Sally Griffin

Introduction Abortion law reforms have been hypothesized to influence reproductive, maternal, and neonatal health services and health outcomes, as well as social inequalities in health. In 2014, Mozambique legalized abortion in specific circumstances. However, due to challenges implementing the law, there is concern that it may have negatively influenced neonatal outcomes. Methods Using a difference-in-differences design, we used birth history data collected via the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) between 2004 and 2018 to assemble a panel of 476 939 live births across 17 countries including Mozambique. We estimated the effect of the abortion reform on neonatal mortality by comparing Mozambique to a series of control countries that did not change their abortion policies. We also conducted stratified analyses to examine heterogeneity in effect estimates by household wealth, educational attainment, and rural/urban residence. Results The reform was associated with an additional 5.6 (95% CI = 1.3, 9.9) neonatal deaths per 1,000 live birth. There was evidence of a differential effect of the reform, with a negative effect of the reform on neonatal outcomes for socially disadvantaged women, including those with no schooling, in poorer households, and living in rural areas. Discussion Given the delay in implementation, our analyses suggest that abortion reform in Mozambique was associated with an initial increase in neonatal mortality particularly among socially disadvantaged women. This may be due to the delay in effective implementation, including the dissemination of clear guidelines and expansion of safe abortion services. Longer-term follow-up is needed to assess the impact of the reform after 2018, when services were expanded. Abortion legal reform without adequate implementation and enforcement is unlikely to be sufficient to improve abortion access and health outcomes.

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.