From ‘sugar daddies’ to ‘sugar babies’: exploring a pathway among age-disparate sexual relationships, condom use and adolescent pregnancy in South Africa

Abstract

Background Adolescent pregnancy has been linked to adverse outcomes. Most studies proposing risk pathways for adolescent pregnancy in South Africa are qualitative, hypothesising links among age-disparate relationships, reduced condom use and higher pregnancy rates. No known South African studies have quantitatively explored pathways to adolescent pregnancy. Objectives: This study aimed to: (i) identify the factors associated with adolescent pregnancy and (ii) explore a pathway of risk by assessing whether condom use mediated the relationship between age-disparate sexual relationships and adolescent pregnancy. Methods: A cross-sectional survey of 447 sexually active girls aged 10–19 years was undertaken in six health districts of South Africa. Multivariate logistic regressions controlled for confounders. Mediation tests used bootstrapping. Results: Consistent condom use (β = –2.148, odds ratio (OR) = 8.566, P ≤ 0.001) and school enrolment (β = –1.600, OR = 0.202, P ≤ 0.001) were associated with lower pregnancy rates. Age-disparate sex (β = 1.093, OR = 2.982, P ≤ 0.001) and long-term school absences (β = 1.402, OR = 4.061, P ≤ 0.001) were associated with higher pregnancy rates. The indirect effect of age-disparate sex on adolescent pregnancy through condom use was significant, irrespective of age, age at sexual initiation, poverty and residential environment (B = 0.4466, s.d. = 0.1303, confidence interval: 0.2323–0.7428). Conclusion: This survey supports hypotheses that inability to negotiate condom use in age-disparate sexual relationships may drive adolescent pregnancy. Interventions addressing these relationships, facilitating condom use and increasing access to sexual health services among adolescents might avert unwanted pregnancies.