Consequences Of Childbearing For Teenagers Social Work Essay
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Public concern over adolescent sexual health and the resolutions to these concerns has over the past three decades generated political debate and academic inquiry the world over. At the core of adolescent sexual health is the issue of teenage pregnancy. South Africa has not been spared from the challenges teenage pregnancy presents. Inquiry into teenage pregnancy in South Africa began in the 1980s. In an effort to control the prevalence of teenage pregnancy, academics and policy makers alike have developed various strategies and policies targeting teenagers. Yet three decades later, teenage pregnancy still remains a topical issue in South Africa.
About 16 million adolescent girls between 15 and 19 years give birth each year worldwide, and 80% of these girls are found in developing countries (World Health Organisation, 2010). In South Africa, 40% of all births involve girls under the age of 19 years, and 35% of these teenagers, give birth before reaching the age of 19 years (Medical Research Council, 2009).According to the Department of Basic Education (2009), in South Africa, a total of 45,000 teenagers were pregnant in 2008, while the number increased to 49,000 in 2009.
This chapter examines literature on teenage pregnancy, and will assist in providing rationale and context for this study. This literature review will deviate from the traditional Knowledge, Attitude and Perception (KAP) literature studies that isolate individuals from social, cultural and economic contexts that influences and shape their lives. The weakness of KAP studies is that they do not acknowledge the effect of cultural, economic and societal factors on human behavior. Jewkes et al. (2001) add that KAP studies on teenage pregnancy in South Africa have mainly been descriptive and do not make an effort to account for the gap between knowledge, attitude and perception. In effort to account for these discrepancies, and come up with gaps in teenage pregnancy research, this literature review has been divided into the following two sections (i) the consequences of child bearing on teenagers, and (ii) factors contributing to teenage pregnancy.
CONSEQUENCES OF CHILDBEARING FOR TEENAGERS
The challenge of unplanned and unwanted pregnancy for a teenager has long-term consequences, not only for the mother, but for society as a whole, with far-reaching implications for economic and social development. Mpanza (2010:66) puts forward that "teenagers who drop out of school due to pregnancy never do well after they return from childbirth", this can be attributed to divided loyalties between taking care of the child and continuation of school. Because of its usually unwanted and unplanned nature, teenage pregnancy always poses a health and social risk, a point further supported by Edgardh (2000), Genius and Genius (2004), Santelli (2000), and Petiffor et al. (2004). These studies confirm that early sexual initiation is a predictor of risky sexual behaviour and is more likely to be non-consensual, unprotected and to be subsequently regretted, resulting in unplanned and unwanted pregnancy.
While the consequences of teenage pregnancy are varied, it is important to acknowledge that teenage pregnancy is a result of a complex set of varied, but interrelated factors. An understanding of these factors will enable a better understanding of the knowledge, attitudes and perceptions of teenagers towards teenage pregnancy.
Disruption of school
Teenage pregnancy has the potential of limiting a learner's future career prospects. For the pregnant learner, impending motherhood forces her to drop out of school as she is unable to continue studying (Macleod &Tracey, 2009). Learners are forced to leave school when their pregnancy has progressed as schools are "considerate of their state" (Bhana & Swartz, 2009). The Department of Education's (DoE) 2007 Measures for the Prevention and Management of Learner Pregnancy "makes it possible for educators to 'request' learners take a leave of absence for up to two years" (Macleod & Tracey, 2009:15). Even with legislation in place, pregnant teenagers are sent away from school earlier than they should (ibid). This is probably due to the perception that pregnant learners are a bad influence to other learners.
Vagueness and ambiguity of the education guideline presents a challenge to the educators who are left to interpret it at their discretion. For instance, the document puts the responsibility of parenting firmly on the learner, and states that a "period of two years may be necessary for this purpose. No learner shall be should be re-admitted in the same year that they left school due to pregnancy" (DoE, 2007:5), educators are left to decide how long the learner stays away from school. This ruling may be in conflict with the desires of the young mother who may have sufficient support at home, which enables her to return to school earlier than expected (Bhana & Swartz, 2009).
Young fathers are also affected by pregnancy, albeit differently. It has been reported that impending fatherhood, cultural and societal expectations may force the young father to leave school and seek employment. This is conditional as it depends on whether the boy accepts responsibility or not (Shefer & Morrell, 2012; Bhana & Swartz, 2009).
However, Macleod and Tracey (2009) argue that the level of disruption caused by pregnancy on learners is debatable as learners drop out of school for various reasons of which teenage pregnancy is one. Preston-Whyte and Zondi (1992) concur with this assertion. Manzini's (2001) study of teenage pregnancy in KwaZulu-Natal (KZN) indicates that more than 20.6% of pregnant teenagers had already dropped out of school before falling pregnant. Apart from falling pregnant, teenagers may leave school due to frustrations associated with the inexperience of teachers, who often are required to teach in areas that are not their expertise, and a lack of relevance of the curriculum and teaching materials (Human Science Research Council, 2007). Among factors within the home that led to drop-out, learners in this study cited the absence of parents at home, financial difficulties and the need to care for siblings or sick family member.
Strassburg et al. (2010) and Fleisch et al. (2010) concur with the 2007 HRSC findings and assert that the reasons teenagers drop out of school are a combination of inter-related factors. As such, Fleisch et al. (2010) note that poverty alone cannot best explain why teenagers drop out of school, because there are other factors such as academic ability of the teenager, teacher-pupil relationship, support from home and school, alcohol and drug abuse and family structure that contribute to school dropout.
Lloyd and Mensch (1995:85) summarise the various reasons why teenagers may drop out of school by stating that,
Rather than pregnancy causing girls to drop out, the lack of social and economic opportunities for girls and women and the domestic demands placed on them, coupled with the gender inequities of the education system, may result in unsatisfactory school experiences, poor academic performance, and acquiescence in or endorsement of early motherhood.
However, pregnancy ranks among the top contributors to school dropout for girls in South Africa (HRSC, 2009).
While pregnancy may not be the reason for leaving school, child care is a reason for not returning to school. Manzini (2001) indicates that young mothers, who have to take care of their babies, and find it difficult to juggle student life and being a mother, ultimately drop out. Various reasons for not returning to school have been explored, among them being a lack of a support structure, financial challenges and access to a Child Support Grant (CSG). Research in South Africa indicates that teenagers who do not have support from their families and struggle financially once the baby is born, usually dropout of school so as to provide for the baby and themselves (Bhana & Swartz, 2009). On the other hand, studies in Brazil and Guatemala indicate that girls are forced to look for jobs to supplement family income and take care of the new family member (Hallman et al., 2005).
Young mothers who have support structures in the form of parents and grandparents have an opportunity of returning to school (Grant & Hallman, 2006). Matthews et al. (2008) concur and maintain that the presence of an older female in the family enables learners to return to school, while the absence of the same forces them to look for alternative ways of making a living. This is the same with teenage fathers who have accepted responsibility and have family that is prepared to support the child (Bhana & Swartz, 2009). The return to school in South Africa is motivated by a desire for a better life. Anecdotal evidence suggests that parents of African teenage mothers usually send the teenager back to school, since she has a higher chance of fetching high bride price in the event that she gets married. In the African belief system, an educated woman is bound to fetch a higher price than that of an uneducated one (Macleod, 2009; Mkwananzi, 2011; Bhana, Swartz & Morrell, 2012). Kaufman, de Wet and Stadler (2000) concur, adding that the fact that the teenager has proven her fertility actually increases her chances of marriage in future. Interestingly, teenagers in Hlabangana's 2012 study in Soweto (South Africa) indicated that falling pregnant before marriage decreases the bride price, as prospective grooms consider the teenage mothers as 'used goods'. Reasons for returning to school after pregnancy may vary for both sexes, but the important part is that the teenager is back in school.
Clearly the effects of teenage pregnancy on the teenager vary for the young parents, the difference may lie in the financial circumstances of the teenagers' family and on the part of the young father whether or not he accepts responsibility of the pregnancy. The consequences of dropping out of school for teenage girls due to pregnancy cannot be overestimated, especially in a continent where the adage 'when you educate a woman , you educate a nation holds true (Hubbard, 2009: 223). The main thrust of the study is to understand why teenagers continue falling pregnant in the face of efforts by the South African government in trying to manage teenage pregnancy. In an effort to control and manage teenage pregnancy, the government has provided youth-friendly clinics, life skills programmes in schools and is currently on a much opposed drive to supply condoms in schools. Opposition for distributing condoms in schools comes from parents who fear that by distributing condoms in schools, teenagers are given indirect permission to indulge in sexual activities.
In light of the efforts made by the South African government and a decade of spending on teenage pregnancy management, figures still indicate that teenage pregnancy rates are on the increase nationwide. Disruption of school, as a consequence of teenage pregnancy merits scrutiny in this study, as it will enable an understanding of their perceived effect of teenage pregnancy on young girls who are pregnant.
Research on health risks associated with early childbirth in teenagers is mainly divided into two main camps. One camp argues that teenagers are at risk of health problems due to their socio-economic status. The other camp, which is scientific, argues that age at first childbirth puts young women at risk of health problems as she is not mature enough to push the baby, and this proves fatal to both mother and child. Some young mothers who have assisted births end up having obstetric complications such as hemorrhaging and damage to the womb. Macleod (2009) identifies paucity of research in South Africa in terms of health risks associated with early childbirth.
Age at first child birth contributes to a range of complications, including pregnancy-induced hypertension, anemia, obstructed and prolonged labour, low birth weight, preterm labour and delivery, perinatal and infant mortality, and maternal mortality (WHO, 2007). These complications are usually associated with the physical immaturity of teenagers, an assertion that Cameron (1996) supports and adds that limited access to health care services is another contributing factor to the range of complications. He suggests that "complications become more pronounced when the teenager decides to terminate pregnancy" (Cameroon, 1996:83).
In South Africa, the Choice on Termination of Pregnancy Act (No. 92 of 1996) allows minors under the age of 18 years to terminate a pregnancy without the consent of either parents or guardians. Manzini (2001) suggests that due to health personnel attitudes, teenagers are forced to have unsafe abortions, which may lead to death. Lack of support structure before and after termination maybe the reason for teenagers resorting to 'self-administered terminations' and this usually leads to irreversible damage to the womb or even death (Petiffor et al., 2005).
Sexually active young fathers face different health challenges from those of the young mother and child. Bhana and Swartz (2009) indicate that young fathers in Cape Town (South Africa), often have multiple and concurrent partners (MCP), and this puts them at great risk of contracting and spreading HIV. However, they are quick to mention that impending fatherhood for those that have accepted responsibility is cause for behaviour change. MCPs are one of the main drivers of the spread of HIV (Halperin & Epstein, 2007). Young men put themselves at risk by practicing unprotected sex with multiple partners who themselves may be part of a potentially sexual network.
Geronimus and Sanders (1992) observe that young African American women who live in conditions of poverty are more prone to problems as they are unable to access pre- and post-natal care. They note that this is different for white teenage mothers who are the bulk of teenage mothers in America. Geronimus and Sanders (1992) suggest that this may be due to the differences in economic status of the teenagers. Macleod (1999) points out that despite their socio-economic status, teenage mothers hardly ever access pre- and post-natal services. This may be due to the 'stigma' associated with teenage pregnancy, and may also be due to the attitudes of service providers. While studies may site negative attitudes of staff towards teenagers (Wood & Jewkes, 2003), Ehlers (2003) paints a more positive picture, arguing that youth-friendly services initiated by South Africa's Department of Health (DoH) have made great strides in addressing the stigma attached to adolescent sexuality.
The Child Support Grant (CSG)
Social grants or assistance can best be described as non-contributory cash transfer programmes set up by the government for the under privileged, aged or vulnerable (Grosh et al., 2008). Social grants are very important as they assist in alleviating poverty, reducing the level of vulnerability of vulnerable groups in society and providing social insurance to the vulnerable groups in society (Neves et al., 2009).
The CSG was first introduced in South Africa in April 1998 as a poverty alleviation strategy for the poorest children (Parliamentary Liaison Office, 2007). Initially restricted to children under the age of seven years, it was later extended to include 14 year olds in 2003. According to Hall (2011), the CSG pay-out in 2011 was R275 per month per child.
A lot of debate surrounds the CSG and teenage pregnancy in South Africa with the media fuelling the opinion that teenagers fall pregnant to access the CSG. Popular opinion states that the CSG has led to a perverse incentive for teenagers to conceive and go on to spend the money on personal goods (Macleod, 2006). In response to the media outcry, the Department of Social Development (DSD) commissioned research into the matter in 2006. The research concluded that there was no direct relationship between CSG and teenage pregnancy (Kesho Consulting, 2006). Other research by Makiwane and Udjo (2006) concluded that there is no evidence that the CSG leads to an increase in welfare dependency in South Africa. Furthermore, during the period in which the CSG has been offered, rates of termination of pregnancy have increased (Macleod, 2009). In 1998, when the CSG was introduced, abortion rates were at 4.1%, a decade later abortion rates were at their all-time high of 8.1 %, and in 2011 they were at 6.3%. Macleod (2009) suggests that the high rate of abortion amongst teenagers, in the face of the CSG, is evidence that there is no relationship between the CSG and teenage pregnancy.
Matsidiso Nehemia Naong (2011) concurs with research that indicates that there is no link between the CSG and teenage pregnancy. In her study of three of South Africa's provinces (Free State, Mpumalanga and Eastern Cape), Naong's sample of 302 school principals and 225 Grade 12 learners indicated that there was no relationship between the CSG and teenage pregnancy. Instead, the study concluded that poverty, peer pressure and substance abuse contributed to teenage pregnancy. Naong concludes that teenage pregnancy and CSG are divorced and any influence between the two is negligible.
Interestingly enough, anecdotal evidence suggests that more and more teenage girls are falling pregnant in an effort to access the CSG so as to complement household earning or in some instances the CSG is the main source of income. In such cases teenage pregnancy ceases to be unplanned and becomes planned and unwanted. In a 2005 study of CSG use in KZN, Case, Hosegood and Lund (2005) showed that 12.1% of pregnant teenagers who had conceived cited the CSG as the reason. Tyali (2012) in his study of HIV and AIDS communication in Platfontein (South Africa) found that teenagers were deliberately falling pregnant so as to access the CSG, while others wanted to access the HIV and AIDS grant.
Marsh and Kau's (2010) study of teenagers' perceptions and understanding of teenage pregnancy, sexuality and abortion concurs with Tyali's (2012) conclusion that teenagers deliberately fall pregnant to access the CSG. Using a population sample of 35 teenagers (24 girls and 11 boys), Marsh and Kau (2010) discovered that the CSG was perceived as means of increasing household income, by having a baby, the teenager then contributes towards the household income through access of the CSG. Interestingly, Marsh and Kau's research population indicated that the influence or pressure to bear children in order to access the CSG came from family. On the other hand other teenagers viewed the CSG as a way of increasing the pocket money for clothes and cell phones.
On the other hand, the CSG has been credited with enabling teenager mothers to return to school. "The CSG is associated with an increase in school attendance and improved child health and nutrition. Thus, the grant can be associated with an improvement in the lives of children whose caregivers receive the CSG on their behalf" (Macleod, 2009:24).
It will be interesting to find out how teenagers perceive the relationship between the CSG and teenage pregnancy. Their attitudes regarding the grant will also be important in the formulation of a communication intervention, and eventually contribute towards efforts to manage teenage pregnancy rates.
CONTRIBUTING FACTORS TO TEENAGE PREGNANCY
The present study does not look at pregnant teenager's knowledge, attitudes and perceptions towards teenage pregnancy; instead it focuses on non-pregnant teenagers' knowledge attitudes and perceptions towards teenage pregnancy. Having said that, contributing factors to teenage pregnancy merit exploration as these factors will shed light on knowledge, attitudes and perceptions towards teenage pregnancy. Understanding how teenagers make meaning of teenage pregnancy through their knowledge, attitudes and skills is important in particular if this understanding is viewed through the contributory factors to teenage pregnancy.
Contributing factors to teenage pregnancy are important for this study as they will put the study in context and enable the researcher not to take the revisionist and reductionist approach towards teenage pregnancy. The reductionist and revisionist approaches to teenage pregnancy ignore other non-sexual factors that contribute to teenage pregnancy. The following contributing factors were apparent in this review of the literature and will be dealt with in the following sections:
Family is an important unit for socialisation as it enables the sharing of beliefs and ideals that lead to societal norms. Research indicates that family relations are an important aspect in teenage pregnancy rates. Eaton (2003) and Bhana (2004) found that teenagers with single parents were prone to risky sexual behaviour, and pregnancy compared to those with both parents. This may be attributed to issues to do with shared control and responsibility of both parents, whereas in single family parents control is vested in one parent. Family form becomes a protective condition to young people. Muchuruza (2000) concurs and puts forward that in Tanzania teenagers coming from single parent families have risky sexual behaviour and are more likely to become young parents. Where the single parent struggles to provide for the girl child, the girl is at greater risk of pregnancy as she has to look for means of survival and usually this is achieved through intergenerational relationships. The major reason why teenagers engage in intergenerational relationships with older men and women is that they see them as providers of social status symbols such as flashy cell phones and jewellery, while at the same time taking care of their basic needs. Such relationships jeopardize the health of the two people involved as the teenager is unable to negotiate for safe sex because of fear of losing their economic goals (Leclerc-Madlala, 2008). Most documented research on intergenerational relationships is between girls and 'sugar daddies'. These 'sugar daddies' feel that such relationships are transactional hence there is no need for them to use protection (ibid). Such relationships leave the teenager vulnerable to HIV and AIDS, pregnancy, Sexually Transmitted Infections (STIs) and to sexual manipulation.
Bhana's (2004) Cape Town (South Africa) study found that 66% of the teenagers reported that family norms enabled them to have people to advise them on how to live a constructive life, while 55% said that availability of family members acted as source of control for their sexual behaviour. This is evidence that family relations play an important part in the behaviour of teenagers and most importantly their sexual behaviour.
The presence of a responsible biological father encourages girls to delay their sexual debut and instils in boys a sense of sexual responsibility. Blum and Mmari (2005) point out that the presence of a male figure in a household and their attitude to sexual behaviour plays an important part in influencing teenagers' sexual behaviour. They found that girls with father figures who were against premarital sex were less likely to engage in premarital sex and experience unplanned pregnancy, compared to those with father figures who had sexually permissive attitudes and those without fathers. In the same context, Loving's (1993) investigation into the connection between family relationships and teenage pregnancy in Durban (South Africa), established that warm relationships between fathers and their daughters played an important role in delaying young girls' sexual initiation.
Mfono (2008) holds the view that teenage girls whose mothers were teenage mothers themselves have a greater chance of being teenage mothers. Arai (2008) observed that in Britain and America, the daughter of a teenage mother is one and a half more likely to become a teenage mother herself than the daughter of an older mother. This, according to Hlabangana (2012) is due to the fact that these teenagers come from communities where it is 'normal' to be a teenage mother, since almost everyone has been or is a teenage mother. The HRSC's 2008 study of perceptions towards teenage pregnancy in Johannesburg, Cape Town and Durban (South Africa) coincides with Hlabangana's assertion that teenage pregnancy has been normalised. According to the respondents of the HRSC study, non-pregnant teenagers are viewed as the 'other', and are asked when they too will be pregnant. Such attitudes make teenage pregnancy a way of life, and teenagers themselves view teenage pregnancy as a reality that forms a part of everyday life rather than an alien occurrence (HRSC, 2008).
This cycle self-perpetuates from one generation to another until it becomes 'acceptable and normal' for teenagers to fall pregnant. The intergenerational cycle is a result of a lack of upward mobility; upward mobility is an individual's ability to rise above their current social or economic position (Hlabangana, 2012). Arai (2008) considers this 'low expectation' on the part of teenagers, as one of the reasons that perpetuates the intergenerational cycle of teenage pregnancy. This she attributes to structural factors in deprived communities such as schools that fail to give teenagers a reason to feel entitled to anything. Knowledge, attitudes and perceptions of teenagers towards teenage pregnancy may be rooted in the 'lack of upward mobility' that Arai refers to.
Arai (2008) notes that in Britain, the low expectation argument for teenage pregnancy is a powerful one as evidenced by many British researchers (Garlick et al., 1993; Rosato, 1999; Selman, 1998; Smith, 1993; Wilson, 1991). She puts forward that in Britain, teenage pregnancy is very high amongst teenagers who do not have family support, come from broken homes, are raised by single parents, have difficulty with school and who come from socially disadvantaged backgrounds. According to Arai (2008), teenagers from such backgrounds have access to contraception and sexual health information, but display a deficiency in their knowledge of sexual health, proper contraceptive use, are shy to engage in sexual health communication and are wary to access services for sexual health.
In a 1999 study in Northumberland, Britain, it was discovered that teenage parents had low educational achievement and low expectations of their future prior to their parenthood Arai (2009). She notes that these teenagers went on to have low paying jobs where they had to work long hours. In another Scottish study, (Smith,1993 in Arai, 2009) observed that teenagers from deprived backgrounds were six times likely to fall pregnant and then abort than their counter parts from well to do areas. These studies, validate Arai (2009) and Hlabangana's (2009) notion of upward mobility and entitlement for more on the part of the teenagers.
Interestingly, Rutenberg et al. (2003:5) in their study of attitudes towards HIV and AIDS and teenage pregnancy in KZN (South Africa) discovered that "for some adolescents, increasing opportunities and aspirations for education and employment, in addition to the perceived risk of HIV and pregnancy, results in many adolescents not wanting an early pregnancy". Rutenberg et al.'s study, validates Arai's (2008) and Hlabangana's (2009) assertion that teenagers with a low sense of upward mobility are most likely to find themselves as teenage parents while those with a high level of upward mobility are most likely to prevent themselves from early parenthood. This study will seek to unearth these varying dynamics in an effort to understand teenagers' attitudes towards other teenagers who fall pregnant.
Pregnancies among teenagers are related to social problems, and this is predominant in developing countries and in particular poverty stricken communities. Risky sexual behaviours among teenagers are more likely to occur in poor families and those with single families. Lack of resources forces girls to become sexually involved in an effort to get material gains (Jewkes, Morrell & Christofides, 2009). Hallman (2004) found that in South Africa low income families contributed to risky sexual behaviour among young people in both rural and urban areas. The study argues that low income accounts for girls' decision to engage in risky sexual behaviour in trying to make ends meet. Macleod (2009) and Manzini (2009) concur with Hallman, and further add that young people from low economic statuses are most likely not to use condoms. This is attributed to lack of access to health services, reproductive health information and proper support structures from other social institutions.
Teenagers who find themselves in intergenerational relationships find themselves unable to negotiate safe sex practices in fear of jeopardising their economic goals (Panday et al., 2009; Leclerc-Madlala, 2008). Many young women not only engage in risky sexual activities to meet their basic 'needs' such as money, food and clothing, but also to satisfy 'wants' such as expensive cell phones, high-class jewellery and rides in luxury cars (Hunter, 2002; Leclerc-Madlala, 2004). Chances of teenage pregnancy become high when the teenager comes from a home without adult supervision and most likely poor economic standing. Mfono (2003) confirms these arguments stating that teenagers are at high risk of pregnancy if they come from financially disadvantaged backgrounds, or if they succumb to peer pressure to engage in sexual activities for economic gain.
On the other hand, teenage girls reject the transactional sex talk and state that they are able to make do with what is available without having to engage in intergenerational and transactional relationships with older partners. Sathiparsad and Taylor's (2011) study of 335 girls and boys in eThekwini Secondary Schools in Durban (South Africa) revealed that girls view themselves as independent and rational thinkers. These girls suggested that they do not think that sex is synonymous with love, and assert their power as individuals by their ability to say no to unprotected sex. This is indicative of girls resisting manipulation and normative submission (ibid). For the purposes of this study, it will be interesting to find out how teenagers perceive economic status as a contributing factor to teenage pregnancy.
The South African DoH's Policy Guidelines for Youth and Adolescent Health (2001) locates gender considerations as fundamental to the health of young people. The policy guidelines identify sexual health and sexual exploitation, sexual abuse, gender-based violence, coercive sex and gang rapes as areas of concern that put young women in particular at risk of HIV and AIDS and teenage pregnancy.
Dunkle et al. (2004) in their study of young women attending ante-natal clinics in Soweto (South Africa) discovered that over half of the women aged between 15 and 30 years had been exposed to sexual violence. Another survey, conducted by the Planned Parenthood Association of South Africa (PPASA) in six of South Africa's provinces, found that 20% of girls reported forced sexual encounters or were sexually assaulted (PPASA, 2003). Similarly, Vundule et al. (2001) found that 33% of girls in South Africa have their first intercourse as a result of force, including rape. Where there is unequal power distribution and lack of negotiation skills, pregnancy ceases to be a matter of choice.
Sexual violence alters the power relations in any relationship, and in most cases women are vulnerable and unable to negotiate safe sex. Teenagers may avoid negotiating contraceptive usage, in particular condoms, for fear not only of violent reactions, but also of emotional rejection, of being labelled unfaithful or HIV positive (Wood, Maforah & Jewkes, 1998). Furthermore, women attempting to use other 'invisible' contraceptive methods, such as the injection, may be accused by their partners of causing 'infertility, 'disabled babies' and vaginal 'wetness', which diminishes male sexual pleasure (ibid). Clearly, men have the upper hand on sexual matters as women are constrained by their subordinate position in gender and social hierarchy, forced and coerced sex and inaccessibility of contraception (Jewkes et al., 2001; Wood & Jewkes, 2006 and Macleod, 1999). Sexual violence is more pronounced between young girls and their older partners, where the relationship is founded on material gain on the part of the teenager (ibid).
In light of contraceptive negotiation, teenagers are coerced into having sexual relations with their partners, leaving them vulnerable, not only to pregnancy, but to HIV. The men have control over sexuality, and as Wood and Jewkes (2006) put forward, some teenagers view coercive sex as an expression of love and as an inevitable part of relationships. Sexual violence also increases the chances of repeat pregnancy. In Sweden, Ekstrand (2008) notes that condom negotiation is also particularly difficult between teenagers and older partners and between teenagers themselves. Ironically, Swedish teenagers agree that contraception is the responsibility of both partners, though some girls want the responsibility to be borne by the boys alone.
Bhana et al. (2008) challenge girls' submissiveness when it comes to sexual intercourse. They put forward that girls are not always the victims of boys' behaviour towards contraceptive use. Bhana et al. (2008) note that girls are also sexual agents, who engage with boys on a sexual level, make decisions and choices consensually and sometimes coercively. Bhana et al.'s assertion seems to validate Bhana and Swatz's (2009) conclusion that boys are also victims of girls who refuse to use condoms and even lie to get their own way when it comes to unprotected sex. Clearly condom negotiation is a contested terrain and merits exploration in this study.
Sathiparsad and Taylor (2011) in their study of 335 teenagers in eThekwini secondary schools in Durban (South Africa) found that boys intentionally impregnated girls so as to 'mark' these girls as their own and ensure ownership. This 'ownership' ritual is perceived as a method of warding off other boys and probably older men who are viewed as threats since they have more economic power than the teenagers. According to Sathiparsad and Taylor (2011) these boys construct themselves as in control of the decision making relating to when sex take places and what happens afterwards. These young men's views on masculinity may be a product of socialisation, where young men are brought up to believe that they are better than their female counterparts, and that a man is always in control. As Arai (2009) and Jewkes and Wood (2008) put it, teenage pregnancy is best understood within the context in which it takes place. This means that for teenage pregnancy to be understood there needs to be an understanding of the background from which these young boys are coming from. One such background is where they are considered as the 'other' in the discourse around teenage pregnancy.
While South African male teenagers may impregnate girls as a sign of ownership and a sign of masculinity, Australian teenage boys perceive having babies as a sign of strengthening relations. In their study of 350 Australian teenage boys, Corkindale et al. (2009) found that Australian boys perceive having babies as a way of bonding with their partners though they are quick to agree that babies are a big responsibility that needs money, money these teenagers do not have. Corkindale et al.'s study is very interesting as these teenage boys deviate from the 'norm' where girls want to have babies to strengthen relationships and not the other way round. It will be interesting to find out the perception and attitudes of teenagers under study in this research towards having babies as a way of bounding in particular from the boys.
Much discourse on teenage pregnancy focuses on the girls who bear and suffer the consequences of teenage parenthood. Very little is said about the males who go on with their lives with little or no disruption at all. Disregarding boys and men as part of the problem is retrogressive to the cause of managing teenage pregnancy levels (Masuku, 1998). Some schools in KZN make sure that if the father is a student at the same school, he is sent away together with the pregnant girl and come back when the girl also comes back after giving birth (Mpanza, 2010). While this may at base seem as 'justice', there is a flip side to it being youth delinquency. Mpanza (2010) contends that this really does not solve the problem at hand, but rather creates a new one, which is social delinquency. Bhana and Swartz (2009) concur though they argue that teenage fathers feel a moral responsibility to take care of the new family though they are unable to do so.
Age at first sex/ Sexual debut
Age at first sex has been identified as another contributing factor to teenage pregnancy. For girls, early age at onset of menstrual cycle increases the possibility of pregnancy at an early age and the risk of contracting HIV. The mean age of onset of menstrual cycle in South Africa is 13 years, and the mean age at first sex is 17 years for girls and 16 years for boys (Reproductive Health Research Unit, 2003). The 2003 RHRU survey on HIV and sexual behaviour among young people in South Africa explored sexual behaviour and perceived risk towards HIV infection. The survey concluded that South African young people are at risk of HIV infection, and possibly teenage pregnancy because they have low self-efficacy and under estimate their risk to HIV and other STIs. It was also found out in the survey that age at sexual debut increased chances of teenage pregnancy.
Age at sexual debut is affected and influenced by various protective and risk factors. A positive relationship with parents and teachers, holding spiritual beliefs and attending school is associated with a decrease in the likelihood of early sexual debut. In contrast risky sexual behaviour, lack of adequate information on sexual health, low economic status and having sexually active friends is associated with early sexual debut (WHO, 2008).
Early sexual debut is a risk factor for unwanted and unplanned teenage pregnancy. Macleod (2009) suggests that this has to do with unequal power relations in the relationships young women find themselves in. Timing of adolescent sexual debut is an important variable in the teenage pregnancy discourse as it affords teenagers an opportunity to at least have information on sexual health (Crockett, 2004:2). Crockett concludes that at sexual debut teenagers do not use protection due to lack of information. Bhana and Swartz (2009) add that teenagers at first sex do not know the consequences of engaging in sexual activities and are 'saddened' when they have to deal with the results.
Peer pressure is a crucial variable in age at first sex. Teenagers with allegedly sexually active friends find themselves giving in to pressure to engage in sexual activities. Pressure is increased where the girl comes from an impoverished background, and is driven by the desire to 'change' their circumstances and fit in the circles. Dlamini et al. (2009) put forward that friends influence the decision to engage in sex. Teenage years are a critical period in the exploration and development of gender identity. For this reason, Wood and Jewkes (2009) state that in the context of poverty and limited alternatives, securing and maintaining sexual relations is critical to both girls and boys.
Delaying sexual debut has been proposed as a means of curbing unwanted and unplanned pregnancies. However, as indicated earlier on this is complex teenagers' sexuality is affected by various reasons "ranging from, peer group in¬‚uences which may contribute to acceptance of sexual aggression and the male dominant culture" (Dlamini et al., 2009:iii). Given the desire to manage and reduce teenage pregnancy prevalence, uncovering factors associated with sexual debut delay merits exploration in the study.
Research evidence indicates that teenagers are aware of contraceptives in all their various forms (Rasch et al., 2000; Jewkes et al., 2001; Manzini, 2001; Dunkle et al., 2007; Mfono, 2008; and Macleod, 2010). However, statistics on contraceptive use, teenage pregnancy and HIV infection rates indicate that contraceptive use is erratic (RHRU, 2003). Knowledge, according to Macleod (2009) is an essential, but not sufficient, element for effective contraceptive usage. As discussed earlier, knowledge also does not translate to health affirming behaviour. This will also merit investigating in the study using a broader theory that does not ignore non-sexual factors that may influence teenage pregnancy.
Contraceptive use is a highly contested domain for most adolescents, and as a result preventing an unwanted pregnancy that may result in abortion is not that easy. This is primarily due to factors such as schools, churches, non-governmental organisations, nurses, adolescent girls' mothers and male sexual partners who may play a pivotal role in the decision making process, and may send contradictory messages to adolescents such as contraceptives can 'completely block the tubes' (Warenuis et al., 2006; Woods & Jewkes, 2006).
Emphasis has been placed on condom education since the condom serves a dual purpose as it protects against pregnancy and contraction of STIs.Rutenberg et al.'s (2001) household survey in Durban and Mtunzini (South Africa) assessing young people's understanding of pregnancy risks, found that 8% were aware of the menstrual cycle and the times women are most fertile for pregnancy during this period. The research sample comprised of Blacks, Indians and Whites. Knowledge increased with age, with the white population having more knowledge than other races. At least 80 % of the sample (both girls and boys) knew that a woman could get pregnant if she had sex only once. Most of the sample (99%) knew of at least one method of family planning, and 72% could name more than two types of contraceptives. The pill, condom and injectable contraceptives were most frequently cited, and abstinence, non-penetrative sex and withdrawal method were mentioned by less than 6% of the respondents (Rutenberg et al., 2001). Although teenagers might have knowledge on contraceptives, the quality of understanding and level of awareness varies considerably (ibid).
According to Arai (2009), in Britain, teenage pregnancy and teenagers' attitudes towards contraception is best explained by reference to the effect of sexual attitudes and knowledge on sexual behaviour. Arai maintains that even in the developed world, teenage pregnancy is a result of contraception ignorance, service provider attitudes, peer pressure and sexual embarrassment. She argues that the answer to teenage pregnancy lies with improved sexual health service, greater use of contraception and increased sexual health knowledge. She however cautions that "the factors would not on their own, reduce teenage pregnancy" (2009:6). Arai advocates for a more comprehensive and holistic approach to the handling of teenage pregnancy because a "linear solution does nothing at all at dealing with the problem" (Arai, 2009:9).
Maria Ekstrand (2008) studied perception of teenage pregnancy, abortion and contraceptive use among Swedish teenagers and her results concur with those Arai (2008) got from her study of Britain teenagers. Ekstrand (2008) found that teenage pregnancy in Sweden was a result of inconsistent use of contraceptives despite the fact that they are readily available, Swedish teenagers also had a healthy mistrust of condoms as they are associated with infidelity. She concludes that teenagers have negative attitudes towards teenage pregnancy as they acknowledge that teenage pregnancy affects future prospects. However, girls have a mistrust of the pill as a contraceptive method as they fear the side effects of the pill. According to Ekstrand, there are still some lingering misconceptions towards contraception as some teenagers believe that they can take breaks from taking contraceptives but still remain protected against pregnancy.
Like in Sweden, misconceptions surrounding contraceptive use still abound in South Africa as evidenced by Oni et al.'s (2005) research on high school students' attitudes, practices and knowledge of contraception in KwaZulu-Natal. At least 21% of the girls in Oni et al.'s study knew that they could fall pregnant after missing their contraceptive pill, while another 12% believed they could not fall pregnant on their first sexual encounter. Clearly, there are some misconceptions, and it is these misconceptions that give rise to unwanted and unplanned pregnancies. Richter and Mlambo (2005) concur and point out those teenagers are exposed to 'sexual myths' such as not falling pregnant the first time they have sexual intercourse, having sex standing and withdrawal before ejaculation prevents conception.
CONTRACEPTIVE USE AMONG TEENAGERS
The South African DoH provides free condoms and a social marketing programme, Society for Health (SFH) provides Lovers Plus condoms at a highly subsidised rate (MacPhail & Campbell, 2001). In South Africa, dedicated condom distribution vans that dispense outside of clinic settings have, however, been discontinued, and it is possible that this has lowered access to the service (Macleod, 2001). Oral and injectable contraceptives are also available, as are emergency contraceptives, free of charge, at government run family planning clinics. At the same time, female condoms are not widely available - an unavailability that, according to Macleod (1999b), has the potential to lessen the ability of girls to negotiate safe sex as the power is taken away from them by mere unavailability of the Femidom. The Femidom is a female condom, worn as a contraceptive to prevent unwanted pregnancy and to reduce risk of infection of STIs. Indeed, access to the femidom seems especially difficult for young women who have to negotiate the negative attitudes of nurses at local clinics, and social norms prevent them from carrying condoms (Macleod, 2010).
Condoms can be sourced from a variety of places, including friends, retail stores, clinics, and clubs and even in schools. This was confirmed by participants in MacPhail and Campbell's (2001) focus group discussion in Khutsong (South Africa) reported receiving male condoms from a variety of sources, including friends, schools and retail stores. The research sample comprised of 44 teenagers in the 13-25 age group. However, the majority made use of the free condoms from the local clinic. Despite the apparently ready availability of condoms, participants still reported having unprotected sex because they had not been able to access condoms. While free condoms are readily available, the lower economic level of young people in general prevents them from purchasing condoms should free condoms not be on hand. Interestingly, teenagers in the HRSC 2008 study on perceptions towards teenage pregnancy said they did not trust the free contraceptives from government and preferred to use the commercial condoms like Durex, Lifestyle and Crown. Of interest in such scenarios is that these teenagers do not have the financial means to afford commercial condoms and yet they do not trust the subsidised condoms provided by government. The cost of condoms is a barrier to access to condom and mistrust of subsidised government condoms is a barrier to condom use, it will be interesting to find out how teenagers perceive this dynamic in the study.
Wood and Jewkes (2006), reporting on South African research conducted in the late 1990s, cite the scolding, stigmatising and harsh treatment of young women at governmental family planning clinics as a reason for the poor access of these services by young people. The negative attitudes of clinic nurses toward young women were also noted by MacPhail and Campbell (2001) in their study of Khutsong teenagers' attitudes towards HIV and contraception. The stigma attached to youth sexuality may also contribute to young people's unwillingness to access these services. While the 2008 HRSC study on perceptions towards teenage pregnancy in Johannesburg, Cape Town and Durban concurs with MacPhail and Campbell (2001), the study notes that it is not that contraceptives are not accessible, they are everywhere, but the attitudes of nurses and fear of being seen by community members who might judge these teenagers and report to their respective family members. It is these fears and the attitudes of the nurses that essentially make contraceptives inaccessible to teenagers.
However, Ehlers (2003) paints a more positive picture of health service provision by South African clinic nurse staff. In a Pretorian sample of adolescent mothers, Ehlers (2003) found that the majority waited only 30 minutes to receive assistance at a family planning clinic, and 86% experienced nurses as very helpful. Only 6.4% waited two hours or longer, and only 15% reported dissatisfaction at the services they had received. Given that the youth-friendly initiative by the DoH was launched in 1999, it is possible that this initiative has had some positive effects in some areas.
While contraceptives are available from many sources, Mfono (1998) found that Gauteng teenagers frequenting urban family planning centres had only visited the centres after several sexual encounters. While these young people do eventually access contraceptives, it is only after a period of sexual activity that puts them at risk for pregnancy and STIs. There are barriers against young people freely accessing services, possibly including financial resource constraints, stigmatisation by service providers, difficulty in travelling long distances to reach a clinic, and difficulty in getting to the clinic during school hours.
High teenage pregnancy rates despite the use of contraceptives may be a sign that there may still be unmet contraceptive needs, including intermittent use of contraceptives and interruption in supply (Rasch et al., 2000). Hickley (1997) and Palamuleni (2002) report that the non-availability of and reluctance to use contraceptives are contributing factors towards the increase in teenage pregnancy. Reluctance to use contraceptives may be attributed to lack of proper information on contraceptive use, as well as perceptions and attitudes towards contraceptives. Reasons for non-contraceptive use include, religious and cultural beliefs, poor quality of services, including the negative attitude of service providers, fear of exposure of their bodies, having adults at the same services and inability to negotiate contraceptive use with sexual partners. Furthermore, misconceptions, fear of side effects and stigma associated with the use of contraceptives as adolescents may be labelled as being promiscuous can also be considered as contributing factors for non-contraceptive use (Chonzi, 2000; Paz Soldan, 2004). There are many misconceptions associated with the lack of information regarding sexual reproductive health. Some of these include oral contraceptives and intrauterine device causes cancer, use of contraceptives before childbearing leading to infertility, and condoms disappearing in the woman's body (Chonzi, 2000).
Bhana and Swartz (2009) in their study on teenage fathers in Cape Town (South Africa) indicated that boys tend to believe information from their girlfriends about contraception use. Girls in turn according to Mfono (1998) tend to lie to their boyfriends about their contraceptive use for fear of rejection. The lies that abound in the discussion about contraception among teenagers are a testimony to the complexity of teenage sexuality as these beliefs and 'lies' are a product of other factors.
Conscious non-contraceptive use has been another factor affecting contraceptive use and in particular the condom. The use of condoms is viewed with reluctance as teenagers prefer to have "skin to skin" or "meat to meat" sex (Bhana & Swartz, 2009). Condomless sex increases sexual pleasure according to teenagers in Bhana and Swartz's interviews. They equate having sex with condoms to "eating a sweet in its wrapper" (ibid).
In their study of teenagers' attitudes towards HIV, contraceptive use and teenage pregnancy, in Durban (South Africa) Sathiparsad and Taylor (2011) found that at least 44% of the 335 teenage boys and girls agreed that desire and fun clouded their ability to think rationally when it comes to protection. Sathiparsad and Taylor's study also revealed that 72% of the males and 55% of the females had negative perceptions towards condoms as they interfered with 'pleasure'. According to Sathiparsad and Taylor (2011), teenagers opt to have unprotected sex inspite of the high risk of HIV infection and pregnancy. The gender differences in perceptions towards condoms in Sathiparsad and Taylor's (2011) study are very significant, indicating that boys have more negative attitudes towards the condom more than the girls. Such attitudes may contribute to the gender dynamics of condom use where girls are unable to negotiate safe sex. Attitudes towards the male condom may also stem from the fact that the male condom is 'readily available' compared to the female condom. Attitudes towards condom use in general may also stem from trust issues with in teenage relationships.
Trust issues between couples are another factor that significantly affects condom use among teenagers. Varga (2000) notes an overarching perception that condoms threaten trust and intimacy between partners. Indeed, not using condoms may also be taken as a sign of seriousness and trust within a relationship, while the desire to use one is viewed as a sign of infidelity (Varga, 2000; Bhana & Swartz, 2009; Ekstrand, 2008; Wood & Jewkes, 2009). In essence teenagers find themselves caught between a desire to maintain and hold a relationship by having condomless sex, while on the other hand there is a genuine desire to protect themselves from STI infection and pregnancy.
Inconsistent contraceptive use among teenagers has been identified as one of the reasons for teenage pregnancy (Varga, 2000; Bhana & Swartz, 2009; Wood & Jewkes, 2009). However, reasons for inconsistent contraceptive use are diverse and complex hence they are not easy to characterise. According to Arai (2009:12) the ' ideal' contraceptive for teenagers is the one that is "safe, provides adequate protection, is reversible, carries minimal side effects, is inexpensive, convenient and can be obtained and used in a private manner".
Negative perceptions of teenage pregnancy are most likely to motivate teenagers to use contraception consistently, while the opposite is also true (Varga, 2000; Wood &Jewkes, 2009). That being said, analysis knowledge, attitudes and perceptions towards contraceptive is important as contraceptive splay an important role in pregnancy prevention.
Sources of information on sexual behaviour and contraceptive use
Central to tackling existing gaps in teen pregnancies and access to contraceptives is education and information dissemination (Brooke, 2006). Teenagers are exposed to information regarding sexuality and contraception through various sources. Sources of information include parents, friends, the media, and institutional sources such as school and church. Since 2002, South Africa has had a publicised and well-coordinated sex education programme, though it still struggles with high teenage pregnancy rates. Parents and guardians are encouraged to speak openly to their children about sexuality as they are the primary sources of information. However, Macleod (2009) argues that this is an unrealistic expectation as parents are unable to do so because of various reasons, one of them being culture, and issue which will be discussed later on in the chapter.
"Certain issues including pregnancy, premarital sexual intercourse, contraception, sexual harassment and molestation are taboo family subjects in certain cultures in South Africa" (Madu, Kropiunigg & Weckenmann, 2002:88). The curtain of silence drawn over these issues results in anxiety, fear and misconceptions ultimately leading to unplanned and unwanted pregnancies. However, Macleod paints a rosy picture and notes that there are programmes that have been put in place to ensure that there is frank discussion between parents and teenagers concerning sexuality. These programmes include the Planned Parenthood Association of South Africa and Love Life's Born Free dialogues.
Teenagers state that they have discussions on sexuality with their parents, though there is no clarity on certain issues and no room for further consultations (MacPhail & Campbell, 2001). Female participants of MacPhail and Campbell's (2001) Khutsong focus group discussions indicated that they were informed to protect themselves from and to stay away from boys, and many did not understand that sexual intercourse could result in pregnancy, meaning that abstinence rather than contraception was emphasised. The perception that talking about contraceptives gives teenagers the license to engage in sexual activities is cited as one of the reasons elders are reluctant to talk about sexuality. MacPhail and Campbell (2001) further suggest that adult surveillance impinges on contraceptive use and knowledge. According to MacPhail and Campbell, (2001) adults in the Khutsong area pass on information to relevant others about young people's visits to family planning clinics, and about these young people's suspected relationships and other indicators of suspected sexual activities. Parents may then reprimand teenagers over their sexual behaviour. Adults' attitude towards teenagers' sexual behaviour prevents young people from accessing clinics for contraceptives and sexual health information.
Where young people cannot access information from their parents, they tend to turn to their friends for information. Peer information is regarded as a double edged sword. Some information from peers is well meant and placed as they encourage each other to use contraceptives. On the other hand, peer information is fatal as they are misinformed themselves, and tend to pass on the same information to their peers. Peers bar young girls who are not sexually active from conversations of a sexual nature, perpetuating the mystification and silence surrounding sex (Wood, Maepa & Jewkes, 1997). They contend that this mounts pressure on the uninitiated to have sex so they can also be included in these 'circles'. Male partners may take advantage of the information lapse and emphasize notions of female availability and male sexual entitlement (Jewkes et al., 2001).
Mass media, including magazines, radio and television broadcasts, provide useful sexual and contraceptive information to young boys and girls. Rutenberg et al.'s 2001 survey in Durban and Mtunzini showed that 52% of the respondents had heard their information on contraceptives from the mass media. Oni et al.'s (2005) smaller survey on high school learners' attitudes, knowledge and practices of contraception in Jozini, KwaZulu-Natal (South Africa), suggests that the reception of such messages may be gendered, with 54.2% of male and only 21.5% of female respondents reporting that they had received a television or radio message about contraception.
Institutional sources, such as life skill education in schools has also been somewhat effective in promoting sexual and reproductive health knowledge and perceived condom self-efficacy in South Africa (Magnani et al., 2005). They however note that effectiveness of life skills education is not uniform across board with some areas having not received life skills packages (ibid). This non-uniformity affects teenagers who are coming from areas where sexual health information is already limited, the decrease in sources of information may somewhat increase misconceptions and myths concerning sexual health and in particular pregnancy prevention.
Health care centres are other sources of information on sexuality. However, they have been under the spotlight for their attitude towards young women who visit clinics in search for contraceptives and any other information. Macleod (2010:29) affirms "indeed, access to contraceptives seems especially difficult for young women who have to negotiate the negative attitudes of nurses at local clinics, and social norms prevent them from carrying condoms". However, Mkwananzi (2010) disputes this, arguing instead that teenagers do not go to clinics with an open mind. In fact, according to Mkwananzi, teenagers are the ones who have negative attitudes towards contraception. It is such attitudes, supposedly, that put teenagers at risk of pregnancy. Wood and Jewkes (2006) and MacPhail and Campbell (2001) concur with Macleod (2010) on negative attitudes of nursing staff. While studies may site negative attitudes of staff towards teenagers, Ehlers (2003) paints a more positive picture, arguing that youth-friendly services initiated by the South Africa's DoH have made great strides in resolving the animosity between health care providers and teenagers.
While services are more plentiful in theory and favourable to girls, there is a dearth in services for young men and failure to provide them with proper health education (Bhana & Swartz, 2009). It is indisputable that health care centres are more women-friendly and are frequented by more women than men who are going about their health care needs (Quinton, 2002). Such an environment marginalises young men who then opt to rely on friends for information. Kiseleca and Sturmer (1993) note that the mixed messages that young men get from society concerning health and masculinity make them shirk their responsibility when it comes to contraception, and claim it to be the responsibility of the girl. It is ironic however to note that it is these same young men who claim that contraception is the responsibility of the woman, who later in life deny women these contraceptives claiming that contraceptives make the 'vagina wet' and condom use interferes with sexual pleasure.
Health seeking behaviour of young men is also affected by beliefs they continue to hold. Traditionally men who seek health services are viewed to be weak and this affects their ability to seek health care services as they strive to keep up appearances (Mfono, 2008). They worry about what other men believe, and how they will be viewed in light of their visits to health care services. Bhana and Swartz (2009) point out that for these reasons boys are wary to visit health care centres for help. They acknowledge the existence of youth-friendly centres and male sensitive health services, but point out that their effectiveness is in question given the policy debates surrounding them.
In response to calls by earlier researchers for the establishment of youth-friendly services, the National Adolescent Friendly Clinic Initiative (NAFCI) was conceptualised and implemented between 1999 and 2005 (MiET Africa, 2011). At least 350 NAFCI sites had been established in South Africa by 2005 and 13% of these in KwaZulu-Natal (ibid). In an evaluative study of NAFCI services in Limpopo, Baloyi (2006) found that teenagers were making use of these clinics, though rates of teenage pregnancy did not decrease. The lack of change in the pregnancy rates may be attributed to other factors that affect decision making in teenagers such as social status, cultural factors and peer pressure just to mention a few.
TEENAGE PREGANANCY CULTURE AND RACE
In most African societies, young women of all ages experience pressure to have children and this cultural demand may further contribute to teenage pregnancy (Preston-Whyte, 1999). Importance is placed on fertility and procreation, such that young women may be labelled as 'barren' if they do not conceive (ibid). Pregnancy is then viewed as a rite of passage, as the epitome of womanhood and raises social status. It is this desire to gain social status that may encourage teenagers to stop using contraceptives, and end up falling pregnant. Such pregnancies become planned though unwanted. However, this does not by
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