- Split View
-
Views
-
Cite
Cite
Elizabeth G. Henry, Nicholas B. Lehnertz, Ashraful Alam, Nabeel Ashraf Ali, Emma K. Williams, Syed Moshfiqur Rahman, Salahuddin Ahmed, Shams El Arifeen, Abdullah H. Baqui, Peter J. Winch, Sociocultural factors perpetuating the practices of early marriage and childbirth in Sylhet District, Bangladesh, International Health, Volume 7, Issue 3, May 2015, Pages 212–217, https://doi.org/10.1093/inthealth/ihu074
- Share Icon Share
Abstract
The practice of adolescent marriage continues in communities throughout Bangladesh, with adolescent childbearing a common result. This early childbearing is associated with increased medical risks for both mothers and their newborns.
Because of the need to understand the persistence of these behaviors in spite of the risks, various qualitative research methods were used to identify and better understand the various socio cultural factors perpetuating the practices of early marriage and childbirth.
Delaying the first birth after marriage can cause rumors of infertility, bring shame on the family, and in some cases lead the husband's family to seek another wife for their son. In addition, social stigma for childless women, emigration of husbands, and the belief that using modern contraceptives prior to the birth of the first child results in infertility also inhibits couples from delaying their first pregnancy.
Future efforts to promote delay in marriage and subsequent early childbearing should focus on allaying the fears of infertility related to delay in childbearing or secondary to contraceptive use, both for newly married couples and household decision-makers such as mothers-in-law.
Introduction
Improving birth outcomes for mothers and their children continues to be a key health priority in Bangladesh. The lifetime risk of maternal death in Bangladesh is 1 in every 170 women, compared to 1 in 180 for the world and 1 in 3800 for developed regions.1 Rates of under-5 and neonatal mortality, at 53 and 32 per 1000 live births respectively, while declining, remain high relative to other developing nations. Importantly, the neonatal mortality rate in Bangladesh is three times the post-neonatal mortality rate2 and neonatal deaths make up an estimated 57% of under-5 child deaths.3 In order to meet Millennium Development Goal 4 of a two-thirds reduction of the under-5 mortality rate by 2015, a focus on reducing neonatal mortality is critical, especially in countries such as Bangladesh.4,5 As part of the effort to meet this goal, a focus on the socio economic factors contributing to neonatal morality rates is imperative.3,6
One factor associated with increasing risk of death and disability to both mother and newborn is early pregnancy, with increasing rates of maternal and neonatal morbidity as maternal age decreases.7,8 In Bangladesh, babies born to women under 20 years of age are more likely to die during the neonatal period, compared to births to mothers aged 20–24 years. Despite a higher risk of neonatal death for first births of all mothers, the risk was higher for second births of teenage (<20) mothers, compared to births to parity 1 mothers in their 20 s, after controlling for socioeconomic status. These findings suggest that physical immaturity may be one important factor in the relationship between teenage fertility and high neonatal mortality.9 In addition, infants of adolescent mothers are at increased risk for low birth weight, preterm delivery, and being small for gestational age, while the very youngest mothers, under age 15, are at increased risk of both maternal and infant death compared to mothers aged 20–24.8
Delaying first pregnancy until women are at least 18 years old could reduce the risk of death for first-born children by 20% on average, with reductions of up to 30% in some countries.10 The promotion of family planning, including the delay of childbearing by the use of contraceptives, has the potential to prevent up to 32% of all maternal deaths and 10% of child deaths in developing countries with high birth rates.11
Pregnancy during adolescence is common in countries with high rates of adolescent marriage. In India and Pakistan, women who have married under the age 18 have lower fertility control and higher overall fertility, including unwanted pregnancies, and rapid repeat pregnancies, with the youngest at most risk.12,13 Recent data indicate that for females in Bangladesh, marriage during adolescence is associated with lack of contraceptive use prior to the first pregnancy, having a pregnancy terminated, and poorer maternity care.14 Despite a law against marriage for girls under the age of 18, there is a long history of adolescent marriage in Bangladesh that continues today, particularly in rural areas.2 It is estimated that in 2011, 65% of women aged 20–24 were married prior to the age of 18, with the median age of 16.6 years.2
In Bangladesh, there are several known determinants that perpetuate the practice of early marriage, despite the reported high demand for healthy birth practices in zero-parity adolescent females.15 These factors include the desire for a husband's family to acquire a young bride for their son; the standard, accepted 8–10 year age difference between spouses; and the parents' wish to protect the sexual virtue of their young daughters in a culture that forbids premarital sex by arranging marriage before they have a chance to engage in such activities. In addition, families of low socioeconomic status may feel there is a lack of alternatives to arranging the marriage of their daughters at a young age. Despite some evidence of norms shifting to favor delayed marriage and increased female educational attainment, for some, particularly the poorest of families, alternatives such as schooling are perceived as too costly and with uncertain outcomes.16 In the context of a culture where the practice of dowry has increased despite being an illegal practice, families facing economic hardship may also be willing to arrange an early marriage for their daughters, incentivized by reduced dowry payments for younger brides.17 The goal of this paper is to identify and describe social and cultural factors that influence the timing of marriage and first birth in a region of rural Bangladesh where there is a high fertility rate and low contraceptive prevalence. Understanding these factors may aid in the development of strategies to promote delayed marriage and timing of firth birth, and ultimately improve birth outcomes for young mothers and their newborns.
Methods
The study was conducted in Sylhet District within Sylhet Division, which has the highest total fertility rate (TFR=3.1) and the highest proportion of births spaced less than 36 months (46.5%) in Bangladesh,2 and is distinct from the rest of Bangladesh in terms of language, patterns of migration, and religious conservatism. As in most regions of Bangladesh, in Sylhet it is traditional for newly married couples to live with the husband's parents and unmarried siblings, and for the new wife to follow the authority of her mother-in-law in the household. This area is also characterized by high levels of male emigration to the Persian Gulf and Europe for work.
Formative research was conducted from January to June 2006 using a variety of methods, in order to identify current fertility-related knowledge and practices, and to inform the development of an intervention to promote healthy fertility practices and birth spacing18 as part of an existing package of maternal and newborn care interventions put in place during a previous cluster-randomized, community-based maternal and neonatal health trial conducted from 2002–2007.19
To begin, a household survey was administered with newly married women, defined as women who had gotten married in the previous 18 months and who had not yet had a live birth by the time of data collection (n=740). This survey was to determine age at marriage, timing of the initiation of first pregnancy, and other socioeconomic and household factors. After the completion of this survey, 80 in-depth interviews were conducted in the homes of both the identified newly married women, along with recently delivered women (mothers of a child between the ages of 6 and 23 months) with birth spacing either greater than 36 or less than 19 months. The husbands of all women and mothers-in-law of recently delivered women were also interviewed (see Box 1 for an outline of all methods used). A semi-structured format was used to elicit information on timing of first birth, contraceptive practices and other issues relating to fertility.
Survey (n=740) | Conducted with women who had gotten married in the previous 18 months (between January 2005 and June 2006) and had not yet had a live birth at the time of data collection (in the last half of 2006) |
In-depth interviewsa (n=80) |
|
In-depth interviews (n=31) | Conducted with community based health care providers (drug sellers/pharmacists, government health workers, homeopaths, traditional healers, village doctors and traditional birth attendants, from both the government and private sectors). |
Focus group discussions (n=2) | Conducted with members of the local government and local religious leaders. |
Survey (n=740) | Conducted with women who had gotten married in the previous 18 months (between January 2005 and June 2006) and had not yet had a live birth at the time of data collection (in the last half of 2006) |
In-depth interviewsa (n=80) |
|
In-depth interviews (n=31) | Conducted with community based health care providers (drug sellers/pharmacists, government health workers, homeopaths, traditional healers, village doctors and traditional birth attendants, from both the government and private sectors). |
Focus group discussions (n=2) | Conducted with members of the local government and local religious leaders. |
a Respondents were selected purposively to have equal representation from high socioeconomic status families (relatives working in the United Kingdom or North America and sending money home to support family members in Bangladesh), middle socioeconomic status families (without relatives abroad), low socioeconomic status families (families of fishermen and farmers), and very low socioeconomic status families (those who had migrated into the area from other parts of Bangladesh).
b Newly married women are defined as women married between January 2005 and June 2006 who had not yet had a live birth at the time of data collection in 2006.
c Recently delivered women are defined as mothers of a child between the ages of 6 and 23 months at the time of the data collection in 2006.
d Recently delivered women birth spacing interval defined as the amount of time between the two most recent pregnancies.
Survey (n=740) | Conducted with women who had gotten married in the previous 18 months (between January 2005 and June 2006) and had not yet had a live birth at the time of data collection (in the last half of 2006) |
In-depth interviewsa (n=80) |
|
In-depth interviews (n=31) | Conducted with community based health care providers (drug sellers/pharmacists, government health workers, homeopaths, traditional healers, village doctors and traditional birth attendants, from both the government and private sectors). |
Focus group discussions (n=2) | Conducted with members of the local government and local religious leaders. |
Survey (n=740) | Conducted with women who had gotten married in the previous 18 months (between January 2005 and June 2006) and had not yet had a live birth at the time of data collection (in the last half of 2006) |
In-depth interviewsa (n=80) |
|
In-depth interviews (n=31) | Conducted with community based health care providers (drug sellers/pharmacists, government health workers, homeopaths, traditional healers, village doctors and traditional birth attendants, from both the government and private sectors). |
Focus group discussions (n=2) | Conducted with members of the local government and local religious leaders. |
a Respondents were selected purposively to have equal representation from high socioeconomic status families (relatives working in the United Kingdom or North America and sending money home to support family members in Bangladesh), middle socioeconomic status families (without relatives abroad), low socioeconomic status families (families of fishermen and farmers), and very low socioeconomic status families (those who had migrated into the area from other parts of Bangladesh).
b Newly married women are defined as women married between January 2005 and June 2006 who had not yet had a live birth at the time of data collection in 2006.
c Recently delivered women are defined as mothers of a child between the ages of 6 and 23 months at the time of the data collection in 2006.
d Recently delivered women birth spacing interval defined as the amount of time between the two most recent pregnancies.
In addition to the newly married women and their families, an additional 31 in-depth interviews were conducted with a variety of community based health care providers in order to identify and describe family planning counseling for newly married couples and related social norms. Finally, two focus group discussions were held with religious leaders and members of the local government on their views of timing of marriage and childbirth.
Household survey data were analyzed using Stata Version 9.0.20 Bivariate analyses were conducted to describe characteristics of newly married women. Local researchers conducted and tape recorded interviews and focus group discussions in either Bangla or the local dialect, and then transcribed them into English. The entire research team then reviewed, analyzed and summarized the transcripts to identify themes and relevant findings.
Results
This section starts by reporting the prevalence of early marriage and first birth among adolescents in our sample. We then explore perceptions of adolescent marriage and childbirth, including societal norms, practices and influential factors that emerged from the in-depth interviews and focus group discussions. The section is organized by the major themes that emerged during the qualitative analysis.
Timing of marriage
More than half of newly married women surveyed (53.1%, n = 393/740) reported that they had married before the age of 18. This finding was consistent with the view of a sub-district health official, who stated that approximately 40% of newly married women were under the age of eighteen. This is despite the fact that the newly married women, husbands and mothers-in-law who were interviewed reported that the ideal age for marriage was between 18 and 20 years. This practice of early marriage is a precursor to early initial pregnancy and birth as outlined below.
Timing of first birth
Nearly 40% (n=289/740) of the newly married women surveyed were already pregnant at the time the household survey was conducted, and 37.7% of adolescent women who had married before the age of 18 (n=148/393) were currently pregnant. Moreover, most newly married women surveyed planned to become pregnant immediately. Among those newly married women who were under the age of 18 and were not already pregnant, 51.9% (n=125/241) of them wanted a child immediately.
Fear of infertility and social expectations
A fear of infertility for both husbands and wives, which can lead to social stigma, teasing and gossip, was cited as a reason for not using contraceptive methods after marriage. One recently married male informant said that he was 36 years old and that he feared he might become infertile soon and so he wanted to have a child as soon as possible. Said a newly married woman regarding infertility:
If you have a baby in the year of your marriage, then the villagers will not say anything bad about you. But if two or three years pass without a baby, then they will call you banja [slang term for an infertile woman] or atkura [slang term for an infertile man]. So, you could avoid all of this gossip if you have a child soon after marriage.
Having a child soon after marriage may also serve to establish a newly married woman's role in the family. Prior to having a child, the newly married woman is often not considered a complete member of her in-law family, having yet to prove her value and her fertility. Having a child soon after marriage can solidify a newly married wife's standing within the family. As a recently delivered woman commented:
When I got married, I was very young, I didn't understand things very well. After I got married, I felt shame talking with my husband [about family planning issues], so I didn't talk to him. After three months, I became pregnant. This is because my husband wanted to take a child right after marriage, since my husband is the eldest son, and my mother-in-law and father-in-law want to see grandchildren before they die.
If the marriage continues for a few years without childbirth, the wife may fear that her husband will want to take another wife, which could further weaken her status within the family. Said one newly married male informant:
During this time, many people were asking me, ‘Why do you keep this [woman]? She is not yet able to produce a child, so why do you keep her?’ Then, my wife got pregnant, but had a stillbirth. Again people said, ‘Why are you still keeping this wife? Leave her and get another wife. What will you do with this? Change it.’ But then, by the grace of Allah I got a child.
Economic factors and emigration
In Sylhet, a significant proportion of the adult male population migrates to the Middle East, Europe or North America for work. In these families, after spending a few weeks or months together after the wedding, the husband and wife frequently live apart for years. Having a child may be one way to cement the bond between the husband and wife before he leaves, and between the wife and the husband's extended family, with which she will live once her husband has migrated.
In contrast, some men described waiting until they felt economically established or ready to have a child before marrying. This view was held primarily among those men who were not going abroad soon, or not visiting home from abroad for a limited time with the goal of finding a bride. One husband expressed a desire to immigrate to another country for work to save money before having children. Another couple interviewed had been married for one year and had no children. The wife wished to bear a child after one year, but her husband wished to wait 4 years, reasoning that they could save money to pay for care if the baby got sick. A few couples said they would prefer to have the chance to enjoy married life for a few years without the pressure of childbearing.
Dowry payments were also cited as an important economic factor for families considering when to arrange marriage for their daughters. Quite often, families of younger women may be allowed to pay smaller dowries than families of older women. Delaying marriage could increase the financial burden for parents of young unmarried women.
Access to information
Health communication campaigns in the area have previously delivered messages about benefits of delayed childbirth and appropriate spacing of births. Sources of this information mentioned by respondents included both mass media, such as billboards, health workers visiting their homes for antenatal visits, and information from family members. Said one newly married woman:
While living in my natal home my brother's wife and my husband's brother's wife informed me that if I have babies with a large gap, my health will remain well. The health of the children will also remain well. I also heard this information from the health workers when they came to talk to my brother's wife when she delivered. Moreover, I watched this on TV at my father's house.
However, the ability to access information varied widely among the respondents. For example, only 10.4% of newly married women (n=77/740) said that a health care worker had actually come to their house to visit them since their marriage, and only another 8.5% (n=63/740) had actually gone from their home to visit a health care worker. Of the newly married women that had any contact with a heath care worker, only 30.7% (n=42/137) reported that they had spoken with them about family planning. Providers that were interviewed said they discourage contraceptive use by newly married couples before their first child, saying that it is a risk to the mother's future fertility. However, among the small group of women who had contact with a health worker, roughly half of them reported that the health worker discussed delaying the first pregnancy, and again half report having received information on the importance of birth spacing.
Men generally have much more access to information regarding contraceptive methods than their wives, partly because they have greater ability to move freely in the community. They described obtaining information from friends, neighbors, family members, ‘village doctors’ (unlicensed rural medicine sellers), and medicine salespersons, and some learn from others they meet when they migrate for work. A newly married woman often must ask for permission to leave the house, even to visit her natal family, and often someone must accompany her. If she wishes to purchase anything with money, she must also ask for permission, further limiting her ability to obtain family planning methods at static clinics. Moreover, traditionally decision-making power primarily lies with the husband, leaving newly married women with little say about their fertility choices.
Familial communication patterns
When they marry, many couples reported discussing their desired number of children and when to begin having them, but most did not discuss family planning method use. In total, 38.9% (n=284/740) of newly married women surveyed reported not having discussed family planning with their husband ever, and another 40.5% (n=300/740) only discussed family planning once or twice in the past year. Even fewer women surveyed reported discussing family planning matters with their mothers-in-law.
Perceived risks of adolescent childbearing
Several newly married men and women identified general risks to the mother associated with early childbearing, with a focus on morbidities rather than mortality. Some women said that they were not physically mature enough for a child and that their body was not prepared. One newly married woman, 16 years old, said that her husband believed that her body would stay healthy longer if the first birth was delayed. Another husband expressed a desire to wait because he was not sure that his wife's body could handle the stress of pregnancy and childbirth.
However, this concern over the risks of early childbirth was not common for all respondents. Some informants reported the opposite, that there were negative physical consequences to delaying childbirth. Said one newly married female informant:
I'll have a baby right now, and then I'll stop having babies after that. Moreover, I have the ability to rear a baby. I don't have any bimar [sickness] in my body. If I delay, then bimar could come to my body. If you delay having first baby, you may not have any in the future.
Many community-based health care providers that were interviewed identified physical risks associated with early childbearing, such as increased risk of obstetric emergency and need to give birth in a facility, though most said that delaying the first child would have no impact on the health of the child.
Discussion
This study has described the considerable social and cultural factors restricting the delay of marriage and childbirth in Sylhet, Bangladesh, including social pressure to have children immediately after marriage to allay both infertility fears and to fulfill familial expectations, particularly in this community of high migration. Parental beliefs and decisions regarding marriage have been previously identified as important predictors of early marriage,21 and adolescent women often get pregnant before they are ready in order to conform to the family pressure and fulfill their own desire to fit in to their new family.22 A childless marriage may be viewed by extended family members as a great disappointment, and previous studies have described extreme pressure for couples to reproduce immediately.16
Contraception for young couples is deemed counterproductive and harmful, and because of this, access to family planning methods is often restricted for young couples by their families. Newly married couples rarely receive visits from community health workers regarding family planning, and they often have limited access to reproductive health services outside the home, especially women.23 Information they receive is often based on misinformation obtained through social networks and even some health care workers, who indicate that using contraceptive methods early in life will lead to a childless marriage.
Young newly married couples and their families in our study were concerned about infertility. A widespread misunderstanding that using modern contraceptives would cause sterility among women who had not yet given birth has been previously reported in Bangladesh16 and in several countries across south Asia and sub-Saharan Africa.24–27 Infertility concerns of young couples are often seemingly validated, given both the patterns of migration in this population and the stigmatization of childlessness. Both women and men who have not had children can be perceived at failing in their roles, with severe social and emotional consequences, including potential social and familial displacement, especially for women.28
Interestingly, a contrasting view of the value of female fertility and the importance of immediate childbirth has emerged since the advent of women's work in the garment industry. One study revealed that young women in the urban environment working in the garment industry experienced their husband's family putting more value on their economic productivity than their reproductive status, since they could contribute to the household earnings,22 a finding that contrasts with our results in Sylhet.
Previous research also has revealed economic concerns about paying for caesarian sections caused by early childbearing as motivation to delay pregnancy in adolescent females.16 This is consistent with some reports in our study of couples wishing to delay childbirth for economic reasons, either for saving money to pay for the care of the child, or to have more freedom as a couple, both consistent with the ideas of changing norms.
Limitations
There are several limitations to our study. The research was conducted in a region of Bangladesh that differs substantially from other areas, especially regarding fertility, limiting generalizability. The small sample size of respondents for the qualitative component may not reflect perspectives of the larger community. The transcription and translation process could have led to misunderstanding of respondents' comments, though the use of local community-based researchers hopefully minimized this issue.
There is reason to believe that the actual proportion of adolescent mothers is higher than our findings suggest. Due to the low literacy rate of the population and non-existence of birth registry at the time the respondents were born in Bangladesh, many of the respondents in this population may have simply estimated their actual age. In addition, women may have overstated their age in order to comply with the legal age of marriage, leading to underreporting of the percentage of women having married before the age of 18.
Conclusions
The results of this study suggest that in order to delay age of marriage and, ultimately, first birth, efforts to promote delay in marriage childbearing should focus on improving communication between husband and the wife, allaying fears of infertility related to contraceptive use and improving the understanding of the benefits and the proper use of contraceptive methods for the delay of immediate childbirth. Reproductive health interventions that have targeted couples have been shown to be more effective than those direct towards either women or men individually regarding contraceptive use.29 In addition intervention strategies should also target their families since the decision to delay childbirth is not only an individual or couple-level decision. Messages delivered should focus on the negative health consequences of adolescent marriage and consequent childbirth. Women under the age of 18 who are engaged to be married could also be targeted, along with the future husband and his family. A similar approach has been tested in nearby India, where a behavior change communication intervention to delay childbirth and encourage birth spacing, targeting couples, in-laws and unmarried youths, increased both demand for and use of contraception. Moreover, the program increased the interval between marriage and first birth and the use of contraceptives among newly married couples. Part of this success was attributed to the focus on spousal communication. The use of educational entertainment and interactive games in group sessions with couples are one possibility for engaging newly married couples in the Bangladeshi setting.30,31 In the past, frequent visits by family planning workers to the home of adolescents to provide family planning advice and counseling has been shown to significantly improve the contraceptive use rate.32 Expanding existing family planning programs to include newly married couples and using married peer educators to provide education has also been shown to be effective in Bangladesh in promoting the use of antenatal care and skilled attendants at birth.33 Using similar models may prove beneficial to disseminating key messages about delaying first birth. Village doctors and traditional birth attendants should also receive support on how to deliver messages about the consequences of early initiation of childbirth and to counsel couples in delaying first birth.
Authors' contributions: PW and AB conceived the study; PW, EH, EW, NL, SMR, SA, and SEA designed the study protocol; AA, NAA, EH, EW, NL collected and analyzed the data; EH, EW and PW drafted the manuscript; NL, AA, SMR, SA, SEA, and AB critically reviewed and revised the manuscript for intellectual content. All authors read and approved the final manuscript. PW is the guarantor of the paper.
Funding: This work was supported by and funding for this study provided by the United States Agency for International Development through the Family Health and Child Survival Cooperative Agreement and the USAID Mission in Dhaka, Bangladesh.
Competing interests: None declared.
Ethical approval: The study was approved by the Ethical Review Committee of the International Centre for Diarrheal Disease Research, Bangladesh.
Comments