Volume 9, Issue 1 (1-2021)                   J. Pediatr. Rev 2021, 9(1): 27-36 | Back to browse issues page


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Azizi M, Abbasi M, Nazem H, Raeis Abdollahi H, Alidost F. The Most Prevalent Intimate Partner Violence; Physical, Sexual, Verbal, or Emotional in Early Marriage: A Narrative Review. J. Pediatr. Rev 2021; 9 (1) :27-36
URL: http://jpr.mazums.ac.ir/article-1-338-en.html
1- PhD Student of Reproductive Health ,Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
2- Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
3- Faculty of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
4- Department of Health Services Management, Faculty of Management, North Tehran Branch, Islamic Azad University, Tehran, Iran.
5- Department of Midwifery and Reproductive, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran. , f.alidost.90@gmail.com
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1. Context

The United Nations International Children’s Emergency Fund has defined child marriage as any formal or informal marriage between a child under 18 and an adult or another child (1). Child marriage is a public health concern because it is a universal human rights violation (2). The International Center for Research on Women (2018) stated that “marrying prematurely ends childhood for 41000 girls around the world every day” (3).
However, the prevalence of child marriage has been declining worldwide, but the World Health Organization (WHO) report shows that 39000 child marriages are happening daily in the world (4). This global problem is much more common in developing countries. For example, 40% of girls get married before age 18, and 12% before age 15 (5). In 2018, according to the United Nations Population Fund, one in five women between the ages of 20 and 24 years reported that they got married as a child (6). In about 82% of those early marriages, the wife is a child; however, child marriage can occur for both sexes (7). The highest prevalence of child marriage is seen in Sub-Saharan Africa and South Asia. Prevalence rates of 20- to 24-year-old females that were married as a child is 42% in West and Central Africa, 68% in the Central African Republic and Chad (8), 52% in Bangladesh, and 47% in India (7). The highest rate of very early child marriage (before age 15) is happening in Bangladesh (9).
In areas where early marriage is common, parents consider it a way to protect their daughters against human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) and guarantee their future economic independence (10). Parents ensure that another family will be responsible for their daughters’ care. Other reasons for parents’ tendency to force girls marrying an early age are being a burden or commodity from the parents’ point of view, considering girls’ marriage as a source of income in places where the groom’s family pays a bride price (6).
Early marriage has harmful effects on a child’s mental, physical, and reproductive health (11, 12). It may limit their knowledge, skills, mobility, autonomy, and social support. Also, it will make them vulnerable and expose them to physical and sexual violence, psychological and economic abuse (13, 14), a dropout from the school (13) because of doing household chores (5), an early pregnancy (13), unintended and high-risk pregnancy, maternal and infant mortality, HIV (14, 15), deprivation of vocational opportunities (16), not using modern methods of contraception, high infertility rate (17, 18) and increasing Intimate Partner Violence (IPV) (19, 20).
Actions including physical aggression, sexual coercion, psychological abuse, controlling behaviors” (21), and stalking (22), are called IPV (23). The worldwide prevalence of IVP indicates that about 1 in 3 (35%) of women have experienced it (24).
Factors that increase IPV include lack of autonomy in women (19, 20), gender inequality, poor education (4), traditional masculine ideologies of their husbands (25), poverty (26), large age gaps between couples (27), power disparities between partners (resulting from large age gaps between couples), reduced economic opportunities (16), financial dependency of the woman on their husband (28), living in a village, consecutive pregnancies (29), and a lack of familiarity before marriage between couples (16).
Partner violence can have harmful outcomes such as sexually transmitted diseases, unintended pregnancies, induced abortions (30), depression, suicide, maternal complications and injury (31), low self-esteem, alcohol or drug abuse (32), persistent fear for their safety, symptoms of post-traumatic stress disorder (PTSD), absence from work or school, and adverse pregnancy outcomes (33, 34) for a woman.
Although many studies on child marriage confirm the increased risk of physical and sexual partner violence (16, 17, 35-37), Akmatov et al. (2008) found no relationship between marriage before the age of 20 and physical partner violence in Egypt (38). Another study in Bangladesh found a significant association between marriage under 18 and physical partner violence, but there was no significant relationship between child marriage and sexual violence (39). Given these contradictions, a review study is needed to find the exact relationship between early marriage and the type of intimate partner violence against women who married as a child.
Researchers and policymakers can use these findings to prevent early marriage and IPV, and the other adverse outcomes of early marriage.

2. Evidence Acquisition

In this narrative review, the research questions were: 1. what type of violence (including physical, sexual, emotional, or verbal) is the most prevalent one in the women who get married as a child? 2. Will the violence against these women improve over time? Is there any link between the average length of the marriage and intimate partner violence in early-age marriage? For this research stage, the narrative analysis was selected to explore the practice context because of the literature small-scale presses about child marriage and type of intimate partner violence. Narratives or stories are a valuable research method for some reasons: creating approaches to solve clinical problems, providing a voice for clients and nurses, informing social authorities, and addressing diversity via understanding (40). Also, a narrative review is utilized when limited studies are available for a meta-analysis on the topic subject (41).
Search strategy
A comprehensive search was conducted from November 30 to December 30, 2019, identifying studies on the relationship between early marriage and IPV. The search strategy for this review involved searching Web of Science, PsycINFO, PubMed (MEDLINE), Scopus, and Google scholar (Table 1). 



The second stage of the search was conducted in grey literature. In this regard, we adopted PECO (Population, Exposure, and Outcomes). The population comprises women who marry as a child. Exposure refers to marriage under 18, and the outcome is any type of violence (physical, sexual, emotional, and verbal). Because we used cross-sectional studies, we did not include C (comparator) component in the search strategy. The approach was used to generate groups of medical subject heading (MeSH) keywords. Besides, we found keywords by reviewing relevant articles and asking the experts. The keywords of “child marriage”, “adolescent marriage”, “early marriage”, “violence”, “intimate partner violence”, “men’s aggression”, “spousal violence”, “domestic violence”, “physical abuse”, “sexual violence”, and “physical violence” were searched and Boolean operators “OR”, “AND”, and “NOT” were used to include, restrict, and eliminate search terms. Then the reference list of all found articles was searched for additional studies.
Inclusion and exclusion criteria
Studies published in English or Persian during 2000-2019 were included. Women who had early marriage were included, and all types of violence (physical, sexual, emotional, and verbal) were considered. Case reports, qualitative, methodological, mixed-method, clinical trial and review studies, and studies with missing data were excluded. Also, studies that investigated the effects of early marriage but neglected boys were excluded. Through using the described search methods and criteria, 12 articles met the inclusion criteria. All authors agreed on the inclusion of these 12 studies.
Study selection
A total of 756 studies were extracted and evaluated by two authors, independently (FA and MA). If authors were not capable of determining the study eligibility from the title or abstract, the full-text of articles would be examined. Any cases of disagreement were resolved through consensus. After eliminating duplicate articles, the titles and abstracts of the remaining 619 studies were assessed, and 580 more papers were excluded. Evaluating the full texts of the remaining 39 articles resulted in the exclusion of 27 ineligible articles and confirmed 12 papers as eligible.
Quality assessment
The attachment of quantitative studies to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was evaluated as a measure of their quality (42). The STROBE guidelines were created to help the author ensure a high-quality presentation of the conducted observational study (43). Studies were classified as high-, medium-, and low-quality if they adhered to all seven items, six items, and two or more items of the STROBE, respectively.
Data extraction
Study selection and validity assessment were independently performed by two authors (FA and MA), and cases of disagreement were resolved by consulting a third researcher. The required data, including the first author’s name, publication year and country, study design, sample size, the applied scale, the participants’ age, type of violence, marriage duration, and key findings, were extracted from all studies and then analyzed.

3. Results

A total of 12 studies met the inclusion criteria and had high quality according to their adherence to the STROBE checklist. As seen in Table 2, the sample size of the selected studies was between 589 and 59841 and provided a pool of 139551 participants. The selected studies were performed in different countries including Pakistan (n=2), Ghana (n=1), Bangladesh (n=2), India (n=3), Vietnam (n=1), Ethiopia (n=1) and two articles were multicenter. One article was a cohort, and 11 articles had a cross-sectional design. Considering the first question of the study, physical and sexual violence of intimate partner are the most prevalent kind of violence among women who married as a child, and verbal and emotional violence were less common. Low level of education and wealth index were the most risk factors of IPV in reviewed articles. The second research question could not be investigated due to the heterogeneity of the studies. 



 

4. Discussion

This narrative review was conducted to establish the relationship between early marriage and the type of IPV against women who got married as a child. Many studies of child marriage have reported domestic violence as a complication of early marriage, but this is the first narrative review that examined the most prevalent type of intimate partner violence. All over the world, child marriage is considered as harmful social act that rooted in gender inequalities (52). Child marriage around the world is decreasing. The largest decline is seen in South Asia, and its drop approached a quarter between 2013 and 2018 (53). Risk factors for early marriage are wars, civil conflicts, economic context, household poverty, low social status (54), low-level education, rural residence (14, 17), economic or emotional deprivation, religion, and culture (17, 55). 
For example, religious principles were used to justify early marriage when society was more traditional (54). On the one hand, conflict, natural disaster, and losing parents result in economic or emotional deprivation, thereby increasing the risk of early marriage. Cultural norms can also lead to early marriage for girls. For example, it is believed that expectations for female subservience in marriage and sexual purity at marriage by having a younger wife are best guaranteed (17, 55, 56). Also, in traditional cultures, parents or elderly family members decide about the girl’s marriage and don’t involve her in their decision (56). As mentioned before, economic conditions and poverty can be another reason for girls’ early marriage.
On the other hand, early marriage limits children’s natural right to train, deprives them of future employment opportunities, creating a cycle of more poverty (57, 58). These girls may have seen that their fathers assault their mothers, or even themselves have undergone abuse by parents. These girls are more likely to get married early. In the long run, they are also subjected to physical and sexual violence by their spouses (50, 59, 60). 
Various studies have investigated the factors that cause a woman to get married as a child and being abused by her husband. These factors involve powerless women (47), justifying wife’s beating from the perspective of women (women married as children were more likely to justify it) (18, 45), poor house management, insufficient care of children, bringing insufficient dowry, behaving against the will of the husband, and the inability to breed a boy child (60), lower level of literacy and unemployment.
In the present study, low education and wealth were the most prevalent risk factors for violence against women by their husbands. Higher education and employment in women can shield them against intimate physical, sexual, and emotional violence (61, 62)—employment causes independence in women. Education creates life skills to deal with conflict conditions in the domestic setting (61). On the other hand, limited employment opportunities for women who married as a child dispose them to partner violence because they may not have enough skills to discuss conflict or the confidence in their relationships (44).
IPV can be physical, sexual, emotional, or verbal. In this narrative review, the most common type of violence was physical and sexual. Physical, sexual, and emotional violence each has considerable mental and physical health consequences. Therefore, women who have experienced multiple types of intimate partner violence are more likely to have serious health consequences (63).
Physical violence can cause head, face, and neck trauma; 81% and 94% of victimized women have facial injuries (64). Intimate partner homicides are relatively rare, but the highest rate of homicide is in the United States (about 1500 murders each year) (65). Concerning the effects of sexual violence from an intimate partner, the findings of the Bonimi et al. in 2007 suggest that sexual violence may put an additional burden on women’s health (66). It also raises the risk of depression in women (67).

5. Conclusion

Since the present study has found physical and sexual violence as the most common type of violence against women and other studies have explicitly pointed to the adverse consequences of such violence, efforts should be made to reduce early marriage by providing economic opportunities and promoting education, and as a result to avoid adverse effects, including partner violence. The studies in the review did not assess IPV with a single standard questionnaire. 

Ethical Considerations

Compliance with ethical guidelines

This research ethically was approved by Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.RETECH.REC.1399.519).

Funding

The authors received financial support from the Medical Ethics and Law Research Center of Shahid Beheshti University of Medical Sciences.

Authors' contributions

All authors equally contributed to preparing this article.

Conflicts of interest

The authors declared no conflict of interests.


 

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Type of Study: Narrative Review | Subject: Clinical Psychology
Received: 2020/06/15 | Accepted: 2020/09/10 | Published: 2021/01/1

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