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

Abstract

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.

Achieving universal reproductive health coverage for deaf women in Ghana: an explanatory study of knowledge of contraceptive methods, pregnancy and safe abortion practices

“…There are lapses in the current SRH policy framework [ 29 , 48 ], which make it difficult for deaf persons to access necessary information. Thus, there is a need for health policymakers to design robust policies tailored to suit the uniqueness of deaf persons.…”

“…There is a corpus of literature on challenges relating to the accessibility of SRH services, especially in sub-Saharan African contexts [ 13 , 16 , 24 – 27 ]. Most studies have reported that challenges such as lack of policies [ 28 , 29 ], low education levels [ 30 ], poverty [ 12 , 24 , 31 , 32 ], culture [ 33 , 34 ], stigma [ 8 , 16 ] and lack of parental support [ 14 , 35 ] contribute to the inability of girls and women to access SRH services. Other studies have also found that a high prevalence of teenage pregnancy is likely linked to factors such as poverty [ 12 , 25 ], illiteracy [ 30 , 36 – 38 ] and lack of awareness of contraceptive methods [ 15 ].…”

COVID-19 and Abortion: Making Structural Violence Visible

“…65 In Malawi, the current colonial-origin law precludes adolescents from accessing a safe procedure, (re-)enacting structural violence through a denial of services and the lack of recognition of adolescents' specific abortion needs. 66 Restrictive abortion laws are experienced as direct forms of violence, but all abortion laws-even more liberal ones-enact barriers to full reproductive freedom. 67 These laws overlap with and are enacted alongside other punitive laws-criminalization of HIV nondisclosure, 68 "defilement laws" 69 or mandatory reporting requirements 70 -that create and legitimize conditions of violence and inequity.…”

Drivers of Marriage and Health Outcomes Among Adolescent Girls and Young Women: Evidence From Sub-Saharan Africa and South Asia

“…In some cases, girls in Malawi may be unable to seek antenatal care because of laws that require the presence of a partner at visits [22]. In contrast, Zambia has better access to sexual and reproductive health services, particularly with access to safe abortion, relative to Malawi [23]. Local laws and policies should focus on identifying those among AGYW who become pregnant before marriage and are at highest risk of insufficient antenatal care in Malawi and make antenatal care more accessible to them, given that the use of maternal health care services is associated with other maternal and child health outcomes [24,25].…”