Improving adolescent access to contraception and safe abortion in sub-Saharan Africa: health system pathways

A substantial proportion (35%) of adolescent pregnancies in sub-Saharan Africa are unintended; 10-19 year olds account for 25% of all abortions in Africa, higher than in any other world region. Unsafe abortion is a major public health problem, not only in countries where access to safe abortion services is highly restricted legally. Even where it is available legally, access, provision and knowledge of services can be inadequate. Adolescents are more likely to have an unsafe abortion and to experience complications (including death) of unsafe abortion compared to older women, even in settings where safe abortion is available. Addressing the age distribution of unsafe abortion, focusing on adolescents, is important in identifying and tackling barriers to health-care access and delivery. The needs of adolescents for contraception and abortion services are substantial; the implications for adolescents of not having access to these services are life-long. Research on unsafe abortion has shown the magnitude and the substantial health systems costs of unsafe abortion and unmet need for contraception, but significant evidence gaps remain for adolescents.

This research aims to establish how the implementation of contraception and abortion services for adolescents in sub-Saharan Africa can be improved. It will do this by comparing services in two types of public facility (tertiary hospital and ASRHS) in three countries: Ethiopia, Malawi and Zambia. These three countries represent a range of abortion legal frameworks, from least restrictive (Ethiopia) to most restrictive (Malawi). The research will generate new evidence by collecting data from two groups: adolescents seeking either safe abortion or post-abortion care at facilities; and, key informants involved in the implementation of contraception and abortion services for adolescents.

Adolescent sexual and reproductive health services (ASRHS) aim to increase access to, and quality of, appropriate healthcare for adolescents, and respond to evidence that shows the significant barriers encountered by adolescents in accessing and receiving sexual and reproductive health services. Each of the three study countries has high-level commitment to the development and provision of YFS, although the rate of roll-out is variable. Systematic research on the implementation of contraception and abortion services for adolescents is absent. The evidence that does exist presents few opportunities for drawing out generalisable understandings across settings.

In all three study countries, the issue of unsafe abortion among adolescents is a policy priority. There is acknowledgement that adolescents represent a group that is at high(er) risk of an unwanted pregnancy, linked to lower levels of access to effective contraceptive services. The team composition, with established and active relationships with policymakers, including Ministries of Health, means that this proposal has been informed and developed with in-country knowledge of what evidence and research is needed in order to improve health systems' capacity to deliver ASRHS effectively. There is an urgent need to understand how contraception and abortion care services can be provided for, and accessed by, adolescents. We focus on abortion care as one key component of the service provision needed to prevent unwanted adolescent pregnancies, which includes access to contraception, including emergency contraception. The evidence we generate will have relevance for other sub-Saharan African countries with a wide range of legal contexts, and will be able to inform current debates about abortion legality, policy and service change.

35% of adolescent pregnancies in sub-Saharan Africa are unintended. Adolescents account for 23% of the global burden of disease (disability-adjusted life years) due to pregnancy and childbirth. 10-19 year olds account for 25% of all abortions in Africa, higher than in any other world region. Unsafe abortion and its sequelae is a major public health problem, not only in countries where access to safe abortion services is highly restricted legally. Limited evidence focuses on adolescents' perceived barriers to accessing sexual and reproductive health services in general, and experiences of navigating these barriers (successfully or unsuccessfully) are under-researched.

We propose a three country (Ethiopia, Malawi, Zambia) comparison of implementation research on contraception and abortion services for adolescents. Within each country, two contrasting study sites (tertiary hospital and designated ASRHS), have been identified. The study design permits 3 analytic levels: within-country by facility; cross-country; and cross-facility. The 3 countries represent a range of ASRHS and abortion legal frameworks and permit a maximum difference design.

We will collect data from adolescents who have either sought a safe abortion or post-abortion care following an abortion initiated elsewhere. For implementation research on ASRHS, this is a critical population to understand (non-)use of services, including the barriers to access and care. By comparing adolescents treated for the consequences of unsafe abortion with adolescents who have navigated complex health systems successfully, we will identify factors critical for reaching this under-served and hard-to-reach group. Combined with key informant interviews and costing analyses, the evidence we generate will mean that we will be able to propose realistic and culturally-appropriate ways to address such sensitive topics as adolescent contraceptive use and abortion.

We will produce evidence to inform the provision of contraception and abortion services for adolescents in low income countries. We will achieve this by focussing research uptake activities on as wide a policy, practitioner, academic and civil society audience as possible. The ultimate beneficiaries of this research should be adolescents seeking to prevent or terminate an unwanted pregnancy; routes to making an impact on them will be complex and extend beyond the duration of the project.

From the start of the project, we will engage with stakeholders about potential outputs so that we can gauge stakeholder interests and needs. Based on team experience and an initial influence and interest matrix, we have identified 3 target audiences in each country we anticipate will have high interest in our research.
1. Policymakers and their influencers
2. Public sector healthworkers
3. Civil society (including NGOs, INGOs and community-based organisations CBOs)

We will ensure that each audience has access to evidence tailored to their needs. We know maintaining a combination of planned activities and ongoing communication and flexible collaboration is likely to yield the most research impact (for example, reacting to specific events as they arise).

Our comparative 3 country study design means that the evidence we generate will have relevance for other sub-Saharan African countries with a wide range of legal contexts for the provision of services for adolescents, from countries with recent abortion law liberalisation to countries with longstanding but limited grounds for abortion, as well as countries with no current plans to liberalise abortion laws.

The team has an established track record in producing research on contraception and abortion that impacts on policy. This includes engaging with high-level national and international policy-making bodies that are well-placed to adopt and implement research findings. Our in-country knowledge of what research is needed to improve adolescent access to, and use of, contraception and abortion care services underpins this research. Co-applicants in each country have thorough understandings of the legal, political and social context and highly developed networks of influence, including:
- Ipas, a global nonprofit that works to increase women's ability to exercise their sexual and reproductive rights. Ipas has offices in each country; this will help ensure effective routes into national policymaking arenas and into the implementation of contraception and abortion services for adolescents. Further, we will work with an Ipas Youth Coordinator in each country, each of whom works with a national network of organisations on SRH needs and services in their country.
- African Institute for Development Policy (AFIDEP), whose mission is to facilitate and build African capacity in synthesis, translation and utilization of health research evidence to improve policy-making and resource allocation in sub-Saharan Africa. In this project, AFIDEP will partner with us to disseminate key lessons to other African countries though their work with national and regional decision-makers in sexual and reproductive health and rights.

To maintain and generate demand before and during evidence generation, we will incorporate communications about our on-going work and outputs using a range of channels (eg: "Lessons from the field" online communications during fieldwork). Towards the end of the project, but timetabled to allow feedback integration, we will host a Social Science Café in each country for invited stakeholders (policymakers, service providers, youth activists, journalists) to stimulate discussion and interaction. Additional outputs will include country-specific and comparative policy briefs based on desk reviews. Through sustained engagement with our partners and stakeholders, more adolescents in low-income countries will be able to access essential reproductive health services.