BACKGROUND

Child marriage, defined as marriage prior to 18 years of age is expected to become the reality of 100 million adolescent girls in the developing world during the next 10 years. Sub-Saharan Africa and South Asia regions have one of the highest rates of child marriages in the world. The practice is prevalent in Pakistan, which disproportionately affects young girls in rural, low income and low education households. Our study objectives were: To determine the association between child marriage and maternal healthcare services utilization in Pakistan beyond those attributed to social vulnerabilities (women’s economic status, education, ethnicity, and place of residence) (Paper I). To determine the association between child marriage and high fertility and poor fertility health indicators beyond those attributed to social vulnerabilities (Paper II). To determine the association between child marriage and morbidity and mortality of children under 5 years of age in Pakistan beyond those attributed to social vulnerabilities (Paper III). To determine the association between child marriage and controlling behaviors and spousal violence by husbands against adolescent and young women in Pakistan beyond those attributed to social vulnerabilities (Paper IV). To describe women’s knowledge and attitude towards child marriage practice who themselves were married as children to gain insight, especially cultural factors for designing future interventions (Paper V).

METHODS

Nationally representative cross-sectional data from Pakistan Demographic and Health Survey (PDHS), 2006-07 was used for papers I, II and III, and PDHS, 2012-13 for paper IV. In paper I, we limited the data to ever-married women aged 15–24 years with at least one childbirth (n=1,404) to identify differences in prenatal care provision (skilled or unskilled medical care provider), antenatal care (antenatal visits; care at home or hospital), care at delivery (assistance by unskilled medical care provider), and place of birth by early (younger than 18 years) compared with adult (18 years or older) age at marriage. In paper II, we limited the data to ever-married women aged 20-24 years (n=1,560) to identify differences in poor fertility outcomes [high fertility (three or more childbirths); rapid repeat childbirth (<24 months between births); unwanted pregnancy (any ever); pregnancy termination (any stillbirth, miscarriage or abortion ever)] by early compared with adult age at marriage. In paper III, we limited the data to children from the past five years, reported by ever- married women aged 15-24 years (n=2630 births of n= 2138 mothers) to identify differences in infectious diseases in past 2 weeks (diarrhea, acute respiratory infection [ARI], ARI with fever), children under 5 years of age mortality and infant mortality, and low birth weight by early compared with adult age at marriage. In paper IV, we limited the data to currently married women aged 15-24 years who had participated in the domestic violence module (n=589) to identify differences in controlling behaviors and spousal violence experiences between early and adult age at marriage. Associations between child marriage and health outcomes were assessed by calculating adjusted odds ratio (AOR) using logistic regression models after controlling for covariates including social equity indicators (education, wealth index, rural residence). In paper V, women of reproductive age (15-49 years) who were married prior to 18 years, for at least 5 years and had at least one childbirth were recruited from most populous slum areas of Lahore, Pakistan. Themes for the interview were developed using published literature and everyday observations of the researchers. Interviews were conducted by trained interviewers in Urdu language and were translated into English. The interviews were tape-recorded, transcribed, analyzed and categorized into themes.

RESULTS

Paper I: Overall, 66.1% of ever-married women aged 15–24 years in Pakistan with at least one childbirth were married before the age of 18 years. More than half (61.9%) of women married as children had no formal education, and the majority (71.0%) resided in rural areas. Child marriage was significantly associated with decreased likelihood of any prenatal care (AOR=0.73; 95% CI: 0.534-0.993) and prenatal care by skilled medical care providers (AOR=0.64; 95% CI: 0.476-0.871), and increased likelihood of delivery assistance by unskilled medical providers (AOR=1.90; 95% CI: 1.435-2.518) and delivery at home (AOR=2.17; 95% CI: 1.617-2.915). Paper II: Overall, 50% of ever-married women aged 20-24 years in Pakistan were married before the age of 18 years. Child marriage was significantly (p<0.001) associated with low social equity indicators (poverty, rural residence, and no formal education). Adjusted logistic regression models showed that girl child marriage was significantly associated with high fertility (AOR=6.62; 95% CI: 3.527-12.429), rapid repeat childbirth (AOR: 2.88; 95% CI: 1.832-4.543), unwanted pregnancy (AOR=2.90; 95% CI: 1.755-4.794), and pregnancy termination (AOR=1.75; 95% CI: 1.097-2.783). Paper III: Majority (74.5%) of births were from mothers aged <18 years. Marriage before 18 years increased the likelihood of recent diarrhea among children born to young mothers (AOR=1.59; 95% CI: 1.18-2.14). Even though maternal child marriage was associated with children under 5 years of age mortality and infant mortality in unadjusted models, associations were lost in the adjusted models. We did not find a relation between child marriage and low birth weight infants, and ARI. Paper IV: About one-third of women aged 15–24 years in Pakistan reported experiencing controlling behaviors (31.8%) and spousal violence (31.3%) by their husbands. Compared to adult marriage, child marriage was significantly associated with controlling behaviors (AOR=1.50; 95% CI: 1.042–2.157), emotional violence (AOR=1.86; 95% CI: 1.254–2.767), and physical violence (AOR=2.44; 95% CI: 1.582–3.760). Paper V: Nineteen of 20 participants who agreed to participate were married between 11-17 years. Most respondents were uneducated, poor and were working as housemaids. The majority participants were unaware of the negative health outcomes of child marriages. They appeared satisfied by the decision of their parents of marrying them before 18 years, and even condemned banning child marriages in Pakistan. Strong influence of culture and community perceptions, varying interpretation of religion, and protecting family honor are some of the reasons that were narrated by the participants, which seems playing a role in continuation of child marriage practice in Pakistan.

CONCLUSIONS

Interventions such as implementation and enforcement of strict laws prohibiting the practice, empowering women by increasing education, promoting civil, sexual and reproductive health rights, creating job opportunities, and enhancing women role in family decision-making can help in tackling child marriage practice in Pakistan. Significant efforts are needed locally and at governmental level to abolish the traditional cultural practices, which can directly reduce the high numbers of child marriages in Pakistan. Efforts to increase the age of marriage and delayed childbearing may have population level effect in reducing disparities between women married as children and adults, and improving maternal and child health in Pakistan.