Chapter 2: Literature Review
In this chapter the relationship between child marriage and birth spacing will be demonstrated. Empirical evidence regarding child marriage and birth spacing is essentially non-existent for the West African region, specifically Niger, where the highest prevalence of child marriage occurs. To compensate for the limited empirical evidence available for the region reviews of literature from other regions with a comparably high prevalence of child marriage and fertility, such as other sub-Saharan African and South Asian countries, will be conducted complemented by grey literature from international organizations such as UNICEF, WHO, and the UN. Of the studies published, many have used DHS data in order to examine trends in child marriage and fertility outcomes while others have employed cross-sectional or case-control samples or other representative surveys (Koski & Nandi n.d.). As the situations in other regions may not be directly applicable to Niger the literature review focused on examining insights, parallels and methodologies that may be extrapolated.
2.1 Definitions of Marriage and Birth Intervals
While the definition of child marriage is well accepted to be a formal or informal union where at least one party is under the age of 18 (USAID 2012), the use of the term marriage is inconsistent depending on the region (Bledsoe & Cohen 1993). Within Africa there are many forms in which marriage can take place, such as legal unions, consensual unions and customary unions making it difficult to draw a relationship between age at marriage and fertility outcomes (Bledsoe & Cohen 1993). In addition, while in many regions marriage is considered to be a single event, in other regions, such as a number within Africa, it is considered a process that can stretch over long periods of time, even years, contributing to the difficulties in collecting accurate reports of age at marriage (Bledsoe & Cohen 1993). In order to achieve as much consistency as possible in the reporting of age of marriage, surveys such as the DHS instead use the term cohabitation (Bledsoe & Cohen 1993)– where couples reside as if married (UNICEF 2005). The limitation here is that while this definition avoids misreporting due to various forms of marriage in Africa, it does not include those who do not reside with their partner (Bledsoe & Cohen 1993), such as those in polygamous relationships living in separate homes (Bongaarts et al. 1984).
A birth interval is defined as the time elapsed between two successive live births (Benga et al. 2013; Hailu & Gulte 2016; Yohannes et al 2011). The definition of optimal birth intervals has changed from the recommended two to three years to a minimum of 24 months with a suggestion of three to five years being most beneficial (USAID 2005; Setty-Venugopal et al 2002; Yohannes et al 2011; Santhya et al 2010; Marston 2005). Optimal birth spacing ensures maximum health benefits for both mother and child (Hailu & Gulte 2016; Benga et al 2013). Birth intervals outside of this optimal range, both above and below, increases risks of maternal and child morbidity and mortality (Yohannes et al 2011; Setty-Venugopal et al 2002). Short birth intervals occur when a live birth occurs less than 24 months after the previous live birth (Marston 2005; INS/Niger & ICF International 2013). Very short birth intervals, those that occur less than 18 months after the previous live birth, pose a much greater risk to both mother and child (Marston 2005; INS/Niger & ICF International 2013).
|Birth Interval||Duration between live births|
|Very Short||< 18 months|
|Short||< 24 months|
|Optimal||Minimum 24 months|
|Long||> 5 years|
|Table 1: Definitions of Birth Intervals|
2.2.1 Child Marriage
Child marriage is a harmful practice deeply rooted in many cultures and traditions (Maswikwa et al 2015; Myers & Harvey 2011). It falls under gender based violence and discrimination, violating children’s basic human rights and affects millions of children, especially girls, worldwide (Hampton 2010; The Population Council 2008; UNICEF 2012; UNICEF 2014). Child marriage does not only impact the lives of adolescent girls aged 16 to 18 but also a large proportion of girls under the age of 16 (Raj et al 2009). Some are even married off at birth and are then forced to move in with their husband as early as the age 7 (Nour 2006). With the highest prevalence of child marriage being in West Africa, particularly Niger, studies into the underlying causes and implications of child marriage are required (UNICEF 2014).
There are many interacting driving factors contributing to the continuation of child marriage such as poverty, perceived protection of girls, culture and tradition, gender inequality, strengthening social ties and a lack of opportunities for girls and women outside of the home setting (Myers & Harvey 2011; Walker 2013; Loaiza & Wong 2012; Nour 2006; UNICEF 2001; Maswikwa et al. 2015; Jensen & Thornton 2003; de Silva-de-Alwis 2008; Davis et al. 2013; Nour 2009). These underlying factors need to be addressed in order to break this cycle and allow for social, health and economic development.
At the centre of child marriage lies gender inequality, with females being most disadvantaged (Wetheridge & Antonowicz 2014). This discrimination is often perpetuated by socio-cultural norms and religious views towards women (Delprato et al. 2015). The degree of gender inequality surrounding child marriage is illustrated through the difference in legal age of marriage between boys and girls (Myers & Harvey 2011). In Niger, the legal age of marriage for girls remains at 15 years old, and with parental consent below 15 whereas the legal age of marriage for boys both with or without consent is 18, the internationally agreed upon legal age of marriage (UN 2011). In regions where child marriage is prevalent, a lower value is placed on girls due to social norms and cultural traditions, leaving them with little choice in terms of the trajectory of their life and health (de Silva-de-Alwis 2008); Loaiza & Wong 2012; WHO Secretariat 2012) .
Poverty and Protection
Child marriage varies across regions but is more prevalent in poor, rural communities (UNICEF 2014; Hampton 2010). For example, in Niger the prevalence of child marriage is approximately double in rural regions compared to urban regions, 85% and 44% married by age 18, respectively (Wetheridge & Antonowicz 2014; UNICEF 2014; USAID 2012).
|Figure X: Proportion of Women Married by Age 18 by Residence
Source: Wetheridge, L & Antonowicz L. (2014) Child Marriage in West Africa and Cameroon: A Desk Review. Plan WARO.
Additionally, girls of the lowest wealth quintiles are 2.5 times more likely to be married as children compared to those of the top wealth quintiles (UNICEF 2014). While child marriage is more prevalent among the rural it is not exclusive to these cohorts and urban girls or those of higher socio-economic status are also at risk (de Silva-de-Alwis 2008). Families often feel they have no choice but to marry off their daughters young in order to reduce economic hardship (Warner 2004; Jain & Kurz 2007; Maswikwa 2015; de Silva-de-Alwis 2008). Girls are often seen as a financial burden, incapable of generating an income and contributing to the family finances. (Walker 2013; Delprato et al. 2015; Nour 2006; Myers & Harvey 2011; Raj 2010). Girls are married young in exchange for a bride-price or dowry, as a way of reducing their financial responsibilities and improving the family’s social standing and honour (Jain & Kurz 2007; Wetheridge & Antonowicz 2014; Warner 2004; Nour 2009; Delprato et al. 2015; UNICEF 2001; Nour 2006; de Silva-de-Alwis 2008). High rates of fertility and rapid population growth further intensify poverty (Cleland et al. 2006). In countries, such as Niger, where fertility rates are high (Jensen & Thornton 2003), at 7.642 children per woman in 2012 (The World Bank 2017), the financial difficulty of raising these children is extreme While parents may see marrying their daughters at such a young age as a form of protection and a pathway out of a world of poverty, this practice instead perpetuates the cycle of poverty for these girls and future generations (de Silva-de-Alwis 2008).
When girls are married young they are often forced to leave their family or support system and school in order to begin their lives as wives and mothers (Davis et al. 2013; USAID 2012; Jensen & Thornton 2003; UNICEF 2012; The Population Council 2008; Wetheridge & Antonowicz 2014). Despite school being free of charge by law, Nigerien girls are often refused the right to an education due to associated incidental costs, including books and uniforms (Wetheridge & Antonowicz 2014). In Niger, girls with no education are more likely than their educated counterparts to be married early (84% vs. 68%), resulting in approximately three-quarters of girls being illiterate and creating a barrier to health care (Wetheridge & Antonowicz 2014). Furthermore, Delprato et al. (2015) found that for every year marriage is postponed for young girls, literacy in sub-Saharan Africa is increased by 22.2%. By terminating their education at such an early age girls are further disadvantaged, as they are not given the opportunity for productivity, and escaping the cycle of poverty (Jensen & Thronton 2003; Mathur et al. 2003; Jain & Kurz 2007; Malhotra et al. 2011). Removal from school in order to become wives and mothers, essentially eliminate opportunities to acquire the knowledge required to make decisions in regards to their own and their family’s health (Marthur et al 2003; Williamson 2013; Kamal & Pervaiz 2012).
A study comparing sub-Saharan Africa and South West Asia found that for every year of marriage postponement for young girls aged 11 to 17 in sub-Saharan Africa there was an increase in the average education attainment – a relationship that grew stronger while accounting for other factors associated with early marriage (Delprato et al. 2015). However, there may be other factors contributing to the low education attainment of young girls such as conflict and poor quality education (Delprato et al. 2015). While lack of female education is both a cause and a consequence of child marriage, male education also plays a role with child marriage being more prevalent in women whose husbands hold a lower level of education when compared to educated males (Raj et al. 2009).
Spousal Age Difference and Autonomy
In countries such as Niger where polygyny is prevalent, the age gap between girls and their husbands are amongst the highest worldwide (Jain & Kurz 2007). Often married to men much older, by an average of nine years (Wetheridge & Antonowicz 2014), young Nigerien girls of child marriage lack autonomy and decision-making power in regards to their own lives and in the home (Das Gupta et al. 2008; Jensen & Thornton 2003; Santhya & Jejeebhoy 2003). Being significantly older means these men are more likely to be able to afford the large dowry of a young bride (Nour 2006; Warner 2004). When girls are taken out of school early to be married, a gap in education attainment forms, and creates an imbalance in the home, putting girls of child marriage at increased risk of violence and sexual abuse (Nour 2006; UNICEF 2005; Jensen & Thornton 2003; UNICEF 2012; Jain & Kurz 2007). These girls often have little autonomy and decision making power and are at the mercy of their husbands in terms of health, finances, and support – a condition that often persists throughout marriage (Jensen & Thornton 2003; Jain & Kurz 2007; Santhya et al. 2010; Nour 2006).
2.2.2 Birth Spacing and Fertility
Fertility is an important aspect of population dynamics with birth spacing directly impacting both population growth and maternal and child health (Benga et al. 2013; Singh et al. 2010; Hailu & Gulte 2016). Referring to Bongaart’s determinants of fertility, fertility is affected by proximate and distal, or socioeconomic, factors – with distal factors influencing proximate factors to impact fertility (Benga et al 2013; Yohannes et al 2011; Bongaarts et al. 1984). With consistently high fertility rates, high maternal and child mortality and low contraceptive use in countries such as Niger, understanding the relationship between underlying contextual, proximate and socio-economic factors is crucial (Bongaarts et al. 1984; UNICEF 2008; Singh & Samara 1996; Sayem & Nury 2011).
Birth spacing is important in protecting the health of both mother and child (Benga et al. 2013; Hailu & Gulte 2016; UNICEF 2008; Sayem & Nury 2011). There are many socio-economic, biological and demographic determinants for birth intervals such as education, modern contraception use, breastfeeding duration, postpartum abstinence and amenorrhea, maternal age, and age at marriage (Benga et al. 2013; Yohannes et al. 2011; Kamal & Pervaiz 2012). However, while child spacing and family planning positively impact maternal and child health outcomes it does not ensure maternal and child health throughout pregnancy and childbirth (UN Secretary-General 2001; Benga et al. 2013).
Optimal Birth Spacing
The optimal time between successive live births is defined as being a minimum of two years to a maximum of five years to maximize maternal and child health (Benga et al. 2013; de Jonge et al 2014; Kamal & Pervaiz 2012; Hailu & Gulte 2016). By practicing optimal birth spacing the mother is able to adequately recuperate following the previous birth, abide to the recommended breastfeeding duration, and allow for the successive pregnancy to be carried to term (Benga et al 2013; Yohannes et al. 2011). Optimal birth spacing offers the best opportunity for healthy development of not only mother and child in question, but also for the other members of the family (Kamal & Pervaiz 2012; Hailu & Gulte 2016; Setty-Venugopal et al 2002). When spaced properly, children are at less risk for being born low birth weigh, preterm, or small for gestational age. Additionally they are able to receive proper nutrition through breastfeeding (USAID 2005). Not practicing traditional methods of contraception, such as breastfeeding for the recommended period of time (24-months), increases the risk of having a short birth interval by forty-nine times (Hailu & Gulte 2016).
Short and Very Short Birth Spacing
Short birth intervals are harmful to both the mother and fetus/child due to stress, hormone imbalance, and maternal depletion syndrome – a syndrome that occurs when the required nutrients to support a pregnancy are not available due to short or very short birth intervals (de Jonge et al. 2014; Adebowale 2011; Stephannsson et al. (2003; King 2003). Maternal depletion syndrome can occur when girls conceive too closely, within two years, to the onset of menarche, or who conceive too closely to their last live birth (King 2003). Defined as a birth interval less than two years, with a very short birth interval being defined as less than 18 months, neonatal and infant mortality and morbidities, such as low birth weight, small for gestational age, and preterm birth, are increased for births within these intervals (Benga et al 2013). This is in part due to the fact that the maternal nutrient stores have not been adequately replaced and therefore cannot support a growing fetus to term (King 2003). However, other factors such as socioeconomic status, maternal education, parity, culture and life style choices may confound any associations between short and very short birth intervals and poor maternal and child health outcomes (Stephannsson et al. 2003; Setty-Venugopal 2002; USAID 2005). Furthermore, closely spaced in births not only have implications on mother, child and their families, but also on society in general as a rapidly growing population undermines economic and social development (USAID 2005).
Long Birth Spacing
Recent studies suggest that birth intervals longer than five years also pose harms to both mother and child as the mother loses any natural protection from previous births therefore putting mothers and children at similar risk as first time mothers and first born children (Hailu & Gulte 2016; Yohannes et al. 2011; Setty-Venugopal et al. 2002)
2.2.3 Child Marriage and Birth Spacing
When girls are forced to leave school at a young age they are often forced to embrace a new life as wives, mothers, and caregivers, especially in rural regions (Myers & Harvey; Bledsoe & Cohen 1993). Early marriage often leads to early childbearing, putting young girls and children at increased risk of mortality and morbidity Malhotra et al 2011). Furthermore, due to their lack of knowledge and autonomy, these girls are more likely to experience poorly spaced births (Santhya & Jejeebhoy 2003).
With optimal birth spacing being most beneficial to both mother and child adherence to these recommendations is key. Exavery et al. (2012) found that the highest proportion of Tanzanian women who did not adhere to WHO birth spacing recommendations was amongst adolescent girls aged 15 to 19 at 76% and declined as age increases, with adolescent girls being approximately 14 times more likely to have poorly spaced births compared to women 45 to 49 years of age. Similar findings from northern Iran show that as maternal age at birth increased birth interval increased (Hajian-Tilaki et al. 2009). In India, Raj et al. (2009) found that women of child marriage were more likely than their adult married counterparts to have experienced any childbirth birth of three or more children and short birth spacing after adjusting for duration of marriage.
22.214.171.124 Socio-Cultural Factors
In cultures where child marriage is prevalent, girls are often not in control of their sexual and reproductive health (Mathur et al. 2003). At a young age girls’ health is in the hands of their father and once married young is put in the hands of their often older husband (Mathur et al. 2003). This limits the girls’ decision-making power in the household as well as the control over their own sexual and reproductive health, including family planning needs (Maswikwa et al. 2015). Combined with a lack of knowledge and information girls of child marriage do not have access to contraceptives and proper, appropriate reproductive health services such as family planning to properly space pregnancies and ensure optimal maternal and child health (Mathur et al 2003). Women who are unable to access health care services on their own due to cultural traditions can also experience negative sexual and reproductive health implications (USAID 2005). Despite the benefits of family planning and birth spacing, very few girls in developing countries will utilize contraceptives to space births or delay childbearing as contraceptives are not widely available and this practice may not be acceptable to family members (UNICEF 2001). Additionally, in some countries adolescents under the age of 18 are unable to access reproductive health care services, denying girls of child marriage access and putting their health at risk (WHO Secretariat 2012). The decision to become pregnant at a young age and how frequently is rarely the choice of the girl but instead that of her husband or in-laws (Williamson 2013). Furthermore, in countries such as Niger where large spousal age gaps exist, young girls are less likely to make decisions regarding their health, especially in regards to the use of contraceptives (Williamson 2013).
126.96.36.199 Socio-Political Factors
Lack of enforcement of national laws and international agreements perpetuates the cycle of child marriage and adverse fertility outcomes by allowing the continuation of a harmful practice (Jensen & Thornton 2003; Walker 2013; Maswikwa et al. 2015). A multi-country study across sub-Saharan Africa by Maswikwa et al. (2015) found that when comparing countries with inconsistent laws on age at marriage, including West African countries such as Burkina Faso, to countries with consistent laws, those with inconsistent laws had a higher prevalence of both child marriage (33% vs. 22%) and early childbearing (40% vs. 24%).
188.8.131.52 Socio-Economic Factors
The association between birth spacing and formal education in the context of age at marriage is complex. The length of time a girl remains in formal school reduces her time spent in marriage during her reproductive life, and in turn shortens her window of childbearing years. Furthermore, by forcefully removing girls from school at an early age they are unable to receive the proper information and knowledge involving sexual and reproductive rights and health (Myers & Harvey 2011; Jain & Kurz 2007). Often under pressure from her husband, family, and society to prove her fertility, girls tend to have more frequent, poorly spaced births when married young compared to their adult married counterparts (Nour 2006). Benga et al. (2013) found that in rural communities in southern Ethiopia short birth intervals were almost twice as likely for mothers who had no formal education compared to their educated counterparts. Similarly a different study in Ethiopia by Hailu and Gulte (2016) found that women who had no formal education were three times more likely to experience short birth intervals when compared to their educated counterparts. This is in line with a study from northern Iran that found the length of birth interval significantly increased when women have a higher level of education (Hajian-Tilaki et al 2009). The length of inter-birth intervals studied in Tanzania was related to the maternal level of educational attainment such that as the level of education increase, length of birth interval increased (Exavery et al. 2012). In Tanzanian women with no education, primary education, and secondary and higher education had increasing adherence to recommendations (52%, 46%, 38% respectively) (Exavery et al. 2012). Furthermore, Tanzanian women with no education were found to be 27% less adherent to WHO recommendations as compared to women with secondary education or higher (Exavery et al. 2012). This increased risk may be attributed to women with no education having less autonomy and decision-making power in the home and being less informed about their reproductive and sexual health (Hailu & Gulte 2016; Santhya & Jejeebhoy 2003). A study in Pakistan found that when the education attainment of the husband is high – greater than primary education – the length of the birth interval is longer (Kamal & Pervaiz 2012). However, in rural Bangladesh, de Jonge et al. (2014) found that women with higher education attainment (secondary or higher) were 26% more likely to have short birth intervals. This may be attributed to the age at which the women are bearing children (de Jonge et al 2014). With every additional year of age, their reproductive window for childbearing is reduced, and the risk of short birth intervals increased by 11% (de Jonge et al. 2014; Raj et al. 2009; UNICEF 2001).
Poverty, Wealth and Place of Residence
The wealth of the population various across regions and can be divided into quintiles from richest to poorest. In regions with distinctive wealth indexes, birth interval is greatly influenced by maternal wealth such that the odds of women in the poorest wealth quintile having short birth intervals are greater than those in the richest wealth quintile (Hailu & Gulte 2016). However in regions such as Niger, characterized by poverty, the wealth index from rich to poor is non-linear making it difficult it attribute trends to wealth (Wetheridge & Antonowicz 2014)
Whether a woman lives in an urban or rural region may influence the likelihood of experiencing short birth intervals. For example, a study in southern Ethiopia found that compared to urban women, rural women were more likely to have short birth intervals (Yohannes et al. 2011). A study in India found a place of residence to be a strong predictor for birth interval (Stephannsson et al. 2003). Non-adherence to birth spacing recommendations among Tanzanian women was greater amongst those living in rural regions compared to their urban counterparts (50% vs. 45%) (Exavery et al. 2012). In countries such as Niger where the majority of the population lives in rural areas, this association may be less obvious (Wetheridge & Antonowicz 2014).
184.108.40.206 Proximate Factors
Birth Spacing and Contraceptive Use
There are many factors that contribute to women having short and very short birth intervals. Low prevalence of modern contraceptive use increases the risk of a woman having a short birth interval by four fold (Hailu & Gulte 2016). With low contraceptive use in West African countries, such as Niger, due to a lack of availability and knowledge and information, young girls of child marriage have little control over family planning and their fertility resulting in high fertility and early childbearing (Bledsoe & Cohen 1993; Raj et al. 2009; The Population Council 2008; UNICEF 2001; Jensen & Thornton 2003; Jain & Kurz 2007; Hampton 2010). The reproductive health of married girls is generally poor as they have little education and knowledge about how to protect themselves and contraception use (Myers & Harvey 2011). Furthermore girls often have little autonomy in the home resulting in being unable to negotiate safe sex and contraceptive use (Loaiza & Wong 2012; WHO 2014; UNICEF 2014; WHO 2011). In cultures and societies where women are lacking autonomy regarding their reproductive health, the level of education attainment of her husband has implications on birth spacing as they make decisions regarding the young girls’ or women’s reproductive health (Kamal & Pervaiz 2012; USAID 2005).
The use of modern contraceptives either before first pregnancy or between successive pregnancies has an effect on birth spacing. When women do not use a modern contraceptive between successive births, Benga et al. (2013) found women in southern Ethiopia were six times more likely to have short birth intervals. Similarly, in a separate Ethiopian study, the likelihood of women experiencing short birth intervals who do not use any form of contraceptive was greater (Yohannes et al. 2011). Furthermore, women married early as children were less likely to use contraceptives before their first pregnancy than those married later as adults (3% vs. 11%) (Santhya et al. 2010).
Postpartum Abstinence and Lactational Amenorrhea
Breastfeeding practice and duration affect the birth interval experienced by the mother. The longer the mother is breastfeeding their child, recommended 2 years, the longer she is protected from subsequent conception due to lactational amenorrhea (Setty-Venugopal et al. 2002; USAID 2005). In populations where the duration of postpartum abstinence is long, breastfeeding is often practiced simultaneously (Bongaarts 1984). The duration of breastfeeding has an impact on birth spacing since women experience lactational amenorrhea during this time (Setty-Venugopal et al. 2002). A study by Hailu and Gulte (2016) in Ethiopia found that women who breastfed the previous child for less than the recommended period of 24 months were approximately 49 times as likely to experience short birth intervals when compared to women who breastfed for at least 24 months. Similarly, a study in northern Iran found that birth intervals were longer when women breastfed the previous child for a longer period of time (Hajian-Tilaki et al. 2009). In contrast, couples that choose not to practice postpartum abstinence or breastfeeding are likely to have shorter birth intervals (Setty-Venugopal et al. 2002).
Women in a polygamous relationship may experience longer birth intervals as the frequency of intercourse is reduced due to being one of multiple wives (Bongaarts 1984). However, if previous wives are infertile, younger wives may experience higher, more frequent fertility (Bongaarts 1984). Additionally, polygyny contributes to longer post-partum abstinence, another proximate determinant of fertility (Bongaarts 1984). West African countries, such as Niger have a high prevalence of polygyny with over one third of women being in a polygynous relationship (Walker 2013; Wetheridge & Antonowicz 2014). Within these polygynous relationships, men are much older than the young wives, with at least a five-year age gap as they must be wealthy enough in order to afford the bride prices of these young girls (Wetheridge & Antonowicz 2014; Jain & Kurz 2007).
220.127.116.11 Consequences of Poor Birth Spacing
Maternal and Child Health
The relationship between child marriage and birth spacing is an important consideration as marriage is a contributing factor to pregnancy (Walker 2013). Early marriage is often followed by early childbearing, often before the girl is physically, emotionally, socially, and psychologically capable of pregnancy and childbirth (Jensen & Thornton 2003; Warner 2004). Having such high, early fertility and parity over the duration of their reproductive life age puts these young girls at increased risk of maternal morbidity and mortality, as well as harming their children (Hampton 2010; Adebowale et al. 2011; Santhya et al. 2010; Jensen & Thornton 2003; USAID 2005). With adolescent births being the leading cause of death for girls aged 15 to 19 years in low- and middle-income countries, high prevalence of child marriage puts girls at an increased risk (Myers & Harvey 2011; WHO 2011). Girls 15 to 19 are twice as likely to die from childbirth and girls under 15 are five times more likely to die from child birth compared to women bearing children later in life (UN Secretary-General 2001). When young girls and women survive childbirth, their children are further disadvantaged as they are less likely to attend school and therefore perpetuate the intergenerational cycle of poverty (Myers & Harvey 2011).
When women do not practice optimal birth spacing both their own and their child’s health and survival are at risk. By waiting the recommended length of time between births, children are approximately twice as likely to survive until their fifth birthday when compared to those born within short birth intervals (Setty-Venugopal et al. 2002; USAID 2005). Furthermore, the health of women is protected when longer spacing is practiced such that when women wait 27 to 32 months between births they are more likely to survive the pregnancy and birth, and less likely to suffer from morbidities as a consequence of child when compared to women practicing very short, short or long birth intervals (Setty-Venugopal et al. 2002). Optimal birth spacing is protective of child health such that children born too closely to the preceding child (under 24 months) or too long after the preceding child (over five years) are more likely to be born low birth weight, small for gestational age, preterm and in the worst cases are at greater risk of perinatal, neonatal and newborn deaths (UNICEF 2008; USAID 2005; King 2003).
High fertility and frequent, short spaced childbearing puts not only the mother and child at increased risk of morbidity and mortality but also has negative implications on society and development as young girls and women are not able to reach their full potential and become active members of society, contributing to economic and social growth and development (Hailu & Gulte 2016).
2.3 Conceptual Framework
To understand the effect of child marriage on fertility outcomes and birth intervals experienced by young women, several spheres were identified for examination to determine the inter-relationships of the underlying factors and the associated consequences. Due to limited empirical evidence in West Africa, in particular Niger, it is important to fully grasp the underlying determinants of child marriage to identify effective policy options to improve maternal and child health consistent with internationally accepted goals.
A conceptual framework, presented in Figure 2, was created as a guide to facilitate identifying relationships between key determinants plus possible changes or sensitivities.
|Figure 2: Conceptual Framework|
At the core is the country context in terms of socio-political and socio-cultural factors including governance, health policy and cultural norms and traditions. Such factors have a great influence on age at marriage, reproductive health and related issues such as birth spacing. Notwithstanding the international convention determining 18 years to be the legal age at marriage, not all countries in the region have followed suit with some having different legal ages for boys and girls (Maswikwa et al. 2015; Myers & Harvey 2011; UN 2011). This difference in legal age demonstrates the lower value placed on girls compared to boys, a socio-cultural factor of child marriage (Myers & Harvey 2011; Loaiza & Wong 2012).
Directly influenced by the contextual factors are causes or casual factors such as socio-economic factors of the region such as poverty, region of residence, access and availability to healthcare, and education. In countries with ineffictive governance and poor legal and social platforms, such as Niger, poverty is consequently high (Walker 2013; Delprato et al. 2015). As a major driver for child marriage, poverty contributes to the perpetuation of a vicious intergenerational cycle of disadvantage and health consequences (Girls Not Brides 2017; Nour 2006; UNICEF 2001; Myers & Harvey 2011; de Silva-de-Alwis 2008; Loaiza & Wong 2012; USAID 2005; Delprato et al. 2015). Part of the disadvantage accompanying poverty is a lack of education attainment, especially among girls, which has negative implications on employment opportunities, autonomy, and access to health care and family planning methods (Nour 2006; Malhotra et al. 2011; WHO 2011; USAID 2012; UNICEF 2005).
The above-mentioned socio-economic factors act in conjunction with age at marriage to influence birth spacing through the Bongaart’s proximate factors of fertility – the only pathway in which this can occur (Bongaarts et al. 1984). The implications of birth spacing have an impact on maternal and child health and well-being both in the short and long term.
2.4 Child Marriage and Family Planning Policies and Programmes
Two international agreements exist that aim to protect and promote the rights of children in sub-Saharan Africa, however, only one of these targets child marriage explicitly (Maswikwa et al. 2015). The 1989 United Nations Convention of the Rights of the Child (CRC) does not explicitly include child marriage, and instead targets underlying causes and consequences of child marriage (Maswikwa et al. 2015). The 1990 African Charter on the Rights and Welfare of the Child (ACRWC) was subsequently introduced and although African countries agreed to be legally obligated by these agreements to protect the rights of children, especially in regards to child marriage, many do not adhere (Maswikwa et al. 2015). Additionally, child marriage is a deeply routed tradition that disproportionately disadvantages girls (Maswikwa et al. 2015). The consequences of non-compliance with these agreements and ignoring of the underlying contextual factors of child marriage and fertility, is that progress is impeded and the cycle of disadvantage and human rights violation will be perpetuated (Maswikwa et al. 2015).
Despite international agreements stating the legal age of marriage for both boys and girls to be 18 years, this is not always practiced (Nour 2006; Mathur 2003). In countries, such as Niger, the legal age of marriage for girls falls below the international agreement at 15 years old, with many girls being married even younger (UN 2011; Walker 2013). Where laws regarding child marriage do exist they are often not enforced and offenders are not prosecuted – giving the impression that such practices are accepted within society and do no harm socially or economically (Warner 2004; Myers & Harvey 2011). By not enforcing these laws, the cycle of child marriage continues, having devastating effects socially and economically (Warner 2004; Walker 2013; Malhotra et al. 2011). National laws may be overruled by customary laws that allows for traditional practices, such as child marriage, to take place with parental or guardian consent (Warner 2004). For countries where vital registration of birth and marriage is low, enforcement of laws regarding child marriage is difficult as law makers are unable to verify the age of these young girls and if they are in a formal or informal union, especially those of traditional ceremony, making it difficult to track prevalence and progress (Jensen & Thornton 2003; UNICEF 2001; Warner 2004; UNICEF 2005).
The United Nations Sustainable Development Goals address the issue of child marriage within Goal 5, specifically Target 5.3 to eliminate harmful practices (UN 2017). However, progress to meet these goals is slow, with approximately 1 in 4 girls being married in 2015, a reduction from 1 in 3 in 2000 (UN Secretary-General 2017). Progress towards ending child marriage requires success of at least six other SDGs that address the underlying factors of child marriage (UN 2017). Addressing these underlying factors draws attention to both the ‘supply’ and ‘demand’ of young girls for marriage (Jensen & Thornton 2003).
Child marriage is a violation of human rights such that the child is unable to give consent, as they are not of legal age, and is often forced to enter the union resulting in these children becoming ‘invisible’, masking the problem and making them unable to benefit from programmes and policies (Nour 2006; UNICEF 2001; Wetheridge & Antonowicz 2014)
Programmes and interventions to end child marriage in West African countries are rare (Malhotra et al. 2011; The Population Council 2008). Often countries with the highest prevalence of child marriage, such as Niger, are being left out (Malhotra et al 2011. Receiving little funding and attention from donors and organizations undermines the high prevalence of child marriage and related consequences such as maternal and child morbidity and mortality, which remain high in these regions (The Population Council 2008). While there has been a rise in programme and interventions addressing child marriage either directly or indirectly through underlying causes in recent years, very few have been implemented in West Africa and evaluation of these programmes is limited (Malhotra et al. 2011). Programmes and interventions in place to aid in ending child marriage or providing support for children of child marriage currently focused on adolescent girls age 15 to 19 however with a high prevalence of girls in Niger being married below the age of 15, this hard to reach, at risk population is overlooked (Williamson 2013; Godha et al. 2013). Furthermore, programmes aiming at keeping children, especially girls, in school longer ignore the risk girls are at for sex and gender based violence (Wetheridge & Antonowicz 2014).
Current programmes target six main themes in order to address the underlying causes of child marriage and poor birth spacing – child rights and protection; girls’ education and empowerment; sexual and reproductive health including family planning; maternal and child health; community awareness an mobilisation; and economic livelihoods such as skills training (Wetheridge & Antonowicz 2014; Cleland et al 2006). Furthermore, in West African countries such as Niger very few programmes and policies exist specifically target child marriage explicitly and programmes that do exist have yet to be evaluated (Wetheridge & Antonowicz 2014; Malhotra et al. 2011). By not having an evaluation of programmes and policies currently in place, it is unknown which interventions work and what progress has been made (Wetheridge & Antonowicz 2014).
2.5 Why: Implications and Future Research
Further and continuous research is required in order to address both the underlying factors or child marriage and birth spacing in these regions in order to protect the health and rights of young girls and their children, in addition to improving social and economic development of these regions. Policies, laws and programmes targeting child marriage and fertility are required and must be enforced in order for progress to occur.
Word Count: 6,301