Young India: Investing in Health Workers Could Save Young Girls’ Lives

When Kajal’s parents announced that it was time for her to get married, she balked. She wanted to keep going to school, she told them. And besides, she was only 16.

Early marriage is common in India, especially in the eastern state of Jharkhand, which has some of the highest rates of underage marriage in the country. Parents like Kajal’s often hope to get their daughters married as early as they can. The longer a girl goes unmarried, the more likely neighbors are to start questioning her virtue. And there are the overwhelming economic difficulties—not only is a married daughter one less mouth to feed, but the cost of weddings and dowries can rise with age.

Many girls in Jharkhand are married well before they reach Kajal’s age. But early marriage, by itself, isn’t necessarily a danger to girls’ health. The greatest risk comes from the inevitable consequence: early pregnancy.

Some 56,000 women die every year in India during pregnancy or childbirth. One of the main reasons for that is a critical shortage of health workers in the country. Another, according to The Lancet, is the number of early pregnancies.

That’s why IntraHealth’s Vistaar Project has been working closely with the state government in Jharkhand to help adolescents, their parents, and their communities understand the health dangers that come with early marriage. It’s no easy task—early marriage has been part of the Indian culture for centuries, especially in rural areas and tribal communities. But now health workers and community leaders are working to change that.

A Matter of Honor

In an effort to crack down on child marriage, in 1978 the Indian government outlawed matrimony for girls under the age of 18 and for boys under the age of 21. The statistics are slowly improving, but still almost half of Indian women are married before they reach the legal age.1

A lot of it has to do with safety. Families worry that their daughters could become pregnant out of wedlock, which would lead to a total loss of a family's honor. Many girls are married before they even start menstruation.

The Vistaar team worked with the government of Jharkhand to train teachers, health workers, and religious leaders in five districts on the health risks of underage marriage and on ways to prevent it. Then the newly trained groups spread the message, educating in-school and out-of-school adolescents and families across Jharkhand. An auxiliary nurse midwife named Sonam Didi, for example, sat down with Kajal’s parents during a community event and spoke with them about the dangers Kajal (and any children she might have) would face if she were married too young.

Having a baby is particularly dangerous for young girls whose bodies are not yet fully developed. In fact, UNICEF estimates that 70,000 girls aged 15-19 die from complications from pregnancy and childbirth every year. Teen mothers face an increased risk during childbirth of pre-eclampsia (skyrocketing blood pressure), eclampsia (seizures brought on by pregnancy), and obstetric fistula (a hole that develops between the vagina and the bladder or rectum). Postpartum hemorrhage is a major cause of death for mothers in their early teens.  "Early marriage usually results in early childbirth, which poses increased health risks for the mothers and babies," says Madhuri Narayanan, director of the Vistaar Project. "And young girls are often not emotionally mature enough to cope well with the challenges of child rearing."

And babies are at risk, too. Chances of premature birth and low birth weight are much higher for babies born to teenage mothers than to mothers in their twenties. There are also high rates of under-nutrition and anemia for Indian adolescent girls, which too often lead to health problems for their infants.

Not all of early marriage’s dangers are physical, though. Getting married too young can be confusing and psychologically scarring. Girls who marry before they turn 18 are more likely to suffer from domestic violence and sexual abuse, according to the International Center for Research on Women. They’re also more likely to develop post-traumatic stress disorder and struggle with the depression and hopelessness that come with it.

Vistaar’s results

In 2008, before even starting the training programs, the Vistaar team surveyed adolescent girls, their mothers, and community leaders in Jharkhand to find out, among other things, how much the population knew about the legal age of marriage, the negative effects of marrying during adolescence, and the benefits of marrying later. The researchers also wanted to know what girls thought about how much time should pass between marriage and the births of their first children, as well as how much time the girls thought should pass between subsequent births.

Then in 2012, the team conducted surveys in two districts to see what, if anything, had changed. A lot had. You can read all the specifics in the end-of-project brief on this topic, but here are some highlights:

  • In 2008, only 55% of girls and 22% of mothers knew that girls must be 18 to be legally married. In 2012, 94% and 65%, respectively, knew the law.

  • Girls’ perceptions of the ideal amount of time between marriage and the birth of the first child went up.

  • The number of girls surveyed who thought that two years was the ideal time between births went up. The number of girls who thought that a year or less between births was sufficient dropped.

  • More than twice as many mothers knew in 2012 than in 2008 that delaying marriage could help their daughters have healthier babies.

  • Only 54% of mothers surveyed in 2008 said they intended to consider their daughters’ consent when it came to marriage. By 2012, that number had risen to 92%.

  • In 2008, only 4% of girls surveyed thought that their families would agree to delay their marriages if they asked. In 2012, 72% thought so.

  • Over the course of the study, the Vistaar team found that religious leaders had more power than anyone to prevent underage marriages. Priests in India are highly respected opinion leaders and were able to influence community members to avoid early marriage for their daughters. Priests also became more vigilant in approving and performing marriage ceremonies.

Young India

India is a young country. Forty-five percent of the population is under twenty years of age. And adolescents between the ages of 15 and 19 account for almost a tenth of the population. Investing in their health and wellbeing today is crucial to ensuring the country’s future.

During her talk with Kajal’s parents, Sonam Didi stressed the benefits of letting their daughter stay in school. Poverty has long been tied to early marriage and lack of education. By encouraging girls to get married later and stay in school, IntraHealth can help the  Indian government reduce poverty and maternal mortality, all while boosting the health of babies, children, and women across the country.

In short, we can help strengthen India’s population for the long run.

After talking with Sonam Didi, Kajal’s parents decided her marriage could wait. They didn’t bring it up again until she was 19. This time, she agreed.

The Vistaar Project is funded by the United States Agency for International Development. IntraHealth partnered with the Child in Need Institute as well as state and district officials from the government of Jharkhand. Laurie Parker, director of IntraHealth’s Asia, Latin America, and Middle East programs; Manju Shukla, state director; and Madhuri Narayanan, project director, provided information for this article.

More information:


1. Read more in UNICEF’s report titled The State of the World’s Children 2012 (PDF).