Associations between lifetime pregnancy and sexual risk behaviors among 15-24-year-old adolescent girls and young women in South Africa: Secondary analyses of the 2016 Demographic Health Survey

Adolescent girls and young women (AGYW) in South Africa are highly vulnerable to HIV and poor sexual and reproductive health (SRH) outcomes. Interventions must respond to the unique needs of different AGYW groups, such as AGYW who have ever been pregnant. The objective of the study is to examine associations between pregnancy and sexual risk behaviors among AGYW in South Africa. This study used the 2016 nationally representative Demographic and Health Survey (DHS) of South Africa (n = 1935, 15–24 years old). Sexual risk behavior outcomes included: early sexual debut (defined as having sexual intercourse before the age of 15 years), age-disparate relationship (defined as having sexual partners who are five years and older in the past one month), multiple sexual partnerships, no condom use at last sex, and lastly, cumulative sexual risk (defined as reporting at least two of the outcomes: early sexual debut, age-disparate relationship, multiple sexual partners, and no condom use at last sex). Data analyses were conducted using logistic regression in STATA version 16. Statistical significance was determined at a P-value less than 0.05, with 95% confidence interval reported. AGYW who experienced lifetime pregnancy were more likely to report early sexual debut (OR = 1.71, 95%CI = 1.30–2.32), age-disparate relationships (OR = 1.58, 95%CI = 1.20–2.08), no condom use at last sex (OR = 2.77, 95%CI = 2.09–3.69), and cumulative sexual risk (OR = 1.82, 95%CI = 1.38–2.41). Multiple sexual partnerships showed no significant associations with lifetime pregnancy. Married or cohabiting AGYW were more likely to report cumulative sexual risk behaviors. (OR = 2.67, 95%CI = 1.91–3.71). Cumulative sexual risk behaviors were lower among AGYW with secondary education (OR = 0.57, 95%CI = 0.33–0.99) and those from rich households (OR = 0.62, 95%CI = 0.43–0.88). The findings underscore the need for interventions promoting safe sex and relationships, especially among AGYW who have experienced pregnancy. Programming should address the structural, socio-economic drivers of early pregnancy.


Introduction
Adolescent girls and young women (AGYW) are confronted with unique sexual health challenges, including early pregnancy, unwanted pregnancy, and HIV, posing significant public health concerns [1].In South Africa, where historical complexity and rich diversity shape the landscape, AGYW face health issues with substantial implications on their wellbeing.The prevalence of early pregnancies, affecting at least 40% of young girls [2], remains a major challenge exacerbated by socio-economic inequality [3], inadequate sexual education [4], and entrenched cultural norms [5].
Within the realm of early pregnancies lies the intricate issue of unwanted pregnancies, influenced by factors such as limited access to comprehensive family planning resources and sociocultural stigma surrounding contraception [6,7].Additionally, AGYW in South Africa confront the persistent threat of HIV, with 38% of new infections occurring in those aged 15 to 24, particularly affecting females in this age group [8].
Considering the diverse and interconnected nature of the AGYW's behaviors, culture, and socio-economic characteristics, it is crucial to examine the factors contributing to multiple sexual risks, which may lead to increased risks of unwanted pregnancy and HIV cases.This study aims to shed light on the diverse array of sexual risks that AGYW encounter, which include various behaviors that pose threats to the reproductive and general health of AGYW.Some of the sexual risk behaviors that AGYW engage in include age-disparate relationships, early sexual debut, multiple sexual partnerships, inconsistent condom use, and transactional sex, among others [4,9,10].Designing focused interventions and public health strategies requires a thorough understanding of the prevalence of these risk factors.Studies have linked the experience of violence [11], lack of comprehensive sexual health education [12], and motherhood status [13] to multiple sexual risks among AGYW.However, there is a notable dearth of research concerning the relationship between lifetime pregnancy and multiple sexual risk behaviors among AGYW in South Africa.Additionally, there is insufficient exploration of how pregnancy status interacts with various sexual risk behaviors among AGYW.Moreover, there is a lack of comprehensive understanding regarding the factors contributing to the prevalence of pregnancy and sexual risk behaviors among AGYW, including the role of socio-economic factors.
To ensure overall health and provide a foundation for a healthier transition to adulthood, it is important to understand the risks AGYW face which are related to pregnancy and a variety of sexual risk behaviors.The aim of this study is therefore, to investigate the associations between pregnancy and sexual risk behaviors while controlling for other factors such as age, marital status, place of residence, education, wealth status, and employment status.This study endeavors to address the significant public health concerns related to pregnancy and various sexual risk behaviors among AGYW in South Africa.By investigating the associations between lifetime pregnancy and sexual risk behaviors, this study aims to provide valuable insights that can guide the development of evidence-based interventions and public health strategies tailored to the diverse challenges faced by AGYW.Further, this study seeks to fill the existing literature gaps by exploring the complex relationships between lifetime pregnancy and sexual risk behaviors among AGYW, contributing to a deeper understanding of the underlying factors that influence these behaviors.The findings from this study also aim to support AGYW in making informed decisions regarding their sexual health and overall well-being, thereby promoting their overall health and future opportunities.

Methodology
This study utilizes data from the 2016 South Africa Demographic and Health Surveys (SADHS), focusing on women aged 15 to 49.From the initial pool of 9878 eligible female Fourth, the multivariable analysis used logistic regression models to investigate the associations between lifetime pregnancy and the outcomes of interest; early sexual debut, age-disparate relationship, multiple sexual partners, no condom use at last sex, and cumulative sexual risk behaviors.
Before the commencement of statistical analyses, data were weighted using the sampling weight to account for the differentials in the sample design and response rate.All data management and statistical analysis were performed using the Stata version 16. Results were interpreted using odds ratios.Statistical significance was declared if the P-value was less than 0.05 while the confidence interval was set at 95%.

Characteristics of the study population
Table 1 presents the characteristics of the study population (n = 1935, 15-24 years).Findings revealed that 24.6% of AGYW started having sexual intercourse before the age of 15 years.Seven percent (6.9%) of AGYW have multiple sexual partners.Forty-five percent of AGYW did not use condoms at last sexual intercourse, and 39.3% were in age-disparate relationships.
Fifty-nine percent of the study population had lifetime pregnancy.About two-thirds (67.5%) of the study population were between 20 and 24 years old, and 17.5% were married or cohabiting at the time of the survey.Sixty-four percent of the study population lived in urban areas, 85.7% were not working, 84.5% had secondary education, and 46.5% were from poor households.The bivariate results showed that 31.6% of AGYW who experienced lifetime pregnancy started having sexual intercourse before the age of 15 years compared to 9% of those who were never pregnant.Approximately 26.6% of AGYW AGYW who experienced lifetime pregnancy engaged in age-disparate relationships, which was significantly lower among AGYW who were never pregnant (12.7%).In terms of multiple sexual partnerships, the prevalence of engaging in multiple sexual partnerships was 3.7% among AGYW who experienced lifetime pregnancy, and 3.2% among those who were never pregnant.Table 1 shows that among AGYW who experienced lifetime pregnancy, 45.1% did not use condoms at last sexual intercourse compared to 11.7% among AGYW who were never pregnant.Furthermore, 30.2% of AGYW engaged in cumulative sexual risk behaviors.

Bivariate associations between pregnancy status and HIV risk behaviors
Regarding ever being married or cohabiting, 15.3% of AGYW who experienced lifetime pregnancy were married or cohabitating with their partners at the time of the survey.The prevalence of lifetime pregnancy was higher (46.8%) among 20-24 years compared to 15-19 years AGYW (12.2%).Fifty percent (50.3%) of AGYW who were not working had experienced lifetime pregnancy compared to 8.7% of AGYW who were working.Concerning place of residence, 36.5% of AGYW who experienced lifetime pregnancy lived in urban areas.For education, the prevalence of lifetime pregnancy was highest among respondents with secondary education (49.7%).Wealth status was significantly associated with lifetime pregnancy, with a higher prevalence among the poor (30.1%) compared to the middle (12.9%).

Multivariable analysis of factors associated with sexual risk behaviors
Table 2 presents the odds ratios between lifetime pregnancy, and sociodemographic factors, and all the sets of outcomes (early sexual debut, multiple sexual partnerships, age-disparate relationships, and no condom use at last sexual intercourse).
Lifetime pregnancy showed no association with multiple sexual partners.However, ever being married or cohabiting and the age of AGYW were found to be associated with multiple sexual partners.The risk of multiple sexual partners was lower among ever-married or cohabiting AGYW (OR = 0.38; 95%CI = 0.18-0.80).
Regarding age-disparate relationships, the multivariate analysis showed that AGYW who experienced lifetime pregnancy were more likely to engage in age-disparate relationships (OR = 1.58; 95%CI = 1.20-2.08).Further, the analysis showed that the likelihood of engaging in age-disparate relationships was two times higher among ever-married or cohabiting AGYW compared to never-married AGYW (OR = 2.01; 95%CI = 1.41-2.82).The risk of not using condoms at last sexual intercourse was higher among AGYW who experienced lifetime pregnancy (OR = 2.77; 95%CI = 2.09-3.69).The likelihood of not using condoms at last sexual intercourse was higher among AGYW who were married or cohabiting compared to never married AGYW (OR = 3.60; 95%CI = 2.68-4.82).The likelihood of not using condoms at last sexual intercourse was lower among AGYW living in urban residences (OR = 0.69, 95%CI = 0.52-0.90),Concerning, cumulative sexual risk behaviors, the multivariate analysis showed that AGYW who experienced lifetime pregnancy were more likely to engage in cumulative sexual risk behaviors (OR = 1.82; 95%CI = 1.38-2.41).AGYW who were married or cohabiting were more likely to engage in cumulative sexual risk behaviors (OR = 2.67; 95%CI = 1.91-3.71).AGYW who had secondary education were less likely to engage in cumulative sexual risk behaviors (OR = 0.57; 95%CI = 0.33-0.99).Lastly, AGYW from rich households were less likely to engage in cumulative sexual risk behaviors (OR = 0.62; 95%CI = 0.43-0.88).

Discussion
The aim of this research was to explore the correlation between lifetime pregnancy and sexual risk behaviors among adolescent girls and young women (AGYW) aged 15 to 24 in South Africa, utilizing data from the 2016 South African DHS.Specifically, the study investigated whether pregnancy status was linked to early sexual debut, multiple sexual partners, age-disparate relationships, condom non-use during last sexual intercourse, and cumulative sexual risk behaviors.Findings indicated that 59% of the study participants had experienced at least one pregnancy.Moreover, AGYW reporting lifetime pregnancy demonstrated higher likelihoods of early sexual initiation, lack of condom usage during last intercourse, engagement in multiple

Factors associated with early sexual debut
The multivariate analysis in this study uncovered a noteworthy association, indicating that Adolescent Girls and Young Women (AGYW) with a history of pregnancy were more likely to experience early sexual debut.This is consistent with findings from prior studies [4,20], which established a link between early sexual debut and increased pregnancy rates among AGYW.This finding suggests that AGYW who experienced pregnancy at a young age may have initiated sexual activities earlier than their counterpart.Older AGYW aged 20-24 years exhibited a lower risk of early sexual debut, emphasizing the role of age in influencing sexual behaviors [9].This association suggests that increased maturity, autonomy, and decision-making skills acquired over time may contribute to a more deliberate initiation of sexual activity.Furthermore, as AGYW enter their early twenties, a shift in priorities towards career and education might lead to delayed sexual activities, aligning with findings from McClinton Appollis et al., (2022) [9].AGYW residing in urban areas demonstrated a heightened inclination toward early sexual debut, underscoring the influence of urbanization on sexual behaviors.While urban settings offer greater access to social and economic opportunities, including educational institutions, employment prospects, and exposure to media and technology, which can benefit AGYW, they also expose them to social pressures that encourage early sexual activity [21].Consistent with previous studies [17,19], AGYW with secondary school and higher education demonstrated a lower tendency for early sexual debut.This association suggests that education plays a crucial role in increasing awareness and knowledge of sexual and reproductive health, empowering AGYW to make informed decisions.Additionally, educational attainment may influence socioeconomic factors, providing opportunities and supportive environments that contribute to a delay in sexual initiation [22].

Factors associated with multiple sexual partners
Regarding multiple sexual partners, AGYW who were married or cohabiting exhibited a lower risk, reflecting the stability and dedication in such partnerships [23].This finding aligns with cultural and societal norms that discourage extramarital sexual partnerships, emphasizing monogamy and commitment.However, AGYW aged 20-24 years were more likely to engage in multiple sexual partnerships compared to their younger counterparts, possibly due to the transitional phase into adulthood, increased independence, and expanded social networks.This aligns with previous studies indicating that this age group may be more inclined to explore relationships and sexuality, exposing them to a variety of potential partners [18,24].

Factors associated with age-disparate relationships
AGYW who had ever been pregnant had a higher risk of involvement in age-disparate relationships.This association may be linked to factors such as a lack of comprehensive sexual education, limited reproductive health resources, or early sexual debut, increasing the likelihood of relationships with older partners.Additionally, socioeconomic factors like poverty or limited educational opportunities may contribute to pregnancies among AGYW, leading them to seek stability or financial support from older partners.AGYW who were married or cohabiting also showed a higher risk of age-disparate relationships, influenced by sociocultural norms and expectations.In some contexts, early marriages are acceptable, and there may be a relationship between marriage or cohabitation and economic factors, where AGYW seeking financial security are more likely to date older partners [18].Power dynamics in such relationships may arise from difficulties in expressing themselves or negotiating safer sexual practices.

Factors associated with no condom use at last sexual intercourse
Regarding no condom use at last sexual intercourse, AGYW who were ever pregnant exhibited higher risks, potentially due to the perception of trust in long-term or stable relationships like marriage or cohabitation [25].Cultural or social norms regarding pregnancy and condom use may also play a role, with a belief that condom use is unnecessary or inappropriate in committed relationships, particularly during pregnancy.Similarly, married or cohabiting AGYW were more likely not to use condoms at last sexual intercourse, reflecting higher levels of trust and perceived intimacy in such relationships.The emphasis on stable relationships might be on family planning rather than disease prevention, contributing to reduced condom use.
This finding suggests that adolescent girls and young women (AGYW) residing in urban areas are less likely to engage in unprotected sexual intercourse compared to their counterparts in rural areas.Several factors may contribute to this trend.Urban environments often provide better access to sexual health resources such as clinics, education programs, and contraception services, which may increase awareness about the importance of condom use and safer sexual practices [26].Additionally, urban areas typically have higher levels of education and socioeconomic status, which can correlate with increased knowledge about sexual health and greater access to condoms.

Factors associated with cumulative sexual risks
The study revealed that AGYW who were ever pregnant had heightened risks of engaging in cumulative sexual risk behaviors, involving early sexual debut, multiple sexual partners, agedisparate relationships, or no condom use at last sexual intercourse.This points to complex interrelated factors making ever-pregnant AGYW more vulnerable, including socio-economic difficulties, limited access to necessary resources, unstable employment, and little opportunity for education.The experience of pregnancy may also influence relationships, self-perception, and mental health, impacting sexual behavior and decision-making.Furthermore, AGYW who had ever been married or cohabiting were more likely to engage in cumulative sexual risk behaviors.This association may be linked to socio-cultural and economic inequalities associated with marriage, limiting autonomy and decision-making power for AGYW.Marital or cohabiting status may contribute to a higher likelihood of engaging in cumulative sexual risk behaviors.
The multivariate analysis revealed that AGYW aged 20-24 years were less likely to engage in cumulative sexual risk behaviors compared to those aged 15-19 years.This association may be attributed to the greater developmental maturity of the older age group, as well as disparities in educational attainment.Older AGYW may have completed higher education, leading to improved health literacy and well-informed sexual behavior decisions.As AGYW enter their twenties, they might become more self-aware and base their decisions on personal values rather than peer pressure.The finding that AGYW with secondary education have a lower risk of engaging in cumulative sexual risk behaviors aligns with previous studies [27,28].Secondary education is linked to increased knowledge, awareness, and decision-making abilities, making it a protective factor.AGYW with secondary education may have a better understanding of the risks associated with risky sexual behaviors, enabling them to make more informed decisions and potentially delaying the onset of sexual activity.Additionally, the study found that AGYW from wealthy households were less likely to engage in cumulative sexual risk behaviors, highlighting the role of higher socioeconomic status as a protective factor.Higher socio-economic status, often associated with wealthy households, can provide AGYW with greater access to resources and opportunities, discouraging engagement in risky behaviors.Financial independence may influence decision-making regarding sexual behaviors, with AGYW from rich households feeling more empowered to avoid cumulative sexual risk behaviors.

Study limitations
While the present study sought to contribute to the existing body of knowledge, some limitations should be considered when interpreting the study's results.First, the possibility of bias in reporting sexual behaviors due to social desirability.Second, recall bias regarding age at first sexual debut, especially among the older AGYW might have contributed to reporting bias.Third, due to the cross-sectional nature of the data, the findings of this study do not allow causal relationships.Lastly, some important sexual behavior variables, such as transactional sex and condom negotiation could not be included in the study due low sample size (response).These limitations notwithstanding, this study provides important insights into factors associated with sexual risk behaviors among AGYW in South Africa.

Conclusion
The findings of this study demonstrate concerning associations between pregnancy among AGYW and an increased likelihood of engaging in cumulative sexual risk behaviors.This study highlights the vulnerability of AGYW who have experienced pregnancy and suggests that this group may face additional challenges and situations that increase their propensity to engage in cumulative sexual risk behaviors.This highlights the importance of targeted interventions that address the specific needs and risks of ever-pregnant AGYW and ensure that comprehensive support mechanisms are in place to reduce the potential impact of risky sexual behaviors.Further, tailored HIV interventions that are specifically designed to address the risks associated with pregnancy and multiple sexual behaviors can effectively reach and support AGYW in lowering their risk of HIV infection as well as pregnancy.Interventions should also consider factors such as marital-related communication, decision-making authority, and access to reproductive health services to promote safer sexual practices and reduce the overall risk of adverse outcomes.This study also demonstrates a significant relationship between cumulative sexual risk behaviors and socioeconomic factors such as education and wealth.The implication of these findings underscores the importance of socioeconomic factors in influencing the sexual behaviors of AGYW.These highlight equipping AGYW with knowledge and awareness, and provision of resources and economic empowerment may contribute to a reduced propensity of engaging in risky sexual behaviors.

Table 1
also presents the bivariate analysis.The bivariate analysis showed that age-disparate relationships, no condom use at last sexual intercourse, cumulated sexual risk behaviors, marriage or cohabitation, age, and wealth index had significant relationships with lifetime pregnancy.

Table 2 . Logistic regression model showing the association between sexual risk behaviors and all the selected characteristics of AGYW in South Africa. Early sexual debut Multiple sexual partners Age-disparate relationships No condom uses at last sexual intercourse Cumulative sexual risk behaviors
https://doi.org/10.1371/journal.pgph.0003317.t002sexual partnerships, involvement in age-disparate relationships, and cumulative sexual risk behaviors.
• Addressing the heightened risks of cumulative sexual behaviors among ever-pregnant AGYW calls for integrated interventions that consider the socio-economic challenges and limited access to resources faced by this group.Strategies should focus on empowering AGYW through educational opportunities, economic support, and mental health services to mitigate the complex interrelated factors contributing to sexual risk behaviors.• Furthermore, the study suggests the significance of considering marital or cohabiting status in sexual health interventions for AGYW.Understanding the dynamics associated with agedisparate relationships and decreased condom use in stable relationships can inform targeted interventions promoting communication, negotiation skills, and safer sexual practices within partnerships.