Assessment of unintended pregnancies, contraception, and abortion in Botswana

Botswana has a policy of contraception for all that is delivered through a rights‐based family planning program. The program combines a “rights‐based family planning approach” with “supportive policies for contraception,” and “a commitment to promote equitable access to modern contraception, and expand availability, method mix and uptake of modern contraceptive methods for all women and girls.” However, abortion is legally restricted up to 16 weeks of pregnancy provided that provisions of Section 160–162 of the Botswana Penal Code Amendment Act 1991 are met, and that the termination of pregnancy is carried out by a registered medical practitioner in a health facility approved for the purpose. In 2020, the Ministry of Health and Wellness, Botswana, in collaboration with United Nations Population Fund and World Health Organization, conducted a strategic assessment of unintended pregnancies, contraception, unsafe abortion, and abortion services in Botswana. A consensus operational plan to address these issues was developed during a national stakeholder meeting in Gaborone, Botswana. The consensus reached was to avert unintended pregnancies, improve access to modern contraception, and open nationwide discussions around abortion in the community to enable positive change and decrease maternal morbidity and mortality from unsafe abortion. This article describes the findings of the assessment and outlines the foundation for new or modified services or practices to be developed and pilot tested.

unintended pregnancy in Botswana. 1 Self-reported prevalence of unintended pregnancies in Botswana is estimated to be around 44%. 2 Additionally, program data suggest that there has been a drop in teenage pregnancy for teenagers younger than 15 years, but that teenage pregnancy is not abating for those aged 15-19 years.
[5][6][7] The graphic shows that between 2015 and 2019, teenage pregnancy for those aged under 15 years has been declining, while teenage pregnancy for the 15-19 age category has been increasing steadily.
Botswana has a policy of contraception for all that is delivered through a rights-based family planning program, with a clear policy on contraception provision. 8While Botswana has progressed well in ensuring that most family planning services are available to citizens, indicators such as teenage pregnancy, unsafe abortion, and maternal mortality show that there is still work that needs to be done. 9 is understood that unmet need for contraception is a key contributor to unintended pregnancies, with contraceptive prevalence in Botswana estimated to be at 67.4%. 10 Use of contraception in Botswana is as follows: male condom 64.2%, injections 17.0%, and the contraceptive pill 12.6%. 10Moreover, data demonstrate that 1.4% of women use an intrauterine device (IUD) and 1.0% use female sterilization.Traditional methods such as withdrawal and prolonged abstinence were specified by 0.5% and periodic abstinence by 0.2%of respondents. 10The overall contraceptive prevalence for married women aged 15-49 was estimated at 67.4%, 10 which increased from 52.8% prevalence rate estimated from the 2007 Botswana Family Health Survey. 2 The male condom is the most used method (Figure 2).This is in line with the findings of the Access, Availability, and use of Family Planning study in 12 selected districts of Botswana F I G U R E 1 Distribution of teenage pregnancy in Botswana by age, 2015-2019.[5][6][7] Teenage Pregnancy rate 8.2% F I G U R E 2 Contraceptive usage by method type in Botswana.Source: Botswana Demographic Survey Report 2017. 10 carried out in 2018, which indicated that most contraceptive users are using the male condom (42%). 1 It is not clear, however, if most of the male condom users prefer this method to avert pregnancy or to prevent HIV and other sexually transmitted infections (STIs).
Although contraceptive prevalence has increased in recent years, 8 provision of contraception alone is not sufficient to reduce unintended pregnancy in Botswana.Moreover, data on the causes and contribution of unsafe abortion to maternal mortality are not known, but it is believed to be high.However, reports by Statistics Botswana on maternal mortality ratio typically cluster causes of maternal deaths due to abortion with other cause like genital tract and pelvic infections following ectopic and molar pregnancy.This makes it difficult to clearly identify the extent to which abortion and unsafe abortion contribute to maternal mortality.
Despite the lack of data related to unsafe abortion, the most common method of termination of pregnancy is reported to be through use of Cytotec (misoprostol; Pfizer), which is readily available on the black market. 11In such cases, individuals may not have access to necessary information or quality assured medicines.Other methods have also been reported, including insertion of objects (feathers, pen cartridges,  straws, etc).Traditional medicine taken orally or placed in the vagina has also been reported. 11Furthermore, widespread abortion stigma and fear of repercussions may contribute to health complications and death from unsafe abortion through delayed care seeking. 8rmination of pregnancy is allowed up to 16 weeks for various reasons including risk to the mental health of the pregnant woman (Box 1).
Knowledge of the legal framework for abortion and understanding of the indications where abortion is permitted is generally good; however, health workers' views related to legalization are mixed, with some feeling that the legislation will curb unsafe abortion if implemented well, while others are concerned about the penal code encouraging "immoral behavior" that would lead to increased HIV infection due to unprotected sex. 11Additionally, national clinical guidelines on safe legal abortion care procedures are lacking, and only misoprostol (the medication most used for medical termination of pregnancy) is included in the national essential medicines list, while mifepristone is not.
In an effort to develop new and strengthen existing sexual and reproductive health policies and programs related to unintended pregnancies, contraception, unsafe abortion, and abortion services in Botswana, the Ministry of Health and Wellness (MOHW) Botswana, with the support of the United Nations Population Fund (UNFPA) and the World Health Organization (WHO) conducted a strategic assessment in 2020.In this paper, we report the methodology, key findings, recommendations, and next steps from this assessment over the past 2 years.

| ME THODOLOGY
The strategic assessment is the first stage of the WHO strategic approach to strengthening reproductive health policies and programs framework. 13Following identification of themes to be investigated by national stakeholders representing various organizations and community structures involved in sexual and reproductive health and rights, a National Research Task Team (NRTT) was developed, which conducted interviews in the field and collected, analyzed, and synthesized the data.Specifically, the 12-person team was composed of individuals from national sexual and reproductive health programs (n = 8), hospitals (n = 3), and the HIV and AIDS program (n = 1).
According to the Strategic Approach, a holistic system-based framework was used, which highlights various sociocultural and economic factors considered to be relevant for decision-making regarding accessing services. 13Emphasis is placed on reproductive rights, equity, gender equality, empowerment, and quality client-centered services that are responsive to community needs. 14The assessment explored the selected themes or study questions through the lenses of the three principles that have guided UNFPA work on sexual and reproductive health and rights: (a) access to affordable, quality, integrated sexual and reproductive health services that meet human rights standards; (b) strengthened accountability to eliminate all forms of discrimination; and (c) empowering the most marginal groups, with a focus on women, adolescents, and youth (particularly girls), and marginal and key populations at higher risk of HIV.

| Data collection
To ensure the quality of the assessment, a 1-week training workshop on the process of qualitative research, developing questions, interviewing, and data analysis was conducted.An interview guide was created and used extensively during the training, thereby familiarizing the researchers with its content and the manner in which it would be best administered.Training was both didactic and practical.A day of training was allocated to experiential learning in the field, with researchers collecting data from healthcare workers and community members using the interview guide intended for the final data collection. 14hical clearance was obtained from the Health Research Development Committee at the Ministry of Health.Written informed consent was obtained from each participant.In each research pair, one individual played the primary role of interviewer while the other took notes.Interviews were conducted in English, Setswana, or a combination of the two depending on the preference of the interviewee.Where the interviewee consented, the interview was audio recorded.Interviews were conducted in private settings in individual offices, clinics, and within the community to ensure confidentiality.On average, interviews lasted 35-45 min. 14

| Study sites
The study was carried out in eight of Botswana's 13 administrative districts in a variety of settings.These districts represented diversity in geography, socioeconomic development, culture, access to health District.In summary, study sites comprised three referral hospitals, two district hospitals, four primary hospitals, and 10 clinics. 14

| Selection of study participants
Participants were selected through purposive and snowball sampling methods.Policy makers, service providers, and community leaders were selected based on the position they held using a preidentified list of stakeholders.Community members, traditional leaders, and healers were identified through the district health management team. 14e age of study participants ranged from 19 to 94 years (Table 1).
Community representatives made up the largest number of participants, followed by professionals and then institutional representatives.
Among the professionals interviewed, most were nurses (Table 1). 14

| Data analysis and validation
Thematic analysis was used at each stage of analysis with themes and subthemes identified firstly in the team, then within the groups, and finally between the groups.Direct quotes from respondents were maintained and used as a means of validating emerging themes and subthemes.

| Limitations
The COVID-19 pandemic posed some logistical challenges for the assessment.Such challenges included travel and availability of study participants for purposes of interviewing.To overcome these, the data collection period was increased such that the assessors interviewed some policy makers outside of the initially anticipated 2 weeks of data collection.Another limitation was that this assessment included 116 participants, thus the study findings from this strategic assessment are not meant to be generalizable.However, because this approach is akin to intensity sampling techniques, it facilitated the collection of information that could be used to inform strategic planning as well as form the basis for further study/full-fledged research.Empowering the most marginal groups with a focus on women, adolescents, and youth (particularly girls), and marginal and key populations at higher risk of HIV The study also revealed that sexual and gender-based violence (SGBV) is rife, and that women and girls experience difficulties when negotiating safe sex, which increases the risk of unintended pregnancy.The inability to negotiate safe sex, including condom use, is a key driver of unintended pregnancy and has been found to be exacerbated by several factors, among them economic dependence on a male partner or intergenerational relationships with associated power imbalances, among others.It was also noted that the absence of or delays in reporting SGBV, including rape, incest, and defilement, could occur due to shame, stigma, attempting to maintain privacy, and/or fear of losing financial support.
From the study it was clear that there is a lack of community involvement in contraception programming and policy making.

| Unsafe abortion
Access to affordable, quality, integrated sexual and reproductive health services that meet human rights standards Abortion is legally permitted in Botswana up to 16 weeks of pregnancy in the case of rape, incest, or defilement; where the physical or mental health of the woman is at risk; or in the case of serious fetal impairment. 12However, despite previous literature that shows the contrary, knowledge of the law on legal abortion in Botswana is limited across all sectors.In this study, it was also established that there is limited knowledge and understanding of the circumstances under which termination of pregnancy is legally permitted.Generally, participants had limited knowledge of abortion law throughout the community, with a common assumption of illegality.Limited knowledge extends to healthcare professionals, law enforcement officials, and community leaders.The assumption of illegality is detrimental as it may cause erroneous denial of abortion services in cases that do meet legal criteria, and/or delays in provision of abortion care.
This negatively impacts on uptake of abortion and postabortion services by those who need them.The absence of clear guidance on the procedural implementation of abortion law is an additional barrier.It further creates obstacles to obtaining safe and legal abortion.

Strengthened accountability to eliminate all forms of discrimination
The absence of specific policy and lack of clear guidance for the procedural implementation of the abortion law, including the Empowering the most marginal groups with a focus on women, adolescents, and youth (particularly girls), and marginal and key populations at higher risk of HIV

| Recommendations and next steps
Based on the findings from the strategic assessment, recommen-

Strengthened accountability to eliminate all forms of discrimination
In the wake of the high rate of unintended pregnancy, it is also par- Empowering the most marginal groups with a focus on women, adolescents, and youth (particularly girls), and marginal and key populations at higher risk of HIV A key action to strengthen the implementation of specific interven-

| CON CLUS ION
The drivers of unintended pregnancy and abortion in Botswana are multifactorial, and so are the barriers to uptake of contraception and abortion services in Botswana.Therefore, a multifaceted and multisectoral approach is required to comprehensively address them.
Improving the implementation of CSE, targeted actions to reduce SGBV, and the widespread provision of family planning services, particularly LARCs and emergency contraception, will have a significant and sustainable impact on reducing unintended pregnancy and its associated harms.Women must be provided with the knowledge and services they need to prevent and manage unintended pregnancy, whatever the circumstances in which that pregnancy arose.This is essential to safeguard the health and wellbeing of women including girls, children, and families, achieve gender equality, and reduce the burden of unintended pregnancy nationwide.
Notwithstanding the above, action to improve access to, and knowledge of, the variety of effective contraception methods available will reduce unintended pregnancy and mortality due to unsafe abortion.It will also empower the whole community, so that women and girls can decide to have children "by choice, not by chance," at the right time for them and their family.Without action, stigma and misinformation surrounding abortion will continue to propagate, preventing timely access to safe, legal abortion; increasing the number of unsafe abortions; and furthering delays to delivering quality postabortion care.Prompt action is key to reducing barriers to accessing safe, legal abortion and postabortion care and will, ultimately: reduce maternal morbidity; prevent maternal mortality; achieve greater gender equality; and safeguard the health and wellbeing of women, children, and families in Botswana.

10 F I G U R E 4
Percentage distribution of women aged 15-49 years by reason for not using contraception.Source: Botswana Demographic Survey Report 2017.Percentage distribution of women aged 15-49 years by main problem experienced after using contraceptive 2017.Source: Botswana Demographic Survey Report 2017.10 to use Partner disapproved Not available

BOX 1
Legal framework for abortion in Botswana (Source: Government of Botswana 12 ) Section 160-162, Botswana Penal Code Amendment Act 1991 Abortion is criminalized except if it is undertaken within the first 16 weeks of pregnancy in the following cases: (a) rape, defilement or incest, according to evidence accepted by the medical practitioner carrying out the abortion, and if requested by the victim or next of kin or guardian acting in loco parentis if the victim lacks the capacity to make such a request; (b) risk to the life of the pregnant woman or injury to her physical or mental health, again if requested by the pregnant woman or next of kin; or (c) risk of such serious physical or mental abnormality that a child, if born, would suffer serious disability or disabling disease.services, and sexual and reproductive-related health outcomes within the country.Gaborone and Francistown are the more developed districts where the country's two cities, as well as the only National Medical Referral Hospitals that cover obstetric and general maternal health, are found.Kgalagadi South and Gantsi are remote districts, with the lowest socioeconomic development in the country.Selibe-Phikwe and Maun are socioeconomically developed, though not as much as Gaborone and Francistown.These districts have semi-urban villages/towns, hence drawing diverse cultures.As per MOHW Program reports, the rate of abortion and teen pregnancy is highest in Selibe-Phikwe while low numbers are recorded in the Kgalagadi Currently a top-down approach to contraception policy making, education, and provision is being practiced, with limited engagement of other line ministries or stakeholders.This is further compounded by low community consultation and engagement when rolling out contraception services, which acts as a barrier to community participation in contraception initiatives.A lack of educational materials about contraception in local languages on accessible platforms creates a barrier to community understanding of contraception options.Men are frequently excluded from education about contraception, despite the important role they play in family planning decision-making.
requirement for third party authorization, leads to lack of clarity and creates obstacles to abortion care, even if the legal criteria are met.In addition, there is absence of standardized guidelines or an up-to-date training curriculum to streamline and facilitate access to safe and legal abortion.A lack of current and standardized guidelines, curriculum, and training on safe and legal abortion care may result in the use of approaches to termination of pregnancy that are not evidence based or pregnancies being terminated with limited training or supervision, hence increasing the risk of complications.A lack of clarity on the roles and responsibilities of key stakeholders involved in access to and the provision of safe, legal abortion (including law enforcement officials, healthcare workers, social workers, community leaders and members) may lead to gatekeepers effectively denying abortions based on their personal beliefs or opinions.
There are high levels of stigma toward abortion among members of society that create high levels of secrecy surrounding abortion within the community.The secrecy prevents necessary community and national discussions about unsafe abortion and how to address issues.Clandestine, dangerous, illegal abortion practices may be encouraged due to concerns around privacy from family, partners, or the community.It was also established that there were delays in presentation to healthcare services following abortion due to stigma and fear of judgment or prosecution.These are important contributors to complications and death from abortion.There is limited training of healthcare providers in postabortion care including the management of postabortion complications.Postabortion care training is currently delivered at national level, limiting the dissemination of guidelines, and restricting the availability of staff trained in postabortion care.The lack of trained postabortion care providers may result in healthcare workers being ill-equipped to manage any life-threatening complications of abortion and could lead to increased morbidity and mortality.
dations related to improvements in policy, program management, service provision, and community-level interventions were developed.These were developed following consultation with key national stakeholders, whereby consensus actions on next steps were identified that included, among others, the development of a costed implementation plan and policy briefs for high-level advocacy.Access to affordable, quality, integrated sexual and reproductive health services that meet human rights standardsTo avert unintended pregnancies and improve contraception access in Botswana it is essential to increase the provision of highly effective methods of contraception (particularly the less user-and supply-dependent LARC methods of contraceptive implant and intrauterine contraceptive device); and emphasize the need for dual protection (condoms in addition to another effective modern contraceptive) for optimal pregnancy, HIV, and STI prevention.The integration of family planning services into other health services, while expanding contraception delivery in community settings, is pivotal to reduce missed opportunities for providing contraception and improve access, thus reducing unintended pregnancies.Expanded access to contraception in the community should include emergency contraception.The decentralization and scale up of contraception training, particularly LARC methods, is essential and will increase the number of competent providers and reduce geographical inequities in provision.Local peer-to-peer training and mentoring on LARC insertion and removal should also be supported to increase the availability of trained LARC providers.This will increase the uptake of LARC methods.Increasing community awareness about LARC methods by providing accessible information in local languages about the methods, how they work, their benefits and adverse effects will also help to increase demand and uptake.
amount to develop specific interventions to prevent unintended pregnancy in adolescents and young people.Youth-friendly sexual and reproductive and contraception services should be strengthened and widely implemented in schools, youth centers, and community groups, empowering young people to make informed decisions regarding their sexual and reproductive health, and preventing adolescent pregnancy.Adolescents and young people should be supported to initiate and continue modern contraceptive methods, particularly LARCs, through youth-friendly health services.On the other hand, CSE educators must be trained to discuss sensitive topics with adolescents and young people, to build capacity for quality CSE provision.Improving educator confidence to deliver CSE should be addressed through dedicated workshops and training on how to address sensitive issues with adolescents and young people, in addition to strengthened training on the curriculum content.Young people should actively participate in the development of CSE curricula to ensure that key areas are covered so that the youth-friendliness, accessibility, acceptability, and the quality of the curricula is assured.Providing quality, youth-friendly sexual and reproductive health and contraception services in schools and youth groups stands to improve access to and uptake of contraception.Providing family planning services outside of traditional healthcare settings, for example in schools or youth groups, pharmacies, and other community settings, will expand access to effective modern methods of contraception.Healthcare workers who are not specialized in sexual and reproductive health should be trained more broadly on how to provide comprehensive contraception counseling.This will enable the integration of contraception services into other healthcare services, including HIV, adolescent and youth, postabortion, postpartum, and community-based services.Integration will reduce missed opportunities for family planning and prevent unintended pregnancy through the improved uptake of contraception.Innovations in family planning should be explored, for example the use of digital health to improve knowledge, capacity, and the quality of contraception services.Information on contraception should be widely disseminated at a community level in local languages on accessible platforms.A specific focus should be placed on targeting those who would not be reached by existing CSE programs.Strengthening commodity supply chains to maintain a continuous supply of contraception will limit-and at the most prevent-stockouts.Weaknesses in contraceptive commodity supply chains should be targeted through the prioritization of contraception commodity procurement and strengthening the forecasting and quantification of contraception need at local and national levels to avert stockouts of family planning commodities.The creation of a separate budget line for contraception commodities in the Central Medical Stores, particularly for LARC methods, and increasing the overall funding for contraception provision, including capacity building, will help to ensure commodity security especially for modern contraception.Policies related to sexual and reproductive health services (contraception, prevention and/or management of unintended pregnancies, SGBV, abortion and postabortion care services) should be reviewed, revised, and harmonized to keep them up to date, commensurate with international best practices.Policy implementation should be strengthened to ensure equitable access to family planning services and education across the country.To reduce barriers to access or denial of provision of emergency contraception, healthcare worker and community trainings should specifically include values' clarification to reduce stigma and misinformation.
tions to prevent SGBV is the targeted provision of information in local languages to increase community knowledge of SGBV, including how to recognize, prevent, and report it.Existing community structures for the prevention of SGBV and unintended pregnancy such as Village Child Protection Committees should be strengthened to improve their effectiveness.Those affected by SGBV need dedicated, holistic support, including immediate access to emergency contraception; signposting toward and support through legal procedures to access safe, legal abortion when needed; and sustained psychological and socioeconomic support.Services and community support networks dedicated for women experiencing SGBV should be strengthened.Healthcare workers, law enforcement officers, social workers, and other key stakeholders should be educated about the importance of providing timely, sensitive, and judgment-free care to those affected by SGBV.In essence, strengthening the implementation of specific interventions for prevention of SGBV and dedicated services for survivors is essential.Community advocacy strategies utilizing peer educators, local traditional and religious leaders, and teachers can be harnessed to improve the community's knowledge and understanding of the drivers of unintended pregnancy; modern contraceptive methods, including emergency contraception; and the circumstances for and ways to obtain safe and legal abortion.Improving community knowledge through targeted education and the provision of information in local languages, available on accessible platforms, may help to reduce stigma regarding contraception, unintended pregnancy, and abortion.Involving the community in family planning program interventions' design and policy making will improve community engagement in family planning initiatives.The community should be encouraged to customize approaches locally, and feedback should be incorporated through a quality improvement process.All finalized family planning policies and guidelines should be widely disseminated once developed to facilitate implementation.Community-based family planning programs could be created to broaden access to and uptake of contraception.Local peer educators should be trained and supported to provide evidence-based contraception education, to improve community understanding of contraception options.Reducing morbidity and mortality from unsafe abortion in Botswana requires a multifaceted approach.It requires engagement in policy, healthcare services, and the community.An overarching policy, directly focused on reducing unsafe abortion, is crucial to tackle the multiple drivers of morbidity and mortality.Therefore, review, revision, and harmonization of policies for safe, legal abortion and postabortion care services should be given priority.Directed policies on comprehensive abortion care, the procedural implementation of abortion law and clear roles and responsibilities are urgently needed to improve the quality and equity of abortion and postabortion care in Botswana, as permitted under the current law.To provide a targeted focus for policy reform, all policies related to family planning, sexual and reproductive health services and education, and the legal system related to abortion, should be holistically reviewed to identify those that are supportive or obstructive.A lack of knowledge on abortion law, a general assumption that all abortion is illegal, and high levels of abortion-related stigma demonstrate the need for comprehensive guidelines on abortion care.Training for healthcare providers should draw from an associated curriculum that includes values clarification and is accompanied by ongoing supervision and mentorship to sustain quality service delivery.Additional training should target individuals beyond the health sector, such as law enforcement officers, social workers, and community and religious leaders.This multi-and intersectoral training curriculum should provide clarity on the procedural implementation of the penal code, and training on issues of SGBV, family planning (including emergency contraception), and how to signpost toward accessing safe, legal abortion.The decentralization and scale-up of postabortion care training will increase the number of trained postabortion care providers.Existing guidelines should be reviewed and updated with evidence-based recommendations and include the provision of postabortion contraception including LARC methods for women who wish to delay or prevent future pregnancies.Knowledge of lifesaving interventions to manage abortion complications, alongside values clarification, should be prioritized in both pre-and in-service training curricula for healthcare workers, to reduce morbidity and mortality following abortion.Strengthening and scaling-up existing postabortion care training (including to intensify efforts toward "train the trainer" models), while establishing new unified training for safe, legal abortion among health professionals, will also improve the quality and safety of these services.An evidence-driven national discussion on unsafe abortion involving the community, healthcare workers, law enforcement, and policymakers will increase knowledge and awareness of unsafe abortion and reduce stigma surrounding abortion.Shifting negative attitudes toward abortion will enable service providers to provide comprehensive, client-centered, rights-based care, and reduce morbidity and mortality related to delays in seeking care or treatment following abortion.Increased community-level education for men and women on issues including consent, the negotiation of safe sex, SGBV, family planning, and the current legal framework for abortion will empower people to make informed choices about their own sexual and reproductive health.Removing barriers to obtaining a safe, legal abortion within the confines of Botswana's current abortion law, and exploring the need for abortion law reform, will require multilevel support.In turn, this could increase support for directed policies and programs that act to improve the provision of and access to safe, legal abortion, as well as providing evidence-based, comprehensive postabortion care.