“You have to make a judgment call”. – Morals, judgments and the provision of quality sexual and reproductive health services for adolescents in South Africa

South Africa's legal framework on sexual and reproductive health (SRH) care for teenagers is complex. On the one hand, the law protects their right to make decisions regarding reproduction – e.g. giving girls of any age the right to terminate a pregnancy, and allowing adolescents to consent to receive contraception from age 12. On the other hand, the Sexual Offences Act sets the age of consent to sex at 16 years, and requires mandatory reporting of anyone younger. These contradictory obligations mean that nurses, doctors and counsellors are expected to provide care, and counsel teenagers about their choices, but also report and enforce the law. They must therefore make judgments about inherently moral issues: should teenagers be having sex, and what services should they receive? Based on in-depth interviews at 28 healthcare facilities conducted in 2012, and data from workshops on the ‘conflicting laws’ held in 2014, the paper uses the theoretical framework of street-level bureaucracy to understand barriers to nurses providing SRH care for teenagers in South Africa, and the implication that this has for adolescents' SRH. The paper argues that nurses' adaptation of the law is a response to significant structural constraints, moral discomfort, and poor understanding of the law – all taken against an ethical framework that emphasizes quality, responsive patient care. The result is uneven implementation that undermines SRH information, access to services, and ultimately increases risks for teens.