14 December 2018

South Africa: Did Teen Pregnancy Really Increase By 80 Percent in This Province?

This province reported skyrocketing rates of teen pregnancy but behind the figures lies a story about sex, knowledge and data.

Angela Baloyi's* old room is empty.

There's a wooden cupboard against one wall and a container with odds and ends in the corner. A black plastic toy motorcycle is on its side in the doorway.

Nothing else.

"She can't fall asleep there anymore," says Baloyi's older sister, Lebo*.

One night, about four months ago, in September, a stranger came into the room where Angela and her younger brother Musa used to sleep every night and switched off the lights. She felt a knife against her throat.

The man raped her, then fell asleep. Angela, 15, didn't move. She was terrified.

But then the stranger woke up and raped her again.

By the time the sun came up, Musa, 5, had built up the courage to slip out and alert the neighbours. The rapist was still asleep next to his sister.

Angela is shy and soft-spoken. But when she talks about that night, she speaks with confidence, and quickly, hardly taking breaths between sentences.

Her eyes are downcast and her hand rests on a small bulge underneath a blue and red checked blanket. "I was eight months pregnant when I got raped."

Back then, Angela had no idea what the difference between sex and rape was. She also didn't know sex without a condom could get her pregnant.

Teenagers are falling through the gaps in knowledge around sex, rape and pregnancy. (Dylan Bush)

A few months before her rape, an aunt took Angela to the local clinic when she complained of feeling nauseous.

Angela had been getting her period for two years, but no one had explained to her that, once girls start menstruating, it's a sign they can get pregnant.

When the nurse told her she was expecting, Angela was shocked. "I was scared and confused," she says. "I didn't believe I could fall pregnant so young."

Yet Angela and her boyfriend had been having sex for months. "My boyfriend and I didn't use anything," she explains shyly. "I didn't think it was necessary because I was only 15."

Angela remembers life orientation teachers talking to her and her classmates about contraceptives such as condoms or the injection. She learned that having sex without a condom put her at risk of contracting viruses such as HIV or bacteria that can cause sexually transmitted infections (STIs).

But she didn't grasp that unprotected sex could also make her fall pregnant. Because she didn't know sex with her boyfriend could get her pregnant, she hadn't used contraceptives.

Angela was not the only teenager who lacked basic reproductive knowledge.

She was one of more than 10 000 underage girls falling pregnant in Mpumalanga between 2017 and 2018, according to health department figures presented in the provincial legislature in August. The data reveals teenage pregnancies in the province shot up by almost 80% from the previous year.

"Sexuality education at schools is failing young girls like Angela," Human Sciences Research Council (HSRC) researcher Roshin Essop says. "We're far away from giving kids relevant information about relationships and sex."

Essop says girls are getting confusing information from their mothers: moms tell their daughters about their periods, but in the same breath, that teenagers shouldn't have relationships.

"Adults want to protect the innocence of young women, especially in rural areas," she explains.

Government's She Conquers campaign is hoping to increase access to sexual and reproductive health services for adolescents and young women through youth-friendly clinics, youth clubs and even parenting classes for teen parents like Angela. The programme is part of a push under the national HIV plan to reduce risky behaviour among young people and specifically teen mothers, that could increase their chances of contracting HIV.

A 2018 South African Journal of Child Health study, conducted among young adolescents in Mpumalanga, confirms this: "The idea of withholding sexuality information from young adolescents is seen as a way to preserve their innocence and purity," the authors write. "This belief fuels negative responses to young adolescents' curiosity about sex and prevents them from accessing sexual and reproductive health information and services."

Children who knew they could get condoms at the nearest clinic also said health workers would probably stop them. "They never ask when older people take them, but they shout at young children, so it won't be easy [to get condoms]," 11-year-old Buzwe told the researchers.

Mokhantso Makoae is a population health researcher at the HSRC. "Sex education, particularly for girls between the ages of 10 and 14, is not reaching adolescents properly," she says. "Whenever I hear of a 'youth programme', I know they won't focus on younger adolescents. Even in cases where nongovernment organisations go into communities to help, this group is not prioritised."

Makoae explains: "The repercussions for young people's lives is far-reaching."

Musa, Baloyi's young brother, was forced to wait until his sister's armed attacker had fallen asleep to slip out and call for help. (Dylan Bush)

Almost 2 000km from the Baloyi family, in a Khayelitsha school, an HSRC researcher sits down with 14-year-old Dineo Tshobo*. "Do you think Noloyiso should tell the police when her boyfriend Xolani forces her to have sex?" the researcher asks.

Dineo replies: "No, no, that's normal. He gives her money for things she needs, so when Xolani wants something [sex] she must give him. He deserves it."

This research is part of a five-year pilot project - called the Kwanele Intervention - that will challenge harmful gender norms uncovered among schoolchildren, including ideas that women should provide sex in exchange for material and emotional support and that those who decline sex are "just playing hard to get".

Through role-playing, children from 20 schools in Khayelitsha near Cape Town learn to rethink toxic notions about relationships, the programme manager at the youth non-profit Grassroot Soccer Mbulelo Malotana explains. The organisation is helping the HSRC to run the project with the health organisation Soul City Institute for Social Justice.

The early results from the study are shocking.

Almost half of primary school pupils in Khayelitsha have experienced sexual violence. Children as young as 10-years-old reported, for instance, being slapped or verbally threatened. A fifth of youngsters were forced to perform humiliating acts or were raped.

Some said they were threatened with a weapon to have sex.

The study also revealed that primary school children are at a higher risk of abuse than their older peers, but they were unequipped to talk about it. Primary school pupils were unlikely to understand that they had been raped and were instead quick to say that they "agreed in the end", lead researcher Ingrid Lynch told Bhekisisa in August.

Back in Bushbuckridge, young girls aren't taught about rape either. "My friends and I have never talked about rape. I had never heard of it before [it happened to me]," Angela says.

As in Angela's case, children are mostly only warned about the dangers and diseases associated with sex, says Benita Moolman, who researches gender at the HSRC. These messages are important, but they can't be taught without explaining how relationships work in real life. "Young people are exploring relationships whether adults tell them it's dangerous or not," she says.

Moolman says teaching young adolescents, and especially young girls, about relationships can help them to avoid the dangerous situations their teachers warn them against. "Instead of telling them not to go into relationships, teach them how to set goals and boundaries."

She concludes: "Such lessons could give girls the self-confidence to leave bad relationships."

What happens when you don't know sex without a condom could get you pregnant? Teen pregnancy rates soar. (Dylan Bush)

When Mpumalanga health MEC Sasekani Manzini revealed that more than 10 000 teenagers in the province had become mothers, it spurred a flurry of news articles.

But these numbers could be misleading. "Teen pregnancies have not necessarily increased that much. We have just been getting better at detecting them," Makoae explains.

At just under 8%, Mpumalanga's teen pregnancy rate is higher than the national average of 6.8%, data from the Health Systems Trust revealed in 2017. But, in total, the number of teenagers giving birth in hospitals in South Africa has dropped by 12% in the past five years.

Without context, dramatic statistics can inflame myths about teenage pregnancies, Makoae says. "In reality, teenage pregnancies are a symptom of society's ignorance of what young girls like Angela need."

For example, Makoae says, media reports have alleged that people get pregnant for grant money.

But there's no proof for that.

A 2015 PLoS ONE study found no evidence that adolescent mothers were deliberately getting pregnant for child grants. In addition, a 2012 household survey published in the journal African Health Sciences revealed that most girls - almost three-quarters - who had children in their adolescence said their pregnancies were unintended. The survey, which was conducted in the Eastern Cape, Gauteng, KwaZulu-Natal and Mpumalanga, revealed that 55.5% of female respondents between 18 and 24 got pregnant the first time because they did not understand the risks involved in what they were doing or did not understand how pregnancy happens.

On paper, South Africa's sexual education policies are leading the way on the continent, Makoae says.

In 2017, South Africa's department of basic education released its first new HIV policy in 20 years. In the document, the department commits to facilitating access to condoms for all learners 12 years or older as well as school staff. It also says that roving health department teams or other qualified health workers will provide sexual and reproductive health services to pupils, including youth-friendly health services such as screening for sexually transmitted infection - preferably in their home languages.

Read the education department's HIV policy

But teachers, who often work in under-resourced schools, frequently don't get the message across, she explains. "Teachers are missing the opportunity to teach children about human sexuality because it often goes against their own beliefs."

In a rural province like Mpumalanga, teachers are sometimes the only ones talking to children about sex, says the HSRC's Roshin Essop. The South African Journal of Child Health research showed that teachers in poorer communities lack the support they need to do this efficiently.

When children go home, Essop says, they often face stigma about sex that stops them from asking their parents questions. But there could be an easy way to make sure children get the information they need by using tools that already exist.

Makoae says the clinic booklets parents get when their children are born could just as easily be used for sex education. These documents make communication between homes and clinics easier by telling parents what health services their child needs in early life. She says a similar booklet with sexual health information for young adolescents could help to bridge the gap between classrooms and clinics. And parents can keep track of what their children are learning, she explains.

Clinics could help to find out why young girls are falling pregnant by simply asking, Democratic Alliance spokesperson for health in Mpumalanga Jane Sithole argues. Health facilities already gather information about patients when they come in. So, adding one or two questions about the reasons the young women fall pregnant could help us to track what information is still missing, she says.

On the 10-minute drive to the hospital, Angela does not say a word. She's gone into labour, but her face doesn't betray a thing

"She doesn't talk much," her sister says. "But she's strong."

*Not their real names.

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