Child Marriages and the Constructions of Mental Health Among Young Female Adults in Africa: A Systematic Literature Review

1. Introduction

Child marriage experience is mentally draining for young female adults who are not psycho-socially prepared for marriage (Burgess, 2022; John et al, 2019). Evidence suggests that marriage below the age of consent leads to mental breakdown (Fan and Koski, 2022). Psychologists have further emphasized that mental health conditions emanate during adolescence, where one in every six individuals at the age of 10-19 years suffer from mental health disorders (Kessler et al., 2007). The lived experiences of young female adults in child marriages usually below the age of 16 or 18 years, depending on the country. have been discussed in the literature as vulnerability and risk to mental health problems (Ahmed et al., 2013, Atiola, 2014; Gore et al., 2011; Groot et.al., 2018 Kidman, 2017).

The objective of this systematic review is to shed light on the constructions of mental health implications because of child marriages, to inform intervention programs and policies, and provide critical areas needing future research.

The present study contributes to the literature by focusing on mental health and child marriage in Africa. In contrast to the Global South, the Global North has discussed more on young female adults' mental health and child marriage (Laurenzi et al., 2020; Barnet et al., 2002). Researchers in the Global South have just recently begun to examine the mental health of young women who are in child marriages. Few studies have looked at the mental health of young women who are HIV/AIDS positive and living in Africa (Roberts et al., 2021; Boyes et al., 2019; Cluver et al., 2022; West et al., 2019 & Woollett et al., 2017). Studies on mental health and child marriage are thus under-researched.

The focus and budget allocations towards HIV/AIDS, tuberculosis, childhood vaccination, and malaria in the African continent are overwhelming. Mental health, neurological, and substance abuse disorders are significantly ignored in the African continent (Lund, 2011). Yet, in Africa, mental health dominates a bigger percentage of the burden of ailments, only 1% of the national health budget is given to mental health (WHO, 2005). The allocated budget covers the colonial age safeguarding psychiatric institutes, contrary to rising data for cost-effective community-based interventions (Patel et al., 2007). To shed light on this under-researched topic, we conducted a systematic literature review to identify gaps and suggest areas for future research and policy guidelines.

2. Methodology

The systematic literature review identifies, selects, and critically appraises research to answer a formulated question (Dewey and Drahota, 2016). The method suits the aim of the study, which is to examine the empirical studies and scholarly articles on the topic of child marriage and the construction of mental health implications for young female adults in Africa.

In this paper, we present the impact of child marriage on the mental health of young female adults exposed to early marriages. To comprehend the topic, we applied a systematic literature review. The following research question guided our study:

• What is the impact of child marriage on young female adults’ mental health and well-being in Africa?

The paper is organised as follows, the first section, presents the introduction of the study. Subsequent sections discuss the methodology, results, discussion of our systematic literature review, recommendations, and conclusion, and insights for future studies.

This paper applied a systematic literature review search to detect the types and motivational factors of child marriages and mental health implications on young female adults in Africa. A systematic literature review was crucial because it offered a thorough and complete summary of the current studies and upheld the development of innovative theories (Webster & Watson, 2002). The advantage of applying a systematic literature review is that it improves the transparency in methodology and makes it better to reproduce the results guided by predefined search strategies (Denyer & Transfield, 2009).

The systematic literature review has three main aspects that the researchers implemented; planning, conducting the review, and reporting, followed by other steps including identification of the resources, selection of the study, and data extraction (Kitchenham, 2004). We started with the planning of how to conduct the overall study; then, worked on the identification of the relevant studies that can answer the research question.

To have suitable data, we followed the procedures drawn by Tranfield et al. (2003). The researchers. We conducted an electronic search; with key terms that were found in scholarly articles including ‘mental health’, ‘young female adults’, ‘child marriages’, and ‘Africa’ were used to search the following databases: Google Scholar, JSTOR, Proquest, PubMed as well as websites of various international organisations active in mental, neurological and substance abuse disorders. After cautious deliberation and examining the title of the articles, research issues, and critical discussions in the abstract of the selected materials, only the most applicable literature on mental health and child marriages among young female adults in Africa was nominated. Table 1 shows the inclusion and exclusion criteria used to select relevant literature used in this paper.

3. Results

A total of one hundred and forty eighty (148) scholarly articles were retrieved. The oldest article was published in 2003 and the latest in 2023. Table 2 presents the number of articles, authors, sample information, research design, and focus area where data were extracted. Majority of the articles directly discussed child marriages and the mental health of young female adults in Africa. Grey literature on mental health and child marriages was also used to give a compelling background on the topic.

4. Characteristics of Included Studies

Characteristics of the 40 included studies are shown in Table 2.

Figure 1. Flow diagram of articles searched.

Figure 1. Flow diagram of articles searched.

Study Characteristics

The study employed 7 mixed methods, 5 qualitative, 12 quantitative, and 16 studies that did not specify their designs but were included because they met the inclusion criteria. The literature was from any African country and was published from 2003 to 2023. The limitation of the study was that most of the literature on mental health focused on the global north. Hence, the full methodology was apparently unavailable to avail in this study.

5. Discussion

We found the following themes regarding the implication of child marriage on young female adults' mental health. The discussion will begin with a brief background of child marriage, then implications of child marriage on young female adults’ mental health with themes, fertility and population growth, labor force and productivity, economic growth, healthcare, intimate partner violence, poverty, marital duties, and responsibilities.

5.1. A Brief Background of Child Marriages

Child marriage and early marriage has received public and academic dialogues, by worldwide international development organisations, generally showing that child and early marriage is a human rights defilement, with many negative health and social impact on girls and women (Chandra-Mouli, et al., 2013; Mathur et al., 2003; UNICEF, 2005). Research has also shown the association between a higher risk of early pregnancy increases the risk of maternal morbidity and maternal death (Svanemyr et al., 2012); significant risk of vesicovaginal and rectovaginal fistula (tearing of the wall separating the bladder or rectum from the vagina) (Meyer et al., 2007); raised risk of HIV infection (Bruce & Clark, 2004; Clark, 2004); and negative implications for mental health (Gage, 2013), poverty (Otoo-Oyortey & Pobi, 2003), reduces girls’ education prospects and reinforces gender inequality (UNICEF, 2006).

Msuya (2020) states that Africa is among the continents with a high rate of child marriages in the whole world. The age of consent in the majority of sub-Saharan African countries is 18 years, however, the marriage of children under the age of 18 remains high. As a result of that child marriage is among the goal targets of the United Nations’ Sustainable Development Goal (SDG) of gender equality (goal 5) (Wagenaar et al, 2020). Apart from its negative impact on physical growth, and emotional development, child marriage is also linked to mental health challenges young female adults go through as a result of getting married at a young age (John et al, 2019).

Research studies have shown that, in Africa, one in three girls is married by the age of 18 years and one in nine by the age of 15 years (UNFP, 2012). Although the largest number of child brides are in South Asian states, those with the highest rates of child marriage are in Africa. Thus, international, 39 percent of women aged between 20 and 26 years, were married before they attained the age of majority, are from sub-Saharan countries. Countries reported to have a high rate of child marriage in Africa are Niger (75 percent), Chad and Central Africa Republic (68 percent), Guinea (63 percent), Mozambique (56 percent), Mali (55 percent), Sudan and Burkina Faso (52 percent), Malawi (50 percent), Madagascar (48 percent), Eritrea (47 percent), Somalia (45 percent), Sierra Leone (44 percent), Zambia (42 percent) and Ethiopia (41 percent) (Maswikwa et al, 2015:19).

Globally, the practice of child marriage is a violation of childhood for both sexes, as 115 million men were married before the age of 18 years. Although boys who marry in childhood do not face the same risks and consequences as girls, due to biological and social differences, they have still experienced violation that shortens their childhood (Gaston et al, 2018). The highest level of child marriage is found in sub-Saharan Africa (UNICEF global databases (2018), based on DHS, MICS, and other national surveys (2010-2017)

5.2. Implications of Child Marriage on Young Female Adults’ Mental Health

5.2.1. Fertility and Population Growth

Child marriage and early childbearing have a critical influence on the development of opportunity, which is related to complex rates of fertility and population growth. At the same time reducing the level of prosperity per person, especially in African countries where there is high population growth (Efevbera et al, 2019). Young female adults who were married before 18 years have higher chances of having more children than young female adults who marry after 18 years or later. Child marriage reduces the ability of the family’s basic needs, for instance, food, education, and healthcare (Efevbera et al, 2019). Child marriage, however, becomes the most convenient solution for the majority of poor family households as they marry off their children to reduce the family’s basic needs burden.

It is estimated that young female adults who start having children below the age of 18 years have a 26 percent chance of having more children compared to those who are married above 18 years or older (Parsons et al, 2015). The increase in childbearing stresses the national budget of the country thus reducing the accessibility of basic services. Young female adults are forced to work for themselves to feed the children as national budgets to fund or provide accessible basic services become strained or none in the majority of African countries (Raj, 2010). Coming up with ways to end child marriages in Africa will reduce early births, thus increasing productivity and economic growth in Africa.

5.2.2. Labour Force and Productivity

Child marriage reduces participation in the labour force and puts young female adults at risk of morbidity that is caused by early and recurrent childbearing. Due to complications surrounding giving birth, young female adults will take time to recover from complications caused during birth (Burgess et al., 2022). Childbirth has physical, emotional, psychological, and social impacts as young female adults withdraw from labour force. Unable to work pose the family with a high risk of continuous poverty and affects human capital development (WHO 2014).

5.2.3. Economic Growth

Child marriages also affect economic growth, economic growth reduces poverty and enhances the quality of life (Burgess et al., 2022; UNFPA, 2012). However, the extent to which the poor partake in this development and share in its proceeds is considered by the degree to which development reduces poverty (UNFPA, 2012). The pace, pattern, and growth of child marriage, which affects child brides’ ability to take part in growth opportunities, has a crucial effect on attempts to reduce poverty (Msuya, 2020). Eradicating this phenomenon will certainly contribute to the reduction of mental health challenges young female adults go through (Burgess et al., 2022; UNFPA, 2012). Child marriage affects young female adults’ mental well-being in various ways, for instance, increased rates of malnutrition, isolation, developing suicidal thoughts, and depression (Burgess et al., 2022; UNFPA 2014 & Gage, 2013). Young female adults encounter maternal mortality and morbidity as a result of intimate partner violence (IPV) (Kidman, 2017; UNFPA 2014). The suffering that young female adults go through is a result of being financially dependent on their husbands/partners and in-laws. Being financially independent increases, the pressure child marriage has on their mental health. Unable to afford healthcare, put a strain on the household and ends up placing young female adults at risk of reducing productivity within the household and workforce (Burgess et al., 2022).

5.2.4. Healthcare

Failure to afford recommended healthcare for themselves also goes to their children who will suffer from poor nutrition, unable to get childhood immunisation, and infant mortality rate increases (Burgess et al., 2022). All these effects affect young female adults and end up suffering from mental health like depression, suicidal thoughts, anxiety, and self-harm (Khan et al., 2013). Those young female adults married as a result of forced marriage experience trauma, rape, and abuse (Burgess et al., 2022). They will be forced to start a family with strangers or older men who were married before or in marriage (Ahmed et al., 2013). In most instances, they do not consent to marriage. The whole process puts young female adults at risk of mental health breakdown and trauma in the long run.

Another implication of child marriage on the mental health of young female adults is unable to deliver children the normal way. They suffer long delivery and gestation, for instance, obstetric fistula, obstructed labour, and death (Meyer et al., 2007; Callaghan et al, 2015). Pregnancy difficulties and childbirth are the second foremost cause of death among young female adults between the age of 15 to 19 years, with nearly 70, 000 dying every year (WHO 2012). The health effects of early marriage go on to the children born by underage mothers. Infant mortality is 60 percent compared to those born with mothers above 18 years or older (UNICEF 2014).

5.2.5. Intimate Partner Violence

Young female adults are also unable to negotiate for safer sex with their partners/husbands which put them at risk of contracting sexually transmitted diseases and failing to do good child spacing (Ahmed et al., 2014). Higher expectations and pressure put upon early brides make them have children early when not ready. Young female adults cannot successfully do child spacing due to being unable to understand how to use family planning methods, the unavailability of healthcare institutions that provide family planning, fear, and cannot afford to buy family planning (UNFPA, 2014; John et al., 2019). All these negatively impact the mental health of young female adults.

5.2.6. Poverty

Children born to young female adults as a result of child marriages have high chances of suffering from poor nutrition, are underweight and prone to illness, and generally have a weak immune system (Ajayi et al., 2023). Growth and development for these children become slow and this affects even their attendance at school, and performance in the personal and public domain. Ajayi et al (2023) further postulate that the stress of having a child who is ill all the time and does not grow like any other child goes on to the mothers (young female adults). Visiting and staying in the hospital all the time is a traumatic experience, elevated with lack of financial support worsened the situation. All this escalates the mental health of young female adults into incapacitated situations.

Child marriage puts young female adults at a lifetime economic disadvantage (Msuya, 2020). Women who are educated, and employed can look after themselves, their families, children, and communities (Atilola, 2014). With poverty increasing in African communities, the hardest stricken population will be young female adults. Becoming an adult whilst being a child is a whole lot of stress (Burgess et al., 2022; Neetu et al., 2019), managing the situation as a child does not spare young female adults from developing lifetime mental health issues. They have no option but to deal with the predicament at hand.

Poverty causes depression and emotional distress in young female adults’ households. Families will be forced to marry off their daughters in exchange for payment of bride price and food. A study contacted in Niger and Ethiopia: ‘Child marriage and psychological well-being’ revealed that mental health disorders are more in children forced into marriage compared to those who marry in their own time. Brides married through forced marriage undergo stress and anxiety and lack purpose in life. They are not ready to take up any responsibilities that come with early marriage (John et al, 2019).

5.2.7. Marital Duties and Responsibilities

Child marriage results in the burden of marital and family responsibilities at a tender age like providing partner sexual satisfaction, childbearing, and child minding, responsible for household chores at the expense of enjoying childhood moments (John et al, 2019). Young female adults got into these responsibilities whilst young with no idea how to handle and solve issues that comes with marriage (Nasiroğlu & Semerci, 2017). Young female adults will not be emotionally, psychologically, and mentally ready (Khan et al., 2013). Support from the husband, in-laws, and their families will be barely minimum. Young female adults end up suffering from depression and emotional distress from tender ages and grow old with the illness.

5.2.8. Recommendations

Recommendations of this paper draw hugely from one of the reviewed studies conducted by Burgess et al., 2022 with the topic entitled ‘Overlooked and unaddressed: A narrative review of mental health consequences of child marriages’.

Table 3. Caption.

Future priorities for the mental health and child marriage field: final consensus statements
Perspectives on early, child, and forced marriage and its relationship to mental health	1. It is important to understand the mental health impacts of child marriage 2. Changing social norms is a mandatory part of reducing mental distress caused by the practice of child marriage 3. An individual’s location within society has a direct impact on the relationship between mental and child marriage (e.g. caste, ethnicity, race, sexuality, class, gender) 4. Intimate partner violence poses significant risks to the mental health of those married young 5. It is important to understand the intergenerational dynamics (i.e. in families or communities across generations) of child marriage.
Perspectives on policy approaches in the field	1. Engagement with policy leaders in child marriage needs new forms of advocacy to highlight mental health as important. 2. Future policy (and research) must reflect the full range of communities where child marriage is practiced (e.g., Jewish Hasidic communities, Pentecostal/Mormon communities, Irish/Roma travelers, and Muslim communities)
Specific priority areas for understanding the mental consequences of child marriage on mental health	1. The impact of child marriage on mental health can include withdrawal, depression, anxiety, suicidal tendencies, and a sense of abandonment. 2. The trauma experienced by people married young and impacts on their mental health 3. Understanding the mental health impacts of child marriage on the children of those married before 18 is important 4. Understanding the mental health impact among people experiencing child marriage, who feel that their marriage is not living up to their expectations is important.
Potential forms of mental health and psychological support	1. Psychosocial treatments are beneficial for people married early, to address the mental health consequences of child marriage 2. Increasing the availability of general mental health support and services in rural or complex settings could benefit the mental well-being of individuals who married early 3. Social interventions to promote the mental health of people who married early should be community-based and locally grounded for the biggest impact 4. The social empowerment of women (e.g. through social-capital interventions) can help to increase autonomy and self-reliance, subsequently reducing child marriage and its impact on mental health

Table 3. Caption.

Future priorities for the mental health and child marriage field: final consensus statements
Perspectives on early, child, and forced marriage and its relationship to mental health	1. It is important to understand the mental health impacts of child marriage 2. Changing social norms is a mandatory part of reducing mental distress caused by the practice of child marriage 3. An individual’s location within society has a direct impact on the relationship between mental and child marriage (e.g. caste, ethnicity, race, sexuality, class, gender) 4. Intimate partner violence poses significant risks to the mental health of those married young 5. It is important to understand the intergenerational dynamics (i.e. in families or communities across generations) of child marriage.
Perspectives on policy approaches in the field	1. Engagement with policy leaders in child marriage needs new forms of advocacy to highlight mental health as important. 2. Future policy (and research) must reflect the full range of communities where child marriage is practiced (e.g., Jewish Hasidic communities, Pentecostal/Mormon communities, Irish/Roma travelers, and Muslim communities)
Specific priority areas for understanding the mental consequences of child marriage on mental health	1. The impact of child marriage on mental health can include withdrawal, depression, anxiety, suicidal tendencies, and a sense of abandonment. 2. The trauma experienced by people married young and impacts on their mental health 3. Understanding the mental health impacts of child marriage on the children of those married before 18 is important 4. Understanding the mental health impact among people experiencing child marriage, who feel that their marriage is not living up to their expectations is important.
Potential forms of mental health and psychological support	1. Psychosocial treatments are beneficial for people married early, to address the mental health consequences of child marriage 2. Increasing the availability of general mental health support and services in rural or complex settings could benefit the mental well-being of individuals who married early 3. Social interventions to promote the mental health of people who married early should be community-based and locally grounded for the biggest impact 4. The social empowerment of women (e.g. through social-capital interventions) can help to increase autonomy and self-reliance, subsequently reducing child marriage and its impact on mental health

6. Conclusions and Insight for Future Studies

The findings from the reviewed literature indicated that female young adults are vulnerable to developing mental health disorders. Through our systematic review study, child marriage and mental health in Africa are under-researched, which explained the noticeable dominance of grey literature in Table 2. Besides, previous studies focused more attention on how lived experiences of young female adults are potential threats to mental health disorders while significantly ignoring intervention solutions. The systematic review has therefore assisted to identify gaps in the literature and created opportunities for future studies.

We observed from the reviewed literature that mental health in young female adults is linked to early and child marriages (Callaghan et al, 2015), which is associated with young female adults low educational achievement, unemployment, substance abuse, risk behaviors, self-harm, poor provision of the healthcare system, and poverty (Kessler et. al, 2007). Their mental health is also associated with their family background, childhood abuse, violence in the neighborhood, loss, and grief, social exclusion, unintended pregnancy, and chronic diseases (WHO, 2021 & 2019; Dahmen et al, 2019 & Hodgkinson et al, 2014). Even their lifestyle includes being forced into sex work, trafficked, disabled, orphaned, HIV/AIDS, suicidal thoughts, and traumatic stress (Shiferaw et al., 2018).

Unfortunately, intervention programs were less investigated. Appropriate cultural-community-based policy initiations were also very silent in the reviewed studies. Future studies should be conducted in these critical identified areas to address child marriage in Africa.