The Effect of Early Teenage Pregnancy on Depression and Mental Health in Malaysia

Abstract
Background: The study focused on analysing the mental health such as emotional, social and psychological well-beings of the teenage girls towards the pregnancy and investigate the various factors such as sexual relationship associated with teenage pregnancy. 
Methods: The study took a cross-sectional approach and adopted convenient sampling method for data collection. Data was collected from teenage girls aged 12 to 21 years from the state of Sabah. Data collection accomplished through survey data assessment, with survey responses data being collected through structured questionnaire as the effective research tool. The collected data is then statistically analysed for regression, ANOVA, one-way ANOVA and correlation analysis.
Results: Exploratory data analysis about the participants were explicated using frequency analysis. The statistical Test outcomes delineated the occurrence of significant relationship between engagements in sexual relationship with the age, marital status, distance of education, school attitude, self-esteem, self-efficacy, perceived social support, Peer community influences, Edinburgh Postnatal Depression Scale (EPDS), coping ability variables and other predictor variables. Similarly One-Way anova test, reveals the existence of statistical significant mean differences among age attribute of teenage girls, their engagement in sexual activity, predictor variables and their demographic details. 
Conclusions: The life of the teenagers who are engaged in sexual activity were observed to be more challenging in terms of medically, psychologically, and physically. The present study strongly recommends that social activists would adopt possible measures in revealing a better solution towards the teenage pregnancy.
Keywords: Teenage pregnancy, Mental health, Edinburgh postnatal depression scale, Perceived social support, Rosenberg’s Self-Esteem Scale, MesH- mental emotional social health, Domestic violence

Introduction
Pregnancy in young girls between the age of 13 and 19 is referred to as teenage pregnancy (1). Pregnancy is the outcome of either voluntary or involuntary sexual activities. Teenage fertility becomes a matter of concern, owing to the increase in the death rate of teenage mothers and their newborn. This is due to the adverse effects of early pregnancy on the physiological, physical, social, and economic status of the females. Bearing children during the teenage affects the educational growth of females (2). Pregnancy during adolescence is a matter of concern in all healthcare systems. This is a social problem where adult practices and activities like sexual intercourse, childbirth, and nursing are being carried out by a person those who are at the age of 12 to 21 years old. Termination of education of the victim of teenage pregnancy is one of the major consequences of this. The uncontrolled pregnancy leads to a consequence like preventing the females from their potential to enjoy basic human rights (3,4). 
Improper antenatal care and missing appointments with the doctors are the reasons for babies delivered by teenage mothers being premature and underweight. They are also at the risk of death during their first year of life. Teenage pregnancy is a crucial matter to be considered in Malaysia and Sabah. Sabah is the state in Malaysia located at the Borneo region. Around 3.5 million population and bordering Indonesia and Brunei by Land and Philippines by Sea. Major Ethnicity of Sabha are Indigenous People such as Dusun, Murut and Kadazan followed with Chinese, Malya and Indian people. Geographically, the land with hills and one of the highest mountain in Asia is located here. (5). Survey shows that 9.6% of the women aged 16-19 were pregnant during the survey or they were already mothers (6).
As a result, the state aims in taking different necessary steps and strategies in preventing early marriage and teenage pregnancy (7). Early marriage is one of the reasons stated by the State Community Development and Consumer Affairs Minister of Sabah for Teenage Pregnancy (8). Statistics carried out by the Health Ministry revealed that around 1500 teenage girls are found to be pregnant every month. But, 25% of the teenagers were unmarried (9). Awareness should be raised on changing the lifestyle of teenagers by educating them about the adverse effects of unsafe sex, where the education about sex is a part of Malaysians’ Curriculum, and people with lack of education are not aware about the safer sex (10). Lack of love and affection from the parents, despite their busy schedule, makes children get involved in these anti-social activities (11).
Malaysia witnessed high teenage pregnancies in the year 2012 and the count was about 18,000 which came down to 7700 in the year 2018 (5). Around 14 out of 1000 teenagers were found to be pregnant every year. This shoots up the count to 18000 each year (12). Reports reveal that females from families with low-income, school dropouts, and the unmarried face these types of issues often. Among the Association of Southeast Asian Nations (ASEAN) countries, Sabah ranked 8th in teenage pregnancy cases. Poverty, negligence of parents, and poor educational background are some of the contributing factors to teenage pregnancy (13). 
Infant mortality is found to be more in children given birth by teenage mothers than the adult ones (14,15). Society throws a negative attitude toward teenage motherhood and pregnancy stating that it is unplanned and highly disadvantageous concerning economical and material aspects (16,17). The teenage marriage and pregnancy in teenage leads to cultural, economic and social problems including domestic-violence. On the basis of research evidences, another research by Sattarzadeh attempted to offer unique documentary domestic violence image in earlier teenage marriages. 
In such an end, the Mental, Emotional, and Social Health (MeSH) keywords like Intimate Partner-Violence (IPV), “dating violence”, “domestic violence” and “teenage marriage” are used and hence a total count of 176 articles are gained and chosen for study. By considering this higher rate, the teenage marriage could be prevented through increasing organisation co-operation and the public awareness (18).
Another important fact to be discussed is the post-partum depression rate which is relatively high in teenage mothers than in adult women (19,20). Psychological literature depicts adolescence as a ‘crisis’ time where an individual struggles to cope with the transition to adulthood from childhood (21). Adolescence usually has a lot of cognitive and emotional changes and so is the case with teenage pregnancy (22,23). This mental and physical stress, combined with the additional responsibilities of parenthood, drastically affects the teenage mother’s health. In recent days, the causes and effects of teenage pregnancies are the major challenging topics for discussions in research and debate. Some studies conclude that the educational and economic status of women get compromised while others state that teenage pregnancy is just a marker of these crucial conditions such as physical and mental stress rather than compromising the same. Teenage pregnancy imposes a very high risk of health factors for both the mother and the fetus. Hypertension, anemia, and premature labor in addition to difficulties in relationships are some of the difficulties induced on teenage women who are pregnant (24). 
They may also face situations like isolation, ostracism, and their family members rejecting them. Most teenagers lack awareness of the terms related to menstrual cycles, coitus, issues in fertility, and child birth (25). Other important factors worth mentioning are peer sexual pressure, low self-image, and identity which lead to the breakdown of the family and tradition.
Therefore, teenage pregnancy remains to be persistent in our community due to a variety of factors and eventually leads to bringing a negative impact on the teenager’s life. The non-completion of proper secondary schooling of these teenagers limits their potential to earn their livelihood which ruins their entire life. Concerning this, the study concentrates on finding and assessing the causes and consequences of teenage pregnancy on the academic performance of teenage students in a school. Also, various strategies for preventing the same and tackling some of the problems associated with teenage pregnancy have been explored, so that the sexually active teenage dropouts from schools in future could continue their education to achieve their career goals. The present study aimed to evaluate the effects of mental health such as depression and anxiety in teenage pregnancy.

Materials and Methods    
The following section enumerated the research method, and the entire research approach of the objectives.
Study design
The study design is a cross-sectional descriptive study using a convenient sampling method and the study area is Sabah (a state in Malaysia). Samples were collected from 4 main districts in Sabah with high populations – Kota Kinabalu, Tawau, Semporna, and Beaufort. All the samples were collected from the district health clinics such as school health unit, maternal health unit, and primary and outpatient care unit that include the entire district health related issues. 

Sample size 
The Sample size of the study consists of 825 participants and the duration of the study is six months. The present study includes all teenagers born in Sabah, Malaysia, aged between 12-21 years old, regardless of their education level, religion and economic status and those willing to participate and obtain consent from parents. 

Inclusion and exclusion criteria
The study excludes the non-residents of Sabah, it was verified by asking them about the place they live. Other exclusion criteria are teenagers who refused to be included in the study. Teenagers who are undergoing court cases were also excluded in order to avoid interruption and repetition in the investigation. Not consented by the parents/guardian and the teenagers above 21 years old are excluded. 

Data collection 
The data collection was done with a well-structured questionnaire that included two parts which are demographic analysis comprising the personal details of the study population like age, ethnicity, marital status, educational background, engagement in a sexual relationship, presence of children, sex education awareness, the distance between the school and residence, educational background of father and mother. 
The second part involves the prediction analysis that focuses on the school attitude, self-esteem and efficacy, perceived social support, influence from the community, depression using Edinburgh postnatal depression scale, and coping ability. Validity denotes the degree to which the instrument explores the precise information by the objective. Our study analysed the state of art methods and developed a well-structured questionnaire with appropriate cross-checking by field experts.

Research tools
A survey assessment on the basis of well-though questionnaire stands as the prominent tool for a research. The survey analysis seems to be the flexible research tool at any research work phase. The outcomes obtained from questionnaire survey offer a valuable tool for the researchers to analyse the quantitative aspects of a problem

Research instruments
The questionnaire constitutes the research instrument, and the proper instructions are provided at beginning of questionnaire section of research and the guideline were given like the way to fill out the questionnaire. The structured questionnaire represents as the research instrument for the quantitative assessment. Similarly, the close-ended questions are considered for quantitative assessment.

Data analysis
The Statistical analysis evaluated with the descriptive inferential statistics was utilized for the determination of the correlation coefficient and consequently the detection of association with the demographic and predictor variables were also performed. Several factors were noted in the Excel sheets and a comparative analysis has been performed with statistical analysis. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.0. Mean standard deviation and range of values were estimated and the correlation coefficient was also determined for every set of values. Microsoft Excel 2010 and SPSS version 20.0 were employed for statistical analysis. 
The demographic physical parameters including age and other factors were presented as the count and percentage using the frequency analysis. Analysis of variance (ANOVA) is a test used to test the significant difference among the groups. If the p-value is smaller than 0.05, it is shown that respondents differ significantly in this study. The Two-way ANOVA test was utilized to assess the differences between the investigated parameters in the different physical parameter groups. The study represents regression analysis and is presented in a table for the depiction of the interrelation of all the parameters for the determination of their corresponding significant value. The attribute of self-esteem is measured using Rosenberg’s self-esteem scale for determining the self-efficacy followed by this. 
It also assessed the perceived social support using Multidimensional Scale of Perceived Social Support (MSPSS) scale for estimating the community influence and school attitude of the population, and the depression level is evaluated using Edinburgh postnatal depression scale (EPDS) for defining the coping ability among the teenage population. The tool utilized in the study is SPSS version 20.0 with MSPSS scale.
The compliance with ethical standards and consent is described as all the participants were treated with informed consent after explaining the study’s nature. The present study was approved by the Institutional Human Ethics committee of University Kebangsaan Malaysia (approval number: JEP-2021-038) and the study is registered by National Medical Research Register Malaysia (NMRR-20-3121-56069). Permissions were obtained from the corresponding parents or guardians. Confidentiality was maintained throughout the study. Wherever necessary the relevant information was cross-checked to maintain the originality. Details about the respondents were kept in a password-protected computer, which was accessed only by the principal investigator. 

Results
Demographic analysis
The following figures deliberate the demographic analysis of the information collected from the study participants.

Demographic assessment
The following figure 1 (A-M) deliberates the demographic analysis of the information collected from the study participants. Figure 1A describes the age-wise distribution of the selected population which state that most of the study population (58.01%) belongs to the age group of 16 to 18 years and the very least number population (3.883%) belongs to the age group above 21 years. Consequently, 31.8% of the study population were below 15 years of age and 6.3% were observed to be in the age range of 19 to 21. This data clearly states that the information collected belongs to teenagers and can reveal their observation according to their age maturity level.
Figure 1B describes the ethnicity of the investigated teenagers in which most of the respondents (27.5%) belong to Bajau followed by Kadazan (24.4%), Dusun (20.2%), Suluk (11.89%), Malay (9.7%), and the least with China (2.3%). This result demonstrates that the investigation has been conducted over a varied geographical area to avoid the regional bias. Meanwhile, Figure 1C revealed the marital status of the respondents to be 95.39% single, only 4.248% married, and 0.36% divorced. 
Accordingly, figure 1d represents the educational background of the teenagers belonging to the study. 81.43% of the respondents completed primary school, 14.8% completed secondary school, and the remaining population has no education or other basic certificates. Figure 1E and F state that the majority (51.21%) of the responders were involved in a sexual relationship and 48.7 % were observed to be not involved in the sexual relationship whilst 91.75% have no children and the remaining 8.25% of the population have children (Figure 1F). Figure 1H represents that 95.39% of the population had no previous sex education and only 4.612% were subjected to previous sex education. 
Therefore, according to Figure G, 51.94% have engaged in unprotected sexual activity and the remaining 48.06% of the population have not engaged with unprotected sexual activity. In specific, sex education has been provided by home members to 58.5% of the exposed teenagers. Figure 1J indicates the family income in terms of Malaysian Ringgit of the respondents in which the maximum of the respondents (46.24%) has a family income of 1000 to 1999. Few (8 to 10%) of the population were observed to have a family income of 3000 and 4000 above. 
Figure 1K denotes that the average distance between the school and the living place is 5 to 10 km and half of the participants were residing within this distance. Only 4% of the population were living at a distance of more than 20 km from school. In figure 1 (A) and 1 (M), it is observed that most of the education of the parents were confined to primary and secondary education. Only minimum parents (<1%) have completed a master’s degree.

Correlation analysis
Correlation between the demographic vari-ables: Table 1A denotes the correlation between age and engagement in a sexual relationship which reveals the significant difference between the two factors. Here, the p-value is 0.000 which is less than 0.05. 

Table 1A. Age and engagement in a sexual relationship

** Correlation is significant at the 0.01 level (Two-tailed).

Table 1B. Engagement in a sexual relationship and Marital Status

** Correlation is significant at the 0.01 level (Two-tailed).

The four different age groups such as below 15 years, 16 to 18 years, 18-21 years and above 21 years were investigated in this study, which may be one of the reasons for their engagement in sexual activity and hence proper awareness has to be created among the girls belonging to 16 to 18 age group.
This correlation and significant difference presented in table 1B between the sexual activity and marital status reveals that even though they are single, the respondents are involved in the sexual activity which necessitates taking possible action among them to understand the ethically non-desirable behavior.
Table 2A represents that there is no correlation and significant difference between engagement in sexual relationships and distance between the school and the living place. Irrespective of the distance from the school to the residence, the respondents were engaged in sexual activity.

Correlation between School attitude and En-gagement in a sexual relationship
Table 2(B) deliberates that the measurement of school attitude helps to understand that the activities and the social network communication in school have a positive correlation with sexual activities. If the teachers in school take prompt measures in resolving the personal problem associated with the girls, there is a chance of awareness generation regarding the sexual relationship.

Table 2A. Correlation between Engagement in sexual relationships and Distance between the school and the living place

Table 2B. Correlation between School attitude and Engagement in a sexual relationship

* Q15 Teachers are willing to help teenagers to solve their personal problem such as school attitude and engagement in sexual relationship. ** Correlation is significant at the 0.01 level (Two-tailed).

Correlation in-between Self-Esteem and En-gagement in a sexual relationship
Table 3 describes that there is a positive correlation and significant difference between self-esteem and engagement in a sexual relationship. Hence, motivational approaches should be handled among teenagers to increase their self-confidence and self-esteem.  

Table 3. Correlation between Self Esteem and Engagement in a sexual relationship

*Q32. At times teenagers think that they were not good at doing things like studying and participating in activities. ** Correlation is significant at the 0.01 level (Two-tailed).

Correlation between Self-efficacy and Enga-gement in a sexual relationship
Table 4 describes that self-efficacy behavior is correlated and significant with sexual activity among the respondents. The resistance toward sexual activity during the non-availability of contraceptives was assessed in table 5. 
This information depicts that self-efficacy has to be greatly improved among the teenage population to decrease their engagement in sexual activity.

Table 4. Correlation between Self-efficacy and Engagement in a sexual relationship

** Correlation is significant at the 0.01 level (Two-tailed)

Correlation between perceived social support and engagement in a sexual relationship
Table 5 defines that there exists a correlation between perceived social support and engagement in a sexual relationship. This states that teenagers should be motivated to speak out about their problems with their friends.

Peer and community influence and en-gagement in a sexual relationship
Table 6 revealed that there exists a correlation and significant difference between peer and community influence and engagement in a sexual relationship. The classmate’s influences also function as a cause for their engagement in their sexual activity.

Table 5. Correlation between Perceived social support and Engagement in a sexual relationship

* Q39 teenager’s share their problems regarding school, sexual relationship, with their friends. ** Correlation is significant at the 0.01 level (Two-tailed)

Table 6. Correlation between Peer and community influence and Engagement in a sexual relationship

* Correlation is significant at the 0.01 level (Two-tailed)

Correlation between Edinburgh Postnatal Depression Scale (EPDS) and Engagement in a sexual relationship
Table 7 mentions that there is a significant difference and correlation between Edinburgh Postnatal Depression Scale (EPDS) and Engagement in a sexual relationship.

Table 7. Correlation between Edinburgh Postnatal Depression Scale (EPDS) and Engagement in a sexual relationship

** Correlation is significant at the 0.01 level (Two-tailed).

Correlation between the ability to cope and Engagement in a sexual relationship
Table 8 denotes the significant difference and cor-relation between the ability to cope and Engagement in a sexual relationship. The girls were instructed to increase their ability to cope to attain self-efficacy and self-esteem.

Table 8. Correlation between the ability to cope and Engagement in a sexual relationship

** Correlation is significant at the 0.01 level (Two-tailed).

Regression analysis
Tables 9A and B describe the regression analysis between the investigated predictor variables and the engagement in the sexual relationship among the study population. The R-value has been observed to be 0.812 and the R square value is 0.659. This states that there is a positive correlation as the value of R is near 1. It shows that the questions and scales used for the survey have been carefully analyzed in improving the social behavior of the teenage respondents.
Table 10A and B describe the regression analysis between the investigated predictor variable age, among the study population. The R-value has been observed to be 0.921 and the R square value is 0.849. This states that there is a positive correlation as the value of R is near 1. It reveals that the questions and scales used for the survey have been carefully analyzed in improving the social behavior of the teenage respondents concerning their age.

Table 9A. Regression analysis in Engagement in a sexual relationship and investigated scales

a: Predictors: (Constant), Q62 Effort and concentration to make the situation better, Q30 I wish I could have more respect for myself, Q54 Being anxious or worried for no good reason, Q48 My Classmates, Q39 I can talk about my problems with my friends., Q33 Sex resistance without the availability of contraceptives, Q32 At times, I think I am no good at all., Q15 Teachers are willing to help in personal problem solving.

Table 9B. Regression analysis in Engagement in a sexual relationship and investigated scales

a: Dependent Variable: Q5. Engagement in a sexual relationship.

Mann-Whitney U Test
The Mann-Whitney U Test performed to assess the relationship between age and sexual relationship states that there exists a significant difference between age and sexual activity among the respondents with a significant difference as p=0.000 (Table 11). Meanwhile, table 12 assessment of the age and predictor variable demonstrates that there exists a significant difference among the respondents with a significant difference of p=0.000.

Table 10A. Regression analysis of age and predictor variables

a: Predictors: (Constant), Q62. Effort and concentration to make the situation better, Q30. I wish I could have more respect for myself, Q54. Being anxious or worried for no good reason, Q48. My Classmates, Q39. I can talk about my problems with my friends., Q33. Sex resistance without the availability of contraceptives, Q32. At times I think I am no good at all., Q15. Teachers are willing to help in personal problem solving.

Table 10B. Regression analysis of age and predictor variables

a: Dependent Variable: Q1. Age.

One-Way ANOVA
Table 13 represents the analysis of variance between the age and predictor variables, table 14 shows the analysis of variance between the sexual activity and predictor variables, and consequently, table 15 denotes the comparison of means by ANOVA among the demographic variables enrolled in the study.

Table 11. Engagement in sexual relationships and age

a: Grouping variable: Q1. Age.

Table 12. Age and predictor variables

a: Grouping variable: Q1. Age.

Table 13. Comparison of mean between age and predictor variables

Table 14. Comparison of mean between Engagement in sexual activity and predictor variables

Table 15. Comparison of mean between demographic variables

Discussion
With the escalation of teenage pregnancy in Malaysia, it is significantly necessary to have a deep understanding of the situation of education and the life characteristics of the victims. Unfortunately, few studies ought to estimate the attributes, perceptions, and beliefs of teenagers who are discussed as follows.
Similar to the present study, Igba et al (26) also investigated the effects of teenage pregnancy. For this purpose, 500 students were enrolled in the Abakaliki zone, and the data required for the evaluation was collected through a well-structured questionnaire. The study used a t-test for hypothesis testing. The findings of the study revealed that peer pressure, bad parental upbringing, depression, poor nutritional complications, lack of sex education awareness among the students, and stigmatism might be the potential causes of pre-marital sex. The study recommended that society needs to take extraordinary support in preventing their termination of secondary education.
Likewise, the UN reports believed that more than 125 girls were exposed to pregnancy in a day around the regions of Namibia. Maemeko et al (27) attempted to determine the influence of teenage pregnancy on academic performance around the Zanbezi region. It utilized a qualitative approach for determining the teenage pregnancy impact in education performance with study population of four pregnant students and two teachers. Maemeko EL et al (27) and Wong SP et al (28) also reported that alcohol influence  and drug abuse apart from other above-discussed factors are responsible for undesirable teenage behaviours. The study also insisted that the influence of teenage pregnancy leads to poor academic performance, followed by dropout due to pregnancy-related negative issues.
Niyonsenga et al (29) identified the factors associated with postpartum depression prevalent in teenage mothers. The authors used a convenient sampling method for a group of 120 teenage mothers aged 15 to 19 years. Further, the study conducted the Edinburgh postnatal depression scale for the assessment of depression. The study suggested that teenage mothers were associated with various problems and risks such as weight or shape disturbances, parental distress, income, and economic and other psychological distresses. However, the reviewed article has the following limitations: it failed to reveal self-efficacy and demographic details, and our study has no such limitations. 
Similarly, Nicolet et al (30) also used the Edinburgh scale for the measuring baseline characteristics of teenage mothers in the urban zone of Cameroon. It includes 1344 women around 20 years of age with the selected questionnaire and revealed that more prevalence of depressive disorder was found in teenage mothers. Motivated by this evaluation, the present study also enrolled the scale for analyzing depression among teenage mothers. Further, it (30) strongly recommends to develop better maternal care programs for supporting teenagers to uplift their education. 
The issues determined from the literature confirm the health risk of teenage pregnancy with induced hypertension, anaemia, loss of education and maturity, etc. Further, the mentioned study suggested that ostracism, rejection by the concerned family, and isolation were also observed to endanger teenagers’ lives. In a similar context, Sulaiman et al (5) aimed to understand the impacts and consequences of increased pregnancy rates among the teenage groups in Malaysia. 
Nasreen et al (31) demonstrated that the victim’s stop of schooling affects their future economic perspective. Sulaiman et al (5) also revealed that low economic groups were affected highly that further enhanced the level of depression (32). The main limitation of the present study was that it faced many underreported cases and stateless teenagers who were not identified. 

Conclusion
The current study has been motivated in drawing attention to the dropout teenage female population mainly due to their engagement in sexual activity. Thus, the study enumerated the factors associated with teenage pregnancy among 825 female population around the surrounding regions of Sabah. The following conclusion was drawn from the statistical analysis. The population life who are engaged in sexual activity were observed to be more challenging medically, psychologically, and physically. They were also found to lack family support in providing awareness about sex-education. The parents of such victims were mostly constrained by education and low income. The depression level is high among the teenage pregnancy-associated population and they seek community or peer support to overcome them. With such feelings and anxiety, they are found to be constantly worried about their future which hampers their life. If they were treated with high care by providing certain awareness programs, they could be able to cope with the competitive world. Furthermore, the school attitude has to be increased to deal with this problem. Meanwhile, the forbidden education has to be made hassle-free among the investigated population. This study strongly recommends that social lovers adopt possible measures in revealing a better solution to the present and future suspects.

Funding 
None.

Ethical committee confirmation 
NMRR ID: NMRR-20-3121-56069 (National Me-dical Research Register Malaysia) Ethics approval reference: JEP-2021-038 (University Kebangsaan Malaysia).

Conflict of Interest 
None.