«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
67 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners High levels of social cohesion within communities can offer protection against adolescent risk behaviour through the collective action of community members to implement informal social control (Sampson, Raudenbush & Earls, 1997). But in an environment of rapid social and cultural change social connectedness can be disrupted because of the lack of common values and goals (Paruk et al., 2005). Ethnographic research to support the implementation of a family and community level response to HIV in rural KwaZulu-Natal reported that an erosion of community members trust in one another – particularly in relation to child sexual molestation in the community, and the tensions between political and traditional community leadership has dampened the willingness of community members to act in the interest of all of its children (Paruk et al., 2005). However, through a family-based intervention delivered at a community level, the social capital of the community was being restored through increased social support and reciprocity among community members, informal social control in regulating school attendance, and confronting drug use and unlicensed alcohol sales in the community, as well as social leverage in encouraging men to be more involved in child rearing and protection (Paruk, Petersen & Bhana, 2009).
Staff at public health clinics, as the gatekeepers to healthcare services, can have a signiﬁcant impact on young people’s sexual behaviour (Eaton et al., 2003). When quality healthcare services are provided by skilled professionals without judgement and respect for the conﬁdentiality of adolescents, they are more likely to use services (WHO, 2002). In addition, services that are convenient in terms of open times, not involving long queues and that are free or at minimum affordable are more likely to attract young people (WHO, 2002). Yet studies the world over have shown that when young people require health services, the public sector is often the last resort. The conditional nature of health services – either through physical distance, poor quality of clinical services, lack of privacy and respect, high costs and a culture of shame that surrounds certain conditions that are reinforced by health care workers, makes healthcare inaccessible, unacceptable and inappropriate (WHO, 2002).
Even though family planning services including condoms and other forms of contraception are available without charge from public health facilities in SA, and most young people do in fact access condoms from health facilities (Shisana et al., 2005), the attitude of health staff serve as a signiﬁcant barrier, especially for young women. Young women trying to access free condoms from clinics choose never to return because of the judgement and scolding of clinic staff (MacPhail & Campbell, 2001; Wood & Jewkes, 2006). Contraceptive use is associated with a culture of fear, shame and poor morality rather than responsible and healthy sexuality.
Adolescents in Limpopo Province reported harassment by health staff not only for their sexuality but for arriving after school for services (as opposed to the morning), for tampering with clinic cards, and for not arriving on the stipulated return date (Wood & Jewkes, 2006). Although this study was conducted in 1997, more recent studies conducted elsewhere indicate that the negative attitude of health staff persists (Matthews et al., 2009).
Even though parental permission is not required for adolescents to use contraception, nursing staff also violate the privacy and conﬁdentiality of young girls by threatening to report condom use to parents (MacPhail & Campbell, 2001). Focus group discussions among Coloured adolescent in the Western Cape also reported that adolescent did not use contraception because of the lack of conﬁdentiality at local clinics (Lesch & Kruger, 2005).
68 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners In some cases, nursing staff, together with mothers, force young girls to use injectables, sometimes at the inception of menstruation to avoid early pregnancy (Wood & Jewkes, 2006). Nursing staff also do not educate young girls sufﬁciently enough on how to take contraceptive pills and on the consequences of missed doses as well as the potential side effects of injectables such as amenorrhea and weight gain (Wood & Jewkes, 2006).
As a result, girls used contraceptives incorrectly (e.g., by taking pills only when partners visited or on some days) and sometimes stop contraceptive use altogether.
As discussed earlier, conscientious objection by health workers and stigmatizing attitudes also limit the availability of emergency contraception (Woods & Jewkes, 2006) and abortion services to young women (Jewkes et al., 2005).
Failure to promote health sexuality among young people and to educate them about contraceptive use represents a missed opportunity for prevention of teenage pregnancy and HIV. Doctors/scientists (87%) are the most trusted source of information on HIV among young people in SA (Kaiser Family Foundation & SABC, 2006). Yet only 12% of young people learned the most about HIV from health workers/nurses/doctors and clinics (Pettifor et al., 2004). Health workers also play the most important role (22%) in educating young people about contraception and pregnancy prevention. The shift towards the provision of adolescent friendly services in SA is therefore a welcomed initiative, though its effectiveness in improving adolescent health outcomes, both locally and internationally, is still to be established (Mathews et al., 2009; Tylee, Haller, Graham, Churchill & Sanci, 2007). In the absence of a supportive health care system for young people, service provision, outside of the health sector may need to be considered.
Much emphasis has been placed on how individual behaviour and social interaction with important others confer risk for pregnancy, STIs and HIV. However, increasingly, the context in which young people grow up is being identiﬁed as the differentiating factor for which young people are protected against negative life outcomes and which are at heightened risk.
The possible impact of culture on attitudes towards teenage pregnancy needs to be considered. In certain cultures, teenage pregnancy is accepted and welcomed (Kirby, 2002; Melby, 2006) and this could impact teenagers’ attitudes towards pregnancy and, in turn, their behaviour. Most research on pregnancy in SA has been conducted on older women and, in particular, among Black women. There is a dearth of literature on teenage pregnancy among Indian and White South Africans (Jewkes & Christoﬁdes, 2008). Understanding the protective factors in these groups could offer important lessons for preventing early childbearing among Black and Coloured adolescents. Anecdotal evidence suggests that pre-marital pregnancy is not accepted in these groups (Jewkes & Christoﬁdes, 2008). Due to the high levels of stigma as well as the higher incentive to continue education and achieve ﬁnancial aspirations as well as better access to reproductive health services, afforded by their generally higher socio-economic status, most White and Indian adolescents avoid pregnancy. When it does occur, pregnancy is either terminated or couples get married and share ﬁnancial and social responsibility for the child. However, in the main teenage pregnancies are avoided through the use of contraception or termination services (Jewkes & Christoﬁdes, 2008).
The high rates of teenage fertility among the Black and Coloured population groups have made it a normative phenomenon. While pregnancies continue to be highly stigmatized, families have adjusted their response to
accommodate early childbearing to mitigate the educational and economic consequences for the teenage mother and her child. There is generally no expectation of marriage in these groups because of early pregnancy.
Research conducted among Black adolescents has pointed towards substantial power imbalances in sexual relationships between men and women. Very little is known about the status that women assume in sexual relationships in other cultures in SA (Eaton et al., 2003). Because of the close association between race, poverty and socio-economic status and their independent associations with sexual coercion and violence, cultural constructions of femininity and masculinity can only in part account for the Black women’s negative experiences in sexual relationships (Eaton et al., 2003). Nevertheless even when the above factors are controlled for, race differences remain, probably a reﬂection of cultural differences related to sexuality (Kirby, 2007).
A substantial discourse on the inﬂuence of African culture, particularly constructions of femininity and masculinity as display of love, womanhood and fertility, and virility respectively, dominated reasons for teenage pregnancy in SA in the early 1990s (Jewkes et al., 2001, Preston-Whyte et al., 1990). While some research indicates that parts of these constructions may still be valid in certain sectors of society, particularly in rural areas (Wood & Jewkes, 2006; Varga, 2003), more recent research indicates that the social and economic transition in the country may have inﬂuenced these views. Varga (2003) in discussions with Zulu-speaking male and female adolescents in both urban and rural KwaZulu-Natal has demonstrated how avoiding pregnancy together with educational, economic and career aspirations have come to deﬁne what would be regarded as ‘respectable’ for young men and women. Although fertility and motherhood continue to be important factors in the life course of women, pregnancy during adolescence was viewed as a major setback in terms of educational and economic aspirations. Even rural girls in this study reported a tension between traditional roles tied to fertility and social respectability associated with education and economic success. While sexual activity is the norm and encouraged among friends, having an early pregnancy is regarded as poor female decorum and subject to severe stigma by family and friends. Young women are stigmatized as ‘bad’, ‘ruined’, and a ‘failure’.
While avoiding pregnancy has now come to deﬁne what it means to be respectable as a young woman, a number of other practices continue to hobble opportunities to avoid pregnancy. These include traditional notions of sexual ﬁdelity and sexual availability to partners, normalised coercive sex, men holding sexual decision-making power and little room to negotiate contraceptive use with partners. However, respectability among men is still strongly tied to their right to make decisions about when, where and how sex happens, to be highly sexually active and to have multiple partners. This highly sexualised notion of respectability is often linked to a biological need for sex. A number of studies have commented on the natural desire among men for sex – a social construction believed by both men and women, as a means to justify multiple sexual partners and coercive sex (Eaton et al., 2003; Jewkes, Penn-Kekana & Junius, 2005, Richter & Dawes, 2008). The socio-economic transition has added a new feature to masculinity – that of material wealth. A man’s ability to display material wealth and success improves his sexual desirability.
Although an early pregnancy seldom leads to marriage in African culture, acceptance or rejection of paternity plays a critical role in determining the respectability of a woman and her child (Kaufman et al., 2001; Varga, 2003). When paternity is accepted, it offers social and ﬁnancial commitment to the child and dignity and respect to the mother and her family. But acceptance or rejection of paternity rests entirely with the males’ family. Because sexual activity and material success rather than fertility have come to deﬁne masculinity and respect, paternity is often denied, particularly in urban environments, to protection educational, ﬁnancial and 70 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners career opportunities. Under these circumstances ‘backstreet’ abortion becomes a real possibility for women to avoid the stigma of an early pregnancy (Varga, 2003). Alternatively, as in most cases, the young women and her family bear ﬁnancial and social responsibility for the child. Even if ‘damage’ payments are made as an acknowledgement of paternity, it does not always lead to continued social and ﬁnancial responsibility for the child (Kaufman et al., 2001).
Socio-economic status and poverty
There is a substantial body of evidence indicating that one of the most consistent risk factors for early pregnancy is lower socioeconomic status and poverty. Several studies conducted in developed and developing countries indicate that adolescent mothers are more likely to have been brought up in a less-advantageous social environments, come from poor families and experience pre-existing disadvantage that results from poorer economic circumstances (Branch, 2006; Hallman, 2004; Hobcraft & Kiernan, 2001; Kirby, Coyle, & Gould, 2001;
Miller et al., 2001; Russell, 2002; Woodward, Horwood & Fergusson, 2001). The cycle of poverty repeats itself, with pregnant adolescents beginning a lifelong trajectory of poverty for themselves and their children through truncated educational opportunities and poor job prospects (Aldaz-Carroll & Moran, 2001). As such, teenage motherhood serves as a mechanism by which poverty is passed down from generation to generation.