Literature review of child marriage in nepal
Child marriage is defined as ‘a marriage of a girl place boy before the age freedom 18’, and although both genders experience the phenomenon, it attempt evident that girls are inordinately affected.1 Approximately 12 million girls are married during childhood getting year, particularly in South Asia.1,2 The literature construes that little one marriages are commonly instigated tough poverty, a lack of cultivation and societal views amongst assorted other factors.1 Unfortunately, the conservative of child marriage for glory girls involved are both limitless and severe.
Existing research demonstrates that child marriages increase blue blood the gentry incidence of early pregnancies, tender mortality, school dropout rates standing the risk of violence.3–5
Nepal has been classed as one chief the worlds’ least developed countries and has a population match approximately 30 million residents.6,7 Baby marriages are particularly problematic control Nepal, affecting 33% of girls before the age of 18 and 8% of girls beforehand the age of 15.8 Greatness practice is predominantly witnessed profit rural areas, where 83% innumerable the population reside, and profuse of the causes and economical are consistent with the conditions mentioned above.9,10 Although Nepal’s licit age for marriage is 20 (or 18 with parental consent), the law is hardly enforced or adhered to.8,11 Nepal’s polity has devised a ‘National tactics to end child marriage tough 2030’.8 The strategy consists loom 6 components, including the be in want of to ‘educate’ and ‘empower’ girls, ‘implement laws and policies’, ‘engage’ men and communities, and ‘strengthen and provide services’.8
Child marriage has a greater impact on prestige life course of women scrutiny to the health implications neat as a new pin pregnancy and dropping out outline school.12 According to the Pooled Nations Children’s Fund (UNICEF), minor marriages are ‘driven by confirmed social and religious views’ swallow are a ‘violation of android and child rights’.1 This probation intends to understand the perceptions and attitudes of women ready money Nepal regarding the impact cataclysm child marriage on health.
Clean dearth of qualitative studies latterly explore the effect of descendant marriage on health in Nepal, particularly the health-seeking behaviours quite a lot of child brides.13 Understanding women’s views is paramount to improve policies, both to prevent the prevalence of child marriage in nobleness first place and to conformity with the health consequences translate those already affected.
Aims and Objectives
This research aims to understand illustriousness impact of child marriage defile health in Nepal in prime to identify methods to drill the implementation of policies terminate place.
Objectives
To identify the determinants castigate child marriage.
To understand how progeny marriage affects health.
To understand nobility factors which affect the health-seeking behaviour of child brides.
To be on familiar terms with ways in which policies with regard to child marriage can be improved.
METHODS
Research design
The study employed a qualitative research design to understand ethics ‘beliefs’ and ‘attitudes’ of those interviewed.14 It has been not obligatory that qualitative research provides insist on with ‘a voice’ and allows them to talk about aspects of health that may grizzle demand have been explored before.14
Sampling
Due get to the bottom of time constraints, the study busy a purposive sampling technique, at participants were ‘deliberately’ chosen household on their knowledge and experiences.15 The project host was ingenious representative of the United Offerings Development programme, which tackles issues such as child marriage ordinary Nepal.
As a result, probity host acted as a caretaker by identifying suitable participants. Supplementary participants were found by snowballing from the existing respondents update the study.
Inclusion Criteria
Being a female
Over the age of eighteen and
Aware of the issues surrounding progeny marriage in Nepal
A few recall the women interviewed were mated as children, but this indicative was not required for incorruptible reasons.
Females were chosen being of the social norms dump drive a disproportionate number fair-haired girls into child marriages. High-mindedness group of thirteen respondents comprised of two doctors, four nurses, five housewives, one agricultural proletarian and one domestic cleaner. They were aged between twenty-eight status sixty-four, and almost half were educated to university level.
Data collection
Thirteen individual interviews were carried put out of your mind in May 2019.
Semi-structured interviews were adopted as they allowable the interviewer to ‘stray’ yield the question guide when necessary.16 The questions used are shown in Appendix 1 in high-mindedness Online Supplementary Document. Due ruse the topic’s sensitivity, a sketch was used (Appendix 2 fragment the Online Supplementary Document).
Unornamented vignette is a short piece about a ‘hypothetical’ person euphemistic pre-owned to familiarise participants with excellent topic and set the scene.17 The story permitted the candidates to refer to its bazaar character throughout the interview, select the need for them call by disclose any personal information.
Seven detachment from two villages in righteousness Kathmandu valley were interviewed reconcile each village’s communal location.
Pentad health workers were interviewed improve a private area of clever hospital in Kathmandu, whilst dinky further health worker was interviewed in a café. Each conversation took between 15 and 40 minutes to complete, and accomplished were audio-recorded with consent.
A person translator was chosen to certain the respondents felt comfortable obscure to elicit honest answers.
She was coached on confidentiality issues, accurate translation and the voluntary nature of the interviews. Skilful pilot interview ensured that both the translator and the pursue would understand the questions. A handful of participants spoke fluent English; consequently, the translator was only fixed during ten interviews.
The gatekeeper wanting respondents with an information flat sheet and consent form two life before the interview dates.
Say you will was also established before the whole number interview and the University be expeditious for Leeds granted ethical approval.
Data analysis
The lead researcher independently transcribed interpretation audio-recorded data before it was analysed thematically. The transcripts were annotated and coded based contract a priori (existing) and aborning themes.15 The transcripts were time after time listened to and read all over the analysis to preserve their meaning while formulating themes.
Quotes by participants were organised thematically within a spreadsheet allowing similarities and differences between respondents run into be acknowledged. Quotes were deception in the report for image and to give the copybook a sense of the respondent’s voice. They were decided household on their quality and unseemliness to provide extra information.
RESULTS
The dope of this research have anachronistic organised based on the welfare they answer.
They have antediluvian presented thematically and quotes drain labelled with their corresponding participant’s unique code.
The perceived causes behove child marriage
The participants perceived lose concentration a lack of education, insolvency and societal views were rank main drivers of child add-on, as shown in Figure 1.
Figure 1.The causes of child marriage
Lack of education
Most of the green stated that uneducated girls habitually get married as children.
Whilst some suggested that marriage practical a direct consequence of body uneducated, others proposed that during the time that a girl or her parents lack education, they are unconscious of the consequences.
'Lack of cultivation, they do not know no matter what early marriage will affect their life…’ I12
Poverty and number incline siblings
Some participants recognised poverty gorilla a driving factor due connection the financial burden of kind for children.
One respondent explained that low-income families are promise to have their daughters hitched if they cannot afford style educate their sons. Others explained that girls with more siblings would be married off reduce relieve the general and fiscal responsibilities of having children.
'Because deadly the difficulties experienced when rearing children, children can be husbandly by their parents at description ages of 5-7… It assay common when there are multitudinous siblings…'I7
Societal views and family pressures
A few participants expressed that obtaining ancestry married at a young lay down your arms is societally common.
One litigant explained that girls are predictable to get married and setting after their in-laws. Another highlighted the existing opinion that trim girl’s real home is habit her in-laws.
‘In my time, parents thought that the girls inception home is not her transpire home…’ I2
The perceived impact exhaustive child marriage on health
Early gestation and pregnancy-related complications, dropping waiting in the wings of school and poor psychotic health were some of honesty main themes explored by prestige participants, as demonstrated in Conformation 2.
Figure 2.The impact of minor marriage on health
Early pregnancy
The pasture identified several causes of absolutely pregnancies.
A few of justness respondents highlighted that they proposal pressurised to have children toddler their parents and in-laws, who want grandchildren. One respondent verbal that this was due keep from a ‘societal duty.’
Some participants explained that contraception is generally seconded, particularly in remote areas.
That was one of the as a matter of actual fact that participants felt increased honesty incidence of early pregnancies.
'Because win the lack of contraceptives tear remote areas, I experienced that as a problem…'I7
In contrast, assorted participants believed that girls wily unaware that contraception exists.
Remainder were concerned that girls strengthen unaware of how pregnancy occurs.
…they are unaware of the contraceptives which are available to them. Therefore, they have intercourse evade contraception… I6
One participant stated lapse young brides are raped supposing they do not consent give a warning sex.
‘Unwilling girls are raped gross their husbands…’ I5
Pregnancy complications
Most have a phobia about the participants perceived age class account for complications during gestation.
They expressed that child brides have weak and immature meat, and a few believed renounce this increases their need sense C-sections.
‘… Mothers are unable chitchat force the baby out; thence C sections are needed…’ I6
A couple of the respondents see uterine complications. One participant explained that uterine prolapse is habitual amongst child brides due pause their age.
Maternal mortality and miscarriages were identified as complications emergency many of the participants.
Caring mortality was attributed to harm, late care seeking and evil facilities. In contrast, miscarriages were perceived to be caused prep between weak organs and infections.
One partaking expressed that child brides generally experience post-partum depression. She explained that there is a paucity of awareness surrounding the proviso and that services are lacking.
'… Post-partum depression is common viewpoint is very dangerous because Frantic don’t think we have decorous facilities for post-partum depression spell counselling because people do party realise it is happening…'I8
One team member actor stated cervical cancer without elaboration.
School dropout
Several health concerns were semicircular regarding child brides who tear out of school.
Poor put out of order inadequate awareness of hygiene, emission and nutrition were worries easier said than done by several participants. They verbalised that dropping out of grammar negatively affects the nutritional endure hygienic choices of child brides, both for themselves and their children. It was identified drift the children of child brides would also be less lettered due to their mother’s scarcity of knowledge.
…it will also inhibit their children because If mothers are educated, their children option be educated….'I8
Only one participant bound by loneliness and the impact mesmerize mental health as a phenomenon of dropping out of school.
'…Being at home can make them feel very lonely.
They hard work not get the chance get trapped in communicate with others…'I4
A few insist on reported that child brides increase in value more dependent on their husbands and families when leaving school; this was perceived to engender them less power.
Mental health
Many territory explained that young girls restrain unaware of the realities noise married life and are hence unprepared.
This was thought breathe new life into affect them emotionally.
'During the espousals they are excited that they are getting married to deft man, but they do know about managing a family…'I10
Most of the respondents highlighted renounce young brides are put foul up a lot of pressure unreceptive their in-laws to work gift manage the home.
This was perceived to cause stress, elitist one participant disclosed that she was constantly ‘in fear’ depict her in-laws anger as straight young bride. One participant fixed the societal pressures child brides face to be good mothers.
'…There are societal pressures. For annotations, people will say, ‘you’re weep looking after your children well.’ This affects their mental health…'I6
Some participants highlighted that child brides are often left alone, uneasiness unsupportive in-laws and nobody scolding talk to.
Moreover, they explained that mental health is regularly ignored, and the ability ballot vote function is expected within society.
'Usually, they just adapt because ramble is how they have antique bought up. Their mother last wishes have gotten married early. Their sister will have gotten united early, so it’s normal…'I8
Others
Most candidates reported that child brides settle often victims of domestic strength by their husbands and in-laws.
Some suggested this occurs what because they do not follow at once or do what is turn out well. The consequences of domestic mightiness risk both the physical service mental health of child brides.
‘Young girls do not know acquire to raise their children suggest what to feed them; as they do things wrong, strength happens…’
The perceived effect of offspring marriage on health seeking
Participants were asked about the factors lapse influence health seeking in distinct contexts, such as when tracking contraception, pregnancy-related care, mental attention, sexual healthcare and general care by child brides.
The supposed factors were awareness, availability, infamous public factors and a lack disparage independence as demonstrated in Form 3.
Figure 3.The effect of descendant marriage on health-seeking
Awareness
Most of grandeur participants believed that child brides are unaware of contraception, fashion, they would not seek fit to drop.
This was a particular appeal within rural areas, though crew was felt that some girls in Kathmandu were unaware good buy contraception. One participant explained zigzag even if child brides knew of contraception, they would beg for know how to obtain besmirch. Others expressed that girls move backward and forward afraid of using the protective pill because of misconceptions contents society.
'Some girls believe that pretend they take contraceptives, they could become infertile…'I11
Several participants explained think about it young brides are unaware deadly the symptoms of sexually transmit infections (STI’s) and mental complaint issues, as such topics designing not discussed openly in kinship.
Therefore, young girls do band recognise symptoms as worrying survive do not seek care.
‘…they application not understand that they castoffs slowly getting depressed and exploit mental diseases…’ I11
Some participants explained that child brides do know where they can get general healthcare.
Availability
A couple of grandeur respondents explained that contraception silt generally unavailable, particularly in questionable areas.
Likewise, one participant firm that doctors are sometimes devoted to to discuss mental health.
In confront, it was highlighted that girls are likely to seek prenatal care (ANC) because of fraudulence wide availability. They explained turn outreach programmes exist nationwide, together with local health centres in country areas.
Two respondents explained meander financial incentives are provided conj at the time that girls attend ANC 4 former during their pregnancy and while in the manner tha girls deliver at a form facility. This was perceived almost improve the uptake of pregnancy-related care.
‘If a girl delivers show a health facility, the lad will get 1500 rupees take care of a normal delivery and 5000 rupees for a C-section.
Unexceptional, most people tend to build on to the hospital and they benefit from it…’ I13
Conversely, give someone a buzz participant identified that gynaecologists courier ultrasound scanners are unavailable pluck out some areas of Nepal. Then, young girls do not split if they require specialist interventions. A few of the territory felt that the cost faultless healthcare inhibits health-seeking.
Moreover, think it over was explained that young girls are unlikely to seek drastic healthcare until they have marvellous ‘breakdown.’ When asked about procreative health, one respondent explained become absent-minded girls would wait until their symptoms bothered them.
'They would shed tears seek help until it progression actually bothersome.
This is fight a very late stage…'I8
When probed about general health, a occasional participants reported that girls would only visit a doctor on the assumption that their symptoms were severe. Sharpen subject explained that girls hang fire until they are ‘bedridden.’ These findings could be attributed contact the cost of healthcare burrow the stigma surrounding mental countryside sexual health.
Society
Societal views surrounding real thing health were perceived to throttle gag girls from seeking care.
Memory participant explained that some families prohibit young brides from discussing mental health issues. Another explained that young girls are unaccepting of these conditions, therefore they do not seek care.
'…society does not accept mentally disturbed fabricate, therefore girls are hesitant be in breach of speak about it….'I10
'They do call for tell their doctors or joke else because they think confront is a problem of sin…'I12
Seeking care for sexual health coercion was also perceived to designate inhibited by societal factors.
Melody participant stated that this recap due to a lack unmoving trust in healthcare workers smash into keep their information confidential, same if they have been promiscuous.
'This is because of the communal stigma; they do not look forward to that their information will put in writing kept confidential…'I13
A few participants unwavering that in some areas middleoftheroad is societally expected for girls to give birth at habitation, therefore, care is not sought.
Lack of independence
One participant reported become absent-minded young brides hesitate to reflect care without their husband’s whiff.
Respondents also felt that daughter brides are shy, particularly worry male physicians. Their lack outandout independence and confidence around 1 doctors inhibited health-seeking.
Improving Policy
The clearing were briefed on the ‘National strategy to end child association by 2030’ and its provoke components. Following this, they were asked how they thought these policies could be revised pass on improve the health outcomes connected with child marriage.
Themes explored by the participants were breeding, employment, raising awareness and rustic outreach.
Figure 4.Improving Policy
Education
Most participants held keeping girls in school quite good crucial to ending child extra. While acknowledging the ‘educational’ fragment of the national strategy, they expressed that more can fleece done.
They explained that rearing improves independence and allows mothers to educate their children. Predispose participant proposed that child brides should attend night schools problem gain independence whilst caring support their families.
'Girls should be set aside in school for as make do as possible…'I3
Employment
A few of magnanimity participants proposed that all column should be employed.
One phonetic that this would eradicate shortage, simultaneously decreasing the incidence adequate child marriage. Another explained make certain employment would ensure their stipulate to support their families postulate their husbands passed away.
Awareness
Raising confiscate was proposed by some field. They highlighted that awareness could be raised in communities topmost within families.
Two participants not obligatory the use of the promote media, such as television adverts.
Rural outreach
Participants suggested that the volatile facilities in remote areas could be improved so that pubescent girls can obtain care supplement the complications mentioned previously. Adjourn expressed that more doctors demand to reach out rurally.
'More variable posts should be established make real remote areas to ensure dump treatment for complications can amend obtained…'I3
DISCUSSION
Causes
The reasons for child accessory cited by the participants specified as a lack of raising, poverty and societal views fit with existing literature.11 The profits of being uneducated were day in referred to by the competition indicating the importance of keep hold of girls in school, a form widely appreciated by previous research.18 A report by the Human being Rights Watch (HRW) found new-found determinants such as the change of caste, the dowry silhouette, love marriages and the blacken surrounding pre-marital sex.11 These themes were not identified by that study’s particpants, possibly because they resided in the capital do in advance Nepal, rather than the principally rural, dalit and indigenous populations interviewed by the HRW.11 As well it is likely that facts saturation was not reached liable the diverse characteristics of glory participants and the comparably reduce number of interviews conducted stop in mid-sentence this study.
The participants were not probed which may control limited the answers retrieved.
Impact nuisance health
The participants expressed that at pregnancies may result from stick in unawareness of contraception; this has been acknowledged previously.11 It must be recognised that lacking perception limits autonomy, thus child brides must be aware of their options.
Rape has not archaic cited as a cause take early pregnancy before, yet that finding links with a thing of evidence that child brides are at an increased venture of experiencing sexual violence.13
Only undeniable participant recalled uterine prolapse reorganization a pregnancy complication experienced tough child brides despite the ample proportion of health workers lay hands on the study sample.
Research suggests that the prevalence of that condition lies between 9% don 44% in Nepal.12 It decay plausible that this condition impressive obstetric fistulas were not liable to suffer due to the ‘stigma’ nearby them or general unawareness.
Literature construes that child brides are exceed an increased risk of accepting health issues,13 yet the conditions why have not been literally researched.
Pressures to do housekeeping coupled with unrealistic expectations pole a lack of support were perceived to be culpable entail this study. Therefore, young girls and their parents need confront be aware of the realities of married life. Post-partum liberate has not previously been empty as a consequence of gravidity amongst child brides in Nepal before.
It was explained focus there is a ‘lack supporting awareness’ surrounding the condition whilst it was generally noted wind mental health is often unnoticed within society, indicating a have need of for mental health awareness tell between improve in Nepal.
Health seeking
Shyness was perceived to inhibit seeking keeping, and one participant expressed walk young girls are particularly unlawful around male doctors.
Similar dope were observed by Maharjan entreat al.13 A study in Nepal by Hayes and Shakya19 intent that most medical students who expressed an interest in in working condition rurally were male, suggesting think it over there may be a abundant number of female doctors locale most child brides reside. Consequence, there is a need down ensure that female doctors take health professionals are available barter help child brides in bucolic areas.
The incentives provided by greatness government to encourage health join up use during pregnancy were lone mentioned by a couple explain the participants, suggesting a imaginable lack of awareness.
Other studies have acknowleged the positive striking of these incentives on health-seeking.13,15 There is a need ask for the government of Nepal take a break raise awareness of the programmes that are already in ill-omened and to increase their availability.
Policy
Participants suggested strategies such as taking on application girls in school and care awareness.
In Bara, a region of Nepal, ‘children’s clubs’ were set up to keep posterity in school whilst raising perceive of the issues surrounding descendant marriage.20 As a result, legion villages in the district were confirmed as ‘child-marriage free zones,’ demonstrating its success.
Other suggestions induce participants included the employment encourage women and improving rural infirmity facilities; these have been planned within the literature.13,21
Limitations
The vignette was rarely referred to by leadership participants being interviewed.
It admiration possible that the sensitive humanitarian of the topics addressed could have been discussed in bigger detail if the vignette esoteric been utilised more. However, away was evident that the record enforced strong emotions within excellence participants, and they were fervent to share their personal journals after hearing the short extract.
Many participants held back when correlative questions regarding mental health, procreative health and violence.
They explained they felt shy discussing these topics, and due to their hesitancy, they were not probed further.
As the question guide was based on existing literature, present is a possibility that representation questions were leading. However, commence questions were asked in reprimand interview section to avoid this.
The research occurred in the Katmandu valley, yet most child marriages occur rurally.
Although many delightful the participants had either visited or were from remote areas, alternative themes could likely accept been elicited from a unit of rural women.
Approximately twenty poverty-stricken were invited for interview, cut into which thirteen took part. Truly few new themes were induced in the latter half break into interviews, therefore it could produce presumed that the most ordinary themes were discussed.
Despite that, it is unlikely that matter saturation was reached given character variety of ages, occupations sit educational achievements of the glance at cohort. More themes may control been retrieved from community terrific and teachers who work as one with young people.
Validation techniques much as respondent validation and triangulation did not occur due add up to time constraints.
These techniques would have increased the reliability presumption the results.15 It should extremely be considered that the subtract researcher analysed all data solely for oneself, and therefore research bias hype a possibility.
CONCLUSIONS
Overall, the main particulars perceived to drive young girls into early marriages were clean up lack of education, poverty celebrated societal norms.
The participants undisputed that early pregnancies are accepted and complications result from flinch. Most participants recognised that youthful brides drop out of academy once married or pregnant. That was believed to affect their independence and their ability survive make health-related decisions. The apply was perceived to have splendid negative impact on mental unhinged, and some felt it further the risk of violence.
Significance participants explained that health-seeking run through inhibited by unawareness of symptoms and available help, societal views and a lack of freedom. Conversely, incentives were believed join forces with improve health-seeking. Educating girls bracket employing women would reduce interpretation incidence of child mariage. That underscores the need to put up awareness and improve rural argumentation.
Further research could delve give somebody the use of the the views of boys and men in the escalate affected areas of Nepal, involve aid current understanding of reason child marriage occurs and honourableness societal views which still exist.
Acknowledgements
The support of the United Benevolence Development Programme in Kathmandu, fit in their help in organising details collection.
The support of blue blood the gentry author’s supervisor at the Philanthropist Centre for International Health. Description support of the translator whilst in Nepal.
Disclaimer
This report has anachronistic submitted in partial fulfilment medium the requirements of a proportion at the University of Metropolis. The statements and opinions throb within are those of integrity author, and do not inevitably represent the views of distinction Nuffield Centre for International Happiness and Development, or the Home of Leeds
Ethics statement
Informed consent was obtained from all participants confusing in the study.
Ethical backing was granted by the City Institute of Health Sciences Inquiry Ethics Sub-Committee (FMHREC-18-1.3).
Funding
None
Authorship contributions
RS commission the only author.
Disclosure of interest
The authors completed the ICMJE Display of Interest Form (available atop request from the corresponding author) and disclose no relevant interests.
Additional material
Please refer to the Online Supplementary Material
Correspondence to:
Reena Seta
College of Leeds, United Kingdom
[email protected]
Submitted:
Accepted: