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Background: Access to safe abortion care is highly unequal and fundamentally rooted in socioeconomic inequalities which are amplified by restrictive social norms and legal systems. We analyse these inequalities along the reproductive health continuum amongst adolescent girls in Zambia. Methodology: This paper draws from 20 focus group discussions conducted in 2021 with community members (young/adult) in five urban, peri urban, and rural sites in Zambia. Data was analysed using thematic analysis. Results: Adolescent pregnancy in the community was reported to be very common across the communities with girls from poorer families being disproportionately affected. Parents were reported to be complicit in facilitating their daughter's sexual-economic exchanges which emerged as a key driver of pregnancies. Young age and unmarried status meant adolescent girls could face triple stigma: stigma around accessing contraception to prevent a pregnancy, stigma in experiencing an unintended pregnancy and stigma around terminating an unintended pregnancy. There were clear socioeconomic differences in adolescent girl's exposure to community and health provider censure and/or acceptance of their pregnancy, and in their ability to conceal an abortion. Having the means to pay for health care allows some adolescents to seek terminations earlier and to access private health facilities while poorer adolescent girls face greater exposure to community censure through their embeddedness within the community. Abortions in this group attracts greater visibility through complications arising from their constrained choice for safe abortion methods. Stigmatising attitudes of community members also undermined adolescents' reproductive agency and mental health. For adolescents who choose to keep an unintended pregnancy, reintegration into school was highly challenging despite a national policy in place, with marriage being viewed as the only future option for poorer teenage mothers. Conclusion: The embeddedness of adolescent pregnancies within community structures of economic insecurity and gendered and age-related power relations highlight the importance of introducing community level approaches to tackle unintended pregnancies and unsafe abortion. Understanding teenage pregnancy as a community issue creates opportunities for community level support to young girls especially when they return to school. [ABSTRACT FROM AUTHOR]

Objective To estimate the direct costs of treating women with maternal near misses and potentially life- threatening conditions in Kenya and the factors associated with catastrophic health expenditure for these women and their households. Methods As part of a prospective, nationally representative study of all women with near misses during pregnancy and childbirth or within 42 days of delivery or termination of pregnancy, we compared the cost of treating maternal near-miss cases admitted to referral facilities with that of women with potentially life-threatening conditions. We used logistic regression analysis to assess clinical, demographic and household factors associated with catastrophic health expenditure. Findings Of 3025 women, 1180 (39.0%) had maternal near misses and 1845 (61.0%) had potentially life-threatening conditions. The median cost of treating maternal near misses was 7135 Kenyan shillings (71 United States dollars, US$) compared with 2690 Kenyan shillings (US$ 27) for potentially life-threatening conditions. Of the women who made out-of- pocket payments, 26.4% (122/462) experienced catastrophic expenditure. The highest median costs for treatment of near misses were in Nairobi and Central region (22 220 Kenyan shillings; US$ 222). Women with ectopic pregnancy complications and pregnancy-related infections had the highest median costs of treatment, at 7800 Kenyan shillings (US$ 78) and 3000 Kenyan shillings (US$ 30), respectively. Pregnancy-related infections, abortion, ectopic pregnancy, and treatment in secondary and tertiary facilities were significantly associated with catastrophic expenditure. Conclusion The cost of treating maternal near misses is high and leads to catastrophic spending through out-of- pocket payments. Universal health coverage needs to be expanded to guarantee financial protection for vulnerable women. Objectif Estimer les couts directs engendres par la prise en charge des meres ayant evite un deces de justesse et par les maladies potentiellement mortelles au Kenya, ainsi que les facteurs lies aux depenses de sante catastrophiques pour ces femmes et leur foyer. Methodes Une etude prospective et representative a l'echelle nationale a ete menee aupres de l'ensemble des femmes ayant evite un deces de justesse durant la grossesse et l'accouchement, ou dans les 42 jours suivant l'accouchement ou l'interruption de grossesse. C'est dans ce contexte que nous avons compare le cout du traitement des deces maternels evites de justesse avec celui des femmes souffrant de maladies potentiellement mortelles. Nous avons procede a une analyse de regression logistique afin d'evaluer les facteurs cliniques, demographiques et domestiques lies aux depenses de sante catastrophiques. Resultats Sur un total de 3025 femmes, 1180 (39,0%) avaient evite un deces de justesse et 1845 (61,0%) presentaient des maladies potentiellement mortelles. La prise en charge des deces maternels evites de justesse coutait en moyenne 7135 shillings kenyans (71 dollars americains), tandis que les maladies potentiellement mortelles revenaient a 2690 shillings kenyans (27 dollars americains). Parmi les femmes contraintes de payer elles-memes ces frais, 26,4% (122/462) ont fait face a des depenses catastrophiques. C'est a Nairobi et dans la Province centrale que la prise en charge des deces evites de justesse s'est averee la plus onereuse (22 220 shillings kenyans; 222 dollars americains). Les couts moyens les plus eleves etaient assumes par les femmes ayant subi des complications a cause d'une grossesse ectopique (7800 shillings kenyans; 78 dollars americains) et des infections liees a la grossesse (3000 shillings kenyans; 30 dollars americains). Les infections liees a la grossesse, l'avortement, les grossesses ectopiques et les traitements dans des etablissements secondaires et tertiaires etaient frequemment synonymes de depenses catastrophiques. Conclusion Le montant que represente la prise en charge des deces maternels evites de justesse est considerable et entraine des depenses catastrophiques lorsqu'il doit etre debourse par la patiente elle-meme. Il est imperatif d'etendre la couverture maladie universelle afin d'assurer la protection financiere des femmes vulnerables. Objetivo Estimar los costes directos del tratamiento de las mujeres con morbilidad materna extrema y con enfermedades potencialmente mortales en Kenia, asi como los factores asociados a los gastos sanitarios catastroficos para estas mujeres y sus hogares. Metodos Como parte de un estudio de cohortes y representativo a nivel nacional de todas las mujeres con morbilidad extrema durante el embarazo y el parto o dentro de los 42 dias posteriores al parto o a la interrupcion del embarazo, se comparo el coste del tratamiento de los casos de morbilidad extrema ingresados en centros de referencia con el de las mujeres con enfermedades potencialmente mortales. Se utilizo un analisis de regresion logistica para evaluar los factores clinicos, demograficos y domesticos asociados a los gastos sanitarios catastroficos. Resultados De 3025 mujeres, 1180 (39,0 %) tuvieron morbilidad materna extrema y 1845 (61,0 %) padecieron enfermedades potencialmente mortales. El coste medio del tratamiento de los casos de morbilidad materna extrema fue de 7135 chelines kenianos (71 dolares estadounidenses, USD), en comparacion con los 2690 chelines kenianos (27 USD) de las enfermedades potencialmente mortales. De las mujeres que pagaron de su bolsillo, el 26,4 % (122/462) tuvo gastos catastroficos. La mediana de los costes mas elevados para el tratamiento de la morbilidad materna extrema se registro en Nairobi y en la region central (22 220 chelines kenianos; 222 USD). Las mujeres con problemas de embarazo ectopico y con infecciones causadas por el embarazo tuvieron los costes medios de tratamiento mas elevados, 7800 chelines kenianos (78 USD) y 3000 chelines kenianos (30 USD), respectivamente. Las infecciones causadas por el embarazo, el aborto, el embarazo ectopico y el tratamiento en centros de atencion secundaria y terciaria se asociaron de manera significativa con los gastos catastroficos. Conclusion El coste del tratamiento de la morbilidad materna extrema es alto y genera un gasto catastrofico mediante los pagos de bolsillo. Se debe ampliar la cobertura sanitaria universal para garantizar la proteccion financiera de las mujeres vulnerables. [phrase omitted], Introduction Many countries in sub-Saharan Africa have increasingly committed to tackling maternal illnesses and deaths through a mix of interventions. For instance, in the past 15 years, the Kenyan government [...]