Young people in Mozambique face a range of challenges in accessing sexual and reproductive health (SRH) services. These barriers can be particularly pronounced for marginalized and vulnerable youth, including young unmarried women, lesbian and bisexual women, and internally displaced persons (IDPs), and are often shaped by stigma and misinformation.
As part of the broader Stand Up for Sexual and Reproductive Health and Rights project, the Guttmacher Institute and Mozambican partner Centro de Pesquisa em População e Saúde (CEPSA, or the Center for Population and Health Research) embarked on a collaborative research effort to better understand these challenges from the perspectives of young people themselves. They conducted a study in 2023 that explored how social norms influence access to information and services for adolescent and young women and men in northern Mozambique. Researchers recruited young people aged 15–24 from three districts—Nampula City, Nacala Porto and Mecubúri—and included both IDPs and non-IDPs, and those either in or out of school, for focus group discussions. Focus group participants were asked about their peers, an effective method for capturing social norms within similar demographic groups. The study team interviewed lesbian and bisexual young women individually. This fact sheet summarizes key findings from the study report and offers recommendations for advocates and health care providers.
Context
Mozambique has low modern contraceptive prevalence among 15–19-year-old women, high unmet need for a method of family planning, a high adolescent birth rate and a high all-women maternal mortality ratio. Despite the law allowing abortion on request during the first 12 weeks of pregnancy and later in all other cases, pregnant adolescents are at risk of unsafe abortion because of stigma, misinformation and other barriers to accessing safe abortion services. The country has one of the world’s highest rates of child marriage: 14% of girls enter into a union before age 15 and 46% before 18. Early marriage linked to intimate partner violence and limited knowledge of sexual and reproductive health (SRH) threaten adolescents’ rights and their ability to access SRH services.
Adolescents’ sexual and reproductive health and rights are also threatened by discrimination and other forms of violence. Although Mozambique removed language criminalizing homosexuality from its penal code in 2014, the country lacks specific protections and effective accountability mechanisms for discrimination against LGBTQI+ populations. Since 2017, northern Mozambique, particularly the province of Cabo Delgado, has been the site of internal armed conflict between government forces and insurgents that has resulted in more than 800,000 internally displaced persons (IDPs).
The research team selected three districts in Nampula Province, which borders Cabo Delgado, as the study setting because of their high-risk demographic profiles.
Contraceptive use
Participants reported that young people have many misconceptions and negative perceptions about using condoms and other forms of contraception. Those include beliefs that:
- Contraceptive use encourages promiscuity and could cause infertility.
They will say that one is planning to be a prostitute, doesn’t want to have children now, is using contraception to be able to continue having sex when she wants to. (young man, focus group with non-IDPs aged 18–21, Mecubúri)
- Condoms can get stuck inside women’s bodies and cause infections or illness.
[A friend can tell you:] You must never use condoms. If you do, you’ll infect yourself with HIV. Sometimes they say that condoms come with disease, come already with a disease, that’s the advice of…that’s what my friends tell me. (young man, focus group with IDPs aged 18–21, Nampula City)
- Adolescents and young women are mainly concerned with preventing pregnancy and, if already using another contraceptive method, do not consider using condoms to protect against STIs.
Recommendations
- Targeted campaigns via social media and community outreach and peer-to-peer education, designed to address misinformation and the benefits of condoms and other contraceptives, are paramount in helping young people avoid unwanted pregnancy and STIs.
- Young people can be trained as peer educators who can speak to those in their age-group about the facts and advantages of using condoms and other contraceptives.
- Health care providers can benefit from more comprehensive and regular training on how to discuss contraception with young people.
STIs
Stigma and shame significantly hinder young people from seeking and receiving treatment for STIs, especially for HIV and AIDS. Besides discomfort with examinations and fear of being recognized at health care facilities, participants described barriers to getting care that include:
- Denying an STI diagnosis or thinking health professionals are being untruthful about a diagnosis, particularly regarding HIV, which continues to be highly stigmatized
- Refusing treatment, including HIV medication
I’d like to give an example of a friend of mine. He also had gonorrhea and he didn’t tell anyone, nor did he go to the hospital. But only after two weeks with gonorrhea did people close to him discover it.…He wasn’t even able to walk, and it was then that people discovered that he had gonorrhea and then they took him for treatment.…But that may be really shame [that prevented him from getting treatment sooner] as my friend was saying. (young man, focus group with IDPs aged 18–21, Nampula City)
- Health care providers who demand that patients bring sexual partners for testing and treatment
Shame and stigma also make many young people reluctant to discuss their STI status, particularly HIV, with partners. Focus group participants reported that young people do not always ask their partners about their STI status, because they fear rejection by the partner; when asked, not everyone is truthful about their STI status, and they rarely reveal if they do have one.
Recommendations
- To encourage young people to seek treatment, health care providers should enhance the confidentiality of STI testing and services at facilities.
- Sensitization efforts aimed at reducing the stigma associated with STIs, including HIV and AIDS, could include radio and visual media campaigns, community-based peer education and the integration of STI-awareness and destigmatization messages into existing health programs.
- Mobile health services and telehealth platforms, such as a free hotline or an app delivering targeted messages about STI prevention, testing locations, appointment reminders and information on confidential counseling services, may increase young people’s willingness to obtain STI care.
Barriers to accessing SRH care
The majority of lesbian and bisexual young women interviewed believe that health care facilities are not prepared to address the sexual and reproductive health and rights of people with diverse sexual orientations. They reported experiencing significant discrimination and hostility in health care settings, which contributes to a lack of adequate health care provision for LGBTQI+ individuals. This discrimination manifests through:
- Health care workers sometimes pressuring their colleagues to treat lesbian patients poorly
- Refusal of treatment
- Ignoring patients or delaying care
- Making derogatory comments and jokes
There are people who do go [to a health facility], and even if they meet a nurse who they think would treat them well...that nurse is influenced by others [to not treat all patients well] who say, “Haa...you can’t treat her, she’s a lesbian, she’s worthless.” (lesbian, aged 22, Nampula City)
Focus group participants reported that adolescent and young women faced significant barriers and discrimination in accessing prenatal care if they are unaccompanied by a partner. These individuals experienced poor treatment from health care providers, including:
- Charges for childbirth services that should be free
- Long delays to receive care
- Visible disdain from providers, even when seriously ill
There are some who don’t go to the hospital because they [the hospital staff] usually want a couple, a woman and a man, to sign up for prenatal care,…but if you’re pregnant and no longer seeing the man who got you pregnant, or he doesn’t take responsibility for the pregnancy.…There’s no way to go to the hospital alone, because they will refuse to give you care,…they turn you away and they tell you, “Bring the man who got you pregnant.”…You go and bring your brother [pretending to be your husband] to the hospital.…There are some [who] sit at home until the child grows up because they have no medical card. (young woman, focus group with non-IDPs aged 20–24, out of school, Nacala Porto)
Recommendations
- Advocates should encourage the implementation of nondiscriminatory health care policies, including addressing women’s right to seek care alone.
- Increased advocacy for and sensitization to the SRH needs of LGBTQI+ individuals can combat discrimination against those with diverse sexual orientations.
- Youth-friendly corners or clinics within existing health care facilities where adolescents and young women can receive care in a supportive and understanding environment could improve the quality of care provided to this vulnerable population.
Abortion
Adolescent and young women seek induced abortion because of partner abandonment, shame, educational aspirations or uncertainty about paternity. Their abortion decisions can sometimes be influenced by the fear of having to disclose the pregnancy to parents. In cases where the partner has not abandoned the young woman, the decision to abort is highly influenced by the man.
It’s not possible for a woman to abort without her partner’s consent. First, she talks with her boyfriend who got her pregnant, and often the person who decides whether you can abort or not is the man. (adolescent woman, focus group with non-IDPs aged 15–19 years, out of school, Nacala Porto)
Despite respondents mentioning that health facilities provide abortion services for free, they reported that only some adolescents and young women they knew obtained abortion services from health facilities. Very few respondents knew about medication abortion. Instead, they indicated that young women primarily use traditional methods to induce abortion with combinations of:
- Coca-Cola
- Powdered detergent
- Strike-anywhere phosphorous matchsticks
- Plant roots and leaves, including aloe vera and moringa
Recommendations
- Establishing confidential, youth-friendly pregnancy counseling services can offer young people a nonjudgmental place to learn about their options for managing an unintended pregnancy, including how to discuss it with their parents.
- Counseling about the dangers of unsafe abortion methods and enhancing outreach and dissemination of information about safe and free abortion options at health facilities may increase abortion safety for young people.
