Association between sexual violence and unintended pregnancy among adolescent girls and young women in South Africa

Unintended pregnancy, especially among adolescent girls and young women (AGYW) remains a concerning health and social problem in sub-Saharan Africa (SSA) and worldwide [1, 2]. Between 2010 and 2014, approximately 44.5% of all pregnancies and 23% of births were unintended worldwide [2]. Unintended pregnancy is the main reason for having an abortion [3]. Of the approximately 99 million unintended pregnancies that occur each year, more than half (56%) end in abortion [2]. Unintended pregnancy has deleterious consequences, including a heightened risk of maternal depression [4], and late initiation of antenatal care [5].

Adolescent girls and young women (aged 15–24 years) are at high risk of having an unintended pregnancy because they are far more likely to enter into sexual relationships and also more likely to delay marriage in order to complete school and become better prepared to join the labour force [6]. A study conducted in Uganda shows that sexually active adolescent girls had the highest rate of abortion (76.1 abortions per 1000 women 15–19) of all women within the reproductive age group [7]. Another study in Kenya shows that severe complications of unsafe abortion were most common among adolescent girls [8].

With figures as high as 102.8 pregnant adolescents per 1000 girls aged 15–19 years, SSA has the highest rates of teenage pregnancies in the world [9]. Early unintended pregnancy has dire health and socioeconomic consequences. Globally, pregnancy and childbirth complications are one of the leading causes of death among adolescent girls. Adolescent mothers face an increased risk of perinatal morbidities such as eclampsia, puerperal endometritis, systemic infections, low birth weight, preterm delivery, and severe neonatal conditions [10‐12]. Indeed, early adolescent pregnancy has been linked with an increased risk of HIV infection [13]. Furthermore, early childbearing also negatively impacts girls’ socioeconomic development and empowerment, further bolstering the vicious cycle of poverty [14‐17].

In South Africa, AGYW continue to get pregnant at alarmingly high rates, with about 28% of girls having begun childbearing by their nineteenth birthday [18]. Contributing factors have been described as multifaceted, and include individual, household, community, and structural factors [19]. At the individual level, the high prevalence of unintended pregnancies has been associated with limited contraceptive knowledge, incorrect and inconsistent contraceptive use, inaccessibility of contraceptives [1, 20‐22]. At the household and family level, household poverty, lack of family support, death of parents, lack of communication with parents about sex encounters, and single-parent family structure are associated with early-unintended pregnancies [23‐27]. At the community level, community-level poverty, rural residence, cultural norms that foster gender inequality and violence against women are among the factors associated with a higher likelihood of unintended pregnancies [23, 24]. Structural factors associated with the increased level of early unintended pregnancy include restrictive policies - such as laws on age of consent for contraception services, healthcare systems failures, inadequate access to contraception as well as epileptic availability and access to reproductive healthcare services [28, 29].

While several studies have focused on the influence of contraceptive access and poverty on the increased risk of having an unplanned pregnancy [1, 20, 23], the contribution of sexual violence to increased risk of unintended pregnancy particularly among AGYW has received limited attention, with only a few studies from other regions focusing on this link [30‐33]. The pathway through which sexual violence could lead to unintended pregnancy is through non-use of contraceptive, underreporting of incidences of sexual violence, and lack of requisite care to address the potential impacts of sexual violence, including unintended pregnancy [34, 35]. Individuals who rape young people are likely not to use condoms, and since the knowledge of emergency contraception is low among AGYW [36, 37], the risk of them having an unintended pregnancy is high. Also, given that victims of sexual violence rarely come forward, the risk of having unintended pregnancy is high as young people are rarely going to know how to prevent pregnancy after exposure to forced and coerced sex.

Several studies have linked sexual violence to increased risk of HIV infection [38, 39], poor mental health outcomes [40, 41], poor self-rated health [41] and non-use of contraceptives [39] among AGYW in South Africa, but sparse attention has been given to the effect of sexual violence and unintended pregnancy. However, studies have examined the link between coerced first sex and unintended pregnancy, reporting contrasting results [13, 42]. Christofides et al. (2014) show that physical abuse is associated with a higher likelihood of unintended pregnancy. But, they found no relationship between coerced first sex and unintended pregnancy in contrast to an earlier study by Maharaj and Munthree (2007). Overall, most studies on unintended pregnancy among AGYW in South Africa focused on the role of gender inequality, socioeconomic inequalities, and lack of contraceptive access and use, with limited attention to the role of sexual violence. As such, the main research question this study examines is: what is the link between sexual violence and unintended pregnancy among AGYW? Our study adds to the growing body of knowledge by determining the magnitude of unintended pregnancies as well as examining the relationship between sexual violence and unintended pregnancies among AGYW in South Africa. The study finding will be useful in developing policies and strategies to improve the sexual and reproductive health outcomes of young people. Specifically, our findings could inform the implementation of youth-friendly sexual and reproductive health services in South Africa.

This study examines the relationship between sexual violence and unintended pregnancies among AGYW in South Africa. We found a high prevalence of unintended pregnancy (41.5%) among AGYW in our study setting, with a quarter of all unintended pregnancies resulting in abortions. Over 91% of pregnancies among AGYW are unintended in our study cohort. Our findings further add to the growing body of knowledge, showing a high prevalence of unintended pregnancy among AGYW in South Africa. Underuse of contraceptives has been attributed to the high rate of unintended pregnancy among AGYW in SSA [20]. Thus, addressing unintended pregnancy among AGYW in South Africa will require increasing access to contraceptive information and services.

Our result, consistent with previous studies [30‐33], demonstrates clear, consistent, and robust evidence supporting our proposition that AGYW with lived experiences of sexual violence (AOR:1.76, 95% CI:1.07–2.90) are more likely to report unintended pregnancies. The pathway through which sexual violence could lead to unintended pregnancy is through non-use of contraceptive, underreporting of incidences of sexual violence, and lack of requisite care to address the potential impacts of sexual violence, including unintended pregnancy. It is clear from extant studies that most victims of sexual violence do not officially report rape incidence or even mention it to other people [34]. Lack of reporting of sexual violence incidences may mean survivors will not receive the necessary care needed. Also, it is well established that most perpetrators of sexual violence are close to the survivors, with friends and boyfriends being the most likely culprits, making the incidence more frequent and the consequences severe [35]. For example, the prevalence of forced sexual initiation ranges from 4 to 31% [40]. AGYW are also at a disadvantage because they have low knowledge of after sex contraception [36, 37], implying that if they fail to report or seek care, their risk of unintended pregnancy increases.

Given that early-unintended pregnancies worsen the socioeconomic outcomes of AGYW [14‐17], there is a need for research that examines how sexual violence against women could worsen gender inequalities and female poverty. Aside from providing access to contraceptive information and services, there is a need for holistic efforts to expand young people’s knowledge and awareness around female sexual and reproductive health rights. Furthermore, it is vital that sex education, which highlights the damaging effects of sexual violence, discourages hegemonic masculinity, and encourages responsible sexual decision making, be included in schools’ curriculums, and be made an integral part of religious/community body events to ensure that out-of-school children are not left out. Parents, caregivers, and guardians should additionally assume the responsibilities of teaching these important lessons at home. As social pressure or fear of stigma may mean that sexual violence cases are underreported, it is crucial that responsible authorities launch appropriate investigations when cases of sexual assaults are reported, and ensure justice served accordingly in addition to providing judgment-free victim support, which will encourage other victims to speak up.

Consistent with previous research in sub-Saharan Africa, our study found a high prevalence of unintended pregnancy among adolescents and young women, suggesting that despite improved access to contraceptives in South Africa, the magnitude of unintended pregnancy remains high. We also found that sexual violence is associated with a higher likelihood of unintended pregnancy. As such, addressing unintended pregnancies among AGYW in South Africa requires interventions that not only increase access to contraceptive information and services but also reduce sexual violence and cater for survivors. Future studies should examine the link between sexual violence and unintended pregnancy among out of school girls as well as the potential link between exposure to sexual violence and gender inequality and female poverty.