title: From 'sugar daddies' to 'sugar babies': exploring a pathway among age-disparate sexual relationships, condom use and adolescent pregnancy in South Africa.
abstract: Background Adolescent pregnancy has been linked to adverse outcomes. Most studies proposing risk pathways for adolescent pregnancy in South Africa are qualitative, hypothesising links among age-disparate relationships, reduced condom use and higher pregnancy rates. No known South African studies have quantitatively explored pathways to adolescent pregnancy.
  
  
  OBJECTIVE
  This study aimed to: (i) identify the factors associated with adolescent pregnancy and (ii) explore a pathway of risk by assessing whether condom use mediated the relationship between age-disparate sexual relationships and adolescent pregnancy.
  
  
  METHODS
  A cross-sectional survey of 447 sexually active girls aged 10-19 years was undertaken in six health districts of South Africa. Multivariate logistic regressions controlled for confounders. Mediation tests used bootstrapping.
  
  
  RESULTS
  Consistent condom use (β=-2.148, odds ratio (OR)=8.566, P≤0.001) and school enrolment (β=-1.600, OR=0.202, P≤0.001) were associated with lower pregnancy rates. Age-disparate sex (β=1.093, OR=2.982, P≤0.001) and long-term school absences (β=1.402, OR=4.061, P≤0.001) were associated with higher pregnancy rates. The indirect effect of age-disparate sex on adolescent pregnancy through condom use was significant, irrespective of age, age at sexual initiation, poverty and residential environment (B=0.4466, s.d.=0.1303, confidence interval: 0.2323-0.7428).
  
  
  CONCLUSIONS
  This survey supports hypotheses that inability to negotiate condom use in age-disparate sexual relationships may drive adolescent pregnancy. Interventions addressing these relationships, facilitating condom use and increasing access to sexual health services among adolescents might avert unwanted pregnancies.
authors.affiliation: Department of Social Policy and Intervention, University of Oxford, 32 Wellington Square, OX1 23R, UK.
authors.forename: Elona
authors.initials: E
authors.lastname: Toska
authors.affiliation: Department of Social Policy and Intervention, University of Oxford, 32 Wellington Square, OX1 23R, UK.
authors.forename: Lucie D
authors.initials: LD
authors.lastname: Cluver
authors.affiliation: School of Psychology and Speech Pathology, Curtin University, GPO Box U1987, Perth, WA 6845, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Boyes
authors.affiliation: Department of Social Policy and Intervention, University of Oxford, 32 Wellington Square, OX1 23R, UK.
authors.forename: Marija
authors.initials: M
authors.lastname: Pantelic
authors.affiliation: Department of Psychiatry and Mental Health, University of Cape Town, J-Block, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa.
authors.forename: Caroline
authors.initials: C
authors.lastname: Kuo