Discussion
CSE, death
COMPLICATIONS
Findings in this paper suggest a significant decline in early and unintended pregnancies within schools featuring integrated CSE linked to SRH information and services, particularly when efforts are made to bring information on SRH services, to schools and linking CSE with health facilities that are sensitized to be more receptive to the ASRH needs of AGYW who may or not be in school. Although there are disparities in achievements, evidence from this paper suggests that pregnancies declined in the two intervention arms, but with room for additional improvement. Although in-school pregnancies were documented across arms following trial implementation, there were significantly greater declines in EUP in the two intervention arms relative to the control arm, which were associated with CSE linked to SRH services and information.Adolescent pregnancy remains a major public health concern, even when there is one pregnancy, it disrupts the learning opportunity of the adolescent, with potential negative health and social consequences. CSE, integrated in the school curriculum, confers opportunities for imparting scientifically accurate information about SRH. Despite having moderate SRH knowledge and acceptability of SRH services, few sexually experienced AGYW utilize SRH services, resulting in high EUP. Multiple reviews and studies across a diverse range of settings in Europe, the United States, Africa, and Mexico confirm that CSE contributes to preventing unintended adolescent pregnancies by providing students with knowledge, life skills, and information on contraceptive options. It can reduce early sexual debut and prevent early and unintended pregnancy among AGYW [A noteworthy finding of this study was that in-school pregnancies did not decline significantly in the CSE-only control arm, which underscores the role of combining CSE implementation with information on available and responsive SRH services. Several studies in Zambia have reported barriers to CSE implementation, including parental objections, perceived incompatibility of curricular material with social norms, inadequate training and support for teachers, instructor discomfort with material or self-efficacy delivering lesson plans, and inattention to health systems-related factors impacting SRH service provision to adolescents and SRH outcomes [According to the Ministry of General Education in Zambia [Teenaged mothers are at higher risk of adverse pregnancy outcomes or complications, and children born to very young mothers are at increased risk of sickness and early death [Sometimes shortages of essential SRH commodities and supplies are a disincentive in accessing and using SRH services in the public sector. Our mitigation approach to this has been through engaging the political leadership, including parliamentary committees, to share our findings, with a view to show and highlight the cost benefits of investing in SRH commodities, whose down-stream consequences, if neglected, far outweigh the initial costs of availing them. Such consequences include high school dropouts, unsafe abortion, maternal mortality and morbidity, needless contribution to high total fertility, and poverty through curtailed economic growth targets.While there could be gaps in the provision of CSE in some schools, based on individual ideological convictions, we did not encounter individual resistances from schools, possibly attributed to the support we received from the combination of Ministry of Education, Ministry of Health and the respective PTAs. During our pre-study orientations, we implored teachers at each school to shun from personal beliefs in approaching the issues of CSE and accessing SRH services by their pupils, in times of need.The study has a number of policy implications for consideration, with a view to reduce in-school pregnancies and allow AGYW to realize their full potential. These include the following:The need for policy decision makers and programme directorates in Ministries of Education, Health and Economic Planning and Finance to work together to facilitate access to CSE that is linked to SRH services and information;The need for constant dialogues and engagement of PTAs by Ministries of Education and Health, on the issues of preventing EUP in schools and encouraging links between provision of CSE and accessing health care.The need for constant orientation of health services and sensitization of health care providers by Ministries of Health, to be more responsive and receptive to the needs of AYP, including in-school pupils.The need for relevant civil society organizations or Development partners, or Ministries of Health, to engage in interactive health education outreach programmes in schools, which place emphasis on prevention of EUP, among other health and social wellbeing issues, such as menstrual hygiene and respectful gender relations.Our study is not without limitations. First, while our primary outcome of interest was early and unintended pregnancy, we also collected data on background characteristics of respondent pupils at each school, other key process or outcome measures, like SRH and gender equity knowledge and behaviours, which could be among mediating factors in the relationship between intervention implementation and pregnancy outcomes. However, to avoid overwhelming this paper, whose explicit measure is pregnancy outcome by study arm intervention, these multiple factors and related outcomes will be the focus of subsequent analyses of these data. Second, pregnancy data were derived from school administrative records, which may not have accurately captured all pregnancies, particularly if AGYW dropped out of school and did not report pregnancy to the school, as the reason for dropping out. However, this limitation would apply to all study arms. Lastly, the unique implementation climate of CSE in North-Western Province and health systems context in Zambia may attenuate the generalizability of our findings outside Zambia. Future research should examine the impact of comparable CSE-linked interventions in other contexts, especially in other countries in the region, affected by high school attrition from EUP.