Presenter: Dr Dina Neelofur Khan

Early marriageDefinitionAs determined by the United Nations

Convention on the Rights of the Child (CRC) occurs when the bride or groom is under 18 years of age

PrevalenceGlobally – 1/3rd of all girls by age 18

1 in 9 by age 15Pakistan – UNICEF & PRB data

7% by age 15

24% by age 18

Early marriage and childbearingSocial and cultural constructSocial and economic outcomes

- loss of peer support- discontinuation of education- fewer future employment opportunities

Consequences of early marriage and childbearingMedical/clinical

Maternal mortality Low birth weightPreterm birthNeonatal, perinatal and infant mortalityProlonged and obstructed labour – VVFAnaemia

Health care seeking behaviour of young married girls

Low utilization of services

Delayed or insufficient utilization of services

Three Delays model – Thaddeus and Maine, 1994

1st delay: delay in deciding to seek care on the part of the individual, family or both

2nd delay: delay in reaching an adequate health care facility

3rd delay: delay in receiving adequate care at the facility

Health care seeking behaviour of young married girls – determinants and barriersIndividual, social and cultural factorsLimited autonomy Financial constraints Restricted mobility Perception of need

Lack of knowledge and education Inability to recognise signs of complication

Lack of information about existing servicesPerception of services – providers’ attitudeViolence and abuse during pregnancy

Policy issues – Health service provisionLack of availability of servicesLack of equipment and suppliesLack of accessibility of servicesDistance to servicesPoor infrastructureNo or minimal transportationTransportation costsProviders training

Health care services for young married women

Neglected cohortDifficult to reachLack of policy and programming

MDGs and early marriage and childbearing

Address morbidity and mortality associated with early childbearing

Invest in policy and programmes to prevent or delay early marriage

Focus on service delivery – strengthen health systems and develop programmatic capacity

Prioritise health and well-being of girls and young women – urged at Women Deliver Conference 2013

To achieve MDGs – Different programmatic approaches and evidence

Approaches - few programmes Preventing complications during pregnancy & childbirthManagement of complications during pregnancy &

childbirth

Interventions and evidencePre-pregnancy counsellingComprehensive ANCIntrapartum care – skilled attendant and EmOCPostpartum care

BUT….. The key issues remain

Timely access and utilization of services

Barriers to access and utilize services

Small scale qualitative study conducted in LebanonAim of the study - identify factors that may influence young

married women’s health care seeking behaviour, their access to and utilisation of health care services

Sampling – purposive – limited to CLAMethodology – in-depth interviews with 3

doctors, 3 nurses and 2 midwives

Selected statistics for comparison

Indicators Palestinian refugees

Pakistan

Youth aged 10-24 years - % of total population

34 32

% of women aged 20-24 years married by age 18

19 24

% of women aged 20-24 years married by age 15

- 7

Total fertility rate 3.2 3

adolescent fertility rate 48 28

Selected findings

Health care seeking behaviour of young married Palestinian refugee girlsInitiation of ANC Number of visits during pregnancy Regularity and punctuality of visitsPostnatal visit

Initiated ANC early in pregnancyFollowed recommended regimenAttended clinics regularityAttended postnatal clinic

Other findingsPreconception classesAppointment systemContinuity of care and familial environmentNo transport costsFree or minimal consultation feesPostnatal home visits

Selected statistics on Palestinian refugees living in Lebanon86.2% ANC coverage6.4 average number of visits during pregnancy86.2% of women with at least 4 antenatal visits92.4% Postnatal visits 100% institutional deliveriesChild immunization – more than 99% Infant mortality – 19/1000 live birthsNeonatal mortality – 14/1000 live birthsMaternal mortality ratio MMR – 14/100,000 live

births among women registered with UNRWA antenatal services

Lessons learned

Increasing accessibility and utilization of services

Health care seeking behaviour can be influenced byIntroduction of preconception classes – health

promotion, counselling, screening/risk assessment, nutrition supplementation

Providing information about servicesMaking services available and affordable to allIncreasing accessibility of services

Reducing distance to facilities Minimising transportation costs

Lessons learned contd:

Improving quality of services Focus on prevention and MCH

MCH programme that reaches out to those in need Accessible to all Addresses the needs of vulnerable groups

Training of health care providersNumber of trained personnel

The way forward:Appropriate policies and proper allocation

regimens.Addressing young married girls in all maternal

and child health (MCH) programmes and policies

Investing in policies and programmes that address young married girls will help accelerate the achievement of internationally-agreed Millennium Development Goals – not only MDG 5 but also MDG 1, 3, 4 and 6.