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African Journal of Reproductive Health, Vol. 12, No. 1, April 2008, pp. 98-110 Social context of premarital fertility in rural South-Africa Contexte social de la fécondité avant le mariage en Afrique du Sud rurale Julien Zwang and Michel Garenne 1SMRU (Shoklo Malaria Research Unit), Wellcome Trust - Mahidol University, Oxford Tropical Medicine Research Programme, Maesod, Thailand 2Directeur de recherche, IRD & Institut Pasteur, Paris, France Code Number: rh08026 ABSTRACT A qualitative study was conducted in Agincourt, a rural area of South Africa, to document the perceptions and attitudes towards premarital fertility and late marriage among young adults of both sexes. Two focus groups and 35 individual interviews were conducted among 17-30 year olds, randomly selected. Most interviewees perceived premarital fertility as undesirable, and a new phenomenon in a context of major social changes, in particular loss of authority of parents and increasing freedom of the youth. In contrast, late marriage was perceived as positive, by both sexes, primarily for economic reasons. Much stigma was associated with premarital fertility, from friends, institutions and families who occasionally apply mild or severe sanctions. Consequences of premarital fertility were numerous: school abandonment, economic adversity, health risks, stigmatization. In extreme cases, premarital fertility might lead to exclusion and deviant behavior. Premarital fertility was ultimately due to a lack of contraception among young women, and to refusal of abortion for religious reasons, and is associated with the risk of contracting STD’s. RÉSUMÉ Une étude qualitative a été menée à Agincourt en Afrique du Sud, pour documenter les perceptions et les attitudes envers la fécondité avant le mariage et le mariage tardif. Deux interviews au niveau de groupes cible et 35 interviews personnelles ont été recueillies auprès des gens âgés de 17 à 30. La plupart des gens interviewés ont perçu la fécondité avant le mariage comme étant désirée et comme un nouveau phénomène dans un contexte de transformations sociales importantes, surtout la perte de l´autorité des parents et la liberté croissante de la jeunesse. Par contre, ils ont apercu le mariage tardif comme positif, principalement pour des raisons économiques. Beaucoup de stigmate était lié à la fécondité avant le mariage de la part des amis, des institutions et des familles qui de temps en temps appliquent de légères sanctions. Les conséquences de la fécondité avant le mariage étaient nombreuses: l´abandon de l´école, l’adversité économique, les risques de santé, la stigmatisation. Dans des cas extrêmes, la fécondité avant le mariage peut entrainer l´exclusion et le comportement deviant. La fécondité avant le mariage a été finalement causée par un manque de contraception chez les jeunes femmes et à cause du refus de l´avortement pour des raisons religieuses et pour des raisons liées au risque de contracter les MSTs. KEY WORDS: Premarital fertility, Age at first marriage, Perception, Attitude, Stigma, Sanction, Qualitative study, Focus group, Shangaan, Agincourt, South Africa Introduction Premarital fertility, defined as a birth taking place before first marriage, varies greatly among African countries, and among ethnic groups (Garenne and Zwang, 2006b). In some areas premarital fertility is virtually inexistent, whereas in others a majority of first births are premarital. South Africa, together with nearby Namibia and Botswana, has the highest prevalence of premarital fertility in the continent. In South Africa, high frequency of premarital first birth is primarily a feature of Black/African and Coloured/Mixed-race populations, and not of other groups such as White/Europeans or Indian/Asian, and is found in both urban and rural areas. Of course, the former and the later groups have had different histories and different social dynamics in the twentieth century. Social change was dramatic in South Africa, especially for the Black/African population, who faced enormous stress. In the late nineteenth century, the Black/ African population was still living in a traditional way, well described by anthropologist such as Junod (1966). In traditional societies, first marriage tends to be early for women, and families exert a high social control on premarital sexual behavior. By the turn of the twenty-first century, Africans were living in a modern society, characterized by a cash economy, urbanization, modern education, new family structures and new values, and much more individual freedom for young adults. In between, important changes occurred: large scale economic development, industrialization, massive migration, critical political changes, in particular during the apartheid period, as well as the emergence of Christian religions. These major social and economic changes had profound effects on marriage patterns, family structures, and fertility behaviors in the African population. So far, little academic work has been devoted to the social context of premarital fertility. Even on the most visible demographic aspects, only few studies were devoted to premarital fertility per se in Africa (Bledsoe and Cohen, 1993; Boult and Cunningham, 1991; Gage-Bredon and Meekers, 1993; Parr, 1995; Gage, 1998; Garenne et al. 2000; Shell-Duncan and Wimmer, 1999; Hardwood-Lejeune, 2000; Garenne and Zwang, 2004 and 2006). On the more social aspects, most of the focus has been on “adolescent fertility” and contraceptive use, and often the distinction is not even made between married and unwed young mothers. (Preston-Whyte, 1990; Preston-Whyte and Zendi, 1992; Preston-Whyte, 1999; Kaufman et al., 2001 and 2004; MacLeod 1999; Buga et al. 1996; Makiwane, 1998; Wood et al. 1998). The aim of this study is to document the social context of premarital fertility in Agincourt, a rural area of South Africa, in a broad historical perspective. This work focuses on perceptions and attitudes towards premarital fertility and late marriage, completing earlier qualitative work (Kaufman et al., 2004) and earlier demographic analysis in the same area (Garenne et al. 2000). Material and methods The qualitative study was conducted from March to May 2003 in Agincourt, a rural Demographic Surveillance System site (DSS), Limpopo Province, in the north-east of South Africa. The area, counting 21 villages and about 70,000 persons, has been under demographic surveillance since 1992, and has been the focus of numerous demographic, health and social research (Tollman, 1999; Tollman et al., 1999; Dolan et al. 1997; Collins et al., 2000; Townsend et al., 2002; Saspi Team, 2004; Golloka-Mutebi and Tollman, 2004). The area is populated by the Shangaan, an ethnic group of Bantu origin, who live in this region as well as on the other side of the border, in nearby Mozambique. About a third of the population are Shangaans from Mozambique, who came in the 1980’s to escape the civil war. The study site was part of the Gazankulu homeland during the apartheid years, and most villages were restructured at that time. The study area is located in the low veld, at the bottom of the Drakkensberg mountains, climate is rather dry and soils are poor, therefore agriculture is not well developed. People survive on a variety of resources, most important being remittances from migrant workers, pensions, tourism industry and other services, as well as from small scale agricul-ture (gardens, cattle, other domestic animals). Income is average by South African standards for rural African populations, and varies greatly, from wealthy families living in modern houses and driving cars to poor families with few modern goods, living in traditional huts, often former Mozambican refugees. Family structures are dominated by the absence of migrant workers most of the year, in particular men (55% of men aged 30-49 are migrant workers). Family size is high (6.4 persons per household on the average) despite a low fertility (Total Fertility Rate TFR= 2.5 in 2003). Household structures often involve three generations (grand-parents, parents and children) or collaterals (Townsend et al. 2002). The study focuses on perceptions and attitudes towards late marriage and premarital fertility and related topics such as contraception, health consequences, child rearing and STD’s (sexually transmitted diseases). The field work was conducted by JZ, who stayed several months in the field, and involved both individual interviews and focus group discussions. Two local assistants, highly experienced in qualitative field methods, were recruited for the field work and the translations. The interviews were conducted in Shangaan, fully recorded, translated in English, and typed on microcomputers. The qualitative study was conducted in 16 of the 21 villages of the Agincourt DSS. For the individual interviews, a total of 35 persons of both sexes, aged between 17 and 30 years (mean age = 24 years), were selected randomly from the census database. The selection included five strata: married and unmarried women / with or without children, and one group of young men, irrespective of their marital or fertility status. Interviewers and interviewees were invited to discuss freely the themes proposed by the guidelines, (Bertaux, 2006; Dubar and Demazière, 2004) and 12 different versions of the guidelines were administered during the study. Individual interviews were conducted in separate quarters, so that persons could freely speak with the fieldworker without being heard from other family members. In addition, two focus group discussions were conducted on the same issues, with seven and eight persons respectively. For the focus groups, the two assistants were present, one acting as the moderator, the other taking notes. Ethical clearance for the individual interviews and focus group discussions was given by the ethical comity of the School of Public Health at the University of the Witwatersrand, Johannesburg. Interviewees gave their informed consent verbally and agreed for the recordings. For the focus group discussions, participants gave a written authorization. More details on the field work are available in a companion working paper (Zwang, 2004). Perceptions: social change and premarital fertility Permissiveness Interviewed persons gave an overwhelming impression that the whole social fabric has changed dramatically in the recent past. People estimate that in earlier times, which relates roughly to two or three generations ago, most marriages were arranged by families, most girls tended to marry early, premarital intercourse was rare, and a premarital pregnancy led inevitably to a marriage. Junod (1966), who studied the Shangaan society in the first decades of the twentieth century, gave a somewhat different account. Although early marriage was obviously the norm, premarital sexual relations were permitted under various conditions. Right after puberty, young unmarried women were allowed, if not encouraged, to flirt with bachelors, a practice called “gangisa”. In case a pregnancy occurred, the father was obliged to marry the girl. Murdock Atlas (1967) describes the Thonga (Shangaan) as very permissive with respect to premarital sexual behavior, with no sanctions associated. It is therefore quite likely that persons now tend to underestimate the degree of freedom of their elders, even though first marriage was much earlier a century ago. This discrepancy might be due to conversion of most of the population to Christian religions during that time interval. Interviewed persons perceived that a premarital pregnancy is well tolerated when young lovers are already in a stable relationship and about to marry. This seems to have been the rule earlier as well, as reported by the ethnographic literature. However, new behaviors, such as letting girls going out at night, is perceived as a new phenomenon, and as a break to tradition which brings bad luck. It should be added that when first marriage is early, the time period during which premarital intercourse might occur is rather short, say a few years, whereas when first marriage occurs around age 30, as it is the case nowadays, girls are exposed for some 15 years, with very different consequences in terms of opportunities, number of partners and risks of pregnancy and STD’s. It is therefore difficult to dissociate the issue of permissi-veness to that of late marriage in contemporary populations. Late marriage Perception of late marriage, say between 25 and 30 years, is rather positive among interviewed persons of both sexes. An age difference of three years is recommended in couples because young men are seen as less mature than young women. Before turning 25, young men can be neither loyal nor responsible enough to meet the requirements of married life. Furthermore, young men and women prefer to remain single for several years for economic reasons. The fact that age at first marriage has risen considerably shows a change in the aspirations of the young as well as in opportunities. An increasing number of young women today want to be financially independent before marrying, so as not to depend on their husband or family to live and raise their children. This implies to finish secondary school, often around age 20, and to find some stable employment, which might require a few years. For men, a first job often implies a migration far away from village of origin, which tends to delay first marriage, and often offers new opportunities in cities or industrial centers, changing the marriage market in the villages. Remaining unwed seems desirable for a few men, who also want to remain childless. A few women also said they prefer to remain single, either to be independent, or because they do not trust men. Marriage and pregnancy Interviewed persons saw marriage in the old times as compulsory in case of pregnancy. Nowadays, men whose girlfriends become pregnant do not feel as obliged to marry, and often leave them. Although there is still social pressure on fathers, it seems to be much less than in the past for a variety of reasons: social, since elders have less influence on young adults; economic, since many very young fathers have no income and no easy way to pay for the bride price (lobola) and to support the new family; geographic, since men might migrate and live far away, so escaping social pressure in the villages. Parental authority and social control Parents are said to have lost their influence, and parent’s authority appears as less respected than before. Indeed, the whole relationship between parents and children has changed. For example, parents know that they can be sued if they beat their children. As a consequence, children have become less liable to their parents, to the extended family and to tribal chiefs than to new symbols of authority, such as police and judges, who are not interfering on premarital sexual behavior. Furthermore, the new family structures are changing the relationships, and many adolescents grow up in households where the father is absent most of the year, and where the authority is shared by the mother, the grand mother and other family members. Peer pressure and mass media Interviewees from all categories agree that the media are one of the reasons accounting for the increase in sexual activity among teenagers, who form a large media audience. Television and radio programs displaying various sexually related behaviors (soap operas, films, talk-shows, health education, family planning campaigns) tend to arouse the desire to experiment with what is perceived as “modern behavior”. Likewise, adolescents are particularly sensitive to peer pressure, and want to behave like their school mates. Ironically, a small scale project to prevent premarital births conducted in the study area among adolescents tended to increase sexual activity and led to more unwanted births probably for this very reason. Peer pressure extends much beyond the desire to experiment sex with school mates. It also leads to searching for relationships with higher status mates, with the aim of receiving gifts or various economic returns, and ultimately might lead to commercial sex. Early maturation Several interviewees mentioned that adolescent girls tend to mature earlier than before, therefore increasing the risk of premarital intercourse and fertility. Many respondents noted that girls have their menstruations earlier (around age 14) than before, and that they can indulge in sexual intercourse at an earlier age, as shown by scientific studies (Cameron et al. 1991; Du Toit, 1987). This earlier maturation is attributed by respondents to better and more diverse foods, in particular to “eggs, cheese, avocado and pears”. Premarital behavior and religion The majority of the population became Christian during the course of the twentieth century. Christian missionaries, protestant on the west side of the border, and Catholics on the east side, came in the late nineteenth century among the Shangaans, and were very influential in the field of health and education. They had a strong influence on numerous behaviors, and in particular on sexual and marital matters. Many of the traditional behaviors were seen as amoral, immoral or even vice by missionaries, well described by Junod (1966). In addition to traditional religious obedience, new religious movements of Christian inspiration developed, such as the influential ZCC (Zionist Christian Church). The Agincourt population is well aware of the religious messages discouraging contraception, and valuing marriage and fidelity. However, little mention was done of these moral principles in the interviews. The most striking remarks focused on the contradiction between official public health messages (use condoms, use contraceptives) and religious principles (marry, be faithful). In contrast, it should be noted that the large majority of the population comply to the prohibition of abortion promoted by the churches, even though induced abortion is legal in South Africa since 1996. Attitudes: stigma and sanctions Although a premarital birth is often well accepted, as common in African societies, it is sometimes subject to a variety of stigma and sanctions. When an unplanned premarital pregnancy occurs in a family and the biological father refuses to acknowledge the child, the young woman is prey to family sanctions. Depending on the social background of the family, sanctions are applied differently. The objective is said to punish the young woman for her immaturity, her lack of respect for the elders, and to prevent the same accident from happening again. In principle, the mother’s parents do not want to bear the financial obligations of the biological father (food, clothing and education). In practice, family members take care of the child as much as possible and provide the basic necessities, but do not give any money to their daughter any longer as a punishment. A typical sanction taken by families consists in no longer buying her clothing, so that she no longer looks attractive to men. Not having pocket money any longer, young women cannot pay for taxi fares to visit friends or go to town. They are obliged to stay at home and to look after their child. In wealthier families, sanction might be milder, whereas in poorer families where an additional child brings heavy economic burden, sanctions might be quite harsh on the mother. In some cases, sanctions involve physical punishment of the faulty girl. In rare cases, the mother might even be chased out of the paternal home or dumped at the door of the boy’s family. In severe stress situations, premarital births predispose young women to serious difficulties. Being exposed to stigmatization and highly vulnerable, some women are somehow excluded. Without personal resources, they are forced to adapt to survive. They can end up committing theft, or resorting to prostitution, or abandon their child, although those cases seem rare in the villages. In Agincourt, most young women who find themselves pregnant before the age of 20 are schooled. As far as female students are concerned, the main drawback of a premarital birth is to have to abandon school during pregnancy. Although many return to school after delivery, parent may forbid her to do so, or may refuse to pay school fees, in particular with the idea of preventing her from having other premarital births. In some cases, abandoning school can be definite, and young mothers might be obliged to find a job to support her child. Returning to school after a delivery, which occurs typically two or three years after, has numerous consequences for a girl, associated with a variety of stigma. The returning girl tends to be now older than her class mates, and has a different social status. Her school performance might be affected by her maternal activities. When a young woman turns from an adolescent into a young mother, she can find herself isolated from friends who no longer want to visit her. Her old friends say that Social context of premarital fertility in rural South-Africa she should now socialize with other mothers. Such isolation from the peer group is often perceived negatively by young women who may end up blaming or neglecting their child. In some cases, the young mother will tend to isolate herself in order to avoid unpleasant comments or mockery that will hurt her. Stigmatization of a woman with a premarital birth has also consequences for later marrying. Young men who want to get married tend to prefer single women who never had a birth. In the Shangaan tradition, a child belongs to the father’s family, so that when a woman has already had a child other men may feel threaten by the former biological father. He has right on the child, and might use this right to keep a privileged relation with the mother. Stigmatization may also apply to the whole family. The mother’s parents are seen as having failed in their duty to teach and control their daughter. Some interviewees estimate that responsibility must be shared by the woman and her parents who did not take action on time and who did not discuss the risk of pregnancy with their daughter. Children born to a non-married woman are also stigmatized and as referred to as “goyas” (i.e. wild cats). This signals social denigration of a child who is seen as an intruder since he does not have the status normally associated with a father and a formal family. Causes and consequences of premarital fertility Birth control Premarital fertility is caused not only by early sexual intercourse, but also by lack of contraception. Contraceptive use has increased dramatically in South Africa since the onset of the national family planning program in the mid 1970’s, and contraceptives are now widely available through-out the country, as it is the case in Agincourt clinics. The most commonly used contraceptives are injectables (DepoProvera), IUD’s, and to a lesser extent pills and condoms. Emergency contraception is seldom used (Klitch, 2002). However, contraception is widely used by married women and women who already had a birth, but not as much by adolescents, who are the most in need. There are several reasons for this. First, the family planning program is not designed for the need of adolescents, and those who go to the clinics are often poorly assisted, if not stigmatized or rejected. Second, families as well as school teachers are rarely able to speak openly about contraception to young girls, and provide little advice. Third, young girls have mixed information, and often are so young at first intercourse that they are still unconscious or semi-conscious about their behavior and its consequence. Last, gender relations, as well as peer pressure, are not in favor of young girls, and women often perceive that they cannot refuse advances, or cannot impose the use of condoms to a partner. Economic rationality behind fertility and marriage Sexual activity and premarital fertility often indicate an economic interest, where young women can later claim marriage. Sexual relations would thus result in a financial or material gain and would create an emotional bond with the young man that would commit the partners to marry. Premarital fertility appears as the result of a rational decision making process. However, in doing so, young women expose themselves to important risks if their partner refuses to marry, or to acknowledge the child, or to grant an allowance. Fatherhood and child identity A main consequence of premarital fertility for the child is the lack of a social father. This has numerous implications. First, fathers are very important in traditional societies, as they provide a name, a social status, and income for raising the child. It is striking to note in Agincourt, as elsewhere in South Africa, that children born to unwed mothers, or to divorced mothers as well, can change their family name, when the mother remarry or even change partners. This has obviously consequences for the child’s identity, not counting the legal aspects. The implications for social status did not come out clearly from the interviews, and would require more research. This was a major concern in earlier times, and Junod (1966) mentions the pressure on biological fathers to marry a pregnant women. Today, the pressure seems more focused on income, since with the monetarization of the economy it is hard to raise a child without money. Fear of having to pay for child’s food, health and education, school fees in particular, seem to be a major deterrent for young men to get married, and might be an indirect cause of premarital fertility. In the traditional system, as well as now throughout South Africa, marriage requires the payment of a bride price by the groom, called “lobola”. The amount of lobola can be quite high and hard to meet by young men. However, a symbolic contribution is often accepted by families who want their daughter to be formally married, so that “lobola” usually does not constitute a definite obstacle to marriage. In addition, “lobola” can be paid over several years, to give time to the future husband to find a job and to gather enough money. Institutional support and child support grants Aside from father’s support, institutions now provide for child care. A large and generous scheme, called the “Child Support Grant” was instituted in April 1998 in South Africa, and designed for poor families to help them with basic child care and school fees. This program is still new and it is hard to evaluate its long term consequences. However, several interviewees mentioned that this could have the effect of inducing premarital fertility. Even families now seem to consider a pregnancy as positive, since the mother will benefit from a child support grant. This grant is normally devoted to South African citizen with birth certificate, and Mozambican refugees who do not have official residence permit or citizenship are not eligible to the grant. Child nutrition and kwashiorkor The most serious disease regularly mentioned by interviewed persons as associated with children born to unmarried mothers is kwashiorkor, a form of severe malnutrition. Kwashiorkor is indeed one of the leading causes of hospitalization and death of preschool children in the Agincourt area (Kahn et al., 2000). Also referred to as the disease of the red hair children, it usually appears when children are a few months old or have just been weaned. It is due to improper weaning food, and often associated with a diet based on maize, with major deficiencies in proteins and certain aminoacids. This type of severe malnutrition results in the presence of edema in the lower limbs and in the face, a strong muscular loss, and skin and hair depigmentation, all symptoms well recognized by the population. The disease also entails psychological disorders, such as sadness, hostility and apathy. It is primarily a disease of poverty and is often found among children of young unmarried mothers from poor families. Mother’s behavior and child care Interviewees perceive adolescent girls as not being attentive mothers. According to them, they are seen as not being able to bath their child daily, to wash their clothes and to feed them properly. Young women who are socially isolated, because of parental sanction or due to family circumstances, lack experience and knowledge in respect of child care. When a child is sick, young mothers often do not know what to do or do not have enough money to take them to clinics or hospitals. Furthermore, young mothers might have adverse behavior when they go out at night: for instance, bringing their children to bars (shebeens), a behavior highly stigmatized in the society, or leaving them alone, with the risk of the child becoming a street child. Mother’s health: maternal risk and STD’s Several female interviewees mentioned maternal risk as typical of adolescent deliveries. Above all, caesarean sections are feared in case of an early first birth. In addition, very young women are more likely to give birth to low birth weight or premature babies, and this is also feared by the respondents. More important however, is the fear of STD’s and in particular of HIV/AIDS. The disease became highly prevalent in the area in the 1990’s and most people now know a family member, a neighbor or a friend who died of AIDS, from far the leading cause of death among adults in their reproductive ages. The perception of HIV/AIDS and the attitudes of young adults are particularly complex, and range from absolute fear and strict protection to frank denial and routine high risk behavior. It is beyond the scope of this paper to discuss perceptions of HIV/ AIDS in this population, and more details can be found elsewhere (Gage, 1998; Fassin and Sheider, 2003; Kaufman et al. 2004; Zwang, 2004). As far as premarital fertility is concerned, there are numerous links with HIV/AIDS. Late marriage implies numerous partners, and therefore high risk of contracting both STD’s and pregnancy. Premarital fertility appears as an indicator of lack of protection from pregnancy, which can be related with the lack of protection from STD’s. It is worth noting that African countries with highest values of premarital fertility, such as Southern African countries, are also places with the highest levels of HIV seroprevalence. Interviewees raised numerous concerns related with the issue of STD’s and fertility. Condom use and faithfulness are seen as good in principle, but obviously poorly practiced in reality. Knowledge of HIV/ AIDS status by some individuals is seen as dangerous, because of the stigma associated with the disease, of the possible sanctions, or the fear that this might lead to the break of a relationship, or of the possible consequences on reproductive decisions. In any case, relationships between STDs and fertility appear as complex, and even though they have a common denominator (control of the consequences of sexual intercourse) they were presented separately in the interviews, and seem to be perceived differently by the interviewees. Conclusions African societies in South Africa underwent dramatic social and economic changes in the twentieth century. One of the most visible changes is late marriage for women, a high proportion of women who never marry, and the emergence of premarital fertility. In the Agincourt study area more than half of the first births were premarital, and about half of women had a child by age 20. Late marriage and economic independence of young women is seen generally as highly desirable. However, a pregnancy prior to marriage, and especially during school years, a most common occurrence, is perceived very negatively by the mothers themselves, by the families who will have to support the child, by institutions, in particular schools and clinics, as well as by the whole society, including peers of the young mothers. The high frequency of premarital fertility occurring in a negative social context is surprising at first glance. It seems due to a combination of factors: permissiveness for premarital intercourse, which has a long history among the Shangaans and seems to last despite Christianization, schooling which delays marriage and favors encounters, to a smaller extent earlier maturation, and most important lack of contraception and refusal of induced abortion for religious reasons. In earlier times, an unwanted pregnancy led to early marriage. Nowadays, men tend to be reluctant to early marriage for a variety of reasons: lack of maturity, desire to leave an independent life, opportunities for migration to the city or elsewhere, lack of income to support a family, and fear of high expenses, in particular lobola and school fees. Consequences of premarital fertility are numerous. For the mother, it means economic burden (raising money for the child), often stopping school, social burden (losing friends, lower social status, stigmatization from family and society, sanctions, time constraints for raising the child), and health burden (risk of early first delivery). In the long term, a premarital birth might imply more difficulties in getting married, more time spent single, risks of multiple partnerships and STD’s. In extreme case, it might lead to various deviant behaviors. For the baby, not having a father also has numerous consequences: identity, social status, income, and possibly health consequences (malnutrition, lack of care, psychological disorders). The future of these trends remains unclear, and should be monitored, since they have so many social and economic consequences. Young adults, men and women, should be encouraged to better control unwanted fertility as well as STD’s. Most of the unwanted births, as well as many of the new HIV infections occur to unmarried women age 15-24. More efforts should be made to reject stigmatization and sanctions, and to promote prevention of all the undesirable effects of premarital sexual intercourse. Acknowledgement Authors wish to thank Prof. Stephen Tollman (Director of Agincourt Health and Population Research Unit, School of Public Health, Witwatersrand University), Dr. Kathleen Khan (Witwatersrand University), Mr. Mark Collinson (Witwatersrand University), the field assistants Regina Mathumbu (AHPP) and Patrick Rikhotso (AHPP) and the Mkhonto family who welcomed Julien Zwang in Metsi (Ireagh B). This study is part of a research program on premarital fertility in sub-Saharan Africa, supported by the Wellcome Trust (Grant # 062886/Z/00/Z). REFERENCES
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