Despite India's economic and educational reform efforts in the last decade, the prevalence of child marriage remains high, fueling the risks of multiple unwanted pregnancies, pregnancy terminations and female sterilizations, according to a new study led by a Boston University School of Public Health (BUSPH) researcher.
The study, led by Anita Raj, PhD, associate professor of Social & Behavioral Sciences at BUSPH, found that nearly half of adult Indian women, aged 20 to 24, were married before the legal age of 18, and that those child marriages were significantly associated with poor fertility outcomes, such as unwanted and terminated pregnancies, repeat childbirths in less than 24 months, and increased sterilization rates.
The study was published online in The Lancet and will be printed in an upcoming issue.
"The prevalence of child marriage remains unacceptably high," Dr. Raj and colleagues wrote. "These results suggest that neither recent progress in economic and women's development, nor existing policy or programmatic efforts to prevent child marriage and promote maternal and child health, have been sufficient to reduce the prevalence of child marriage in India to that of most other developing nations."
The study found that 44.5 percent of women ages 22 to 24 were married before age 18. More than one in five – 22.6 percent – were married before age 16, while 2.6 percent were married before age 13.
India, the largest and most prosperous nation in south Asia, raised the legal age for marriage to 18 in 1978. In the past 15 years, national policy efforts have been developed to increase educational and economic opportunities for girls and women, reduce child marriage and expand family-planning support.
The authors said that while there had been a slight reduction – 5 percent -- in the rate of child marriage compared with national data from 1998-99, the continued prevalence of the practice and its association with poor fertility outcomes highlights "the crucial need for increased family-planning interventions tailored to married adolescents."
"National economic development gains have inadequately targeted the most rural and poor populations, which might have hindered further reduction in child marriage," they wrote.
The study found that women who married younger than 18 were significantly more likely to report no contraceptive use before their first childbirth than were those who married as adults. Nearly half – 48.4 percent – of women who were married as children reported giving birth before they turned 18. Women married as children also were more likely to have had repeat childbirths in less than 24 months and to have had three or more childbirths, than those married as adults.
Child marriage also was associated with an increased prevalence of unwanted pregnancies and an increased prevalence of pregnancy termination, defined as miscarriage, abortion or stillbirth.
The study found sterilization rates were higher for women married as children than for those married as adults – 19.5 percent, compared to 4.6 percent. Overall, more than one in eight women, or 13.4 percent, had been sterilized.
Of those not sterilized, more than three-quarters reported no present contraception use, the research found.
"Increased prevalence of sterilization in young women married as children could be attributable to these women having their desired number of children at an earlier age, as indicated by their high fertility," the authors wrote. "However, our findings suggest that sterilization might also be the consequence of inadequate fertility control, which is evident from the increased risk of unwanted pregnancies in women married as children."
The authors recommend that existing intervention programs should be broadened to emphasize contraception other than sterilization, especially among young women who are married as children. They said such interventions also should include husbands and in-laws, "who might have more control of family planning."
Other authors on the study were Niranjan Saggurti, PhD, of the Population Council, New Delhi, India; Donta Balaiah, PhD, of the National Institute for Research in Reproductive Health, Indian Council of Medical Research, Mumbai, India; and Jay G. Silverman, PhD, associate professor of the Department of Society, Human Development, and Health, Harvard School of Public Health.
The study was funded by a grant from the U.S. National Institutes of Health and the Indian Council on Medical Research Indo-US Program on Maternal and Child Health and Human Development.
Contact for Dr. Silverman: Todd R. Datz, 617-432-3952; tdatz@hsph.harvard.edu
Journal
The Lancet