Comprehensive sexuality education linked to SRH services reduces early and unintended pregnancies in Zambia

1 March, 2023

Dear HIFA and HIFA-Zambia colleagues,

The cumulative evidence is overwhelming. And yet many countries restrict comprehensive sexuality education. Citation, abstract and comment from me below.

CITATION: Comprehensive sexuality education linked to sexual and reproductive health services reduces early and unintended pregnancies among in-school adolescent girls in Zambia

Michael T. Mbizvo, Kondwani Kasonda, Nelly-Claire Muntalima, Joseph G. Rosen, Sophie Inambwae, Edith S. Namukonda, Ronald Mungoni, Natasha Okpara, Chifundo Phiri, Nachela Chelwa & Chabu Kangale

BMC Public Health volume 23, Article number: 348 (2023)


Background: Advancing the health of adolescents, particularly their sexual and reproductive health, including HIV prevention and care, is a development imperative. A critical part for improving their wellbeing and economic development is the social status accorded to adolescent girls and young women (AGYW). However, AGYW in many countries including Zambia, encounter health challenges that stem from gender inequalities, lack of empowerment, inaccurate knowledge on sexuality, and poor access to sexual and reproductive health (SRH) services and information. Addressing the knowledge gaps through comprehensive sexuality education (CSE) and improving access to SRH services and appropriate information, should reduce school attrition from early and unintended pregnancies (EUP) and enhance realization of their full potential.

Methods: The aim was to reduce EUP and improve SRH outcomes among AGYW in Zambia through provision of CSE linked to receptive SRH services. A 3-Arm randomized control study collected cross-sectional data at baseline, midline and Endline. Schools where CSE was being routinely provided were randomized into a non-intervention arm (arm1), an intervention arm in which information on available SRH services was provided in schools by health workers to complement CSE, (arm 2), and arm 3 in which pupils receiving CSE were also encouraged or supported to access pre-sensitized, receptive SRH services.

Results: Following 3 years of intervention exposure (CSE-Health Facility linkages), findings showed a significant decline of in-school pregnancies amongst AGYW in both intervention arms, with arm two exhibiting a more significant decline, having recorded only 0.74% pregnancies at endline (p < 0.001), as well as arm 3, which recorded 1.34% pregnancies (p < 0.001). No significant decline was recorded in the CSE only control arm. Trends in decline of pregnancies started to show by midline, and persisted at endline (2020), and when difference in differences test was applied, the incident rate ratios (IRR) between the none and exposed arms were equally significant (p < 0.001).

Conclusion: Linking provision of CSE with accessible SRH services that are receptive to needs of adolescents and young people reduces EUP, which provides the opportunity for higher retention in school for adolescent girls.



1. The UNESCO site 'CSE implementation at regional and country levels' notes that 'Western Europe pioneered the introduction of school-based sexuality education programmes 50 years ago. Countries such as Sweden, Norway, and the Netherlands, with long-standing sexuality education programmes in schools, have significantly lower adolescent birth rates than countries in Eastern Europe and Central Asia, where open discussion of issues related to sexuality and sexual and reproductive health and rights (SRHR) in schools remains more sensitive.'

2. As we have noted previously, universal access to reliable sexual and reproductive services is emphasised in the sustainable development goals, which have been ratified all the world's 191 countries. How do policymakers in CSE-restricted countries justify their contradictory stance? Do they fully understand the benefits of CSE?

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Best wishes, Neil

Joint coordinator, HIFA project on Mental health: meeting information needs for substance use disorders - Tobacco, Alcohol, Opiates

HIFA profile: Neil Pakenham-Walsh is coordinator of HIFA (Healthcare Information For All), a global health community that brings all stakeholders together around the shared goal of universal access to reliable healthcare information. HIFA has 20,000 members in 180 countries, interacting in four languages and representing all parts of the global evidence ecosystem. HIFA is administered by Global Healthcare Information Network, a UK-based nonprofit in official relations with the World Health Organization. Email: