Principal Investigator: Ernestina Coast
Start Date: 01 April 2017
End Date: 31 October 2020
Regions: Africa
Countries: Ethiopia, Malawi, Zambia
Keywords: Contraception, adolescent, sub-Saharan Africa, policymaking, interviews

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 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:

• Policymakers and their influencers
• Public sector healthworkers
• Civil society (including NGOs, INGOs and community-based organisations CBOs)