«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
Conclusions and Recommendations Fertility The report set out to document the prevalence and determinants of, as well key interventions for, teenage pregnancy in SA. 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 SA.
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. South African fertility has been declining over several decades. 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 and 2001. A further decline in fertility has been 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 and Coloured adolescents, fertility among White and Indian 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. Analysis of provincial trends shows a concentration of learner pregnancies in the Eastern Cape, KwaZulu-Natal and Limpopo. Despite the limitations 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.
Abortion 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 pregnancies 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. Yet 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 in many cases, illegally.
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 risk 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 contestation as to whether teenage pregnancy is a cause 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, namely, 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 deep sense of 107 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners 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 deeply entrenched 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 with 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.
In keeping with the multiple spheres of inﬂuence on adolescent sexual behaviour, a number of prevention interventions have been instituted in SA. These include school-based sex education, peer education programmes, adolescent friendly clinic initiatives, mass media interventions as well as community level programmes. While the focus of these interventions has primarily been on preventing HIV, they have conferred beneﬁt to teenage pregnancy because of their impact on sexual behaviour. While separate interventions for teenage pregnancy and HIV are neither desirable nor feasible, to prevent pregnancy from being overshadowed by a focus on HIV a distinct focus on teenage pregnancy is required. But the range, scale and reach, as well as the quality of implementation of programmes vary widely and have limited their impact on adolescent sexuality. In addition, the small number and lack of rigour of evaluation studies limit the conclusions that can be reached about the effectiveness of interventions. However, based on the growing body of evidence in both developed and developing countries, particularly with regards to HIV, recommendations for effective/promising approaches can be made. These need to be taken to scale to increase the reach and impact of programmes.
What is evident is that a magic bullet for teenage pregnancy does not exist. Given the multiple levels of inﬂuence on adolescent sexual behaviour, and, in turn, pregnancy, single intervention strategies by single sectors of society will not solve teenage pregnancy. What is required is comprehensive approaches within the home, the school, the community, the health care setting and at a structural level. In addition, while each sector should act within its strength and foster linkages with other sectors, an integrated strategy is required to ensure that all sectors act towards achieving a common goal.