«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
Source: Kaiser/SABC Survey, 2006 In addition, a signiﬁcant proportion of young people (43%) perceive themselves to be at great risk for unplanned pregnancy (see Figure 12). Despite the increased emphasis on HIV and AIDS in SA, equal proportions of young people perceive themselves to be at risk for pregnancy and HIV. The assessment of risk of pregnancy corresponds well with the large percentage of youth in SA who report unprotected sex. It is noteworthy, however, that over a third of young people (37%) do not perceive themselves to be at risk for unplanned pregnancy.
Figure 12: Perception of risk for unplanned pregnancy, STIs, HIV and sexual assault, 2003
Substance use Adolescents who participate in one form of risk behaviour often also partake in other risk behaviours (Essau, 2004). Many studies have shown for example the co-occurrence of substance use and sexual activity (Shrier, Emans, Woods & DuRant, 1996; Flisher et al., 2000). Alcohol and drug use increases an adolescent’s chances of unprotected sexual intercourse and, in turn, pregnancy (Kirby, 2002; Limmer, 2008). While the association between alcohol and sexual risk behaviour has long been established (Limmer, 2008), few studies have investigated the direct links between alcohol and pregnancy (Alcohol Concern, 2002). Studies in the US report that between a third and half of adolescent pregnancies are the result of alcohol use (Kaiser Family Foundation;
1996; The National Center on Addiction and Substance Abuse, 2002).
South Africa has the dual burden of high risk sexual behaviour and substance use. At a national level about a third (31.8%) of adolescents report past month drinking and a quarter report binge drinking (Reddy et al., 2003).
Several studies have reported that between 6-12% of adolescents have used drugs in their lifetime (Brook, Morojele, Zhang & Brook, 2006; Madu & Matla 2003; Rocha Silva, De Miranda & Erasmus, 1996). A signiﬁcant proportion (13.3%) of sexually active learners in SA also report using alcohol or drugs before sex (Reddy et al., 2003). In fact, data from Cape Town has shown that when learners use drugs (methamphetamine) they are more likely to have anal, vaginal and oral sex as well as to be pregnant or responsible for a pregnancy (Pluddemann et al., 2008). Although the association between lifetime sexual behaviour and alcohol or marijuana use is strong, the biggest risk that substance use confers to adolescent sexual behaviour is that adolescents are more likely to engage in causal sex (Palen et al., 2006). In fact, studies have shown that when young women initiate sex with a steady boyfriend and someone they know for a while, they are less likely to experience an early pregnancy (Jewkes et al., 2001).
Within the rubric of a dual burden of HIV and substance use in the country, several studies have focused on the ways in which alcohol and drug use serve as precursors for risky sex (Kalichman et al., 2007; Kalichman, 2008; Morojele et al., 2006; Morejele, Brook, & Kachieng, 2006; Palen et al., 2006). The psychoactive effects of alcohol and drug use are thought to increase sexual arousal and desire, decrease inhibition and tenseness, diminish decision-making capacity, judgement and sense of responsibility, and generally disempower women to resist sex (Morejele et al., 2006). Studies have reported on the increased risk of forced sex and the decreased likelihood of using condoms when under the inﬂuence of alcohol (Morojele et al., 2006). These effects are facilitated in a context of high unemployment, and in an environment where peer norms promote heavy drinking, alcohol and drugs are easily accessible and casual sex readily available.
Childhood sexual and physical abuse
Although the evidence of the relationship between childhood sexual abuse and adolescent pregnancy has been mixed, a recent review reported nine studies that supported such a relationship (Francisco et al., 2008).
In addition, a number of studies found a strong relationship between child sexual abuse and risky sexual behaviour (Francisco et al., 2008). Studies have shown that a disproportionately large number of adolescent mothers report a history of past sexual and physical abuse (Francisco et al., 2008; Hillis et al., 2004; Kirby, 2002; Van Der Hulst et al., 2006; Lansford et al., 2007; Pallitto & Murillo, 2008).
Data is not available in SA on the link between child sexual abuse and early pregnancy. However, it is well known that SA is a violent society. Although state institutionalised violence under Apartheid has been replaced by a rights-based framework, violence has come to be entrenched in our interpersonal interactions, at home, 61 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners in schools and communities. Child abuse – whether physical, sexual or psychological is rife in SA. It is difﬁcult to quantify the extent of abuse because of variability in how it is deﬁned, its hidden nature and differences in community understanding and willingness to report abuse (Richter & Dawes, 2008). South African Police Service data on reported crimes provide a potential gauge. However, these are likely to be grossly underreported. For the year 2004-2005, children were victims of almost half of all indecent assaults (48.2%), close to half of all rapes (42.7%) and one in 10 common assaults (11.4%) (Richter & Dawes, 2008). Children are also the victim of physical abuse by their families. In 2005, Dawes and colleagues measured parent’s social attitudes to physical punishment in SA. Over half of the sample (57%) had smacked their child in the past year and of these 3 out of 5 (60%) had used a belt or another object to beat their child. Most children who were smacked were 3 years and those who were beaten with an object were 4 years.
A number of reasons have been provided to explain the link between prior abuse and increased risk of teenage pregnancy. Adolescents with a history of child sexual abuse have experienced a violation of their most intimate boundaries. This can lead to a sense of powerlessness in relationships and may inﬂuence their ability to negotiate contraceptive use (De Bellis, 2001). Traumatized adolescents turn to substance use, prostitution and running away from home, increasing their risk of early pregnancy (Pike & Wittstruck, 2000; Saewyc, Magee, & Pettingell, 2004; Silverman, Raj, Mucci et al., 2001). They often partner with adult men as these relationships are viewed as more advantageous in terms of the resources they are able to provide (Darroch, Landry & Oslak, 1999; Elstein & Davis, 1997). While such a partnering may initially offer the means necessary to escape a violent family of origin, the imbalance of power and control limits their ability to negotiate contraceptive use (Harner, 2005). Adolescents who report a history of sexual abuse are less likely to use contraceptives that those who are not abused (Kirby, 2002; Koenig et al., 2004; Saewyc et al., 2004).
Interpersonal factors The day-to-day social environment in which young people participate and develop can have a profound effect on behaviour. Families, together with partners, peers and schools play a signiﬁcant role in identity formation and decision-making (NRC & IOM, 2005).
Families Many aspects of family life exert substantial inﬂuence on adolescents’ sexual behaviours and pregnancy risk (Miller, Benson, Galbraith, 2001; Miller, 2002). These include socio-economic status (discussed later on), family type, parental values and role-modelling, parental style, monitoring and support and parent-child communication.
Family structural characteristics play a vital role in understanding and determining teenage sexual behaviour including pregnancy. Many studies have shown that family structure is strongly correlated with teenage pregnancy (Langille, Flowerdew & Andreou, 2004; Miller, Bayley, Christensen Leavitt & Coyl, 2003). Growing up in a single-parent home (Bonell et al., 2006; Kirby, 2002; Miller et al., 2001) or without any parents places adolescents at elevated risk of early pregnancy (Miranda & Szwarcwald, 2007; Zeck, Bjelic-Radisic, Haas & Greimel, 2007). Even when family factors associated with father absence are controlled for, the association between mothers’ single parenting and daughters’ early pregnancy persists (Ellis, Bates, Dodge et al., 2003).
Teenagers who are raised in larger families are also at increased risk of earlier sex than those who are not.
This results from teenager’s replicating their siblings’ sexual behaviour or because parental monitoring is spread too thin when more children live in the home (East & Jacobson; 2001; East & Shi, 1997).
The link between family structure and youth sexual behaviour has been attributed to single or divorced parents more permissive sexual attitudes and values (Dittus & Jaccard 2000; Jaccard, Dittus & Gordon, 2000), lesser parental supervision and monitoring and the parents own dating activity (Whitbeck, Simons & Koa, 1994).
Furthermore, household characteristics such as family income and maternal employment may be associated with both poor parenting and family structure (Antecol & Bedard, 2007), in turn, affecting adolescent sexual behaviour. Quantitative data among adolescents from KwaZulu-Natal showed that poverty leads to distant parent-child relationships affecting behavioural and personality attributes of adolescents (Brook et al., 2006).
This, in turn, increases the likelihood of association with deviant peers and ultimately, risky sexual behaviour.
Household structure is a subject of much debate in SA because of the effects of a migrant labour system that separated production and reproduction, early fertility, delayed marriage, HIV and AIDS deaths and economic and cultural factors that promote and support multigenerational living. Studies have shown that SA does not follow a single pattern of living arrangements. While White families generally follow the Western model of nuclear families, Black, and Coloured families and increasingly Indian families support extended family living arrangements because of the factors mentioned above (Amoateng, Heaton & Kalule-Sabiti, 2007). Father absence from the home has come to characterise South African living arrangements, largely because of the persistence of unemployment forcing men and, increasingly women to migrate to urban centres in search of work. According to the 2001 population census a ﬁfth of African men (19.2%) lived apart from their wives compared to only 4% among White families (Amoateng, Heaton & Kalule-Sabiti, 2007). The demographic surveillance site in Agincourt, Mpumalanga has reported an increase in female-headed households between 1992 (27.6%) and 2003 (35.9%) as well as the number of households with orphaned and fostered children.
National data conﬁrms the concentration of poverty in female-headed households (60.6% for women vs. 38.3% for men at R322 a month poverty line), despite improvements since 1995 (Bhorat & van der Westhuizen, 2008). In addition, female-headed households account for a disproportionate share of the poor compared to their share of the population. Half of individuals considered poor in 2005 lived in female-headed households.
Parental values and role-modelling
The family has a very early and extensive impact on an adolescent’s belief systems and values, and hence on their behaviour (Gordon, 1996). Consistent parental values have been recognised as a vital factor that inﬂuences later sexual debut and decreases the risk of unintended pregnancies (Berglas et al., 2003). Adolescents whose parents are clear about the value of delaying sex are less likely to have intercourse at an early age (Blum & Rinehard, 1998). Parents’ values against adolescent sexual intercourse (or unprotected intercourse) decrease the risk of adolescent pregnancy (Miller et al., 2001). However, parents with permissive attitudes about sex or premarital sex, or those that have negative attitudes about contraception have teenagers who are more likely to have unsafe sex and become pregnant (Dittus & Jaccard 2000; Jaccard et al., 2000; Kirby, 2002).
Family members also serve as role models to their children. Adolescents are more likely to initiate sex and experience pregnancy if their parents or other family members have sex outside of marriage, are cohabitating with a romantic or sexual partner or have had a child outside of marriage (Kirby 2001). In addition, several studies have demonstrated that having a mother or sister who was a teenage parent is strongly linked with a teenager herself falling pregnant (East & Jacobson, 2001; East et al., 2006; Vikat et al., 2002).
Parental style, monitoring and support The nature and quality of relationships shared between an adolescent and their parent can have a major inﬂuence on the decisions that they make about sex. Teenagers whose parents provided a warm, loving, and nurturing environment are less likely to engage in sex (Cox, 2007). A review of more than twenty studies demonstrated that parent-child connectedness (support, closeness, and parental warmth) decrease the risk of adolescent pregnancy by inﬂuencing adolescent sexual and contraceptive behaviours (Miller et al., 2001).
However, overly strict and authoritarian parenting style is associated with a greater risk of teen pregnancy (Miller, 1998).
A failure to share a close connection with adolescents often heightens the inﬂuence of peers on sexual activity.
This could account for the association between poor or distant parent-child relationships and risky adolescent sexual behaviour (Feldman & Brown, 1993). Adolescents who describe their relationships with their parents as coercive or conﬂictual, for example, are more likely to be involved with deviant peer groups, and the peers become most important and inﬂuential. Conversely, adolescents whose parents have more authoritative parenting styles are more likely to belong to a peer group that supports both adolescent and parent norms (Perrino et al., 2000).