“I am carrying a baby whose father I do not know.” Experiences and context of girls pregnant from rape and sought sexual and reproductive health services

“I am carrying a baby whose father I do not know.” Experiences and context of girls pregnant from rape and sought sexual and reproductive health services | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “I am carrying a baby whose father I do not know.” Experiences and context of girls pregnant from rape and sought sexual and reproductive health services Patani Mhango, Medrina Mtende, Godfrey Kangaude, Mphatso Mapemba, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5322790/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Access to safe abortion and post-abortion care plays a crucial role in promoting comprehensive sexual and reproductive health and rights. While abortion is legal in the majority of countries, there are often restrictive laws and criminal regulations that impede access, resulting in unsafe abortions. Unsafe abortions are especially prevalent among girls and women in developing countries. Even though Malawi has ratified the Maputo Protocol, which obligates states to provide abortion on several grounds, Malawi continues to restrict access, thereby presenting significant health, social and legal obstacles for women. The present study aims to delve into the experiences of pregnant girls and young women as they navigate sexual and reproductive health services within the confines of this legal framework. Methodology: This exploratory qualitative study aimed to understand the lived experiences of pregnant girls (aged 13–17 years) seeking sexual and reproductive health services within the restrictive legal context of Malawi. Semi-structured in-depth interviews, Key Informant Interviews, and focus group discussions were conducted with a diverse group of stakeholders, including girls who had experienced sexual assault, their parents or guardians, community leaders, healthcare providers, and policy-makers. Data collection took place in February and March 2023, with interviews conducted in the participant’s preferred language. Thematic content analysis was used to identify key themes and sub-themes from the qualitative data. Results The study included 36 participants: 14 girls aged 13–17 and 22 adults; including parents/guardians, healthcare workers, and different stakeholders at the community and policy level. Four main themes emerged from the data: experiences of pregnancy resulting from rape, ineffective legal recourse, reflections on the need for safe abortion services, and perspectives on the Termination of Pregnancy Bill. Young girls reported fear, embarrassment, and significant mental health challenges due to unintended pregnancies and lack of access to safe abortion. Parents and community members expressed disappointment with the judicial system and highlighted the physical and mental health risks associated with restrictive abortion laws. There was a strong demand for safe abortion services, especially in cases of rape and incest. However, awareness and knowledge about safe abortion services and the Termination of Pregnancy Bill were limited among community stakeholders. Conclusion The study emphasizes the urgent need for legal and policy reforms to improve access to safe abortion services in Malawi. The restrictive legal framework not only endangers the health and well-being of young girls and women but also perpetuates stigma and inequality. Introduction Access to safe abortion and post-abortion care is recognised as a key component of comprehensive sexual and reproductive health and rights [ 1 ]. However, despite abortion being lawful in almost all countries, there is considerable variation in the circumstances in which an individual may access abortion with many countries using criminal laws and penal codes to regulate access [ 2 – 4 ]. The World Health Organization (WHO) 2022 abortion care guidelines note that the legal status of abortion dramatically affects women’s access to safe abortion; despite being a common procedure, 45% of all abortions are unsafe [ 2 ]. Poor, vulnerable and marginalised girls and women are particularly affected by the lack of access to safe abortion and those living in developing countries account for 97% of all unsafe abortions [ 2 ]. The UNFPA report Seeing the Unseen: The Case for Action in the Neglected Crisis of unintended pregnancy notes that 13% of all young women in developing countries begin childbearing while still children (ages 10–17) and these adolescents go on to account for a large proportion of all adolescent births [ 5 ]. Other estimates posit that 50% of adolescent pregnancies are unintended [ 6 ]. The reasons young girls and women become pregnant are complex. As the report illustrates, adolescent girls may feel that marriage and childbearing are a way out of poverty or otherwise fragile domestic and economic situations (described as the “illusion of choice”). There is also a correlation between sexual violence, specifically rape (forced or coerced into sex) and unintended pregnancy among adolescents. The Violence Against Children and Youth Surveys (VACS) estimates that between 11% and 26% of girls and young women in the sub-Saharan African countries surveyed have experienced sexual violence in the past 12 months [ 7 ]. And young girls and women who survive rape and become pregnant face particular risks, including eclampsia, puerperal endometriosis, systemic infections, unsafe abortion, maternal mortality, and mental health challenges [ 8 ]. Multiple international declarations and treaties exist to guarantee the rights of women and girls to bodily autonomy and comprehensive sexual and reproductive health interventions, including safe abortion. In Africa, the Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa ("Maputo Protocol") guarantees women’s rights to sexual and reproductive health, including safe and legal abortion[ 9 ]. Under Article 14(2)c of the Maputo Protocol, State Parties are obligated to “protect the reproductive rights of women by authorizing medical abortion in cases of sexual assault, rape, incest and where the continued pregnancy endangers the mental and physical health of the mother or the foetus” [ 10 ]. In Malawi, 42% of girls experience physical violence before their 18th birthday [ 11 ], and for 38% of girls who had intercourse before age 18, this experience was physically forced or coerced and 33% of these girls became pregnant [ 12 ]. However, despite the devastating consequences of sexual violence, only 9% received services [ 12 ]. During the first wave of COVID-19, there was an increase in reports of sexual violence, child labour, teenage pregnancies and child marriage in Malawi and this follows an established trend of sexual violence increasing during times of crisis [ 13 ]. Though Malawi is a signatory to the Maputo Protocol, existing domestic legislation restricts abortion only to cases where the pregnant woman’s life is at risk. Under the Penal Code, obtaining an abortion outside these circumstances is punishable by up to 14 years’ imprisonment [ 14 ]. Access to healthcare for those who have sought an abortion in Malawi is poor. Despite The Standards and Guidelines for Post Abortion Care 2020 recommending that all women with complications from abortion should have access to high-quality comprehensive abortion care services, including counselling and family planning to prevent repeat abortion [ 15 ], only 38% of women with an induced abortion are estimated to receive treatment for complications, with 22% reporting untreated complications [ 16 ]. Abortion stigma, gender-based power imbalances, lack of high-quality sexual education, poor availability, restrictive abortion laws and religion are all contributing factors to these statistics. A study by the International Community of Women Living with HIV/AIDS published in 2009, is one of a few documents which tell the story of different women in Malawi who had accessed abortion following sexual violence [ 17 ]. In the last decade, legal advocates and campaigners have been working towards reforming abortion law in Malawi. In 2015, the Malawi Law Commission proposed the Termination of Pregnancy (ToP) Bill. This draft legislation sought to legalize abortion on three additional grounds beyond the threat to life: 1) in cases of injury to the women’s mental and physical health; 2) fetal malformation; 3) rape or incest. However, in 2021, plans to debate the Bill in Parliament were blocked [ 18 ]. More recently, legal advocates have adapted their efforts and are exploring public interest litigation as a complementary approach to legal reform. Under this strategy, activists and lawyers have facilitated bringing a case to the High Court to seek legal interpretation regarding pregnancies that pose a risk to the lives of pregnant girls. The cases of girls who have become pregnant as a result of sexual violence (with the life-threatening complications this entails) are a specific focus. However, while judicial decisions are important, so too is the public interest and perceived need for justice in cases where rights have been violated and to contribute to legal reforms. As such, multiple and multi-pronged concerted advocacy efforts are still required to build support among various community constituencies, movements and coalitions. To maintain this momentum, more research is critically needed, especially to bring out the experience of girls and women themselves. The last public testimonials are the powerful stories from the International Community of Women Living with HIV/AIDS, but these were published in 2009. Ensuring access to current and comprehensive data is essential for advocating effectively and upholding the rights and well-being of survivors. This study was commissioned to address this critical gap and advance our understanding of the contemporary realities faced by pregnant girls and young women. Methodology Study Aim and Design This was an exploratory qualitative study aimed at understanding the lived experiences of pregnant girls and young women who sought sexual and reproductive health services and the surrounding legal context. The specific objectives of the study were to: Understand the lived experiences of pregnant girls and young women who had been raped, sought, and were refused access to safe abortion. Explore the interpretation and impact of the current legal frameworks on the services the girls and young women were able to access and the results of this. Understand the perceptions and attitudes of community stakeholders as well as policymakers and program representatives on the safe abortion context in Malawi. Study site The study was conducted at Kamuzu Central Hospital One Stop Centre (KCH-OSC). The facility was selected based on willingness to participate in the study. We also ensured that the OSC had the referral networks in place for participants in the study. Study Population To address our study objectives and the complexity of the issue from a range of perspectives, we interviewed the following stakeholders. Girls or young women under the age of 18 (and therefore legally defined as a child and below the age of consent) who were or had previously been pregnant following rape and sought services at the One-Stop Centre (OSC). Parents/guardians of girls and young women who had become pregnant following rape Community-level stakeholders, including leaders and traditional birth attendants. Health service providers, including those at the OSC. Policy and program managers responsible for the development and implementation of sexual and reproductive health guidelines and services. This included representatives from the Ministry of Health Reproductive Health Directorate, the Ministry of Justice, and the Parliamentary Committee on Health. Sexual and Reproductive Health and Rights coalitions and non-governmental organisations (NGOs) involved in sexual and reproductive health. Participant Selection Purposive sampling with maximum variation was used to select all participants involved in the study to ensure rich data was collected. The OSC identified girls who were or had previously been pregnant following rape, informing them of the research and requesting their consent to be contacted by the research team, alongside their parent or guardian. In consultation with the Ministry of Health Officials and the study task force, we selected key stakeholders and program staff working at the site where data collection took place. Data Collection Data collection for the study was conducted in February and March 2023. The research study utilised qualitative research methods, including semi-structured in-depth interviews, key informant interviews, and focus group discussions, to generate a comprehensive understanding of the unique individual experiences of participants. Topic guides were informed by survivor-centred literature. All interviews were conducted by research assistants trained in human subject protection training and safeguarding. All interviews were conducted in a private and convenient location and were conducted in the participant’s preferred language (Chichewa or English) using the semi-structured data collection guides. Interviews were recorded using digital audio recorders, with participants’ permission. Data Management and Analysis The audio-recorded interviews conducted in Chichewa or English were translated and transcribed verbatim by trained transcribers in Microsoft Word. Each audio-recorded interview was given a unique identification code that also appeared in the file name. All files were password-protected. Before analysis, transcripts were anonymised by removing the names of individuals, schools, or health facilities. Qualitative transcripts were reviewed by the study investigators as they were transcribed. The study supervisor performed quality control over all the transcripts by checking each transcript against the recorded data to ensure that there was no misrepresentation of data. A thematic content analysis approach was followed during the data analysis process. Analysis used a hybrid of the deductive and inductive approaches where a coding scheme (or codebook) was developed that combined a priori codes for key concepts related to the study objectives with additional data-driven codes identified through repeated reading of the transcripts. Ethical Considerations Ethical approval to conduct the study was provided by the Malawi College of Medicine Research and Ethics Committee (COMREC). All interviewers were provided with training in psychosocial support to help their management of the interviews and ensure they handled participants sensitively and safely. All participating girls and their parents/guardians were also provided with referrals to the OSC to receive psychosocial support after the interview. Protocols and procedures were put in place to ensure the anonymity and confidentiality of participants, with participants free to withdraw from the study at any time. Contact details for the Centre for Reproductive Health were provided to all participants so they could follow up directly or anonymously with an independent body with any questions they had following interviews. In addition, the name and telephone number of the chairperson of the COMREC were also provided in case the participants had any concerns they felt may not be adequately resolved by the research agency. To ensure robust delivery and reporting of this research, a Task Force Committee was established. This Committee included representatives from the Ministry of Health Reproductive Health Directorate, Medical Professionals, legal practitioners, communications experts, National Assembly representatives, youth, faith-based organizations, implementing partners, coalition representatives, and researchers. This Task Force Committee has been advising on the study design, implementation, reporting, and dissemination. Results Data collection involved young girls who were raped, their parents/guardians, and other different stakeholders. A total of 36 individuals took part in the study. Young girls’ demographic characteristics According to Table 1 below, 14 young girls took part in the study. The age range for the girls was 13–17 years old, with the majority being 16 years old. Half had primary education while the other half had reached the secondary level. The majority (93%) were Christians. Table 1 Girls’ demographic characteristics No Variables Attributes Number % 1 Age 13yrs 3 21% 14yrs 2 14% 15yrs 2 14% 16yrs 4 29% 17yrs 3 21% 2 Highest Education Level Primary 7 50% Secondary 7 50% 3 Religion Christianity 13 93% Islam 1 7% 4.1.2 Adult participant characteristics As per Table 2 below, a total of 22 adult participants were involved in the study. These were parents/guardians (n = 6), community-level stakeholders (n = 5), healthcare workers (n = 6) and policy/program-level stakeholders (n = 5). Almost three-quarters (73%) were female and half had attained tertiary education. On religious beliefs, the majority were Christians (91%). Table 2 Adult Participants Demographic Characteristics No Variables Attributes Number % 1 Age 20–29 4 18% 30–39 4 18% 40–49 5 23% 50–59 5 23% 60–69 4 18% 2 Gender Female 16 73% Male 6 27% 3 Highest Education Level Primary 7 32% Secondary 4 18% Tertiary 11 50% 4 Religion Christianity 20 91% Islam 2 9% Themes and sub-themes Four main themes emerged after the analysis. These are experiences of pregnancy as a result of rape, legal recourse, reflections on the need for safe abortion services and termination of pregnancy bill as in Table 3 below: Table 3 Themes and sub-themes Theme Sub-theme Experiences of pregnancy following rape Fear and embarrassment Unwanted pregnancies Consequences of lack of access to abortion Mental health challenges Parental and community reactions Legal Recourse Ineffective police response Disappointment with the judicial system Reflections on the need for abortion services Demand for abortion services Lack of access and awareness Physical and mental health risks Safe Abortion Policy Landscape Protection against unsafe abortions Community attitudes and perceptions towards Termination of Pregnancy Bill Advocacy approach Experiences of pregnancy following rape Fear and embarrassment Fear and embarrassment were commonly reported emotions among girls, their parents, and communities. These emotions were influenced by various interconnected factors, including the fear of death during pregnancy or childbirth, concerns about retaliation from men and/or relatives, and worries about how the community would judge them upon learning about their pregnancy. “ I was afraid since I could hear other people say that a certain 14-year-old girl had passed away during the time she was trying to deliver. This was making me afraid of what it would be like for me when the time came for me to deliver .” 17-year-old girl. “ The man who forced me to sleep with [him] threatened to kill me if I told my mother that I am pregnant .” 15-year-old girl. “ I was feeling embarrassed because I was impregnated by an older man and he must be in his 40’s. He was forcing me to sleep with him… He slept with me at the river where he was fetching for sand .” 16-year-old girl. Unwanted pregnancies Some girls expressed their desire for an abortion upon discovering their pregnancy. “I wanted to abort because I don’t know the man who raped me. I am carrying a baby whose father I don’t know.” 13-year-old girl. “I wanted to abort but I was afraid due to what people were saying that abortion is deadly.” 15-year-old girl. Consequences of lack of access to abortion Without access to safe abortion, girls face numerous health and social consequences. Many participants emphasized that young girls are forced to drop out of school, negatively affecting their future earning potential and overall well-being. “ It was a painful pill for me to swallow because when I think of goals I had in the future to help my parents, I just felt that they were swept away. … I am worried about my future because now I can no longer go back to school. I stay with a single mother, so my goal was to go very far with my education so that I should be able to support my mother .” 14-year-old girl. Additionally, it was noted that they experience increased social stigma within their communities as their pregnancy progresses, leading to abandonment by loved ones and friends as they near childbirth. “ It has been hard. Some people have been judging me, stopped involving me in youth activities, calling me all sorts of names. I am struggling to say the truth ” 13-year-old girl. “ She was angry and disappointed and said I should move out of her house. She said I should go to the man responsible for my pregnancy .” 16-year-old girl. Mental health challenges Young girls and health providers noted the impact of these challenges on the mental health of the girls and young women, specifically mentioning the potential for suicidal ideation. “Some pregnant girls get stigmatized by their family members and when they get stigmatized, they start having suicidal thoughts and start thinking of terminating their own life .” 13-year-old girl. “ Young girls experience various challenges when they are pregnant. Firstly, they are stigmatized by their peers, and when they are stigmatized, some resolve to commit suicide .” Health care provider Parental and community reactions Parents and caregivers of pregnant young girls often face scrutiny and criticism from their communities. Participants mentioned that parents can often be blamed, with others in the community implying that their parenting strategies contributed to the rape or that they were poor role models. Participants also mentioned instances where community leaders interrogated parents, demanding explanations for their daughter or young relative's pregnancy. “ This happens because some people look at the parents of the child who is pregnant as lacking that parental guidance on the child that is why the child happens to be pregnant ” Community-level stakeholder. “… other community members will be saying negative things in regards to the parents of the pregnant minors, saying things like the parents did not raise their child appropriately. Others say that the parents should have been advising their children on what to do and what not to do. Now that their child is a minor who is pregnant, they will say that it just shows that the parents were not very much involved in raising that child. ” Community level stakeholder Legal Recourse Ineffective police response When asked about legal recourse mechanisms, participants said that survivors do try to seek justice by taking legal action against perpetrators. However, many expressed dissatisfaction with the treatment they received from the police. Even when the perpetrators confessed to their crimes, no action was taken against them as long as they committed to supporting the pregnant girl. In some cases, the police dismissed reports of rape from complainants who were 16 or 17 years old, even though this is still a crime as they are below the age of consent. “However, after we had gone to the Police Victim Support Unit, and after they had called him… The police detained him overnight and the next day he was released.” 17-year-old girl. The police officer said that since she was 17 years old and had just remained for some months to turn 18 years old, and the man was 23 years old, they would not arrest him. They said the rest depended on how the parents agreed on how this should have proceeded. … we were told that since we were just neighbours who are close to each other, we should not take this issue very far, instead just get home and talk this out and see how best you can proceed.” Parent. Disappointment with the judicial system For those cases that made it to court, participants often felt disappointed and let down by the judicial system. This was because of the lengthy delays in the court process and the perception that their testimonies were not given the appropriate consideration. “… the court must be handling cases in time, they should be handling cases in time for the safety of our children …when cases happened ​ a long time ago, and for them to pile cases without making judgments, that make cases to be forgotten and be buried…the court should be helping us when such cases happen.” Parent “Mine is just a plea…you call yourself NGOs and you say that you stand for children…, we need you to help us so that when these cases go to court they should be handled in time, some of us spend a lot on transportation by going to court…we go to court and they tell us to go again another day and when we go again on the day that they told us, we return without being assisted as expected.” Parent. Reflections on the need for abortion services Demand for abortion services Young girls, parents, and health providers were in agreement that in circumstances of rape and/or when a girl or young woman had become pregnant as a result of rape, access to abortion should be allowed. “ I think it is good that maybe they should provide an opportunity for the people to choose by themselves considering that the pregnancy is unwanted; thus, to provide the abortion services to the minors who are raped or sexually assaulted .” 14 year-old girl. “ When the pregnancy is small, the pregnant minor should be allowed to access abortion services, when they do an abortion…when a minor is pregnant, they should be allowed to have an abortion .” Parent “ As the one who has been working with girls, … it would be better if there were laws that would allow us to terminate these minors’ pregnancies .” Healthcare provider Lack of access and awareness None of the participants reported being offered or provided with either legal or illegal abortions. Young girls and their parents expressed limited awareness or knowledge of abortion services. Health providers confirmed this, explaining that they were unable to offer abortion services due to policy limitations. “ To say the truth, we didn’t know what to do [after being denied at the OSC] because we had no knowledge of where we could go and do that [procure abortion] so we just thought of keeping it because it had already happened .” Parent “ The laws of Malawi prohibit that [abortion] unless it’s a life-threatening situation that’s when they can actually perform the abortion on the minor. ” Health care provider Physical and mental health risks Policy-level stakeholders reflected on the physical and mental health risks to girls and young women with unintended pregnancies as a result of rape. In these instances, they stated the law does allow for termination of pregnancy and health providers, lawmakers and communities need to understand this. “…a pregnancy that results from sexual assault, actually would constitute an emergency for an abortion. And that answer is found in law. I think actually at the moment the law allows that. I am not so sure if people know that you can get an abortion when you are raped. Yes, so the problem is that you are only concentrating on the physical health, physical wellbeing but also look at the mental wellbeing… So, if you look at a minor, the mental wellbeing might be affected but that decision, that decision is on the doctor performing the abortion or making the assessment in this case…actually the law at the moment allows for such kind of a procedure to be performed on girls who are minors. ” Policy-level stakeholder Safe Abortion Policy Landscape Protection against unsafe abortions The ToP Bill seeks to expand legal abortion from only cases where the woman’s life is at risk to cases of rape, incest, fetal abnormalities, and threats to mental and physical health, which would also align with the Maputo Protocol. In 2021, the ToP Bill was withdrawn from the Parliamentary Order Paper and consequently never debated. Among the policymakers interviewed, there was consensus that passing the ToP Bill would protect girls and young women who become pregnant as a result of sexual assault, enabling them to protect their physical and mental health. Others felt that passing the Bill would prevent any fallout from unsafe abortions that might be sought in the absence of a safe and regulated service. “ Despite setting up strict or tough rules, we have to set our laws that should empower people, uhm…. there are laws surrounding safe abortion but there is a condition attached to it which is that it (abortion) should only be done in life-threatening situations. Yeah, so we should take out these conditions and make safe abortion legal, so let’s stop cheating ourselves, young girls are dying and there are statistics to prove that … .” Policy-level stakeholder Community attitudes and perceptions towards ToP Bill Among the community stakeholders, there was a lack of knowledge and comprehension regarding the ToP Bill. The majority of stakeholders at the community level were uninformed about the contents of the Bill and its progression through Parliament. Even among those who possessed some level of awareness, the Bill was regarded with mixed feelings. “ The pregnancy termination bill is a bad one, but it is also good in cases where the pregnancy is causing some complications and my plea to the government is that they should … not just allow anyone to come in and terminate the pregnancy, no, because terminating a pregnancy is the same as killing a person…. When the girl or the woman has not followed proper child spacing which in turn has put her in a position of not being able to take care of the pregnancy, they have to abort …, but terminating the pregnancy for no good reason should not be allowed. ” Community-level stakeholder “ Biblically, termination of pregnancy is something that is not allowed. However, when we look at the burdens that come due to unplanned pregnancies, I will not rule out abortions, we need the bill. If you look at the way our population is growing, I will give you an example of how the population is growing in Malawi …, we will have no space even for farming …. It will be difficult, so abortion would be good… because most of these children, the population is growing because most of these children are giving birth at a very tender age. ” Community-level stakeholder Advocacy approach Policy-level stakeholders expressed concerns that the advocacy strategies used during campaigns for the ToP Bill placed too much emphasis on politicians and not enough focus on mobilizing support among grassroots youth organizations, who are most affected by the Bill. “ The other problem that we have is the approach that we used to advocate for this Bill, maybe we started approaching the people on top of the hierarchy instead of starting with the people at the bottom of the hierarchy. Had it been we started advocating for this from, say, primary schools so that the communities and the young people should clearly understand this. So just because most of the lawmakers were not informed of it they just left it in the hands of the chair of parliament as if it only belongs to him yet in actual sense it is not just for him to handle. … we are just cheating ourselves yet the thing is happening underground, so why can we not just formalize it? Should our children continue dying because of unsafe abortion? ” Policy-level stakeholder Discussion Findings from this research reveal significant challenges that girls who have become pregnant after being raped face, including fears of childbirth, societal judgment, and limited future opportunities. Many of these girls consider abortion but lack access to safe services. This lack of access can have severe health and social consequences, such as dropping out of school and mental health issues, including thoughts of suicide. Instead of offering support, parents and community members often blame the survivor's family, further isolating and adding to their difficulties. Unfortunately, the legal and judicial systems often fail to adequately support survivors, resulting in dissatisfaction and a lack of trust. Stakeholders are advocating for the expansion of legal abortion access to protect the physical and mental health of young girls. However, the ToP Bill was withdrawn from Parliament in 2021 and more work is needed to mobilise community support for such a bill. Insights from this research build on the findings of other regional studies which have demonstrated that teenage pregnancy poses a greater risk of maternal mortality and health complications compared to pregnancies in adults [ 19 , 20 ] and that affected girls experience severe consequences such as dropping out of school, diminished prospects, heightened social stigma [ 21 – 24 ], isolation, abandonment, and mental health issues, including suicidal ideation [ 19 , 25 ]. These findings underscore the importance of comprehensive SRH/FP support encompassing accessible abortion services, mental health resources, and community education to reduce stigma and provide assistance to affected girls and their families, while also safeguarding their health, well-being, and human rights. The research findings unveil significant issues about the handling of rape cases involving girls under the age of 18 by law enforcement agencies and the judiciary in Malawi. The findings of the present study indicate dissatisfaction with how judicial institutions deal with such cases. Concerns include a relaxed approach by the police, resulting in some perpetrators escaping arrest or facing minimal repercussions. Similar instances of inaction against offenders have been reported in other countries [ 21 , 23 ]. The police have also been accused of prematurely assuming the innocence of the accused. In the courtroom, survivors have felt betrayed by judgments that ruled against them despite providing detailed testimonies, suggesting that their accounts were not given due weight. The sluggish pace of court proceedings has further aggravated the frustration of parents, similar to a study conducted in Ghana [ 23 ]. The narratives of girls and their parents or guardians highlight the necessity for enhanced training, professionalism, and sensitivity within these institutions to ensure the equitable treatment of survivors and the proper dispensation of justice. The current study highlights a consensus among girls, parents/guardians, and healthcare providers who supported the provision of safe abortion services to survivors of rape, citing the need for personal choice and the alleviation of distress caused by unwanted pregnancies. However, despite this demand, there is a significant gap in access and awareness. No survivors who participated in the study reported being offered legal abortions, reflecting the restrictive legal environment. Health providers echoed this sentiment, noting their inability to provide abortions due to policy constraints, which has also been reported in earlier studies [ 26 , 27 ]. The findings highlight the urgent need for policy reform to improve access to safe abortion services, particularly for survivors of rape. Policymakers who were interviewed largely expressed support for expanding legal access to safe abortion in cases of rape, arguing that it would protect young women and girls from the risks associated with unsafe abortions and enable them to safeguard their physical and mental well-being. This is consistent with previous studies [ 28 – 30 ], which have highlighted the close correlation between criminalization and the prevalence of illegal abortions, thereby posing significant threats to women's health and compromising their fundamental rights [ 28 ]. The importance of empowering individuals through laws that legalize safe abortions beyond life-threatening situations was emphasized, as existing restrictions contribute to avoidable deaths. There was a significant lack of awareness and understanding of the ToP Bill among young girls and community stakeholders, many of whom expressed mixed views on the issue. This aligns with previous studies highlighting a general lack of knowledge about abortion laws, even in countries with more liberal policies [ 31 – 33 ]. While some community members recognised the Bill’s potential to address complications from unplanned pregnancies, others opposed it on moral or religious grounds. Interestingly, despite this opposition, there appears to be some practical tolerance, particularly when the issue is framed around health needs and the prevention of unsafe abortions. This suggests a potential entry point for policy change, especially as policymakers have emphasised the need for greater engagement with grassroots communities. Policy stakeholders critiqued the current advocacy efforts for focusing too much on politicians and not enough on mobilising community-level support, noting that with better education and outreach, there could be broader acceptance and reduced misconceptions [ 32 , 34 ]. The study possesses several strengths that have the potential to yield valuable insights into a highly sensitive and significant topic. The utilisation of an exploratory qualitative design facilitated the collection of rich and comprehensive data, allowing participants to express their experiences in their own words. Consequently, the data obtained captures the intricate complexities and nuances inherent in the girls' experiences. Additionally, the study successfully explores a unique perspective that often goes unexamined in research on sexual violence. By centering on the lived experiences of pregnant girls, the study presents a more holistic understanding of the impact of sexual violence and the restrictive legal framework on this vulnerable population. Nonetheless, there are certain limitations to consider. Firstly, recruiting participants proved challenging. Both parents/guardians and rape survivors exhibited reluctance in sharing their experiences due to feelings of shame, stigma, and fear of retribution from their families and communities at large. This hesitance may have compelled some participants to provide socially acceptable responses, potentially hindering their ability to freely discuss their experiences and resulting in the underreporting of negative encounters. Secondly, the findings of the study may lack generalizability to other populations or settings owing to differences in cultural norms, healthcare accessibility, legal systems, and other contextual factors. Thirdly, time constraints imposed limitations on conducting further rigorous analysis of the study. Furthermore, there is a pressing need for additional research on various issues, such as community attitudes towards pregnancy and child-rearing, the service delivery environment, service providers' knowledge of existing laws, the functionality of One-Stop Centers (OSCs), and the handling of sexual assault cases by the police. Conducting longitudinal studies on the mental health impacts of denied abortion services is also imperative. Conclusions The research indicates that adolescent girls who experience pregnancy as a result of rape encounter significant emotional, social, and psychological difficulties. These challenges are exacerbated by limited access to secure safe abortion services leading to severe health and societal consequences. Furthermore, the prevalence of victim-blaming attitudes within families and communities, coupled with the inefficiencies of legal and judicial systems, further isolates and traumatises these girls. The findings underscore the pressing necessity for comprehensive support, including easily accessible safe abortion services, mental health resources, and community education, to reduce stigma and provide vital assistance. Improving training and sensitivity within law enforcement and judicial institutions is crucial to guaranteeing survivors justice. Furthermore, advocacy for legal reforms, such as those proposed in the ToP Bill, and enhanced awareness and comprehension of existing laws are essential measures to safeguard the health, well-being, and rights of these survivors of rape. Abbreviations COMREC College of Medicine Research Ethics Committee FP Family planning NGO Non-Governmental Organization OSC One Stop Centre SRH Sexual Reproductive Health ToP Termination of Pregnancy UNFPA United Nations Population Fund VACS Violence Against Children and Youth Surveys WHO World Health Organisation Declarations Availability of data and materials The datasets used in the study are available from the corresponding author on request. Acknowledgements We appreciate the support we received from the management and staff of KCH - OSC where the study was conducted. We also thank the study task force, research assistants who collected and transcribed the data, and all the participants for participating in the study. Funding: This research was funded by Options Consultancy Services Ltd. Contributions PM, MM, WS, GK, FK, and EC designed the study, while PM, MM, and EC developed the data collection tools and developed the analysis plan. PM, MM, and EC collected part of and supervised data collection. PM, MM, and EC analysed the data while PM, and MM drafted the manuscript. PM, MM, WS, PD, GK, FK, and EC critically reviewed the manuscript and approved the final version. Ethics approval and consent to participate The study was approved by the COMREC (Protocol # P.11/22/3878). The study was conducted according to the regulations and guidelines of the Declaration of Helsinki. We obtained written informed consent from each participant before any interview was conducted. Participants who could not read nor write thumb printed on the informed consent form after it was read to them in the presence of an impartial witness. The thumb-printed informed consent form was approved by the COMREC. Consent for publication: Not applicable. Clinical trial number: Not applicable. Competing interests: The authors declare that they have no competing interests. References Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher–Lancet Commission. Lancet. 2018;391:2642–92. World Health Organization. Abortion Care Guideline [Internet]. WHO, Geneva S. 2022. https://apps.who.int/iris/handle/10665/349316 Ambast S, Atay H, Lavelanet A. A global review of penalties for abortion-related offences in 182 countries. BMJ Glob Heal. 2023;8. Lavelanet AF, Schlitt S, Johnson BR, Ganatra B. Global Abortion Policies Database: A descriptive analysis of the legal categories of lawful abortion. BMC Int Health Hum Rights BMC Int Health Hum Rights. 2018;18:1–10. United Nations Population Fund. State of the World Population: Seeing the unseen. The case for action in the neglected crisis of unintended pregnancy. 2022. World Health Organisation. Adolescent pregnancy [Internet]. 2023 [cited 2024 May 14]. https://www.who.int/news-room/fact-sheets/detail/adolescent-pregnancy Center for Diseases Control and Prevention. Preventing Violence Against Children and Youth Globally [Internet]. 2021 [cited 2024 May 14]. https://www.cdc.gov/violenceprevention/childabuseandneglect/vacs/fastfact.html Ahinkorah BO, Seidu AA, Appiah F, Oduro JK, Sambah F, Baatiema L, et al. Effect of sexual violence on planned, mistimed and unwanted pregnancies among women of reproductive age in sub-Saharan Africa: A multi-country analysis of Demographic and Health Surveys. SSM - Popul Heal. 2020;11:100601. Thompson J, Undie C-C, Amin A, Johnson BR, Khosla R, Ouedraogo L et al. Harmonizing national abortion and pregnancy prevention laws and policies for sexual violence survivors with the Maputo Protocol: proceedings of a 2016 regional technical meeting in sub-Saharan Africa. BMC Proc. 2018;12:1–16. African Union. Protocol to the African Charter on Human and Peoples’ Rights on the Rights of Women in Africa. Maputo: African Union; 2003. Equality Now. Holding Malawi Accountable At The ACERWC For Denying Justice To Survivors Of Trafficking For Sexual Exploitation: Maggie’s Case [Internet]. 2022 [cited 2024 May 27]. https://equalitynow.org/news_and_insights/holding-malawi-accountable-acerwc-justice-maggies-case/ Together for Girls. Malawi Country Fact Sheet [Internet]. 2013. https://files.mutualcdn.com/tfg/assets/files/Malawi-country-fact-sheet.pdf Gender Focus. Project: Sexual abuse and unwanted pregnancies amongst women and girls in Malawi during the COVID-19 pandemic [Internet]. 2024 [cited 2024 May 23]. https://genderfocus.org/project-sexual-abuse-and-unwanted-pregnancies-amongst-women-and-girls-in-malawi-during-the-covid-19-pandemic/ Kangaude GD, Mhango C. The duty to make abortion law transparent: A Malawi case study. Int J Gynecol Obstet. 2018;143:409–13. Government of Malawi. Standards and Guidelines for Comprehensive abortion Care 2020. Lilongwe, Malawi Ministry of Health.; 2020. Polis CB, Mhango C, Philbin J, Chimwaza W, Chipeta E, Msusa A. Incidence of induced abortion in Malawi, 2015. PLoS ONE. 2017;12:e0173639. ICW-Malawi. Unwanted pregnancy and abortion Experiences of women in Malawi [Internet]. 2009; https://salamandertrust.net/ Kangaude GD, Sibande CG, Ross SD, Liu MX. Abortion law reform in Malawi: a case study in stakeholder engagement, public education, and human rights advocacy. In: Ziegler M, editor. Res Handb Int Abort law. Edward Elgar Publishing; 2023. pp. 82–102. Crooks R, Bedwell C, Lavender T. Adolescent experiences of pregnancy in low-and middle-income countries: a meta-synthesis of qualitative studies. BMC Pregnancy Childbirth. 2022;22:1–18. Mangeli M, Rayyani M, Cheraghi MA, Tirgari B. Exploring the Challenges of Adolescent Mothers From Their Life Experiences in the Transition to Motherhood: A Qualitative Study. J Fam Reprod Heal. 2017;11:165–73. Coast E, Mwali MM, Isimbi R, Ngabonzima E, Pereznieto P, Buzby S, et al. If She’s Pregnant, then that Means that Her Dreams Fade Away’: Exploring Experiences of Adolescent Pregnancy and Motherhood in Rwanda. Eur J Dev Res. 2021;33:1274–302. Govender D, Naidoo S, Taylor M. I have to provide for another life emotionally, physically and financially: understanding pregnancy, motherhood and the future aspirations of adolescent mothers in KwaZulu-Natal South, Africa. BMC Pregnancy Childbirth. 2020;20:1–21. Kotoh AM, Sena Amekudzie B, Opoku-Mensah K, Baku EA, Glozah FN. Pregnant adolescents’ lived experiences and coping strategies in peri-urban district in Southern Ghana. BMC Public Health. 2022;22:157–69. Thongmixay S, Essink D, Kahrs T, Vongxay V, Wright P, Sychareun V, et al. Isolation: The experience of adolescent motherhood in Laos. Front Glob Women’s Heal. 2023;4:1–13. Konadu Gyesaw NY, Ankomah A. Experiences of pregnancy and motherhood among teenage mothers in a suburb of Accra, Ghana: A qualitative study. Int J Womens Health. 2013;5:773–80. Oberman M, Lehmann LS. Doctors’ duty to provide abortion information. J Law Biosci. 2023;10:1–27. Vázquez P, Nigri C, Pingray V, Gibbons L, Formia S, Messina A, et al. Factors associated with provider unwillingness to perform induced abortion in Argentina: A cross-sectional study in four provinces following the legalization of abortion on request. PLoS ONE. 2023;18:1–16. De Londras F, Cleeve A, Rodriguez MI, Farrell A, Furgalska M, Lavelanet A. The impact of criminalisation on abortion-related outcomes: A synthesis of legal and health evidence. BMJ Glob Heal. 2022;7:1–13. Fathallah Z. Moral work and the construction of abortion networks: Women’s access to safe abortion in Lebanon. Health Hum Rights. 2019;21:21–31. Påfs J, Rulisa S, Klingberg-Allvin M, Binder-Finnema P, Musafili A, Essén B. Implementing the liberalized abortion law in Kigali, Rwanda: Ambiguities of rights and responsibilities among health care providers. Midwifery. 2020;80. Assifi AR, Berger B, Tunçalp Ö, Khosla R, Ganatra B. Women’s awareness and knowledge of abortion laws: A systematic review. PLoS ONE. 2016;11. de Vries I, van Keizerswaard LJ, Tolboom B, van der Bulthuis S, Tank J, et al. Advocating safe abortion: outcomes of a multi-country needs assessment on the potential role of national societies of obstetrics and gynecology. Int J Gynecol Obstet. 2020;148:282–9. Mekuria M, Daba D, Girma T, Birhanu A. Assessment of knowledge on abortion law and factors affecting it among regular undergraduate female students of Ambo University, Oromia Region, Ethiopia, 2018: a cross sectional study. Contracept Reprod Med. 2020;5:1–8. Kayondo SP, Kaye DK, Nabatanzi SL, Nassuuna S, Musana O, Namagembe I, et al. Challenges and opportunities from using abortion harm reduction and value clarification and attitude transformation engagements for safe abortion advocacy in Uganda. Reprod Health. 2023;20:1–12. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5322790","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374321696,"identity":"f3bb29e5-c041-48d9-b655-2d5bf378d012","order_by":0,"name":"Patani Mhango","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYFACHjApJwFlEK/FmHQtiTOI1mIudvbg54JfNukzZ+QefPiDwU6eQeyMAV4tlrPzkqVn9qXlzpbISzbmYUg2bJDOwa/F4HaOgTRvz+HceRI5ZtIMDMwJDNK5GwhpMf4N1JIuJ5Fj/vMHQz1RWsykeX4cTpAG2gIMgcOEtVjOzjGz5m1IM5zZ88ZYmsfguGGbdP4HvFrMpXOMb/P8sZGXOJ5j+PFHRbU8v3RaAn6HgQjGNiQuG171MC0MfwgpGwWjYBSMghENAIp2PbGQtJk9AAAAAElFTkSuQmCC","orcid":"","institution":"Centre for Reproductive Health, Kamuzu University of Health Sciences","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Patani","middleName":"","lastName":"Mhango","suffix":""},{"id":374321698,"identity":"83960a4f-7f4f-4298-b571-615da2ef2c8d","order_by":1,"name":"Medrina Mtende","email":"","orcid":"","institution":"Centre for Reproductive Health, Kamuzu University of Health Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Medrina","middleName":"","lastName":"Mtende","suffix":""},{"id":374321700,"identity":"c7448abe-a4a0-4fc2-8880-91ac78177398","order_by":2,"name":"Godfrey Kangaude","email":"","orcid":"","institution":"Rhodes University, Critical Studies in Sexualities and Reproduction","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Godfrey","middleName":"","lastName":"Kangaude","suffix":""},{"id":374321702,"identity":"9db194b9-336e-467d-957e-16c2e1707783","order_by":3,"name":"Mphatso Mapemba","email":"","orcid":"","institution":"Options Consultancy Services Ltd","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mphatso","middleName":"","lastName":"Mapemba","suffix":""},{"id":374321703,"identity":"be71c604-ccaa-4776-a62c-8102f75d0d19","order_by":4,"name":"Patricia Doherty","email":"","orcid":"","institution":"Options Consultancy Services Ltd","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"","lastName":"Doherty","suffix":""},{"id":374321704,"identity":"c1c524d9-e3cb-4e96-bc2e-00458b546e43","order_by":5,"name":"Wina Sangala","email":"","orcid":"","institution":"Options Consultancy Services Ltd","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wina","middleName":"","lastName":"Sangala","suffix":""},{"id":374321705,"identity":"b7d68ed7-2867-467f-a626-82bd0accecfa","order_by":6,"name":"Fannie Kachale","email":"","orcid":"","institution":"Ministry of Health, Reproductive Health Directorate","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fannie","middleName":"","lastName":"Kachale","suffix":""},{"id":374321706,"identity":"a4f5eeb9-443f-4d7c-abd4-f84655e40628","order_by":7,"name":"Effie Chipeta","email":"","orcid":"","institution":"Centre for Reproductive Health, Kamuzu University of Health Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Effie","middleName":"","lastName":"Chipeta","suffix":""}],"badges":[],"createdAt":"2024-10-24 05:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5322790/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5322790/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":99207958,"identity":"3384cff0-ad6a-49f0-9c6e-892ed1e4bfe9","added_by":"auto","created_at":"2025-12-30 07:09:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1025411,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5322790/v1/3f1dc4b8-7bc7-405b-ae5a-eb816a9487a7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“I am carrying a baby whose father I do not know.” Experiences and context of girls pregnant from rape and sought sexual and reproductive health services","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccess to safe abortion and post-abortion care is recognised as a key component of comprehensive sexual and reproductive health and rights [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, despite abortion being lawful in almost all countries, there is considerable variation in the circumstances in which an individual may access abortion with many countries using criminal laws and penal codes to regulate access [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The World Health Organization (WHO) 2022 abortion care guidelines note that the legal status of abortion dramatically affects women\u0026rsquo;s access to safe abortion; despite being a common procedure, 45% of all abortions are unsafe [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Poor, vulnerable and marginalised girls and women are particularly affected by the lack of access to safe abortion and those living in developing countries account for 97% of all unsafe abortions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe UNFPA report \u003cem\u003eSeeing the Unseen: The Case for Action in the Neglected Crisis of unintended pregnancy\u003c/em\u003e notes that 13% of all young women in developing countries begin childbearing while still children (ages 10\u0026ndash;17) and these adolescents go on to account for a large proportion of all adolescent births [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Other estimates posit that 50% of adolescent pregnancies are unintended [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The reasons young girls and women become pregnant are complex. As the report illustrates, adolescent girls may feel that marriage and childbearing are a way out of poverty or otherwise fragile domestic and economic situations (described as the \u0026ldquo;illusion of choice\u0026rdquo;).\u003c/p\u003e \u003cp\u003eThere is also a correlation between sexual violence, specifically rape (forced or coerced into sex) and unintended pregnancy among adolescents. The Violence Against Children and Youth Surveys (VACS) estimates that between 11% and 26% of girls and young women in the sub-Saharan African countries surveyed have experienced sexual violence in the past 12 months [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. And young girls and women who survive rape and become pregnant face particular risks, including eclampsia, puerperal endometriosis, systemic infections, unsafe abortion, maternal mortality, and mental health challenges [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMultiple international declarations and treaties exist to guarantee the rights of women and girls to bodily autonomy and comprehensive sexual and reproductive health interventions, including safe abortion. In Africa, the Protocol to the African Charter on Human and Peoples\u0026rsquo; Rights on the Rights of Women in Africa (\"Maputo Protocol\") guarantees women\u0026rsquo;s rights to sexual and reproductive health, including safe and legal abortion[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Under Article 14(2)c of the Maputo Protocol, State Parties are obligated to \u0026ldquo;protect the reproductive rights of women by authorizing medical abortion in cases of sexual assault, rape, incest and where the continued pregnancy endangers the mental and physical health of the mother or the foetus\u0026rdquo; [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Malawi, 42% of girls experience physical violence before their 18th birthday [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and for 38% of girls who had intercourse before age 18, this experience was physically forced or coerced and 33% of these girls became pregnant [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, despite the devastating consequences of sexual violence, only 9% received services [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. During the first wave of COVID-19, there was an increase in reports of sexual violence, child labour, teenage pregnancies and child marriage in Malawi and this follows an established trend of sexual violence increasing during times of crisis [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThough Malawi is a signatory to the Maputo Protocol, existing domestic legislation restricts abortion only to cases where the pregnant woman\u0026rsquo;s life is at risk. Under the Penal Code, obtaining an abortion outside these circumstances is punishable by up to 14 years\u0026rsquo; imprisonment [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Access to healthcare for those who have sought an abortion in Malawi is poor. Despite The Standards and Guidelines for Post Abortion Care 2020 recommending that all women with complications from abortion should have access to high-quality comprehensive abortion care services, including counselling and family planning to prevent repeat abortion [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], only 38% of women with an induced abortion are estimated to receive treatment for complications, with 22% reporting untreated complications [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Abortion stigma, gender-based power imbalances, lack of high-quality sexual education, poor availability, restrictive abortion laws and religion are all contributing factors to these statistics.\u003c/p\u003e \u003cp\u003eA study by the International Community of Women Living with HIV/AIDS published in 2009, is one of a few documents which tell the story of different women in Malawi who had accessed abortion following sexual violence [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In the last decade, legal advocates and campaigners have been working towards reforming abortion law in Malawi. In 2015, the Malawi Law Commission proposed the Termination of Pregnancy (ToP) Bill. This draft legislation sought to legalize abortion on three additional grounds beyond the threat to life: 1) in cases of injury to the women\u0026rsquo;s mental and physical health; 2) fetal malformation; 3) rape or incest. However, in 2021, plans to debate the Bill in Parliament were blocked [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMore recently, legal advocates have adapted their efforts and are exploring public interest litigation as a complementary approach to legal reform. Under this strategy, activists and lawyers have facilitated bringing a case to the High Court to seek legal interpretation regarding pregnancies that pose a risk to the lives of pregnant girls. The cases of girls who have become pregnant as a result of sexual violence (with the life-threatening complications this entails) are a specific focus. However, while judicial decisions are important, so too is the public interest and perceived need for justice in cases where rights have been violated and to contribute to legal reforms. As such, multiple and multi-pronged concerted advocacy efforts are still required to build support among various community constituencies, movements and coalitions.\u003c/p\u003e \u003cp\u003eTo maintain this momentum, more research is critically needed, especially to bring out the experience of girls and women themselves. The last public testimonials are the powerful stories from the International Community of Women Living with HIV/AIDS, but these were published in 2009. Ensuring access to current and comprehensive data is essential for advocating effectively and upholding the rights and well-being of survivors. This study was commissioned to address this critical gap and advance our understanding of the contemporary realities faced by pregnant girls and young women.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Aim and Design\u003c/h2\u003e \u003cp\u003eThis was an exploratory qualitative study aimed at understanding the lived experiences of pregnant girls and young women who sought sexual and reproductive health services and the surrounding legal context. The specific objectives of the study were to:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUnderstand the lived experiences of pregnant girls and young women who had been raped, sought, and were refused access to safe abortion.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eExplore the interpretation and impact of the current legal frameworks on the services the girls and young women were able to access and the results of this.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUnderstand the perceptions and attitudes of community stakeholders as well as policymakers and program representatives on the safe abortion context in Malawi.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy site\u003c/h3\u003e\n\u003cp\u003eThe study was conducted at Kamuzu Central Hospital One Stop Centre (KCH-OSC). The facility was selected based on willingness to participate in the study. We also ensured that the OSC had the referral networks in place for participants in the study.\u003c/p\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eTo address our study objectives and the complexity of the issue from a range of perspectives, we interviewed the following stakeholders.\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eGirls or young women under the age of 18 (and therefore legally defined as a child and below the age of consent) who were or had previously been pregnant following rape and sought services at the One-Stop Centre (OSC).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eParents/guardians of girls and young women who had become pregnant following rape\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCommunity-level stakeholders, including leaders and traditional birth attendants.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHealth service providers, including those at the OSC.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Policy and program managers responsible for the development and implementation of sexual and reproductive health guidelines and services. This included representatives from the Ministry of Health Reproductive Health Directorate, the Ministry of Justice, and the Parliamentary Committee on Health.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eSexual and Reproductive Health and Rights coalitions and non-governmental organisations (NGOs) involved in sexual and reproductive health.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\n\u003ch3\u003eParticipant Selection\u003c/h3\u003e\n\u003cp\u003ePurposive sampling with maximum variation was used to select all participants involved in the study to ensure rich data was collected. The OSC identified girls who were or had previously been pregnant following rape, informing them of the research and requesting their consent to be contacted by the research team, alongside their parent or guardian. In consultation with the Ministry of Health Officials and the study task force, we selected key stakeholders and program staff working at the site where data collection took place.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData collection for the study was conducted in February and March 2023. The research study utilised qualitative research methods, including semi-structured in-depth interviews, key informant interviews, and focus group discussions, to generate a comprehensive understanding of the unique individual experiences of participants. Topic guides were informed by survivor-centred literature. All interviews were conducted by research assistants trained in human subject protection training and safeguarding. All interviews were conducted in a private and convenient location and were conducted in the participant\u0026rsquo;s preferred language (Chichewa or English) using the semi-structured data collection guides. Interviews were recorded using digital audio recorders, with participants\u0026rsquo; permission.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Management and Analysis\u003c/h2\u003e \u003cp\u003eThe audio-recorded interviews conducted in Chichewa or English were translated and transcribed verbatim by trained transcribers in Microsoft Word. Each audio-recorded interview was given a unique identification code that also appeared in the file name. All files were password-protected. Before analysis, transcripts were anonymised by removing the names of individuals, schools, or health facilities. Qualitative transcripts were reviewed by the study investigators as they were transcribed. The study supervisor performed quality control over all the transcripts by checking each transcript against the recorded data to ensure that there was no misrepresentation of data.\u003c/p\u003e \u003cp\u003eA thematic content analysis approach was followed during the data analysis process. Analysis used a hybrid of the deductive and inductive approaches where a coding scheme (or codebook) was developed that combined a priori codes for key concepts related to the study objectives with additional data-driven codes identified through repeated reading of the transcripts.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e Ethical approval to conduct the study was provided by the Malawi College of Medicine Research and Ethics Committee (COMREC). All interviewers were provided with training in psychosocial support to help their management of the interviews and ensure they handled participants sensitively and safely. All participating girls and their parents/guardians were also provided with referrals to the OSC to receive psychosocial support after the interview. Protocols and procedures were put in place to ensure the anonymity and confidentiality of participants, with participants free to withdraw from the study at any time.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eContact details for the Centre for Reproductive Health were provided to all participants so they could follow up directly or anonymously with an independent body with any questions they had following interviews. In addition, the name and telephone number of the chairperson of the COMREC were also provided in case the participants had any concerns they felt may not be adequately resolved by the research agency.\u003c/p\u003e \u003cp\u003e To ensure robust delivery and reporting of this research, a Task Force Committee was established. This Committee included representatives from the Ministry of Health Reproductive Health Directorate, Medical Professionals, legal practitioners, communications experts, National Assembly representatives, youth, faith-based organizations, implementing partners, coalition representatives, and researchers. This Task Force Committee has been advising on the study design, implementation, reporting, and dissemination.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eData collection involved young girls who were raped, their parents/guardians, and other different stakeholders. A total of 36 individuals took part in the study.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eYoung girls\u0026rsquo; demographic characteristics\u003c/h2\u003e \u003cp\u003eAccording to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below, 14 young girls took part in the study. The age range for the girls was 13\u0026ndash;17 years old, with the majority being 16 years old. Half had primary education while the other half had reached the secondary level. The majority (93%) were Christians.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGirls\u0026rsquo; demographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttributes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17yrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHighest Education Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e93%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.1.2 Adult participant characteristics\u003c/h2\u003e \u003cp\u003eAs per Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below, a total of 22 adult participants were involved in the study. These were parents/guardians (n\u0026thinsp;=\u0026thinsp;6), community-level stakeholders (n\u0026thinsp;=\u0026thinsp;5), healthcare workers (n\u0026thinsp;=\u0026thinsp;6) and policy/program-level stakeholders (n\u0026thinsp;=\u0026thinsp;5). Almost three-quarters (73%) were female and half had attained tertiary education. On religious beliefs, the majority were Christians (91%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAdult Participants Demographic Characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttributes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHighest Education Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChristianity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIslam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThemes and sub-themes\u003c/h2\u003e \u003cp\u003eFour main themes emerged after the analysis. These are experiences of pregnancy as a result of rape, legal recourse, reflections on the need for safe abortion services and termination of pregnancy bill as in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and sub-themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSub-theme\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eExperiences of pregnancy following rape\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFear and embarrassment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnwanted pregnancies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsequences of lack of access to abortion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental health challenges\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParental and community reactions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLegal Recourse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIneffective police response\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisappointment with the judicial system\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eReflections on the need for abortion services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDemand for abortion services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of access and awareness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysical and mental health risks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSafe Abortion Policy Landscape\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProtection against unsafe abortions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity attitudes and perceptions towards Termination of Pregnancy Bill\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvocacy approach\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eExperiences of pregnancy following rape\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eFear and embarrassment\u003c/h2\u003e \u003cp\u003eFear and embarrassment were commonly reported emotions among girls, their parents, and communities. These emotions were influenced by various interconnected factors, including the fear of death during pregnancy or childbirth, concerns about retaliation from men and/or relatives, and worries about how the community would judge them upon learning about their pregnancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI was afraid since I could hear other people say that a certain 14-year-old girl had passed away during the time she was trying to deliver. This was making me afraid of what it would be like for me when the time came for me to deliver\u003c/em\u003e.\u0026rdquo; 17-year-old girl.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe man who forced me to sleep with [him] threatened to kill me if I told my mother that I am pregnant\u003c/em\u003e.\u0026rdquo; 15-year-old girl.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI was feeling embarrassed because I was impregnated by an older man and he must be in his 40\u0026rsquo;s. He was forcing me to sleep with him\u0026hellip; He slept with me at the river where he was fetching for sand\u003c/em\u003e.\u0026rdquo; 16-year-old girl.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eUnwanted pregnancies\u003c/h2\u003e \u003cp\u003eSome girls expressed their desire for an abortion upon discovering their pregnancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I wanted to abort because I don\u0026rsquo;t know the man who raped me. I am carrying a baby whose father I don\u0026rsquo;t know.\u0026rdquo;\u003c/em\u003e 13-year-old girl.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I wanted to abort but I was afraid due to what people were saying that abortion is deadly.\u0026rdquo;\u003c/em\u003e 15-year-old girl.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eConsequences of lack of access to abortion\u003c/h2\u003e \u003cp\u003eWithout access to safe abortion, girls face numerous health and social consequences. Many participants emphasized that young girls are forced to drop out of school, negatively affecting their future earning potential and overall well-being.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIt was a painful pill for me to swallow because when I think of goals I had in the future to help my parents, I just felt that they were swept away. \u0026hellip; I am worried about my future because now I can no longer go back to school. I stay with a single mother, so my goal was to go very far with my education so that I should be able to support my mother\u003c/em\u003e.\u0026rdquo; 14-year-old girl.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdditionally, it was noted that they experience increased social stigma within their communities as their pregnancy progresses, leading to abandonment by loved ones and friends as they near childbirth.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIt has been hard. Some people have been judging me, stopped involving me in youth activities, calling me all sorts of names. I am struggling to say the truth\u003c/em\u003e\u0026rdquo; 13-year-old girl.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eShe was angry and disappointed and said I should move out of her house. She said I should go to the man responsible for my pregnancy\u003c/em\u003e.\u0026rdquo; 16-year-old girl.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eMental health challenges\u003c/h2\u003e \u003cp\u003eYoung girls and health providers noted the impact of these challenges on the mental health of the girls and young women, specifically mentioning the potential for suicidal ideation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Some pregnant girls get stigmatized by their family members and when they get stigmatized, they start having suicidal thoughts and start thinking of terminating their own life\u003c/em\u003e.\u0026rdquo; 13-year-old girl.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eYoung girls experience various challenges when they are pregnant. Firstly, they are stigmatized by their peers, and when they are stigmatized, some resolve to commit suicide\u003c/em\u003e.\u0026rdquo; Health care provider\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eParental and community reactions\u003c/h2\u003e \u003cp\u003eParents and caregivers of pregnant young girls often face scrutiny and criticism from their communities. Participants mentioned that parents can often be blamed, with others in the community implying that their parenting strategies contributed to the rape or that they were poor role models. Participants also mentioned instances where community leaders interrogated parents, demanding explanations for their daughter or young relative's pregnancy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThis happens because some people look at the parents of the child who is pregnant as lacking that parental guidance on the child that is why the child happens to be pregnant\u003c/em\u003e\u0026rdquo; Community-level stakeholder.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eother community members will be saying negative things in regards to the parents of the pregnant minors, saying things like the parents did not raise their child appropriately. Others say that the parents should have been advising their children on what to do and what not to do. Now that their child is a minor who is pregnant, they will say that it just shows that the parents were not very much involved in raising that child.\u003c/em\u003e\u0026rdquo; Community level stakeholder\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLegal Recourse\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eIneffective police response\u003c/h2\u003e \u003cp\u003eWhen asked about legal recourse mechanisms, participants said that survivors do try to seek justice by taking legal action against perpetrators. However, many expressed dissatisfaction with the treatment they received from the police. Even when the perpetrators confessed to their crimes, no action was taken against them as long as they committed to supporting the pregnant girl. In some cases, the police dismissed reports of rape from complainants who were 16 or 17 years old, even though this is still a crime as they are below the age of consent.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;However, after we had gone to the Police Victim Support Unit, and after they had called him\u0026hellip; The police detained him overnight and the next day he was released.\u0026rdquo;\u003c/em\u003e 17-year-old girl.\u003c/p\u003e \u003cp\u003e\u003cem\u003eThe police officer said that since she was 17 years old and had just remained for some months to turn 18 years old, and the man was 23 years old, they would not arrest him. They said the rest depended on how the parents agreed on how this should have proceeded. \u0026hellip; we were told that since we were just neighbours who are close to each other, we should not take this issue very far, instead just get home and talk this out and see how best you can proceed.\u0026rdquo;\u003c/em\u003e Parent.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eDisappointment with the judicial system\u003c/h2\u003e \u003cp\u003eFor those cases that made it to court, participants often felt disappointed and let down by the judicial system. This was because of the lengthy delays in the court process and the perception that their testimonies were not given the appropriate consideration.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; the court must be handling cases in time, they should be handling cases in time for the safety of our children \u0026hellip;when cases happened\u003c/em\u003e ​\u003cem\u003ea long time ago, and for them to pile cases without making judgments, that make cases to be forgotten and be buried\u0026hellip;the court should be helping us when such cases happen.\u0026rdquo;\u003c/em\u003e Parent\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Mine is just a plea\u0026hellip;you call yourself NGOs and you say that you stand for children\u0026hellip;, we need you to help us so that when these cases go to court they should be handled in time, some of us spend a lot on transportation by going to court\u0026hellip;we go to court and they tell us to go again another day and when we go again on the day that they told us, we return without being assisted as expected.\u0026rdquo;\u003c/em\u003e Parent.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eReflections on the need for abortion services\u003c/h2\u003e \u003cdiv id=\"Sec24\" class=\"Section4\"\u003e \u003ch2\u003eDemand for abortion services\u003c/h2\u003e \u003cp\u003eYoung girls, parents, and health providers were in agreement that in circumstances of rape and/or when a girl or young woman had become pregnant as a result of rape, access to abortion should be allowed.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI think it is good that maybe they should provide an opportunity for the people to choose by themselves considering that the pregnancy is unwanted; thus, to provide the abortion services to the minors who are raped or sexually assaulted\u003c/em\u003e.\u0026rdquo; 14 year-old girl.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWhen the pregnancy is small, the pregnant minor should be allowed to access abortion services, when they do an abortion\u0026hellip;when a minor is pregnant, they should be allowed to have an abortion\u003c/em\u003e.\u0026rdquo; Parent\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eAs the one who has been working with girls, \u0026hellip; it would be better if there were laws that would allow us to terminate these minors\u0026rsquo; pregnancies\u003c/em\u003e.\u0026rdquo; Healthcare provider\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eLack of access and awareness\u003c/h2\u003e \u003cp\u003eNone of the participants reported being offered or provided with either legal or illegal abortions. Young girls and their parents expressed limited awareness or knowledge of abortion services. Health providers confirmed this, explaining that they were unable to offer abortion services due to policy limitations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eTo say the truth, we didn\u0026rsquo;t know what to do [after being denied at the OSC] because we had no knowledge of where we could go and do that [procure abortion] so we just thought of keeping it because it had already happened\u003c/em\u003e.\u0026rdquo; Parent\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe laws of Malawi prohibit that [abortion] unless it\u0026rsquo;s a life-threatening situation that\u0026rsquo;s when they can actually perform the abortion on the minor.\u003c/em\u003e\u0026rdquo; Health care provider\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003ePhysical and mental health risks\u003c/h2\u003e \u003cp\u003ePolicy-level stakeholders reflected on the physical and mental health risks to girls and young women with unintended pregnancies as a result of rape. In these instances, they stated the law does allow for termination of pregnancy and health providers, lawmakers and communities need to understand this.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;a pregnancy that results from sexual assault, actually would constitute an emergency for an abortion. And that answer is found in law. I think actually at the moment the law allows that. I am not so sure if people know that you can get an abortion when you are raped. Yes, so the problem is that you are only concentrating on the physical health, physical wellbeing but also look at the mental wellbeing\u0026hellip; So, if you look at a minor, the mental wellbeing might be affected but that decision, that decision is on the doctor performing the abortion or making the assessment in this case\u0026hellip;actually the law at the moment allows for such kind of a procedure to be performed on girls who are minors.\u003c/em\u003e\u0026rdquo; Policy-level stakeholder\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eSafe Abortion Policy Landscape\u003c/h2\u003e \u003cdiv id=\"Sec28\" class=\"Section4\"\u003e \u003ch2\u003eProtection against unsafe abortions\u003c/h2\u003e \u003cp\u003eThe ToP Bill seeks to expand legal abortion from only cases where the woman\u0026rsquo;s life is at risk to cases of rape, incest, fetal abnormalities, and threats to mental and physical health, which would also align with the Maputo Protocol. In 2021, the ToP Bill was withdrawn from the Parliamentary Order Paper and consequently never debated. Among the policymakers interviewed, there was consensus that passing the ToP Bill would protect girls and young women who become pregnant as a result of sexual assault, enabling them to protect their physical and mental health. Others felt that passing the Bill would prevent any fallout from unsafe abortions that might be sought in the absence of a safe and regulated service.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eDespite setting up strict or tough rules, we have to set our laws that should empower people, uhm\u0026hellip;. there are laws surrounding safe abortion but there is a condition attached to it which is that it (abortion) should only be done in life-threatening situations. Yeah, so we should take out these conditions and make safe abortion legal, so let\u0026rsquo;s stop cheating ourselves, young girls are dying and there are statistics to prove that \u0026hellip;\u003c/em\u003e.\u0026rdquo; Policy-level stakeholder\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eCommunity attitudes and perceptions towards ToP Bill\u003c/h2\u003e \u003cp\u003eAmong the community stakeholders, there was a lack of knowledge and comprehension regarding the ToP Bill. The majority of stakeholders at the community level were uninformed about the contents of the Bill and its progression through Parliament. Even among those who possessed some level of awareness, the Bill was regarded with mixed feelings.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe pregnancy termination bill is a bad one, but it is also good in cases where the pregnancy is causing some complications and my plea to the government is that they should \u0026hellip; not just allow anyone to come in and terminate the pregnancy, no, because terminating a pregnancy is the same as killing a person\u0026hellip;. When the girl or the woman has not followed proper child spacing which in turn has put her in a position of not being able to take care of the pregnancy, they have to abort \u0026hellip;, but terminating the pregnancy for no good reason should not be allowed.\u003c/em\u003e\u0026rdquo; Community-level stakeholder\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eBiblically, termination of pregnancy is something that is not allowed. However, when we look at the burdens that come due to unplanned pregnancies, I will not rule out abortions, we need the bill. If you look at the way our population is growing, I will give you an example of how the population is growing in Malawi \u0026hellip;, we will have no space even for farming \u0026hellip;. It will be difficult, so abortion would be good\u0026hellip; because most of these children, the population is growing because most of these children are giving birth at a very tender age.\u003c/em\u003e\u0026rdquo; Community-level stakeholder\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAdvocacy approach\u003c/h3\u003e\n\u003cp\u003ePolicy-level stakeholders expressed concerns that the advocacy strategies used during campaigns for the ToP Bill placed too much emphasis on politicians and not enough focus on mobilizing support among grassroots youth organizations, who are most affected by the Bill.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe other problem that we have is the approach that we used to advocate for this Bill, maybe we started approaching the people on top of the hierarchy instead of starting with the people at the bottom of the hierarchy. Had it been we started advocating for this from, say, primary schools so that the communities and the young people should clearly understand this. So just because most of the lawmakers were not informed of it they just left it in the hands of the chair of parliament as if it only belongs to him yet in actual sense it is not just for him to handle. \u0026hellip; we are just cheating ourselves yet the thing is happening underground, so why can we not just formalize it? Should our children continue dying because of unsafe abortion?\u003c/em\u003e\u0026rdquo; Policy-level stakeholder\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eFindings from this research reveal significant challenges that girls who have become pregnant after being raped face, including fears of childbirth, societal judgment, and limited future opportunities. Many of these girls consider abortion but lack access to safe services. This lack of access can have severe health and social consequences, such as dropping out of school and mental health issues, including thoughts of suicide. Instead of offering support, parents and community members often blame the survivor's family, further isolating and adding to their difficulties. Unfortunately, the legal and judicial systems often fail to adequately support survivors, resulting in dissatisfaction and a lack of trust. Stakeholders are advocating for the expansion of legal abortion access to protect the physical and mental health of young girls. However, the ToP Bill was withdrawn from Parliament in 2021 and more work is needed to mobilise community support for such a bill.\u003c/p\u003e \u003cp\u003eInsights from this research build on the findings of other regional studies which have demonstrated that teenage pregnancy poses a greater risk of maternal mortality and health complications compared to pregnancies in adults [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and that affected girls experience severe consequences such as dropping out of school, diminished prospects, heightened social stigma [\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], isolation, abandonment, and mental health issues, including suicidal ideation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. These findings underscore the importance of comprehensive SRH/FP support encompassing accessible abortion services, mental health resources, and community education to reduce stigma and provide assistance to affected girls and their families, while also safeguarding their health, well-being, and human rights.\u003c/p\u003e \u003cp\u003eThe research findings unveil significant issues about the handling of rape cases involving girls under the age of 18 by law enforcement agencies and the judiciary in Malawi. The findings of the present study indicate dissatisfaction with how judicial institutions deal with such cases. Concerns include a relaxed approach by the police, resulting in some perpetrators escaping arrest or facing minimal repercussions. Similar instances of inaction against offenders have been reported in other countries [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The police have also been accused of prematurely assuming the innocence of the accused. In the courtroom, survivors have felt betrayed by judgments that ruled against them despite providing detailed testimonies, suggesting that their accounts were not given due weight. The sluggish pace of court proceedings has further aggravated the frustration of parents, similar to a study conducted in Ghana [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The narratives of girls and their parents or guardians highlight the necessity for enhanced training, professionalism, and sensitivity within these institutions to ensure the equitable treatment of survivors and the proper dispensation of justice.\u003c/p\u003e \u003cp\u003eThe current study highlights a consensus among girls, parents/guardians, and healthcare providers who supported the provision of safe abortion services to survivors of rape, citing the need for personal choice and the alleviation of distress caused by unwanted pregnancies. However, despite this demand, there is a significant gap in access and awareness. No survivors who participated in the study reported being offered legal abortions, reflecting the restrictive legal environment. Health providers echoed this sentiment, noting their inability to provide abortions due to policy constraints, which has also been reported in earlier studies [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The findings highlight the urgent need for policy reform to improve access to safe abortion services, particularly for survivors of rape.\u003c/p\u003e \u003cp\u003ePolicymakers who were interviewed largely expressed support for expanding legal access to safe abortion in cases of rape, arguing that it would protect young women and girls from the risks associated with unsafe abortions and enable them to safeguard their physical and mental well-being. This is consistent with previous studies [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], which have highlighted the close correlation between criminalization and the prevalence of illegal abortions, thereby posing significant threats to women's health and compromising their fundamental rights [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The importance of empowering individuals through laws that legalize safe abortions beyond life-threatening situations was emphasized, as existing restrictions contribute to avoidable deaths.\u003c/p\u003e \u003cp\u003eThere was a significant lack of awareness and understanding of the ToP Bill among young girls and community stakeholders, many of whom expressed mixed views on the issue. This aligns with previous studies highlighting a general lack of knowledge about abortion laws, even in countries with more liberal policies [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. While some community members recognised the Bill\u0026rsquo;s potential to address complications from unplanned pregnancies, others opposed it on moral or religious grounds. Interestingly, despite this opposition, there appears to be some practical tolerance, particularly when the issue is framed around health needs and the prevention of unsafe abortions. This suggests a potential entry point for policy change, especially as policymakers have emphasised the need for greater engagement with grassroots communities. Policy stakeholders critiqued the current advocacy efforts for focusing too much on politicians and not enough on mobilising community-level support, noting that with better education and outreach, there could be broader acceptance and reduced misconceptions [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study possesses several strengths that have the potential to yield valuable insights into a highly sensitive and significant topic. The utilisation of an exploratory qualitative design facilitated the collection of rich and comprehensive data, allowing participants to express their experiences in their own words. Consequently, the data obtained captures the intricate complexities and nuances inherent in the girls' experiences. Additionally, the study successfully explores a unique perspective that often goes unexamined in research on sexual violence. By centering on the lived experiences of pregnant girls, the study presents a more holistic understanding of the impact of sexual violence and the restrictive legal framework on this vulnerable population. Nonetheless, there are certain limitations to consider. Firstly, recruiting participants proved challenging. Both parents/guardians and rape survivors exhibited reluctance in sharing their experiences due to feelings of shame, stigma, and fear of retribution from their families and communities at large. This hesitance may have compelled some participants to provide socially acceptable responses, potentially hindering their ability to freely discuss their experiences and resulting in the underreporting of negative encounters. Secondly, the findings of the study may lack generalizability to other populations or settings owing to differences in cultural norms, healthcare accessibility, legal systems, and other contextual factors. Thirdly, time constraints imposed limitations on conducting further rigorous analysis of the study. Furthermore, there is a pressing need for additional research on various issues, such as community attitudes towards pregnancy and child-rearing, the service delivery environment, service providers' knowledge of existing laws, the functionality of One-Stop Centers (OSCs), and the handling of sexual assault cases by the police. Conducting longitudinal studies on the mental health impacts of denied abortion services is also imperative.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe research indicates that adolescent girls who experience pregnancy as a result of rape encounter significant emotional, social, and psychological difficulties. These challenges are exacerbated by limited access to secure safe abortion services leading to severe health and societal consequences. Furthermore, the prevalence of victim-blaming attitudes within families and communities, coupled with the inefficiencies of legal and judicial systems, further isolates and traumatises these girls. The findings underscore the pressing necessity for comprehensive support, including easily accessible safe abortion services, mental health resources, and community education, to reduce stigma and provide vital assistance. Improving training and sensitivity within law enforcement and judicial institutions is crucial to guaranteeing survivors justice. Furthermore, advocacy for legal reforms, such as those proposed in the ToP Bill, and enhanced awareness and comprehension of existing laws are essential measures to safeguard the health, well-being, and rights of these survivors of rape.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOMREC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCollege of Medicine Research Ethics Committee\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFamily planning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNGO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNon-Governmental Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOSC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOne Stop Centre\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSRH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexual Reproductive Health\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eToP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTermination of Pregnancy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNFPA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Nations Population Fund\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVACS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eViolence Against Children and Youth Surveys\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organisation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used in the study are available from the corresponding author on request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe appreciate the support we received from the management and staff of KCH - OSC where the study was conducted. We also thank the study task force, research assistants who collected and transcribed the data, and all the participants for participating in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research was funded by Options Consultancy Services Ltd.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePM, MM, WS, GK, FK, and EC designed the study, while PM, MM, and EC developed the data collection tools and developed the analysis plan. PM, MM, and EC collected part of and supervised data collection. PM, MM, and EC analysed the data while PM, and MM drafted the manuscript. PM, MM, WS, PD, GK, FK, and EC critically reviewed the manuscript and approved the final version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the COMREC (Protocol # P.11/22/3878). The study was conducted according to the regulations and guidelines of the Declaration of Helsinki. We obtained written informed consent from each participant before any interview was conducted. Participants who could not read nor write thumb printed on the informed consent form after it was read to them in the presence of an impartial witness. The thumb-printed informed consent form was approved by the COMREC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStarrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. 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PLoS ONE. 2016;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ede Vries I, van Keizerswaard LJ, Tolboom B, van der Bulthuis S, Tank J, et al. Advocating safe abortion: outcomes of a multi-country needs assessment on the potential role of national societies of obstetrics and gynecology. Int J Gynecol Obstet. 2020;148:282\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMekuria M, Daba D, Girma T, Birhanu A. Assessment of knowledge on abortion law and factors affecting it among regular undergraduate female students of Ambo University, Oromia Region, Ethiopia, 2018: a cross sectional study. Contracept Reprod Med. 2020;5:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKayondo SP, Kaye DK, Nabatanzi SL, Nassuuna S, Musana O, Namagembe I, et al. Challenges and opportunities from using abortion harm reduction and value clarification and attitude transformation engagements for safe abortion advocacy in Uganda. Reprod Health. 2023;20:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5322790/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5322790/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eAccess to safe abortion and post-abortion care plays a crucial role in promoting comprehensive sexual and reproductive health and rights. While abortion is legal in the majority of countries, there are often restrictive laws and criminal regulations that impede access, resulting in unsafe abortions. Unsafe abortions are especially prevalent among girls and women in developing countries. Even though Malawi has ratified the Maputo Protocol, which obligates states to provide abortion on several grounds, Malawi continues to restrict access, thereby presenting significant health, social and legal obstacles for women. The present study aims to delve into the experiences of pregnant girls and young women as they navigate sexual and reproductive health services within the confines of this legal framework.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e \u003cp\u003eThis exploratory qualitative study aimed to understand the lived experiences of pregnant girls (aged 13\u0026ndash;17 years) seeking sexual and reproductive health services within the restrictive legal context of Malawi. Semi-structured in-depth interviews, Key Informant Interviews, and focus group discussions were conducted with a diverse group of stakeholders, including girls who had experienced sexual assault, their parents or guardians, community leaders, healthcare providers, and policy-makers. Data collection took place in February and March 2023, with interviews conducted in the participant\u0026rsquo;s preferred language. Thematic content analysis was used to identify key themes and sub-themes from the qualitative data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study included 36 participants: 14 girls aged 13\u0026ndash;17 and 22 adults; including parents/guardians, healthcare workers, and different stakeholders at the community and policy level. Four main themes emerged from the data: experiences of pregnancy resulting from rape, ineffective legal recourse, reflections on the need for safe abortion services, and perspectives on the Termination of Pregnancy Bill. Young girls reported fear, embarrassment, and significant mental health challenges due to unintended pregnancies and lack of access to safe abortion. Parents and community members expressed disappointment with the judicial system and highlighted the physical and mental health risks associated with restrictive abortion laws. There was a strong demand for safe abortion services, especially in cases of rape and incest. However, awareness and knowledge about safe abortion services and the Termination of Pregnancy Bill were limited among community stakeholders.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study emphasizes the urgent need for legal and policy reforms to improve access to safe abortion services in Malawi. The restrictive legal framework not only endangers the health and well-being of young girls and women but also perpetuates stigma and inequality.\u003c/p\u003e","manuscriptTitle":"“I am carrying a baby whose father I do not know.” Experiences and context of girls pregnant from rape and sought sexual and reproductive health services","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-08 19:39:02","doi":"10.21203/rs.3.rs-5322790/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ae1a4f91-f651-47de-9732-c04566f1d59b","owner":[],"postedDate":"November 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-30T07:09:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-08 19:39:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5322790","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5322790","identity":"rs-5322790","version":["v1"]},"buildId":"369fNeqWncA4NS6XSWjrt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}