t age 21, she has been married now for three years to a young man she met just after finishing secondary school. He treats her well. She almost died during the birth of their first child, born a year after their marriage; the second child, born 18 months later, was also a girl. Lately she and her husband quarrel frequently. She wants to use contraception—and go to vocational school to gain skills to supplement the household income—but his mother insists on grandsons.

Health Risks of Early Marriage

Early marriage is still the norm in many parts of the world. Early marriage usually leads to early motherhood. In many developing countries, at least 20 per cent of women—in some countries about half of all women—give birth to their first child before age 18. Expectations from parents, in-laws and society are to produce a child as soon after marriage as possible. Many young wives feel pressure to bear sons. This typically results in pregnancies being spaced too closely together, in addition to occurring too soon in the young mother’s life.

In developing countries, more than half a million women die every year from pregnancy-related causes. There are four important reasons for these deaths. Births are either "too soon, too close, too many, or too late". Statistically, it is young women who most often die during pregnancy.

Women who marry or enter union at a young age are likely to have husbands who are much older than they are—up to 15 years older in some countries. This difference in age reduces the chance that the woman will be able to participate in decisions about childbearing or be able to negotiate the use of contraceptives.

Family Forms and Norms are Changing

Everywhere the family is in transition. Marriage and unions increasingly take a great variety of forms:

• In many countries, the expectation of marriage leading to immediate childbearing is eroding and new types of relationships are becoming common.
  
  
• In Latin America and the Caribbean, many couples live in consensual unions without legally marrying.
  
  
• In developing countries, the proportions of young people who are unmarried into their thirties continues to increase.
  
  
• Everywhere the proportion of female-headed households is increasing. Whatever form a particular family takes, the challenge remains for children born to be given the best possible chances for a good future.

Family Planning and Contraception

One of the most important choices a woman or couple can make is the decision to use contraception. Even if a couple wants a child as soon as possible after marriage, the use of contraception thereafter—for child "spacing"—is a sensible decision. Data show that optimal spacing between children is at least three to four years. Family planning allows parents to give the child the best chance possible for the nourishment and nurturing it needs—before another child is born. Spacing is also important for the health of the child’s mother and the harmony and financial health of the family unit. Similarly, using contraception to limit the number of children to only those that the couple can truly care and provide for is also a wise decision. For many couples, use of contraception also contributes to a more satisfying sexual relationship by reducing or eliminating the fear of accidental unwanted pregnancy.

It is crucial for the well-being of children, families, and communities that family planning information and services be available to help women and men learn about and effectively use a method of contraception.

Husband-Wife Communication

The ideal situation is good communication between husband and wife about the spacing and number of children they will have. Some women are lucky and are able to make decisions about family planning and family size in collaboration with their husbands. Others, particularly newly married and younger women, have little or no decision-making power in the home, and husbands, parents or mothers-in-law decide for them. Still others use contraception clandestinely, fearing husbands or relatives will disapprove.

Women may be afraid out of a sense of modesty or shame to talk to their husbands about family planning. Some say they are too shy to begin discussions with their husbands; others fear their husband's response or worry that their knowledge of sexual issues could be interpreted as promiscuity or infidelity. Conflicts arise about when to have intercourse, whether to use contraception, which method to use, spacing of children, and when the children already born are enough. Many men say their role as financial provider gives them authority to decide how many children the family can afford. Contraceptive use, however, is usually considered the woman's responsibility.

In many cultures it is believed that men have rights to control their wives’ childbearing. Thus in many countries the law requires a husband’s consent when a woman wants to undergo sterilization. With higher levels of education, couples are increasingly likely to communicate effectively on family planning and use of contraception to space their children and keep their families small. And increasingly men are adopting new models of masculinity that include being a responsible, caring husband and father.

Impacts of Unwanted Pregnancy

Many women in every country—more than half in some countries—say their last pregnancy or child was unwanted or mistimed. Unwanted pregnancies and births can have many negative consequences, for the children themselves, their siblings, their parents, and the society as a whole. Older women, and women who have already borne several children, face increased risk of complications and death in childbirth, especially in conditions of poverty and where health facilities are far away.

More than one in four pregnancies worldwide each year ends in abortion, many performed under clandestine and unsafe conditions. Unsafe abortion is a major cause of maternal death worldwide and has a devastating public health impact—as measured by deaths, illnesses, injuries and the costs of emergency care. More than half of women seeking abortions are married with children, although in many countries the proportion of young, unmarried women having abortions is increasing. Expanding family planning services reduces the numbers of abortions—and the number of women who die as a consequence of unsafe abortion. This is especially true when greater access to contraception is combined with effective sexuality education.

Safe Motherhood

Half a million women die each year due to complications of pregnancy and childbirth; 99 per cent of these deaths occur in developing countries. Increased access to family planning can reduce the maternal mortality rate by reducing the number of pregnancies among women of reproductive age.

The primary means of preventing maternal deaths is to provide rapid access to emergency obstetric care, including treatment of haemorrhage, infection, hypertension and obstructed labour. It is also important to ensure that someone with midwifery training is present at every delivery; in the developing countries, only 51 per cent of all births are professionally attended. Life-saving interventions, such as transportation to medical centres, antibiotics and surgery, are unavailable to many women, especially in rural areas. These women may lack the money for health care or transport, or may simply lack the permission of their husbands to leave the village to seek care.

Sexual Health, STDs and HIV/AIDS

Sexual health and a healthy sexual relationship are important in a marriage and in holding a family together. Unfortunately, sexually transmitted diseases (STDs), including HIV/AIDS, are an increasingly common threat to a healthy marriage. A husband’s extramarital relations now carry the risk that not only he may become infected but that he may bring home infection that could also kill his wife. The converse is also true, though less frequently so.

Today an estimated 33.6 million people are infected with HIV/AIDS. About 5.6 million people became newly infected in 1999. 35 More than 90 per cent of these live in developing countries where HIV is most commonly spread through heterosexual transmission. 36 HIV/AIDS has become a global pandemic, recognizing no national borders and posing threats that many countries have yet to acknowledge. The pandemic is a profoundly destabilizing force, destroying families and communities, sowing misery and tragedy on a wide scale and retarding the development prospects of entire nations.

Men are twice as likely as women to infect their partners. Women are biologically more vulnerable to infection. In addition, many women do not understand the nature of STD/HIV trans-mission and many are in denial about their husband’s extramarital sexual activity. Finally, most women do not have the power to deny intercourse to their husbands or partners, or to insist they use a condom.

The transmission of HIV is facilitated by the presence of other sexually transmitted infections, especially ulcerative infections. Each year there are 12 million new cases of syphilis, 89 million of chlamydia, 62 million of gonorrhoea, and 170 million of trichomoniasis. Here, too, women are at greater risk.