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Rev Obstet Gynecol. 2009 Winter; 2(1): 51–56.
PMCID: PMC2672998

Child Marriage: A Silent Health and Human Rights Issue

Nawal M Nour, MD, MPH

Abstract

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.

Key words: Child marriage, Early marriage, Maternal mortality

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).

Figure 1
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 ...
Figure 2
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: ...

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 8:1.24

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

Figure 3
(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 ...

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

Figure 4
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 ...

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.

Discussion

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.

References

1. 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. pp. 1–15.
2. United Nations, authors. World Marriage Patterns. New York: United Nations Population Division, Department of Economic and Social Affairs; 2000.
3. Population Reference Bureau, authors. The World’s Youth 2006 Data Sheet. Washington, DC;: Population Reference Bureau; 2006. [Accessed February 25, 2009]. http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf.
4. Alan Guttmacher Institute, authors. Into a New World: Young Women’s Sexual and Reproductive Lives. New York: Alan Guttmacher Institute; 1998.
5. Nour NM. Health consequences of child marriages in Africa. Emerg Infect Dis. 2006;12:1644–1649. [PMC free article] [PubMed]
6. Bruce J, Clark S. Including Married Adolescents in Adolescent Reproductive Health and HIV/AIDS Policy. Geneva: World Health Organization; 2003.
7. Joint United Nations Programme on HIV and AIDS, authors. World AIDS Campaign 2004: Women, Girls, HIV and AIDS. Strategic Overview and Background Note. [Accessed February 25, 2009]. http://www.etharc.org/aidscampaign/publications/wac2004.pdf.
8. Zhang ZF, Parkin DM, Yu SZ, et al. Risk factors for cancer of the cervix in a rural Chinese population. Int J Cancer. 1989;43:762–767. [PubMed]
9. Dzeing-Ella A, Nze Obiang PC, Tchoua R, et al. Severe falciparum malaria in Gabonese children: clinical and laboratory features. Malar J. 2005;4:1. [PMC free article] [PubMed]
10. World Health Organization, authors. Malaria and HIV Interactions and Their Implications for Public Health Policy. Geneva: World Health Organization; 2004. [Accessed February 25, 2009]. http://www.who.int/malaria/malaria_HIV/MalariaHIVinteractions_report.pdf.
11. Marriage and the family. [Accessed February 25, 2009]. Interactive Population Center Web site. http://www.unfpa.org/intercenter/cycle/marriage.htm.
12. United Nations, authors. We the Children: End-Decade Review of the Follow-Up to the World Summit for Children. Report of the Secretary-General (A/S-27/3) New York: United Nations; 2001.
13. United Nations Children’s Fund, authors. Fistula in Niamey, Niger. New York: United Nations Children’s Fund; 1998.
14. Adhikari RK. Early marriage and childbearing: risks and consequences. In: Bott S, Jejeebhoy S, Shah, Puri C, editors. Towards Adulthood: Exploring the Sexual and Reproductive Health of Adolescents in South Asia. Geneva: World Health Organization; 2003. pp. 62–66.
15. Walt V. A 10-year-old divorcée takes Paris. Time. 2009. Feb 3 [Accessed February 25, 2009]. http://www.time.com/time/world/article/0,8599,1876652,00.html.

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