Age at Marriage, Women's Education, and Mother and Child Outcomes in Bangladesh

孟加拉国的结婚年龄、妇女教育以及母婴结局

• 批准号: 8301796
• 负责人: ERICA M FIELD
• 金额: $ 11.19万
• 依托单位: MASSACHUSETTS INSTITUTE OF TECHNOLOGY
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/8301796
• 关键词: 10 year old; AIDS/HIV problem; Address; Adherence; Adolescence; Adolescent; Adolescent Health Services; Adult; Africa; Africa South of the Sahara; Age; Asia; Awareness; Bangladesh; Behavior; Behavioral; Birth; Birth Intervals; Brazil; Caribbean region; Caring; Cause of Death; Cessation of life; Child; Child Mortality; Child health care; Childbirth; Communities; Complex; Consent; Contraceptive Agents; Contraceptive Usage; Contraceptive methods; Country; Data; Decision Making; Demographic and Health Surveys; Developing Countries; Discipline of obstetrics; Dominican Republic; Drops; Economics; Education; Effectiveness; Egypt; Elements; Ethiopia; Etiology; Evaluation; Expenditure; Face; Family; Family Planning; Female; Female Adolescents; Fertility Rates; First Births; Fistula; Future; Government; Growth; Health; Health Care Seeking Behavior; Health Services; Health Services Accessibility; Health Status; Healthcare; Home environment; Household; Husband; Ice; Immunization; Incentives; Income; India; Infant; Infant Mortality; Institute of Medicine (U.S.); Intervention; Kenya; Knowledge; Latin America; Laws; Lead; Legal; Life; Link; Literature; Mali; Marriage; Marriage Ages; Maternal Mortality; Maternal and Child Health; Medical; Mental Health; Methods; Morbidity - disease rate; Mothers; National Research Council; Necrosis; Nepal; Outcome; Participant; Pattern; Physiological; Physiology; Policies; Population; Postnatal Care; Pregnancy; Pregnancy Complications; Pregnant Women; Prevention strategy; Price; Probability; Qualitative Research; Randomized; Reproductive Health; Research; Research Project Grants; Resources; Risk; Role; Running; Rural; Savings; Schools; Secondary Schools; Services; Sexuality; Source; South Africa; Southern Asia; Spouses; Stress; Tanzania; Time; Tissues; Translating; UNFPA; UNICEF; United States; United States Public Health Service; Unmarried; Woman; Women' s Health; Work; Youth; age difference; aged; arm; checkup examination; child bearing; cost effective; design; empowerment; expectation; experience; feeding; girls; health care service utilization; improved; meetings; mortality; next generation; offspring; older men; older women; pregnant; pressure; programs; reproductive; skills; teenage mother; theories; working group; young mother

Female marriage age, education, income, and health B1.1 Existing evidence: early marriage and female and child health In much of the developing worid, early female marriage¿defined as marriage before the age of 18¿ remains widespread despite age of consent laws banning the practice, government and NGO efforts to curtail it, increasing educafion levels, and economic growth (National Research Council and Institute of Medicine, 2005). A recent study by UNICEF revealed that in Latin America and the Caribbean 29 percent of women were married by the fime they turned 18; in Africa, 42 percent; and in Southern Asia, 48 percent (UNICEF, 2005). Bangladesh has one of the highest rates of adolescent and child marriage in the worid: Although the legal age of marriage for females is 18, nearly 50 percent of all girls and 75 percent of rural giris are estimated to be married by age 15 (UNICEF 2006). There is substantial literature showing a correlation between eariy marriage and women's health, [and health-seeking behavior]. In general, women who marry early begin childbearing at a young age (Jensen and Thornton, 2003), and complicafions in pregnancy and delivery are a leading cause of death among giris aged 15 to 19. Maternal mortality in this group is double the rates for women in their 20s. Giris who marry as adolescents face greater health risks associated with lower age of first birth, higher fertility rates, and shorter birth spacing related to lower contraceptive use (UNICEF, 2001). About 60 percent of adolescent giris in Bangladesh are mothers by age 19, and nearly all of them married (UNICEF, 2006). The 2004 Demographic Health Survey (DHS) found that 40.7 percent become mothers between 15 and 17 years, and 19.5 percent between ages 18 and 19 (NIPORT, Mitra Associates and ORC Macro, 2005). Childbearing during adolescence, when physiology is likely to be underdeveloped, is widely believed to result in higher levels of maternal mortality and morbidity, although the degree to which age infiuences reproductive outcomes is not well established. Giris age 14 and younger are five times as likely to die from pregnancy complications and their offspring are also less likely to survive (UNFPA, 2004). The discrepancy in maternal mortality by age persists even in countries where maternal mortality is low, such as Brazil and the United States (Mathur, et al., 2003). In Bangladesh, maternal mortality and severe morbidity from childbirth is neariy twice as high and rates of postnatal care are 50 percent lower for adolescent giris compared to women ages 20 to 35. Furthermore, married women ages 15 to 19 are less likely to use modern contraceptives than married women ages 20 to 24 (Population Reference Bureau. 2006). Young mothers also have higher maternal morbidity rates, including severe complicafions, such as obstructed labor or obstetric fistula, which occur primarily among young women (UNFPA and EngenderHealth, 2003; Jarrett, 1994). Without fimely intervention obstructed labor can lead to tissue necrosis, which can result in permanent maternal morbidity, if not mortality. Data on maternal morbidity is scarce, and only available for a handful of settings. In Ethiopia, where 24 percent of women give birth by age 18, obstructed labor is the immediate cause in 46 percent of maternal deaths, and three in 1,000 pregnant women develop fistula, which is also common in Bangladesh (Populafion Reference Bureau, 2006; UNFPA, 2003; Akhter, et al., 1996). Of fundamental importance is the fact that the medical community currenfiy does not know the degree to which the well-documented relafionships between age of childbearing and reproducfive outcomes are physiological consequences of eariy childbearing. Hence, this research has important scienfific value. In addition to the physiological channels, eariy marriage may also impact health through behavioral channels. First, youth is associated with less-active health-seeking behavior and limited health information, which has a negative impact on the health status of married adolescent giris. In Bangladesh, 70 percent of pregnant giris younger than 20 receive no antenatal care and 90 percent deliver their babies at home. Their access to health information is poor: 20 percent of adolescent mothers have little knowledge of life-threatening conditions during pregnancy, and the majority (married and unmarried) have no informafion on sexuality, contraception, or sexually transmitted infecfions or HIV/AIDS (Haider, et al., 1997; Nahar, et al., 1999; Barkat, et al., 2000; Bruce and Clark, 2004). Adolescent giris' access to reproductive health care and services is also poor: In Bangladesh, the need for contraception is not met for 27 percent of mothers below age 20, compared with 10 percent among those aged 20 to 35 (NIPORT, Mitra Associates and ORC Macro, 2001). Moreover, married adolescents use contraception at much lower rates than older women. In South Asia, 9 percent of married women ages 15 to 19 use modern contraception compared to 24 percent of women ages 20 to 24. In Bangladesh, the rates are 34 percent and 47 percent, respectively (Population Reference Bureau, 2006). Lower usage may refiect lack of awareness about family planning, expectations to have the first child immediately, and more limited access to health services among adolescents. In addition, younger girls tend to marry significantly older men. Research in sub-Saharan Africa found that the husbands of giris ages 15 to 19 years are on average 10 years older (UNICEF 2001). Mean spouse age difference is decreasing with women's age at first marriage throughout the worid. In West Africa, the mean spouse age difference is 12 years for girls aged 14 to 15 at first marriage, and 8 years for women married at 24 to 25 years; the same pattern is found in Southern Asia (UNFPA 2004). The presence of a large age gap between spouses can contribute to poor outcomes in a number of ways. First, older husbands tend to be more sexually experienced, which implies greater risk of sexually transmitted infecfion (Clark, 2004; Luke and Kurz, 2002). The age gap is also associated with lack of agency in marriage for the adolescent giri, which may contribute to poor health outcomes. Lack of decision-making power may translate into lower reproducfive control, or capacity to negofiate sexual relations, contracepfion, and childbearing. Qualitative research also suggests that most young married giris face pressure to get pregnant eariy in marriage and lack reproductive control to avoid it (Bledsoe and Cohen, 1993; Mensch, Bruce, and Greene, 1998; Bruce and Clark, 2004). There is qualitative but little rigorous analysis suggesfing that isolation, restricted mobility, and lack of control over household resources are more common among young married giris (Mensch, et al., 1998). Isolation and the increased stress of adult responsibilifies may have a direct detrimental impact on psychological health. Lack of mobility is also likely to contribute to low healthcare utilization among married adolescent giris. Research in India has documented that married adolescent giris' healthcare decisions are mostly controlled by husbands and mothers-in-law (Barua and Kurz, 2001). Taken together with restricted mobility, this may limit the ability of adolescent giris to access health services for themselves and their children. Finally, the negafive associafion between eariy marriage and health extends to the next generation. Children born to women under age 20 have higher infant mortality rates (IMR) through the age of five. In Mali, the Infant mortality rate is 181 per 1,000 for children of mothers under 20 compared to 111 per 1,000 for children of mothers aged 20 to 29. Similariy, these rates are 164 and 88 in Tanzania, 108 and 68 in Nepal, and 71 and 28 in the Dominican Republic (Marthur, Green, and Malhotra, 2003). In Bangladesh, the IMR is 86 for infants born to mother under 20 compared to 60 for mothers aged 20 to 29 (NIPORT, Mitra Associates and ORC Macro, 2005). Child mortality rates (CMR) are also higher for children of adolescent mothers. In Kenya, the rate is 48 per 1,000 for children born to mothers under 20 compared to 32 for children born to mothers aged 20 to 29. Comparable figures are 90 and 83 in Ethiopia; 40 and 19 in South Africa; and 15 and 13 in Egypt (Marthur, Green, and Malhotra, 2003). In Bangladesh, the CMR is 106 per 1,000 for children of mothers under 20 compared to 84 for children born to mothers aged 20 to 29 (NIPORT, Mitra Associates and ORC Macro, 2005). [How much of this correlation is due to lower utilization of health care (e.g., lower immunization rates) or less knowledge of good health practices by mothers on the part of children is unclear.]

女性结婚年龄、教育程度、收入和健康 B1.1 现有证据：早婚与女性和儿童健康 在许多发展中国家，女性早婚（定义为 18 岁之前结婚） 尽管同意年龄法禁止这种做法、政府和非政府组织努力限制这种做法、提高教育水平和经济增长，但这种行为仍然很普遍（国家研究委员会和医学研究所，2005年）。联合国儿童基金会最近的一项研究显示，在拉丁美洲和加勒比地区，29% 的女性在年满 18 岁时结婚；在非洲，42%；在南亚，这一比例为 48%（联合国儿童基金会，2005 年）。 孟加拉国是世界上青少年婚姻和童婚率最高的国家之一：尽管女性的法定结婚年龄为 18 岁，但据估计，近 50% 的女孩和 75% 的农村女孩在 15 岁之前结婚（联合国儿童基金会，2006 年）。 有大量文献表明早婚与女性健康[以及寻求健康行为]之间存在相关性。一般而言，早婚女性很早就开始生育（Jensen 和 Thornton，2003），怀孕和分娩并发症是 15 至 19 岁女性死亡的主要原因。这一群体的孕产妇死亡率是 20 多岁女性的两倍。在青少年时期结婚的吉里斯面临着更大的健康风险，这些风险与较低的第一胎年龄、较高的生育率以及与避孕药具使用率较低相关的较短的生育间隔有关（联合国儿童基金会，2001年）。孟加拉国大约 60% 的青少年女孩在 19 岁时就成为了母亲，而且几乎所有人都结婚了（联合国儿童基金会，2006 年）。 2004 年人口健康调查 (DHS) 发现，40.7% 的人在 15 至 17 岁之间成为母亲，19.5% 在 18 至 19 岁之间成为母亲（NIPORT、Mitra Associates 和 ORC Macro，2005）。 人们普遍认为，青春期生育可能会导致孕产妇死亡率和发病率升高，但年龄对生育结果的影响程度尚未明确。 14 岁及以下的吉里人死于妊娠并发症的可能性是其他人的五倍，而且他们的后代存活的可能性也较小（联合国人口基金，2004 年）。即使在巴西和美国等孕产妇死亡率较低的国家，按年龄划分的孕产妇死亡率差异仍然存在（Mathur 等人，2003 年）。在孟加拉国，与 20 至 35 岁的妇女相比，青春期女孩的孕产妇死亡率和严重分娩发病率几乎是 20 至 35 岁妇女的两倍，产后护理率低 50%。此外，15 至 19 岁的已婚妇女比 20 至 24 岁的已婚妇女使用现代避孕药具的可能性更小（人口参考局，2006 年）。 年轻母亲的孕产妇发病率也较高，包括严重并发症，例如 难产或产科瘘管病，主要发生在年轻女性中（人口基金和 EngenderHealth，2003 年；Jarrett，1994 年）。如果不及时干预，难产可能会导致组织坏死，从而导致产妇永久性发病，甚至死亡。关于孕产妇发病率的数据很少，并且仅适用于少数情况。在埃塞俄比亚，24% 的妇女在 18 岁之前分娩，难产是 46% 孕产妇死亡的直接原因，每 1,000 名孕妇中就有 3 人患有瘘管病，这 这种情况在孟加拉国也很常见（人口参考局，2006 年；人口基金，2003 年；Akhter 等人，1996 年）。最重要的是，医学界目前还不知道生育年龄与生殖结果之间的关系在多大程度上是早育的生理后果，这一关系已有充分记录。因此，本研究具有重要的科学价值。 除生理途径外，早婚还可能通过行为影响健康 渠道。首先，青少年寻求健康行为较少，健康信息有限，这对已婚青少年的健康状况产生负面影响。在孟加拉国，70% 20 岁以下的孕妇没有接受产前护理，90% 在家分娩。她们获得健康信息的机会很少：20%的青少年母亲对怀孕期间危及生命的情况知之甚少，大多数（已婚和未婚）没有关于性、避孕、性传播感染或艾滋病毒/艾滋病的信息（Haider等人，1997年；Nahar等人，1999年；Barkat等人，2000年；Bruce和Clark，2004年）。 青少年获得生殖保健和服务的机会也很差：在孟加拉国，27%的20岁以下母亲的避孕需求得不到满足，而20至35岁的母亲中这一比例为10%（NIPORT、Mitra Associates和ORC Macro，2001年）。此外，已婚青少年使用避孕措施的比例比老年妇女低得多。在南亚，15 至 19 岁的已婚妇女中有 9% 使用现代避孕措施，而 20 至 24 岁的妇女中这一比例为 24%。在孟加拉国，这一比例分别为 34% 和 47%（人口参考局，2006 年）。使用率较低可能反映出缺乏计划生育意识、对立即生育第一个孩子的期望以及青少年获得医疗服务的机会更加有限。 此外，年轻女孩往往会嫁给年长得多的男性。对撒哈拉以南非洲地区的研究发现，15 至 19 岁的吉里斯的丈夫平均比自己大 10 岁（联合国儿童基金会，2001 年）。全球范围内，配偶平均年龄差异随着女性初婚年龄的增加而减小。在西非，14至15岁初次结婚的女孩的平均配偶年龄差异为12岁，24至25岁结婚的女性的平均配偶年龄差异为8岁；南亚也存在同样的情况（联合国人口基金，2004 年）。配偶之间年龄差距较大可能会在很多方面导致不良结果。首先，年长的丈夫往往有更多的性经验，这意味着性传播感染的风险更大（Clark，2004；Luke和Kurz，2002）。年龄差距还与青少年吉里缺乏婚姻自主权有关，这可能导致健康状况不佳。缺乏决策权可能会导致生育能力下降 控制或协商性关系、避孕和生育的能力。定性研究还表明，大多数年轻的已婚女性面临着婚前怀孕的压力，并且缺乏避免怀孕的生殖控制（Bledsoe 和 Cohen，1993；Mensch、Bruce 和 Greene，1998；Bruce 和 Clark，2004）。 定性但很少严格的分析表明，孤立、行动受限和缺乏对家庭资源的控制在年轻已婚吉里人中更为常见（Mensch 等，1998）。 孤立和成人责任压力的增加可能会对他们产生直接的有害影响 心理健康。行动不便也可能导致已婚青少年的医疗保健利用率较低。印度的研究表明，已婚青少年女孩的医疗保健决定主要由丈夫和婆婆控制（Barua 和 Kurz，2001）。加上行动不便，这可能会限制青少年为自己及其子女获得医疗服务的能力。 最后，早婚与健康之间的负面关联会延续到下一代。 20 岁以下女性所生孩子在 5 岁之前的婴儿死亡率 (IMR) 较高。在马里，20 岁以下母亲的婴儿死亡率为每 1,000 人中 181 人，而 20 至 29 岁母亲的孩子的婴儿死亡率为每 1,000 人 111 人。同样，坦桑尼亚的婴儿死亡率为 164 例和 88 例，尼泊尔为 108 例和 68 例，多米尼加共和国为 71 例和 28 例（Marthur、Green 和 Malhotra， 2003）。在孟加拉国，20 岁以下母亲所生婴儿的 IMR 为 86，而 20 至 29 岁母亲所生婴儿的 IMR 为 60（NIPORT、Mitra Associates 和 ORC Macro，2005）。青春期母亲的孩子的儿童死亡率（CMR）也更高。在肯尼亚，20 岁以下母亲所生孩子的这一比例为每 1,000 人 48 人，而 20 岁至 29 岁母亲所生孩子的这一比例为每 1,000 人 32 人。埃塞俄比亚的这一数字为 90 人，83 人；南非 40 和 19；埃及的 15 和 13（Marthur、Green 和 Malhotra，2003 年）。在孟加拉国，母亲的孩子的 CMR 为每 1,000 人 106 20 岁以下的孩子，而 20 至 29 岁母亲所生的孩子为 84 岁（NIPORT、Mitra Associates 和 ORC Macro，2005 年）。 [尚不清楚这种相关性在多大程度上是由于儿童对医疗保健的利用率较低（例如，免疫接种率较低）或母亲对良好健康习惯的了解较少所致。]