«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
Teenage pregnancy has also been associated with domestic violence and family disruptions (Kissin et al., 2008). Studies from sub-Saharan Africa, US and Europe have indicated that teenage mothers face a high frequency of physical abuse (UNFPA, 2007). Teenage pregnancy feeds into existing gender imbalances by rendering the young mother more economically vulnerable and reliant on male partners, thus exposing them to negative trajectories (UNFPA, 2007). Given the almost endemic levels of sexual and physical violence in
intimate partner relationships in SA - both risk factors for early pregnancy (Jewkes et al., 2001), such negative trajectories are likely to exist among young mothers.
The most negative and costly outcomes of teenage pregnancy are intergenerational (Kirby, 2007). Children of teenage mothers are more likely to drop out of school, obtain lower grade point averages and report poorer school attendance records (Cassell, 2002; Kirby, 2007). Research from the National Study on Family Growth (2002) indicates that the characteristics of the adolescent mother have an impact on the timing of ﬁrst birth of their children. For teenagers whose mother had an adolescent birth, 32% had given birth by the age of 20 compared to 11% of those whose mothers delayed child bearing beyond 20 years of age. In this way the intergenerational transmission of poverty is perpetuated between mothers and daughters (Botting et al., 1998;
Cassell, 2002: Kiernan, 1995). For sons, teenage motherhood increases the risk of behaviour problems and, particularly, for imprisonment (Hoffman, 2006).
Determinants Conceptual framework There is a substantial body of literature about the varied, inter-related and complex interplay of factors that determine sexual behaviour and that result in pregnancy, STIs and HIV (Dogan-Ates & Carrion-Basham, 2007;
Kirby, 1997; Meade & Ickovics, 2005). Sexuality among teenagers, often characterised as, and associated with deviance, is in fact a healthy, normative part of the natural course of development of all adolescents. As such, at some stage of their life, nearly all teenagers experience some pressure to have sex, whether internally or externally driven, and may be at risk of becoming pregnant (Kirby, 2002). However, some adolescents are placed at much higher risk than others based on the balance of risk and protective factors. As the number of risk factors increase and the number of protective factors decrease in a teenager’s life, the probability of engaging in unprotected sex and becoming pregnant increases.
Over half a century of investment in public health research has demonstrated that health behaviour is seldom the result of single, individually attributable factors. Although a number of behavioural theories (such as Health Belief Model (Rosenstock, 1974), Theory of Planned Behaviour (Azjen & Fisbein, 1980), Social Cognitive Theory (Bandura, 1986), have been helpful in identifying individual cognitions that inﬂuence sexual behaviour, they have not resulted in substantive and sustained behaviour change. Contemporary health promotion has undergone a paradigm shift from a singular focus on health education for individuals to changing institutional behaviour, inﬂuencing physical and social environments and advocating for enabling and supportive policy (National Cancer Institute, 2005). Such an ecological approach recognises the multiple spheres of inﬂuence on health behaviour and emanates from the seminal work of Bronfenbrenner (1979) that contextualised individual behaviour within the families, communities and societies in which they are nested.
Some of these inﬂuences are more direct or proximal (such as perception of risk, knowledge, attitudes, beliefs, subjective norms, self-efﬁcacy and intention). Yet others are indirect or distal (such as poverty, and socioeconomic status), mediated by more proximal factors but nonetheless powerful determinants of behaviour.
The approach also recognises that behaviour takes place in a dynamic social context. Individuals are seldom passive recipients of external inﬂuence from the social environment. Termed, reciprocal causation, the ecological perspective asserts that social environments are as much shaped by individual behaviour as individual behaviour is shaped by the social environment and that the context in which behaviour takes place is constantly evolving (National Cancer Institute, 2005).
While a range of factors that inﬂuence risky sexual behaviour have been identiﬁed, the weight that can be assigned to any single factor (Kirby, 2002) or how factors interact or act cumulatively to increase risk is not fully understood (Meade & Ickovics, 2005). Behaviour change programmes have shown successes in small, localised contexts but what is not clear is how to achieve radical behaviour change among sufﬁciently large numbers of people at risk, in changing contexts and over time, to drive down the rate of unprotected sex (Coates, Richter & Caceres, 2008), and as a result, teenage pregnancy, STIs and HIV.
The ecological systems model provides a useful way to organise factors associated with complex social problems such as teenage pregnancy (Cocoran, 1999). The conceptual framework used in this study adopts a multi-level approach to account for the complex web of personal, social, economic and cultural forces that inﬂuence the life trajectory of adolescent and subsequently, their behaviour (Cassell, 2002). Five levels of inﬂuence are considered: (1) intrapersonal or individual factors; (2) interpersonal or relational factors; (3)
institutional or organisational factors; (4) structural factors; and (5) public policy (see Table 3).
Table 12: An ecological perspective: levels of inﬂuence
Source: Adapted from McLeroy et al.,1988 in National Cancer Institute, 2005 Each level of inﬂuence can have an effect on sexual behaviour and, in turn, pregnancy. For example, a young woman delays accessing contraception even though she is sexually active. At the individual level, she may have incomplete knowledge about types of contraception and how to use them. At the interpersonal level, her partner may refuse to use contraception, labelling it a trust issue, her peers may not believe that it is important to use contraception and her parents may not have discussed contraception with her. At the institutional level, access to contraception may be difﬁcult at public clinics because of the judgemental attitude of health staff. At the structural level, she may come from a poor socio-economic background where educational and ﬁnancial aspirations are stunted and the only opportunity for upward mobility is through a relationship. At the policy level, lack of policy on youth friendly services or poor implementation therefore may affect her ability to access contraception.
Literature review The following sub-sections explore each of the systemic levels in more detail, highlighting the key determinants of teenage pregnancy.
Intrapersonal factors Individual or interpersonal factors are those attributes of an individual that increases his/her likelihood of engaging in risky behaviour by inﬂuencing how he/she interacts with the other contexts, and the inﬂuence that those contexts bring to bear on him/her (Bronfenbrenner, 1979).
Sexual behaviour The sexual behaviour of adolescents has the potential to confer signiﬁcant risk to adolescents experiencing early pregnancy and contracting STIs and HIV.
Sexual experience When teenagers initiate their sexual life early on, they place themselves at increased risk for early pregnancy, STIs and HIV (Kirby, 2007). Early sexual debut remains an area of intractability in adolescent sexual behaviour in SA. Data from the 2003 RHRU survey shows that the median age at ﬁrst sex among 15-24 year olds was 16 years for males and 17.0 years for females. The 2005 SABSMM survey reported that the median age of sexual debut for youth aged 15 to 24 years was 17 for both males and females. In fact, inter-age analysis from the 2005 SABSMM survey showed a trend towards earlier (rather than later) sexual debut among younger respondents than older respondents. Boys generally report earlier sexual debut than females and Black youth are more likely to begin sexual activity earlier than other groups.
High levels of sexual experience are also reported among youth and this has not shifted over time. Both the 2003 RHRU and the 2006 Kaiser/SABC surveys revealed that 67% of young South Africans had ever had sexual intercourse. Slightly lower percentages of youth (57.9%) aged 15-24 years reported ever having sex in the 2005 SABSMM survey. Rates were higher among females (62.3%) than among males (53.9%) and particularly, among Black (60.6%) and Coloured (52.3%) youth when compared to White (38.3%) and Indian (32.4%) youth. As is expected, the study also reported that sexual experience increased with age. While only 10.1% of 15 year olds reported being sexually active, by 19 years of age 60.6% were sexually active.
Multiple sexual partnerships increase the risk of STIs and HIV (Kirby, 2007) and this remains an area of intractability, particularly among young men. Contrary to popular perceptions about the sexual promiscuity of young people, 25% of males and 45% of females aged 15-24 years reported one lifetime sexual partner in the 2003 RHRU survey. While the mean number of lifetime sexual partnerships was higher among males (4.9) than females (2.3), the difference between males (1.8) and females (1.1) in the mean number of sexual partners in the past 12 months was less pronounced. Females in this age group show a greater propensity to stick to one partner over the past 12 months (90.4%) and this trend has persisted since 2002. Males, however, report more frequent partner change and this confers signiﬁcant risk for HIV. While three quarters (72.8%) of sexually active males reported one partner during this period, a third (27.2%) had more than one partners in the past 12 months. In fact, almost half of 15-19 year old men (45.2%) and almost a third (28.0%) of women in this age group reported more than one current sexual partnership.
Sexual frequency The more frequently young people have sex, the greater the likelihood that they will become pregnant (Kirby, 2007). Jewkes et al., (2001) showed that when young women have sex once a week or more they are at signiﬁcantly increased risk of falling pregnant. Low levels of frequent sexual activity are reported among youth in SA and a signiﬁcant proportion practise secondary abstinence. Almost half of young people in the 2002 and 2005 SABSMM surveys reported have sex 1-4 times in the past month and almost a quarter did not have sex in the past month. The 2003 RHRU survey also reported low levels of frequent sex amongst youth with over 90% of males and females reporting sex less than ﬁve times in the past month.
When young people have sex with partners older themselves they are at increased risk of engaging in sexual activity, not using contraception, contracting an STI and becoming pregnant (Kirby, 2007). The 2003 RHRU survey reported that for young men the average age of sexual partners was one year younger than themselves but for females, their partners were on average four years older. While almost all males (98%) aged 15-19 in the 2005 SABSMM survey reported that their partner was within ﬁve years of their age, 18.1% of females in this age group, reported a partner ﬁve years older than themselves. This latter trend conferred signiﬁcant risk for HIV. The study showed that when young women’s partners were within a ﬁve year age range, HIV prevalence was 17.2%. However, HIV prevalence almost doubled (29.5%) when partners were ﬁve years older than themselves.
Contraceptive use represents a signiﬁcant area of progress among youth in SA and has been partly credited with the ﬁrst signs of decline in HIV among youth and overall declines in teenage fertility. The 2003 RHRU survey reported that over half of sexually active women (52.2%) aged 15-24 years were currently using contraception.
Two thirds (66.6%) reported using hormonal methods only, under a third (26.5%) used condoms only and under 10% (6.8%) used dual methods (condoms and hormones). Contraceptive use, particularly condom use, has increased signiﬁcantly since the 1998 SADHS. The latter study reported that 28.5% of 15-19 year olds and 57.2% of 20-24 year olds used the pill (3.5%, 9.6%), an IUD (0.1%, 0.4%), injectables (22.9%, 42.5%) or condoms (2.0%, 3.5%) (DOH, MRC & Measure DHS, 2002).
Condom use has increased dramatically since the 1990s. The 1998 SADHS reported that only 7.6% of sexually active females aged 20-24 years used a condom at last sex. This increased to 47% in the 2002 SABSMM survey and to 55.7% by the 2005 SABSSM survey. Similarly, the 2003 RHRU survey showed that 52% of youth who reported ever having had sex had used a condom at last sex. The proportion had increased to 62% in the 2006 Kaiser/SABC survey.
While reports of condom use has increased for both males and females, rates of use are still almost 20 percentage points lower among females than among males. Rates among young men increased from 57.1% in 2002 SABSMM survey to 72.8% in 2005 SABSMM survey. Using the 2003 RHRU survey, Harrison (2008b) showed that condom use in fact peaks at a young age for women (16 years) but declines thereafter. Rates of condom use among men remain consistently high until about 21 years where after it declines.
While condom use has increased over time, low condom use during sexual debut and inconsistent condom use signiﬁcantly increases the risk for unplanned pregnancy and HIV. Under half of young people (46%)
reported using a condom during sexual debut in the 2003 RHRU survey and only a third report always using a condom with their most recent partner.