«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
17 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners In addition, given that stigma about adolescent sexuality and imbalanced gender relations are often generated at community level and replicated within homes and the health setting, instituting interventions to shift community norms may be an effective method to open up channels of communication about sex, to improve young people’s access to health services and to foster equitable gender relations.
Given the inextricable link between adolescent motherhood and poverty and socio-economic disadvantage, efforts to empower young women through skills development and opportunities for developing sustainable livelihoods may assist in minimising trade offs between health and economic security. In fact a cluster randomised trial that tested a microﬁnance structural intervention on economic security, empowerment of women and intimate partner violence, was able to half the risk of physical and sexual violence after 2 years (Kim et al., 2007). Such interventions that create synergy between health and development goals, may offer promising approaches for pregnancy and HIV risk reduction.
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.
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 most parents lack both knowledge and skill to talk openly about sex and felt disempowered to parent their children in an environment that emphasizes a rights-based 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 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 form part of a comprehensive strategy towards teenage pregnancy.
19 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners Introduction The transition to parenthood is a major event in the lifespan of any individual, but takes on special signiﬁcance when it occurs early on, particularly in a changing global context for young people (National Research Council & Institute of Medicine, 2005). Being ready to take on the lifelong responsibility of rearing a child, and in many respects shaping the outcomes of the next generation, requires not only physiological and psychological maturity, but also family circumstances that can offer the support necessary to make a successful transition to parenthood. First time parents are more successful when they have completed their other transitions - to education, to work, to citizenship and to marriage (NRC & IOM, 2005). It is through these transitions that young people begin to build the skills, experience and social stock necessary to succeed as parents (NRC & IOM, 2005). And, although alternative pathways to parenthood occur and are tolerated to some extent, institutional support for parenthood is still geared towards a traditional sequencing of transitions (NRC & IOM, 2005).
But in a rapidly changing global context with new found opportunities and risks for young people, the benchmarks for successful transition to adulthood have changed. Youth today are the best educated ever in human history and the majority of young people aspire towards, and see the beneﬁts of, education. Advances in healthcare mean that many more children are able to enter youth healthier than ever before, and access to contraception means that family sizes are diminishing too. The spread of democratic governance offers many young people the opportunity to participate in civic and political life (NRC & IOM, 2005).
But the future has never been as precarious for young people. While the quantity of education is expanding, its quality is contracting; when more young people can access education for longer, fewer are able to ﬁnd work;
when healthcare has advanced exponentially in the last century, new communicable diseases are hobbling the opportunities of young people; when rights to participate in decision making is entrenched in law, too many are withdrawing their participation; and in the age of an information, communication and technology explosion, behaviour change has never been as difﬁcult to bring about. In such a context, where the linearity of transitions has been fractured, early childbearing and its consequences for individuals and for institutions take on new levels of signiﬁcance and meaning.
HIV and AIDS is now recognised as the primary reproductive health concern for adolescents, overtaking the long-standing emphasis on adolescent fertility. Yet childbearing among teenagers remains a common social and public health concern worldwide, affecting nearly every society (Dangal, 2006; Hogan, Sun & Cornwell, 2000; Shaw, Lawlor & Najman, 2006). Even though public health literature and family planning services treat pregnancy and HIV as distinct, they share the common antecedent of unprotected sex. In fact, there is evidence that pregnancy and lactation increases the susceptibility to HIV infection by induced immunological changes (Gray et al., 2005). As such teenage mothers, and in particular, pregnant women represent an important target group for HIV prevention.
The Millennium Development Goals (MDGs) deﬁned by Heads of State in 2000 placed maternal health ﬁrmly on the international agenda by identifying it as the ﬁfth of eight goals that the world must respond to decisively by 2015 (United Nations, 2000). Because of the physiological risks associated with early childbirth, and the risk to the overall wellbeing of the mother and their children, decreasing adolescent fertility is identiﬁed as one of the indicators to monitor progress in achieving this developmental target. Teenage fertility, establishes the pace and level of fertility over a woman’s entire reproductive life span (Ventura, Abma, Mosher & Henshaw, 2008; Woodward, Harwood & Fergusson, 2001). This has an impact not only on women’s health, but on the socio-economic status and general wellbeing of the population.
20 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners Adolescence and early adulthood are considered the healthiest stages of the lifespan. Yet young people contribute substantively to the quadruple burden of disease proﬁle in South Africa (SA). While deaths from HIV and injuries peak in the youthful years, the risk factors for death from non-communicable disease are also initiated during adolescence and early adulthood. In fact, unsafe sex/sexually transmitted infections (31.5%), interpersonal violence (8.4%), alcohol use (7%) and tobacco use (4%) - the vast majority of which are initiated during adolescence - are the leading risk factors for the burden of disease proﬁle in SA (MRC, 2008).
HIV is the most critical threat to the health and overall wellbeing of youth in SA. Because the epidemic is driven by infections among young people, they are a critical group to intervene with to halt the spread of AIDS and reduce new infections (UNAIDS, 2004). There is a strong association between pregnancy and HIV infection in SA. Antenatal data shows that 12.9% of 15-19 year old pregnant women are HIV positive (DOH, 2008b). From age 17 onwards, every second women who has been pregnant is infected with HIV (Harrison, 2008a).
Even though teenage fertility has been the subject of substantial debate in the social science research and policy circles, concern has not emanated from the increased risk that pregnancy confers to HIV. While current political and media depictions imply that SA is confronted with an escalating epidemic of teenage pregnancies, available data suggests that it is an area in which substantial progress has been made since democracy. Yet teenage pregnancy has grown in signiﬁcance as a social construct and come to represent one of several indicators of burgeoning adolescent delinquency, sexual permissiveness and moral decay.
The moral panic about teenage pregnancy re-emerges perennially through media reports of links between teenage pregnancy and the child support grant, rising school dropout rates because of pregnancy and the increased visibility of pregnant girls in schools (see for example ‘Pupil dies after giving birth’ The Star’, February 13 2009; ‘Teenage pregnancy no surprise?’, The Mercury, May 9 2008; ‘Pregnant pupils expelled’, The Mercury, May 8 2008; ‘Pregnancy Blues’, February 13 2008; ‘Child grants used for booze – NGOs’, Cape Argus, September 29 2008; ‘Maternity leave for SA’s pregnant pupils’, The Times, May 30 2007).
Such a negative and moralistic framing of the issue shifts the focus away from the successes that have been achieved in decreasing teenage pregnancy and coping with its consequences. It is victim—blaming, placing the responsibility for teenage pregnancy squarely on the shoulders of individuals and drowns out evidencebased rationale (such as the critical link between pregnancy and HIV) for why public expenditure should continue to focus on teenage pregnancy.
Despite the legislative and biomedical successes in positively inﬂuencing the trajectory of teenage pregnancy in SA, rates still remain unacceptably high. In part, this can be explained by the demographic transition that SA is undergoing resulting in a shift in fertility to younger ages. But for most parts, it can be explained by the range of deeply rooted social drivers, common to many public health issues that are yet to be adequately addressed in SA. Factors such as low levels of skills to negotiate sexuality, poor access to healthcare services, gender power imbalances, sexual coercion and violence, poverty, low socio-economic status and poor life opportunities to further education or to establish livelihoods lie at the heart of early pregnancy, HIV and other sexually transmitted infections among young people.
Education is central to the development of young people as it prepares them for the world of work and for life. In line with global trends, young people in SA are spending more years acquiring the requisite levels of education. Enrolment rates in primary and secondary school are high in SA. But rates of repetition, drop out, late entry and re-entry persist, implying that age for grade matching is poor. Aspirations for education are high 21 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners in SA and many older learners can still be found in secondary school. As such, as part of the natural course of development, sexual experimentation and maturity is increasingly coinciding with secondary schooling.
For most, it remains at the level of experimentation and if sex occurs, indications are that it is more likely to be protected when young people are still at school (NRC & IOM, 2005). However, for a minority, it results in unwanted pregnancy, HIV and other sexually transmitted infections. This has implications for continued educational opportunities.
In a rights-based society, young girls who experience early pregnancy should not be denied access to education and this has been entrenched in law through the Constitution and Schools Act of 1996, but has largely been the practice before the transition to democracy. However, without policy to govern practice, implementation has been uneven and some girls continue to be stigmatized, suspended, or expelled from school when they experience an early pregnancy. Schools, require guidelines on how to uniformly and optimally prevent and respond to early pregnancy such that the right of the adolescent to education is protected and equally balanced against their need to access healthcare and support, and to maintain the focus on learning within the school environment.