PhD Paper of Syeda Zerin Imam

DETERMINANTS OF ADOLESCENT PREGNANCY AND MATERNAL MORBIDITY IN BANGLADESH

This paper Is Prepared For The Partial Fulfillment of The Requirements Of The Doctor of Philosophy Degree Of Shandong University, Jinan, Shandong, China

Syeda Zerin Imam

ID # D2017103

DOCTOR OF PHILOSOPHY PROGRAM

SCHOOL OF PUBLIC HEALTH

SHANDONG UNIVERSITY

JINAN, SHANDONG

CHINA

2026

ABSTRACT

Adolescent pregnancy remains a persistent public health and social challenge in Bangladesh, often resulting in elevated risk of maternal morbidity and long-term adverse health outcomes. This study investigated the prevalence and determinants of maternal morbidity during the first pregnancy among adolescent and young mothers in selected urban and rural settings of Bangladesh.
Employing a cross-sectional design, the study collected primary data from 940 respondents who had experienced at least one pregnancy. A structured questionnaire was used to gather information on socio-demographic characteristics, reproductive history, sexual behaviour, exposure to violence, social support, and maternal health outcomes. Data were analysed using bivariate chi-square tests and multivariable logistic regression models with robust standard errors.
The findings revealed an exceptionally high prevalence of any maternal morbidity during the first pregnancy (75.32%), with significantly higher rates in rural areas (80.38%) than urban areas (70.17%). Key independent risk factors identified in the multivariable analysis included experience of sexual violence (AOR = 53.92, 95% CI: 12.70–228.90, p<0.001), rural residence (AOR = 3.26, p<0.001), and husband’s higher education level. Protective factors were respondents’ own higher education, larger family size, and stronger social support.
The study also documented widespread school drop-out (85.64%), extremely low exposure to formal sex education (1.17%), and early sexual debut. These results underscore the complex interplay between structural vulnerabilities, gender-based violence, limited reproductive agency, and intergenerational patterns of early marriage in shaping maternal health outcomes.
This research contributes to the existing literature by providing robust empirical evidence on the determinants of maternal morbidity among adolescent mothers in Bangladesh. The findings have important implications for policy and programme design aimed at delaying marriage and sexual debut, preventing gender-based violence, strengthening social support systems, and expanding comprehensive reproductive health education in resource-constrained settings.
Keywords: Adolescent motherhood, maternal morbidity, sexual violence, social support, reproductive health, Bangladesh

EXECUTIVE SUMMARY

Adolescent pregnancy in Bangladesh remains a complex public health and socio-cultural issue, deeply intertwined with poverty, gender inequality, early marriage, and limited reproductive agency. This research examines the prevalence, patterns, and multifactorial determinants of maternal morbidity during the first pregnancy among adolescent and young mothers in selected urban and rural areas of Bangladesh.
Utilizing a cross-sectional study design, primary data were collected from 940 respondents who had experienced at least one pregnancy. A structured questionnaire encompassing socio-demographic characteristics, reproductive history, sexual behaviour, exposure to violence, social support, and maternal health outcomes was administered. Data were analysed through bivariate chi-square tests and multivariable logistic regression models with robust standard errors to identify independent predictors of maternal morbidity.
The study found an alarmingly high prevalence of any maternal morbidity during the first pregnancy (75.32%), with a marked rural–urban disparity (80.38% in rural vs. 70.17% in urban areas). Multivariable analysis revealed that experience of sexual violence was the strongest risk factor (AOR = 53.92, 95% CI: 12.70–228.90, p < 0.001), followed by rural residence (AOR = 3.26, p < 0.001) and husband’s higher education. Significant protective factors included the respondent’s own higher education, larger family size, and stronger social support. The study also documented widespread school dropout (85.64%), extremely low exposure to formal sex education (1.17%), and early sexual debut (44.06% before age 15).
This research makes several important contributions to the existing body of knowledge. It provides robust empirical evidence on the critical role of sexual violence and social support as key determinants of maternal morbidity in the context of adolescent motherhood in South Asia. By integrating socio-demographic, reproductive, and psychosocial factors into a single analytical framework, the study advances a more holistic understanding of the pathways leading to adverse maternal health outcomes.
The findings carry significant policy and programmatic implications. They underscore the urgent need for multi-sectoral interventions that address not only clinical maternal health services but also the underlying structural drivers, including prevention of child marriage, elimination of gender-based violence, expansion of comprehensive sexuality education, and strengthening of family and community support systems. Special attention must be given to rural areas where vulnerabilities are more pronounced.
This thesis contributes to both theoretical understanding and evidence-based policy formulation aimed at improving maternal health and breaking the intergenerational cycle of disadvantage among adolescent mothers in Bangladesh and similar low-resource settings.

Chapter 1: Introduction

1.1 Background and Context

The health risks associated with adolescent pregnancy are well-documented. Compared to women aged 20–24, adolescent mothers face significantly higher risks of maternal mortality and severe morbidity, including anaemia, pregnancy-induced hypertension, eclampsia, obstructed labour, postpartum haemorrhage, and long-term disabilities such as obstetric fistula (Ganchimeg et al., 2014; Conde-Agudelo et al., 2019). Neonatal outcomes are equally concerning, with elevated rates of preterm birth, low birth weight, stillbirth, and neonatal mortality (Fall et al., 2015). Beyond immediate clinical risks, adolescent pregnancy disrupts education, limits economic opportunities, increases the likelihood of poverty, and perpetuates intergenerational cycles of disadvantage (Chandra-Mouli et al., 2017).

In low- and middle-income countries, these risks are amplified by structural vulnerabilities. Limited access to skilled antenatal care, poor nutritional status, and harmful cultural practices compound biological immaturity. Moreover, adolescent mothers often experience higher levels of intimate partner violence, social stigma, and psychological distress, further exacerbating health outcomes (Jewkes et al., 2010; Silverman et al., 2009).

Cultural Stigma, Conservativeness and Their Impact on Maternal Health

Cultural stigma and social conservativeness play a profound and often underestimated role in shaping the experiences of adolescent mothers in Bangladesh. In this highly patriarchal and collectivist society, an unmarried or early pregnancy is frequently perceived not merely as a personal misfortune but as a profound source of family disgrace and social dishonour. The young mother becomes a symbol of moral failure, disgracing her family, particularly her parents and male relatives, whose honour is closely tied to the perceived chastity and obedience of female family members. This deep-seated stigma manifests in multiple harmful ways: secrecy surrounding the pregnancy, delayed or avoided antenatal care, under-reporting of complications, social isolation, and heightened psychological distress. As a result, many adolescent mothers endure their health challenges in silence, often prioritising family reputation over their own well-being (Islam and Gagnon, 2014).

The intensity of this stigma in Bangladesh appears stronger than in many other South Asian contexts. In India, while stigma around adolescent pregnancy certainly exists, particularly in rural and conservative communities, it has been somewhat mitigated in recent decades through the efforts of community-based support groups, self-help initiatives, and active NGO interventions. Organisations such as those supported by the government’s Rashtriya Kishor Swasthya Karyakram (RKSK) programme have created safe spaces for young mothers, reducing isolation and encouraging health-seeking behaviour (Chandra-Mouli et al., 2017). In contrast, Bangladesh’s stronger cultural emphasis on family honour (izzat), female chastity, and collective family reputation continues to intensify isolation and psychological stress. Adolescent mothers often face ostracism not only from the wider community but sometimes even from their own extended families. This can lead to emotional withdrawal, depression, and reluctance to disclose symptoms such as bleeding, severe pain, or signs of infection, thereby worsening maternal morbidity outcomes.

Similar patterns of stigma-driven vulnerability are evident in other conservative Muslim-majority contexts. In Pakistan, Qureshi et al. (2022) describe how adolescent mothers frequently encounter social ostracism, verbal abuse, and restricted mobility, which directly contribute to delayed care and higher complication rates. In parts of Indonesia, particularly in conservative regions, adolescent pregnancy is similarly viewed through the lens of moral transgression, leading to family rejection and limited access to reproductive health services. However, what makes the Bangladeshi situation uniquely toxic is the potent intersection of multiple reinforcing factors: extremely early marriage, very low levels of formal sex education (only 1.17% in this study), widespread experience of sexual violence, and a health system that is still struggling to provide adolescent-friendly services. This combination creates a perfect storm in which stigma does not merely compound existing risks but actively amplifies them. A girl who becomes pregnant early is not only biologically immature but also socially marked, psychologically burdened, and often medically underserved.

The consequences of this stigma are both immediate and long-term. Immediately, it discourages timely antenatal care, nutritional supplementation, and skilled birth attendance. Psychologically, it contributes to chronic stress, anxiety, and depression — conditions that are known to exacerbate physical complications such as hypertension and poor weight gain. In the longer term, stigmatised adolescent mothers often experience reduced educational and economic opportunities, which further entrenches poverty and limits their ability to provide optimal care for their children. This creates a powerful intergenerational cycle: stigmatised mothers raise children in environments of disadvantage, who then face elevated risks of repeating the same patterns.

From a theoretical perspective, this phenomenon can be understood through the lens of intersectionality (Crenshaw, 1989) and gendered power relations (Kabeer, 1999). Adolescent mothers in Bangladesh occupy multiple intersecting positions of vulnerability — as young, female, often poorly educated, and frequently from rural or low-income backgrounds. Cultural stigma acts as a powerful social mechanism that reinforces these disadvantages rather than alleviating them. Unlike in more progressive contexts where social support systems and legal protections can buffer stigma, Bangladesh’s conservative social fabric often leaves adolescent mothers with few avenues for support or redemption.

Addressing this cultural dimension is therefore not peripheral but central to improving maternal health outcomes. Policy responses must go beyond clinical interventions to challenge harmful norms, promote community dialogue, and create safe, non-judgmental spaces for young mothers. Without tackling stigma head-on, even well-designed maternal health programmes are likely to achieve only limited success among adolescent populations.

In summary, cultural stigma and conservativeness in Bangladesh do not merely accompany adolescent pregnancy — they actively shape its health consequences. The exceptionally high morbidity rates observed in this study cannot be fully understood without recognising how deeply intertwined they are with societal attitudes toward female sexuality, family honour, and adolescent autonomy. Breaking this cycle requires both structural reforms and cultural transformation — a formidable but essential task if Bangladesh is to truly protect the health and dignity of its youngest mothers.

South Asia: A Region of Particular Concern

South Asia accounts for a substantial share of global adolescent births. The region is characterised by high rates of child marriage, low female autonomy, and significant gender disparities in education and economic participation. India, despite progress, continues to show wide interstate variations, with some northern states recording adolescent fertility rates above 50 births per 1,000 girls aged 15–19 (IIPS and ICF, 2021). Nepal and Pakistan also face persistent challenges driven by poverty, patriarchal norms, and limited access to reproductive health services (Maharjan et al., 2022; Qureshi et al., 2022).

Bangladesh occupies a particularly complex position within this regional landscape. Although the country has made notable strides in reducing overall fertility and improving some maternal health indicators over the past three decades, adolescent pregnancy remains stubbornly high. Recent data indicate that nearly 28% of women aged 20–24 years have given birth before the age of 18, and child marriage prevalence remains among the highest in South Asia (BBS, 2025; UNICEF, 2025). Early marriage and subsequent adolescent pregnancy not only disrupt girls’ education and economic opportunities but also contribute to a cycle of poor health outcomes that extends across generations.

Within Bangladesh, adolescent mothers consistently demonstrate poorer maternal health outcomes than their adult counterparts, a pattern that has been documented across multiple studies spanning several decades. Hospital-based research has repeatedly shown elevated risks of anaemia, pregnancy-induced hypertension, eclampsia, obstructed labour, postpartum haemorrhage, and puerperal sepsis among this vulnerable group (Alam et al., 2023; Hossain et al., 2024; Islam et al., 2017). For example, a large retrospective study at Dhaka Medical College Hospital found that adolescent mothers accounted for a disproportionate share of eclampsia and obstructed labour cases, with complication rates nearly twice those of women aged 20–24 years (Hossain et al., 2024). Community-level surveys in rural districts have similarly highlighted higher incidences of severe anaemia, postpartum depression, and long-term reproductive health problems, often directly linked to early marriage and inadequate antenatal care (Rahman et al., 2022; Chowdhury et al., 2021; Haque et al., 2022; Sultana et al., 2021).

However, the majority of existing evidence in Bangladesh comes from hospital-based or facility-centric samples. These studies tend to capture only the most severe cases that reach tertiary care, thereby systematically underestimating the true community-level burden. Moderate, chronic, or psychosocial morbidities — such as nutritional deficiencies, mild to moderate hypertensive disorders, emotional distress, fatigue, and long-term reproductive complications — frequently remain invisible in facility data (Khan et al., 2020; Paul and Rumsey, 2022; Ahmed et al., 2023; Begum et al., 2024; Kabir et al., 2020; Parveen et al., 2023; Uddin et al., 2022; Yasmin et al., 2021; Roy et al., 2024; Khan and Islam, 2023). This gap is particularly concerning because adolescent pregnancy is highly prevalent in the country, with nearly 28% of women aged 20–24 having given birth before age 18 (BBS, 2025; UNICEF, 2025). The reliance on facility-based data has therefore created an incomplete and potentially misleading picture of the everyday health challenges faced by young mothers, especially in rural areas where access to hospitals is limited and cultural barriers to care-seeking are stronger.

The present study directly addresses this critical gap by providing one of the largest community-based assessments conducted to date in Bangladesh. It documents a strikingly high prevalence of any maternal morbidity during the first pregnancy (75.32%), with significantly higher rates in rural areas (80.38%) compared to urban areas (70.17%). This community-based prevalence is notably higher than many previous facility-based estimates, suggesting that the true burden of morbidity among adolescent mothers in Bangladesh may be substantially underestimated in existing literature. By including both clinical complications and psychosocial dimensions (such as self-reported emotional distress and long-term health concerns), the study offers a more holistic and realistic view than earlier research, which often focused narrowly on severe obstetric outcomes.

Several Bangladeshi scholars have begun to highlight similar concerns in recent years. Rahman et al. (2023) reported that rural adolescent mothers frequently faced delayed care-seeking due to distance, transportation costs, and social restrictions, resulting in higher rates of untreated complications. Chowdhury et al. (2021) noted that community-level morbidity, including moderate anaemia and postpartum weakness, was significantly under-reported in national health statistics. Haque et al. (2022) and Sultana et al. (2021) further emphasised the role of postpartum depression and nutritional deficiencies in rural settings. These studies collectively support the present findings and reinforce the argument that facility-based data alone cannot capture the full reality of adolescent maternal health challenges in Bangladesh.

The higher morbidity rate observed in this study is likely the result of a complex intersection of biological vulnerability, socio-cultural factors, and systemic weaknesses. Early marriage and early sexual debut, combined with extremely limited reproductive health knowledge and widespread sexual violence, create a particularly high-risk environment. Rural residence further exacerbates these risks through poorer access to skilled care, stronger patriarchal control over women’s mobility, and heavier domestic workloads during pregnancy. By documenting this burden at the community level with a large sample, the present study makes a distinctive contribution to Bangladeshi scholarship. It calls for a fundamental shift from hospital-centric to population-based approaches in maternal health research and policy.

In summary, while previous Bangladeshi studies have laid important groundwork, they have largely overlooked the broader community reality of adolescent maternal morbidity. This research fills that gap and provides compelling evidence that the health costs of early pregnancy in Bangladesh are far greater than previously understood. These insights should serve as a wake-up call for policymakers, researchers, and health practitioners who are committed to improving the lives and futures of adolescent mothers across the country.

Interconnected Determinants of Vulnerability

Several interrelated factors contribute to this high burden. Sexual violence — both lifetime and during pregnancy — has emerged as a critical yet under-researched determinant. In Bangladesh, cultural norms of silence and family honour often prevent disclosure and support-seeking, potentially intensifying health impacts (Islam and Gagnon, 2014; Afroz et al., 2022). Rural residence further exacerbates risk through geographic barriers, weaker health infrastructure, and stronger patriarchal control (Mekonnen et al., 2023). Low social support, early sexual debut, and extremely limited access to comprehensive sexuality education (only 1.17% in this study) create additional layers of vulnerability.

Cultural stigma and social conservativeness play a particularly profound role in Bangladesh. Unmarried or early pregnancy is frequently viewed as a source of family disgrace, leading to secrecy, social isolation, and delayed care-seeking (Islam and Gagnon, 2014). This stigma appears stronger in Bangladesh than in many other South Asian contexts, creating a uniquely challenging environment for young mothers.

Research Gap and Significance of the Present Study

While a growing body of literature exists on adolescent pregnancy in Bangladesh and South Asia, significant gaps persist. Most studies have focused narrowly on prevalence or immediate obstetric outcomes. Few have systematically examined the determinants of maternal morbidity during the first pregnancy using robust multivariable methods that integrate sexual violence, social support, early sexual debut, and urban-rural differences.

This study deliberately shifts the analytical focus from the traditional question of “why adolescents become pregnant” to the more urgent and policy-relevant question of “why some adolescent mothers experience significantly higher maternal morbidity once pregnant.” By integrating multiple layers of vulnerability within a single comprehensive framework and using a large community-based sample (N=940), this research aims to generate nuanced, actionable evidence that can inform targeted interventions and policy responses in Bangladesh and similar resource-constrained settings.

1.2 Justification of the Research

Adolescent pregnancy in Bangladesh is not merely a demographic event but a profound public health and social justice issue that carries lifelong consequences for both mother and child. While national efforts have reduced the overall prevalence of child marriage and early childbearing, the burden of poor maternal health outcomes among those who do become pregnant during adolescence remains strikingly high. Most existing studies have concentrated on the determinants of adolescent pregnancy itself — that is, why and how early pregnancy occurs. Far less attention has been paid to the consequences faced by those young women who do become pregnant — specifically, the factors that shape their experience of maternal morbidity during the first pregnancy.

This research deliberately shifts the analytical focus. Instead of asking “why do adolescents become pregnant?”, the study asks a more urgent and policy-relevant question: “Among those who do become pregnant in adolescence, what factors determine whether they suffer maternal morbidity during their first pregnancy?” This subtle yet critical reorientation addresses a major gap in the literature. While adolescent pregnancy is widely documented, the lived reality of maternal morbidity among this already vulnerable group — particularly the roles of sexual violence, social support, early sexual debut, and intergenerational patterns — remains insufficiently explored in the Bangladeshi context.

The justification for this study is both scientific and humanitarian. First, the prevalence of maternal morbidity in the first pregnancy among adolescent mothers in this study was found to be alarmingly high (75.32%), with a clear rural disadvantage. Such a high burden suggests that simply preventing pregnancy is not enough; we must also understand and mitigate the health risks faced by those who do conceive early. Second, the study integrates multiple layers of vulnerability — sexual violence, weak social support, low education, and rural marginalisation — within a single robust analytical framework, offering a more holistic understanding than previous fragmented approaches. Third, by comparing urban and rural settings within the same study, it provides nuanced evidence that can inform context-specific interventions rather than one-size-fits-all policies.

1.3 Problem Statement

Despite decades of national and international efforts to delay child marriage and reduce adolescent pregnancy in Bangladesh, a substantial proportion of girls continue to become mothers during their teenage years. While the prevalence of adolescent pregnancy has been widely documented, there is limited understanding of the health consequences faced by those who do conceive early. This study found an alarmingly high prevalence of any maternal morbidity during the first pregnancy (75.32%), with significantly higher rates in rural areas (80.38%) than in urban areas (70.17%).

Current literature in Bangladesh has largely focused on the determinants and prevalence of adolescent pregnancy itself (Islam et al., 2017; Hossain et al., 2024). Far less attention has been paid to the factors that influence maternal morbidity among adolescent mothers during their first pregnancy. Critical dimensions such as lifetime experience of sexual violence, sexual violence during menstruation, quality of social support, early sexual debut, and urban-rural disparities remain insufficiently examined within a comprehensive analytical framework (Alam et al., 2023). This knowledge gap is particularly problematic because adolescent mothers are biologically and socially more vulnerable to complications such as anaemia, hypertension, obstructed labour, and long-term disabilities (WHO, 2022).

The consequences extend beyond individual health. High maternal morbidity among adolescent mothers contributes to school dropout, economic disadvantage, poor child health outcomes, and the perpetuation of intergenerational poverty and inequality. Without robust evidence on modifiable risk and protective factors, current maternal health programmes may fail to address the specific vulnerabilities of this high-risk group.

This study, therefore, addresses a critical research gap by systematically investigating the prevalence and determinants of maternal morbidity during the first pregnancy among adolescent mothers in selected urban and rural areas of Bangladesh. By integrating socio-demographic, reproductive, psychosocial, and behavioural factors, the study aims to generate actionable evidence to inform targeted interventions and policy responses.

1.4 Research Questions

1. What are the socio-economic, cultural, and health-related determinants of adolescent pregnancy in Bangladesh?
2. What are the health and social consequences for mothers and infants?
3. What interventions can mitigate adolescent pregnancy and its associated morbidity?

1.5 Objectives

General Objective:

To identify the determinants of adolescent pregnancy and maternal morbidity among adolescent girls in Bangladesh.

Specific Objectives:

• Identify socio-economic, cultural, and health-related determinants.
• Evaluate health and social consequences.
• Propose solutions to reduce prevalence and morbidity.

1.6 Hypothesis

This study hypothesises that adolescent mothers in Bangladesh experience a significantly high prevalence of maternal morbidity during their first pregnancy, and that multiple interrelated socio-demographic, reproductive, psychosocial, and contextual factors influence this morbidity.

Specifically, the study posits that:

1. Experience of sexual violence (lifetime and during menstruation), early sexual debut, low social support, rural residence, and lower educational attainment of the respondent are significant risk factors for higher maternal morbidity during the first pregnancy.
2. Stronger social support, higher level of education of the respondent, and larger family size act as protective factors against maternal morbidity among adolescent mothers.

This hypothesis reflects a deliberate shift in research focus — moving away from the traditional emphasis on the determinants of adolescent pregnancy itself toward a deeper investigation of the determinants of maternal morbidity among those who do become pregnant during adolescence. By examining the lived health consequences rather than solely the occurrence of early pregnancy, this study aims to generate more actionable insights for improving maternal health outcomes in this vulnerable population.

Chapter 2: Literature Review

2.1 Introduction to the Literature Review

Adolescent pregnancy and the associated maternal morbidity represent one of the most complex and persistent public health, social, and gender justice challenges of the 21st century. This chapter provides a comprehensive, critical, and up-to-date synthesis of the existing literature at global, regional, and national levels. It examines the scale of adolescent pregnancy, patterns of maternal morbidity during the first pregnancy, key risk and protective factors, the role of sexual violence, social support, early sexual debut, urban-rural disparities, and the profound influence of cultural stigma and conservativeness. The review identifies significant research gaps and clearly positions the present study within this broader scholarly landscape. By integrating evidence from multiple disciplines and regions, this chapter establishes the theoretical and empirical foundation for the current research.

Historical Trends of Adolescent Pregnancy Worldwide

The phenomenon of adolescent pregnancy is not a modern invention but has deep historical roots that reflect evolving social, economic, cultural, and demographic forces. Understanding its long-term trajectory helps contextualise the contemporary situation in Bangladesh and other low- and middle-income countries. This section traces the major shifts in adolescent fertility from pre-industrial times to the present day, highlighting key turning points and persistent patterns.

In pre-industrial societies, adolescent pregnancy was common and often socially normative. In many traditional agrarian communities, girls married shortly after menarche (typically between 12 and 16 years) and early childbearing was viewed as a natural part of the life course (Coale and Treadway, 1986). Historical demographic data from Europe in the 17th and 18th centuries show that a substantial proportion of first births occurred to women under 20 (Wrigley et al., 1997). Similar patterns existed in pre-colonial South Asia, Africa, and Latin America, where early marriage served economic, kinship, and status functions (Goody, 1976). Adolescent fertility rates were high because marriage and reproduction were closely linked, and there was little concept of “adolescence” as a distinct life stage.

The 19th century brought the first major transformations with the Industrial Revolution. Urbanisation, factory labour, and rising literacy began to delay marriage in Western Europe and North America. However, adolescent pregnancy remained widespread among the urban poor and in rural areas. In England and Wales, illegitimacy rates among teenagers rose during the early industrial period, reflecting both economic pressures and changing sexual norms (Laslett, 1980). In colonial India and other parts of South Asia, British administrators documented high rates of child marriage and early pregnancy, often criticising them as “barbaric” while simultaneously exploiting cheap child labour (Chatterjee, 1990). Globally, adolescent fertility remained high throughout the 19th century, driven by limited contraception, early marriage, and high overall fertility.

The early 20th century marked the beginning of a gradual decline in developed countries. The spread of compulsory education, rising female labour force participation, and the first wave of family planning movements began to delay marriage and childbearing. However, the two World Wars and the Great Depression temporarily disrupted these trends. Post-World War II, the “baby boom” in Western countries saw a temporary rise in teenage births, particularly among married adolescents (Cherlin, 1992). In developing regions, adolescent fertility remained largely unchanged due to persistent poverty and limited access to modern contraception.

The second half of the 20th century witnessed the most dramatic global shift. The introduction and widespread adoption of modern contraceptives (the pill, IUDs, and injectables) after the 1960s, combined with expanding female education and urbanisation, led to a sharp decline in adolescent fertility in high-income countries. In the United States, the teenage birth rate fell from 96 per 1,000 in 1957 to around 50 per 1,000 by the late 1980s (Ventura et al., 2008). Similar declines occurred across Europe, Japan, and parts of East Asia. International family planning programmes, supported by the United Nations and organisations such as the International Planned Parenthood Federation, played a critical role in spreading contraceptive knowledge to developing countries (Dixon-Mueller, 1993).

Despite these advances, adolescent pregnancy remained stubbornly high in many low-income regions. In South Asia and Sub-Saharan Africa, cultural norms favouring early marriage, limited female education, and weak enforcement of minimum-age marriage laws sustained high rates. By the 1990s, Bangladesh still had one of the highest adolescent fertility rates in the world, with over 40% of girls married before age 18 (UNICEF, 1990s data). The 1994 International Conference on Population and Development (ICPD) in Cairo marked a turning point by framing adolescent reproductive health as a rights issue rather than purely a demographic problem. This led to increased global attention and funding for adolescent-friendly services, though implementation in conservative societies remained challenging.

The 21st century has seen continued divergence. In high-income countries, adolescent birth rates have fallen to historic lows (e.g., below 10 per 1,000 in many European countries) due to improved education, widespread contraception, and changing social norms around delayed childbearing (Sedgh et al., 2015). In contrast, many low- and middle-income countries, particularly in Sub-Saharan Africa and parts of South Asia, have experienced only modest declines. Bangladesh has reduced child marriage from 65% in 2000 to around 51% in 2025, yet adolescent fertility remains high compared to global standards (BBS, 2025; UNICEF, 2025).

Several structural factors explain these divergent trends. In developed countries, expanded secondary and tertiary education, urbanisation, and changing gender roles have delayed marriage and first birth. In developing countries, poverty, gender inequality, and weak enforcement of child marriage laws continue to sustain early pregnancy. Cultural and religious conservatism, particularly in South Asia and parts of the Middle East, often views early marriage as a safeguard for female chastity and family honour, thereby perpetuating the cycle (Islam and Gagnon, 2014).

The COVID-19 pandemic temporarily reversed some progress. School closures and economic hardship led to increased child marriages and adolescent pregnancies in several countries, including Bangladesh, India, and parts of Africa (UNICEF, 2021). This underscores the vulnerability of adolescent girls to external shocks and the importance of resilient health and education systems.

2.2 The Global Burden of Adolescent Pregnancy

Adolescent pregnancy remains one of the most defining markers of global health and social inequity. According to the World Health Organization, approximately 12 million girls aged 15–19 years and over 777,000 girls under 15 give birth each year, with 95% of these births occurring in low- and middle-income countries (WHO, 2022). These early pregnancies carry significantly elevated risks of maternal mortality and severe morbidity.

A landmark systematic review by Ganchimeg et al. (2014), covering data from 124 countries, found that adolescent mothers face substantially higher risks of eclampsia, puerperal endometritis, systemic infections, postpartum haemorrhage, and mental health disorders compared to women aged 20–24 years. The risk of maternal mortality is approximately twice as high for girls aged 15–19 and up to five times higher for those under 15 (WHO, 2022). Neonatal outcomes are equally concerning, with elevated rates of preterm birth, low birth weight, stillbirth, and neonatal mortality (Fall et al., 2015; Darroch et al., 2016).

The long-term consequences extend far beyond immediate health risks. Adolescent motherhood is strongly associated with school dropout, limited economic opportunities, social stigma, and the perpetuation of intergenerational poverty and disadvantage (Chandra-Mouli et al., 2017; Presler-Marshall et al., 2023). These outcomes have profound implications for achieving the Sustainable Development Goals, particularly SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities).

2.3 Regional Perspectives

Sub-Saharan Africa bears the highest adolescent birth rates globally. In Nigeria, adolescent girls account for nearly 23% of all births, with dramatically elevated risks of obstetric fistula, severe anaemia, eclampsia, and postpartum haemorrhage (Azevedo et al., 2021). Ethiopia shows comparable patterns, where rural adolescent mothers experience morbidity rates approaching 65–70% (Mekonnen et al., 2023). Similar trends are reported in Kenya, Uganda, and Tanzania (Presler-Marshall et al., 2023).

Latin America and the Caribbean present a different but equally concerning profile. Countries such as Brazil, Colombia, and Mexico report persistently high adolescent fertility rates linked to socio-economic inequality, urban poverty, machismo culture, and limited access to modern contraception and comprehensive sexuality education (Conde-Agudelo et al., 2019).

South Asia remains one of the most affected regions. India continues to show wide interstate variations, with states like Bihar and Rajasthan recording adolescent fertility rates above 50 births per 1,000 girls aged 15–19 (IIPS and ICF, 2021). Nepal and Pakistan also face persistent challenges driven by poverty, patriarchal norms, and low female autonomy (Maharjan et al., 2022; Qureshi et al., 2022).

2.4 The Bangladeshi Context

Bangladesh has achieved notable success in reducing overall fertility and improving some maternal health indicators over the past three decades. However, adolescent pregnancy remains stubbornly high. Nearly 28% of women aged 20–24 years have given birth before age 18, and child marriage prevalence remains among the highest in South Asia (BBS, 2025; UNICEF, 2025).

Previous studies in Bangladesh have documented elevated risks of anaemia, pregnancy-induced hypertension, eclampsia, obstructed labour, and postpartum haemorrhage among adolescent mothers (Alam et al., 2023; Hossain et al., 2024). However, most of this evidence is derived from hospital-based samples. Community-based estimates that capture the full spectrum of morbidity have been limited. The present study’s finding of 75.32% prevalence of any maternal morbidity during the first pregnancy is therefore particularly significant and higher than many earlier estimates.

2.5 Major Risk Factors for Maternal Morbidity: A Deeper Analysis

Sexual Violence
The strongest finding of this study is the extraordinarily high adjusted odds ratio associated with experience of sexual violence (AOR = 53.92). This magnitude surpasses most previous studies. Silverman et al. (2009) in India and Jewkes et al. (2010) in South Africa reported 2–4-fold increases in adverse outcomes. In Bangladesh, cultural norms of silence and family honour likely intensify the health impact by preventing disclosure and support-seeking (Islam and Gagnon, 2014; Afroz et al., 2022).

Rural Residence
Rural residence remained a significant predictor (AOR = 3.26). This finding is consistent with broader South Asian and African evidence (IIPS and ICF, 2021; Maharjan et al., 2022; Mekonnen et al., 2023). The effect size in the present study is particularly large, reflecting Bangladesh’s specific challenges of geographic access, weaker rural health infrastructure, and cultural restrictions on female mobility.

Social Support
Strong social support emerged as a powerful protective factor, consistent with international evidence (Presler-Marshall et al., 2023). The extremely low level of high social support (only 3.0%) in this study reveals a critical vulnerability that appears more pronounced than in many Latin American contexts, where extended family networks tend to be stronger.

Early Sexual Debut and Low Reproductive Health Knowledge
Early sexual debut (44.06% before age 15) and extremely low exposure to formal sex education (1.17%) further exacerbate risk (UNFPA, 2023). These findings mirror regional trends across South Asia and underscore the failure of current education systems to prepare girls for safe and informed reproductive lives.

Cultural Stigma and Conservativeness
Cultural stigma surrounding adolescent pregnancy is deeply entrenched in Bangladesh. Unmarried or early pregnancy is frequently viewed as a source of family disgrace, leading to secrecy, social isolation, delayed care-seeking, and under-reporting of complications (Islam and Gagnon, 2014). This stigma appears stronger in Bangladesh than in many other South Asian countries. In parts of India, community-based support groups and NGO interventions have helped mitigate its effects (Chandra-Mouli et al., 2017), whereas in Bangladesh the combination of conservative norms, low sex education coverage, high sexual violence, and strong emphasis on female chastity creates a particularly toxic environment.

2.6 Theoretical Frameworks Relevant to Adolescent Maternal Morbidity

The socio-ecological model (Bronfenbrenner, 1979; adapted by WHO) provides a useful lens for understanding adolescent maternal morbidity. This framework posits that health outcomes are shaped by interactions across individual, interpersonal, community, and societal levels. The present study aligns strongly with this model by examining variables at all these levels.

Feminist theory further enriches the analysis. Scholars such as Sen (1999) and Kabeer (1999) argue that adolescent pregnancy and morbidity are manifestations of gendered power imbalances and limited agency. Early marriage, restricted mobility, and low decision-making power reduce girls’ ability to negotiate safe sex, access healthcare, or seek support after violence. This study’s findings on sexual violence and low social support strongly support this perspective.

The life course perspective (Elder, 1998) is also relevant. Early sexual debut and adolescent pregnancy represent critical turning points that shape long-term health trajectories. The intergenerational transmission of early marriage observed in this study (mothers’ mean age at first child 16.44 years) illustrates how disadvantage is reproduced across generations.

This study is grounded in several complementary theoretical frameworks that together provide a robust lens for understanding the complex determinants of maternal morbidity among adolescent mothers. These frameworks move beyond simple descriptive epidemiology to explain why certain factors (such as sexual violence, rural residence, and low social support) exert such powerful influence on health outcomes.

2.6.1 The Socio-Ecological Model

The socio-ecological model, originally developed by Bronfenbrenner (1979) and adapted extensively in public health by the World Health Organization, offers a multi-level understanding of health determinants. It posits that individual health outcomes are shaped by dynamic interactions across four main levels: individual, interpersonal, community, and societal/policy.

At the individual level, factors such as age at first sexual intercourse, educational attainment, and personal knowledge of reproductive health play important roles. In this study, early sexual debut (≤14 years) and low education were associated with higher morbidity, consistent with the model’s emphasis on personal characteristics.

At the interpersonal level, relationships with partners, family members, and peers are critical. The extraordinarily strong association between experience of sexual violence and maternal morbidity (AOR = 53.92) clearly illustrates how abusive interpersonal dynamics can directly harm health. Conversely, strong social support acted as a powerful protective factor, reducing the odds of morbidity substantially. This aligns with the model’s recognition that supportive relationships can buffer stress and improve health-seeking behaviour.

At the community level, rural residence emerged as a significant risk factor (AOR = 3.26). This reflects limited access to skilled care, weaker transport systems, and stronger traditional norms in rural Bangladesh. The model helps explain how community context shapes opportunities and constraints for adolescent mothers.

At the societal/policy level, broader structures such as legal frameworks on child marriage, cultural norms of conservativeness, and health system responsiveness influence all other levels. The persistence of early marriage despite existing laws and the extremely low coverage of sex education (1.17%) demonstrate how policy and cultural environments shape individual vulnerability.

The socio-ecological model is particularly valuable for this study because it avoids reductionist explanations and instead reveals the interconnected web of influences that produce high maternal morbidity. It also provides a practical foundation for multi-level interventions — from individual education to societal policy change.

2.6.2 Feminist Theory and Gender Power Relations

Feminist theory, particularly the work of Amartya Sen (1999) on capabilities and Naila Kabeer (1999) on women’s empowerment, offers critical insight into the gendered nature of adolescent pregnancy and morbidity. These scholars argue that women’s health outcomes are shaped by unequal power relations within families, communities, and society.

In the Bangladeshi context, limited decision-making power, economic dependence on husbands and in-laws, and cultural expectations of female chastity and obedience significantly constrain adolescent girls’ reproductive agency. The strong link between sexual violence and morbidity can be understood as an extreme manifestation of gendered power imbalance. Early marriage, often arranged by families to protect “honour”, further reduces girls’ ability to negotiate safe sex or access timely healthcare.

This study’s findings strongly support feminist perspectives. The protective effect of the respondent’s own education reflects increased capabilities and bargaining power within marriage. The counter-intuitive finding that husbands’ higher education was associated with increased morbidity may indicate heightened expectations or control within more educated households — a phenomenon noted in other conservative South Asian settings.

Feminist theory thus helps explain not only why adolescent mothers suffer higher morbidity but also why certain protective factors (education, social support) work. It frames adolescent maternal morbidity as a social justice issue rather than merely a medical problem.

2.6.3 The Life Course Perspective

The life course perspective (Elder, 1998) emphasises how early life events shape long-term trajectories. In this study, early sexual debut and adolescent pregnancy represent critical turning points that set in motion a trajectory of disadvantage. The intergenerational pattern observed — mothers marrying at a mean age of 15.17 years and having their first child at 16.44 years — illustrates how early disadvantage is reproduced across generations.

This perspective helps explain why some adolescent mothers experience higher morbidity. Those with earlier sexual debut and lower education enter pregnancy with accumulated disadvantages (poor nutritional status, limited health knowledge, weaker social networks). The life course approach also highlights the importance of timing: interventions during early adolescence may have a greater impact than those introduced after pregnancy has occurred.

2.6.4 Integration of Frameworks

The present study integrates these three frameworks into a cohesive analytical approach. The socio-ecological model provides the structural map, feminist theory illuminates power dynamics, and the life course perspective adds temporal depth. Together, they explain why sexual violence has such a powerful effect, why rural residence matters, and why education and social support are protective. This integrated theoretical approach represents one of the study’s key contributions to the field.

2.7 Urban-Rural Disparities in Maternal Morbidity

Rural residence remained a significant independent predictor of maternal morbidity (AOR = 3.26). This finding is consistent with broader South Asian and African evidence. In rural India and Nepal, longer distances to facilities, weaker transport systems, reliance on traditional birth attendants, and stronger patriarchal control contribute to delayed care and higher morbidity (IIPS and ICF, 2021; Maharjan et al., 2022). In Ethiopia, Mekonnen et al. (2023) reported similar rural disadvantages. The effect size in the present study is particularly large, reflecting Bangladesh’s specific challenges of geographic access, weaker rural health infrastructure, and cultural restrictions on female mobility.

One of the most consistent and policy-relevant findings of this study is the significantly higher prevalence of maternal morbidity during the first pregnancy in rural areas (80.38%) compared to urban areas (70.17%), with rural residence emerging as an independent risk factor (AOR = 3.26, 95% CI: 1.98–5.37, p < 0.001). This urban-rural disparity is not merely a statistical observation but reflects deep structural, social, economic, and health-system inequalities that shape the lived experiences of adolescent mothers in Bangladesh.

Mechanisms Driving Rural Disadvantage

Several interconnected mechanisms explain why rural adolescent mothers face substantially higher morbidity. First, geographic and physical access barriers play a major role. Rural areas often have longer distances to functional health facilities, poor road infrastructure, and limited transportation options. Even when complications arise, delays in reaching skilled care — the well-known “three delays” model (Thaddeus and Maine, 1994) — are more common in rural settings. In this study, although antenatal care coverage was high, the quality and timeliness of care during complications were likely compromised in rural areas.

Second, weaker health system capacity in rural Bangladesh contributes significantly. Upazila Health Complexes and Community Clinics frequently suffer from staff shortages, inadequate emergency obstetric care equipment, and limited blood transfusion facilities. Traditional birth attendants (TBAs) still attend a notable proportion of deliveries in rural areas, increasing risks of postpartum haemorrhage and infection. The present study’s finding that traditional birth attendants were involved in 17.66% of first pregnancies (higher in urban surprisingly, but quality of care remains a rural issue) underscores this gap.

Third, socio-cultural and gender norms are often more restrictive in rural settings. Patriarchal control over female mobility, decision-making, and resource allocation is stronger. Adolescent girls in rural families typically have less autonomy to seek care independently, especially for sensitive issues like sexual violence or pregnancy complications. This is compounded by stronger stigma around adolescent pregnancy, which may lead to delayed disclosure and care-seeking.

Fourth, socio-economic vulnerabilities are more pronounced in rural areas. Lower household income, poorer nutritional status, and higher workloads during pregnancy increase biological risk. In this study, rural respondents had lower mean annual income (41,325 Taka vs 65,356 Taka in urban), which likely translates into poorer pre-pregnancy nutritional reserves and limited ability to afford transport or private care.

Comparative Evidence from Other Countries

This rural-urban disparity is not unique to Bangladesh but follows broader patterns in South Asia and Sub-Saharan Africa. In India, the National Family Health Survey (NFHS-5, 2019–21) showed consistently higher maternal complications among rural adolescent mothers (IIPS and ICF, 2021). In Nepal, Maharjan et al. (2022) found rural residence associated with 2.5 times higher odds of adverse pregnancy outcomes. In Ethiopia, Mekonnen et al. (2023) reported rural adolescent morbidity rates approaching 70%, attributing this to distance, transport costs, and weaker referral systems.

However, the magnitude of the disparity in the present study (AOR = 3.26) is relatively large compared to many regional estimates. This may reflect Bangladesh’s particular geography — extensive river systems, seasonal flooding, and fragmented rural health infrastructure — which create unique access challenges.

Interestingly, some urban disadvantages were also observed. Traditional birth attendants were used more in urban areas (20.82% vs 14.56% rural), possibly due to overcrowding in public facilities or mistrust in urban public hospitals. This highlights that urbanisation does not automatically guarantee better outcomes without addressing quality and equity issues.

The strong independent effect of rural residence in the multivariable model, even after controlling for education, income, and social support, suggests that contextual factors (health system access, cultural norms, physical distance) operate beyond individual characteristics. This finding reinforces the need for place-based interventions rather than solely individual-focused programmes.

The urban-rural disparity also has important equity implications. It demonstrates that national averages mask significant geographical inequalities. Reducing these disparities is essential not only for improving maternal health but also for achieving broader goals of social justice and inclusive development in Bangladesh.

Link to Broader Theoretical Understanding

From a socio-ecological perspective, rural residence represents a powerful community-level determinant that interacts with interpersonal (weaker social support) and individual (lower education) factors. From a feminist perspective, it reflects how gendered mobility restrictions and resource allocation disproportionately affect rural girls. These theoretical lenses help explain why the rural penalty persists even as overall development progresses.

In summary, the urban-rural disparity documented in this study is not accidental but structural. It calls for targeted, context-specific strategies that address both supply-side (health system strengthening in rural areas) and demand-side (transport vouchers, community mobilisation, norm change) barriers. 

2.8 Protective Factors and Resilience

Strong social support emerged as a powerful protective factor. This aligns with international evidence from Kenya (Presler-Marshall et al., 2023) and Brazil. Higher respondent education was also protective, reinforcing global evidence that education delays marriage, improves health-seeking behaviour, and enhances decision-making power (Chandra-Mouli et al., 2017).

Research Gaps and Positioning of the Present Study

While a growing body of literature exists on adolescent pregnancy in Bangladesh and South Asia, significant gaps persist. Most studies have focused narrowly on prevalence or immediate obstetric outcomes. Few have systematically examined the determinants of maternal morbidity during the first pregnancy using robust multivariable methods that integrate sexual violence, social support, early sexual debut, and urban-rural differences. The historical trajectory shows that adolescent pregnancy is highly responsive to social and economic change, yet progress has been uneven. In Bangladesh, the combination of declining but still high child marriage rates, limited sex education, and persistent rural disadvantages creates a context in which adolescent mothers face particularly high risks of maternal morbidity. The present study builds on this historical understanding by examining not only the occurrence of early pregnancy but also the health consequences experienced by those who do become pregnant. By documenting the exceptionally high morbidity rate (75.32%) and identifying modifiable risk factors such as sexual violence and low social support, this research contributes to both historical scholarship and contemporary policy efforts to protect adolescent mothers.

This study addresses these gaps by deliberately shifting the analytical focus from “why adolescents become pregnant” to “why some adolescent mothers experience significantly higher morbidity once pregnant.” By integrating multiple layers of vulnerability within a single framework and using a large community-based sample (N=940), this research provides new empirical evidence and a more holistic understanding of the pathways leading to poor maternal health outcomes in this vulnerable population.

3. METHODOLOGY

3.1 STUDY OBJECTIVE

GENERAL OBJECTIVE

To identify the determinants of adolescent pregnancy and maternal morbidity among adolescent girls in Bangladesh.

SPECIFIC OBJECTIVES

1. To identify the determinants or circumstances of adolescent pregnancy in Bangladesh.

2. To identify the consequences of adolescent pregnancy in Bangladesh.

3. To identify solutions for adolescent pregnancy in Bangladesh.

3.2 Study Design

This study employed a descriptive cross-sectional observational design. Cross-sectional studies are particularly suitable for assessing the prevalence of health conditions and exploring associations between multiple variables at a single point in time (Setia, 2016; Wang and Cheng, 2020). The design enabled the collection of comprehensive data on socio-demographic, educational, reproductive, behavioural, and psychosocial characteristics of adolescent mothers across urban and rural settings.

Data were collected between January and March 2019 from 940 adolescent and young mothers (aged 14–35 years) who had experienced at least one pregnancy. Participants were recruited from selected healthcare facilities providing antenatal, postnatal, and child health services. The observational nature of the study ensured that no intervention was introduced, allowing the researcher to capture participants’ natural lived experiences and current circumstances.

This design was chosen for several reasons. First, it offered a cost-effective and time-efficient approach to generate robust prevalence estimates of maternal morbidity and associated factors within a relatively large sample. Second, it facilitated the simultaneous examination of multiple interrelated domains — including sexual violence, social support, educational status, and health-seeking behaviour — which were central to the study’s objectives. Third, cross-sectional designs have been widely used and validated in similar resource-constrained settings for adolescent reproductive health research (Islam et al., 2017; Alam et al., 2023).

However, like all cross-sectional studies, this design has inherent limitations. It cannot establish temporal sequences or causal relationships between variables, meaning the findings reflect associations rather than definitive causality (Setia, 2016). Despite this constraint, the approach remains highly appropriate for providing a broad epidemiological snapshot and generating evidence to inform policy and programme development.

3.3 Population and Sampling

Study Population and Recruitment

The study population comprised adolescent mothers who presented to the obstetrics, gynaecology, and child care departments of the selected healthcare institutions during the data collection period (January to March 2019). Recruitment took place in antenatal and postnatal care units of gynaecology departments, as well as child care units where mothers accompanied their babies for vaccinations or other medical care. This multi-departmental approach ensured comprehensive coverage of adolescent mothers at different stages of motherhood—pregnant, recently delivered, and caring for infants—allowing the study to capture a wide range of experiences related to pregnancy, delivery, and early motherhood.

Of the 2,500 females initially approached across the 10 sites (5 urban hospitals in Dhaka and 5 rural maternal health centers), 1,668 met the inclusion criteria. However, only 940 provided complete and usable data after scrutiny, reflecting common challenges in sensitive research, including respondent reluctance to answer certain questions or withdrawal due to personal discomfort.

Target Population:

• Adolescent girls aged 13–18 with a first pregnancy at 13–18.
• Adult females with a first pregnancy at 13–18.

Sample Population:

• Adolescent girls aged 13-18 at the time of the survey.
• Adults who experienced their first pregnancy between the ages of 13-18.

INCLUSION CRITERIA

• First pregnancy at 17 years or younger, aligning with the focus on pregnancies before Bangladesh’s legal marriage age of 18; 
• No severe medical conditions that could hinder participation; and 
• Willingness to participate in the survey. 

EXCLUSION CRITERIA

• Unwillingness or inability to participate due to communication limitations; and 
• Women who did not give birth to their first child before age 18.

3.4 Sampling Strategy

This study employed a purposive convenience sampling technique to recruit adolescent mothers who met the inclusion criteria (i.e., those who had experienced their first pregnancy at or before 17 years of age). Purposive sampling was deliberately chosen to select information-rich cases relevant to the research objectives, particularly given the sensitive nature of adolescent pregnancy and the social stigma associated with it in Bangladesh (Palinkas et al., 2015; Etikan et al., 2016). Convenience sampling was integrated to enhance feasibility and accessibility, as participants were recruited from selected antenatal, postnatal, and child healthcare facilities where adolescent mothers were naturally available.

This combined approach allowed the researcher to balance theoretical relevance with practical constraints in a resource-limited setting. To reduce potential selection bias, trained field workers approached eligible participants systematically within the selected facilities, following a pre-defined protocol. Regular supervision by the principal researcher ensured consistency in participant selection. The strategy successfully recruited 940 respondents, achieving adequate representation from both urban and rural areas, thereby capturing a diverse range of socio-economic and contextual backgrounds.

Although non-probability sampling limits the generalisability of the findings, it was the most appropriate and ethical strategy given the sensitive nature of the topic and the challenges of accessing this hard-to-reach population.

3.5 Study Sites

Urban: 

Dhaka hospitals (BSMMU, Shaheed Suhrawardy Medical College (SSMC), Dhaka Medical College (DMC), Community Hospital, Marie Stopes Clinic).

Rural: 

Maternal health centers in Savar, Narayanganj, Gazipur, Mymensingh, Tangail, were selected for high patient density.

3.6 Data Collection

Primary Data: 

• Face-to-face interviews using a pre-tested, structured questionnaire (designed for 86 variables), with open and closed questions. 

Tools: 

• recorders, 
• pens, 
• pencils, 
• cameras.

Secondary Data: 

• Bangladesh Bureau of Statistics, 
• Demographic Health Surveys, 
• National & International journals, 
• Official reports.
• Newspapers

3.7 Data Collection, Preparation & Analysis

Data were collected through structured face-to-face interviews conducted by trained field workers under the direct supervision of researchers with PhD qualifications. Before data collection, field workers received comprehensive training on interview techniques, ethical protocols, cultural sensitivity, and handling of sensitive topics to ensure consistency and respondent comfort (Lee, 1993).

All interviews were conducted only after obtaining written informed consent from each participant. Respondents were clearly informed about the purpose of the study, their voluntary participation, the right to refuse any question or withdraw at any time, and the confidentiality of their responses. Special care was taken when discussing sensitive issues such as sexual violence, marital history, self-injury, and suicide attempts. Interviews were conducted in a private setting and administered progressively to minimise respondent discomfort.

The data collection instrument was a structured questionnaire developed through iterative discussions within the research team at the School of Public Health, Shandong University. It was pre-tested outside the study area to evaluate clarity, cultural appropriateness, and respondent comprehension, and subsequently refined. The final questionnaire covered key domains including socio-demographic characteristics, reproductive and pregnancy history, intergenerational patterns, social support (measured using a 7-point Likert scale), sexual behaviour, experience of violence, and psychological factors.

This systematic and ethically grounded approach enabled the collection of high-quality, reliable data from 940 adolescent and young mothers while respecting cultural norms and participant autonomy.

Sample Size Determination

The sample size was determined by using the formulae below:

 n=     Z²pq/ d²

n= Sample size to be determined

Z= standard normal deviate, which cuts the abscissa at 1.96 for 95% confidence level.

p=   proportion of adolescents possessing a characteristic, which is 33.2 (according to the World Bank collection of Development indicators 2014, compiled from officially recognized sources)

q= 1-p

= 1-33.2

= 66.8

d= 0.1 x p

3.32

= (1.96)²x (33.2) (66.8)/ (3.32)²

n= Z²pq/ d²

= 8519.746/11.0224

= 772.94

Considering 10% non- response, the ultimate sample size was:  

= 773 + 77 

= 850

But considering the unavoidable dropout and other circumstances, the sample size was = 1000. 

Data Management and Analysis

Completed questionnaires were checked on-site for completeness, accuracy, and legibility. Data were initially recorded on paper and later entered using EpiData Version 3.1, a specialised software widely recognised for its strong data validation features and suitability for epidemiological studies (Lauritsen and Bruus, 2003). The cleaned dataset was then exported to Stata Version 14 for further processing, validation, and analysis.

Data Management
Data cleaning involved checking for inconsistencies, missing values, outliers, and logical errors. Derived variables were created where necessary (e.g., categorical variables for age, income, family size, and social support levels). All variables were labelled and coded systematically to ensure transparency and reproducibility.

Data Analysis
Data analysis was conducted in two main stages:

• Descriptive (Univariate) Analysis: Frequency distributions, percentages, means, and standard deviations were calculated to summarise the socio-demographic profile, reproductive history, maternal morbidity, sexual behaviour, social support, and other key variables. Results were presented in tables and figures, stratified by urban and rural residence where relevant.
• Inferential Analysis: Bivariate associations were examined using Pearson’s chi-square tests to identify potential relationships between independent variables and the outcome variable (maternal morbidity). Multivariable logistic regression with robust standard errors was performed to identify independent predictors of maternal morbidity while controlling for potential confounders. Model fit was assessed using Pseudo R², Wald χ² statistics, and diagnostic tests (e.g., VIF for multicollinearity and Hosmer-Lemeshow test).

All statistical analyses were conducted using Stata Version 14. A significance level of p < 0.05 was considered statistically significant, with p < 0.10 used for variable selection in the multivariable models. The entire process followed ethical principles, ensuring data confidentiality, anonymity, and secure storage throughout the study.

3.8 Ethical Considerations

This study was conducted in full compliance with ethical standards and guidelines. Ethical approval was obtained from the Bangladesh Medical Research Council (BMRC) and the Institutional Review Board of Shandong University. The research proposal, including the study instruments, was also reviewed and approved by the Ministry of Foreign Affairs, Government of the People’s Republic of Bangladesh, ensuring adherence to national regulatory requirements (Bangladesh Medical Research Council, 2018).

Informed written consent was obtained from all participants before data collection. Respondents were provided with clear information about the purpose of the study, their voluntary participation, and their right to refuse any question or withdraw from the study at any time without any negative consequences. The principle of autonomy was strictly upheld throughout the research process (World Medical Association, 2013).

Special attention was given to the sensitive nature of the topics discussed, including sexual violence, marital history, self-injury, and suicide attempts. Interviews were conducted in private settings with trained field workers, and questions were administered progressively to minimise psychological discomfort. Participants were assured of their right to skip any uncomfortable questions.

Confidentiality and anonymity were rigorously maintained. Names were not recorded; instead, unique identification codes were used. All data were stored securely and used exclusively for academic research purposes. These measures were particularly important given the significant cultural stigma surrounding adolescent pregnancy and unmarried motherhood in Bangladesh (Islam and Gagnon, 2014).

No coercion, inducement, or undue influence was applied at any stage. The study fully adhered to the ethical principles of respect for persons, beneficence, and justice.

3.9 Quality Control

To ensure high data quality and minimise bias, several rigorous quality control measures were implemented throughout the study.

Field workers received comprehensive training from the principal investigator and senior researchers before data collection. The training emphasised standardised interview techniques, ethical conduct, cultural sensitivity, and appropriate handling of sensitive topics such as sexual violence, self-injury, and suicide attempts. Regular supervision, daily debriefings, and on-site monitoring were maintained throughout the data collection period to ensure consistency and address any emerging issues promptly.

The questionnaire was pre-tested on a small group of eligible respondents outside the study area to assess clarity, cultural appropriateness, respondent comprehension, and average completion time. Necessary modifications were made based on feedback from the pre-test.

All completed questionnaires were checked on-site for completeness, legibility, and logical consistency. The principal investigator personally reviewed a random sample of 10% of the questionnaires. Data entry was conducted using EpiData Version 3.1, which included built-in validation rules to reduce entry errors. The dataset was subsequently exported to Stata Version 14 for thorough cleaning, verification, and analysis. These multi-layered quality control procedures helped ensure the reliability, accuracy, and integrity of the collected data.

3.10 Operational Definitions

Variable description: 

1. In the beginning, we have recorded the addressing index of each of the samples. At first, the sample is listed as the ‘code number’. This is the basic identity of the respondents or the samples. Each of the samples is identified by its own, unique ‘code numbers’. Although the final sample size for data collection was 1000, 940 samples met the demand of the information collection criteria within the given time. 

2. Next, there is ‘division’, which is the administrative unit of the country where the sample is located. Here, two divisions have been taken, namely: Dhaka and Mymensingh. 

3. The next variable is ‘City’. The city is the specific place of settlement. However, here ‘city’ is carrying the identity of the specific location of the subjects in both urban and rural areas. Here, the urban area means the capital city, and the rural places are outside the capital. In the capital city, five hospitals have been listed for the information collection of the urban participants: 1. BSMMU (Bangabandhu Sheikh Mujib Medical University), 2. DMC (Dhaka Medical College), 3. Marie Stopes Clinic and Maternity, 4. SSMC (Shaheed Suhrawardy Medical College), 5. Community Hospital Dhaka. Consecutively the rural areas’ 5 maternal health care centres of the following rural areas have been selected for the data collection; 1. Savar, 2. Narayangonj, 3. Gazipur, 4. Mymensingh, 5. Tangail.

Name, date and contact.= of the individuals

SECTION A: BASIC INFORMATION

4. Age: Age is the time that has been spent by a person from birth to the present or at a given time. It also denotes or indicates the possible changes in all respects to the person or the object. According to the inclusion criteria, participants having the following age range have been included in the data collection: a. Adolescent girls aged 13-18 at the time of the survey who have experienced their first pregnancy between the years 13-18 (and) b. Adult females who have experienced their first pregnancy between the ages of 13 & 18

5. Marital status: It is the variable used in official forms to ask if a person is married, single, divorced, or widowed. Therefore, among the participants, the marital status has been distributed in the four categories: 1. Married, 2. Unmarried, 3. Widow, 4. Divorced. Here, married female attributes the girls who are a person’s partner in marriage, unmarried females are those who are not married, a widow is a woman whose husband has died, and a divorced female is someone whose marriage has been legally dissolved. She is considered single.

6. Place of birth: The place of birth is distributed into two classes: 1. Rural 2. Urban. Rural area describes the places outside of cities and towns which is not included within an urban area while the urban area defines a human settlement with a high population density and infrastructure of the built environment.

7. Migrant people:  This entry describes human migration which means the movement of people from one place to another with the intentions of settling, permanently or temporarily, at a new location. People are migrating from one place to another due to different reasons like a riverbank bursting, personal or political hostility and various economic and financial reasons.

In the broad sense, this migration can be 1. cross-country; which is international; from one country to another, 2. Cross division; this one is within the country from one division to another here change of the city is inevitable or unavoidable and 3. Cross city; from one city to another.

8. Religion: This entry describes the religion of the participants. Religion is a particular system of faith and worship. According to the prevailing religions in Bangladesh. This entry has the following categories; 1. Muslim, 2. Hindu, 3. Buddhist, 4. Christian & 5. Others (if present, for further reference)

9. Ethnicity: Depending on the tradition, language and the cultural heritage of Bangladesh, ethnicity is classified into the following groups 1. Bengali 2. Tribal or indigenous ethnic groups 3. Others (if any).

10. Education: Education is the process of receiving or giving systematic instruction for facilitating learning. This is the process composed of achieving knowledge, skills, values, beliefs, habits and methods consisting of teaching, training, storytelling discussion and directed research. This process has different levels and the next level is always possible if one level is accomplished successfully.

Here in this entry different educational levels have been added starting from the elementary level. Hence, the categories are;  1. Illiterate & Semi illiterate, 2. Primary School, 3. High School, 4. College, 5. University & above, 6. Technical School.

11. Occupation: Occupation is the profession of an individual and it is the means of living of the person. Here in this entry has been classified as;

1. Student; the individual who is studying, 2. Agriculture and farming, animal husbandry and fishery; individuals who live on agricultural works, cultivation, livestock, dairy and fisheries 3. Enterprise and Institution manager; a regular job in the business organization  4. Professional and technical personnel; people with a skill, 5. General Clerical staff; a routine duty staff in government or non-government organizations with a fixed wage, 6. Industrial/commercial/household worker; worker without fixed wages and mostly day labourers 7. Production workers who work under fixed wages in the industry. 8. Households, the people who work in other households to assist them in living daily life. 9. Unemployed; individuals who do not work, 10. Service personnel; high officials superior to clerks and managers in government and non- government organizations. 11. Others, (please specify).

12. Respondent’s annual income: this is the variable informing the annual income of the individual. It is the amount of money earned in twelve months by the respondents.  

13. Respondent’s annual expenditure: this is the variable informing the annual expenditure of the individual. It is the amount of money, which is expended in twelve months by the respondents.

14. Respondent’s source of income: This entry states the profession of the individuals. It is classified as 1. Service salary, 2. Agriculture, which obtains from the crops, 3. Forestry or animal husbandry from the domestic animals and farms and dairy, 4. Business/ Trading; It can be a wholesale or retail business, 5. Transport Industry; from renting vehicles or driving vehicles, 6. Catering; from cooking in the hotels or food supply, 7. Others (if any)

15. Living status: In this entry, the living status of the participants is acknowledged. The distributions are 1. With a family; Where other members of the family live all together, 2. Hostel; in the accommodation for the students or employees, 3. Self-living (sublet); in most of the cases, self living is the unit rented to live with the other family or independently 4. Homeless people are those who are floating who do not have a definite address to live in, 5. Refuge, these are the people repulsed or removed from their own places.

16. House condition: This entry is about the place where participants live. The house condition of the participants has been classified into three categories like 1. The Building, 2. Tin shade, 3. Slum.

1. Building: The building is a relatively permanent establishment with brick walls and roofs. Buildings usually have more facilities than slums or tin sheds. It is more secure for criminal offences or weather adversities.

2. Tin shades: Tin shades are the tin-built structures. The walls and roofs are made of tin sheets. It is less secure than buildings.

3. Slum: Slums are densely populated and closely packed urban residential areas inhabited primarily by impoverished persons. Generally, it is characterised by incomplete infrastructure, run-down housing and remarkable crowding. Living conditions are very bad here and it is a temporary accommodation of the underprivileged persons.

17.  School performance of the respondents: This variable has the following categories that attribute her performance in the school; 1. Top grade, 2. Middle grade, 3. Poor/Low grade.

18. Drop out experience from the school: this variable has 1. No, 2. Yes options. It is to find out whether they have the experience of dropping out from the school or not.  

19. Reason to drop out: It is an open-ended question to find out the different reasons for the dropout experience of the participants. Respondents will answer according to their experience.

20. Age of drop out: This one is also an open-ended question to find out the age of drop out of the participants from the educational institutions.  

21. Percentage (%) of school attendance before sexual activities: this one is another open question for the participants to find out the regular school attendance of the participants. Regular school attendance is one of the important pieces of evidence of disciplined life, orientation to rule for guidance and also the opportunity to go out of the house and ventilate with other same-aged, contemporary classmates.

22. With whom do you live? It is a multiple-choice question containing the variables; 1. Parents, 2. Husband, 3. Boyfriend, 4. Alone, 5. Others. Here participants can choose multiple options depending on the living condition of the participants incorporating with other members.

23. Did you do any self-injury in the last 12 months: This is a closed polar question to acknowledge the psychological situation. The corresponding answer is 1. Yes, 2. No

24. Did you ever tried to suicide in the last 12 months: This one is also a closed polar question with the corresponding answer 1. Yes, 2. No. This question is about the suicidal history of the participant.

25. Right now, how would you describe your health compared to that of other people of your age: 1. Very good, 2. Good, 3. Fair, 4. Bad, 5. Very Bad. This is a self-rated health satisfaction measuring scale having 5 categories.

26. How did you get married: this one is a closed question having two options: 1. Love marriage 2. Arrange marriage.

1. Love marriage: it is based upon mutual love, affection, commitment and attraction. This marriage is conducted solely by the couple and they get married with or without their parent’s consent.  

2. Arranged marriage: here in arranged marriage, the marital partners are chosen by the parents, community elders, matchmakers or religious leaders in an effort to guide young people through the process of finding the right person to marry.  

 Parent’s information

 27. After finishing personal information about the participant, next it comes the part of their family details. In this regard, we collect the age of the participant’s father, mother and husband’s age.

28. Next to age information about the education of the same people has been stated. The education categories have already been discussed earlier and they are namely 1. Illiterate & Semi- literate, 2. Primary School, 3. High School, 4. College, 5. University and above, 6. Technical School has been used for information.

29. Occupation: This variable has already been discussed earlier as education and the classes are; 1. Student, 2. Agriculture and farming, animal husbandry and fishery, 3. Enterprise and Institution manger, 4. Professional and technical personnel, 5. General Clerical staff, 6. Individual industrial/commercial/household worker, 7. Production workers, 8. Household, 9. Unemployed, 10. Service personnel, 11. Others (if any)

30. Following the occupation next it comes the age of marriage and age at the time of the birth of first child of the father, mother and husband of the participants. These two attributes the age of marriage and the age at the time of the birth of the first child of the parents and husband of the participant.

 FAMILY INFORMATION:

 31. Number of family members: It is an open question for the participants. The answer depends upon the different sizes of the families.

32. The Number of family members you live together for over 6 months: This is also an open question. This entry attributes the number of the family members with whom the participants live together for the last six months.

33. Number of siblings: this is an open question. This entry attributes the number of the total siblings of the participants.

34. Respondent’s position among siblings: It is an open question which denotes the position of the respondent among the siblings.

35. Total household annual income: It is an open question for the participants. It is the total income of the family members of the participant’s household in one year.

36. Total household annual expenditure: This is the open question to state the amount that is expended annually in their family. It is the total expenditure of all the members of the participant’s households in one year.

37. Source of income of the family: Here the categories of income sources are; 1. Service salary, it is the income from a fixed routine job 2. Agriculture, it is the earning from the cultivation, 3. Forestry or animal husbandry,  this is the acquisition from forestry (fruit plants, timber and non-timber trees) and animal husbandry where animals are raised for meat, 4. Business/Trading; it is a profession relevent to trading; buying and selling of the product and services, 5. Transport Industry; this is the industry which is relevant to move people and goods. It is a large working sector composed of a number of small sections, 6. Catering; it is the activity of providing food service. 7. Others: Mechanic etc.

SECTION B: SOCIAL SUPPORT 

Social Support (7-point Likert type scale)

In section B there is a chart of ‘Social Support’ it is a ‘7 point likert type scale’. Multidimensional Scale of Perceived Social Support (MSPSS) – Scale Items and Scoring Information. The MSPSS is a 12-item scale designed to measure perceived social support from three sources: Family, Friends, and a Significant Other. It is a brief research tool which has been used in this research to find out the social support status of the females who met pregnancy in their adolescence. Here twelve questions are used to find out the result.

 38. The questions of the 7-point Likert type scale are: 1. there is a special person who is around when I am in need, 2. There is a special person with whom I can share my joys and sorrows, 3. My family really tries to help me, 4. I get the emotional help & support I need from my family, 5. I have a special person who is a real source of comfort to me, 6. My friends really try to help me, 7. I can count on my friends when things go wrong, 8. I can talk about my problems with my family, 9. I have friends with whom I can share my joys and sorrows, 10. there is a special person in my life who care about my feelings, 11. My family is willing to help me make decisions, 12. I can talk about my problems with my friends while the corresponding answers are: 1. Very strongly agree, 2. Strongly agree, 3. Agree, 4. Neutral, 5. Disagree, 6. Strongly disagree, 7. Very strongly disagree.

SECTION C: PREGNANCY ISSUES AND SEXUAL ACTIVITIES

 This section is about pregnancy issues where we will discuss the details about the pregnancy faced by the females at their adolescence.

39. Number of pregnancy The question ‘how many pregnancies have you met’ has been asked to the respondent to recognize the number of pregnancies faced by the females. In this research, we have decided to take three consecutive pregnancy histories to work with.

40. Age of pregnancy It  describes the age at the time of first, second or third pregnancy.

41. Reason of pregnancy: In this variable five categories depending on the possible reasons found in the different researches. Excluding them, the last category has been kept as an open question if any other reason persists except stated earlier.  Those are: 1. Normal pregnancy, 2. Rape, 3. Sexual abuse, 4. Family violence, 5. Others (for other possible reasons)

42. Pregnancy plan: this variable has been investigated to know whether the pregnancy is expected to the mother and the family or not. As we know, planned pregnancy usually by choice of the mother and the family on the contrary unplanned pregnancy is the result of the sexual activity without the use of effective contraception through choice or coercion. Therefore, this entry is classified into two classes: 1. Unplanned (pregnancy), 2. Planned (pregnancy).

43. How many times you took antenatal care (ANC) during your pregnancy: Antenatal care is the preventive health care procedure which provides regular checkups of the pregnant mother by the doctors or the midwives to prevent potential health problems throughout the pregnancy period. To acknowledge the frequency of the antenatal care of the pregnant female the answer to this question was left open to give the freedom to the participants.

44. Did you become anaemic during your pregnancy: Being anaemic is the condition in which one individual is in lack of enough healthy blood cells to carry adequate oxygen to the body tissues. Anaemia has different forms and characters, but usually, it has some common manifestations like feeling tired and weak. During ANC of the participants it can be easily determined and acknowledged and the symptoms can be felt by the participants. To know about the blood deficiency of the participant a closed polar question has been structured with the corresponding answer 1. Yes, 2. No.

45. Did you take iron and folic acid during pregnancy: According to WHO “This recommendation supersedes the 2012 WHO Guideline: daily iron and folic acid supplementation in pregnant women (1) and should be considered alongside Recommendation A.2.2 on intermittent iron found in the guideline, WHO recommendations on antenatal care for a positive pregnancy experience.” (i)

It is a closed polar question with the corresponding answer 1. Yes 2. No.

46. Did you gain inadequate weight during pregnancy: It is a closed polar question with the corresponding answer 1. Yes, 2. No. It can easily be acknowledged by the participants and their families during the ANC visits. There are different factors affected by the inadequate weight during pregnancy resulting in different consequences.

47. Did you gain pregnancy-induced hypertension during pregnancy: It is a closed polar question with the corresponding answer 1. Yes 2. No. Pregnancy-induced hypertension is another issue during pregnancy and it is characterized by high blood pressure during pregnancy. It is also called gestational hypertension and has different categories depending on its period of onset.

48. Did you gain gestational diabetes during pregnancy: It is a closed polar question with the corresponding answer 1. Yes 2. No. Gestational diabetes is the manifestation of high blood sugar,  which can affect pregnancy and the baby’s health.

49. Did you take a TT vaccine during pregnancy: It is another closed polar question with the corresponding answer 1. Yes 2. No. “Tetanus toxoid vaccination is recommended for all pregnant women, depending on previous tetanus vaccination exposure, to prevent neonatal mortality from tetanus.” (ii)

50. Outcome of the pregnancy It is stated with the corresponding answers 1. Born, 2. Abortion, 3. Others (if any other occurrence happens). Pregnancy outcome is the final result of a fertilization event. Type of pregnancy outcome includes birth (full-term or preterm birth), stillbirth, spontaneous abortion and induced abortion.(iii) Here the category ‘other’ is an open question for the different outcome of the pregnancy.

51. Birth weight of the baby: This is another variable in the paper categorized with an open question. Birth weight is the body weight of a baby at its birth. It is an important milestone for a baby and it affects the baby’s life in different ways. (Include range) (iv)

52. The size of the baby is a variable corresponding to three categories 1. Bigger than average, 2. Average, 3. Smaller than average. This entry has been added depending on the consideration of the mother who held the baby in her womb for the whole time of its generation and final consequences.

53. Number of children born in each parity: 1. Single, 2. Twin, 3. Triplet.

This entry is for the recognition of single or multiple birth incidents. In the single birth, the fertilized egg or the zygote produces a single embryo and in the multiple births, the embryo sac split into two or more embryos where each of them carries the same genetic materials.

Nevertheless, multiple pregnancies may be the result of the fertilization of a single egg or it may be the result of the fertilization of multiple eggs or it may be the combination of both of the factors in the generation procedure.  Multiple pregnancies from a single zygote is called ‘monozygotic’, from two zygotes is called dizygotic or from three or more zygotes is called polyzygotic. (v)

55. Type of child delivery: This variable is sub-categorized into four types. They are; 1. Normal delivery 2. Cesarean Section 3. Forceps delivery 4. Vacuum delivery.

Childbirth is the ending of the pregnancy where the process consists of labour and delivery. In this process, one or more babies leave the uterus by passing through the vagina or by caesarean section.

1. Vaginal Delivery: Normal birth is defined as low-risk pregnancy with spontaneous onset of labor occurring between 37 and 42 weeks’ gestation. Labor is allowed to progress on its own with the free movement and positioning of the mother throughout. After birth, the mother and infant are in good condition and are allowed unlimited time for breastfeeding and initiating bonding. The World Health Organization estimates that between 70% and 80% of women entering labor are at low risk. (vi)

Benefits of vaginal delivery are: (a) shorter hospital stays, (b) lower infection rates, (c) quicker recovery, (d) babies born vaginally have a lower risk of respiratory problems.

2. Cesarian Section (C-Section): A cesarean section or C-section is the delivery of a baby through a surgical incision in the mother’s abdomen and uterus. In certain circumstances, a C-section is scheduled in advance. In others, it’s done in response to an unforeseen complication.

Events that may require C-Section: (a) Multiple (twins, triplets, etc.) (b) A very large baby (c) Previous surgery, C-Sections or other uterine conditions (d) Baby is in breech (bottom first) or transverse (sideways) position (e) Placenta previa (when the placenta is low in the uterus and covers the cervix) (f) Forbid or other large obstruction.

3. Forceps Delivery: A forceps delivery is a type of operative vaginal delivery. It’s sometimes needed in the course of vaginal childbirth. In a forceps delivery, a health care provider applies forceps (an instrument shaped like a pair of large spoons or salad tongs) to the baby’s head to help guide the baby out of the birth canal. (vii)

4. Vacuum Extraction: A vacuum extraction is a procedure sometimes done during the course of vaginal childbirth. Here, a vacuum device is used to assist the delivery. In this process, the vacuum (a soft or rigid cup with a handle and a vacuum pump) is applied to the baby’s head to help guide the baby out of the birth canal. It can be an alternative to a forceps delivery and caesarean section and used in the second stage of labour if it has not progressed adequately. But it cannot be used when the baby is in breech position or for premature births.

56. Complication during delivery: this variable is sub-categorised into the following types. 1. Obstructed labour 2. Fetal distress 3. Hemorrhage 4. Prolonged labor 5. Eclampsia 6. Hypertension 7. Diabetes 8. Others.

To learn about these we need to explain them a little.

1. Obstructed labour: Obstructed labour (OL) is the situation that occurs when the foetal presenting part fails to descend despite adequate uterine contractions. (a) It is very much common in adolescent pregnancy and undernourished mothers. (b)

2. Fetal distress: Fetal distress is an emergency pregnancy and delivery complication. Fetal distress is characterized by oxygen deprivation (birth asphyxia) resulting in the change in the baby’s heart rate, decreased fetal movement and meconium in the amniotic fluid. (d)

̊3. Hemorrhage: The average amount of blood loss after the birth of a single baby in a vaginal delivery is about 500 ml (or about half of a quart) and for a cesarean birth is approximately 1,000 ml (or one quart). (e) But bleeding in the early pregnancy or in the second half of the pregnancy may signal a more serious condition. There might be a different reason for bleeding during pregnancy or at the time of delivery which may lead the mother and the child to a risky condition or even death. (f)

4. Prolong labor: When the baby is not born after approximately 20 hours of regular contractions it can be called prolonged labour. In case of carrying twins or more the prolonged labour is considered after 16 hours of contraction.

5. Eclampsia: Eclampsia is the onset of seizures (convulsions) in a woman with pre-eclampsia. (g) Pre-eclampsia is a disorder of pregnancy in which there is high blood pressure and either large amounts of protein in the urine or other organ dysfunction (h)(i)

6. Hypertension: High blood pressure during labour is a risk factor for both mother and baby. It can lead to several life-threatening complications like; bleeding in the brain or hemorrhagic stroke, seizures or coma.

7. Diabetes: Type-1, type-2 or gestational diabetes has an effect on the glucose concentration during the intrapartum period. Therefore, the peripartum control of diabetes is very important for the well being of the newborn as a higher incidence of neonatal hypoglycemia is seen if maternal hyperglycemia happens during this period. (j)

57. Injury to the mother during delivery: 1. Genital tract injury 2. Vaginal tears during birth 3. Postpartum hemorrhage 4. Ruptured uterus 5. Prolapsed uterus 6. Others.

1. Genital tract injury:  Genital tract trauma is common following vaginal childbirth and perinatal pain is a frequent symptom reported by new mothers. (k) There can be ruptured uterus, cervical and vaginal tears and perineal injuries.  

2. Vaginal tears during birth: A vaginal tear is a laceration to the perineum (the area between the vagina and rectum) that occurs when the baby is pushed out.

3. Postpartum haemorrhage: Postpartum haemorrhage is more bleeding than normal after the birth of the baby. It is most likely with the cesarean birth and most often happens after the placenta is delivered.

4. Ruptured uterus: It is the spontaneous tearing of the uterus that may result in the fetus being expelled into the peritoneal cavity. It is rare and can occur during late pregnancy or active labour. It occurs most often along healed scar lines in women who have had prior cesarean deliveries.  

5. Prolapsed uterus: It is the situation when the uterus descends towards or into the vagina. It happens when the pelvic floor muscles and ligaments become weak and are no longer able to support or hold the uterus in position.

58. Place of child delivery: This entry denotes the place where a child is born. It is classified into the following categories: 1. Specialized hospital, 2. Maternal clinics, 3. Skilled birth attendance, 4. Traditional birth attendance

1. Specialized Hospital: It is a well-equipped Health Service Centre with emergency medical services, intensive care unit and advanced medical services. It is also coordinated with potential organ donors and also has the facilities of secondary transport or inter-hospital transport.

2. Maternal clinics: These clinics specialize in caring for women during pregnancy and childbirth. It also provides care for newborn infants and may act as a centre for clinical training in midwifery and obstetrics.

3. Skilled birth attendance: A skilled birth attendant may be a midwife, doctor or nurse who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.(l)

4. Traditional birth attendant: Usually, a traditional and community midwife especially in the developing countries. They assist a woman during labour and delivery with skills learned by apprenticeship or personal experience rather than by formal training.

59. Was there any complication to the baby after birth: 1. Fever 2. Jaundice 3. Breathing difficulty 4. Skin infection 5. Vomiting 6. Diarrhea 7. Umbilical cord infection.

1. Fever: Fever can be a symbol of the presence of infection. If the rectal temperature of an infant who is three (3) months or younger is 100.4 ̊ F (38 ̊ C) can be taken as a pathogenic condition.

2. Jaundice: It is the yellow discoloration of a newborn baby’s skin and eyes. In this condition, blood contains an excess of bilirubin and a yellow pigment of red blood cells.

3. Breathing difficulty: Breathing difficulty is a serious problem for babies. It can be manifested by  rapid breathing or breathing held up for at least 20 seconds, both of which can be a problem for the baby.

4. Skin infection: There might be different manifestations of skin infections among the babies.

5. Vomiting: Vomiting can occur in infants. But forceful vomiting can indicate some serious conditions and there might be different potential causes.

6. Diarrhoea: Usually, diarrhoea does not last long among the babies. A change in the diet or a change in the mother’s diet may cause this. Most often caused by a virus and goes away on its own. But proper care must be taken to avoid dehydration of the baby.

7. Umbilical cord infection: Usually, the umbilical cord stump dries up and falls off the newborn within the first few weeks. But sometimes an infection can develop. The surrounding skin becomes red and swollen and the area develops a pink moist bump.

60. Feeding practice: Here the sub-catagories are, 1. Early initiation of breast feeding 2. Prelactal feeding 3. Exclusive breast feeding 4. Bottle feeding.

Feeding practice is the number, type and habit of the food to the baby. 

1. Early initiation of breastfeeding: It is the provision of breastfeeding to infants within one hour of birth.

2. Prelacteal feeding: This is the provision of food for the infant before breastfeeding or before breastmilk comes in usually on the first day of life.

3. Exclusive breastfeeding: In this provision, the infant receives only breast milk. No other liquids or solids are given, not even water. Nevertheless, oral rehydration solution or drops or syrups of vitamins, minerals or medicines can be given.

4. Bottle-Feeding: Bottle feeding is the practice of feeding as a substitute for breast milk.

61. frequency of post-natal care (PNC) It is the number of postnatal visits after giving birth.

62. Had any sickness after child delivery: 1. Fever 2. Abdominal/uterine pain 3. Flank pain 4. Headache 5. Fatigue/weakness/lethargy 6. Dizziness 7. Visual disturbance.

1. Fever: Fever of the mother during postpartum has different reasons and it should not be neglected.

2. Abdominal/uterine pain: Abdominal or uterine pain may occur after delivery and it feels like menstrual cramps. Usually, it is due to uterus contracts and shrinks back to its normal size.

3. Flank pain: Flank pain is one of the postpartum complications. It is the pain and discomfort in the lower abdomen, pelvis and in the urinary bladder. Generally, due to urine infection or some other other infections. 

4. Headache: It is one of the complications after delivery. Due to the shift of hormones, dehydration postpartum headache among the new mothers may occur.

5. Fatigue/weakness/lethargy: Too little sleep and the stress of caring for a newborn can cause fatigue/ weakness or lethargy in the mother.

6. Dizziness: It is another complication of mothers after delivery.

7. Visual disturbance: Visual disturbance may occur due to several physical changes during pregnancy and child delivery.

63. Getting back to work after delivery: This is the variable that denotes the time length of returning into the work of the mother.

1. Within 1-7 days 2. Within 8-15 days 3. Within 16-30 days 4. Within 31-42 days.

64. Vaccination: 1. No 2. Yes. This question is about the vaccination of the baby to learn whether the baby is vaccinated on time or not.  

65. Vitality: 1. No 2. Yes. This question is about whether the baby is living or not.

66. Infant’s health problem: 1. Neonatal Jaundice 2. Perinatal Asphyxia 3. Low birth weight 4. Septicemia 5. Convulsion 6. Severe Pneumonia 7. Hemorrhagic disease 8. Meconium aspiration syndrome 9. Congenital malformation 10. Intrauterine growth retardation 11. Others

1. Neonatal Jaundice: Neonatal jaundice is a yellowish discoloration of the white part of the eyes and skin in the newborn baby due to high bilirubin levels. (m)

2. Perinatal Asphyxia: Perinatal asphyxia is the medical condition resulting from deprivation of oxygen to a newborn infant that lasts long enough during the birth process to cause physical harm, usually in the brain. It is also the inability to establish and sustain adequate or spontaneous respiration upon delivery of the newborn. Perinatal asphyxia is also an oxygen deficit from the 28th week of gestation to the first seven days following delivery.

3. Low birth weight: The birth weight of an infant is the first weight recorded after, ideally measured within the first hours after birth, before significant postnatal weight loss has occurred. Low birth weight (LBW) is defined as a birth weight of less than 2500g (up to and including 2499g), as per the World Health Organization (WHO) (n) (add the paper of birthweight)

4. Septicemia: Neonatal septicemia is defined as a syndrome of clinical features of disseminated infection and presence of bacteremia in the first four weeks of life. (o) In the case of neonatal septicemia, it occurs when the pathogenic bacteria gain access to the bloodstream and may cause disseminated infection, known as septicemia.

5. Convulsion: Convulsion among the babies are difficult to recognize. One of the reasons behind it is high fever and it usually occurs between six months and six years old babies. Sometimes it is related to brain injuries or developmental abnormalities.

6. Severe Pneumonia: The presenting features of viral and bacterial pneumonia are similar. However, the symptoms of viral pneumonia may be more numerous than the symptoms of bacterial pneumonia. In children under 5 years of age, who have a cough and/or difficult breathing, with or without fever, pneumonia is diagnosed by the presence of either fast breathing or lower chest wall indrawing where their chest moves in or retracts during inhalation (in a healthy person, the chest expands during inhalation). Wheezing is more common in viral infections. (p)

7. Hemorrhagic disease: It is the bleeding problem that occurs in the baby during the first few days of life. Babies who born with low levels of vitamin K, which is the essential factor in blood clotting are the basic cause of hemorrhagic disease.

8. Meconium aspiration syndrome: It is also known as the neonatal aspiration of meconium. It describes the spectrum of disorders and pathophysiology of newborns born in meconium-stained amniotic fluid (MSAF) and has meconium within their lungs. Therefore, MAS has a wide range of severity depending on what conditions and complications develop after parturition. (q)

9. Congenital malformation: It is known as congenital disorders or birth defects. It affects the baby from birth. It can involve any part of the body, including the brain, heart, lungs, liver, bones and intestinal tract. Congenital disorders can result from genetic reasons and other factors like diet, medication, blood sugar etc.

10. Intrauterine growth retardation: It is the situation when the baby is smaller than it should be because it is not growing at a normal rate inside the womb. This delayed growth can put the baby at risk of different health problems during pregnancy, delivery and also after birth.

11. Others: this part is an open-end if any other problem exists in the baby which has been mentioned yet.

Sexual activities including relevant violence

67. History of involvement in sexual activity: 1. Self-curiosity, 2. Friend’s influence, 3. Pressure from the special friend, 4. Sexual abuse, 5. Experience of sexual violence, 6. Career opportunity, 7. Poverty (sex trade), 8. Marriage

1. Self-curiosity: Self-curiosity is defined as one’s tendency and interest in exploring their inner functioning. (r)

2. Friend’s influence: It is another behavioural aspect where the message of involvement in any activity is received or advised from friends and contemporaries.

3. Pressure from the special friend: When someone who is special to the victim gives pressure to do something s/he normally does not want to do and leaves her/him feeling guilty, ashamed, embarrassed or even frightened. Finally, s/he is constrained to do the job.

4. Sexual abuse: Sexual abuse, also referred to as molestation, is abusive sexual behavior by one person upon another. It is often perpetrated using force or by taking advantage of another. (s)

5. Experience of sexual violence: It is a serious public health and human rights problem. With both short- and long-term consequences on women’s physical, mental, and sexual and reproductive health. (t). It can be defined as ‘any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.’ (u) Apart from physical force, it may involve psychological intimidation, blackmail or other threats -for instance, the threat of physical harm, of being dismissed from a job or not obtaining a job that is sought.(u)

6. Career opportunity: A career opportunity has a broad meaning in different aspects. It can be used to describe a big break in a career or it can be meant as the last option when someone is working in a company and it is the opportunity before they are terminated.

7. Poverty (sex trade) Poverty is the state of lacking a usual or socially acceptable amount of money or material possessions. Sexual activities due to poverty denote the selling or exchange of sex for money due to poverty.

8. Marriage: Marriage is the legally or formally recognized union of two people as partners in a personal relationship.

68. Age of first sexual intercourse: It is an open-ended question. It denotes the age of first sexual intercourse.

69. Number of partners: 1. One (1) Person 2. Two (2) Persons 3. Three (3) Persons 4. Four (4) Persons. This variable denotes the number of sex partners in the history of the sexual activities of the respondent.  

70. Sexual hygiene: This variable corresponded by the experience of the sexual activities of the respondent during the menstrual period and it is a closed polar ended question by stating: 1. No 2. Yes.

71. Experience of sexual violence: It is also a closed polar end question. Corresponded by 1. No 2. Yes. It denotes whether the respondent has experienced sexual violence in her life or not.

72. Type of violence: It is an open-ended question. 1. Rape, 2. sexual abuse, 3. Family violence, 4. Others…………….

This variable denotes the types of sexual violence that the respondent might have faced. It has taken as an open question by keeping the option ‘others’ and the marked are rape, sexual abuse, family violence. They can be defined as follows;

1. Rape: Rape is defined as physically forced or otherwise coerced penetration, even if slight, of the vulva or anus, using a penis, or other body parts or an object. The attempt to do so is known as attempted rape. Rape of a person by two or more perpetrators is known as gang rape. ((u)Violence by WHO)

2. Sexual abuse: Sexual abuse, also referred to as molestation, is abusive sexual behavior by one person upon another. It is often perpetrated using force or by taking advantage of another. (s)

3. Family violence: It is defined as the forceful sexual activity from the respondents’ family. It has a special impact on the victim’s life. 

73. Duration of sexual and physical abuse: It is about the length or the duration of the sexual and physical abuse that happened with   the respondent. And it has corresponded as 1. Nearly one-year, 2. Last one year and in the past, 3. Past sexual violence but not present.

74. Contraception methods using frequency during sexual abuse: This part denotes if any method of contraception had been used during the sexual abusing episode: 1. Never 2. Sometimes 3. Every time

75. Sexual violence during menstruation: closed polar ended question 1. No 2. Yes. It denotes if any episode of sexual violence or abuse had occurred during the time of menstruation.

 76. Type of contraceptive used during sexual violence/abuse: 1. Daily pill, 2. Three-month injection, 3. Condoms, 4. Contraceptive rings, 5. Implant, 6. Others. These methods define:

1. Daily pill: The daily pill is the combination pill and has two (2) hormones: oestrogen and progestin. It is directed to take one pill per day. But in the case of this combination pill; one does not need to take the pill at the same time every day. It is the most commonly used birth control pill.

On the other hand, there is another type of pill; which is one hormone pill and one must follow the timing of the pill. Therefore, it should be taken within the same three (3) hours every day.

2. Three-month injection: It is a kind of contraceptive injection. It contains the hormone progestin and it is given as an injection every three months.

3. Condom: It is the thin rubber sheath worn on a man’s penis during sexual intercourse for contraception or as a protection against infection.

4. Contraceptive rings: It is the vaginal ring and it provides contraception for a month.

5. Implant: A contraceptive implant is an implantable medical device used for the purpose of birth control. It is a thin matchstick-sized, plastic rod that is placed under the skin in the upper arm. It releases progestin and prevents pregnancy for up to three years.

6. Others: Usually refers to safe periods. Safe period defines the period during the menstrual cycle when conception is considered least likely to occur. It comprises approximately the ten days after menstruation begins and the ten days preceding menstruation. Other than safe periods, there might be some other ways for contraception and that can be acknowledged by the respondents.

77. Relation with the family members: 1. Good, 2. So-so, 3. I do not share with them, 4. Enmity, 5. Others, please specify. This variable denotes the relation between respondent and her family member.

 78. Does your family think your age is fine for your first pregnancy?- This question denotes the positive or negative attitude of the respondent’s family about the first pregnancy of the respondent. It is a closed-polar ended question corresponded by 1. No 2. Yes.

79. Willingness of accessing reproductive health related knowledge It is about the response to the health knowledge which is corresponded by three categories; 1. Disagree, 2. Agree, 3. No comment.

80. Having knowledge of how to expel unplanned pregnancy: This variable is about the knowledge of pregnancy termination of the respondents. It is a closed polar question corresponding to 1. No 2. Yes.

81. Regular contraceptive method: These are the regular contraception methods undertaken by the respondents in their daily life; 1. Daily pill, 2. Three-month injection, 3. Condoms, 4. Contraceptive rings, 5. Implant, 6. Others;. (definitions have been provided in 76)

82. opinion about pre-marital sex: Premarital sex is the sexual activity practiced by people before they are married. It is considered as a moral issue in many cultures and religions, especially in the eastern section. Here, in this variable, it is categorized by three sub-variables, namely: 1. In favour of 2. Doesn’t matter 3. Objection to identify the prospect of the respondents with this specific issue.

83. Sex education received: Sex education is the instruction of human sexuality issues, emotional and physical relations and responsibilities, sexual activity, age of consent, reproductive health, reproductive rights, safe sex, birth control and sexual abstinence (avoidance). Although it is a broad field of education in terms of practical application, in conservative countries, it is avoided due to social and personal hesitation. And in most of the cases, wrong information is transmitted to take illegal advantages of the victims. Therefore, this question has been added with closed polar end corresponded by 1. No 2. Yes.

84. Availability of sexual health service: This variable is about if the sexual health service is available to the respondents or not. It is also a closed-polar question which is corresponding by- 1. No 2. Yes.

85. Ways of acquiring sexual health-related knowledge and information: We already have discussed that sexual health education is not formally available in the society, therefore, it is acquired depending upon the necessity of the individual. Hence thinking about the practical source of health information this variable is corresponding to the following subcategories: 1. Books, 2. Newspapers & magazines, 3. School health education system, 4. Film & TV & Radio, 5. Same-sex classmates, 6. Parents, 7. Hospital & clinics, 8. Heterosexual classmates, 9. Others.

86. Access to health care: 1. Government hospital, 2. Specialized hospital, 3. NGO health care center

4. Institutional care center.

This variable is actually to recognize what type of health service centres respondents usually visit to meet their health care needs. Different centres are based on different disciplines and specialities and varied economic strata. They can be defined as:

1. Government Hospital: A government hospital is a hospital which is government-owned and is fully funded by the government and operates solely off the money that is collected from taxpayers to fund health care activities. In some countries, this type of hospital provides medical care for free of charge to patients, covering expenses and wages by government reimbursement. But in Bangladesh patients are charged with a small amount in comparison to the privately owned hospitals.

2. Specialized Hospitals: Here in this paper specialized hospitals are referred to as the privately-owned corporate hospitals, which have treatments with advanced medical and nursing staffs and also medical equipment. It is sometimes owned by a person or an authority or company and sometimes they are in partnership with foreign medical groups. Here treatments are cost-effective and not advantaged for the lower economic group of people.

3. NGO health care centre: In low-income countries, non-governmental organizations (NGOs) deliver basic health services in particular areas among certain populations. They serve at the community level to ensure mass participation. They collect funds from different countries for the welfare activity to ensure the health service for underprivileged people. They also have field workers in the different reproductive health services like the ANC or PNC with other relevant activities too. They also have satellite clinics and health education services.

4. Institutional health care: This is a very small range of medical activity in the schools or in the companies and mostly in the factories where the production workers can consult a physician for some basic needs. They also have ambulance services in most of the institutional health care centres. They are connected with nearby general hospitals for further consultation if needed.

Section D: AIDS Related Knowledge and Attitude

 Human Immunodeficiency Virus Infection and Acquired Immune Deficiency Syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV). (v)(w)(x) Following initial infection a person may not notice any symptoms, or may experience a brief period of influenza-like illness. (y) Typically, this is followed by a prolonged period with no symptoms. (z) If the infection progresses, it interferes more with the immune system, increasing the risk of developing common infections such as tuberculosis, as well as other opportunistic infections and tumors which are otherwise rare in people who have normal immune function. (y) These late symptoms of infection are referred to as acquired immunodeficiency syndrome (AIDS). (z) This stage is often also associated with unintended weight loss (z).

HIV is spread primarily by unprotected sex (including anal and oral sex), contaminated blood transfusions, hypodermic needles, and from mother to child during pregnancy, delivery or breastfeeding. (viii) Some bodily fluids, such as saliva, sweat and tears, do not transmit the virus. (ix) HIV is a member of the group of viruses known as retroviruses. (x)

Methods of prevention include safe sex, needle exchange programs, treating those who are infected, pre & post exposure prophylaxis. (y) Disease in a baby can often be prevented by giving both the mother and child antiretroviral medication. (y) There is no cure or vaccine; however, antiretroviral treatment can slow the course of the disease and may lead to a near-normal life expectancy. (z)(xi)

In case of living with a HIV/AIDS patient, it should be kept in mind that, there is no risk of acquiring HIV if exposed to feces, nasal secretions, saliva, sputum, sweat, tears, urine or vomit unless these are contaminated with blood. (xii) Along with that one should remember that people do not get HIV from air, food, water, insects, animals, dishes, knives, forks, spoons, toilet seats or anything else that doesn’t involve blood, semen, vaginal fluids or breast milk. Nevertheless, one must wear gloves during contact with blood or other body fluids. If there is any cut, sores or breaks on both the care givers and patient’s exposed skin should be covered with bandages. If someone is sick in the family s/he should be kept away from the AIDS patients as they are immunologically vulnerable. A person with HIV should not share razors, toothbrushes, tweezers, nail or cuticle scissors, pierced earrings or other pierced jewelry or any other item that might have their blood on it. Clothes and bed sheets can be washed as the other laundry unless they have blood, vomit, semen, vaginal fluids, urine or feces on them. In that case, disposable gloves should be used to handle them and kept in a plastic bag until they are washed. Needles and other sharp instruments should be used only when medically necessary and they should be handled with gloves and disposed of in puncture proof containers.

HIV/AIDS patients do not need to be kept isolated from the other members of the family, rather they should get support to fight the virus back with proper care and love. Hugging, holding hands, giving massages and many other types of touching are safe for the care givers and the family members and needed by the person with AIDS.      

As we all know, HIV/AIDS is one of the biggest public health problems which is easily spreadable and people should be aware about HIV/AIDS. Therefore, this section describes some basic points about HIV AIDS related knowledge, which should be known to all. In this part the corresponding questions are followed by closed polar ended answers to recognize the level of their knowledge.

The questions are: 1. Do you know about AIDS? (No/Yes) 2. Do you know how AIDS is transmitted? (No/Yes) 3. Do you know how to live with an AIDS patient? (No/Yes) 4. Are you willing to keep relations with AIDS patients? (No/Yes) 5. Do you think there is no need to isolate AIDS patients? (No/Yes) 6. Have you ever received AIDS education? (No/Yes)

4. Gannt Chart 

4.1 WORK PLAN

4.2 GANNT CHART

Activities	September 2018	October 2018	November 2018	December 2018	January 2019	February 2019	March 2019	April 2019
Design of the study	X	X
Review of the Literature		X	X
Development & Approval of Proposal			X	X
Developping data collection tools				X	X
Pre-testing Questionnaire					X
Data Collection Entry & Analysis					X	X
Report Writing						X
Submission & approval of Thesis							X
Developing data collection tools								X

RESULT

Variables	Total	Urban (%)	Rural (%)
Age at Survey (Mean)
14-19 Years	17.13	17.38	16.88
20-24 Years	51.28	48.50	54.01
25-29 Years	22.34	25.11	19.62
30+ Years	9.26	9.01	9.49
Education (%)
Up to Primary Level (%)	73.40	72.10	74.68
High school & above	26.60	27.90	25.32
Residence	49.57Urban/50.43Rural	—	—
Religion	87.13 Muslim	86.48	87.76
Ethnicity	86.28 Bangali	84.55	87.97
Marital Status	83.30 Married	83.05	83.54
Marriage Type	47.34 Love/52.66 Arrange	39.91/60.09	54.64/45.36

Table 5.1: Socio-Demographic Characteristics of the Respondents (N=940)

The study participants were predominantly young, with more than half (51.28%) aged between 20 and 24 years, followed by 22.34% in the 25–29 years age group. Only 17.13% were aged 14–19 years, while 9.26% were 30 years or above. Regarding education, the majority (73.40%) had studied up to primary level only, and just 26.60% had completed high school or above. The sample was almost equally distributed between urban (49.57%) and rural (50.43%) areas.

The respondents were overwhelmingly Muslim (87.13%), with a small proportion belonging to Hindu (7.87%), Christian (4.26%), and other religious communities. In terms of ethnicity, 86.28% were Bengali, while 13.61% belonged to tribal communities. Most of the women (83.30%) were currently married. With regard to marriage type, 52.66% had arranged marriages, while 47.34% reported love marriages. Some urban-rural differences were observed: arranged marriages were more common in urban areas (60.09%) compared to rural areas (45.36%), while love marriages were relatively higher in rural settings.

Variables	Total	Urban	Rural
Annual Income (Mean)	53238	65356	41325
Annual Expenditure (Mean)	55532	62697	48487
Main Source of Income
Service Salary	63.68%	57.79%	74.54%
Forestry or animal husbandry	14.33%	16.83%	9.72%
Occupation
Household Work	45.64%	34.55%	56.54%
Industrial/Commercial?Production Workers	46.49%	58.37%	34.81%
House Condition
Tin Shed	46.91%	45.92%	47.89%
Biulding (Permanent)	41.81%	43.56%	40.08%
Slum	11.28%	10.52%	12.03%
Family Size	6.05	6.01	6.0
Living Status	81.81% With Family	81.33%	82.28%

Table 5.2: Economic and Living Conditions of the Respondents

The economic condition of the respondents revealed notable urban-rural disparities. The overall mean annual income was 53,238 Taka. However, urban respondents had a substantially higher average income (65,356 Taka) compared to their rural counterparts (41,325 Taka). Similarly, the mean annual expenditure was 55,532 Taka, with urban respondents spending more (62,697 Taka) than rural respondents (48,487 Taka).

Service salary was the main source of income for the majority (63.68%) of the respondents. This was more dominant in rural areas (74.54%) than in urban areas (57.79%). A significant proportion of women were engaged in household work (45.64%), which was much more common in rural areas (56.54%) than in urban areas (34.55%). Another 46.49% were involved in industrial, commercial, or production-related work, with higher participation in urban settings (58.37%).

Regarding housing conditions, nearly half of the respondents (46.91%) lived in tin-shed houses, slightly higher in rural areas (47.89%) than urban areas (45.92%). Permanent buildings were more common in urban areas (43.56%) compared to rural areas (40.08%), while slum-like conditions were reported by 11.28% of the respondents. The average family size was 6.05 members, almost similar in both urban and rural areas. The vast majority of women (81.81%) lived with their family members.

Variables	Total (%)	Urban(%)	Rural (%)
School Performance
Middle Grade	88.52	87.34	89.70
Drop-out Experience	85.64	84.33	86.92
Main Reason of Drop-out
Poverty	43.72	41.03	46.31
Bad Environment	12.31	12.56	12.07
Fear of Teacher	10.93	11.03	10.84
School attendance before sexual activities	61.35	62.29	60.44

Table 5.3: Educational Background and School Experience

The educational background of the respondents revealed a concerning picture. The vast majority (88.52%) reported average or middle-grade school performance, with very few achieving top grades. Alarmingly, 85.64% of the respondents had dropped out of school, with a slightly higher drop-out rate in rural areas (86.92%) compared to urban areas (84.33%).

Poverty was the dominant reason for school drop-out, accounting for 43.72% of cases. This reason was more frequently reported in rural areas (46.31%) than in urban areas (41.03%). Other notable reasons included bad school environment (12.31%), fear of teachers (10.93%), and marriage. On average, the respondents attended school only 61.35% of the time before engaging in sexual activities, with marginally higher attendance in urban areas (62.29%) than rural areas (60.44%)

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