«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
Although studies have reported on the positive impact that the legislation has had on abortion-related morbidity and mortality in SA (Jewkes & Rees, 2005; Jewkes et al., 2005), much more needs to be done to make services accessible and acceptable to young people. In the most basic form, young people and important decision makers in their lives – older women and young men, in particular, lack basic information about the Act and its speciﬁcations. Although value clariﬁcation among health workers did precede the introduction of the Act, ensuring that TOP is available as part of the Adolescent Friendly Clinics Initiative (NAFCI) will assist young people in viewing legal termination as a viable option.
46 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners Consequences of Early Childbearing While a number of studies in the US have commented on the consequences of early childbearing on the life course of adolescents, few studies have been conducted in sub-Saharan Africa. Yet the outcome of teenage pregnancy can be vastly different depending on the context (Falk, Ostlund, Magnuson, Schollin, & Nilsson,
2006) because of the inextricable link between poverty and childbearing. Poverty is now recognised as both a cause and consequence of early childbearing (Kirby, 2007). Earlier research may have overestimated the consequences of early childbearing because of the assumption that poverty and socio-economic disruption were a consequence of teenage pregnancy (Kirby, 2007). But the wealth of research demonstrating association and causality between socio-economic disadvantage and pregnancy makes it difﬁcult to attribute negative life events to early pregnancy alone as opposed to pre-existing disadvantage. This is particularly the case in sub-Saharan African countries that experience inordinate levels of poverty (Hoffman, 2006; NRC, & IOM, 2005). However, the general consensus is that since teenage pregnancy is mostly unplanned (Cassel, 2002;
Pettifor et al., 2004), and often coincides with other transitions such as schooling it can result in negative consequences for the teenage mother and more especially for the child (Ashcraft and Lang, 2002; Kirby, 2007;
Finer & Henshaw, 2006).
Table 11 summarise the health and socio-economic consequences of teenage pregnancy.
Table 11: Consequences of early childbearing
Source: Breheny & Stephens, 2007; Hoffman, 2006; Kirby, 2007 Health consequences There is conﬂicting evidence on the health risks associated with teenage pregnancy. While some studies suggest that pregnancy before 20 carries more health risks than pregnancies at older ages, others suggest that the greatest risk are for those at younger ages, if any at all (NRC & IOM, 2005). Risks associated with physiological immaturity include cephalo-pelvic disproportion, toxemia, hypertension and vagio-rectal or urethral ﬁstulae and placental abruption (Blum, 2007; Blum & Nelson-Mmari, 2004). Estimates provided by UNFPA (2007) indicates that the risk of death after pregnancy for women aged 15-19 is twice that of those 47 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners aged 20-24. Annually up to 70 000 15-19 year old girls worldwide die due to pregnancy and childbirth-related complications (UNFPA, 2007). The health consequences of early pregnancy are 600 times higher in subSaharan Africa than in developed countries (Blum, 2007). Studies conducted in SA in the eighties and nineties reported similar health consequences for early childbearing (Gallais, 1996; Goldberg & Craig, 1983).
Much of the health risks associated with early motherhood can be prevented through timely and good quality antenatal care. The health outcomes of pregnancy are worse for women aged 15-19 because of three main
reasons (UNFPA, 2007):
1) Young women may not know when and where to seek help and may not have the ﬁnancial resources or the necessary family support;
2) Adolescent girls may only initiate antenatal care at a later stage than those who planned their pregnancies;
3) The quality of health services available to pregnant teenagers may not be optimal.
Even though teen pregnancy is common among Coloured and Black adolescents in SA, it is still highly stigmatized. Young women refer to the trauma that they experience when they realise that they are pregnant and the difﬁculty they face in deciding who to tell and what to do, as well as the negative response they receive from family and friends (Kaufman et al., 2001; Varga, 2003). Antenatal care has been available to pregnant women without charge since 1994. Yet the embarrassment and discrimination that young women face within the health care system is a deterrent to seeking care early in their pregnancy (Kaufman et al., 2001; Varga, 2002).
The research ﬁndings on adverse health outcomes of children born to teenage mothers are more deﬁnitive (NRC & IOM, 2005). International studies indicate that children of teen mothers are more likely to experience health problems compared to children of older mothers (Shaw et al., 2006). Low birth weight is associated with negative outcomes later in life such as cognitive and physical disabilities and lower educational attainment (De Villiers, 2004). Studies in the US (Botting, Rosato & Wood, 1998; National Campaign To Prevent Teen Pregnancy, 2002) and UK (Pevalin, 2003) report lower birth weight among infants born to teen mothers.
South African studies also support this claim (Cameron, Richter, McIntyre, Dlamini & Garstang, 1996). Low birth weight is a signiﬁcant risk factor for infant mortality. In fact, low birth weight is the number two killer among South African children under ﬁve, second only to HIV and AIDS (Bradshaw, Bourne & Nannan, 2003).
Breast feeding is crucial for the early development of a baby. Studies conducted in the US have indicated that women with mistimed and unwanted pregnancies are less likely to breastfeed (Chandra et al., 2005; Dye et al., 1997). In addition, children of teen mothers are more likely to be malnourished and suffer from developmental problems (UNFPA, 2007).
Child mortality is a critical indicator of the health and state of development of a population. Although SA is economically developed compared to other African states, its child mortality is increasing. In 1990 the under-5 mortality was 60 per 1000 live births; by 2000 this had increased to 95 per 1000 live births (Bradshaw, Bourne & Nannan, 2003). No doubt HIV and AIDS is a critical determinant of increasing infant and child mortality but nevertheless early childbearing is an important contributor to both infant and child mortality (UNFPA, 2007).
Educational and economic consequences South Africa has one of the highest literacy levels exceeding many other countries in sub-Saharan Africa. In a knowledge-based economy, education is essential to secure future employment. Teenage pregnancy can have a profound impact on young mothers and their children by placing limits on their educational achievement and economic stability and predisposing them to single parenthood and marital instability in the future (Ashcraft and Lang, 2006; National Campaign to Prevent Teen Pregnancy, 2002; Olausson, Haglund, Weitloft & Cnattingius, 2001). ‘The price of adolescent pregnancy is lost potential’ (UNFPA, 2007) because teenagers become mothers without the necessary knowledge, skills, resources, and networks to cope with the demands of parenthood.
The impact of teenage pregnancies on educational achievement and economic progress later in life remains negative and signiﬁcant even after controlling for other social factors such as coming from a disadvantaged background (Klepinger, Lundberg & Plotnick, 1995). Teenage mothers tend to have fewer years of education compared to those who have their ﬁrst child after 20 years of age (Berglas, Brindis & Cohen, 2003; Fergusson and Woodard, 2000; Klepinger et al., 1995). Fergusson and Woodward (2000) postulate that the impact of teenage pregnancy on young women’s educational achievement is driven by the timing of the pregnancy and the manner in which the young woman and her family respond to the pregnancy. Despite the progressive legislation in SA allowing young women to return to school post-pregnancy only around a third actually re-enter the schooling system (Grant & Hallman, 2006). Data is not available in SA on the number of teen mothers who go on to complete school or on their academic achievement.
Early childbearing requires strong familial support for girls to return to school. Studies in the US have shown that child-rearing, lack of parental support and lack of support from peers, all contribute to high dropout rates (Cassell, 2002). In fact Grant and Hallman (2006) have shown that the availability of an adult caregiver in the home was a strong determinant of whether girls in SA would return to school post-pregnancy. When girls were solely responsible for childcare they were less likely to return to school. Qualitative research indicates that some families enable girls to return to school to protect their educational opportunities, but for others, new familial responsibilities limit such possibilities (Kaufman et al., 2001).
Ultimately due to larger families and low education, the labour force earnings of mothers who are teens or who had an early teenage pregnancy are not satisfactory (Berglas et al. 2003; Hoffman, 2006). Thus young mothers are barred by a lack of education and inexperience from earning a sound living (Bissell, 2000). The disruption that pregnancy inﬂicts on the educational and occupational outcomes of young mothers both maintains and exacerbates poverty. Research conducted in US indicates that more that a quarter of teen mothers live in poverty well into their twenties compared to seven percent of their peers who delayed childbearing (Darroch and Singh, 1999). Early childbearing may not necessarily lead to poverty, but it certainly can worsen the economic situation of young women (Cassell, 2002; Shaw et al., 2006).
As a result of the lower earning capacity of teen mothers, they are more likely than their peers to receive child welfare for a longer period (National Campaign to Prevent Teen Pregnancy, 2002). Ironically, despite the availability of the child support grant in SA and assertions that young women are falling pregnant to receive the grant, in 2005, only 2.69% of grant recipients were mothers between the age of 15 and 19 years (Makiwane, Desmond, Richter & Udjo, 2006).
Social consequences The age old practice of sending pregnant girls away to live with relatives has been replaced by pregnant girls remaining in their homes, choosing to raise their children and continuing to attend school (Wiemann, Rickert, Berenson & Volk, 2005). Adolescents who become pregnant are therefore highly visible in the community, in school and to families (Wiemann et al., 2005), often erroneously leading to the conclusion that teen pregnancy is increasing. But increased visibility also means increased stigma. Because of the relation of teen pregnancy, contraceptive use, HIV and STIs to sexuality, it will forever remain bounded with morality and stigma. Stigma during or after pregnancy can lead to depression, social exclusion, low self esteem and poor academic performance affecting the prospects of employment in the future (Abe & Zane, 1990).
Despite the normalisation of teen pregnancy in Black and Coloured communities in SA, in part related to high prevalence and to some extent cultural acceptance previously, early childbearing is highly stigmatized. Girls report the trauma, fear, shame, and embarrassment of having to reveal an early pregnancy to family, partners and peers. In studying third generation pregnancies in the Birth to Twenty longitudinal cohort in Soweto, Richter, Norris and Ginsburg (2006) commented on the ‘silence of fear and shame’ that lock families into inaction in both preventing pregnancy and accessing healthcare services once girls become pregnant. Even though girls are legally allowed to attend school during and after pregnancy in SA, they are often confronted by the stigma of teachers and peers in the school environment (Varga, 2003).
Teenage pregnancy also affects the marriage prospects of young women. Studies carried out in the US have reported that teen mothers are more likely to be single parents and if married to experience high divorce rates (Ashcraft and Lang, 2006; National Campaign to Prevent Teen Pregnancy, 2002; UNFPA, 2007). Premarital fertility is high in SA and in the Black and Coloured communities, it does not necessarily lead to marriage.
However, acknowledgement of paternity is critical to reduce stigma of early pregnancy and for the child to receive social and ﬁnancial support from the father. Ironically, women report that young fathers often deny paternity to protect their own educational and ﬁnancial aspirations. (Varga, 2003). This is in contrast to more recent studies among young men, who report high levels of responsibility for children and that few deny paternity (Swartz & Bhana, 2009).
Women who begin childbearing in their teen years are at increased risk of having more children over a short space of time. In the US, twenty ﬁve percent of teen mothers have another child within two years of the ﬁrst child (National Campaign to Prevent Teen Pregnancy, 2002). SA deviates from this norm. Although age at ﬁrst birth is low in SA, women signiﬁcantly delay second birth. Using data from the Agincourt surveillance system Garenne, Tollman and Kahn (2000) showed a bimodal pattern of fertility among young women, with a ﬁrst peak in the teenage years and a second in the mid-to late 20s. Studies have also reported much higher contraceptive use among those teenagers who have had an early pregnancy. MacPhail and colleagues (2007) reported that pregnancy was a signiﬁcant determinant of contraceptive use among women aged 15-24 years in SA. Qualitative research indicates that educational aspirations are a signiﬁcant reason why young women delay second birth (Kaufman et al., 2001) in SA.