ECONOMIC IMPACTS OF CHILD MARRIAGE: WOMEN’S HEALTH BRIEF Page 1 · ECONOMIC IMPACTS OF CHILD MARRIAGE: WOMEN’S HEALTH BRIEF June 2017 ECONOMIC IMPACTS OF CHILD MARRIAGE: WOMEN’S HEALTH BRIEF OVERVIEW Each day, more than 41,000 girls worldwide are married while still children, often before they may be physically and emotionally ready to become wives and mothers. Child marriage, defined as marriage or a union taking place before the age of 18, endangers the life trajectories of these girls in numerous ways. Child brides are at greater risk of experiencing a range of poor health outcomes, having children at younger ages, having more children over their lifetime, dropping out of school, earning less over their lifetimes and living in poverty than their peers who marry at later ages. Child brides may also be more likely to experience intimate partner violence, have restricted physical mobility, and limited decision- making ability. Most fundamentally, these girls may be disempowered in ways that deprive them of their basic rights to health, education, equality, non-discrimination, and to live free from violence and exploitation, which continue to affect them into adulthood. These dynamics affect not only the girls themselves, but their children, households, communities and societies, limiting their ability to reach their full social and economic potential. While child marriage is widely considered a human rights issue closely connected to gender inequality,1 the significance of the practice’s impacts at both the individual and societal levels suggests that ending child marriage may play an important role in alleviating poverty and in promoting economic development. Ending child marriage can improve health at the individual and population levels, increase productivity and enhance the opportunity to realize the gains in a country’s economic growth that can result from declining birth rates and a shifting population age structure, commonly referred to as the ‘demographic dividend.’ To date, however, there has been relatively little in the way of rigorous assessment of the economic impacts of child marriage or how much child marriage may “cost” countries and societies. To address this gap, the World Bank and the International Center for Research on Women (ICRW) collaborated on an extensive and innovative research project to assess the impacts of child marriage on a range of development outcomes, and to understand the economic costs associated with these impacts across countries. By establishing the effects that child marriage has on economic outcomes, the research project aimed to catalyze more effective and evidence-based action to prevent it. The conceptual framework that guided our work follows: 1 As enshrined in UN General Assembly Resolution 71/175 (December, 2016), “child, early and forced marriage is a harmful practice that violates, abuses or impairs human rights.” Page 1 · ECONOMIC IMPACTS OF CHILD MARRIAGE: WOMEN’S HEALTH BRIEF June 2017 Domains of Impact Aggregate Measures Development Of Impacts And Costs Outcomes Fertility and population growth CHILD MARRIAGE Earnings, productivity & Health, nutrition and violence consumption per capita Multiple pathways Educational attainment and learning and intergenerational Perpetuation Of Extreme effects through which Poverty And Private impacts are observed & public Inequality Participation in the labor force expenditures and type of work Participation, decision-making and investments Non-monetary and social costs This brief summarizes results from an analysis of the impacts of child marriage on a few selected health outcomes, specifically early childbirths, maternal mortality and intimate partner violence. It does not include analyses for other aspects of women’s health that are likely to be affected What Do We Mean by child marriage to various extents, such as maternal by Impacts and morbidity, obstetric fistula, female genital mutilation/cutting, sexually-transmitted infections (including HIV and AIDS) Associated Costs? and psychological well-being. This brief and selected other publications from the study can be found at The aim of the study is to estimate www.costsofchildmarriage.org  the impacts of child marriage on development outcomes and the economic costs associated with some IMPACT OF CHILD MARRIAGE ON of these impacts. The term “impact” EARLY CHILDBIRTHS is used for simplicity, but one must be careful about not necessarily inferring causality. Most estimates of impacts are There is a close relationship in many countries between obtained through regression analysis in child marriage, early pregnancy and early childbirth; that is, order to control for other variables that pregnancies or childbirths by girls under the age of 18. Early may affect the outcomes of interest. childbearing can have dramatic consequences for young In some cases, simulations are used. women as well as their children. What is measured are thus statistical associations, and not necessarily The United Nations Population Fund (UNFPA) estimates that impacts as could be observed, for some 7.3 million girls under the age of 18 give birth each year, example, with randomized control or roughly 20,000 births to adolescent mothers each day. In trials. Since child marriage cannot be Table 1, we provide estimates of the share of early childbirths randomized, we must rely on regression that can be attributed to child marriage for the core 15 analysis in order to estimate likely countries that were included in our study. These estimates impacts, but there is always a risk suggest that, in most of these countries; a large majority of bias in the measures of the likely of early childbirths are due to child marriage. In the case of impacts of child marriage. Based on Bangladesh, for example, the share of women having their first measures of likely impacts, costs child before age 18 as a result of child marriage is estimated to associated with selected impacts are be 80.8 percent. In addition, 85.4 percent of children born to then computed. Note that we provide mothers younger than 18 in Bangladesh are attributed to child cost estimates only for some, and not all marriage. impacts. These costs rely on a number of assumptions and are thus tentative. These findings suggest that ending child marriage should Overall, the costs represent an order of therefore have a major positive impact on reducing early magnitude of potential costs rather than childbirths. It is important to place this finding in context, precise estimations. For more details on however. In some countries that have experienced increases the methodology and how it relates to in the age of marriage, age at first sex has not necessarily key empirical findings, see Wodon (2017). Page 2 · ECONOMIC IMPACTS OF CHILD MARRIAGE: WOMEN’S HEALTH BRIEF June 2017 increased in tandem. That is, increases in the age at first TABLE 1: SHARE OF EARLY CHILDBIRTHS FOR marriage need not necessarily result in increases in the age MOTHERS AND CHILDREN ATTRIBUTED TO at first sex, as adolescents may continue to engage in sexual CHILD MARRIAGE activity regardless of marriage. Even as countries work to eliminate child marriage, therefore, it is critical that they also Share of girls Share of ensure the availability of comprehensive sexuality education having their first children born and access by adolescents to youth-friendly reproductive child before 18 of mothers health information and services, as adolescents are likely attributed younger than to continue to engage in sexual activity, regardless of the to child marriage 18 attributed prevalence of child marriage. (%) to child marriage (%) Country Bangladesh 80.8 85.4 “I was depressed and cried Burkina Faso 77.3 82.8 all the time… How do you Dem. Rep. of Congo 60.0 66.5 think it feels to be forced Egypt 93.9 97.7 into a marriage and a life Ethiopia 79.7 86.0 with someone you didn’t Malawi 63.9 70.1 choose or know? ” Mali 59.8 73.3 Mozambique 43.4 59.5 “Two young women died Nepal 91.5 95.1 Niger 69.6 75.7 in childbirth during the Nigeria 76.8 84.4 first week of our stay Pakistan 73.1 86.3 in the community. The Republic of Congo 30.9 43.4 first woman married at Uganda 52.4 56.4 fourteen and had three Zambia 39.4 40.0 children.” Source: Wodon et al. (2017). QUALITATIVE DATA COLLECTED BY ICRW AND THE WORLD BANK. IMPACT OF CHILD MARRIAGE ON MATERNAL MORTALITY The literature suggests higher rates of maternal mortality and morbidity for adolescent girls who give birth at a very young age as compared to women who are just a few years older. This does not mean, however, that ending child marriage would necessarily reduce maternal mortality ratios. Indeed, while delaying marriage should reduce the risks of maternal mortality and morbidity when giving birth at a very young age, we still don’t know enough about the relationship between delaying child marriage and the risks of giving birth later in life. This study does not provide detailed estimates of child marriage on maternal mortality ratios, nor does it address the costs of maternal mortality or morbidity, but basic data from Nove et al. (2014) help to understand some of the complex dynamics that could play out if child marriage were ended. Across 144 countries and territories, Nove et al. find an increased risk of mortality in adolescents (260 per 100,000) as compared to women aged 20–24 years (190 per 100,000), although the confidence intervals for both estimates overlap significantly. There is also a lot of heterogeneity between countries, as shown in Table 2 for the core set of 15 countries considered in this study. It is also important to note that basic statistical comparisons of maternal mortality ratios by age groups, such as those in Table 2, do not imply causality, as they Page 3 · ECONOMIC IMPACTS OF CHILD MARRIAGE: WOMEN’S HEALTH BRIEF June 2017 TABLE 2: MATERNAL MORTALITY RATIOS BY AGE BRACKET Surveys 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Bangladesh 2007–10 93 180 270 680 860 660 2,300 Burkina Faso 2003–10 330 430 330 460 570 760 2,500 D. R. Congo 2002–06 350 370 720 790 450 3,400 3,500 Egypt 2000–09 18 27 40 65 120 180 360 Ethiopia 2003–10 760 610 610 1,200 2,300 2,400 4,500 Malawi 2003–10 240 260 710 1,200 3,200 4,300 5,700 Mali 1999–06 720 580 910 720 1,000 2,100 8,000 Mozambique 2004–11 520 560 910 880 1,200 1,800 2,300 Nepal 1999–06 390 230 190 850 780 2,400 - Niger 1996–06 600 650 830 770 1,200 2,900 7,300 Nigeria 2001–08 780 720 770 1,300 1,900 2,400 1,900 Pakistan 2003–06 220 190 200 200 520 690 400 Rep. Congo 1998–05 550 580 800 740 1,700 2,300 510 Uganda 2004–11 400 330 640 1,100 1,800 3,200 5,300 Zambia 2000–07 150 300 630 1,300 1,600 1,600 4,000 Source: Nove et al. (2014). do not control for other factors that affect maternal mortality. to be indirect effects at work through the negative impact that Levels of maternal mortality could be higher among young child marriage has on girls’ educational attainment, given that mothers due to lower access to health care and lower socio- a reduction in IPV is often observed for women with a higher economic status. Further simulation analysis would be needed level of education. to establish a stronger link between ending child marriage, early childbearing and maternal mortality. The last two columns in Table 3 provide results on the reduction in IPV at the national level that could result from IMPACT ON INTIMATE ending child marriage, considering only direct effects. In some countries, the reduction in IPV that would occur is substantial, PARTNER VIOLENCE and in four countries, IPV could be reduced by more than 10 percent if child marriage were eliminated. Estimates of Research suggests that marriage at an early age may increase potential impacts are also provided for a pooled dataset using risks of intimate partner violence (IPV) for women throughout DHS surveys for Africa, with IPV reduced by just under six the life course. The health implications of IPV, as well as their percent. In sum, ending child marriage could make a major potential costs for women and households, can be serious. difference in reducing IPV in the majority of the studied Analysis carried for this study suggests that when girls marry countries. These reductions would be larger if the impacts of very early (at or under 15 years of age), there are statistically child marriage on education were also taken into account. significant impacts on IPV in the majority of countries. In order to assess the potential reduction in IPV that could be achieved by ending child marriage, we use Demographic and Health Survey (DHS) data for eight sub-Saharan countries as well as Nepal and Pakistan. For Ethiopia and Niger, given that the module on violence was not included in the latest DHS, the analysis follows the same approach but is based on surveys implemented for this project. The intensity of IPV is captured through an index that takes a value between zero (no violence at all) and 100 (worst cases of violence). Table 3 provides estimates of the impact of child marriage on the IPV index, after controlling for other variables also likely to affect IPV. The analysis is conducted for all married women in the sample. In a majority of countries, marrying at 15 or earlier is associated with a higher risk of IPV. For example, in Malawi, marrying at age 15 or less increases the index of IPV by 1.42 points on the scale from zero to 100. When marrying at age 16 or 17, direct impacts tend not to be statistically significant. In addition to these direct effects, however, there are also likely Page 4 · ECONOMIC IMPACTS OF CHILD MARRIAGE: WOMEN’S HEALTH BRIEF June 2017 TABLE 3: IMPACT OF CHILD MARRIAGE ON INTIMATE PARTNER VIOLENCE, WOMEN AGES (INDEX FROM 0 TO 100) Marginal impact of child marriage National Impact Marrying Marrying Marrying Absolute Percentage change at 15 or less at 16 at 17 change (%) Burkina Faso 0.77 NS NS -0.18 -7.33 Dem. Rep. of Congo NS NS NS - - Egypt NS NS NS - - Ethiopia 2.39 NS NS -0.92 -10.37 Malawi 1.42 NS NS -0.37 -5.49 Mali 1.04 NS NS - - Mozambique NS NS NS -0.96 -13.17 Nepal 0.083 NS NS -0.35 -4.78 Niger NS NS NS - - Nigeria 0.73 0.73 1.23 -0.46 -12.57 Pakistan NS NS NS - - Uganda 6.34 5.87 NS -2.63 -18.04 Zambia 1.14 NS NS -0.23 -2.81 Africa data sets 0.56 NS NS -0.17 -5.83 Source: Savadogo and Wodon (2017); see also Steinhaus et al. (2017) for Niger and John et al. (2017) for Ethiopia. Note: NS = Not statistically significant at the 10 percent level. CONCLUSIONS Child marriage and associated early childbirths can have multiple health implications for girls, both during their adolescence and later in life. Noting that the analysis conducted for this study and summarized in this brief does not address all aspects of health that may be affected by child marriage, such as obstetric fistula and other maternal morbidities, sexually-transmitted infections (including HIV and AIDS), or mental health, for example, the magnitude of the impacts of child marriage on early childbearing, maternal mortality, and the risk of intimate partner violence can be summarized as follows. First, our analysis suggests that in a set of 26 countries that account for an overwhelming majority of child marriages and early childbirths in the world, 84.4 percent of children born to mothers younger than 18 are likely to be due to child marriage and three in four women who had their first child before 18 probably did so because they married as children. Ending child marriage should therefore have a major positive impact towards reducing early childbirths globally. Second, a recent study utilizing data from 144 countries suggests that adolescent girls ages 15-19 have an increased risk for maternal mortality as compared to women in their 20s, but this is not the case for most core focus countries for our study. Data are lacking for girls younger than 15, for whom the risks of maternal mortality and morbidity would likely be higher. This analysis is therefore limited, and due to desired fertility patterns, while ending child marriage should reduce risks of maternal mortality for adolescent girls, the overall effect on national maternal mortality ratios is not clear. Additional analysis would be needed to estimate the potential effect of ending child marriage on maternal mortality. Third, the literature also suggests linkages between IPV and child marriage. Our study finds evidence of impact when considering women who married at age 15 or earlier in a majority of countries, but impacts when marrying at age 16 or 17 tend not to be consistently statistically significant. We further find that more than half of the countries in our study could see reductions in IPV at the national level if child marriage were eliminated. In some cases, the reductions are small, but in others they are quite large. Page 5 · ECONOMIC IMPACTS OF CHILD MARRIAGE: WOMEN’S HEALTH BRIEF June 2017 This particular brief in our series does not include cost estimates for some of the impacts being documented. This does not mean that the impacts have no associated costs. For example, by leading to early childbirths, child marriage has a large welfare cost due to its impact on population growth, as documented in the separate brief on that topic. Overall, the impacts of child marriage on women’s health observed in this study, combined with the literature base on other potential health impacts for women, suggest that the practice has a number of negative health consequences, warranting interventions to end the practice. REFERENCES John, N. et al. (2017). Child Marriage and Intimate Partner Violence in Ethiopia. Washington, DC: International Center for Research on Women. Nove, A., Z. Matthews, S. Neal, and A. V. Camacho (2014). Maternal Mortality in Adolescents Compared with Women of Other Ages: Evidence from 144 Countries, The Lancet Global Health 2(3): 155-64. Savadogo, A. and Q. Wodon (2017). Impact of Child Marriage on Intimate Partner Violence across Multiple Countries. Education Global Practice. Washington, DC: The World Bank. Steinhaus, M. et al. (2017) Child Marriage and Intimate Partner Violence in Niger. Washington, DC: International Center for Research on Women. Wodon, Q., C. Male, and A. Onagoruwa (2017). A Simple Approach to Measuring the Share of Early Childbirths Likely Due to Child Marriage in Developing Countries. Education Global Practice. Washington, DC: The World Bank. Wodon, Q. (2017). Estimating the Economic Impacts and Costs of Child Marriage Globally: Methodology and Estimates. Education Global Practice. Washington, DC: The World Bank. The Economic Impacts of Child Marriage project is a collaborative Information and illustrations contained in this report may be freely effort by the International Center for Research on Women (ICRW) reproduced, published or otherwise used for noncommercial and the World Bank, with funding from the Bill & Melinda Gates purposes without permission from the World Bank or ICRW. Foundation and the Children’s Investment Fund Foundation, and However, the World Bank and ICRW request that the original additional support from the Global Partnership for Education. This source be cited as the source. series of papers is jointly produced by the International Center for Research on Women and the World Bank and is available at Recommended citation: Wodon, Q., C. Male, N. Onagoruwa, A. www.costsofchildmarriage.org  The findings, interpretations Savadogo, John, N., and Petroni, S. (2017). Economic Impacts of Child and conclusions expressed in this paper are entirely those of the Marriage: Women’s Health. Washington, DC: The World Bank and author(s) and should not be attributed in any manner to the World International Center for Research on Women. Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and © 2017 The International Bank for Reconstruction and Development / the use of material presented in this series should take into account The World Bank and the International Center for Research on Women (ICRW), this provisional character. The World Bank does not guarantee the Washington, DC 20433. accuracy of the data included in this work. The boundaries, colors, denominations and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. 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