«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
• To assess the individual, familial and educative impact of teenage pregnancy;
• To identify and assess the impact of interventions for teenage pregnancy; and
• To propose a conceptual framework for research and interventions to prevent and mitigate the impact of teen pregnancy.
Methods The study involved a desktop review of literature supported by secondary data analysis to provide an overview of research on the prevalence, determinants and interventions for teenage pregnancy.
Although the study focused on pregnancy, the detailed trends presented in the report are on fertility.
Understanding the distinction between pregnancy and fertility is essential. Fertility rates refer only to pregnancies that have resulted in live births while pregnancy rates include both live births and pregnancies that have been terminated. Before the introduction of the termination of pregnancy legislation, fertility closely approximated pregnancy rates. Since the legalisation of abortion, however, this can no longer be assumed to be the case. Trends in pregnancy rates in SA cannot be accurately estimated for two reasons. First, it is not known whether pregnancies that were terminated early on are well captured in survey data and school record systems. Second, a comprehensive national register of abortion is not maintained in the country.
SA lacks vital statistics on fertility, pregnancy and abortion. Nevertheless, fertility rates could be reliably estimated from Census data and the Demographic and Health Surveys. For the purposes of this study, trends in teenage fertility were investigated in three stages: (1) mapping the overall trends in fertility in SA; (2) documenting trends in teenage fertility relative to overall fertility; and (3) analysing learner pregnancies reported through the Education Management Information System (EMIS).
The literature review focused on studies dated between 2000 and 2008 but included seminal works prior to
2000. In view of the high rates of HIV infection among young people in SA, sexual behaviour of adolescents has received much national scholarly interest. The literature review was able to draw on four national studies conducted to understand youth sexual behaviour.
Secondary analysis was also conducted on the HSRC 2003 Status of Youth Survey, a nationally representative study of more than 3 500 young people aged between 18 and 35 years. The purpose of the secondary data analysis was to identify factors that are associated with early pregnancy. This included family structure, type of childhood residence, childhood poverty and school dropout.
Main Findings Fertility The overall decline in fertility in South Africa has run a long course of almost 50 years but at differential rates for the population groups. To date, SA has the lowest fertility rate in mainland sub-Saharan Africa. While over time teenage fertility has been declining, this has been at a slower pace than overall fertility. The slower decline in teenage fertility may be attributed to interruptions in fertility associated with national epochs. For example, the interruption of schooling during the struggle years was associated with a rise in teenage fertility. Similarly, the spike in fertility in the mid nineties is associated with political changes during that period when there were concerns for the large cohort of young people who had become marginalised from mainstream systems of education, work, healthcare and family life. However, it must be noted, that teenage fertility has declined by 10% between 1996 (78 per 1000) and 2001 (65 per 1000). A further decline in teenage fertility (54 per 1000) was reported in the 2007 Community Survey.
Older adolescents aged 17-19 account for the bulk of teenage fertility in SA. While rates are signiﬁcantly higher among Black (71 per 1000) and Coloured (60 per 1000) adolescents, fertility among White (14 per
1000) and Indian (22 per 1000) adolescents approximates that of developed countries. This difference can in all likelihood be accounted for by the wide variation in the social conditions under which young people grow up, related to disruptions of family structure, inequitable access to education and health services, as well as the concentration of poverty and unemployment in Black and Coloured communities. However, international research shows that even when the above factors are controlled for, differences between populations groups persist, indicative of cultural differences with regards to pregnancy.
Analysis of the EMIS data on teenage pregnancy shows an increase in learner pregnancies between 2004 and 2008. However, this trend is contrary to national trends in fertility and is more likely the result of improved reporting, rather than a real increase in fertility. Analysis of provincial trends shows a concentration of learner pregnancies in the Eastern Cape, Kwazulu-Natal and Limpopo. Despite the incompleteness of the EMIS data, it does provide some indications of the types of schools in which learner pregnancies are concentrating.
Learner pregnancies are higher in schools that are poorly resourced (lower in specialised schools), those located in poor neighbourhoods (no fee schools and schools located on land independently owned), as well as in schools that involve considerable age mixing (combined schools). Targeted interventions may be required for combined schools and those located in the poorest neighbourhoods.
Despite the legalisation of abortion in SA in 1996 and the progressive increase of service availability in public and private facilities over time, few teenagers report using legal services for termination of pregnancy in both quantitative (3%) and qualitative data. Administrative data from the Department of Health, however, suggests much higher levels (30%) of usage of legal services by young women aged 15-19. These data sources need to be reconciled to establish a true estimate of use of services. Failure to use legal services is related to the ensuing lack of information about the costs of termination and the stage of gestation at which legal termination can take place, as well as the stigma of pregnancy and abortion generated in the community and replicated within the health system. Although abortion is recognised as morally and religiously objectionable, young people apply a ‘relative morality’ to abortion to circumvent both social and ﬁnancial hardships and to protect their educational opportunities. So termination does take place, albeit, illegally.
Determinants What the analysis of the trends in fertility show is that the moral panic about rising teenage pregnancy in SA is unfounded. It is one area in which policy instruments related to information dissemination (primarily related to HIV), family planning services, and expanding access to education, have been effective. In fact, with the changing socio-economic landscape in SA, positive attitudes towards early pregnancy reported in the early 1990s have shifted. Over two thirds of young women report their pregnancies as unwanted because it hobbles educational aspirations and imposes greater ﬁnancial hardships in a context of high levels of poverty and unemployment. What is more, signiﬁcant progress has been noted in dramatically increasing contraceptive use among young people, in particular, condom use.
Yet rates of teenage pregnancy remain unacceptably high. Despite high levels of knowledge about modern methods of contraception, a large cohort of young people do not use contraception and many use them inconsistently and incorrectly. What the moral panic argument does is associate teenage sexuality and failure to use contraception with deviant individual-level behaviour. Yet the literature review and secondary analysis shows that teenage fertility is, in fact, the result of a complex set of varied and inter-related factors, largely
related to the social conditions under which children grow up. These factors include:
• When young people dropout of school early on, often because of economic barriers and poor school performance, they are at signiﬁcantly heightened risk for early pregnancy;
• When they grow up in residential areas where poverty is entrenched (informal areas and rural areas), they are at risk of experiencing an early pregnancy;
• When both parents, and in particular, the mother, is present in the home, risk for early pregnancy is decreased;
• When stigma about adolescent sexuality abounds, few opportunities exist for open communication about sex with parents and partners, and access to judgement-free health services are constrained. As a result, gaps in knowledge about, and access to, contraception is limited;
• When young women are involved in relationships where power is imbalanced, men decide the conditions under which sex happens. All too often, this involves coerced or forced sex;
• When young women struggle to meet immediate material needs, they make trade-offs between health and economic security. Reciprocity of sex in exchange for material goods leads to young women remaining in dysfunctional relationships, engaging in multiple sexual partnerships and involvement with older men.
Under such conditions, there are few opportunities to negotiate safe sex and the risk for pregnancy is increased.
Pervasive poverty in SA stacks these overlapping sources of risks among some young people, offering them limited information to make optimal choices and few incentives to protect themselves against pregnancy.
Role of education Education is highly valued by young people in SA and aspirations for education are high. It is therefore not surprising that the rise in access to education since the 1970s, particularly for young women, has been met with a concomitant decline in teenage fertility. Despite the debate as to whether teenage pregnancy is a cause 12 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners of, or results from, dropout, local and international studies show that both share the common antecedent of poverty and poor school performance. While pregnancy may be the endpoint most directly associated with dropout, it is often not the cause. Girls who perform poorly at school are more likely to dropout of school, experience early fertility and less likely to return to school following a pregnancy. In fact data from SA shows that dropout often precedes pregnancy. Incomplete education has been identiﬁed as a signiﬁcant risk factor for negative reproductive health outcomes, including early pregnancy and HIV.
Even when girls have experienced an early pregnancy, South Africa’s liberal policy that allows pregnant girls to remain in school and to return to school post-pregnancy, has protected teen mother’s educational attainment and helped delay second birth. However, only about a third of teenage mothers return to school. This may be related to uneven implementation of the school policy, poor academic performance prior to pregnancy, few child-caring alternatives in the home, poor support from families, peers and the school environment, and the social stigma of being a teenage mother. South African data shows that the likelihood of re-entering the education system decreases when childcare support is not available in the home and for every year that teen mothers remain outside of the education system.
Instituting strategies to retain girls in school by addressing both ﬁnancial and school performance reasons, as well as ensuring early return post-pregnancy, may be the most effective social protection that the education system can offer to prevent and mitigate the impact of early pregnancy. When learners do dropout of school, concerted effort is required to re-enrol them in school or in alternative systems of education.
Despite the growing focus of research on fatherhood in SA, scant data is available, both locally and internationally, on young fatherhood. Available international research suggests that the proﬁle of young fathers is no different from young women – they tend to come from low income homes, have poor school performance, low educational attainment and seldom have the ﬁnancial resources to support the child and the mother. Our secondary analysis shows that premature exit from the schooling system almost doubles the odds of becoming a father early on in SA.
Qualitative research among young fathers in SA reports that much like young women, young men experience a strong emotional response on hearing about their impending fatherhood. Contrary to the perception of young women that many young fathers deny paternity, most young men in the study expressed a sense of responsibility for the child and a willingness to be actively involved in the child’s life, motivated by the absence of their own fathers in their lives. But the acknowledged caring role of a father is overtaken by a need to provide ﬁnancially for the child. In a context of pervasive unemployment, few young men can fulﬁl this role often leading to estrangement from the child. In addition, poor relations between the female partner and her family, together with cultural factors related to negotiation of paternity and ongoing responsibility for the child also serve as barriers to young men fulﬁlling their role as father.
Much more empirical research is required in SA on young fatherhood and to understand the role of culture and its impact on continued father involvement in children’s lives. However, other policy options may have to be considered to ensure paternal support for children. These include gender-based interventions that extend the repertoire of fatherhood beyond ‘providing’ to being ‘present and talking’, especially in impoverished conditions where unemployment and poverty is high. In addition, consideration should be given to legal child support arrangements, much like in the US, where legislative interventions have resulted in increased levels of paternal involvement among children of teenage mothers.