Early Marriage Determinants and Implications among Egyptian Women in Gharbia Governorate

Background: Early marriage with its harmful effects on women’s health is one of the most important public health issues. Objective: This study was designed to explore the perception and determinants of early marriage and its harmful consequences on females in urban and rural areas of Gharbia Governorate, Egypt. Methods: A cross-sectional study was conducted for 3 months and included 1,293 women from family health facilities in Gharbia Governorate, Egypt. A predesigned interview questionnaire was used to collect related data. Results: Of the participants, 36.7% married before the age of 20 years: this phenomenon was significantly more prevalent in rural than in urban areas (45.5% vs. 27.8%, respectively). Significant factors associated with early marriage included low educational level of the females and their parents (p > 0.001(. Conclusion: Early marriage is still practiced in Egypt with misconceptions about the proper age of marriage. This harmful practice might lead to adverse implications on women’s social and psychological aspects and children’s health. Therefore, formulating an integrated approach, including enforcing the law and motivating community stakeholders and health authorities to combat this phenomenon, is necessary.


INTRODUCTION
arriage is an important social system that affects the building structure of the community. (1) Early marriage is a global issue and a widespread harmful practice, which affects an enormous number of girls. (2)(3)(4)(5)(6) According to human rights and international laws, early marriage refers to children who get married before reaching the age of 18 years and is recognized as a human right violation. (5) Although the average age of marriage is rising for both sexes, early marriage has remained a problem in developing societies. (2) According to the United Nations Population Fund, nearly one in three girls marries as a teenager in many parts of the developing world. (7) However, the rates vary greatly between and within countries. The highest rates were reported in South Asia (44%) and Sub-Saharan Africa (39%). (4) In the Arab region, between 14% and 24% of girls married under the age of 18 years. (8) Egypt harbors a considerable number of early married females in the Middle East Region. (8) According to the National Council of Childhood and Motherhood, in 2017, nearly one in every 20 girls (5%) between the ages of 15 and 17 years and one in every 10 (10%) adolescent girls aged 15-19 years are either currently married or were married before this age, with large differences between those who live in rural areas and those living in urban areas. (9) In 2008, Egyptian child protection laws raised the legal age of marriage for girls to 18 years to be the same as that of boys. However, legal loopholes render it unenforceable. (10) Early marriage is often associated with lower socioeconomic status, fair education, wrong beliefs, and adherence to misconception of religion and discriminatory gender practices. (11) Girls who marry before the age of 18 years experience negative implications on their health, education, and productive work. (2) Early marriage not only affects the girls' wellbeing but also negatively affects the M Original Article community, with evident influences on fertility rates and health risks on children and their mothers. (12) This study was designed to explore the perception and determinants of early marriage and its harmful consequences among females attending rural and urban primary healthcare facilities in Gharbia Governorate, Egypt.

METHODS
A cross-sectional study was conducted in Tanta City and El-Santah district, Gharbia Governorate, over a period of 3 months from January 2018 to March 2018. The study was conducted at three family healthcare facilities: one urban facility in Tanta City and two rural units in El-Santah district, Gharbia Governorate, Egypt. Respondents were recruited using a multistage stratified random sampling technique. In the first stage, Gharbia Governorate was stratified into urban and rural areas. Tanta City and El-Santah district were randomly chosen to represent urban and rural areas, respectively. In the second stage, one urban facility of four centers in Tanta City and two rural units of 29 units in El-Santah district were selected. Since the attendance rate in rural facilities was lower than that in urban ones, two rural units were chosen to make an equal representative sample between the two areas.
The following healthcare facilities of Gharbia Governorate were included in the study: 1-Urban Saeed Family Health Center located in Tanta City is the largest urban center serving more than 60,000 citizens, with approximately 80 daily visitors.

2-Rural Meet Ghazal Family Health Unit located in
El-Santah district is one of the largest rural units serving more than 15,000 citizens, with approximately 30 daily visitors.

3-Rural Shoubra Kas Family Health Unit located in
El-Santah district is one of the largest rural units serving more than 16,000 citizens, with approximately 35 daily visitors. In the last stage, females attending the selected healthcare facilities during the study period were selected using a systematic random sampling method, taking every third one. The study included 1,293 females aged from 15 to 45 years. Females attending the chosen three healthcare facilities during three randomly selected days per week for data collection were recruited for the 3-month study period. The response rate was 98.6%. The participants were interviewed using a predesigned questionnaire sheet. The questionnaire was structured by the investigators based on a review of similar literature, which was then validated by three experts with a reliability of Cronbach α = 0.89. The questionnaire was divided into two parts: the first one included sociodemographic characteristics and marriage-related conditions (e.g., parents' education, occupation, residence, age at marriage, age at first pregnancy, and number of children). Educational level was classified as low (i.e., illiterate, read and write, primary or preparatory), middle (i.e., secondary or diploma), and high (i.e., university or post-graduate studies). The second part was related to the participants' perception about early marriage (e.g., females' opinion about the most suitable age for marriage and first pregnancy, suitable number of children, and suitable age difference between spouse and their opinion about early marriage as a harmful traditional practice threatening family life and health, including their children's health). The responses were dichotomous (i.e., agree and disagree). Moreover, other items included questions concerning spouse relationship (e.g., the use of contraception and exposure to husband's physical and/or psychological violence) and negative consequences of early marriage.

Statistical analysis
The organization, tabulation, presentation, and analysis of the data collected were performed using Statistical Package for the Social Sciences (version 21).
Variables including sociodemographic characteristics and marriage-related conditions were presented as frequency and percentage. The chi-square test or Monte Carlo exact test was used to test the association between qualitative variables. P-values of less than 0.05 were used to denote statistical significance.

Ethical considerations
Ethical approval for the study was granted from the Research Ethical Committee at the Faculty of Medicine, Tanta University (approval reference No. 33992/8/20) and the responsible health authorities in Gharbia Governorate. Verbal consent was obtained from the females to participate in the study after explaining the nature of the study and assuring the confidentiality of data, and those who refused to participate were excluded from the study. Table 1 presents the sociodemographic variables among the participants under study. More than half of them (52.9%) were aged 15 to <20 years, and those who were 40-45 years old represented only 3.1% of the study population. The respondents were nearly equally distributed between urban and rural communities. Regarding parents' education, more than half of the participants' fathers and mothers had middle-level education (62.7% and 66.4%). Most fathers were employees or had professional jobs (65.9%), whereas approximately three-fourths (72.6%) of the participants' mothers were housewives. Of the 550 married participants, 36.73% were married before the age of 20 years, and only 7.1% married at the age of 25 years and more.  Table 2 explains demographic variables and marital circumstances relative to age of marriage among the participants under study. Most married participants were aged between 20 and 30 years (71%), whereas 15.4% were aged below 20 years. More than half of the participants attained high education (55.3%). A statistically significant difference in educational level was recorded between females married before the age of 20 years and those married after the age of 20 years, where 23.6% of those who married before the age of 20 years were highly educated, whereas 76.4% of those who married above the age of 20 years were highly educated (p = 0.0001). Moreover, the proportion of parents who attained high education in the younger group (<20 years) were less than that in the older group (>20 years) (20.3% vs. 79.7% among fathers and 12.8% vs. 87.2% among mothers) (p < 0.0001 and 0.0001, respectively). Similarly, a significant difference in parents' job was detected between both groups. Most parents (73.7% and 81.8%) in the older group were employees or had professional jobs, whereas only 26.3% and 18.2% were employees or had professional jobs in the younger group (p < 0.0001). Table 3 compares the opinions about marriagerelated circumstances between participants from urban and rural communities. Approximately 5% of all participants agreed that the suitable age for marriage is between 15 and 20 years, whereas the majority (80.3%) believed that the suitable age for marriage is between 20 and 25 years. Moreover, 17.9% of participants from urban communities preferred marriage above 25 years compared with 11.7% among participants from rural communities (p = 0.001). Meanwhile, 2.8 %(n = 37) of the participants viewed that the suitable age for the first pregnancy is between 15 and 20 years. Approximately one-fifth of the participants believed that the proper age difference between them and their spouses should be between 5 and 10 years. The percentage of rural females who agreed that they should get the permission of their husband for visiting their families and even for what to cook was higher than that of urban females (p = 0.008, 0.001, and 0.004 respectively). Meanwhile, most urban (81.8%) and rural females (74.3%) agreed that early marriage threatens children' health with a statistically significant difference (p = 0.001). Table 4 compares urban and rural married females regarding marriage-related circumstances. The percentage of rural females who were married before the age of twenty years was significantly higher than that of urban females (45.5% vs. 27.8%, respectively) (p < 0.0001). Moreover, the percentage of urban women (61.9%) and their husbands (62.6%) who were highly educated was significantly higher than that of rural women and their husbands (49.1% and 48.4%, respectively) (p = 0.009 and 0.002, respectively). Most married women (89.3%) had their first pregnancy at the age of 20-30 years and were equally distributed between the two residences. The overall contraception rate was 40.5% with a significant higher usage reported among married women of urban residence (44.7%) than in those (36.5%) of rural residence.    Table 5 shows the association between early marriage and negative consequences among the urban and rural married females under study. The percentage of females who married before the age of 20 years and experienced all negative consequences was significantly higher than that of those married above the age of 20 years, including abortion (19.8% vs. 14.9%), having a child with chronic illness (6.5% vs. 4.1%), exposure to husband's violence (11.3% vs. 6.9%), and suffering financial problems (16.8% vs. 12.9%). However, these associations were not significant (p = 0.14, 0.2, 0.06, and 0.2 respectively).

DISCUSSION
In this study, we highlighted women's perception of early marriage and its determinants and associated physical, psychological, and social consequences in Gharbia Governorate as it is the largest governorate in the Middle Delta region of Egypt. Among the 550 married females included in this study, 36.75% were married before the age of 20 years, with a higher percentage of them living in rural communities (45.5%) than those living in urban communities (27.8%) with a significant difference. These figures were higher than that reported in the 2017 Egyptian Census (4% and 11% among girls aged 15-17 and 15-19 years, respectively). (2) However, they were approximately similar to regional rates, that is, 40% and 49% and 46% and 29% in Central/West Africa and Latin America, respectively. (4,13,14) This study reported that 3.2% and 6.7% of urban and rural respondents agreed that the proper age of marriage is between 15 and 20 years, whereas more than three-fourths of them (urban 79% and rural 81.6%) mentioned that the proper age is between 20 and 25 years. More than half of them (58.5% and 57.1%, respectively) reported that the suitable age for pregnancy is between 20 and 25 years. The same age range was reported by Mohamed (2015) and Cherri et al. (2017). (15,16) Besides, in Arab communities, parents may see early marriage as a protective mechanism against premarital sexual activity, unintended pregnancies, and sexually transmitted diseases. (15) Most married respondents reported that their age at the time of the first pregnancy was between 20 and 30 years, without difference between those living in urban areas and those living in rural areas. This reflects the awareness of the participants regrading healthy age of conception.
Moreover, most females under study who married above the age of 20 years were highly educated compared with those married before the age of 20 years with a significant difference between both groups (76.4% vs. 23.6%, respectively). When girls drop out of school, they are more at risk of child marriage, as education is a reason to delay marriage for girls to the age of 18-19 years until they finish high school. They could continue their studies at a university, while being married. (16) Nawal and Nour (2006) have stated that women who were married early often bear children quickly to secure their social identity and status. As a result, these young wives have high total fertility rates but have missed the opportunities to be fully maturated, become highly educated, and build social skills. (14) Furthermore, similar studies in Bangladesh and Syria have documented that higher education plays an important role in reducing early marriage. (15,17) Poverty plays a central role in perpetuating child marriage. Moreover, daughters are considered an economic burden, especially in rural communities. Parents want to ensure their daughters' financial security and believe that marriage opportunities decrease as the girl gets older, which may render parents to have their daughters married at younger ages. (14) In 2015, an Egyptian study has determined that the main drives for parents to get their daughters married were financial strain (69.6%) and fear that the girl will never be married (36.2%). (1) It is worthy to note that 7.4% and 5.2% of rural and urban respondents, respectively, accepted the idea of marriage before the age of 18 years, which may reflect the existence of underlying social concepts regarding early marriage.
Furthermore, studies have indicated that due to limited resources, families viewed early marriage as a way to lessen the financial burden of the family and to improve their social condition. (3,13,14) This is supported by our results where the rate of unemployed fathers was significantly higher among women who married before the age of 20 years (53.7%) than that among those who married after the age of 20 years (46.3%), and most mothers of those married above the age of 20 years worked in professional jobs compared with those of women married before the age of 20 years with a significant difference (81.1% vs. 18.2%).
Kirst et al. (2014) have reported that family structure was a basic factor that push girls to marry early, including family norms, communication, and the balance of power within the family system. (12) Similarly, this study investigated some family structures that affected early marriage in both urban and rural communities, and it was found that low educational levels of both parents were a significant factor for early marriage.
Additionally, most participants experienced low autonomy in decision-making, for example, having their husbands' approval before going outdoors, even before visiting their families, and the type of food cooked with a significant difference between urban and rural women (88.5%, 82.1%, and 39.3% vs. 92.8%, 88.8%, and 47.3% respectively). Moreover, most respondents (95.8%) agreed that they had the right to choose their husbands with a significantly higher percentage of them living in rural areas (97%).
Regarding spousal abuse, more women who married before the age of 20 years reported exposure to husband's violence than those who married above the age of 20 years (11.3% vs. 6.9%). This finding is related to a previous report that detected a high prevalence of physical spousal violence at a rate of 50%, which was significantly associated with young age of the inflicted wife. (18) Moreover, 15.4% (n = 85) of married participants were aged less than 20 years during the study, indicating that they were married at a younger age with a significantly higher proportion of them living in rural areas (20.2%) that those living in urban areas (10.6%).
Social norms play an important role in the practice of early marriage; this phenomenon is not exclusive to a particular religion but runs deep in Egyptian culture. (8) Inequitable gender norms were detected in this study where more than one-third of both of urban (36.1%) and rural women (33.8%) accepted that there should be an educational gap between them and their spouses without significant difference between both residences. As expected, more women of rural background believed that the acceptable age difference between them and their spouses should be 5-10 years (22% vs. 16.3% of urban women). This finding might explain why females get married at a younger age; they might want to have a big age difference with their partners.
However, much of the literature presented early marriage as a decision taken by the family, without the bride's opinion into consideration. (17,19) However, in this study, most married respondents (97.3%) were asked for their opinion, and the final decision to get married was taken by themselves without family pressure, irrespective to their residential background. However, studies in Iran and South East Asia (3,14) have reported that approximately two-thirds of the respondents were forced to marry (36.8% were Syrian refugee women). (16) In contrast, this study reported that the negative consequences of early marriage included abortion, chronic illness of children, exposure to husband's violence, and financial problems. The rate of negative consequences between those married before the age of 20 was significantly higher than that in those who married above the age of 20 years, though no significant difference was observed. This finding is supported by the fact that girls who marry early are at a higher risk of certain adverse health consequences since they are not physically and psychologically well prepared for marriage and conception. (14,(20)(21)(22) Similarly, Santhya et al. (2015) have reported that females who married early have high rates of abortion, preterm labor, delivery of low-birth-weight babies, and fetal and maternal mortality. (8) Moreover, Ahmed et al. (2014) and Mouli et al. (2013) have reported that girls who are married as teenagers are also psychologically affected and are more likely to experience depression and anxiety and at risk of physical and sexual violence within marriage. (20,23) Additionally, early marriage denies females' abilities to continue education, reduces work opportunities, limits social skills, separates them from family and friends, and enhances their vulnerability to considerable health and socioeconomic constrains. (24)

CONCLUSION AND RECOMMENDATIONS
This study highlighted some factors associated with early marriage, such as low educational level of married women, rural background, low job rank, and educational level of their parents, along with false beliefs about the suitable age of marriage and misconception of social norms. This harmful practice might have negative implications on women's health, though they were of limited incidence. Finally, an integrated approach is needed to combat this phenomenon, including enforcing the law, motivating community stakeholders and health authorities to propagate awareness of healthy marriage, and correcting cultural misconceptions.