This study described the behavioural, familial and social factors associated with pregnancy among teenage girls aged 13–19 years in Lira District, Uganda. At bivariate analyses, all variables except alcohol consumption were significantly associated with teenage pregnancy. At multivariable analyses: age of respondents, place of residence, school attendance, multiple sexual partners, frequent of sex, contraceptive use, socio-economic status, domestic violence, physical neglect, parental divorce/separation, peer pressure, sexual abuse, control over sex and awareness on adolescent sexual and reproductive health were found to be significantly associated with teenage pregnancy.
In the paragraphs that follow, a discussion of the key findings is presented with respect to the sub-topics: demographic, behavioural, familial, and social factors.
The results showed that age of the respondents and place of residence of respondents were not significantly associated with teenage pregnancy after adjusting for all independent factors. However, after effect modification by marital status, older teenagers (15–19) were found to be less likely at risk of teenage pregnancy as compared to younger teenagers (13–14). Teenage girls who resides in rural areas were twice more likely to become pregnant. On the other hand, being in school was found to be protective against teenage pregnancy. These findings are consistent with the previous studies in Uganda , Ethiopia  and Nepal . Being young and living in rural areas may expose girls to early pregnancy due to: lack of information, peer influence and sexual abuse. This situation could put them in a higher risk of not only becoming pregnant but contracting sexually transmitted infections (STI). However, being in school may provide periods of supervision of teenage girls by teachers as well as parents, which could reduce opportunities for sexual activity .
Behavioural factors and teenage pregnancy
The multivariable analysis on behavioural factors and teenage pregnancy shows that multiple sexual partners, frequency of sex, and contraceptive use were significantly associated with teenage pregnancy. Not having multiple sexual partners, having sex less than twice a week and regular use of contraceptive methods were all protective against teenage pregnancy. These results concur with a national study conducted in Uganda by the Uganda Bureau of Statistics (UBOS) in 2011 . Another form of risky behaviour that result into teenage pregnancy have been found to be irregular use of contraceptive methods [13, 27,28,29], which is in agreement with our finding. As confirmed by this study, having multiple sexual partners puts teenage girls at greater risk of pregnancy . Although this study did not address reasons for irregular contraceptive use, some of the contributory factors may be inadequate access, stigma and limited information on availability of contraceptive methods.
Familial factors and teenage pregnancy
Multivariable analysis of familial factors and teenage pregnancy found a significant association only with marital status after adjustment with all other factors. However, at bivariate analysis, all familial factors were significantly associated with teenage pregnancy. However, after effect modification by marital status, socio-economic status, domestic violence, physical neglect, and parental divorce were found to be significantly associated with teenage pregnancy. These changes in the results are due to effect modification by marital status. Thus, marital status in this study should be taken as an effect modifier other than an independent predictor. Other studies found predominant association of early marriages (marriage of young girls) with teenage pregnancy [29, 31], which is consistent with this results. Low socio-economic status, and cultural traditions, especially payment of dowry as a source of income is most likely the issue exacerbating early marriages in Uganda. Economic deprivation is likely to influence teenage behaviours and heighten their exposure to early pregnancy as observed in Uganda , Nigeria , Sri Lanka , Senegal and Bangladesh , and Nepal . Furthermore, there is growing concern that physical neglect of teenage girls could foster relationships with older men which is seen as more beneficial when daily needs such as food, shelter, clothing and money are not met by parents/caregivers .
Social factors and teenage pregnancy
The results of multivariable analysis on social factors and teenage pregnancy reveals that peer pressure, sexual abuse, lack of control over sex and lack of awareness were significantly associated with teenage pregnancy. These results concur with some studies that have postulated that sexual abuse place girls at higher risk of experiencing teenage pregnancy [35,36,37]. Whereas, some researchers attribute the link between sexual abuse and teenage pregnancy to the adolescents’ behaviours , others maintain that existing evidence is still not conclusive . Research supports the widespread idea that peers play an important role in teenage lives; teenagers with sexually active friends are more likely to have sex themselves . Peers can influence the views of their age groups, hence, bad influence leading to risky behaviours such as: alcohol and drug abuse, dropping out of school, unprotected sexual activity which may lead to pregnancy . This study concur with this analogy, as those who were not sexually abused were less likely to become pregnant. Community awareness on adolescent sexual and reproductive health was found to be significantly associated with teenage pregnancy after effect modification by marital status. This finding is similar to other studies that have demonstrated awareness creation as effective in reducing teenage pregnancy [11, 40, 41]. Furthermore, a survey of countries to assess their progress in implementation of the 1994 International Conference on Population and Development (ICPD) confirms that higher literacy rates among women between ages 15–19 was significantly associated with lower teenage birth rates .
Implications for policy and programmes
This study provides useful findings that can be used to formulate policies and programmes towards addressing teenage pregnancy. The current study showed that teenage pregnancy is associated with teenage behaviours being perpetuated by familial and social factors. The current laws of Uganda; Penal Code Act (2007), which criminalizes sex with girls below 18 years (capital offense - punishable by death sentence) and National Adolescent Reproductive Health Policy (2004) are no longer current and are not fully operationalized by government institutions and society at large. The Uganda National Development Plan (NDP 2010–2014) acknowledges child marriage as a negative social cultural practice that increases the rate of early pregnancy, which is partly responsible for the persistent poor health outcomes for children and women especially high maternal and infant mortality rates and high fertility . The Uganda government need to review existing legal, medical and social barriers to adolescent access to health information and reproductive health services, and further protect the rights of girls against all forms of abuse and harmful traditional practices. Provision of specific programmes that allow contraceptive use among teenage girls (from 13 to 19 years) in communities, sex education so that teenage girls avoid early sexual encounters and multiple sexual partners. The government should make necessary efforts to accommodate married and pregnant girls in schools. However, fresh philosophy on the effects of education on well-being also postulates that education alone is not enough to achieve successful transitions from adolescent into adulthood, and that girls need critical thinking skills as well as an enabling environment such as family and societal commitment and capacity for educating girls .
Due to some methodological limitations in the study, caution should be taken when generalizing these findings. However, it can be applied to other areas with low-income settings.
Strengths and limitations of the study
The case-control design was used due to the fact that it is suitable when comparing two study groups (in this study cases and controls) and when exploring multiple exposures with one single outcome (teenage pregnancy). Besides, controls were drawn from the same population as cases thus minimising potential biases from both groups. Furthermore, simple random sampling technique allows even distribution of confounders among study participants. Adjusting for all other factors and assessing for effect modification helped to further reduce potential biases. Therefore, strengthening the association between predictor variables and the outcome. Lastly, the large sample size of 480 participants could have increased the power of the study as well.
The study has several limitations which are worth mentioning: only quantitative data was available for this study and yet it would have provided concretised findings had there been qualitative data; case-control design is prone to recall bias as participants have to recall some events that occurred sometimes in their lives and selection bias due to the fact that some girls selected as controls may have in fact been cases because of lack of disclosure caused by stigma surrounding teenage pregnancy. The results for school attendance and control over sex showed high point estimates with wide confidence intervals which could have reduced the level of precisions of their measures. Furthermore; pregnancy test was not conducted to confirm the pregnancy status of teenage girls, those who were one or 2 weeks pregnant could have not realized they were pregnant and therefore included as controls (non-pregnant).