The role of education in child and adolescent marriage in rural lowland Nepal.

Marriage during childhood and adolescence adversely affects maternal and child health and well-being, making it a critical global health issue. Analysis of factors associated with women marrying ≥18 years has limited utility in societies where the norm is to marry substantially earlier. This paper investigated how much education Nepali women needed to delay marriage across the range of ages from 15 to ≥18 years. Data on 6,406 women aged 23-30 years were analysed from the Low Birth Weight South Asia Trial on the early-marrying and low-educated Maithili-speaking Madhesi population in Terai, Nepal. Multivariable logistic regression models assessed the associations of women's education with marrying aged ≥15, ≥16, ≥17 and ≥18 years. Cox proportional hazards regression models quantified the hazard of marrying. Models adjusted for caste affiliation. Women married at median age of 15 years and three-quarters were uneducated. Women's primary and lower-secondary education were weakly associated with delaying marriage, whether the cut-off to define early marriage was 15, 16, 17 or 18 years, with stronger associations for secondary education. Caste associations were weak. Overall, models explained relatively little of the variance in the likelihood of marriage at different ages. The joint effects of lower-secondary and higher caste affiliation and of secondary/higher education and mid and higher caste affiliation reduced the hazard of marrying. In early-marrying and low-educated societies, changing caste-based norms are unlikely to delay women's marriage. Research on broader risk factors and norms that are more relevant for delaying marriage in these contexts is needed. Gradual increases in women's median marriage age and increased secondary education may, over time, reduce child and adolescent marriage.

Independent associations of women's age at marriage and first pregnancy with their height in rural lowland Nepal.

OBJECTIVES: In many South Asian communities, the majority of women are married during adolescence and reproduce before 20 years. Early reproduction may adversely affect maternal nutrition and linear growth, however whether early marriage has similar effects is unknown. Shorter women might also be preferentially chosen for earlier marriage. We hypothesized that early marriage and early pregnancy may each be associated with women's shorter height, independent of any selection effects. MATERIALS AND METHODS: We analyzed cross-sectional data on 7,146 women aged 20-30 years from rural lowland Nepal. Linear regression models tested associations of early marriage and early reproduction with height, adjusting for women's education and husbands' characteristics (education and wealth) that might index preferential selection of short young women for marriage. RESULTS: Median ages at marriage and first pregnancy were 15 and 18 years, respectively, with 20% pregnant <16 years. Both early marriage and early pregnancy were independently associated with shorter stature, accounting for a decrement of 1.4 cm, which decreased to 1 cm after adjusting for women's education. Effects of early marriage and reproduction persisted after adjusting for the tendency of poorer and less educated men to marry young and short women, indicating a role for social selection. DISCUSSION: The decrements in height associated with early marriage and reproduction are indicative of broader adverse effects on maternal metabolism during a "critical period" of growth and maturation in the life-course of women. Although the magnitudes of effect are relatively small, they affect large numbers of women in this population.

Maternal physical, socioeconomic, and demographic characteristics and childbirth complications in rural lowland Nepal: Applying an evolutionary framework to understand the role of phenotypic plasticity.

OBJECTIVES: Evolutionary perspectives on human childbirth have primarily focused on characteristics of our species in general, rather than variability within and between contemporary populations. We use an evolutionary framework to explore how physical and demographic characteristics of mothers shape the risks of childbirth complications in rural lowland Nepal, where childbearing typically commences in adolescence and chronic undernutrition is widespread, though maternal overweight is increasing in association with nutrition transition. METHODS: We conducted secondary analyses of data from a cluster-randomized trial. Women aged 14-35 years were categorized by age, number of previous pregnancies, height, body mass index (BMI), husband's education, and household wealth. Multivariable logistic regression models tested whether these characteristics independently predicted risks of episiotomy and cesarean section (CS, n = 14 261), and obstructed labor (OL, n = 5185). RESULTS: Risks were greatest among first-time adolescent mothers, though associations with age varied by outcome. Independent of age and parity, short stature and high BMI increased risks of CS and OL, whereas associations were weaker for episiotomy. Male offspring had increased risk of CS and OL but not episiotomy. Wealth was not associated with OL, but lower wealth and lower husband's education were associated with lower likelihood of episiotomy and CS. CONCLUSIONS: At the individual level, the risk childbirth complications is shaped by trade-offs between fertility, growth, and survival. Some biological markers of disadvantage (early childbearing, short stature) increased the risk, whereas low socio-economic status was associated with lower risk, indicating reduced access to relevant facilities. Independent of these associations, maternal age showed complex effects.

The association of maternal nutrition and children's pre-primary experience with over-age attendance in secondary school: evidence from lowland Nepal.

•Over-age attendance is increasing but remains under-studied in South Asia.•Children fall behind by entering pre-primary or primary late, and by repeating a grade during/after primary school.•Rural location, thin and uneducated mothers predicted late pre-primary entry.•Educational research and interventions need to focus on the earlier time-point of pre-primary.•Improving maternal nutrition and education may ensure timely progression of children in school.

Associations of extracurricular physical activity patterns and body composition components in a multi-ethnic population of UK children (the Size and Lung Function in Children study): a multilevel modelling analysis.

BACKGROUND: Body Mass Index (BMI) is a common outcome when assessing associations between childhood overweight and obesity and physical activity patterns. However, the fat and fat-free components of BMI, measured by the Fat Mass Index (FMI) and Fat-Free Mass Index (FFMI), may show contrasting associations with physical activity, while ethnic groups may vary in both physical activity patterns and body composition. Body composition must therefore be evaluated when assessing the associations between childhood overweight and obesity and physical activity in multi-ethnic populations. METHODS: This cross-sectional study investigated associations of BMI, FMI and FFMI z-scores with extracurricular physical activity for 2171 London primary schoolchildren (aged 5-11 years) of black, South Asian and white/other ethnicity. Multilevel mixed-effects ordered logistic modelling was used, adjusting for age, sex and family and neighbourhood socioeconomic status as potential confounders. RESULTS: Controlling for ethnicity and individual, family and neighbourhood socioeconomic confounders, actively commuting children had significantly lower Odds Ratios for being in high BMI (Odds Ratio (OR) = 0.678; 95 % Confidence Interval (CI) = 0.531 - 0.865; p - value = 0.002) and FMI z-score groups (OR = 0.679; 95 % CI = 0.499 - 0.922; p = 0.013), but not FFMI z-score groups, than passive commuters. Children doing sports less than once a week had lower Odds Ratios for being in high BMI (OR = 0.435; 95 % CI = 0.236 - 0.802; p = 0.008) and FFMI (OR = 0.455; 95 % CI = 0.214 - 0.969; p = .041) z-score categories compared to daily active children. Differences in FMI between groups did not reach the significance threshold. A trend towards statistical significance was obtained whereby children's complete inactivity was associated with higher odds for being in higher BMI (OR = 2.222 : 95 % CI = 0.977 - 5.052; p = .057) and FMI z-score groups (OR = 2.485 : 95 % CI = 0.961 - 6.429; p = .060). FFMI z-scores did not show a similar trend with complete inactivity. CONCLUSIONS: Active commuting was objectively associated with lower adiposity, while more frequent extracurricular sports participation was correlated with greater fat-free mass accretion. These relationships were independent of ethnicity and individual, family or neighbourhood socioeconomic confounding factors.

Maternal mental health and economic autonomy in lowland rural Nepal: Do parents-in-law provide constraint or support?

Background and objectives: In patrilocal societies, married women typically co-reside with their parents-in-law, who may act in their son's reproductive interests. These relationships may shape maternal mental health and autonomy. Few studies have examined these dynamics from an evolutionary perspective. Theoretically, marital kin may increase their fitness by increasing maternal investment or by reducing paternity uncertainty. We explored how co-residence with parents-in-law and husband is associated with maternal outcomes to evaluate whether marital kin provide support or constraint. Methodology: We analysed data from 444 households in rural lowland Nepal. Maternal mental health was assessed by General Health Questionnaire. Logistic regression models investigated whether, relative to mothers living with both husband and parents-in-law, those co-resident with other combinations of relatives had poorer mental health and lower household economic autonomy (decision-making, bargaining power), adjusting for socio-economic confounders. Results: Co-residence with husband only, or neither husband nor parents-in-law, was associated with higher odds of mothers reporting feeling worthless and losing sleep but also earning income and making household expenditure decisions. Husband co-residence was associated with overall maternal distress but also with less unpaid care work and greater decision-making responsibility. There were no differences in maternal outcomes for mothers living with parents-in-law only, relative to those living with both husbands and parents-in-law. Conclusions and implications: Co-residence of parents-in-law and husbands was associated with contrasting patterns of maternal mental health and economic autonomy. We suggest that different marital kin place different economic demands on mothers, while restricting their autonomy in different ways as forms of 'mate-guarding'.

Biosocial life-course factors associated with women's early marriage in rural India: The prospective longitudinal Pune Maternal Nutrition Study.

OBJECTIVES: By convention, women's early marriage is considered a sociocultural decision sensitive to factors acting during adolescence such as poverty, early menarche, and less education. Few studies have examined broader risk factors in the natal household prior to marriage. We investigated whether biosocial markers of parental investment through the daughters' life-course were associated with early marriage risk in rural India. We used an evolutionary perspective to interpret our findings. MATERIALS AND METHODS: A prospective cohort recruited mothers at preconception. Children were followed from birth to age 21 years. Multivariable logistic regression models estimated odds ratios of marrying early (<19 years) associated first with wealth, age at menarche and education, and then with broader markers of maternal phenotype, natal household characteristics, and girls' growth trajectories. Models adjusted for confounders. RESULTS: Of 305 girls, 71 (23%) had married early. Early married girls showed different patterns of growth compared to unmarried girls. Neither poverty nor early menarche predicted early marriage. Girls' non-completion of lower secondary school predicted early marriage, explaining 19% of the variance. Independent of girls' lower schooling, nuclear household, low paternal education, shorter gestation, and girls' poor infant weight gain were associated with marrying early, explaining in combination 35% of the variance. DISCUSSION: Early marriage reflects "future discounting," where reduced parental investment in daughters' somatic and educational capital from early in her life favors an earlier transition to the life-course stage when reproduction can occur. Interventions initiated in adolescence may occur too late in the life-course to effectively delay women's marriage.

Associations of age at marriage and first pregnancy with maternal nutritional status in Nepal.

Background and objectives: Women's nutritional status is important for their health and reproductive fitness. In a population where early marriage is common, we investigated how women's nutritional status is associated with their age at marriage (marking a geographical transfer between households), and at first pregnancy. Methodology: We used data from a cluster-randomized control trial from lowland Nepal (n = 4071). Outcomes including body mass index (BMI) were measured in early pregnancy and trial endpoint, after delivery. We fitted mixed-effects linear and logistic regression models to estimate associations of age at marriage and age at pregnancy with outcomes, and with odds of chronic energy deficiency (CED, BMI <18.5 kg/m2), at both timepoints. Results: BMI in early pregnancy averaged 20.9 kg/m2, with CED prevalence of 12.5%. In 750 women measured twice, BMI declined 1.2 (95% confidence interval 1.1, 1.3) kg/m2 between early pregnancy and endpoint, when CED prevalence was 35.5%. Early pregnancy was associated in dose-response manner with poorer nutritional status. Early marriage was independently associated with poorer nutritional status among those pregnant ≤15 years, but with better nutritional status among those pregnant ≥19 years. Conclusions and implications: The primary determinant of nutritional status was age at pregnancy, but this association also varied by marriage age. Our results suggest that natal households may marry their daughters earlier if food insecure, but that their nutritional status can improve in the marital household if pregnancy is delayed. Marriage age therefore determines which household funds adolescent weight gain, with implications for Darwinian fitness of the members of both households.

Girls start life on an uneven playing field: Evidence from lowland rural Nepal.

Background and objectives: Evolutionary research on the sex ratio at birth (SRB) has focused on explaining variability within and between populations, and whether parental fitness is maximized by producing daughters or sons. We tested predictors of SRB in a low-income setting, to understand whether girls differ from boys in their likelihood of being born into families with the capacity to invest in them, which has implications for their future health and fitness. Methodology: We used data from a cluster randomized control trial from lowland rural Nepal (16 115 mother-child dyads). We applied principal component analysis to extract two composite indices reflecting maternal socio-economic and reproductive (parity, age) capital. We fitted mixed-effects logistic regression models to estimate odds ratios of having a girl in association with these individual factors and indices. Results: The SRB was 112. Compared to the global reference SRB (105), there were seven missing girls per 100 boys. Uneducated, early-marrying, poorer and shorter mothers were more likely to give birth to girls. Analysing composite maternal indices, lower socio-economic and reproductive capital were independently associated with a greater likelihood of having a girl. Conclusions and implications: In this population, girls start life facing composite disadvantages, being more likely than boys to be born to mothers with lower socio-economic status and reproductive capital. Both physiological and behavioural mechanisms may contribute to these epidemiological associations. Differential early exposure by sex to maternal factors may underpin intergenerational cycles of gender inequality, mediated by developmental trajectory, education and socio-economic status.

Quantifying the association of natal household wealth with women's early marriage in Nepal.

BACKGROUND: Women's early marriage (<18 years) is a critical global health issue affecting 650 million women worldwide. It is associated with a range of adverse maternal physical and mental health outcomes, including early childbearing, child undernutrition and morbidity. Poverty is widely asserted to be the key risk factor driving early marriage. However, most studies do not measure wealth in the natal household, but instead, use marital household wealth as a proxy for natal wealth. Further research is required to understand the key drivers of early marriage. METHODS: We investigated whether natal household poverty was associated with marrying early, independently of women's lower educational attainment and broader markers of household disadvantage. Data on natal household wealth (material asset score) for 2,432 women aged 18-39 years was used from the cluster-randomized Low Birth Weight South Asia Trial in lowland rural Nepal. Different early marriage definitions (<15, <16, <17 and <18 years) were used because most of our population marries below the conventional 18-year cut-off. Logistic mixed-effects models were fitted to estimate the probabilities, derived from adjusted Odds Ratios, of (a) marrying at different early ages for the full sample and for the uneducated women, and (b) being uneducated in the first place. RESULTS: Women married at median age 15 years (interquartile range 3), and only 18% married ≥18 years. Two-thirds of the women were entirely uneducated. We found that, rather than poverty, women's lower education was the primary factor associated with early marriage, regardless of how 'early' is defined. Neither poverty nor other markers of household disadvantage were associated with early marriage at any age in the uneducated women. However, poverty was associated with women being uneducated. CONCLUSION: When assets are measured in the natal household in this population, there is no support for the conventional hypothesis that household poverty is associated with daughters' early marriage, but it is associated with not going to school. We propose that improving access to free education would both reduce early marriage and have broader benefits for maternal and child health and gender equality.

Looking for an explanation for the excessive male mortality in England and Wales since the end of the 19th century.

Several papers have primarily considered a female disadvantage in mortality as something to explain, considering a male disadvantage to be a "natural condition". Even if, due to biological reasons, shorter life expectancy among males has been demonstrated, other factors need to be involved to explain firstly the increasing, and then the decreasing, of the male relative disadvantage over the past century. The principal aim of this paper is to provide a clearer picture of the major age-class and cause-of-death contributions to male excess mortality in England and Wales from 1881 to 2011. Results indicate a clear shift in contributions to the male disadvantage from differences occurring during the first year of life to those occurring in ageing people, and from tuberculosis, respiratory diseases, external causes and perinatal and congenital conditions to neoplasms and circulatory diseases. In contrast, the narrowing of the gap since 1981 seems to be most closely related to the decrease in the male disadvantage in respiratory diseases and to the simultaneous increasing in the female disadvantage in old-age diseases. The most important novelty of this research relates to the method: instead of using ratios to investigate gender differences in health, we use decomposition methods.

Associations of the objective built environment along the route to school with children's modes of commuting: A multilevel modelling analysis (the SLIC study).

As active commuting levels continue to decline among primary schoolchildren, evidence about which built environmental characteristics influence walking or cycling to school remains inconclusive and is strongly context-dependent. This study aimed to identify the objective built environmental drivers of, and barriers to, active commuting to school for a multi-ethnic sample of 1,889 healthy primary schoolchildren (aged 5-11) in London, UK. Using cross-sectional multilevel ordered logistic regression modelling, supported by the spatial exploration of built environmental characteristics through cartography, the objective built environment was shown to be strongly implicated in children's commuting behaviour. In line with earlier research, proximity to school emerged as the prime variable associated with the choice for active commuting. However, other elements of the urban form were also significantly associated with children's use of active or passive modes of transport. High levels of accidents, crime and air pollution along the route to school were independently correlated with a lower likelihood of children walking or cycling to school. Higher average and minimum walkability and higher average densities of convenience stores along the way were independently linked to higher odds of active commuting. The significance of the relations for crime, air pollution and walkability disappeared in the fully-adjusted model including all built environmental variables. In contrast, relationships with proximity, traffic danger and the food environment were maintained in this comprehensive model. Black children, pupils with obesity, younger participants and those from high socioeconomic families were less likely to actively commute to school. There is thus a particular need to ensure that roads with high volumes of actively commuting children are kept safe and clean, and children's exposure to unhealthy food options along the way is limited. Moreover, as short commuting distances are strongly correlated with walking or cycling, providing high-quality education near residential areas might incite active transport to school.

How Much Education Is Needed to Delay Women's Age at Marriage and First Pregnancy?

Background: Early childbirth is associated with adverse maternal and child health outcomes. In South Asia, where women generally marry before having children, public health efforts need to focus on delaying marriage. Female education is widely considered the primary means to achieve this. However, it remains unclear how much education is required to delay marriage to the universal minimum age of 18 years, or what predicts marriage age in women lacking any education. This is crucial to address in the Terai region of Nepal which has the highest proportion of children out of school and where girls marry and have their first pregnancy early. Methods: We analyzed data from 6,406 women aged 23-30 years from a cluster-randomized trial in lowland Terai Nepal. Using Kaplan-Meier survival analysis, multivariable logistic and Cox proportional hazards regression models, we investigated associations between women's education level and age at marriage and first pregnancy, and the interval between these events. Among the uneducated women, we investigated associations of husband's education level with the same outcomes. Results: Compared to uneducated women, educated women had a greater probability of delaying marriage until the age of 18 years and of pregnancy until 20 years. Women needed to complete grade 9, and ideally 11, to substantially increase their odds of marrying after 18 years. Delaying first pregnancy to 20 years was largely due to marrying later; education had little extra effect. The association of marriage with first pregnancy age worked independently of education. However, later-marrying women, who generally had completed more education, had their first pregnancy sooner after marriage than earlier marrying women. Most uneducated women, regardless of their husbands' level of education, still married under the legal age of marriage. Conclusion: Delaying marriage to majority age requires greater efforts to ensure girls get to school in the first place, and complete secondary education. Since currently only 36% of girls in the Terai attend secondary school, parallel efforts to delay marriage are crucial to prevent early childbearing. Sexual and reproductive health programmes in school and in women's groups for married and uneducated adolescents may help prepare for marriage and pregnancy.

Women's Marriage Age Matters for Public Health: A Review of the Broader Health and Social Implications in South Asia.

In many traditional societies, women's age at marriage acts simultaneously as a gateway to new family roles and the likelihood of producing offspring. However, inadequate attention has previously been given to the broader health and social implications of variability in women's marriage age for public health. Biomedical scientists have primarily been concerned with whether the onset of reproduction occurs before the woman is adequately able to nurture her offspring and maintain her own health. Social scientists have argued that early marriage prevents women from attaining their rightful education, accessing employment and training opportunities, developing social relationships with peers, and participating in civic life. The aim of this review article is to provide comprehensive research evidence on why women's marriage age, independent of age at first childbirth, is a crucial issue for public health. It focuses on data from four South Asian countries, Bangladesh, India, Nepal, and Pakistan, in which marriage is near universal and where a large proportion of women still marry below the United Nations prescribed minimum marriage age of 18 years. Using an integrative perspective, we provide a comprehensive synthesis of the physiological, bio-demographic, and socio-environmental drivers of variable marriage age. We describe the adverse health consequences to mothers and to their offspring of an early age at marriage and of childbearing, which include malnutrition and high rates of morbidity and mortality. We also highlight the complex association of marriage age, educational attainment, and low societal status of women, all of which generate major public health impact. Studies consistently find a public health dividend of increased girls' education for maternal and child nutritional status and health outcomes. Paradoxically, recent relative increases in girls' educational attainment across South Asia have had limited success in delaying marriage age. This evidence suggests that in order for public health initiatives to maximize the health of women and their offspring, they must first address the factors that shape the age at which women marry.