Evidence on Populations and Programs to Support Contraceptive Service Design, with special reference to Adolescents in Sub Saharan Africa : Tsogolo Langa Desk review

The government of Malawi has committed to improving the Sexual and Reproductive Health Rights and Family Planning (SRHR/FP) across the country, including for adolescents. However, challenges to contraceptive uptake and access to FP services prevail. To address the modest fall in age-specific fertility seen among adolescents in Malawi in recent years with its related adverse social and health consequences, all available relevant evidence that could inform programming is needed. This desk review focused on two main objectives with a specific focus on adolescents: 1. Evidence on factors that underlie reproductive health decision making and specifically contraceptive use amongst adolescents including vulnerable sub-groups such as young people with disabilities in Sub Saharan Africa 2. Review of scientific papers and programme reports that contain analytical findings about contraceptive service delivery An electronic search was undertaken using a formal search strategy. Working papers and reports that may contain relevant studies from Tsogolo Langa partners were also sought. In response to objective 1, the literature review identified 388 potentially related sources of which 29 were found to be informative. The review identified evidence falling into three key thematic areas: cultural belief systems including prevalent gender norms, lack of confidentiality and shame, and influencers of contraceptive use. To address the second objective, 2,341 potential sources were identified from the search. An initial review of titles and abstracts resulted in 241 sources retained, and of these 38 were reviewed in detail. Main findings • There are a number of powerful disincentives for adolescents in Malawi to access and use contraceptives, including cultural beliefs that prevail about fertility, masculinity and misconceptions about fertility linked to contraceptive use, alongside issues related to confidentiality and shame regarding accessing services. These are compounded by influencers, including parents, partners and peers, and traditional initiation practices. Furthermore, providers’ unwillingness to provide contraceptive services to unmarried adolescents also hinder the contraceptive uptake by this age-group. As such, the Malawian context for adolescents accessing SRHR/FP demands further research. • In terms of effective platforms from which to engage adolescents, there were a number of key findings to consider. A lesson from peer education and schoolbased intervention studies is that only modest impact can be expected when educational strategies do not include access to services. Post abortion care is an important setting for providing contraception to adolescents. In addition, according to published evidence, in Malawi the use of Health Surveillance Assistants to drive community-based provision may not be an ideal approach. • Through the desk review, specific knowledge gaps were identified and should be considered for examination. - The SRHR/FP experience of adolescents living with disabilities and those of boys and young men; interventions targeting adolescents with disabilities. - Lower use of emergency contraception (EC) in Malawi than other countries resulting in preventable unintended pregnancy. - Concentration of information about EC pertains to urban/educated adolescents with little to no information on rural populations. - As national policy for Pre Exposure Prophylaxis for HIV prevention (PrEP) extends to AGYW, strategies for integration with other SRHR/FP services is a key priority. Conclusion To drive effective evidence based SRH programming that addresses the needs of adolescents (male and female), exploration of their wider needs for health services, including optimal access points and the mix of services is needed. Social networks need to be explored as channels for accessing information about services and spreading correct understanding about non contraceptive benefits of method use, to dispel misconceptions and myths. A special focus on LARC is needed so that longer acting methods can be made fully accessible to adolescents, in parallel with ready access to EC