Cross-Sectional Time Series Analysis of Associations between Education and Girl Child Marriage in Bangladesh, India, Nepal and Pakistan, 1991-2011

<div><p>Background</p><p>Girl education is believed to be the best means of reducing girl child marriage (marriage <18 years) globally. However, in South Asia, where the majority of girl child marriages occur, substantial improvements in girl education have not corresponded to equivalent reductions in child marriage. This study examines the levels of education associated with female age at marriage over the previous 20 years across four South Asian nations with high rates (>20%) of girl child marriage- Bangladesh, India, Nepal and Pakistan.</p><p>Methods</p><p>Cross-sectional time series analyses were conducted on Demographic and Health Surveys (DHS) from 1991 to 2011 in the four focal nations. Analyses were restricted to ever-married women aged 20–24 years. Multinomial logistic regression models were used to assess the effect of highest level of education received (none, primary, secondary or higher) on age at marriage (<14, 14–15, 16–17, 18 and older).</p><p>Results</p><p>In Bangladesh and Pakistan, primary education was not protective against girl child marriage; in Nepal, it was protective against marriage at <14 years (AOR = 0.42) but not for older adolescents. Secondary education was protective across minor age at marriage categories in Bangladesh (<14 years AOR = 0.10; 14–15 years AOR = .25; 16–17 years AOR = 0.64) and Nepal (<14 years AOR = 0.21; 14–15 years AOR = 0.25; 16–17 years AOR = 0.57), but protective against marriage of only younger adolescents in Pakistan (<14 years AOR = 0.19; 14–15 years AOR = 0.23). In India, primary and secondary education were respectively protective across all age at marriage categories (<14 years AOR = 0.34, AOR = 0.05; 14–15 years AOR = 0.52, AOR = 0.20; 16–17 years AOR = 0.71, AOR = 0.48).</p><p>Conclusion</p><p>Primary education is likely insufficient to reduce girl child marriage in South Asia, outside of India. Secondary education may be a better protective strategy against this practice for the region, but may be less effective for prevention of marriage among older relative to younger adolescents.</p></div

Adjusted odds ratios showing associations between secondary education and girl child marriage, 1991 to 2011.

<p>Adjusted odds ratios showing associations between secondary education and girl child marriage, 1991 to 2011.</p

Multinomial model assessing odds of marrying at ages <14, 14–15, 16–17, compared to marrying at 18 or older in Bangladesh, India, Nepal and Pakistan.

<p>Adjusted for education level by survey year interaction. Interactions terms were significant (p<.05) for India, Nepal, Pakistan.</p>†<p>Higher education estimates may be inaccurate due to small cell sizes.</p>§<p>Years of completed education of wife subtracted from years of completed education of husband.</p><p>Multinomial model assessing odds of marrying at ages <14, 14–15, 16–17, compared to marrying at 18 or older in Bangladesh, India, Nepal and Pakistan.</p

Education levels of ever married 20–24 year old women in Bangladesh, India, Nepal, and Pakistan, 1991–2011.

<p>Education levels of ever married 20–24 year old women in Bangladesh, India, Nepal, and Pakistan, 1991–2011.</p

Making the continuum of care work for mothers and infants: Does gender equity matter? Findings from a quasi-experimental study in Bihar, India

<div><p>Background</p><p>Improvements in continuum of care (CoC) utilization are needed to address inadequate reductions in neonatal and infant mortality in India and elsewhere. This study examines the effect of Ananya, a health system training and community outreach intervention, on reproductive, maternal and newborn health continuum of care (RMNH CoC) utilization in Bihar, India, and explores whether that effect is moderated by gender equity factors (child marriage, restricted mobility and low decision-making control).</p><p>Methods</p><p>A two-armed quasi-experimental design compared districts in Bihar that did/did not implement Ananya. Cross-sections of married women aged 15–49 with a 0–5 month old child were surveyed at baseline and two year follow-up (baseline n = 7191 and follow-up n = 6143; response rates 88.9% and 90.7%, respectively). Difference-in-difference analyses assessed program impact on RMNH CoC co-coverage, defined by 9 health services/behaviors for the index pregnancy (e.g., antenatal care, skin-to-skin care). Three-way interactions assessed gender equity as a moderator of Ananya’s impact.</p><p>Findings</p><p>Participants reported low RMNH CoC co-coverage at baseline (on average 3.2 and 3.0 of the 9 RMNH services/behaviors for Ananya and control groups, respectively). The Ananya group showed a significantly greater increase in RMNH CoC co-coverage (.41 services) compared with the control group over time (p<0.001), with the primary drivers being increases in clean cord care, skin-to-skin care and postpartum contraceptive use. Gender equity interaction analyses revealed diminished intervention effects on antenatal care, skilled birth attendance and exclusive breastfeeding for women married as minors.</p><p>Conclusion</p><p>Ananya improved RMNH CoC co-coverage among these recent mothers, largely through positive health behavior changes. Child marriage attenuated Ananya’s impact on utilization of key health services and behaviors. Supporting the health system with training and community outreach can be beneficial to RMNH CoC utilization; additional support is needed to adequately address the unique issues faced by women married as minors.</p></div

Participant characteristics (N = 30), 2010–2011.

a<p>Median (range).</p>*<p>Categories not exclusive.</p><p>NOTE: Data are N (%) of women, unless otherwise indicated.</p

Sociodemographic, Biologic, Behavioral Characteristics associated with FSWs' Condom Negotiation with Patrons.

*<p>p<.05.</p>a<p>self-reported.</p>b<p>Yes-No responses on type/how often drugs used.</p>c<p>never = 1, 1–2×/month = 2, 1×/week = 3, often not daily = 4, daily = 5; Note: Due to missing data, certain percentages may reflect denominators smaller than N given in the column head.</p

Micro-Social Environmental Factors Associated with FSWs' Condom Negotiation with Venue Patrons.

<p>p<.05.</p>**<p>p<.10.</p>a<p>Sex workers had lower emotional, tangible social support (Norbeck scale) compared to a general sample.</p>b<p>(never = 1, always = 5);Due to missing data, certain percentages may reflect denominators smaller than N in column head.</p

Adaptation of Rhodes' Risk Environment Framework.

<p>Adaptation of Rhodes' Risk Environment Framework.</p

Multivariate assessment of the effect of the Ananya program on the RMNH CoC in Bihar, India (n = 13,334).

<p>Multivariate assessment of the effect of the Ananya program on the RMNH CoC in Bihar, India (n = 13,334).</p