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Case Study Series

Child Marriage: a Practice of the Past or an Uncomfortable Reality of the 21st Century?

A case study on how child marriage affects health outcomes in an adolescent’s life

One quiet Monday afternoon, a nutrition counselor, a senior volunteer, and I set off to meet Ishita (name changed for privacy). Ishita is a young woman we met at a public health clinic in Coimbatore, Tamil Nadu, and we hoped to learn more about her childhood and marriage. Upon entering her village, amidst the narrow roads and small homes tightly placed together, our team stepped out of the car. A very young girl – bright-eyed and smiling – came running towards us. Assuming her to be Ishita’s family member, I watched as she spoke with our nutrition counselor to find plastic chairs from a neighbor. When the chairs had been brought into the single-room home, our senior volunteer and I sat down. The young, energetic girl who had greeted us sat with us too. It was at that point, I realized this beautiful, bustling girl was none other than Ishita herself.

In South Asian cultures, marriage is frequently considered an important part of one’s life. Nearly all individuals are socially expected to get married at some point. However, the age at which one gets married and the subsequent changes in life have great implications for public health. Child marriage – defined as a formal marriage or an informal union entered by at least one individual under the age of 181 – is often a topic of international discussion. Child marriage is a global challenge. Child marriage includes boys, but most children married under the age of 18 are girls.2 In India, it is particularly relevant as the country has one of the highest number (in absolute terms) of married girl children, with estimates ranging from 12.1 million to an overwhelming 15.5 million.3,4 A marriage involving a still-developing adolescent may lead to issues in reproduction, early childbearing, and poor maternal health.5 Furthermore, a child marriage can prevent women from completing their education, accessing employment opportunities, and having a strong social support system.6 By addressing the age at which women marry, public health personnel will have an opportunity to work with young girls and women to lead and live a healthy life as well as positively impact the generations that follow.

To better understand the health consequences and social vulnerability of child marriages, the aspects being examined in this review are:

  • The policies pertaining to child marriage in India
  • The story of an adolescent mother and her child marriage
  • The health indicators associated with child marriage
  • The policies pertaining to child marriage in India

    After coming into effect in 2016, the United Nations Sustainable Development Goals (SDGs) embodied a universal call to action to protect all people and to ensure peace, prosperity, and human rights.7 SDG target 5.3 aims to “eliminate all harmful practices, such as child, early and forced marriage and female genital mutilations.”6 Significant acceleration and scaling up of efforts are needed to meet this goal globally by 2030.8 Eliminating child marriage is crucial to achieving the SDGs as well as ensuring that every child has an opportunity to live a healthy and peaceful life.

    It is important to ask: are there repercussions for not acting to end child marriage practices?”

    Although the SDGs are important for the improvement and well-being of the global community, they are aspirational goals. Governments are expected to do their best to meet the goals, but they are not legally bound.9 On the other hand, the United Nations Convention on the Rights of the Child (CRC) legally binds countries to ensuring children have the right to life, survival, and development.10 While the CRC does not have a specific provision on child marriage, in its General Comments, the CRC Committee has advocated for the minimum age of marriage to be set at 18 years.11 Minimum ages often signal the transition from childhood to adulthood; a minimum age in the case of marriage ensures children are not burdened with marital and adult responsibilities too early.11 Ultimately, each country’s government makes the decision of legislating a minimum age. A 2013 report reveals only 11 countries have established a minimum legal age at 18 years without any exceptions.11 73 countries have a minimum age of 18 years but allow exceptions, usually for girls.11 102 countries have no clear information or no established minimum age.11 Despite the minimum age that each country’s government has set – or lack thereof – all members of the CRC must ensure that children marrying under the age of 18 years do not face gender discrimination, their evolving capacities are respected, and the best interests of the children are a primary consideration.10,11 India has taken the lead on this issue and in its Prohibition of Child Marriage Act 2006, the government took a legal stance to prohibit the formalization of marriage for females under the age of 18 years and males under the age of 21 years.4 The National Commission for Protection of Child Rights further emphasizes the protection of all children under the age of 18 years.12 India’s federal and state governments have also promoted youth empowerment programs, awareness campaigns, and financial incentives to discourage child marriage and encourage education among girls.3

    The crucial question is: with many government interventions (from policy to ground level interventions) discouraging child marriage, why is child marriage still prevalent?

    Even with such powerful commitments, marriage age may still be culturally defined. In India, the prevalence of child marriage among 15-19 year old girls in 2015-2016 was 11.9%, with most occurring in families in the bottom tercile of wealth and living in rural areas.4 Girls Not Brides reports that this practice is driven by a variety of factors, such as: the perception that daughters are an economic burden, the consideration that educating daughters is a lower priority relative to sons, the view that marriage prevents pre-marital sex, and the fear of violence against women in public areas.3 Often, in these scenarios, a child (or both children) may not have full and free consent in the marriage decision. However, there are cases where an adolescent, an individual between the ages of 10 and 19 years,13 makes the decision to get married before the age of 18. These experiences are less studied but have equally profound impacts on the lifestyle and health of young people. This is the case in Ishita’s story as well. By understanding the individual narrative and the health indicators with a consented child marriage like Ishita’s, healthcare providers and policymakers can address the factors that lead to better health care and health outcomes.

    The story of an adolescent mother and her child marriage

    At the young age of 19 years, Ishita is the wife of a 21-year-old man and the mother of a 13-month-old child.

    Ishita studied at a local Tamil medium government school through tenth standard/grade. It was at this time that she started training to become a beautician. With her friends, she would sometimes go to her local park when not in class – just enjoying, laughing, and living. Her husband, Keshav (name changed for privacy), was a bus conductor and through friends, Ishita (then 17 years) and Keshav (then 19 years) started spending time together at the park. Young love blossomed and the two felt physically attracted to each other, envisioning a bright future together. Whereas Keshav’s parents did not accept the relationship at the time, Ishita’s parents did agree to it; however, Ishita’s parents encouraged her to complete her beautician training and wait two years before getting married. Keshav’s sister had eloped with someone and this scared Keshav. He did not want to lose Ishita while waiting for two years. Although Ishita had envisioned getting married in a big hall surrounded by the love and warmth of many guests, the two went to a temple and were secretly married in the presence of a priest and Keshav’s friends.

    When Ishita got married, she thought life would be a lot of fun. The two of them would enjoy a new journey. That changed soon after they moved in together. Within five months of their wedding, Ishita became pregnant with their daughter, Sridevi (name changed for privacy). For a few months after conception, she continued to go to the beautician’s course, but soon, that became physically and socially difficult and she had to leave the program. Her dream of opening her own beauty parlor was put on hold. Keshav believes once the baby is 3 years old, Ishita can join her coursework again. Ishita, too, would still like to work on that dream once Sridevi is no longer breastfeeding. For now, she is taking care of the house and her child throughout the day and night. Ishita shares she would strongly advise her younger peers to refrain from getting married at an early age like she did. Calling her actions, “a mistake,” she encourages young women to establish their careers before getting married.

    During the interview, Keshav entered twice in search for items to use at work. He had been informed by our team that we would be coming to have a conversation with Ishita, but other than a brief acknowledgment, he grabbed a marker and rushed out to go to work. He had the responsibility of earning for his young family.

    The financial burdens at home have caused a lot of stress. Although Keshav is now working as a driver for a travel agency, the costs of a rented home and survival needs with a young family have been steep. Ishita now has a cordial relationship with her in-laws and her parents, so whenever the need arises, she does reach out to them for help. In addition to financial stresses, Ishita says there are times of emotional stress too. Keshav drinks alcohol very frequently and under its influence, he hits and kicks Ishita and often quarrels with her. On Sundays, he spends time with his friends and further engages in activities like drinking and smoking. Despite these behaviors, Ishita says Keshav is supportive. When he comes back from work, Sridevi spends most of her time with him and falls asleep on him.

    As Ishita shared the stories of her childhood and married life, sweet Sridevi jumped around. Her charming laughter intertwining with the sound of her mother’s voice. Her eyes sparked as she made eye contact with everyone in the room and then hid her face. From time to time, she bit her mother as her developing gums and teeth sought comfort. The mother-child bond continued as Sridevi eventually found her way for a quick session of breastfeeding and a brief period of silence ensued as the little one hid underneath a small blanket.

    Ishita shared that Sridevi was born at a government hospital, where her baby weighed approximately 2 kilograms, a measure of low birth weight. Her delivery had no complications. Ishita continues to take the baby back to the hospital regularly every month. There is a nurse who lives near Ishita and she often coordinates with her for vaccination at a local government primary health center. Sridevi is currently breastfeeding, but at around the age of eight months, Keshav and Ishita started the process of weaning and introducing her to idli and rice. Both Ishita and Sridevi are currently underweight. In addition, Ishita has been advised by the government hospital staff to come back for some tests due to a suspected thyroid issue. She has also been counseled to increase her intake of iron, meat, and vegetables. Overall, Ishita says she finds it easy to understand the health instructions. Additionally, Ishita attended a clinic at the International Center for Child and Public Health (ICPH) where both Sridevi and her received preventive care services. It was at this clinic that the nutrition counselor met her. Ishita shared she liked the clinic and intends to return there regularly when seeking health care.

    Ishita has a vision of returning to school again and completing her beautician’s course. The dream of opening her own parlor is still very much alive. She is just waiting for her breastfeeding days with Sridevi to be completed and then she will leave the child with a neighbor or her mother-in-law. Keshav, for now, will continue his work as a driver. As for the baby, Keshav wants her to become a dancer. For Ishita, there is no particular career she envisions for her child. She just wants Sridevi to be happy and enjoy her full freedom. Ishita adds she hopes Sridevi will not make the same “mistake” as her in getting married at a young age.

    The health indicators associated with child marriage

    A child marriage is associated with a range of public health and social vulnerabilities (see Table 1). While the motivations for child marriage vary across cultures, lack of appropriate healthcare services and discussions can perpetuate it. This section will focus on the environmental (intimate partner violence and mental health) and individual (nutritional status and well-being) indicators of health. These matters greatly affect adolescents who get married before the age of 18 years, including Ishita. Additionally, in South Asian culture, women usually tend to get pregnant in the early years of marriage. Thus, girls who get married at an early age may get pregnant at an early age as well. Research on young and developing minds, intimate partner violence, mental health, nutritional status, and well-being can help guide healthcare professionals on how to improve health outcomes for this very specific population.

    A) Young and Developing Minds
    Keshav and Ishita are just one example of a marriage where the adolescents made the decision to marry. The argument to have a legal age of marriage is because with marriage come many great responsibilities. It is vital for the couple to understand the consequences of marriage.11 For example, Keshav and Ishita were married at 19 years and 17 years, respectively, ages when the brain is still developing. Whereas an older adult thinks with the prefrontal cortex (rationally driven), a young adult may often process information with the amygdala (emotionally driven).14 In the teenage years, young folks are particularly vulnerable to social pressures and impulsive thinking. This is not unique to a specific case, but something that affects all adolescents during the later stages of childhood. Thus, legal and healthcare frameworks should take into consideration the evolving capacities and maturity of a child in unison with their protection.11 Healthcare professionals and parents can have a strong, long-lasting, positive effect on adolescents as they make important decisions while developing their voices and identities. By openly listening, educating, and discussing issues on health, hormones, and attraction, older adults can open a line of communication to discussing the possible long-term consequences of life-changing actions. Culture, stigma, and a lack of access to resources often make it difficult to reach every adolescent, but these are some factors that healthcare programs should consider when planning interventions to encourage delaying child marriage. Most importantly, it is imperative to include the adolescents themselves when these conversations occur, so that they can make informed decisions and be aware of their rights.

    B) Intimate Partner Violence and Mental Health (IPV)
    A low level of education and child marriage often contribute to low empowerment for women. This is further exacerbated by social issues like intimate partner violence (IPV), which is linked with younger women’s lower ability to resist such behaviors.5 Girls Not Brides reports that around the world, 44% of girls between the ages of 15 and 19 years think their husband or partner is justified in violently behaving (e.g. hitting, beating) their wife or partner.15 A 2017 comparative study of 34 countries discovered that women who are married under the age of 18 years are more likely to experience physical or sexual violence compared to those married after the age of 18 years.5,16 In five Indian states with high numbers of under-18 marriages, a study of over 8000 women shared that women married after 18 were 1.2 times more likely to reject wife beating and physical violence than women married under 18.17 Furthermore, a cross-sectional survey of approximately 2500 women between the ages of 18 and 45 years in Goa, India, revealed that sexual violence by husbands, low levels of support from one’s family, and other indicators of gender disadvantage increased the prevalence of common mental disorders, most commonly mixed anxiety-depressive disorder.18 This behavior of violence is often normalized from a young age; however, it has long lasting effects on the emotional and mental health of the girls who experience it. Healthcare professionals must be sensitive to not only the unique physical health of this population, but the emotional and mental needs which accompany developing adolescents, regardless of their marital status. With greater self-empowerment and support from healthcare teams, these young women may be able to better protect themselves from the harms of IPV and other behaviors. Because the act of separation is still seen as taboo and cultural factors impact it, a healthcare provider can play an important role in the health and healing process of a woman experiencing IPV.

    C) Nutritional Status and Well-Being
    Research studies show that in India, about one-third of girls married and giving birth before the age of 18 years had a BMI of less than 18.5 (underweight) and over half had mild anemia.5 Women who are married before the age of 18 years are twice as likely to be undernourished compared to those married after the age of 25 years.5,19 Because a significant percentage of the adult weight and height are gained between the ages of 10 and 19, undernourished adolescents who begin their childbearing years during this critical time of growth and development may have increased health complications.5,20 The consequences of poor nutrition and early childbearing extend beyond the mother. Mothers younger than 18 years have a higher risk of delivering a preterm or low birth weight child compared to mothers older than 19 years.2 Children of mothers who experience early childbirth are also likely to be at a high risk of undernourishment, which can affect the development of the brain, cognitive capabilities, and physical health in the long run.5,21 Thus, healthcare providers must be cognizant of the nutritional status and well-being of the adolescent mother and child when sharing recommendations for improving health outcomes. In addition to nutrition and health education, public health programs may consider providing vital nutrients and adequate nutrition at a low cost to vulnerable or at-risk women. Healthcare providers have a pivotal responsibility of working to delay child marriage, but even among married adolescents, they can play a role in delaying childbirth. This can be through an explanation on contraception or discussion about the risk of poor maternal health with an early childbirth. Through delaying child marriage, delaying childbirth, and providing education on nutrition and general well-being practices, health outcomes for young mothers and their children can be improved.

    Table 1: List of health indicators associated with child marriage
    Compared to women above the age of 18 years, women married before the age of 18 years are:
    • More likely to be denied their childhood experience5
    • More likely to experience physical or sexual violence5,16
    • More likely to be undernourished 5
    • More likely to bear children in their earlier years of marriage4,5
    • More likely to face maternal morbidities and mortality5
    • More likely to be from poorer households4
    • Less likely to have knowledge about and access to contraception5
    • Less likely to have used contraceptives to delay their first pregnancy17
    • Less likely to complete their secondary education4,6

    Power of a single story

    As we began to leave, Sridevi started mischievously smiling, moving a heart-shaped box around her head to see if we could spot her. Finally, she had all our undivided attention and she made sure to hold on to it for as long as possible. Watching us walk up the steps from her home to the road, she kept waving and squealing, “Ta-ta,” and then burying herself in her mother’s arms. We opened the doors to the car and as we stepped in, the last sounds we heard were Sridevi’s melodious giggles as she sent us on our way.

    Marriage is often socially considered to be an integral part of South Asian culture and many policies are in place to ensure the responsibilities of marriage do not fall upon premature shoulders; however, child marriage still occurs for cultural, religious, and personal reasons. There are many cases of children getting married without their freedom of choice and full consent, but there are also stories of adolescents making the decision to commit to marriage. Stories like Ishita’s have been studied less and require further probing. Her story reminds us of our healthcare responsibilities and the young women we must not forget. In alignment with the healthcare field and human rights frameworks like the CRC,10,11 we have a unique responsibility to address each child’s capacities and maturities as they progress with age, support their full growth and development, and advise on their best interests, regardless of marital status.

    Medical and public health professionals have the privilege of addressing issues at both population and individual levels. They can work towards mitigating the health indicators associated with child marriage, such as decision-making, intimate partner violence, mental health, nutrition, and well-being. When they have an opportunity to address an adolescent’s health vulnerability, they can greatly affect that person’s health status as well as that of the next generation. This can be done through discussions, education, and material items. As research shares, where young mothers have the knowledge and access to resources for strong life choices, and the autonomy and empowerment to act on these, their health and their children’s health will improve.5,22 Healthcare professionals and organizations, like ICPH, can be the spark to fuel a new trajectory for an adolescent and their descendants.

    The work of our generation of rising leaders in medicine, public health, and public policy is to continue keeping our minds open to learning through observation, research, and education. This can be done by volunteering locally and globally as well as engaging in dialogue with international health leaders and local community members. It is always humbling listening to each person’s voice. When I first arrived in Tamil Nadu, I knew anecdotally that some adolescents marry prematurely, but it was the power of a single story – Ishita’s story – that reminded me of the journey that still needs to be travelled. Ishita’s tired yet sparkling face, the bare walls of her 15 ft by 15 ft home, and the smiles of her baby are engraved in my mind. These images will return with me and help me evolve into a better ally, advocate, and future physician, at home and abroad. Over the past few weeks, I have observed that the narratives of young women who had a child marriage are not distant or foreign, but rather, they are quiet and unheard, right here.

    Regardless of the country we reside in, as healthcare leaders, we must always remember that each child, each adolescent, each individual has a story to tell. That story may appear to be a single thread, but we have the honor of collecting these threads and weaving them into a fabric of change. In our individual practices and larger community actions, may we continue to diligently work towards ensuring every child’s human rights are recognized and every child has an opportunity to achieve their full potential.

    The work of our generation of rising leaders in medicine, public health and public policy is to continue keeping our minds open to learning through observation, research, and education. This can be done by volunteering locally and globally as well as engaging in dialogue with international health leaders and local community members. It is always humbling listening to each person’s voice……for the power of a single story can sustain our inspiration and move us to act!

    For pdf Click Here: Case-study-2-Child-Marriage-of-young-mother-27.7.2019.pdf

    The work of our generation of rising leaders in medicine, public health and public policy is to continue keeping our minds open to learning through observation, research, and education. This can be done by volunteering locally and globally as well as engaging in dialogue with international health leaders and local community members. It is always humbling listening to each person’s voice……for the power of a single story can sustain our inspiration and move us to act!

    Bhaani Kaur Singh
    Osteopathic medical student at Touro University California College of Osteopathic Medicine

    About the Writer:Bhaani Kaur Singh was an intern with the International Center for Child and Public Health, an initiative of Shanti Ashram, from May 27 to July 5, 2019. She earned her Bachelor's degree in Public Health and Integrative Biology at the University of California, Berkeley (2015). She proceeded to complete her Master of Public Health degree at the University of California, Davis (2017). Bhaani is currently an osteopathic medical student at Touro University California College of Osteopathic Medicine and intends to pursue a career in primary care in low-resource settings. Bhaani is deeply passionate about health equity as well as children and women's health. She hopes to work towards a world where health care is practiced as a human right.

    Photo credits: Bhaani Kaur Singh