Policy environment on adolescents: A UNICEF (2002) needs assessment on youth health services reported poor quality services (negative and/or judgmental service providers, inconvenient opening hours, unaffordable). This UNICEF assessment led to increased government attention about Youth Friendly Health Services (YFHS). The National Survey of Adolescent (2004), Malawi Demographic Health Survey (2004) and the Multiple Indicator Cluster Survey (2006) all reinforced concerns about adolescent sexual and reproductive health (high rates of unmet need, low rates of contraceptive use at first sex, high rates of adolescent fertility. The National Standards on Youth Friendly Health Services (2007) provide impetus for change and started the implementation of a YFHS programme and made efforts to scale up. By 2010 64/266 sites were ready for accreditation as YFHS. Adolescents still face challenges in accessing SRH services, despite these scaling up attempts. A comprehensive evaluation of the YFHS program to assess its scope, quality, and outcomes since the inception of the YFHS standards found multiple barriers to YFHS use:
– Low knowledge of the programme among youth, parents and the community
– Concerns about confidentiality and privacy
– Inappropriate protocols in some settings eg: compulsory HIV testing before eg: condom dispensing
– Community (including parental) concerns that provision of services would lead to more risky behaviour, leading to low support for YFSH
– Geographic distance to some services
– Patchy coverage of training for youth service providers
– Treatment of abortion complications in hospitals: ranged from 0% (South East) – 40% (Central East)
-Training in contraceptive counselling: 25% (Central West) to 75% (North)
– The majority of young people mentioned public health facilities and markets/shops as sources of contraceptives for future sex. Other private sources and the Christian Health Association of Malawi health facilities were not mentioned as significant sources of contraceptive methods for youth.
The National Youth Friendly Health Services Strategy 2015–2020 looks to address these barriers.
Adolescent population: (sources: PRB, 2014 and Health Policy Project). With sustained high fertility in the last 20 years, the age structure of Malawi’s population is extremely youthful. Two-thirds of the population is under age 25, placing a significant burden on the working-age population to provide the basic health and education needs required by children and youth. Sexual awareness among early adolescents ages 10–14 years is high, with more than 76 percent of males and 66 percent of females in this age group having heard of or talked about sex. Over 12 percent of those ages 10–14, and almost 52 percent of those ages 15–19, reported to have had sex. Among sexually active young people, a higher percentage of males reported to have had sex. Regarding age differential among sexual partners, 87 percent of males reported to have had sex with younger or same-age partners; while 63 percent of females reported that their sexual partners were older than them. Adolescent girls ages 15 to 19 are 10 times more likely to be married than adolescent boys. Early marriage puts young girls at risk of early childbearing and birth complications, prevents them from completing school, and limits their economic opportunities. In Malawi, a child is legally defined as any person under age 18. More than 1 in 5 adolescent girls have begun bearing children by age 17. Early childbearing is a major health concern because of the increased risks of death and disability to both mother and child during pregnancy and childbirth. The percentage of youth aged 15-24 who have had sex before the age of 15 is 14% female and 22% male. Completion of secondary education is low among young adults ages 20 to 24, particularly for girls. Those in the wealthiest income level have the highest completion rates. Students who stay in school longer tend to delay marriage, have smaller families and more economic opportunities, and are better informed about health-related behaviors.
Adolescent contraceptive use: (Sources PRB, 2014 and Health Policy Project). Use of contraception is low among sexually active 15-to-19-year-olds, especially among married girls. Fewer than 1 in 3 unmarried girls and 2 in 5 boys are using a modern method of contraception. Young people often face obstacles to accessing contraceptives and health services, increasing the risk of unintended pregnancies. The percentage of women aged 15-19 using a modern method of contraception was 26%. according to the Health Policy Project fewer than half of sexually experienced young people reported the use of a contraceptive method during first sex, exposing many young people to unwanted pregnancies and sexually transmitted infections, including HIV. However, almost all young people (94%) who used a contraceptive method at first sex used the male condom. Contraceptive use increased at last sex, with preference for contraceptive methods broadening: 86 percent of males used the male condom, while among female youth, 42 percent used the male condom, and 42 percent used injectables. Youth have a strong desire to use contraceptives during future sex: 86 percent of male youth expressed a high preference for condoms, while 40 percent of females expressed preference for injectable contraceptives, 37 percent for condoms, and about another 5 percent for oral pills (see Figure 1). Reasons for not intending to use contraceptives were varied and included the desire to become pregnant, difficulty in obtaining the methods, and fear of side effects. The majority of young people mentioned public health facilities and markets/shops as sources of contraceptives for future sex. Other private sources
Adolescent abortion: According to the Ministry of Health (2010) about 24.4 abortions per 1,000 women of reproductive age (15–49 years) (70,000 per year) and of those 25% for those below 25 years and 7.4% abortions were among adolescents aged 12–17 years. Polis et al. (2015) states that Malawi, abortion is legal only if performed to save a woman’s life; other attempts to procure an abortion are punishable by 7–14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi’s high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained.