Public concern over adolescent sexual health and the resolutions to these concerns has over the past three decades generated political debate and academic inquiry the world over. At the core of adolescent sexual health is the issue of teenage pregnancy. South Africa has not been spared from the challenges teenage pregnancy presents. Inquiry into teenage pregnancy in South Africa began in the 1980s. In an effort to control the prevalence of teenage pregnancy, academics and policy makers alike have developed various strategies and policies targeting teenagers. Yet three decades later, teenage pregnancy still remains a topical issue in South Africa.
About 16 million adolescent girls between 15 and 19 years give birth each year worldwide, and 80% of these girls are found in developing countries (World Health Organisation, 2010). In South Africa, 40% of all births involve girls under the age of 19 years, and 35% of these teenagers, give birth before reaching the age of 19 years (Medical Research Council, 2009).According to the Department of Basic Education (2009), in South Africa, a total of 45,000 teenagers were pregnant in 2008, while the number increased to 49,000 in 2009.
This chapter examines literature on teenage pregnancy, and will assist in providing rationale and context for this study. This literature review will deviate from the traditional Knowledge, Attitude and Perception (KAP) literature studies that isolate individuals from social, cultural and economic contexts that influences and shape their lives. The weakness of KAP studies is that they do not acknowledge the effect of cultural, economic and societal factors on human behavior. Jewkes et al. (2001) add that KAP studies on teenage pregnancy in South Africa have mainly been descriptive and do not make an effort to account for the gap between knowledge, attitude and perception. In effort to account for these discrepancies, and come up with gaps in teenage pregnancy research, this literature review has been divided into the following two sections (i) the consequences of child bearing on teenagers, and (ii) factors contributing to teenage pregnancy.
CONSEQUENCES OF CHILDBEARING FOR TEENAGERS
The challenge of unplanned and unwanted pregnancy for a teenager has long-term consequences, not only for the mother, but for society as a whole, with far-reaching implications for economic and social development. Mpanza (2010:66) puts forward that “teenagers who drop out of school due to pregnancy never do well after they return from childbirth”, this can be attributed to divided loyalties between taking care of the child and continuation of school. Because of its usually unwanted and unplanned nature, teenage pregnancy always poses a health and social risk, a point further supported by Edgardh (2000), Genius and Genius (2004), Santelli (2000), and Petiffor et al. (2004). These studies confirm that early sexual initiation is a predictor of risky sexual behaviour and is more likely to be non-consensual, unprotected and to be subsequently regretted, resulting in unplanned and unwanted pregnancy.
While the consequences of teenage pregnancy are varied, it is important to acknowledge that teenage pregnancy is a result of a complex set of varied, but interrelated factors. An understanding of these factors will enable a better understanding of the knowledge, attitudes and perceptions of teenagers towards teenage pregnancy.
Disruption of school
Teenage pregnancy has the potential of limiting a learner’s future career prospects. For the pregnant learner, impending motherhood forces her to drop out of school as she is unable to continue studying (Macleod &Tracey, 2009). Learners are forced to leave school when their pregnancy has progressed as schools are “considerate of their state” (Bhana & Swartz, 2009). The Department of Education’s (DoE) 2007 Measures for the Prevention and Management of Learner Pregnancy “makes it possible for educators to ‘request’ learners take a leave of absence for up to two years” (Macleod & Tracey, 2009:15). Even with legislation in place, pregnant teenagers are sent away from school earlier than they should (ibid). This is probably due to the perception that pregnant learners are a bad influence to other learners.
Vagueness and ambiguity of the education guideline presents a challenge to the educators who are left to interpret it at their discretion. For instance, the document puts the responsibility of parenting firmly on the learner, and states that a “period of two years may be necessary for this purpose. No learner shall be should be re-admitted in the same year that they left school due to pregnancy” (DoE, 2007:5), educators are left to decide how long the learner stays away from school. This ruling may be in conflict with the desires of the young mother who may have sufficient support at home, which enables her to return to school earlier than expected (Bhana & Swartz, 2009).
Young fathers are also affected by pregnancy, albeit differently. It has been reported that impending fatherhood, cultural and societal expectations may force the young father to leave school and seek employment. This is conditional as it depends on whether the boy accepts responsibility or not (Shefer & Morrell, 2012; Bhana & Swartz, 2009).
However, Macleod and Tracey (2009) argue that the level of disruption caused by pregnancy on learners is debatable as learners drop out of school for various reasons of which teenage pregnancy is one. Preston-Whyte and Zondi (1992) concur with this assertion. Manzini’s (2001) study of teenage pregnancy in KwaZulu-Natal (KZN) indicates that more than 20.6% of pregnant teenagers had already dropped out of school before falling pregnant. Apart from falling pregnant, teenagers may leave school due to frustrations associated with the inexperience of teachers, who often are required to teach in areas that are not their expertise, and a lack of relevance of the curriculum and teaching materials (Human Science Research Council, 2007). Among factors within the home that led to drop-out, learners in this study cited the absence of parents at home, financial difficulties and the need to care for siblings or sick family member.
Strassburg et al. (2010) and Fleisch et al. (2010) concur with the 2007 HRSC findings and assert that the reasons teenagers drop out of school are a combination of inter-related factors. As such, Fleisch et al. (2010) note that poverty alone cannot best explain why teenagers drop out of school, because there are other factors such as academic ability of the teenager, teacher-pupil relationship, support from home and school, alcohol and drug abuse and family structure that contribute to school dropout.
Lloyd and Mensch (1995:85) summarise the various reasons why teenagers may drop out of school by stating that,
Rather than pregnancy causing girls to drop out, the lack of social and economic opportunities for girls and women and the domestic demands placed on them, coupled with the gender inequities of the education system, may result in unsatisfactory school experiences, poor academic performance, and acquiescence in or endorsement of early motherhood.
However, pregnancy ranks among the top contributors to school dropout for girls in South Africa (HRSC, 2009).
While pregnancy may not be the reason for leaving school, child care is a reason for not returning to school. Manzini (2001) indicates that young mothers, who have to take care of their babies, and find it difficult to juggle student life and being a mother, ultimately drop out. Various reasons for not returning to school have been explored, among them being a lack of a support structure, financial challenges and access to a Child Support Grant (CSG). Research in South Africa indicates that teenagers who do not have support from their families and struggle financially once the baby is born, usually dropout of school so as to provide for the baby and themselves (Bhana & Swartz, 2009). On the other hand, studies in Brazil and Guatemala indicate that girls are forced to look for jobs to supplement family income and take care of the new family member (Hallman et al., 2005).
Young mothers who have support structures in the form of parents and grandparents have an opportunity of returning to school (Grant & Hallman, 2006). Matthews et al. (2008) concur and maintain that the presence of an older female in the family enables learners to return to school, while the absence of the same forces them to look for alternative ways of making a living. This is the same with teenage fathers who have accepted responsibility and have family that is prepared to support the child (Bhana & Swartz, 2009). The return to school in South Africa is motivated by a desire for a better life. Anecdotal evidence suggests that parents of African teenage mothers usually send the teenager back to school, since she has a higher chance of fetching high bride price in the event that she gets married. In the African belief system, an educated woman is bound to fetch a higher price than that of an uneducated one (Macleod, 2009; Mkwananzi, 2011; Bhana, Swartz & Morrell, 2012). Kaufman, de Wet and Stadler (2000) concur, adding that the fact that the teenager has proven her fertility actually increases her chances of marriage in future. Interestingly, teenagers in Hlabangana’s 2012 study in Soweto (South Africa) indicated that falling pregnant before marriage decreases the bride price, as prospective grooms consider the teenage mothers as ‘used goods’. Reasons for returning to school after pregnancy may vary for both sexes, but the important part is that the teenager is back in school.
Clearly the effects of teenage pregnancy on the teenager vary for the young parents, the difference may lie in the financial circumstances of the teenagers’ family and on the part of the young father whether or not he accepts responsibility of the pregnancy. The consequences of dropping out of school for teenage girls due to pregnancy cannot be overestimated, especially in a continent where the adage ‘when you educate a woman , you educate a nation holds true (Hubbard, 2009: 223). The main thrust of the study is to understand why teenagers continue falling pregnant in the face of efforts by the South African government in trying to manage teenage pregnancy. In an effort to control and manage teenage pregnancy, the government has provided youth-friendly clinics, life skills programmes in schools and is currently on a much opposed drive to supply condoms in schools. Opposition for distributing condoms in schools comes from parents who fear that by distributing condoms in schools, teenagers are given indirect permission to indulge in sexual activities.
In light of the efforts made by the South African government and a decade of spending on teenage pregnancy management, figures still indicate that teenage pregnancy rates are on the increase nationwide. Disruption of school, as a consequence of teenage pregnancy merits scrutiny in this study, as it will enable an understanding of their perceived effect of teenage pregnancy on young girls who are pregnant.
Research on health risks associated with early childbirth in teenagers is mainly divided into two main camps. One camp argues that teenagers are at risk of health problems due to their socio-economic status. The other camp, which is scientific, argues that age at first childbirth puts young women at risk of health problems as she is not mature enough to push the baby, and this proves fatal to both mother and child. Some young mothers who have assisted births end up having obstetric complications such as hemorrhaging and damage to the womb. Macleod (2009) identifies paucity of research in South Africa in terms of health risks associated with early childbirth.
Age at first child birth contributes to a range of complications, including pregnancy-induced hypertension, anemia, obstructed and prolonged labour, low birth weight, preterm labour and delivery, perinatal and infant mortality, and maternal mortality (WHO, 2007). These complications are usually associated with the physical immaturity of teenagers, an assertion that Cameron (1996) supports and adds that limited access to health care services is another contributing factor to the range of complications. He suggests that “complications become more pronounced when the teenager decides to terminate pregnancy” (Cameroon, 1996:83).
In South Africa, the Choice on Termination of Pregnancy Act (No. 92 of 1996) allows minors under the age of 18 years to terminate a pregnancy without the consent of either parents or guardians. Manzini (2001) suggests that due to health personnel attitudes, teenagers are forced to have unsafe abortions, which may lead to death. Lack of support structure before and after termination maybe the reason for teenagers resorting to ‘self-administered terminations’ and this usually leads to irreversible damage to the womb or even death (Petiffor et al., 2005).
Sexually active young fathers face different health challenges from those of the young mother and child. Bhana and Swartz (2009) indicate that young fathers in Cape Town (South Africa), often have multiple and concurrent partners (MCP), and this puts them at great risk of contracting and spreading HIV. However, they are quick to mention that impending fatherhood for those that have accepted responsibility is cause for behaviour change. MCPs are one of the main drivers of the spread of HIV (Halperin & Epstein, 2007). Young men put themselves at risk by practicing unprotected sex with multiple partners who themselves may be part of a potentially sexual network.
Geronimus and Sanders (1992) observe that young African American women who live in conditions of poverty are more prone to problems as they are unable to access pre- and post-natal care. They note that this is different for white teenage mothers who are the bulk of teenage mothers in America. Geronimus and Sanders (1992) suggest that this may be due to the differences in economic status of the teenagers. Macleod (1999) points out that despite their socio-economic status, teenage mothers hardly ever access pre- and post-natal services. This may be due to the ‘stigma’ associated with teenage pregnancy, and may also be due to the attitudes of service providers. While studies may site negative attitudes of staff towards teenagers (Wood & Jewkes, 2003), Ehlers (2003) paints a more positive picture, arguing that youth-friendly services initiated by South Africa’s Department of Health (DoH) have made great strides in addressing the stigma attached to adolescent sexuality.
The Child Support Grant (CSG)
Social grants or assistance can best be described as non-contributory cash transfer programmes set up by the government for the under privileged, aged or vulnerable (Grosh et al., 2008). Social grants are very important as they assist in alleviating poverty, reducing the level of vulnerability of vulnerable groups in society and providing social insurance to the vulnerable groups in society (Neves et al., 2009).
The CSG was first introduced in South Africa in April 1998 as a poverty alleviation strategy for the poorest children (Parliamentary Liaison Office, 2007). Initially restricted to children under the age of seven years, it was later extended to include 14 year olds in 2003. According to Hall (2011), the CSG pay-out in 2011 was R275 per month per child.
A lot of debate surrounds the CSG and teenage pregnancy in South Africa with the media fuelling the opinion that teenagers fall pregnant to access the CSG. Popular opinion states that the CSG has led to a perverse incentive for teenagers to conceive and go on to spend the money on personal goods (Macleod, 2006). In response to the media outcry, the Department of Social Development (DSD) commissioned research into the matter in 2006. The research concluded that there was no direct relationship between CSG and teenage pregnancy (Kesho Consulting, 2006). Other research by Makiwane and Udjo (2006) concluded that there is no evidence that the CSG leads to an increase in welfare dependency in South Africa. Furthermore, during the period in which the CSG has been offered, rates of termination of pregnancy have increased (Macleod, 2009). In 1998, when the CSG was introduced, abortion rates were at 4.1%, a decade later abortion rates were at their all-time high of 8.1 %, and in 2011 they were at 6.3%. Macleod (2009) suggests that the high rate of abortion amongst teenagers, in the face of the CSG, is evidence that there is no relationship between the CSG and teenage pregnancy.
Matsidiso Nehemia Naong (2011) concurs with research that indicates that there is no link between the CSG and teenage pregnancy. In her study of three of South Africa’s provinces (Free State, Mpumalanga and Eastern Cape), Naong’s sample of 302 school principals and 225 Grade 12 learners indicated that there was no relationship between the CSG and teenage pregnancy. Instead, the study concluded that poverty, peer pressure and substance abuse contributed to teenage pregnancy. Naong concludes that teenage pregnancy and CSG are divorced and any influence between the two is negligible.
Interestingly enough, anecdotal evidence suggests that more and more teenage girls are falling pregnant in an effort to access the CSG so as to complement household earning or in some instances the CSG is the main source of income. In such cases teenage pregnancy ceases to be unplanned and becomes planned and unwanted. In a 2005 study of CSG use in KZN, Case, Hosegood and Lund (2005) showed that 12.1% of pregnant teenagers who had conceived cited the CSG as the reason. Tyali (2012) in his study of HIV and AIDS communication in Platfontein (South Africa) found that teenagers were deliberately falling pregnant so as to access the CSG, while others wanted to access the HIV and AIDS grant.
Marsh and Kau’s (2010) study of teenagers’ perceptions and understanding of teenage pregnancy, sexuality and abortion concurs with Tyali’s (2012) conclusion that teenagers deliberately fall pregnant to access the CSG. Using a population sample of 35 teenagers (24 girls and 11 boys), Marsh and Kau (2010) discovered that the CSG was perceived as means of increasing household income, by having a baby, the teenager then contributes towards the household income through access of the CSG. Interestingly, Marsh and Kau’s research population indicated that the influence or pressure to bear children in order to access the CSG came from family. On the other hand other teenagers viewed the CSG as a way of increasing the pocket money for clothes and cell phones.
On the other hand, the CSG has been credited with enabling teenager mothers to return to school. “The CSG is associated with an increase in school attendance and improved child health and nutrition. Thus, the grant can be associated with an improvement in the lives of children whose caregivers receive the CSG on their behalf” (Macleod, 2009:24).
It will be interesting to find out how teenagers perceive the relationship between the CSG and teenage pregnancy. Their attitudes regarding the grant will also be important in the formulation of a communication intervention, and eventually contribute towards efforts to manage teenage pregnancy rates.
CONTRIBUTING FACTORS TO TEENAGE PREGNANCY
The present study does not look at pregnant teenager’s knowledge, attitudes and perceptions towards teenage pregnancy; instead it focuses on non-pregnant teenagers’ knowledge attitudes and perceptions towards teenage pregnancy. Having said that, contributing factors to teenage pregnancy merit exploration as these factors will shed light on knowledge, attitudes and perceptions towards teenage pregnancy. Understanding how teenagers make meaning of teenage pregnancy through their knowledge, attitudes and skills is important in particular if this understanding is viewed through the contributory factors to teenage pregnancy.
Contributing factors to teenage pregnancy are important for this study as they will put the study in context and enable the researcher not to take the revisionist and reductionist approach towards teenage pregnancy. The reductionist and revisionist approaches to teenage pregnancy ignore other non-sexual factors that contribute to teenage pregnancy. The following contributing factors were apparent in this review of the literature and will be dealt with in the following sections:
Family is an important unit for socialisation as it enables the sharing of beliefs and ideals that lead to societal norms. Research indicates that family relations are an important aspect in teenage pregnancy rates. Eaton (2003) and Bhana (2004) found that teenagers with single parents were prone to risky sexual behaviour, and pregnancy compared to those with both parents. This may be attributed to issues to do with shared control and responsibility of both parents, whereas in single family parents control is vested in one parent. Family form becomes a protective condition to young people. Muchuruza (2000) concurs and puts forward that in Tanzania teenagers coming from single parent families have risky sexual behaviour and are more likely to become young parents. Where the single parent struggles to provide for the girl child, the girl is at greater risk of pregnancy as she has to look for means of survival and usually this is achieved through intergenerational relationships. The major reason why teenagers engage in intergenerational relationships with older men and women is that they see them as providers of social status symbols such as flashy cell phones and jewellery, while at the same time taking care of their basic needs. Such relationships jeopardize the health of the two people involved as the teenager is unable to negotiate for safe sex because of fear of losing their economic goals (Leclerc-Madlala, 2008). Most documented research on intergenerational relationships is between girls and ‘sugar daddies’. These ‘sugar daddies’ feel that such relationships are transactional hence there is no need for them to use protection (ibid). Such relationships leave the teenager vulnerable to HIV and AIDS, pregnancy, Sexually Transmitted Infections (STIs) and to sexual manipulation.
Bhana’s (2004) Cape Town (South Africa) study found that 66% of the teenagers reported that family norms enabled them to have people to advise them on how to live a constructive life, while 55% said that availability of family members acted as source of control for their sexual behaviour. This is evidence that family relations play an important part in the behaviour of teenagers and most importantly their sexual behaviour.
The presence of a responsible biological father encourages girls to delay their sexual debut and instils in boys a sense of sexual responsibility. Blum and Mmari (2005) point out that the presence of a male figure in a household and their attitude to sexual behaviour plays an important part in influencing teenagers’ sexual behaviour. They found that girls with father figures who were against premarital sex were less likely to engage in premarital sex and experience unplanned pregnancy, compared to those with father figures who had sexually permissive attitudes and those without fathers. In the same context, Loving’s (1993) investigation into the connection between family relationships and teenage pregnancy in Durban (South Africa), established that warm relationships between fathers and their daughters played an important role in delaying young girls’ sexual initiation.
Mfono (2008) holds the view that teenage girls whose mothers were teenage mothers themselves have a greater chance of being teenage mothers. Arai (2008) observed that in Britain and America, the daughter of a teenage mother is one and a half more likely to become a teenage mother herself than the daughter of an older mother. This, according to Hlabangana (2012) is due to the fact that these teenagers come from communities where it is ‘normal’ to be a teenage mother, since almost everyone has been or is a teenage mother. The HRSC’s 2008 study of perceptions towards teenage pregnancy in Johannesburg, Cape Town and Durban (South Africa) coincides with Hlabangana’s assertion that teenage pregnancy has been normalised. According to the respondents of the HRSC study, non-pregnant teenagers are viewed as the ‘other’, and are asked when they too will be pregnant. Such attitudes make teenage pregnancy a way of life, and teenagers themselves view teenage pregnancy as a reality that forms a part of everyday life rather than an alien occurrence (HRSC, 2008).
This cycle self-perpetuates from one generation to another until it becomes ‘acceptable and normal’ for teenagers to fall pregnant. The intergenerational cycle is a result of a lack of upward mobility; upward mobility is an individual’s ability to rise above their current social or economic position (Hlabangana, 2012). Arai (2008) considers this ‘low expectation’ on the part of teenagers, as one of the reasons that perpetuates the intergenerational cycle of teenage pregnancy. This she attributes to structural factors in deprived communities such as schools that fail to give teenagers a reason to feel entitled to anything. Knowledge, attitudes and perceptions of teenagers towards teenage pregnancy may be rooted in the ‘lack of upward mobility’ that Arai refers to.
Arai (2008) notes that in Britain, the low expectation argument for teenage pregnancy is a powerful one as evidenced by many British researchers (Garlick et al., 1993; Rosato, 1999; Selman, 1998; Smith, 1993; Wilson, 1991). She puts forward that in Britain, teenage pregnancy is very high amongst teenagers who do not have family support, come from broken homes, are raised by single parents, have difficulty with school and who come from socially disadvantaged backgrounds. According to Arai (2008), teenagers from such backgrounds have access to contraception and sexual health information, but display a deficiency in their knowledge of sexual health, proper contraceptive use, are shy to engage in sexual health communication and are wary to access services for sexual health.
In a 1999 study in Northumberland, Britain, it was discovered that teenage parents had low educational achievement and low expectations of their future prior to their parenthood Arai (2009). She notes that these teenagers went on to have low paying jobs where they had to work long hours. In another Scottish study, (Smith,1993 in Arai, 2009) observed that teenagers from deprived backgrounds were six times likely to fall pregnant and then abort than their counter parts from well to do areas. These studies, validate Arai (2009) and Hlabangana’s (2009) notion of upward mobility and entitlement for more on the part of the teenagers.
Interestingly, Rutenberg et al. (2003:5) in their study of attitudes towards HIV and AIDS and teenage pregnancy in KZN (South Africa) discovered that “for some adolescents, increasing opportunities and aspirations for education and employment, in addition to the perceived risk of HIV and pregnancy, results in many adolescents not wanting an early pregnancy”. Rutenberg et al.’s study, validates Arai’s (2008) and Hlabangana’s (2009) assertion that teenagers with a low sense of upward mobility are most likely to find themselves as teenage parents while those with a high level of upward mobility are most likely to prevent themselves from early parenthood. This study will seek to unearth these varying dynamics in an effort to understand teenagers’ attitudes towards other teenagers who fall pregnant.
Pregnancies among teenagers are related to social problems, and this is predominant in developing countries and in particular poverty stricken communities. Risky sexual behaviours among teenagers are more likely to occur in poor families and those with single families. Lack of resources forces girls to become sexually involved in an effort to get material gains (Jewkes, Morrell & Christofides, 2009). Hallman (2004) found that in South Africa low income families contributed to risky sexual behaviour among young people in both rural and urban areas. The study argues that low income accounts for girls’ decision to engage in risky sexual behaviour in trying to make ends meet. Macleod (2009) and Manzini (2009) concur with Hallman, and further add that young people from low economic statuses are most likely not to use condoms. This is attributed to lack of access to health services, reproductive health information and proper support structures from other social institutions.
Teenagers who find themselves in intergenerational relationships find themselves unable to negotiate safe sex practices in fear of jeopardising their economic goals (Panday et al., 2009; Leclerc-Madlala, 2008). Many young women not only engage in risky sexual activities to meet their basic ‘needs’ such as money, food and clothing, but also to satisfy ‘wants’ such as expensive cell phones, high-class jewellery and rides in luxury cars (Hunter, 2002; Leclerc-Madlala, 2004). Chances of teenage pregnancy become high when the teenager comes from a home without adult supervision and most likely poor economic standing. Mfono (2003) confirms these arguments stating that teenagers are at high risk of pregnancy if they come from financially disadvantaged backgrounds, or if they succumb to peer pressure to engage in sexual activities for economic gain.
On the other hand, teenage girls reject the transactional sex talk and state that they are able to make do with what is available without having to engage in intergenerational and transactional relationships with older partners. Sathiparsad and Taylor’s (2011) study of 335 girls and boys in eThekwini Secondary Schools in Durban (South Africa) revealed that girls view themselves as independent and rational thinkers. These girls suggested that they do not think that sex is synonymous with love, and assert their power as individuals by their ability to say no to unprotected sex. This is indicative of girls resisting manipulation and normative submission (ibid). For the purposes of this study, it will be interesting to find out how teenagers perceive economic status as a contributing factor to teenage pregnancy.
The South African DoH’s Policy Guidelines for Youth and Adolescent Health (2001) locates gender considerations as fundamental to the health of young people. The policy guidelines identify sexual health and sexual exploitation, sexual abuse, gender-based violence, coercive sex and gang rapes as areas of concern that put young women in particular at risk of HIV and AIDS and teenage pregnancy.
Dunkle et al. (2004) in their study of young women attending ante-natal clinics in Soweto (South Africa) discovered that over half of the women aged between 15 and 30 years had been exposed to sexual violence. Another survey, conducted by the Planned Parenthood Association of South Africa (PPASA) in six of South Africa’s provinces, found that 20% of girls reported forced sexual encounters or were sexually assaulted (PPASA, 2003). Similarly, Vundule et al. (2001) found that 33% of girls in South Africa have their first intercourse as a result of force, including rape. Where there is unequal power distribution and lack of negotiation skills, pregnancy ceases to be a matter of choice.
Sexual violence alters the power relations in any relationship, and in most cases women are vulnerable and unable to negotiate safe sex. Teenagers may avoid negotiating contraceptive usage, in particular condoms, for fear not only of violent reactions, but also of emotional rejection, of being labelled unfaithful or HIV positive (Wood, Maforah & Jewkes, 1998). Furthermore, women attempting to use other ‘invisible’ contraceptive methods, such as the injection, may be accused by their partners of causing ‘infertility, ‘disabled babies’ and vaginal ‘