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Early Marriage and Sexual and Reproductive Health Vulnerabilities of Young Women: a Synthesis of Recent Evidence from Developing Countries K.G

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Early Marriage and Sexual and Reproductive Health Vulnerabilities of Young Women: a Synthesis of Recent Evidence from Developing Countries K.G Early marriage and sexual and reproductive health vulnerabilities of young women: a synthesis of recent evidence from developing countries K.G. Santhya Population Council, New Delhi, India Purpose of review Correspondence to K.G. Santhya, Associate, To review current evidence on the links between early marriage and health-related Population Council, Zone 5A, Ground Floor, India outcomes for young women and their children. Habitat Centre, Lodhi Road, New Delhi 110003, India Tel: +91 11 2464 2901/2902; Recent findings fax: +91 11 2464 2903; Every third young woman in the developing countries excluding China continues to e-mail: [email protected] marry as a child, that is before age 18. Recent studies reiterate the adverse health Current Opinion in Obstetrics and Gynecology consequences of early marriage among young women and their children even after a 2011, 23:334–339 host of confounding factors are controlled. The current evidence is conclusive with regard to many indicators: unintended pregnancy, pregnancy-related complications, preterm delivery, delivery of low birth weight babies, fetal mortality and violence within marriage. However, findings present a mixed picture with regard to many other indicators, the risk of HIV and the risk of neonatal, infant and early childhood mortality, for example. Summary The findings call for further examination of the health consequences of early marriage. What are even less clear are the pathways through which the associations between early marriage and adverse outcomes take place. There is a need for research that traces these links. At the same time, findings argue strongly for programmatic measures that delay marriage and recognize the special vulnerabilities of married adolescent girls. Keywords developing countries, early marriage, infant and child health, sexual and reproductive consequences, young women Curr Opin Obstet Gynecol 23:334–339 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-872X and sexual and reproductive health vulnerabilities of Introduction young women in developing countries. Although the prevalence of early marriage is declining, considerable proportions of young women continue to In this overview, I have gathered evidence from studies marry as children, that is before age 18 [1,2]. It is globally published primarily in the last 3 years on early marriage recognized that early marriage truncates girls’ childhood and its consequences. Most studies that have explored and circumscribes several rights of girl children outlined consequences of early marriage included in this review in the 1989 Convention on the Rights of the Child (CRC), are cross-sectional which raises concerns about inferring including the right not to be separated from their parents causality. I note, however, that early marriage occurred against their will (Article 9), the right to freedom of much before the outcomes assessed in these studies and, expression (including seeking and receiving information therefore, temporal ordering of events and causal influ- and ideas, Article 13), the right to education (Articles 28 ence of early marriage can be safely assumed. and 29), the right to rest and leisure and to engage in play and recreational activities (Article 31) and the right to protection from sexual exploitation and abuse Magnitude of early marriage (Article 34) [3]. Moreover, an increasing body of evidence The State of the World’s Children 2011 that focuses from diverse settings suggests that the long-held assump- on adolescence observes that every third young woman tion that marriage is a safe haven for adolescent girls is (20–24 year old) in the developing countries, excluding untenable and that a number of health consequences are China (data on the prevalence of early marriage are not associated with early marriage. This article synthesizes available for China; moreover, early marriages are rare in what is known about the links between early marriage China, for example data for the year 2000 indicate that 1040-872X ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/GCO.0b013e32834a93d2 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Sexual and reproductive health consequences of early marriage Santhya 335 just 1% of 15–19 year-old girls were ever married and that Key points the singulate mean age at marriage for women was 23.3 years), was married as a child [1]. Moreover, one in nine Every third young woman in the developing young women was married by age 15 [2]. These averages, countries excluding China continues to marry as a however, mask the huge variations within and between child, that is before age 18. regions across the world. For example, in south Asia and Early marriage is clearly correlated with a range of sub-Saharan Africa, 46 and 38% of young women, respec- adverse health consequences among young women and their children even after a host of confounding tively, were married as children; the proportion is as factors are controlled: unintended pregnancy, preg- high as 55 and 50% in the rural areas of these two regions, nancy-related complications, preterm delivery, fetal respectively [1]. In countries such as Bangladesh, Central mortality and violence within marriage. African Republic, Chad, Ethiopia, Guinea, Malawi, Mali, Findings are not conclusive about the association Mozambique, Nepal and Niger, one-half to three-quarters between early marriage and the risk of HIV and the of girls were married before their 18th birthday [2]. risk of neonatal, infant and early childhood mortality. Sexual and reproductive health marriage on a young woman’s ability to effectively prac- consequences tise contraception. For example, a number of studies in Studies reviewed in this article, by and large, indicate that India show that young women who married early were early marriage is associated with a range of adverse sexual less likely than their late-marrying counterparts to have and reproductive health outcomes for young women and used contraceptives to delay their first pregnancy [4,7]. poor health outcomes for children they bear. Findings, moreover, show that it compromises young women’s HIV ability to adopt health promoting practices and seek Studies exploring the links between early marriage and timely care. sexually transmitted infections have focused on young women’s risk of HIV; most of these studies were con- Unintended pregnancy ducted in sub-Saharan African countries. Evidence from Studies in a number of south Asian countries, including these studies presents a mixed picture with regard to the Bangladesh, India and Nepal, show a direct association links between early marriage and young women’s risk between early marriage and unintended pregnancy, irre- of HIV. spective of the measure of unintended pregnancy or the study sample used in the analysis. For example, a study of Studies that have compared the prevalence of HIV infec- married young women aged 20–24 years in India reports tion in married adolescents aged 15–19 years and their that young women married early were 1.7 times more sexually active unmarried counterparts in a number of likely than those married late to have experienced any sub-Saharan African countries – Kenya, Tanzania and unwanted pregnancy even after controlling for confound- Cameroon for example – suggest that married adolescent ing factors such as level of education, place of residence, girls have higher rates of HIV infection than do sexually household economic status and religion. They were, active unmarried girls [8]. It is argued that being married moreover, more than twice as likely to have experienced at a young age is associated with engaging in frequent multiple unwanted pregnancies [4]. Similarly, a study of unprotected sex, having older sexual partners and having married women of reproductive ages who were pregnant less exposure to sources of information, all of which at the time of the survey in Nepal reports that almost half increase married adolescent girls’ vulnerability. (46%) of women married below 16 years compared with one-third (36%) of those married at 16 years or later This assertion, however, has been questioned by several reported their current pregnancy as unintended; the recent studies. Using ecological data from 33 countries in association remained significant in the multivariate sub-Saharan Africa and individual-level data from Kenya analysis too [odds ratio (OR) 0.94] [5]. A study in and Ghana, a study found that a long period of premarital Bangladesh, likewise, reports that women who married sexual experience contributes to the spread of HIV (an below 18 years were somewhat more likely than their additional year of premarital sexual intercourse raised late-marrying counterparts to report the most recent birth HIV prevalence by 1.52%) and that the annual risk of during the 5 years preceding the interview as unintended; infection is significantly higher for exposure before than the association, however, did not assume statistical after first marriage (OR 1.21 vs. 1.11 in Kenya; 1.22 vs. significance in the multivariate analysis [6]. 1.08 in Ghana) [9]. The higher risk of HIV infection among sexually active never married women is attributed The exact pathways through which early marriage leads to a higher rate of partner change and higher infectivity of to unintended pregnancy need further study. However, a partners. Similar findings were observed in studies in primary explanation lies in the constraining effect of early Tanzania and Cameroon as well. For example, a study of Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 336 Adolescent and pediatric gynecology 3780 women attending antenatal clinics in Tanzania premature rupture of membrane, antepartum haemor- reports that the odds of infection increased by 10% rhage and postpartum haemorrhage (44 vs. 22%, respec- for each extra year spent sexually active before marriage tively); incidence of such conditions as eclampsia and [10]. Similarly, a study of women aged 20–24 years in preeclampsia was six times higher among adolescents Cameroon reports that women married at age 20 or later than adult women (20 vs.
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