IJG-08594; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa Linda R. Vollmer ⁎, Zephne M. van der Spuy Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
a r t i c l e
i n f o
Article history: Received 13 July 2015 Received in revised form 14 October 2015 Accepted 15 January 2016 Keywords: Adolescents Contraception Pregnancy Teenagers
a b s t r a c t Objective: To evaluate knowledge and use of contraception among pregnant teenagers in the Cape Town metropolitan area. Methods: A cross-sectional study enrolled women aged 16 to 19 years who were pregnant and attending prenatal clinics, and prenatal and labor wards at regional hospitals and midwife-run obstetric clinics in the Cape Town area between March 1, 2011 and September 30, 2011. Data were collected using an administered questionnaire. Results: The study enrolled 314 participants. Of the participants, 240 (76.4%) felt their pregnancies had occurred at the “wrong time” but only 38 (12.1%) were using contraception at the time of conception. The form of contraception that participants most commonly had knowledge of was injectable hormonal contraception (274 [87.3%]). Contraception use was low, with 126 (40.1%) participants having never used contraception. The forms of contraception used most commonly were the male condom (106 [33.8%]) and injectable contraception (98 [31.2%]). The majority of participants found it easy to get contraception (192 [61.1%]) and felt that information regarding contraception was readily available (233 [74.2%]). Conclusion: Contraception use is suboptimal but this may not simply be a reflection of ineffective family-planning services. Further research is needed to fully explain the lack of contraceptive use in this population. © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The provision of effective contraception to all women is a global priority in keeping with Millennium Development Goals 5A and 5B, which aim to improve maternal and reproductive health. Female adolescents, defined by WHO as women aged 10–19 years, represent a group where unintended pregnancies often have the most far reaching consequences. It has been estimated that 13 million adolescents give birth worldwide each year, 90% of these occur in low-income countries [1]. According to the 2003 South African Demographic and Health Survey [2], by the time they reach 19 years of age, 27.3% of women in South Africa have been pregnant. In the province of the Western Cape, approximately 10% of women younger than 19 years old are parents. According to the HIV and AIDS national strategic plan from the South African Department of Health, “teenage pregnancy is by definition indicative of unsafe sex and should be understood in the context of the HIV/AIDS epidemic” [3]. In 2007, the South African Minister of Education, Naledi Pandor, described teenage pregnancy as one of the reasons for gender inequality in education [4]. Data from the Annual Surveys of Ordinary Schools [5]
⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Stellenbosch, P.O. Box 19081, Tygerberg 7505, South Africa. Tel.: + 27 21 938 9209; fax: +27 21 938 9849. E-mail address: [email protected] (L.R. Vollmer).
show that 45 276 South African learners were reportedly pregnant in 2009, with most of these believed to be younger than 16 years of age. Contraceptive use among teenagers in South Africa has been reported to be 59% [6]. However, many teenagers only come into contact with family planning services once they are already pregnant. These services have often been described as being inadequate, necessitating the provision of adolescent-focused contraceptive services. These include community education and the inclusion of contraceptive services and education at schools. Countries such as the Netherlands, which have lower teen pregnancy rates and a later age of sexual debut, have prepared for an increasingly sexual society and ensure that their youth are well informed [7]. The present study was designed to evaluate the timing of pregnancies and to determine the knowledge and use of contraceptives among pregnant teenagers who were attending obstetric services. A secondary aim was to identify where teenagers access contraception and to examine their perception of available family planning services. 2. Materials and methods In a descriptive cross-sectional study, women aged 16–19 years were recruited from the prenatal clinics, and prenatal and labor wards of two regional hospitals and three midwife-run obstetric clinics in the Cape Town metropolitan area between March 1, 2011 and September 30, 2011. Approval for the study was granted by the Human Research Ethics Committee of the Faculty of Health Sciences at the
http://dx.doi.org/10.1016/j.ijgo.2015.10.011 0020-7292/© 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Vollmer LR, van der Spuy ZM, Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.10.011
2
L.R. Vollmer, Z.M. van der Spuy / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx
University of Cape Town (HREC REF 561/2010) and from the Provincial Health Research Council of the Western Cape (RP 82/2011). Members of the Human Research Ethics Committee of the University of Cape Town Faculty of Health Sciences, including a community representative, advised that it was justified to waive parental consent for women under the age of 18 years owing to the minimal risk involved and because the questions were considered by the Human Research Ethics Committee to be non-invasive. All participants provided verbal consent to participate in the present study. All women aged 16–19 years attending the study clinics and wards were eligible for enrollment. They were informed of the study and given an information leaflet to read. Women under the age of 16 years were excluded from the trial; ethical constraints made the recruitment of these women without parental consent difficult. Additionally, there are difficulties in the reporting and follow-up for individuals younger than the legal age of consent as stipulated in the Sexual Offences Act. Data collection was performed using an administered questionnaire. The questionnaire was piloted and administered by members of the research team (L.V. with the assistance of a research nurse) from the Reproductive Medicine Unit at the University of Cape Town; the team administering the questionnaire was not involved in the obstetric care of the participants. All participants were given the option of including parents or guardians in the interview. All patients who agreed to participate were counselled and interviewed in private. The anonymity and confidentiality of the study were guaranteed to all participants. Eligible patients who refused to participate in the study were assured that this would not jeopardize their present or future treatment. Participation was entirely voluntary and patients were not offered any monetary incentive for participating in the study. According to routine practice at the study institution, all patients under the age of 18 years received a pre- or post-natal referral to a social worker to address any social issues of importance. All data from completed questionnaires were entered into a database using Epidata version 3.1 (The EpiData Association, Odense, Denmark). All data were double entered and questionnaires were securely retained and stored at the Reproductive Medicine Unit. Statistical analysis was performed using Stata version 11 (StataCorp, College Station, TX, USA) with the assistance of Henri Carrara from the School of Public Health and Family Medicine in the University of Cape Town. Demographic details were presented in a descriptive manner. 3. Results In total, 318 women agreed to participate in the study. It was necessary to exclude four volunteers because they were found to be younger than their stated age of 16 years, resulting in the study group comprising 314 patients. The mean age of participants was 18.1 years. Of the respondents, 281 (89.5%) were primigravidas, 30 (9.6%) were experiencing their second pregnancy, and the current pregnancy was the third pregnancy for 3 (1.0%) participants. In total, 3 (1.0%) individuals had previously undergone an induced abortion (Table 1). No participants took up the option of having their parents or guardians present for the interview. Among the participants, 240 (76.4%) described their pregnancies as having occurred at the “wrong time”. When asked when they would have preferred to be pregnant for the first time, 137 (57.1%) would have preferred to wait 5 years and 47 (19.6%) stated that they would Table 1 Characteristics of the study population (n=314). a Characteristic
Value
Age, y Primigravida Multigravida Parous Participant has previously undergone an induced abortion
18.1 (16–19) 281 (89.5) 33 (10.5) 19 (6.1) 3 (1.0)
a
Values are given as mean (range) or number (percentage) unless indicated otherwise.
have delayed their first pregnancy by 10 years. Of the 55 participants aged 16 years, 51 (92.7%) answered that they would have waited 5–10 years before their first pregnancy. Despite the majority of respondents stating their pregnancies had not occurred at the right time, only 38 (12.1%) of all participants were using contraception at the time of conception. Of the 55 participants aged 16 years, only 4 (7.3%) were using contraception. Despite not using contraception, 135 (43.0%) participants described having been concerned about the possibility of an unintended pregnancy. Women were asked to name, without prompting, methods of contraception they had heard of and the methods of contraception they had used previously. The best-known form of contraception among participants was injectable hormonal contraception (274 [87.3%]), followed by the male condom (197 [62.7%]). Other methods of contraception mentioned were the oral contraceptive pill (187 [59.6%]), the female condom (63 [20.1%]), and the intrauterine contraceptive device (22 [7.0%]). Induced abortion was listed as a method of contraception by 5 (1.6%) participants. Emergency contraception was mentioned by 18 (5.7%) individuals as a form of contraception. Only 22 (7.0%) participants said abstinence could prevent pregnancy (Table 2). When asked what methods of contraception they had used previously, contraception usage was very low overall. In total, 126 (40.1%) participants had never used any form of contraception. The most commonly used forms of contraception were the male condom (106 [33.8%]) and injectable contraception (98 [31.2%]). The oral contraceptive pill had been used by 23 (7.3%) participants (Table 3). When asked about emergency contraception specifically, 126 (40.1%) participants said they had heard of it. Using emergency contraception had been considered previously by 26 (8.3%) individuals and 107 (34.1%) knew where to access it; however, only 3 (1.0%) participants had ever used emergency contraception. Induced abortion, which is available on request within the public health service, had been considered to end the current pregnancy by 83 (26.4%) participants, but they had not used this option. The majority of participants reported finding it easy to access contraception (192 [61.1%]). The most commonly reported source of contraception was family planning clinics (120 [38.2%]) but other outlets were mentioned, including day hospitals, general practitioners, schools, and youth centers. In total, 233 (74.2%) participants reported feeling that information regarding contraception was readily available. Only 43 (13.7%) patients stated that they would value receiving more information regarding contraception, sexual health, and women’s health. 4. Discussion The present study provides data about knowledge and use of contraception among female adolescents in the Cape Town metropolitan area. Whereas participants were aware of a variety of contraceptive methods and reported finding information on contraception readily available, usage rates were generally low.
Table 2 Knowledge of contraceptive methods among study participants (n=314). Method of contraception
No. (%)
Diaphragm Intrauterine contraceptive device Injectable hormonal contraception Combined oral contraceptive pill Female sterilization Male sterilization Induced abortion Emergency contraception Female condom Male condom Abstinence
4 (1.3) 22 (7.0) 274 (87.3) 187 (59.6) 11 (3.5) 2 (0.6) 5 (1.6) 18 (5.7) 63 (20.1) 197 (62.7) 22 (7.0)
Please cite this article as: Vollmer LR, van der Spuy ZM, Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.10.011
L.R. Vollmer, Z.M. van der Spuy / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx Table 3 Contraceptive methods previously used by study participants (n=314). Method of contraception
No. (%)
Injectable hormonal contraception Combined oral contraceptive pill Emergency contraception Female condom Male condom Abstinence No previous use of contraception
98 (31.2) 23 (7.3) 3 (1.0) 8 (2.5) 106 (33.8) 2 (0.6) 126 (40.1)
It is concerning that only 12.1% of participants reported using contraception at the time of conception. This figure is lower that than reported by Vundule et al. [6] in a study with a similar study population who were pregnant in the Cape Town area; the study found that 19.6% of participants were using contraception in the previous year. Of note, non-pregnant individuals recruited to a control group in this study reported a contraceptive-usage rate of 59% (odds ratio 0.15; 95% confidence interval 0.10–0.25) [6]. The low level of contraceptive use must be interpreted together with the finding that the majority of individuals in this study said their pregnancies had occurred at the wrong time, with 19.6% of these participants stating their pregnancies had occurred 10 years earlier than they would have preferred. The effects of an earlier pregnancy can have a significant impact on both parents and children, including a loss of further education, employment opportunities, resultant poverty, and unstable relationships [8]. It is difficult to explain why, despite not using contraception, only 43.0% of women were concerned about unintended pregnancy. Of the 23.6% of participants who felt their pregnancies had occurred at the right time, it is uncertain whether these pregnancies were intentional. It was felt that exploring pregnancy intendedness fell outside of the scope of the present study. It is possible that some participants intended to become pregnant at a young age and the reasons for this would need further investigation. It is clear that attitudes toward sexual activity in this population require further investigation. In a study from the United States, Zabin et al. [9] reported that twice as many teenagers visited a family planning clinic because they suspect pregnancy compared with the number who attended for the provision of contraception. It seems clear that improving family planning services cannot entirely solve this problem if teenagers do not access contraception before becoming sexually active. This theme was also demonstrated when comparing knowledge of contraception and the use of contraception by adolescents. The majority of participants knew of injectable contraception and the oral contraceptive pill; however, most had never used these methods despite the fact that they are available free of charge. There seems to be a barrier between providing contraception and educating young women about safe sex, and the uptake and reliable use of these services. A study by Wood and Jewkes [10] could help aid understanding of teenage perceptions of contraception. The adolescents interviewed for the study (all from a rural area in South Africa) had received very little information regarding menstruation, sex, and contraception, and many were misinformed. They perceived the nursing staff to be judgmental and scolding, with very little respect for privacy. It is interesting that, in the present study, 233 (74.2%) participants reported that information regarding contraception was readily available, with only 48 (15.3%) participants finding fault with contraceptive services. It appears that, for the majority of patients, inadequate provision of family planning services did not play a role in them not having used contraception. However, this study was not designed to determine teenagers’ attitudes toward contraceptive services in great depth and it is possible that there could be underlying factors impacting on contraceptive use that can only be fully appreciated with qualitative research. Furthermore, the fact that 38.8% of participants reported having difficulty in obtaining family planning services demands further interrogation.
3
It also concerning that only 62.7% of participants in the present study named the male condom as a form of contraception. While it is assumed that all the participants had heard of the male condom, it is possible that condoms are considered to be used for the prevention of HIV/AIDS and not for contraception. This possibility is echoed by a study conducted by Kenyon et al. [11] in Cape Town, which found that condoms were less likely to be used with regular “faithful” partners compared with more casual relationships or sexual encounters. MacPhail et al. [12] also found that condom use declines as relationships progress. This supports the theory that condoms are used mainly to prevent HIV but that once in a stable relationship where women deem themselves to no longer be at risk of HIV, condom use declines, increasing the risk of unintended pregnancy if no additional contraceptive method is being used [12]. Several limitations were identified in the present study. When using the administered questionnaire, participants could have inadvertently excluded some important information, potentially introducing study bias. It was unfortunate that individuals younger than 16 years were excluded from the present study because they represent a particularly at-risk and vulnerable group. Ethical constraints made the recruitment of these women without parental consent difficult and including only individuals whose parents or caregivers were available to provide consent could have introduced further bias. Additionally, there are difficulties in the reporting and follow-up of these participants, as stipulated in the Sexual Offences Act. According to the Sexual Offenses Act 32 of 2007, any sexual act involving an individual younger than 16 years, even if consensual, is classified as statutory rape and must be immediately reported. Individuals in this age group are also more likely to have adverse social circumstances, possibly having been victims of abuse. It was felt that any investigation enrolling such a population should be performed by a research team equipped to report this appropriately, as well as provide the necessary counselling and support. The present study is an exploratory study and, as such, provides an overview of contraceptive usage and the timing of pregnancy among teenage patients accessing services at the study centers. It was not possible to explore all themes fully for practical reasons and some areas demand further research. It was felt, at the onset of the present study, that some questions would have been better answered by qualitative research for fear of over simplifying very complex issues. Specific issues identified include pregnancy intendedness, reasons for not using contraception, and barriers to contraceptive use. Qualitative research enrolling a similar group of patients, as well as a case–control study of pregnant versus matched non-pregnant controls, could yield more information and provide greater insight into perceptions around sexual relationships, contraception, and teen pregnancy. Adolescent pregnancy is an issue of global importance, particularly in Africa where the most economically and socially disadvantaged young women often experience the consequences of unintended pregnancies. It is clear that contraception use was poor in the study group but the reasons why this was the case are complex. It is important to not simply regard this as a reflection of ineffective family planning services. The uptake of contraception is an important issue and reflects attitudes among adolescents regarding sex and relationships in general. The present study suggests that young people should be provided with information about contraception at a young age, before they become sexually active. This should ideally be combined with HIV-prevention education and programs designed to empower young women to make responsible life choices and negotiate their own relationships. Acknowledgements JS Scratchley Trust provided funding for this study. Conflicts of interest The authors have no conflicts of interest.
Please cite this article as: Vollmer LR, van der Spuy ZM, Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.10.011
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L.R. Vollmer, Z.M. van der Spuy / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx
References [1] United Nations Population Fund. State of World Population 2003. http://www. unfpa.org/sites/default/files/pub-pdf/swp03_eng.pdf. [Published 2003. Accessed 3 April, 2012]. [2] Department of Health, Pretoria, South Africa. 2. South African Demographic and Health Survey 2003. https://dhsprogram.com/pubs/pdf/FR206/FR206.pdf. [Published 2007. Accessed 22 April, 2012]. [3] Berry L, Hall K. Teenage Pregnancy. www.childrencount.ci.org.za/uploads/NSPteenage-pregnancy.pdf. [Published 2009. Accessed 4 September, 2013]. [4] Address by the Minister of Education Naledi Pandor at the National Youth Commission conference on Young Women and Development, Johannesburg. http://polity. org.za/article/sa-pandor-national-youth-commission-conference-on-youngwomen-and-development-2007-08-30. [Published 2007. Accessed 22 April, 2012]. [5] Department of Basic education, Republic of South Africa. Report on the 2009/2010 Annual Surveys for Ordinary Schools. http://www.education.gov.za/LinkClick.aspx? fileticket=iY%2BR%2Bgav688%3D&tabid=57&mid=2632. [Published 2012. Accessed 4 September, 2013].
[6] Vundule C, Maforah F, Jewkes R, Jordaan E. Risk factors for teenage pregnancy among sexually active black adolescents in Cape Town. A case control study. S Afr Med J 2001;91(1):73–80. [7] Kmietowicz Z. US and UK are top in teenage pregnancy rates. BMJ 2002;324(7350): 1354. [8] Klein JD. American Academy of Pediatrics Committee on Adolescence. Adolescent pregnancy: current trends and issues. Pediatrics 2005;116(1):281–6. [9] Zabin LS, Clark Jr SD. Why they delay: a study of teenage family planning clinic patients. Fam Plann Perspect 1981;13(5):205–7 211–7. [10] Wood K, Jewkes R. Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa. Reprod Health Matters 2006;14(27):109–18. [11] Kenyon C, Boulle A, Badri M, Asselman V. "I don't use a condom (with my regular partner) because I know that I'm faithful, but with everyone else I do": The cultural and socioeconomic determinants of sexual partner concurrency in young South Africans. SAHARA J 2010;7(3):35–43. [12] MacPhail C, Pettifor AE, Pascoe S, Rees HV. Contraception use and pregnancy among 15-24 year old South African women: a nationally representative cross-sectional survey. BMC Med 2007;5:31.
Please cite this article as: Vollmer LR, van der Spuy ZM, Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.10.011
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa Linda R. Vollmer ⁎, Zephne M. van der Spuy Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
a r t i c l e
i n f o
Article history: Received 13 July 2015 Received in revised form 14 October 2015 Accepted 15 January 2016 Keywords: Adolescents Contraception Pregnancy Teenagers
a b s t r a c t Objective: To evaluate knowledge and use of contraception among pregnant teenagers in the Cape Town metropolitan area. Methods: A cross-sectional study enrolled women aged 16 to 19 years who were pregnant and attending prenatal clinics, and prenatal and labor wards at regional hospitals and midwife-run obstetric clinics in the Cape Town area between March 1, 2011 and September 30, 2011. Data were collected using an administered questionnaire. Results: The study enrolled 314 participants. Of the participants, 240 (76.4%) felt their pregnancies had occurred at the “wrong time” but only 38 (12.1%) were using contraception at the time of conception. The form of contraception that participants most commonly had knowledge of was injectable hormonal contraception (274 [87.3%]). Contraception use was low, with 126 (40.1%) participants having never used contraception. The forms of contraception used most commonly were the male condom (106 [33.8%]) and injectable contraception (98 [31.2%]). The majority of participants found it easy to get contraception (192 [61.1%]) and felt that information regarding contraception was readily available (233 [74.2%]). Conclusion: Contraception use is suboptimal but this may not simply be a reflection of ineffective family-planning services. Further research is needed to fully explain the lack of contraceptive use in this population. © 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The provision of effective contraception to all women is a global priority in keeping with Millennium Development Goals 5A and 5B, which aim to improve maternal and reproductive health. Female adolescents, defined by WHO as women aged 10–19 years, represent a group where unintended pregnancies often have the most far reaching consequences. It has been estimated that 13 million adolescents give birth worldwide each year, 90% of these occur in low-income countries [1]. According to the 2003 South African Demographic and Health Survey [2], by the time they reach 19 years of age, 27.3% of women in South Africa have been pregnant. In the province of the Western Cape, approximately 10% of women younger than 19 years old are parents. According to the HIV and AIDS national strategic plan from the South African Department of Health, “teenage pregnancy is by definition indicative of unsafe sex and should be understood in the context of the HIV/AIDS epidemic” [3]. In 2007, the South African Minister of Education, Naledi Pandor, described teenage pregnancy as one of the reasons for gender inequality in education [4]. Data from the Annual Surveys of Ordinary Schools [5]
⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Stellenbosch, P.O. Box 19081, Tygerberg 7505, South Africa. Tel.: + 27 21 938 9209; fax: +27 21 938 9849. E-mail address: [email protected] (L.R. Vollmer).
show that 45 276 South African learners were reportedly pregnant in 2009, with most of these believed to be younger than 16 years of age. Contraceptive use among teenagers in South Africa has been reported to be 59% [6]. However, many teenagers only come into contact with family planning services once they are already pregnant. These services have often been described as being inadequate, necessitating the provision of adolescent-focused contraceptive services. These include community education and the inclusion of contraceptive services and education at schools. Countries such as the Netherlands, which have lower teen pregnancy rates and a later age of sexual debut, have prepared for an increasingly sexual society and ensure that their youth are well informed [7]. The present study was designed to evaluate the timing of pregnancies and to determine the knowledge and use of contraceptives among pregnant teenagers who were attending obstetric services. A secondary aim was to identify where teenagers access contraception and to examine their perception of available family planning services. 2. Materials and methods In a descriptive cross-sectional study, women aged 16–19 years were recruited from the prenatal clinics, and prenatal and labor wards of two regional hospitals and three midwife-run obstetric clinics in the Cape Town metropolitan area between March 1, 2011 and September 30, 2011. Approval for the study was granted by the Human Research Ethics Committee of the Faculty of Health Sciences at the
http://dx.doi.org/10.1016/j.ijgo.2015.10.011 0020-7292/© 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Vollmer LR, van der Spuy ZM, Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.10.011
2
L.R. Vollmer, Z.M. van der Spuy / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx
University of Cape Town (HREC REF 561/2010) and from the Provincial Health Research Council of the Western Cape (RP 82/2011). Members of the Human Research Ethics Committee of the University of Cape Town Faculty of Health Sciences, including a community representative, advised that it was justified to waive parental consent for women under the age of 18 years owing to the minimal risk involved and because the questions were considered by the Human Research Ethics Committee to be non-invasive. All participants provided verbal consent to participate in the present study. All women aged 16–19 years attending the study clinics and wards were eligible for enrollment. They were informed of the study and given an information leaflet to read. Women under the age of 16 years were excluded from the trial; ethical constraints made the recruitment of these women without parental consent difficult. Additionally, there are difficulties in the reporting and follow-up for individuals younger than the legal age of consent as stipulated in the Sexual Offences Act. Data collection was performed using an administered questionnaire. The questionnaire was piloted and administered by members of the research team (L.V. with the assistance of a research nurse) from the Reproductive Medicine Unit at the University of Cape Town; the team administering the questionnaire was not involved in the obstetric care of the participants. All participants were given the option of including parents or guardians in the interview. All patients who agreed to participate were counselled and interviewed in private. The anonymity and confidentiality of the study were guaranteed to all participants. Eligible patients who refused to participate in the study were assured that this would not jeopardize their present or future treatment. Participation was entirely voluntary and patients were not offered any monetary incentive for participating in the study. According to routine practice at the study institution, all patients under the age of 18 years received a pre- or post-natal referral to a social worker to address any social issues of importance. All data from completed questionnaires were entered into a database using Epidata version 3.1 (The EpiData Association, Odense, Denmark). All data were double entered and questionnaires were securely retained and stored at the Reproductive Medicine Unit. Statistical analysis was performed using Stata version 11 (StataCorp, College Station, TX, USA) with the assistance of Henri Carrara from the School of Public Health and Family Medicine in the University of Cape Town. Demographic details were presented in a descriptive manner. 3. Results In total, 318 women agreed to participate in the study. It was necessary to exclude four volunteers because they were found to be younger than their stated age of 16 years, resulting in the study group comprising 314 patients. The mean age of participants was 18.1 years. Of the respondents, 281 (89.5%) were primigravidas, 30 (9.6%) were experiencing their second pregnancy, and the current pregnancy was the third pregnancy for 3 (1.0%) participants. In total, 3 (1.0%) individuals had previously undergone an induced abortion (Table 1). No participants took up the option of having their parents or guardians present for the interview. Among the participants, 240 (76.4%) described their pregnancies as having occurred at the “wrong time”. When asked when they would have preferred to be pregnant for the first time, 137 (57.1%) would have preferred to wait 5 years and 47 (19.6%) stated that they would Table 1 Characteristics of the study population (n=314). a Characteristic
Value
Age, y Primigravida Multigravida Parous Participant has previously undergone an induced abortion
18.1 (16–19) 281 (89.5) 33 (10.5) 19 (6.1) 3 (1.0)
a
Values are given as mean (range) or number (percentage) unless indicated otherwise.
have delayed their first pregnancy by 10 years. Of the 55 participants aged 16 years, 51 (92.7%) answered that they would have waited 5–10 years before their first pregnancy. Despite the majority of respondents stating their pregnancies had not occurred at the right time, only 38 (12.1%) of all participants were using contraception at the time of conception. Of the 55 participants aged 16 years, only 4 (7.3%) were using contraception. Despite not using contraception, 135 (43.0%) participants described having been concerned about the possibility of an unintended pregnancy. Women were asked to name, without prompting, methods of contraception they had heard of and the methods of contraception they had used previously. The best-known form of contraception among participants was injectable hormonal contraception (274 [87.3%]), followed by the male condom (197 [62.7%]). Other methods of contraception mentioned were the oral contraceptive pill (187 [59.6%]), the female condom (63 [20.1%]), and the intrauterine contraceptive device (22 [7.0%]). Induced abortion was listed as a method of contraception by 5 (1.6%) participants. Emergency contraception was mentioned by 18 (5.7%) individuals as a form of contraception. Only 22 (7.0%) participants said abstinence could prevent pregnancy (Table 2). When asked what methods of contraception they had used previously, contraception usage was very low overall. In total, 126 (40.1%) participants had never used any form of contraception. The most commonly used forms of contraception were the male condom (106 [33.8%]) and injectable contraception (98 [31.2%]). The oral contraceptive pill had been used by 23 (7.3%) participants (Table 3). When asked about emergency contraception specifically, 126 (40.1%) participants said they had heard of it. Using emergency contraception had been considered previously by 26 (8.3%) individuals and 107 (34.1%) knew where to access it; however, only 3 (1.0%) participants had ever used emergency contraception. Induced abortion, which is available on request within the public health service, had been considered to end the current pregnancy by 83 (26.4%) participants, but they had not used this option. The majority of participants reported finding it easy to access contraception (192 [61.1%]). The most commonly reported source of contraception was family planning clinics (120 [38.2%]) but other outlets were mentioned, including day hospitals, general practitioners, schools, and youth centers. In total, 233 (74.2%) participants reported feeling that information regarding contraception was readily available. Only 43 (13.7%) patients stated that they would value receiving more information regarding contraception, sexual health, and women’s health. 4. Discussion The present study provides data about knowledge and use of contraception among female adolescents in the Cape Town metropolitan area. Whereas participants were aware of a variety of contraceptive methods and reported finding information on contraception readily available, usage rates were generally low.
Table 2 Knowledge of contraceptive methods among study participants (n=314). Method of contraception
No. (%)
Diaphragm Intrauterine contraceptive device Injectable hormonal contraception Combined oral contraceptive pill Female sterilization Male sterilization Induced abortion Emergency contraception Female condom Male condom Abstinence
4 (1.3) 22 (7.0) 274 (87.3) 187 (59.6) 11 (3.5) 2 (0.6) 5 (1.6) 18 (5.7) 63 (20.1) 197 (62.7) 22 (7.0)
Please cite this article as: Vollmer LR, van der Spuy ZM, Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.10.011
L.R. Vollmer, Z.M. van der Spuy / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx Table 3 Contraceptive methods previously used by study participants (n=314). Method of contraception
No. (%)
Injectable hormonal contraception Combined oral contraceptive pill Emergency contraception Female condom Male condom Abstinence No previous use of contraception
98 (31.2) 23 (7.3) 3 (1.0) 8 (2.5) 106 (33.8) 2 (0.6) 126 (40.1)
It is concerning that only 12.1% of participants reported using contraception at the time of conception. This figure is lower that than reported by Vundule et al. [6] in a study with a similar study population who were pregnant in the Cape Town area; the study found that 19.6% of participants were using contraception in the previous year. Of note, non-pregnant individuals recruited to a control group in this study reported a contraceptive-usage rate of 59% (odds ratio 0.15; 95% confidence interval 0.10–0.25) [6]. The low level of contraceptive use must be interpreted together with the finding that the majority of individuals in this study said their pregnancies had occurred at the wrong time, with 19.6% of these participants stating their pregnancies had occurred 10 years earlier than they would have preferred. The effects of an earlier pregnancy can have a significant impact on both parents and children, including a loss of further education, employment opportunities, resultant poverty, and unstable relationships [8]. It is difficult to explain why, despite not using contraception, only 43.0% of women were concerned about unintended pregnancy. Of the 23.6% of participants who felt their pregnancies had occurred at the right time, it is uncertain whether these pregnancies were intentional. It was felt that exploring pregnancy intendedness fell outside of the scope of the present study. It is possible that some participants intended to become pregnant at a young age and the reasons for this would need further investigation. It is clear that attitudes toward sexual activity in this population require further investigation. In a study from the United States, Zabin et al. [9] reported that twice as many teenagers visited a family planning clinic because they suspect pregnancy compared with the number who attended for the provision of contraception. It seems clear that improving family planning services cannot entirely solve this problem if teenagers do not access contraception before becoming sexually active. This theme was also demonstrated when comparing knowledge of contraception and the use of contraception by adolescents. The majority of participants knew of injectable contraception and the oral contraceptive pill; however, most had never used these methods despite the fact that they are available free of charge. There seems to be a barrier between providing contraception and educating young women about safe sex, and the uptake and reliable use of these services. A study by Wood and Jewkes [10] could help aid understanding of teenage perceptions of contraception. The adolescents interviewed for the study (all from a rural area in South Africa) had received very little information regarding menstruation, sex, and contraception, and many were misinformed. They perceived the nursing staff to be judgmental and scolding, with very little respect for privacy. It is interesting that, in the present study, 233 (74.2%) participants reported that information regarding contraception was readily available, with only 48 (15.3%) participants finding fault with contraceptive services. It appears that, for the majority of patients, inadequate provision of family planning services did not play a role in them not having used contraception. However, this study was not designed to determine teenagers’ attitudes toward contraceptive services in great depth and it is possible that there could be underlying factors impacting on contraceptive use that can only be fully appreciated with qualitative research. Furthermore, the fact that 38.8% of participants reported having difficulty in obtaining family planning services demands further interrogation.
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It also concerning that only 62.7% of participants in the present study named the male condom as a form of contraception. While it is assumed that all the participants had heard of the male condom, it is possible that condoms are considered to be used for the prevention of HIV/AIDS and not for contraception. This possibility is echoed by a study conducted by Kenyon et al. [11] in Cape Town, which found that condoms were less likely to be used with regular “faithful” partners compared with more casual relationships or sexual encounters. MacPhail et al. [12] also found that condom use declines as relationships progress. This supports the theory that condoms are used mainly to prevent HIV but that once in a stable relationship where women deem themselves to no longer be at risk of HIV, condom use declines, increasing the risk of unintended pregnancy if no additional contraceptive method is being used [12]. Several limitations were identified in the present study. When using the administered questionnaire, participants could have inadvertently excluded some important information, potentially introducing study bias. It was unfortunate that individuals younger than 16 years were excluded from the present study because they represent a particularly at-risk and vulnerable group. Ethical constraints made the recruitment of these women without parental consent difficult and including only individuals whose parents or caregivers were available to provide consent could have introduced further bias. Additionally, there are difficulties in the reporting and follow-up of these participants, as stipulated in the Sexual Offences Act. According to the Sexual Offenses Act 32 of 2007, any sexual act involving an individual younger than 16 years, even if consensual, is classified as statutory rape and must be immediately reported. Individuals in this age group are also more likely to have adverse social circumstances, possibly having been victims of abuse. It was felt that any investigation enrolling such a population should be performed by a research team equipped to report this appropriately, as well as provide the necessary counselling and support. The present study is an exploratory study and, as such, provides an overview of contraceptive usage and the timing of pregnancy among teenage patients accessing services at the study centers. It was not possible to explore all themes fully for practical reasons and some areas demand further research. It was felt, at the onset of the present study, that some questions would have been better answered by qualitative research for fear of over simplifying very complex issues. Specific issues identified include pregnancy intendedness, reasons for not using contraception, and barriers to contraceptive use. Qualitative research enrolling a similar group of patients, as well as a case–control study of pregnant versus matched non-pregnant controls, could yield more information and provide greater insight into perceptions around sexual relationships, contraception, and teen pregnancy. Adolescent pregnancy is an issue of global importance, particularly in Africa where the most economically and socially disadvantaged young women often experience the consequences of unintended pregnancies. It is clear that contraception use was poor in the study group but the reasons why this was the case are complex. It is important to not simply regard this as a reflection of ineffective family planning services. The uptake of contraception is an important issue and reflects attitudes among adolescents regarding sex and relationships in general. The present study suggests that young people should be provided with information about contraception at a young age, before they become sexually active. This should ideally be combined with HIV-prevention education and programs designed to empower young women to make responsible life choices and negotiate their own relationships. Acknowledgements JS Scratchley Trust provided funding for this study. Conflicts of interest The authors have no conflicts of interest.
Please cite this article as: Vollmer LR, van der Spuy ZM, Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.10.011
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L.R. Vollmer, Z.M. van der Spuy / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx
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Please cite this article as: Vollmer LR, van der Spuy ZM, Contraception usage and timing of pregnancy among pregnant teenagers in Cape Town, South Africa, Int J Gynecol Obstet (2016), http://dx.doi.org/10.1016/j.ijgo.2015.10.011
