Health, psychology, economic resilience and wellbeing: Long-term effects on family welfare of early marriage [version 1; peer review: 1 not approved]

Background : Early marriage is a social problem that can have various impacts. This study aims to determine the long-term impact of early marriage compared to adult marriage on the aspects of health, psychology, economic survival and welfare in a comprehensive manner. Methods : This study used a cross-sectional study design. The sampling unit for this study was early marriage families from 3 sub-districts in Ponorogo district, namely Sawoo, Ngrayun and Pulung. The number of samples used were 104 families. The variables in this study consisted of health, husband's psychology, wife's psychology, economic resilience and well-being. The analysis to construct composite variables was polychoricpca analysis. Results : The long-term effects of early marriage can be seen comprehensively using polychoric PCA analysis. Based on the polyuchoric PCA analysis, a composite variable was obtained, namely Maternal Health (λ=2.79; CE 0.35); Infant health (λ=2.23; CE 0.45); Wife's psychology (λ=6.78; CE 0.56); Husband's psychology (λ=5.59; CE 0.56); Wellbeing (λ=2.07; CE 0.30); Economic resilience (λ=1.60; CE 0.40). The results of this study indicate that the long-term impact of early marriage compared to adult marriage is on the poorer aspects of maternal health, poorer infant health, poorer wellbeing and worse Economic Resilience. Conclusions : There needs to be special monitoring of cases of early marriage, so that it will suppress the bad impact.


Introduction
Early married is a global problem. [1][2][3] Globally, early marriage rates reach 12 million per 4 years. 4 In Indonesia, data shows that over the last decade, the number of early marriages in Indonesia has fallen by 3.5%. However, this reduction will require systemic and integrated efforts to reach the target of 8.74% in 2024 and 6.94 percent in 2030. 5 East Java is one of the regions with the highest early marriage rate. Early marriages in Ponorogo increased by 100% in 2020. 6 Based on the area of residence, the rural area (16.87%) has a higher early marriage rate than urban areas (7.15%). 7 The occurrence of early marriage in rural areas is a common practice. This is the the result of poor parenting environments, lack of maternal and paternal education, and lack of communication between parents and adolescents regarding reproductive and social issues. 8 Rural communities assume that remarriage will not significantly affect their lives. Research has shown that the effect of early marriage includes maternal health, early school dropout, infantfeeding, early pregnancy, and economic well-being. [9][10][11] Research is needed to determine the long-term effect of simultaneous early marriage on aspects of health, psychology, wellbeing and economic resilience. It can be used by advocacy groups as policy material to develop programs to reduce the impact of early marriage.

Study design
This study used a cross sectional study design. The research was conducted in 3 sub-districts in Ponorogo district: Pulung, Ngrayun and Sawoo. Sampling of respondents was based on data from the office of religious affairs. Respondents in this study were couples who married in 2015-2017 based on the marriage certificates in the Ministry of Religion Office.

Sampling
We used a probability sampling technique, namely by using cluster random sampling in each sub-district. The sample unit of this research is early marriage families who married in 2015-2017. The number of samples in this study were 104 families. The sampling selection was carried out in two stages: stratified random sampling for each sub-district. Furthermore, sampling was carried out using random cluster sampling based on villages in each sub-district.

Data collection
This study's population was couples married in 2015-2017 based on marriage registration at the Religious Defense Office. A list of married couples registered at the office of religious affairs was used as the basis for sampling. Sampling took two stages: stratified random sampling in 3 sub-districts and cluster random sampling in villages. Respondents selected based on the 2-stage sampling then completed a questionnaire. The questionnaire consisted of 2 types for wives and husbands.
The questionnaire used has been tested on 30 respondents. The results of the trials carried out have fulfilled the validation with the results R more than 0.361 (r table with 30 samples). The wife's questionnaire contained questions on maternal health, child health, maternal psychology, welfare and economic resilience. Meanwhile, the husband's questionnaire consisted of the husband's psychology. This study uses principal component analysis to construct index composites to measure each variable. The analysis used is polychoricpca. The variables constructed using the composite index are wife's health, children's health, husband's psychology, wife's psychology, economic resilience and wellbeing. Wife's health is built from the components Mother's age during childbirth, Antenatal care checker, Place of Antenatal care, Danger signs of pregnancy, Iron Tablet consumption, Birth attendant, Place of birth and Type of delivery. Infant's health is built from the components of Low Birth Weight (LBW), Exclusive breastfeeding, Immunization, Vitamin A, Anthelmintic. Wife's psychology and Husband's psychology were built from the components Satisfaction, Disappointment, Cries, Anxiety, Associations, Decision, Effort, Sleep quality, Feelings of offense, Concentration, Fatigue, Interest in sex. Wellbeing is built from the components Live with, Source of clean water, Toilet facility, Vehicle ownership, Agricultural land, Livestock ownership and Bank account ownership. Economic resilience is built from components of Financial Manager, Business ownership, Ownership of health insurance, Recipients of social programs.

Ethical considerations
Respondents signed the informed consent form before proceeding with the questionnaire. Respondents were informed that their data would be used for research purposes only and would be deidentified before publication. Ethical approval was obtained from the Ethics Committee of the Faculty of Health Sciences, Universitas Muhammadiyah Ponorogo with the number 99/ER/KEPK/2021 on June 18, 2021.

Data analysis
This study uses polychoric PCA analysis to compile a composite index of wife's health, infant's health, husband's psychology, wife's psychology, economic resilience and well-being to compare the conditions of the effects of early marriage and adult marriage. The principal component analysis creates one index variable from correlated variables. Polychoricpca is used on the categorical scale items.

Results
This research was conducted in a rural area in Ponorogo Regency, namely Ngrayun, Sawoo and Pulung sub-districts, with a total of 104 respondents of which 63.5% of respondents married in their teens (<19 years) and 37.5% of adults (≥19 years). The following is the frequency distribution of the respondents' characteristics (Table 1).
In this study, the table above shows that the wives when getting married were still adolescent, the husbands when getting married had been an adult, the wives' and husbands' last education was junior high school, the wives was unemployed after the marriage, the mothers' health was poor, the children's health was good, the psychological state of the wives and husbands was good, the level of family welfare of the early-married couple was in the prosperous category, and family economic resilience was in the non-survival category. The constituent variables are listed in Table 2.
The results of polychoric PCA analysis for each composite variable are shown in Table 3. In the Maternal Health variable, 35% of the variation can be explained by the variables Mother's age during childbirth, Antenatal care Checker, Place of antenatal care, Danger signs of pregnancy, Iron Tablet consumption, Birth attendant, Place of delivery and Type of delivery. In the infant health variable, 44% of the variation can be explained by the variables of low birth weight, breast milk, immunization, vitamin A, and worming. The wife's psychological variables 56% can be explained by the variables Satisfaction, Disappointment, Cries, Anxiety, Associations, Decision, Effort, Sleep quality, Feelings of offense, Concentration, Fatigue, and Interest in sex. On the husband's psychological variables, 56% can be explained by the variables Satisfaction, Disappointment, Anxiety, Associations, Decision, Effort, Sleep quality, Feelings of offense, Concentration, Fatigue, and Interest in sex. The 30% wellbeing variable can be explained by place of residence, clean Based on Figure 1, it can be seen that there is a comparison of variables in the early marriage group with adult marriage. The variables include maternal health, infant health, wife's psychology, husband's psychology, welfare and economic resilience. The group of individuals who had early marriages (adolescents) had worse maternal health conditions, poorer infant health, poorer welfare, poorer economic resilience compared to the adult marriage group. This can be seen from the higher percentage of adolescents from each variable. However, the psychological condition variable of the wife and husband is better at the age of adolescence.

Discussion
Early marriage has a tremendous impact, not only on couples but also on children born to teenage mothers, and causes changes in the welfare and economic resilience of the family.
Married couples and their families often want to get pregnant soon after marriage, without acknowledging the dangers for young women who get pregnant under the age of 19 years. Adolescent pregnancy can also make the mother's health worse than adult pregnancy. Adolescent pregnancies come with a 2-4 times higher likelihood of causing death than adult pregnancies, 12 can cause incidences of anemia and chronic energy deficiency caused by the growth period of adolescents who still require sufficient energy and high use of iron in the body. 13,14 The impact of anemia causes bleeding and the condition of fetal development is hampered. Adolescents aged 15-19 years are 1.234 times more likely to experience pregnancy complications than women aged 20-24 years, such as hypertension and gestational diabetes, anemia. 15,16 Adolescent pregnancy will also increase fertility rates. Women who had a delivery were 8.00 times more likely to have 3 children (lifelong fertility), compared with adult pregnancy (OR = 8.00; 95% CI: 7.52, 8, 46). 17,18 Adolescents married before the legal age were 1.27 times as likely to have a terminated pregnancy, compared to women married at 18 years (OR = 1.27; 95%CI: 1.20, 1.34). 17 Adolescent pregnancy can cause the health of babies born to be worse than pregnancy in adulthood. Adolescent pregnancies are at risk of causing babies to be born with low birth weight (LBW), premature, and have abnormalities in the respiratory tract. 12 Infants born to young mothers with repeated pregnancies had at least 0.15 (95% CI -0.23, 0.08) lower LAZ and had a higher chance of stunting at least 40% (95% CI 1.19, 1,67) at the age of 12 and 24 months. 19 Likewise, another study stated that the stunting prevalence was also higher in children under five years from adolescent pregnant women (44.4%) compared to mothers who were of sufficient age (35.6%). Adolescent pregnancy is associated with the incidence of stunting. A married teenage woman is 1.2 times at risk, and a pregnant woman who is less than 20 years old is 1.3 times at risk of having a stunting toddler. 20 Adolescent pregnancy also contributes to the wife's poor economic, emotional, social and health conditions, which are exacerbated by inadequate nutritional intake. 16 In rural areas, the risk of age-related pregnancy is often compounded by malnutrition, poor socioeconomic conditions, low literacy rates and limited access to maternal health care. 12 In this study, the psychological sub-variable of the wife in early marriage is better than in adult marriage. This contrasts with previous research which states the impact of early marriage on adolescents from a psychological aspect is anxiety and stress. 21 Anxiety experienced by an adolescent wife who makes early marriages will feel afraid and anxious in dealing with problems that arise in the family. 22 Most women who marry early do not have the power to make decisions. We found that the psychological condition of husbands in early marriage couples is better than that of adult marriages. This study's results differ from previous studies, which state that adolescents must have a higher commitment, so psychological conditions may be worse than in adult marriages. 23 The welfare of the families of early married couples is worse than that of families of adult married couples. Low economic income had no effect on marital satisfaction. 24 This shows that physical well-being is not always the main benchmark in a family. Efforts to strengthen the welfare of families with low economic income are expected to improve the ability to adjust to new roles with partners, with extended families, manage family stress and minimize vulnerable conditions. 25 The risk of unemployment and poverty increases in couples who marry early 21 and they often live in poverty and under pressure. 26 In accordance with the results of previous studies that found women who marry young have a higher percentage of living in poverty when they are older, the results of this study imply that decisions women make early in life can have long-term consequences. 27

Strengths and limitations
This study identifies the impact of early marriage by collecting data directly from brands. The use of validated tools and enumerators improved data quality. However, this study was conducted at the local level thus limiting generalizability. In addition, the health of the mother and baby was assessed only by interview without directly checking the health condition of the mother and baby. Therefore, for further research, it is necessary to increase the scale of the study, carry out further analysis and carry out examinations for mothers and babies.

Conclusion
The long-term impact of early marriage compared to adult marriage is on the poorer aspects of maternal health, poorer baby health, poorer wellbeing and worse economic resilience There needs to be special monitoring of cases of early marriage, so that it will suppress the negative impact.

Margaret E Greene
GreeneWorks, Washington, USA Objective This paper notes the need to "determine the long-term effect of simultaneous (?) early marriage on aspects of ..wellbeing." Yet the analysis uses a cross-sectional design, including "early marriage families" who married in 2015-2017. Between the design, the selection of couples who married young, and the recency of their marriages, the study is not well set up to assess the long-term impact of marrying early, nor to compare the impact of marrying early to marrying later.
The terms describing the statistical method used, polychoric PCA analysis, are frequently mashed into one word, all lower case, which was initially confusing.
The description of the frequency distribution in Table 1 is strange and uses the majority distribution as describing everyone, e.g., "the wives when getting married were still adolescent" (63.5% were adolescents). What is more, the data collection suggests that the sample was collected from people who were young at the time of marriage, so this is doubly confusing.
To set up the polychoric PCA analysis shown in Table 3, a frequency distribution of the composite variables by age at marriage is needed.
The analysis is very thin, with tables and graphs presented and limited interpretation. Then the discussion seems to be based on a return to a literature review. I don't believe the studies cited substantiate the statement "adolescent pregnancies come with a 2-4 times higher likelihood of causing death than adult pregnancies" or cause energy deficiency. Those studies were not structured so as to show that relationship (reference numbers 12,13,14).
Not sure what "collecting data directly from brands" means in the strengths and limitations section.
Once some of the substance of the paper is strengthened, it would benefit from English language editing.