key: cord-0912257-08e9p12l
authors: Temmerman, Marleen
title: Family planning in COVID-19 times: access for all
date: 2021-05-18
journal: Lancet Glob Health
DOI: 10.1016/s2214-109x(21)00231-x
sha: 731f46bba8547abca437df1fdae9a0c8f82ef75d
doc_id: 912257
cord_uid: 08e9p12l

nan

The COVID-19 pandemic has substantially strained health systems and transformed the sexual and reproductive health environment worldwide. A WHO survey showed that across 105 countries, 90% have had health service disruptions as a result of the COVID-19 pandemic. 1 One of the most commonly disrupted areas is family planning services, with 68% of countries reporting service disruptions. The Guttmacher Institute estimated that a 10% decline in use of short-term and long-acting reversible contraceptives across 132 lowincome and middle-income countries would increase the unmet need for contraception over the course of 1 year to 48·6 million women, resulting in 15 million additional unintended pregnancies, 1·7 million additional women with major obstetric complications without care, and more than 3 million additional women resorting to unsafe abortions. 2 COVID-19 mitigation measures as well as weak preparedness and overload of health service systems will affect health and health seeking behaviour, especially in sensitive domains such as sexual and reproductive health.

However, the actual effect of the pandemic on women's contraceptive behaviour, unmet family planning needs, and unintended pregnancy risk, particularly in sub-Saharan Africa, is largely unknown. In their study in The Lancet Global Health, Shannon Wood and colleagues 3 examined population-level changes in women's needs for and use of contraception during the COVID-19 pandemic in four African settings (Burkina Faso, Kenya, Kinshasa [Democratic Republic of the Congo], and Lagos [Nigeria]) through a populationbased telephone survey between 2017 and 2020, including 7216 married women or women in union aged 15-49 years. Wood and colleagues found that during the pandemic, a significantly higher proportion of women in Lagos were in need of contraception than before the pandemic (5·81 percentage point increase [74·5% to 80·3%]), and there was a significant increase in contraceptive use among women in need in rural geographies in Kenya (7·35 percentage point increase [71·6% to 78·9%]) and Burkina Faso (17·37 percentage point increase [30·7% to 48·1%]). 3 This study does not support the anticipated deleterious effects of women's access to and use of contraceptive services in the early stages of the pandemic. These data are encouraging and require further follow-up, including of single women and adolescents, in the later stages of the pandemic when there were potentially more service disruptions and supply issues. Similar data have been reported on the use of contraceptive health services by women referred via community health promoters in two large urban and peri-urban areas of Mozambique, during the period immediately surrounding the national state of emergency declaration linked to the COVID-19 pandemic. 4 The data reported for 109 129 women served by 132 unique promoters and 192 unique public health facilities showed that the state of emergency was associated with a modest short-term reduction in both service provision and use, followed by a rapid rebound. These data suggest that the accessibility of reproductive health services was not substantially reduced during the first phase of the pandemic-related emergency. 4 In a separate study, Weinberger and colleagues 5 attempted to quantify potential shifts in contraceptive use that could result from COVID-19 mitigation strategies. Their results suggested a potential decreased demand during the COVID-19 pandemic for products that require face-to-face contact with a health-care provider or that might be more difficult to obtain, including intrauterine devices, implants, and provideradministered injections. These changes would run counter to recent trends in contraceptive use and public sector procurement. In Kenya, around 40% of women are already using a long-acting or permanent method of contraception. 5 Because implant use in Kenya has increased in recent years, only a small proportion of users would be due for implant removal or replacement in the coming months in 2021. Furthermore, based on evidence that many long-acting reversible contraceptive methods can safely be used beyond their labelled duration, it is reasonable to assume that many users with a scheduled method replacement in 2021 could remain protected from unintended pregnancy without an additional service during COVID-19 disruptions should they desire to continue using their existing method. However, when women do require the removal of a contraceptive device, efforts should be made to ensure safe access to services. 5 The COVID-19 pandemic has also leveraged innovations and new technologies that might See Articles page e793

www.thelancet.com/lancetgh Vol 9 June 2021 become routine standard of care in the future, including telemedicine in contraception initiation and continuation. Mickler and colleagues 6 have outlined evidence-based interventions for consideration in family planning, including digital health technologies to improve data for decision-making, manage logistics, reduce contraceptive stockouts, and improve providerclient capacity. Supporting mobile outreach service delivery to provide a wide range of contraceptives, including both short-acting and long-acting reversible methods, allows for flexible and strategic delivery of family planning services in areas with poor access to health-care providers. Providing family planning information, counselling, and methods including oral contraceptives, condoms, and injectable contraceptives through drug shops and pharmacies, might expand family planning access and availability, particularly in low-income or rural areas. In addition, integrating trained, equipped, and supported community health workers into the health system can increase family planning access by bringing services directly to clients. 6 Integration of family planning services with child immunisation services (one of the most equitable and well used health services around the world), or offering family planning immediately post-partum rather than after 6 weeks, can provide unique platforms to integrate family planning and reproductive health care. [6] [7] Global and national authorities should consider classifying family planning as an essential health service and emphasising prompt port and customs clearances and distribution logistics for contraceptives. 6 Additionally, ensuring the continuity of funding, including domestic public financing, for family planning services and supplies is crucial. 6 I support the call by Wenham and colleagues 8 for governments and global health institutions to consider the sex and gender effects of the COVID-19 outbreak, both direct and indirect, and to analyse the gendered impacts of the multiple outbreaks, incorporating the voices of women on the front line of the response to COVID-19 and of those most affected by the disease within preparedness and response policies or practices going forward.

Pulse survey on continuity of essential health services during the COVID-19 pandemic

Estimates of the potential impact of the COVID-19 pandemic on sexual and reproductive health in low-and middle-income countries

Need for and use of contraception by women before and during COVID-19 in four sub-Saharan African geographies: results from population-based national or regional cohort surveys

Short-term effects of the COVID-19 state of emergency on contraceptive access and utilization in Mozambique

Doing things differently: what it would take to ensure continued access to contraception during COVID-19

Applications of the high impact practices in family planning during COVID-19

The negative impact of COVID-19 on contraception and sexual and reproductive health: could immediate postpartum LARCs be the solution?

COVID-19: the gendered impacts of the outbreak