Between opportunities and risks : adolescent sexual and reproductive health in Zambia

Background: Adolescence is a dynamic period in life with both opportunities and risks related to the culturally constructed gender norms. Many adolescents in sub-Saharan countries, Zambia included, lack control over their own sexual and reproductive lives, due to factors such as gender inequality, poverty, and sociocultural and religious norms.

Aim: The aim of this thesis was to explore, from a gender perspective, how sexuality and reproduction are conceptualised and communicated among Zambian adolescents as a basis for future interventions and for development of effective strategies to reduce adolescent reproductive health problems.

Specific objectives: These objectives were to explore adolescent boys' perceptions about their transition into manhood (I) and their perceptions about premarital sexual relationships (II); to describe characteristics of adolescent girls admitted to hospital for incomplete abortions, partner relationships, views on contraception, and whether abortion was spontaneous or induced (III); to elucidate the situation of adolescent girls who had had an unsafe abortion, and gather data on abortion providers and methods used (IV).

Methods: The studies were conducted from 2000 to 2005 in Lusaka and Kitwe, Zambia. Both quantitative and qualitative methods were used. Seven focus group discussions were held with adolescent boys (n=53) (I, II), and 12 adolescent boys participated in letter writing (I). A hospitalbased interview study was done with 87 adolescent girls admitted to hospital for incomplete abortions (III, IV). Descriptive quantitative analysis was used and the qualitative data was analysed by applying qualitative content analysis technique.

Results: Growing up in Zambia entails exposure to contradictory messages, influenced by traditional and new norms on purported appropriate social and sexual behaviour. Many boys received the messages that they were the privileged sex and the decision makers in sexual relationships. Peers were important in the identity building process (I). Premarital sexual relationships are common and considered a prerequisite for boys to achieve adult male autonomy and status, gender roles which influence Zambian boys' male identity. However, they see in the gender imbalance a potential to adjust their behaviour in premarital relationships, but lack adult guidance (II). Of the adolescent girls admitted for incomplete abortions, 39% alleged having had an unsafe abortion. They were more often single, in school, and had reached higher grades. More of the girls with spontaneous abortions were traditionally married and cohabitating with their partners. At first sexual intercourse 39% of the girls had been forced to have sex, and 41% perceived they had little or no risk of contracting HIV. Most of the girls were not aware of their partner's previous sexual history (III). The primary reasons given for performing an unsafe abortion were fear of facing personal shame, social stigma and the wish to continue education. Several of the girls had heard about or knew classmates who had been severely ill or had died from complications after unsafe abortions. The majority of the pregnancies were terminated before the end of 12 the gestational week. Oral and vaginal abortifacients were used, including both traditional and modem medicine and foreign bodies inserted into the cervix. Traditional healers and older women performed almost half of the methods cited (IV).

Conclusion: Lack of sexual education and limited access to contraception and safe abortion care, expose both adolescent girls and boys to adverse transitions into adulthood. Girls in subordinate positions, carry consequences like premarital unintended pregnancies often followed by unsafe abortions. The educational programmes should pay due attention to adolescents' needs, and particularly address male adolescents' responsibilities for sexually related behaviour to reduce sexual coercion and unwanted pregnancies.

List of scientific papers

I. Dahlback E, Makelele P, Phillimon N, Bawa Y, Bergtrom S, Ransjo-Arvidson AB. (2003). "I am happy that God made me a boy": Zambian adolescent boys' perceptions about growing into manhood. Afr J Reprod Health. 7(1): 49-62.
https://pubmed.ncbi.nlm.nih.gov/12816313

II. Dahlbäck E, Makelele P, Yamba CB, Bergström S, Ransjö-Arvidson A-B (2006). Zambian male adolescents perceptions about premarital sexual relationships. African Journal of AIDS Research. 5: 257-65.

III. Dahlbäck E, Maimbolwa M, Yamba CB, Kasonka L, Bergström S, Ransjö-Arvidson A-B (2006). The prevalence of unsafe abortions among adolescent girls admitted to hospital for incomplete abortion in Lusaka. [Submitted]

IV. Dahlbäck E, Maimbolwa M, Kasonka L, Bergström S, Ransjö-Arvidson A-B (2006). Unsafe induced abortions among adolescent girls in Lusaka. [Submitted]