Integrated multisectoral approaches to adolescent pregnancy prevention: a case study of the Momentum Tikweze Umoyo Project in Malawi

¹Amref Health Africa Malawi, Lilongwe, Malawi, ²Amref Health Africa, Headquarters, Nairobi, Kenya

^&Corresponding author
Alfred Mang´ando, Amref Health Africa Malawi, Lilongwe, Malawi

Introduction    

Situation analysis: teenage pregnancy has emerged as a significant global health problem in recent years. According to the World Health Organization (WHO), nearly 16 million teenagers of 15-19 years and two million girls under the age of 15 give birth each year [1]. Globally, adolescent mothers (aged 10-19 years) face higher risks of complications such as eclampsia, puerperal endometritis, and systemic infections compared to women aged 20-24. Additionally, their babies are more likely to experience low birth weight, preterm birth, and severe neonatal conditions [2].

Over 90% of the global births from adolescents occur in low- and middle-income countries [1]. In Africa, the prevalence of adolescent pregnancy in 2018 was reported at 19%, with the sub-Saharan African region slightly higher at 19%. Southern Africa demonstrates pooled prevalence rates ranging from 19% to 22%. Studies highlight that teenage pregnancy impacts educational opportunities, population growth, and maternal health outcomes [2,3].

In Malawi, adolescent pregnancy rates are alarmingly high. The pooled prevalence in the country is 32.79%, significantly higher than the Southern Africa regional average [4]. The Malawi Indicator Cluster Survey (MICS) 2021 report indicates that teenage pregnancies are more common among adolescents with low education levels and those in poorer communities. Contributing factors include limited access to contraceptives, poverty, sexual violence, school dropout, and engaging in unprotected sex due to a lack of knowledge or awareness [4].

Malawi´s Maternal Mortality Ratio (MMR) stands at 439 per 100,000 live births, with adolescents contributing 25% of these deaths. Pregnancies in low-resource settings increase the risk of both maternal and neonatal morbidity [5]. Adolescent pregnancies are also linked to child marriage, with more girls being married before the age of 18 compared to boys, highlighting gender disparities. This issue not only affects health but also intersects with child protection, education, and economic challenges [2].

The Malawi government and other development partners are addressing this problem through various interventions. One such intervention is the Momentum Tikweze Umoyo (Let Us Scale Up Health) project, which is a five-year USAID-funded initiative (August 2022 - August 2027), and aims to reduce maternal, newborn, and child morbidity and mortality. The project was being implemented in five of Malawi´s 29 districts. Data from DHIS2 for the period of July 2022 to June 2023 revealed concerning levels of adolescent pregnancies. Chitipa had the highest proportion at 40%, followed by Nkhotakota at 37% [6], compared to a national prevalence of 32.79% [7] (Table 1).

The main objective of this case study is to demonstrate the potential and benefits of multisectoral collaboration at the district and community level in increasing service uptake of FP/SRH for the youth. The increased service uptake, when sustained for a long period, can subsequently contribute to the reduction of teen pregnancies and the associated complications, including unsafe abortions and maternal deaths.

Health system in Malawi: the Malawian health system is a 3-tiered structure including primary (community and health centre), secondary (district hospital), and tertiary (central hospital) [8]. Integrated sexual and reproductive health services are offered at all levels, with primary care focusing primarily on prevention, while secondary and tertiary levels emphasize curative services over preventive care. Malawi has a well-established youth-friendly health services programme that aims to provide information and services to the youth in established safe spaces, which can either be static or mobile. These safe spaces help to address social barriers that prevent the youth from accessing quality Family Planning and Sexual, Reproductive Health (FP/SRH) services.

At the community level, Health Surveillance Assistants (HSAs) (equivalent of Community Health Workers (CHW)) and volunteers are critical in delivering basic health services, including FP/SRH services. However, the health system is inadequately funded, affecting access to FP/SRH services by the youth, including adolescents. Different development partners come in to complement the government's effort to reduce the funding gap and increase access to FP/SRH services by the youth. Malawi faces several challenges, including limited healthcare infrastructure, a shortage of healthcare professionals, and socio-cultural barriers that restrict adolescents' access to FP/SRH services. These barriers often result in high rates of adolescent pregnancies, which contribute significantly to maternal and neonatal mortality.

Legal framework: the laws of Malawi have recently been revised to strengthen the protection and ensure proper care of children. The 2017 amendment to Malawi´s constitution maintained the legal marriage age at 18 years and above, removing the provision that allowed parental consent for the marriage of children aged 16 years and above [9]. This coincided with the amendment of the penal code, which raised the age for defilement from 16 years to 18 years to align with the constitution and other related legislations, including the Marriage and Relations Act, and Child Care Act [10]. This legislation deters individuals from indulging in sexual activities with children in fear of stiff penalties provided for the amended penal code.

In terms of access to SRH services, the reproductive health policy 2024 promotes the availability of youth-friendly health services at all levels [11]. The policy is complemented by a youth-friendly health services strategy which advocates for strengthening systems and structures to support multi-sectoral collaboration, coordination, partnerships, and networking for effective implementation of Youth Friendly Health Services (YFHS) programs at all levels [12].

The decentralization policy of 1998 transfers administrative and political authority from the central government to district-level governance structures [13]. The highest-level governance structure at the district level is the district full council. This council comprises members of parliament, ward councilors, chiefs, and representatives of interest groups like youths, women, and people with disabilities.

This case study shares the experience of a USAID Momentum Tikweze Umoyo project that engaged multiple stakeholders as well as utilized multiple interventions to address the problem of teenage pregnancies in Malawi. Adolescents and young people face significant barriers to accessing sexual and reproductive health (SRH) services, including service unavailability, lack of awareness, and fear of social stigma from parents and the community.

Case study     

Setting: case studies play a crucial role in documenting and evaluating public health interventions, providing valuable insights into best practices and lessons learned. Case study research, as an overall approach, is based on in-depth explorations of complex phenomena in their natural, or real-life, settings [14]. The case study was conducted in Malawi involving 5 districts, namely Chitipa and Karonga in the northern region and Kasungu, Nkhotakota, and Salima in the southern region. The implementation was guided by national policies as presented in the sections above.

Actors: this case study presents the experience of the Momentum Tikweze Umoyo project in Malawi, which engaged multiple stakeholders at the district level and employed multisectoral interventions to reduce adolescent pregnancies. Key participants included district government officers from various sectors (health, education, youth, judiciary, gender, police, social welfare, and community development), chiefs, parliamentarians, ward councilors, faith leaders, local civil society organizations (CSOs) and more importantly the youths including adolescents (boys and girls) themselves.

Activities: the project implemented a number of interventions aimed at increasing access to Maternal, Neonatal and Child Health (MNCH) series, including Family Planning/Sexual Reproductive Health) (FP/SRH) services for both adults and youths. These interventions were spread across all five targeted districts.

Initial project interventions

Increasing access to youth-friendly health services to adolescent boys and girls: to address the access challenge, the project youth targeted outreach (YTO) clinics, identified and trained some youths as youth community based distribution agents (YCBDAs), some youths were trained as youth champions for FP/SRH while others were trained in a gender transformative barbershop toolkit. The combination of these interventions aimed at raising awareness of the available services, mobilizing youth for the services, sustaining access to the services in between outreach clinics, and addressing gender norms that negatively impact FP service uptake among the youths.

Youth community-based distribution agents training: Momentum Tikweze Umoyo supported refresher training for 160 YCBDAs (96 females and 64 males) from March 20-24, 2023, across the implementation districts. The purpose was to update and reinforce their knowledge and skills related to FP/SRH, ensuring they are well-prepared to continue providing accurate information, service delivery, and support to their communities. The training, which focuses on screening and provision of some FP products like condoms and pills, was conducted both through classroom sessions and field practicum.

The project, in addition, conducted an orientation for youths to sensitize them on FP/RH issues. Twenty-two young people (12 females and 10 males) from all ten traditional authorities (TAs) and 18 health centres in Karonga District participated in a workshop on FP/RH in Karonga District to become youth champions on FP/SRHR, to boost demand creation in their communities, and promote upcoming mobile outreach clinics.

Barbershop toolkit training: recognizing gender disparities in SRH access, the project employed gender-transformative approaches, including male-focused interventions such as the barbershop toolkit. These efforts aimed to increase male involvement in reproductive health discussions and address restrictive gender norms. The project provided training for 319 volunteers of the reproductive age group, selected by the community and linked to HSAs, utilizing the barbershop toolkit.

This approach encourages men to actively engage in male-to-male discussions on gender equality within safe environments while also amplifying women's voices in these spaces. It provides guidance on involving men in promoting gender equality, including the use of male role models. The Barbershop Toolkit also creates opportunities for both women and men to address gender equality together. Additionally, adolescent boys and young men are trained through the toolkit to become champions of family planning (FP), advocating for their peers, as well as for girls and young women.

The training was conducted across all five intervention districts: Chitipa 44 (males), Nkhotakota (19 males), Salima 63 (61 males, 2 females), Kasungu (100 males), and Karonga 82 (28 males, 56 females). The primary objective was to utilize barbershops and other male-oriented spaces like fishing areas, betting places, and kabanza (bicycle taxis) stations (places where bicycle taxis are parked) as platforms for educating and raising awareness about SRHR and family planning, with a specific focus on male clients and community members. Through these efforts in 2024, a total, 121,140 (61,198 males, 59,942 females) were reached with various FP/SRH services, marking a significant improvement of 430% compared to previous year´s reach of 22,855 youths (11,724 males, 11,131 females). This increase can be attributed to the use of engaging activities, such as football bonanzas, and the mobilization of youth networks for the YTOs. During this reporting period, 142 YTOs were mobilized through these strategies.

Strengthening the capacity of health care providers

Health workforce capacity building: enhance skills through targeted training targeting newly recruited health workers and continuous mentorship in maternal and newborn health, focusing on managing key issues, such as hemorrhage and neonatal complications. Training included helping babies breathe (essential neonatal resuscitation skills to support babies that do not breathe on their own after birth), and kangaroo mother care (skills of caring for preterm or low-birth-weight infants, through prolonged skin-to-skin contact with the mother), just to mention a few. This initiative benefited 376 health workers (242 men and 134 women) from various cadres through capacity-building efforts such as training, mentorship, and supportive supervision. Similarly, in 2024, 165 health workers (72 men and 93 women) received comparable support.

Strengthening basic emergency obstetric and newborn care (BEmONC) and comprehensive emergency obstetric and newborn care (CEmONC) facilities: sustain improvements in maternal and newborn care by supporting training, mentorship, coaching, and quarterly skills drills. Essential medical equipment distribution was also supported, in addition to regular updates to clinical guidelines and capacity building for health workers. The goal was to maintain and expand the number of fully functional BEmONC sites to improve access to quality health services.

Strengthening community-based maternal and newborn care (CBMNC): in 2023, the project successfully strengthened the capacity of Community Midwife Assistants (CMAs) and HSAs by providing essential tools, training, and mentorship to improve access to quality maternal, newborn, and child health (MNCH) services at the community level. A total of 18 mentors were trained, who later on reached 259 community health workers with supportive supervision and mentorship.

These interventions improved tracking of pregnant women, encouraged early antenatal care (ANC) visits, promoted facility-based deliveries, and facilitated home-based postnatal care. MNCH volunteers were oriented to enhance CHW surveillance and follow-up through home visits. Additional steps were taken to further strengthen CBMNC, which included distributing maternal and postnatal care kits, comprehensive training in maternal and newborn health, and equipping workers with referral tools for managing high-risk cases at the community level.

Additional interventions: multisectoral collaboration: the multisectoral collaboration was added to the existing project interventions and started in Chitipa and Karonga in 2023 before scaling up to the other 3 districts in 2024.

Engagement of a multidisciplinary district-level team to co-create ideas: in addition, the project identified key sectors that require close collaboration with the health sector for a sustainable impact on the reduction of adolescent pregnancies. The sectors identified included: education, gender, social welfare, police, judiciary, and community development. The project observed that there was limited collaboration among these sectors in relation to addressing issues of adolescent health, particularly pregnancies.

The project then convened a district-level team comprising representatives from all these sectors and CSO network representatives to review data related to adolescent pregnancy and co-create solutions that can work in their respective districts to address the problem. This activity helped to identify serious gaps that existed within the district that if addressed the issue of adolescent pregnancies can be significantly reduced. The co-creation meeting came up with the following resolutions: 1) action point: come up with an advocacy paper for the district full council. Progress: an advocacy paper for increased support towards addressing teenage pregnancies and child marriages was developed; 2) action point: engage relevant committees of the full council to lobby for the presentation of the advocacy paper in the full council. Progress: the social and development service committee of the full council was engaged; 3) action point: make the presentation to the full council. Progress: the full council was convened, and the advocacy paper presented; 4) action point: work with relevant full council representatives in the implementation of the resolution of the district full council. Progress: the district team started following up on the popularization of the resolutions of the full council at the community level.

Engagement of district full councils to advocate for political will and leadership support: during the co-creation workshop, the district core team also realized the need to engage other stakeholders in the line of authority to amplify the political will in the fight against adolescent pregnancies. As a result, the resolution was to come up with an advocacy paper to engage with full councils in their respective councils, which the project supported. The district level team resolutions from the co-creation workshop included the need to improve inter-sectoral referral and linkages as well as engaging the full council to advocate for a specific commitment from different players represented in the full council. Momentum Tikweze Umoyo supported the districts in implementing their ideas and monitored the impact on a regular basis. The project started this initiative in two districts of Chitipa and Karonga before scaling up to the other three districts.

The full councils deliberated on the advocacy paper and resolved to do the following: 1) Chiefs and councilors should advocate for a mindset change on child marriages and put in place and enforce social norms that penalize child marriages and teenage pregnancies at the community level; 2) chiefs should take the lead in dissolving child marriages and reporting those who marry children below the age of 18 to authorities and report the same to police; 3) government and non-governmental organization should increase support for case management for children affected by child marriages and teenage pregnancies; 4) members of parliament (MPs), and the district councils should ensure the proper utilization of the 10% youth and women empowerment fund so that women whose children dropped out of school are also supported; 5) the bursary fund should be increased through multiple channels, including Members of Parliament (MPs) allocating more funds within the Constituency Development Fund (CDF), the council secretariat designating a portion of its revenue, and the establishment of a district bursary fund to encourage contributions from well-wishers; 6) the council should consider establishing a bursary committee for the proper coordination of the bursary in the district; 7) the health and social welfare sectors of the district councils should work with the police and judiciary to improve law enforcement on cases of child marriages, which are also defilement cases according to Malawi laws.

Key findings/insights

Multiplier effect: after the full council, the chiefs and ward councilors mobilized other local leaders in their jurisdiction to share with them the commitments they had made at the full council and asked for their active participation. During these meetings, the chiefs invited the district-level officers to provide technical support in articulating the problem of teenage pregnancies and their consequences on children. This helped the project to reach an additional 266 leaders at no additional cost.

In Chitipa district, the meeting reached a total of 75 local leaders (15 females, 60 male), while in Karonga, 191 participants (163 males, 28 female) attended the follow-up meetings, during which, data on teenage pregnancies and child marriages was discussed and stakeholders planned together on how they can continue to address these issues. During these discussions, several challenges were identified by local leaders and other stakeholders, including: age cheating: parents falsely claim that their children are older than their actual age; intimidation: fear of parental hostility when addressing child marriage cases´ limited access to police services: particularly in remote areas, which discourages reporting of cases; weak law enforcement: police often do not arrest perpetrators of reported cases; limited community involvement: key community structures, such as community policing and mother groups, are not adequately engaged in addressing child marriage.

Increased access to FP/SRH services by the youths as a result of the community leader´s involvement: in 2024, a total of 121,140 youths aged 10 to 24 years (61,198 males and 59,942 females) were reached through various outreach activities, including youth-targeted outreach clinics (YTOs) and community mobilization efforts. This marks a significant improvement of 430% compared to the previous year´s reach of 22,855 youths (11,724 males and 11,131 females).

Increased uptake of MNCH services: the performance of CBMNC improved significantly by strengthening the capacity of CMAs and HSAs through essential tools, comprehensive training, and enhanced referral support. Key interventions included distributing maternal and postnatal care kits to facilitate health monitoring and safe deliveries, providing in-depth training on maternal and newborn health management, and equipping healthcare workers with referral tools to address high-risk cases at the community level. These efforts resulted in measurable improvements, including: a 69% increase in early antenatal care visits, from 10,764 in 2023 to 18,204 in 2024; a 28% rise in facility-based deliveries, from 62,814 in 2023 to 80,535 in 2024; a 37% improvement in postnatal care follow-ups within 48 hours after delivery, from 39,408 in 2023 to 53,860 in 2024. The combined impact of these interventions enhanced the quality of care for pregnant and lactating mothers, including youth, at the community level.

Prevalence of teenage pregnancies: from 2022 baseline to 2024, the prevalence of teen pregnancies varied across the districts. There was a 21% drop in teen pregnancies in Chitipa from 3,402 in 2022 to 2,695 in 2024. Surprisingly, there was an increase in teen pregnancies in Karonga from 2022 to 2024. Both districts had a similar slight decrease from 2022 to 2023 of 5% in Chitipa (3,402 to 3,226) and 8% in Karonga (2,212 to 2,027). Unlike Chitipa, Karonga was hit by a natural disaster (floods) in 2024, which displaced people, forcing them into a camp for over 6 months. This disaster could have contributed to the increase in teen pregnancies due to the disruption of service provision. For the other 3 districts where the multisectoral stakeholder engagement was introduced later in 2023, teen pregnancies increased at different levels. In Kasungu district, cases increased from 6798 in 2022 to 8774 (29%) in 2023 before decreasing to 7531 (11% increase from the 2022 baseline) in 2024. In Nkhotakota District, cases increased from 5309 in 2022 to 5549 (5%) in 2024. Also, in Salima, the cases increased from 3438 in 2022 to 4526 (32%) in 2024. Though there was a net increase of teen pregnancies in Kasungu in the 3-year period (2022 to 2024), there was a decrease in cases from 8,774 in 2023 to 7,531, representing a 14% decrease. The increase in teen pregnancies in Nkhotakota can be attributed to the disaster (flooding) that affected the delivery of services in the district. On the other hand, the trends in Salima might be attributed to its high level of urbanization, and additional assessments are needed to understand the root causes. These results are shown in Figure 1.

Discussion     

Community engagement as a catalyst for change: the findings from this case study highlight the central role that local leadership can play in addressing adolescent sexual and reproductive health (ASRH) challenges. The “multiplier effect” observed after full council meetings, where 266 additional community leaders were reached without incurring extra costs, underscores the cost-effectiveness and sustainability of leveraging decentralized governance structures. Similar approaches have proven effective in other low-resource settings, where community-led interventions increased local ownership and accountability in health outcomes [15]. Reducing unintended pregnancies requires changing community attitudes toward youth contraception use and fostering collaboration among parents, educators, CSOs, and religious leaders [6]. This observation aligns with the commonly identified root causes of adolescent pregnancy, which include limited education, low socioeconomic status, inadequate access to contraception, and cultural practices such as early marriage [15].

Moreover, the involvement of district-level officers in these meetings contributed to informed discussions and facilitated evidence-based decision-making at the local level. This aligns with another study, which emphasized the importance of participatory governance and technical support in achieving health-related behavior change [16]. A World Bank report underscores that community-anchored, multisectoral approaches—especially those targeting adolescent girls are most effective when integrated into strong partnerships between government and non-state actors [17]. On the other hand, decision-makers at the local level appreciate local data on the magnitude of adolescent pregnancy specific to areas of their jurisdiction. Having this data also allows advocates to frame targeted, evidence-based messaging to the decision-makers [18].

Barriers to ending child marriage and teenage pregnancy: despite the positive momentum, persistent challenges such as age misreporting, fear of parental retaliation, limited access to justice, and weak enforcement mechanisms continue to hinder progress. These are not unique to this context; another study documented similar challenges across sub-Saharan Africa, where socio-cultural norms and weak legal systems hinder the reporting and resolution of child marriage cases [4]. Furthermore, the limited engagement of community structures such as community policing forums and mother groups suggests a gap in inclusive planning. Strengthening these local systems could enhance community surveillance, support prevention efforts, and bridge the trust gap between communities and formal service providers [19].

Improved access and uptake of SRH and MNCH services: the study recorded a 430% increase in youth reached with FP/SRH services between 2023 and 2024 — a dramatic improvement that illustrates the power of multisectoral collaboration and youth-focused outreach. This is consistent with evidence showing that engaging traditional and religious leaders can improve adolescent access to SRH services by dismantling taboos and increasing community buy-in [15]. Likewise, the positive trends in MNCH service utilization, including early antenatal care visits (+69%), facility-based deliveries (+28%), and postnatal care follow-ups (+37%), point to the effectiveness of combining community-level health worker capacity building with strengthened referral pathways. These findings corroborate previous research indicating that training and resourcing community health workers improve maternal and newborn outcomes. For example, mothers reported fewer depressive symptoms, attended more antenatal visits, and had better baby-feeding practices [20].

The disruption of progress by natural disasters: one key insight from this study is the vulnerability of reproductive health interventions to external shocks, such as natural disasters. Karonga and Nkhotakota experienced flooding in 2024, which likely contributed to the increase in teenage pregnancies by disrupting services, displacing families, and limiting access to youth-friendly spaces. This aligns with another study, which demonstrated how humanitarian crises often exacerbate adolescent vulnerability, especially where ASRH services are not integrated into emergency response plans [20].

Timing and duration of interventions matter: the variation in outcomes across districts also highlights the importance of timely implementation. Districts where multisectoral stakeholder engagement began in 2022 (Chitipa and Karonga) showed more positive or stable outcomes compared to those where the model was introduced a year later (Kasungu, Salima, Nkhotakota). This finding supports the notion that community transformation takes time and that consistent, long-term investment is critical to achieving and sustaining impact [21].

Limitations: this study primarily used program monitoring data, which may limit the generalizability of findings. Additionally, some qualitative insights (e.g. community leader perceptions) were based on anecdotal reports rather than structured assessments. Future studies could benefit from mixed-method approaches to capture the depth of community engagement and youth perspectives.

Implications for policy and practice: the results support the need for integrating multisectoral collaboration into district development plans, particularly those targeting adolescent health and well-being. Policymakers should prioritize community-led planning, invest in capacity-building for frontline workers, and strengthen links between traditional authorities and formal health systems. Furthermore, embedding ASRH services into disaster preparedness and resilience frameworks will be crucial in ensuring continuity of care in times of crisis.

Recommendations: 1) government and implementing partners should strengthen multi-sectoral coordination and collaboration among government agencies, CSOs, and community stakeholders to create a cohesive policy framework that effectively addresses adolescent pregnancy. This includes ensuring that policies and programs are evidence-based and aligned with national development and health strategies; 2) government and implementing partners should integrate and prioritize youth-friendly health services in disaster response plans to ensure uninterrupted access to family planning (FP) and sexual and reproductive health (SRH) services for young people. Policymakers should mandate that disaster preparedness policies explicitly include adolescent SRH needs, ensuring their implementation in emergency settings; 3) government and implementing partners should enhance safeguarding measures and prevention of gender-based violence (GBV) at disaster relief campsites by institutionalizing protective policies, such as mandatory reporting mechanisms, safe spaces for adolescents, and strengthened law enforcement to prevent exploitation and abuse; 4) government and implementing partners should institutionalize routine data collection and analysis on adolescent pregnancy at the district and national levels to inform policy decisions and enable timely interventions. Policymakers should allocate resources to sustain and expand data-driven advocacy efforts.

Conclusion     

Adolescent pregnancy among individuals aged 10-19 years remains a significant public health and social challenge in Malawi, as evidenced by data from the five districts analyzed in this study. The project demonstrated that collective bargaining is a powerful advocacy tool, effectively engaging full councils and securing commitments through collaboration with relevant government sectors and civil society organizations (CSOs). Environmental factors, particularly disasters such as floods, have exacerbated the issue, as seen in Karonga and Nkhotakota districts, where health facilities in flood-affected areas reported significant increases in teenage pregnancies. This underscores the need for integrating adolescent reproductive health interventions into disaster preparedness and response frameworks. A data-driven approach played a crucial role in achieving impactful results within a short timeframe. By identifying high-burden facilities and implementing targeted interventions, the project contributed to a measurable reduction in adolescent pregnancy rates. Moreover, presenting multi-sectoral data facilitated informed decision-making at the council level, enhancing commitment and accountability among policymakers.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors read and approved the final version of this manuscript.

Table and figure     

Table 1: adolescent pregnancies in project project-targeted area in 2022

Figure 1: teenage pregnancies in the Momentum Tikweze Umoyo project Districts

References