«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
In 2007, the Department of Education released Measures for the Prevention and Management of Learner Pregnancy. Not without controversy, the measures continue to advocate for the rights of pregnant girls to remain in school, but suggest an up to two year waiting period before girls can return to school in the interest of the rights of the child. Any proposed shift in policy and practice needs to be informed by a well-rounded understanding of the context of teenage pregnancy. It is in this light that UNICEF, on behalf of the Department of Education, commissioned the Human Sciences Research Council (HSRC) to consolidate the available research on teenage pregnancy in SA, with a focus on pregnancy in the school setting.
Methods Terms of reference Aims The purpose of the study is to document, review and critically analyse literature on teenage pregnancy with a focus on school-going adolescents.
The speciﬁc objectives are as follows:
• To review existing literature and conduct statistical analyses to establish the prevalence and determinants of teenage pregnancy;
• To assess the individual, familial and educative impact of teenage pregnancy;
• To identify and assess the impact of interventions for teenage pregnancy; and
• To propose a conceptual framework for research and interventions to prevent and mitigate the impact of teen pregnancy.
Approach to the study The study involved a desktop review of literature supported by secondary data analysis to provide an overview of research on the prevalence, determinants and interventions for teenage pregnancy.
Literature review 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 those that were terminated. Before the introduction of the termination of pregnancy legislation, fertility closely approximated pregnancy rates. Since the legalisation of abortion, however, this cannot be assumed to be the case. Trends in pregnancy rates in SA are not well known 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. Secondly, a comprehensive national register of abortion is not maintained in the country.
SA lacks vital statistics on fertility, pregnancy and abortion. Nevertheless, national trends in teenage fertility could be gauged from the 1996 and 2001 Census data as well as the 1996 South African Demographic and Health Survey (SADHS). Some caution has to be exercised in interpreting the Census data as a signiﬁcant amount of data had to be imputed because of missing information. The fertility data collected in the 2003 SADHS is unreliable due to problems with ﬁeldwork in KwaZulu-Natal. Hence national data on teenage fertility is not available in SA post 2001. However, trends in fertility can be estimated from demographic surveillance sites in rural KwaZulu-Natal and Bushbuckridge in Limpopo province. Both sites have collected fertility data over the past two decades providing an overall picture of the trends in teenage fertility pre- and post 2001.
The literature review comprised the following steps:
Keyword searches were conducted for each level of review (prevalence, determinants and interventions) for local and international articles in English on the following six public research databases (Ebscohost, ProQuest, ScienceDirect, SABINET, African Health link and African Journals online). For a detailed description of the databases covered see Appendix 1.
Studies dated between 2000 and 2008 were eligible for inclusion. However, seminal works prior to 2000 were also considered. The search focused on teenagers between the ages of 15-19 years. However, age deﬁnitions used in studies may differ from country to country and if these studies were included, the age ranges are speciﬁed. Reference lists of seminal articles were also scanned to identify papers and reports. The searches included published peer-reviewed journal articles, conference presentations, reports, book chapters, abstracts, as well as evaluations of interventions targeting youth and adolescents.
Through the HSRC’s own work on adolescent risk behaviour, particularly, teenage fertility, sexual behaviour, and behaviour change models, an extensive bibliography on the prevalence, determinants and interventions for adolescent risk behaviours had been developed and this was included as part of the review.
In view of the high rates of HIV infection among young people in SA, sexual behaviour of adolescents has received much national scholarly interest. Four national studies were used extensively in the review to
characterise youth sexual behaviour. These include:
• The 2003 Reproductive Health Research Unit survey on HIV and sexual behaviour of youth aged 15-24 years (Pettifor et al., 2004), referred to in the study as the 2003 RHRU survey;
• The 2006 SABC and Kaiser Family Foundation survey that focused on HIV awareness, sexual behaviour and broadcast media among youth aged 15-24 years (Kaiser Family Foundation & SABC, 2006), referred to in the review as the 2006 Kaiser/SABC study; and
• The 2002 and 2005 HSRC South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Surveys (SABSMM) (Shisana & Simbayi, 2002; Shisana et al., 2005), referred to as the 2002 and 2005 SABSMM survey, respectively.
Review of information collected by Departments of Education, Health, Social Development, Statistics South Africa, Medical Research Council, Reproductive Health Research Unit, loveLife and other key research organisations also assisted in establishing the focus, scope and coverage of information on teenage pregnancy.
In addition, key policy documents from the Department of Education, Health and Social Development, pertaining to adolescent health were reviewed to sketch the policy context.
Several studies have been commissioned by the Department of Social Development to assess the link between the child support grant and teenage pregnancy. The key ﬁndings from these studies are summarised to provide an assessment of this link.
The literature review also included a search and review of teen pregnancy, STI and HIV prevention programmes in South Africa, speciﬁcally those supported by government with the aim of identifying best practice models.
Secondary data analysis
The following datasets were analysed to establish statistical and demographic trends in teenage fertility:
• Department of Education, Education Management Information System (EMIS) data;
• HSRC, Status of Youth Survey 2003;
EMIS is a Department of Education information management system that contains selected administrative attributes of all school in SA. For the purposes of this analysis, the EMIS data set was integrated with pregnancy rates recorded in South African schools for the period 2004-2008. To provide more textured analyses of the types of schools in which pregnancies are concentrating, the following variables were captured from the
Department of Education website:
• School fees: fee school and no fee school;
• The level of school specialisation: ordinary, comprehensive and specialized;
• Institutional phase of the school: primary, intermediate, secondary and combined; and
• Land ownership of the school: public and independent ownership The EMIS data available for the study did not include variables often posited in national and international literature as having a bearing on learner pregnancy rates. These include among others, school pass rates, learner dropout rates and socio-economic levels of the school community. Nevertheless, the variables selected above do give some information on the context of the school which is relevant for the differentiation of school pregnancy rates.
The HSRC 2003 Status of Youth Survey (Richter et al., 2005) was a nationally representative study of more than 3 500 young people aged between 18 and 35 years. The survey was commissioned by the Umsobomvu Youth Fund to provide a broad national picture of young people in the key domains of education, labour market participation, inequality, health and disability, crime and violence, and social integration. The data set has a number of questions that are related to the reproductive history of young people. These questions include the age at sex debut and of ﬁrst pregnancy and the history of contraceptive use. In addition to these questions, the study included a number of questions about young people’s childhood experiences. These include whether the young persons’ biological parents were part of their childhood household; economic status of the household;
and the residential type of the area. Of importance to this study, is the question that asked the age at which young people left school. This question enabled us to assess whether premature exit from the schooling system increased or decreased the chances of young people experiencing early pregnancy. More details on the study methodology can be found in Appendix 2.
The purpose of the secondary data analysis conducted for this review was to identify factors that are associated with early pregnancy. Cox regression was used for the analysis. Cox regression techniques were applied to examine the net effect of selected eco-developmental factors on early pregnancy. The selection of the independent variables was determined largely by the availability of relevant variables in the datasets collected for the study.
25 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners Cox regression is a life table method that assesses the relationship between independent variables (e.g., family structure, type of childhood residence, childhood poverty and school dropout) and a dependent variable (early pregnancy) that is continuous and is censored by the interview process. In this study, the technique was used to determine the number of years a woman takes from birth to the time of experiencing ﬁrst pregnancy, when not all women interviewed have actually fallen pregnant (censored by the interview process). In addition, an assessment was made of childhood experiences mentioned above that lead to women having earlier or later pregnancy.
Deﬁnitions Adolescent fertility rate (also known as teenage fertility rate or teenage birth rate) is deﬁned as the number of live births per 1000 women aged 15-19 years.
Teenage pregnancy rates include number of stillborns, abortions and miscarriages. Data on abortion rates are often unavailable and unreliable, especially in developing countries, due to variations in the legal status of abortion. Hence adolescent fertility rates may be a more reliable measure.
Age speciﬁc fertility rate is deﬁned as the incidence of live births per female population of a given age group per year.
Total fertility rate is deﬁned as the mean number of children a woman would have by the end of her childbearing years if she were to pass through these years bearing children at the age-speciﬁc rates.
Both local and international studies use variable deﬁnitions of adolescent fertility, and these are often not clearly deﬁned. In some cases, only live births are reported, in others, pregnancy rates (that include stillborns, abortions and miscarriages) are reported, and yet in others conception rates (excluding stillborns, abortions and miscarriages) are reported. This makes the interpretation of ﬁndings and comparability of rates across studies difﬁcult. Because abortion is illegal in many countries and statistics are not always reliable in countries where it is legalised, the study primarily reports on adolescent fertility rates. However, where data is only available on teenage pregnancy rates, these are speciﬁed.
Trends in Teenage Fertility Literature review International Fertility rates for all women continue to fall worldwide. Adolescent fertility rates were fairly high at a global level prior to the early 1990s. However, fertility rates have progressively declined over time or remained constant (Santelli, Carter, Orr & Dittus, 2009; Santelli, Durberstein-Lindberg, Finer & Singh, 2007). Adolescent fertility rates fell in almost all developing countries between 1990 and 2000. However rates either stagnated or increased marginally between 2000 and 2005 (see Figure 1) (United Nations, 2008). Sub-Saharan Africa has the highest teenage fertility rates in the world and rates have declined only marginally between 1990 and 2005 (United Nations, 2008). Although overall fertility has declined substantively in Latin America and the Carribean as well as South-Eastern Asia over the past two decades, little progress has been made in declining adolescent fertility in these two regions (United Nations, 2008). Global declines in overall fertility have been attributed to the increased availability of family planning, but there is as yet a substantial unmet gap for contraception among young women (United Nations, 2008).
Developed countries experienced a long period of industrialization which was accompanied by declining overall fertility levels and a rise in the age at ﬁrst marriage since the 1970s (Singh & Darroch, 2000). The United States (US), however, has had one of the highest teenage fertility rates and the decline has been slow (Singh & Darroch, 2000). This has been related to higher levels of inequality in the population (The Alan Guttmacher Institute, 2001). Similarly, the UK reports the highest levels of teenage fertility in Western Europe. However, dramatic declines in teenage fertility have been reported in the US in the past decade and to a lesser extent in the UK through a number of focused policy strategies. While teenage fertility rates decreased in the US by 35% between 1991 and 2005 (Ventura et al., 2008), rates in the UK declined by 10.6% between 1994-98 and 1999-2003 (Wilkinson et al., 2006).