Risk Factors For Adolescent Pregnancy In The New Normal Era Of The Covid-19 Pandemic: A Case-Control Study

. Cases of early marriage are reported to have increased during the pandemic due to stressed teenagers with the pressure of online learning. The increase in this number plays a role in increasing the risk of teenage pregnancy. This study aimed to analyse the risk factors for adolescent pregnancies during the new normal era of the COVID-19 pandemic. A case-control design using a simple random sampling technique involved 40 pregnant adolescents aged 15-19 years and 80 non-pregnant adolescents during the online learning period (July 2021 to January 2022) in Ngawi Regency, Indonesia. Data obtained from interviews were analysed to find Odds Ratio (OR) with a 95% Confidence Interval (CI). Results showed factors associated with adolescent pregnancies were underpaid parental income (OR 4.00, 95%CI 1.64–9.74), authoritarian and permissive parenting (OR 12.75, 95%CI 4.71–34.46), lack of exposure to media about reproductive health (OR 7.91, 95%CI 3.32–18.84), risky dating behaviour (OR 37.09, 95%CI 4.86–283.25), and smoking habit (OR 5.57, 95%CI 1.03– 30.12). Preventing adolescent pregnancies could be done through public health education focusing on adolescent communities, parent-child discussion on reproductive health, as well as exposure to educative media related to reproductive health and the impacts of juvenile delinquency.


Introduction
The adaptation period to a new normal era of the COVID-19 pandemic has already happened. A new normal era is an abrupt change in certain lifestyles after the crisis [1]. A "new normal" policy which is a scenario for accelerating the handling of health and socio-economic aspects, as well as education during pandemic has widely been used across countries affected [2], [3].
In education sector, learning has been modified to deal with the COVID-19 pandemic after certain events occur. Technology-based or online learning emerged to sustain learning during the adaptation period [4].
However, online learning produces negative consequences such as stress among adolescents. An increase in cases of early marriage was reported to have occurred during the pandemic due to teenagers who were stressed by the pressure of online learning, teenagers felt tired and even frustrated because the online learning process was so complicated, so teenagers preferred to get married at an early age [5]. Several studies mention some impacts of the pandemic on the lives of adolescents, 55.1% of adolescents expressed stress and 40% of anxiety [6] internet addiction, cybersexual addiction, cyber-relational problems, net compulsions, overload information, and computer addiction [7].
Besides, the COVID-19 pandemic impacts various health aspects, including reproductive health. The impact on reproductive health is related to not achieving the target of the agespecific fertility rate (15-19 years) [8]. Adolescent pregnancy is still a public health problem in the world. Developing countries have a higher risk of adolescent pregnancies, and abortions [9], [10]. Adolescent pregnancies may cause female adolescents to be dropped out from school. They might have low education and skills, conflict in their new role as a mother, and be imposed with the needs of adolescence [10], [11]. Low birth weight live infants and the risk of maternal death are other consequences of adolescent pregnancies [12].
Factors that contribute to adolescent pregnancies based on socio-demographics include adolescent education, parental education, knowledge, parents' income, age of marriage, and place of residence [13]- [15]. Others include discussions about reproductive health, religious observance, media exposure, and dating behavior [16]- [20]. Another study mentioned a family history of adolescent pregnancies is also a risk factor [14]. Adolescent pregnancies are influenced by the role of health workers, accessibility of health services, and utilization of reproductive health programs [21], [22]. Culture, peer influence, family support, parent's marital status, parenting, and smoking status also had some influence on adolescent pregnancies [13], [15], [23], [24].
Teenage pregnancy is a contributor to maternal mortality because adolescents are biologically and psychologically not ready to get pregnant and give birth. Ngawi Regency, Indonesia shows an increase in the age at first marriage of fewer than 20 years in 2017 by 526 from 5536 (8.56%), in 2018 by 190 from 3136 (6.06%), increasing again in 2019 to 506 from 6148 (9.14%). There were 199 applications for marriage dispensation which is a legal concession for those who do not meet the legal requirements for a legal marriage, namely the minimum age limit for marriage is 19 years in Ngawi Regency in 2020, an increase of 206% from the previous year [25], [26]. The increase in this number plays a role in increasing the risk of teenage pregnancy in Ngawi Regency. Currently, Indonesia is in a period of adapting to new habits, the education system is designed to deal with the COVID-19 era marked by technology-based or online learning. Cases of early marriage were reported to have increased during the pandemic due to stressed teenagers with the pressure of online learning which had an impact on increasing teenage pregnancies.
However, little research explored risk factors for adolescent pregnancies during the new normal era of the COVID-19 pandemic. This study framed the issue during the period because adaptation to new habits is considered a predictor of adolescent pregnancies [27].

Materials and Methods
The current research was analytic observational research with a quantitative approach and a case-control design. The population in this study consisted of a case population and a control population. The case population was all pregnant adolescents aged 15-19 years in the Ngawi District Health Center. The control population was all unpregnant adolescents aged 15-19 years in the Ngawi Regency area. In determining the sampling, this study had the inclusion and exclusion criteria for the samples. In the case group, the inclusion criteria were adolescents who were pregnant for the first time and who schools in the Ngawi Regency from July 2021 to January 2022. While the exclusion criteria for this group were adolescents who were pregnant due to sexual violence, and had been married for more than 1 year. In the control group, this study selected adolescents who were attended schools in the Ngawi Regency from July 2021 to January 2022. While adolescents who had been married for more than 1 year were excluded from this group.
The sample size in this study were 40 samples included. This study using a ratio of 1: 2 (40 cases and 80 controls). The samples were selected through simple random sampling. The independent variables included age, education, parental income, family history of adolescent pregnancies, parenting, access media on reproductive health, dating behavior, smoking status, and utilization of reproductive health services. Meanwhile, the dependent variable was adolescent pregnancies. Data collection was carried out in July 2022. Data processing passed some stage i.e., editing, coding, entry, and cleaning. Data analysis was done to obtain an odds ratio (OR) with a 95% Confidence Interval (CI).
The study received a certificate of ethical decency with the number 141/EA/KEPK/2022 after passing the research ethics test from the ethics committee of the faculty of public health at Universitas Airlangga.

Results and Discussion
The results in Table 1 show risk factors for adolescent pregnancies. The risk factors i.e., age, education, family history of adolescent pregnancies, and utilization of reproductive health services had no significant effects on the occurrence of adolescent pregnancies. All pregnant and non-pregnant adolescents in this study resided in rural areas with state school status in Ngawi Regency.
This study showed that parents' income influenced the incidence of adolescent pregancies. Adolescents with parents whose income was less than the regional minimum wage had a 4.00 chance of being pregnant compared to adolescents with parents whose income is more than the same as the regional minimum wage. This result is in line with previous research stating that families with higher income found their adolescent children had the lowest chances of pregnancies than those with low income. Adolescents from low income family tend to marry at an early age, while those who have high-income parents continue to pursue education and other career goals [17], [28]- [30]. Previous research [31]- [34] also confirmed that the risk of adolescent pregnancies is higher in adolescents from loweconomic families than from high-economic ones. However, another study in Sri Lanka had a contrast finding that both low and high-economic groups of family had no difference in the incidence of adolescent pregnancies [35]. In fact, teenage pregnancy was proven to have a higher risk in families with higher economic conditions (≥ regional minimum wage) which were 5.8 times compared to adolescents in low-income families. This is related to the opportunity for adolescents to obtain opportunities for adolescents to obtain facilities that support sexual intercourse [13].
Our research shows that authoritarian and permissive parenting gave a 12.75 times chance to adolescents to bear pregnancies compared to democratic parenting. In previous research, adolescents with authoritarian and permissive parenting were also known to have a higher chance of pregnancy before marriage than adolescents with democratic parenting. Authoritarian parenting employs strict control from parents, thus making children decided to seek freedom outside. Permissive parenting allows children to develop on their own. In this type of parenting, all things are allowed, and parents do not forbid children to prevent quarrels and tensions. However, children under permissive parenting tend to perceive that life is free [18]. While democratic parenting is defined as the interaction between parents and children by giving freedom to children under parents' supervision. The current results demonstrated that children with high adoption of democratic parenting had low premarital sexual behavior which leads to the low incidence of adolescent pregnancies [36]. However, it is different from research [37] explains that authoritarian and protective parents are strongly correlated with a decrease in risky sexual behavior and adolescent pregnancy rates.  Furthermore, using media for reproductive health education is another important variable to prevent adolescent pregnancies. Adolescents who did not access media on reproductive health were 5.80 times likely to bear pregnancies compared to adolescents who access media on reproductive health. Previous research in adolescents under 19 years old found lower access to media may cause a greater chance of pregnancy in adolescents. Poor use of media on this topic contributes to low awareness of safe sexual behavior and poor prevention of unplanned pregnancy [38]. Research in Nepal also revealed that adolescents who had access to mass media about public health issues developed protection from early pregnancies. Accessing media on related subjects may improve knowledge about public health issues including family planning and the risks of adolescent pregnancies and childbirth [24].
Besides access to media, dating behavior should be taken into account. Adolescents with risky dating behavior could have 37.09 times chances to be pregnant compared to adolescents with non-risky dating behavior. Light and severe risky dating behavior such as hugging and kissing, which is a considered a common thing when dating, may lead to premarital sexual behavior as a cause of adolescent pregnancies [39]. From several studies, it is known that courtship behavior increases the risk of premarital sexual intercourse because in courtship behavior it is known that there is an activity with the opposite sex, whether there is physical contact or not. Courtship behavior starts from just dating, seducing, teasing, touching, kissing, and stimulating sex organs to force sexual intercourse [40], [41]. In contrast to research [42] which states that there is no relationship between dating behavior and pregnancy in adolescents, this is because modern dating is considered a natural thing, and so that in general, teenagers do courtship. In courtship behavior there are levels, ranging from just holding hands, kissing lips, and touching sensitive body parts to having sex. Not all teenagers who are dating have sexual relations, so even though many teenagers are dating but do not experience pregnancy.
Another negative behavior considered causing the trend was smoking habit. Previous research discovered female adolescents with smoking habits were significantly more likely to become pregnant compared to female adolescents without smoking habits. Few studies examine the relationship between smoking habits and adolescent pregnancies in developing countries. Smoking during adolescence is considered a risk-taking behavior, and thus it has a higher possibility of causing adolescent pregnancies [24]. Teenagers become restless to abandon the stereotype of a teenager and to give the impression that they are almost an adult. Adolescents begin to focus on behaviors associated with adult status, namely smoking or engaging in sexual acts. They assume that this behavior will give them the image they want. This has an impact on increasing the incidence of teenage pregnancy cases [43].

Conclusion
Age, education, family history of adolescent pregnancies, and utilization of reproductive health services had no significant effects on the occurrence of adolescent pregnancies. Factors associated with adolescent pregnancies were underpaid parental income, authoritarian and permissive parenting, no access to media on reproductive health, risky dating behavior, and smoking habit.
Since parenting has a great contribution to children's thinking, parents are expected to actively participate in parenting training or seminars to practice democratic parenting skills. Additionally, parents are expected to supervise their children's courtship behavior. Both parents and children need to increase access to information on reproductive health to improve knowledge of sexual health, safe sexual behavior, and safe sexual norms to prevent adolescent pregnancies. Last but not least, policyholders and primary healthcare centers have to provide seminars or training on reproductive health topics such as parenting, use of media, and healthy dating behavior by involving adolescent and their parents.