Background: India as one of the rapidly developing economies where health challenges are myriad at the population level has the highest number of maternal death in the world. Understanding risk factors for maternal mortality is paramount because maternal health is the basic indicator for the overall adequacy of healthcare of a country. This study was conducted to review on the various risk factors of maternal mortality and the multifarious challenges for maternal health in India. Methods: A literature search was conducted with PubMed and Google scholar using the key words of (“risk factors” AND (“maternal mortality” OR “maternal death”) AND India) for articles published from 1970 to May 2014. PubMed was primarily used for the systematic search. Findings: Twelve studies were identified for the final review of which six were case series studies, three were case studies and three were case control studies. Most of the studies were conducted in institutional settings from the five regions (North, South, West, Central and East) of India with different range of Maternal Mortality Rate (MMR) estimates. Previous literature had highlighted socio economic disadvantages as important determinants for maternal mortality. The current review shows a complex interplay of four factors in general in India: social, obstetrical, behavioural and medical factors. Variables of both social demographic and economic factors such as median age of the women at childbirth, literacy rate of the female population and area of residences are put together in the social factors of this study. Compared to the causes, descriptions on behavioural risk factors were rather limited and so the requisite to examine the risk factors affecting maternal mortality is justified. Intervention strategies include conditional cash transfer scheme, voucher scheme, training of village health volunteers and training of auxiliary mid wives’. Conclusions: India has a unique social system of diversity and stratification. The pattern of maternal mortality in India is different and varied widely in zones or regions. The variations of challenges should be highlighted so as to give a clear grasp of the inequalities of maternal health as well as also help in reducing the MMR substantially. / published_or_final_version / Public Health / Master / Master of Public Health

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A thesis submitted to the faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa; in fulfillment of the requirements for the award of PhD in Demography and Population Studies. September, 2016. / Background: While there has been a significant global reduction in maternal mortality rates from 546 000 in 1990 to 287 000 in 2010 (Zureick-Brown et al., 2013;Merdad, et al., 2013), maternal mortality in Zambia continues to be above at 483 per 100 000 live births, eluding the millennium development target of 162 (CSO, 2012). Data on maternal mortality are not disaggregated by provinces. Various studies on maternal mortality conducted in Zambia (Ahmed et al., 1999; Banda et al., 2007; Hazemba & Siziya, 2009; Kilpatrick, Crabtree & Kemp, 2002) have evaluated maternal deaths at national level using direct death inquiry and though it is useful for international comparisons, neither one of these approaches are appropriate for evaluating maternal mortality in small districts where safe motherhood initiatives are often carried out. These studies have rarely included neighbourhood influence on maternal mortality risks. Moreover, no known study has attempted to use the Zambia Demographic and Health Survey maternal health indicators to evaluate maternal mortality by regions in Zambia. Yet, analyses of differentials within small districts provide an improved awareness of the social situation in which the risks are high for regional priority interventions. In addition, other researchers (Achia & Mageto 2015; Stephenson & Elfstrom 2012) have all posted that inclusion of neighbourhood level variables is helpful to understand several maternal health outcomes. Objective: Guided by the conceptual framework developed by McCarthy & Maine (1992), this study contributes the new method of use of the mean Maternal Death Risk Factor Index model to estimate the levels and differentials in the risks of maternal mortality by regions and enhance the understanding of determinants of maternal mortality risks. This model is helpful in that it highlights regional and socioeconomic differentials in maternal mortality risks and ranks regions according to their potential maternal mortality burdens. Benchmarks are set by using this model and indicators are used to identify probable high-risk areas or regions. Methodology: The study utilised existing data sources from the 2007 Demographic and Health Surveys (DHS) and 2011-2013 Health Management Information System Routine Data (HMIS). Bivariate analysis was utilised to investigate the distribution and differentials in exposure to maternal mortality risks. Multilevel logistic regression was performed to investigate the independent and moderating functions of neighbourhood aspects on exposure to maternal mortality risks and the moderating functions of neighbourhood causes on the relationship between individual circumstances and exposure to maternal mortality risks. The mean Maternal Death Risk Factor Index (MDRFI) model that uses the history of individual women health indicators was used to predict maternal mortality and highlight regional and socioeconomic differentials of maternal mortality risks. The analysis was based on 5 410 women aged 15 to 49 who had a live birth in the five years prior to the 2007 Zambian Demographic and Health Surveys. The HMIS 2011-2013 data was also utilised for a comparative analysis and complementing DHS data on maternal health matters in Zambia. Results: The predicted maternal mortality ratios (MMRs) values by region showed larger regional disparities. All the seven rural regions had MMR above the national average (591/100 000 live births); the highest being in Northern Zambia (738 per 100 000 live births) and Central Zambia (679 per 100 000 live births). The predicted ratios in the two urban regions of Lusaka and Copper-belt were significantly below the national average. The findings of both bivariate and multivariate analyses showed that skilled birth attendance at delivery significantly lowered the risks of exposure to adverse pregnancy outcome. The likelihood of using skilled personnel at birth was advanced for women who resided in neighbourhoods, with advanced proportion of women who utilized skilled delivery at birth compared to women who lived in neighbourhoods that had a high proportion of women giving birth at home. The outcome from the multilevel analysis showed that the consequence of individual and neighbourhood influences on the exposure to high risk pregnancy in Zambia operates at different levels. Women with no education were found to be more exposed to high risk pregnancy than women with post primary education. The rate of women in the neighbourhood who utilized skilled birth attendance had a strong positive impact on the reduction of exposure to high risk pregnancy. In the analysis of autonomy level – although results indicated that women with low autonomy had higher odds of exposure to high risk pregnancy compared to women with high autonomy – the results were not significant, and therefore autonomy level in terms of exposure to high risk pregnancy was not supported in this study. Conclusion: The MDRFI model is much easier to use at any level and quicker to forecast interventions as well as prevent probable risks compared to the use of the sisterhood method. The model proposed here could serve as the basis for a new and better system of mortality estimation for populations with incomplete data. The results reveal a number of challenges to confront with the purpose of reducing maternal mortality in Zambia. Women’s high risk reproductive behaviours and the use of imperative fertility healthcare utilities have yet to increase considerably to result in a decrease in maternal deaths in the nation. The continuous disparities in maternal death hardship by province, rural-urban dwelling and socioeconomic position of the society further heightened the issue, making attempts to enhance maternal health and thereby decrease maternal deaths more demanding. Advancements to lower maternal mortality should either lessen the probability that a woman will become pregnant or lower the possibility that a pregnant woman will experience adverse reactions during pregnancy or childbirth or better the outcomes for women with complex pregnancies. This research makes it evident that programs to combat maternal mortality risks in the country require several avenues that embrace diverse protective measures looking beyond the individual level as women’s health is essentially affected by their social environment. The amount of differential at neighbourhood and individual level found in our study indicates the need to contextualise efforts to increase resources towards mitigating exposure to high risk pregnancy. Hence, adopting neighbourhood-specific strategies along with identifying and addressing neighbourhood factors affecting the exposure to high risk pregnancy would give better results. The use of multilevel analysis in this research has shown that individual and neighbourhood aspects are crucial components associated with the exposure to high risk pregnancy. The multilevel framework demonstrated crucial neighbourhood differentials in the exposure to high risk pregnancy. Improving quality and access to health services is essential if the most deprived are to benefit. The Ministry of Health should align its plans of action to Zambia’s development strategy articulated in its own Vision 2030. Neighbourhood health workers need to be involved in sensitising pregnant women about the risks of maternal mortality, for instance short birth interval, risky maternal age and danger signs during pregnancy. To close the gap in exposure to high risk pregnancy between neighbourhoods, interventions should aim at poverty reduction, increasing neighbourhood maternal education and facility delivery in deprived neighbourhoods. The model used in this study could serve as the basis for a new and better system of mortality estimation for populations with incomplete data and will be much easier to use at any level, as well as vital for quick forecasting of priority interventions. / GR2017

While significant progress has been made towards improving health outcomes in low-resource settings, unacceptably high maternal mortality remains a problem. Efforts to improve maternal mortality in low-resource settings did not yield intended results. One hypothesized reason for insufficient maternal mortality progress is poor interpersonal quality of care during childbirth at health facilities. Qualitative studies support the assumptions of quality of care frameworks that connect structural inputs (e.g. drugs and supplies, equipment, human resources) to interpersonal quality. However, there is no quantitative evidence for this relationship. Further, although maternal health researchers developed quantitative tools to measure interpersonal quality of care, the construct is mainly operationalized as a single, bipolar dimension, measured as respectful maternity care (good care) or disrespect and abuse (poor care). To address these limitations, this dissertation used an epidemiologic perspective to test the underlying assumptions of quality of care frameworks and to create a robust measure of interpersonal quality of care. This dissertation consists of three parts: an empirical study to test the hypothesis that structural inputs have a positive effect on interpersonal quality of care; a systematic review of the literature of instruments measuring the construct of interpersonal quality of care and their reliability, validity, and dimensionality; and an empirical study to assess the dimensionality and construct validity of the Maternal Health Interpersonal Quality Scale, a measure of interpersonal quality of care. The first empirical study did not find meaningful associations between HIV structural inputs and maternal health structural inputs and interpersonal quality of care during childbirth. These results do not support the assumptions of quality of care frameworks nor qualitative evidence linking structural inputs and interpersonal quality of care. The systematic review suggested that the construct of interpersonal quality of care is not well-defined, that few instruments met psychometric standards for adequate reliability and validity, and that studies that assessed the instruments were generally of poor quality. The second empirical study found that interpersonal quality of care formed a two-dimensional, correlated structure, with one dimension measuring respectful maternity care and one dimension measuring disrespect and abuse. Overall, this dissertation used an epidemiologic lens to address an implementation problem in maternal health. While there is a need to improve interpersonal quality of care during childbirth, in order to impact change and to avoid implementation failure, it is imperative to ensure interventions have a strong evidence base and to use validated measures of the construct.

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The SA National Department of Health made maternal deaths notifiable in 1997. It also commissioned a National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) to confidentially investigate all maternal deaths, to write the "Saving Mothers Report" and to make recommendations based on the findings of the study. The Department of Health in 2003 commissioned an evaluation of the extent to which the 10 recommendations contained in the first "Saving Mother's Report" had been implemented. This rapid appraisal was carried out by Centre for Health and Social Studies (CHESS), University of Natal. A report 'The Progress with the Implementation of the Key Recommendations of the 1998 "Saving Mothers Report" on the Confidential Enquiry into Maternal Deaths in South Africa - A Rapid Appraisal," was published in 2003. The data collected on Recommendation 5 on the use of the obstetric partogram in 46 selected provincial hospitals in all the 9 provinces was only partially analysed in this report. This study reports on a secondary analysis of the 942 questionnaires that were completed on the use and application of the partogram in hospitals in South Africa. In the rapid appraisal experienced field workers evaluated the use of the partogram using a 36-point checklist. Provincial and national averages for each of these variables were calculated and hospitals were evaluated into how they performed according to these averages using Lot Quality Assurance Sampling methodologies. Using national and provincial averages, the hospitals in each province are compared with one another provincially and nationally. In addition, the application and use of partograms in areas and levels of hospitals are described. An attempt is made to show if there is relation between the number of deliveries and the recording of the partogram. The main findings were that, of all the provinces KwaZulu-Natal had the lowest number variables below the national average from the 36 variables used as a checklist. Eastern Cape and Limpopo had the highest number of variables below the national average. The hospital with the highest number below the national average is in the Eastern Cape. In the recording of the chart rural and level one hospitals are low in comparison with urban and level three hospitals. There was no relation in the recording of the chart and the number of deliveries. / Thesis (M.PH.)-University of KwaZulu-Natal, 2004.

The introduction outlines the reasons for the priority of maternal and child health emphasizing the relatively simple resources required. The aims of such programmes must be identified and the results measured so that services can be monitored and evaluated. Categories of measurement are defined and indicators of maternal child health identified within these categories. A chapter is devoted to an outline of the principal non-medical determinants based on material from the Inter-American Investigation of Childhood Mortality. The significance of the principal indicators viz. the perinatal mortality rate, the infant mortality rate, the maternal mortality rate and growth and development data are compared. Chapter lV presents a report of a questionnaire study into local indices viz. Stillbirth rates, Caesarean Section rates and Maternal Mortality rates. The uptake of certain clinic services was also determined. Differences between groups and possible reasons for these are discussed. The final chapter points out the need for accurate birth and death registration and a reliable health information system and suggests methods for achieving this. Recommendations are made for upgrading the collection of data and for improving maternal and child health by research and peripheralization of services. / Thesis (M.Med.)-University of Natal, Durban, 1981.

Theses ( MPH.) -- University of Limpopo, 2021 / Background: Maternal mortality is a significant public health problem worldwide, and is a vital indicator of the functioning of a health system. The South African maternal mortality ratio is higher than other countries with same economic growth, despite people having free access to maternal health. How to develop relevant policies and programmes to reduce maternal mortality factors contributing to maternal mortality was investigated. Aims of the Study: To investigate the factors contributing to maternal mortality in public health institutions in the Sekhukhune District, Limpopo Province, South Africa. Methods: A quantitative, retrospective study was undertaken where 138 medical records of maternal mortality cases reported between 2013 to 2017 were reviewed. A simple random sampling method was used to select files that met the selection criteria from seven hospitals in the Sekhukhune District, Information was collected on maternal demographics and health service-related characteristics, including age, marital status, parity, antenatal care utilisation of services and delivery type. Inferential data were analysed using the student t-test and SPSS version 25. Results: The mean age of the women involved in this study was 30 years, with a standard deviation of 5.7. All the women who participated in the study were black African. The majority of maternal mortality occurred in hospital. The women in the majority of maternal mortality cases were unemployed, at 93.5%, while most of the maternal mortality cases involved single women (71%).The women involved in these maternal mortality cases booked their ANC care and the major health provider was a professional nurse (58.0%), while 57.2% of the participants attended their ANC at primary healthcare facilities. Most of the maternal deaths occurred after delivery (58.7%) and, in most deliveries, the Partogram was not used (66%). HIV testing occurred in 99% of the maternal mortality cases. The causes of maternal mortality were both direct (71.0%) and indirect (23.9%) causes. The leading cause of maternal mortality was direct haemorrhage (33%), followed by eclampsia (27%) and infection (16%). The leading indirect cause was respiratory causes (22%) and retro viral disease (RVD) (9%). The personal factor that contributed most to maternal mortality was delay in seeking help (62%). v Conclusion and Recommendations: The personal factor, delay in seeking medical help by the women, contributed to maternal mortality and it was further concluded that the majority of maternal mortality cases did not occur as a result of any complications in ANC and delivery. It is recommended that the training of healthcare providers in the utilisation of the Partogram be implemented to improve skills in the management of haemorrhage and eclampsia. Furthermore, the management of complications needs to be strengthened through a multi-sectorial approach. / SAMRC

BACKGROUND: Maternal mortality remains a persistent public health concern in Sub-Saharan African countries such as Ethiopia. The Ethiopian Ministry of Health has made it a priority to improve maternal health outcomes within the country. Health information technology (HIT) solutions are a flexible and low-cost method for improving health outcomes and have been proven beneficial in low-to-middle income countries, like Ethiopia. The aims of this dissertation were: (a) to characterize the use of HIT usability evaluations in Africa; (b) to quantify facility clinical readiness for obstetric emergencies; (c) to explore the obstetric emergency supply chain dynamics and information flow; (d) to create a visualization dashboard to monitor obstetric emergency readiness; and (e) to evaluate the usability of the dashboard. METHODS: This dissertation comprised six studies with a variety of quantitative and qualitative methods: (1) a scoping review of the literature to identify the types and timing of HIT evaluations occurring in Africa; (2) a prospective, cross-sectional, facility-level comparison of obstetric emergency clinical readiness in Amhara, Ethiopia as measured by the Signal Functions and Clinical Cascades methods; (3) qualitative semi-structured interviews to gain an understanding of the current supply chain in the region, communication flow, and the current barriers and facilitators to success; (4) a case study summarizing the process for the development of the dashboard prototype through integrating existing technology, current literature, and qualitative interview findings; (5) user-centered design sessions with individuals who interact with the obstetric emergency supply chain to create an electronic dashboard prototype to monitor facility readiness to manage obstetric emergencies; and (6) expert review of the dashboard including sessions with a domain expert and information visualization experts and a heuristic usability evaluation with human-computer interaction experts to evaluate and improve the ease of use and usefulness of the prototype. RESULTS: The scoping review found that many usability evaluations in Africa lacked theoretical frameworks to support their work, and that most studies occurred later in the development process when the HIT was close to implementation in practice. The quantitative analysis of facility readiness found that many facilities were missing critical supplies for managing obstetric emergencies and identified a 29.6% discrepancy between the Signal Function tracer items and the Clinical Cascades readiness classifications indicating that the former, which is recommended by the World Health Organization, overestimates facility readiness. The qualitative interviews identified several locations within the current obstetric emergency supply chain where barriers such as bridging the gap of data availability between facilities and regional hubs could be addressed to improve overall facility-level readiness and pointed towards a dashboard as a potential solution. Once a prototype dashboard was developed, user-centered design sessions refined the terminology and colors that should be used throughout the dashboard screens and identified critical graphics and data elements that users believed should be included. Following domain and visualization expert review and iterative refinement of the dashboard, human-computer interaction experts rated the dashboards highly usable. CONCLUSIONS: Dashboards are a novel method for promoting facility-level readiness to manage obstetric emergencies. By exploring the existing supply chain and including targeted end-users and experts in the design process the author was able to tailor the dashboard to meet user needs, fit into the existing integrated pharmaceutical logistics system, and ensure that it follows best practices. Consequently, these studies contribute to strategies to address maternal mortality in Ethiopia.

Over the last 20 years, adolescent health researchers, practitioners and advocates have zeroed-in on the global problem of ‘child marriage.’ Defined as a formal or informal marital union before 18 years, child marriage affects both boys and girls, but disproportionally affects girls. Globally, child marriage is noticeably prevalent but on a downward trend, with the proportion of 20-24 year old women marrying before 18 years decreasing from 25% to 19%, from 2008 to 2020 (UNICEF, 2018; 2022). Extensive research has shown the adverse consequences of marrying during adolescence, ranging from increased risk of maternal mortality and birth complications, intimate partner violence (IPV), adverse mental health and intergenerational poverty outcomes (Burgess et al., 2022; Clark, 2004; Nour, 2009; Otoo-Oyortey & Pobi, 2003; UNICEF, 2018). From a rights perspective, child marriage is considered a violation of girls’ and boys’ ‘right’ to fully consent into marriage before reaching age of majority, internationally recognized as 18 years of age (Bruce, 2003; Nour, 2009). As such, child marriage is recognized as a human rights violation under several international treaties, including the Convention on the Rights of the Child (CRC). The term ‘child marriage’ is commonly used to convey the human rights violations that early marital practices have for under-age girls and boys. While the term ‘child marriage’ has mobilized consensus and solidarity toward the issue, this terminology also homogenizes the issue of marriage as a problem affecting the ‘girl child’ with little to no agency in the marriage decision-making process. More specific to Uganda, this ‘child marriage’ terminology can be problematic where marriage more commonly occurs during middle to late adolescence (15-19 years) and when adolescents may exert varying degrees of agency and consent in the marital decision-making process. Except for Chapter 1 which explores ‘child marriage’ global and national movements, I intentionally use the terminology ‘adolescent marriage’ (as marriage before age 18), rather than ‘child marriage,’ throughout this dissertation. Despite the global push to ‘end child marriage’ over the last decade, there is limited research about how broader social and structural factors may be driving declines in adolescent marriage (Muthengi et al., 2021; Plesons et al., 2021). In particular, we have a limited understanding about how global efforts, social processes and norms might work together to drive marriage declines among adolescents. Through a mix of policy, quantitative and qualitative methods, this dissertation examines the policy, structural and social mechanisms that have contributed to declining adolescent marriage among adolescent girls in the context of southcentral Uganda. Chapter 1 begins with a broader contextual lens, examining the political evolution of the global ‘child marriage’ movement, and how the ‘problem’ of child marriage was then taken-up by government and civil society actors in Uganda. This chapter is informed by 20 key informant interviews with Ugandan and global stakeholders working on child marriage and a desk review of over 130 documents gathered across four years. This chapter highlights how the global ‘child marriage’ movement marked a political shift in adolescent girl funding, repackaging the issue of early marriage as an issue of ‘child protection.' The focus on child protection, rather than adolescent sexuality, was instrumental in mobilizing attention from liberal and conservative funders in the Global North and policy-makers in the Global South. In the priority country of Uganda, multiple factors influenced the national policy uptake of child marriage, including: 1. Regional campaigns that created consensus among Eastern and Southern African country leadership to address child marriage; 2. The availability of national data that showed the reach and severity of child marriage within Uganda; 3. The cultural and political appeal of child marriage as an issue of ‘child rights’, rather than one of ‘sexuality,’ and; 4. A network of government leaders, academics, international non-governmental organizations (INGOs) and civil society organizations (CSOs) who coalesced behind the issue in Uganda. Chapter 2 focuses-in on the southcentral region of Uganda, leveraging close to 20 years of quantitative data to understand how social and structural factors are affecting adolescent marriage declines in the region. Using data from 13 surveys (1999-2018) of the Rakai Community Cohort Study (RCCS), I couple decomposition and causal inference methods to assess how social determinants and adolescent pregnancies have contributed to adolescent marriage declines among 15 to 17 year old girls. I find that both marriages and pregnancies among adolescent girls substantially declined over the last 20 years, from 24% to 6%, and 28% to 8%, respectively, between 1999 and 2018, as a result of educational and economic improvements. Among all social determinants, girls’ secondary schooling was more closely associated with lower risk of marriage and pregnancy (aOR marriage = 0.09; 95%CI=0.07, 0.12; aOR pregnancy = 0.14; 95% CI=0.11; 0.19). In the causal mediation analyses, lower pregnancy rates partially explained the positive effect of higher secondary schooling on lower risk of adolescent marriage. Decomposition analyses showed that the declines in adolescent marriage between 1999 to 2018 were primarily attributed to pregnancy declines, and to a lesser extent, improvements in education and SES. These findings reemphasize the sizeable role of education in preventing adolescent marriages, in line with Uganda’s national educational investments such as universal primary education (UPE). Yet, these findings also underline the importance of adolescent pregnancy prevention to delay age at marriage. In the same region of southcentral Uganda, Chapter 3 uses secondary ethnographic data to more deeply explore the social mechanisms and norms that have contributed to changes in adolescent marriages. I qualitatively explore how the region’s social and economic changes have affected social norms about adolescent sex, courtship, and marriage in Rakai, Uganda. This analysis is informed by 16 focus group discussions and 15 key informant interviews conducted in 2018 with younger and older women and men, ranging from 16 to 77 years old. In comparing generational perspectives, I identify a ‘normative transition’, in which new structures are transforming courtship and marriage processes for young people. First, the HIV epidemic significantly weakened family structures, and in the process, courtship and marriage guidance previously provided by families and elders; second, the loss of land ownership in between generations has made marriage preparations more difficult for young people; and third, new social spaces outside the family home – including discos, mobile phones and schools - have expanded young people’s romantic geographies prior to marriage. These changes have reduced the importance of the family institution in the marital decision-making process, while increasing young women’s and men’s autonomy in engaging in premarital sex, choosing their partners, and delaying marriage. Although these changes have delayed age at marriage beyond adolescence, this transition has introduced unanticipated challenges for young people as they enter adulthood, including lack of overall parental, familial and elder guidance in their relationship and marriage formation processes. Taken together, these findings highlight the complexity of adolescent marriage changes and prevention efforts at the global, Ugandan, and southcentral region of Uganda. First, global and national ‘child marriage’ movements played a significant role in the uptake of child marriage as an issue of ‘child protection’, rather than one about ‘sexuality’ in Uganda. Yet looking at the context of southcentral Uganda, adolescent pregnancies and adolescent marriages declines appear to be closely linked, highlighting the importance of conceptualizing adolescent marriage as not just a child protection issue, but one of adolescent sex and sexuality. Lastly, I find that broader structural and social changes in Rakai have substantially changed adolescent norms around sex, courtship, and marriage, delaying age at marriage in between generations. However, young people are encountering new challenges as they enter adulthood and romantic relationships in the absence of pre-existing elder and familial systems and networks. Additional research should focus on understanding the unintended consequences of catalyzing norm change and delaying age at marriage, including how these changes might affect familial and community relationships and kinships. Twenty years into the global push to end ‘child marriage’, this dissertation research provides new insights into the complex structural, social and sexuality drivers of adolescent marriage changes in Uganda. Despite the substantial progress in adolescent marriage declines, this research points to key gaps that will need to be addressed to improve adolescent SRH rights and needs in Uganda, the East African region, and beyond. Of particular importance is the need to center adolescent sexuality within current child marriage efforts, as well as focusing on the broader social changes affecting adolescent relationship formation, rather than exclusively focusing on age at marriage as a marker of social change.