MAPUTO, Mozambique — On a hot and humid day in Mozambique’s capital city, high school students are asking questions in a sex education class.
They talk knowledgeably about the many contraceptive options available at the school’s on-site family planning clinic, including condoms, implants, and injectables.
Toward the end of the class, one student asks about traditional methods. She has heard that some couples bury a piece of sanitary pad in the ground to prevent pregnancy.
That comment “was even a surprise to me,” said biology teacher Vasco Nhamussa after the class, explaining that such questions are now rare.
“What we have to understand is that each child comes with a culture of their own,” he added.
Mozambique has one of the highest rates of teenage pregnancy in the world, with 40% of girls pregnant by the age of 18 as of 2011, the latest year for which there is comprehensive data.
Yet out of thousands of students, the Armando Emílio Guebuza school in Chamanculo, a relatively disadvantaged district of Mozambique's capital Maputo, has managed to get its caseload down to just one or two a year, with the help of the on-site clinic, which offers free contraceptives and consultations, and regular sex education classes.
That has come alongside nationwide advancements — hard-won by civil society campaigners — such as the decriminalization of abortion in 2014; the rollout of sex education as a mandatory part of the school curriculum; and the creation of a network of youth-friendly sexual health clinics across the country, promising free and nonjudgemental service to those aged 10-24.
All of that has made Mozambique one of the most progressive countries in Africa in providing sexual and reproductive health care for its young people.
It has been the most successful of the FP2020 family planning partnership countries in increasing the proportion of women using modern contraceptives each year. Although there hasn’t been a large-scale survey on teenage pregnancy since 2011, the U.N. Population Division projects the adolescent fertility rate to be steadily declining.
But Mozambique also has one of the lowest income per capita in the world, meaning it has been heavily reliant on outside help to fund its efforts. Around 80% of aid for reproductive health and family planning between 2015-2017 came from the United States.
That left the country highly exposed when U.S. President Donald Trump implemented an expanded version of the “global gag rule,” or Mexico City Policy, in January 2017. The order withdrew U.S. government funding from foreign NGOs involved in any aspect of abortion work, including counselling and legal advice.
When the order kicked in later that year, NGOs in Mozambique lost millions of dollars. A stream of clinics were closed. Hundreds of jobs were lost.
When Trump announced in late March that he would be expanding the rule yet further, to cover not only organizations that discuss abortion but also those that fund or support them, activists said they didn’t know what the impact would be. “We are afraid because we made a lot of progress in the last few years,” said Santos Simione, executive director at AMODEFA, Mozambique’s oldest sexual and reproductive health NGO. “If we stop, what will happen?”
A success story
Simione’s NGO has been working on reproductive rights in Mozambique for 30 years — through the end of a long-running civil war, the country’s first democratic elections, and several devastating cyclones.
The level of teenage pregnancy has remained a constant challenge, linked in part to high rates of early marriage, but advocates also described a cultural resistance to talking about issues around sexual health. That has often meant young people don’t have access to the information and services they need to prevent early pregnancy, putting their health and education at risk.
“The first barrier, I would say, is our culture. It’s to do with our beliefs, our values,” said Marcia Mandlate, president at Mozambique’s Youth Action Movement. “Some parents, when you start teaching the youth [about family planning], they think you’re promoting promiscuity or [bad values]. So these are our biggest problems.”
Even with sex education a mandatory part of the school curriculum, some conservative teachers refuse to teach it. Since it is currently relegated to the final part of the biology curriculum, it is easy to avoid. Ministry of education officials said efforts were underway to integrate sex education throughout the curriculum, but that the sensitivity of the issue among parents complicated matters.
To combat the problem, NGOs have developed a network of thousands of “peer educators” across the country. These young people are engaged and trained on the issue, and paid a small amount to spread the word by visiting schools and going door to door in local communities. They play a crucial role in reaching girls who have been married early and taken out of school, who typically have no other access to information about sexual health.
It is not a job for the fainthearted, however. Peer educators must navigate local hierarchies to gain access to women and run the constant risk of a hostile reaction.
In addition, the government has been working to roll out “counselling corners” in every high school, consisting of a nurse who can provide guidance and free contraception.
But the on-site family planning clinic at Armando Emílio Guebuza school is almost unique in Africa, serving the school's sizeable population as well as the surrounding community.
Teenagers who visited the clinic regularly told Devex they found it easier to absorb information learned there than in the classroom; that it empowered them to resist peer pressure to start having sex at a young age; and better prepared them to share their knowledge with others in the community, including friends and family members.
“There are people who say [adolescent pregnancy] is not a problem but in reality you see outside it is a problem because … there are people who get pregnant, they cannot go to school or complete their dreams,” said 13-year-old Kelvin Sousa Samal. By learning about sexual health, “we can protect ourselves [and our partners],” he said.
Chantelle Cumbane, also 13, said she would not think about starting a family until she had finished her education, including ambitions to complete a master’s degree. “After that, we can start thinking about planning a family,” she said.
Advocates said having a clinic on-site means young people don’t have to take time out of school to access services. It makes it more convenient, and allows them to avoid the risk of bumping into family members and acquaintances at mainstream clinics, which might otherwise deter them.
“When I started working here, the nurses from the other clinics [in the area] … said they used to see a lot of students that were pregnant,” said nurse Esparanca Americo, who has run the school clinic since 2016. “It’s helped a lot ... because the rate of pregnancy has reduced at this school, and it’s the same for STIs [sexually transmitted infections].”
She complained that a lack of resources prevented the clinic from reaching maximum impact. But the Maputo school is lucky compared to others.
‘Backwards 10 years’
Reinstating the global gag rule was one of the first things Trump did after entering the White House in January 2017. Although the order has regularly been deployed by Republican presidents, Trump oversaw an unprecedented expansion that potentially affects billions of dollars worth of aid. It was extended further again in March.
In Mozambique, the impact has varied across the country, depending on how reliant a region’s services were on U.S. funding. In Gaza province, for example, a three-hour drive north along the coast from Maputo, they were decimated. Two-thirds of AMODEFA’s youth-friendly clinics in the province were shuttered; more than half its staff laid off; and 95% of its 600 peer educators let go. Like Maputo, Gaza used to have a school clinic of its own — the only other one in the country. That, too, was forced to close.
The most commonly requested service in the area is contraception, especially the implant, according to Felismina Maoda, AMODEFA’s Gaza coordinator. “They’re usually young wives who come in. Their husbands can’t know [they are using family planning] so they choose the implant,” which can be hidden more easily, she said.
In the immediate aftermath of the policy, the NGO went from assisting around 8,000 young people a month in Gaza, to just a few hundred. The handful of peer educators that are left say their work has become much harder.
“I haven’t seen anything like this” in 12 years working in sexual and reproductive health care, Maoda said. “People are not being served properly … [and] these young people feel lost.”
Most of the clinics forced to close were in more remote areas, which take more resources to reach, leaving some of the poorest and most marginalized people without information and services.
Overall, AMODEFA estimates that half a million people lost access to projects that were helping them as a result of the global gag rule, including in their HIV, tuberculosis, and malaria programs, which previously received U.S. funding. It has also limited their ability to assist the tens of thousands of people displaced by cyclones Kenneth and Idai earlier this year, including pregnant women.
Although updated figures are not yet available, advocates expect the number of unplanned pregnancies and unsafe abortion attempts among young people to rise. That can include using sticks or taking a cocktail of herbs and drugs.
Dr. Marcelo Kantu, a team lead with AMODEFA, explained that the early years of the organization had been focused on awareness-raising and breaking the taboo of talking about sexual health. Eventually, they had been able to start offering products and services. But their hopes of scaling up have, for now, been stymied by the gag rule.
“We see ourselves as having gone backwards 10 years,” he said.
Despite the devastation wreaked by the global gag rule on services in Mozambique, there was an alternative. Some NGOs were too reliant on U.S. funding to avoid signing the order — including some of AMODEFA's partners. That has forced them to dismantle their coordinated approach to outreach.
Organizations that continue to accept U.S. funding are restricted from speaking out against the policy publicly, but many say it has seriously impacted their work.
In Mozambique, NGOs have tried to minimize the overall impact on services by sharing opportunities between themselves in a community-spirited approach. When AMODEFA receives interest from an organization with U.S. funds, for example, it refers them to organizations that are able to accept them.
Although they cannot match the funding power of the U.S., other donors have also helped plug the gap. Of AMODEFA's 22 youth-friendly clinics nationwide, 10 were saved by funding from She Decides, a movement set up by European governments to limit the damage caused by the global gag rule. Another two have continued to operate with funding from the International Planned Parenthood Federation, of which AMODEFA is a member, but which itself lost funding after it refused to sign the order.
Mozambique has also been chosen for funding from the United Kingdom’s new Women’s Integrated Sexual Health, or “WISH,” program. Launched in 2018, the £200 million program ($254.3 million) aims “to increase the use of family planning methods to reduce maternal deaths and prevent the use … [of] unsafe abortion.”
Reproductive health advocates in Mozambique are now looking ahead to the 2020 U.S. presidential election, in hopes that their funding might be returned. But even if it is, it will take a long time and additional funds to rebuild what was lost. Many say they are working hard to diversify their funding sources, so they won’t be so vulnerable to outside policy changes again.