«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
Interventions 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. Separate interventions for teenage pregnancy and HIV are neither desirable nor feasible. To prevent pregnancy from being overshadowed by a focus on HIV, however, 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.
As all young people will confront their sexuality at some point in time, universal access to information and skills are required early on to enable them to make informed choices. However, where conditions stack high and overlapping levels of risk among some young people, targeted and more intensive intervention strategies will be required. It is clear, and rightly so, that the sexual risk factors are often targeted in programmes because they are more directly related to pregnancy and HIV and are more amenable to change. However, what the study has demonstrated is that non-sexual risk factors such as relational (family structure, gender relations) and structural factors (education, poverty) are critical determinants in SA. Yet the thrust of our interventions has been on sexual risk factors. Without interventions that target relational and structural factors, substantive declines in the rates of teen fertility will not be achieved. In addition, sexuality is a shared activity between two partners. It makes little sense to empower women about their sexuality without concomitant efforts to empower men about equitable gender relations.
Although strong arguments exist for the thrust of interventions for adolescents to focus on prevention, the unabated and increasing levels of marginalisation of young people across a range of domains provide impetus for a more systematic focus on treatment, care and support. Even if we instituted the most rigorous prevention programmes, some young women will experience early pregnancy. Although remediation is costly and difﬁcult to achieve, it far outweighs the costs to a society of lost human capital potential. 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, and in all likelihood are small scale and seldom evaluated. A systematic and more formalised system of support is required for those who do experience early pregnancy.
Recommendations Based on the assessment of the determinants of teenage pregnancy and a review of key interventions, the following recommendations are made for interventions within the education system. Recommendations are also made for interventions within other sectors with the aim of achieving a comprehensive and integrated approach towards adolescent reproductive health.
• Universal implementation of sex education The international evidence for the effectiveness of sex education programmes is substantive. Although the South African evaluation studies are less convincing, sex education should form a critical component of a comprehensive strategy towards reducing teenage pregnancy. However, a number of steps need to be taken to improve the focus, quality and level of implementation of programmes in South African schools. These
• Ensuring that programmes meet most of the 17 criteria identiﬁed for effective sex education programmes in developed and developing countries. These criteria focus on the process of developing the curriculum, the context of the curriculum and implementation of the curriculum;
• Including a deﬁnitive focus on pregnancy (rather than only HIV) by addressing knowledge and beliefs about contraception, conception and pregnancy and focusing on responsibilities of parenthood, knowledge and skills required for successful parenthood, together with an understanding of the importance of planning for and timing of parenthood;
• Adopting a comprehensive approach that addresses both abstinence and safe sex practices, rather than an abstinence-only focus. The focus of the programme (abstinence or safe sex) should be dependent on the stage of development/age of the learner, rather than the grade. This will ensure that learners who are older for their grade (due to high levels of repetition – a known risk factor for dropout, and, in turn pregnancy) receive developmentally appropriate messaging;
• Focusing on both the biological and social risk factors (such as gender power relations, poverty, early school dropout) that lead to early pregnancy;
• Addressing barriers to the full implementation of programmes in schools including raising the level of priority it assumes within the education system, addressing community perceptions and stigma, and improving teacher willingness and readiness to deliver the programme;
• Engaging peer educators or youth/community organisations as a support to teachers in and outside of the classroom. While the beneﬁts of peer education may be greatest to peer educators themselves, this could make an important contribution to generating a new cadre of leaders at community level who can serve as role models for among others positive sexuality and equitable gender relations; and
• Setting up a number of rigorously evaluated effectiveness studies that focus on pregnancy as a distinct outcome using biological measures.
As a support to comprehensive sex education in schools, an assessment of the availability of condoms in the community should be conducted. Where community availability of condoms to young people is low, consideration should be given to making condoms available through the school system.
• Targeted interventions for high risk groups A number of adolescents are at elevated risk for teenage pregnancy because of the social conditions in which they live. Markers of learners at elevated risk include those repeating grades, frequently absent from school, learners with a history of childhood sexual or physical abuse, learners who use/misuse substances and learners living under conditions of extreme poverty. An early warning system must be established such that teachers can identify learners at elevated risk and refer them to systems within the school or in the community for more individualised and intensive intervention.
Our secondary analysis of EMIS data indicates that higher rates of learner pregnancies are reported in schools located in poor neighbourhoods (measured by no fee schools and farm schools) and those in which age-mixing is signiﬁcant (measured by combined schools), indicative of gender power imbalances. As part of a phased approach towards teenage pregnancy within the school system, interventions should be targeted at combined schools and those located in the poorest communities.
• Interventions to retain learners in school The traditional approach of health promotion within the school setting has been to focus on improving the health of learners to facilitate learning outcomes. However, given the signiﬁcant protection that education can offer to health outcomes, improving both the quality and quantity of education may confer signiﬁcant beneﬁt.
Incomplete schooling is a signiﬁcant risk factor for both pregnancy and HIV in SA. Instituting interventions that promote uninterrupted schooling may be an effective method to prevent early pregnancy and HIV. As ﬁnancial concerns and high levels of repetition are two of the chief reasons for inordinate levels of dropout in SA, addressing the ﬁnancial barriers to schooling and setting up a system for the remediation of school performance for those learners repeating grades may be effective interventions. Conditional cash transfer programmes have proven to be effective in improving school attendance in Mexico, Bangladesh, Nicaragua and Brazil. Plans are underway to test such a programme in SA with HIV as an outcome measure. Such an intervention may also confer beneﬁt to teenage pregnancy but would need to be a distinct outcome measure of the trial.
When learners do dropout of school, a systematic process is required to re-enrol them in school or in alternative systems of education. To dramatically increase the number of young people enrolled in alternative pathways such as Further Education and Training or Adult Basic Education and Training, however, a number of gaps need to be addressed. These include ensuring that programmes are adequately resourced, provide quality education services, and are reframed as legitimate and credible systems linked to mainstream pathways (HSRC, 2007). In addition, alternative systems must offer viable exit opportunities for participants by cohering with further education and economic opportunities. Young people using alternative pathways rarely experience difﬁculties in only one aspect of their lives (Yohalem and Pittman, 2001). They often require support on multiple fronts. Service provision must be comprehensive and tend to development in a holistic manner. The structure of second chance programmes must also be ﬂexible to accommodate the economic imperatives and family commitments that make young people turn to alternative systems.
• Service learning Service learning that involves community service that is either voluntary or linked to the school curriculum has shown positive effects on sexual activity and pregnancy in the US even when programmes have not addressed sexuality directly. Instituting such interventions may be a cost effective youth development strategy that is in line with the goals of the second generation youth policy in SA. These include promoting community participation among school going learners and providing much needed work experience for young people – a prerequisite for employment, while concomitantly offering protection to reproductive health outcomes.
As in most other countries that have developed ﬂexible school policies regarding pregnancy, policy effectiveness in SA is limited by the extent to which it is consistently implemented. In particular, the core constituency – young men and women, need to be empowered about their right to education to enable them to demand access when provision is denied.
Much advocacy work is also required 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.
An enabling policy needs to be supported by a programmatic focus that addresses the barriers to learning. Chief among these is ensuring the prompt return of girls post-pregnancy into the schooling system. The suggestion of ‘up to a two year waiting period’ before return to school in the Department of Education learner pregnancy guidelines, may be counterproductive to both maternal and child outcomes. In addition, catch-up programmes with respect to the academic curriculum will need to be provided and, in particular, remedial education to improve school performance 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 - in particular access to contraception to prevent second birth - child support grants and to develop appropriate parenting skills to mitigate the intergenerational transmission of early parenthood. While a mass-based system is effective for the prevention of pregnancy, teenage mothers beneﬁt more from intensive, individualised support.
Setting up a one-on-one relationship with an educator or community organisation will assist teen mothers in negotiating the range of new economic, educational and social imperatives that they face.
Other sectors Communities There is ample empirical evidence to show that when young people are excluded from mainstream systems such as education, they are at increased risk for high risk behaviour. This is clearly evident in SA with regards to the link between school dropout and risk for pregnancy and HIV. While interventions are instituted to prevent recurring marginalisation from the school system, concomitant efforts are required within the community to support young people at high risk for pregnancy. But community participation among young people is very low in SA and the reach of large-scale interventions in the community such as loveLife is not optimal. Expanding participation in community-based interventions represents a potential growth area in responding to adolescent sexual and reproductive health in SA although more rigorous evaluation studies are require to demonstrate their efﬁcacy.