Study on the effectiveness and resourcing of interventions to prevent unintended early pregnancy in South Africa and Malawi

The French Embassy in South Africa, Lesotho and Malawi commissioned Southern Hemisphere to conduct a study on measures to prevent unintended early pregnancies in both South Africa and Malawi. This study falls under the cooperation programme Strengthening of the prevention of unintended early pregnancy in South Africa and Malawi, which echoes France’s commitment to advancing sexual and reproductive health and rights (SRHR) globally under  the Generation Equality initiative.

The study has two components:

• A study on the relevance, effectiveness, coherence and adequacy of interventions for the prevention of early, unintended pregnancy in South Africa and Malawi

[download the full report | download the literature review]

• An expenditure analysis/review and building of costing models for 4 selected interventions aimed at preventing early, unintended pregnancy in South Africa and Malawi

[download the full report | download the costing models for Partners in Sexual Health’s Common Good Youth Project / Soul City’s Women’s Rise Clubs / Girls Empowerment Network / Developing Radio Partners]

Key take-aways

• South Africa has seen an increase in the teenage pregnancy rate in the past few years, with a 48.7% increase among girls aged 10-14 between 2017-2021. In Malawi, the birth rate for girls aged 15-19 was 141 births per 1000 girls (2018), compared to a global estimated average of 44 births per 1000 girls aged 15 to 19 years.
• The staggering increase in unintended early pregnancy is a social and public health concern. For both countries, the study findings on relevance reveal that adolescent girls and young women face significant challenges related to sexual and reproductive health (SRH) including inadequate access to and limited utilisation of SRH services, hindered by both demand and supply side barriers. Social norms, including beliefs about the inappropriateness of sex and SRH for young girls, contribute to stigma and limited access to services. Patriarchal norms and gender-based violence further restrict girls’ and women’s agency in negotiating safer sex and accessing SRH resources. Risky behaviours, such as unsafe sex and intergenerational relationships driven by unemployment and poverty, also increase the risk of unintended early pregnancy.

Problems faced by AGYW in Malawi

• In both countries, the programmes aimed at preventing unintended early pregnancy have strengths in terms of collaboration with external stakeholders and implementation of adolescent and youth-friendly services. However, in South Africa challenges such as limited resources and resistance from parents and caregivers regarding sexual and reproductive health topics need to be addressed. In Malawi, in addition to the implementation of youth-focused programme activities, all programmes reviewed in the study include extensive engagement with local community leaders as well as collaboration with district government officials and community structures. This collaboration ensures high levels of support and cooperation within targeted districts.
• Key changes and outcomes achieved at individual level by the eight interventions reviewed include improved understanding of sexual and reproductive health and rights among the target groups; increased self-belief, self-confidence, and self-efficacy as a result of their participation in the programmes; and economic empowerment of adolescents and young people.
• At community level, the interventions led to improved access to adolescent and youth-friendly services and increased uptake of SRH services. Referrals to clinics, the presence of youth-friendly zones, and the inclusion of young programme participants as service providers inside and outside of health care facilities were identified as key enablers. In Malawi specifically, there has been a positive shift in family and community awareness of the sexual and reproductive health and rights of adolescent girls and young women, resulting in support for education and discouragement of early marriages.

Key sustainability enablers in Malawi

• Prevention programmes and services in relation to unintended early pregnancy are aligned to national priorities and policies in both countries. With regards to sustainability, programmes addressing social norms in South Africa have shown positive outcomes in terms of prevention. However, the inclusion of boys and men, religious and traditional leaders in these programmes remains a challenge. In Malawi, barriers to sustainability include limited engagement with parents / caregivers and the broader community, a high level of reliance on donor support, lack of resources for sexual and reproductive health and rights programmes, transportation challenges, and inactivity of some youth clubs.

Recommendations:

Emerging from the research and engagements with multiple stakeholders from government and civil society in both countries, a set of recommendations have been captured  in the study .These include:

• Layered interventions and adoption of a holistic approach: Addressing early, unintended pregnancy requires a comprehensive approach that tackles multiple contributing factors, including social, cultural, behavioural, and structural drivers. Such an approach involves layering interventions such as comprehensive sexuality education (CSE) in and out of school, youth-friendly services in clinics, and economic empowerment programmes, while addressing misconceptions through information, education, and communication.
• Improving access to youth-friendly services: It is important to scale up access to youth-friendly services that provide confidential, non-judgmental and accessible options for young people. Starting in areas with a high prevalence of early and unintended pregnancy is recommended.
• Psycho-social support: Offer psycho-social support and programmes that address substance abuse, while integrating sexual and reproductive health and HIV services into such programmes.
• Targeted interventions: Develop differentiated interventions for boys, persons with disabilities, substance users, young people living with HIV, and LGBTQI+ groups. Age-specific interventions should also be considered.
• Stakeholder engagement and coordination: Engage all stakeholders at different levels (provincial/district/community) to collaborate and address the multi-dimensional nature of early and unintended pregnancy.
• Youth participation and engagement: Involve young people in the design and implementation of pregnancy prevention programmes to ensure relevance. Create safe spaces for youth to engage with each other, express their opinions, and provide peer-to-peer education and outreach.

The findings of the study are informing further exchange of good practices between South Africa, Malawi and France, as well as dialogue to encourage the upscaling of impactful interventions and partnerships between actors committed to tackling the issue.