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      Determinants of child and forced marriage in Morocco: stakeholder perspectives on health, policies and human rights

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          Abstract

          Background

          In Morocco, the social and legal framework surrounding sexual and reproductive health has transformed greatly in the past decade, especially with the introduction of the new Family Law or Moudawana. Yet, despite raising the minimum age of marriage for girls and stipulating equal rights in the family, child and forced marriage is widespread. The objective of this research study was to explore perspectives of a broad range of professionals on factors that contribute to the occurrence of child and forced marriage in Morocco.

          Methods

          A qualitative approach was used to generate both primary and secondary data for the analysis. Primary data consist of individual semi-structured interviews that were conducted with 22 professionals from various sectors: health, legal, education, NGO’s and government. Sources of secondary data include academic papers, government and NGO reports, various legal documents and media reports. Data were analyzed using thematic qualitative analysis.

          Results

          Four major themes arose from the data, indicating that the following elements contribute to child and forced marriage: (1) the legal and social divergence in conceptualizing forced and child marriage; (2) the impact of legislation; (3) the role of education; and (4) the economic factor. Emphasis was especially placed on the new Family Code or Moudawana as having the greatest influence on advancement of women's rights in the sphere of marriage. However, participants pointed out that embedded patriarchal attitudes and behaviours limit its effectiveness.

          Conclusion

          The study provided a comprehensive understanding of the factors that compound the problem of child and forced marriage in Morocco. From the viewpoint of professionals, who are closely involved in tackling the issue, policy measures and the law have the greatest potential to bring child and forced marriage to a halt. However, the implementation of new legal tools is facing barriers and resistance. Additionally, the legal and policy framework should go hand in hand with both education and increased economic opportunities. Education and awareness-raising of all ages is considered essential, seeing that parents and the extended family play a huge role in marrying off girls and young women.

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          Most cited references17

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          Early marriage and HIV risks in sub-Saharan Africa.

          This article examines the effects of girls' early marriage on their risk of acquiring HIV/AIDS. By comparing several underlying HIV risk factors, it explores the counterintuitive finding that married adolescent girls in urban centers in Kenya and Zambia have higher rates of HIV infection than do sexually active unmarried girls. In both countries, we find that early marriage increases coital frequency, decreases condom use, and virtually eliminates girls' ability to abstain from sex. Moreover, husbands of married girls are about three times more likely to be HIV-positive than are boyfriends of single girls. Although married girls are less likely than single girls to have multiple partners, this protective behavior may be outweighed by their greater exposure via unprotected sex with partners who have higher rates of infection. These results challenge commonly held assumptions about sex within marriage.
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            Health Consequences of Child Marriage in Africa

            Nawal Nour (2006)
            Awareness of reproductive health issues in developing nations is growing. Critical issues are the high prevalence of HIV/AIDS among young people; childbearing by young girls, which can lead to obstetric fistulas and death of the mother; and child marriage. Child marriage, defined as marriage of a child 10 children), polygamous husbands (>2 wives), and poor genital hygiene (no tap water available and reuse of sanitary napkins). Another study in Morocco had similar findings ( 26 ), with cervical cancer risk factors identified as child marriage, high parity, long-term use of oral contraceptives, and poor genital hygiene (control participants bathed more frequently, and case-participants used homemade sanitary napkins more frequently). Other studies have also implicated hygiene as a possible factor ( 22 , 27 ). Children Bearing Children Pregnancy poses many challenges for young girls. Because pregnancy suppresses the immune system ( 28 ), pregnant girls are at increased risk of acquiring diseases like malaria. Malaria kills >1 million people each year, 90% of them in Africa. Approximately 25 million pregnant women are exposed to malaria per year, and pregnant women are among the most severely affected by malaria. About 10.5 million become infected during their second or third trimester ( 29 ), and among these, the mortality rate is ≈50% ( 30 ). Not only are pregnant women most susceptible to malaria during their first pregnancy ( 31 ), but they also have higher rates of malaria-related complications (predominantly pulmonary edema and hypoglycemia) and death than do nonpregnant women. Malaria parasite density is significantly higher in pregnant girls 19 years ( 32 ). However, a woman who has had malaria during pregnancy is less susceptible to malaria during subsequent pregnancies, unless the woman is also HIV infected ( 31 ). The interaction between HIV and malaria in young married girls is devastating. Rates of coinfection are highest in Central African Republic, Malawi, Mozambique, Zambia, and Zimbabwe, where >90% of the population are exposed to malaria and >10% are HIV positive. HIV-infected patients are much more susceptible to infection with Plasmodium falciparum. Pregnant women have high malaria parasitemia in the placenta and more severe clinical disease, which affects not just the first pregnancy but all subsequent pregnancies. HIV-infected patients also do not respond as well to standard antimalaria treatment. Finally, malaria increases HIV viral load and raises the risk for mother-to-child HIV transmission ( 29 ). The biologic interaction between these diseases not only complicates treatment in an already challenging setting but also presents a serious risk for death to pregnant girls 20 years of age, girls 10–14 years of age are 5–7 times more likely to die from childbirth, and girls 15–19 years of age are twice as likely ( 34 ). For example, in Mali, the maternal mortality rate for girls aged 15–19 is 178 per 100,000 live births and for women aged 20–34, only 32 per 100,000. In Togo, for the same age groups, these rates are 286 and 39, respectively ( 1 ). Reasons for these high death rates include eclampsia, postpartum hemorrhage, HIV infection, malaria, and obstructed labor. Obstructed labor is the result of a girl's pelvis being too small to deliver a fetus. The fetus's head passes into the vagina, but its shoulders cannot fit through the mother's pelvic bones. Without a cesarean section, the neonate dies, and the mother is fortunate if she survives. If sepsis or hemorrhage does not occur and the girl does survive, the tissue and bones of the neonate will eventually soften and the remains will pass through the vagina. Many times, obstructed labor leads to fistulas; the pressure of the fetal head on the vaginal wall causes tissue necrosis, and fistulas develop between the vagina and the bladder or rectum after the necrotic tissue sloughs. More than 2 million adolescents are living with fistulas, and fistulas develop in ≈100,000 more each year ( 35 ). Girls ages 10–15 years are especially vulnerable because their pelvic bones are not ready for childbearing and delivery. Their risk for fistula is as high as 88% ( 36 ). Once a fistula is formed, fecal or urinary incontinence and peroneal nerve palsy may result and may lead to humiliation, ostracism, and resultant depression. Unless the fistula is surgically repaired, these girls have limited chances of living a normal life and bearing children. Effects on Offspring Child marriage affects more than the young girls; the next generation is also at higher risk for illness and death. Adolescent mothers have a 35%–55% higher risk than older women for delivering infants who are preterm and of low birthweight. Mortality rates are 73% higher for infants born to mothers 20 years ( 38 ). Discussion Child marriage has far-reaching health, social, economic, and political implications for the girl and her community. It truncates a girl's childhood, creates grave physical and psychological health risks, and robs her of internationally recognized human rights. Ending child marriage requires the consent of all those involved, including fathers and religious, community, and tribal leaders. To break the cycle of poverty, programs are needed to educate and empower women. In 2000, eight Millennium Development Goals outlined a vision that committed member countries to eradicate extreme poverty and hunger, educate all children through primary school, empower women, reduce childhood death, improve mothers' health, combat HIV/AIDS and malaria, ensure environmental sustainability, and develop a global partnership for development by the year 2015. Most of these goals directly affect child marriage. Data show that improvements are being made and that sub-Saharan Africa has the most obstacles to overcome ( 39 ). In some countries, child marriage has been declining. Increasing mean age for marriage often results in part from overall advancement of an economy. In some countries, such as Korea, Taiwan, and Thailand, decreasing poverty effectively decreased child marriage by enabling these countries to improve education, increase employment, and provide better health care for the whole nation. Education is a key factor for delaying first sexual activity, pregnancy, marriage, and childbearing. Programs that specifically focused on the status of girls may have directly or indirectly reduced the number of child marriages. Successful programs have provided economic and educational opportunities to young women and their families by employing girls with the specific goal of delaying marriage ( 40 ), giving families financial incentives to keep their daughters in school ( 1 ), or feeding children during school to decrease families' expenses. Keeping girls in school or vocational training not only helps protect them from HIV infection, pregnancy, illness, and death but also enhances their earning potential and socioeconomic status. Educated girls can contribute to the health and welfare of their family and marry men of their own choosing and age. Lack of enforcement renders laws against child marriage ineffective. Through media campaigns and educational outreach programs, governments need to take responsibility for stopping this practice. Local, regional, and national governments can also implement health outreach programs for girls and boys. Learning about reproductive and sexual health, STD prevention, contraception, AIDS, and how to seek health care helps girls negotiate safer sex. Governments must incorporate preventive and treatment programs for reproductive health issues into their health services. Necessary preventive services include supplying mosquito netting and condoms; educating patients about contraceptive methods; providing diagnostic screening for HIV and HPV; and offering treatment options such as medications, cesarean sections, and postpartum care. Ending child marriage requires a multifaceted approach focused on the girls, their families, the community, and the government. Culturally appropriate programs that provide families and communities with education and reproductive health services can help stop child marriage, early pregnancies, and illness and death in young mothers and their children.
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              Ecological and individual level analysis of risk factors for HIV infection in four urban populations in sub-Saharan Africa with different levels of HIV infection.

              To identify factors that could explain differences in rate of spread of HIV between different regions in sub-Saharan Africa. Cross-sectional study. The study took place in two cities with a relatively low HIV prevalence (Cotonou, Benin and Yaoundé, Cameroon), and two cities with a high HIV prevalence (Kisumu, Kenya and Ndola, Zambia). In each of these cities, a representative sample was taken of about 1000 men and 1000 women aged 15-49 years. Consenting men and women were interviewed about their socio-demographic background and sexual behaviour; and were tested for HIV, herpes simplex virus type 2 (HSV-2), syphilis, Chlamydia trachomatis and Neisseria gonorrhoea infection, and (women only) Trichomonas vaginalis. Analysis of risk factors for HIV infection was carried out for each city and each sex separately. Adjusted odds ratios (aOR) were obtained by multivariate logistic regression. The prevalence of HIV infection in sexually active men was 3.9% in Cotonou, 4.4% in Yaoundé, 21.1% in Kisumu, and 25.4% in Ndola. For women, the corresponding figures were 4.0, 8.4, 31.6 and 35.1%. High-risk sexual behaviour was not more common in the high HIV prevalence cities than in the low HIV prevalence cities, but HSV-2 infection and lack of circumcision were consistently more prevalent in the high HIV prevalence cities than in the low HIV prevalence cities. In multivariate analysis, the association between HIV infection and sexual behavioural factors was variable across the four cities. Syphilis was associated with HIV infection in Ndola in men [aOR = 2.7, 95% confidence interval (CI) = 1.5-4.91 and in women (aOR = 1.7, 95% CI = 1.1-2.6). HSV-2 infection was strongly associated with HIV infection in all four cities and in both sexes (aOR ranging between 4.4 and 8.0). Circumcision had a strong protective effect against the acquisition of HIV by men in Kisumu (aOR = 0.25, 95% CI = 0.12-0.52). In Ndola, no association was found between circumcision and HIV infection but sample sizes were too small to fully adjust for confounding. The strong association between HIV and HSV-2 and male circumcision, and the distribution of the risk factors, led us to conclude that differences in efficiency of HIV transmission as mediated by biological factors outweigh differences in sexual behaviour in explaining the variation in rate of spread of HIV between the four cities.
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                Author and article information

                Contributors
                Journal
                BMC Int Health Hum Rights
                BMC Int Health Hum Rights
                BMC International Health and Human Rights
                BioMed Central
                1472-698X
                2013
                16 October 2013
                : 13
                : 43
                Affiliations
                [1 ]ICRH - International Centre for Reproductive Health, Faculty of Medicine & Health Sciences, Ghent University, De Pintelaan 185 UZP114, 9000 Ghent, Belgium
                [2 ]AEDF - Association El Amane pour le Développement de la Femme, Avenue Ben Noussair, Sidi Youssef Ben Ali, Marrakech, Morocco
                [3 ]WHO - World Health Organization, Geneva, Switzerland
                [4 ]Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
                Article
                1472-698X-13-43
                10.1186/1472-698X-13-43
                3853335
                24131501
                e61d1cde-a565-4478-97b8-84004f74d5cc
                Copyright © 2013 Sabbe et al.; licensee BioMed Central Ltd.

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 23 January 2013
                : 18 September 2013
                Categories
                Research Article

                Health & Social care
                child and forced marriage,morocco,women’s rights,sexual and reproductive health,violence

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