Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: Findings from a health and demographic surveillance system

PLOS ONE RESEARCH ARTICLE Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: Findings from a health and demographic surveillance system Kyu Han Lee ID1, Atique Iqbal Chowdhury2, Qazi Sadeq-ur Rahman2, Solveig A. Cunningham3, Shahana Parveen4, Sanwarul Bari2, Shams El Arifeen2, Emily S. Gurley ID1* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America, 2 Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh, 3 Department of Global Health, Emory University, Atlanta, Georgia, United States of America, 4 Infectious Diseases Division, icddr,b, Dhaka, Bangladesh * Abstract OPEN ACCESS Citation: Lee KH, Chowdhury AI, Rahman QS-u, Cunningham SA, Parveen S, Bari S, et al. (2023) Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: Findings from a health and demographic surveillance system. PLoS ONE 18(7): e0288746. https://doi.org/10.1371/journal.pone.0288746 Editor: Fadhlun Alwy Al-beity, MUHAS: Muhimbili University of Health and Allied Sciences, UNITED REPUBLIC OF TANZANIA Received: September 23, 2022 Accepted: June 27, 2023 Published: July 19, 2023 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pone.0288746 Adolescent pregnancies, a risk factor for obstetric complications and perinatal mortality, are driven by child marriage in many regions of South Asia. We used data collected between 2017–2019 from 56,155 married adolescents and women in a health and demographic surveillance system to present a population-level description of historical trends in child marriage from 1990–2019 as well as epidemiologic associations between maternal age and pregnancy outcomes in Baliakandi, a rural sub-district of Bangladesh. For pregnancies identified between 2017–2019, we used Kaplan-Meier estimates to examine timing of first pregnancies after first marriage and multinomial logistic regression to estimate associations between maternal age and perinatal death. We described the frequency of self-reported obstetric complications at labor and delivery by maternal age. In 1990, 71% of all marriages were to female residents under 18 years of age. This decreased to 57% in 2010, with the largest reduction among females aged 10–12 years (22% to 3%), and to 53% in 2019. Half of all newly married females were pregnant within a year of marriage, including adolescent brides. Although we observed a decline in child marriages since 1990, over half of all marriages in 2019 were to child brides in Baliakandi. In this same population, adolescent pregnancies were more likely to result in obstetric complications (13–15 years: 36%, 16–17 years: 32%, 18–34 years: 23%; χ2 test, p<0.001) and perinatal deaths (13–15 years: stillbirth OR 2.23, 95% CI 1.01–2.42; 16–17 years: early neonatal death OR 1.57, 95% CI: 1.01–2.42) compared to adult pregnancies. Preventing child marriage can improve the health of girls and contribute to Bangladesh’s commitment to reducing child mortality. Copyright: © 2023 Lee et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PLOS ONE | https://doi.org/10.1371/journal.pone.0288746 July 19, 2023 1 / 13 PLOS ONE Data Availability Statement: All data files are available from the Harvard Dataverse (https://doi. org/10.7910/DVN/93PYJC). Funding: This work was supported by the Bill & Melinda Gates Foundation, Seattle, WA [award number OPP1126780). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Child marriage, obstetric complications, and perinatal death in rural Bangladesh Introduction Girls who become pregnant during adolescence are at increased risk for obstetric complications including pregnancy-induced hypertension, obstructed labor, obstetric fistula, and postpartum hemorrhage [1–4]. These complications are the leading cause of death among adolescent girls [5] and those who survive with conditions such as obstetric fistula experience devastating psychosocial disabilities spurred by shame, stigma, and rejection [6]. Adolescent pregnancies are also more likely to result in perinatal death [7], defined as fetal demise at or after 28 weeks of estimated gestational age (i.e. stillbirth [8]) or death within the first 7 days after live birth (i.e. early neonatal death [9]). While remarkable reductions in global under-five mortality have been observed over the past two decades, progress has been slower in preventing neonatal deaths, which made up nearly half of the estimated 5 million under-five deaths in 2019 [10]. Even less progress has been made in preventing stillbirths, which sums to an estimated 2 million fetal deaths each year [11]. Adolescent pregnancies are exacerbated by the practice of child marriage [12]. Child marriage, defined as the formal or informal union of a child under 18 years of age [13], is a human rights violation that disproportionately affects girls particularly in low- and middleincome countries [14], and contributes to severe social, developmental, and reproductive harms [15]. Globally, an estimated 16 million girls aged 15–19 become pregnant each year and 90% of these adolescent pregnancies occur within marriage [12]. Given societal and familial pressures to bear children immediately after marriage in many communities [15], marriage often means the beginning of a sexual relationship for children who are still in the process of maturing physically and psychologically [7]. Although extensive global efforts have been made to end child marriage, progress has been stagnant in recent years. In 2018, 21% of women aged 20–24 years worldwide were married before 18 years of age and, assuming the current rate of decline continues, it would take at least 50 years to end child marriage [14]. Some of the highest rates of child marriage in the world are found in Bangladesh. In 2018, 59% of women aged 20 to 24 years were married before 18 years of age and 28% of married adolescents aged 15 to 19 reported ever being pregnancy [16]. Much of our current understanding of child marriage prevalence in Bangladesh and the relationship with adverse pregnancy outcomes are derived from the Bangladesh Demographic and Health Survey, which utilizes a cross-sectional two-stage cluster sampling approach [16–18]. Although nationally representative, d (...truncated)