Why the Promotion of Family Planning Makes More Sense Now Than Ever Before?

Abstract

The COVID-19 pandemic presents unprecedented scenarios and challenges for programme managers. Health systems have been overwhelmed with the increasing number of cases, and the focus has shifted to saving lives. Furthermore, lockdowns have adversely affected the production and distribution of products and availability of commodities, while the restrictions in movement have limited individuals’ access to services. This article analyses the possible consequences of the pandemic on the rights of individuals and couples and endeavours to provide justifications for continued national commitment and investments in family planning, especially during these challenging times. As sexual and reproductive health and reproductive rights are fundamental to achieving the Sustainable Development Goals, it is critical to focus on ensuring rights-based family planning, because it is intimately associated with fundamental human rights, addresses the issue of equity, equality and universality and provides valid and practical solutions to the vital economic quagmire that has unfolded as a consequence of this global crisis.

Introduction

The first case of pneumonia caused by a novel coronavirus was reported to the World Health Organization (WHO) from Wuhan (Hubei province) in China on 31 December 2019. Subsequently, the disease COVID-19 spread and was reported in other parts of the world. WHO declared it a Public Health Emergency of International Concern on 30 January 2020. The disease was further escalated to the status of a pandemic on 11 March 2020. As per the latest estimates, more than 19 million persons have been reported to be diagnosed with the COVID-19 infection, and more than 720,000 related deaths have been reported globally (WHO, 2020).

As a response to the pandemic, governments imposed travel bans on an unprecedented scale to contain the transmission, closing their borders and implementing mandatory screening of citizens returning from heavily affected areas. In addition, many countries enforced partial or complete lockdowns, restricting the movement of their citizens to ‘shelter in place’. Governments also introduced stringent population-based interventions, such as physical distancing, surveillance with testing and contact tracing, quarantine and isolation, to slow the rate of transmission, thereby avoiding a surge of demand on the already-strained health care systems (CDC, 2020; Parmet & Sinha, 2020), and to flatten the epidemic curve of new infections. Despite these measures, the numbers of COVID-19 cases and deaths continue to rise globally (CDC, 2020).

The global lockdown, with the ensuing declining production and industrial outputs, has rendered millions of workers jobless, and some countries are witnessing unprecedented requests for unemployment benefits (Fineberg, 2020). Humanity has rarely faced such large-scale lockdowns and restrictions in mobility, and the COVID-19 pandemic offers a hitherto unfamiliar programmatic scenario. This article analyses the possible consequences of the pandemic on the rights of individuals and couples to family planning and endeavours to provide justifications for continued commitment and investment in family planning, especially during these challenging times. As sexual and reproductive health and reproductive rights are fundamental to achieving the Sustainable Development Goals (the 2030 Agenda), upholding such fundamental human rights, especially during these unprecedented times of the pandemic, is crucial to ensuring that there is no regression of progress made to date.

The Rationale for Promoting Family Planning at This Time

Increased Demand for Modern Contraceptive Methods

Restrictions in movement and lockdowns result in cloistering of individuals, couples and families. Historically, research has demonstrated that during lockdowns that completely restrict movement, and when people spend more time at home, there is a possibility of increased unprotected sex or increased sexual activity, because couples are less occupied by other recreational activities outside of the home or under stress (PAHO, 2019; Rodgers, 2005). In such situations, there is a probability that commonly used contraceptive methods (especially short-acting reversible methods, such as condoms or oral contraceptive pills) will only be available for a limited period of time, and couples are likely to run out of stock after some time. The situation may be more complex for couples who were not using a method earlier and were planning to start one around this time. For couples using reversible contraceptive methods, there might be a need for replacement (due to side effects, complications or completion of duration) or switching to another method. During such scenarios, going out to procure a contraceptive could be relatively difficult because of limitations in access to health services caused by the lockdown, and also because of the fear associated with the risk of acquiring the infection when venturing out of the house. This could lead to a reduction in contraceptive utilisation and a potential surge in unintended and unplanned pregnancies (Evans et al., 2007).

In addition, a number of countries have witnessed mass-scale movement of migrant workers from their place of place of work, back to their homes (either within the country or from abroad) as a result of prolonged periods of lockdown or closure of their work facilities. This phenomenon, which generally occurs during holiday seasons, may lead to unplanned sexual activity, as couples are reunited after a long period of time. Moreover, it can be assumed that, given the scenario of widespread restrictions on movement, these couples may also have limited access to modern contraception and, hence, may be at a higher risk of unplanned pregnancies.

During quarantine and lockdowns, rates of intimate-partner violence appear to have increased, which sometimes includes sexual coercion and sexual assault. In such cases, emergency contraception should be made available.

Health Risks Associated with Unplanned and Unintended Pregnancies

It is important to note that unplanned and unintended pregnancies (especially in women who are too young, are too old, have had too many pregnancies or have had pregnancies too close together) are associated with higher adverse pregnancy outcomes, maternal morbidity and maternal mortality. Women who are unable to obtain modern contraception and who get pregnant could decide to either continue their pregnancy (that will require antenatal care and support during delivery) or may opt for an abortion. The COVID-19 response has already brought about substantial financial hardship for many families, and not having the money to support an additional child may be a reason for couples to choose to avoid an unintended pregnancy or terminate one (Bayefsky et al., 2020). The decision to opt for an abortion will also involve increased contact with health care providers, thereby augmenting the risk of infection to both patients and staff. In situations where abortions are unsafe or illegal, the chances of complications and life-threatening risks are considerably heightened.

There is insufficient information on the impact of the COVID-19 infection on pregnant women and, currently, no evidence that they are at a higher risk of severe illness than the general population. While limited, the current evidence does not reveal increased risk of adverse pregnancy outcomes in women infected in late pregnancy (Yu et al, 2020), but the effect of COVID-19 infections during the first trimester on pregnancy outcomes have not been fully studied to date. Thus, while there is inadequate data on the adverse consequences of the COVID-19 infection on pregnancy outcomes (Luo & Yin, 2020), the influenza epidemic of 1918, the Asian flu epidemic of 1957, the SARS coronavirus infections and data from seasonal influenza demonstrated adverse impacts on pregnancy outcomes (Lam et al., 2004). Studies have cited some severe respiratory viral infections associated with higher maternal mortality (Siston et al., 2010). This has been explained by the physiological changes in pulmonary function during late pregnancy. The gravid uterus has been shown to elevate the diaphragm by up to 4 cm in the third trimester. At the same time, oxygen consumption is increased by 20 per cent in pregnancy, and functional residual capacity is decreased, thereby rendering the woman intolerant to hypoxia (Wong et al., 2004). While epidemiological studies of pregnant women with COVID-19 are limited, the risks for pregnant women could be compounded by restrictions of movement and limited access to maternity, including antenatal care, skilled birth attendance and emergency obstetric care.

The current situation is unprecedented, and it is unclear how long lockdowns and restrictions on movement will last. Past experience from various humanitarian crises has shown that emergencies are associated with higher levels of maternal malnutrition, which has long been recognised as a determinant of foetal growth, birth weight and infant mortality (WHO, 2016). Women with unintended pregnancies and maternal malnutrition are more likely to be associated with poor pregnancy outcomes (Ramchandran, 2002), hence the importance of preventing unintended pregnancies, especially during humanitarian contexts.

In the absence of global guidelines and standardised treatment protocols, the impact of medicines used for the treatment of COVID-19 infections on pregnancy outcomes is yet to be determined (Rasmussen & Hayes, 2005). Extensive and long-term clinical trials will be required to prove the effectiveness of drugs and their effects on the foetus to establish a standardised treatment for pregnant women with COVID-19. In such situations, it makes programmatic sense to prevent pregnancies by promoting access to modern contraception.

Systemic Factors Affecting Modern Contraceptive Use During the Pandemic

During humanitarian crises, with shifting priorities, government funding is often diverted to life-saving efforts (rescue, relief and rehabilitation), and sexual and reproductive health (SRH) services do not receive the attention they deserve. Furthermore, even within health care facilities, the immediate focus is on life-saving interventions and on treating cases of the infection, meaning that family planning services might be neglected. This was also documented during the Ebola epidemic in West Africa (Elston et al., 2017; Jones et al., 2016; Parpia et al., 2016).

Due to various compounding factors (such as reduced productions at the manufacturer level, delays in shipments, delays in receipt of shipped goods and delays in in-country transportation), disruptions of SRH supplies (particularly contraceptives) may also be expected. Under such programmatic contexts, where supply chains are under pressure and at suboptimal levels of performance, supplies of contraceptives that are often not deemed as ‘essential supply’ are most affected.

During phases of global economic slowdown and impending recession, it makes more programmatic sense for governments to invest in interventions with proven investment benefits and robust returns. A study commissioned by United Nations Population Fund (UNFPA, 2019) has clearly shown that to end the unmet need for family planning by 2030, an investment of US$68.5 billion is required—the per capita equivalent being only US$1.4 per person per year. In such scenarios, investing in family planning is logical because of the high returns that it yields. Every US$1 invested in meeting the unmet need for contraceptives can yield up to US$120 in accrued annual benefits in the long term (US$30–50 in benefits from reduced infant and maternal mortality and US$60–100 in long-term benefits from economic growth) (FP2020, 2018).

The Potential Impact of a Decrease in Family Planning During the Pandemic

We analysed the impact of COVID-19 on the use of family planning services by modelling the effect that the pandemic could have on access to modern contraception and family planning choices. Our analysis took into consideration the 14 countries across Asia-Pacific that currently have a high maternal mortality ratio of above 100 maternal deaths per 100,000 live births,* which is often correlated with lower access to and utilisation of key health services such as contraception, skilled birth attendance and facility-based deliveries. Based on preliminary assessments conducted for these high-priority countries, we have modelled a best case and a worst case scenario of COVID-19’s impact—a 20 per cent decrease or a 50 per cent decrease, respectively—in the coverage of access to contraception, using the Lives Saved Tool (LiST) software on Spectrum (Avenir Health, 2019).

Even by modelling a drop in coverage in 2020 alone, the effects could already be devastating, with a risk of reversal of the progress made until now in building functioning health systems and improving women’s health through access to the contraceptive method of choice. As it is likely that the negative consequences of COVID-19 will last much longer in these countries, the results of our analysis should be considered a conservative estimate.

In this analysis, as shown in Figure 1, the combined effects of these different factors on the availability of contraceptive services would mean that the unmet need for family planning could spike in 2020, increasing by 42 per cent or 79 per cent, on average, compared to the 2019 baseline in the 14 Asia-Pacific countries. In the worst case scenario, it could reach a peak of 32 per cent of women of reproductive age being unable to meet their family planning needs in 2020, with the effects of such disruption in access to services manifesting until the end of the decade.

Fear of contracting the virus might discourage women and couples from going to health centres or pharmacies to get contraceptive supplies, even when they could physically reach health providers. Border closures and disruptions to procurement and in supply chains might substantially reduce the availability of contraceptive commodities in many countries, which often experience stock-outs even during normal situations. In addition, with the restrictive measures imposed on public movement, women might not be able to access family planning services, especially if such services are not deemed essential.

Figure 1.

Source: The authors.

What Needs to Be Done

Development partners and multilateral agencies need to support national governments to ensure that their responses are comprehensive as well as equitable and inclusive, so that no one is left out and countries can continue to make progress in achieving the Sustainable Development Goals. Policymakers must ensure that universal health coverage includes pregnant women, adolescents and marginalised groups and must designate SRH, including family planning, as an essential health service, reallocating resources accordingly (Hall et al., 2020; Fineberg, 2020).

Ensuring Family Planning Service Provision

• National governments should prioritise adequate personal protective equipment (PPE) for all health workers. Family planning care providers (including midwives and all cadres of health staff providing family planning), whether based in health facilities or within the community, are essential health care workers and must be protected and prioritised to continue providing care for women of reproductive age. To be able to provide essential health services, including family planning, service providers should be able to feel safe that they are protected against potential exposure to persons with COVID-19 infections.

• With large-scale lockdowns and limited availability of various contraceptive options, it will be important to review programmatic challenges concerning changes in contraceptive choices and behaviour of couples that will impact the method mix in the country. It will be important to analyse changes in contraceptive choices and explore possible solutions, such as innovative telemedicine or internet apps and messages on mobile phone for counselling services.

• It is critical to address issues related to the availability of trained human resources. Shortage of health care providers may be due to illness, physical distancing measures and/or partial or complete lockdowns that hamper their ability to travel to their workplaces. These need to be tackled at the policy level.

• The concept of promoting community-based distribution of contraceptives such as condoms and oral contraceptive pills through community volunteers and depot holders should be explored.

• Governments may consider relaxing restrictions on the maximum quantities (cycles) of short-acting contraceptives dispensed to users to avoid frequent repeat visits.

• Health systems need to be prepared to meet an increased demand for emergency contraception, as a result of unplanned sexual activities.

• Governments may consider promoting long-acting reversible contraceptive methods, such as implants, that do not require frequent replenishment and can withstand pressures of supply chain weaknesses. Intrauterine device (IUD) insertions and tubal ligation may be provided to postpartum women who opt for such methods. However, it may not be advisable to support permanent methods, such as non–postpartum sterilisation, under routine programming, to reduce contact of women with health facilities and health providers, and to reduce the workload on health facilities. The removal of IUDs may be required if necessitated because of side effects and/or complications. In such cases, other modern methods should be made available for women to choose.

• Governments may also consider promoting ‘Task Shifting’ and permitting other cadres of trained health workers to provide some contraceptive methods such as injectables and oral contraceptive pills.

• In some countries where childhood immunisation programmes are continuing, synchronising supplies of essential SRH commodities with national immunisation programme (EPI) supplies has been implemented to overcome challenges related to supplies of short-acting contraceptives. Governments may also consider integrating essential family planning services with essential maternal and newborn care, adolescent health care, psychosocial counselling and other services, both in static sites and during outreach sessions to expand access.

Suggestions at a glance:

• Greater domestic investment in health system strengthening, including in human resources for health, to achieve universal health coverage

• Provisions should be made for extra supplies of short-acting reversible methods and emergency contraception

• Relaxation of norms on quantities of short-acting contraceptives to be dispensed to clients

• Helplines should be initiated which can provide counselling and information on the places where clients can obtain contraceptives, including emergency contraception

• Strengthened coordination at all levels to improve data collection and reporting. Monthly stock updates and inter-state transfer of essential commodities to prevent stockouts

• Synchronisation of sexual and reproductive health (SRH) supplies with supplies for routine immunisation programme (EPI)

• Expansion of partnership with other ministries and the private sector for transportation and distribution of SRH supplies

• Partnership with manufacturers and providers of raw materials for improved supplies of essential commodities, including contraceptives

• Partnership with individual private health care providers and community-based distribution to avoid shortages in remote areas

Meeting Supply Chain Challenges

• Governments may consider strengthening federal coordination among various agencies and departments to identify and address supply chain issues and gaps, such as systemic bottlenecks to access to contraceptives.

• It is important for governments to consider undertaking frequent and rapid (at monthly intervals) assessments of the health supply chain status and enforce remedial measures to address any identified weaknesses.

• Better coordination and data availability of stock balances for contraceptives can enable governments to promote sharing or inter-regional transfers of overstocked commodities in cases where one region has excess stocks while another region is facing limited availability, thereby reducing stock-outs, as well as unnecessary wastages.

• Shortage of commodities has multiple causes, including problems with decreased manufacturing levels, reduced supplies of raw material, reduced freight options and weakened global supply chains. While governments can consider asking manufacturers to maximise production, they can also direct their suppliers and others to maximise the availability of raw materials. Promoting procurement of generic products may also be considered for maximising cost efficiency.

• Ministries of health may also explore the possibility of partnering with other ministries and departments (agriculture, forestry, internal security, etc.), and possibly with private logistics solutions providers, for efficient transportation and distribution of contraceptives and other commodities.

Public–Private Partnerships

• It is important to promote public–private partnership, especially with individual health care providers in rural areas, to deliver contraceptives to their clients, where the reach of the health system is poor, or in places with vacancies of health staff.

• Governments may also consider partnering with faith-based and religious organisations and civil society organisations for supporting social distancing measures and promoting family planning, including removing myths and misinformation against contraception, as well as promoting the distribution of contraceptive supplies.

• It is advisable for governments to consider setting up helplines to provide information on the places where clients can go to obtain contraceptives, including emergency contraception. Such helplines could also be used for counselling purposes to provide evidence-based information to clients. This can also be supplemented by web-based consultancy platforms and involve the private or NGO sectors.

• The possibility of partnering with information technology (IT) and communications agencies should also be explored for promoting telemedicine and for developing free apps (providing information on contraception availability and use) for mobile phones that can be popularised among young people and couples.

The COVID-19 pandemic has affected human life in a unique and hitherto inconceivable manner. The UN Secretary-General Antonio Guterres has called it the world’s greatest test since World War II. As confirmed cases of COVID-19 mount, the pandemic is claiming numerous lives, overwhelming health systems and, by all signs, triggering geopolitical change that will extend well into the future. While the health impact has been devastating, the effect on the economy and the lives of individuals, especially the most marginalised, has been unparalleled. During such unfortunate circumstances, it is vital to also focus on ensuring rights-based family planning, because it is intimately associated with fundamental human rights, addresses the issue of equity, equality and universality and provides valid and practical solutions to the vital economic quagmire that has unfolded as a consequence of this global crisis.