«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
One of the earliest health interventions instituted by the democratic government in SA was the provision of free healthcare (including contraception) at primary healthcare clinics as well as to pregnant and lactating women and to children until 6 years. However, for various reasons, related to accessibility and acceptability of services as well as fear and shame regarding teenage pregnancy, young women avoid accessing family planning services or delay accessing antenatal services until very late in their pregnancy (Richter, Norris & Ginsberg, 2006). Over two decades of research have demonstrated the various barriers that young people face when
trying to access health services (Tylee et al., 2007). These include:
• Availability: lack of primary healthcare services and restrictive laws and policies that prevent adolescents from accessing certain services;
• Accessibility: lack of convenience in terms of long travelling distances, inconvenient opening times, costs of services and poor knowledge of services being offered;
• Acceptability: lack of trust in, and conﬁdentiality by, health workers, poor physical environment of the clinic that does not lend itself to maintaining conﬁdentiality, judgemental attitude of health workers and poor quality of health services; and
• Equitability: services are friendlier to youth from high socioeconomic groups that youth from disadvantaged backgrounds such as young people living and working on the streets Health services can play an instrumental role in sexual and reproductive health of adolescents when services are youth friendly: that is they are accessible, acceptable, appropriate, effective and equitable (WHO, 2002).
Access to healthcare, particularly reproductive health, is a human right obligation and, in particular, critical for reducing the impact of the HIV and AIDS epidemic (Dick et al., 2006). As such, over the past two decades, there has been growing awareness of the need to make health services more responsive to the needs of adolescents. However, available data to monitor health service provision is weak and what data is available suggests that there has been slow progress in increasing access to services to all young people and those most at risk (Dick et al., 2006).
A recent review of 16 evaluation studies on the provision of health services to young people in developing countries, 12 of which were in Africa and one in SA, reported that a combination of strategies are used to
improve access to healthcare (Dick et al., 2006). These include:
• Improving the knowledge and skills of service providers;
• Making facilities responsive to the need of adolescents by changing opening times and improving the physical environment;
• Reaching out from health facilities into the community to provide information;
• Generating demand for services in the community and creating community support for health services;
• Involving other sectors such as schools and the media; and
• Providing information and mobilising the community.
Evaluation of the effectiveness of the studies was limited by the range and poor choice of evaluation methods, incomplete description of interventions, variation in the scale of evaluation (10 studies involving fewer than 10 clinics, and remainder varying from 15 clinics to 328 clinics) and in the duration and intensity of interventions.
While most studies focused on improving existing services within public health facilities, 11 of the 16 studies were multi-component interventions involving other sectors. Half of the studies used peer educators, some based in clinics and others in the community, to generate demand, refer young people to health services, ensure that health services were welcoming and provide information about sexual and reproductive health services.
Despite the limitations of the data, there is sufﬁcient evidence to promote the wide scale implementation of programmes that seek to train service providers and other clinic staff and improve the conditions of the facility, supported by efforts to inform and generate demand for services among community members (Dick et al., 2006). These interventions will require careful monitoring of their coverage and quality.
89 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners loveLife has been instrumental in introducing and disseminating the concept of youth friendly clinics through the National Adolescent-Friendly Clinic Initiative (NAFCI). NAFCI is a collaborative project between loveLife, the Reproductive Health Research Unit and the Department of Health. Together they have established national standards for public health clinics to be accredited as adolescent-friendly. These include a practical, self-assessment audit and an external assessment. The objectives of the programme are to improve the accessibility and acceptability of public health services by adolescents and to build the capacity of health workers to provide quality care to young people (Dickson-Tetteh, Pettifor & Moleko, 2001). A key part of the NAFCI service is peer outreach that encourages young people to use health care services. This outreach is provided by groundBREAKERS who are trained peer educators located at each clinic with the purpose of promoting positive lifestyles and healthy sexuality.
Three studies evaluating the effectiveness of adolescent friendly services in SA showed mixed results. The ﬁrst evaluation, included in the WHO study (see Dick et al., 2006) reviewed 32 clinics participating in the national programme between 2002 and 2004. The evaluation reported signiﬁcant increases in service utilisation by young people as well as increases in voluntary counselling and testing. However, visits to the clinic for STI treatment, pregnancy or contraception did not increase over the time period. It must be noted that the weight that can be assigned to the evaluation is limited because of the failure to include control clinics in the evaluation.
A second study that compared NAFCI clinics to control clinics showed that NAFCI accredited clinics performed better in providing adolescent friendly services with respect to determining adolescent needs in a community, knowledge of adolescent rights, availability of adolescent speciﬁc information and non-judgemental attitude of staff (Dickson, Ashton & Smith, 2007). However, overall quality of care was not signiﬁcantly different from control clinics.
Similarly, a third study using adolescent simulated requests for HIV testing from NAFCI and regular clinics showed that NAFCI clinics performed better on only 1 indicator – namely accessibility of HIV testing (Matthews et al., 2009). Young people visiting NAFCI clinics were less likely to be turned away without a test. However, NAFCI clinics did not increase the acceptability of services as measured by the attitude of health staff towards youth, and respect for conﬁdentiality, nor did it improve the appropriateness of counselling services offered to young people.
In line with problems experienced in the school setting, implementation may be comprised by the physical constraints of the clinic setting as well as the work culture adopted in clinics that are more task-oriented rather than holistic in approach (Rohleder & Swartz, 2005) and therefore not conducive to the provision of adolescent friendly services. Although there is global consensus on the need for adolescent friendly health services, much more rigorous evaluation studies are required at a global and local level to demonstrate their effectiveness in improving access to health services and, particularly, in improving health outcomes (Tylee et al., 2007).
Termination of pregnancy services
Early in the transition to democracy, SA promulgated the Choice of Termination of Pregnancy Act (Act No.92 of
1996) to reduce abortion-related morbidity and mortality and to protect women’s reproductive health choices as well as their right to access safe reproductive healthcare services. Available data suggests that the Act has had a positive impact on both morbidity and mortality. Comparing abortion-related mortality between 1994 and 1998-2001, Jewkes and Rees (2005) reported a 91% reduction in deaths from unsafe abortion. More recent reports of the Conﬁdential Enquiries into Maternal Deaths also show a decline in abortion related-deaths.
Whereas abortion accounted for 5.7% of maternal deaths in 1998, it dropped to 3.5% in the 2002-2004 report 90 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners (DOH, 2006). The expected dramatic decline in abortion-related morbidity, however, has not manifest in SA.
Comparison of incomplete abortion between 1994 and 2000 show no statistical evidence of change (Jewkes et al., 2005). However, there has been a signiﬁcant reduction in unsafe abortion among teenagers. While the 1994 study showed that teenagers were most at risk for unsafe abortion with one ﬁfth in the high severity category, by 2000, they were more likely to be in the low severity category.
Most young women are able to balance the moral, cultural and religious ideology about early pregnancy and termination with the pragmatics of early motherhood (Varga, 2002). So they do seek termination. But the stigma of the community and the health care system prevents them and important decision-makers in their lives (mothers, older women in the family and partners) from choosing safe reproductive health options available to them (Jewkes et al., 2005). They opt for backstreet abortions rather than legal and safe abortions. Much like HIV, concerted community level efforts are required to shift social norms about pregnancy and termination and to empower young women and their families using a rights-based framework to balance provision of suboptimal healthcare services with demand for services that are of appropriate quality.
Mass media campaigns
Mass media is an appealing strategy to inﬂuence young people’s sexual and reproductive health because of its ability to reach large numbers of young people (NRC & IOM, 2005). Given the appeal and allure of mass media to young people, it has been used extensively to change knowledge, attitudes and behaviour regarding HIV and AIDS (Bertrand & Anhang, 2006). But mass media communication is often difﬁcult to evaluate because of its national scale, precluding the use of randomised control trials, the difﬁculty of attributing effects to the media component when such interventions are often multi-component programmes, and separating the effects of a particular intervention, in an environment in which multiple interventions or campaigns are taking place (Bertrand & Anhang, 2006; Shisana et al., 2005). Communication interventions use a wide spectrum of media including radio, television, video, print, and the Internet, and these can take a variety of forms including talk shows, public service announcements, soap operas, billboards, pamphlets, posters and interactive websites (Bertrand & Anhang, 2006).
A recent review of mass media interventions focused on changing HIV-related behaviour among youth in developing countries, synthesized the effectiveness of 15 evaluation studies – 11 from Africa and 3 from SA, in order to make recommendations for the wide-scale implementation of such interventions (Bertrand & Anhang, 2006). The evaluation studies were classiﬁed into three categories: radio only, radio with supporting media such as print, videos, theatre and school workshops, and radio and television with supporting media. Review of these studies show that mass media interventions are able to impact on one or more sexual behaviour and psychosocial factors inﬂuencing behaviour. Interventions showed positive effects on knowledge, self-efﬁcacy to use condoms and actual condom use, some shifts in social norms, increased interpersonal communication and greater awareness of health services. However, the programmes reviewed did not improve abstinencerelated self-efﬁcacy, delay age at sexual debut or decrease multiple partners. While there was little evidence to support radio-only interventions, there was little that separated radio with supporting media versus radio and television with supporting media in terms of effects on multiple outcomes. Studies that measured doseresponse effects showed that young people who had high exposure to the campaign via multiple channels were more likely to change behaviour. Although costs and use of a particular media channel may determine the mix of media used, the review concluded that there was sufﬁcient evidence to recommend the wide-scale implementation of mass media campaigns that use multiple media channels and that are closely co-ordinated to other interventions such as school-based or clinic-based interventions.
91 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners However, given the high costs of media interventions, many more rigorous evaluation studies are required on large-scale comprehensive communication interventions to demonstrate their effects at a population level and to determine their costs (Bertrand & Anhang, 2006). As randomised control trials cannot be used to evaluate national interventions, a recommendation is made for the use of quasi-experimental designs together with analytic approaches to infer causality.
SA has launched several national mass media campaigns in response to the HIV and AIDS epidemic. These have included radio, television, print and outdoor media supported by more localised activities such as workshops, participation in clubs and access to services. While most of these interventions do not target teenage pregnancy explicitly as an outcome, they do confer beneﬁt because of their focus on sexual behaviour and practices common to both pregnancy and HIV. In addition, over and above mass campaigns, several more localised forms of social communication around HIV and AIDS also provide information, and inﬂuence behaviour and practice (see Table 18). Herein lies the difﬁculty of evaluating effects of mass media campaigns.
While evaluation of media campaigns focus on single interventions, they seldom take into account the multiple sources of information from a range of interventions (Shisana et al., 2005).
Table 17: Sources of information related to HIV and AIDS for young people in SA