors that can predict unintended pregnancies highlighted in our study should be acknowledged while counseling.

Association between Sociodemographic Factors and Abuse by a Parent or Intimate Partner Violence among Haitian Women: A Population-Based Study

One in three Haitian women, and two in three Haitian children, experience physical abuse. This study aims to assess characteristics of abused Haitian women and identify effective sources of support. This cross-sectional study used multiple logistic regression models to analyze sociodemographic characteristics of Haitian women, associations with abuse-exposure from a parent/intimate partner (IPV)/any perpetrator, and impacts of seeking help for abuse, from police/doctors/family. About 9.1% experienced abuse by a parent, 8.6% from IPV. Women abused by a parent were less likely to be employed (OR = 0.74, [95% CI = 0.59–0.93]) and more likely to have an often-drunk partner (2.10, [1.54–2.87]). IPV-exposed women were more likely to have primary education (1.56, [1.12–2.16]), an often-drunk partner (3.07, [2.24–4.22]) and less likely to live rurally (0.65, [0.47–0.89]). Seeking help from own family for IPV exposure was strongly associated with having a job (2.00, [1.04–3.89]) (P for interaction = 0.039) and seeking help from partner’s family for IPV was strongly associated with having an often-drunk husband (8.80, [3.07–25.23]) (p for interaction <0.001). We recommend family-based interventions targeting men’s perceptions about abuse and their alcohol consumption, introducing programs/policies integrating women into the workforce, and havens for abuse victims to confidentially receive individualized support.

Reproductive health among married and unmarried mothers aged less than 18, 18-19, and 20-24 years in the United States, 2014-2019: A population-based cross-sectional study

BACKGROUND

Studies in low- and middle-income regions suggest that child marriage (<18 years) is a risk factor for poor reproductive outcomes among women. However, in high-income-country contexts where childbearing before age 18 occurs predominantly outside marriage, it is unknown whether marriage is adversely associated with reproductive health among mothers below age 18. This study examined the joint associations of marriage and adolescent maternal age group (<18, 18-19, and 20-24 years) with reproductive, maternal, and infant health indicators in the United States.

METHODS AND FINDINGS

Birth registrations with US resident mothers aged ≤24 years with complete information on marital status were drawn from the 2014 to 2019 Natality Public Use Files (n = 5,669,824). Odds ratios for the interaction between marital status and maternal age group were estimated using multivariable logistic regression, adjusting for covariates such as maternal race/ethnicity and nativity status, federal program participation, and paternal age. Marriage prevalence was 3.6%, 13.2%, and 34.1% among births to mothers aged <18, 18-19, and 20-24 years, respectively. Age gradients in the adjusted odds ratios (AORs) were present for most indicators, and many gradients differed by marital status. Among births to mothers aged <18 years, marriage was associated with greater adjusted odds of prior pregnancy termination (AOR 1.64, 95% CI 1.52-1.77, p < 0.001), repeat birth (AOR 2.84, 95% CI 2.68-3.00, p < 0.001), maternal smoking (AOR 1.24, 95% CI 1.15-1.35, p < 0.001), and infant morbidity (AOR 1.07, 95% CI 1.01-1.14, p = 0.03), but weaker or reverse associations existed among births to older mothers. For all maternal age groups, marriage was associated with lower adjusted odds of late or no prenatal care initiation, sexually transmitted infection, and no breastfeeding at hospital discharge, but these beneficial associations were weaker among births to mothers aged <18 and 18-19 years. Limitations of the study include its cross-sectional nature and lack of information on marriage timing relative to prior pregnancy events.

CONCLUSIONS

Marriage among mothers below age 18 is associated with both adverse and favorable reproductive, maternal, and infant health indicators. Heterogeneity exists in the relationship between marriage and reproductive health across adolescent maternal age groups, suggesting girl child marriages must be examined separately from marriages at older ages.

Comparing the timeliness and adequacy of antenatal care uptake between women who married as child brides and adult brides in 20 sub-Saharan African countries

CONTEXT

Considering the persistent poor maternal and child health outcomes in sub-Saharan Africa (SSA), this study undertook a comparative analysis of the timing and adequacy of antenatal care uptake between women (aged 20-24 years) who married before age 18 and those who married at age 18 or above.

METHOD

Data came from Demographic and Health Surveys of 20 SSA countries. We performed binary logistic regression analysis on pooled data of women aged 20-24 (n = 33,630).

RESULTS

Overall, the percentage of child brides in selected countries was 57.1%, with the lowest prevalence found in Rwanda (19.1%) and the highest rate in Chad (80.9%). Central and West African countries had the highest prevalence of child marriage compared to other sub-regions. Bivariate results indicate that a lower proportion of child brides (50.0%) had 4+ ANC visits compared to the adult brides (60.9%) and a lower percentage of them (34.0%) initiated ANC visits early compared to the adult brides (37.5%). After controlling for country of residence and selected socio-economic and demographic characteristics, multivariable results established significantly lower odds of having an adequate/prescribed number of ANC visits among women who married before age 15 (OR: 0.63, CI: 0.57-0.67, p<0.001), and women who married at ages 15-17 (OR: 0.81, CI: 0.75-0.84, p<0.001) compared to those who married at age 18+. Similar results were established between age at first marriage and timing of first ANC visit. Other interesting results emerged that young women who married earlier than age 18 and those who married at age 18+ differ significantly by several socio-economic and demographic characteristics.

CONCLUSION

Efforts to improve maternal and child health outcomes in SSA must give attention to address the underutilization and late start of antenatal care uptake among child brides.

A mediation analysis of the role of girl child marriage in the relationship between proximity to conflict and past-year intimate partner violence in post-conflict Sri Lanka

Background

Studies from many contexts indicate that proximity to conflict is associated with increased likelihood of intimate partner violence (IPV), and girl child marriage is associated with both proximity to conflict and increased IPV. In this study, we consider whether girl child marriage acts as a mediator of the association between proximity to conflict and IPV in the context of Sri Lanka, which sustained long-term conflict until 2009.

Methods

We analyzed responses of currently partnered women between ages 18 and 49 in the 2016 Sri Lankan Demographic and Health Survey (N = 13,691). Using logistic regression analyses, we measured associations between proximity to conflict (residence in districts which were central, proximal, or distal to the regions where the war occurred) and the outcomes of IPV and girl child marriage, and secondarily assessed girl child marriage as a possible mediator of the association between proximity to conflict and past year IPV.

Results

Women residing in districts central to conflict, as compared to districts distal to conflict, had increased odds of past year sexual, physical, and emotional IPV, with the odds of sexual IPV increasing the most (adjusted odds ratio/aOR 4.19, 95% confidence interval/CI 2.08–8.41). Residing in districts proximal to conflict compared to those distal to conflict was associated with lower odds of past year physical and emotional IPV, with the greatest decrease in emotional IPV (aOR 0.31, CI 0.18–0.54). Girl child marriage was more likely in districts central to conflict as opposed to those distal to conflict (aOR 1.89, CI 1.22–2.93), and partially mediated the relationship between centrality to conflict and IPV.

Conclusions

Our findings demonstrate that residing in districts central to conflict compared to those distal to conflict is associated with greater odds of IPV and girl child marriage in post-conflict Sri Lanka, with girl child marriage partially mediating the association between centrality to conflict and IPV. Residence in districts proximal to conflict appears protective against IPV. Future research should investigate what factors are responsible for decreased IPV in districts proximal to violence, and whether these factors can be reproduced to mitigate the increased prevalence of IPV in districts central to conflict.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-022-00436-2.

The health consequences of child marriage: a systematic review of the evidence

Background

Child marriage, defined as marriage before 18 years of age, is a violation of human rights and a marker of gender inequality. Growing attention to this issue on the global development agenda also reflects concerns that it may negatively impact health. We conducted a systematic review to synthesize existing research on the consequences of child marriage on health and to assess the risk of bias in this body of literature.

Methods and findings

We searched databases focused on biomedicine and global health for studies that estimated the effect of marrying before the age of 18 on any physical or mental health outcome or health behaviour. We identified 58 eligible articles, nearly all of which relied on cross-sectional data sources from sub-Saharan Africa or South Asia. The most studied health outcomes were indicators of fertility and fertility control, maternal health care, and intimate partner violence. All studies were at serious to critical risk of bias. Research consistently found that women who marry before the age of 18 begin having children at earlier ages and give birth to a larger number of children when compared to those who marry at 18 or later, but whether these outcomes were desired was not considered. Across studies, women who married as children were also consistently less likely to give birth in health care facilities or with assistance from skilled providers. Studies also uniformly concluded that child marriage increases the likelihood of experiencing physical violence from an intimate partner. However, research in many other domains, including use of contraception, unwanted pregnancy, and sexual violence came to divergent conclusions and challenge some common narratives regarding child marriage.

Conclusions

There are many reasons to be concerned about child marriage. However, evidence that child marriage causes the health outcomes described in this review is severely limited. There is more heterogeneity in the results of these studies than is often recognized. For these reasons, greater caution is warranted when discussing the potential impact of child marriage on health. We provide suggestions for avoiding common biases and improving the strength of the evidence on this subject.

Trial registration

The protocol of this systematic review was registered with PROSPERO (CRD42020182652) in May 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12707-x.

Severity of Lifetime Physical Intimate Partner Violence and Controlling Behavior in Sub-Saharan Africa

Evidence suggests women in sub-Saharan Africa may be more likely to experience intimate partner violence (IPV) than women anywhere else in the world. Data was obtained from women (n = 29,444) who completed the Demographic Health Survey's (DHS) domestic violence module in seven countries in sub-Saharan Africa countries between 2011 and 2015. Women who reported controlling behavior by a spouse/partner were more likely to have experienced less severe lifetime physical violence (adjusted odds ratio (AOR) 3.02, 95% confidence interval (CI) 2.63, 3.47) and severe violence (AOR 4.27, 95% CI 3.32, 5.49). Partner's controlling behavior may increase the likelihood of experiencing both less severe and severe lifetime physical violence.

Understanding the impacts of child marriage on the health and well-being of adolescent girls and young women residing in urban areas in Egypt

BACKGROUND

Egypt has made progress in delaying age at marriage, but child marriage continues to be practiced in many places across the country. This study investigates the impacts of child marriage on the health and wellbeing of girls residing in urban Egypt using a multi-method approach.

METHODS

The quantitative component leveraged data from the 2014 Egypt Demographic and Health Survey and focused on (1) reproductive health, (2) maternal health and (3) social outcomes among a subsample of ever-married urban women ages 20-24 (N = 1041). Simple and multivariable logistic regressions were used to estimate prevalence odds ratios and 95% confidence intervals for associations between child marriage and the three sets of outcomes. The qualitative component drew from 11 focus groups, 23 in-depth interviews, and 13 key informant interviews conducted in three urban sites in Egypt. The data was thematically analyzed using a combination of inductive and deductive coding.

RESULTS

The prevalence of marriage under age 18 was 13.22%. Child marriage was significantly associated with ever use of contraception (Adjusted Odds Ratio (AOR) 2.95 95% CI 1.67-5.19), multiple births (AOR 12.93 95% CI 5.45-30.72), rapid repeat childbirth (AOR 2.20 95% CI 1.34-3.63), and pregnancy termination (AOR 1.89 95% CI 1.11-3.23). Many of these associations disappeared after adjusting for marriage duration. Girls married under age 18 had larger spousal age gaps (AOR 2.06; 95% CI 1.24-3.41) and higher odds of FGM (AOR 2.14; 95% CI 1.11-4.13). They were significantly more likely to report receiving no ANC care (AOR 0.39; 95% CI 0.19-0.80), and less likely to deliver through C-section (AOR: 0.53; 95% CI 0.34-0.83). Consequences emerging from the qualitative data centered around five themes: (1) Access to and use of sexual and reproductive health services; (2) exposure to FGM; (3) marriage and birth registration; (4) marital relations; and (5) relationship with in-laws.

CONCLUSION

Findings provide important insights into the practice of child marriage in urban areas in Egypt and illustrate a range of adverse consequences associated with the practice.

The development of adolescent agency and implications for reproductive choice among girls in Zambia

Background

A substantial proportion of adolescent girls in Zambia lack the ability to decide their reproductive future. We examined the role of agency in early and unwanted adolescent childbearing.

Methods

Using latent transition analysis, we characterized a multi-dimensional profile of adolescent agency annually over a four-year period. We investigated the influence of early life access to resources and time-varying predictors (school retention, violence, early marriage and unwanted/mistimed pregnancy and childbearing) on agency profile membership as well as transitions in agency status over time.

Results

Four agency profiles were identified, with differences by age cohort (10–14 years vs. 15–19 years). Three profiles identified in both age cohorts were: Low-moderate agency, Self-assured gender conformers, and High agency. Unique to younger girls was the Gender conscious, low belief in abilities status, while among older girls was the Self-assured selective gender conscious status. While younger girls were likely to transition to the highest agency status over time, high agency membership declined among older girls. Early life resources were associated with augmented agency while exposure to negative events, particularly early marriage, were associated with detraction from high agency status. Girls who expressed high self-efficacy but gender-conforming values were most at risk of early marriage and unwanted/mistimed pregnancy while High agency girls were at comparatively low risk.

Conclusions

Results show agency is dynamic but less mutable with increasing age. Early adolescent strategies which address inequitable gender norms and limit early marriage, may guard against losses to agency which contribute to unwanted fertility outcomes.

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Findings support agency as a dynamic, multidimensional construct in adolescence.

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In general, access to resources promoted agency across dimensions.

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Time-varying events, particularly early marriage, detracted from agency status.

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Agency dimensions combined in unique ways with distinct implications for early/unwanted fertility.

Freedom of Movement and Adolescent Sexual Violence in India

This study assesses associations between freedom of movement and sexual violence, both in marriage and outside of marriage, among a representative sample of adolescents in India. We analyzed data from girls aged 15 to 19 years (n = 9,593) taken from India's nationally representative National Family Health Survey 2015-2016. We defined freedom of movement using three items on whether girls could go unaccompanied to specified locations; we summated responses and categorized them as restricted, or unrestricted. We used multivariable regression to assess associations between restricted movement and nonmarital violence, and with marital sexual violence among ever-married girls. Results show that only 2% of girls reported nonmarital sexual violence, among married and unmarried girls; 6% of married girls reported marital sexual violence. Most girls (78%) reported some restriction in movement. Restricted movement was negatively associated with nonmarital sexual violence (adjusted odds ratio [AOR] = 0.52, 95% confidence interval [CI] = [0.31, 0.87], p = .01) but positively associated with marital sexual violence (AOR = 3.87, 95% CI = [1.82, 8.25], p < .001). Further analyses highlight that the observed association with nonmarital sexual violence was specific to urban and not rural girls. These findings reveal that approximately one in 30 adolescent girls in India has been a victim of sexual violence. Restricted movement is associated with lower risk for nonmarital sexual violence for urban adolescent girls, possibly due to lower exposure opportunity. Married girls with restricted movement have higher odds of marital sexual violence, possibly because these are both forms of control used by abusive husbands. Freedom of movement is a human right that should not place girls at greater risk for nonmarital violence or be used as a means of control by abusive spouses. Social change is needed to secure girls' safety in India.

New estimations of child marriage: Evidence from 98 low- and middle-income countries

The Sustainable Development Goals include a target on eliminating child marriage, a human rights abuse. Yet, the indicator used in the SDG framework is a summary statistic and does not provide a full picture of the incidence of marriage at different ages. This paper aims to address this limitation by providing an alternative method of measuring child marriage. The paper reviews recent data on nuptiality and captures evidence of changes in the proportion married and in the age at marriage, in 98 low- and middle-income countries (LMICs). Using data collected from nationally representative Demographic and Health Surveys and Multiple Indicator Cluster Surveys, survival analysis is applied to estimate (a) age-specific marriage hazard rates among girls before age 18; and (b) the number of girls that were married before age 18 in 2020. Results show that the vast majority of girls remain unmarried until age 10. Child marriage rates increase gradually until age 14 and accelerate significantly thereafter at ages 15-17. By accounting for both single-year-age-specific child marriage hazard rates and the age structure of the population with a survival analysis approach, lower estimates in countries with a rapid decrease in child marriage and higher estimates in countries with constant or slightly rising child marriage rates relative to the direct approach are obtained.

Care of women and girls after sexual assault in Geneva: A descriptive study between 2005 and 2014

BACKGROUND AND PURPOSE

We aimed to examine epidemiological data and identify risk factors for sexual assault. This study included women seeking care at the Geneva University Hospitals emergency obstetrics and gynaecological unit.

METHOD

Retrospective, sociodemographic, and clinical data were collected from the medical reports.

RESULTS

We reviewed 836 medical charts and registered 92.8 women and girls per year who consulted the emergency department after sexual assault. The average age was 26 (±12) years, with a median of 23 years. Body lesions were reported in 525 patients (63%) and genital traumatic lesions were reported in 230 (28%) patients. Sexual assault by a stranger was reported in 436 cases (52%). Thirty percent of patients knew their aggressor. Aggressions were predominantly committed on the weekend, accounting for 367 cases (46%), with nearly two-thirds (65%, n = 474) occurring between 10 pm and 6 am. In total, 399 (48%) patients who were sexually assaulted reported having consumed alcohol and 102 (12%) reported having taken drugs prior to the aggression; 80 (10%) patients had consumed both and 286 (34%) had amnesia. Half of the sample sought and received medical care within 24 h from the time the aggression took place.

CONCLUSION

Sexual assault risk factors in our study population in Geneva included use of drugs and alcohol, with amnesia. Future prevention and education interventions should target these areas.

Association between intimate partner violence during pregnancy and risk of preterm birth

Background

Preterm birth is a risk factor for child survival in both the short and long term. In Zimbabwe, the prevalence of preterm birth is rising, and there are growing concerns about the adverse consequences. This study explored the association between intimate partner violence (IPV) during pregnancy and preterm birth in Zimbabwe.

Methods

Using data from the 2015 Zimbabwe Demographic and Health Survey, we applied propensity score matching to estimate the effect of IPV during pregnancy on preterm birth among women of reproductive age (15–49 years). A total of 4833 pregnant women who gave birth during the five years preceding the survey were analysed.

Results

We successfully matched 79 women who were exposed to IPV during pregnancy to 372 unexposed during pregnancy. Using the matched sample, the probability of preterm delivery was significantly higher among women who were exposed to IPV during pregnancy than those who were not exposed. The findings showed that 7 out of 79 (8.9%) of women exposed to IPV during pregnancy experienced preterm delivery, and 11 out of 372 (3.0%) of those who were not exposed to IPV during pregnancy experienced preterm delivery. In the urban areas, those exposed to IPV during pregnancy were almost five times more likely to experience preterm delivery (OR = 4.8, 95% CI 2.0–11.6), but the association was not significantly different among women in rural areas.

Conclusion

The findings showed that women exposed to IPV during pregnancy were at increased risk of preterm birth. Some of the risk factors associated with IPV were urban residence, low economic status and unemployment. Effective policies and programmes are required to address the issue of IPV in Zimbabwe.

Marrying Young: Limiting the Impact of a Crisis on the High Prevalence of Child Marriages in Niger

Child marriage is a harmful and discriminatory global practice, robbing millions of girls of their childhood. Global attention and momentum to end early marriage has increased over the years; however, the impact of the COVID-19 pandemic has affected this progress. It has been predicted that over the next decade up to 10–13 million more girls will be at risk of child marriage because of the pandemic. Since Niger has consistently had the highest rate of child marriage in the world, this study will explore the impact of the COVID-19 pandemic on child marriages within the west and African region but specifically within Niger. This article will look at past response efforts to other pandemics, specifically Ebola, and show how the girl-child remains disproportionately disadvantaged, especially during pandemics. The article will conclude with recommendations on the importance of incorporating a gender analysis into preparedness and response efforts to eliminate child marriages.

The impact of girl child marriage on the completion of the first cycle of secondary education in Zimbabwe: A propensity score analysis

BACKGROUND

The association between girl child marriage and education is widely acknowledged; however, there is no large body of demographic studies from Zimbabwe that have addressed this aspect. This study aimed to examine the extent to which child marriage affects one academic milestone, i.e. completion of the Ordinary Level, the first cycle of high school, which is also the most critical indicator of educational achievement in Zimbabwe.

METHODS

We used the 2015 Zimbabwe Demographic and Health Survey and extracted 2380 cases of ever-married women aged between 20-29 years. We applied a propensity score-based method, which allowed us to mimic a hypothetical experiment and estimate outcomes between treated and untreated subjects.

RESULTS

Our results suggest that child age at first marriage is concentrated between the ages of 15-22, with the typical age at first marriage being 18 years. Both logistic regression and PSM models revealed that early marriage decreased the chances of completing the first cycle of high school. Regression adjustment produced an estimate of prevalence ratio (PR) of 0.446 (95% CI: 0.374-0.532), while PSM resulted in an estimate (PR = 0.381; 95% CI: 0.298-0.488).

CONCLUSION

These results have implications for Zimbabwe's development policy and suggest that girl-child marriage is a significant barrier to educational attainment. If not addressed, the country will most likely fail to meet sustainable development Goal 4.2 and 5.3. Social change interventions that target adults and counter beliefs about adolescent sexuality and prepubescent marriage should be put in place. Moreover, interventions that keep teenage girls in school beyond the first cycle of high school should be prioritised.

Anaemia among under-five children: Is maternal marriage at 18th birthday and above protective? Evidence from 15 countries in Sub-Saharan Africa

Prevalence of child marriage has remained high in many parts of Africa despite its multisectoral adverse effect. As it is now being suggested to have intergeneration impact, we examined if marriage at or after 18th birthday is associated with the risk of anaemia among under-five children. Cross-sectional data from Demographic and Health Surveys (DHS) conducted between 2010 and 2018 in 15 African countries as of August 2020 were used. Maternal age of marriage was defined as when they started living with their husband or partner. Children with haemoglobin level below 11.0 g/dl after adjustment for altitude were categorised to be anaemic. The study involved a multivariable logistic regression analysis of 17,033 children data born by women between the childbearing ages. About 65% of under-five children in Sub-Saharan Africa (SSA) were anaemic, ranging from 40% in Rwanda to 82% in Mali. Girl child marriage ranged from 40% in South Africa to 97% in Niger with an average of about 60%. We observed a significant reduction (20%) in the risk of anaemia among under-five children when their mothers married after at or after their 18th birthday. Country-specific analysis showed that increased risk of anaemia was strongly associated with early marriage in Côte d'Ivoire and Mozambique. This study contributed to the growing evidence that maternal age of marriage might have an intergenerational impact. Maternal marriage at or after their 18th birthday reduces the risk of anaemia among under-five children in Africa. Interventions aimed at tackling anaemia in Africa should capture and affect household socioeconomic risks and children's exposures.

Understanding female and male empowerment in Burkina Faso using the project-level Women's Empowerment in Agriculture Index (pro-WEAI): a longitudinal study

BACKGROUND

Achieving gender equality and women's empowerment is a major global priority. The purpose of this study was to determine whether the Building the Resilience of Vulnerable Communities in Burkina Faso (BRB) project, an agricultural development program, improved women's empowerment, as measured by the project-level Women's Empowerment in Agriculture Index (pro-WEAI).

METHODS

This study used a longitudinal, quasi-experimental study design. Participants included both treatment and comparison groups (total N = 751) comprising female members of savings groups and their husbands or main male household member in Burkina Faso. All participants completed the pro-WEAI questionnaire at both baseline and endline. The treatment group received a comprehensive intervention package consisting of agriculture loans and services, microenterprise loans, and education, nutrition education, and women's empowerment programs including gender-based discussions designed to facilitate personalized changes in gender relations.

RESULTS

The proportion of the treatment group achieving empowerment did not change from baseline for women, but improved substantially for men. Women from the comparison group saw an increase in empowerment at endline while men saw a substantial decrease. Gender parity was high for women in both groups at baseline and increased slightly at endline. Women were more likely to have adequate empowerment in input in productive decisions, group membership, and membership in influential groups than men while men were more likely to have adequate empowerment in attitudes about domestic violence, control over use of income, and work balance than women. Participants from the treatment group reported an increase in the average number of empowerment indicators that they were adequate in while the comparison group saw a decrease in average adequacy over time (p = 0.002) after controlling for age, sex, and level of education.

CONCLUSION

Despite starting at an empowerment disadvantage, the treatment group experienced gains in individual indicators of empowerment while the comparison group men and women experienced mixed results, with the women gaining, and the men losing empowerment. This research suggests that the BRB intervention may have provided some protection for the treatment group when they faced an economic down-turn prior to the endline, indicative of household resilience. Future research should consider and strengthen relationships between resilience and empowerment.

Child marriage among Somali refugees in Ethiopia: a cross sectional survey of adolescent girls and adult women

BACKGROUND

Despite child marriage receiving increased attention over the past two decades, research on child marriage in humanitarian settings remains scarce. This study sought to quantify child marriage among Somali adolescent girls residing in Kobe refugee camp in Ethiopia and to identify its correlates and consequences.

METHODS

A cross-sectional survey was conducted using multi-stage cluster-based sampling with probability proportional to size. We randomly sampled households that have at least one female aged 15-49 and at least one adolescent female aged 10-19. In addition to calculating the proportion of girls married under age 18, we used survival methods - namely Kaplan Meier graphs and Cox proportional hazard models - to identify risk factors associated with child marriage in this context. We also used descriptive statistics to describe marital age preferences among female adults and presented measures of important sexual and reproductive health indicators among married adolescent girls.

RESULTS

A total of 603 adult women were surveyed and a household roster was created with information on 3319 household members, of whom 522 were adolescent girls aged 15-19. Of those, 14% were currently married (95% Confidence Interval [CI] 0.11-0.18), and 11% were ever married under age 18 (95% CI 8-15%). Several variables were found to be significantly associated with hazard of child marriage including schooling, sex and employment status of head of household, as well as number of girls under age 18 in the childhood home.. Adult women tended to incorrectly identify minimum legal age at marriage and preferred low marital age for boys and girls - particularly in households of child brides. Among married adolescent girls, contraceptive use was very low (11%; 95% CI 4.94-22.40), and early childbearing was common (60%; 95% CI 45.56-72.89).

CONCLUSIONS

This research contributes to the evidence base on child marriage in humanitarian settings. Insights generated from this study have the potential to inform programs and interventions aiming to prevent and mitigate the impacts of this harmful practice.

Drivers and consequences of child marriage in a context of protracted displacement: a qualitative study among Syrian refugees in Egypt

Background

Child marriage is a human rights violation disproportionately impacting girls in low- and middle-income countries. In the Middle East region, conflict and displacement have prompted concerns that families are increasingly resorting to child marriage to cope with economic insecurity and fears from sexual violence. This study set out to examine child marriage among Syrian refugees residing in Egypt with the aim of understanding drivers of child marriage in this context of displacement as well as how child marriage affects refugee girls’ wellbeing.

Methods

This analysis draws from 15 focus group discussions (FGD) conducted with married and unmarried girls, as well as parents of adolescent girls in three governorates in Egypt. FGDs included a participatory ranking exercise and photo-elicitation. Additionally, we conducted 29 in-depth interviews with girls and mothers, as well as 28 key informant interviews with health providers, community leaders, and humanitarian actors. The data was thematically analyzed using a combination of inductive and deductive coding.

Results

A prevalent phenomenon in pre-war Syria, child marriage has been sustained after the influx of Syrian refugees into Egypt by pre-existing cultural traditions and gender norms that prioritize the role of girls as wives and mothers. However, displacement into Egypt engendered different responses. For some families, displacement-specific challenges such as disruptions to girls’ education, protection concerns, and livelihood insecurity were found to exacerbate girls’ vulnerability to child marriage. For others, however, displacement into urban areas in Egypt may have contributed to the erosion of social norms that favored child marriage, leading to marriage postponement. Among girls who were married early, we identified a range of negative health and social consequences, including lack of family planning use, disruption to schooling and curtailment of girls’ mobility as well as challenges with marriage and birth registration which accentuated their vulnerability.

Conclusion

Efforts to address child marriage among Syrian refugees must acknowledge the different ways in which displacement can influence child marriage attitudes and practices and should capitalize on positive changes that have the potential to catalyze social norm change. Moreover, targeted, focused and contextualized interventions should not only focus on preventing child marriage but also on mitigating its impacts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10718-8.

"I have never seen something like that": Discrepancies between lived experiences and the global health concept of child marriage in northern Tanzania

BACKGROUND

The concept of 'child marriage' in global health distinguishes ostensibly harmful from healthy ages to marry at a universally-applied threshold of 18-years. With intensifying efforts to end child marriage, targeted communities are increasingly asked to change their perception of such marriages from relatively benign to profoundly problematic. The objective of this study is to understand how this shift in perception is navigated by adolescent girls and young women (AGYW).

METHODS

Using qualitative data collected in 2019 from a semi-urban community in Tanzania where marriage under 18-years is common and campaigns to end child marriage ongoing, we contrast reports of lived experiences of marriage under 18-years among AGYW to views of child marriage as an abstract concept. Thirteen in-depth interviews with AGYW, as part of a wider qualitative study, were recorded, transcribed, and analyzed using a framework analysis approach.

RESULTS

While many AGYW had heard of child marriage, the concept was routinely conflated with forced marriage, which is rare in the community, and non-marital teenage sex and pregnancy, which are common. As a likely consequence, participants disagreed on whether or not child marriage occurs locally. Furthermore, accounts of real-life marriages under 18 sometimes aligned with, but often departed from, common narratives about the purported causes and harmful consequences inherent to the global health concept of child marriage.

CONCLUSIONS

We argue that engaging with diverse local views and experiences of marrying young is essential to producing culturally-sensitive, effective initiatives addressing the vulnerabilities of female adolescence.

The Invisible Burden of Violence Against Girls and Young Women in Mexico: 1990 to 2015

The increasing burden of interpersonal violence in women in Mexico is a neglected social and health problem that competes with other leading causes of premature death, disability, and health losses in young women. In this article, we focus on revealing the burden of violence in girls and young women and its implications for public policy. This study presents the subnational analysis of Mexico from the Global Burden of Disease study (1990-2015). The global study harmonized information of 195 countries and 79 risk factors. The study analyzed the deaths, years of life lost to premature death (YLL), years lived with disability (YLD), and the healthy years of life lost or disability-adjusted life year (DALY) related to violence. Nationwide, violence in young women accounts for 7% of all deaths in the 10 to 29 years age group and arises as the second most important cause of death in all age groups, except 10 to 14 years old, where it stands in the seventh position from 1990 to 2015. The health losses and social impact related to violence in young women demands firm actions by the government and society. It is urgent for health institutions to focus on the health of girls and young women because gender inequities have an enormous effect on their lives. Girls and women are nearly universally less powerful, less privileged, and have fewer opportunities than men.

Intimate partner violence and exclusive breastfeeding of infants: analysis of the 2013 Nigeria demographic and health survey

BACKGROUND

Existing knowledge on the relationship between intimate partner violence (IPV) and exclusive breastfeeding (EBF) in the context of Nigeria is minimal and limited to a lifelong measure of IPV experience. An abuse experienced a long time ago may not have as much negative effect as that encountered at a more proximal time to the breastfeeding phase. To this effect, we examined this relationship with maternal IPV experienced around the time of pregnancy and postpartum.

METHOD

We analyzed data from the 2013 Nigeria Demographic and Health Survey. The sample includes 2668 breastfeeding mothers having a child aged under 6 months. The outcome variable was EBF or mixed-feeding (24 h recall). The exposure variables were: the maternal experience of psychological, physical, and sexual intimate partner violence. Also, there was an experience of any form of IPV and frequency score of intimate partner violence. Analysis includes chi-square and t-test bivariates, complete case and imputed logistic regressions for binary outcome.

RESULTS

In the imputed analysis, compared to mothers who experienced no IPV, those who experienced IPV had a 26% reduced likelihood of EBF practice (AOR 0.74; 95% CI 0.55, 1.00). Also, a unit dose of maternal IPV experience was associated with a 5% reduced likelihood of EBF practice (AOR 0.69; 95% CI 0.49, 0.98). Among the three forms of IPV, physical IPV had the highest effect size. Physical IPV was associated with a 37% reduced likelihood of EBF practice (AOR 0.63; 95% CI 0.44, 0.90), while psychological IPV was associated with a 34% reduced likelihood of EBF practice (AOR 0.66; 95% CI 0.47, 0.92), when compared to the respective reference groups. On the other hand, those who reported sexual IPV were just as likely to breastfeed as those who did not (AOR 0.94; 95% CI 0.62, 1.41).

CONCLUSIONS

In this study, maternal IPV is associated with EBF practice. Policies aimed at promoting EBF should also be framed to combat IPV against pregnant women and nursing mothers.

Attitudes to and experiences of intimate partner violence among Rohingya women who married before eighteen years of age

Currently, around a million Rohingya refugees live in Cox's Bazar, Bangladesh. This study examines the attitudes toward physical abuse and experiences of intimate partner violence (IPV) of Rohingya refugee women who experienced child marriage. A cross-sectional survey was conducted in the Rohingya refugee settlement at Cox's Bazar, Bangladesh. Attitudes towards physical abuse have been assessed by a set of five questions that asked the situation under which 'hitting or beating' one's wife is justifiable. Multivariable logistic regressions are used to examine the associations of exposure to child marriage with (i) attitudes towards the justification of physical abuse by one's husband and (ii) experiences of IPV in the 12 months prior to the survey. Data are available for 486 participants. Overall, 61.32% of women experienced child marriage (married before 18 years of age) and they were more likely to have strongly justified beatings/hitting one's wife under certain circumstances (Adjusted Odds Ratio (AOR) = 2.71; 95%CI: 1.78, 4.11), and to have experienced such IPV by their husbands in the 12 months prior to the survey (AOR = 1.72; 95%CI: 1.13, 2.61). These AORs are higher for women married at ages 12-14 than those married at 15-17. Having some formal education among husband and wife is protective of abuse within a marriage. Rohingya women's attitudes towards and experiences of IPV are associated with their exposure to child marriage. Interventions for stopping child marriage, marriage registration, social support group, and legal interventions are needed. Offering formal education to all children needs to be prioritized.

Early marriage and women's empowerment: the case of child-brides in Amhara National Regional State, Ethiopia

BACKGROUND

Women, especially those who marry as children, experience various forms and degrees of exclusion and discrimination. Early marriage is a harmful traditional practice that continues to affect millions around the world. Though it has declined over the years, it is still pervasive in developing countries. In Ethiopia, Amhara National Regional State (or alternatively Amhara region) hosts the largest share of child-brides in the country. This study aimed at assessing the effects of early marriage on its survivors' life conditions - specifically, empowerment and household decision-making - in western Amhara.

METHODS

This study employed community-based cross-sectional study design. It adopted mixed method approach - survey, in-depth interview and focus group discussion (FGD) - to collect, analyse and interpret data on early marriage and its effects on household decision-making processes. The survey covered 1278 randomly selected respondents, and 14FGDs and 6 in-depth interviews were conducted. Statistical procedures - frequency distribution, Chi-square, logistic regression - were used to test, compare and establish associations between survey results on women empowerment for two groups of married women based on age at first marriage i.e., below 18 and at/after 18. Narratives and analytical descriptions were integrated to substantiate and/or explain observed quantitative results, or generate contextual themes.

RESULTS

This study reported that women married at/after 18 were more involved in household decision-making processes than child-brides. Child-brides were more likely to experience various forms of spousal abuse and violence in married life. The study results illustrated how individual-level changes, mainly driven by age at first marriage, interplay with structural factors to define the changing status and roles of married women in the household and community.

CONCLUSION

Age at first marriage significantly affected empowerment at household level, and women benefited significantly from delaying marriage. Increase in age did not automatically and unilaterally empowered women in marriage, however, since age entails a cultural definition of one's position in society and its institutions. We recommend further research to focus on the nexus between the household and the social-structural forms that manifest at individual and community levels, and draw insights to promote women's wellbeing and emancipation.

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.

When marriage is the best available option: Perceptions of opportunity and risk in female adolescence in Tanzania

Global health studies typically characterise adolescent marriage as a fundamental risk to female wellbeing. In contrast, ethnographic research among communities 'at risk' identifies that early marriage is often viewed as an opportunity weighed against locally feasible alternatives. Addressing this contradiction, we document perceived risks and opportunities of marriage, positioning them among wider concerns facing female adolescents in north-western Tanzania. On the basis of these data, we then provide recommendations for global efforts to end the marriage of minors. Thirteen focus groups and 26 in-depth interviews were conducted in 2019 with female adolescents, young women and men, and parents of female adolescents from a semi-urban community where adolescent marriage is normative. Data were compiled to synthesise narratives of adolescent risk and opportunity. Marriage was viewed as an opportunity for adolescent girls, bringing benefits such as increased social status. Risks sometimes outweighed benefits of marriage, but marriage remained desirable when structural constraints, like poverty, limited feasible alternatives and when adolescents faced similar risks, like pregnancy, outside of marriage. We conclude that remaining unmarried does not shield adolescents from adversity, and campaigns targeting adolescent marriage via criminalisation, without diminishing other risks of adolescence, may further limit rather than expand options for adolescent girls.

Spousal violence and its determinants among married adolescent girls in Upper Egypt

INTRODUCTION

In Egypt, many girls are still married before the age of 18, which is a fundamental violation of the girls' human rights. Early marriage is associated with an alarmingly elevated risk of all types of intimate partner violence that have various negative consequences. The purpose of this study was to identify the predictors of exposure to spousal violence among the early married girls in rural Upper Egypt.

METHODS

A household survey was carried out and covered 23 villages in Assiut and Sohag governorates reaching to a sample of 729 married girls before the age of 20. Listing and enumeration of 4 districts was done to identify the study participants. Data was collected by personal interviews using a structured questionnaire. Bivariate and stepwise regression analyses were performed to identify the predictors of exposure to spousal violence.

RESULTS

It was found that 15.2% of the study participants were exposed to physical violence while 17.8% were exposed to sexual violence and 7.3% were exposed to both types. Girls married before the age of 18 were more exposed to spousal violence. Stepwise regression analysis found that girls' acceptance to get married was a protective factor against exposure to physical (β = - 1.07, OR 0.34) and sexual (β = - 0.68, OR 0.51) violence. The perceived attitude of husbands and mothers-in-law about considering wife beating "a husband's right" was found to be a risk factor of exposure to physical and sexual violence. Longer duration till the first pregnancy was also associated with more exposure to sexual violence (β = 0.04, OR 1.04).

CONCLUSION

Married adolescent girls (MAGs) are highly exposed to physical and sexual violence. This is mainly due to ignoring girls' preference to postpone their marriage, cultural concepts of accepting violence against women, and low sexual satisfaction. This study shows that most determinants of spousal violence were related to culture issues. Identifying these determinants is required to combat such a crucial public health problem that has serious consequences on adolescent health.

Leaving a Violent Child Marriage: Experiences of Adult Survivors in Uganda

Violence against women and girls remains a major public health threat the world over. A significant amount of violence experienced by women is perpetrated by their intimate partners. Moreover, the risk of experiencing intimate partner violence is amplified for women and girls who get married before turning 18. However, there is little documented information on how they escape such violent relationships. This article provides insight into the factors that help survivors of child marriage to leave violent relationships. It is based on in-depth interviews with 26 Ugandan women who married before they were 18. Four main factors helped child marriage survivors to leave violent unions: (1) having a secure base to return to; (2) reaching a tipping point in the relationship; (3) financial independence; and (4) intervention of a significant other. The significance of some factors varied with the age of the survivor at the point of leaving. It is concluded that parental support is a key facilitative factor for leaving violent relationships in the context of child marriage within a low resource setting. Interventions to promote positive parenting may significantly contribute to minimising the proportions of girls trapped in violent unions and incidences of child marriage in the long run.

Associations of spousal communication with contraceptive method use among adolescent wives and their husbands in Niger

OBJECTIVES

This study aims to examine associations between spousal communication about contraception and ever use of modern contraception, overt modern contraceptive use (with husband's knowledge), and covert modern contraceptive use (without husband's knowledge) among adolescent wives and their husbands in Niger.

STUDY DESIGN

Cross-sectional data, from the Reaching Married Adolescents Study, were collected from randomly selected adolescent wives (ages 13-19 years) and their husbands from 48 randomly selected villages in rural Niger (N = 1,020 couples). Logistic regression models assessed associations of couples' reports of spousal communication about contraception with wives' reports of contraception (overall, overt, and covert).

RESULTS

About one-fourth of adolescent wives and one-fifth of husbands reported spousal communication about contraception. Results showed couples' reports of spousal communication about contraception were positively associated with ever use of modern contraception. Couples' reports of spousal communication about contraception were negatively associated with covert modern contraceptive use compared to overt use. Wives' reports of spousal communication were marginally associated with covert use compared to no use but husbands' reports were not.

CONCLUSION

Among a sample of couples in Niger, spousal communication about contraception was positively associated with modern contraceptive use (compared to no use) and negatively with covert use (compared to overt use) but wives' and husbands' reports showed differential associations with covert use compared to no use. Since there is little understanding of couple communication surrounding covert contraceptive use decisions, research should focus on characterizing content and context of couple communication particularly in cases of disagreement over fertility decisions.

Associations between village-level norms on marital age and marital choice outcomes among adolescent wives in rural Niger

Social norms, the often unspoken rules that dictate behavior, are increasingly understood to play a role in child, early and forced marriage (CEFM) practices, but are less frequently examined in quantitative research on CEFM. No research on this topic has focused on Niger, despite the country having the highest prevalence of child marriage in the world. This study examines the associations of community and individual-level norms on marital age and marital choice with the outcomes of girls' age at marriage and choice in marriage. We used data from a family planning evaluation trial conducted in three districts within the Dosso region of Niger. Survey data were collected from adolescent wives and their husbands (N = 582) on demographics, normative beliefs regarding girls' age at marriage and marital choice, and among wives, age at marriage and engagement in marital choice. We developed our community-level norm variables by using the aggregate data from husbands' and wives' norms and wives' CEFM experiences. Using crude and adjusted regression models, we assessed the associations between our norms variables and our CEFM outcomes. In this context of very high prevalence of CEFM, we found that village-level norms related to marital choice, particularly the norms of men, are associated with younger age of girls at marriage. We also found that younger age of girls at marriage is positively associated with lower likelihood of their engagement in marital choice. Further, we find that village-level norms related to a later age of marriage and support for marital choice, as well as adolescent wives' perceptions of community norms related to a higher age of marriage, are associated with higher odds of a wife having had marital choice. These findings suggest the value of community level social norms change on CEFM in Niger, and the importance of focusing on child marriage and girls' marital choice simultaneously given their interconnection.

Investigation of the key factors that influence the girls to enter into child marriage: A meta-synthesis of qualitative evidence

In this study, we synthesized findings from qualitative studies to identify the key factors that influence child marriage. We used a meta-ethnographic approach coupled with thematic synthesis. We searched literature from nine databases, which were in English language, covering areas in public health, psychology, and social science between 2008 and 2018. Twelve studies were included in the synthesis. We identified six main themes: human insecurity and conflict; legal issues; family values and circumstances; religious beliefs; individual circumstances, beliefs, and knowledge; and social norms. Our findings highlight the impact of human insecurity and conflict, as well as legal issues. In spite of global progress scaling up legislation against child marriage, the legal framework is insufficiently enforced in many settings. Most of the included studies were from the Middle East, Africa, and South Asia. Studies from other parts of the world such as Latin America and Southeast Asia, which have the highest rates of child marriage, are needed.

Traumatic Childhood Experiences and Psychiatric Outcomes of Adolescent Mothers in Turkey

The present study aimed to define the sociodemographic characteristics of adolescent mothers in Turkey as well as to compare their traumatic childhood experiences and their depression and anxiety levels with those of adult mothers. Sixty-eight mothers participated in this cross-sectional study. The frequency of traumatic childhood experiences and the severity of depression and anxiety symptoms among the adolescent mothers were found to be significantly lower than among the adult mothers, except for emotional neglect. The severity of anxiety symptoms was found to be significantly higher in those adolescent mothers who did not intend to become pregnant and who live with their own family or in institutional care than in those who live with their partner and/or his family. This is the first study to evaluate the traumatic childhood experiences of adolescent mothers in Turkey. Further, this cross-sectional study demonstrates that the initial psychiatric assessment of adolescent mothers who intended to become pregnant might reflect their level of psychiatric wellbeing. It is clear that additional policies concerning the prevention of adolescent pregnancy and the follow-up of adolescent mothers need to be developed in Turkey.

Associations of reproductive coercion and intimate partner violence with overt and covert family planning use among married adolescent girls in Niger

BACKGROUND

In Niger the prevalence of girl child marriage and low female control over family planning (FP) has resulted in the world's highest adolescent fertility. Male control of FP is associated with intimate partner violence (IPV) and reproductive coercion (RC). We assessed associations of IPV and RC with FP use among married adolescent girls (ages 13-19 years) in Dosso, Niger (N = 1072).

METHODS

Multivariable, cross-sectional regression models assessed associations between physical IPV, sexual IPV, and RC and any FP use, FP use with husband knowledge (overt use), and FP use without husband knowledge (covert use).

FINDINGS

One in four married adolescent girls using FP reported doing so without husband's knowledge. Unadjusted and adjusted models indicated that physical IPV and RC were associated with covert FP use (vs. no use and vs. overt use), but not with overt use vs. no use. Only physical IPV remained significantly associated with covert use in models including all three forms of violence (AOR: 1.94 vs. any use; AOR: 3.63 vs. overt use).

INTERPRETATION

Married adolescents experiencing physical IPV or RC were more likely that others to use FP without their husbands' knowledge. No form of GBV affected odds of FP use with husbands' knowledge. Current results suggest caution regarding promoting engagement of men in decisions to use FP in this context, as this may undermine the reproductive autonomy of girls and women who will choose to use FP without the knowledge of their male partners.

Improved child marriage laws and its association with changing attitudes and experiences of intimate partner violence: a comparative multi-national study

Background

Intimate partner violence (IPV) is a multi-national problem with many health consequences. Some research suggests that reducing rates of child marriage can improve gender norms and health outcomes related to IPV. Here, we examine whether changes in national child marriage laws can improve attitudes about domestic violence and reduce intimate partner violence at scale.

Methods

Data on attitudes towards violence and violence experienced were obtained from the Demographic and Health Surveys (DHS) and longitudinal data on child marriage policy from WORLD and MACHEquity databases (1995-2012). Treatment countries were included if they improved their national child marriage policies from harmful (under 18) to more protective and control countries were included if they had a constant child-marriage policy that allowed girls to marry under the age of 18. Our final data set included 5 treatment and 14 control countries for women’s outcomes, 2 treatment and 9 control countries for men’s outcomes and 2 treatment and 7 control countries for IPV outcomes (for which fewer countries collect data). We combined individual level responses to five questions on attitudes about domestic violence to create a scale from 0 (always unacceptable) to 5 (always acceptable). All analyses employed a difference-in-differences approach adjusting for individual and country level predictors.

Results

Data were available for 532 255 women, of which 96 414 also completed the domestic violence modules, and 104 704 men. National changes to a protective child marriage policy were associated with improved attitudes towards violence among women (-0.21 points, 95% confidence interval (CI) = -0.28, -0.14) and men (-0.98 points, 95% CI = -1.13, -0.83). Additionally, the risk of women experiencing physical and sexual abuse reduced by a greater proportion in treatment compared to control countries (odds ratio OR = 0.65, 95% CI = 0.50, 0.84; OR = 0.63, 95% CI = 0.45, 0.88, respectively).

Conclusions

Our large multi-national study is the first of its kind to critically evaluate the role of national policy on attitudes towards and experiences of IPV among both men and women, and finds that these laws have protective outcomes. Our results are consistent with the hypothesis that gender egalitarian laws positively influence norms and health at the national level.

Displacement-related factors influencing marital practices and associated intimate partner violence risk among Somali refugees in Dollo Ado, Ethiopia: a qualitative study

Background

Child and forced marriage have negative health consequences including increased risk of intimate partner violence (IPV) for women and girls. War and humanitarian crises may impact decision-making around marriage and risks of IPV for displaced populations. A qualitative study was conducted among Somali refugees in Dollo Ado, Ethiopia to understand the interplay of factors that contribute to IPV and to inform an intervention. This secondary analysis aims to explore the influence of displacement on marital practices and associated IPV risk.

Methods

Interviews and focus group discussions were conducted in 2016 in Dollo Ado, Ethiopia, among Somali women and men living in Bokolmayo refugee camp, host community members, non-governmental staff and service providers, stakeholders, and community and religious leaders (N = 110). Data were transcribed, translated to English, and coded and analyzed thematically using Dedoose software and a codebook developed a priori.

Results

Findings reveal numerous displacement-related factors that led to perceived shifts in marital practices among refugees, including reductions in child and forced marriages. NGO awareness-raising programs and Ethiopian laws prohibiting child marriage as well as increased access to education for girls were reported to have contributed to these changes, despite continued economic hardship and high perceived risk of non-partner sexual violence within the camp and host community. Polygamy was also perceived to have decreased, primarily due to worsening economic conditions. Forced marriage, polygamy and dowry were reported to contribute to physical IPV, and sexual IPV was reported as common in all types of marital unions. However, there was no evidence that changes in these marital practices contributed to any perceived declines in IPV within this context.

Conclusion

Safe access to education for girls should be prioritized in humanitarian settings. Interventions to address child and forced marriage should address gender and social norms. Intimate partner violence prevention programming should include specialized content taking into account marital practices including child and forced marriage and polygamy. Laws recognizing sexual IPV within marital relationships are needed to reduce sexual IPV.

Child marriage in Canada: A systematic review

Child marriage, defined by the United Nations as marriage before the age of 18, is considered a violation of human rights with negative consequences for girls' health. We systematically reviewed existing academic literature and news media to learn what is known about the frequency of child marriage in Canada and its effects on health. Approximately 1% of 15-19-year-olds in Canada were married or in common law unions in 2016. News reports document cases of child marriage among religious minority communities but no nationwide estimates of the frequency of marriage before the age of 18 were identified. Sources consistently show girls are more likely to marry as teens than boys. Information on married teens between 15 and 19 years of age suggests similarities in marriage patterns among this age group in Canada and child marriage practices globally. Further research is needed to measure Canada's progress toward eliminating child marriage.