DOI: 10.31038/AWHC.2026912

Introduction

Mobility practices have been understood as practices that consume distance [1]. This research note investigates the gender dimensions of mobility practices and their components, as well as their links with sustainability issues. Particular focus is given to car commuting. The context studied is Belgium, a federal country comprising three regions – Flanders, Wallonia, and Brussels – each of which has competence in housing, mobility, and other socio-economic matters. Regarding mobility, rules, signs and even city names can vary between regions, meaning commuters effectively commute between different mobility systems.

In Belgium, most people are mobile (making at least one trip on the reference day): in 2024–25, the average number of trips per day is 3.53 for men aged 18 and over and 3.30 for women of the same ages, with 85% and 82% of men and women respectively making at least one trip on the reference day (Service Public Fédéral Mobilité et Transports, 2025a: 6–7). Most round trips are made mainly by car, with little difference by gender (61% for men and 59% for women). However, women walk slightly more often (23% versus 20% for men) and use local public transport (bus, tramway, or metro) more frequently (6% versus 4%). Meanwhile, men cycle more often (12% versus 10%) and use the train slightly more frequently (3% versus 2%) (Ibidem: 11). Almost four-fifths (78%) of the total daily distance is travelled by car for both men and women (Ibidem: 12). This figure has remained stable for 25 years, despite the increase in cycling (Ibidem: 28). However, men spend more time on daily travel (69 minutes) than women (60 minutes) (Ibidem: 13).

Conceptual Framework: The Social Theory of Practice

As car is the main mode of transport, let us focus on the practice of commuting by car, with reference to the sociological theory of practice. Its main author ([2]: 89) defines a practice as both a performance and a coordinated entity. For him, practice as performance ‘denotes the doing, the actual activity or energization, at the heart of action […] and reminds us that existence is a happening taking the form of a ceaseless performing and carrying out’ ([2], 90). As coordinated entities, practices are ‘open spatial-temporal nexuses of doings and sayings that are linked by arrays of understandings, rules and end-task-action combinations (also emotions and even moods) that are acceptable for or enjoined of participants’ ([3], 15). A practice as a coordinated entity is thus a pattern for action. Understandings refer to the know-how and competences needed to carry out the practice, as well as the mental and bodily routines involved. Rules are explicit, such as ‘principles, precepts, instructions, and the like [which] means that people take account of and adhere to these formulations when participating in the practice’ ([2], 100). Previously, rather than ‘end-task-action combinations’, Schatzki writes about ‘teleo-affective structures’, which he defines as ‘embracing ends, projects, tasks, purposes, beliefs, emotions and moods’ ([2], 89). [4,5], and the same later together with Watson ([6], 82) define materials as a component of a practice. As material arrangements and infrastructures are of special interest for mobility studies based on practice theory, they are included in this research.

When applying the practice theory framework, the practice under study – in this case, commuting by car – is considered the unit of analysis rather than the commuters themselves and their individual characteristics that could explain their behaviour. To understand the difference between a practice and behaviour (as studied in economics, psychology, and geography), it is helpful to make a comparison: behaviour (such as a car journey) is like the visible part of an iceberg, whereas the components of a practice – the understandings, rules, teleo-affective structure, and material arrangements – are the submerged part of the iceberg. Therefore, to understand and possibly change a practice, these components must be studied. The components of the car commuting practice are described in section 4 below. The data and methods used are presented in the following section.

Data and Methods

Along with published statistics, data come from two dozen in-depth interviews conducted with car commuters during the spring of 2022 and 2023. In spring 2022, fuel prices were high. The interviewees represented a variety of ages, genders, locations and car types, whether private or company-owned.

In-depth interviews resemble a conversation between familiar acquaintances, but the interviewer should not know the interviewee beforehand [7]. Open-ended questions allow the interviewee to express themselves, and many follow-up questions help to create empathy. Most interviews were conducted face-to-face, with only a few conducted online by my appropriately trained students. The interviews lasted between 35 and 75 minutes. To ensure comparability between the interviews, a common, detailed interview guide was developed.

All interviews were recorded and then fully transcribed. Based on a content analysis, they were analysed using a common framework based on the concepts of practice theories, particularly to describe and compare the four components that underpin commuting to Brussels by car, whether private or company. Parts of the analysis are derived from [8].

Results

Rules

The company car system replaces part of an employee’s salary by providing them with a car as a form of payment in kind, which they can use for work-related reasons or otherwise [9]. The system has existed in Belgium since the 1970s, and since the 1990s, the company car has often simply been a ‘wage car’. In practice, the company car system is a legal tax avoidance scheme from which both the employer and the employee benefit [9,10]. This form of remuneration is unfair, particularly from a distributional perspective, as neither the employee nor the employer pays tax on this portion of their wages, resulting in the state losing out on tax revenue. In 2007, 272,000 company cars were granted to 7.4% of employees, and this figure increased by around 5% each year, reaching 627,600 cars granted to 14.9% of employees by 2025. However, both figures remained stable between 2024 and 2025 ([11]: 3).

Company cars were more often provided to men in 2010 [9] and 2021 [12]. Among employees with the right to alternative financial benefits in 2023, 16.67% of women have a company car for private use, compared to 27.99% of men ([13]: 34). However, these figures should be adjusted for other factors. For example, it is well established that company cars mainly benefit higher earners (Ibidem, 36), raising issues of social justice [14]. Additionally, women tend to earn less than men. Controlling for income decile, sector of activity, age group, number of workers, and status (white- versus blue-collar), men are 1.85 times more likely than women to have a company car for private use ([13]: 77).

Since 2019, the mobility budget has set new rules to correct the fiscal advantages of company cars. It proposes alternatives to employees in the form of in-kind benefits, such as a budget for public transport, electric scooters or bicycles, smaller and less expensive company cars, and, under certain conditions, a housing cost contribution. The mobility budget can also be used as a wage supplement for the remaining part, if any [15]. Although the adoption of the mobility budget has been slow, it is increasing. Most beneficiaries choose other benefits over a company car. In 2022, there were 4,865 beneficiaries of a mobility budget who did not receive a company car. This figure increased to 9,592 in 2023 and 17,157 in 2024 ([11]: 4). In 2023, 60% of all beneficiaries of a mobility budget were men, enjoying an average financial advantage of €7,263, while 40% were women, enjoying a lower advantage of €6,660 [13]: 46). Thus, among employees granted a company car or a mobility budget, women are more likely to choose a more environmentally friendly option.

Material Arrangements

As [8] describe in detail, there are some significant material differences between commuting by private car and commuting by company car: the characteristics of the car used – company cars are generally larger and more powerful than private cars ([16]: 8), places for refuelling and repairs (specific garages for company cars). Although the same network of highways and roads is used, commuting with a company car involves longer journeys. Company cars are often granted a ‘free’ petrol or diesel card. To the best of my knowledge, there are no gender-specific statistics for any of these aspects.

Company cars offer better protection in the event of a road accident [17]. Women are less likely to be involved in road accidents than men at all ages below 65. As ([16]: 15) shows, men driving company cars are much more often involved in road accidents than men driving private cars, especially between the ages of 25 and 59. The figures are more similar and lower for women, except after the age of 55, when there is a higher incidence of road accidents involving women driving private cars. Regarding accidents involving bodily injury, 3.8 deaths occur among occupants of company cars compared to 8.8 in private cars. However, company cars cause more serious damage to third parties: 6.8 deaths as opposed to 5.0 deaths caused by private cars ([16]: 16). There are no gender-specific statistics regarding injuries.

Understandings

No difference in driving or navigation skills was found among our interviewees of different genders. Among those who commute by private car, men may have more knowledge and practice of economical driving, although our sample is too small to be conclusive in this respect. Those commuting by private car are more familiar with public transport alternatives than those travelling by company car, but there is no gender difference in this regard.

Some pragmatic versatility – taking the train once in a while for example – is shown by several women of all ages among our interviewees and by a few young men, whether they use their private car or a company car. Women thus seem to have more environmentally friendly practices than men, but this should be confirmed, or not, with a larger sample size.

Teleo-affective Structure

Autonomy, social success, efficiency, and safety are the four values structuring the practice of commuting by car. All are enhanced if commuting by company car.

Women place greater importance on flexibility and time-saving when using a car. In particular, the mothers in the sample consider the car to be essential for fulfilling their responsibilities, such as taking the children to school or their activities. [18] also highlight the dependence of mothers on cars for childcare-related tasks. Therefore, gender roles also structure mobility practices.

In addition, women attach greater importance than men to the fact that the car provides a sense of security, particularly at night and/or in areas deemed insecure, such as near large train stations.

Concluding Discussion: Gender and Environmentally Friendly Practices

As this research shows, women are less likely to have powerful vehicles or SUVs than men because they are less likely to benefit from a company car. Furthermore, when given the option of a mobility budget, women are more likely to choose this than men. Additionally, women appear to demonstrate greater pragmatic versatility, such as occasionally taking the train, than men, although this result requires confirmation with a larger sample size. Thus, women appear to engage in more environmentally friendly practices than men. However, in order to fulfil their gender role as mothers, women rely on cars, which are seen as a necessity. According to [19], representations of gender roles relating to obligations towards children and family are stronger for mothers than for fathers.

MacGregor analyses the increased gender differentiation in institutional and individual responses to climate change both as ‘a masculinization of environmentalism’ and what she calls ‘ecomaternalism’ ([20]: 128, 136). For her, “[i]n so far as consumption is a private sphere activity, and women tend to be principally responsible for household consumption, it is likely that exhortations to ‘live green’ are directed at (and will be received primarily by) women. Men may hear them, but expect women to do the work” ([20]: 134). Her examples are conserving energy, taking public transportation, recycling waste and avoiding flights.

[21] in the UK and [22] in Belgium found that women engaged in more ‘green’ practices than men. Men use more energy than women, particularly in terms of mobility and meat consumption [23]. When it comes to changing practices, [24] notes that ‘the lifestyle changes were gender-biased, with the women as driving forces but also bearing most of the extra workload’.

More sustainable mobility practices, by train or by cycling for example, were also found to be ‘compensatory practices’: some mothers reported that they could only compensate the lack of environmentally friendlier actions of their family members by changing their own practices, here for their daily trips. [25].

Overall, a practice-based approach to car commuting, combined with a gender analysis, has yielded significant findings. While women may exhibit certain mobility practices that are slightly more sustainable than men, even in the case of car commuting, for care-taking trips, cars remain a crucial necessity. The apparent conflict between caring for children and caring for the environment is thus a salient concern.

In the future, more statistics on mobility should be published by gender. Further research on a larger sample would be necessary to investigate knowledge of and practice in economical driving, pragmatic versatility, and the material arrangements and policies governing compatibility between caring for others (namely children) and caring for the environment [26,27].

References

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DOI: 10.31038/AWHC.2025844

Abstract

Purpose: The purpose of this study was to assess differences in perceptions of the healthcare community across annual income and perceived stress levels, and the relationship between perceived stress, perceived racism, postpartum depression, and the perceptions of the healthcare community among Black women.

Methods: Two Hundred Nineteen Black mothers participated in this study. To better understand the relationship between the primary variables, Spearman Rho, Correlations, and a Non-Parametric Independent Sample T test were run. Standard, Multiple, and Hierarchical regressions were used to measure the moderating role of perceptions of racism on perceptions of the healthcare community and perceived stress.

Results: Results indicated that higher levels of stress in Black women were related to lower perceptions of the healthcare community, and there was evidence to support perceived racism as a moderator between perceptions of the healthcare community and perceived stress. There were unique differences in perceived racism across income and middle-income individuals reported less perceived racism. Lastly, perceptions of the healthcare community and annual pre-tax income combined were found to be better predictors of postpartum depression than either variable alone.

Conclusion: By understanding these factors as contributors to maternal mortality rates among Black women, it can influence training and professional development for new and existing mental health practitioners.

Keywords

Healthcare community, Income, Perceived stress, Perceived racism, Postpartum depression

Introduction

Black mothers are dying at 3 to 4 times the rate of non-Hispanic white mothers [1]. Seven hundred individuals die during pregnancy or in the year after in the United States while Black mothers represent almost 45% of the deaths [2]. The etiology of maternal-related mortality disproportionately affecting Black women is quite complex. Three key issues have been presented to explain this difference in outcomes: 1- Black women are more susceptible to having a pre- existing cardiovascular morbidity; 2- Black women are more likely to experience adverse pregnancy outcomes including a high risk for cardiovascular disease, and; 3- racial bias of providers and perceived racial discrimination of themselves as a patient [3].

As important as maternal mortality is in representing differences in outcomes, maternal morbidity rates may best represent the size of the problem for many women. Koblinsky (2012) defined maternal morbidity as a term that refers to any physical or mental illness or disability related to pregnancy and/or childbirth [4]. Examples of maternal morbidity include, but are not limited to, diabetes, high blood pressure, preeclampsia, blood clots, hemorrhage, and anemia. On average, more than 60,000 women in the United States affected by severe maternal morbidity annually. The rates of morbidity for Black women exceeds that of their white counterparts in 22 of the 25 severe morbidity indicators [2,4]. The Center for Disease Control (CDC) has reduced the original list of indicators to now represent 21 items that correspond to severe maternal morbidity (SMM) [2].

Pieterse et al. (2012) suggest that perceived racial discrimination can occur on multiple levels (interpersonal, institutional, cultural) and can be stressful for Black individuals negatively affecting their mental and physical health. Black individuals, on average, report higher levels of exposure to racism and discrimination than any other marginalized group [5]. Persistent high levels of stress can cause a deterioration of mental, emotional, and physical health. Persistent high levels of stress have been linked, but are not limited to heart disease, high blood pressure, heart attacks, depression, anxiety, and stroke.

Black individuals deal with racism-related stress daily, and it is very prominent in every aspect of living in the United States and thusly creating grave concern as it pertains to the healthcare system. Black individuals have not been afforded non-racial biased treatment, whether it was for a physical or mental ailment. Researchers previously found that there is a significant racial difference in mistrust of medical care settings for Black individuals. This was due to the Tuskegee Study and from broader personal and historical experiences [6]. Over time, the mistrust of the healthcare community has influenced the Black community to not seek medical attention when needed. Furthermore, it discourages Black mothers from seeking proper prenatal care out of fear of getting racially biased treatment from their nurses and doctors.

Perceptions of the Healthcare Community

One’s view of something or someone can influence how they interact with it. Perceptions of the healthcare community are having an impact on how Black women are viewing their quality of healthcare. This is evidenced by a study conducted by Blair and her colleagues (2013) that involved administration of a telephone survey on White and Black patients completing the Primary Care Assessment Survey. The Primary Care Assessment survey assessed the patients’ view of the clinicians’ interpersonal treatment, communication, trust, and contextual knowledge. They also had a panel of 134 clinicians that completed the explicit/implicit ethnicity/race bias assessments. The findings from this study revealed that clinicians with greater implicit bias were rated lower in patient-centered care by their Black patients as compared to the White patients. Another study conducted by Cuevas and her colleagues (2016) involved focus groups of Black women and men discussing their perceptions of racism in the medical setting, mistrust in medical settings, poor communication from doctors, and race discordance. The findings from this study revealed that Black women perceived higher discrimination than Black men feeling as though their symptoms were being discredited and ignored [7,8].

Perceptions of the Healthcare Community and Income

The intersectionality of income and race has shown to have an impact on the quality of care you may receive and your perception of your quality of healthcare. This is evidenced by a study conducted by Oliha and her colleagues (2020), which involved in-depth interviews of low-income Black women. Black women in this study reported receiving less than satisfactory patient care. The findings from this study attributed their less than satisfactory patient care to three significant themes: 1) perceived discrimination based on race, 2) perceived discrimination based on socioeconomic status, and 3) stereotypical assumptions (i.e., drug-seeking or having an STD) (Oliha et. al., 2020). Another study conducted by Berry and Colleagues (2009) examined the effects of race on cancer outcomes by performing a retrospective study. The methodology involved analyzing the cancer registry, billing, and medical records for Black and White patients diagnosed with Stage 4 cancer between the years of 2000 and 2005. The findings from this study revealed that even after controlling for insurance, income, and disease severity, Black patients were receiving lower quality care [9,10].

A pivotal survey was conducted by the Commonwealth Fund in 2001 to assess the quality of healthcare based on race. The study was conducted using a sample size of 1,037 Americans that identify as Black or Black out of a total sample size of 6,722 [11]. Results from this survey provided evidence of racial disparities economically and in the quality of healthcare.

Income and access make a difference on your quality of healthcare or whether you end up receiving healthcare at all. This is evidenced by a survey conducted by Collins and Colleagues (2001). The results revealed that 59% of Black individuals were less likely to have job-based insurance and were more likely to rely on public programs. The survey also revealed that 50% of Black individuals reported annual income at or near poverty levels as compared to 30% of White individuals. Furthermore, regular doctor access was assessed as consistent access to a doctor that knows of your health status and that addresses all your concerns. It was found that 28% of Black individuals reported not having a regular doctor and cite emergency rooms, “nowhere”, and clinics as usual sources of care as compared to 9% of white individuals. This previous evidence suggests that income does not protect a Black woman from the risk of dying from pregnancy complications. It is a racial systematic issue that needs to be considered [11].

Perceived Stress and Postpartum Depression

The interaction of perceived stress and postpartum depression has an impact on the mothers’ postpartum experience, which can be detrimental for the mother and the baby. This is evidenced by a study conducted by Sidor and his colleagues (2011) that involved assessing Black non-clinical mother-infant dyads at psychosocial risk. The psychosocial risks they focused on included poverty, alcohol or drug abuse, and lack of social support. The findings from this study suggested that mothers that reported higher postpartum depression reported higher perceptions of parenting stress. Another study conducted by Suárez-Rico and his colleagues (2021) involved collecting data on postpartum Mexican mothers between August and September 2020. The purpose of this study specifically was to look at the perceived stress accumulated from COVID-19 by a postpartum mother. The findings from this study revealed that depression, anxiety, and perceived stress was higher during the COVID-19 pandemic lockdown for Mexican postpartum mothers than previously reported in literature [12,13].

Postpartum depression also known as perinatal depression is a mood disorder that can affect women during and after childbirth. Symptoms include anxiety, feelings of extreme sadness, and fatigue that can make it difficult for them to carry out daily tasks, including caring for themselves and others. Previous research suggests that postpartum depression is caused by an integration of environmental and genetic factors. Some environmental factors could be experiences of past trauma, while genetic factors can be a family history of depression.

Previous studies have measured postpartum depression by using the tool known as the Edinburgh Postnatal Depression Scale, which screens women for psychological distress. The prevalence of depression and anxiety for women during pregnancy was 16 percent and 19 percent after pregnancy. Halbreich and Karkun (2006) conducted a comprehensive review of depression attributing the cultural differences in young women reporting and understanding depression. Perinatal depression is another form of depression that constitutes being depressed during pregnancy. The risk for suicidality is significantly elevated among depressed women in the perinatal period and has been found to be the second leading cause of death in the depressed population of pregnant women [14-16].

Perceived Racism and Postpartum Depression

The relationship of perceived racism and postpartum depression is important to look at given that systemic racism is constantly negatively impacting Black women and mothers. This is evidenced by a study conducted by Stepanikova & Kukla (2017), which involved collecting survey data mid-pregnancy and at 6 months postpartum on Black mothers with low and high education. The findings revealed that Black mothers with low education perceived higher racism and discrimination, which was in turn associated with higher odds of postpartum depression. Another study by Rosenthal and colleagues (2015) involved examining changes across pregnancy and postpartum as it relates to perceived discrimination for Black and Hispanic mothers [18]. The findings revealed that according to the age of the mother, perceived discrimination increased and decreased between trimesters and strongly predicted anxiety and depression among Black and Hispanic mothers that reported food insecurity [17,18].

The current study assessed the differences in perceptions of the healthcare community across annual income and perceived stress levels, and the relationship between perceived stress, perceived racism, postpartum depression, and the perceptions of the healthcare community among Black women. With the minimal amount of information on this topic there is a need for further research on maternal mortality and solutions as it pertains to Black Women and the role of perceived discrimination. The following research questions were explored (1) Are there differences in perceptions of the healthcare community for women that report high levels of stress and those that report low levels of stress? (2) Do the perceptions of racism moderate the relationship between Black women’s perceptions of the healthcare community and stress and (3) Are there differences in the perceptions of the medical health care community for Black women across income level? (4) Does the combination or combined influence of perceptions of the healthcare community and income predict postpartum depression than either variable alone?

Methods

Research Design

To understand the differences in perceptions of the healthcare community across annual income, and the relationship between perceived stress, perceived racism, & postpartum depression among Black women, survey methodology was used. Twenty percent of data were randomly reentered. Frequency and distributions were run to ensure data is in acceptable data ranges. Non-Parametric Independent Sample T-tests were run to investigate differences in the perceptions of the healthcare community across stress and income. Spearman Rho correlations were run to investigate relationships between primary variables. Standard, Multiple, and Hierarchical regressions were run to investigate the moderating role of perceived racism and combined influence of perceptions of the healthcare community and annual pre-tax income.

Participants

Two-Hundred Nineteen Black mothers were recruited for the present study and solicited through agencies that provide services to expecting mothers in the Triangle Area. Black mothers were also solicited via online platforms such as Facebook, Instagram, and Tiktok. The only requirements or exclusions were that all participants must be at least 18 years of age or older, had a baby within the last two years, and identify as Black or of African descent. Finally, Cohen’s (1992) power analysis determined that for results to be significant at the .05 alpha level, and using a medium effect size, the present study needed a total of at least 85 participants to assess perceptions of the healthcare community, perceived stress, perceived racism, and postpartum depression. However, given that regression analysis needed to be performed, 200 was needed according to Fidell [19,20].

Regarding the participants in this study, 9.6% were 18-25 years old, 20.5% were 25-30 years old, 32.9% were 30-35 years old, and 37% were 35 years of age or older. In terms of their level of education, 6.4% of the participants were continuing education students, 1.4% non-degree seeking, .5% undergraduate freshmen, 2.3% sophomore, 3.7% junior, 6.4% senior, 42.5% Bachelor’s, 10% Master’s/Doctoral, and 19.6% Associate’s. 95.9% of the participants reported being enrolled full-time in school. 33.8% of the participants in the study reported being married.

In terms of socioeconomic status, 2.7% reported having an income of $15,000 or less, 34.7% reported having an income of $45,001-$60,000, and 5.5% reported making approximately over $100,000 a year. Regarding children, 74.5% of the participants reported having 3 children or less, while 6.4% of participants reported having a total of five or more children. Regarding children that were given birth to within the last five years, 89.4% of the participants reported having 1-2 children, while 1.9% of the participants reported having a total of four or more children. In terms of prenatal care, 95% of the participants reported having received it, while 5% reported not receiving prenatal care.

Regarding mental health counseling during or after pregnancy, 22.9% of the participants reported having received counseling, while an average of 89% of participants reported not receiving counseling and 92.2% of the participants reported experiencing financial difficulties, while 7.8% reported experiencing no financial difficulties. Roughly 90.9% of the participants reported being the primary caregiver of their children. Fifty point two percent of the participants reported having 3-4 family members or friends that help raise the child, while 33.8% of the participants reported having 4 or more family members or friends that help.

Forty-five-point two percent of the participants reported that they have sometimes seen media coverage regarding maternal health, while 7.8% of the participants reported that they have very often seen media coverage regarding maternal health. Thirty-nine point three percent of the participants reported that they have sometimes heard family or friends discuss maternal health, while 11.4% of the participants reported that they have very often heard family or friends discuss maternal health. Thirty point six percent of the participants reported having attended maternal health support groups sometimes, while 19.2% of the participants reported having attended maternal health support groups very often (Table 1).

Table 1: Descriptive Statistics for Participants’ Demographic Information.

Measures

Demographics

Demographic information was collected by asking the participants to indicate their age, race or ethnicity, region of the U.S. in which they were born, current or previous enrollment status in school, highest level of education received, marital status, annual pre-tax income, number of children, number of children they had within the last five years, whether they received prenatal care during pregnancy, whether they experienced pregnancy complications, whether they received counseling during or after pregnancy, whether they experienced financial difficulties during pregnancy, how many hours a week they work, how many jobs they hold, whether they are the primary caregiver, and number of family or friends that help with child caring. The questionnaire also assessed aspects of the individual’s awareness about maternal health outcomes and if they have attended maternal health support groups for women of color.

Perceptions of the Healthcare community

The Discrimination in Medical Settings Scale

In 1997, David Williams and his colleagues cultivated a scale known as the Everyday Discrimination Scale (EDS) [21]. This widely utilized and measure of self-reported discrimination was adapted and modified into the DMS. The Discrimination in Medical Settings Scale is a 7-item 5-point Likert scale (1-never, 2-rarely, 3-sometimes, 4-most of the time, 5-always) used to assess discrimination in medical settings. Some examples of items are as follows: 1) You are treated with less respect than other people. 2) A doctor or nurse is not listening to what you were saying. 3) A doctor or nurse acts as if he or she thinks you are not smart. 4) The doctor or nurse acts as if he or she is afraid of you. This measure was found to be of good internal reliability; Cronbach’s alpha for the 7-item scale was 0.89 or higher. This measure also expanded upon the previous measures of discrimination and provided more focus on defining experiences of discrimination in healthcare settings.

Perceived Stress

Perceived Stress Scale

In 1983, Sheldon Cohen and his colleagues cultivated a scale known as the Perceived Stress Scale (PSS) [22]. This is the most widely used psychological instrument for measuring the perception of stress within the last 30 days. The Perceived Stress Scale (PSS) is a 10-item 4-point Likert scale (0-never, 1-almost never, 2-once in a while, 3-often, 4-very often). Some examples of items are as follows: 1) In the last month, how often have you felt that things were going your way? 2) In the last month, how often have you found that you could not cope with all the things that you had to do? 3) In the last month, how often have you felt nervous and stressed? 4) In the last month, how often have you felt that you were on top of things? This measure was found to be of good internal reliability; Cronbach’s alpha for the 10-item scale was 0.70 or higher. This measure also expanded upon the previous measures of stress.

Perceived Racism

The Perceived Racism Scale.

In 1996, Mcneily and her colleagues cultivated a scale known as the Perceived Racism Scale (PRS) [23]. This scale was created to assess the experiences of white racism against Blacks in multiple domains including employment and public domains. The Perceived Racism Scale (PSS) is a 14-item 4-point Likert scale (0-never, 1-rarely, 2-sometimes, 3- fairly often, 4-very often). Some examples of items are as follows: 1) How often in the past year have you had difficulty getting a loan because you are Black? 2) How often during your life have waiters and waitresses ignored you and served whites first? 3) How often in the past year have people “talked down” to you because you are Black? 4) How often in the past year have you experienced being followed, stopped, or arrested by White police more than others because of your race? This measure was found to be of good internal reliability; Cronbach’s alpha for the 14-item Likert scale was 0.70 or higher. This measure also expanded upon the previous measures of racism.

This scale was adapted to be appropriate for use in a cohort of Black mothers that have had a baby within the last two years. The Adapted Perceived Racism Scale (PSS) is a 12-item 5-point Likert scale (1-never, 2-less than once a year, 3-a few times a year, 4- about a few times a month, 5-once a week or more). Some examples of items are as follows: 1) How often have you been made to feel intimidated or less intelligent by doctors or nurses? 2) How often have you had a doctor or nurse make minimal eye contact with you or don’t give you a thorough physical examination? 3) How often do you feel that you have had to work twice as hard to explain your symptoms to a doctor for them to take you seriously? 4) How often do you feel that you are ignored or not taken seriously by doctors or nurses? This measure was found to be of good internal reliability; Cronbach’s alpha for the 12- item scale was 0.925. This measure also expanded upon the previous measures of racism.

Postpartum Depression

The Edinburgh Postnatal Depression Scale

In 1987, Cox and colleagues developed this scale to assist health professionals in detecting mothers that are suffering from postpartum Depression [24]. Postpartum is defined as a prolonged “blues” that can begin for the mother within a week after delivery of the baby. The Edinburgh Postnatal Depression Scale (EDPS) is a 10-item 3-point Likert scale (0-yes, all of the time, 1-yes, most of the time, 2-no, not very often, 3-no, not at all). Some examples of items are as follows: 1) I have felt miserable or sad.2) I have been so unhappy that I have been crying. 3) The thought of harming myself has occurred to me. 4) I have been so unhappy that I have had difficulty sleeping.

Procedures

To assess the differences in perceptions of the healthcare community across annual income, and the relationship between perceived stress, perceived racism, and postpartum depression, the present researcher submitted the study to the NCCU Institutional Review Board for approval. After receiving approval, the researcher contacted maternal health agency directors to gain permission to solicit participation from their mothers. The researcher also solicited participation from social media platforms such as Facebook, Instagram, and TikTok. The data was collected via an online survey on Qualtrics where the participants first completed a consent from, the demographic measure, and then completed the Discrimination in Medical Settings Scale, Perceived Stress Scale, The Perceived Racism Scale (Adapted), and The Edinburgh Postnatal Depression Scale to examine the variables. Participants were provided with a list of local mental health resources at the end of the survey [14-21].

Results

Data analysis was conducted using the SPSS 29.0 software. Frequency distributions were run to ensure that the data was within normative ranges. Spearman Rho correlations were calculated to examine the primary variables and demographic variables. Multiple and hierarchical regressions were utilized next to view to what extent perceived racism is a moderator for perceptions of the medical health community and perceived stress. As well as the combined influence of perceptions of the healthcare community and annual pre-tax income as predictors of postpartum depression. Median scores were created for each scale (see Table 2).

Table 2: Psychometric Properties (Medians and Ranges for Primary Variables).

Preliminary Analysis

In order to understand differences in the healthcare community across income, and the relationship between perceived stress, perceived racism, and postpartum depression among Black women Spearman Rho correlations were run. Spearman Rho correlations to assess the relationship between primary variables. The results revealed that there was a significant positive relationship between perceptions of the healthcare community and perceived stress (r_s=.75, p≤0.001). Perceptions of the healthcare community was related to perceived racism (r_s=.67, p≤0.001). Perceived racism was related to perceived stress (r_s=.68, p≤0.001). Perceived stress and postnatal depression were negatively associated and not significant, however, it was approaching (r_s=-.13, p=.06). Perceived stress and postnatal depression were negatively related (r_s=-.14, p≤0.05). The Annual Pre-Tax Income was not significantly related to any of the primary variables (Tables 2 and 3).

Table 3: Correlation Results for Primary Variables

p<.05* p<.01** p<.001***

Hypothesis 1: Differences in Perceptions of the Healthcare Community Across Levels of Stress

To assess differences in perceptions of the Healthcare community across levels of stress, a Mann Whitney U Test was run. The Mann Whitney U Test indicated that negative perceptions of the healthcare community were greater for individuals that reported higher levels of stress (Mdn=29) than those that had lower levels of stress (Mdn=21) (See Table 4a) that reported high levels of perceived stress (U=10638.5, p≤0.05) (see Table 4b).

Table 4a: Statistics: Perceptions of the Medical HealthCare.

Table 4b: Independent -Samples Mann-Whitney U.

Hypothesis 2: Perceptions of Racism as a Moderator between Perceptions of the Healthcare Community and Stress

In the first regression analysis, perceptions of racism were examined as a moderator between the perceptions of the healthcare community and perceived stress. The first regression model accounted for 49% of the variance (R²=.49., F (1,218)=, p≤0.001). Independently, perceived racism was associated with perceived stress among Black women (b=.70, p≤0.001). The results of the second regression model explained that these combined variables accounted for 62% of the variance (R²=.617, F (2,218)=, p≤0.001) and perceptions of the healthcare community was associated with perceived stress in Black women (b=.53, p≤0.001). In the third model of the regression analysis, the interaction term (perceptions of the healthcare community x perceived racism) was entered into the model to determine the possibility of moderation. The model was significant and accounted for 63% of the variance (R²=.63, F (3,218)=, p≤0.001), and there was evidence for moderation (∆R²=.009, ∆F=4.95). Independent Samples Non-Parametric Mann Whitney U Tests were run and individuals who were high in perceived stress (Mdn=52) reported significantly more racism than individuals that were low in perceived stress (Mdn=43) (U=10077.5, p≤0.001)) (Table 5).

Table 5: Moderator Analysis: Perceived Racism and Perceptions of the Medical Health Care Community on Perceived Stress.

*p< .05, **p<.01, ***p<.001

Hypothesis 3: Perceptions of the Healthcare Community and Income

To assess mean differences in the perceptions of the healthcare community, a One-Way ANOVA was run. Results of the ANOVA indicated that there was significant mean difference in perceptions across income F(6, 218)=6.79, p≤0.001) (Table 6). Post Hoc analysis using Tukey and Bonferroni indicated that individuals that made $45,000-$60,0000 reported more favorable views of the healthcare community than those who made $30,000 and less and individuals who made over $100,000.

Table 6: One-Way ANOVA: Perceptions of the Medical Health Care Community across Income.

p< .05* p< .01** p< .001***

Hypothesis 4: Perceptions of the Healthcare Community and Annual Pre-Tax Income as Predictors Postpartum Depression

The fourth hypothesis predicted that Perceptions of the Healthcare community and Annual Pre-Tax Income combined will be better predictors of Postpartum Depression than either variable alone. Standard and multiple regressions were run. Independently, perceptions of the healthcare community accounted for 3% of the variance in postpartum depression among Black women F(1, 218)=5.52, p≤0.05) (See Table 7) and was a significant negative predictor of postpartum depression among Black women (b=-.16, p≤0.05). Independently, annual pre-tax income accounted for less than 1% of the variance in postpartum depression among Black women F(1,218)=.25, p=ns and was not significantly associated with postpartum depression (b=.03, p=ns). Combined in the regression model, perceptions of the healthcare community and annual pre- tax income accounted for 3% of the variance and the model was approaching significance F(2, 218)=2.962, p≤0.054 (See Table 7). Thus, hypothesis 4 was not supported but approaching significance.

Table 7: Predictors of Postpartum Depression.

*p< .05, **p<.01, ***p<.001.

Discussion

Findings

The current study was conducted to better understand differences and relationships in perceptions of the healthcare community, annual pre-tax income, perceived stress, perceived racism, and postpartum depression. In doing so, we hoped to provide detailed results about the relationships between these variables while also pinning down potential underlying factors. Research on perceptions of the healthcare community, annual pre-tax income, perceived stress, perceived racism, and postpartum depression among Black women has been largely qualitative. The current study sought to assess the relationship between perceptions of the healthcare community, annual pre-tax income, perceived stress, perceived racism, and postpartum depression.

We found a statistically significant difference in perceptions of the healthcare community between participants reporting high versus low perceived stress. This finding is consistent with prior literature examining healthcare mistrust, discrimination, and stress among Black women. Previous studies have shown that negative healthcare experiences and perceived discrimination are associated with increased psychological distress and stress-related outcomes [18-25]. For example, Cuevas and colleagues have documented that African American adults who report greater mistrust in healthcare institutions also report poorer psychological outcomes, including heightened stress and negative emotional responses related to healthcare encounters. Qualitative and quantitative studies by Cuevas and colleagues further indicate that experiences of discrimination, poor communication, and lack of respect in medical settings contribute to diminished trust and increased stress among Black patients [8,25]. These experiences are frequently framed as discrimination-related stressors rather than isolated interpersonal events. Related work has also demonstrated that medical mistrust and perceived discrimination are associated with adverse mental health outcomes among Black patients, including anxiety and depressive symptoms. Studies using established measures of physician mistrust and institutional medical mistrust have shown that discriminatory healthcare experiences contribute to stress and disengagement from care [26,27].

We found evidence of a moderation effect; women that were low on the PRS reported higher stress and those that were high in PRS reported less stress. Black women who had higher perceptions of racism reported higher levels of stress, whereas Black women that had lower perceptions of racism reported lower levels of stress. These findings are consistent with previous research by Suárez-Rico and his colleagues (2021) involved collecting data on postpartum Mexican mothers between August and September 2020 [13]. The purpose of this study specifically was to look at the perceived stress accumulated from COVID-19 by a postpartum mother. The findings from this study revealed that depression, anxiety, and perceived stress was higher during the COVID-19 pandemic lockdown for Mexican postpartum mothers than previously reported in literature.

We also found that there was a statistically significant mean difference in perceptions of the healthcare community across incomes. More specifically, we found that lower and higher income Black mothers reported less favorable views of the healthcare community than the middle-class income Black mothers. These findings could indicate that lower income women have a perceptual bias or potentially received subpar levels of care. Middle-class income women have insurance and certain expectations along with a certain level of education about the prenatal process. High income women have insurance, have the money to pay for prenatal health experts, and may live with a heightened awareness of racism. and the resources to pay for experts.

We lastly found that perceptions of the healthcare community accounted for more of the variability in postpartum depression than annual pre-tax income as an independent predictor. These findings are consistent with previous research while adding more information to the literature about Black women [28].

Conclusions

The purpose of this study was to assess differences in perceptions of the healthcare community across annual income, and the relationship between perceived stress, perceived racism, and postpartum depression. The results from this study give distinctive insight into Black women’s pregnancy and birthing experience, as well as how varying factors such as annual pre-tax income and social support, can act as potential buffers for postpartum depressive symptomatology. Future research is warranted given maternal and mental health challenges among the population and continued systematic racism and negative perceptions of the healthcare community.

Future studies investigating the relationship between perceptions of the healthcare community, perceived stress, perceived racism, and postpartum depression may benefit greatly from more extensive participant solicitation techniques via the internet (i.e., snowballing, purposive sampling) and in-person data collection in maternal health agencies. It is imperative that the researcher takes time to build relationships (i.e., volunteering, participating in different events or activities, etc.) with the maternal health agencies before soliciting participants. It is also imperative that future research focus on empowering Black women, through programmatic activities, to be aware of and then effectively manage the morbidities that are most associated with poor clinical maternal outcomes [29].

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DOI: 10.31038/AWHC.2025843

Abstract

The South African government has introduced various policies designed to prevent and manage learner pregnancy within schools. These initiatives form part of a broader national effort to address the social and health challenges that young people encounter across the country. Despite various interventions, teenage pregnancy remains a persistent social and public health challenge in South Africa with the rates of pregnancy and subsequent school dropouts among these young mothers persist, leading to severe economic consequences and perpetuating cycles of poverty. This paper examines how cultural education affects fertility behaviors among schoolgirls in South Africa, drawing from contemporary literature on cultural norms, teenage pregnancy, and school-based interventions. Evidence suggests that culturally grounded learning improves critical awareness, supports contraceptive uptake, and empowers girls to navigate pressures from families and communities. However, cultural barriers, religious norms, and moralistic attitudes often limit the effectiveness of these initiatives.

Keywords

Teenage pregnancy, Poverty, Cultural barriers, Prevention, Contraceptives

Introduction

Teenage pregnancy is a major concern in South African schools, with thousands of pregnancies recorded each year [1]. In support of this is [2] who argues that South Africa has one of the highest teenage pregnancy rates in the world, with nearly one in four girls becoming pregnant before the age of 20. According to Statistics South Africa, 90,037 girls aged 10 to 19 gave birth across the nine provinces between March 2021 and April 2022 (Stats SA [3]). This pattern highlights the urgent need for comprehensive sexual and reproductive health education and adolescent‑focused services to help curb rising teenage pregnancy rates, particularly during periods of crisis [4].

Many of pregnancies occur in contexts shaped by cultural expectations related to femininity, sexuality, and motherhood [5]. According to [6] cultural norms often transmitted through families, communities, and religious institutions play a significant role in shaping adolescents’ fertility decisions. Hence, [7], argues that 85% of pregnant women indicated that their families favoured their pregnancy. Research also shows that peer education and cultural dialogue are important interventions in addressing contraceptive behavior [8] and [2], but these efforts must meaningfully engage cultural and religious influences to be effective.

Therefore, cultural education, when integrated into school curricula, can challenge harmful norms, promote informed reproductive choices, and empower schoolgirls. Hence, is of paramount important to undergo this study as it aims to explore how such education affects fertility behavior among schoolgirls.

Literature Review

Cultural Norms as Predictors of Fertility Behavior

Socio‑cultural factors such as religion, ethnicity, and community beliefs significantly predict teenage pregnancy in South Africa. In the same vein, [9] argus that cultural beliefs and principles play a significant role in shaping the social landscape of the macrosystem. For instance, cultural predictors such as religious affiliation and ethnicity strongly influence adolescent fertility, especially in urban areas. In the same breath, [1] argues that the influence of ethnicity and religion play a crucial role more so in urban areas than in rural areas. All these are found in the macrosystem the adolescent leaves in. Above all, these norms shape beliefs about ideal family size, the acceptability of contraceptive use, and the meaning of womanhood [2]. In the same breath, [10] argues that women’s fertility preferences such as the number of children they desire and their willingness to use modern family planning methods are shaped by a complex interplay of social, economic, and cultural factors operating at multiple levels, often reinforcing or counterbalancing one another. Demographic characteristics including age and geographic context, levels of education [11‑13], religious orientation [14], as well as prevailing social norms and cultural beliefs [15], all play influential roles in determining women’s fertility aspirations and their adoption of family planning practices. Together, these factors contribute significantly to broader fertility patterns.

The Role of Education in Shaping Reproductive Behavior

Educational interventions, particularly peer education programs, have been shown to improve young people’s sexual health knowledge and reduce risky behavior. Hence, [2] argues that cultures, values, and traditions influence the prevailing negative perception of teenage mothers. However, their effectiveness is constrained if they do not address cultural and religious pressures. As one study found, cultural norms, church teachings, and community expectations limited adolescents’ ability to mentor peers on contraception, despite improved knowledge [1]. In the same vein, [16], argues that such perceptions have a key influence on decision‑ making processes and behaviour and may be particularly important in contexts of subsistence livelihoods and resource constraints, where households are vulnerable to both food insecurity and environmental degradation.

School Policy, Gender Norms, and Reproductive Outcomes

South African schools often operate within moralistic and conservative discourses around sexuality. These school‑based cultural norms can affect students’ reproductive choices. Research indicates that dominant school cultures that frame teenage pregnancy as moral failure reinforce shame, exclusion, and silence factors that limit informed fertility choices [17].

Cultural Education as an Intervention

Cultural education helps learners question harmful traditions, challenge myths about contraception, and understand the cultural roots of gender expectations. By discussing cultural norms openly, girls can develop stronger decision‑making skills. Literature further suggests that including cultural discussions in reproductive health interventions increases adolescents’ acceptance of contraception and reduces pregnancy risk [18]. On the other hand, [19] argues that cultural education serves as a mechanism to challenge and reshape these dominant social norms by engaging students in discussions about traditions, beliefs, and cultural misconceptions.

Theoretical Framework

This study is underpinned by Social Norms Theory (SNT). Social norms theory explains how individuals often misjudge the attitudes or behaviours of their peers and wider community, assuming them to differ from their own. This pattern of misunderstanding referred to as pluralistic ignorance [20] can arise in relation to both risky or problematic behaviours as well as healthy or protective ones. Such misperceptions may lead people to modify their own behaviour to align with what they mistakenly believe to be the norm [21]. As a result, individuals may adopt or justify harmful behaviours or, conversely, suppress positive, health‑promoting behaviours.

The Social Norms Theory asserts that individuals’ behaviours are shaped by perceived social expectations, cultural beliefs, and community norms. This theory deemed relevant to the current study as it allows the researcher to explain why schoolgirls may conform to social expectations encouraging early sexual activity or discouraging contraceptive use. Furthermore, it will guide the researcher to propose the interventions which will correct these misperceptions by revealing the actual, healthier norm that will have a beneficial effect on adolescent girl in, to reduce their participation in potentially problematic behaviour or be encouraged to engage in protective, healthy behaviours [22].

Methodology

Research Design

The methodology employed in this study involved the implementation of a systematic literature review research strategy synthesizing findings from peer‑reviewed studies, government reports, and policy documents exploring cultural influences on adolescent fertility. The researcher searched for peer‑reviewed studies on socio‑cultural predictors of teenage pregnancy, school‑based responses to teenage pregnancy, South African public health and educational reports and studies examining the interaction between culture and contraceptive use via google scholar.

This approach involved the meticulous identification and selection of relevant articles, as well as the exclusion of those that did not meet the predetermined inclusion criteria [2]. The detailed process of article retrieval, inclusion, and exclusion is elaborated upon in this section. According to [23], as cited in [24], conducting reviews transparently and reproducibly is what the systematic literature review as a research method aims to achieve. Above all, it enables the researcher to make selection of articles to incorporate or omit in the study [24]. Upon completing the reading, themes were identified across the literature reviewed, which includes, cultural norms and fertility, school‑based cultural influences, effects of cultural education, and barriers to culturally relevant sexual education.

Discussion

Cultural Education Improves Reproductive Knowledge

Evidence shows that when cultural beliefs are openly discussed in education settings, students gain a more nuanced understanding of fertility and contraception. Peer‑education programs, when culturally grounded, increase knowledge and enable adolescents to critically examine cultural messages about sexuality [1].

Challenging Myths and Misconceptions

Several scholars [25‑27] contend that rumours surrounding contraceptives such as beliefs that injectable methods damage the body negatively and oral contraceptives cause lower rates of acne, hirsutism, and weight gain, but higher rates of venous thromboembolism [28] influence both access to and utilisation of contraception. These misconceptions contribute to low contraceptive uptake, which in turn results in high levels of unmet need and increased rates of unintended pregnancy among adolescent girls and women. Similarly, [29] notes that many individuals are more preoccupied with the perceived negative side effects of contraceptives than with their effectiveness in preventing unwanted pregnancies. [27] further report that numerous adolescent girls and women cite side effects such as weight gain or loss, irregular bleeding, amenorrhea, and other bodily changes as reasons for avoiding contraceptive use. Participants also expressed fears that contraception could cause infertility or make the vagina “too wet,” leading to concerns about being viewed as undesirable by partners. Condoms, on the other hand, were often associated with discomfort, irritation from lubricants, and suspicions of infidelity. These misconceptions persist largely due to limited contraceptive education, particularly in low‑ and middle‑income countries (LMICs) [27]. Cultural beliefs such as the idea that contraceptives cause infertility also to exacerbate these concerns. [30] argue that dismissing these beliefs as mere rumours simply because they stem from social accounts of other women’s experiences rather than from clinical providers undermines a valuable and legitimate source of knowledge for many women.

Consequently, Jones (2023) argues that the decision to initiate contraception and select a method requires careful consideration; however, conflicting and confusing information often leaves individuals without the necessary knowledge to make informed choices. Culturally sensitive education has therefore been identified as essential for dispelling myths, reducing fear, and promoting informed contraceptive decision‑making. On the other hand, many programs recommend that providers address women’s concerns about the possible negative health effects of contraceptive methods by reassuring them that such fears are unfounded and that any side effects are likely to be minimal [31,32]. This type of counselling is commonly advocated in research that identifies associations between women’s beliefs and their contraceptive use [26,33‑35].

Empowering Girls Against Harmful Gender Norms

Many South African girls face cultural pressure to prove fertility, maintain submissiveness to partners, or conform to traditional femininity. Cultural education empowers girls to question these norms, advocate for themselves, and resist early sexual debut. According to [1] statistics of girls affiliating to traditional African religion were significantly positive with a 24% higher likelihood of pregnancy compared with Christian girls, while it was not significant and almost equal with a 1% lower chance of pregnancy among rural dwellers. This indicates that cultural education has its ways of decreasing teenage pregnancy. As observed in a practice of Basotho culture, where girls are not allowed to eat food such as eggs and intestine . This kind of practice is pass down to girls through gathering such as pitiki. According to [36], Basotho women gather during pitiki celebrations to support one another, share their experiences, and offer advice on addressing various challenges, particularly those involving their marriages or relationships with men. Consequently, ([37]: 88) agrees with [36] by pointing out that ‘we need new alternatives and sometimes this means revisiting the old wisdoms and tapping into the maternal legacies of knowledge in Africa’. Hence, pitiki is seen as a good space were Indigenous Basotho women’s knowledges related to sexual, reproductive health and well‑being, maternal and child health within and around the Indigenous are discussed [38]. In this space, girls are free to discuss any matters related to sex, as such this helps to reduce teenage pregnancy.

Addressing Cultural and Religious Barriers

Studies show that religion and cultural identity strongly influence teenage fertility. Cultural education enables learners to navigate these influences by offering critical reflection rather than dismissing cultural identity. Programs that ignore culture tend to be ineffective [2]. Previous research has highlighted religion understood as systems of faith and worship as a factor that influences teenage pregnancy [39,40]. In the South African context, the influence of religion on teenage pregnancy appears to stem largely from religious teachings that discourage the use of contraceptives. For example, a study conducted in the North‑West province found that 6.83% of participants believed that using contraception was against their religious beliefs [41]. Likewise, research carried out in the Vhembe district of Limpopo reported that, because most teenagers (94.1%) identified as Christian, religious beliefs played a significant role in teenage pregnancy, as contraception was generally not supported [42]. Concurring to this is [1] who argues that the most affected groups are Nguni group (51%), Christian faith (84.9%) and lived in urban areas (53%) in KwaZulu‑Natal (21%). Therefore, understanding these cultural and religious influences is essential for developing effective, culturally and religiously sensitive reproductive health strategies that respect community beliefs while promoting women’s autonomy and well‑being.

The Role of Schools

The South African government has introduced various policies designed to prevent and manage learner pregnancy within schools. Amongst those policies is the Policy on the Prevention and Management of Learner Pregnancy in that was finalised in 2021 by the Department of Basic Education. The policy expressly provides that a school may not discriminate against a learner based on her pregnancy status [43]. The School Governing Body (SGB) is given the mandate to implement and fulfil the need of the policies governing the school [44]. This suggest that SBG in their policy will be in position to suggest the programmes that raise awareness on teenage pregnancy. Therefore, these initiatives form part of a broader national effort to address the social and health challenges that young people encounter across the country.

To reduce the likelihood of young people engaging in unsafe sexual practices, it is essential to equip them with the knowledge and skills necessary for practicing safe sex [45‑47]. Schools serve as an ideal setting for delivering this education, as they provide access to most children and adolescents. I therefore, argue that recently schools often perpetuate moralistic messages about sexuality, which create stigma around pregnancy and contraceptive use. This is because teachers offering sex education often use more passive forms of learning and tend to disregard skill‑oriented learning activities [48‑50]. On the same breath, [51] argue that cultural and societal taboos surrounding sexual and reproductive health strongly shape both educational content and public health policies. In many countries, school‑based sex education is either highly restricted or entirely absent due to cultural sensitivities and political opposition. The United States, for example, has long experienced controversy over abstinence‑only versus comprehensive sex education, with the preference for abstinence‑only approaches often grounded in religious and cultural norms [52]. In contrast, nations that adopt more open and comprehensive approaches to sexual health such as the Netherlands report lower rates of teenage pregnancy and sexually transmitted infections [53]. These comparisons demonstrate how cultural contexts are both reflected in and reinforced by policy choices, which signal varying levels of societal comfort and openness toward sexual and reproductive health topics. Therefore, changing school culture through inclusive cultural education can create safer environments for discussing reproductive choices [2].

Conclusion

It has been observed that fertility choices such as preferred family size, timing of childbearing and contraceptive use are deeply shaped by cultural and religious norms as well as social expectations. In many communities, beliefs about womanhood, lineage continuation, masculinity, religious teachings, and social status influence how women make reproductive decisions. Cultural education significantly shapes fertility behavior among South African schoolgirls. By addressing cultural norms, challenging myths, and empowering girls, it contributes to informed reproductive decision‑making and helps reduce teenage pregnancy. However, cultural education must be delivered in ways that respect community traditions while promoting girls’ rights and autonomy. Schools, families, and communities must collaborate to develop culturally sensitive and empowering educational interventions. As observed, high fertility rates pose challenges not only for country, but also for food security and the general welfare of households [54].

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