Child Marriage in Mainland China.

Child marriage, defined as marriage before 18 years of age, has harmful consequences for health and development and is an indicator of gender inequality. We used publicly available data from the 2000 and 2010 censuses to estimate the national and provincial-level prevalence of child marriage across mainland China. Between 2000 and 2010, the prevalence of child marriage rose from 2.41 percent to 2.85 percent among women and from 0.54 percent to 0.77 percent among men. The 2010 estimates are equivalent to roughly 1.8 million women and 0.5 million men. Child marriage was more common in western provinces among both girls and boys. Provincial prevalence estimates ranged from 0.44 percent in Beijing to 12.94 percent in Qinghai among girls. Among boys, estimates ranged from 0.13 percent in Beijing to 5.03 percent in Tibet. The gender gap widened across much of the country between censuses. Our results indicate that child marriage continues across mainland China despite laws that ostensibly prohibit the practice. They also draw attention to the global nature of child marriage as a threat to gender equality.

The health consequences of child marriage: a systematic review of the evidence.

BACKGROUND: Child marriage, defined as marriage before 18 years of age, is a violation of human rights and a marker of gender inequality. Growing attention to this issue on the global development agenda also reflects concerns that it may negatively impact health. We conducted a systematic review to synthesize existing research on the consequences of child marriage on health and to assess the risk of bias in this body of literature. METHODS AND FINDINGS: We searched databases focused on biomedicine and global health for studies that estimated the effect of marrying before the age of 18 on any physical or mental health outcome or health behaviour. We identified 58 eligible articles, nearly all of which relied on cross-sectional data sources from sub-Saharan Africa or South Asia. The most studied health outcomes were indicators of fertility and fertility control, maternal health care, and intimate partner violence. All studies were at serious to critical risk of bias. Research consistently found that women who marry before the age of 18 begin having children at earlier ages and give birth to a larger number of children when compared to those who marry at 18 or later, but whether these outcomes were desired was not considered. Across studies, women who married as children were also consistently less likely to give birth in health care facilities or with assistance from skilled providers. Studies also uniformly concluded that child marriage increases the likelihood of experiencing physical violence from an intimate partner. However, research in many other domains, including use of contraception, unwanted pregnancy, and sexual violence came to divergent conclusions and challenge some common narratives regarding child marriage. CONCLUSIONS: There are many reasons to be concerned about child marriage. However, evidence that child marriage causes the health outcomes described in this review is severely limited. There is more heterogeneity in the results of these studies than is often recognized. For these reasons, greater caution is warranted when discussing the potential impact of child marriage on health. We provide suggestions for avoiding common biases and improving the strength of the evidence on this subject. TRIAL REGISTRATION: The protocol of this systematic review was registered with PROSPERO (CRD42020182652) in May 2020.

Recent Trends in Premarital Fertility across Sub-Saharan Africa.

The rising age of first marriage across sub-Saharan Africa over the past 25 years has led many scholars to predict a concurrent increase in premarital childbearing. We examine whether this anticipated increase has materialized using data from 27 countries. Our results reveal considerable heterogeneity. Although levels of premarital fertility have risen by up to 13 percent in recent years in some African countries, other countries have experienced a 7 percent decline. Adolescent premarital childbearing, in particular, has shown marked decline in several countries. Furthermore, although the rising age of marriage exerts clear upward pressure on premarital fertility, decomposition analyses indicate that in half of the countries examined, other factors such as delayed sexual debut and use of contraception counteract this effect. These results temper concerns about the rising numbers of unwed mothers and demonstrate that countries can simultaneously delay marriage and achieve relatively stable, or even declining, levels of premarital childbearing.

Increased Duration of Paid Maternity Leave Lowers Infant Mortality in Low- and Middle-Income Countries: A Quasi-Experimental Study.

BACKGROUND: Maternity leave reduces neonatal and infant mortality rates in high-income countries. However, the impact of maternity leave on infant health has not been rigorously evaluated in low- and middle-income countries (LMICs). In this study, we utilized a difference-in-differences approach to evaluate whether paid maternity leave policies affect infant mortality in LMICs. METHODS AND FINDINGS: We used birth history data collected via the Demographic and Health Surveys to assemble a panel of approximately 300,000 live births in 20 countries from 2000 to 2008; these observational data were merged with longitudinal information on the duration of paid maternity leave provided by each country. We estimated the effect of an increase in maternity leave in the prior year on the probability of infant (<1 y), neonatal (<28 d), and post-neonatal (between 28 d and 1 y after birth) mortality. Fixed effects for country and year were included to control for, respectively, unobserved time-invariant confounders that varied across countries and temporal trends in mortality that were shared across countries. Average rates of infant, neonatal, and post-neonatal mortality over the study period were 55.2, 30.7, and 23.0 per 1,000 live births, respectively. Each additional month of paid maternity was associated with 7.9 fewer infant deaths per 1,000 live births (95% CI 3.7, 12.0), reflecting a 13% relative reduction. Reductions in infant mortality associated with increases in the duration of paid maternity leave were concentrated in the post-neonatal period. Estimates were robust to adjustment for individual, household, and country-level characteristics, although there may be residual confounding by unmeasured time-varying confounders, such as coincident policy changes. CONCLUSIONS: More generous paid maternity leave policies represent a potential instrument for facilitating early-life interventions and reducing infant mortality in LMICs and warrant further discussion in the post-2015 sustainable development agenda. From a policy planning perspective, further work is needed to elucidate the mechanisms that explain the benefits of paid maternity leave for infant mortality.

Accessibility and potency of uterotonic drugs purchased by simulated clients in four districts in India.

BACKGROUND: Surveillance of drug quality for antibiotics, antiretrovirals, antimalarials and vaccines is better established than surveillance for maternal health drugs in low-income countries, particularly uterotonic drugs for the prevention and treatment of postpartum hemorrhage. The objectives of this study are to: assess private sector accessibility of four drugs used for uterotonic purposes (oxytocin, methylergometrine, misoprostol, valethamate bromide); and to assess potency of oxytocin and methylergometrine ampoules purchased by simulated clients. METHODS: The study was conducted in Hassan and Bagalkot districts in Karnataka state and Agra and Gorakhpur districts in Uttar Pradesh state. A sample of 877 private pharmacies was selected (using a stratified, systematic sampling with random start), among which 847 were successfully visited. The target sample size for assessment of accessibility was 50 pharmacies per drug, per district. The target sample size for potency assessment was 100 purchases each of oxytocin and methylergometrine across all districts. Successful drug purchases varied by state. RESULTS: In Agra and Gorakhpur, 90%-100% of visits for each of the drugs resulted in a purchase. In Bagalkot and Hassan, only 29%-52% of visits for each drug resulted in a purchase. Regarding potency, the percent of active pharmaceutical ingredient was assessed using United States Pharmacopeia monograph #33 for both drugs; 193 and 188 ampoules of oxytocin and methylergometrine, respectively, were assessed. The percent of oxytocin ampoules outside manufacturer specification ranged from 33%-40% in Karnataka and from 22%-50% in Uttar Pradesh. In Bagalkot and Hassan, 96% and 100% of the methylergometrine ampoules were outside manufacturer specification, respectively. In Agra and Gorakhpur, 54% and 44% were outside manufacturer specification, respectively. CONCLUSION: Private sector accessibility of uterotonic drugs in study districts in Karnataka warrants attention. Most importantly, interventions to assure quality oxytocin and particularly methylergometrine are needed in study districts in both states.

State and sex-specific trends in the annual incidence of child marriage in the United States since the year 2000.

OBJECTIVES: Child marriage, defined as marriage before 18 years of age, is a violation of human rights with harmful consequences for population health, educational attainment, and economic opportunities. Child marriage is legal across most of the United States but how often it happens is challenging to estimate. We measured state and sex-specific trends in the annual incidence of child marriage in 41 states and the District of Columbia. METHODS: We collected data from marriage certificates filed between 2000 and 2019. These certificates allowed us to identify marriages that occurred within each state and involved a spouse under the age of 18. We divided the number of 15-17-year-olds married in each year by the number of children in that age range living in the state in that year and graphed these annual rates to present trends over time. RESULTS: The rate of child marriage declined substantially across the United States between 2000 and 2019. Over 75 % of all married children in each state were girls. Girls married men who were an average of 4 years older than they were, and the age gap was substantially larger when girls married than when boys married. CONCLUSIONS: Child marriage continues across most of the United States and reflects gender inequities in American society. The continued legality of marriage before the age of 18 is at odds with the country's commitment to eliminate child marriage by the year 2030 and violates the human rights of children, primarily girls, across the country.

Challenges to the Provision of Services for Sexual and Intimate Partner Violence in Canada During the COVID-19 Pandemic: Results of a Nationwide Web-Based Survey.

The COVID-19 pandemic increased women's vulnerability to intimate partner and sexual violence (IPV/SV), as well as challenging organizations' ability to respond. This research is based on a 2021 nationwide survey about the impacts of COVID-19 on IPV/SV services across Canada. Nationwide, organizations adopted several measures to reduce the risk of COVID-19 transmission, including scaling back services, reducing or stopping their volunteers, and reducing the number of in-shelter clients. Organizations detailed several financial challenges including increased costs and cancelation of fundraising events. Organizations also reported many staffing challenges, from increased workloads to staff leaves of absence due to childcare responsibilities, mental health reasons, or contracting COVID-19. Policies ensuring adequate financial support to IPV/SV services in nonemergency times could help minimize disruption to service delivery during crisis situations.

A protocol for a controlled, pre-post intervention study to change attitudes toward child marriage in Southwestern Nigeria using targeted radio programming.

BACKGROUND: Child marriage hinders progress toward population health and development goals. Cost effective interventions that address the root causes of child marriage are needed to speed progress toward ending the practice. Nigeria is home to the largest number of married girls in Africa and many of these girls are members of the Hausa ethnic group, making efforts to tackle this issue particularly urgent among this population. METHODS: Radio programs have the potential to inform large numbers of people about the harms of child marriage and change their support for the practice at low cost. We will develop a series of radio programs that address gender inequitable attitudes that motivate child marriage among Hausa communities in Ibadan, Nigeria. The content of the series will be based on input from the Hausa community. A baseline survey that measures knowledge of and support for child marriage will be conducted among randomly selected samples of Hausa adults in two cities: Ibadan, which will serve as the intervention site, and Akure, the control site. The radio programs will then air on Hausa-language stations in Ibadan over a three-month period, with the aim of informing persons of the potential harms of child marriage and reducing their support for the practice. A follow-up survey with the same individuals surveyed at baseline will be conducted in both cities. We will measure the impact of this intervention by comparing changes in these outcomes over time in the intervention site (Ibadan) with changes in the same outcomes in the control site (Akure). CONCLUSION: This study will investigate whether a series of targeted radio programs can reduce support for child marriage. The intervention is readily scalable and cost-effective and, if it effectively shifts attitudes toward child marriage, could represent a promising way of addressing child marriage in Nigeria.

Child Marriage or Statutory Rape? A Comparison of Law and Practice Across the United States.

PURPOSE: In many U.S. states, children can legally marry at an earlier age than they can legally consent to sex, leading to situations in which sex between spouses may be a criminal act. Some states exempt sex between married persons from their definition of statutory rape, which may create perverse incentives for child marriage. We estimated the number of child marriages that violated statutory rape laws across the United States since January 1, 2000. METHODS: We created a longitudinal database of statutory rape laws in place from 2000 to 2020 in each state. Using data from marriage certificates filed in 44 states and Washington, DC, we compared the age of married spouses with the text of state-specific statutory rape laws in place at the time the marriages occurred. RESULTS: Child marriages violated statutory rape laws in 14 states. The proportion of child marriages that violated statutory rape laws varied from 1% to over 50%. In 33 states, some or all statutory rape laws exempted sex between married couples from the definition of crimes. In these states, the proportion of child marriages that would have been crimes, without these exemptions, varied from less than 1% to over 80%. CONCLUSIONS: Our results highlight the blurred legal and conceptual boundaries between child marriage and sexual violence. The simultaneous legality of child marriage and marital exemptions to statutory rape laws provide legal loopholes for sexual acts with children that would otherwise be considered crimes. Marital exemptions to statutory rape laws may also incentivize a substantial portion of child marriages.

Physical violence by partner during pregnancy and use of prenatal care in rural India.

The role of physical violence during pregnancy on receipt of prenatal care is poorly understood, particularly for South Asian countries that have high levels of both fertility and domestic violence. Data from the 1998/1999 Indian National Family Health Survey and a 2002/2003 follow-up survey that re-interviewed women in four states were analyzed, examining the association between physical violence during pregnancy and the uptake of prenatal care. Women who experienced physical violence during pregnancy were less likely to receive prenatal care, less likely to receive a home-visit from a health worker for a prenatal check-up, less likely to receive at least three prenatal care visits, and less likely to initiate prenatal care early in the pregnancy. This study highlighted the constraining effect that the experience of physical domestic violence during pregnancy had on the uptake of prenatal care for women in rural India. Maternal health services must recognize the unique needs of women experiencing violence from their intimate partners.

Child marriage in Canada: A systematic review.

Child marriage, defined by the United Nations as marriage before the age of 18, is considered a violation of human rights with negative consequences for girls' health. We systematically reviewed existing academic literature and news media to learn what is known about the frequency of child marriage in Canada and its effects on health. Approximately 1% of 15-19-year-olds in Canada were married or in common law unions in 2016. News reports document cases of child marriage among religious minority communities but no nationwide estimates of the frequency of marriage before the age of 18 were identified. Sources consistently show girls are more likely to marry as teens than boys. Information on married teens between 15 and 19 years of age suggests similarities in marriage patterns among this age group in Canada and child marriage practices globally. Further research is needed to measure Canada's progress toward eliminating child marriage.

Cash transfer programs have differential effects on health: A review of the literature from low and middle-income countries.

BACKGROUND: Cash transfer programs have grown increasingly popular and are now used as interventions to target a wide array of health outcomes across many diverse settings. However, cash transfer experiments have yielded mixed results, highlighting gaps in our understanding of how these programs work. In particular, we do not yet know whether cash transfers are more effective for certain health outcomes compared to others, or are more effective for some population subgroups compared to others. Here, we ask whether the effects of cash transfers on health outcomes differ across study subgroups. METHODS: We reviewed the literature on cash transfer experiments conducted in low and middle income countries, published in English between 1985 and 2015. We documented whether the investigators reported either i) stratum-specific estimates or ii) the interaction term between subgroups and exposure to the intervention. For studies that presented stratum-specific estimates without statistical tests for heterogeneity, we assessed heterogeneity across subgroups with a Cochran Q test. RESULTS: Of the 56 studies we reviewed, 40 reported effects on study subgroups. The majority of the cash transfer interventions had different magnitudes of effects on health across subgroups. This heterogeneity was often underreported or not formally analyzed. We find substantial heterogeneity of cash transfers on child health and on adult health yet little heterogeneity of cash transfers on sexual and reproductive health. CONCLUSIONS: Accounting for the heterogeneous impacts of cash transfers during program design and evaluation is necessary to better target cash transfer programs and generate more precise data on their effects.

Changes in support for the continuation of female genital mutilation/cutting and religious views on the practice in 19 countries.

Campaigns to end female genital mutilation/cutting (FGM/C) have been ongoing for decades. Many countries have adopted legislation that criminalises the practice and programmatic interventions aim to reduce support for it by presenting it as a violation of human rights and by highlighting associated health risks. We used Demographic and Health Survey data from 19 countries to measure national-level trends in the prevalence of FGM/C, reported support for the continuation of the practice, and the belief that it is a religious requirement among men and women. Levels and patterns in each of these outcomes vary markedly between countries. More than half of men and women born in recent years in Guinea and Mali support the continuation of the practice and believe that it is a religious requirement. Support for the continuation of FGM/C has fallen in Benin, Burkina Faso, Chad, Egypt, Ethiopia, Kenya, Senegal, and Tanzania, but has risen in Guinea, Niger, Nigeria, and Sierra Leone. The belief that FGM/C is a religious requirement is common, particularly in countries with high prevalence of cutting. Changes in support for cutting mirror those in the belief that it is a religious requirement.

The Lived Experience of Child Marriage in the United States.

Despite international and domestic calls to end child marriage, 48 U.S. states permit the marriage of minors younger than age 18 as of August 2018. In developing nations, child marriage is associated with a wide range of adverse economic, health, and mental health outcomes, yet little research has been done to understand its effects on developed nations such as the United States. This study is the first to interview adults who were married as children in the United States, to investigate the reasons why the marriages occurred, and qualitatively understand the experiences of married American children. 21 participants (20 females and 1 male) self-selected into this study to complete an online questionnaire and be interviewed by phone. Participants were married between ages 13 and 17. Most participants (n = 18) reported physical, sexual, financial, or emotional abuse during their marriage as well as unwanted and/or unplanned pregnancies. This study shows some important social justice issues related to consent and the qualitative differences inherent in deciding to marry during childhood. Notably, this study did not find that pregnancy was the reason most participants married as minors, as some policy debates across the U.S. report.

Child Marriage in the United States: How Common Is the Practice, And Which Children Are at Greatest Risk?

CONTEXT: Marriage before the age of 18, commonly referred to as child marriage, is legal under varying conditions across the United States. The prevalence of child marriage among recent cohorts is unknown. METHODS: American Community Survey data for 2010-2014 were used to estimate the average national and state-level proportions of children who had ever been married. Prevalence was calculated by gender, race and ethnicity, and birthplace, and the living arrangements of currently married children were examined. RESULTS: Approximately 6.2 of every 1,000 children surveyed had ever been married. Prevalence varied from more than 10 per 1,000 in West Virginia, Hawaii and North Dakota to less than four per 1,000 in Maine, Rhode Island and Wyoming. It was higher among girls than among boys (6.8 vs. 5.7 per 1,000), and was lower among white non-Hispanic children (5.0 per 1,000) than among almost every other racial or ethnic group studied; it was especially high among children of American Indian or Chinese descent (10.3 and 14.2, respectively). Immigrant children were more likely than U.S.-born children to have been married; prevalence among children from Mexico, Central America and the Middle East was 2-4 times that of children born in the United States. Only 20% of married children were living with their spouses; the majority of the rest were living with their parents. CONCLUSIONS: Child marriage occurs throughout the country. Research on the social forces that perpetuate child marriage is needed to inform efforts to prevent it.

The impact of eliminating primary school tuition fees on child marriage in sub-Saharan Africa: A quasi-experimental evaluation of policy changes in 8 countries.

BACKGROUND: Child marriage harms girls' health and hinders progress toward development goals. Randomized studies have shown that providing financial incentives for girls' education can effectively delay marriage, but larger-scale interventions are needed in light of slow progress toward curbing the practice. Many sub-Saharan African countries eliminated primary school tuition fees over the past two decades, resulting in massive increases in enrolment. We measured the effect of these policies on the probability of primary school completion and of marriage before 15 and 18 years of age. METHODS: We used Demographic and Health Surveys to assemble a dataset of women born between 1970 and 2000 in 16 countries. These data were merged with longitudinal information on the timing of tuition fee elimination in each country. We estimated the impact of fee removal using fixed effects regression to compare changes in the prevalence of child marriage over time between women who were exposed to tuition-free primary schooling and those who were not. RESULTS: The removal of tuition fees led to modest average declines in the prevalence of child marriage across all of the treated countries. However, there was substantial heterogeneity between countries. The prevalence of child marriage declined by 10-15 percentage points in Ethiopia and Rwanda following tuition elimination but we found no evidence that the removal of tuition fees had an impact on child marriage rates in Cameroon or Malawi. Reductions in child marriage were not consistently accompanied by increases in the probability of primary school completion. CONCLUSIONS: Eliminating tuition fees led to reductions in child marriage on a national scale in most countries despite challenges with implementation. Improving the quality of the education available may strengthen these effects and bolster progress toward numerous other public health goals.

Thirty-year trends in the prevalence and severity of female genital mutilation: a comparison of 22 countries.

INTRODUCTION: Female genital mutilation (FGM) harms women's health and well-being and is widely considered a violation of human rights. The United Nations has called for elimination of the practice by 2030. METHODS: We used household survey data to measure trends in the prevalence of FGM in 22 countries. We also examined trends in the severity of the practice by measuring changes in the prevalence of flesh removal, infibulation and symbolic 'nicking' of the genitals. We evaluated the extent to which measurement error may have influenced our estimates by observing the consistency of reports for the same birth cohorts over successive survey waves. RESULTS: The prevalence of all types of FGM fell in 17 of 22 countries we examined. The vast majority of women who undergo FGM have flesh removed from their genitals, likely corresponding to the partial or total removal of the clitoris and labia. Infibulation is still practised throughout much of sub-Saharan Africa. Its prevalence has declined in most countries, but in Chad, Mali and Sierra Leone the prevalence has increased by 2-8 percentage points over 30 years. Symbolic nicking of the genitals is relatively rare but becoming more common in Burkina Faso, Chad, Guinea and Mali. CONCLUSION: FGM is becoming less common over time, but it remains a pervasive practice in some countries: more than half of women in 7 of the 22 countries we examined still experience FGM. The severity of the procedures has not changed substantially over time. Rigorous evaluation of interventions aimed at eliminating or reducing the harms associated with the practice is needed.

Direct observation of uterotonic drug use at public health facility-based deliveries in four districts in India.

OBJECTIVE: To describe intrapartum uterotonic drug use and related behaviors in public health facility-based deliveries and to describe drug storage conditions in associated pharmacies. METHODS: A descriptive study was conducted between August and November 2011 to document practices related to uterotonic administration and storage based on direct observation of deliveries at public health facilities in four Indian districts (n=97, n=89, n=91, and n=89) with contrasting maternal health and socioeconomic indicators. RESULTS: Uterotonic drug use before and after delivery was common among the 366 study participants. Labor augmentation rates ranged from 53.5%-93.0% of deliveries across districts, with many receiving multiple uterotonics and administration via intramuscular injection or intravenous push. Uterotonic use following delivery ranged from 78.6%-99.1% across districts, with correct use of uterotonics for postpartum hemorrhage prevention varying from 6.0%-8.8% in Uttar Pradesh and 41.2%-76.4% in Karnataka. Active management of the third stage of labor following Indian guidelines was less than 10% in all districts. Storage of uterotonics at room temperature was common. CONCLUSION: Given that labor augmentation is nearly routine and at odds with Indian guideline recommendations, rigorous research is needed to assess maternal and fetal outcomes of current versus guidelines-based practice. Active management of the third stage of labor as per Indian guidelines was minimal.

Uterotonic use during childbirth in Uttar Pradesh: accounts from community members and health providers.

OBJECTIVE: this qualitative study aimed to document provider and community practices regarding uterotonic use during labour and delivery in Uttar Pradesh, India, as well as the knowledge, attitudes, and values that underlie such use. METHODS, SETTING, AND PARTICIPANTS: a total of 140 in-depth interviews were conducted between May and July 2011 in Agra and Gorakhpur districts, with clinicians, nurses, recently delivered women, mothers-in-law with at least one grandchild, traditional birth attendants, unlicensed village doctors, and pharmacist assistants at chemical shops. FINDINGS: interviews reveal that injectable uterotonic use for the purposes of labour augmentation is widespread in both clinical and community settings. However, use of uterotonics for postpartum haemorrhage prevention and treatment appears to be relatively limited and was rarely discussed by respondents. Key beliefs underlying uterotonic use were identified, including high valuation of labour pain, rapid delivery, and biomedical intervention, particularly administration of medicines. Other factors promoting the use of uterotonics for labour augmentation included lack of knowledge about adverse effects, provider beliefs that prolonged labour poses risks to the baby, community perceptions that modern women are less able to have spontaneous delivery, and financial incentives for uterotonic administration. CONCLUSIONS AND IMPLICATIONS: major challenges to overcome in minimising uterotonic misuse include entrenched use for labour augmentation in both institutional and community deliveries, perceptions of injectable uterotonics as curative agents symbolic of biomedical care, and the widespread availability of these drugs. The findings demonstrate a need for programmes that reduce inappropriate use of uterotonics, promote appropriate use for postpartum haemorrhage prevention and treatment, and ensure adherence to evidence-based guidelines.