Understanding the role of child marriage on reproductive health outcomes: evidence from a multi- country study in South Asia Deepali Godha, David Hotchkiss, and Anastasia Gage Tulane University

Background  Child marriage remains a pervasive problem in South Asia and sub-Saharan Africa  Increasingly recognized as a violation of human rights  Previous research has associated child marriage with a number of adverse health and social outcomes  But most studies to date have focused on India – very little research in other countries

Purpose of study  To assess the association of child marriage and reproductive health outcomes in four South Asian countries after controlling for individual-, and household- level factors  Prevalence of child marriage in South Asia is high  Among currently married women 20 to 24 years of age, percent married prior to age 15 ranged from 10 percent in Nepal to 38 percent in Bangladesh.

Data  Most recent Demographic and Health Surveys in four countries  India (2005/6)  Bangladesh (2007)  Nepal (2006)  Pakistan (2006/7)  Sample: Ever-married women years of age  Sample size ranged from 1,546 in Pakistan to 22,807 in India

Methods (1)  Dependent variables  Fertility  Early fertility – childbirth within the first year of marriage  Multiple unwanted pregnancies  Having had at least one pregnancy termination  Having had at least one unwanted pregnancy  Fertility control  Lack of fertility control prior to the first birth  Low lifetime fertility control – history of rapid repeat childbirth  Maternal health care utilization

Methods (2)  Independent variables  Age at marriage dummy variables  Married at 14 years of age or younger  Married at 15 to 17 years of age  Other individual- and household-characteristics  Statistical methods  Logistic regression models to examine the association between various outcome variables and age of marriage  Unit of analysis is individual woman

Descriptive results CharacteristicIndia BangladeshNepalPakistan Total married 17 years of age or younger Married years of age Married 14 years of age or younger Husband older by 10 years of age or more Primary or no education Percent of women married as children ranges from 50% to 77%

Descriptive results CharacteristicIndiaBangladeshNepalPakistan Fertility Early fertility Pregnancy termination Unwanted pregnancy Multiple unwanted pregnancy Fertility control Lack of fertility control prior to 1 st birth NA Low lifetime fertility control Percent of women with various fertility and fertility control outcomes

Logistic regression results CharacteristicIndiaNepal Married ≤ 14Married 15-17Married ≤ 14Married Fertility Early fertility Pregnancy termination Unwanted pregnancy Multiple unwanted pregnancy Fertility control Lack of fertility control prior to 1 st birth Low lifetime fertility control Odds ratios: comparison group is women married at 18 years and older Blue font indicates statistical significance (p<0.05)

Logistic regression results CharacteristicBangladeshPakistan Married ≤ 14Married 15-17Married ≤ 14Married Fertility Early fertility Pregnancy termination Unwanted pregnancy Multiple unwanted pregnancy Fertility control Lack of fertility control prior to 1 st birth NA Low lifetime fertility control Odds ratios: comparison group is women married at 18 years and older Blue font indicates statistical significance (p<0.05)

Conclusions  In South Asia, child marriage is significantly associated with many negative fertility and fertility control outcomes (and maternal health care utilization)  Women married in early adolescence show a higher propensity towards most negative outcomes than women married in middle adolescence  Child marriage adds a layer of vulnerability to women that leads to poor fertility control and fertility related outcomes

Limitations  Outcomes are self-reported: may be prone to bias  Data are cross-sectional: difficult to attribute causality  High odds ratios and wide confidence intervals may be an indication of small cell sizes or small probabilities  Cannot distinguish between natural and induced pregnancy termination

MEASURE Evaluation PRH is a MEASURE project funded by the United States Agency for International Development (USAID) through Cooperative Agreement GHA-A and is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill in partnership with Futures Group International, Management Sciences for Health, and Tulane University. Views expressed in this presentation do not necessarily reflect the views of USAID or the U.S. Government. MEASURE Evaluation PRH supports improvements in monitoring and evaluation in population, health and nutrition worldwide.