«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
As in most other countries that have developed ﬂexible school policies, policy effectiveness is limited by the extent to which it is consistently implemented. In particular, the core constituency – young men and women, need to be made aware of their right to education to enable them to demand access where it is denied. In addition, much advocacy work will need to be done to ensure that the gatekeepers of education - principals, teachers and fellow learners, buy into the policy to reduce the stigma that often turns young mothers away from the doors of learning. Although SA has instituted an enabling policy environment for young mothers in the school environment, it needs to be supported by a programmatic focus that addresses the barriers to learning.
These include catch-up programmes with respect to the academic curriculum and, in particular, remedial education that often leads to dropout. Strong referral networks are also required with relevant government departments and other community structures that can support learners with childcare arrangements, access to reproductive health services, child support grants and to develop appropriate parenting skills to mitigate the intergenerational transmission of early parenthood.
What works best for second chance programmes
No doubt, second chance programmes are being provided in SA and other developing countries, often by community-based organisations. However, available evidence suggests that they are few (NRC & IOM, 2005), and in all likelihood are small scale and seldom evaluated. Important lessons can be learned from a number of second chance programmes that have been trialled in the US since the 1960s with the explicit goal of delaying second births. It must be noted that the scope, coverage and level of documented success of these interventions in no way match the range and scale of prevention programmes undertaken.
A recent review of 19 programmes to prevent additional births to teenage mothers in the US identiﬁed ﬁve categories of programmes, although many were considered multi-component (Klerman, 2004). Programmes offered various combinations of the following services – health services either provided directly or via referral to teenagers and in some cases to children, education including formal schooling, training for employment, developing parenting skills, and social services provided by social workers, case managers, nurses and in
some cases paraprofessionals. The ﬁve categories of interventions include:
• Community-based programmes offered in multiple sites most often by community-based organisations (4 studies): these programmes offer various combination of interventions such as service coordination for employment training, development of individualised plans, peer support and role modelling by community volunteers, home visiting, parent support groups, and ﬁnancial assistance conditional on pregnant teens participating in workshops designed to improve personal and parenting skills, use of family planning and preparation for education, training and employment.
• Interventions conducted in medical settings (four studies): these programmes generally include various combinations of prenatal and postpartum care, nutritional services, family planning, as well as reproductive health and family life education;
• School-based interventions (three studies): while some interventions use alternative school models for pregnant girls that provide an academic curriculum combined with pregnancy-related education as well as
social and medical services, others link mainstream schooling to school-based clinic and support group services;
• Home-visiting programmes (three studies): these generally involve trained professionals such as nurses who visit teens at their homes initiated during pregnancy and continued for up to two years post-pregnancy.
Programmes provide among others parenting education, building informal support systems and links with community services to access resources and support. An alternative model used welfare agency staff with limited experience in home visiting and imposed sanctions on cash assistance grants if teenage mothers did not comply with home visits or participation in skills programmes;
• Contraceptive implants (two studies): use of contraceptive implants that avoid the use of daily dosage (as is the case with contraceptive pills) or at the sexual encounter (as is the case with condoms); and
• Other interventions (one study) - these programmes offer ﬁnancial incentives for avoiding a second birth and are supported by peer support meetings that discuss family planning as well as education and training needs.
Two additional programmes, not included in the review, focused on encouraging teenage mothers to attend and complete secondary school while a third provided housing and on-site social support to pregnant teens through second chance homes.
The review of the 19 studies produced mixed ﬁndings. Although half of the studies reviewed report positive effects on additional births, only three of these studies (two nurse home-based visits and one health-based intervention) were based on rigorous evaluation designs of randomised control trials. In addition, the size of the positive effects was mostly small and the number of subsequent births was large. Nevertheless, the evaluation studies, do offer some direction for what works in comprehensive second chance programmes.
• Developing a close and ongoing relationship with the teenage mother: The best evidence for programme efﬁcacy comes from home-based interventions where programme personnel develop a close relationship with the teen mother beginning during pregnancy and sustained two years post-pregnancy. Even though group formats for education or counselling may be more cost-effective models of delivery, teenage mothers seem to beneﬁt the most from more individualised, intensive interaction;
• Programmes should be offered by personnel who have been trained and have the authority and willingness to counsel in sensitive areas such as family planning;
• Focus on family planning: Although the evidence for the success of programmes focused on family planning is inconclusive, second chance programmes that do not focus on reproductive health are unlikely to be successful. As such, programmes should make explicit the detrimental effects of additional births and assist teen mothers in setting targets for future births contingent on achievement of educational, economic and familial milestones. In addition, a comprehensive approach towards contraceptive use is required. This should include provision of support to choose and consistently use a method of contraception including accompanying teenage mothers to family planning services. Teenagers also need to be made aware of the side effects of contraceptives and provided with necessary support to choose alternatives. In addition, dual contraceptive methods should be promoted to prevent pregnancy and STIs including HIV. Consideration should be given to long-lasting hormonal contraception such as hormonal injections; and 102 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners
• Encouraging education: When young women return to school after ﬁrst birth and complete secondary school, even if educational aspirations are low, they are more likely to delay second birth. As such countries make worthy investments when substantial resources are devoted to remove barriers to return to, and complete school. Promising methods include alternative schools that offer remedial education as well as childcare support to allow young women to engage in educational and economic activities. It must be noted that remedial education is particularly important as poor performance often leads to dropout and in many cases predates pregnancy.
Child support grant
Another effective policy instrument to reduce the impact of poverty on children, including those born to teenage mothers, is the provision of social security. In spite of the documented beneﬁts that child support confers to the nutritional status of children as measured by height for age (Aguero, Carter and Woolard, 2006), arguments persist that the provision of welfare to single mothers encourages dependence on the state and promotes teen and premarital fertility. This thinking is not unique to SA. In 1996, the US changed its welfare policy, placing restrictions on the conditions under which teenage and unmarried mothers could access welfare.
These included that welfare could only be provided for a maximum of ﬁve years over the mother’s lifetime, that the teen mother had to be enrolled in school and that she had to reside with a parent or adult caregiver. Studies that have attempted to measure the extent to which declines in teen fertility in the US could be attributed to welfare reform have produced mixed outcomes (Brindis, 2006; Garﬁnkel, Huang, McLanahan & Gaylin, 2003;
Lopoo & DeLeire, 2006). Brindis (2006) asserts that the difﬁculty to establish direct causality is linked to the multiple policy interventions that were taking place at the same time. These include increasing availability of long-acting contraceptive methods, increased education about HIV and AIDS as well as a vibrant economy and stronger enforcement of child support policies that increased men’s responsibility for children.
Similar concerns about social security namely, the child support grant (CSG) providing a perverse incentive for young women to fall pregnant has been reported in SA. Yet available evidence suggests that SA had relatively high rates of teenage fertility before the introduction of the CSG and that teenage fertility has been declining throughout the period that the CSG has been available in SA. Controversy may have arisen due to the fact that teenage fertility has declined at a slower rate than overall fertility. This may be related to a spike in teenage fertility that predates the introduction of CSG. An examination of the determinants of teenage fertility shows that it is a complex, deeply rooted social phenomenon. Pre-marital fertility is a well-established phenomenon among African teenagers and predates the introduction of the CSG.
Analysis of Department of Social Development data has demonstrated that the number of CSG beneﬁciaries has grown signiﬁcantly in recent years. However, if a comparison is made between the numbers of teenagers receiving the CSG with the incidence of teenage births in the national population, uptake of the CSG by teenage mothers remains low. In October 2005, teenagers (younger than 20 years) represented 5% of all CSG recipients. Teenagers claiming the CSG were considerably lower than the proportion of teenage mothers (13% lower) in the South African population (mothers younger than 30 years).
The CSG was introduced for younger children to provide ﬁnancial support during the window period when good nutrition has the most signiﬁcant effect on the development of a child (within the ﬁrst three years of a child’s life). However, the majority (53%) of CSG recipients apply for the CSG when their children are much older. Reasons for the relatively late uptake probably related to lack of knowledge about the CSG and the difﬁculty that caregivers experience in obtaining the required documentation.
103 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners A number of studies have been undertaken in SA to assess whether the increase in CSG has had a bearing on the level of teenage fertility. Studies include the following papers: Makiwane & Udjo (2006), a later version was released by Makiwane (2007); Woolard et al., 2005; and Goldblatt & Solange, 2005. Below is the summary of the above mentioned papers that argue that there is no evidence that the introduction of CSG has resulted in
an increase in teenage fertility:
Summary of Evidence
• Research on the CSG indicates that there has been signiﬁcant growth in the number of beneﬁciaries in recent years;
• There is no evidence of an increase in teenage births during the period in which the CSG has been introduced (1995-2005);
• There is a low uptake of CSG by teenagers. Most beneﬁciaries of CSG are older women, who, in most cases become the primary caregivers of children born to teenagers;
• The CSG has been found to be an effective strategy of targeting children in poor households, as demonstrated by a signiﬁcant improvement in child health and nutrition (as measured by height-for-age);
• Further analysis reveals that whereas only 5.3% of CSG mothers are in the 15-19 year age category, the category accounts for 18% of all mothers in the 2001 Census. This implies that teenage mothers are under-represented among CSG beneﬁciaries and thus in most cases unlikely to be deliberately becoming pregnant to claim the CSG;
• The uptake of CSG overwhelmingly by women rather than men is consistent with the measure being perceived to be for children rather than to increase general household income;
• It is arguable that the increased uptake of the CSG is attributable to a growing awareness of its availability and active measures by government to promote uptake. The CSG reaches 93% of poor children whose carers/parents apply, suggesting that the grant is effective;
• Throughout the period when the CSG was in operation, there has been an increase in the number of teenagers who undergo termination of pregnancy; and
• Uptake is relatively low in the poorest areas of South Africa because parents/caregivers lack the required documentation.