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. 2023 Jul 19;18(7):e0288746. doi: 10.1371/journal.pone.0288746

Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: Findings from a health and demographic surveillance system

Kyu Han Lee 1, Atique Iqbal Chowdhury 2, Qazi Sadeq-ur Rahman 2, Solveig A Cunningham 3, Shahana Parveen 4, Sanwarul Bari 2, Shams El Arifeen 2, Emily S Gurley 1,*
Editor: Fadhlun Alwy Al-beity5
PMCID: PMC10355438  PMID: 37467226

Abstract

Adolescent pregnancies, a risk factor for obstetric complications and perinatal mortality, are driven by child marriage in many regions of South Asia. We used data collected between 2017–2019 from 56,155 married adolescents and women in a health and demographic surveillance system to present a population-level description of historical trends in child marriage from 1990–2019 as well as epidemiologic associations between maternal age and pregnancy outcomes in Baliakandi, a rural sub-district of Bangladesh. For pregnancies identified between 2017–2019, we used Kaplan-Meier estimates to examine timing of first pregnancies after first marriage and multinomial logistic regression to estimate associations between maternal age and perinatal death. We described the frequency of self-reported obstetric complications at labor and delivery by maternal age. In 1990, 71% of all marriages were to female residents under 18 years of age. This decreased to 57% in 2010, with the largest reduction among females aged 10–12 years (22% to 3%), and to 53% in 2019. Half of all newly married females were pregnant within a year of marriage, including adolescent brides. Although we observed a decline in child marriages since 1990, over half of all marriages in 2019 were to child brides in Baliakandi. In this same population, adolescent pregnancies were more likely to result in obstetric complications (13–15 years: 36%, 16–17 years: 32%, 18–34 years: 23%; χ2 test, p<0.001) and perinatal deaths (13–15 years: stillbirth OR 2.23, 95% CI 1.01–2.42; 16–17 years: early neonatal death OR 1.57, 95% CI: 1.01–2.42) compared to adult pregnancies. Preventing child marriage can improve the health of girls and contribute to Bangladesh’s commitment to reducing child mortality.

Introduction

Girls who become pregnant during adolescence are at increased risk for obstetric complications including pregnancy-induced hypertension, obstructed labor, obstetric fistula, and postpartum hemorrhage [1–4]. These complications are the leading cause of death among adolescent girls [5] and those who survive with conditions such as obstetric fistula experience devastating psychosocial disabilities spurred by shame, stigma, and rejection [6].

Adolescent pregnancies are also more likely to result in perinatal death [7], defined as fetal demise at or after 28 weeks of estimated gestational age (i.e. stillbirth [8]) or death within the first 7 days after live birth (i.e. early neonatal death [9]). While remarkable reductions in global under-five mortality have been observed over the past two decades, progress has been slower in preventing neonatal deaths, which made up nearly half of the estimated 5 million under-five deaths in 2019 [10]. Even less progress has been made in preventing stillbirths, which sums to an estimated 2 million fetal deaths each year [11].

Adolescent pregnancies are exacerbated by the practice of child marriage [12]. Child marriage, defined as the formal or informal union of a child under 18 years of age [13], is a human rights violation that disproportionately affects girls particularly in low- and middle-income countries [14], and contributes to severe social, developmental, and reproductive harms [15]. Globally, an estimated 16 million girls aged 15–19 become pregnant each year and 90% of these adolescent pregnancies occur within marriage [12]. Given societal and familial pressures to bear children immediately after marriage in many communities [15], marriage often means the beginning of a sexual relationship for children who are still in the process of maturing physically and psychologically [7]. Although extensive global efforts have been made to end child marriage, progress has been stagnant in recent years. In 2018, 21% of women aged 20–24 years worldwide were married before 18 years of age and, assuming the current rate of decline continues, it would take at least 50 years to end child marriage [14].

Some of the highest rates of child marriage in the world are found in Bangladesh. In 2018, 59% of women aged 20 to 24 years were married before 18 years of age and 28% of married adolescents aged 15 to 19 reported ever being pregnancy [16]. Much of our current understanding of child marriage prevalence in Bangladesh and the relationship with adverse pregnancy outcomes are derived from the Bangladesh Demographic and Health Survey, which utilizes a cross-sectional two-stage cluster sampling approach [16–18]. Although nationally representative, demographic indicators such as age at marriage may be underreported when collected retrospectively through cross-sectionally surveys, potentially to reduce dowry costs, which increase with the bride’s age, and to meet the “preferred age” of brides, which is typically under 20 years [19, 20]. This type of misreported age may lead to overestimates of child marriage prevalence as well as introduce bias to epidemiologic associations between maternal age and adverse pregnancy outcomes.

In 2017, the Child Health and Mortality Prevention Surveillance (CHAMPS) network established a health and demographic surveillance system in Baliakandi, a rural sub-district of Bangladesh with approximately 216,000 residents [21]. We used data from nearly every resident in Baliakandi to observe how common child marriage was in this sub-district. Further, we conducted an in-depth investigation of the relationship between female age at marriage and timing of first pregnancies as well as the relationships between maternal age at delivery and key health outcomes such as obstetric complications and perinatal death.

Methods

Ethics statement

The study was approved by the icddr,b human subjects review committee (PR-16082). Written informed consent was obtained from adult participants and from married participants under 18 years of age.

Inclusivity in global research

Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in S1 Checklist.

Health and demographic surveillance system

We used data from an ongoing HDSS established by the Child Health and Mortality Prevention Surveillance (CHAMPS) network in Baliakandi, Bangladesh. All residents of Baliakandi sub-district were eligible for enrollment. Baseline surveys were conducted between March and August 2017 during which household and sociodemographic data were collected from every resident. Additional details on the Baliakandi HDSS are described by Cunningham et al. [21].

Historic data

Married females under 50 years of age completed a birth history questionnaire either during baseline surveys or after in-migration. The questionnaire included questions regarding the date of marriage and prior pregnancies (S1 Table).

Prospectively collected data

We conducted eleven rounds of household visits between September 2017 and February 2020. Frequent visits allowed for prompt identification of key demographic events such as marriages, pregnancies, pregnancy outcomes, deaths, and out-migrations. Pregnant residents provided the date of the last menstrual period, which was used as a proxy of pregnancy date and to estimate gestational age. If a resident was not present during a visit, demographic events missed during that round were later captured at subsequent household visits. We observed consent rates at or greater than 99% among all households in Baliakandi each year (approximately 52,000 households). These high consent rates indicate the HDSS captures demographic data and events from nearly every resident of Baliakandi. Given regular follow up, missing demographic data were uncommon for events included in this study.

Age distribution of brides

For 1990 and 2016, we calculated the age distribution of brides using data from the birth history questionnaire (categorical age in years: ≤12, 13–15, 16–17, and ≥18). For 2017 to 2019, the annual proportion of marriages was estimated using marriages prospectively identified during HDSS household visits between September 2017 and December 2019. Data from the birth history questionnaire were used for in-migrants (S1 Fig).

Time to pregnancy

We calculated the time between first marriage and pregnancy among female residents under 35 years of age and whose marriages were prospectively identified through the HDSS. Women 35 years and older were excluded as marriages were rare for this age group. As newly married brides often out-migrated with their husbands soon after marriage, we restricted the analysis to individuals who remained a resident of Baliakandi for at least 180 days after marriage (S1 Fig). We used Kaplan-Meier estimates to examine the time it took for a female resident to become pregnant after their first marriage and whether this relationship differed by age at marriage (categorical age in years: 12–15, 16–17, and 18–34).

Perinatal death

We used multinomial logistic regression to estimate the association between maternal age at delivery (age category in years: 13–15, 16–17, and 18–34) and stillbirths and early neonatal deaths among all singleton births that occurred between September 2017 and August 2019 (S2 Fig). Mothers aged 35 and older were excluded as births were rare for this group and advanced maternal age is a known risk factor of perinatal deaths [22]. We defined stillbirth as fetal demise at or after 28 weeks of estimated gestational age and early neonatal death as death within the first 7 days after live birth. To consider the influence of nulliparity and household wealth, we repeated the model after restricting the analysis to nulliparous pregnancies and adjusting for household wealth (categorical quintile based on the Demographic and Health Survey wealth index score [23]).

Obstetric complications during labor and delivery

In December 2018, we supplemented the Baliakandi HDSS with additional surveys that identified adverse events during the pregnancy and up to 48 hours after delivery (S2 Table). All pregnant women identified during HDSS household visits were contacted within 3 days of giving birth and a survey on self-reported obstetric complications during labor and delivery was conducted by staff trained to describe these complications in lay language. We calculated the frequency of complications—prolonged/obstructed labor/failure to progress, birth trauma or difficult delivery, high blood pressure, heavy bleeding during delivery, severe headaches with blurred vision, fetal malpresentation, high fever with abdominal pain, high fever with smelly discharge, unplanned hospital admission for delivery (planned to deliver outside a hospital), and preterm birth—by age group for all births between January and August 2019 (S2 Fig). Preterm birth was defined as a birth before an estimated gestational age of 37 weeks. Chi-squared test and Fisher’s exact test were used to test for statistical differences in the frequency of complications by maternal age.

Results

Age at marriages among female residents

A total 56,155 female residents of Baliakandi were married between 1990 and 2019; all provided age at marriage. Among female residents married in 1990, 71% were married before 18 years of age (915/1,284) (Fig 1). This proportion dropped to 57% among female residents married in 2010 (1,185/2,063). Between 1990 and 2010, the proportion of marriages to females under 13 years decreased from 22% (288/1,284) to 3% (72/2,063), females aged 13–15 years decreased from 32% (411/1,284) to 26% (538/2,063) and females aged 16–17 years increased from 17% (216/1,284) to 28% (575/2,063). The mean age at marriage increased from 15.3 years (standard deviation (SD) 3.2) in 1990 to 17.3 years (SD 3.4) in 2010.

Fig 1. Age at marriage among 56,155 female residents of Baliakandi sub-district, Bangladesh, 1990 to 2019.

Fig 1

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Bars represent the annual proportion of marriages to specific age groups. Points and error bars represent the mean age at marriage and standard deviation.

Between 2010 and 2019, the overall proportion of marriages to female residents under 18 years dropped from 57% (1,185/2,063) to 53% (1,698/3,210). The proportion to females under 13 years decreased from 3% (72/2,063) to 1% (28/3,210), females aged 13–15 years decreased from 26% (538/2,063) to 21% (671/3,210), females aged 16–17 years increased from 28% (575/2,063) to 31% (999/3,210). The mean age at marriage increased from 17.3 years (SD 3.4) in 2010 to 18.2 years (SD 4.2) in 2019.

Characteristics of first marriages

A total of 3,764 female residents under 35 years of age reported first marriages in Baliakandi between September 2017 and August 2019 (S3 Table); household wealth was available for all but one and age of the groom was available for all but one. Younger brides were more likely to be in the lowest household wealth quintile: 25% among ages 10–15 years (271/1,077), 20% among ages 16–17 years (227/1,150), and 15% among females ages 18–34 years (236/1,537) (χ2 test, p<0.001). Among all first marriages, males were a median of 8 years (interquartile range (IQR) 5–10) older than their female spouses. The median age difference was 9.5 years (IQR 8–12) for females married before 13 years of age, 9 years (IQR 6 to 12) for those married at ages 13–15 years, 8 years (IQR 6–10) for those married at ages 16–17 years, and 6 years (IQR 3–9) among those married at ages 18–34 years.

Time between first marriage and pregnancy

Approximately half of all newly married females who remained in Baliakandi for 180 days (N = 1,320) had a pregnancy within 365 days of marriage; Kaplan-Meier estimates: 52% (95% confidence interval (CI) 47–57%) among those married at 12–15 years, 53% (95% CI 48–59%) among those married at ages 16–17 years and 50% (95% CI 45–54%) among those married at ages 18–34 years (Fig 2). We found no statistically significant difference by age at first marriage (log-rank test, p = 0.535).

Fig 2. Cumulative incidence of pregnancies after first marriage and 95% confidence intervals, by age at marriage.

Fig 2

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Among 1,320 females under 35 years of age who resided in Baliakandi for at least 180 days after marriage, Baliakandi sub-district, Bangladesh. Grey dashed line indicates 365 days after marriage.

Maternal age at birth and perinatal mortality

We identified a total 8,806 singleton births among female residents under 35 years of age between September 2017 and August 2019. A total of 198 births were stillborn and 188 live births resulted in early neonatal death (Table 1). We observed a stillbirth rate of 22 stillbirths per 1,000 singleton births and early neonatal mortality rate of 22 deaths per 1,000 singleton live births. Sixteen percent of perinatal deaths were among mothers under 18 years of age (61/386) and 52% were among first-time mothers (202/386). We did not observe any singleton births among females under 13 years of age during this period.

Table 1. Characteristics of 8,806 singleton births among females under 35 years of age, Baliakandi sub-district, Bangladesh, September 2017 to August 2019.

Characteristic All births N = 8,806 n (%) Live births surviving 7 days N = 8,420 n (%) Stillbirths N = 198 n (%) Rate Early neonatal deaths N = 188 n (%) Rate
Maternal age at delivery (years)*
 13 to 15 238 (3%) 221 (3%) 11 (6%) 46 per 1,000 births 6 (3%) 26 per 1,000 live births
 16 to 17 769 (9%) 725 (9%) 20 (10%) 26 per 1,000 births 24 (13%) 32 per 1,000 live births
 18 to 29 6,601 (75%) 6338 (75%) 135 (68%) 20 per 1,000 births 128 (68%) 20 per 1,000 live births
 30 to 34 1,198 (14%) 1136 (13%) 32 (16%) 27 per 1,000 births 30 (16%) 26 per 1,000 live births
Parity
 Nulliparous 3,827 (43%) 3,625 (43%) 103 (52%) 99 (53%)
 1 3,252 (37%) 3,146 (37%) 57 (29%) 49 (26%)
 2 1,315 (15%) 1,261 (15%) 26 (13%) 28 (15%)
 3+ 412 (5%) 388 (5%) 12 (6%) 12 (6%)
Household wealth quintile
 Highest 1,815 (21%) 1,751 (21%) 28 (14%) 36 (20%)
 High 1,863 (21%) 1,786 (21%) 45 (23%) 32 (22%)
 Middle 1,809 (21%) 1,727 (21%) 42 (21%) 40 (21%)
 Low 1,689 (19%) 1,610 (19%) 37 (19%) 42 (17%)
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*No singleton births were reported among mothers under 12 years of age. Births among women over 34 years were excluded.

Compared to mothers ages 18–34 years, mothers ages 13–15 years had higher odds of stillbirth (OR 2.23, 95% CI 1.19–4.16) and females ages 16–17 years had higher odds of early neonatal death (OR 1.57, 95% CI 1.01–2.42). Among nulliparous mothers (N = 3,827), the association between ages 13–15 years and stillbirth was not statistically significant (adjusted odds ratio (aOR) 1.77, 95% CI 0.92–3.41) and the association between ages 16–17 years and early neonatal death was not statistically significant (aOR 1.28, 95% CI 0.41–2.04), after adjusting for household wealth (S4 Table). Nulliparous mothers in the two highest household wealth quintiles had lower odds of early neonatal deaths (highest: aOR 0.52, 95% CI 0.27–0.97; high: aOR 0.46, 95% CI 0.24–0.88).

Obstetric complications during labor and delivery

Information on self-reported obstetric complications during labor and delivery were collected for 3,286 singleton births (99% of total 3,311 singleton births) between January and August 2019 among female residents who were under 35 years of age at time of birth. Complications were common in Baliakandi regardless of maternal age, with 24% of all births (803/3,286) reporting at least one obstetric complication, including prolonged/obstructed labor or failure to progress, birth trauma or difficult delivery, and heavy bleeding (Table 2). Nineteen percent (610/3,286) involved unplanned hospital admissions. Based on HDSS data, 19% of live births (604/3,223) were considered preterm according to estimated gestational age and 38% (180/604) of preterm births involved pre-labor cesarean sections. Fifty-two percent (1662/3221) of singleton births involved a cesarean section and vacuum extraction was not reported in any vaginal deliveries. Maternal deaths were infrequent. We identified a total seven deaths among all female residents who had any type of pregnancy outcome (miscarriage or birth) between January and August 2019 (n = 3912). All deaths were among women 19 to 35 years of age who had a singleton live birth. Six deaths were likely related to pregnancy, occurring within a month of birth. One death occurred approximately 9 months after birth.

Table 2. Self-reported obstetric complications during labor and delivery among 3,286 singleton births by female residents under 35 years of age, by maternal age at birth, Baliakandi sub-district, Bangladesh, January to August 2019.

Events All N = 3,286 n (%) 13 to 15* years N = 101 n (%) 16 to 17 years N = 291 n (%) 18 to 34 years N = 2,894 n (%) P-value†
Any complications‡ 803 (24%) 36 (36%) 93 (32%) 674 (23%) <0.001
 Prolonged/obstructed labor/failure to progress 267 (8%) 14 (14%) 33 (11%) 220 (8%) 0.008
 Birth trauma or difficult delivery 276 (8%) 17 (17%) 42 (14%) 217 (8%) <0.001
 High blood pressure 145 (5%) 4 (4%) 15 (5%) 126 (5%) 0.728
 Heavy bleeding during delivery 120 (4%) 9 (9%) 10 (3%) 101 (4%) 0.029
 Severe headaches with blurred visions 114 (3%) 5 (5%) 11 (4%) 98 (3% 0.550
 Fetal malpresentation 39 (1%) 2 (2%) 2 (1%) 35 (1%) 0.456
 High fever with abdominal pain 29 (1%) 1 (1%) 1 (0%) 27 (1%) 0.548
 High fever with smelly discharge 19 (1%) 1 (1%) 0 (0%) 18 (1%) 0.297
Unplanned hospital admission for delivery 610 (19%) 28 (28%) 79 (27%) 503 (17%) <0.001
Preterm birth• 604/3,223 (19%) 14/98 (14%) 51/287 (18%) 539/2838 (19%) 0.456
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*No singleton birth among children under 13 years of age with data on obstetric complications.

†Chi-squared test or Fisher’s exact test; comparing all three age groups

‡Includes any of the complications listed below

•Only among live births

Compared to females ages 18–34 years, adolescents were more likely to report at least one complication (13–15 years: 36%, 16–17 years: 32%, 18–34 years: 23%; χ2 test, p<0.001) and have unplanned admissions (13–15 years: 28%, 16–17 years: 27%, 18–34 years: 17%; χ2 test, p<0.001). Among specific complications, prolonged/obstructed labor or failure to progress (13–15 years: 14%, 16–17 years: 11%, 18–34 years: 8%), birth trauma or difficult delivery (13–15 years: 17%, 16–17 years: 14%, 18–34 years: 8%), and heavy bleeding were more common among females under 18 years of age (13–15 years: 9%, 16–17 years: 3%, 18–34 years: 4%), compared to ages 18–34 years (χ2 test or Fisher’s exact test, all p<0.050).

Discussion

In this study, we examined how common child marriage was in Baliakandi, rural region of Bangladesh, and investigated the relationship between child marriage, adolescent pregnancies, and adverse pregnancy outcomes such as perinatal death and obstetric complications. Using data from a HDSS covering approximately 216,000 residents in a rural sub-district of Bangladesh, we found that more than half of all marriages in Baliakandi were to child brides in 2019, a number that has remained unchanged from the prior decade. Despite differences in study design, our findings were consistent with national trends described in the 2017–2018 Bangladesh Demographic Health Survey [16] and highlights the need to accelerate ongoing commitments to end child marriage and promote additional widespread interventions.

In Baliakandi, approximately half of all newly married female residents, including adolescents, became pregnant within a year of marriage. Although childbearing should be delayed among adolescent girls to protect the health of the mother and newborn [7, 15, 24], our study showed no evidence of postponed pregnancies. These findings are consistent with earlier studies which showed the frequency of early fertilization (birth within the first year of marriage) did not differ significantly by age at marriage in Bangladesh, India, Nepal, and Pakistan [18, 25]. Adolescent pregnancies are likely driven by the social value placed on childbearing for wives in Bangladesh and the prospect of improving one’s status within the husband’s family through childbirth [26, 27]. Many newly married adolescents lack power and social status to negotiate delays in pregnancy, coupled with a lack of knowledge or misconceptions of contraceptives. One example of misconceptions is that contraceptives can lead to infertility [27]. In contrast, wives who delay childbearing often experience stigma of perceived infertility, abuse by in-laws, and rumors of infidelity [26]. These dynamics may drive low contraceptive use among adolescent brides [16].

Adolescents who become pregnant are more likely to experience obstetric complications such as prolonged and obstructed labor, which can cause long-term physical consequences [6, 28, 29] as well as devastating psychosocial disabilities even after treatment, as girls deal with shame, stigma, and rejection by their families and communities [6]. In Baliakandi, obstetric complications were twice as likely for pregnant adolescents compared to adults. A quarter of deliveries among adolescent girls involved an unplanned hospital admission. A third of reported complications included prolonged or obstructed labor, birth trauma or difficult deliveries, and heavy bleeding, which are related to physical immaturity [7] and can lead to severe, long-term urologic, gynecologic and neurologic injuries as well as secondary infertility [6, 28, 29]. In addition to complications, adolescent girls who became pregnant were approximately twice as likely to have a stillbirth or for their babies to die in the first few days of life than adult women, consistent with associations reported in the 2017–2018 Bangladesh Demographic and Health Survey [30, 31]. The high risk of perinatal death could partially be explained by adolescents being more likely to be nulliparous, a risk factor for obstetric complications and perinatal death in Bangladesh [31, 32]. Associations between adolescence and perinatal outcomes are less consistent in earlier studies in South Asia but this may be due to differences in study population and how maternal age was categorized [33, 34].

Our findings highlight the role of poverty in both child marriage and perinatal death. In Bangladesh, girls are often viewed as financial burdens for the family and dowries paid to the groom’s family are typically smaller for younger brides [35]. In addition, perinatal deaths are more likely to occur in less wealthy households, perhaps due to poor nutrition, lack of resources, and less access of health care [36–39]. The preterm birth rate in Baliakandi (19% of all singleton live births) was consistent with national estimates, which is one of the highest in the world [40]. Preterm births may be common due to the regular practice of elective cesarean sections in Baliakandi which may occur without medical indication due to a fear of vaginal deliveries and a general belief that cesarean deliveries are safer for the mother and baby [41, 42].

A notable strength of this study was the use of prospectively collected HDSS data to investigate child marriage. Nearly all estimates of child marriage in Bangladesh and epidemiologic investigations of adolescent pregnancies and adverse pregnancy outcomes are based on the Bangladesh Demographic and Health Survey [16, 17, 30]. The Baliakandi HDSS allows us to piece together a detailed picture of maternal and child health over time—at marriage, during pregnancies and delivery, and as a mother. Although Baliakandi represents a small portion of rural Bangladesh, our findings may reflect circumstances in other rural regions of the country given regional similarities in child marriage prevalence, adolescent childbearing, and age at first birth [14]. Our study did not include female residents who out-migrated nor those who died. It is unclear how these deaths might impact our estimates. Further, obstetric complications were self-reported. To minimize potential reporting bias, obstetric complications were described in lay language and questions were asked by data collectors trained to explain these complications.

The problem of child marriage is daunting; it is a practice deeply rooted in social and gender norms and sustained by gender inequality, poverty and insecurity [15, 35, 43, 44]. These relationships caution a likely increase in rates of child marriage during the COVID-19 pandemic due to school closures and increased social insecurities [45]. Given these challenges, we recognize the notable increase in mean age among child brides in Baliakandi and the promising global and national efforts to end child marriage [14, 46]. Findings from a cluster randomized controlled trial in Bangladesh show interventions such as education support for adolescents, gender rights awareness, and livelihood training can lead to a 25% to 30% reduction in child marriage [46]. Only by accelerating ongoing commitments and promoting additional widespread interventions we can truly eliminate child marriage. By addressing child marriage, we improve the health of two groups of children: adolescent girls and infants. We can prevent a chain of harmful social, developmental, and reproductive harms that have lasting impacts on adolescent girls while reducing the global burden of stillbirths and neonatal deaths.

Conclusion

Our study shows over half of all marriages in Baliakandi, Bangladesh, were to child brides in 2019. In this community, early marriage contributes to adolescent pregnancies, a risk factor for perinatal death and obstetric complications. These findings highlight the need to accelerate national and global commitments to end child marriage, protect the health of adolescent girls and, reduce the burden of perinatal mortality in Bangladesh.

Supporting information

S1 Fig. Baliakandi health and demographic surveillance system data and analyses used to estimate proportion of marriage to female children and time between first marriage and pregnancy in Baliakandi, Bangladesh.

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S2 Fig. Baliakandi health and demographic surveillance system data and analyses used to examine relation between maternal age at birth, complications during delivery, and perinatal mortality in Baliakandi, Bangladesh.

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S1 Table. Excerpt from birth history questionnaire.

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S2 Table. Excerpt from pregnancy surveillance questionnaire.

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S3 Table. Characteristics of female residents under 35 years of age who had first marriages, Baliakandi sub-district, Bangladesh, September 2017 to August 2019.

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S4 Table. Crude and adjusted odds ratios of stillbirth and early neonatal death, compared to live births surviving more than 7 days.

Adjusted model restricted to nulliparous mothers and adjusted for maternal age and household wealth. Total 8,806 singleton births among female residents under 35 years at birth, Baliakandi sub-district, Bangladesh, September 2017 to August 2019.

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S1 Checklist. Inclusivity in global research.

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Data Availability

All data files are available from the Harvard Dataverse (https://doi.org/10.7910/DVN/93PYJC).

Funding Statement

This work was supported by the Bill & Melinda Gates Foundation, Seattle, WA [award number OPP1126780). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

References

  • 1.Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, Zhang J, et al. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG Int J Obstet Gynaecol. 2014;121: 40–48. doi: 10.1111/1471-0528.12630 [DOI] [PubMed] [Google Scholar]
  • 2.Conde-Agudelo A, Belizán JM, Lammers C. Maternal-perinatal morbidity and mortality associated with adolescent pregnancy in Latin America: Cross-sectional study. Am J Obstet Gynecol. 2005;192: 342–349. doi: 10.1016/j.ajog.2004.10.593 [DOI] [PubMed] [Google Scholar]
  • 3.Melah GS, Massa AA, Yahaya UR, Bukar M, Kizaya DD, El-Nafaty AU. Risk factors for obstetric fistulae in north-eastern Nigeria. J Obstet Gynaecol J Inst Obstet Gynaecol. 2007;27: 819–823. doi: 10.1080/01443610701709825 [DOI] [PubMed] [Google Scholar]
  • 4.UNFPA. State of World Population 2013: Motherhood in Childhood: Facing the challenge of adolescent pregnancy. New York: UNFPA; 2013. https://www.unfpa.org/publications/state-world-population-2013
  • 5.UNFPA, WHO, UNICEF, World Bank Group, United Nations Population Division. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. https://www.unfpa.org/featured-publication/trends-maternal-mortality-2000-2017
  • 6.Bomboka JB, N-Mboowa MG, Nakilembe J. Post—effects of obstetric fistula in Uganda; a case study of fistula survivors in KITOVU mission hospital (MASAKA), Uganda. BMC Public Health. 2019;19: 696. doi: 10.1186/s12889-019-7023-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Dixon-Mueller R. How Young Is “Too Young”? Comparative Perspectives on Adolescent Sexual, Marital, and Reproductive Transitions. Stud Fam Plann. 2008;39: 247–262. doi: 10.1111/j.1728-4465.2008.00173.x [DOI] [PubMed] [Google Scholar]
  • 8.World Health Organization. Stillbirth. In: Stillbirth [Internet]. [cited 5 Dec 2022]. https://www.who.int/health-topics/stillbirth
  • 9.World Health Organization. Neonatal mortality rate. In: Neonatal mortality rate [Internet]. [cited 5 Dec 2022]. https://www.who.int/data/gho/indicator-metadata-registry/imr-details/67
  • 10.UN IGME. Levels and Trends in Child Mortality: Report 2020, Estimates developed by the United Nations Inter-agency Group for Child Mortality Estimation. New York: UNICEF; 2020. https://data.unicef.org/resources/levels-and-trends-in-child-mortality/
  • 11.UN IGME. A Neglected Tragedy: The global burden of stillbirths. New York: UNICEF; 2020. https://data.unicef.org/resources/a-neglected-tragedy-stillbirth-estimates-report/
  • 12.UNFPA. Girlhood, Not Motherhood: Preventing Adolescent Pregnancy. New York: UNFPA; 2015. https://www.unfpa.org/publications/girlhood-not-motherhood
  • 13.UNICEF. Child marriage. [cited 6 Apr 2021]. https://www.unicef.org/protection/child-marriage
  • 14.UNFPA, UNICEF. Global Programme to Accelerate Action to End Child Marriage Annual Report 2018. UNFPA and UNICEF; 2019 Aug. https://www.unfpa.org/sites/default/files/resource-pdf/UNFPA-1.PDF
  • 15.UNICEF Innocenti Research Centre. Early Marriage: Child Spouses. Florence, Italy: UNICEF; 2001 Mar. Report No.: 7. https://www.unicef-irc.org/publications/291-early-marriage-child-spouses.html
  • 16.NIPORT, ICF. Bangladesh Demographic and Health Survey 2017–18: Key Indicators. Dhaka, Bangladesh and Rockville, Maryland, USA: NIPORT and ICF;
  • 17.Kamal SMM. Decline in Child Marriage and Changes in Its Effect on Reproductive Outcomes in Bangladesh. J Health Popul Nutr. 2012;30: 317–330. doi: 10.3329/jhpn.v30i3.12296 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Godha D, Hotchkiss DR, Gage AJ. Association Between Child Marriage and Reproductive Health Outcomes and Service Utilization: A Multi-Country Study From South Asia. J Adolesc Health. 2013;52: 552–558. doi: 10.1016/j.jadohealth.2013.01.021 [DOI] [PubMed] [Google Scholar]
  • 19.Amin S, Huq L. Marriage considerations in sending girls to school in Bangladesh: Some qualitative evidence. New York: Population Council; 2008.
  • 20.Streatfield PK, Kamal N, Ahsan KZ, Nahar Q. Early marriage in Bangladesh: Not as early as it appears. Asian Popul Stud. 2015;11: 94–110. doi: 10.1080/17441730.2015.1012785 [DOI] [Google Scholar]
  • 21.Cunningham SA, Shaikh NI, Nhacolo A, Raghunathan PL, Kotloff K, Naser AM, et al. Health and Demographic Surveillance Systems Within the Child Health and Mortality Prevention Surveillance Network. Clin Infect Dis. 2019;69: S274–S279. doi: 10.1093/cid/ciz609 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Raymond EG, Cnattingius S, Kiely JL. Effects of maternal age, parity, and smoking on the risk of stillbirth. BJOG Int J Obstet Gynaecol. 1994;101: 301–306. doi: 10.1111/j.1471-0528.1994.tb13614.x [DOI] [PubMed] [Google Scholar]
  • 23.Rutstein S. The DHS Wealth Index: Approaches for Rural and Urban Areas. Calverton, Maryland, USA: Macro International; 2008 Oct.
  • 24.Finlay JE, Özaltin E, Canning D. The association of maternal age with infant mortality, child anthropometric failure, diarrhoea and anaemia for first births: evidence from 55 low- and middle-income countries. BMJ Open. 2011;1: e000226. doi: 10.1136/bmjopen-2011-000226 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Raj A, Saggurti N, Balaiah D, Silverman JG. Prevalence of child marriage and its effect on fertility and fertility-control outcomes of young women in India: a cross-sectional, observational study. The Lancet. 2009;373: 1883–1889. doi: 10.1016/S0140-6736(09)60246-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Samandari G, Sarker BK, Grant C, Huq NL, Talukder A, Mahfuz SN, et al. Understanding individual, family and community perspectives on delaying early birth among adolescent girls: findings from a formative evaluation in rural Bangladesh. BMC Womens Health. 2020;20: 169. doi: 10.1186/s12905-020-01044-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Sethuraman K, Gujjarappa L, Kapadia-Kundu N, Naved R, Barua A, Khoche P, et al. Delaying the First Pregnancy: A Survey in Maharashtra, Rajasthan and Bangladesh. Econ Polit Wkly. 2007;42: 79–89. [Google Scholar]
  • 28.Wall LL, Arrowsmith SD, Briggs ND, Browning A, Lassey A. The Obstetric Vesicovaginal Fistula in the Developing World. Obstet Gynecol Surv. 2005;60. doi: 10.1097/00006254-200507001-00002 [DOI] [PubMed] [Google Scholar]
  • 29.Miller S, Lester F, Webster M, Cowan B. Obstetric Fistula: A Preventable Tragedy. J Midwifery Womens Health. 2005;50: 286–294. doi: 10.1016/j.jmwh.2005.03.009 [DOI] [PubMed] [Google Scholar]
  • 30.Kamal SMM, Hassan CH. Child Marriage and Its Association With Adverse Reproductive Outcomes for Women in Bangladesh. Asia Pac J Public Health. 2015;27: NP1492–NP1506. doi: 10.1177/1010539513503868 [DOI] [PubMed] [Google Scholar]
  • 31.Kamal SMM. What Is the Association Between Maternal Age and Neonatal Mortality? An Analysis of the 2007 Bangladesh Demographic and Health Survey. Asia Pac J Public Health. 2015;27: NP1106–NP1117. doi: 10.1177/1010539511428949 [DOI] [PubMed] [Google Scholar]
  • 32.Sikder SS, Labrique AB, Shamim AA, Ali H, Mehra S, Wu L, et al. Risk factors for reported obstetric complications and near misses in rural northwest Bangladesh: analysis from a prospective cohort study. BMC Pregnancy Childbirth. 2014;14: 347. doi: 10.1186/1471-2393-14-347 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Paul P. Maternal Age at Marriage and Adverse Pregnancy Outcomes: Findings from the India Human Development Survey, 2011–2012. J Pediatr Adolesc Gynecol. 2018;31: 620–624. doi: 10.1016/j.jpag.2018.08.004 [DOI] [PubMed] [Google Scholar]
  • 34.Althabe F, Moore JL, Gibbons L, Berrueta M, Goudar SS, Chomba E, et al. Adverse maternal and perinatal outcomes in adolescent pregnancies: The Global Network’s Maternal Newborn Health Registry study. Reprod Health. 2015;12: S8. doi: 10.1186/1742-4755-12-S2-S8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Chowdhury FD. The socio-cultural context of child marriage in a Bangladeshi village. Int J Soc Welf. 2004;13: 244–253. doi: 10.1111/j.1369-6866.2004.00318.x [DOI] [Google Scholar]
  • 36.Hasan MM, Uddin J, Pulok MH, Zaman N, Hajizadeh M. Socioeconomic Inequalities in Child Malnutrition in Bangladesh: Do They Differ by Region? Int J Environ Res Public Health. 2020;17. doi: 10.3390/ijerph17031079 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Abdullah K, Malek MA, Faruque ASG, Salam MA, Ahmed T. Health and nutritional status of children of adolescent mothers: experience from a diarrhoeal disease hospital in Bangladesh. Acta Paediatr. 2007;96: 396–400. doi: 10.1111/j.1651-2227.2007.00117.x [DOI] [PubMed] [Google Scholar]
  • 38.Killewo J, Anwar I, Bashir I, Yunus M, Chakraborty J. Perceived Delay in Healthcare-seeking for Episodes of Serious Illness and Its Implications for Safe Motherhood Interventions in Rural Bangladesh. J Health Popul Nutr. 2006;24: 403–412. [PMC free article] [PubMed] [Google Scholar]
  • 39.Ahmed NU, Alam MM, Sultana F, Sayeed SN, Pressman AM, Powers MB. Reaching the Unreachable: Barriers of the Poorest to Accessing NGO Healthcare Services in Bangladesh. J Health Popul Nutr. 2006;24: 456–466. [PMC free article] [PubMed] [Google Scholar]
  • 40.Chawanpaiboon S, Vogel JP, Moller A-B, Lumbiganon P, Petzold M, Hogan D, et al. Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis. Lancet Glob Health. 2019;7: e37–e46. doi: 10.1016/S2214-109X(18)30451-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Neuman M, Alcock G, Azad K, Kuddus A, Osrin D, More NS, et al. Prevalence and determinants of caesarean section in private and public health facilities in underserved South Asian communities: cross-sectional analysis of data from Bangladesh, India and Nepal. BMJ Open. 2014;4: e005982. doi: 10.1136/bmjopen-2014-005982 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Kamal SMM. Preference for Institutional Delivery and Caesarean Sections in Bangladesh. J Health Popul Nutr. 2013;31: 96–109. doi: 10.3329/jhpn.v31i1.14754 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Yount KM, Crandall A, Cheong YF, Osypuk TL, Bates LM, Naved RT, et al. Child Marriage and Intimate Partner Violence in Rural Bangladesh: A Longitudinal Multilevel Analysis. Demography. 2016;53: 1821–1852. doi: 10.1007/s13524-016-0520-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Schuler SR, Bates LM, Islam F, Islam MdK. The timing of marriage and childbearing among rural families in Bangladesh: Choosing between competing risks. Soc Sci Med. 2006;62: 2826–2837. doi: 10.1016/j.socscimed.2005.11.004 [DOI] [PubMed] [Google Scholar]
  • 45.Hossain MdJ, Soma MA, Bari MdS, Emran TB, Islam MdR. COVID-19 and child marriage in Bangladesh: emergency call to action. BMJ Paediatr Open. 2021;5: e001328. doi: 10.1136/bmjpo-2021-001328 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Amin S, Saha JS, Ahmed JA. Skills-Building Programs to Reduce Child Marriage in Bangladesh: A Randomized Controlled Trial. J Adolesc Health. 2018;63: 293–300. doi: 10.1016/j.jadohealth.2018.05.013 [DOI] [PubMed] [Google Scholar]

Decision Letter 0

Forough Mortazavi

23 Nov 2022

PONE-D-22-26467Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: findings from a health and demographic surveillance systemPLOS ONE

Dear Dr. Gurley,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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PLOS ONE

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Additional Editor Comments:

Dear authors,

Thank you for working on this topic. Please clarify how women especially uneducated ones could report difficult to diagnose birth complications such as labor/failure to progress, birth trauma or difficult delivery, high blood pressure, heavy bleeding during delivery, fetal malpresentation, high fever with abdominal pain, and high fever with smelly discharge,? How reliable are the collected data?

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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Reviewer #1: Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: findings from a health and demographic surveillance system

Thank you for providing this opportunity for me to review this manuscript. Please see my comments as follows:

Abstract:

1. Please report how many women were assessed?

2. And please report timeline of the study.

Methods

1. Please mention the design of the study.

2. Please provide reference for stillbirth, preterm birth and early neonatal death.

3. Please write the inclusion/exclusion criteria.

4. Overall, please re-arrange the manuscript according to STORBE guideline.

5. As some maternal and neonatal deaths are contributed to place of birth (home or hospital), birth attendant (skilled midwife or other health provider), or the number of prenatal care, there are need more information such as did adolescents delivered in hospital, and who was their birth attendants? skilled midwife or nurse? These information should be controlled when you report maternal or neonatal death.

Results

1. What was the ratio of vaginal delivery to cesarean section and also what was the rate of vaginal delivery using instrument such as vacuum?

2. Please put some information such as educational level of participants and their husbands, household member in demographic table.

3. Please report maternal death and its cause.

4. Table 2: Authors mention severe headache with blurred vision. Did they mean preeclampsia? If so, please use its correct term.

5. Again, for high fever and smelly discharge, did they mean postpartum infection?

6. What authors mean about un-planned hospital delivery? Is that mean women delivered at home and only some of them go to hospital?

7. Please provide a table for multiple logistic regression, until readers to be able to see what confounders were controlled.

Discussion

1. Please mention the objective/s of the study at the beginning of the discussion.

2. Discussion needs more comparison between the findings of the study and results of other studies.

3. What was the limitations of the study?

4. What was the conclusion according to the objectives of the study?

**********

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Reviewer #1: Yes: Parvin Abedi

**********

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PLoS One. 2023 Jul 19;18(7):e0288746. doi: 10.1371/journal.pone.0288746.r002

Author response to Decision Letter 0

20 Dec 2022

Response to journal requirements:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

The manuscript has been revised to match the PLOS ONE style templates.

2. Please include a complete copy of PLOS’ questionnaire on inclusivity in global research in your revised manuscript. Our policy for research in this area aims to improve transparency in the reporting of research performed outside of researchers’ own country or community. The policy applies to researchers who have travelled to a different country to conduct research, research with Indigenous populations or their lands, and research on cultural artefacts. The questionnaire can also be requested at the journal’s discretion for any other submissions, even if these conditions are not met. Please find more information on the policy and a link to download a blank copy of the questionnaire here: https://journals.plos.org/plosone/s/best-practices-in-research-reporting. Please upload a completed version of your questionnaire as Supporting Information when you resubmit your manuscript.

The questionnaire has been completed and uploaded as Supporting Information S1 Checklist.

3. You indicated that you had ethical approval for your study. Please clarify whether minors (participants under the age of 18 years) were included in this study. If yes, in your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

Married minors are included in this study. Written informed consent was directly obtained from these participants. This clarification has been added to the ethics statement, now in the Methods section (lines 83-86)

4. Please include your ethics statement in the Methods section of your manuscript. In the Methods section of your revised manuscript, please include the full name of the institutional review board or ethics committee that approved the protocol, the approval or permit number that was issued, and the date that approval was granted.

The ethics statement has been added to the Methods section (lines 83-86).

Response to Editor Comments

Thank you for working on this topic. Please clarify how women especially uneducated ones could report difficult to diagnose birth complications such as labor/failure to progress, birth trauma or difficult delivery, high blood pressure, heavy bleeding during delivery, fetal malpresentation, high fever with abdominal pain, and high fever with smelly discharge,? How reliable are the collected data?

Thank you for your comment. Complications were self-reported. To minimize potential reporting bias, we used common language rather than clinical definitions (e.g. high fever with abdominal pain) or included multiple terms that may represent the same conditions (e.g. prolonged labor, obstructed labor, or failure to progress). All questions were asked by data collectors who were trained to thoroughly describe these conditions. We included a clarification in line 151 and added a limitation statement in the discussion (lines 321-323). If there is a relationship between reporting and education, we would expect bias towards the null, with fewer complications reported among less educated adolescents.

Response to Review Comments

Reviewer #1: Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: findings from a health and demographic surveillance system

Thank you for providing this opportunity for me to review this manuscript. Please see my comments as follows:

Thank you for your insightful comments. Please see our responses below.

Abstract:

1. Please report how many women were assessed?

The total number was added in line 20.

2. And please report timeline of the study.

The study years were added in line 20.

Methods

1. Please mention the design of the study.

The study design is a health and demographic surveillance system. It is included in the title and in the Methods section (lines 93-94).

2. Please provide reference for stillbirth, preterm birth and early neonatal death.

References were added to lines 44-46.

3. Please write the inclusion/exclusion criteria.

Data were from a health and demographic surveillance system with the only inclusion criterion being a resident of the catchment area. We have added a clarifying statement in lines 94-95.

4. Overall, please re-arrange the manuscript according to STORBE guideline.

STROBE does not recommend a specific arrangement. According to the original article describing STROBE (Elm 2007), “the order and format for presenting information depends on author preferences, journal style, and the traditions of the research field.” If there are elements in reporting that the reviewer feels are missing, we are happy to address those.

Reference: Elm et al. 2007. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61602-X/fulltext#article_upsell

5. As some maternal and neonatal deaths are contributed to place of birth (home or hospital), birth attendant (skilled midwife or other health provider), or the number of prenatal care, there are need more information such as did adolescents delivered in hospital, and who was their birth attendants? skilled midwife or nurse? These information should be controlled when you report maternal or neonatal death.

Thank you for your thoughtful comment. We consider these factors to be mediators between adolescence and perinatal deaths, rather than confounders. We understand these mediators are critical for maternal health. However, for this study, we wanted to focus on what the public health community could do at the beginning of the causal chain, which in this case is child marriage, rather than untangling potential mediators of this relationship.

Results

1. What was the ratio of vaginal delivery to cesarean section and also what was the rate of vaginal delivery using instrument such as vacuum?

We’ve included the proportion of all singleton births with cesarean section and the proportion of all vaginal deliveries involving vacuum extraction in lines 240-242.

2. Please put some information such as educational level of participants and their husbands, household member in demographic table.

To capture socio-economic indicators of study participants, we used a household wealth index instead, which is included in the demographic table (Table 1). Education level was not considered an optimal indicator as the upper bound would be limited by age (e.g., mothers aged 12-15 would only have partial secondary education), and would be less useful for comparing groups.

3. Please report maternal death and its cause.

We identified a total 7 deaths among residents who had any pregnancy outcome (miscarriage or birth) between January and August 2019. All deaths were among women 19 to 35 years of age who had a singleton live birth. Six deaths were likely related to pregnancy, occurring within a month of birth. One death occurred approximately 9 months after birth. These results were added to lines 242-246. Unfortunately, the cause of maternal death was not systematically investigated.

4. Table 2: Authors mention severe headache with blurred vision. Did they mean preeclampsia? If so, please use its correct term.

Complications were self-reported in a population that may not be familiar with clinical definitions such as “preeclampsia”. To minimize potential reporting bias, we used common language rather than clinical definitions (e.g. high fever with abdominal pain) or included multiple terms that may represent the same conditions (e.g. prolonged labor, obstructed labor, or failure to progress). All questions were asked by data collectors who were trained to describe these conditions. We included a clarification in lines 151 and added a limitation statement in the discussion (lines 321-323).

5. Again, for high fever and smelly discharge, did they mean postpartum infection?

Please see response to #4 above.

6. What authors mean about un-planned hospital delivery? Is that mean women delivered at home and only some of them go to hospital?

Yes, this meant the mother planned to deliver at home but ended up at the hospital for delivery. A clarification was added to lines 155.

7. Please provide a table for multiple logistic regression, until readers to be able to see what confounders were controlled.

This information is available as Table S4.

Discussion

1. Please mention the objective/s of the study at the beginning of the discussion.

We have included the objectives of the study as requested.

2. Discussion needs more comparison between the findings of the study and results of other studies.

We expanded our literature search to other studies including those in South Asia [lines 277-279, 302-304].

3. What was the limitations of the study?

We believe the main limitations of this study is 1) the role of out-migration and deaths among female residents (lines 319-320) and the self-reported nature of complications. We’ve added the second point in lines 320-323 in response to your earlier comment.

4. What was the conclusion according to the objectives of the study?

A conclusion section was added (lines 339-343).

Attachment

Submitted filename: Response to Reviewers_PLOS One.docx

Click here for additional data file. (22.8KB, docx)

Decision Letter 1

Fadhlun Alwy Al-beity

7 May 2023

PONE-D-22-26467R1Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: findings from a health and demographic surveillance systemPLOS ONE

Dear Dr. Emily Gurley

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit .

There is one minor comment by Reviewer 2 that I would like you to invite before we proceed 

Please submit your revised manuscript by Jun 21 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Fadhlun Alwy Al-beity, MMed, PhD (ongoing)

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

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Reviewer #1: Thank authors as they responded all of my comments, and the manuscript is not ready for publication.

Reviewer #2: The authors have addressed all comments well. While I have no concerns and its not necessary to make any edits, the one thing that might be helpful would be to provide an assessment in the discussion of how generalizable these results from a fairly small rural sub-district might be to all of rural Bangladesh.

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Reviewer #1: No

Reviewer #2: Yes: Russell S. Kirby

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PLoS One. 2023 Jul 19;18(7):e0288746. doi: 10.1371/journal.pone.0288746.r004

Author response to Decision Letter 1

22 May 2023

We thank the reviewers for their feedback and comments. Please find our response to the comment listed by Reviewer #2.

Reviewer #2: The authors have addressed all comments well. While I have no concerns and its not necessary to make any edits, the one thing that might be helpful would be to provide an assessment in the discussion of how generalizable these results from a fairly small rural sub-district might be to all of rural Bangladesh.

We have added a statement on generalizability in the discussion section [lines 319-322].

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (12.3KB, docx)

Decision Letter 2

Fadhlun Alwy Al-beity

4 Jul 2023

Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: findings from a health and demographic surveillance system

PONE-D-22-26467R2

Dear Dr. Gurley Emily ,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Fadhlun Alwy Al-beity, MMed, PhD 

Academic Editor

PLOS ONE

Acceptance letter

Fadhlun Alwy Al-beity

10 Jul 2023

PONE-D-22-26467R2

Child marriage in rural Bangladesh and impact on obstetric complications and perinatal death: findings from a health and demographic surveillance system

Dear Dr. Gurley:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Fadhlun Alwy Al-beity

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Fig. Baliakandi health and demographic surveillance system data and analyses used to estimate proportion of marriage to female children and time between first marriage and pregnancy in Baliakandi, Bangladesh.

    (TIF)

    Click here for additional data file. (209.3KB, tif)
    S2 Fig. Baliakandi health and demographic surveillance system data and analyses used to examine relation between maternal age at birth, complications during delivery, and perinatal mortality in Baliakandi, Bangladesh.

    (TIF)

    Click here for additional data file. (171.5KB, tif)
    S1 Table. Excerpt from birth history questionnaire.

    (DOCX)

    Click here for additional data file. (19.5KB, docx)
    S2 Table. Excerpt from pregnancy surveillance questionnaire.

    (DOCX)

    Click here for additional data file. (17.6KB, docx)
    S3 Table. Characteristics of female residents under 35 years of age who had first marriages, Baliakandi sub-district, Bangladesh, September 2017 to August 2019.

    (DOCX)

    Click here for additional data file. (13.9KB, docx)
    S4 Table. Crude and adjusted odds ratios of stillbirth and early neonatal death, compared to live births surviving more than 7 days.

    Adjusted model restricted to nulliparous mothers and adjusted for maternal age and household wealth. Total 8,806 singleton births among female residents under 35 years at birth, Baliakandi sub-district, Bangladesh, September 2017 to August 2019.

    (DOCX)

    Click here for additional data file. (15KB, docx)
    S1 Checklist. Inclusivity in global research.

    (DOCX)

    Click here for additional data file. (68.6KB, docx)
    Attachment

    Submitted filename: Response to Reviewers_PLOS One.docx

    Click here for additional data file. (22.8KB, docx)
    Attachment

    Submitted filename: Response to reviewers.docx

    Click here for additional data file. (12.3KB, docx)

    Data Availability Statement

    All data files are available from the Harvard Dataverse (https://doi.org/10.7910/DVN/93PYJC).

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