Málica de Melo

Adolescents and young women in Mozambique experience high levels of unintended pregnancies, with induced abortion being a common outcome. Stigma and gender norms are likely to negatively impact experiences of pregnancy and abortion, and hamper access to information and services. We assessed knowledge, attitudes, practices, and experiences around pregnancy and abortion in six communities in Nampula and Zambézia provinces. We conducted 19 triad interviews with young women and girls, 19 focus group discussions with male and female adult community members, and 15 in-depth interviews with young women with abortion experience. Participants described how gender values, norms, and practices affect girls’ risk of unintended pregnancy and their experiences of pregnancy and abortion. The drivers of adolescent pregnancy included transactional sex and gender-based violence, including early marriage, and gender roles and expectations that lead parents and others to oppose contraception. Stigma around abortion, early or unintended pregnancy, and adolescent sexuality is fueled by gender norms and contributes to girls seeking unsafe abortions. Pregnancy and abortion decision making often involves male partners and family members. In conclusion, gender norms strongly influence the occurrence and outcome of unintended pregnancies and abortion in Mozambique. While abortion legislation was recently liberalized, gender values, norms, and practices inhibit young women’s and girls’ access to services and need to be addressed in policy and programming.

Enabling contraceptive use is critical for addressing high adolescent pregnancy rates in low- and middle-income countries (LMICs). Broader or ‘upstream’ determinants, such as poverty, education, and social norms, can affect the knowledge, attitudes, motivation, and ability to access and use contraception. Structural interventions aim to address these broader determinants, e.g., through poverty alleviation from livelihood training or cash transfers, increasing school participation, or changing social norms. We conducted an evidence synthesis using intervention component analysis, a case-based approach, following a systematic mapping of the evidence base. We identified 17 studies with 29 structural intervention arms, which reported adolescent contraceptive use outcomes compared to a control group or baseline. It was not possible to identify with certainty which interventions were ‘likely effective’ or ‘likely ineffective’ due to the high heterogeneity of the methods. We built on an existing framework of family planning use to propose three steps to designing interventions: (1) tailor interventions to adolescents’ life stages; (2) assess the baseline situation; and (3) select appropriate activities to match the gaps. These steps will aid developers and evaluators of structural adolescent contraceptive interventions to develop an evidence base that is of use across a wide range of settings and use scenarios.

Reducing adolescent childbearing is a global priority, and enabling contraceptive use is one means of achieving this. Upstream factors, e.g., gender inequalities, fertility norms, poverty, empowerment and schooling, can be major factors affecting contraceptive use. We conducted a systematic map to understand which structural adolescent contraception interventions targeting these upstream factors have been evaluated in LMICs. We searched eight academic databases plus relevant websites and a 2016 evidence gap map and screened references based on set inclusion criteria. We screened 6993 references and included 40 unique intervention evaluations, reported in 138 papers. Seventeen evaluations were reported only in grey literature. Poverty reduction/economic empowerment interventions were the most common structural intervention, followed by interventions to increase schooling (e.g., through legislation or cash transfers) and those aiming to change social norms. Half of the evaluations were RCTs. There was variation in the timing of endline outcome data collection and the outcome measures used. A range of structural interventions have been evaluated for their effect on adolescent contraceptive use/pregnancy. These interventions, and their evaluations, are heterogenous in numerous ways. Improved understandings of how structural interventions work, as well as addressing evaluation challenges, are needed to facilitate progress in enabling adolescent contraceptive use in LMICs.

Background: The role of the male partner and wider family in maternal health, especially in case of emergencies, has been receiving increasing attention over the last decade. Qualitative research has highlighted that women depend on others to access high quality maternity care. Currently little is known about these factors in relation to maternal health in Mozambique. Methods: A cross sectional household survey was conducted with men and women in southern Mozambique about decision making, financial support and knowledge of danger signs. A multivariable logistic model was used to identify factors associated with knowledge of danger signs and Cohen’s kappa for agreement among couples. Results: A total of 775 men and women from Marracuene and Manhica districts were interviewed. Maternal health care decisions were frequently made jointly by the couple (32–49%) and financial support was mainly provided by the man (46–80%). Parental and parent-in-law involvement in decision making and financial support was minimal (0–3%). The average number of danger signs respondents knew was 2.05 and no significant difference (p = 0.294) was found between men and women. Communication with the partner was a significant predictor for higher knowledge of danger signs for both men (p = 0.01) and women (p = 0.03). There was very low agreement within couples regarding decision making (p = 0.04), financial support (p = 0.01) and presence at antenatal care consultations (p = 0.001). Results suggest women and men have a high willingness for more male participation in antenatal care, although their understanding of what constitutes this participation is not clear. Conclusion: The study findings highlight the important role men play in decision making and financial support for maternal health care issues. Strengthening male involvement in antenatal care services, by investing in counselling and receiving couples, could help accelerate gains in maternal health in Mozambique. Maternal health care studies should collect more data from men directly as men and women often report different views and behavior regarding maternal health care issues and male involvement.

In Mozambique, both the government and partners have undertaken efforts over the last decade to improve FP (family planning) services, especially through training health care providers and promoting the uptake of LARCs (Long Acting Reversible Contraceptives). Despite this, uptake of FP methods has not increased significantly. This study aims to examine women’s knowledge on LARCs, including their main sources of information, and the quality of care of FP services in rural areas. We conducted a repeated cross-sectional study, interviewing 417 women leaving FP consultations in 15 health facilities in Maputo Province, Mozambique. The main quality outputs measured were: 1)discussed, preferred and received contraceptive methods, 2)information received on usage and side-effects, 3)client-provider interaction, 4)being informed about the need for a follow-up visit 5)health examinations conducted and travel time to the facility. In addition, knowledge on LARCs was measured among the clients as well as sources of information regarding FP methods. Taking into account the design effect of the study, Chi-square statistics were used to detect differences between groups and linear regression analyses to identify associations between sources of information and higher knowledge. We found that IUDs (intrauterine devices) and implants were discussed in 23 and 33% of the consultations respectively, but only administered in a very few cases(< 1%). Half of the women were counselled on side-effects of contraceptives; this did not differ between first time clients and follow-up clients. Almost all women(98%) were satisfied with the received service and 83% of the women found the waiting time acceptable. Health examinations were performed on 18% of the women. Overall, women’s knowledge about LARCs was poor and misconceptions are still common. Women who had received FP information through outreach activities had better knowledge than those counselled at a facility. Our study highlights that only a minority of the women received information regarding LARCs during the consultation and that usage is almost non-existent. Counseling about all types of contraceptives during the consultation is sub-optimal, resulting in poorly informed clients. Multifaceted long-term interventions, focusing on both users and providers, are needed to improve uptake of contraceptives (including LARCs) in rural areas.

Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a ‘diagonal’ intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance. Applying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions’ feasibility, acceptability by providers, managers and policy makers, and potential sustainability. The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.

Good progress is being made towards universal access to contraceptives, however stock-outs still jeopardize progress. A seldom considered but important building block in optimizing supply management is the degree to which health workers feel motivated and responsible for monitoring supply. We explored how and to what extent motivation can be improved, and the impact this can have on avoiding stock-outs. Fifteen health facilities in Maputo Province, Mozambique, were divided into 3 groups (2 intervention groups and 1 control), and 10 monthly audits were implemented in each of these 15 facilities to collect data through examination of stock cards and stock-counts of 6 contraceptives. Based on these audits, the 2 intervention groups received a monthly evaluation report reflecting the quality of their supply management. One of these 2 groups was also awarded material incentives conditional on their performance. A Wilcoxon-Mann Whitney test was used to detect differences between the groups in the average number of stocked-out centres, while changes over time were verified through applying a Friedman test. Additionally, staff motivation was measured through interviewing health care providers of all centres at baseline, and after 5 and 10 months. To detect differences between the groups and changes over time, a Kruskal Wallis and a Wilcoxon signed-rank test were applied, respectively. Motivation reported by providers (n = 55, n = 40 and n = 39 at baseline, 1st and 2nd follow-up respectively) was high in all groups, during all rounds, and did not change over time. Facilities in the intervention groups had better supply management results (including less stock-outs) during the entire intervention period compared with those in the control group, but the difference was only significant for the group receiving both material incentives and a monthly evaluation. However, our data also suggest that supply management also improved in control facilities, receiving only a monthly audit. During this study, more stock-outs occurred for family planning methods with lower demand, but the number of stock-outs per family planning method in the intervention groups was only significantly lower, compared with the control group, for female condoms. While a rise in motivation was not measurable, stock management was enhanced possibly as a result of the monthly audits. This activity was primarily for data collection, but was described as motivating and supportive, indicating the importance of feedback on health workers’ accomplishments. More research is needed to quantify the additional impact of the interventions (distribution of evaluation reports and material incentives) on staff motivation and supply management. Special attention should be paid to supply management of less frequently used contraceptive methods.