|Year : 2020 | Volume
| Issue : 4 | Page : 137-143
Determinants of teenage marital pregnancy among bangladeshi women: An analysis by the cox proportional hazard model
Md Alamgir Sarder, Sharlene Alauddin, Benojir Ahammed
Statistics Discipline, Khulna University, Khulna, Bangladesh
|Date of Submission||15-Mar-2020|
|Date of Decision||20-Aug-2020|
|Date of Acceptance||21-Aug-2020|
|Date of Web Publication||8-Sep-2020|
Khulna University, Khulna
Source of Support: None, Conflict of Interest: None
Introduction: Teenage marital pregnancy is a critical issue responsible for complex and life threatening health problems of both mother and children. This study aimed to determine various demographic, socioeconomic, and spatial factors responsible for teenage pregnancy in Bangladesh. Methods: This study used Bangladesh Demographic and Health Survey 2014 data. A sample of 4,608 teenage (age<20years) married women were included in the analysis. Kaplan Meier Product Limit approach was used to estimate the mean and median teenage pregnancy, and the log-rank test was used to test whether two (or more) groups were equal or not. Finally, Cox proportional hazard model was used to determine the risk factors of teenage pregnancy. Results: Among participants, approximately 90% had experienced teenage pregnancy. The mean (±standard deviation) age of the teenage pregnancy was 17.7 (±2.79) years. Among the demographic and socioeconomic factors, women's and their husband's lower education, lowest wealth index, Islamic faith, unemployment, and no access to mass media were the risk factors associated with the teenage pregnancy. Furthermore, spatial variables, residence in Rangpur division, and rural areas also had higher odds of getting pregnant at teenage. Conclusion: Government should initiate different protective and preventive measures to minimize early marriage and pregnancy, including improvement of female enrolment and completion rate of education, encouragement of female employment opportunities to increase wealth index for women through financial support and technical skill development, and reinforcement family planning utilization using religious texts and knowledge among people at individual and community levels.
Keywords: Bangladesh, marriage, pregnancy, teenage, women
|How to cite this article:|
Sarder MA, Alauddin S, Ahammed B. Determinants of teenage marital pregnancy among bangladeshi women: An analysis by the cox proportional hazard model. Soc Health Behav 2020;3:137-43
|How to cite this URL:|
Sarder MA, Alauddin S, Ahammed B. Determinants of teenage marital pregnancy among bangladeshi women: An analysis by the cox proportional hazard model. Soc Health Behav [serial online] 2020 [cited 2020 Oct 29];3:137-43. Available from: https://www.shbonweb.com/text.asp?2020/3/4/137/294538
| Introduction|| |
Teenage pregnancy is a major health concern worldwide. According to the World Health Organization (WHO), globally, an estimated 16 million teenage girls give birth each year, accounting 11% of all birth, and around 12 million of such pregnancies took place in developing countries. Teenage pregnancy is characterized as the participation of young women, between the ages of 15–19, in sexual activity and getting pregnant willingly or unwillingly. The reasons behind teenage pregnancy in developing countries are early marriage, lower socioeconomic status, lack of knowledge, and access to contraceptives. Teenage pregnancy adversely affects not only the physical and mental health of the teenagers but also the socioeconomic prospect of their families and communities. The consequences of teenage pregnancy are unsafe abortion, pregnancy-induced hypertension, maternal anemia, spontaneous miscarriage, eclampsia, puerperal endometritis, systemic infection, and babies with low birth weight, high perinatal and postneonatal morbidity and mortality,, as well as high maternal mortality., The majority of teenage births take place in the developing countries, but there are tangible regional odds with the lowest in East Asia and highest in West and Central Africa., Even, the rate of teenage pregnancy is generally higher in developing countries compared to developed countries.,
Bangladesh is a developing country where teenage pregnancy is more prevalent. According to the World Bank, the global teenage fertility was 42/1000 women in 2018, while it was 82 for Bangladesh. The highest rate of teenage pregnancy was 210/1000 women in 1960, while globally, it was only 79/1000 women. Bangladesh is ranked first to South Asia in 2018, with the highest rate of teenage pregnancy and followed by Nepal (64), Bhutan (38) Pakistan (38), Myanmar (28), Sri Lanka (21), and Maldives (7). To reduce teenage pregnancy, the identification of associated factors is critical to rectify the current national preadult well-being system, and relevant programs. Several empirical studies have shown the complex underpinnings those influence teenage pregnancies in various pathways.,,, Some key drivers for teenage pregnancy include the practice of early marriage, rural birthplace,, poor wealth index,,,,, illiteracy among female teenagers,,,,,, administrative areas, joint family, age gap between spouses, religious conservatism,, unemployment,, and no access to mass media.,
Yet, there was a shortage of comprehensive study on socioeconomic factors related to teenage pregnancy. However, in Bangladesh, a study addressing the association between socioeconomic and demographic factors were influencing nutritional status among early childbearing young mothers but, they were unable to discover the association of various factors with teenage pregnancies. Another study was initiated in Bangladesh using Bangladesh demographic and health survey (BDHS) (1993–2014) datasets simultaneously to find out the overall scenario of teenage motherhood in Bangladesh, and still, it could not uncover the actual situation of teenage pregnancies. Hence, the objective of this study was to identify the determinants of teenage pregnancy among married women in Bangladesh using the latest demographic and health survey data. We expect that this study will contribute towards a better comprehension of the elements of teenage pregnancy in Bangladesh, and it will help to formulate better policies and strategies required for positive changes in teenage pregnancy in Bangladesh. Such would guarantee the quality existence of teenagers and the sound existence of mother and children specifically.
| Methods|| |
Data and sampling design
This study used data from the 2014 BDHS, the latest and largest national household survey designed to provide the national demographic and health indicators, including information concerning various reproductive health issues. The survey included a nationally representative sample of 17,989 households and 18,245 eligible ever-married women aged 15–49 years. The final sample size for this study consisted of 4608 married women aged 15–19 years. Full circumstantial of sampling methods, utilized for acquiring the information, has been published somewhere else.
Variables of interest
The response variable for this study is teenage pregnancy. Pregnancy is the time during when one or more babies develop inside a woman. Successful pregnancy of a woman before the age of 20 years is considered a success event and otherwise censored. The event time is defined as the interval between the date of marriage and pregnancy of a woman or censoring. Based on the previous literature, several demographic, socioeconomic, and spatial variables were included in the analysis as predictors of teenage marital pregnancy.,,,,,,,,,, Demographic variables, such as religion (Islam and others), the spousal age gap (<5 years, 5–10 years, and >10 years), were included in the analysis. Women education (no education, primary, and secondary and higher), Husband education (no education, primary, and secondary and higher), family type (nuclear and joint), wealth index (poor, middle, and rich), employment status (unemployed and employed), access to media exposure (no and yes) were used as socioeconomic variables. Women's birthplace (rural and urban) and division (Barisal, Chittagong, Dhaka, Khulna, Rajshahi, Rangpur, and Sylhet) were included in the analysis as spatial variables.
The analysis initially presents the descriptive statistics of teenage marital pregnant women according to their background characteristics. Kaplan–Meier Product-Limit (P-L) approach has been used for bivariate analysis to estimate the mean and median teenage pregnancy. Log-rank test was used to determine the significant difference in teenage pregnancy status for two or more groups for the selected covariates. Cox proportional hazard (PH) was utilized to predict the quality of the relationship between the selected variables and teenage marital pregnancy. The results of Cox regression were presented as hazard ratios (HRs) with a 95% confidence interval (CI). All analyses were performed using SPSS (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.), and “survival” packages of R (R-4.0.2 for Windows) programming software.
The National Institute of Population Research and Training conducted the BDHS in 2014 under the Ministry of Health and Family Welfare of the Government of Bangladesh. Mitra et al. surveyed, while USAID and ICF international provided funding and technical assistance through the Demography and Health Surveys (DHS) program. The BDHS data set was available from https://dhsprogram.com/data. Since BDHS is a secondary dataset from DHS provided by Marco International, there was no ethical approval required. It should, however, be noted that Macro International obtained informed consent from individuals who participated in the DHS surveys.
| Results|| |
[Table 1] shows the background characteristics of teenage pregnant women. The results reveal that teenage marital pregnancy was higher in the Rangpur division (92.1%) and lower in the Sylhet division (88.3%). The highest mean and median age of teenage pregnancy was for the Dhaka division (19.08 years), while the lowest was for the Rangpur division (17.35 years). The teenage pregnancy was more prevalent among rural women (90.9%) than their urban compatriots; they had the lowest mean (18.05 years) and median (17 years) age of the pregnancy. Despite having secondary or more education, about 92.3% of women had pregnancy at teenage, while it was 91.8% and 89.9% for women with primary and no education, respectively. In contrast, teenage pregnancy seems to lower with higher spousal education as 81.2% of spouses with secondary and higher education had teenage pregnant wives, and it was 91.6% for spouses with no education at all. As expected, the lowest mean and median age of pregnancy were found in relation to no education; on the contrary, the highest mean and median was observed among individuals with secondary and higher levels of education.
|Table 1: Descriptive statistics and log-rank test for teenage marital pregnancy of background characteristics|
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The result shows that women in joint families had higher teenage pregnancy (91.4%), and lower mean and median age of the pregnancy. Likewise, the prevalence of teenage pregnancy was higher among women from poor and middle wealth index families. Muslim women (90.3%) had an early chance to get pregnant as their mean and median age of pregnancy were lower than those women from other religious groups. It was also apparent that greater age gap between spouses contributed substantially in early teenage pregnancy as both mean and median of age of pregnancy tend to decrease with the increasing spousal age gap (10< years = 17.6 [standard deviation (SD) =16.0] years compared to <5years = 19.8[SD = 18.0] years). Unemployment of the women (91.3%) was another factor for early pregnancy as the mean and median age of pregnancy were higher for employed women. The prevalence of teenage marital pregnancy was highest among women with no access to mass media (90.8%), with a mean and median age of pregnancy were 16.99 years and 16 years, respectively. [Table 1] also exhibits the significant difference in teenage pregnancy status between two or more groups for the selected covariates obtained from the P-L method along with the log-rank test (P values). The variables as division, birthplace, women education, spousal education, family type, wealth index, religion, spousal age gap, employment status, and access to mass media were found significantly associated with teenage marital pregnancy at 5% level of significance, and these variables were considered in the Cox PH analysis.
[Table 2] reveals the estimated HR obtained using the Cox PH model along with P values to test whether the variables have a significant effect on teenage marital pregnancy or not. In the case of division, the chance of being teenage marital pregnancy was significantly higher for Rangpur (HR = 1.312, CI = [1.130,1.523], P < 0.001) and Rajshahi (HR = 1.225, CI = [1.057, 1.420], P = 0.007), Chittagong (HR = 1.148, CI = [1.020, 1.232], P = 0.046), Khulna (HR = 1.138, CI = [1.021, 1.221], P = 0.005), Dhaka (HR = 1.126, CI = [1.025, 1.236], P = 0.007) and Barisal (HR = 1.057, CI = [1.001, 1.213], P = 0.037) compared to Sylhet division. For birth place, the hazard of being teenage marital pregnancy was higher (HR = 1.081, CI = [1.005, 1.164], P = 0.037) for rural women than those from urban areas. The women with no education (HR = 1.446, CI = [1.132, 1.500], P = 0.032) and primary education (HR = 1.151, CI = [1.061, 1.248], P = 0.001) had higher risks of teenage marital pregnancy compared to the women with secondary and more education. Similar observation was noted in the case of spousal education. The risk of teenage pregnancy was higher among spouses with no education (HR = 1.612, CI = [1.428, 1.820], P < 0.001) and primary education (HR = 1.527, CI = [1.362, 1.713], P < 0.001). Women from nuclear families (HR = 0.925, CI = [0.869, 0.984], P = 0.013) had less hazard of teenage marital pregnancy compared to women from joint families. The risk of teenage marital pregnancy was higher among poor (HR = 1.151, CI = [1.052, 1.259], P = 0.002), and middle-class women (HR = 1.084, CI = [1.002, 1.160], P = 0.031) compared to those from rich families. Muslim women (HR = 1.122, CI = [1.009, 1.248], P = 0.034) had higher risk of getting pregnant at teenage. In contrast, the spousal age gap had a negative impact on teenage marital pregnancy. Women's age gap <5years (HR = 0.709, CI = [0.648, 0.776], P < 0.001) and 5–10 years (HR = 0.934, CI = [0.769, 0.998], P = 0.043) with their husband had significantly lower hazard of teenage marital pregnancy compared to the women's age gap 10< years with their husband. Unlike spousal age gap, the risk of teenage marital pregnancy was found higher among unemployed women (HR = 1.076, CI = [1.008, 1.148], P = 0.028) as well as women with no access to mass media (HR = 1.721, CI = [1.672, 1.774], P < 0.001).
|Table 2: Cox proportional hazard model results of the effects of selected characteristics on teenage marital pregnancy|
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| Discussion|| |
This study investigates the determinants of teenage pregnancy of early married women (age <20years) in Bangladesh using the data from BDHS, 2014. The findings of this study suggest that teenage marital pregnancy remained higher in Bangladesh, therefore, complementing the findings of a previous study. The plausible reasons for teenage marital pregnancy are the failure of preventing child marriage as well as the lower rate of contraceptive use among teenage women., In fact, the contraceptive use among teenage women is still much lower compared to that of adult women. The higher risk of teenage pregnancy is also arising from the expectation of husband and/or other family members.
A significant difference in teenage pregnancy was observed among the divisions of Bangladesh. These results are in line with the findings of the previous study. The risk of early marriage in the Sylhet division was very low; therefore, the risk of getting pregnant at teenage was also low. The differences in the prevalence of poverty, child marriage, and contraceptive use are the key determinants of the variations in teenage pregnancy among the geographical areas. Rural women has the highest proportion, and they are at the greatest risk of teenage marital pregnancy in Bangladesh. A similar result was reported in Bangladesh and Nepal. Possible reasons could be population density, illiteracy, and lack of proper knowledge among the health risks of teenage pregnancy. Hence, to reduce teenage marital pregnancy, the prevention of early marriage with the expansion of female education and awareness about teenage pregnancy is warranted.,
Education of both spouses was significantly associated with teenage pregnancy. Those with no education were more likely to experience teenage pregnancy. Having no education increased the odds of teenage pregnancy by approximately 45% for women and 61% for their partners. Previous studies also found that teenagers with at least primary education were significantly less likely to have had pregnancy than those without any education., The education of mother and their husband also play an important role in teenage marital pregnancy. Therefore, it is necessary to emphasis on and ensures female education with a grass-root centric awareness programs about reproductive health to minimize teenage pregnancy. Reproductive health education also increases the use of contraception and allows women and their husbands to understand sex education resources. The current study identified that women from the nuclear family were significantly less likely to experience teenage marital pregnancy. Early studies found no significant associations between family type and teenage marital pregnancy., This study, thus, provide a strong evidence of the influence of nuclear family on teenage marital pregnancy. Financial stability is the probable reason for the lower risk of teenage marital pregnancy in the nuclear family. In modern societies, a real insight against teenage marital pregnancy is that the family restricts to a single level of parentage or alliance: the nuclear family.,
Similar to education, poor wealth indexes were also associated with higher rate and hazards of teenage pregnancy, supporting the results of some previous studies.,,,, This study found that women from poor or middle-class families had higher hazards of being pregnant compared to those from rich families. Both developed and developing countries have been consistently reported wealth index is a significant factor of teenage marital pregnancy. The higher risk of teenage marital pregnancy among women from poor families in Bangladesh might be enraged because of the financial crisis that frequently left women vulnerable as they grow older. Parents from poor families often take the decisions to marry their daughters because of poverty. After marriage, the responsibility of daughters is on the daughters' partners. The presence of a son-in-law within a poor family is also considered an extra help for earning life and living. Such family fails to consider the possible negative impacts of teenage pregnancy. Muslims were found to have a higher hazard of teenage marital pregnancy in Bangladesh. A pooled analysis conducted in Bangladesh found no significant difference in teenage marital pregnancy between Muslims and other religious women. These contrasting findings about the impact of religion on teenage marital pregnancy can be explained by the role of religion on various characteristics of individual's natural life and on fertility behavior in particular has been diminishing over time due to the impact of modernization, urbanization. A higher spousal age gap was found to be associated with higher teenage marital pregnancy. Our study finding matches with a trend and determinants analysis in Bangladesh. The probable reasons may be that higher spousal age prompts unequal force relations in the family and low degree of inter-spouse communication, which converts into women's lower interest in the dynamic family procedure, including the choice to use contraceptives. In addition, this study revealed that teenage women without access to mass media were more likely to experience marital pregnancy and similar results found in several studies.,, The media was an important source of knowledge and evidence on contraception and elaborately delivers information about reproductive and sexual health and issues. The restriction on the access to information, however, is associated with poor or no knowledge of the use of contraception services and pregnancy prevention strategies.
This study has several unique strengths. First, BDHS data covered both urban and rural areas in all administrative divisions within Bangladesh. This data provided a nationally representative sample in Bangladesh. The response rate of the survey was also high. Even with the strengths, this study also has some limitations. BDHS was a cross-sectional survey; so, the misclassification biasness may be raised in this technique. This study did not investigate some known risk factors for teenage marital pregnancy, such as fathers' working status, household head, contraceptive use, knowledge about contraceptives, and so on. It is, along these lines, conceivable that other important variables are affecting teenage marital pregnancy and recommending a more inside and out future investigation considering the broad socioeconomic context for better understanding factors influencing teenage marital pregnancy.
| Conclusions|| |
Teenage maternal pregnancy is now a global concern because it creates not only the maternal and child health problem but also imposes huge health burden and economic on the family as well as on the country. This study indicates that around nine out of every ten teenage women are getting pregnant in Bangladesh. Rangpur division, rural birthplace, lower education level, joint family, poor socioeconomic status, religious belief, higher spousal age gap, female unemployment, and no access to mass media were found to have association with higher risk of teenage marital pregnancy. Awareness about the consequences of early marriage and early pregnancy should be publicized using popular mass media. Educational opportunities and facilities should be increased to reach out the girls from poor families. The availability of low-price contraceptives should be ensured. Finally, obligatory sex education and women empowerment can enable the young girls to set them up for late marriage, planned and deferred pregnancy, and better motherhood. Overall, public health efforts are urgently warranted for effective prevention and control of the teenage pregnancy for a diverse group of people from different administrative areas on a priority basis to reduce maternal and child health risk as well as an economic burden.
The authors are grateful to the MEASURE DHS (Demography and Health Surveys) for making data available for this study by the request of the corresponding author.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]