«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
Parental practices impact both the emotional and social development of adolescents. Parents who set and enforce rules, monitor behaviour and provide support can positively impact sexual behaviour. Studies have shown that parental regulation through house rules, supervision and monitoring can delay sexual debut, reduce the number of partners (Cohen, Farley, Taylor, Martin & Schuster, 2002; Huebner & Howell, 2003), increase contraceptive use (Miller et al., 1999; Rodgers, 1999) and decrease pregnancy risk (Miller et al., 2001).
Among the various dimensions of family social support, parent-adolescent communication on issues of sexual behaviour and childbearing has received considerable attention (Camlin & Snow, 2008; Wilson & Donenber, 2004). Positive, open and frequent family communication about sex is linked to postponement of sexual activity, increased contraceptive use and fewer sexual partners (Blake, Simkin, Ledsky, Perkins & Calabrese, 2001;
Dittus & Jaccard 2000; Hutchinson, Jemmott, Jemmott, Braverman & Fong, 2002; Karofsky, Zeng & Kosorok, 2000). Similarly, parent-child communication is vital for the prevention and reduction of teenage pregnancy (Hollander, 2003). Many adolescents concur that it would be easier for them to avoid teen pregnancy if they were able to have more open and honest conversations about these topics with their parents (Albert, 2004).
Parent-child communication about sex increases the likelihood that sexual risk will be discussed with partners and can mediate negative peer norms about sexual behaviour (Whitaker & Miller, 2000).
Despite the importance of parent-adolescent communication about sexual behaviour, the timing, frequency, content, developmental appropriateness and quality may mediate the outcomes of communication (Dittus & Jaccard 2000; Whitaker et al., 1999; Blake, Simkin, Ledsky et al., 2001; Miller, Benson, & Galbraith, 2001).
Communication between parents and adolescents about sexual risk behaviour represents a missed opportunity in SA. Even though 79% of adolescents regard parents as a trusted source of information about HIV (Kaiser Family Foundation & SABC, 2006), even more so than friends, only 4% of adolescent report learning the most about HIV from their parents (Pettifor et al., 2004). In addition, 15% reported learning the most about contraception and pregnancy prevention from their parents. Adolescents in SA report poor communication with 64 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners parents about sexual matters in that parents refuse to hold conversation with them about sex, provide only vague indications rather than direct and correct information, and may even punish them for bringing up the topic (Eaton et al., 2003; Kelly, 2000; Kelly & Parker, 2000; Lesch & Kruger, 2005).
Focus group discussions conducted among Coloured adolescents in the Western Cape reported that there was little space for open communication about sexuality with their mothers (Lesch & Kruger, 2005). Mothers used a discourse of danger about sex linked to religious violations, to dissuade their daughters from sexual activity. To protect a close relationship with their mother’s, a culture of silence was maintained about sexuality even though there were clear signs that daughters were sexually active. Richter et al. (2006), commenting on third generation pregnancies in the BT20 cohort in Soweto, also noted the culture of silence around teenage fertility even though it is wholly apparent that girls are sexually active and pregnant. Young women in the Western Cape also do not seek contraception because of the fear that their mothers’ will discover that they are sexually active (Lesch & Kruger, 2005).
Ethnographic research that preceded a family-based intervention to improve communication between parents and children about HIV and sexuality in rural KwaZulu-Natal, titled CHAMPSA, showed that parents lack both knowledge and skill to talk openly about sex and felt disempowered to parent their children in an environment that emphasizes a rights-based culture for children (Paruk et al., 2005). In addition, the generational knowledge gap, fuelled by the educational gap between parents and children, also contributed to their sense of disempowerment. The loss of traditional customs where girls and boys were schooled about sexuality by appointed members in the community as well as the sense of social cohesion where parents shared collective responsibility for raising children in a community, have left parents confused as to how to respond to the HIV epidemic and pregnancy. To compensate for the disempowerment, parents resort to misinformation and myths as well as a punitive parenting styles involving physical violence to discourage girls from sexual activity (Paruk et al., 2005). Following the intervention, both quantitative (Bell et al., 2008) and qualitative research (Paruk, Peterson & Bell, 2009) reported an improvement in parents knowledge about HIV, increased comfort in talking about sensitive issues with their children including the discourse of rights and responsibilities, and greater monitoring and control of children’s whereabouts.
Gender power inequities play a signiﬁcant role in women’s vulnerability to early and unprotected sex as well as pregnancy in SA. Sexual and physical violence have come to characterise relationships between men and women in some communities in SA. The 2003 RHRU survey reported that 2% of 15-24 year old males and 10% of females had been physically forced to have sex. In a case control study among pregnant teenagers in Cape Town, Jewkes et al. (2001) demonstrated that only a quarter (25.7%) of pregnant teens reported having sex willingly the ﬁrst time; 2 out of 4 were persuaded (42.4%) and a third were raped (31.9%). In fact 72% of pregnant teens in the study reported coercive sex and a tenth (11.1%) reported rape. Forced sex or coercion is often accompanied by physical assault. In this study 3 out of 5 pregnant teens (59.8%) reported being beaten by their boyfriends and almost 4 out of 5 (77.9%) were afraid that they would be beaten if they refused sex. Both sexual coercion and greater frequency of beatings were signiﬁcant risk factors for pregnancy in the study.
There is rich qualitative data in SA describing the context of ﬁrst sexual experiences of young women (Wood et al., 1998; Woods & Jewkes, 1997; MacPhail & Campbell, 2001; Varga, 2003; Morojele, Brook & Kachieng,
2006). Women are often forced or tricked into having sex for the ﬁrst time, usually involving physical violence to ensure acquiescence, and this pattern characterises their sexual relationships well into the future. The practice is so widespread in some communities that peers reinforce it as a normative and accepted practice; women come to believe that they are beaten as a show of love; and men take advantage of the initial sexual naivety of women by equating penetrative sex as proof of love. Several studies have in fact reported that women do not recognise forced sex as rape when it involves a boyfriend.
Violence is used to ensure the sexual availability of women, to punish alleged inﬁdelity when women refuse sex (although men view it as a right to have multiple partners), and to prevent women from ending relationships.
The threat of violence or of rejection is a signiﬁcant deterrent to discussing contraceptive use. Despite the extent of violence experienced and their general cognisance of the power imbalances and contradictions in their relationships, few in fact consider leaving (Jewkes et al., 2001). It is hypothesized that in a context of pervasive poverty and unemployment, being in a relationship is one area in which women can achieve success and self esteem can be gained. In addition, although not recognised as transactional sex, relationships often afford women material gains which would otherwise not be accessible to them. In such a context where sexual and physical violence has become a social construct of relationships, individually focused interventions that merely promote ‘choice’ among women are unlikely to achieve much success (Wood, Maforah & Jewkes, 1998; Woods & Jewkes, 1997). Sexuality has to be renegotiated within the context of a relationship and this requires a concerted effort to involve men in behaviour change interventions.
As children make the transition from childhood to adolescence and engage in the process of identity formation, their reliance on parents and siblings as the sole sources of inﬂuence and decision-making begins to change.
Increasing interaction with other role models - best friends, peers, teachers and community members, begin to expand their sphere of inﬂuence. Peer attitudes, norms and behaviour as well as perceptions of norms and behaviour among peers have a signiﬁcant and consistent impact on adolescent sexual behaviour. Studies have shown that when teenagers believe that their friends are having sex, they are more likely to have sex and when a positive perception about condom use is perceived among peers, adolescents are more likely to use condoms and contraceptives (Kirby, 2002; Sieving et al., 2006).
While there is some evidence of the inﬂuence of peers on teenage pregnancy in SA, much of the literature on peer inﬂuence revolves around contraceptive use and sexual behaviour. In a study on the risk factors related to teenage pregnancy in Cape Town, Jewkes et al., (2001) reported that sex often happened because most adolescents perceived that people of their age were sexually active (Jewkes et al., 2001). Similar ﬁndings were reported among adolescent girls in KwaZulu-Natal. While peers encourage sexuality among friends, pregnancy itself is highly stigmatized as it is regarded as a poor showing of female decorum (Kaufman et al., 2001). The study also reported that while constructions of femininity require women to be chaste and adhere to sexual ﬁdelity, girls often feel pressure from friends to maintain multiple sexual partnerships as a means to gain peer group respect (Kaufman et al., 2001). Similarly, Wood, Maepa & Jewkes, (1997) reported that girls who were sexually inexperienced were excluded from friendship circles when issues of sexuality were discussed because they were regarded as ‘children’.
Because sexual activity has come to deﬁne what it means to be successful as a man, young men, in particular, received signiﬁcant social pressure and support from peers to be sexually active and maintain multiple sexual partnerships (MacPhail & Campbell, 2001; Varga, 2003). In the same vein, negative peer norms around condom
use have been internalised by young men dissuading them from using condoms (MacPhail & Campbell, 2001;
Morojele et al, 2006).
While much of the SA literature on peer norms are derived from qualitative research, a quantitative study in KwaZulu-Natal has shown that deviancy among peers – measured by delinquency, smoking, drinking, marijuana use and sexual intercourse, has a direct and independent relationship with risky sexual behaviour (number of sex partners, frequency of condom use and sex while using drugs or alcohol). The 2003 RHRU survey also provides some indication of the degree of peer inﬂuence on sexual behaviour. While 68% of youth reported that they received no pressure from friends to have sex, 10% reported that they received a lot of pressure to have sex. Females (74%) were more likely than males (61%) to report no pressure at all to have sex. In addition, 29% of teens aged 15-19 years thought that all off their friends were sexually active and an equal percentage reported that half or more of their friends were having sex. Even though friends (40%) are the least trusted source of information about HIV (Kaiser Family Foundation & SABC, 2006), 72% of young people have talked to their friends about HIV, far exceeding conversations with any other group (such as teachers, partners, siblings and health workers) (Pettifor et al., 2004). Shifting peer norms through strategies such as peer education is critical to alter risk for pregnancy and HIV.
The socio-economic status of communities, the sense of social cohesion in the community that allows for informal social control as well as the roll modelling offered by adult members of a community can have a bearing on the sexual behaviour of adolescents. Social disorganisation, high levels of disadvantage and poor achievement of members of a community increase the likelihood of young people engaging in sex earlier and having early pregnancies (Kirby, 2002). Low levels of education, income and employment as well as high rates of crime amongst community members are risk factors for early pregnancy. Conversely, when community members are high achievers in terms of education, income and employment and they place a greater emphasis on higher education, pursuing career goals and avoiding teenage pregnancy, teenage pregnancy rates are likely to be low (Kirby, 2002).
Despite high rates of unemployment and poverty that concentrate in certain sectors of the South African society, few studies have examined community level impact on sexual risk behaviour. Using the Cape Area Panel Study data for 2002 and 2005, Dinkelman, Lam and Leibbrandt (2008) showed that community level poverty signiﬁcantly predicts early sexual debut for both males and females and higher rates of unprotected sexy for males. When young people can’t complete school and struggle to ﬁnd work and see few opportunities for economic security, they are likely to discount the costs of pregnancy, HIV and display a willingness to take greater risks (Kaufman et al., 2004).
Data from the KZN Transitions Study showed mixed effects of community levels of education, income and participation in organised activity for boys and girls (Kaufman, Clark, Manzini & May, 2004). Higher levels of opportunity for education, income and participation in sport among girls, decreased their likelihood of having sex in the past year. However, for boys, each of these community attributes decreased the likelihood of condom use. These ﬁndings may be reﬂective of the underlying gender dynamics in communities within a context of relative poverty, where access to privilege for men confers entitlement not to use condoms and to engage in other high risk behaviours.