An Analysis of Adolescent Content in South Africa's Contraception Policy Using a Human Rights Framework.

PURPOSE: To evaluate whether the updated South African national contraception policy and guidelines adequately address the needs of adolescents.
METHODS: We used the World Health Organization (WHO) guidance and recommendations on ensuring human rights in the provision of contraceptive information and services as an analytic framework. We assessed the South African policy in relation to each WHO summary recommendation. Specifically, we determined where normative guidance pertaining to adolescents is present and whether it is adequate, normative guidance pertaining to all populations but not specifically adolescents is present, or normative guidance for that recommendation is missing from the policy. We developed an analytic table to discuss with coauthors and draw conclusions.
RESULTS: We found specific guidance for adolescents relating to 6/9 WHO summary recommendations and 11/24 subrecommendations. Adolescents are highlighted throughout the policy as being at risk for discrimination or coercion, and laws protecting the rights of adolescents are cited. Confidentiality of services for young people is emphasized, and youth-friendly services are described as a key element of service delivery. Areas to strengthen include the need for normative guidance ensuring both availability of contraceptive information and services for young people and adolescent participation in development of community programs and services.
CONCLUSIONS: South Africa's contraception policy and guidelines are comprehensive and forward looking. Nevertheless, there are gaps that may leave adolescents vulnerable to discrimination and coercion and create barriers to accessing contraceptive services. These findings provide insight for the revision and development of adolescent health policies in South Africa and other settings.

Laws and policies that improve adolescents' access to contraceptive services, irrespective of marital status and age, can contribute to preventing unwanted pregnancies. This study used a novel analytic framework to determine where South Africa's updated contraception policy and guidelines address the needs of adolescents and identified areas to be strengthened.

Policies that improve adolescents' access to contraceptive information and services, irrespective of marital status and age, can prevent early and unwanted pregnancy [1]. However, to date, no systematic study of inclusion of adolescent-specific issues in national policies and guidelines has been performed. This article examines how well the recently updated South African contraception and fertility planning policy and guidelines address the specific needs of adolescents.

Approximately one-quarter of women aged 15–19 years in South Africa report having been pregnant [2]. Although teen fertility has mirrored a decline in fertility among all women in South Africa, South African teens experience a birth rate of 54 per 1,000 women aged 15–19 years, twice that of teens in the United States. [3], [4], [5], [6]. Six percent of female high school learners report ever having had an abortion, and 1 in 10 report being forced to have sex [7]. Observed declines in teen childbearing may be attributed to national school-based and peer sex education efforts, adolescent-friendly clinic initiatives, and community level programs including mass media interventions [5].

Young women in South Africa also have a disproportionately high rate of HIV infection despite national efforts focused on HIV prevention, 113,000 new infections occurred in 2012 among women aged 15–24 years in the country, which is more than four times the incidence among young men [8]. This disparity is attributed both to social-behavioral risks faced by young women, often in sexual relationships with older men, as well as possible greater biologic vulnerability to HIV infection [9]. Not only has contraception been highlighted as a key strategy to reduce maternal and child mortality from complications related to early childbearing, access to comprehensive contraceptive services has also been demonstrated to be a highly effective strategy for HIV prevention and is a pillar of Prevention of Mother to Child Transmission initiatives [10], [11], [12], [13], [14]. The need to ensure access to high-quality and equitable contraceptive services to South African adolescents has never been more pressing.

South Africa revised its contraception policy in 2012 in the form of two documents, the National Contraception and Fertility Planning Policy and Service Delivery (PSD) and the complementary National Contraception Clinical Guidelines [15], [16]. These, hereafter referred to as the PSD guidelines and clinical guidelines, were updated from existing contraception policies established a decade earlier and were formally launched in 2014 [17], [18]. This study addresses a gap in global health literature by analyzing these important national normative documents to improve understanding of best practices for adolescent reproductive health policies and guidelines. The objective of this study was to evaluate whether the South African policy and clinical guidelines address adolescents' needs adequately using a human rights analytic framework.

Methods

A focused literature review of adolescent contraceptive trends and service provision in South Africa from 2000 onward was conducted to gain familiarity with the policy context. Subsequently, the previous (2001, 2003) and updated (2012) contraception policy and guidelines were examined, searching for specific instances where adolescents are referenced. This was done through careful reading of the text as well as electronic word searching for “adolescent,” “youth,” or “young” in all documents.

On identification of instances where adolescents were described or mentioned in the updated policy and guidelines documents, an evaluation of the human rights characteristics of the two documents was conducted by applying each of the summary recommendations found within the World Health Organization (WHO) 2014 publication titled “Ensuring human rights in the provision of contraceptive information and services.” [19] This WHO document is intended to provide guidance for policy-makers, managers, providers, and other stakeholders in the health sector on priority actions necessary to ensure integration of a human rights-based approach to the provision of contraception. A human rights-based approach aims to improve outcomes by analyzing and addressing inequalities, discriminatory practices, and unjust power relations [20]. Health services that apply human rights principles ensure fully informed decision-making, respect for dignity, autonomy, privacy and confidentiality, and sensitivity to individuals' needs and perspectives [19].

The contraception-specific guidance and recommendations were developed through a structured WHO guidelines development process performed by a group of public health and human rights experts and included the identification of priority questions and outcomes, a systematic review of evidence, and formulation of recommendations. The result of this process was a document containing nine summary recommendations, some including subrecommendations, for a total of 24 unique recommendations (Table 1).

Table 1

Recommendations from “Ensuring human rights in the provision of contraceptive information and services” (WHO, 2014)

Recommendation	Subrecommendations
1. Non-discrimination in provision of contraceptive information and services	1.1 Recommend that access to comprehensive contraceptive information and services be provided equally to everyone voluntarily, free of discrimination, coercion or violence (based on individual choice)
	1.2 Recommend that laws and policies support programs to ensure that comprehensive contraceptive information and services are provided to all segments of the population. Special attention should be given to disadvantaged and marginalized populations in their access to these services
2. Availability of contraception information and services	2.1 Recommend integration of contraceptive commodities, supplies and equipment, covering a range of methods, including emergency contraception, within the essential medicine supply chain to increase availability. Invest in strengthening the supply chain where necessary to help ensure availability.
3. Accessibility of contraceptive information and services	3.1 Recommend the provision of scientifically accurate and comprehensive sexuality education programs within and outside schools that include information on contraceptive use and acquisition.
	3.2 Recommend eliminating financial barriers to contraceptive use by marginalized populations including adolescents and the poor, and make contraceptives affordable to all.
	3.3 Recommend interventions to improve access to comprehensive contraceptive information and services for users and potential users with difficulties in accessing services (e.g., rural residents, urban poor, adolescents).
	3.4 Recommend special efforts be made to provide comprehensive contraceptive information and services to displaced populations, those in crisis settings, and survivors of sexual violence, who particularly need access to emergency contraception.
	3.5 Recommend that contraceptive information and services, as a part of sexual and reproductive health services, be offered within HIV testing, treatment and care provided in the health care setting.
	3.6 Recommend that comprehensive contraceptive information and services be provided during antenatal and postpartum care.
	3.7 Recommend that comprehensive contraceptive information and services be routinely integrated with abortion and post-abortion care.
	3.8 Recommend that mobile outreach services be used to improve access to contraceptive information and services for populations who face geographical barriers to access.
	3.9 Recommend elimination of third-party authorization requirements, including spousal authorization for individuals/women accessing contraceptive and related information and services.
	3.10 Recommend provision of sexual and reproductive health services, including contraceptive information and services, for adolescents without mandatory parental and guardian authorization/notification, to meet the educational and service needs of adolescents.
4. Acceptability of contraceptive information and services	4.1 Recommend gender-sensitive counseling and educational interventions on family planning and contraceptives that are based on accurate information, that include skills building and that are tailored to meet communities' and individuals' specific needs.
	4.2 Recommend that follow-up services for management of contraceptive side effects be prioritized as an essential component of all contraceptive service delivery. Recommend that appropriate referrals for methods not available on site be offered and available.
5. Quality of contraceptive information and services	5.1 Recommend that quality assurance processes, including medical standards of care and client feedback, be incorporated routinely into contraceptive programs.
	5.2 Recommend that provision of long-acting reversible contraception (LARC) methods should include insertion and removal services, and counseling on side effects, in the same locality.
	5.3 Recommend ongoing competency-based training and supervision of health care personnel on the delivery of contraceptive education, information, and services. Competency-based training should be provided according to existing WHO guidelines.
6. Informed decision-making	6.1 Recommend the offer of evidence-based, comprehensive contraceptive information, education, and counseling to ensure informed choice.
	6.2 Recommend every individual is ensured the opportunity to make an informed choice for their own use of modern contraception (including a range of emergency, short-acting, long-acting, and permanent methods) without discrimination.
7. Privacy and confidentiality	7.1 Recommend that privacy of individuals is respected throughout the provision of contraceptive information and services, including confidentiality of medical and other personal information.
8. Participation	8.1 Recommend that communities, particularly people directly affected, have the opportunity to be meaningfully engaged in all aspects of contraceptive program and policy design, implementation and monitoring.
9. Accountability	9.1 Recommend that effective accountability mechanisms are in place and are accessible in the delivery of contraceptive information and services, including monitoring and evaluation, and remedies and redress, at the individual and systems levels.
	9.2 Recommend that evaluation and monitoring of all programs to ensure the highest quality of services and respect for human rights must occur. Recommend that, in settings where performance-based financing (PBF) occurs, a system of checks and balances should be in place, including assurance of noncoercion and protection of human rights. If PBF occurs, research should be conducted to evaluate its effectiveness and its impact on clients in terms of increasing availability

WHO = World Health Organization.

Assessment process

The PSD and clinical guidelines were assessed in relation to each of these WHO summary recommendations and subrecommendations. Specifically, the assessment determined where (1) specific normative guidance pertaining to adolescents is present and whether it is adequate, (2) normative guidance pertaining to all populations (but not specifically adolescents) is present (and whether adolescent-specific guidance is needed), or (3) normative guidance for that recommendation is missing from the guidelines. This process led to an analytic table which was then used for discussion with coauthors to draw conclusions and recommendations (Appendix).

The analytic team was strategically selected and consisted of an adolescent medicine clinician (A.H.); a physician and public health professional with expertise in designing, implementing, and evaluating adolescent-friendly health services (V.C.); an obstetrician-gynecologist and family planning clinical researcher who had served as a consultant for the South African guideline development (P.S.); a United Nations Populations Fund adolescent program specialist with expertise in adolescent policy and programs in sub-Saharan Africa (T.S.); and a key informant who participated in development of the updated guidelines (M.P.). One author (A.H.) reviewed the guideline documents to assess their content alongside the human rights analytic framework. Another author (V.C.) verified these assessment findings. Two authors (P.S. and T.S.) provided information on the country level context when necessary, and an additional author (M.P.) reviewed the findings for accuracy.

Results

We found specific normative guidance for adolescents relating to six of nine WHO summary recommendations and to 11 of 24 subrecommendations. Our findings for each recommendation (1–9), specific to each subrecommendation as indicated (e.g., 1.1), are summarized in the following sections, with detailed quotations and citations included in the Appendix.

1. Non-discrimination in provision of contraceptive information and services (1.1–1.2)

Both documents include adolescent-specific normative guidance related to this recommendation. The clinical guidelines address equal access free from discrimination (1.1) by specifically stating that contraceptive method provision should not be denied on the grounds of young age alone. More generally, in a section on migrant populations, the PSD guidelines explicitly mandate that health workers offer health services without discrimination. The PSD guidelines state that adolescents face “negative and judgmental health care provider attitudes,” highlighting their vulnerability to discrimination. They address laws and policies to prevent discrimination (1.2), referring to The Children's Act which prohibits restricting condoms and access to other contraceptives to adolescents and state that adolescents may access contraceptive methods without parental or caregiver consent at age 12 years and older.

2. Availability of contraceptive information and services (2.1)

This recommendation describes ensuring availability of contraceptive commodities (2.1), including a range of method types in sufficient quantity, functional supply chains, and equipment and facilities necessary to provide these services. Although we found no adolescent-specific normative guidance related to the recommendation, the PSD guidelines include guidance for ensuring availability of contraception for all population groups, citing adequate stock of drugs and equipment as a key area for quality improvement.

3. Accessibility of contraceptive information and services (3.1–3.10)

The subrecommendations on accessibility address potential barriers to contraception information and services being accessible to everyone without discrimination. Barriers may include lack of knowledge, poor communication, limited financial resources, geographic barriers, or concerns about confidentiality. We identified adolescent-specific normative guidance in 5/10 subrecommendations (3.1, 3.3, 3.5, 3.7, and 3.10), and nearly all were addressed for the general population.

In regard to provision of comprehensive sexuality education programs (3.1), the PSD guidelines include adolescent-specific normative guidance on linkage points for integration with school health to improve access to quality contraceptive and fertility planning services. The guidelines also describe the importance of information, education, and communication (IEC)/behavior change communication (BCC) services being linked to school-based education services. The guidelines refer to the Integrated School Health Policy, which mandates that a package of health services be provided to learners in schools [21]. In terms of normative guidance for all populations, the importance of providing sexuality education outside schools is emphasized, as the PSD guidelines describe levels of care where IEC delivery should take place, including education institutions, workplaces, retail (community) pharmacies, and the community.

We found no normative guidance for adolescents related to eliminating financial barriers to contraceptives (3.2). However, the guiding principles of the PSD guidelines state that cost be removed as a barrier to contraception access, which is consistent with current provision of free contraceptives in the public sector. Related to the summary recommendation for interventions to improve access to contraceptive information and services (3.3), the PSD guidelines refer to the importance of youth-friendly service provision to promote access to contraceptive information and services and reference policy guidelines for Adolescent and Youth Health for more specific guidance. Among key areas of quality improvement, the PSD guidelines describe efforts to accommodate adolescents who may not be comfortable accessing services. Generally, strategies are described for integration with other channels to reach those with difficulties in accessing services, and adolescents are included among those groups.

No adolescent-specific normative guidance was identified on the subrecommendation of special efforts for displaced populations (3.4), but adequate considerations for contraceptive and fertility planning services for migrant populations are outlined in the PSD guidelines without specific reference to adolescents. On the subrecommendation that contraceptive information and services be offered within HIV testing and treatment services (3.5), the PSD guidelines describe perinatally HIV-infected youth and AIDS orphans as clients with specific needs in terms of pregnancy prevention, fertility planning, and HIV prevention and management. More generally, integration of contraceptive information and services into HIV services is highlighted as a key area for quality improvement. In contrast, considering the subrecommendation to ensure contraceptive information and services during antenatal and postpartum care (3.6), the integration of these services into maternal health services is referenced without normative guidance for adolescents.

On integration of contraceptive information and services into abortion and postabortion care (3.7), the PSD guidelines describe a law that allows minors to consent for abortion without parental consent, and more generally, provision of abortion services is included in the guidelines as part of primary health center services. The subrecommendation describing mobile outreach services (3.8) was highlighted in the PSD guidelines, where mobile services are described as key elements of primary level of care without specific mention of adolescents. We found no normative guidance for any population in regard to elimination of third-party (i.e., spousal) authorization requirements (3.9). Subrecommendation 3.10 describes provision of sexual and reproductive health services for adolescents without mandatory parental/guardian authorization; the PSD guidelines refer to the Children's Act that prohibits restricting condoms and access to other contraceptives to adolescents. Furthermore, confidentiality of contraception counseling is emphasized for adolescents.

4. Acceptability of contraceptive information and services (4.1–4.2)

There was limited adolescent-specific guidance on subrecommendation for gender-sensitive counseling and education interventions tailored to meet individual needs (4.1). Age-appropriate IEC/BCC initiatives are highlighted as a key area for quality improvement. More general normative guidance on contraceptive counseling includes mention of gender without specific reference to adolescents, and key considerations for contraceptive and fertility planning services for migrant populations cite the importance of gender-appropriate translators. Furthermore, considerations related to contraceptive and fertility counseling for lesbian, gay, bisexual, transgender/transsexual, intersex clients includes reference to gender-neutral vocabulary as well as those additional considerations for male clients. We found no adolescent-specific normative guidance on follow-up services for management of contraceptive side effects (4.2) for adolescent clients; however, we identified general normative guidance without specific reference to adolescents in the PSD guidelines, describing barriers to follow-up and strategies to support clients to overcome them.

5. Quality of contraceptive information and services (5.1–5.3)

In regards to quality assurance processes and medical standards of care specific to adolescents (5.1), we found limited normative guidance in the PSD guidelines describing quality youth-specific services as a key element of service delivery. Additionally, the guidelines devote a chapter to quality of care and include a table of key areas for quality improvement in contraceptive and fertility planning services. The WHO guidance recommends provision of long-acting reversible contraception methods and insertion and removal services and counseling on side effects to be offered in the same locality (5.2). We found no normative guidance specific for adolescents on this topic, but the PSD guidelines highlight the promotion of an expanded method mix without including guidance for insertion, removal, and counseling being available at the same locality. Additionally, there was no normative guidance for ongoing competency-based training and supervision of health care personnel specific to contraceptive education, information, and services for adolescents (5.3). However, the objectives of the PSD guidelines include general guidance for training and capacity building and highlight the need for research on competency-based training and supervision.

6. Informed decision-making (6.1–6.2)

No normative guidance specific to adolescents was found related to evidence-based comprehensive contraceptive information, education, and counseling to ensure informed choice (6.1) or to ensure that every individual has the opportunity to make an informed choice for their own use of contraception without discrimination (6.2). More generally, the importance of client knowledge of available contraceptive methods and specific strategies to ensure effective education and counseling are emphasized within the general principles guiding the policy. Furthermore, provider bias is noted as a potential barrier to informed, voluntary decision making.

7. Privacy and confidentiality (7.1)

We identified multiple points of guidance on the subrecommendation to ensure confidentiality of contraceptive information and services to minors (7.1). The PSD guidelines refer to The Children's Act, which requires providers to maintain confidentiality when providing contraception services to minors. It is also noted that the child's best interest should be considered when making a decision to breach confidentiality and report cases of physical and sexual abuse. Ethical challenges for health workers based on current mandated reporting laws and recent related judicial decisions are described. More generally, confidentiality and privacy are cited as key elements of a rights-based approach to contraception and fertility planning, particularly for people living with HIV but without specific reference to adolescents.

8. Participation (8.1)

We found no normative guidance on the recommendation that communities, particularly people directly affected, have the opportunity to be meaningfully engaged in all aspects of contraceptive program and policy design, implementation, and monitoring (8.1). More generally, community participation is cited as a key element of a rights-based approach to contraception and fertility planning without specific mention of adolescents. The PSD guidelines promote non–clinic-based delivery systems through community-based programs or community health workers and an enhanced role of retail pharmacists, which could contribute to community participation.

9. Accountability (9.1–9.2)

The WHO guidance contains recommendations to ensure accountability, including that effective accountability mechanisms, specifically monitoring and evaluation, exist, and that remedies and redress be available at individual and systems levels (9.1). We found that normative guidance for accountability mechanisms or mechanisms for remedy or redress was missing from the PSD guidelines, with the exception of a general key objective calling for appropriate monitoring and evaluation as well as a description of relevant indicators and their possible sources of data (9.2). However, we found a number of indicators for monitoring and evaluation specific to young clients, including the teenage pregnancy rate and inclusion of women who are unmarried in the calculation of unmet need for contraceptive services.

Discussion

To our knowledge, this is the first analysis of adolescent-specific content of a national contraceptive policy or guidelines. Our study applied a novel analytic approach using WHO Human Rights Guidance and Recommendations for the Provision of Contraceptive Information and Services. Using this approach, we demonstrate that the PSD and clinical guidelines are firmly grounded in a human rights framework and are inclusive of adolescents in many regards. Specifically, adolescents are highlighted throughout the guidelines as being at risk for discrimination or coercion, and laws and policies protecting the rights of adolescents are cited. Confidentiality of services for young people is emphasized, and youth-friendly services are described as a key element of service delivery.

We found notable areas to strengthen in regard to adolescent-specific guidance to ensure the availability of contraceptive information and services, the importance of informed decision-making of adolescents, and support for adolescent participation in development of community programs and services. Finally, a lack of key adolescent-specific health service quality indicators limits knowledge about uptake and service provision, highlighting the need for data disaggregation by adolescent age groups. Based on these findings, we identified potential opportunities to strengthen the guidelines by including adolescent-specific considerations within program planning and management and contraceptive provision (Table 2).

Table 2

Potential opportunities to strengthen South Africa's National Contraception and Fertility Planning Policy and Service Delivery Guidelines and National Contraception Clinical Guidelines

Programme planning and management

Identify and accommodate adolescents who are part of disadvantaged and marginalized populations (e.g., LGBTI, ethnic minorities, displaced populations)

Address adolescents in outreach programs

Involve adolescents in selected aspects of planning, implementation, and evaluation

Continually assess adolescent-friendliness of health workers and health systems

Contraception provision

Call for provision of contraception to adolescents in antenatal, postpartum, and abortion care

Call for provision of contraception without consent of romantic partners or spouses

Identify and address barriers to adolescents following up for side effects and complications of contraception

Support providers to ensure that adolescents of all ages make well-informed decisions

LGBTI = lesbian, gay, bisexual, transgender/transsexual, intersex.

Adolescents have unique needs and experience more barriers to accessing available reproductive health services than adults because of restrictive laws and policies, limited awareness of available services, knowledge gaps, lack of transportation or financial resources, stigma, and lack of community support [22]. The South African Ministry of Health recognizes these needs and barriers and has made a significant attempt in its normative guidance to address them, reflecting an improvement in this regard from previous policies. In addition to these documents, a number of health-related policies has been developed related to the health needs of young people, including a Youth and Adolescent Health Policy (2001) and National Youth Policy (2009–2014), both of which identify teenage pregnancy and reproductive and sexual health as key priorities, and the Integrated School Health Policy (2012) that promotes the provision of skills-based health education and school-based health and nutrition services [21], [23]. These youth policies may have quality assurance and accountability mechanisms applicable to the PSD and clinical guidelines, although these policies are not explicitly linked.

Youth-specific policies have been complemented by multiple programmatic initiatives. A national initiative to accredit adolescent-friendly health clinics has expanded clinical services for youth, and numerous school- and community-based education programs and mass media campaigns have promoted sexual and reproductive health knowledge among school-going youth [24], [25], [26], [27]. However, challenges remain in terms of implementation of policies, due to inadequate infrastructure, sociocultural norms within communities, or resistance from community gate keepers [28], [29]. For example, the implementation of the Integrated School Health Policy has been limited by insufficient financial and human resources and lack of training and standard practices for schools and primary health care facilities adopting the policy [30]. Additionally, sexuality education for out-of-school youth is primarily conducted by civil society organizations, and efforts lack coordination to ensure adequate and consistent provision of information and skills to this vulnerable population [31], [32]. Considering experiences with the Integrated School Health Policy, the contraception guidelines could be strengthened by the government including implementation support and resources. For example, health officials may consider producing a job aid for health workers that contains all adolescent-specific policies and guidelines in one accessible document.

The strengths of the PSD and clinical guidelines, as identified in this study, may provide a model which other countries can review and adapt during similar policy updates. As these guidelines are implemented in South Africa, impact evaluation will be necessary to assess whether they translate into increased access to contraception information and services for adolescents and ultimately improved reproductive health outcomes. A recent United States review of state policies found that policies that increase adolescent access to family planning services and contraceptives are associated with lower teen birth rates [33]. However, analyses of this nature are seldom conducted, despite the clear need to determine impact. National policies, strategies, and guidelines enable action to address specific issues and may describe how to address them. To achieve meaningful improvements in adolescent health, documents must be applied and their effects evaluated. Without adequate application and evaluation, impact is minimal or unknown, regardless of their quality and content.

We have limited our analysis to the two contraception policy and guideline documents specific to contraception and fertility planning. We have not reviewed all youth-related health and social policies that likely impact adolescent access to and utilization of contraception information and services. Additionally, existing legal frameworks for some services such as legal access to abortion may compensate for the lack of normative guidance [34]. Because this is the first time these human rights guidance and recommendations have been used for this purpose, there may be limitations in applicability to adolescent-specific needs. We cannot comment on how our findings compare to those of other studies given this novel approach.

The WHO Human Rights Guidance and Recommendations provide a useful tool to analyze a contraception policy from a human rights perspective. South Africa's PSD and clinical guidelines have incorporated a deliberate rights-based approach. Adolescent considerations have been addressed throughout, but when subjected to rigorous scrutiny, as this study has done, important gaps are uncovered in terms ensuring availability, informed decision-making, and participation of adolescents in program development. These are essential components for comprehensive, quality contraceptive services for adolescents. These findings may provide useful insights for the revision and development of adolescent and other sexual and reproductive health policies and may also inform the development of an adolescent-specific analytic tool to develop and evaluate policies and guidelines from an adolescent perspective in other settings. Future research on impact of these updated guidelines will inform how they influence adolescent reproductive health and social outcomes.