93542 Knowledge Brief Health, Nutrition and Population Global Practice SOCIOECONOMIC DIFFERENCES IN ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH: MARRIAGE Rafael Cortez, Jennifer Yarger, Mara Decker and Claire Brindis January 2015 KEY MESSAGES:  Marriage marks the beginning of exposure to the risk of pregnancy, sexually transmitted infections, and gender-based violence. Early marriage often limits young girls’ autonomy, knowledge, resources, and decision-making power.  Among the five countries studied, rates of marriage among women aged 15–19 are highest in Niger, where nearly two thirds (64 percent) adolescent women have been married. Approximately one third of adolescent women in Burkina Faso and one quarter of those in Ethiopia, Nigeria, and Nepal have been married.  Adolescent marriage—at any age and before age 15—is more common among adolescent women who live in rural areas and have less wealth and education. Introduction Furthermore, research in Ethiopia has found that adolescent females who marry before the age of 15 are at Adolescent Sexual and Reproductive Health (ASRH) is higher risk of intimate partner violence and coercive sex one of five areas of focus of the World Bank’s than those who marry between ages 15–18 (Erulkar, Reproductive Health Action Plan 2010–2015 (RHAP), 2013). which recognizes the importance of addressing ASRH as th a development issue with important implications for At the 65 World Health Assembly, representatives poverty reduction. Delaying childbearing and preventing agreed that early marriage is a violation of the rights of unintended pregnancies during adolescence has been children and adolescents. Early marriage is illegal in most shown to improve health outcomes and increase of the places where it occurs. It limits young girls’ opportunities for schooling, future employment, and autonomy, knowledge, resources, and decision-making earnings (Greene and Merrick, 2005). power (World Bank, 2014). Adolescent marriage is also much more likely to affect females than males; in the Early marriage often marks the beginning of exposure to developing world, 16 percent of females are married in the risk of pregnancy and sexually transmitted infections comparison to 3 percent of males (UNFPA, 2013). (STIs). Research has shown that adolescent marriage is Data from UNFPA (2012) indicate that adolescent associated with unplanned pregnancy, rapid repeat marriage or being in a union is common and closely childbirth, inadequate use of maternal health services, intertwined with social disadvantage in all regions of the and poor birth outcomes, among other negative maternal world. South Asia (SA) has the highest prevalence of and child health outcomes (Godha, Hotchkiss, and Gage, women 20–24 years of age who were married or in a 2013; Raj and Boehmer, 2013; Santhya, 2011). union by age 18 (46 percent), followed by West and Central Africa (41 percent), and East and South Africa (34 percent). Adolescents are less likely to be married or in a Page 1 HNPGP Knowledge Brief  union in Latin America and the Caribbean (29 percent) Figure 1. Percentage of women aged 15–19 who have ever and East Asia and the Pacific (EAP) (18 percent). In SA been married, by country and EAP, adolescent marriage is more common in rural areas (54 percent and 23 percent, respectively) than in 63% urban areas (29 percent and 11 percent, respectively). The disparity by wealth quintile is largest in SA: 72 percent of adolescents within the poorest quintile are married before turning 18 years of age, compared to 18 32% percent in the richest quintile. In EAP, 29 percent of 29% 29% 23% adolescents in the poorest wealth quintile are married, compared to 7 percent of adolescents in the richest quintile. This brief is part of a larger study whose overall purpose Burkina Ethiopia Nepal Niger Nigeria is to: (i) highlight the multisectoral determinants of ASRH Faso outcomes; (ii) explore further the multisectoral supply- and demand-side determinants of access, utilization, and Source: Burkina Faso DHS 2010, Ethiopia DHS 2011, Nepal DHS 2011, provision of services relevant to identified ASRH Niger DHS 2012, Nigeria DHS 2008. outcomes; and (iii) identify multisectoral programmatic and policy options to address critical constraints to In all countries studied, the prevalence of marriage is improving ASRH outcomes. The goal is to incorporate the higher among adolescent women in rural than in urban main findings and recommendations into existing and new areas. The rural-urban disparity in adolescent marriage is World Bank lending operations while simultaneously greatest in Niger (74 percent in rural areas versus 24 informing ASRH policies, policy dialogue and percent in urban areas) (Figure 2). interventions for inclusion in country strategies. Figure 2. Percentage of women aged 15–19 who have ever been married, by country and residence Using data from the most recent Demographic and Health 80 Surveys (DHS) on female respondents ages 15 –19, this brief examines the current status of adolescent marriage 70 and compares indicators of adolescent marriage by 60 socioeconomic status (SES) in 5 countries: Burkina Faso, Ethiopia, Nepal, Niger, and Nigeria. 50 Percent 40 Cross tabulations between socioeconomic characteristics 30 and marriage outcomes within each country were completed if at least 10 percent of the population reported 20 the outcome. Pearson’s chi-squared tests were used to 10 assess the statistical significance of differences in marriage outcomes by rural/urban residence, education 0 level, employment status, and household wealth quintile. Urban Rural Throughout the report, only differences significant at the 0.05 level (two-tailed tests) are discussed. All data in this Burkina Faso* Ethiopia* Nepal* report are weighted. Niger* Nigeria* *Statistically significant difference (p<.05) Study Findings Source: Burkina Faso DHS 2010, Ethiopia DHS 2011, Nepal DHS 2011, Niger DHS 2012, Nigeria DHS 2008. EVER MARRIED In all countries studied, adolescent women from the At least one in five adolescent women have been married poorest households are more likely to have been married in all countries studied (Figure 1). Marriage is most than those from the wealthiest households. There is a common in Niger where 63 percent of adolescent women negative linear relationship between household wealth have been married. Approximately one third of adolescent and adolescent marriage in Nigeria. In Niger, Burkina women in Burkina Faso (32 percent) and one quarter of Faso, Nepal, and Ethiopia marriage rates are lower for those in Ethiopia (23 percent), Nigeria (29 percent), and adolescent women in the top two wealth quintiles (Richer Nepal (29 percent) have been married. and Richest), compared to those in the bottom three wealth quintiles (Poorest, Poorer, and Middle) (Figure 3). Page 2 HNPGP Knowledge Brief  Figure 3. Percentage of women aged 15–19 who have ever Figure 5. Percentage of women aged 15–19 who have ever been married, by country and wealth quintile been married, by country and education level 90 100 80 80 70 60 60 Percent Percent 50 40 40 30 20 20 10 0 0 None Incomplete Complete More than Poorest Poorer Middle Richer Richest primary primary primary Burkina Faso* Ethiopia* Nepal* Burkina Faso* Ethiopia* Nepal* Niger* Nigeria* Niger* Nigeria* *Statistically significant difference (p<.05) *Statistically significant difference (p<.05) Source: Burkina Faso DHS 2010, Ethiopia DHS 2011, Nepal DHS 2011, Source: Burkina Faso DHS 2010, Ethiopia DHS 2011, Nepal DHS 2011, Niger DHS 2012, Nigeria DHS 2008. Niger DHS 2012, Nigeria DHS 2008. In Niger and Ethiopia, unemployed adolescent women MARRIED BEFORE 15 YEARS OF AGE have higher rates of marriage than those who are working. The opposite is true in Nigeria (Figure 4). Among the countries studied, marriage before age 15 is most common in Niger (24 percent) and Nigeria (12 Figure 4. Percentage of women aged 15–19 who have ever percent). Less than 10 percent of adolescent women were been married, by country and employment status married before age 15 in Burkina Faso (6 percent), Ethiopia (8 percent), and Nepal (5 percent) (Figure 6). 70 60 Figure 6. Percentage of women aged 15–19 who were married before age 15, by country 50 40 Percent 24% 30 20 10 12% 8% 0 6% 5% Not working Working Burkina Faso Ethiopia* Nepal Niger* Nigeria* Burkina Ethiopia Nepal Niger Nigeria Faso *Statistically significant difference (p<.05) Source: Burkina Faso DHS 2010, Ethiopia DHS 2011, Nepal DHS 2011, Source: Burkina Faso DHS 2010, Ethiopia DHS 2011, Nepal DHS 2011, Niger DHS 2012, Nigeria DHS 2008. Niger DHS 2012, Nigeria DHS 2008. In all countries studied, marriage is more common among Significant socioeconomic differences in marriage before less-educated adolescent women (Figure 5). The disparity age 15 were found in Niger and Nigeria. Results indicate is greatest in Nigeria where 83 percent of adolescent that in both countries, marriage before age 15 is more women with no education have been married, compared common in rural (29 and 17 percent, respectively) than in to 28 percent of those with incomplete primary education, urban areas (5 and 4 percent, respectively). Wealth is 33 percent who have completed their primary education, negatively associated with marriage before age 15 among and 7 percent with more than a primary education. adolescent women in both countries. However, in Niger, Page 3 HNPGP Knowledge Brief  marriage before age 15 is far less common in the richest Conclusion wealth quintile (10 percent) than in the bottom four wealth quintiles, which have early adolescent marriage rates This study highlights the high prevalence of adolescent ranging from 31 percent in the poorest quintile to 26 marriage and the subsequent ASRH challenges that girls percent in the second wealthiest quintile. face, including high fertility rates. Early marriage is strongly associated with poverty, low educational While marriage before age 15 is more common among attainment, and rural residence. Increasing knowledge unemployed adolescent women in Niger, the opposite is among families and communities about the benefits of true in Nigeria. In both countries, marriage before age 15 delaying early marriage can lead to greater educational is most common among adolescent women with no achievement for all, lower fertility, increased life education and relatively uncommon among women who expectancy for women, and benefits to children’s health have completed their primary education and beyond. and education. Political will, aligned with effective programs and policies, will enable millions of adolescent females and their families to reach their potential. Policy Challenges Although the majority of countries have signed References international charters and covenants that discourage adolescent marriage, and have laws and policies that Erulkar, A. 2013. Early Marriage, Marital Relations and Intimate Partner Violence in Ethiopia. International Perspectives on Sexual and make early marriage illegal, it is still pervasive. Early Reproductive Health, 39(1), 6-13. marriage threatens efforts to create more educated, Godha, D., D.R. Hotchkiss, and A.J. Gage. 2013. Association healthier, and economically stable populations (ICRW, Between Child Marriage and Reproductive Health Outcomes and 2010). It not only puts adolescent females at risk for poor Service Utilization: A Multi-Country Study from South Asia. Journal of Adolescent Health, 52(5), 552-558. health outcomes, such as high adolescent fertility and maternal mortality rates, but they also enter adulthood in Greene, M.E., and T. Merrick. 2005. Poverty Reduction: Does Reproductive Health Matter? HNP Discussion Paper. Washington, D.C: extremely unequal conditions. They are less likely to The World Bank. attend school and experience higher levels of fertility over International Center for Research on Women. 2010. Child Marriage. their lifetime in comparison to women who marry at later Washington, D.C. ICRW. ages (UNFPA, 2013). The WBG’s RHAP is supporting Raj, A., and U. Boehmer. 2013. Girl Child Marriage and Its better access to, and provision of, affordable ASRH Association with National Rates of HIV, Maternal Health, and Infant Mortality Across 97 Countries. Violence Against Women, 19(4), 536-551. services and strengthening monitoring and evaluation. Santhya, K.G. 2011. Early Marriage and Sexual and Reproductive Post-2015, the WBG is working to ensure Universal Health Vulnerabilities of Young Women: A Synthesis of Recent Evidence Health Coverage (UHC) of sexual and reproductive health from Developing Countries. Current Opinion in Obstetrics and (SRH) by helping countries build healthier, more equitable Gynecology, 23(5), 334-339. societies. To do this requires the following, adapted to UNFPA. 2013. Adolescent Pregnancy: A Review of the Evidence. New York: UNFPA. each country’s unique needs: UNFPA. 2012. Marrying Too Young: End Child Marriage. New York: UNFPA.  Scaling up the most effective ways to incentivize World Bank. 2014. Regional Reports from Latin America and the demand for ASRH, including family planning at the Caribbean, South Asia, East Asia and the Pacific, and West and Central country level Africa.  Delivering on the continued need to strengthen country capacity  Leveraging the WBG’s multisectoral advantage to This HNP Knowledge Brief was prepared by a team of World Bank staff and consultants including Rafael Cortez (Task Team Leader), Jennifer improve ASRH outcomes, including SRH as a tool for Yarger Mara Decker, Claire Brindis and Diana Lara (University of women’s empowerment California, San Francisco), as part of the World Bank’s Economic Sector  Reaching the poorest, marginalized, and vulnerable Work on Adolescent Sexual and Reproductive Health (P130031) funded populations to facilitate access to health services and by the World Bank-Netherlands Partnership Program (BNPP). promote UHC and equity. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health Page 4