ECONOMIC IMPACTS OF CHILD MARRIAGE: CHILD HEALTH AND NUTRITION BRIEF Page 1 · ECONOMIC IMPACTS OF CHILD MARRIAGE: CHILD HEALTH AND NUTRITION BRIEF June 2017 ECONOMIC IMPACTS OF CHILD MARRIAGE: CHILD HEALTH AND NUTRITION BRIEF OVERVIEW Each day, more than 41,000 girls worldwide are married while still children, often before they may be physically and emotionally ready to become wives and mothers. Child marriage, defined as marriage or a union taking place before the age of 18, endangers the life trajectories of these girls in numerous ways. Child brides are at greater risk of experiencing a range of poor health outcomes, having children at younger ages, having more children over their lifetimes, dropping out of school, earning less over their lifetimes and living in poverty than their peers who marry at later ages. Child brides may also be more likely to experience intimate partner violence, have restricted physical mobility, and limited decision-making ability. Most fundamentally, these girls may be disempowered in ways that deprive them of their basic rights to health, education, equality, non-discrimination, and to live free from violence and exploitation, which continue to affect them into adulthood. These dynamics affect not only the girls themselves, but their children, households, communities and societies, limiting their ability to reach their full social and economic potential. While child marriage is widely considered a human rights issue closely connected to gender inequality,1 the significance of the practice’s impacts at both the individual and societal levels suggests that ending child marriage may play an important role in alleviating poverty and in promoting economic development. Ending child marriage can improve health at the individual and population levels, increase productivity and enhance the opportunity to realize the gains in a country’s economic growth that can result from declining birth rates and a shifting population age structure, commonly referred to as the ‘demographic dividend.’ To date, however, there has been relatively little in the way of rigorous assessment of the economic impacts of child marriage or how much child marriage may “cost” countries and societies. To address this challenge, the International Center for Research on Women (ICRW) and the World Bank collaborated on an extensive and innovative research project to assess the impacts of child marriage on a range of development outcomes, and to understand the economic costs associated with these impacts across countries. By establishing the effects that child marriage has on economic outcomes, the research project aimed to catalyze more effective and evidence-based action to prevent it. The conceptual framework that guided our work follows: 1 As enshrined in UN General Assembly Resolution 71/175 (December, 2016), “child, early and forced marriage is a harmful practice that violates, abuses or impairs human rights.” Page 1 · ECONOMIC IMPACTS OF CHILD MARRIAGE: CHILD HEALTH AND NUTRITION BRIEF June 2017 Domains of Impact Aggregate Measures Development Of Impacts And Costs Outcomes Fertility and population growth CHILD MARRIAGE Earnings, productivity & Health, nutrition and violence consumption per capita Multiple pathways Educational attainment and learning and intergenerational Perpetuation Of Extreme effects through which Poverty And Private impacts are observed & public Inequality Participation in the labor force expenditures and type of work Participation, decision-making and investments Non-monetary and social costs This brief summarizes results from an analysis of the impacts of child marriage on two health outcomes - under-five mortality and stunting - for young children. For the purposes of this brief, we focus on the impact of child marriage through early childbirths, as this is the mechanism through which child What Do We Mean health and nutrition outcomes are most directly affected. by Impacts and There is a close correlation between child marriage and early childbirths in most countries - at a global level, six out of Associated Costs? seven early childbirths take place within the context of child marriage. The brief does not include analyses for other aspects The aim of the study is to estimate of child health that may also be affected by child marriage, nor the impacts of child marriage on does it consider costs that may be incurred by health systems development outcomes and the as a result of poor child health. This brief and selected other economic costs associated with some publications from the study can be found at: of these impacts. The term “impact” www.costsofchildmarriage.org  is used for simplicity, but one must be careful about not necessarily inferring causality. Most estimates of impacts are obtained through regression analysis in IMPACT OF CHILD MARRIAGE ON order to control for other variables that UNDER-FIVE MORTALITY AND may affect the outcomes of interest. In some cases, simulations are used. STUNTING What is measured are thus statistical associations, and not necessarily Adolescent girls face serious health risks when giving birth impacts as could be observed, for at an early age. These health effects extend beyond the girl example, with randomized control herself and can impact her children in several ways. Overall, trials. Since child marriage cannot be infant mortality and morbidity among children born to randomized, we must rely on regression mothers under the age of 18 is higher as compared to those analysis in order to estimate likely born to older mothers. Children of adolescent mothers are impacts, but there is always a risk also more likely to have low birth weight and have poor of bias in the measures of the likely nutritional status when they are born and throughout their impacts of child marriage. Based on childhood. These children are further disadvantaged because measures of likely impacts, costs women married as children tend to have less spacing between associated with selected impacts are births, as well as more children over their lifetimes than those then computed. Note that we provide married later, which can also negatively impact child health. cost estimates only for some, and not all impacts. These costs rely on a number In our study, we analyze the impact of early childbirths of assumptions and are thus tentative. (defined here as births to a mother younger than 18) on Overall, the costs represent an order of under-five mortality and malnutrition using Demographic magnitude of potential costs rather than and Health Surveys (DHS) for 15 countries. The focus is on the precise estimations. For more details on impact at the margin of early childbirths on the probability the methodology and how it relates to that a child will die before age five and on the probability that key empirical findings, see Wodon (2017). Page 2 · ECONOMIC IMPACTS OF CHILD MARRIAGE: CHILD HEALTH AND NUTRITION BRIEF June 2017 a child will be stunted. Following standard conventions, a TABLE 1: INCREASE IN UNDER-FIVE MORTALITY child is considered stunted if s/he has a height more than two AND STUNTING DUE TO EARLY CHILDBIRTHS standard deviations below the median reference height for their age. Stunting often results from persistent insufficient Marginal National National nutrient intake and infections. It may lead to delayed motor Impact Impact Reduction vs. development and poor cognitive skills that can affect school (%) Baseline (%) performance as well as productivity and earnings later in life. Under-five Mortality Table 1 provides the key results from our analysis. Our results Bangladesh NS - - indicate large and statistically significant impacts of early childbirth on under-five mortality and stunting in a majority Burkina Faso 6.0 0.30 3.4% of the countries. In Niger, for example, controlling for a wide Dem. Rep. 3.9 0.24 3.4% range of factors, when a child is born of a mother younger than Congo 18, the risk of under-five mortality (represented in the upper Egypt NS - - part of the table) increases by 3.0 percentage points, while the risk of under-five stunting (in the lower part of the table) Ethiopia 3.8 0.20 3.0% increases by 6.9 percentage points. Malawi NS - - When aggregating to the national level, these impacts are Mali 6.9 0.61 8.7% smaller because proportionally few children are born of Mozambique 4.8 0.48 6.9% mothers younger than 18, as compared to all children born Nepal NS - - in a country. Consider again the case of Niger. Nationally, the elimination of early childbirths is estimated to reduce under- Niger 3.0 0.22 2.7% five mortality by 0.22 percentage points, while stunting would Nigeria 4.8 0.34 4.0% be reduced by 0.45 percentage points. Said differently, as Pakistan NS - - shown in the last column of Table 1, given prevailing rates of under-five mortality, for every 100 children who die before the Rep. of Congo NS - - age of five in Niger, roughly 2.7 are likely to die directly because Uganda 4.7 0.27 4.1% of an early childbirth. Similarly, for every 100 stunted children, one is likely stunted because of the impact of early childbirth Zambia 3.4 0.27 5.0% (Table 1). Under-five Stunting Bangladesh 5.2 0.75 1.8% Burkina Faso NS - - “My first baby was small. Dem. Rep. 7.2 0.32 0.7% The second was 5 months Congo Egypt 7.5 0.17 0.8% old, and I was pregnant Ethiopia NS - - again as my husband did Malawi NS - - forceful contact with me.” Mali 10.3 0.74 1.9% Mozambique 7.8 0.57 1.3% “[She] was 12 years old Nepal 9.5 0.64 1.6% when she married. She Niger 6.9 0.45 1.0% lost her first child at age Nigeria 4.3 0.44 1.2% fourteen and was advised Pakistan NS - - to wait several years Rep. of Congo NS - - before trying again. Her Uganda 22.0 1.03 3.1% last pregnancy came with Zambia 4.7 0.25 0.6% a series of complications Sources: Onagoruwa and Wodon (2017a, 2017b). Note: NS = Not statistically significant at the 10 percent level. that finally claimed her life a week after delivery.” QUALITATIVE DATA COLLECTED BY ICRW AND THE WORLD BANK. Page 3 · ECONOMIC IMPACTS OF CHILD MARRIAGE: CHILD HEALTH AND NUTRITION BRIEF June 2017 Using results from these estimated impacts, along with Table 3 provides the results of our analysis in terms of the extrapolations for other countries, we conducted simulations economic benefits that would result from a reduction in to estimate the number of children who could survive beyond under-five mortality and stunting. We consider the impacts the age of five and the number of children who could avoid of both ending child marriage, as well as ending all early stunting globally if early childbirths were avoided, as well as if childbirths. It is important to note that these estimates should child marriage were to end, taking into account the fact that not be treated as precise, given that they depend on both not all early childbirths can be attributed to child marriage. a range of assumptions and on econometric estimates that have standard errors. Regardless of these limitations, these Our results suggest that over the time period of 2016 to 2030, estimates provide an idea of the potential magnitude of costs an estimated 2.1 million children could survive past age five associated with child health as a result of child marriage and if child marriage was eliminated entirely, while 3.6 million early childbirths. children could avoid stunting. The estimates are larger when ending all early childbirths, including those not due to child Our estimates indicate that eliminating child marriage would marriage. The estimates in Table 2 cover the cumulative effects lead to annual economic benefits from the reduced deaths over a 15-year period. Hence, on average, 140,000 children’s of children in the amount of $41.6 billion in 2016 and $81.6 lives could be saved on a yearly basis if child marriage was billion in 2030 (in purchasing power parity terms). The benefits eliminated, and 167,000 each year if all early childbirths were from ending early childbirths are slightly higher because some to end. Similarly, some 240,000 children a year would avoid early childbirths take place outside of marriage. The increase being stunted if child marriage were to end immediately, and over time in benefits is mainly due to the higher value placed 290,000 if early childbirths were eliminated. on each life saved as GDP per capita rises due to economic growth. For the reduction in stunting, the benefits from ending child marriage are valued at about $9.1 billion in 2016, rising to TABLE 2: NUMBER OF CHILDREN AVOIDING $15.8 billion in 2030. DEATH BY AGE FIVE OR AVOIDING STUNTING, 2016 TO 2030 Number of Children (Millions) TABLE 3: GLOBAL ANNUAL BENEFITS FROM REDUCED UNDER-FIVE MORTALITY AND Not Dying Not Stunted STUNTING, 2016 AND 2030 Ending child 2.1 3.6 2016 2017 marriage Reduced Mortality Ending early 2.5 4.4 ($ Billion, purchasing power parity) childbirth Ending child 41.6 81.6 Source: Wodon (2017b). marriage Ending early 46.2 90.2 childbirth ECONOMIC IMPACTS OF CHILD Reduced Stunting MORTALITY AND STUNTING ($ Billion, purchasing power parity) Ending child 9.1 15.8 For children and for their families, the cost of lives lost or marriage stunting are not primarily economic. At the same time, Ending early 9.7 19.1 understanding the economic costs of child marriage and early childbirth childbirths on under-five mortality and stunting may be useful for pursuing policy changes to end child marriage and early Source: Wodon (2017b). childbearing. We used the following assumptions to estimate these potential costs: ww Cost of lives lost: One of several approaches used in the literature to estimate costs consists of valuing a child’s life in terms of GDP per capita. Acknowledging that this implicitly values a life in a poorer country at a lower value than in a richer country, this is the approach followed here. ww Cost of stunting : Research suggests that stunted children are likely to have lower earnings in adulthood, with losses typically estimated at 20 to 25 percent. Therefore, the benefits from avoiding stunting are costed based on expected future GDP per capita, multiplied by an approximate share of wages in GDP and the share of wages lost due to stunting. ww Discount rates: Discount rates are needed to value future incomes. The choice of discount rate affects valuations, and it is good practice to conduct estimations for multiple discount rates. For this analysis, we apply the commonly used discount rate of five percent. Page 4 · ECONOMIC IMPACTS OF CHILD MARRIAGE: CHILD HEALTH AND NUTRITION BRIEF June 2017 CONCLUSIONS Child marriage and early childbearing have significant implications for the health of the children born of young mothers. Econometric analysis suggests that in many countries, children of mothers younger than 18 are more likely to die by age five or be stunted than children of mothers older than 18, even after controlling for other factors. While national rates of under-five mortality and stunting would not dramatically change if child marriage and early childbirths were ended, many children would survive past age five or avoid stunting if this were the case. Our analysis suggests that ending child marriage and early childbirths could bring significant economic benefits to countries through their respective impacts on child mortality and stunting. With a discount rate of five percent, ending child marriage and early childbirths could generate between $56 billion and $109 billion in purchasing power parity terms annually in benefits due to reductions in stunting and under-five mortality. This analysis thus provides a strong economic rationale for investing in programs and policies to end child marriage and thereby improve outcomes for young children. Page 5 · ECONOMIC IMPACTS OF CHILD MARRIAGE: CHILD HEALTH AND NUTRITION BRIEF June 2017 REFERENCES [1] Onagoruwa. A. O. and Q. Wodon (2017a). Impact of Early Childbirth on Under-five Mortality across Multiple Countries. Education Global Practice. Washington, DC: The World Bank. [2] Onagoruwa. A. O. and Q. Wodon (2017b). Impact of Early Childbirth on Under-five Malnutrition across Multiple Countries. Education Global Practice. Washington, DC: The World Bank. [3] Wodon, Q. (2017a). Estimating the Economic Impacts and Costs of Child Marriage Globally: Methodology and Estimates. Education Global Practice. Washington, DC: The World Bank. [4] Wodon, Q. (2017b). Global Cost of Under-five Mortality and Malnutrition Due to Child Marriage. Education Global Practice. Washington, DC: The World Bank. The Economic Impacts of Child Marriage project is a collaborative Information and illustrations contained in this report may be freely effort by the International Center for Research on Women (ICRW) reproduced, published or otherwise used for noncommercial and the World Bank, with funding from the Bill & Melinda Gates purposes without permission from the World Bank or ICRW. Foundation and the Children’s Investment Fund Foundation, and However, the World Bank and ICRW request that the original additional support from the Global Partnership for Education. This source be cited as the source. series of papers is jointly produced by the International Center for Research on Women and the World Bank and is available at Recommended citation: Wodon. Q., N. Onagoruwa, and N. John www.costsofchildmarriage.org  The findings, interpretations (2017) , Economic Impacts of Child Marriage: Health and Nutrition for and conclusions expressed in this paper are entirely those of the Children of Young Mothers. Washington, DC: The World Bank and author(s) and should not be attributed in any manner to the World International Center for Research on Women. Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and © 2017 The International Bank for Reconstruction and Development / the use of material presented in this series should take into account The World Bank and the International Center for Research on Women (ICRW), this provisional character. The World Bank does not guarantee the Washington, DC 20433. accuracy of the data included in this work. The boundaries, colors, denominations and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Page 6 · ECONOMIC IMPACTS OF CHILD MARRIAGE: CHILD HEALTH AND NUTRITION BRIEF June 2017