Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia

Universal Health Coverage (UHC) forces governments to consider not only how services will be provided–but which services–and to whom, when, where, how and at what cost. This paper considers the implications for achieving UHC through the lens of abortion-related care for adolescents. Our comparative study design includes three countries purposively selected to represent varying levels of restriction on access to abortion: Ethiopia (abortion is legal and services implemented); Zambia (legal, complex services with numerous barriers to implementations and provision of information); Malawi (legally highly restricted). Our policy and legal analyses are supplemented by comparative vignettes based on interviews (n = 330) in 2018/2019 with adolescents aged 10–19 who have sought abortion-related care in each country. We focus on an under-considered but critical legal framing for adolescents–the age of consent. We compare legal and political commitments to advancing adolescent sexual and reproductive health and rights, including abortion-related care. Ethiopia appears to approach UHC for safe abortion care, and the legal provision for under 18-year-olds appears to be critical. In Malawi, the most restrictive legal environment for abortion, little progress appears to have been made towards UHC for adolescents. In Zambia, despite longstanding legal provision for safe abortion on a wide range of grounds, the limited services combined with low levels of knowledge of the law mean that the combined rights and technical agendas of UHC have not yet been realised. Our comparative analyses showing how policies and laws are framed have critical implications for equity and justice

Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia

Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation

Youth talk about sexuality: A participatory assessment of adolescent sexual and reproductive health in Lusaka, Zambia

Thirty-six percent of Zambia’s 9 million inhabitants are between 10 and 19 years of age, and most adolescents are sexually active by their mid-teens. Pregnant teenagers have an elevated risk of maternal mortality and complications related to birth. In 1990, at Lusaka’s University Teaching Hospital, self-induced abortion accounted for up to 30 percent of maternal mortality, and one-quarter of these deaths occurred in women under 18 years. Sexually transmitted infections (STIs) are a major health problem for adolescents, yet only a small proportion protect themselves from pregnancy and STIs. There are many barriers to improving the situation, including opposition by parents and teachers to the use of modern contraceptive methods. CARE Zambia is conducting a study to test community-based strategies that increase knowledge of, demand for, and use of barrier methods to reduce unprotected intercourse among out-of-school adolescents in peri-urban Lusaka. As noted in this report, adolescent behavior change will be measured as the prevalence of barrier method use, number of sexual partners, FP attitudes, and measures of self-esteem and responsibility among participants

Investing in youth: Testing community-based approaches for improving adolescent sexual and reproductive health

The world is now sustaining the largest number of youth in human history; today there are nearly 900 million 10–19-year-olds and their health and livelihood issues are becoming increasingly important to policymakers worldwide. In Zambia, as in many other countries, young people face severe problems, including limited access to jobs, secondary education, and health care. The social, economic, and peer pressures that youth face often lead to high levels of sexual activity, often with subsequent negative impacts on their sexual and reproductive health. In spite of the magnitude of the reproductive health problems facing youth, they still have limited access to effective programs and services to address these problems. In an effort to address this need, CARE Zambia, in collaboration with the Planned Parenthood Association of Zambia and Makeni Ecumenical Center, with technical assistance and funding from the Population Council’s Africa Operations Research and Technical Assistance Project II, have conducted a study to test community-based approaches for improving adolescent sexual and reproductive health. As noted in this report, the study followed a pre-post test design to assess the impact of the interventions and to make comparisons between the different interventions

Adolescent sexual and reproductive health and universal health coverage : a comparative policy and legal analysis of Ethiopia, Malawi and Zambia

Universal Health Coverage (UHC) forces governments to consider not only how services will be provided – but which services – and to whom, when, where, how and at what cost. This paper considers the implications for achieving UHC through the lens of abortion-related care for adolescents. Our comparative study design includes three countries purposively selected to represent varying levels of restriction on access to abortion: Ethiopia (abortion is legal and services implemented); Zambia (legal, complex services with numerous barriers to implementations and provision of information); Malawi (legally highly restricted). Our policy and legal analyses are supplemented by comparative vignettes based on interviews (n = 330) in 2018/ 2019 with adolescents aged 10–19 who have sought abortion-related care in each country. We focus on an under-considered but critical legal framing for adolescents – the age of consent. We compare legal and political commitments to advancing adolescent sexual and reproductive health and rights, including abortion-related care. Ethiopia appears to approach UHC for safe abortion care, and the legal provision for under 18-year-olds appears to be critical. In Malawi, the most restrictive legal environment for abortion, little progress appears to have been made towards UHC for adolescents. In Zambia, despite longstanding legal provision for safe abortion on a wide range of grounds, the limited services combined with low levels of knowledge of the law mean that the combined rights and technical agendas of UHC have not yet been realised. Our comparative analyses showing how policies and laws are framed have critical implications for equity and justice.MRC/DFIDhttps://www.tandfonline.com/loi/zrhm21am2021Centre for Human Right

Integrating child rights standards in contraceptive and abortion care for minors in Africa

Minor girls in Africa face challenges in accessing high-quality contraceptive and abortion services because laws and policies are not child-friendly. Many countries maintain restrictive laws, policies, or hospital practices that make it difficult for minors to access contraception and safe abortion even when the pregnancy would risk their life or health. Further, the clinical guidelines on contraceptive and abortion care are silent, vague, or ambiguous regarding minors' consent. African states should remedy the situation by ensuring that clinical guidelines integrate child rights principles and standards articulated in child rights treaties to enable health providers to facilitate full, unencumbered access to contraceptive and abortion care for minor girls. A sample of clinical guidelines is analyzed to demonstrate the importance of explicit, consistent, and unambiguous language about children's consent to ensure that healthcare workers provide sexual and reproductive health care in a manner that respects child rights

Contraception and abortion in times of crisis: results from an online survey of Venezuelan women

IntroductionIn the last decade, Venezuela has experienced a complex humanitarian crisis that has limited access to healthcare. We set out to describe Venezuelan women's experiences accessing sexual and reproductive health services, including abortion, which is heavily restricted by law.MethodsWe fielded an online survey in July of 2020 among Venezuelan women recruited through social media advertisements. We conducted descriptive statistical analyses using Excel and STATA SE Version 16.0.ResultsWe received 851 completed survey responses. Almost all respondents experienced significant hardship in the last year, including inflation (99%), worries about personal safety (86%), power outages (76%), and lack of access to clean water (74%) and medications (74%). Two thirds of respondents used contraception in the last two years, and almost half (44%) of respondents had difficulty accessing contraception during that same time period. About one fifth of respondents reported having had an abortion; of these, 63% used abortion pills, and 72% reported difficulties in the process. Half of those who had an abortion did it on their own, while the other half sought help – either from family members or friends (34%), from providers in the private health sector (14%), or from the Internet (12%).ConclusionsVenezuelan women who responded to our survey describe a harsh context with limited access to sexual and reproductive health services. However, they report relatively high rates of contraceptive use, and abortion seems to be common despite the restrictive legal setting