Factor influence pre-marital pregnancy in Yogyakarta, Indonesia: a qualitative study

Article history Received, 4 April 2020 Revised, 28 November 2020 Accepted, 28 November 2020 Getting pregnant before married will raise the multifaceted consequence that can affect to the maternal mental health. In Indonesia, the incident stigmatized as the negative event and particularly, female, will have insecure feeling in their own family as well as in the community. However, the studies have been recognized the predictors of getting pregnant before married among adult. This study aimed to explore the predictors of unwanted pregnancy among Indonesian adults. Qualitative approach has been established and in-depth interview has been applied.


Introduction
In 2016, data from National Family Planning Coordinator Agency (BKKBN, 2017) reported, there were about 20.9% teenager getting pregnant before married in Indonesia (BKKBN, 2017). While criminology study center in Indonesia Islam University recorded roughly 846 couple bridesmaid,

Article history
Received, 4 th April 2020 Revised, 28 th November 2020 Accepted, 28 th November 2020 Getting pregnant before married will raise the multifaceted consequence that can affect to the maternal mental health. In Indonesia, the incident stigmatized as the negative event and particularly, female, will have insecure feeling in their own family as well as in the community. However, the studies have been recognized the predictors of getting pregnant before married among adult. This study aimed to explore the predictors of unwanted pregnancy among Indonesian adults. Qualitative approach has been established and in-depth interview has been applied.
The researcher invited teenager who eligible such as female, aged under 18, and they got pregnant before married in Bantul Regency. The main resource of data was based on the local Civil Registry Office, and the secondary data based on headman of targeted districts. Sample sized is determined using snowball sampling. The researcher has assisted by health cadres for each districts for facilitating the process of data collection. To test the validity, triangulation has been used. The parents and partner of participants have participated in this study. The observation during interaction with participants also has been done to support the validity of the result. The researcher have found in relationship, lack of knowledge, and social, as well as lack of awareness from parents are the main factors influence to getting pregnant before married among teenager in Yogyakarta, Indonesia.
The findings is important for parents to build positive communication with their adolescence children. The local Civil Registry Office need to consider to collaborate with health care provider to provide information on the consequence of pregnancy before married through the program of local Civil Registry Office goes to school. Nurse and midwives need to advocate an unexpected women to have access of health. 26,35 % among them having sexual intercourse before married and is estimated 50% impacted to the pre-marital pregnancy. However, during 2015, Health Ministry in Yogyakarta Province reported there were 1,078 school age girl giving birth their baby and out of 976 are become mother prior married (Ministry of Health, 2018). Geographically, Yogyakarta consisted of five districts, Bantul, Yogyakarta City, Sleman, Gunungkidul and Kulonprogo, while the prevalence of pre-marital pregnancy occur spread evenly among thus districts (276 cases, 228 cases, 219 cases, 148 cases and 105 cases, respectively) (BKKBN, 2015). At the time of this study conducted, based on married law in Indonesia, to fulfill the marriage certificate or legal marriage, the spouse have to meet the minimum age criteria; 19 years for prospective groom, and 16 years for prospective bride. However, for bridesmaids who have not meet the criteria, they have to obtain married dispensation that is issued by authorized office. In fact, the number of married dispensation has been increased significantly during 2010 to 2013 (115 cases, 145 cases, and 423 cases, respectively) (primary data from KUA Sewon, Bantul).
Previous study mentioned the consequence of pre-marital pregnancy among teenager include psychosocial problem such as withdrawal from the community and lack of attachment (Sukriani & Suryaningsih, 2018), and increase girls thought and feeling . The pregnant teenager also face double the risk from dying-pregnancy-related complications (Bennett L R, 2014b). They may feel shy and isolated, as bad stigma remain exist in Indonesia (Astuti et al., 2019). However, pregnancy is the crucial period during women's life cycle and the significant process to becoming a mother. To prevent pre-marital pregnancy in Indonesia, some program has been done by government collaborate with the community such as, establishing Bina Keluarga Remaja (BKR) or a community group which aimed to strengthening adolescent health and wellbeing, Adolescent Health and Reproductive Information Center or Pusat Informasi Kesehatan Remaja, as well as Integrated Service Post or Posyandu Remaja. However, based on the preliminary study in the Religious Affairs Office (KUA) in South Region of Yogyakarta, about 66 letters of marriage recommendation has been released by the authorized government in the end of January 2016. Based on the background described, This study aimed to explore the predictors of unwanted pregnancy among Indonesian adults.

Research Design
This study was exploring the factor that can influence the incident of pre-marital pregnancy among teenager. The population in this study was the couples who registered their marital status in the religious affairs (KUA) and recorded getting pregnant prior the marital date in South Region of Yogyakarta. The inclusion criteria were: (i) teenage pregnancy, (ii) any gestational of weeks, (vi) agreeable to share their experience about the issue. Out of 54 pregnant women, eight were interviewed after met criteria and achieving saturation.

Data Collection
After obtained ethical clearance from Institutional Board Review, then the primary investigator (PI) have approached to the head office of Religion Office Board (KUA) in the South Part of Yogyakarta, to explain aim and procedures of the study. Then, investigated the name and address as well as cellphone of bridesmaids who meet the criteria based on data from KUA was done by PI assisted by one trained research assistant. Next, PI contacted the addressed cadre as the mediator in this study. after procedures and aim of the study has been explained by PI, then the informed consent will be given to the respondents and their parents. Next, appointment to have interview have made according to available time from respondent. The interview was conducted in the different places for each respondents and the duration was about 60-90 minutes and were recorded and transcribed verbatim. Consent regarding the project well-informed and the rights of the informant has explained. The privacy of the interview room was established to decrease the bias due to an inappropriate situation. The guideline was: (i) Could you please to share me your daily activity before you know you are getting pregnant?, (ii) Could you please to share me a bit about your personally life? Maybe about boyfriend?, (iii) How about your social life in the school and community? At the end of the interview, the closing question "is there anything else you would like to share with me?" also has been given by the researcher (Polit & Beck, 2017).

Data Analysis
The author followed Collaizi's seven-step standard set (Morrow & King, 2015). The first step, we red all the protocols to acquire an experience of teenager, then each protocol has been reviewed and extracted to highlight the significant statement. Next, organized the formulated meanings into clusters of themes has been established. This step consists two sub-steps:(i) refer these clusters back to the original protocols to validate them, (ii) note discrepancies among or between the various clusters, avoiding the temptation of ignoring data or themes that do not fit. Then, after that, we integrated results into an exhaustive description of the phenomenon under study. Furthermore, we formulated an exhaustive description of the phenomenon under study. However, the rigor of credibility, fittingness, and confirmability, were obtained along with the audit trail, member check and peer debriefing. For the credibility, the researcher was peer debriefed regarding data analysis by three professionals on the expert panel with the experiences in a particular area and have published many works in the qualitative study.

Ethical research
Permission for data collection was taken from the Institutional Review Board of Yogyakarta (No.1303/KEP-UNISA/XI/2018). The researcher also ensured to obtain ethical consideration includes achieved informed consent from respondents as well as consider their privacy and confidentiality of the data.

Result
Four emergent themes were identified to illustrate the factor influence pre-marital pregnancy among teenager in South Part of Yogyakarta. These themes were: (i) boyfriend; (ii) knowledge; (iii) community; and (iv) lack of awareness from parents. All the significance statement, sub theme and theme were present in the table 1 below.

Discussion
This study conducted at the community in South Part of Yogyakarta covered four districts assisted by health cadre for each districts. Pre-marital teenage pregnancy is defined as under age pregnant usually between 13 to 19 years old. In this study, all the respondents (n=8) are under 19 years old (both of couple) when they decided to have married. They also decided to stay with their parent after marriage. The social background, education level and ethnicity has been considered as the same in this study.
Based on table 1 above, we may discuss for each theme as bellow:

Boyfriend or peer
All the respondent mention if they urge to have sexual activity belong to their peer or boyfriend. This factor has been considered as the most frequent statement form the respondents such as the duration for having boyfriend, their style in relationship, how many time they met in a week and what sexual activity they did in, and how they spent the meeting time include the chance to having sex. More than 50% of the informants said if they have the relationship more than ten months with the peers. As the additional information, some of the informants mentioned if they have boyfriend more than two times prior the incident of pre-marital pregnancy. One respondent shared their sexual activity clearly. She mentioned if the meaning of having relationship with friend initially is lifestyle then turn to needs of sex. She acknowledges if there is a desire to having sexual activity with her boyfriend every time they have chance such as kissing for every single dating, followed by necking and end up to intercourse. This process pattern seems the same for mostly respondents even though they have not stated it briefly. This study is congruent with (Kisriyati, 2013), that the teenager sexual activity will lied on their perception to the relationship itself. In her study, she was interviewed 11 informants that five of them stated if having boyfriend is a lifestyle, while four others mentioned as needs of sex, and only two of them said economic factor. Mostly the informants in her study also mentioned if they were coming into the same pattern sexual activity as in this study, include holding hands, hugging, kissing, wet kissing, necking, petting, oral sex, moderate petting, heavy petting, making love and then intercourse (Kisriyati, 2013). This result also supported by others study conducted by (Sari & Rokhanawati, 2018), as they found if dating with boyfriend has correlation on their sexual behavior (Sari & Rokhanawati, 2018). Peer also contribute to the pre-marital pregnancy as reveal by a study conducted in Indonesia (Astuti et al., 2020). This result is validated by other studies (Capeli, 2019)(Isiugo-abanihe et al., 2012 (Mulugeta & Berhane, 2014) (Sychareun et al., 2013).

Knowledge
According to the interviewed above, one of the informant mentioned if she knew about the consequence of having sex before married from her friend. However, she did not mentioned clearly what kind of information she figure out. We can assumed if the informant may doubt on herself about the consequence and lack of knowledge of health reproductive issue. Similarly, other studies underlined the lack of knowledge regarding health reproductive, particularly on the pre-marital sexual behavior will lead to the high risk sexual activity (Mahmudah et al., 2016) (Putri & Panjaitan, 2016). In their study, Mahmudah et al. found, out of 158 respondents, 72.9% among them agree the statement in the questionnaire if one time-intercourse will not impact to the unwanted pregnancy. Furthermore, the researchers mentioned if the information regarding health reproduction was obtained from peer, health care, social media as well as mass media such as magazine, VCD/DVD (Video Compact Disc/ Digital Video Disc), film, and radio (Mahmudah et al., 2016). In addition, according to the bivariate analysis, the researchers also found if the high-risk sexual behavior was addressed to the low level knowledge group (33,3%), compare with high level knowledge group (20,6%). This result also supported by other study conducted by Pratiwi and Basuki in 2010. They found there is a significant relationship between the level of knowledge of sexual reproduction and their sexual behavior. The respondents who have low level of sexual reproduction knowledge tend to be more have high-risk sexual behavior. Contrary, respondents who have high level of sexual reproduction knowledge tend to be more have low-risk sexual behavior (Pratiwi & Basuki, 2010). In line, current study found the same result. (Asnuddin & Haryono, 2020) found the significance relationship between level of knowledge and social environment, and the pre-marital sexual behavior among teenager (Asnuddin & Haryono, 2020).
Community ISSN 2620-5653 Journal of Health Technology Assessment in Midwifery 5 Vol. 4, No. 1, May 2021, pp. 1-7 Gau Meei-Ling and Endang Koni Suryaningsih (Factor influence pre-marital pregnancy in Yogyakarta...) Community in this study defined as the environment where the informant have interaction with others, particularly their peers. this include environment in the school and environment in the society. One informants described her daily interaction with peers that have marriage due to pregnant. While, another mentioned if she has a schoolmate who have pregnant then the school authority was expelled her out. The result of this study was supported by previous research conducted by Khaparista and Edward (2015). They found if the environment is the powerful factor contributed to the adolescence. The researchers explored the factors contributed to the incident of early marriage among teenager. They found if the environment is the most contributed factor (Khaparistia & Edward, 2015). The four main source for individual to gain learning process is through their environment, called vicarious. These individual will cope and imitate the environment they belief in and affected to them to make the decision in their life. Therefore, if the individual who emerge in the positive environment, he will have positive cognitive and positive decision rather than those who emerge in the negative. Many other studies has the same result (Jain et al., 2018) (Tu et al., 2012(Tu et al., )(P.S.F et al., 2013.

Lack of parent's awareness
Out of two informants in this study stated if their parents were know if they have dating with someone. However, according to them, parent's lack awareness factor contribute them to let their selfexploring their own sexual experiment with boyfriend. Many studies highlight if there is a relationship contribution factor between boyfriend or peer with the lack of awareness from parents in term of monitoring for their children (Bennett L R, 2014) (Khaparistia & Edward, 2015) (Kisriyati, 2013) (Nguyen et al., 2016)(W Ounjit, 2011) (Pratiwi & Basuki, 2010). All those researchers have the congruent found if parents do have their roles and big responsibilities in their children's development, particularly during adolescence. They should avoid to distancing themselves from their children. The study conducted in Vietnam found if several individual characteristics of adolescence who are at risk of unsafe-premarital sexual behavior include easily influenced by peers who participate in problem behavior, low attachment as well as weak parental bonding (Nguyen et al., 2016). This result also supported by other study. Jamaludin (2016) point out that irresponsible parent has contribute to their pre-marital pregnancy children as well as to the abortion (Jamaluddin, 2016).
In this study, one informant stated if her parents just asking general question, nor in depth question exploring what she has done with the boyfriend. Therefore, assume if her parent have not control strictly and lack of discipline that affected to inability to control herself and falling pregnant. This result also congruent with the senior study conducted by Yip et al (2013). They deeply discussed the impact of poor parenting on adolescent pregnancies according to the teenagers' view, both boy and girl. Out of 11 informant in the focus group discussion describe how the poorness control from their parent could led them to the uncontrol sexual behavior before married. Researchers also conducted in-depth interviews with schoolteachers and local leaders. Those resources confirmed their views that if the parents did not sufficiently monitor their daughters' movement, just become the whole for adolescent girl had freedom to access bad habits and engaging in sexual activities and thus became pregnant (Yip et al., 2013). In addition, other researchers in China also found if the absence of information and guidance about sexuality and information on the use of family planning and contraceptives also the most factor contributed the adolescent girls getting pregnant (Liu, Fuller, Hutton, & Grant, 2017).

Limitation
The major limitation in this study was the sensitivity of the topic of private experience which may have caused some participants reserved about what they had to say or provide some information. The culture issue also contribute as the inhibiting factor to explore in-dept interview for more detail useful information. Even though all the respondents are girls, which majority gender may also influenced the outcomes for more female participant who tended to be more comfortable discussing sexuality than the male, however, they personal character is acknowledge as the minor limitation as well. This study did not actively seeks dyads of parents as the comparison resources, thus, the result of this study are totally according to the adolescents' assumption.

Recommendation
Finding of this study recommend that both young girls and boy need support for essential information and education of health reproductive particularly on sexuality and the impact of sexual behavior to the unwanted or unplanned pregnancy and its continuing impact for their multifaceted life. Programs are needed to support both parents and young girls as well as young boy to become more