School-based comprehensive sexuality education (CSE) can help adolescents achieve their full potential and realize their sexual and reproductive health and rights. This is particularly pressing in low- and middle-income countries (LMICs), where high rates of unintended pregnancy and STIs among adolescents can limit countries’ ability to capitalize on the demographic dividend. While many LMICs have developed CSE curricula, their full implementation is often hindered by challenges around program planning and roll-out at the national and local level. A better understanding of these barriers, and similarities and differences across countries, can help devise strategies to improve implementation; yet few studies have examined these barriers. This paper analyzes the challenges to the implementation of national CSE curricula in four LMICs: Ghana, Kenya, Peru and Guatemala. It presents qualitative findings from in-depth interviews with central and local government officials, civil society representatives, and community level stakeholders ranging from religious leaders to youth representatives. Qualitative findings are complemented by quantitative results from surveys of principals, teachers who teach CSE topics, and students aged 15–17 in a representative sample of 60–80 secondary schools distributed across three regions in each country, for a total of around 3000 students per country. Challenges encountered were strikingly similar across countries. Program planning-related challenges included insufficient and piecemeal funding for CSE; lack of coordination of the various efforts by central and local government, NGOs and development partners; and inadequate systems for monitoring and evaluating teachers and students on CSE. Curriculum implementation-related challenges included inadequate weight given to CSE when integrated into other subjects, insufficient adaptation of the curriculum to local contexts, and limited stakeholder participation in curriculum development. While challenges were similar across countries, the strategies used to overcome them were different, and offer useful lessons to improve implementation for these and other low- and middle-income countries facing similar challenges.

Family planning services were introduced in Senegal in the early 1960s at the private Blue Cross Clinic in Dakar, but it was only in 1981 that the government developed an administrative structure capable of directing a national program and began to provide information, education and counseling support and family planning services. Factors contributing to unmet need for family planning in developing countries include lack of contraceptive knowledge; poor quality of and access to family planning services; method cost; women's concerns about side effects; and women's, husbands' or family members' objections to contraceptive use. 4,5 According to a descriptive analysis of Urban Reproductive Health Initiative data, women's beliefs and misconceptions about contraceptives, husbands' objections to contraceptive use and the poor quality of family planning services are the most frequent reasons deterring women in urban Senegal from practicing contraception. 6Youth constitute a key target in reproductive health strategies and, in Senegal, appear to have particularly low levels of contraceptive use. For example, in 2010-2011, only 2% of all 15-19-year-olds and 6% of all 20-24-yearolds reported using a modern method; 2 the proportions among currently married women in those age-groups were slightly higher (5% and 8%, respectively). Access to reproductive health services remains an issue for young women

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The successful implementation of comprehensive sexuality education (CSE) programmes in schools depends on the development and implementation of strong policy in support of CSE. This paper offers a comparative analysis of the policy environment governing school-based CSE in four low-and middle-income countries at different stages of programme implementation: Ghana, Peru, Kenya and Guatemala. Based on an analysis of current policy and legal frameworks, key informant interviews and recent regional reviews, the analysis focuses on seven policy-related levers that contribute to successful school-based sexuality education programmes. The levers cover policy development trends; current policy and legal frameworks for sexuality education; international commitments affecting CSE policies; the various actors involved in shaping CSE; and the partnerships and coalitions of actors that influence CSE policy. Our analysis shows that all four countries benefit from a policy environment that, if properly leveraged, could lead to a stronger implementation of CSE in schools. However, each faces several key challenges that must be addressed to ensure the health and wellbeing of their young people. Latin American and African countries show notable differences in the development and evolution of their CSE policy environments, providing valuable insights for programme development and implementation. ARTICLE HISTORY

BackgroundOver six million induced abortions were reported in Africa in 2008 with over two million induced abortions occurring in Eastern Africa. Although a significant proportion of women in the region procure more than one abortion during their reproductive period, there is a dearth of research on factors associated with repeat abortion.MethodsData for this study come from the Magnitude and Incidence of Unsafe Abortion Study conducted by the African Population and Health Research Center in Kenya in 2012. The study used a nationally-representative sample of 350 facilities (level II to level VI) that offer post-abortion services for complications following induced and spontaneous abortions. A prospective morbidity survey tool was used by health providers in 328 facilities to collect information on socio-demographic charateristics, reproductive health history and contraceptive use at conception for all patients presenting for post-abortion services. Our analysis is based on data recorded on 769 women who were classified as having had an induced abortion.ResultsAbout 16 % of women seeking post abortion services for an induced abortion reported to have had a previous induced abortion. Being separated or divorced or widowed, having no education, having unwanted pregnancy, having 1–2 prior births and using traditional methods of contraception were associated with a higher likelihood of a repeat induced abortion.ConclusionsThe findings point to the need to address the reasons why women with first time induced abortion do not have the necessary information to prevent unintended pregnancies and further induced abortions. Possible explanations linked to the quality of post-abortion family planning and coverage of long-acting methods should be explored.