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Biomedical scientists have primarily been concerned with whether the onset of reproduction occurs before the woman is adequately able to nurture her offspring and maintain her own health. Social scientists have argued that early marriage prevents women from attaining their rightful education, accessing employment and training opportunities, developing social relationships with peers, and participating in civic life.

It focuses on data from four South Asian countries, Bangladesh, India, Nepal, and Pakistan, in which marriage is near universal and where a large proportion of women still marry below the United Nations prescribed minimum marriage age of 18 years.

Using an integrative perspective, we provide a comprehensive synthesis of the physiological, bio-demographic, and socio-environmental drivers of variable marriage age. We describe the adverse health consequences to mothers and Sex afspraakje horn chat their offspring of an early age at marriage and of childbearing, which include malnutrition and high rates of morbidity and mortality.

We also highlight the complex association of marriage age, educational attainment, and low societal status of women, all of which generate major public health impact. This evidence suggests that in order for public health initiatives to maximize the health of women and their offspring, they must first address the factors that shape the age at which women marry. Marriage before 18 years is considered to be a harmful practice because it denies girls the right to the highest attainable standard of general, sexual, and reproductive health, and to a life free from violence 12. Under-age marriage also constrains evolving physical, emotional, and personal maturity required to safely and successfully transition to adulthood 34.

It places restrictions on opportunities in life, such as the right to education. Collectively, these consequences have major implications for public health. Several UN agreements define parameters relating to marriage and reproduction, including establishing a minimum allowable marriage age. Women also have the right to good reproductive and sexual health. This includes a satisfying and safe consensual sexual experience, the capability to reproduce, and the freedom to decide if, and when, to bear. Access to timely and adequate health care for women and their children is also essential 5.

Since marriage entails adult responsibilities and also understanding of its consequences, setting a minimum age is a legal guarantee that adult responsibilities are not ased to children prematurely 6. The age at which legal majority or adulthood is reached is thus important for establishing a minimum age of marriage: Human Rights Conventions set both at 18 years 37. By ratifying these international agreements, governments are expected to legislate a minimum age at marriage for both sexes, ideally at 18 years.

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In absolute terms, only 11 countries have established a minimum legal marriage age at 18 years without any dispensation; 73 have an ascribed minimum age but allow exceptions below 18 years, usually for girls; and have unclear information or no established minimum marriage age 6. Inan estimated million women aged 18 years or older were married under-age compared with million boys 8. The reasons for which the two sexes marry under-age most likely differ and merit appropriate consideration. However, in this review of public health implications, we focus on why girls marry under-age.

Between andone in three women aged 20—24 years in the global south excluding China were estimated to have married before they reached the age of 18 years 9. At the current rate, 39, girls are projected to marry under-age age each day, amounting to over The region with the highest national prevalences comprises central Africa, however, in absolute terms nearly half of all under-age marriages worldwide occur in South Asia.

Figure 1. Global distribution of women aged 20—24 years married below the United Nations prescribed minimum age of 18 years.

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Data compiled from Demographic Health Surveys reports in by Ref. While its importance is recognized across different academic fields, they approach the issue from contrasting perspectives. For example, social scientific research identifies how early marriage is associated with adverse human capital outcomes such as limited opportunities for personal and educational development.

However, in traditional societies childbirth usually follows soon after marriage 12 In the four South Asian countries with the highest prevalence of under-age marriage, first childbirth occurred on average 2. Marriage age remains the most consistent influence on the first birth interval, even after controlling for birth cohort, gendered context 2spousal educational attainment, and socio-economic characteristics This evidence suggests that the key decision which needs to be delayed in this population is marriage age, which will invariably lead to an older age at childbirth.

Figure 2. Adapted and redrawn with permission from Ref. We go beyond what has ly been done by synthesizing key insights and inter-linkages from the demographic, health, and human capital literatures. We searched relevant databases e. Some of our findings are likely to apply more widely. Others might relate to the socio-cultural context of marriage. A complexity in understanding these inter-linkages is the inconsistent disaggregation of age-categorizations across studies. We address this by adopting a dual spatio-temporal approach.

Data on the generation of women aged Sex afspraakje horn chat years enables us to illustrate secular changes in marriage age and childbearing, and also to emphasize the consequences and benefits conferred to variable marriage age.

Data on the most recent cohort of women aged 20—24 years who married below 18 years provides critical insights on the penalties of marrying young in contemporary societies. There are four sections to this review. It also describes changes in the prevalence of under-age marriage in the four South Asian countries of our review. We recognize that separating the consequences from the predictors is in part artificial because of the potential two-way direction of association.

However, this approach enables us to critically assess why the high prevalence of under-age marriage persists despite increasing knowledge of its consequences. In the geographical region of South Asia, complex cultural and religious dynamics set parameters around marriage. Generally, for both sexes, marriage is perceived as an essential stage in the life-course and there are strong social sanctions for childbearing outside of marriage As a social institution, marriage is identified by some studies as near universal Generally, any variation relates to the age at which marriage takes place, rather than whether it happens at all.

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Women also tend to marry younger than men. Recent DHS data from to show that Bangladesh, India, Nepal, and Pakistan have the highest prevalence of women aged 20—24 years marrying under-age 59, 27, 37, and 21, respectively 141520 This translates into tens of millions of girls in each of these countries. This was largely attributed to fewer marriages below 15 years. The change in the prevalence of marriages at 16—17 years varied across the four countries. There was a marginal decrease in Pakistan and a slight increase in India.

However, the proportion of girls marrying in late-adolescence increased substantially in Nepal and Bangladesh These patterns are important to recognize because the predictors and consequences of marriage in these different age groups are likely to be different.

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Disaggregated data by age groups were not yet available. While this trend is promising, a large proportion of women still marry soon after 18 years. These women may experience some of the consequences of those who married under-age, in late-adolescence.

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Figure 3. Prevalence of under-age marriage among women aged 20—24 years in South Asian countries. A Change in prevalence between andB,C prevalence in — and —, respectively. Data for A,B were taken from Ref. Despite having ratified international conventions protecting the rights of children and women generally, many South Asian countries have not ratified agreements directly addressing under-age marriage and the universally ascribed minimum age of 18 years.

Table 1 uses data produced by the UN Office for the High Commissioner and the international advocacy group, Girls Not Brideson the ratification status of these international agreements 23 — Table 1. International agreements and national law on minimum marriage age and marriage and birth registration in South Asia. Table 1 shows that national secular legislation allows marriage at 16 years in Pakistan, 18 years in India, and 20 years in Nepal However, Sharia and Mohammedan law permit marriage for girls at 14—15 years in Bangladesh, India, and Pakistan Weak national marriage and birth registration systems mean that even the current high prevalence of under-age marriage and rates of adolescent fertility are likely to be under-estimated 14152021 This section focuses on the association between under-age marriage and demographic outcomes of fertility and population growth and its related implications for sex-selective abortion and contraception.

Implications for maternal and child mortality are addressed in the following section on health consequences. The mechanisms through which these effects operate relate partly to exposure and opportunities for getting pregnant, partly through generation length, and partly through biological, behavioral, and socio-economic factors. The magnitude of this problem is large in the South Asia region, as demonstrated below. In South Asia, unlike many other parts of the world, marriage is still the main context for sexual intercourse. Getting married therefore als the start of exposure to the chance of becoming pregnant and the earlier a woman gets married, the longer she will spend exposed during her fertile years.

Studies find that in the absence of modern contraception, the age at which women marry is the main determinant of the of children each woman will have Marriage age also plays a very important role in lowering fertility levels from the biological maximum. The availability of reliable contraception offers the chance to thwart this relationship by stopping at a particular desired of children or by increasing the spacing between births.

However, simulations have shown that women who marry young still have more children at the end of their reproductive careers because there is more time for them to increase their desired s of births and more opportunity for contraceptive failure to increase fertility Empirical studies find that despite some teenage sub-fecundity, early marriage is associated with higher completed fertility at the end of the childbearing years.

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Women’s Marriage Age Matters for Public Health: A Review of the Broader Health and Social Implications in South Asia