Pii: s0277-9536(00)00299-9

Social Science & Medicine 52 (2001) 1815–1826 Adolescent girls, illegal abortions and ‘‘sugar-daddies’’ in Dar es Salaam: vulnerable victims and active social agents Margrethe Silberschmidta,*, Vibeke Raschb a Department of Women and Gender Research in Medicine, Institute of Public Health, Panum Institute, University of Copenhagen, Blegdamsvej 3, 2200 Copenhagen N, Denmark b Department of Obstetrics and Gynaecology, Odense University Hospital, DK-5000 Odense C, Denmark Adolescent girls’ early sexual activity, early pregnancy, induced abortions and the increase in HIV infections have become major concerns in Sub-Saharan Africa. Efforts, though, to understand their sexual behaviour and to preventreproductive health problems are almost non-existent. Adolescent girls are normally seen as victims and easy preys of(often older and married) men’s sexual exploitation. This article, which is based on a qualitative study of 51 adolescentgirls who had just had an illegal abortion in Dar es Salaam, Tanzania, reveals that these girls are not only victims butalso willing preys and active social agents engaging in high-risk sexual behaviour. In order to get material benefits theyexpose themselves to serious health risks, including induced abortion } without realising their own vulnerability. Inour study, one out of four girls had more than one partner at the time they became pregnant, and many counted on anillegally induced abortion if they got pregnant. Even if adolescents are now allowed free access to family planninginformation, education and services, our study shows that this remains in the realm of theory rather than practice.
Moreover, most adolescent girls are not aware about their right to such services. The paper concludes that thevulnerability of adolescent girls increases without the recognition that sexuality education and contraceptive services donot constitute a licence to practice illicit sex } but rather a means to create more mature and responsible attitudes andto increase sexual and reproductive health. # 2001 Elsevier Science Ltd. All rights reserved.
Keywords: High-risk sexual behaviour; Adolescent girls; Induced abortion; Sugar-daddies; Dar es Salaam; Tanzania HIV infections occur among the 15–24 years old, withyoung girls being at particular risk from contact with Promoting adolescent sexual and reproductive health older men (Key actions for further implementation of } in particular that of girls } in the developing world has become a major issue on the international agenda.
The issue of induced abortion in most sub-Saharan Close to 17 million girls under the age of 20 give birth countries is highly controversial } as the heated each year. Most of these pregnancies are unplanned, and discussions at the International Conference on Popula- it is estimated by the WHO that as many as 4.4 million tion and Development in Cairo in 1994 clearly reflected.
abortions are sought by adolescent girls each year The issue is even more controversial when it concerns (WHO, 1998). In addition, more than 50% of all new adolescent girls, who are not expected to be sexuallyactive, though it has been repeatedly documented thatthey are (Bledsoe & Cohen, 1993). Their early sexual *Corresponding author. Tel.: +45-353-27987; fax: +45-353- activity is generally attributed to fundamental socio- E-mail address: m.silberschmidt@pubhealth.ku.dk economic change, the erosion of moral codes, familial control and abandoned rituals such as initiation 0277-9536/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 2 9 9 - 9 M. Silberschmidt, V. Rasch / Social Science & Medicine 52 (2001) 1815–1826 ceremonies which served to prepare adolescents for their abortions constitute 13% of all maternal deaths roles and responsibilities as adults. As such, early sexual (WHO, 1998). In Tanzania, illegal abortions are punish- activity is perceived as a moral problem.
able by imprisonment of up to 14 years for the Adolescent girls’ ‘illegitimate’ sexual activity, unin- abortionist, seven years for the woman herself and three tended pregnancies, induced abortions and deteriorating years for any person supplying drugs or instruments to sexual and reproductive health are often linked to the induce such an abortion. Illegal abortions, however, are fact that young girls are objects of (older) men’s choices.
hidden realities. Although the law is very strict, The ‘sugar daddy’ phenomenon which is particularly prosecutions for abortion are rare (Tumbo-Masabo & widespread in African cities is well described in the Liljestro¨m, 1994). High morbidity is connected with literature (see, for example Mpangile, Leshabari, Kayaa, illegal abortions as most are performed unsafely and by & Kihwele, 1996; Haram, 1995; Komba-Malekela & unskilled persons. This is reflected in the increasing Liljestro¨m, 1994; Bledsoe & Cohen, 1993). With number of women who have become infertile after an increasing awareness of HIV/AIDS, these men are now induced abortion (ibid). Tubal block is a principal cause increasingly blamed for luring younger, ‘safer’ girls who of failure to conceive and about 25% of these women are hopefully too young to be infected by HIV into have a history of adolescent septic abortion (ibid). Thus, sexual relations by promising them some degree of the risk of being prosecuted seems negligible compared financial security. The character, though, of these with the health risks involved in induced abortions.
relationships, the role that these men play in the girls’ The rates of unplanned pregnancies and induced lives, the use of contraceptive measures and the degree abortions in Tanzania are much higher than generally of male involvement in the girls’ induced abortion are perceived by parents, teachers and policy makers (Mpangile & Mbunda, 1993). A study of four public In Tanzania, adolescent girls’ sexual activity is on the hospitals in Dar es Salaam showed that about a third of rise, and their unwanted pregnancies and illegal abor- the women admitted with complications from an illegal tions constitute a major threat to their sexual and abortion were teenagers } 41.3% of whom aged 17 or reproductive health (UMATI, 1994; Tanzania Demo- under Mpangile, Leshabari, and Kihwele (1993). In the graphic and Health Survey, 1993, 1997). In order to early 1990s, 22% of women who delivered at the obtain a deeper insight into sensitive and less visible Muhimbili Medical Centre in Dar es Salaam were aspects of such adolescent girls, a qualitative study was teenagers. Among women hospitalised in Muhimbili undertaken in a hospital setting in Dar es Salaam. The gynaecological wards due to abortion-related complica- aim was to understand illegal abortions in a broader tions, 54% were teenagers (Tumbo-Masabo & Liljes- socio-economic and cultural context } to acquire an in- tro¨m, 1994). A study carried out from 1991–1993 in Ilala depth knowledge of adolescent girls’ sexual activity, District, Dar es Salaam showed that illegally induced their relation with their partners, to find out whether the abortions contributed to 15% of maternal deaths in that girls were ‘lured’ into unprotected sexual activity, or if district. One-third of these abortions occurred among they were active social actors themselves. Emphasis was also made to explore their access to contraceptives, and Nystrom, 1996). Studies from other sub-Saharan coun- the factors that influenced them to have an illegal and tries report similar findings (Kinoti, Gaffikin, L, Benson, expensive abortion. Although Tanzania’s Strategy for Reproductive Health and Child Survival 1997–2001 A recent hospital-based study from Dar es Salaam (1997) does give priority to adolescents’ reproductive indicates that of the 362 women who had allegedly health, there are no well co-ordinated programmes that miscarried the majority had in fact had an illegal address adolescents’ sexual and reproductive health abortion. Half of the women were aged 20 years and needs and issues. Consequently, our aim was also to under (Rasch, Silberschmidt, & Mchumvu (2000a); contribute knowledge for future reproductive health Rasch, Muhammad, Uric, & Bergstro¨m (2000b)).
initiatives aimed at adolescent girls.
Similar findings are reported in hospital-based studiesfrom other sub-Saharan countries (ibid). In general,though, the data on the extent of induced abortions in sub-Saharan Africa are unreliable. Accurate reporting isdiscouraged by the sensitive nature of the issue: Only very few African countries (e. g. Zambia, community-based surveys tend to produce gross under- Burundi and recently South Africa) permit induced estimates, and underreporting constitutes a major abortion for reasons other than those threatening life.
problem. As a result, many aspects of adolescent girls’ Elsewhere, induced abortions being illegal, the number sexual behaviour, and why they are having an induced of safely induced abortions in sub-Saharan Africa is unknown. According to the WHO, 5,000,000 unsafe Until 1994, family planning in Tanzania would be abortions are performed annually in Africa; these used solely for child-spacing purposes. Hence family M. Silberschmidt, V. Rasch / Social Science & Medicine 52 (2001) 1815–1826 planning advice was given primarily to married clients partner, the circumstances under which they met, and with at least one child. Adolescents’ access to education the girls’ feelings and expectations toward their partner.
and information on sexual matters, including contra- Other questions addressed whether the interviewee was ception had been seriously neglected, largely because of certain that a particular partner had made her pregnant, fear of encouraging any ‘immoral’ or unrestrained if she had other partners at the time she became sexual behaviour. However, acknowledging the increas- pregnant, and if she would have continued the relation- ing problem of pregnancies among adolescents, the ship had she not received material benefits.
National Policy Guidelines and Standard for Family The principal investigator collaborated very closely Planning were revised in, 1994 (Tanzania National with the interviewer during the data collection, and each Policy Guidelines and Standards for Family Planning interview was discussed in detail and repeatedly. The Service Delivery and Training, 1994). It now states that insight gathered from the initial interviews was used to ‘‘all males and females of reproductive age, including develop and add more in-depth guideline questions.
adolescents irrespective of their parity and marital Each interview lasted from two to two-and-a half hours.
status, shall have the right of access to family planning No incentives were given, but the interviewee was information, education and services’’ (1984, p. 83).
offered a refreshment during the interview. Afterwards, However, as will be discussed below, a wide discrepancy our interviewer accompanied the girl to the family exists between these guidelines and their practical planning clinic at the hospital. Here she was provided application to adolescents’ access to services.
with a choice of contraception and given a date toreturn.
All interviews were entered into a computer and grouped thematically and according to the followingcategories: age, religion, tribe, civil status, education, The present study was carried out in Dar es Salaam, occupation and place of residence of the interviewees; the capital of Tanzania, which has about two million age at first time of sexual contact; number of partners inhabitants and is divided into three districts. Each since first intercourse; number of partners when inter- district has one district hospital, and the city has one viewee became pregnant; planned or unplanned preg- referral hospital. The data collection took place at nancy; contraceptive knowledge, attitude and practice; district hospital level in one of the districts.
access to contraception; number of STDtreatments; From July to September 1997, a group of adolescents number of previously induced abortions. Each inter- registered in the admission book with the diagnosis viewee was also asked to identify what type of relation- ‘incomplete abortion’ were approached consecutively.
ship she had with the partner responsible for the Fifty-one adolescents who admitted having had an pregnancy and provide information on partner’s age, induced abortion were included in the study. Thirty- civil status, number of children and occupation of eight had the abortion performed under safe conditions partner; length of relationship with partner; frequency at the hospital where the interviews were carried out.
of sexual meetings; material exchange between inter- The remaining thirteen were admitted with complica- viewee and partner; partner’s attitude to use of contra- tions from an unsafe abortion performed by an unskilled person. All patients were informed that participation in pregnancy; partner’s (relatives’ or friends’) involvement the study was voluntary and would not affect their in providing access to and paying for the abortion; further treatment. Informed, oral consent was obtained, whether the interviewee was still seeing the partner, and if she expected the relationship to continue after the The interviews took place in a private room in the gynaecological ward. One female nurse-midwife with Because of the open-ended nature of the interview, the extensive experience in interviewing women who had an many different case stories and many quotations, each abortion, conducted the interviews. In order to establish interview was scrutinised and analysed individually. This a comfortable interaction between the interviewer and was done in order to capture all nuances, and to get a the respondent, an open, sympathetic and trustworthy full picture of the interviewee, her situation, and how she approach, free of moral judgements, was taken. Open- ended questions on sexual activity, access and use of In order to contrast our data } obtained in a district contraception, the reason for having an induced abor- hospital setting } with data collected in a non-hospital tion, and partner’s role and involvement, etc., were setting, one focus group discussion was carried out in developed. The interviewer used guideline questions to the village of Bunjo, a rural area of Dar es Salaam with a focus the discussion, but was encouraged to probe group of nine young unmarried women (15–29 years).
respondents, follow leads and note as many quotations, All of them had several self-induced abortions provoked details and case stories as possible. Special emphasis was by using locally grown herbs. They knew each other very placed on eliciting information on the relationship with well, and had agreed to participate after being informed M. Silberschmidt, V. Rasch / Social Science & Medicine 52 (2001) 1815–1826 beforehand about the theme of the discussion. The school uniform to a dress, which they had brought principal investigator and two of her research assistants along. The partner rented a room in a lodging.
led the discussion that lasted three and a half hours. The According to most girls, as both they and their partner same type of themes/questions were asked as were in the were afraid of being discovered, the intercourse took place in a great hurry. In most cases, the sexual activitylasted from 15 to 30 min.
Condoms were hardly ever used. According to the Analysis of Data from the hospital setting interviewees, the reasons given by the men were that‘they did not get the full pleasure out of the activity’ (a viewpoint that was shared by some of the girls);‘condoms delayed the activity’; ‘they are against God’s All 51 girls interviewed were unmarried. Their age will’; ‘they give discomforts and skin reactions’. The varied from 15 to 19 (on average 17.5). They had withdrawal method had not been practised. It was a different ethnic backgrounds. Eighteen of them were ‘killer procedure’, some men argued. Besides, many girls Christians and 33 were Muslims. Twenty-five of them had been told by their partner that sperm entering their (close to 50%) were still in school and resided with their vagina were good for them; ‘sperm should not be parents or relatives. The other 26 girls (51%) who were employed as house girls, barmaids or engaged in petty A few girls overlooked the possibility of becoming trade, stayed in a room at their workplace or rented a pregnant. Some thought they were too young to room. Nineteen girls (27%) had finished primary school.
conceive. ‘‘Only girls over 18 can get pregnant’’, one Age at time of first sexual contact varied from 13 to 16.
16-year old girl said. A few others believed that when Several girls said they been forced by another adoles- the sexual act was carried out in a hurry, or in a cent, a houseboy or a schoolteacher to have sex, mainly standing position, it was not possible to get pregnant.
the first time. Most of the girls’ current sexual partners Another few argued that they had not become were married men twice their age. Five of the girls pregnant with their previous partners. Therefore, it (10.2%) had had an abortion before. One of them had did not occur to them that they would get pregnant three abortions before this one. One girl had a child.
with this one. Most of the girls, though, were aware thatthey could get pregnant through unprotected sex.
However, it was not a major worry. Many thought ofthe possibility of having an abortion if they did get As described in the literature, gaining trustworthy pregnant. They also relied on their partner’s support, as answers, in general, and on sexual activity, in particular, some of them had promised assistance to ‘‘solve the has proven to be difficult due to the sensitive character problem’’ in case of pregnancy. Quite a few kept their of the issue (Rosenthal, Burklow, Biro, Pace, & DeVellis, 1996). When evaluating the first 35 interviews Only five of our respondents became pregnant after the first month of interviewing, it was found that intentionally. They had expected their partner to marry the majority of the girls claimed to have had two or three them if they did get pregnant. When their partner failed sexual partners (on average 2.7) since their sexual debut.
to recognise paternity, they decided on an abortion. One The interviewer was then urged to elaborate (with 18-year old house girl had, in fact, used contraceptives sensitivity and a caring attitude free of any moral which she purchased from a woman who worked at a judgement) on this issue and to ascertain if this really family planning clinic. When she met her present corresponded to the reality: the average number of partner, she stopped using them because her partner sexual partners rose from 2.7 to 5.6 with the number of promised to marry her. She was convinced that if she got sexual partners varying from one to eight in the pregnant, ‘there was no way for him to leave her’.
remaining 16 interviews, and with many of girls However, when she revealed that she was pregnant he reporting that they had several partners simultaneously.
denied responsibility: he was married, had two children, Twenty-five percent of the total sample admitted to loved his wife and refused to see her anymore. She having had more than one sexual partner at the time of decided to have the pregnancy aborted.
conception. These girls could not say who was Most of the girls were also aware of the possibility of contracting a sexually transmitted disease (STD) but All the girls had regular intercourse, one to three they were not very concerned. Some of the girls had been times a week. None of the 25 girls staying with their told by their partner that there was no reason to fear parents (except one) had told them that they were HIV since they were the only one the partner had sexually active, and that they had regular intercourse.
relations with. Others did not know if their partner had Their sexual encounters were carried out in secrecy } other relations. Seven of the girls reported having often after school. Many would change from their previously had a STD. These girls had all been treated, M. Silberschmidt, V. Rasch / Social Science & Medicine 52 (2001) 1815–1826 and mentioned that if they were to contract a STDagain they could always get treated for it.
None of the girls in our sample lived with their sexual partner. As mentioned earlier, the vast majority wasinvolved with a man who was twice as old. Forty-five In a study of induced abortions in four public percent of them were between 30 and 39 years and hospitals in Dar es Salaam (Mpangile et al., 1993), 27.5% 40 and over. Only seven girls (13.7%) reported 88.5% of adolescent girls aged 17 and under did not that their partners aged 25 and under. In another study know about any contraceptive method. In our study, all of abortion in Dar es Salaam almost a third of the the girls except one illiterate girl knew of several types of adolescent girls had male partners aged 45 or above contraceptive measures, in particular, oral contracep- (Mpangile, Kihwele, Munos, & Indriso, 1997). Most of tives and injections (such as Depo-ProveraTM).
the men were businessmen, involved in petty business However, even if they were able to mention different (e.g., selling oranges and coconuts, etc.). A few were contraceptive methods, their knowledge was very super- shopkeepers. One was a banker who had a relationship ficial. A common belief was that the pill should only be with his house girl. According to the girls in our study, taken on the day of intercourse. Nine girls had tried oral half of their partners were already married } or said contraceptives. Some had stopped using them because of they were. This is a much higher number than reported side effects (e.g. irregular bleeding), and some because in other studies. However, as also noted in Mpangile’s they wanted to become pregnant } hoping that study, the marital status of men who have affairs with pregnancy would result in marriage. Others had become teenage girls is difficult to establish from the teenagers’ pregnant while using contraception. Three girls com- accounts. They rarely inquire about the marital status of plained of having become pregnant after having been their sexual partners, and if they do, it is unlikely that injected with Depo-ProveraTM. This is a recurring the truth will be revealed. In our study, 15 girls knew of phenomenon, often mentioned by other women inter- their partners having children. The remaining 36 girls viewed (Silberschmidt, unpublished). It is assumed that did not know whether their partners had any children.
these women did not get their follow-up injection at the The length of the relationships varied, but they seemed fairly stable with ten of them having lasted one A vast majority of the girls had heard about different year or more. Twenty-nine had lasted from 5 to 12 side-effects such as irregular bleeding and abdominal months. The girls reported regular sexual contact with pain, both from oral contraception and injections. They their partners (one to three times a week). Over 30 of the had also heard rumours that oral contraception might girls said that they were still seeing their partner at the lead to infertility if taken by a girl/woman who had not time of the interview. Fifteen girls said that they were given birth, and had received this information from definitely not seeing the partner anymore: the partner friends or relatives. One 18-year old student had been had either disclaimed paternity or had disappeared as told by her 40 year-old partner that contraceptives were soon as the girl had revealed the pregnancy. The rest of dangerous for her. In two cases, a mother had advised the girls said that they were still seeing their partner.
her daughter not to use contraception because it could However, some of them admitted that they did not correspond now as much as before and some felt a bit However, the majority of the adolescent girls we ignored. A couple of the girls suspected that their interviewed had never used any contraception, nor did partner had found another girlfriend. Apart from the they know that they were entitled to receive free five girls who had counted on marriage and therefore contraceptives from a family planning centre. To their had intentionally become pregnant, the rest of the girls knowledge, only women who had children were allowed never intended to marry their partner, and their at the family planning clinics. A few girls had purchased contraception from health personnel that they knew or In a study of the role of male partners in induced had heard about and who were selling these on the side abortions among teenagers in Dar es Salaam, three types to supplement their salary. When checking at one of the of relationships are identified (Mpangile et al., 1996).
government health centres if adolescents had access to The first is rafiki } a boyfriend with whom the girl has family planning measures, we were immediately told regular contact. The second is mshikaji wa muda } a about the new health policy (1994) that allowed temporary partner; regularity of contact varies. Such a adolescents access. However, we were also told that relationship can range from short-term to a complex only two 16-year-old girls had received any family longer-term symbiotic relationship, often involving planning measure (in this instance, Depo-ProveraTM) acquisition of property (varying from food and clothes during the past year at this centre. And they were to more expensive items). In the city of Dar es Salaam, prostitutes, according to the judgement of the FP-nurse relationships with men identified as rafiki receive more social acceptance and recognition than relationships M. Silberschmidt, V. Rasch / Social Science & Medicine 52 (2001) 1815–1826 with a mshikaji wa muda (Mpangile et al., 1996). The An 18 year-old girl who worked in a bar complained third category comprises men with whom contact is about her partner: ‘I tried my best to make him give me infrequent or men that a girl has only had a single some money, but he only gave me beer and food. When I told him I was pregnant, I never saw him again’.
In our sample, a fourth type of relationship was However, she was not sure if he was the one who had mentioned by a couple of girls: mpenzi} someone they made her pregnant. She also had other partners because considered having a love relationship with and even } as she said } her salary was small, and she needed hoped to marry. However, the vast majority of girls referred to their partner as a mshikaji wa muda asa buzi (a goat to milk). A 17-year old student who had Men’s role in advising/paying for the induced abortion a relationship with a 22 year-old man } referred tohim as a mshikaji wa muda. Most of the time, she As mentioned above, in the existing literature on received money from him in exchange for sex } but induced abortions in Sub-Saharan Africa, there is hardly not always. ‘Something is better than nothing’, she any information about the role that men play in the reasoned. She was now, however, looking for a man decision of a woman to terminate her pregnancy, who could give her more money. She had also had beyond an indication that some men pay for induced sexual encounters with other partners at the time she abortion (Kinoti et al., 1997). In the early 1990s, when teenagers constituted 22% of women who delivered at All the girls were provided with small ‘luxuries’ such the Muhimbili Medical Centre in Dar es Salaam, 40% of as underwear, soap, cream and also pocket money and them did not have a partner willing to acknowledge textbooks in exchange for their sexual services. ‘No paternity (Tumbo-Masabo & Liljestro¨m, 1994). In a money } no sex’ was a recurring remark. One girl study by Mpangile et al. (1993), men responsible for the mentioned that her 40 year-old, married partner had pregnancies did not assist in looking for a solution to the fallen in love with her. He gave her 5,000 Tanzanian problem (e.g. abortion services) to the same extent that shillings (Tsh) (roughly US$8) the first time they had other social support networks, such as mothers and intercourse. Other days he gave her 3,000 to 4,000 Tsh, other female relatives, did. Nevertheless, the men but not always. In spite of the fact that, according to the responsible tended to end up paying the bills. In a later girl, they were in love, she had no intention of study by Mpangile et al. (1996), one-third of the continuing the relationship if she did not receive money partners had advised the girls where to go for an from her partner. As she said: ‘there is no use of a abortion, and almost half of them had paid the fees partner who has no money’. Some girls also had a meal required for the abortion. According to a study by when they met with their partner. Others who were only Leshabari, Mpangile, Kaaya, and Kihwele (1994), only treated with sodas and snacks were looking for a new 60% of the girls had initially confided in the men with whom they had conceived. Nearly all these men had One 19 year-old girl, who worked as a hair-maker, assisted in looking for an abortionist and paying for the found that ‘life is difficult without a buzi. Her buzi was also her landlord, and he let her stay in her rented room In our study, all the girls had informed their partner for free. He was 45 years-old, married and had six of their pregnancy. Twenty-one (41%) of the partners children. ‘He comes to me to escape frustrations from had advised the girls where to go for the abortion and home’. ‘He takes me out for beer and snacks’. She took had also paid for the procedure (i.e. about 30,000 Tsh) no sexual pleasure at all from the sexual activity and when the abortion had been carried out at a hospital.
‘wanted to get it over with as quickly as possible’, ‘but he Seventeen of the girls had been advised by a girlfriend is my major source of income, and I use him as my buzi.
and had provided the money themselves. The majority She was not concerned about getting a STD. It had of these girls had their abortion performed outside the happened to her twice before, and she had received hospital at the cost of about 10,000 Tsh. They were the treatment. If she got HIV now, it would be purely ones in our sample who had been admitted to the accidental } it would be ajali kazini (accident at work).
hospital with complications. The remaining 14 girls had This was her second abortion. As she had other partners confided in their social support network and had she did not know who had made her pregnant this time.
received advice and financial assistance from mothers But she had ‘decided to give the burden to this buzi because he had money’. She had been convinced that Summing up, even if most relationships in this study she could make him pay for an abortion if she got seemed relatively stable, none of the men (or the girls for pregnant. She was right. He facilitated her abortion at that matter) intended to have a child with their partner the hospital and paid Tsh. 35,000 (roughly US$58. The (see below). And there was no disagreement between the government minimum monthly wage for an unskilled girl and her partner in terms of the termination of the pregnancy. With men refusing to use condoms and with M. Silberschmidt, V. Rasch / Social Science & Medicine 52 (2001) 1815–1826 many of them promising an induced abortion in case of 1995). We assume that the interaction between the pregnancy, it must be assumed that they were well aware interviewer and the respondents explains the much that their young girlfriend might end up with a higher numbers of sexual partners admitted to by the pregnancy. And while some refused to acknowledge paternity, twenty-one did take responsibility.
‘I love him because he gives me money’ As noted by Bledsoe and Cohen (1993), documenting trends in adolescent fertility is a much easier task than According to Bledsoe and Cohen (1993), becoming explaining these trends. The same can be said about our pregnant deliberately is often a strategy for obtaining a attempt to explain adolescent girls’ sexual behaviour in husband and gaining in social status. Linked to this, Dar es Salaam. Contrary to boys, girls are easily most adolescent girls seem to believe that the need to dismissed by the community as promiscuous, if it is find a suitable husband and begin a family far outweighs known that they are sexually active. Consequently, and the costs to their education and career opportunities although girls are today exposed to freer and more (ibid). However, none of the girls in our sample } but unrestrained behaviour regarding love and sex, their for five } had any intention of ‘trapping’ a husband.
sexual experiences are still surrounded by secrecy. Peers, Also, even if their relationships seemed fairly stable, the not parents, are the most important source of knowledge fact that they referred to their ‘benefactors’ as mshikaji on sexual matters (Fuglesang, 1997). Many parents, wa muda implies that most girls had no long-term goals though, are perfectly aware of their daughters’ esca- for the relationship. Nor did they plan to get pregnant.
pades, and that they barter their sexuality for economic On the contrary, they counted on an abortion in the gains. But they choose to close their eyes because it event of pregnancy. The same attitude has also been relieves them of their financial responsibilities.
reported in Studies from Kenya and Nigeria (Barker & As to the girls in our sample, even if it may not be socially acceptable to have a mshikaji, they were proud While most of the girls in our sample were aware that of having a mshikaji wa muda or a buzi as their ‘financial they could get pregnant if they had unprotected sex } resource’. They were also flattered by older men’s except for those few who had used a contraceptive interest in them. As documented in other studies, a buzi method } they accepted the fact that their partners gives prestige among peers since a girl’s status within refused to use condoms. They were not in a position of this group is often dependent on having nice clothes and negotiation, because they either did not dare to propose other material possessions. Such things are achieved condom use for fear of loosing their partner, or it did most easily by entering a sexual relationship with a man not occur to them that they could propose condom use.
who is willing to provide. Moreover, not many girls or They did not expect to propose condom use. Not even a women would enter into a premarital sexual relationship wife would dare to propose that her husband used a without the potential for material recompense. It is condom for fear of being accused of having had other believed that sexual services are commodities that sexual relations. Even if she suspected/knew that her should be paid for. Only women with no self-respect husband had been unfaithful, she could not ask him to would give such services for free (Silberschmidt, use a condom } this would imply a lack of respect on unpublished data). Men are aware of this conception, her part. Only prostitutes can ask their clients to use a and they accept it as a fact. In exchange for financial compensation men gain sexual access and control over As a result, abortion was used as a contraceptive young women, a relationship which acts as a booster to method, because cultural and practical barriers } their virility and self-esteem (Silberschmidt, 2001, 1999, including access to contraception } present greater obstacles (shame) than the risk (fear) of having an While the girls in our study were involved in overtly abortion. Moreover, with 25% of girls having more than transactional sex, this exchange was by no means one sexual partner at a time, the non-use of condoms, comparable to or associated with prostitution. In fact, the not-knowing who was responsible for the pregnancy, and as mentioned above, most women in a Tanzanian or and 14% of girls having had a STDpreviously, all point an East African context } married or not } with any to high-risk sexual behaviour on the part of the self-respect would be very reluctant to engage in a sexual adolescent girls. Other Tanzanian studies of adolescent relationship with a man without any material benefits.
girls have stated a lower number of sexual partners Men who are unable to provide such benefits are met (Kapiga, Hunter, & Nachtigal, 1992; Kapiga, Lwihula, with contempt (Silberschmidt, 1999, 2001). It was also Shao, & Hunter, 1995; Weinstein, Ngallaba, Cross, & apparent to the adolescent girls in our study that no man Mburu, 1995; Mnyika, Kvale, & Ole, 1997), and also would give them money or other material benefits lower numbers of STDinfections (Weinstein et al., without receiving something in return. Sexual services M. Silberschmidt, V. Rasch / Social Science & Medicine 52 (2001) 1815–1826 were all these girls could bargain with. And they were men that ought to be targeted in the first place in very willing to offer their services. Not as a means of Tanzania (Mpangile et al., 1992, 1996). This is in line survival } but rather as a means to gain access to small with the increasing international focus on the vulner- ‘luxuries’, textbooks, etc. not to mention prestige from ability of adolescent girls, the advocacy for gender peers. Even if the word ‘love’ was used by many during equality and the promotion of male responsibility and the interview, it was closely associated with money. ‘No partnership with women in sexual and reproductive money, no sex’ was a recurrent remark. A 16 year-old health (The Hague International Forum, 1999; Overall student said about her 30 year-old partner: ‘I love him review and appraisal of the implementation of the and enjoy sex with him, because when I buy coconuts Programme of Action of the ICPDReport of the Ad from him, I do not pay, and I can use the money as Hoc Committee of the Whole of the 21 Special Session pocket money’. Or as one of them said, ‘I love him, of the General Assembly, 1999; UNAIDS, 2000).
because he gives me money’. Also girls who said they However, this being said, our data also indicate that loved their partner would not continue the relationship the relationship between our interviewees and their without material benefits. Some of them were actually ‘sugar-daddies’ was not a one-way exploitation. While planning to find one more partner ‘in order to increase young girls are often regarded as objects of other their financial resources’. The same observations are people’s choices } often those of ‘sugar daddies’ } made in a study from northern Tanzania, where the these girls are also active social agents, entrepreneurs transactional aspect of sexual relationships is crucial.
who deliberately exploit their partner(s). However, they Once gifts cease to flow the relationship will soon come are unaware of the potential consequences of their high- risk sexual behaviour, and the health hazards that they Contrary to boys, who often refer to their ‘lust’ and expose themselves to. Moreover, while the ‘sugar regard sex as the most pleasureful activity, (Silbersch- daddies’ trust that they are having ‘safe sex’ with their midt, unpublished) the majority of the girls in this study young girlfriends, they may, in fact, be jeopardising their did not consider sex as an activity by which their own own health, that of their wife and other partners.
sexual needs would be met. Sex was something that girls Consequently, both the behaviours of adult men and of provided in return for a material benefit. As one of them the adolescent girls they engage with need to be said, ‘I only engage ‘minimum’ with this buzi. I enjoy sex addressed. If behavioural change is proposed as an more with other partners’. A buzi or a ‘sugar daddy’, intervention, it should target not only male irresponsible however, is a good source of income that most girls do behaviour but also that of young girls. To the knowl- edge of the author of this article, no interventions in While the young girls were overtly entrepreneurial and Tanzania have so far addressed the issue of adolescent risk-taking in their approach to sex they were at the girls’ irresponsible behaviour. However, the ‘sugar- same time little aware of their own vulnerability having, daddy’ phenomenon is well known, and young girls for instance, no negotiating power in terms of contra- are advised to avoid such ‘daddies’.
ception. Moreover, they did not appear motivated orconcerned. On the economic front, the consensus was Urban versus rural girls and their access to safe abortion that had they tried to negotiate condoms, they mighthave lost their buzi. On the health front, some girls The girls in our study represent a privileged group of would note ‘he looks healthy so why bother’.
women who were either able to have their partner/ Higher HIV seroprevalence rates amongst girls are relative pay or raise the money themselves for a safe now being recorded in Tanzania, (Tanzania Demo- abortion or have their complications treated profession- graphic and Health Survey, 1997) as in other East ally. From this point of view, our sample is biased. It African countries (Barnett & Blaikie, 1992 and many represents a group of privileged young girls. They can others). This increase is closely associated with the certainly not be compared with the young girls living in ‘sugar daddy’ phenomenon } such men are seen as the streets of Dar es Salaam, who, in order to survive, responsible for bringing the AIDS virus to the teenage engage in sexual contact with poor men who cannot afford ‘more sophisticated prostitutes’ and are often Urassa, 1998). If this is the case, there are serious drawn into life-threatening relationships (Bamurange, implications for the teenage female population, which in 1998). Nor can they be compared to the nine adolescent turn increase the risk associated with abortions. Thus, girls/young women (15–29) from Bunjo, rural Dar es the sexual irresponsibility of the men carries some Salaam, who did not have a ‘sugar-daddy’ to pay for a serious repercussions on their young partners. From a safe abortion or were able to raise the money needed to gender point of view, the male partner exploits and takes advantage of the adolescent girl, who, without realising In Bunjo, we learnt during a focus group discussion what she exposes herself to, ends up in a life-threatening that many unmarried girls bleed to death or become situation. Therefore, it is the behaviour of these adult infertile after six to eight induced abortions. All the girls M. Silberschmidt, V. Rasch / Social Science & Medicine 52 (2001) 1815–1826 who participated in the discussion had had several self- unable to care for a child, or when she was afraid of induced abortions using locally grown herbs. They were ‘missing’ a husband, because her pregnancy might have very knowledgeable about many different types of roots been caused by someone other than her fiance´. In that which could be used (muharobaini, mlonge, paw paw, case, inducing an abortion can be a way of trying to mmavimavi, etc.) sometimes combined with chloroquine ‘save face,’ and ‘it must be a personal secret’.
or cafanol tablets which are sold over the counter andrequire no prescription. One of the girls, though,admitted that she almost died once, when she combined ‘one tea cup of boiled muharobaini roots with eightchloroquine tablets’. The girls recommended ‘cassava Although this study was carried out in Tanzania, the leaf sticks’ (which contain cyanide) as the safest remedy.
issue of illegal induced abortions has wider implications.
Even if they were aware of potential ‘misfortunes’ when As do the issues of adolescent sexuality, family planning, inducing an abortion, they were not overtly concerned.
abortion, communication with one’s partner, STD/HIV Five of the young women, though, who were in their as well as male responsibility. In Sub-Saharan Africa } mid- to late 20s had no children. They were all sexually as elsewhere in the world } these issues are pertinent, active but did not use any type of contraception. Why and at the forefront of public health discussions. At the did they opt for induced abortion rather than trying to Cairo+5 conference meeting in the Hague (1999), prevent getting pregnant? ‘It is very difficult to get these adolescents’ sexual and reproductive health was re- modern methods, because many of us are still young and garded as one of the major challenges national govern- unmarried’. ‘The modern devices are given to married ments and non-governmental agencies face worldwide.
women who have children. Therefore, most of us resort Governments are now being urged to promote women’s, to traditional methods, which are cheap and easy to get: and, in particular, adolescent girls’ sexual and repro- for instance, we make knots (mafundo) on a special ductive health (Key Actions, 1999). However, in spite of string and tie it around the waist. One knot equals one the growing acceptance of the importance of addressing year. So it depends on someone’s plans: the number of reproductive health care needs, such acceptance must be knots equals the number of years that one wants to wait translated into adequate operational action at the before getting pregnant’. However, if these traditional methods did not work as a contraceptive method, the As reported in an increasing number of studies from girls agreed that then ‘you can tell your friend who is Tanzania (Leshabari, 1988; Kapiga et al., 1992; Lesha- somehow adult that she goes to the hospital and bari, & Muhondwa, 1992; Leshabari, & Kaaya, 1996; pretends that she needs family planning pills. And when Klepp, Biswalo & Talle, 1995; Rwebangira & Liljestro¨m, she gets them she can give them to you’. This was the 1998) and underlined in our study, adolescent girls have only way for young unmarried women to gain access to an urgent need for sexual and reproductive health information as well as access to preventive measures.
All of the girls we spoke to in Bunjo knew of where These girls are engaging in high-risk sexual behaviours, and clandestine, usually unsafe, abortions have become ‘professional’ as well as its cost (Tsh 10,000 for a one- a common occurrence. While more privileged women month pregnancy, Tsh 30,000 for a three-month can afford to pay for an abortion that will be performed pregnancy). However, ‘we have no money, and it is safely in a hospital setting, most women though, have to difficult to request money from parents or relatives to go resort to much less safe interventions. They are the ones and have a properly performed induced abortion.
admitted to the hospital with complications (Justesen, Therefore, we decide to perform it ourselves and get Kapiga, & van Asten, 1992; Mpangile et al., 1997) unless ready for any complication. Because we are sure that they bleed to death before getting there. However, the 51 parents will be forced to take us to the hospital for more girls in our study from urban Dar es Salaam were also care. They cannot afford to see us dying. So it is easier to putting their health and lives at risk. The way in which force them to take care of complications than requesting they negotiate their own sexuality leaves them extremely vulnerable, and their economic gains seem negligible None of the girls relied on assistance from a partner.
compared with the health risks they unknowingly take.
The age of their partners ranged from 22 to 35 and The Tanzanian Government is aware that teenagers above. The younger ones ‘tended to insist on sex only’, are sexually active and, in 1994, launched a policy to whereas the older ones were ‘quite helpful’ with small encourage the provision of family planning information luxuries. However, the latter had big families, many and measures to people in need, including teenagers.
children, felt no responsibility and, according to the Information and services to adolescents also figure girls, would run away if they got pregnant. Therefore, prominently in Tanzania’s Strategy for Reproductive the decision to induce the abortion was made by the girls Health and Child Survival 1997–2001 (1997). However, themselves. Often because the girl was still in school and there is still a vast discrepancy between policy guidelines M. Silberschmidt, V. Rasch / Social Science & Medicine 52 (2001) 1815–1826 and their practical application. Adolescent girls face children, particularly their daughters in order to enable serious cultural barriers, not the least from the health them to take responsibility for their own lives (ibid).
services where health workers have strong moral How this is to be carried out in practice and under harsh objections to offer them the services that they are socio-economic decline is yet to be seen (Silberschmidt, entitled to according to the revised National Policy 1999, 2000). The concept of ‘male involvement’ which was emphasised both at the ICPDin Cairo (1994), and However, even if adolescents do have access to again at the Hague Forum reflects the recent emphasis information and services, evidence from around the on encouraging men to be supportive and involved world shows that abortions cannot be completely partners. It recognises that the health and socio- eradicated (Kulczycki, Potts, & Rosenfield, 1996).
economic problems of women cannot be solved without Therefore, as abortions continue to happen, the involving men. However, there is so far no generally controversial issue and ethical challenge of how to make accepted understanding of what male involvement clandestine abortions safe is now receiving increasing actually means. In the meantime, adolescent girls as international as well as national attention. According to those in this study cannot wait for their sugar-daddies to recommendations from The Centre for Reproductive become responsible partners. They need to be assisted Law and Policy (1999), there is a need to address the both in the development of more mature and responsible practice of unsafe abortions, particularly its high attitudes as well as in gaining access to information and incidence among adolescents. Linked to this, govern- services, so that they can begin to take better care of ments should consider enacting laws that permit abortion on broad grounds. In addition, law enforce- A few health and family planning initiatives specifi- ment officials should refrain from prosecuting women cally aimed at addressing adolescents’ needs are now who have undergone abortion procedures and the operated by NGOs in Tanzania. These initiatives are the providers who have performed abortions (ibid). This is ‘Youth Friendly Services’ and ‘Youth Family Planning in line with observations already made among others by Services through Peers’, which provide education, Kinoti et al. (1997), Sai (1996), and Rogo (1996), who information and services to adolescents. However, as argue that abortion laws not only in Tanzania but in virtually no operational research has been carried out on Africa, in general, need to take into account adolescent how information and services can best be designed to girls’ vulnerability and consider how clandestine abor- meet the needs of adolescent girls (Kinoti et al., 1997), tions can be made safe. Even if abortion is legalised, there is still an urgent need for such research. There is a unsafe abortions will continue to be performed because particular need for research on how such services can be of health budget constraints in developing countries.
made sustainable. More research is also needed on men’s However, legalisation means transforming abortion perspectives on their own role, responsibility and the from a ‘guilty secret’ into a socially accepted method implications of their relationships with adolescent girls.
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