«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
A randomised control trial that tested the Stepping Stones intervention in rural Eastern Cape among youth aged 15-26 showed mixed results (Jewkes et al., 2008). Stepping Stones is a community-based HIV prevention programme – run by the Planned Parenthood Association that aims to build gender equitable relationships by drawing on everyday experiences to discuss sex and love, conception and contraception, unwanted pregnancy, sexually transmitted infections, motivation for sexual behaviour, dealing with grief and loss, and communication skills. While the programme did not have an impact on HIV incidence, it did reduce the incidence of herpes simplex 2. However, unwanted pregnancy seemed to have increased in the intervention arm at the 12 month and 24 month follow up periods. While behaviour change was not evident among women in the intervention, men reported lower levels of transactional sex at 12 months and perpetration of intimate partner violence at the 12 and 24 month follow up periods.
Expanding participation in community-based interventions represents a potential area of growth in responding to adolescent sexual and reproductive health in SA although more rigorous evaluation studies are required to demonstrate their efﬁcacy. This is especially important for young people who exit the schooling system prematurely and who are at increased risk for early pregnancy and HIV.
Youth development programmes As discussed earlier, when young people perform well at school, are connected to the school, their families and other institutions in the community, and have deﬁnitive plans for the future, they are less likely to fall pregnant (Kirby, 2007). Given the number of non-sexual factors that inﬂuence sexual behaviour, a range of youth development programmes that focus on the whole person have been trialled in the US to inﬂuence adolescent reproductive health. While some modalities show positive results, others show no effects. In addition, the few evaluation studies limit ﬁrm conclusions about the effectiveness of youth development programmes as a whole. One modality that shows promise is service learning involving community service that is either voluntary or linked to an academic programme. Four studies, three of which were conducted in multiple locations in the US, have shown consistently positive effects on sexual activity or teenage pregnancy even when programmes did not address sexuality directly (Kirby, 2007). Although the precise reasons for the effect of service learning on sexual behaviour have not been identiﬁed, a number of mechanisms have been postulated. These include developing strong bonds with programme facilitators, increased competency in relationships with peers and adults, developing a sense of purpose about the future, making a difference in someone’s life; and engaging in a time-intensive programme (average of 44-77 hours in a year) thus reducing the time available for engaging in risk behaviour.
Vocational education and employment programmes that provide academic remediation and life skills education, however, did not have an impact on pregnancy or birth rates (Kirby, 2007). Three other comprehensive and intensive youth development programmes that focused on improving academic achievement and social competence, school attachment and parenting skills respectively, showed consistently positive effects although the number of evaluation studies was too small to draw ﬁrm conclusions.
Although a number of youth development programmes are provided, particularly for vulnerable groups in developing countries, evaluation studies are rare (NRC & IOM, 2005; World Bank, 2006). Both the 2007 World Development Report (World Bank, 2006) and the Panel on Transitions to Adulthood in Developing Countries (NRC & IOM, 2005) make reference to the Better Life Options programme in India targeted at young women aged 12-20 who are out of school and who reside in rural areas or peri-urban slums. The programme provides non-formal education with links to formal education, vocational skills, health education, access to reproductive health services and empowerment of women through public awareness and advocacy. Evaluation of the programme effects showed that girls participating in the programme were more likely to delay marriage, have fewer children, use contraception, participate in formal schooling, be employed and make use of antenatal care and hospital services for deliveries (NRC & IOM, 2005; World Bank, 2006).
Given that incomplete schooling is a signiﬁcant risk factor for both pregnancy and HIV, instituting interventions that promote schooling may be an effective method to prevent pregnancy and HIV. Because of the tradeoffs between child labour and education, conditional cash transfers have been used in Mexico to increase participation in education, health and nutrition programmes (IFPRI, 2002). The PROGRESA Program provided a food and educational grant to poor rural families conditional on their children attending school regularly and receiving periodic medical checkups. The programme produced a proportional increase in enrolment at secondary school level of about 8% for boys and 14% for girls (Schultz, 2000). It also ensured that students entered school at earlier ages, decreased grade repetition and improved grade progression. The programme was particularly effective in decreasing dropout between the transition from primary to secondary school (IFPRI, 2002). It also promoted re-entry into school among students who dropped out prior to the initiation of the programme, although subsequent dropout among these students was high. Although PROGRESA did not
explicitly focus on reproductive health outcomes, given the well established beneﬁts that schooling confers to reproductive health, it does offer a promising approach to delay pregnancy and protect against HIV.
Financial concerns are the chief reason cited by most young people in SA for not continuing their education (Richter et al., 2005; Stats SA, 2008b). Yet when children, particularly, young women, live in households that receive social grants, they are more likely to attend school (Samson et al., 2004). Failure to complete school, as opposed to high risk sexual behaviour, has been identiﬁed as a signiﬁcant risk factor for HIV among young women in SA (Pettifor et al., 2008). In light of these ﬁndings and the success of conditional cash transfers in other setting, the Reproductive Health Research Unit is in the process of testing such a programme to retain girls in school in SA. Such an intervention may also confer beneﬁt to teenage pregnancy but would need to be a distinct outcome measure of the trial.
Second chance programmes
When young people’s transition to education and work is interrupted by early parenthood, especially under poverty-stricken circumstances, institutional-level support is required to mitigate educational, economic, health and childcare barriers (World Bank, 2006).
Flexible school policies
One of the most cost effective interventions that countries can introduce is ﬂexible school policies. In fact, increasing access to second chance programmes such as high school equivalence programmes in the US has allowed teenage mothers to continue their education thereby limiting the impact of pregnancy on a range of outcomes (World Bank, 2006). More progressive policies adopted in sub-Saharan Africa and Latin America post-2000 means that many more young women can stay in school and complete their education (World Bank, 2006). While some countries allow young women to remain in school during pregnancy, others require them to take a leave of absence for a speciﬁed period, after which they may re-enter school (NRC & IOM, 2005).
However the extent to which policies are actually implemented are unknown and the effects of such policies are yet to be evaluated (NRC & IOM, 2005).
SA is one of several countries in sub-Saharan Africa that has taken steps to protect young mothers’ right to education. Even before the transition to democracy, in the absence of a formal policy, schools allowed pregnant girls to remain in school and to return to school post delivery. The introduction of the Constitution in 1996 together with the Education Act and Schools Act in the same year formalised this practice. In July 2000, the Council of Education Ministers pronounced speciﬁcally on teenage pregnancy, indicating that pregnant learners could not be expelled from school. Yet this practice persists. Anecdotal reports through the media as recent as 2008, indicate that girls continue to be expelled when they become pregnant (‘Pregnant pupils expelled’, The Mercury, May 8 2008).
In 2007, the Department of Education, motivated by a concern for learner pregnancies in public schools, introduced guidelines for the prevention and management of learner pregnancy (DOE, 2007a). The guidelines recognise the responsibility and inﬂuence that the education system shares with the larger community to prevent and manage teenage pregnancy. It emphasizes a prevention focus to reduce teenage pregnancy, HIV and other sexually transmitted infections. This goal can be achieved through sexuality education provided by the Life Orientation learning area, HIV and AIDS programmes and peer education among learners. However, the guidelines recognise that unplanned pregnancies do occur and that the education system requires policies and procedures to manage these events appropriately. The guidelines attempt to balance the right of the
pregnant teenager to education and equality against the rights of the newborn child to care and support. Three
potential areas of concern arise in the guidelines:
1) The strong focus on abstinence messaging;
2) The suggestion that pregnant learners exit the schooling system for a period of up to two years in the interest of pre- and postnatal care as well as parenting responsibilities; and
3) The association of teenage pregnancy with poor morality and being contrary to the value system of some community members.
When abstinence is promoted as a behavioural choice within the ambits of a comprehensive programme on sexuality that includes information on contraception, it can delay sexual debut (Kirby, 2008). However, a systematic review in the US found little scientiﬁc evidence that abstinence-only programmes delay initiation of sexual intercourse. In fact the lack of scientiﬁc rigour of abstinence only programmes compromise the ability to evaluate their effectiveness. A recent review of abstinence only education in the US (Santelli et al., 2006) reported that many teens who express interest in abstaining fail to do so and when they do initiate sex, they often fail to use contraception. In addition, a substantive proportion of school going learners require information on contraception and reproductive health services because they are sexually active. The 2002 Youth Risk Behaviour Survey in SA reported that at least a third of adolescents in schools are sexually active (Reddy et al., 2003). To prevent pregnancy, STIs and HIV, sexually active learners have the right to access complete and accurate information about contraception and reproductive health services, none of which can be provided in abstinence only programmes (Santelli et al., 2006). Comprehensive sexuality programmes on the other hand, have consistently demonstrated the ability to delay sexual debut, to reduce frequency of sex, to reduce the number of sexual partners and to increase condom and contraceptive use (Kirby, 2008). A mixed approach is therefore required driven by the developmental stage of adolescents. For most children who have not initiated sex, abstinence only messages are appropriate but at the cusp of puberty when the chances of sexual initiation increases, both abstinence and responsible sexuality need to be promoted (Kirby, 2007).
The two year waiting period suggested in the DOE guidelines may compromise the educational attainment of young mothers. As discussed earlier, data from the KZN Transitions study showed that for every year that passes after pregnancy-related school dropout, young women are signiﬁcantly less likely to return to school (Grant & Hallman, 2006). Even if the recommendation is motivated by the interest of the child in the short-term, in the medium to long-term the child’s interest are better served by an educated mother, as maternal education has been identiﬁed as an important determinant of a range of child outcomes including child school enrolment and attainment (NRC & IOM, 2005). Hence, facilitating the early re-entry of young mothers into the schooling system – whether mainstream or otherwise, may be protective of their and their children’s educational, health, economic and social outcomes.
Sexual experimentation is a normal part of the course of development of all adolescents. When it occurs in the context of comprehensive sexuality education, initiation of sex can be delayed (Kirby, 2007). However, if adolescents choose to have consensual sex and are educated to use appropriate protection, there is little evidence that it is harmful (Santelli et al., 2006). The association of teenage sexuality or pregnancy with poor morality is an individualised, victim-blaming and stimatising approach. What this review has attempted to demonstrate is that teenage pregnancy is seldom the result of individual sexual permissiveness. Rather it emanates from a complex interplay of risk factors that stack overlapping and cumulative levels of disadvantage 100 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners among some teenagers. By giving recognition to the multiple sources of inﬂuence of teenage pregnancy, many well beyond the control of adolescents, the education system can play a signiﬁcant role in debunking the myth of sexual permissiveness among teenagers and in destigmatizing teenage pregnancy.