thesis statement about child marriage

• Open access
• Published: 14 February 2022

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

• Suiqiong Fan 1 &
• Alissa Koski 1 , 2  

BMC Public Health volume  22 , Article number:  309 ( 2022 ) Cite this article

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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.

Peer Review reports

Introduction

Marriage before the age of 18, often referred to as child marriage, is a violation of human rights that hinders educational attainment and literacy and may increase the likelihood of living in poverty in adulthood [ 1 , 2 , 3 , 4 , 5 ]. Girls are far more likely to marry than boys, and these consequences contribute to existing gender gaps in educational outcomes in some settings [ 6 , 7 ]. The United Nations Sustainable Development Goals list child marriage as an indicator of gender inequality and call for an end to the practice by the year 2030 [ 8 ]. Child marriage remains ongoing throughout much of the world despite intensifying efforts to eliminate it [ 9 ].

In addition to its consequences on education, growing attention to child marriage as a global development issue also seems to reflect increasing consideration of its potential impacts on population health. Multinational organizations including the World Bank, the United Nations Population Fund (UNFPA), and the United Nations Children’s Fund (UNICEF) include the potential for harmful consequences on health among the foremost concerns regarding this practice [ 2 , 10 , 11 , 12 , 13 ]. These organizations highlight relationships between child marriage and early childbearing [ 11 , 12 , 13 ], obstetric complications [ 12 , 13 ], violence [ 2 , 12 ], and sexually transmitted infections [ 12 ], among other adverse outcomes.

We undertook this systematic review to synthesize the results of existing research regarding the impact of child marriage on the health of persons who marry before the age of 18. We evaluated the range of health outcomes that have been studied and the geographic distribution of those studies. We also assessed the risk of bias in individual studies and the likelihood that their results reflect causal relationships.

We searched three databases for literature on the relationship between child marriage and health: MEDLINE, Embase, and Ovid Global Health. These databases were chosen because they focus on biomedicine and human health. We aimed to include as broad a range of health outcomes as possible and focusing our search within these databases allowed us to avoid defining specific health outcomes within our search terms. Instead, we searched for studies of child marriage within these databases. This approach made our search terms more concise and the range of outcomes more inclusive. Specific search terms used for each database are included in Supplementary File 1 . We registered our protocol with PROSPERO (CRD42020182652) in May 2020 and conducted our database searches shortly afterward.

We also searched Google Scholar to identify relevant grey literature. Haddaway et al. [ 14 ] found that the majority of grey literature tends to appear within the first 200 citations returned by Google Scholar and recommend focusing on the first 200-300 records. We followed this recommendation and evaluated the first 300 records returned, as sorted by relevance. Search terms used in Google Scholar are also included in Supplementary File 1 . We reviewed the bibliographies of all included studies in an effort to identify any relevant citations not picked up through searches of the databases described above. The search strategy was developed with assistance from a research librarian at McGill University.

Citations returned from searches of all four databases were imported into EndNote X9 and duplicate citations removed [ 15 ]. We transferred all unique citations into Rayyan to facilitate the review process [ 16 ]. A single reviewer (SF) examined the title and abstract of each unique citation for eligibility according to pre-defined criteria specified in the registered protocol. Articles were brought forward for full-text review if they described etiologic studies that used quantitative methods to estimate the effect of child marriage on one or more health outcomes. We defined child marriage as formal or informal union prior to the age of 18. If the title and abstract did not specify the age thresholds used to define child marriage, they were brought forward for full-text review. For example, abstracts that referred to the effect of adolescent or teen marriage without explicitly stating how those exposures were defined were brought forward. Eligible health outcomes included physical or mental health disorders or symptoms of those disorders, as well as health behaviours. Eligible health behaviours included actions like smoking or dietary habits as well as health care seeking, such as prenatal care. We restricted our review to studies in which outcomes were measured at the individual level and to those that measured the effect of child marriage on the individuals married; studies that examined the effect of age at marriage on the offspring of the persons who married were excluded. Studies written in English, French or Chinese were eligible for inclusion.

We excluded studies that used solely qualitative methods and quantitative studies that relied exclusively on hypothesis testing to indicate differences between groups. For example, studies that used chi-squared tests to indicate whether the distribution of some characteristic differed between persons married before the age of 18 and those married at older ages were excluded, even if the authors seemed to interpret their results as causal, because such testing does not result in a comparative effect measure (e.g., a risk difference or an odds ratio) and does not account for potential biases. We also excluded studies in which persons who married before the age of 18 were incorporated into a larger aggregate age category, making the effect of child marriage unidentifiable. For example, comparisons of outcomes among persons who married between 15 and 19 years of age with those who married between 20 and 24 years of age were not eligible for inclusion. Conference presentations and abstracts were also excluded.

Both authors read the full text of each article brought forward from the title and abstract review and independently judged their eligibility according to the inclusion and exclusion criteria described above. Discrepancies were resolved through discussion. The following information was extracted from each included study: authors, title, year of publication, the language of publication, country/region in which the study was conducted, study design, study population, sample size, data sources, statistical methods, outcomes, and results.

Risk of bias assessment

We assessed the risk of bias within each included study using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool developed by members of the Cochrane Bias Methods Group and the Cochrane Non-Randomised Studies Methods Group [ 17 ]. ROBINS-I is designed to evaluate the risk of bias in non-randomized studies by considering how closely the study’s design and methods approximate an ideal randomized trial. To illustrate, in a hypothetical cluster-randomized trial to estimate the causal effect of child marriage on a specified health outcome, the treatment or intervention would be marriage before the age of 18 years. All children in a specific area (a region, a state, a community, etc.) would be randomized at a very young age to one of two treatment groups: those randomized to the intervention would marry at some point prior to their 18th birthdays (a = 1), while those randomized to the control group would marry on their 18th birthday or any later age (a = 0). All children would then be followed up over a period of time sufficient to observe the specified outcome of interest. In the ideal randomized trial, all persons would adhere to their assigned treatment (i.e., remain married) and would remain in the study until follow-up was complete. After the follow-up period, the probability of the outcome among those assigned to a = 1 would be compared with the same probability among those assigned to a = 0. Under these conditions, we could expect that there would be no differences between those children who married before the age of 18 and those who married afterward aside from age at marriage. As a result, if the probability of the outcome among those randomly assigned to marry as children differed from the probability among those randomly assigned to marry after their 18th birthdays, one could interpret that difference as the causal effect of child marriage [ 18 ].

Of course, a randomized trial like this would be unethical and could never actually be conducted. Researchers interested in the effects of child marriage on health must rely on non-randomized study designs to estimate the causal effect of interest. Without the benefit of randomization, it becomes challenging to identify the causal effect of child marriage because those who marry as children are different from those who marry at later ages in many ways. For example, girls who marry before the age of 18 come from poorer households and from communities with greater gender inequality, on average, compared to those who marry at later ages. These differences are likely to affect their health through causal pathways other than age at marriage, such as the experience of violence or limited ability to access education or health care. This means that a naïve comparison of health outcomes between those who marry as children and those who marry as adults is likely to mix up the consequences of age at marriage with the consequences of childhood poverty and gender inequality.

The ROBINS-I tool requires assessors to carefully consider the potential for multiple sources of bias including confounding, inappropriate selection of participants into the study (i.e., selection bias), mishandling of missing data, and problems with the measurement of exposures and outcomes (i.e., information bias). The potential for bias in each domain is assessed through a series of signaling questions and a summary judgement of low, moderate, serious, or critical risk of bias is then made within each domain. A cross-domain judgement of the risk of bias for the entire study is made based on the risk within each individual domain. Both authors independently assessed the risk of bias in each included study. Disagreements in any single domain or across domains were resolved by discussion.

We identified a set of variables likely to confound estimates of the effect of child marriage on a wide range of health outcomes in advance to facilitate assessment of bias in this domain. These variables and their relationships to child marriage and health, broadly defined, are illustrated in the simplified Directed Acyclic Graph (DAG) in Fig.  1 . The prevalence of child marriage has fallen over time in many countries, which means that the likelihood of marrying before the age of 18 differs across birth cohorts [ 6 , 19 ]. As discussed above, childhood socioeconomic conditions and gender inequality may lead to child marriage. They may also influence health later in life through a variety of causal pathways. We also considered spousal characteristics a source of confounding because the presence of an available spouse may drive child marriage. For example, a potential husband willing to pay a bride price for a young wife may motivate a family to marry a girl child. The same characteristics of the spouse that may motivate the marriage, such as his age, wealth, and attitudes regarding gender equity, may influence the married child’s health later in life through mechanisms like controlling behaviour. In studies that use pooled data from across multiple regions or countries, it is also important to control for confounding by country/regional-level variables that affect both the probability of child marriage and health. The DAG also illustrates our assumption that the effects of child marriage on health are often mediated through educational attainment and socioeconomic conditions after marriage.

Directed acyclic graph illustrating assumed causal relationships between child marriage and a wide range of health outcomes

We synthesized results narratively. Included studies considered a wide range of health outcomes, as intended given our search strategy. We found it most intuitive and pragmatic to synthesize results within broad outcome categories, such as the effects of child marriage on contraceptive use, on maternal health care, and on mental health. These categories emerged from the data and were not pre-specified. Meta-analyses were not conducted because the studies examined a wide range of health outcomes that were measured in different ways. The serious risk of bias in all included studies, discussed below, also made quantitative synthesis inappropriate.

Our search strategy returned a total of 2767 unique records from MEDLINE, Embase, Ovid Global Health and Google Scholar, as shown in Fig.  2 . After title and abstracting screening, the full text of 126 articles was reviewed. Fifty-six of these studies met our inclusion criteria and two additional eligible studies were identified through citation tracking, for a total of 58 included articles.

PRISMA flow diagram illustrating the process used to identify eligible studies

Selected characteristics of all 58 studies included in our review are presented in Table  1 . These studies were published between 1989 and 2020 but the vast majority ( n  = 55, 95%) were published in 2010 or later and more than half ( n  = 31, 53%) were published between 2016 and 2020, which reflects the relatively recent rise of child marriage on global health and development agendas. Included studies were based in 70 countries across the globe, as illustrated in Fig.  3 . Nearly all studies, 57 of 58, were based in low- and middle-income countries according to World Bank classifications [ 20 ]; the single exception was a study based in the United States [ 21 ]. The geographic distribution of studies included in our review was heavily focused in South Asia ( n  = 30, 52%) and Sub-Saharan Africa ( n  = 27, 47%), which is perhaps unsurprising given that countries in these regions have some of the highest rates of child marriage in the world [ 9 ]. However, more than half of the studies included in our review were based in just three countries: India ( n  = 13), Bangladesh ( n  = 8) and Ethiopia ( n  = 11). Studies from regions other than South Asia or Sub-Saharan Africa were nearly all included in a handful of studies that analyzed survey data from multiple countries simultaneously [ 22 , 23 , 24 ].

Nearly all included studies, 55 of 58 (95%), were based on the analysis of cross-sectional survey data. More than half ( n  = 34, 59%) relied on data from a single source, the Demographic and Health Surveys (DHS), or their precursor, the World Fertility Surveys (WFS).

Geographic distribution of included studies

Bias assessment

All studies included in our review were determined to be at serious or critical risk of bias based on assessment using ROBINS-I. The summary risk of bias assessment for each study is listed in Table  1 ; risk of bias within each ROBINS-I domain in each study is detailed in Supplementary File 2 . Confounding was the most prevalent concern. Every study was deemed to be at serious to critical risk of bias in this domain, most often because of failure to account for important sources of confounding and inappropriate adjustment for variables affected by age at marriage that are on the causal pathway. Cross-sectional surveys like the DHS often do not collect information necessary to control for confounding. Failure to control for major sources of confounding like childhood poverty and gender inequality may result in overestimation of the harmful effects of child marriage. The second common source of bias was adjustment for variables measured after marriage that are likely on the causal pathway between age at marriage and the health outcomes being studied. To illustrate, the authors of many studies included in this review acknowledged that age at marriage may dictate how long a girl stays in school and that her educational attainment may subsequently influence a wide range of health outcomes. Unfortunately, they then adjusted for educational attainment in regression analyses. This will very likely result in biased estimates because educational attainment was measured after marriage and is more likely to be a mediator than a confounder (Fig.  1 ) [ 79 , 80 ]. Adjusting for it may remove some of the effect of child marriage on health and lead to underestimates of effect. Given that these two issues may bias results in different directions, predicting the net direction of confounding within studies is challenging. Other sources of bias also affected many of the studies in this review, including selection and measurement biases. Few authors discussed the potential influence of bias on their estimates or their conclusions.

The health consequences of child marriage

Studies included in our review estimated the effect of child marriage on a variety of health outcomes. The most common outcomes were measures of reproductive health, such as fertility and fertility control, maternal health care utilization, intimate partner violence, mental health, and nutritional status. The following paragraphs synthesize the literature in each of these categories. In light of the serious risk of bias in all included studies, we interpreted these results with a high degree of caution. We assessed the direction of effect measures, meaning whether the study found that child marriage increased or decreased the probability of experiencing the outcome, and the consistency of directionality across studies within each outcome category. We also assessed the precision of effect measures by evaluating the width of confidence intervals surrounding those measures. We did not interpret the magnitude of the effect estimates from individual studies due to the risk of bias.

The effect of child marriage on the number and timing of births

Eleven studies estimated the effect of child marriage on the number of children born, though this outcome was not consistently measured. Some studies estimated the effect of child marriage on the odds of having given birth to any children [ 34 , 50 , 63 ], the odds of having three or more children [ 24 , 46 , 50 , 63 , 75 ], four or more children [ 34 ], five or more children [ 37 , 69 ], or a continuous measure of the total number of children ever born [ 24 , 25 , 30 , 46 , 54 ]. The age ranges of the people included in these studies also differed, leading to variation in the time frame over which these births could have occurred. Child marriage was correlated with higher fertility in nearly all studies regardless of how the outcome was defined. The only exception was a study from Ethiopia that found no effect [ 30 ]. Ten of these studies focused on fertility exclusively among women. Misunas et al. [ 24 ] focused on men and came to similar conclusions: child marriage increased the odds that men aged 20-29 had fathered three or more children and increased the average number of children fathered by the ages of 40-49 [ 24 ].

A second commonly examined outcome was the likelihood of giving birth within the first year of marriage. Four studies based on data from South Asia [ 39 , 46 , 50 , 63 ] and one study based on pooled data from multiple countries in Africa [ 75 ] examined this outcome. Three of these studies [ 46 , 50 , 75 ] reported that marriage before the age of 18 decreased the odds of giving birth within the first year of marriage. The remaining two [ 39 , 63 ] did not find any evidence of a relationship between child marriage and this outcome.

We also identified five studies that estimated the effect of child marriage on the likelihood of giving birth before a specified age, often referred to as early, teen, or adolescent pregnancy [ 23 , 26 , 31 , 32 , 34 ]. Three of these studies found that child marriage increased the odds of giving birth before the age of 20 [ 26 , 31 , 32 ], the other two reported that child marriage increased the odds of giving birth before the age of 18 [ 23 , 34 ]. Two studies also estimated the effect of child marriage on mean age at first birth and found that those who married before the age of 18 gave birth for the first time at younger ages, on average, than those who married at older ages [ 32 , 46 ].

Collectively, this evidence indicates that women who marry as children often begin having children of their own at earlier ages when compared to their peers who marry after their 18th birthdays, and that they tend to have a larger number of children over their lifetimes. This is not surprising, given that marriage changes sexual behavior in ways that increase the risk of pregnancy. Essentially, girls who marry at earlier ages spend a longer time at risk of pregnancy than those who marry later.

The effect of child marriage on birth intervals

The World Health Organization recommends an interval of at least 24 months between a live birth and a subsequent pregnancy to reduce the risk of poor maternal health outcomes [ 81 ]. Five studies included in our review estimated the effect of child marriage on the likelihood of repeated childbirths in less than two years [ 39 , 50 , 62 , 63 , 75 ]. All five used samples of women between the ages of 20 and 24 who were included in DHS. A sixth study based on a small cross-sectional sample of women aged 15-49 from Ethiopia estimated the effect on repeated childbirth in less than three years [ 27 ]. These studies came to different conclusions. Two studies by the same author reported that child marriage increased the odds of repeated childbirth within two years in India [ 62 , 63 ] but another study based on the same data source found that women who married as children were less likely to have two births within a two-year period than those who married at older ages [ 39 ]. There were also differences in the results of research from Pakistan: one study reported that child marriage made it more likely that women would have two births within two years [ 50 ] while another found no evidence that child marriage influenced this outcome [ 39 ]. Child marriage protected against short birth intervals in Nepal [ 39 ] and in an analysis of data from 34 African countries [ 75 ]. There was no evidence that child marriage influence the likelihood of short birth intervals in Bangladesh [ 39 ].

These results, which range from harmful to protective effects, indicate that child marriage is not clearly or consistently correlated with short birth intervals.

Child marriage, unwanted or mistimed pregnancy, and pregnancy termination

Seven studies estimated the effect of child marriage on the likelihood of experiencing a mistimed or unwanted pregnancy [ 39 , 46 , 47 , 50 , 62 , 63 , 75 ]. All seven were based on analyses of DHS data. The DHS typically asks women whether pregnancies were wanted at the time they occurred, wanted later (i.e., mistimed), or not wanted. Interestingly, six of the seven studies that examined this outcome reduced these categorical responses into a binary measure: women were categorized as having an unwanted pregnancy if they reported that they had a mistimed pregnancy or if they became pregnant when they did not want any more children [ 39 , 46 , 50 , 62 , 63 , 75 ]. The rationale for doing this was not explained in any of the studies. The remaining study [ 47 ] only categorized instances in which a woman became pregnant at a time when she did not want any more children as unwanted.

Estimates of the effect of child marriage on this outcome are mixed. A study from 34 countries in Africa reported that child marriage protected against mistimed/unwanted pregnancies [ 75 ]. Studies from India, Pakistan, and Nepal concluded that child marriage increased the odds of experiencing mistimed/unwanted pregnancy [ 39 , 50 ]. Three studies from Bangladesh came to different conclusions. One found no relationship between child marriage and this outcome [ 39 ] while another reported that child marriage increased the odds of mistimed/unwanted pregnancy [ 46 ]. The third used a different definition of the outcome and found that marriage before the age of 15 was positively associated with unwanted pregnancy (mistimed pregnancies were treated as wanted) but no evidence that marriage between the ages of 15 and 17 affected the likelihood of unwanted pregnancy [ 47 ].

Three of these studies also estimated the effect of child marriage on the likelihood of experiencing two or more mistimed or unwanted pregnancies [ 39 , 62 , 63 ]. Godha et al. reported a large effect of child marriage on having multiple mistimed/unwanted pregnancies in India, Bangladesh, and Pakistan but results were inconclusive in Nepal [ 39 ]. Two studies by the same author reported that child marriage increased the odds of having multiple mistimed/unwanted pregnancies in India [ 62 , 63 ].

We identified eight studies of the effect of child marriage on pregnancy outcomes [ 39 , 47 , 48 , 50 , 57 , 63 , 66 , 75 ]. Six of these relied on the DHS, which typically asks female respondents, “Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?” [ 82 ]. The wording of this question makes it impossible to examine these outcomes separately. As a result, most studies based on the DHS used a composite outcome that grouped these three events despite differences in their intendedness. Five studies based on the DHS concluded that child marriage increased the odds of having a pregnancy end in either miscarriage, abortion, or stillbirth [ 39 , 48 , 50 , 63 , 75 ]. Exceptionally, the 2007 Bangladesh DHS asked a yes or no question regarding whether a woman had ever terminated a pregnancy. Using responses to this question, Kamal reported that marriage before the age of 15 was correlated with higher odds of termination but no evidence that marriage between 15 and 17 years of age influenced this outcome [ 47 ].

Two studies from India used other cross-sectional data sources and defined their outcomes differently. Santhya et al. used a combined outcome of miscarriage and stillbirth and found that child marriage increased the likelihood of experiencing either of these birth outcomes. [ 66 ]. Paul considered stillbirth and miscarriage separately. Marriage before the age of 15 increased the odds of stillbirth and miscarriage, but marriage between the ages of 15-17 was no less risky in this regard than marriage at 18 or later [ 57 ].

Child marriage and contraceptive use

Fifteen of the studies included in our review estimated the effect of child marriage on various aspects of contraceptive use [ 23 , 24 , 32 , 39 , 40 , 41 , 43 , 46 , 53 , 56 , 62 , 63 , 65 , 66 , 75 ]. All were based on cross-sectional data and thirteen used data from the DHS.

Of these fifteen studies, eight estimated the effect of child marriage on the likelihood that women were using contraception at the time the surveys were conducted [ 32 , 39 , 40 , 46 , 53 , 62 , 63 , 65 ]. As with other outcomes, results were mixed. Child marriage reportedly increased the likelihood of using modern contraception in India and Bangladesh [ 39 ]. Results from Pakistan and Nepal indicate that the same may be true in those countries but the estimates were imprecise [ 39 ]. A second study from Nepal concluded that child marriage led to lower odds of using modern contraception [ 65 ]. The two studies from Nepal used different samples of women, which may partially explain the differences in their results. A study based on pooled data from 18 African countries found that child marriage was correlated with a lower likelihood of using modern contraception [ 53 ]. However, results varied markedly between countries and across geographic regions; in some, child marriage appeared to increase the likelihood of using modern contraception [ 53 ]. In Ghana, de Groot et al. found that child marriage was not correlated with the odds of using any form of contraception or with the use of modern contraceptives [ 32 ].

Two other studies investigated the effect of child marriage on the use of any method of contraception, including those not classified as modern [ 40 , 46 ]. Marriage prior to the age of 15 led to lower odds of contraceptive use in Rwanda, but there was no indication that those who married between 15 and 17 years of age were any more or less likely to use contraception than those who married at older ages [ 40 ]. In Bangladesh, women who married as children were more likely to be using some form of contraception at the time of the survey than those who married at the age of 18 or older [ 46 ]. In yet another iteration of this outcome, Yaya [ 75 ] reported that women who married as children were more likely to have ever used modern contraception. A single study estimated the effect of child marriage among men on the likelihood that they were using modern contraception [ 24 ]. In five of ten countries studied, child marriage was not related to modern contraceptive use. In two (Honduras and Nepal), child marriage seemed to slightly increase the odds of contraceptive use, but it decreased the likelihood in Madagascar [ 24 ].

A second outcome that has received particular focus is whether a woman used contraception before her first pregnancy. All four studies that examined the effect of child marriage on this outcome were based on data from South Asia [ 39 , 56 , 63 , 66 ] and concluded that marrying as a child decreased the likelihood that a woman used contraception prior to her first pregnancy [ 39 , 56 , 63 , 66 ]. The authors of these studies frequently interpreted their results as an indicator of uncontrolled fertility that may place girls and their children at risk of poor health outcomes [ 39 , 56 , 63 ]. However, this relationship is more challenging to interpret because the outcome variables used did not capture whether pregnancies were desired shortly after marriage or the outcomes of those pregnancies.

Four studies estimated the impact of child marriage on the likelihood that a woman had an unmet need for contraception [ 23 , 32 , 41 , 43 ]. This outcome was conceptually defined as a woman who is sexually active but not using contraception and who reports a desire to delay the next birth (a need for spacing), have no more births (a need for limiting), or a combination of the two. Once again, conclusions differ between studies. Using pooled DHS data from 47 countries, Kidman and Heymann found that marrying as a child increased the likelihood that women had an unmet need for contraception to either space or limit births [ 23 ]. An analysis of DHS data from Ethiopia found that women who married as children were less likely to have an unmet need for spacing and less likely to have an unmet need for limiting births compared to women who married at older ages [ 41 ]. In Zambia, child marriage was correlated with a greater unmet need for spacing and for limiting [ 43 ]. In Ghana, de Groot et al. found that child marriage was not correlated with an unmet need for limiting [ 32 ]. These studies all used different samples, which may partially explain the differences in their results.

Child marriage and use of maternal health care

Nine of the studies included in our review estimated the effect of child marriage on the use of health care during pregnancy, at the time of delivery, and during the post-partum period, which we collectively refer to as maternal health care [ 33 , 39 , 49 , 53 , 58 , 62 , 66 , 67 , 74 ].

Studies of prenatal care defined their outcomes as the receipt of at least one prenatal checkup [ 49 , 62 ], the receipt of four or more prenatal checkups [ 49 , 58 , 67 ], or a count of the total number of prenatal checkups received [ 39 , 53 ]. Once again, results within countries come to different conclusions. In Nepal, one study found that women who married as children were less likely to receive four or more prenatal checkups [ 67 ] while another found no evidence that child marriage influenced this outcome [ 39 ]. A study from India found no indication that child marriage affected prenatal care [ 39 ] but two others concluded that child marriage decreased the likelihood of receiving at least one checkup and of receiving at least four checkups [ 58 , 62 ]. In one study from Pakistan, women who married as children were less likely to receive any prenatal care than those who married at older ages, but there was no difference in the likelihood of receiving four or more checkups [ 49 ]. A separate study from the same country reported that child marriage had no effect on the number of prenatal care checkups [ 39 ]. The effect of child marriage on the number of prenatal care visits varied between geographic regions in Africa. In some, child marriage appeared correlated with a decrease the number of visits while in others there was no effect [ 53 ].

Compared to other outcomes, the results of studies that estimated the impact of child marriage on the likelihood of delivering in a health care facility were remarkably consistent. Across geographic locations, all seven studies that examined this outcome concluded that child marriage reduced the likelihood of delivery in a health care facility [ 39 , 49 , 53 , 58 , 66 , 67 , 74 ]. Six of the same studies also found that women who married as children were less likely to have a skilled health care provider present during delivery [ 39 , 49 , 53 , 58 , 67 , 74 ].

Only two studies considered post-natal care [ 58 , 67 ]. One reported that child marriage led to lower likelihood of a post-natal checkup within 42 days of delivery in India [ 66 ] while the other found a lower likelihood of a checkup within 24 h of delivery in Nepal [ 75 ].

Child marriage and intimate partner violence

Sixteen studies estimated the effect of child marriage on the likelihood of experiencing intimate partner violence [ 22 , 23 , 29 , 35 , 38 , 42 , 51 , 53 , 55 , 60 , 62 , 64 , 66 , 70 , 71 , 77 ]. Fifteen of these studies were based on cross-sectional data [ 22 , 23 , 29 , 35 , 38 , 42 , 51 , 53 , 55 , 60 , 62 , 64 , 66 , 70 , 71 ] and eight (50%) were based on the DHS [ 22 , 23 , 51 , 53 , 60 , 62 , 64 , 70 ]. The DHS measures intimate partner violence by asking female respondents a series of questions regarding their experience of specific acts. For example, physical violence is assessed by asking women whether they have been slapped, kicked, or pushed, among other actions. Sexual violence is assessed by asking whether the respondent’s husband has forced her to have sex or perform sex acts when she did not want to. Emotional violence is measured by asking whether her spouse has humiliated or threatened her [ 83 ]. Studies based on data from sources other than the DHS tended to use the same or very similar questions to measure the experience of violence.

Physical violence was the most frequently examined outcome but was measured over different time frames across studies. Some estimated the likelihood of ever having experienced physical violence from a husband or partner while others considered only the year prior to the survey. Still, others focused on the 3 months prior to the survey [ 35 ], the 9 months between survey waves [ 77 ], or during pregnancy [ 38 ]. Regardless of the time period during which violence was measured, the conclusions of these studies were fairly consistent: nearly all reported that marrying as a child increased the likelihood of experiencing physical violence [ 22 , 38 , 51 , 55 , 60 , 64 , 66 , 71 , 77 ]. A study from Ethiopia found no indication that child marriage had an effect on this outcome but it considered a relatively short time period of 3 months [ 35 ].

Estimates of the effect of child marriage on the experience of sexual violence were much less consistent. Two studies from India came to conflicting conclusions. Raj et al. found that child marriage did not increase the likelihood of experiencing sexual violence at any point or in the year prior to the 2005-06 National Family Health Survey [ 64 ]. However, a study by Santhya et al. based on survey data collected from five Indian states between 2006 and 2008 found that child marriage did increase the likelihood of ever experiencing sexual violence [ 66 ]. Studies from Bangladesh and Ghana reported that women who married as children were no more or less likely to experience sexual violence than those who married at later ages [ 60 , 71 ]. Two studies that pooled DHS data across multiple countries also found mixed results [ 22 , 53 ]. Olamijuwon used data from 18 African countries and found that child marriage increased the odds of experiencing sexual violence in Central, East, and Southern Africa, but there was no evidence of a statistical relationship in West Africa [ 53 ]. Kidman used DHS data from 34 countries across the globe and reported that child marriage seemed to increase the odds of experiencing sexual violence in the year prior to the surveys in all included geographic regions except Europe and Central Asia [ 22 ]. Erulkar found that women who married as children in Ethiopia were more likely to report that their first sexual experience was forced [ 35 ].

Only two studies, one from Pakistan and one from Ghana, considered emotional violence as a stand-alone outcome. Both concluded the child marriage led to an increase in the likelihood of ever experiencing emotional violence from an intimate partner [ 51 , 71 ].

Five studies considered only combined outcomes that mixed indicators of physical and sexual violence [ 62 , 70 ], or physical, sexual, and emotional violence [ 23 , 29 , 42 ]. All of these found that child marriage was associated with increased reporting of these composite measures of violence, but some results were sensitive to the sample used and were inconsistent across locations [ 70 ]. Hong Le et al. considered whether child marriage affected the likelihood of violence among boys but was underpowered to detect any effect [ 42 ].

Child marriage and mental health

Five of the studies included in our review estimated the effect of child marriage on various aspects of mental health. These studies relied on cross-sectional data collected from Ghana, Iran, Ethiopia, Niger and the United States [ 21 , 32 , 36 , 44 , 45 ]. Women in the United States who married before the age of 18 were more likely to report experiencing a wide range of mood, anxiety, and other psychiatric disorders in adulthood when compared to those who married at later ages [ 21 ]. The authors of a small study from a single county in Iran found that women who married as children reported more depressive symptoms than those who married at the age of 18 or older [ 36 ]. John, Edmeades, and Murithi examined the relationship between child marriage and multiple domains of psychological well-being in Niger and Ethiopia [ 44 ]. The authors found that marriage before the age of 16 was correlated with poorer overall psychological well-being, but no evidence that marriage between the ages of 16 and 17 was associated with poorer outcomes when compared to women who married at the age of 18 or later [ 44 ]. In Ghana, child marriage seemed to protect against measures of stress. The Ghanaian study also found no indication of differences in levels of social support between women who married before the age of 18 and those who married after their 18th birthdays, though these odds ratio estimates were very imprecise [ 32 ].

Child marriage and nutritional status

Six studies included in our review estimated the effect of child marriage on indicators of nutritional status [ 28 , 34 , 52 , 61 , 76 , 78 ]. Four focused exclusively on pregnant women. Two studies from Ethiopia examined the relationship between child marriage and mid-upper arm circumference (MUAC) [ 52 , 76 ]. One reported that pregnant women who married before the age of 18 were more likely to have an MUAC less than 22 cm, often interpreted as a marker of undernutrition [ 84 , 85 ], compared to those who married later on [ 52 ]. The other found that marrying before the age of 15 increased the likelihood of MUAC <22 cm but no evidence that marrying between the ages of 15 and 17 affected this outcome [ 76 ]. A third study from Ethiopia reported that child marriage led to an increase in the prevalence of Vitamin A deficiency among pregnant or recently post-partum women [ 28 ].

Two other studies focused on women who were not pregnant and used body mass index (BMI) as the indicator of nutritional status [ 34 , 78 ]. Their results diverge. Yusuf et al. found that women in Nigeria who married as children were more likely to have a BMI less than 18.5, frequently interpreted as underweight among adults. However, in a study of 35 African countries, Efevbera et al. reported that child marriage was protective against being underweight (BMI<18.5) [ 44 ]. Interestingly, the authors of these studies offered plausible explanations for effects in either direction. Efevbera et al. hypothesize that girls who marry as children may gain access to more plentiful food at an earlier age and that repeated pregnancies during adolescence might result in greater weight gain relative to those who marry at later ages [ 34 ]. In contrast, Nigatu et al. note that repeat pregnancies in quick succession may have a detrimental impact on cumulative nutritional status [ 52 ]. This suggests that the mechanisms through which age at marriage may affect subsequent nutritional status have not been thoroughly considered.

Other health consequences of child marriage

A few of the studies included in our review examined outcomes other than those discussed above. We note them briefly here. A case-control study from India reported that women diagnosed with cervical cancer were more likely to have been married before the age of 18 [ 72 ]. A large, pooled analysis of DHS data from 47 countries reported that child marriage was associated with symptoms of sexually transmitted infections [ 23 ]. A small, cross-sectional study from a single Indian state found no evidence that child marriage led to an increase in the odds of obstetric fistula [ 68 ]. A third study from India examined the effect of child marriage on the odds of experiencing at least one complication during pregnancy, delivery, or within two months after delivery [ 57 ]. Marriage before the age of 15 seemed to increase the likelihood of pregnancy complications, but there was no evidence of an effect for marriage between 15 and 17 years. Child marriage was not associated with delivery complications, but was associated with postnatal complications [ 57 ]. A study from Ghana found no indication that child marriage influenced the likelihood of self-reported poor health, of being ill in the two weeks prior to the survey, or of having a health insurance card but did report that child marriage increased the odds of having difficulty with activities of daily living, such as bending or walking [ 32 ].

Our systematic review synthesized research on the health consequences of marrying before the age of 18. Studies almost uniformly found that women who married before the age of 18 began having children of their own at earlier ages and gave birth to more children over the course of their reproductive lives when compared to those who married at the age of 18 or later. Whether these outcomes, considered alone, are harmful to health is not clear. Though there are many reasons to be concerned about adolescent childbearing, none of the studies of the effect of child marriage on the timing of births considered whether those pregnancies were planned or desired or whether they resulted in obstetric complications or maternal morbidity or mortality [ 23 , 26 , 31 , 32 , 34 , 39 , 46 , 50 , 63 , 75 ]. Similarly, having multiple births, especially at short intervals, may increase the risk of obstetric complications and subsequent morbidity or mortality. However, studies that compared the number of children born to women who married before the age of 18 with the number born to those who married at later ages also did not measure whether those pregnancies were planned or whether they led to harm [ 24 , 25 , 30 , 34 , 37 , 46 , 50 , 54 , 63 , 69 , 75 ]. Rather, studies seemed to assume that these are negative outcomes without directly measuring intentions or harms.

A separate set of studies that estimated the effect of child marriage on the experience of mistimed or unwanted pregnancies came to divergent conclusions: some found that child marriage increased the likelihood of these outcomes but others found that child marriage protected against them or had no effect. Studies of whether child marriage affected the likelihood of obstetric complications, miscarriage or stillbirth did not consider maternal age when those events occurred [ 39 , 47 , 48 , 50 , 57 , 63 , 66 , 75 ]. Moreover, the fact that child marriage corresponds with a larger number of pregnancies means that girls who married prior to the age of 18 had more opportunities to experience these events compared to those who married later; this was not discussed in any of the studies we identified.

The results of studies in other outcome domains are very mixed and challenge some common narratives regarding child marriage. To illustrate, studies included in this review came to conflicting conclusions regarding whether child marriage increases or decreases the use of modern contraception, the likelihood of giving birth within the first year of marriage, and the likelihood of repeated childbirth within two years. Conclusions regarding mistimed and unwanted pregnancies were also mixed, as noted above. Collectively, these results suggest that child marriage is not uniformly characterized by an inability to control the number or timing of births and suggests that a more cautious approach to discussions of agency within these marriages is warranted, at least regarding fertility and fertility control.

Across studies, women who married as children were less likely to give birth in a health care facility or with assistance from a skilled health care provider. These findings raise concerns about access to emergency obstetric care and subsequent birth outcomes for both mother and child. However, we found only one study that estimated the effect of child marriage on the likelihood of complications during pregnancy, delivery, and the postpartum period [ 57 ] and consideration of the consequences for the infants born was beyond the scope of this review. This statistical relationship could be confounded by lack of access due to geographic distance. Child marriage is more common in rural areas, where health care facilities and skilled health care providers may be more spread out. It may also be a function of gender inequality, which may manifest as an inability to seek care without permission. Future research should consider the potential for confounding by these and other variables and investigate whether place modifies this relationship.

Child marriage could plausibly affect many aspects of maternal and reproductive health through complex causal pathways. However, most of the studies included in our review did not discuss causal mechanisms in detail, which may have hindered their ability to identify and account for various sources of bias. More thorough consideration and discussion of these mechanisms would strengthen the theoretical underpinnings of this body of literature and help mitigate biases. For example, use of Directed Acyclic Graphs to illustrate assumed causal relationships would help to clarify the causal pathways being studied and identify sources of bias [ 86 ].

The effects of child marriage among boys have been almost entirely overlooked. Only 2 of the 58 studies included in this review considered boys or men and one of them was underpowered to generate informative estimates [ 42 ]. This intense focus on child marriage among girls reflects the gendered nature of the practice. However, a substantial proportion of boys also marry before the age of 18 in some countries [ 7 , 24 ] and further inquiry into the health consequences among boys is warranted.

The geographic distribution of research on child marriage and health is highly skewed. The focus on South Asia and sub-Saharan Africa may be justified since these regions have some of the highest rates of child marriage in the world. However, it is unclear why just three countries, India, Bangladesh, and Ethiopia, have received such focused attention while other countries in these regions have received very little. Child marriage is certainly ongoing in many other regions of the world that have received little or no research attention, including high-income countries [ 9 , 87 , 88 ].

The geographic distribution of these studies and the range of outcomes considered is clearly reflective of heavy reliance on the DHS. The DHS is appealing because it collects information on age at marriage that is comparable across settings and over time, data are readily accessible and of high quality, and samples are typically nationally representative. However, defaulting to this data source may also have restricted the range of outcomes studied. The DHS focuses primarily on reproductive health and our review included many studies of the effect of child marriage on fertility, contraceptive use, and intimate partner violence. Far less attention has been paid to other potential harms of child marriage that are not included in the surveys, such as indicators of mental health. Importantly, the DHS does not collect information on some of the strongest confounders of many relationships between child marriage and health, including childhood socioeconomic conditions and measures of gender equality. Other data sources will be necessary to increase the geographic scope of this body of research and to overcome some of the limitations inherent in the use of cross-sectional data to estimate causal effects.

All studies included in our review were at serious to critical risk of bias. Quantification of the net magnitude of different biases on the results of each study would have made the project untenable. Considering pervasive bias, we avoided interpreting the magnitude of reported estimates from individual studies and instead took only the directionality of the estimates at face value. This allowed us to assess the (in)consistency of conclusions within domains of health. However, it is entirely possible that bias could lead to a reversal of effects, i.e., estimating a positive effect when the true effect is negative or vice versa. The bias in these studies means that it is unclear whether any of the relationships described are causal.

Nearly all studies included in our review relied on cross-sectional data. There are severe limitations to using cross-sectional research designs to estimate causal effects, and more rigorous designs are needed to further our understanding of the consequences of child marriage. Quasi-experimental designs that more effectively mitigate confounding would strengthen this body of literature and have already been used to study the effect of child marriage on educational attainment and literacy. For example, Field and Ambrus and Sunder used age at menarche as an instrumental variable to study the effect of child marriage on these outcomes [ 3 , 4 ]. Encouragement trials that randomly assign exposure to interventions meant to prevent child marriage could also be used to estimate the effects of child marriage on health outcomes, though such trials are more resource intensive to conduct [ 89 ]. However, given that the DHS and other cross-sectional data sources will likely continue to be used to investigate these relationships, the use of quantitative bias analyses to examine how sensitive estimates are to various sources of bias would be an improvement [ 90 ].

There are several limitations to this systematic review. First, to capture as wide a range of health outcomes as possible, we searched databases focused on human health and biomedicine. Relevant studies from other academic disciplines such as economics and sociology may have been missed using this approach. Second, our search was conducted in English and all included studies were published in English. Eligible studies published in other languages may have been missed, which could influence our conclusions regarding the geographic distribution of research. Finally, as noted in the introduction, child marriage may have consequences beyond the domain of health. We focused our systematic review on the health consequences of child marriage in response to growing rhetoric regarding child marriage as a population health concern. Rigorous systematic reviews of the effect of child marriage on educational and economic outcomes would be a valuable addition to the literature.

Availability of data and materials

The PROSPERO protocol and the data extraction form are publicly available through the Open Science Foundation at https://osf.io/32mu7/ .

Abbreviations

Body Mass Index

Cross-Sectional

Directed Acyclic Graph

Demographic and Health Surveys

Mid-Upper Arm Circumference

Risk Of Bias In Non-randomised Studies - of Interventions tool

Socio-Economic Status

United Nations Population Fund

United Nations Children’s Fund

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Acknowledgements

We thank Genevieve Gore at the McGill University Library for her assistance in developing the search terms used in this review.

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SF and AK were responsible for the study conception and design. SF conducted database searches. SF and AK screened eligible studies and extracted data from included studies. SF and AK conducted the analysis, interpreted the results, and collaboratively wrote the manuscript. SF prepared the tables and figures. AK supervised the study. The author(s) read and approved the final manuscript.

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Correspondence to Alissa Koski .

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Fan, S., Koski, A. The health consequences of child marriage: a systematic review of the evidence. BMC Public Health 22 , 309 (2022). https://doi.org/10.1186/s12889-022-12707-x

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Child Marriage: A Silent Health and Human Rights Issue

Marriages in which a child under the age of 18 years is involved occur worldwide, but are mainly seen in South Asia, Africa, and Latin America. A human rights violation, child marriage directly impacts girls’ education, health, psychologic well-being, and the health of their offspring. It increases the risk for depression, sexually transmitted infection, cervical cancer, malaria, obstetric fistulas, and maternal mortality. Their offspring are at an increased risk for premature birth and, subsequently, neonatal or infant death. The tradition, driven by poverty, is perpetuated to ensure girls’ financial futures and to reinforce social ties. One of the most effective methods of reducing child marriage and its health consequences is mandating that girls stay in school.

Child marriage, defined as marriage of a child under 18 years of age, is a silent and yet widespread practice. Today, over 60 million marriages include girls under the age of 18 years: approximately 31 million in South Asia, 14 million in sub-Saharan Africa, and 6.6 million in Latin America and the Caribbean ( Figure 1 ). Each day, 25,000 girls are married and an anticipated 100 million girls will be married in 2012. 1 Over 60% of girls are married under the age of 18 in some sub-Saharan countries and Bangladesh, and 40% to 60% of girls undergo child marriage in India ( Figure 2 ).

Number of women aged 20–24 who were married or in union before age 18, by region (2006). CEE/CIS, Central and Eastern Europe and the Commonwealth of Independent States. Reproduced with permission from United Nations Children’s Fund. Progress for Children: A World Fit for Children Statistical Review. New York: UNICEF; 2007. http://www.unicef.org/publications/files/Progress_for_Children_No_6_revised.pdf .

Percentage of women aged 20–24 who were married or in union before age 18 (1987–2006). Reproduced with permission from United Nations Children’s Fund. Progress for Children: A World Fit for Children Statistical Review. New York: UNICEF; 2007. http://www.unicef.org/publications/files/Progress_for_Children_No_6_revised.pdf .

Child marriage has been referred to as early marriage or child brides , but these terms are not optimal. Early marriage does not imply that children are involved, and the term is vague because an early marriage for one society may be considered late by another. The term child brides glorifies the tradition by portraying an image of joy and celebration. Most of these marriages are arranged by parents, and girls rarely meet their future husband before the wedding. The girls know that after the wedding they will move to their husband’s household, become the responsibility of their in-laws, and might not see their own family or friends for some time.

Although child marriage includes boys, most children married under the age of 18 years are girls. In Mali, the ratio of married girls to boys is 72:1; in Kenya, it is 21:1; in Indonesia, it is 7.5:1; in Brazil, it is 6:1; and even in the United States, the ratio is 8:1. 2 – 4

Human and Children’s Rights

The United Nations and other international agencies have declared that child marriage violates human rights and children’s rights. The Universal Declaration of Human Rights states that individuals must enter marriage freely with full consent and must be at full age. In 1979, the Convention on the Elimination of All Forms of Discrimination Against Women stated that child marriage is illegal. In 1989, the Convention on the Rights of the Child defined children as persons under the age of 18 years. Many countries passed laws changing the legal age of marriage to 18 years, but enforcement of these laws, and of laws requiring marriages to be registered, is weak. 5 For example, although the legal age of marriage is 18 years, in Mali 65% of girls are married at a younger age; in Mozambique, it is 57%; and in India, it is 50% ( Figure 3 ). In some parts of Ethiopia, although the legal age of marriage is 15 years, 50% of younger girls are married, and in Mali, 39% of younger girls are married. Furthermore, in some regions, an arranged marriage occurs at birth. 6

(A) Percentage of girls (aged 15–19 years) who are currently married. (B) Percentage of women aged 20 to 24 years married before age 18. Reproduced with permission from Mathur S, Greene M, Malhotra A. Too Young to Wed: The Lives, Rights, and Health of Young Married Girls. Washington, DC: International Center for Research on Women; 2003. http://www.icrw.org/docs/tooyoungtowed_1003.pdf .

Factors Driving Child Marriage

Three main forces drive child marriages: poverty, the need to reinforce social ties, and the belief that it offers protection. Child marriage is predominantly seen in areas of poverty. Parents are faced with 2 economic incentives: to ensure their daughter’s financial security and to reduce the economic burden daughters place on the family.

Child marriage is first and foremost a product of sheer economic need. Girls are costly to feed, clothe, and educate, and they eventually leave the household. Marriage brings a dowry to the bride’s family. The younger the girl, the higher the dowry, and the sooner the economic burden of raising the girl is lifted.

By marrying their daughter to a “good” family, parents also establish social ties between tribes or clans and improve their social status. Parents also believe that marrying their daughters young protects them from rape, premarital sexual activity, unintended pregnancies, and sexually transmitted infections, especially human immunodeficiency virus (HIV) and AIDS. 5

Health Consequences of Child Marriage

Isolation and depression.

Once married, girls are taken to their husband’s household, where they assume the role of wife, domestic worker, and, eventually, mother. These new homes can be in a different village or town. Because of the high dowry paid, husbands are usually much older than the girls (and thus have little in common with them) and their new brides are expected to reproduce. Polygamy may also be acceptable in some of these regions. As a result, the girls feel rejected, isolated, and depressed. Some girls realize that survival requires embracing their new environment and proving their fertility. They lose their childhood and miss the opportunity to play, develop friendships, and be educated.

Risk of Sexually Transmitted Infection and Cervical Cancer

Parents believe that marrying their daughters early protects them from HIV/AIDS. Research has shown the opposite: marriage by the age of 20 years is a risk factor for HIV infection in girls. 7 In Kenya, married girls are 50% more likely than unmarried girls to become infected with HIV. In Zambia, the risk is even higher (59%). And in Uganda, the HIV prevalence rate of married girls and single girls between the ages of 15 and 19 years is 89% and 66%, respectively. Their husbands infected these girls. Because the girls try to prove their fertility, they had high-frequency, unprotected intercourse with their husbands. Their older husbands had prior sexual partners or were polygamous. In addition, the girls’ virginal status and physical immaturity increase the risk of HIV transmission secondary to hymenal, vaginal, or cervical lacerations. 5 Other sexually transmitted infections, such as herpes simplex virus type 2, gonorrhea, and chlamydia, are also more frequently transmitted and enhance the girls’ vulnerability to HIV. Research demonstrates that child marriage also increases the risk of human papillomavirus transmission and cervical cancer. 8

Risks During Pregnancy

Pregnant girls in malaria regions were found to be at higher risk for infection. Of the 10.5 million girls and women who become infected with malaria, 50% die. Their highest risk is during their first pregnancy. Pregnancy not only increases the risk of acquiring malaria, but pregnant girls under the age of 19 have a significantly higher malaria density than pregnant women over the age of 19. 9 They are also at significant risk of malaria-related complications such as severe anemia, pulmonary edema, and hypoglycemia.

Rates of HIV and malaria coinfection are highest in Central African Republic, Malawi, Mozambique, Zambia, and Zimbabwe, where more than 90% of the population is exposed to malaria and more than 10% are HIV positive. Having both diseases complicates the management and treatment of each. HIV-infected patients have a higher likelihood of getting a more severe form of the malaria parasite, Plasmodium falciparum . They are less likely to respond as well to antimalaria medication. Malaria increases HIV viral load and increases the mother-to-child HIV transmission rate. Data demonstrate that the combination of these diseases proves deadly to the young pregnant mother. 10

Risks During Labor and Delivery

Deliveries from child marriages are “too soon, too close, too many, or too late.” 11 Forty-five percent of girls in Mali, 42% in Uganda, and 25% in Ethiopia have given birth by the age of 18. In Western nations, the rates are 1% in Germany, 2% in France, and 10% in the United States ( Figure 4 ). Girls between the ages of 10 and 14 years are 5 to 7 times more likely to die in childbirth; girls between the ages of 15 and 19 years are twice as likely. 12 High death rates are secondary to eclampsia, postpartum hemorrhage, sepsis, HIV infection, malaria, and obstructed labor. Girls aged 10 to 15 years have small pelvises and are not ready for childbearing. Their risk for obstetric fistula is 88%. 13

Percentage of women, aged 20 to 24 years, married and giving birth by age 18. Reproduced with permission from Mathur S, Greene M, Malhotra A. Too Young to Wed: The Lives, Rights, and Health of Young Married Girls. Washington, DC: International Center for Research on Women; 2003. http://www.icrw.org/docs/tooyoungtowed_1003.pdf .

Risks for Infants

Mothers under the age of 18 have a 35% to 55% higher risk of delivering a preterm or low-birthweight infant than mothers older than 19 years. The infant mortality rate is 60% higher when the mother is under the age of 18 years. Data demonstrate that even after surviving the first year, children younger than 5 years had a 28% higher mortality rate in the young mothers cohort. 14 This morbidity and mortality is due to the young mothers’ poor nutrition, physical and emotional immaturity, lack of access to social and reproductive services, and higher risk for infectious diseases.

Disheartening as this information may be, there is encouraging news. Data show that in countries where poverty has decreased, such as Korea, Taiwan, and Thailand, the incidence of child marriage has also declined.

Media attention raises awareness of the issue and can prompt change. After a highly publicized story in 2008, in which a 10-year-old Yemeni girl fled her husband 2 months after being married and successfully obtained a divorce, Yemen increased the legal age for marriage from 15 to 18 years. More importantly, numerous children, inspired by this case, have sued for divorce. 15

Research has long enforced the importance of education for girls and their families. Child marriage truncates girls’ childhood, stops their education, and impacts their health and the health of their infants. Governmental and nongovernmental policies aimed at educating the community, raising awareness, engaging local and religious leaders, involving parents, and empowering girls through education and employment can help stop child marriage. Programs that have shown success are those that give families financial incentives to keep their daughters in school, those that feed children during school hours so parents do not have to bear that responsibility, and those that promise employment once girls have completed their schooling. 1 Education not only delays marriage, pregnancy, and childbearing, but school-based sex education can be effective in changing the awareness, attitudes, and practices leading to risky sexual behavior in marriage.

Main Points

• Over 60 million marriages include a girl under the age of 18 years.
• The main forces that drive child marriage are poverty, the need to reinforce social ties, and the belief that marriage at an early age protects girls from rape, unintended pregnancy, and sexually transmitted infection.
• Marriage before the age of 18 increases the rate of human immunodeficiency virus (HIV) infection in girls.
• High death rates during pregnancy are secondary to eclampsia, postpartum hemorrhage, sepsis, HIV infections, and obstructed labor. The infant mortality rate is 60% higher when the mother is under the age of 18 years.
• Education not only delays marriage, pregnancy, and childbearing, but school-based sex education can be effective in changing the awareness, attitudes, and practices leading to risky sexual behavior in marriage.

Understanding and addressing child marriage A scoping study of available academic and programmatic literature for the 'Her Choice' Alliance

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Child marriage - Free Essay Examples And Topic Ideas

Child marriage is a global issue where minors are married off, often before they are physically or emotionally mature. Essays on child marriage could explore the sociocultural or economic factors contributing to its prevalence, the legal frameworks surrounding it, or its impact on individuals and communities. Analyzing efforts to combat child marriage, the role of education, and the impact of global advocacy can provide a nuanced understanding of the challenges and potential solutions associated with addressing child marriage. We’ve gathered an extensive assortment of free essay samples on the topic of Child Marriage you can find at PapersOwl Website. You can use our samples for inspiration to write your own essay, research paper, or just to explore a new topic for yourself.

Child Marriage: Legal Dilemmas and Cultural Clash

Child marriage is the marriage that an individual performs without reaching the physical and mental maturity necessary to act as an adult. Child marriage usually means the marriage of a 18-year-old child. Early marriage, these minors are from their families, friends and future; education, deprives the school of life and pushes it under very difficult responsibilities. We see such marriages more especially in developing and underdeveloped countries. In our country's legal system; According to the Turkish Civil Code, the Turkish […]

Child Marriage: Uncovering the Causes and Consequences in Contemporary Society

Child marriage is a formal or informal marriage of a child under the age of 18. Generally it is a marriage of a young girl with older man. There are approximately 700 million women around the world today who got married at young age. There would be a few factors that lead to child marriage and the effect that it gave to our society. Firstly, unwanted early pregnancies contribute to the ubiquity of child marriage in Malaysia. A high number […]

What we Do: Economic Empowerment

Abstract : Education is widely understood as an indicator of women status and even more importantly as a factor for the empowerment of women. Women have such unexplored potential which has never been tapped. For centuries women were not treated equal to men in many ways. Today we can see that women occupies respectable positions in all walks of life. Yet, they are not absolutely free, due to discriminations and harassments of the society. A few number of women have […]

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Essay about Gender Segregation

The developing world has encountered various forms of gender inequality or segregation. In education, when discrimination is mentioned, most people happen to think about African or Middle Eastern. The question commonly asked is how often women can be involved in this issue of segregation in education? Recently, women have gone through tremendous struggles for them to be granted the same rights for education like those given to men. Gender segregation can be defined as the concentration of one gender in […]

India and Muslims

Presentation: India has a historical significance and, according to some estimates, Indian civilization dates back to over five thousand years. Therefore, it is natural that its society is also very old and complex. Throughout its long-spanning history, India has witnessed and absorbed several waves of immigrants including Aryans, Muslims etc. These immigrants brought their own ethnicities and cultures, contributing to the country's diversity, richness, and vitality. As such, Indian society is a complex mix of diverse cultures, people, beliefs, and […]

A Marriage that Means Nothing but Necessities

Marriages of convenience are undertaken for many other reasons than that of a relationship of love and affection. Instead, the marriages are based upon personal gain for either one or both people in the marriage. In most cases, people typically marry only so one of them can have a visa. Women in poor countries often marry men in exchange for a better life, uprooting themselves and leaving their families, children, and everything they have ever known behind. First, I will […]

Beyond Tradition: Analyzing Global Efforts to Combat Child Marriage

Stepping into the global arena, the battle against child marriage intensifies, challenging longstanding norms and traditions. This pervasive issue, involving the union of individuals before the age of 18, has triggered a synchronized international effort to dismantle its foundations and usher in a more equitable future. The discourse surrounding child marriage now transcends cultural confines, evolving into a universal call for action. It goes beyond the mere overhaul of legal frameworks, delving into the complexities of societal attitudes that sustain […]

The Impact of Early Unions: Examining the Causes and Consequences of Child Marriage

Child marriage, an enduring societal dilemma, casts a lengthy shadow over the destinies of numerous young souls globally. This practice, involving the union of individuals before the age of 18, unfolds against a tapestry of cultural traditions, economic pressures, and gender imbalances. The repercussions of early unions are profound, shaping the trajectories of those involved and perpetuating a cycle of disadvantage. In this exploration, we delve into the labyrinth of causes and consequences surrounding child marriage, striving for a comprehensive […]

Rethinking Love and Relationships in the Battle against Child Marriage

In a world steeped in age-old traditions and norms, the mere mention of redefining love and relationships to combat the blight of child marriage might sound like a whimsical fairy tale. Yet, here we are, delving into the labyrinth of change armed with skepticism. As a psychologist, I find myself navigating through the unexplored corridors of human behavior, questioning the efficacy of rewriting the narrative of love in the fight against an entrenched social ill. Love, an elusive emotion, has […]

Skeptic’s Perspective on Digital Guardians: Rethinking Technology in the Battle against Child Marriage

Child marriage, a deeply entrenched societal issue, has stirred global conversations and efforts aimed at finding innovative solutions. Advocates often champion technology as a digital guardian capable of combating this grave problem. However, as a skeptic psychologist, I approach this notion with caution, questioning the effectiveness and potential unintended consequences of relying solely on technology to address such a complex and deeply rooted cultural phenomenon. The proponents of utilizing technology in the fight against child marriage argue that digital tools […]

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Child Marriage Essay

500 words child marriage essay.

Child Marriage continues to be a prevalent practice in many parts of the world . Even though the world is evolving at a fast pace, there are some regions that can’t seem to move on with times. What’s sad is the dark reality of child marriage which is not considered often. Child marriage is basically the formal or informal marriage of a child with or without their consent, under the age of 18. In most cases, the boy or man is older than the girl. Through a child marriage essay, we will throw light on this social issue.

Causes and Impact of Child Marriage

Child marriage is no less than exploitation of right. In almost all places, the child must be 18 years and above to get married. Thus, marrying off the child before the age is exploiting their right.

One of the most common causes of child marriage is the tradition which has been in practice for a long time. In many places, ever since a girl is born, they consider her to be someone else’s property.

Similarly, the elders wish to work out their family’s expansion so they marry off the youngsters to characterize their status. Most importantly, poor people practice child marriage to get rid of their loans, taxes, dowry and more.

The impact of child marriage can be life-changing for children, especially girls. The household responsibilities fall on the children. They are not mentally or physically ready for it, yet it falls on them.

While people expect the minor boys to bear the financial responsibilities, the girls are expected to look after the house and family. Their freedom to learn and play is taken away.

Further, their health is also put at risk due to the contraction of sexually transmitted diseases like HIV and more. Especially the girls who get pregnant at a young age, it becomes harmful for the mother as well as the baby.

Get the huge list of more than 500 Essay Topics and Ideas

How to End Child Marriage

Ending child marriage is the need of the hour. In order to end this social evil, everyone from individuals to world leaders must challenge the traditional norms. Moreover, we must do away with ideas that reinforce that girls are inferior to boys.

We must empower the children, especially girls, to become their own agents of change. To achieve this, they must get access to quality education and allow them to complete their studies so they can lead an independent life later on.

Safe spaces are important for children to be able to express themselves and make their voices heard. Thus, it is essential to remove all forms of gender discrimination to ensure everyone is given equal value and protection.

Conclusion of Child Marriage Essay

To sum it up, a marriage must be a sacred union between mature individuals and not an illogical institution which compromises with the future of our children. The problem must be solved at the grassroots level beginning with ending poverty and lack of education. This way, people will learn better and do better.

FAQ on Child Marriage Essay

Question 1: What are the causes of child marriage?

Answer 1: The causes of child marriages include poverty, dowry, cultural traditions, religious and social pressures, illiteracy, and supposed incapability of women to work for money.

Question 2: How can we end child marriage?

Answer 2: To end child marriage we must also raise awareness about this issue and educate both parents and kids. Further, we must encourage them to be independent first and then search for a partner only after attaining a specific age. Laws should be introduced to tackle this social issue.

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Child marriage and its impact on health: a study of perceptions and attitudes in Nepal

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In Nepal, child marriage affects approximately 33% of girls prior to the age of 18, and 8% of girls by the age of 15. The practice has various causes, which include a lack of education, poverty and societal norms. Literature indicates that child marriages have a more significant impact on women’s health because of early pregnancies and the consequences of dropping out of school. This study aims to understand the impact of child marriage on health by exploring the perceptions held by women in Nepal. Understanding the opinions of those most affected is imperative to influence and improve policy.

13 semi-structured interviews occurred in the Kathmandu Valley in May 2019. Participants were selected purposively by the project host who acted as a gatekeeper and further participants were identified via snowballing. The data was analysed thematically.

The perceived causes of child marriage in Nepal were a lack of school level education, poverty, having numerous siblings, a low social status and societal views. The impacts on health include a high incidence of early pregnancy complications, and the effects of dropping out of school. The mental health of young brides was perceived to be affected by pressures to work in the home, being isolated and being too young for marriage. Factors such as awareness, availability, societal pressures and independence affected the health-seeking behaviours of child brides. The participants highlighted that raising awareness, reaching out rurally, and educating and employing women would tackle the problem.

Conclusions

Many of the themes discussed agreed with the existing literature. The effect of dropping out of school and the impact of child marriage on mental health have not yet been explored qualitatively. Factors that affect health-seeking agree with the limited research available, indicating a need to make services more accessible.

Child marriage is defined as ‘a marriage of a girl or boy before the age of 18’, and although both genders experience the phenomenon, it is evident that girls are disproportionately affected. 1 Approximately 12 million girls are married during childhood each year, particularly in South Asia. 1 , 2 The literature construes that child marriages are commonly instigated by poverty, a lack of education and societal views amongst various other factors. 1 Unfortunately, the consequences of child marriage for the girls involved are both vast and severe. Existing research demonstrates that child marriages increase the incidence of early pregnancies, maternal mortality, school dropout rates and the risk of violence. 3–5

Nepal has been classed as one of the worlds’ least developed countries and has a population of approximately 30 million residents. 6 , 7 Child marriages are particularly problematic in Nepal, affecting 33% of girls before the age of 18 and 8% of girls before the age of 15. 8 The practice is predominantly witnessed in rural areas, where 83% of the population reside, and many of the causes and consequences are consistent with the reasons mentioned above. 9 , 10 Although Nepal’s legal age for marriage is 20 (or 18 with parental consent), the law is hardly implemented or adhered to. 8 , 11 Nepal’s government has devised a ‘National strategy to end child marriage by 2030’. 8 The strategy consists of 6 components, including the need to ‘educate’ and ‘empower’ girls, ‘implement laws and policies’, ‘engage’ men and communities, and ‘strengthen and provide services’. 8

Child marriage has a greater impact on the life course of women due to the health implications of pregnancy and dropping out of school. 12 According to the United Nations Children’s Fund (UNICEF), child marriages are ‘driven by deep-seated social and religious views’ and are a ‘violation of human and child rights’. 1 This research intends to understand the perceptions and attitudes of women in Nepal regarding the impact of child marriage on health. A dearth of qualitative studies currently explore the effect of child marriage on health in Nepal, particularly the health-seeking behaviours of child brides. 13 Understanding women’s views is paramount to improve policies, both to prevent the incidence of child marriage in the first place and to deal with the health consequences of those already affected.

Aims and Objectives

This research aims to understand the impact of child marriage on health in Nepal in order to identify methods to improve the implementation of policies in place.

To identify the determinants of child marriage.

To understand how child marriage affects health.

To understand the factors which affect the health-seeking behaviour of child brides.

To identify ways in which policies regarding child marriage can be improved.

Research design

The study employed a qualitative research design to understand the ‘beliefs’ and ‘attitudes’ of those interviewed. 14 It has been suggested that qualitative research provides respondents with ‘a voice’ and allows them to talk about aspects of health that may not have been explored before. 14

Due to time constraints, the study employed a purposive sampling technique, where participants were ‘deliberately’ chosen based on their knowledge and experiences. 15 The project host was a representative of the United Nations Development programme, which tackles issues such as child marriage in Nepal. As a result, the host acted as a gatekeeper by identifying suitable participants. Further participants were found by snowballing from the existing respondents in the study.

Inclusion Criteria

Being a female

Over the age of eighteen and

Aware of the issues surrounding child marriage in Nepal

A few of the women interviewed were married as children, but this characteristic was not required for ethical reasons. Females were chosen because of the social norms that drive a disproportionate number of girls into child marriages. The group of thirteen respondents comprised of two doctors, four nurses, five housewives, one agricultural worker and one domestic cleaner. They were aged between twenty-eight and sixty-four, and almost half were educated to university level.

Data collection

Thirteen individual interviews were carried out in May 2019. Semi-structured interviews were adopted as they allowed the interviewer to ‘stray’ from the question guide when necessary. 16 The questions used are shown in Appendix 1 in the Online Supplementary Document . Due to the topic’s sensitivity, a vignette was used ( Appendix 2 in the Online Supplementary Document ). A vignette is a short extract about a ‘hypothetical’ person used to familiarise participants with a topic and set the scene. 17 The story permitted the participants to refer to its main character throughout the interview, eliminating the need for them to disclose any personal information.

Seven women from two villages in the Kathmandu valley were interviewed in each village’s communal location. Five health workers were interviewed in a private area of a hospital in Kathmandu, whilst a further health worker was interviewed in a café. Each interview took between 15 and 40 minutes to complete, and all were audio-recorded with consent.

A female translator was chosen to ensure the respondents felt comfortable and to elicit honest answers. She was coached on confidentiality issues, accurate translation and the optional nature of the interviews. A pilot interview ensured that both the translator and the respondents would understand the questions. Three participants spoke fluent English; thus, the translator was only required during ten interviews.

The gatekeeper provided respondents with an information sheet and consent form two days before the interview dates. Consent was also established before each interview and the University of Leeds granted ethical approval.

Data analysis

The lead researcher independently transcribed the audio-recorded data before it was analysed thematically. The transcripts were annotated and coded based on a priori (existing) and emerging themes. 15 The transcripts were repeatedly listened to and read throughout the analysis to preserve their meaning while formulating themes. Quotes by participants were organised thematically within a spreadsheet allowing similarities and differences between respondents to be acknowledged. Quotes were included in the report for transparency and to give the reader a sense of the respondent’s voice. They were decided based on their quality and ability to provide extra information.

The findings of this research have been organised based on the objectives they answer. They have been presented thematically and quotes are labelled with their corresponding participant’s unique code.

The perceived causes of child marriage

The participants perceived that a lack of education, poverty and societal views were the main drivers of child marriage, as shown in Figure 1 .

Lack of education

Most of the participants stated that uneducated girls commonly get married as children. Whilst some suggested that marriage is a direct consequence of being uneducated, others proposed that when a girl or her parents lack education, they are unaware of the consequences.

' Lack of education, they do not know how early marriage will affect their life…’ I12

Poverty and number of siblings

Some participants recognised poverty as a driving factor due to the financial burden of caring for children. One respondent explained that low-income families are likely to have their daughters married if they cannot afford to educate their sons. Others explained that girls with more siblings would be married off to relieve the general and financial responsibilities of having children.

'Because of the difficulties experienced when raising children, children can be married by their parents at the ages of 5-7… It is common when there are many siblings…'I7

Societal views and family pressures

A few participants expressed that getting married at a young age is societally common. One respondent explained that girls are expected to get married and look after their in-laws. Another highlighted the existing opinion that a girl’s real home is at her in-laws.

‘In my time, parents thought that the girls birth home is not her real home…’ I2

The perceived impact of child marriage on health

Early pregnancy and pregnancy-related complications, dropping out of school and poor mental health were some of the main themes explored by the participants, as demonstrated in Figure 2 .

Early pregnancy

The participants identified several causes of early pregnancies. A few of the respondents highlighted that they are pressurised to have children by their parents and in-laws, who want grandchildren. One respondent expressed that this was due to a ‘societal duty.’

Some participants explained that contraception is generally unavailable, particularly in remote areas. This was one of the factors that participants felt increased the incidence of early pregnancies.

'Because of the lack of contraceptives in remote areas, I experienced this as a problem…'I7

In contrast, several participants believed that girls are unaware that contraception exists. Others were concerned that girls are unaware of how pregnancy occurs.

…they are unaware of the contraceptives which are available to them. Therefore, they have intercourse without contraception… I6

One participant stated that young brides are raped if they do not consent to sex.

‘Unwilling girls are raped by their husbands…’ I5

Pregnancy complications

Most of the participants perceived age to account for complications during pregnancy. They expressed that child brides have weak and immature organs, and a few believed that this increases their need for C-sections.

‘… Mothers are unable to force the baby out; therefore C sections are needed…’ I6

A couple of the respondents mentioned uterine complications. One participant explained that uterine prolapse is common amongst child brides due to their age.

Maternal mortality and miscarriages were identified as complications by many of the participants. Maternal mortality was attributed to bleeding, late care seeking and poor facilities. In contrast, miscarriages were perceived to be caused by weak organs and infections.

One participant expressed that child brides often experience post-partum depression. She explained that there is a lack of awareness surrounding the condition and that services are lacking.

'… Post-partum depression is common and is very dangerous because I don’t think we have proper facilities for post-partum depression and counselling because people do not realise it is happening…'I8

One participant stated cervical cancer without elaboration.

School dropout

Several health concerns were raised regarding child brides who drop out of school. Poor or inadequate awareness of hygiene, menstruation and nutrition were worries raised by several participants. They expressed that dropping out of school negatively affects the nutritional and hygienic choices of child brides, both for themselves and their children. It was identified that the children of child brides would also be less educated due to their mother’s lack of knowledge.

…it will also hamper their children because If mothers are educated, their children will be educated….'I8

Only one participant discussed loneliness and the impact on mental health as a consequence of dropping out of school.

'…Being at home can make them feel very lonely. They do not get the chance to communicate with others…'I4

A few respondents reported that child brides are more dependent on their husbands and families when leaving school; this was perceived to give them less power.

Mental health

Many participants explained that young girls are unaware of the realities of married life and are therefore unprepared. This was thought to affect them emotionally.

'During the wedding they are excited that they are getting married to a man, but they do not know about managing a family…'I10

Most of the respondents highlighted that young brides are put under a lot of pressure by their in-laws to work and manage the home. This was perceived to cause stress, and one participant disclosed that she was constantly ‘in fear’ of her in-laws anger as a young bride. One participant identified the societal pressures child brides face to be good mothers.

'…There are societal pressures. For example, people will say, ‘you’re not looking after your children well.’ This affects their mental health…'I6

Some participants highlighted that child brides are often left alone, with unsupportive in-laws and nobody to talk to. Moreover, they explained that mental health is often ignored, and the ability to function is expected within society.

'Usually, they just adapt because that is how they have been bought up. Their mother will have gotten married early. Their sister will have gotten married early, so it’s normal…'I8

Most participants reported that child brides are often victims of domestic violence by their husbands and in-laws. Some suggested this occurs when they do not follow orders or do what is expected. The consequences of domestic violence risk both the physical and mental health of child brides.

‘Young girls do not know how to raise their children and what to feed them; when they do things wrong, violence happens…’

The perceived effect of child marriage on health seeking

Participants were asked about the factors that influence health seeking in various contexts, such as when seeking contraception, pregnancy-related care, mental healthcare, sexual healthcare and general healthcare by child brides. The perceived factors were awareness, availability, societal factors and a lack of independence as demonstrated in Figure 3 .

Most of the participants believed that child brides are unaware of contraception, thus, they would not seek it. This was a particular concern within rural areas, though it was felt that some girls in Kathmandu were unaware of contraception. One participant explained that even if child brides knew of contraception, they would not know how to obtain it. Others expressed that girls are afraid of using the contraceptive pill because of misconceptions within society.

'Some girls believe that if they take contraceptives, they could become infertile…'I11

Several participants explained that young brides are unaware of the symptoms of sexually transmitted infections (STI’s) and mental health issues, as such topics are not discussed openly in society. Therefore, young girls do not recognise symptoms as worrying and do not seek care.

‘…they do not understand that they are slowly getting depressed and getting mental diseases…’ I11

Some participants explained that child brides do not know where they can obtain general healthcare.

Availability

A couple of the respondents explained that contraception is generally unavailable, particularly in remote areas. Likewise, one participant identified that doctors are sometimes unavailable to discuss mental health.

In contrast, it was highlighted that girls are likely to seek antenatal care (ANC) because of its wide availability. They explained that outreach programmes exist nationwide, including local health centres in rural areas. Two respondents explained that financial incentives are provided when girls attend ANC 4 times during their pregnancy and when girls deliver at a health facility. This was perceived to improve the uptake of pregnancy-related care.

‘If a girl delivers in a health facility, the girl will get 1500 rupees for a normal delivery and 5000 rupees for a C-section. So, most people tend to come to the hospital and they benefit from it…’ I13

Conversely, one participant identified that gynaecologists and ultrasound scanners are unavailable in some areas of Nepal. Therefore, young girls do not know if they require specialist interventions. A few of the participants felt that the cost of healthcare inhibits health-seeking. Moreover, it was explained that young girls are unlikely to seek mental healthcare until they have a ‘breakdown.’ When asked about sexual health, one respondent explained that girls would wait until their symptoms bothered them.

'They would not seek help until it is actually bothersome. This is at a very late stage…'I8

When probed about general health, a few participants reported that girls would only visit a doctor if their symptoms were severe. One subject explained that girls wait until they are ‘bedridden.’ These findings could be attributed to the cost of healthcare or the stigma surrounding mental and sexual health.

Societal views surrounding mental health were perceived to inhibit girls from seeking care. One participant explained that some families prohibit young brides from discussing mental health issues. Another explained that young girls are unaccepting of these conditions, therefore they do not seek care.

'…society does not accept mentally disturbed people, therefore girls are hesitant to speak about it….'I10

'They do not tell their doctors or anybody else because they think it is a problem of sin…'I12

Seeking care for sexual health problems was also perceived to be inhibited by societal factors. One participant stated that this is due to a lack of trust in healthcare workers to keep their information confidential, especially if they have been promiscuous.

'This is because of the social stigma; they do not trust that their information will be kept confidential…'I13

A few participants identified that in some areas it is societally expected for girls to give birth at home, therefore, care is not sought.

Lack of independence

One participant reported that young brides hesitate to seek care without their husband’s help. Respondents also felt that child brides are shy, particularly around male physicians. Their lack of independence and confidence around male doctors inhibited health-seeking.

Improving Policy

The participants were briefed on the ‘National strategy to end child marriage by 2030’ and its six components. Following this, they were asked how they thought these policies could be revised to improve the health outcomes associated with child marriage. Themes explored by the participants were education, employment, raising awareness and rural outreach.

Most participants believed keeping girls in school is crucial to ending child marriage. While acknowledging the ‘educational’ component of the national strategy, they expressed that more can be done. They explained that education improves independence and allows mothers to educate their children. One participant proposed that child brides should attend night schools to gain independence whilst caring for their families.

'Girls should be kept in school for as long as possible…'I3

A few of the participants proposed that all women should be employed. One expressed that this would eradicate poverty, simultaneously decreasing the incidence of child marriage. Another explained that employment would ensure their ability to support their families if their husbands passed away.

Raising awareness was proposed by some participants. They highlighted that awareness could be raised in communities and within families. Two participants suggested the use of the mass media, such as television adverts.

Rural outreach

Participants suggested that the health facilities in remote areas could be improved so that young girls can obtain care for the complications mentioned previously. One expressed that more doctors need to reach out rurally.

'More health posts should be established in remote areas to ensure that treatment for complications can be obtained…'I3

The reasons for child marriage cited by the participants such as a lack of education, poverty and societal views agree with existing literature. 11 The consequences of being uneducated were consistently referred to by the participants indicating the importance of retaining girls in school, a concept widely appreciated by previous research. 18 A report by the Human Rights Watch (HRW) found further determinants such as the influence of caste, the dowry system, love marriages and the stigma surrounding pre-marital sex. 11 These themes were not identified by this study’s particpants, possibly because they resided in the capital of Nepal, rather than the mainly rural, dalit and indigenous populations interviewed by the HRW. 11 Furthermore it is likely that data saturation was not reached given the diverse characteristics of the participants and the comparably lower number of interviews conducted in this study. The participants were not probed which may have limited the answers retrieved.

Impact on health

The participants expressed that early pregnancies may result from an unawareness of contraception; this has been acknowledged previously. 11 It should be recognised that lacking awareness limits autonomy, thus child brides must be aware of their options. Rape has not been cited as a cause of early pregnancy before, yet this finding links with a body of evidence that child brides are at an increased risk of experiencing sexual violence. 13

Only one participant recalled uterine prolapse as a pregnancy complication experienced by child brides despite the large proportion of health workers in the study sample. Research suggests that the prevalence of this condition lies between 9% and 44% in Nepal. 12 It is plausible that this condition and obstetric fistulas were not discussed due to the ‘stigma’ surrounding them or general unawareness.

Literature construes that child brides are at an increased risk of mental health issues, 13 yet the reasons why have not been explicitly researched. Pressures to do housework coupled with unrealistic expectations and a lack of support were perceived to be culpable in this study. Therefore, young girls and their parents need to be aware of the realities of married life. Post-partum depression has not previously been cited as a consequence of pregnancy amongst child brides in Nepal before. It was explained that there is a ‘lack of awareness’ surrounding the condition whilst it was generally noted that mental health is often ignored within society, indicating a need for mental health awareness to improve in Nepal.

Health seeking

Shyness was perceived to inhibit seeking care, and one participant expressed that young girls are particularly shy around male doctors. Similar findings were observed by Maharjan et al. 13 A study in Nepal by Hayes and Shakya 19 identified that most medical students who expressed an interest in working rurally were male, suggesting that there may be a limited number of female doctors where most child brides reside. Therefore, there is a need to ensure that female doctors and health professionals are available to help child brides in rural areas.

The incentives provided by the government to encourage health service use during pregnancy were only mentioned by a couple of the participants, suggesting a possible lack of awareness. Other studies have acknowleged the positive impact of these incentives on health-seeking. 13 , 15 There is a need for the government of Nepal to raise awareness of the programmes that are already in place and to increase their availability.

Participants suggested strategies such as retaining girls in school and raising awareness. In Bara, a district of Nepal, ‘children’s clubs’ were set up to keep children in school whilst raising awareness of the issues surrounding child marriage. 20 As a result, numerous villages in the district were confirmed as ‘child-marriage free zones,’ demonstrating its success.

Other suggestions by participants included the employment of women and improving rural health facilities; these have been proposed within the literature. 13 , 21

Limitations

The vignette was rarely referred to by the participants being interviewed. It is possible that the sensitive nature of the topics addressed could have been discussed in greater detail if the vignette had been utilised more. However, it was evident that the vignette enforced strong emotions within the participants, and they were eager to share their personal experiences after hearing the short extract.

Many participants held back when answering questions regarding mental health, sexual health and violence. They explained they felt shy discussing these topics, and due to their hesitancy, they were not probed further.

As the question guide was based on existing literature, there is a possibility that the questions were leading. However, open questions were asked in each interview section to avoid this.

The research occurred in the Kathmandu valley, yet most child marriages occur rurally. Although many of the participants had either visited or were from remote areas, alternative themes could likely have been elicited from a cohort of rural women.

Approximately twenty individuals were invited for interview, of which thirteen took part. Very few new themes were elicited in the latter half of interviews, therefore it could be presumed that the most common themes were discussed. Despite this, it is unlikely that data saturation was reached given the variety of ages, occupations and educational achievements of the study cohort. More themes may have been retrieved from community leaders and teachers who work closely with young people.

Validation techniques such as respondent validation and triangulation did not occur due to time constraints. These techniques would have increased the reliability of the results. 15 It should also be considered that the lead researcher analysed all data independently, and therefore research bias is a possibility.

CONCLUSIONS

Overall, the main factors perceived to drive young girls into early marriages were a lack of education, poverty and societal norms. The participants agreed that early pregnancies are common and complications result from age. Most participants recognised that young brides drop out of school once married or pregnant. This was believed to affect their independence and their ability to make health-related decisions. The practice was perceived to have a negative impact on mental health, and some felt it increased the risk of violence. The participants explained that health-seeking is inhibited by unawareness of symptoms and available help, societal views and a lack of independence. Conversely, incentives were believed to improve health-seeking. Educating girls and employing women would reduce the incidence of child mariage. This underscores the need to raise awareness and improve rural support. Further research could delve into the the views of boys and men in the most affected areas of Nepal, to aid current understanding of why child marriage occurs and the societal views which still exist.

Acknowledgements

The support of the United Nations Development Programme in Kathmandu, for their help in organising data collection. The support of the author’s supervisor at the Nuffield Centre for International Health. The support of the translator whilst in Nepal.

This report has been submitted in partial fulfilment of the requirements of a degree at the University of Leeds. The statements and opinions presented within are those of the author, and do not necessarily represent the views of the Nuffield Centre for International Health and Development, or the University of Leeds

Ethics statement

Informed consent was obtained from all participants involved in the study. Ethical approval was granted by the Leeds Institute of Health Sciences Research Ethics Sub-Committee (FMHREC-18-1.3).

Authorship contributions

RS is the only author.

Disclosure of interest

The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.

Additional material

Please refer to the Online Supplementary Material

Correspondence to:

Reena Seta University of Leeds, United Kingdom [email protected]

Submitted : August 28, 2023 BST

Accepted : October 10, 2023 BST