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.
