Unmet need for contraception among adolescent girls and young women (AGYW) contributes to high teenage pregnancy rates, which are decreasing at a slower rate in South Africa compared to other low- and middle- income countries (LMICs). In South Africa, about one in five (19%) women of reproductive age (15–49 years) have an unmet need for contraception, with even higher unmet need among adolescent girls aged 15–19 years at 31%, and 28% for young women aged 20–24 years.[1] A range of contraceptive methods including oral contraceptives, injectable contraceptives, subdermal implants, contraceptive patches, and barrier methods such as condoms and diaphragms, are provided at no cost at public health services in South Africa. However, AGYW are often offered fewer choices of contraceptive methods compared to older women and given limited explanation of mechanisms of action and side effects of the different contraceptive methods.[2–4] As a consequence, adolescents who use contraception use a limited range of methods, with most using injectable contraceptives (70%) followed by the pill (20%) and very few using other methods.[5–7] A consequence of inadequate education about contraception is that adolescents report fear of side-effects, which is an important factor hindering contraceptive use especially in LMIC.[8]
Socio-cultural beliefs, myths and misinformation about contraceptives are negatively associated with contraceptive use.[9–11] Rumours, another concept linked to myths and misperceptions, defined as ‘unverified and instrumentally relevant information statements in circulation that arise in the context of ambiguity and that function primarily to help people to make sense and manage threat’,[12] are also barriers to uptake of health interventions.[13] Rumours are neither true nor false, and their authenticity does not need to be proven beyond merely being discussed.[14] In public health, understanding the genesis of rumours is critical given the potentially adverse effects rumours may have on health-related behaviours and medical decision-making.[15] Rumours about contraception, such as that the contraceptive injection damages the body, negatively affect access and use of contraceptives.[5,9−10] Rumours together with myths and misinformation are likely to contribute to the low uptake of contraceptives and subsequently the high unmet need and unintended pregnancy rates among AGYW.
In this paper, we employ the term “unintended pregnancy” rather than “unplanned pregnancy”, however, we do so with consideration given its problematic nature. “Unplanned pregnancies” have been defined as pregnancies which occur when a woman is using contraceptives or did not wish to become pregnant, with traditional measurements dichotomously classifying pregnancies as intended or not, based on a woman’s intentions before she became pregnant.[16–17] The framing and concept of ‘unintended’ pregnancy was not the focus of investigation in this study and therefore we cautiously use the term ‘unintended’, and where possible, we use the words of AGYW respondents themselves when describing their unexpected discovery of a pregnancy, rather than categorizing the pregnancies as ‘unintended’ or not.
Reducing the unmet need for contraceptives and unintended pregnancies among AGYW requires improving the availability and accessibility of acceptable sexual and reproductive health (SRH) services that provide comprehensive contraception information and services. Ideally, SRH services would include, amongst other things, sexual rights education; information on all available contraceptive methods; confidential, non-judgemental, unbiased person-centred contraception counselling and services including explanations of mechanisms of action and side effects; and a choice of contraceptive options. Additionally, SRH services would include treatment and prevention of sexually transmitted infections (STIs) including HIV, and information and counselling services about sexuality. If SRH services are available, accessible, and acceptable to AGYW, this is likely to improve knowledge and information about different methods of contraceptives, and subsequently increase contraceptive uptake. While contraception services are primarily delivered within public health facilities in South Africa, with minimal service outreach programmes to communities and schools, the new Integrated School Health Program’s (ISHP) presented an opportunity to expand access for AGYW in schools. Unfortunately, the full implementation of the ISHP did not take off as intended, and contraceptive services are limited to public health facilities and a few outreach programmes.[18] This limits the accessibility of contraception services to AGYW in-schools.
To improve and expand access to SRH services for AGYW, a combination HIV prevention intervention was implemented between 2016 and 2019 (https://www.samrc.ac.za/intramural-research-units/HealthSystems-HERStory).[7] The intervention was implemented in ten South African districts with a high burden of HIV and where AGYW face multiple deprivations, such as limited access to health services, gender-power dynamics and limited financial resources. It aimed to promote, amongst other things, access to comprehensive HIV, TB and SRH services and SRH education for AGYW. Reducing unintended pregnancies among AGYW was one of the five key goals of the combination HIV prevention intervention, and this was to be achieved through SRH education, and linkage and referral to health services. The intervention components comprising SRH education and services would improve AGYW’s contraceptive knowledge, and thereby dispel rumours, myths and misperceptions relating to contraceptive methods. This study explores whether the existing myths and misperceptions, including rumours about contraceptives, were barriers to access and use of contraceptives among AGYW who were beneficiaries of the combination HIV prevention intervention in five South African districts.[7]