Lupine Publishers | Factors of Early Marriage and its Consequences on Reproductive Health from Teenage Mothers’ Perspectives and their Families

 Lupine Publishers | Journal of Nursing & Health Care

Abstract

Background: Earlier marriage (EM) is a threatening concern for young females. The healthy young females reproduce a healthy prospect generation. While women’s reproductive health complications such as bleeding, low birth weight, premature birth, miscarriage, and unwanted pregnancy will reproduce weak, and ill generation. Purpose of the study to determine early marriage factors and its consequences on reproductive health from teenage mothers’ perspectives and their families.

Method: The study used a descriptive-cross-sectional design. The study conducted at the outpatient clinic in Women’s Health Hospital and four maternal and child health centers in Assiut University. Study Sample: A convenient sample of teenage mothers recruited to achieve the aims of this study. A Structured interview questionnaire used for data collection.

Results: The total teenage mothers were (112). The mean age + (SD) at the time of marriage is 16.62±1.74.and current age is 24.95±5.95. About 60% of the currently married women were aged (18-22) years old. Two-thirds of participants revealed that early fertility was one of the essential factors of early marriage. Complications of early marriage were CS, bleeding, perineal tear, preeclampsia and one-fifth of newborn had physiological jaundice and health problems. There was a statistically significant difference between teenagers’ mothers and parents’ perspectives regarding consequences of early marriage.

Conclusion: The study reveals significant differences in most of the factors and also consequences. The study concludes that perspectives of adolescents’ women match with the findings of the previous studies, reflecting their accurate perspectives regarding early marriage and its consequences.

Implications for practice: Initiates an obligation session for each woman in maternal outpatients/clinics, especially in rural/ remote areas, to increase awareness regarding early marriage consequences and integrates the health education regarding early marriage consequences in the school curriculum to increase awareness level among adolescents’ girls.

Keywords: Early Marriage; Factors; Consequences; Reproductive Health; Teenage Mothers and Families

Introduction

Early marriage defined as any marriage carried out below the age of 18 years before the girl is physically, physiologically, and psychologically ready to carry the responsibilities of marriage and childbearing [1]. Child marriage is a human rights violation and has adverse effects on the future of their girl’s children (overwhelmingly girls) who enter into these marriages, creating an intergenerational cycle of disadvantage [2]. Adverse health consequences of child marriage include poor maternal and reproductive health.

Early marriage negatively affects the health and well–being of women and children [3]. It leads to early child-bearing, closed spaced pregnancies, unwanted pregnancy, pregnancy termination, maternal morbidity, and mortality [4]. It also increases the risk of intimate partner violence [5], which further linked to sexually transmitted diseases, including HIV. Early Child Marriage also associated with increased risk of children’s physical growth, lower educational attainment, morbidity, and mortality [6,7].

The World Health Organization (WHO) defines adolescents as those between 10 and 19 years of age. It considered a period of transition from childhood to adulthood. Adolescent girls constitute about 1/5th of the total female population in the world. The period of adolescence for a girl is a period of physical and psychological preparation for safe motherhood. As direct reproducers for future generations, the health of adolescent girls influences not only their health but also the health of future generations [8].

Millions of girls are affected by child marriage (CM) throughout the world. It widely practiced in the countries of South Asia, where millions of girls-preteens and teens become the wives of older men every year. Young girls are married when they are still children. It is a violation of human rights. Their development is limited due to early marriage (EM) and often results in early pregnancy and social isolation (UNCF, 2014).

The causes of early child marriage occurrence depend on the condition, the community’s social life, the culture, and contextspecific norms. First, early marriage is a strategy to survive economically [9]. Poverty is one of the main factors that pivot the foundation for early marriage [10]. Poverty forces parents to marry–off their daughter at a very early age because the demand for dowry is low for younger girls. [11,12].

The second cause is to protect their daughter. Marriage is one way to ensure their daughter protected as a wife from non-marital sexual behavior or non-marital pregnancy. [Wikigender 2016,12]. Besides education and economic status, there are several other factors such as level of development, socio-cultural and religious norms, women’s status, and geographical residence have significant influence in determining girls’ age at marriage [13,4].

Significance of the Study

Globally, 36% of women aged 20-24 were married or in a union, forced or consensual, before they had reached 18 years. An estimated 14 million teenage women between the ages of 15 and 19 give birth each year. They are twice more likely to die during pregnancy or childbirth than women in their 20 years. Girls who marry between the ages of 10 and 14 are five times as likely to die during pregnancy or childbirth as women in their early 20s [UNICEF,2019]. early child-bearing increases risks to women’s health, as maternal disorders1 including complications during pregnancy and childbirth, are the leading cause of death among women aged 20–24 years globally and the second leading cause among adolescent girls aged 15 to 19 years.

In Egypt, early marriage is very high. The women ages 18-22 who married as young is 16.5 percent. In addition to very early marriage, of female before the age of 15-year-old. Early marriage is allied with poverty, lesser education levels, and higher nonemployment condition or low wages. These are however only correspondences, in addition to negative series of consequences and potential causal effects such as reproductive consequences [14]. So, this study aimed to determine factors of early marriage and its consequences on reproductive health from teenage mother’s perspectives and their families.

Research Question

1-What are the factors and consequences of early marriage on reproductive health from teenage mother’s perspectives.

Subjects and Method

Research design: A descriptive- cross-sectional design used in this study.

Study settings: The study conducted at Women’s Health Hospital, Assiut University. It included many units that provided the services the clients needed; these units included labor, postpartum, high-risk maternity unit, and gynecologic units. In addition to four maternal and child health centers in Asyut city, as El-Arbaen, Qulta, El-waleedea, and Gharb district.

Sample: A convenient sample of teenage mothers recruited to achieve the aims of this study. They recruited during their follow up at the previously mentioned clinical settings from March to June 2016. The participants selected according to the following:

Inclusion criteria: mothers who fewer than 18 years old and agreed to participate voluntarily in the study. The study conducted within three months from the period of the beginning of June until to August 2018

Sample size: The sample size calculated based on Raosoft application program (2004) the margin error (α error probability = 0.05) and confidence level (Cl) = 0.90) and the population was 160 per 3 months, so the sample size in adolescents’ mothers’ group = 101 but to avoid withdrawal rate we increased the sample size to be 112.

Tools of the study: Tool (1) A Structured interview questionnaire developed by the researchers based on previous studies [15-34] Prakash et al. 2011; ARWAO, 2006]. It consisted of three parts: The tool composed of 75 items divided into the following parts.

a) First part: demographic data included six items: marital status, age at marriage, and current age and residence, religion, and education levels of the wife. Obstetric data included 12 items such as current mode of delivery, the complication of delivery, new-borns condition of after delivery, skilled attendance at birth, number of children born, died, live births, most recent pregnancy, first pregnancy, unintended pregnancy, complication during pregnancy and antenatal visit during pregnancy. Contraceptive data included (3) items such as using family planning method, types of family planning, duration of uses family planning, and termination of pregnancy. Labor data included 3 items such as complications of labor, new-born status, and new-born weight.

b) Second part: Factors affecting early marriage included 22 items, 12 items regarding social factors, five items regarding economic factors, and five items regarding education factors.

c) Third part: Consequences of early marriage included 28 items, four items regarding economic consequences of early marriage, and seven items psychiatric consequences of early marriage. Nine items were regarding early marriage’s social consequences, and the last eight items were about the reproductive health consequences of early marriage.

Validity and Reliability

The content validity of tools was established by five experts in (obstetrics and gynecology and gynecological nursing and community health nursing) who reviewed the data collection tool for clarity, relevance, comprehensiveness, understanding, and applicability. The modifications made accordingly, and then the tool is re-designed for the final format and tested. The content reliability was estimated by Cronbach’s test. The tool proved to be reliable and acceptable at (0.81).

Ethical consideration

The written approval obtained from the faculty, research committee, and Ethical committee. In addition to the approval from the director of Woman health hospital and all maternal and child health centers in Assiut to collect the necessary data. Then the researcher obtained written informed consent from each woman intend to participate in the study after explanation of the study aim. Participant’s privacy considered during the collection of data. Anonymity, confidentiality assured, and the right to refuse participation emphasized to the participants.

Statistical Analysis

Data was collected and coded through SPSS (Statistical Package for Social Science) program version 20. The descriptive statistics are done in the form of frequency and mean ± SD also used t-Test to compare the groups of the quantities data. In addition to correlation test (Pearson r test) to correlate between teenage mothers and parents’ perceptions. Also, P-value considered statistically significant if it is less than 0.05. The analysis is done in two categories in the first category. The study focused on factors and consequences of early marriage of women, while in the second category, the analysis focused on the association between selected demographic factors and consequences on women’s reproductive health outcomes. There was no missing data in the statistical analysis.

Results

Table 1 shows the three categories of participants’ age at marriage per socio-demographic characteristics. The mean age + (SD) at the time of marriage is 16.62±1.74.and current age is 24.95±5.95. The most sociodemographic characteristics (45.5%)) categorized in age (15-17), (42.9%) aged (<18) and 11.6% aged (<14) years old respectively. About 60% of the currently married women were aged (18-22) years old. The majority (80 %) lived in rural areas aged (15-17), (100%) were Muslims aged (<18) while (11.8 %) were Christians and aged (15-17) years old. Regarding education, the majority (84.6%) of the primary level was (<14) years old, while (37 .5%) of secondary and (16 .7%) of universitylevel were aged (<18) years old.

Table 1: Distribution of socio-demographic data for Study sample (N=112).

Figure.1 illustrates the obstetric characteristics of the total (112) participants. The mean (SD) of Gravidity, number of dead and living children, reveals 2.95±1.86, 1.62±0.94, and 2.88±1.78, respectively. Two-thirds (66.1%) of participants reveals that early fertility was one of the essential factors of early marriage, while (1.8%) not have the desire in the first pregnancy. Complications during pregnancy, occurred in (44.8 %) and revealed that (21.4%) had an abortion, ectopic pregnancy and unintentional were (5.4%), stillbirth and IUGR) occurred equally (3.6%) illustrates the childbirth complications among the participants. More than One-third (38%) of participants delivered by CS, while the vast majority (94.6%) of the labor process managed by obstetricians. Regarding childbirth complications, it reveals that (14.3 %) had bleeding, (4.6%) had a perineal tear, and (3.6%) had pre-eclampsia. Regarding new-born condition, about one-fifth (21.4%) born had physiological jaundice, (8.9%) admitted to nursery, while (17.9%) had health problems. Table 2 shows the difference between teenage mothers and parents’ perspectives toward the factors of early marriage. Social and tradition factors reveal that both adolescents and parents referees to customs and traditions among families, the desire to drop out of education, desire to multiply offspring, and family keen not to fall in the underworld girl as a factor of early marriage and there is a statically significant difference at (p=0.008, p=0.001, p=0.001p=0.004 ) respectively. The Psychological factors reveal a statistically significant difference in the belief in marriage as destiny and protecting youth from delinquency (p= 0.001& p=0.000). Regarding the economic factors, the participants reveal a statistically significant difference in the feeling of that girl is an economic load, and the family preserves a financial wealth and the poor economic status at (p= 0.001, p= 0.021 & p= 0.035) respectively. Factors associated with education, reveals a statistically significant difference in the inability of the family resources to complete the education stages, family direction to education, preference between males and the inability of mothers either widow or divorced to educate their children at (p=0.002, p=0.001, p=0.005 & p=0.021) respectively.

Figure 1: Correlation between age at marriage and reproductive outcomes. **Correlation is significant at the 0.01 level (2-tailed).

Table 2: Comparison between perspectives participants and their parents toward factors of early marriage.

*” The significance level p<0.05”.

Table 3: Teenage mothers and parents’ perspectives on early consequences marriage on reproductive health. Total are more than 112 due to more than one perspective for each participant.

*” The significance level p<0.05”

Table 3 illustrates that the difference between teenage mothers and parents’ perspectives toward the consequences of early marriage on the reproductive health. The consequences on maternal health revealed that (76.9 vs. 35.4) % of adolescent mothers versus parents confirmed a fatigue due to load married life was one of the consequences, there is a statistically significant difference (p= 0.001). However, the maternal mortality consequence showed that (61.5 vs. 16.9) % with a statistically significant difference (p= 0.001) while increase maternal morbidity surprisingly, showed that (44.6 vs. 76.9) % with a statistically significant difference (p= 0.001). Regarding childbirth consequences, the early abortion and post-partum hemorrhage showed similarity (76.9 vs. 44.6) % and (75.4 vs. 56.9) % with a statistically significant difference (p= 0.001 and p= 0.026) respectively. The violence consequence showed that Physical violence was similar in both groups (60.0 vs. 58.5) % with no statistically significant difference, while sexual violence showed (50.8 vs. 13.8) % with a statistically significant difference at (p= 0.001). The consequence on the newborn showed (73.8vs. 12.3)% while low birth babies showed (47.7 vs. 18.5)% and neonatal mortality showed (26.2 vs. 63.1)% with a statistically significant difference at (p= 0.001, p= 0.001 & p= 0.001) respectively. illustrates the correlation between age at marriage and reproductive outcomes. This figure showed longitudinal Axis (r values) and horizontal Axis (Reproductive outcomes) and Red, and the blue line is the P values of age in correlation with reproductive outcomes. There is no correlation between the reproductive outcomes and the age of marriage. The only clear correlation occurs between the age and the increasing maternal mortality rate, which showed a significant relationship with (Pearson r = 0.259) and (p=0.007) between age at marriage and increased maternal mortality rate. Table 4 shows the relationship between age at marriage and the complication during pregnancy and labor. This table shows that the most categorized in age (15-17), (52.9) % (61.5) % aged <14) and (37.5) % aged (<18) years old complain from abortion. While (30.8) % <14 and (35.3) % (15-17) aged years old were IUGD and equally in pre-eclampsia. There was a statistically significant with p≤0.05) association between participant’s age, and sepsis.

Table 4: Relationship between age at marriage and the complication during pregnancy and labor.

*” The significance level p<0.05”

Discussion

Early or child marriage (CM) considered a violation of young female’ rights because they cannot complete their education, and their health is influenced by it. The timing of first marriage is an important factor in women’s reproductive behavior. Adolescents are mostly affected by CM, mainly adolescent girls. (Zannatul & Zebunnesa, 2019). The study of Knox, 2017, recommended that there is a need to search about responding to the indirect factors encouraging adolescent girls towards early marriage. However, the reasons for early marriage depend on the culture and specific traditions or poor economic status, which is a common cause due to the release of the financial burden of girls’ education (UNCF, 2015). So this study highlighted the perspectives of young women who married early during the adolescent stage and their families toward social, psychological, economic, and educational factors that motivated the early marriage and its consequences on reproductive health. Therefore, this study revealed that women who married early more compromised by severe consequences on reproductive health, including childbirth outcomes.

Relationship Between Socio-Demographic Characteristics and Early Marriage

Since this study about the early marriage of females so, the socio-demographic characteristics of participants age showed that the age at early marriage ranged from less than fourteen up to eighteen years old. The most socio-demographic characteristics categorized in the first category early age, which was less than 18 years-old as the majority lived in rural areas. The majority were in the primary level of education. Similarly, Prakash et al. study, 2011 & Afrouz et al 2018) revealed that the majority of who got married at an early age lived in rural areas. Hence, the age category in our study ended at 18 years-old to focus on the consequence of early marriage on reproductive health; however, Prakash’s study was based on the whole reproductive age from fifteen to forty-nine to compare the early marriage before eighteen and after eighteen-years- old.

Regarding increased early marriage based on residence area, a study by Barry et al. 2016 who reflected similarity as indicated that education and place of residence have a significant impact on early marriage which matching the fact that for each extra year of education, the possibility of early marriage reduced by 4.5 percent (DHS/MICS, 2012). Moreover, Iranian study by studies Mardi et al. 2018, showed that teenage marriage end the education process, as adolescents forced to leave school before or after marriage, while in continuing. In the same line, Safavi et al. 2015 reported that the majority of teenage women only had elementary education. Similarly, Zahangir et al. 2011, confirmed their findings and concluded that early marriage was an obstacle to public education. Our findings revealed a statistically significant difference between adolescents and parents regarding customs and traditions among families, which encouraged the parents to drop out of the adolescents from education, desire to multiply offspring, and avoidance of girls’ underworld problem. However, the psychological factors revealed a statistically significant difference in the belief in marriage is destiny, and protecting youth from delinquency. On the other hand, the economic factors revealed a statistically significant difference regarding the feeling that girl is an economic load. The family preserves a financial wealth and the poor economic statuseven the economic status associated with the inability of the family resources to complete the education stages. Likewise, Barry et al. study 2016 in Nigeria showed that early marriage considered a value, as marriage improves the social status and self-respect of the women in the local societies. In the same way, (IntHEC, 2010). & Abedokun, Adeyemi and dauda (2016) confirmed that marriage also serves a social purpose: preventing potential family humiliation associated with early sexual behavior and premarital pregnancies.

The Consequences of Early Marriage on The Reproductive Health

The main goal of this study, and the findings, to find out the effect of early marriage on the reproductive health. So, it showed that two-thirds of participants reported that early fertility was an important factor in early marriage, while less than twopercentage did not want in the first pregnancy. During pregnancy, complications occurred in fifty percent and revealed abortion, ectopic, stillbirth, unintentional pregnancy, and IUGR. In the same line, Prakash et al. study, 2011 confirmed that the same group age of early marriage intensifying the risk of pregnancy complications such as higher fertility and more unplanned pregnancies, abortions, and stillbirths. The findings our study, also revealed maternal and infant complications as more than One-third of participants delivered by Cesarean section, in addition to postpartum bleeding, perineal tear, and pre-eclampsia. As well as new-born condition, as physiological jaundice, and admission to nursery. In the same line, Irani and Latifnejad study in 2019 reported that early marriage threats sexual and reproductive health in different ways. Such as the maternal and infants who exposed to the adverse outcomes of early marriage. Reproductive health problem experiences by early married respondents were infection, bleeding LBW, premature birth, and unwanted pregnancy. In the present study, most items in consequences agree with Rosmala, et al. 2019 early–age marriage and the impact of health reproduction women. The highest percentage of disorder was hemorrhage, infection, preterm babies, and malnutrition. There was a significant relationship between the age of early marriage ant disorders; this was presumably because pregnancy and childbirth for women below 20 years have not matured physically and psychologically so that the risks of death were much higher than the age of 20 years and above. Not only mothers and children who born also have a risk of death or highrisk disability. In the same lines with Abedokum, et al. 2016 who found that very high reproductive health disorders occurring in married couples at an early age that allows for a long reproductive period unwanted pregnancies and abortion and disagree with the present study in a negative effect on nutrition status. That evidenced (DHS/MICS 2012 and WHO, 2011) reports, which reflected that more than one-third (35 percent) of maternal mortality occurred among adolescents 15 to 19 years of age, also increases the risk for dystocia, fistula, and other damaging outcomes to the reproductive system. The study from Niger similarly confirmed that neonatal mortality is high among adolescent pregnancies. Fifteen percent of children born from married adolescent girls were stillborn or died soon after birth. Also, 14 percent of adolescent mothers gave low birth babies less than 2.5 kilograms (Barroy, et al. 2016).

The Participants’ Perspectives Regarding Early Marriage

Participants’ perspectives regarding the consequences of early marriage on maternal health revealed that a statistically significant difference between adolescent mothers versus parents confirmed fatigue due to load married life was one of the consequences. Also, the maternal mortality consequence showed a statistically significant difference, while increase maternal morbidity surprisingly showed a statistically significant difference, but the parent perspective was higher than adolescents’ perspectives. Besides, the correlation between age at marriage and reproductive outcomes showed a significant relationship between age at marriage and increased maternal mortality rate. The consequences from participants ‘perspectives on the childbirth showed a statistically significant difference regarding early abortion and postpartum hemorrhage. In accord with Mardi et al. 2018 study, which confirmed the consequence of the new-born showed a statistically significant difference regarding low birth babies and neonatal mortality. However, disagrees with Nasrullah et al. (2014). Knowledge and attitude towards child marriage practice among women married as a children-a qualitative study in Lahore, Pakistan, among married age at 11-17 years revealed the majority participants were unaware of the adverse health outcomes of early marriage. This difference interpreted by the age group started with 11 years while our group started with 14 years-old which reflect little awareness in our study participants. Regarding to the marriage life load, our findings showed a statistically significant difference between adolescent mothers and parents perspectives which confirmed that the fatigue due to load married life was one of the consequences. This finding matches the Mardi et al. 2018 study, which showed that most teenage women complained about the heavy load of life and the ambiguous future. Regarding maternal mortality, Ganchimeg et al. 2014 study confirmed that early marriage means a high mortality rate due to the complication of early pregnancy and delivery. Since, the violence perspectives is a necessary consequence, our study focused only on Physical violence, in which, two-thirds of adolescents and parents confirmed it as an extraordinary consequence.

In contrast, sexual violence showed a statistically significant difference in both group perspectives, with fifty percent of adolescents’ women versus only thirteen of parents who confirmed it; this reflected that sexual violence is an impressing issue for parents to disclose while the physical violence is visible and cannot hide. In the same line, a study in Niger reported that sexual violence was more likely to affect younger than older adolescents. However, instead of that, sexual violence was confirmed as rare in Niger as it was socially condemned. Therefore, the families in rural areas handled the retribution by hiding this issue, which is similar to our finding as to the majority the parents denied it (Barroy, et al. 2016). Moreover, the findings of Mardi et al. 2016 showed that early marriage has led to unpleasant or coercive sexual experiences for some of them. Correspondingly, Allen et al. 2017 found that teenage women suffered from the health risks and social costs of early enforced marriage and coercive sexual relationships.

Conclusion

This study spotting lights on the factors motivate early marriage and its consequences on reproductive health from the two essential members of this issue “adolescent women and their parents” to detect how their perspectives are matching or different. The study reveals significant differences in most of the factors and also consequences except in maternal morbidity consequences perspective was higher among parents than adolescents’ women may be because the parents always in the first line when their daughters diseased. The study concludes that perspectives of adolescents’ women matching with the findings of the previous studies, which reflects their accurate perspectives regarding early marriage and its consequences and reflects that the circumstances drive parents and their daughters to accept the undesirable early marriage.

Implications for practice

a) Initiates an obligation session for each woman in maternal outpatients/clinics, especially in rural/remote areas, to increase awareness regarding early marriage consequences.

b) Integrates the health education regarding early marriage consequences in the school curriculum to increase awareness level among adolescents’ girls.

c) Further studies should be on the actual plans of adolescents’ mothers regarding the avoidance of early marriage to their daughters.

d) Strengths: This is the first study done Egypt to discuss the problem of early marriage from participants and their parents who are the main backbone of the problem.

Limitation

The number of participants supposed to be more than current sample but it was limited due to the estimated time for data collection.

Conflicts of interest:

There is no conflicts of interests regarding this study.

Funding:

There is no funding resources issued in this study.

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