Child Brides, Damaged Lives

Moni Mostafa felt a growing sense of desperation. Her parents had arranged for her to marry a neighbor in her small village in rural Bangladesh, something Moni didn't want. At 13, she didn't feel ready. A bright, bubbly girl with large, dark eyes, she had dreams of being a teacher, not spending her life bearing one child after another.

But her situation was hardly unusual. In Moni's village, many girls were married at 12 or 13—and bearing children a year or two later, according to Mohammad Shamimul Islam, a program director with the Bloomberg School's Center for Communication Programs (CCP) in Bangladesh, which operates a health and life skills program there.

Not surprisingly, early marriage often leads to early childbirth, and the health consequences for mother and baby can be devastating, says Saifuddin Ahmed, PhD '96, an assistant professor in Population, Family and Reproductive Health (PFRH), who has worked extensively in Bangladesh. Many girls, their young hips still narrow, labor for days without medical assistance. If the baby's head presses against the walls of the birth canal for too long, it cuts off the blood supply and causes the mother's tissue to die, creating a hole called a fistula. Most obstetrical fistulas form between the vagina and the bladder/urethra, causing a woman to become incontinent and constantly leak urine.

Many people who live in areas where fistulas are a problem—such as the "Fistula Belt," just south of the Sahara, including Niger, Nigeria and Ethiopia—are not only poor, but often must travel for days to reach a hospital. Almost 90 percent of the children delivered during these prolonged labors are stillborn, says Ahmed. And without a child, the bond between husband and wife frequently dissolves.

While fistulas can usually be repaired through surgery, the relatively high cost ($300 per repair) puts the procedure out of reach of many impoverished women in these regions, Ahmed notes. Concerned that most research to date has focused on fistula repair, rather than prevention, he undertook one of the first studies to identify the risk factors for fistula. (Collaborators on the study included doctoral candidate Andreea Creanga, and Amy Tsui, PhD, a PFRH professor and director of the Bill and Melinda Gates Institute for Population and Reproductive Health.)

The Bloomberg School researchers found that the greatest risk was for girls whose first pregnancy was before age 18, increasing again for girls who gave birth before 15. Because most of these deliveries take place without skilled medical care, it is difficult to know exactly how many girls develop a fistula during labor and delivery, says Ahmed.

The most obvious solution to preventing fistulas in millions of girls throughout the world is to prevent early marriage and early pregnancy—a solution that is simple, but not easy to effect. "Making laws about age at marriage is artificial and is not likely to work. Change is needed in cultural expectations about age at marriage," says Michelle Hindin, PhD '98, MHS '90, a PFRH associate professor.

Adding to the cultural expectation is extreme poverty that increases the pressure for early marriage so the family will have one less mouth to feed. To Hindin, the best prevention is to keep girls in school longer. "The girls can be economically productive rather than be married off and need a dowry," she says.

Hadiza Babayaro agrees. "The best contraceptive," she says, "is female education." Babayaro is a CCP senior program officer for Ku Saurara! (Listen Up!) in northern Nigeria. Listen Up! has aired radio and television messages about reproductive health aimed at young people. It has also provided information on healthy motherhood and post-abortion care. Although Nigeria still has very high rates of obstetrical fistulas, a woman's average age at marriage has been steadily rising in the past decade.

In Bangladesh, this hope of staying in school and finishing her studies prompted Moni to seek out a new program in her area. A sister program to the one in Nigeria, the Bangladesh CCP program teaches adolescent girls and boys life skills, communication strategies and reproductive health. Through the CCP program, Moni learned the health dangers of early marriage and childbearing, as well as the benefits of staying in school. With the skills she learned, she persuaded her parents to call off the marriage, says Islam.

Today, at age 15, Moni remains in school and is planning to become a teacher.