key: cord-0872742-ngvulv5m authors: Roland, Noémie; Drouin, Jérôme; Desplas, David; Duranteau, Lise; Cuenot, François; Dray-Spira, Rosemary; Weill, Alain; Zureik, Mahmoud title: Impact of Coronavirus Disease 2019 (COVID-19) On Contraception Use in 2020 and up until the end of April 2021 in France date: 2021-12-29 journal: Contraception DOI: 10.1016/j.contraception.2021.12.002 sha: e25aae0a65c44ec7e2d6a8490a05fbe3c765ac2c doc_id: 872742 cord_uid: ngvulv5m OBJECTIVES: : To assess the impact of the COVID-19 pandemic on the use of reimbursed contraceptives in France after 15 months of the pandemic, according to age-group and updating previous data only pertaining to the first lockdown (two months). STUDY DESIGN: : We conducted a national register-based study by extracting all reimbursements of oral contraceptives (OC), emergency contraception (EC), intra-uterine devices (IUD) and implants from the French National Health Insurance database (SNDS), which includes and covers 99.5% of the French population, in 2018, 2019, 2020 and from 01/01/2021 to 04/30/2021. We calculated the expected use of contraceptives in 2020 and 2021 in the absence of the pandemic, based on 2018 and 2019 usage and taking annual trends into account. We assessed the difference between observed and expected dispensing rates by contraceptive type and by age-group (≤18 years old, 1835). RESULTS: : Dispensing of all contraceptives decreased compared to expected dispensing numbers: -2.0% for OC, -5.3% for EC, -9.5% for LNG-IUS, -8.6% for C-IUD, and -16.4% for implant. This decrease in the dispensing of contraceptives was observed in all age-groups, but mainly concerned women under the age of 18 years (-22% for OC, -10% for EC, -37.2% for LNG-IUS, -36.4% for C-IUD, -26.4% for implant) and those aged 18-25 (-5.1% for OC, -11.9% for EC, -18.1% for LNG-IUS, -15.9% for C-IUD, -17.6% for implants). CONCLUSIONS: : Our study showed that the dispensing of contraceptives in France was markedly impacted by the COVID-19 pandemic. Prescriptions for long-acting contraceptive use and women under the age of 25 years were the most substantially impacted. Ensuring access to contraceptive methods during health emergencies must be a public health policy priority. -Contraceptive methods -Covid-19 -Reproductive health -Healthcare access -Sexual Health The COVID-19 pandemic strongly impacted the dispensing of contraceptives in France with varying degrees of decreased dispensing according to the type of contraceptive, the age-group and the level of pandemic-related restrictions. The impact of these restrictions on unintended pregnancy at the population level remains undetermined. Health systems all over the world have been overwhelmed by the COronaVIrus Disease 19 pandemic and have struggled to maintain routine services. Difficulties accessing family planning services in 2020 have been reported even in high-income countries [1] . To reduce the spread of COVID-19, French authorities imposed 3 national lockdowns in 2020 and 2021. The first and most restrictive lockdown lasted from March 17 to May 11, 2020. People were required to stay at home, except when shopping for essential items (including pharmacy-related items), attending medical appointments that could not be conducted by telemedicine or postponed, or assisting vulnerable people. Schools and universities were closed and people were strongly encouraged to work at home. Health services focused on emergencies and managing of the pandemic. The second lockdown began on October 29, and ended on December 15, 2020 and was less restrictive: schools, public services and some -non-essential‖ shops remained open. A nationwide curfew from 8pm to 6am was then enforced in December, and then from 6pm to 6am in January 2021. Finally, a third lockdown was implemented from April 3 to May 3, 2021: schools were closed and working from home was encouraged, but shops remained open ( Figure 1 ). Some French recommendations may have encouraged access to contraception, such as a decree authorizing French pharmacists to fill expired prescriptions without requiring a new medical consultation [2] , but the effectiveness of these recommendations have not yet been studied. Our group has previously demonstrated profound changes in contraceptive use observed during the first lockdown in 2020 (two months): numbers of Oral Contraception (OC), Emergency Contraception (EC) and levonorgestrel intra-uterine system (LNG-IUS) prescriptions decreased during the lockdown and one month after compared to expectations [3] . An update of our results was needed after over one year of health crisis. We added an analysis by age-groups for a more accurate description of the impact of the pandemic on younger users whose sex lives may have changed substantially due to decreased social interaction. We also added the contraceptive implant and the Copper Intra-uterine Device (C-IUD) to our analysis to gain a more comprehensive vision of the main contraceptive methods in France. We conducted a national register-based cross-sectional study on OC, EC, implant, C-IUD and LNG-IUS dispensing during 2020 and up to April 2021 to assess the impact of the COVID-19 pandemic on contraceptive prescriptions in France. This study analyzed data from the French National Health Data System (SNDS), which provides information on health insurance claims for 99.5% of the population living in France (67,000,000 people). This database includes information on hospitalizations, outpatient care and reimbursed drugs, and is regularly used for monitoring drug utilization [4, 5] . Drugs are coded according to the Anatomical Therapeutic Chemical (ATC) classification, and medical devices are coded according to the list of medical devices and services (LPP). We screened all dispensing of contraceptives in pharmacies during 2018, 2019 and 2020, and from January 1 to April 30 2021 (i.e. incidence for EC, C-IUDs, LNG-IUSs and implants, and incidence and prevalence for OC). Details on the methods used for this study are accessible online [6] . The first lockdown lasted from 03/17/2020 to 05/11/2020, the second lockdown lasted from 10/30/2020 to 12/15/2020, and the third lockdown lasted from 04/03/2021 to 05/03/2021. Our analysis was based on the period from the beginning of the first lockdown to the end of the third lockdown, i.e. from 03/16/2020 to 04/30/2021. The curfew period was defined from 12/15/2020 to 04/02/2021. We extracted all instances of dispensing of solely OC reimbursed in France (i.e. progestogen- Lastly, we analyzed the percentage variation between observed and expected dispensing numbers according to four age-groups (≤18 years old, between 18 and 25, between 25 and 35 and >35 years old) during the follow-up period. All analyses were performed with SAS Enterprise Guide software 7.1 (SAS Institute, Cary, NC). This study was conducted in line with Decree 2016-1871 dated December 26, 2016 relating to French law articles R. 1461-13 and 14 [7] . As a permanent user of SNDS, Institutional Review Board approval is waived for the author's team. The percentage changes for each contraceptive are presented in Table 1 and the percentage changes for each contraceptive by age-group are presented in Table 2 . OC dispensing decreased slightly between lockdowns, with a net decrease of -2.0% at the end of the study period (Table 1 ). It is estimated that OC dispensing numbers during the pandemic were down of 317,495 on expected numbers. Dispensing to women under the age of 18 years was impacted most, with a 22.0% decrease for this age-group, followed by the 18-25 group (-5.1%) ( Table 2) . [ Table 2 ] Dispensing of EC decreased substantially from the beginning of the first lockdown (03/16-05/11/2020) compared to expected dispensing numbers. Dispensing of EC did not increase between lockdowns, and after a surge during the first fortnight of November 2020 (+13.8%), EC dispensing decreased during the second lockdown and in 2021 (Figure 2 ). At the end of the follow-up period, we estimated that 37,884 women (-5.3%) did not use EC (-10.0% for ≤18 years old, -11.9% for women 1835). [ Figure 2] After analyzing data from the whole French population, our study showed that contraceptive dispensing in France was strongly impacted by the COVID-19 pandemic, with varying degrees of decreased dispensing depending on the type of contraceptive, the agegroup, and the level of necessary restrictions implemented for safety reasons. OC dispensing decreased very slightly compared to expected contraceptive use. Dispensing of EC and intrauterine contraceptives decreased more substantially during the first lockdown and then increased moderately at the end of 2020 and in 2021. Lastly, implant use decreased constantly during the follow-up period and was associated with the most marked negative balance. French women under the age of 25 years were the most severely impacted by the observed decrease in dispensing for the five contraceptives. To our knowledge, no other study has examined the use of contraceptives during the pandemic according to age-groups. During the COVID-19 pandemic, the estimated decrease in contraceptive use in low-income countries was 10% [8] . In France, a high-income country with a high contraceptive coverage of 71.8% of women of reproductive age [9] , our study showed that contraceptive use was also strongly impacted by the pandemic. Our study highlighted a difference between contraceptives dispensed directly to women by pharmacies and those requiring health professional intervention for insertion. Fears of OC shortage and lack of visibility could explain the OC stockpiling behavior during the first weeks of the first two lockdowns. This behavior was also observed in a South African study that reported increased OC use during the first five weeks of national lockdown, whereas Long-Acting Reversible Contraception (LARC) prescriptions decreased [10] . A Spanish study reported that 96.6% of the women surveyed continued their combined OC during lockdown despite decreased sexual activity among one-half of them. Moreover, Women who already used LARC before 2020 may had postponed device removal/replacement beyond the expiry date, as recommended by gynecological organizations during the pandemic [11, 12] . Some women who would have considered LARC removal to become pregnant may also have postponed trying for a baby during the pandemic. We performed some additional analysis to support this hypothesis. We observed indeed a decrease of about 11% of the IUD removal in 2020 compared with expectations. This decrease could reflect the fact that some women had postponed device removal. Surprisingly, our study showed a difference between the three types of LARC. A significant decrease of the dispensing of implants was observed in 2020 and 2021 compared to expected numbers and compared to intrauterine contraceptive devices. Implants are the least commonly used contraceptive method in France and are mostly prescribed for younger women (4.3% of all women, but 9.6% of the 20-24 year age-group [9] ). Due to the impact of lockdowns and curfews on their sex lives, younger women may have postponed their decision to have an implant inserted. In contrast, after a marked decrease during the first lockdown, LNG-IUS and C-IUD dispensing gradually increased. To our knowledge, no other study has reported a difference between C-IUD and LNG-IUS use during the pandemic [10] . Both types of IUD have different indications, and different user and prescriber profiles [13] but it would appear that the pandemic had similar impacts on their use. In line with WHO guidelines [14] , the French National College of Gynecologists and Obstetricians encouraged gynecologists to initiate or renew OC prescription using telemedicine, to propose intra-uterine device insertion during physical consultations only under safe conditions, and to postpone LARC removal procedures [12] . These guidelines were also applied in the USA [15] and in Italy [16] . A systematic review has shown that telemedicine improved obstetric outcomes [17] , but did not improve contraceptive follow-up, although women reported an overall positive experience with telemedicine for contraceptive counselling during the pandemic in New York [18] . As telemedicine was not fully implemented in France prior to the COVID-19 pandemic, no data are available concerning the acceptance of gynecological telemedicine by French patients and physicians. Telemedicine could possibly accentuate health access inequalities due to unequal access to technology, especially in the context of a health and social crisis [19] . The decreased use of EC and LARC during lockdowns could have led to unplanned pregnancies, especially among younger and women in more precarious circumstances. Moreover, difficulties were encountered accessing safe abortion care during the pandemic [20] . In the US, the women most economically affected by COVID-19 pandemic were more likely to have difficulties accessing contraception, despite a greater need of preventing pregnancy [21] . Lockdowns have a huge impact on unmet family planning needs: the United Nations sexual and reproductive health agency estimated that every three months of lockdown in the world could lead to an additional 2 million women losing access to modern contraceptives [22] resulting in numerous unintended pregnancies [23] . To tackle the issue, the French government decided to extend the legal limit for medical abortion (to 9 weeks of amenorrhea instead of 7 weeks) during and after the 2020 lockdowns [2] . In 2020, 220 000 abortions were recorded in France, which represents a 4% decrease compared to 2019. At the same time, a decreased birth rate was observed in France in 2020 (1.84 children per woman, -1.8% compared to 2019) [24] . Consequently, the decreased dispensing of EC and LARC might be the result of decreased sexual activity of women in France during the pandemic, due to decreased social interactions, rather than an unmet demand for contraception. A negative impact of the first lockdown on sexual activity was highlighted in another French study (but concerning men who have sex with men) [25] . Similarly, a decreased interest in sex during quarantine was observed in Australia [26] . Australian women also delayed their pregnancies during the first lockdown [27] , and Turkish women reported a reduced desire to have a child during the pandemic [28] . The SNDS database does not include information about contraceptives not reimbursed by national health insurance such as male and female condoms (available over the counter) and pills including desogestrel, gestoden or drospirenon (prescribed by a health practitioner). Women in our study may have discontinued their contraception in 2020 and switched to nonreimbursed contraceptives. However, non-reimbursed pills only represent 14% of all pills prescriptions in France and their use may not be different from reimbursed pills during the crisis [29] . We used C-IUD and LNG-IUS dispensing as a proxy for device placement and use, as we considered it unlikely that women obtained the device from a pharmacist without device placement over the following days/weeks. This study reflects the impact of the COVID-19 pandemic on the use of the main contraceptives in France over a whole year, as already demonstrated for other types of medications [30, 31] . Younger French women were impacted most by the decrease observed in the dispensing of contraceptives. Ensuring access to contraceptive methods during health emergencies must be a public health policy priority. In accordance with data protection legislation and the French regulation, the authors can not publicly release the data from the SNDS. However, any person or structure, public or private, for-profit or non-profit, is able to access SNDS data upon authorization from the French Data Protection Office (CNIL), in order to carry out a study, research or an evaluation in the public interest (https://www.snds.gouv.fr/SNDS/Processus-d-acces-aux-donnees and https://www.indsante.fr/). Figure 1 : Timeline of the restrictions during 15 months of the COVID-19 pandemic in France Access to modern methods of contraception in Italy: Will the COVID-19 pandemic be aggravating the issue? 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Dossier thématique -Contraception -ANSM n Mandatory Infant Vaccinations in France During the COVID-19 Pandemic in 2020 Intravitreal anti-VEGF use in France: a cross-sectional and longitudinal Nationwide observational study Figure 2: Observed and expected dispensations of oral contraceptive (A), emergency contraception (B), levonorgestrel-releasing intrauterine system (C), Copper-Intrauterine Device (D) and Implant (E) users during Each author has confirmed compliance with the journal's requirements for authorship.We thank Anthony Saul for his help in correcting and clarifying the manuscript. The authors declare that they have no conflicts of interest.