Sarah Brittingham, Senior Technical Officer, FHI 360
When the pandemic started, there was a sense of urgency for data to inform our understanding of COVID’s implications on access to essential services like FP. Would adolescent pregnancy rates skyrocket? Would discontinuation lead to plummeting rates of contraceptive use? Since then, we’ve made steady progress to strengthen the FP – COVID evidence base. We’ve learned, for example, the importance of maintaining up-to-date policy guidelines during crises, that the pandemic aggravated existing inequities related to family planning and postpartum care and access, that service disruptions were mostly limited to April and May 2020 in low-and middle-income countries, that self-care helped fill service delivery gaps, and that many FP practices were adapted to adjust to COVID-related challenges.
The quiet end to this third pandemic year offered me an opportunity to reflect on the contribution of one prospective, longitudinal study on women’s experiences with family planning during COVID-19. The study generated information from the perspectives of women in Malawi, Nepal, Niger, and Uganda who used modern nonpermanent contraceptive methods or who did not want to get pregnant within 2 years but were not using a modern contraceptive method. The study illustrates the potential ways in which the pandemic may have affected their journey as these women attempted to access and use family planning services. This assessment involved a short survey with mobile phone users ages 18 to 49, followed by three rounds of follow-up interviews, spaced by four months, targeting women in potential need of contraception (non-pregnant women using modern non-permanent contraception or not wanting a child within two years). The women reached by the study were young overall, with 70% or more aged 15-24 across countries. Between December 2020 and January 2022, we reached 21,692 women with the initial survey and followed up with 5,124 women to examine:
- access-related reasons for not using family planning that led to unintended pregnancies,
- their ability to obtain their preferred method (among users of modern contraception), and
- barriers to family planning access and use (among non-users of modern contraception).
Reaching over 20,000 women across four countries during COVID and following thousands of them for a multi-round survey is no simple task. A consortium of partners including FHI 360, EVIHDAF, PSI, and Makerere University School of Public Health partnered with Viamo, a global social enterprise specialized in use of digital technology with a large reach to facilitate recruitment of women and rapid data collection by phone using interactive voice response, thus avoiding contact with participants during lockdowns and periods of high COVID transmission.
In this blog, we’ll highlight key learnings and insights from the study.
First, the good news:
• Method choice was mostly realized among modern users. Over 79% of women already using modern contraception were able to access their preferred method during the pandemic across survey rounds and countries.
And now, some challenges encountered by the women in our assessment:
• Some women attributed their unintended pregnancies to the pandemic. Across countries, 74%-87% of respondents with unintended pregnancies indicated that the pandemic had affected their ability to delay or avoid getting pregnant. Specific reasons included: preferred method unavailability, service closure, and fear of infection while seeking services, especially in Malawi and Uganda.
• Some non-users of modern contraception who tried to get a method were unable to get one. Others didn’t try. 52% of non-users in Malawi, 29% in Nepal, 37% in Niger, and 53% in Uganda had tried obtaining a method between March 2020 and the first panel round. 32-37% of non-users in Malawi, 19-21% in Nepal, 35% in Niger, and 40-41% in Uganda, had tried obtaining a method between subsequent rounds. Unavailability of their desired method was the main barrier to uptake.
Additionally, 8-20% of non-users across countries and rounds had wanted to use a method but not tried to obtain one. Fear of infection was almost always the main reason for not trying to get a method. In Malawi, service closures were also reported as a barrier.
In sum…
Given the paucity of data available from the perspective of women early on in the pandemic, this study provided important information on the potential ways their ability to access and use family planning may have been affected by the pandemic across four countries. The women we surveyed attributed unintended pregnancies to the pandemic due to both supply- (method unavailability, service closures) and demand-side challenges (fear of infection, cost). While most users were able to access their preferred method, there were missed opportunities among non-users who were afraid to seek services or who accessed services but left without a method.
As the survey rounds came to a close, stakeholders in each country gathered to digest the data. In meetings following the final survey round, they identified opportunities to apply learnings, which they articulated in country-specific recommendations (see box at right).
Illustrative Stakeholder Recommendations from Malawi, Nepal, Niger, and Uganda
Malawi
• Address hesitancy to access health services at health facilities through social and behavioral change communications.
Nepal
• Improve availability of the full method mix through the public and private sector.
Niger
• Strengthen the provision of quality services through community-based distribution of contraceptives including injectables.
Uganda
• Encourage vaccination of health providers, which increases women’s confidence to access services.
(Note: These recommendations were published in our manuscript as well.)
Stakeholders in Nepal gather to digest study data and generate recommendations.
How to apply these learnings in 2023 and beyond
It is important to emphasize that these results are not generalizable, but instead offer insights into the experience of the subset of women surveyed. While the results from each country and ensuing recommendations varied, the study’s global results offer some key lessons to improve preparedness for future crises.
- The barriers that emerged from this assessment were not all clearly related to COVID-19 and associated response measures. Rather, our findings highlight the potential for crises to compound pre-existing health system challenges such as those related to method availability.
- On the demand-side, while more or less marked across countries and time points, fear of getting infected while seeking services was a recurring theme. This points to the need for comprehensive public messaging integrating infection control with guidance on how to continue accessing care.
- Taken together, our findings show that improved preparedness will require improving the resilience of health systems and being poised to deploy additional contextual measures when crises arise.
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