«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
Despite signiﬁcant advancements at policy and programmatic levels to improve the availability and accessibility of health services to young people, usage is compromised by lack of acceptability of services. Even with the roll out of the Adolescent Friendly Clinic Initiative in SA, young people are still confronted with the negative and stigmatizing attitudes of health staff. Thus young women would rather not use contraception, delay accessing antenatal care when they are pregnant, or resort to illegal means for termination of pregnancy. Much more rigorous effort is required to roll out adolescent friendly services and to entrench its key principles among the custodians of healthcare. In addition, the full range of preventative services for pregnancy should be made available and accessible to young people. In particular, emergency contraception, that is considered safe and effective, and that does not increase sexual activity among young people, should be deregulated to increase availability and usage.
Until the quality of healthcare services can be improved for young people, consideration should be given to making available health services outside of the health system. For example, mobile services are proving to be an effective means to provide voluntary counselling and testing services to young people, in particular, young men, who do not generally attend traditional health services.
Parents As the primary socialising agents of children, parents are a trusted source of information about sexuality for young people. Yet this represents a missed opportunity because parents lack both knowledge and skill to talk openly about sex and felt disempowered to parent their children in an environment that emphasizes a rightsbased culture for children. In addition, the generational knowledge gap, fuelled by the educational gap between parents and children, also contributed to their sense of disempowerment. However, family level interventions trialed in SA have shown that programmes can promote open communication between parents and children about sensitive subjects and foster strong parent-child bonds, as well as teach parents how to set and enforce rules. As a support to sexuality education in the school setting, consideration should be given to wide scale implementation of such programmes.
Mass media campaigns in SA have played a seminal role in improving knowledge about sexual behaviour and, in particular, about HIV. Three multi-media campaigns, namely loveLife, Soul City and Khomanani have reached high levels of coverage among young people – the former two above the 80% mark required for high intensity and high frequency coverage. Evidence for the cumulative effect of a range of mass media programmes suggest that they have been effective in shifting a number of health behaviours including condom use, self-efﬁcacy to use condoms, communication with partners and peers about HIV testing and faithfulness to partners. While there is support for the increased coverage and intensity of media programmes, a distinct focus on teenage pregnancy is required. In addition, because of the threshold effect of exposure to media programmes, such interventions need to be supported by other intervention strategies.
Scope and coverage of research Fertility SA does not collect vital statistics on fertility, pregnancy and abortion. While trends in fertility (measures live births) can be reliably estimated from national datasets, pregnancy rates (that include abortions) cannot be reliably estimated. Trends in teenage fertility were estimated from the 1996 and 2001 census as well as the 1998 Demographic and Health Survey. However, the 2003 SADHS could not be used because of the problems with ﬁeldwork in KZN. As such reliable national data on teenage fertility is not available post 2001. A strong recommendation is made for the annual collection of national vital statistics on fertility, pregnancy and abortion that are differentiated by age groups.
The Education Management Information System collects data from schools through the annual school survey.
Pregnancy is estimated using a single question: ‘Number of female learners (that you are aware of) that fell pregnant over the previous academic year’. It is not known, if the pregnancy statistics reported in the EMIS data includes pregnancies that were terminated. Our assessment of the EMIS data is that it most likely approximates fertility (that is live births), as pregnancies are more likely to be reported/discovered late into the gestation period, well past the period for safe termination. Clarity is required on how information on pregnancy is collected in the annual survey. To provide more nuanced information on fertility, pregnancy and termination, a range of questions should be included in the annual school survey.
113 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners To differentiate schools in which learner pregnancies concentrate, four variables that characterise schools (school fees, level of school specialisation, institutional phase and land ownership) were captured from available data on the Department of Education website. While the analyses do provide some indications of types of schools in which learner pregnancies are higher, the incompleteness of the data limit the extent to which ﬁrm conclusions can be reached. In order to provide reliable estimates of learner pregnancies, comprehensive administrative data is required that combines demographic data with academic performance, school level data as well as pregnancy-related variables.
Administrative data should include a variable that indicates the enumeration area of the school in accordance with Statistics South Africa data such that schools can be characterised by neighbourhood factors.
Setting up a longitudinal study in a number of carefully selected schools/neighbourhoods would allow for a better understanding of how teenage fertility is inﬂuenced by national epochs.
While current administrative data focuses on what happens before pregnancy, to determine the effectiveness of school policy on pregnancy, data needs to be collected on social, educative and economic outcomes of teen mothers including dropout related to pregnancy, school completion, academic performance and second birth.
Exploratory studies are also required on the factors that facilitate and prevent teen parents from re-entering the school system. Such studies would enable the development of appropriate second chance interventions.
Determinants A substantial body of research has been conducted on the determinants of teenage fertility in the US.
Several studies are also available from the UK, Nordic countries and other countries from the European Union (EU). Similarly, teenage pregnancy received much scholarly attention in SA in the late 80s and the 1990s. However, studies tended to be descriptive in nature, highlighting biological risks and were localised to particular geographical settings and population groups. Lack of methodological rigour, in some cases, limits the generalisability of these studies. In addition, a limited number of studies are available in SA on the determinants of teenage pregnancy, particularly from the late 1990s. Many of these are qualitative in nature.
With the explosion of the HIV epidemic in SA in the late 1990s, the focus seems to have shifted from teenage pregnancy to HIV. National data became available on both the trends and determinants of sexual behaviour of adolescents. As unprotected sex results in both pregnancy and HIV, the review was able to draw on this larger body of literature. It is noteworthy that a distinct focus of research on teenage pregnancy has been overtaken by HIV and AIDS research.
Research on the risks factors related to teenage pregnancy has primarily been conducted among African and Coloured adolescents for whom rates are high. As such research on the determinants of teenage pregnancy is not available for the White and Indian population groups, for whom rates tend to be much lower. Important lessons can be learnt about protective factors among White and Indian population groups.
The focus of research on teenage pregnancy has been among young women. Very little data is available on the proﬁle, determinants and experiences of young fathers. Given that sexuality is a shared experience and that many of the risks that young women face are through imbalanced gender relations, much more emphasis needs to be placed on the role of young men in teenage pregnancy. Studies need to explore the discordant views that paint young men as perpetrators and disengaged from their familial responsibilities
from the perspective of young women, as opposed to the view of young men that they hold a deep sense of responsibility for their children and want to be involved in their lives.
When risk factors are governed by cultural and socio-economic conditions, they are also time dependent and need to be reviewed regularly. SA has undergone signiﬁcant socio-economic shifts since the 1990s when a large body of literature on teenage pregnancy was generated. While positive attitudes towards teenage pregnancy were linked to cultural endorsements of fertility, attitudes have shifted signiﬁcantly over the past decade, strongly inﬂuenced by increasing educational and economic aspirations and opportunities. Hence regular determinants studies are required in keeping with changes in cultural and socio-economic conditions.
Although a range of interventions have been implemented in SA to inﬂuence adolescent sexual behaviour, their focus is generally on preventing HIV rather than pregnancy. In addition, the small number of, and lack of rigour with which, evaluation studies are conducted limit the extent to which ﬁrm conclusions can be reached about their efﬁcacy. Nevertheless, when combined with the larger body of literature available internationally, a number of promising approaches can be identiﬁed. However, many more rigorously evaluated efﬁcacy (to show that programmes work) and, in particular, effectiveness (to show how programmes can be implemented within existing infrastructure) intervention studies are required. While pregnancy prevention programmes should not be separated from HIV programmes because of their common antecedents, caution is required to prevent pregnancy from being subsumed and, in some respects, neglected in favour of the overwhelming challenges that HIV presents to young people. Pregnancy prevention needs to be a distinct outcome of reproductive health programmes.
In addition, a distinct focus of research on second chance programmes for reproductive health is required to respond to the large cohort of young people who have, and will continue to experience unintended pregnancies.
No doubt a number of community organisations are providing a range of prevention and second chance programmes for teenage pregnancy in SA. However, without adequate documentation of the programme or evaluation of its efﬁcacy, it is difﬁcult to make recommendations regarding wide-scale implementation.
A mapping exercise should be considered to identify the range and scope of interventions currently being provided in SA.
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