«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
Knowledge, beliefs and attitudes about contraception Even though most pregnancies are unwanted in SA, over half of young people do little to prevent them. Over two thirds (66%) of young women who reported ever being pregnant in the 2006 Kaiser/SABC study, identiﬁed failure to use contraception as the main reason for pregnancy (see Figure 10). This by far outweighed other potential reasons including wanting to have a baby (28%), pregnancy as a proxy for fertility (8%) and pregnancy as a way of gaining respect (6%).
Figure 10: Reasons for teenage pregnancy among young women who have ever been pregnant
20% 60% 0% 40% 80% 100% Source: Kaiser/SABC Survey, 2006 Although poor knowledge is often cited as a reason for ineffective or non-use of contraceptives (Arai, 2003, Bankole, Ahmed, Neema, Ouedraogo & Konyani, 2007), studies have shown that most young people are wellinformed about modern methods of contraception. The 1998 SADHS reported almost universal knowledge of modern methods of contraception among unmarried sexually active women (99.2%) and similar high percentages of knowledge about the pill (96.4%) and condoms (94.3%). Slightly lower levels of knowledge (85.5%) about modern methods of contraception were reported among sexually inexperienced women in the study. Similarly, qualitative research among young mothers in Soweto reported that lack of education on sexuality and information on contraception could not be used as a legitimate reason for pregnancy as these were widely available (Kaufman et al., 2001).
While adolescents have high levels of knowledge about contraceptive methods, gaps exist in the accuracy of their knowledge or skill regarding correct use of contraception (Conover & Chaudry, 2008; Abiodun & Balogun, 2008; Bankole et al., 2007). Incorrect usage can lead to tears in condoms and missed doses of birth control pills can lead to ovulation. Because of poor education by health staff, girls in Limpopo province reported only using contraceptive pills when partners visited them, using half the number of pills to reduce weight gain or stopping contraceptive use altogether due to side effects such as amenorrhoea (Wood & Jewkes, 2006). These errors can decrease the effectiveness of the contraceptive method and increase chances of experiencing a pregnancy (Conover & Chaudry, 2008). But data from the 2003 RHRU survey has shown that when young 56 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners people feel conﬁdent about their ability to use condoms, they are more likely to use them (Hendriksen et al., 2007). Sexuality education that reaches beyond awareness raising to improve accuracy and completeness of knowledge about contraception as well as condom use self-efﬁcacy, can play a critical role in encouraging safe sexual behaviour.
Negative perceptions about contraceptives play a signiﬁcant role in whether adolescents will use them.
Such perceptions often arise from false beliefs about contraception such as a condoms could slip off during intercourse and be left inside a women’s vagina (Jackson & Harrison, 1999; Tillotson & Maharaj, 2001; Wood & Jewkes, 2006), condoms reduce sexual enjoyment (Maharaj, 2006; Morojele, Brook & Kachieng, 2006), condoms are of poor quality (Temin et al., 1999), and fear of the physical effects (weight gain or nausea) (Varga, 2003; Wood & Jewkes, 2006) and fertility-related side effects of contraceptive use (Varga 2003; Wood & Jewkes, 2006).
Qualitative research conducted among young people in Khutsong about condom use in the context of an HIV epidemic has identiﬁed a complex interplay of factors that determine its use (MacPhail & Campbell, 2001). At the individual level, most young people did not use condoms because they did not perceive themselves to be at risk of HIV infection. At a relational level, young men in particular, have internalised the frequently reported negative attitudes expressed by peers towards condom use. Condom use has also come to be negatively associated with trust, respect and ﬁdelity within steady relationships, but is generally accepted within casual encounters. In fact, Hendriksen et al., (2007) showed that young people who were married or in a relationship of six months or longer in duration were less likely to use condoms. Young people erroneously evaluate trustworthiness within relationships based on subjective criteria (appearance and reputation of the partner), rather than on objective criteria (a negative HIV test and discussion of sexual history). Worryingly, 31% of youth in the 2003 RHRU survey still believe that using a condom is a sign of not trusting one’s partner.
Power imbalances also play a role in women’s ability to negotiate safe sex. In a context of high levels of sexual coercion, women seldom have the power to negotiate sex or condom use in relationships (Wood & Jewkes, 1998). In the Khutsong study, male participants referred to tricking women into having sex, lying about using condoms and forcing women to have sex with groups of friends (MacPhail & Campbell, 2001). In discussions with Zulu young men and women in KwaZulu-Natal, Varga (2003) reported that avoiding conception has come to be deﬁned as part of female sexual respectability and attractiveness. There is general agreement that women hold responsibility for contraception in the relationship although there is little space for open discussion about contraceptive choices with male partners. Although many participants in the study supported contraceptive use, it is still a stigmatized practice bearing the negative social connotation of being promiscuous.
Women also have little room to suggest condom use as it is considered inappropriate and indicative of sexual permissiveness (Varga, 2003).
At an organisational level, despite the increasing availability of condoms at public clinics, the negative and moralising attitude of health staff in the Khutsong study, limited accessibility and few young people could afford to buy condoms. At the structural level, pervasive poverty also forced some young women in the Khutsong study to engage in sexual relationships in exchange for lifts home from school, and gifts and money for subsistence. Similarly, Zulu girls from KwaZulu-Natal reported economic security as one of the reasons for having more than one partner, although multiple sex partners compromised their respectability (Varga, 2003).
Under such conditions, women seldom possess the power to demand safe sex.
Attitudes towards teenage pregnancy Extensive research has been conducted on teenagers’ knowledge, beliefs and attitudes about sexuality, high risk behaviours and about contraceptive use. However, not as much attention has been devoted to adolescents’ attitudes about pregnancy and parenthood. International studies have shown that young girls are capable of assessing their odds of pregnancy fairly well, and that their parenting desires and expectations are predictive of their subsequent fertility outcomes (Bruckner, Martin & Bearman, 2004; East, Khoo & Reyes, 2006).
Adolescents’ who express low intentions and desire for childbearing are less likely to experience teenage pregnancy (East et al., 2006).
However, even slightly ambivalent attitudes toward early pregnancy increase the risk for early childbearing, probably due to a lack of adequate understanding and appreciation of the negative consequences of early parenting (Bruckner et al., 2004). Ambivalent attitudes are common among teenagers from disadvantaged backgrounds and those who have low future aspirations. For them the beneﬁts of childbearing - maturity, love, responsibility, and the perception that it will lead to a better relationship with the baby’s father, outweigh any possible risks (Frost & Oslak, 1999). For such adolescents, the desire to avoid pregnancy is not strong enough to motivate action.
Much of the literature on teenage pregnancy has tended to concentrate on the factors that hinder contraceptive use, and have failed to effectively address the possibility that a signiﬁcant proportion of female adolescents may view immediate pregnancy and parenthood in a positive light. International research has reported that some adolescents intentionally become pregnant (Unger, Molina & Teran, 2000; Cater & Coleman, 2006;
Condon & Corkindale, 2001). Choosing to become pregnant is seen as a positive decision, offering a sense of purpose and future direction. Such a path is chosen to correct negative childhood experiences characterised by dysfunctional family relationships, poor scholastic experiences, and growing up in homes and neighbourhoods where teenage pregnancy was normative (Cater & Coleman, 2006).
Substantive literature existed in SA in the early 1990s that indicated that pregnancy was welcomed, particularly among young Black women and their families as a sign of ‘love, womanhood and fertility’ and potential bride wealth and that men felt pride in bearing a child as a sign of their masculinity (Preston-Whyte & Zondi, 1992;
Caldwell & Caldwell, 1993; Jewkes et al., 2001). However, a shifting socio-economic landscape has brought about changes in the aspirations of young people, particularly in urban areas, and, in turn, altered cultural expectations of young women and men. Over two thirds of adolescent who have ever been pregnant in SA report their pregnancies as unwanted (Pettifor et al., 2004). In addition, only eight percent of women who had been pregnant in the 2006 Kaiser/SABC study reported proof of fertility as a reason for early childbearing. In fact, cultural constructions of femininity have altered to include education, stable employment, career goals and the avoidance of pregnancy (Varga, 2003). In line with increasing opportunities and aspirations for education, and pervasive unemployment, most Black adolescents do not welcome early pregnancy (Kaufman et al., 2001;
MacPhail & Campbell, 2001; Rutenberg et al., 2003; Varga, 2003).
A 1996 study of Black adolescents reported that the overwhelming majority of girls did not want to have a child until they had completed school and obtained the ﬁnancial means to care for a child (Richter, 1996). In 1998, young Black mothers in Soweto spoke of the difﬁculty of coming to terms with an early pregnancy, coping with betrayal of parents, partners and friends and the trauma associated with weighing options regarding the continuation of the pregnancy, whom to tell and whether to continue education (Kaufman et al., 2001). In 1999, the Transitions to Adulthood study in KwaZulu-Natal reported that Black young women were more likely than 58 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners White and Indian women to regard teenage pregnancy as a big problem because of its impact on educational and employment opportunities (Rutenberg et al., 2003). In the context of an HIV epidemic, there are also indications that the perceived risk of HIV may mediate negative attitudes about pregnancy (Rutenberg et al., 2003).
While extensive research has been conducted in SA on knowledge and beliefs about HIV transmission and contraceptive use, most research on knowledge and beliefs about teenage pregnancy has been derived from qualitative research conducted in the 1990s as well as inferred from studies on contraceptive use and HIV. Whether young people understand the biology and detail of how pregnancy happens is unclear. A 1997 study conducted among rural adolescents in Limpopo Province reported a number of myths about teenage pregnancy (Wood & Jewkes, 2006). These include that ‘the blood of each sexual partner had to get used to that of the other through a number of sexual encounters before conception could occur and that multiple sexual partners would prevent conception because the blood was different each time’. A number of practices involving traditional medicine were also reported to prevent conception and avoiding sex during menstruation which they believed was the most likely time for conception to occur. Although more recent qualitative research has indicated that young people receive sufﬁcient sex education to know how pregnancy occurs (Kaufman et al., 2001), quantitative data is not available on knowledge and beliefs about pregnancy. In addition, Wood & Jewkes (2006) indicate that more recent research conducted elsewhere in SA showed that myths about conception still hold, particularly, that most conception occurs during menstruation.
Young people in SA report learn the most about pregnancy prevention from health workers (22%) and schools (17%), parents (15%) and from friends (9%) (Pettifor et al., 2004). For good reason, sexuality education within these environments has focused on the risk for HIV. However, equal focus needs to be given to pregnancy prevention.
When young people perceive themselves to be at risk for pregnancy or HIV, they are more likely to adopt protective behaviours (Kirby, 2007). Although adolescents may have the competency to accurately identify the presence of risk, they do not always have the required capability to sufﬁciently evaluate the consequences or costs of the risk prior to taking action (Greene, Krcmar, Walters, Rubin & Hale, 2000). In addition, adolescents immature cognitive functioning may limit their ability to apply knowledge to their own behaviour, appraise their risk and to apply skills for safer sexual behaviours (Pedlow & Carey, 2004). Thus they fail to appreciate the chance of the harm happening.
Despite the normalisation of early childbearing in SA, many adolescents still identify teenage pregnancy as a signiﬁcant issue facing young people (see Figure 11) (Kaiser Family Foundation & SABC, 2006).
Figure 11: Perception of the most important issues facing youth in South Africa, 2003 Perception of issues facing young South Africans What do you think is the most important issue or problem facing young people your age in South Africa? Is there another issue you think is almost as important? (Open-ended, adds up to more than 100% because multiple responses allowed)