Trends and social determinants of adolescent marriage and fertility in China
Authors: Yuanyuan Wang, Jie Qiao
Journal: The Lancet Global Health (2020)

Early marriage and fertility are key issues in social inequality and global health, which have been associated with a wide range of short-term and long-term negative social and health consequences for young mothers and their offspring. Consequences include pregnancy complications, maternal and neonatal deaths, mental and physical diseases and disabilities, malnutrition and developmental delay during early childhood, as well as other disadvantages in education, employment, and other socioeconomic factors.1WHODepartment of maternal, newborn, child and adolescent health. Preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries: what the evidence says. World Heath Organization, Geneva2012Google Scholar In the Sustainable Development Goals (SDGs), early marriage rate (proportion of individuals who were married or in a union before the age of 15 years and before 18 years in women aged 20–24 years) is one key monitoring indicator for goal 5—gender equality, while adolescent fertility rate (livebirths per 1000 individuals aged 10–14 years and 15–19 years) is another key monitoring indicator for goal 3—good health and wellbeing.2UNStatistics Division, department of economic and social affairs. Statistical annex: global and regional data for Sustainable Development Goal indicators. [E/2019/68] United Nations.https://unstats.un.org/sdgs/files/report/2019/secretary-general-sdg-report-2019--Statistical-Annex.pdfDate: 2019Date accessed: April 10, 2020Google Scholar Globally, the proportion of women aged 20–24 years who were married or in a union before age 15 showed a consistently declining trend from 8·1% in 2003 to 6·4% in 2013 and 5·0% in 2018, while that proportion before age 18 declined from 27·2% in 2003 to 22·2% in 2013 and 20·8% in 2018. Meanwhile, the adolescent fertility rate also showed a similar trend from 56 births per 1000 girls and women aged 15–19 years in 2000 to 45 births in 2015, and 44 births in 2018; whereas there was major geographical variation in the two SDG indicators (gender equality and good health and wellbeing).2UNStatistics Division, department of economic and social affairs. Statistical annex: global and regional data for Sustainable Development Goal indicators. [E/2019/68] United Nations.https://unstats.un.org/sdgs/files/report/2019/secretary-general-sdg-report-2019--Statistical-Annex.pdfDate: 2019Date accessed: April 10, 2020Google Scholar Childbearing among girls aged younger than 15 years is currently uncommon in most societies, except for some of the least developed countries. During the past few decades, China has seen rapid transitions in its socioeconomic structures, which might have affected adolescent attitudes and behaviours regarding marriage and sexual activity. However, there has been limited research on the temporal trends in and macroscopic factors affecting adolescent marriage and fertility patterns across China. In The Lancet Global Health, Dongmei Luo and colleagues present a secondary analysis of aggregated data obtained from the Chinese National Population Census and the Chinese 1% National Population Sample Survey between 1990 and 2015.3Luo D Yan X Xu R et al.Chinese trends in adolescent marriage and fertility between 1990 and 2015: a systematic synthesis of national and subnational population data.Lancet Glob Health. 2020; 8: e954-e964Google Scholar The study showed that the ever-married rate and age-specific fertility rate (ASFR) among girls and women aged 15–19 years in China was at a low level relative to global patterns, but with a rebound, declining from an ever-married rate of 4·7% in 1990 to 1·2% in 2000 and an ASFR of 22·0 per 1000 individuals in 1990 to 6·0 per 1000 in 2000, and then rebounding to an ever-married rate of 2·4% and an ASFR of 9·2 per 1000 in 2015. At the individual level, girls and women with less education or living in rural areas or the western provinces of China were more likely to be married or to have given birth. At the provincial level, those provinces with a higher proportion of poorly educated girls or ethnic minorities, a higher ratio of males to females, or lower gross domestic product per capita were associated with a greater risk of adolescent marriage and childbearing. On the basis of the results from the study and previous literature, Luo and colleagues link the rebound with some presumptive drivers—a male-biased sex ratio, a large population of internal migrant workers, and more sexual activity among adolescents. They thereby call for a range of adolescent-targeted strategies, including scaling up comprehensive sexuality education, ensuring that girls continue in school, and providing adequate reproductive health services for sexually active adolescents. In China, economic growth and social progress has improved the sexual and reproductive health and rights of adolescents, similarly to other areas of health for this population. However, there are deviations among different subgroups and fluctuations during this stage of rapid transition. Besides directly resulting in negative social and health consequences for young mothers and their offspring, early marriage and fertility also indicate other potential risks to sexual and reproductive health among adolescents—especially girls. Increased risks include early sexual initiation, unprotected intercourse, unintended pregnancy, unsafe abortion, vulnerability to sexually transmitted infections, sexual coercion or violence, and other negative sexual experiences and consequences.1WHODepartment of maternal, newborn, child and adolescent health. Preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries: what the evidence says. World Heath Organization, Geneva2012Google Scholar However, there is little high-quality research on these issues in China. Based on only a few national surveys or surveillance among adolescents in China,4Dong Y Wang L Burgner DP et al.Infectious diseases in children and adolescents in China: analysis of national surveillance data from 2008 to 2017.BMJ (Clinical research ed). 2020; 369m1043-mGoogle Scholar, 5Zheng X Chen G Report on the basic data of Chinese adolescent reproductive health access survey.Popul Develop. 2010; 16: 2-16Google Scholar, 6Zhao R Zhang L Fu X Su C Zhang Y Sexual and reproductive health related knowledge, attitude and behavior among senior high school and college students in 11 provinces and municipalities of China.Chin J Publ Health. 2019; 35: 1330-1338Google Scholar more than a half did not use any contraception measures when they first had intercourse; one of every five instances of sexual intercourse was without contraception; 20 of every 100 girls who were sexually active were pregnant, more than 90% of whom had had an abortion and nearly 20% of whom had multiple abortions; and 13% of girls who were sexually active experienced sexual coercion in the past year. Among adolescents aged 14–22 years, the incidence of HIV and AIDS, gonorrhoea, and syphilis have increased rapidly and HIV and AIDS is now the most common cause of death from infectious diseases. All of these issues are strongly associated with individuals that form the support network, including peers, parents, family members, teachers, health-care workers, and communities. Besides promoting gender equality, sex education, and the reproductive health services recommended in the study, we urgently need to create a youth-friendly society in which adolescents' sexual needs and activities are treated as a natural part of their lives, without any stigmatisation or judgment, so as to ensure every adolescent has access to adequate information, services, and safeguards for their sexual and reproductive health and rights. Another point worth noting in the study is the consistently declining trend in ever-married rate or ASFR in women aged 20–24 years: the ever-married rate declined from 58·6% in 1990 to 25·5% in 2015, and the ASFR decreased from 198·8 per 1000 in 1990 to 55·0 in 2015. This phenomenon improves with socioeconomic advantage (eg, regional economic development or individual income level, education, employment, gender equality, among others), especially for young women. However, such socioeconomic advantage is also linked with postponement of childbearing, advanced maternal age, and even infertility,7Guzzo KB Hayford SR Lang VW Adolescent fertility attitudes and childbearing in early adulthood.Popul Res Policy Rev. 2019; 38: 125-152Crossref Scopus (7) Google Scholar, 8Frederiksen LE Ernst A Brix N et al.Risk of adverse pregnancy outcomes at advanced maternal age.Obstet Gynecol. 2018; 131: 457-463Crossref PubMed Scopus (52) Google Scholar which will exacerbate the low fertility rate and ageing population in China impacting all aspects of society. Some research suggests that the ideal maternal age for a woman biologically is 22–28 years, which is the peak of fecundity or ovarian function with minimum risk of adverse pregnancy outcomes.9Kelsey TW Wright P Nelson SM Anderson RA Wallace WHB A validated model of serum anti-müllerian hormone from conception to menopause.PLoS One. 2011; 6e22024Crossref PubMed Scopus (296) Google Scholar, 10Broekmans FJ Soules MR Fauser BC Ovarian aging: mechanisms and clinical consequences.Endocr Rev. 2009; 30: 465-493Crossref PubMed Scopus (579) Google Scholar Therefore, avoiding early marriage and childbearing among adolescents and then encouraging it during the optimal childbearing years has become a huge challenge for Chinese society. Further studies and policies are needed to balance and address both sides of this issue. We declare no competing interests. Chinese trends in adolescent marriage and fertility between 1990 and 2015: a systematic synthesis of national and subnational population dataAlthough China's total fertility rate remains far less than replacement, after a period of steady decline, there has been a rebound in adolescent marriage and childbearing in the past decade. A range of adolescent-targeted strategies will be needed across provinces, including scaling up comprehensive sex education, ensuring that girls continue in school, and providing adequate reproductive health services, which specifically meet the needs for modern contraception in sexually active unmarried girls. Full-Text PDF Open Access