This article was downloaded by: [Emory University] On: 16 October 2009 Access details: Access Details: [subscription number 907001400] Publisher Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Culture, Health & Sexuality Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713693164 Empowering teenagers to prevent pregnancy: lessons from South Africa Rachel Jewkes a; Robert Morrell b; Nicola Christofides a a Gender and Health Research Unit, Medical Research Council, Pretoria, South Africa b School of Education Studies, University of KwaZulu Natal (Edgewood Campus), Ashwood, South Africa First Published:October2009 To cite this Article Jewkes, Rachel, Morrell, Robert and Christofides, Nicola(2009)'Empowering teenagers to prevent pregnancy: lessons from South Africa',Culture, Health & Sexuality,11:7,675 — 688 To link to this Article: DOI: 10.1080/13691050902846452 URL: http://dx.doi.org/10.1080/13691050902846452 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article may be used for research, teaching and private study purposes. 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The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. Culture, Health & Sexuality Vol. 11, No. 7, October 2009, 675–688 Empowering teenagers to prevent pregnancy: lessons from South Africa Rachel Jewkesa*, Robert Morrellb and Nicola Christofidesa a Gender and Health Research Unit, Medical Research Council, Pretoria, South Africa; bSchool of Education Studies, University of KwaZulu Natal (Edgewood Campus), Ashwood, South Africa Downloaded By: [Emory University] At: 11:20 16 October 2009 (Received 1 August 2008; final version received 24 February 2009) Reducing rates of teenage pregnancy is an important part of the agenda of action for meeting most of the Millenium Development Goals. South Africa has important lessons for other countries in this regard as the rate of teenage pregnancy is high but has declined very substantially over the last twenty years. The country experiences waves of moral panic about teenage pregnancy, with assertions that current problems are rooted in accepting or even encouraging the sexual appetites of young people rather than sternly disciplining them. In this paper, we argue that the key to success in teenage pregnancy reduction has been an empowering social policy agenda that has sought to work with young people, making them aware of their rights and the risks of sexual intercourse. Furthermore, family responses and education policy have greatly reduced the potential negative impact of teenage pregnancy on the lives of teenage girls. There is tremendous scope for further progress in reducing teenage pregnancy and we argue that this lies in paying more attention to issues of gender and sexuality, including the terms and conditions under which teenagers have sex. There needs to be critical reflection and engagement with men and boys on issues of masculinity, including their role in child rearing, as well as examination within families of their engagement with supporting pregnancy prevention and responses to pregnancies. Keywords: gender; pregnancy; prevention; post-apartheid; Africa Introduction Becoming pregnant and having a child are major formative experiences for women the world over and have substantial implications for their health and lives. Whilst some teenage women marry and desire pregnancy, others find having a child as a teenager and a school pupil quite unwelcome. Global attempts to delay sexual debut and pregnancy stem from an understanding that they pose health, educational and broader social risks for young women (Bledsoe and Cohen 1993). It is largely girls who bear the consequences of having children and, when unmarried, they and their families shoulder the financial burden. Furthermore their subordinate position in the gender and social hierarchy constrains their ability to make real choices around pregnancy. Sex is often coerced, condom-use hard to negotiate, contraception inaccessible and they are very vulnerable to pressure from their male partners and others (Jewkes et al. 2001; Wood and Jewkes 2006). *Corresponding author. Email: rjewkes@mrc.ac.za ISSN 1369-1058 print/ISSN 1464-5351 online q 2009 Taylor & Francis DOI: 10.1080/13691050902846452 http://www.informaworld.com Downloaded By: [Emory University] At: 11:20 16 October 2009 676 R. Jewkes et al. Improving the life opportunities of women and young girls has long been a feature of development agendas and is now prominent in the Millennium Development Goals, designed to halve extreme poverty by 2015. Six of the eight goals impact on policy towards teenage pregnancy. They are: (1) to eradicate extreme poverty and hunger; (2) to achieve universal primary education; (3) to promote gender equality and empower women; (4) to reduce child mortality; (5) to improve maternal health; and (6) to combat HIV/AIDS, malaria and other diseases. Delaying pregnancy would assist in the achievement of each of these. Implicit in this is an understanding that teenage pregnancy is not just an issue of reproductive health and young women’s bodies but, rather, one, in its causes and consequences, that is rooted in women’s gendered social environment. Positioning the focus of teenage pregnancy on gender has implications for policy. It involves a recognition that ideas of masculinity that confer on men an ability to unduly influence the health of women and encourage women to equate femininity with acquiescence to male wishes. A recognition that these ideas normalise controlling, and often violent, behaviour of men towards women, influence the choices that women make and constrain their agency. It highlights the subordinate position of women and explains why and how they carry the bulk of blame in cases of teenage pregnancy. It shows how the position of women has resulted in the devaluing, under-resourcing and often prohibition of health services that specifically confer on women the opportunity to control their own fertility, particularly those related to contraception and termination of pregnancy. In South Africa, substantial efforts have been made to empower women and improve gender equity in the last 15 years. The rates of (mostly extra-marital) teenage pregnancy have been very high but have declined steadily, yet teen pregnancy persists as a source of public and policy concern. Socially conservative politicians from a range of political parties, including the current President of the African National Congress, Jacob Zuma, have drawn attention to the high rates and frequently assert that policy has been too permissive, teenagers too indulged and that the solution requires ‘tough love’ (e.g. News24 2008). Zuma has suggested this might take the form of boot camps for teenage mothers. Forcibly separated from their child, they would be sent to a rural village and made to study. Whilst the values underlying such positions have been vigorously challenged, the situation of teenage pregnancy in South Africa and the policies developed there deserve careful reflection. In this paper we argue that teenage pregnancy needs to be understood in historical and social perspective and it is only through doing this that the value of social policy that explicitly seeks to achieve gender equity and empower young women becomes apparent and new directions for prevention emerge. This has important implications for many countries. Teenage sexuality and pregnancy in historical perspective The recent history of sexuality in South Africa has been one characterised by a competition and interplay between two discourses that have had a profound influence on sexual practices and teenage pregnancy rates. The first, rooted historically in African1 culture, is characterised by openness towards sex and a view of it as a healthy and normal feature of all stages of the life cycle, including childhood (Delius and Glaser 2002; Jewkes, Penn-Kekana and Rose-Junius 2005). In accordance with this, in various ways the sexuality of teenage girls is both acknowledged and celebrated (e.g. Mager 1999). Continuities are seen in the highly sexualised modern day representations of teenagers in print media and by advertisers and in traditional festivals such as the Reed Downloaded By: [Emory University] At: 11:20 16 October 2009 Culture, Health & Sexuality 677 Dance, where every year hundreds of teenage virgins present themselves clad in beaded traditional attire, with naked breasts and buttocks, before the Zulu king. The second discourse, which has its roots in Victorian ideas of Christian morality, is that sex is shameful, should not be spoken of and should be confined to marriage (Delius and Glaser 2002; Jewkes, Penn-Kekana and Rose-Junius 2005). The second discourse is commonly presented narrowly as the frame for discussion of teenage pregnancy, especially in assertions that it reflects a problem which is novel, escalating and reflects a ‘disintegration of society’ (News24 2008). It often influences health workers’ responses. The historical record, however, provides a picture that is much more complex. Historical sources from the 1930s– 1950s concur that whilst extra-marital teenage pregnancy was generally prohibited, adolescent sex per se was not (reviewed in Delius and Glaser 2002). Indeed, the ethnographers Peter and Ilona Mayer, who conducted fieldwork in the 1950s in the rural Eastern Cape, argued that ‘adolescence is seen as a time when sex should be practiced vigorously’ (Mayer and Mayer 1970, 159). The caveat, however, was that among adolescents full penetrative sex was prohibited and those found practising it were punished by their peers, who were socialised into youth structures that regulated behaviour in various ways (Mager 1999). Mager (1999) describes how young people were expected to conduct their sexual activity in a communal building and on top of blankets so that peers were able to monitor what took place. Thus it was possible to bring together a concern to avoid pregnancy before marriage with an acknowledgement that adolescents are sexually active. Historians argue that the regulation of sexual behaviour in this way was dependent on the existence of youth structures and the facility for communal sexual activity (Delius and Glaser 2002). The growth of urbanisation in the second half of the twentieth century had a marked impact on sexual socialisation and teenage pregnancy, most notably because of the breakdown of these structures. In urban areas, in the face of sexual interest, opportunity and a lack of recreational alternatives, a considerable amount of teenage sexual activity took place, but it was in private, where it could not be regulated. Furthermore, Christian teachings that sex should be prohibited outside marriage and should not be a topic of discussion with children made it hard for parents and caregivers to fill the gap in sexual socialisation. The demands of employment meant that urban teenagers where to a great extent outside parental supervision. Penetrative sex began to be seen by men and women alike as ‘modern’ and more fun. In the absence of contraception, the inevitable consequence was a substantial rise in teenage pregnancy, as well as abortion and infanticide. Whilst often presented as an emerging problem, teenage pregnancy has been viewed as highly prevalent in urban African families from the 1950s and, indeed, at that time half of urban African mothers were estimated to have had an extra-marital pregnancy, usually whilst at school (Mayer 1961). Whilst there is considerable evidence that from the 1950s African communities regarded teenage pregnancy as a ‘problem’ (Khanyile 1974; Delius and Glaser 2002), in the 1980s it was also actively deployed as a resource in the name of the struggle. The 1980s saw the emergence of comrade culture in much of South Africa and, although it took many forms, Delius and Glaser (2002) reflect that it included in part attitudes towards women that reflected a marked sense of gender hierarchy: ‘it was regarded almost as a political duty for young women to reward the bravery of young lions [sexually]’ (48). Both Niehaus (2000) and Delius (1996) described how, in the northern and eastern Transvaal in the 1980s, comrades expected girls both to comply with sexual demands and conceive children to replace fallen comrades. They describe how those who refused were beaten and raped. Downloaded By: [Emory University] At: 11:20 16 October 2009 678 R. Jewkes et al. Rates and trends in teenage pregnancy It is not hard to see how teenage pregnancy rates could have become very high and, since for decades most African women have married late, if at all, (median age 28), almost all of these are extra-marital pregnancies (Department of Health 1999, 2004). The 1998 South Africa Demographic and Health Survey (Department of Health 1999) found that by the age of 19 years, more than one-third of women (35.1%) had been pregnant. Yet the data suggest that since the 1980s teenage pregnancy and births have been declining. The comparable data from successive Demographic and Health Surveys have shown that there has been a marked downwards trend in the age-specific fertility rate for 15 –19-year-olds over the last two decades. In the period 1987– 1989 it was estimated as 124 births per 1000 women, in 1998 it was 81 and the 2003 estimate was 54 (Department of Health 1999, 2004). In the 2003 Demographic and Health Survey, 27.3% of teenage women had been pregnant (Department of Health 2004). Whilst there have been suggestions that the 2003 survey over-estimated the extent of the decline in fertility nationally, conservative estimates from further analysis of the data confirm the overall trend of declining fertility (Department of Health 2004). Both the 1998 and 2003 South Africa Demographic and Health Surveys (Department of Health 1999, 2004) showed that teenage pregnancy displays marked social patterning. Being a teenage mother was much more prevalent in rural areas (60% more likely), amongst women with lower educational attainment (a three-fold difference between completion of primary school and matric) and amongst African and Coloured women (a seven-fold difference between African and Coloured women, on the one hand, and White and Indian women, on the other). The incidence was much higher amongst 18- and 19-year-olds than those in the earlier teenage years. Urban/rural residence, educational level, race and age are best viewed as markers for high-risk groups and indicative of sets of social dynamics that influence the consequences and risk of pregnancy. Gender and teenage sexuality Despite declining rates of teenage pregnancy, levels are high. South Africa’s teenage birth rate is more than twice that of the UK, for example, where teenage pregnancy rates are the highest in Western Europe. The challenge therefore is to explain why teenage pregnancy rates should be falling and what further should be done to reduce the high rates. An exploration of the gendered social context of African teenage sexual and pregnancy is required to understand this further. Research on teenage sexuality, mostly conducted amongst Africans, shows that young boys report their first experiences at a younger age than women do (Manzini 2001). By the age of 17, half of all teenagers are sexually active. The teenage years are an important period in exploration and development of gender identity and, in a context of poverty and limited alternatives, securing and maintaining sexual relationships are critical to self-evaluations of masculine success as well as male peer group positioning (Wood and Jewkes 2001). Similarly, relationships are very important to women in their evaluations of their femininity and processes of exploration of their identity and power as women. Despite the commonness of gender-based violence, both teenage girls and boys are generally active and willing participants in their sexual relationships (O’Sullivan et al. 2006). The influence of the more traditional discourse of sexual openness has retained a pervasive parental acknowledgement that boys will experiment with sex, although rules of respect require it to be conducted outside the gaze of their parents (Wood 2003). Indeed, Downloaded By: [Emory University] At: 11:20 16 October 2009 Culture, Health & Sexuality 679 the widespread practice of moving African boys, of all social classes, out of the main house and into a room with a separate entrance is an indication of parental acknowledgement of the need to provide opportunity for this, and questions are not asked about who sex will take place with, or under what terms. In marked contrast, teenage girls are kept as closely as possible under the surveillance of elders and stay within the main house usually with much of their time occupied with household chores in an effort to restrain them from exploring their sexuality, although the evidence on age at first sex and pregnancy shows that neither surveillance nor the moral authority of mothers is usually enough to prevent it (Salo 2003). South African society is characterised by a prominent age and gender hierarchy, which accords young women relatively little power (Jewkes, Penn-Kekana and Rose-Junius 2005; Bhana 2006). Thus, whilst women are generally willing participants in relationships, they are not willing participants in all sexual acts. Coerced first sexual intercourse is common. Rates from South Africa vary between studies, but it appears to be experienced by between 10 –20% of women (Dunkle et al. 2004a). Young women who have experienced coerced first sex usually remain sexually active. Gender power inequities thus have a major impact on the age from which penetrative sex commences (Wood, Maforah and Jewkes 1998). One of the studies with the most detailed questions on child sexual abuse found that 39% of women experienced some form of contact sexual abuse (mainly coerced sexual intercourse) before the age of 18 years (Jewkes, personal communication). The experience, and threat, of rape conveys important messages to young women about gender power dynamics and their limited ability to exercise agency within relationships. These are reinforced by very high levels of physical violence from partners and often substantial age differences between teenage girls and their male partners (Wood et al. 1998; Jewkes et al. 2001; Varga 2003; Jewkes et al. 2006). They are further compounded by norms that extend from provision of gifts by male partners to frank economic transaction in exchange for sex, which may be desired by women, but still constrain their agency in sexual encounters (Dunkle et al. 2004b). Gender power inequities may reduce women’s ability to influence the timing and circumstances of sex and to regard their body and sexuality as domains over which they should ultimately exert control. The high prevalence of child sexual abuse is also important as it very commonly results in depression and alcohol abuse (Jewkes, personal communication), as well as post traumatic stress disorder (Green et al. 2005). In the absence of well-developed mental health services, these consequences persist for years with important negative consequences for emerging sexuality (Filipas and Ullman 2006). Research has shown just how important coerced sex is on teenage pregnancy. In research from Cape Town on young teenage pregnancy (Jewkes et al. 2001), women under 19 who had been pregnant were 14 times more likely to report forced first sex than their peers. Many African men view fathering as a matter of pride and evidence of masculinity (Morrell 2006) and seek an opportunity to father children (Morrell 2007). Teenage women often describe considerable pressure to conceive and report their partners forbidding them from using contraception, refusing condoms and begging them to get pregnant to ‘prove love’ (Wood and Jewkes 2006). Coerced conception can be seen as one of the group of related practices that are indicative of a very gender hierarchical model of masculinity, including having multiple partners, with payment for sex, controlling the behaviour towards female partners, with violence if necessary, and alcohol abuse (Hunter 2005). Thus, it is not surprising that even where conception is coerced, paternity is often not formally accepted and, even if it is, this may not be accompanied by financial or practical support for the child. Downloaded By: [Emory University] At: 11:20 16 October 2009 680 R. Jewkes et al. It is easy to see how in the face of such overwhelming power inequities many young women are unable to prevent pregnancy and, indeed, many find the manipulation of boyfriends hardest to resist. Most African women know their families and communities do not expect them to get pregnant as teenagers. Furthermore, the contraceptive norm for young African women is a progestogen depo injection administered two or three times monthly and this can be used covertly (Kaler 1998). Research suggests that teenage women infrequently make a decision to get pregnant, but much more commonly take few steps to prevent it (Wood and Jewkes 2006). It is impossible to escape a conclusion that part of the reason for this is that they do not see it as such a bad thing for their lives and may perceive it to be desirable or advantageous. In the short term, pregnancy is important for many women in self-evaluations of femininity. It may be valued per se as evidence of women’s reproductive powers or because of positive influences on other aspects of women’s lives (Harrison and Montgomery 2001). Within a relationship, and in a context of men and women often having long term multiple partners, acknowledged pregnancies are seen often to strengthen bonds. In a context where youth femininity is very importantly evaluated in terms of an ability to secure a boyfriend, this is critical. Relationships between men and women who have children together often last much longer than would otherwise occur. Even if they have ceased to be each others’ main partner (if indeed they ever were), one of the circumstances in which long-term concurrent partnerships occur is between men and women who have had a child together, who may engage intermittently in sexual relations for years (Dunkle et al. 2004b). If the child is fathered by a man of some means, becoming pregnant may entail an expectation of some form of ongoing financial support. This can be important for economically marginal rural women (Wood and Jewkes 2006). Family responses to teenage pregnancy In families and the broader social environment, social reactions to teenage women who become pregnant show diversity, particularly between racial groups, change at different points during the pregnancy and after birth, and depend on the circumstances of the pregnancy. African traditional ideals are that pregnancy should be confined to marriage, but social norms have deviated from this for a long time. The delay and decline in formal marriage and the acceptance of sex outside marriage has led to extra-marital pregnancy becoming common. As a consequence it is now readily accepted, well accommodated and, sometimes, even encouraged. It is also perhaps salient that many of the teenagers’ mothers were pregnant as teenagers themselves. Some African teenagers report that their mothers or grandmothers are pleased when they get pregnant and even encourage it, as babies are highly regarded in families and are often seen by rural women as providing a diversion (Wood and Jewkes 2006). Infertility is regarded by families as a very much more serious problem than extra-marital teenage pregnancy and a widely expressed view, particularly in rural areas where ethnomedicine most vigorously competes with the bio-medical system, is that once girls become sexually active it is better to conceive and then use contraception, than to prevent pregnancy with a perceived risk of never being able to conceive (Wood and Jewkes 2006). Family responses, however, are various, and many teenage girls hugely fear the response of families to their pregnancy and some are punished for it and may experience stigma in the community (Varga 2003). With customary pragmatism and in keeping with a culture that views children as belonging to broader families and communities rather than individuals, African teenage girls are rarely expected to raise their children alone. Babies are often raised by the Downloaded By: [Emory University] At: 11:20 16 October 2009 Culture, Health & Sexuality 681 maternal grandmother as the de facto youngest child of the family or raised by other relatives. The extent to which the biological mother will be involved in child care, or expected to financially support the child, is highly variable and at times neither of these are expected, at least until the grandmother dies or in the normal course of events the mother can support herself financially. The social status of teenage girls who have given birth may change. Childbirth, whether in or outside marriage, is traditionally regarded as the ultimate rite of passage to womanhood and thus elevates a girl’s social status (Preston-Whyte and Zondi 1992). A changed social status for young teenagers may be a mixed blessing, as it may distance a girl from her peers, but in a context in which teenage pregnancy is common (among African and Coloured girls), it is rarely a lonely position to be in (Varga 2003). These social reactions buffer the potential impact of teenage pregnancy on the lives of teenagers who become pregnant in functional families. The experience may be very different for teenage girls who come from highly dysfunctional families, particularly those without a strong mother figure in the home. Amongst Africans, there is generally no expectation that teenagers will marry or that pregnancy will precipitate marriage and limited expectation of male involvement in childcare. What is expected is recognition of paternity, which is important for social reasons, as it provides a sense of belonging, and for spiritual reasons, as it determines which set of ancestors have responsibility for guardianship of the child. When unmarried African women get pregnant their family approaches the family of the identified father with a request for acknowledgement of paternity, which implies a social and nominal financial commitment to a child (Preston-Whyte and Zondi 1992; Varga 2003). The process of acceptance of paternity follows rituals, which include the payment of ‘damages’, which was traditionally set as the value of a cow. The decision to accept paternity is taken by a family and reasons for young men not accepting paternity can be linked to monetary considerations as well as a threat to their educational and career aspirations (Varga 2003; Hunter 2006). In recent years, legislation on the payment of maintenance has sought to create an environment of both legal and financial responsibility amongst even young men (through their families) for children they father, but in practice regular and meaningful maintenance is often not paid. In 2002, for example, in Umlazi (Durban) only 7000 out of 67,000 people ordered to pay maintenance complied while in the same year district courts received 372,000 complaints of maintenance default (Richter and Morrell 2006, 5). Social space is created for men to father children without any long-term responsibility in terms of expectations of involvement in child care or long-term financial commitment. Teenage pregnancy is not considered ‘a problem’ for Indian and White South Africans and so there is little research with them. Anecdotal evidence suggests that extra-marital pregnancy (and to varying extents sex) are generally very much less acceptable among White and Indian families. It is unclear how far this results in delayed or less frequent sex, but being highly stigmatised, responses to pregnancy have tended towards either terminating the pregnancy or expecting marriage. In the case of marriage, both the man and woman take responsibility for the pregnancy, both socially and financially, and clearly there are often very substantial implications for their lives. Thus pregnancies and births are more likely to be avoided. The different racial profiles of teenage pregnancy rates discussed above reflect different social realities that themselves can best be explained with reference to the racialised apartheid past. Access to resources, family structure, access to education and life prospects were and are shaped by the racialised location occupied by South Africa’s various people. Although the strict relationship of race to wealth is breaking down, it is still 682 R. Jewkes et al. Downloaded By: [Emory University] At: 11:20 16 October 2009 the case that the poorest of South Africa’s population are Black African and it is within this population that gender inequalities present most strongly. In general, the ability of teenagers to navigate their sexuality and prevent unwanted pregnancy (or not want a pregnancy) depends sharply on their ability to control their environment and access resources. Gender power inequities intersect with other dimensions to teenagers’ power, including: socio-economic status; education; social skills and confidence; and age-related social status. Socio-economic status influences access to high quality contraceptive services and pregnancy termination as well as teenagers’ social environment, including: adult supervision; recreation opportunities; power within relationships; parental engagement; aspirations; and access to information and to better education. And all of these relational aspects are in some or other way raced. Policy responses to teenage pregnancy Policy responses to teenage pregnancy since democracy in 1994 have focused on empowering teenagers to prevent pregnancy (and birth) and mitigating the adverse consequences for the mother and baby. In the health sector, contraception is widely available free of charge from clinics, which are generally agreed to be geographically accessible. The national Department of Health adopted Policy Guidelines for Youth and Adolescent Health in 2001 and Contraception Policy Guidelines in 2003 (Department of Health 2001, 2003), both of which state that a range of contraceptives, including emergency contraception and male condoms, should always be in stock at all health facilities and that information, choice and confidentiality are essential parts of the service. The guidelines emphasise that healthcare providers should be trained with an emphasis on providing care in a non-judgmental manner. The decline in teenage pregnancy shows that, increasingly, teenagers do use contraception, at least some of the time, and many use condoms. There is further tangible evidence of teenage sexual behaviour change visible in the sustained decline in the proportion of pregnant teenagers with HIV (Department of Health 2008). Yet the level of pregnancy shows that many teenagers do not use contraception consistently. It seems likely that there are still explanations for this within the services, as policy is often not implemented and research shows that many health workers still restrict access to information that would enable teenage girls to understand and better control their sexual relationships and fertility. These same health workers also verbally chastise contraceptive seekers, do not offer contraceptive method choice for fear of ‘non-compliance’ and inadequately assist contraceptive users who complain of side-effects (Wood and Jewkes 2006). In an effort to reduce teenage pregnancy, contraceptive services could still be further improved. In 1996, the South African Parliament adopted the Choice in Termination of Pregnancy Act, which is regarded as one of the most liberal pieces of legislation in the world, providing for termination of pregnancy on request up to 20 weeks gestation. Teenagers do not need to get parental consent for the procedure. Access to terminations in the public sector is still geographically somewhat patchy, and much better in urban centres, yet about 80,000 terminations are now conducted annually on women of all ages. An early evaluation of the Act, conducted in 2000, showed that despite problems in access to services, especially for second trimester abortions, morbidity from incomplete abortion showed a differential benefit amongst teenagers compared to older women (Jewkes, Rees et al. 2005). This certainly suggests that teenagers have accessed legal services where once they illegally aborted. However, there are still considerable barriers to service use, Downloaded By: [Emory University] At: 11:20 16 October 2009 Culture, Health & Sexuality 683 including lack of information about services, hostile attitudes of health workers, inadequate access and failure to confirm pregnancy early enough (Jewkes, Gumede et al. 2005). Information is an important element in understanding about sexuality and reproduction and accessing to services for pregnancy prevention. The HIV epidemic has opened up debate around sexuality and created new spaces to discuss sexual health in families, schools and in the media (Posel 2005). Discussion has largely focused HIV prevention, whereas talk about avoiding pregnancy has been more muted. The educational system has a particular role to play in this regard and the current curriculum does cover basic reproductive physiology and related issues, but the extent to which lessons about reproductive health are taught is unsatisfactory and, furthermore, these topics are only covered in the final grades of high school, which is a level which many learners never reach, or only reach some years after the commencement of sexual activity. It seems likely that this is part of the explanation for why teenage learners who are struggling at school are more vulnerable to pregnancy. Access to information is crucial for young people who want to prevent pregnancy. Whilst concerns that providing information will ‘encourage’ teenagers to become sexually active feature prominently in discourses around teenage sexuality, international experience over several decades has shown that the country in Europe with the most extensive and open approach to sexuality education, the Netherlands, has the best record in terms of teenage pregnancy prevention (Singh and Darroch 1999). There is also a growing literature on parent child communication about sex, which has been shown to influence some areas of sexual behaviour (Ogle, Glasier and Riley 2008). This suggests that comprehensively empowering teenagers with information and skills to negotiate sexuality results in better rather than worse outcomes. The key words are support and openness. The challenge of teenage pregnancy has to be tackled from two ends – helping young people to avoid conception, on the one hand, and helping them to deal with conception (and childbirth), on the other. There are two key planks to the policy of mitigating the consequences of teenage pregnancy. The first is the 1996 South African Schools Act, which made it illegal to expel pregnant learners (Perry and Fleisch 2006). Girls could remain in school until the end of their pregnancy and return at an appropriate stage after the birth. Nevertheless a great many (mostly African) girls still have their education interrupted by pregnancy. Between 2002 and 2006 between 11.8 –17.4% of teenage girls that were not in an educational institution reported pregnancy as the main reason, this amounted to 66,000 and 86,000 learners (Lehohla 2007). The overall picture suggests that this legislation has been fairly effective. The rate of school dropout amongst African girls exceeds that of other race groups, but it has decreased dramatically over the last thirty years. Whilst between a quarter and a third of teenage girls become pregnant, there are 10% more female than male learners enrolled in secondary school grades (Department of Education 2003) and fewer girls than boys repeat secondary school grades (Unterhalter 2005). This further reminds us that there are many threats to the education of impoverished South African youth. Interestingly, the Demographic and Health Surveys clearly show that 15 –19-year-olds who are achieving well below the expected level of educational attainment for their age are at much greater risk of pregnancy and, thus, already have learning difficulties (Department of Health 1999, 2004). It seems to be the case that young women who are educationally disempowered are much more vulnerable to pregnancy, but after pregnancy many girls return to school so the overall impact on their education is mitigated. 684 R. Jewkes et al. Downloaded By: [Emory University] At: 11:20 16 October 2009 The second aspect of policy is aimed at preventing extreme child poverty. A Child Support Grant was initiated in 1998 and is payable each month to the primary care giver of a child up to 14 years of age. The Grant is quite small, but makes an important difference in the very poorest households. There has been considerable contention about whether the Grant itself may encourage teenagers to become pregnant. This is not supported by the evidence. Indeed one of the problems with the Grant is that many intended beneficiaries do not access it. In 2005, only 45% of children received the grant and only 2.7% of beneficiaries were 15– 19 years old. Nearly half of all babies are born to women under 25 years, yet only 19.3% of Grant beneficiaries were aged 15 –24 years (Makiwane and Udjo 2006). One reason for this is that an identity book is needed to get the grant and many young mothers do not have one. Another explanation is that it is the de facto child carers, the grandmothers, who are claiming the grant on behalf of children (while the biological mothers get on with their lives, including attending school). Future directions There is clearly a biological aspect to teenage pregnancy, which is acknowledged in health sector policy, and scope for improving contraceptive and pregnancy termination services and providing better information in schools to learners. This should be done. Yet services are quite extensive and the review of the broader context of teenage sexuality and pregnancy suggests that a missing piece has been a failure to adequately acknowledge and address the gendered dimensions of the problem. Viewed through a gender lens, the alignment of teenage pregnancy with aspirations of successful femininity become visible. Pregnancy is often perceived as advancing social status (a key part of processes of transition to womanhood) and may strengthen and potentially cement a relationship with a man who may be a potential husband. It may secure financial contributions in contexts of acute poverty and need and is also proof of sexual desirability. Some women value the baby as something to love, cherish and occupy them. In a context of poverty and high female unemployment, many teenagers lack other avenues through which to feel needed and fulfilled. There is evidence that it may have a similar impact on men and their self-assessment of manhood. Whilst not wanting to over-generalise, and noting that the reality of pregnancy may differ from the ideal, we suggest that it is often hopes and dreams that influence actions, rather than reality. Two important implications stem from this. The first is that for these groups of men and women, teenage pregnancy prevention requires the meaning of pregnancy for them to be changed through providing tangible alternative routes to achieving the level of affirmation and positive self-evaluation which is currently perceived as being attained through pregnancy. The second implication is that interventions to reduce teenage pregnancy need to focus on both men and women. African men have particularly been left out of the equation, yet very commonly women become pregnant as teenagers because their male partner wants them to and make it very difficult for them to resist. Social expectations that men will not be substantially involved in child care or financial support of children, critically influence the meaning and costs to men of fatherhood. Interventions have been developed to build alternative and more gender equitable models of masculinity, such as Stepping Stones, which has been rigorously evaluated and in this respect proven to be successful (Jewkes et al. 2008) and Engenderhealth’s ‘Men As Partners’ programme or Sonke’s ‘One Man Can’ campaign, ensuring that they include work with men to change expectations of engagement in child care will contribute to teenage pregnancy prevention. Culture, Health & Sexuality 685 Downloaded By: [Emory University] At: 11:20 16 October 2009 Interventions to reduce teenage pregnancy need to be framed in a way that is fundamentally empowering for teenage women. This requires interventions to address the larger picture of teenagers’ economic and future aspirations, but they also need to be framed within an overall set of values related to respect for teenagers human rights and empowerment. Instilling in health service staff ideas of respect for teenagers’ rights, is critical of efforts to improve the quality of care are to succeed and for contraceptive services to be delivered effectively. Similarly in schools, acknowledging the rights of teenagers to receive information about their bodies and sexuality in order to empower them as individuals, rather than just in order to secure completion of curriculum for an exam, is critical if this is to be provided to young people when they need it rather than when they reach the appropriate point in the educational programme (Pattman and Chege 2003). Conclusion Teenage pregnancy is perceived to be a problem that limits the life opportunities of young women and, in so doing, contributes to gender inequality and perpetuates the subordinate position of women. Reducing rates of teenage pregnancy is thus a part of the Millenium Development Goals. International policy has for some time now been attempting to address the position of women and has focused on empowering women (developing their agency) and removing obstacles that stand in their way. For the last 15 years, South Africa has followed this trend but in the very recent period a different approach has been suggested by some South African politicians. This approach seeks a return to ‘tough love’ in which girls are held to be responsible for ‘the problem’ of pregnancy and are closely monitored and disciplined in order to prevent sexual intercourse and conception. A departure from current practice, which has seen a dramatic decline in pregnancy rates, by adopting an empowering social policy agenda related to teenage sexuality, is not warranted. ‘Tough love’ or boot camps for pregnant women will strengthen gender inequalities, disempower girls and let boys off the hook. Teenage pregnancy is a deeply embedded social phenomenon. Whilst teenage women contribute to shaping it, their attitudes and actions are critically shaped by the environment in which they are socialised and the relationships which they develop. Placing the burden of responsibility for these on their shoulders alone ignores this broader understanding. There is scope for further progress in reducing teenage pregnancy but we suggest that this lies in paying more attention to the gendered features of sexuality and the terms and conditions under which they have sex. There needs to be critical reflection and engagement with men and boys on issues of masculinity, including their role in child rearing, as well as examination within families of their engagement with supporting pregnancy prevention and responses to pregnancies. Note 1. Apartheid racial classification designated South Africa’s population to be White, Coloured, African and Indian. 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Social Science and Medicine 47, no. 2: 233– 42. 688 R. Jewkes et al. Downloaded By: [Emory University] At: 11:20 16 October 2009 Résumé La réduction des taux de grossesses chez les adolescentes est une composante importante des actions à mener pour atteindre la majorité des objectifs du Millénaire pour le développement. Dans ce domaine, avec des taux de grossesses chez les adolescentes considérablement réduits ces vingt dernières années (bien qu’encore élevés), l’Afrique du Sud a une expérience importante à partager avec d’autres pays. Le pays connaı̂t des vagues de panique morale par rapport à ces taux de grossesse, engendrées par des affirmations selon lesquelles le probléme est enraciné dans l’acceptation, voire l’encouragement, de l’appétit sexuel des jeunes, quand celui-ci devrait plutèt être sévèrement contrôlé. Dans cet article, nous soutenons que les clés du succès de la réduction des grossesses chez les adolescentes résident dans les programmes d’une politique sociale conduisant à l’empowerment qui a intégré la collaboration avec les jeunes pour leur faire prendre conscience de leurs droits et des risques liés aux rapports sexuels. De plus, les ripostes familiales et la politique d’éducation ont fortement réduit l’impact négatif potentiel de ces grossesses sur la vie des adolescentes. Le champ d’actions pouvant avoir pour conséquence des progrès plus importants dans la réduction des taux de grossesse chez les adolescentes est vaste, et nous soutenons qu’il doit être fondé sur une prise en compte plus importante des questions de genre et de sexualité, incluant les termes et les conditions selon lesquels les jeunes ont des rapports sexuels. Il apparaı̂t nécessaire d’initier une réflexion et un engagement critiques avec les hommes et les garçons sur les questions de masculinité, notamment leur rôle dans l’éducation des enfants, ainsi qu’un examen de l’engagement des familles à participer à la prévention et à la gestion des grossesses chez les adolescentes. Resumen Reducir las tasas de embarazos adolescentes es una parte importante de las medidas para cumplir la mayorı́a de los objetivos de desarrollo del Milenio. A este respecto, Suráfrica tiene importantes lecciones que enseñar a otros paı́ses porque su tasa de embarazos adolescentes es alta pero ha disminuido considerablemente en los últimos veinte años. El paı́s sufre repetidas olas de pánico moral debido a los embarazos adolescentes y argumentan que los problemas actuales se deben al hecho de que se aceptan o incluso estimulan los apetitos sexuales de los jóvenes en vez de disciplinarles severamente. En este artı́culo sostenemos que el secreto del éxito para reducir los embarazos adolescentes ha sido un programa de polı́tica social emancipadora cuya finalidad era trabajar con los jóvenes y hacerles saber sus derechos y los riesgos de las relaciones sexuales. Asimismo las respuestas de las familias y la polı́tica educativa han reducido en gran medida el posible impacto negativo de los embarazos adolescentes en las vidas de las chicas adolescentes. Todavı́a queda mucho camino por hacer para conseguir reducir los embarazos adolescentes y sostenemos que la solución serı́a prestar más atención a cuestiones sobre género y sexualidad, incluyendo los términos y las condiciones en las que los adolescentes practican las relaciones sexuales. Es necesario una reflexión crı́tica y hacer participar a hombres y chicos en cuestiones de masculinidad, por ejemplo, cuál es su papel en la crianza de los hijos, ası́ como analizar cómo participan las familias en apoyar la prevención de embarazos y cómo responden si ocurren embarazos.