Malawian women in all sectors of society are suffering from social implications of unwanted pregnancy and unsafe abortion. Unwanted pregnancies occur among women who have limited access to family planning and safe abortion. A legally restrictive setting for safe abortion services leads many women to unsafe abortion, which has consequences for them and their families. In-depth interviews were conducted with 485 Malawian stakeholders belonging to different political and social structures. Interviewees identified the impact of unwanted pregnancy and unsafe abortion to be the greatest on young women. Premarital and extramarital pregnancies were highly stigmatized; stigma directly related to abortion was also found. Community-level discussions need to focus on reduction of stigma.

In 2009, many women seeking postabortion care in Malawi presented with complications. Advocacy is needed to influence policies that will allow expanded access to safe abortion services for women of all ages and in all areas.

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Universal Health Coverage (UHC) forces governments to consider not only how services will be provided – but which services – and to whom, when, where, how and at what cost. This paper considers the implications for achieving UHC through the lens of abortion-related care for adolescents. Our comparative study design includes three countries purposively selected to represent varying levels of restriction on access to abortion: Ethiopia (abortion is legal and services implemented); Zambia (legal, complex services with numerous barriers to implementations and provision of information); Malawi (legally highly restricted). Our policy and legal analyses are supplemented by comparative vignettes based on interviews ( n = 330) in 2018/2019 with adolescents aged 10–19 who have sought abortion-related care in each country. We focus on an under-considered but critical legal framing for adolescents – the age of consent. We compare legal and political commitments to advancing adolescent sexual and reproductive health and rights, including abortion-related care. Ethiopia appears to approach UHC for safe abortion care, and the legal provision for under 18-year-olds appears to be critical. In Malawi, the most restrictive legal environment for abortion, little progress appears to have been made towards UHC for adolescents. In Zambia, despite longstanding legal provision for safe abortion on a wide range of grounds, the limited services combined with low levels of knowledge of the law mean that the combined rights and technical agendas of UHC have not yet been realised. Our comparative analyses showing how policies and laws are framed have critical implications for equity and justice.

Age of consent criminal laws imposed on African states during colonialism were inherently patriarchal and gender-stereotypic, and continue to influence country approaches toward adolescent consensual sexual conduct. There are two major policy positions: a punitive and a nonpunitive approach. Most countries adopt the punitive approach. Mostly, legislation does not explicitly criminalize consensual sexual conduct between adolescents, and this leaves a gray area to be filled in by social and cultural norms that perceive adolescent sexual conduct negatively. Punitive approaches have been justified as necessary to curb harms to adolescents resulting from sexual conduct, including teenage pregnancies and sexual abuse. Age of consent laws, especially in their original colonial formulation deny adolescents, especially girls, sexual autonomy and agency. States focus more on punishment than on taking measures to address the structural antecedents of harms associated with sexual intercourse. States should reform age of consent laws to decriminalize consensual sex between adolescents in accordance with recognized rights of the child.