Gender-transformative, community-based intervention and changes in long-acting reversible contraceptive use among adolescent girls and young women in underserved districts of Mozambique

Background Modern contraceptive use among adolescents in Mozambique remains constrained by limited access and restrictive gender norms that reduce girls and young women’s autonomy over reproductive decision-making. Evidence on large-scale gender-transformative interventions that influence modern contraceptive and long-acting reversible contraceptive (LARC) uptake among adolescent girls and young women (AGYW) remains limited. The IMPACTO project (2018–2024) implemented a multi-level intervention across underserved districts of Manica and Tete provinces combining gender-transformative community strategies with youth-responsive service strengthening. This study assessed changes in modern contraceptive use and LARC uptake following implementation. Methods A repeated cross-sectional household survey was conducted at baseline (2018–2019) and endline (2023) across nine underserved districts in central Mozambique. AGYW aged 15–24 years and men aged 18–49 years were selected using a random walk household sampling approach. Data were collected using tablet-based questionnaires capturing contraceptive use, attitudes toward family planning services, gender norms, household decision-making, gender-based violence (GBV) attitudes, and awareness of abortion legislation. Differences in proportions between baseline and endline were assessed using chi-square tests, and 95% confidence intervals were estimated. Results A total of 4,861 respondents participated at baseline and 5,028 at endline. Modern contraceptive use among sexually active AGYW increased from 43.3% to 56.4% (p<0.0001). Implant use rose substantially from 3.0% to 15.4%, representing a four-fold rise in LARC uptake. Improvements were observed in contraceptive attitudes, gender-equitable norms among AGYW (17.4% to 41.8%) and men (33.1% to 49.3%), joint household decision-making (16.0% to 65.0%) and reductions in early marriage and GBV. Awareness of abortion decriminalization increased from 10.9% to 40.7%. Descriptive parallel improvements across behavioural, normative, and structural indicators were consistent with the intervention’s theory of change. Conclusions A gender-transformative community intervention combined with youth-responsive service strengthening was associated with substantial increases in modern contraceptive use and a pronounced shift toward LARC methods use among AGYW in underserved districts of Mozambique. Improvements in service delivery alone are unlikely to result in equitable access to highly effective contraception for adolescents without concurrent transformation of social and gender norms.