By Melinda Young

EXECUTIVE SUMMARY

The COVID-19 pandemic has placed hardships on women seeking contraceptives and abortion care worldwide. It has been particularly deleterious to vulnerable populations.

  • A shadow pandemic has developed of reproductive health disparities and more barriers to contraception.
  • One study revealed Black women were 38% more likely to have access issues than were white women.
  • State and federal governments need to prioritize the needs of women.

Early data on the effects of the COVID-19 pandemic on reproductive health services show disparities persisted across women with different socioeconomic backgrounds.

For example, the Coronavirus Aid, Relief, and Economic Security (CARES) Act included anti-abortion provisions that place more burden on vulnerable populations, says Nelia Viveiros, EdD, vice chancellor for diversity, equity, and inclusion at the University of Colorado Denver Anschutz Medical Campus. (More information is available at this link: https://rewirenewsgroup.com/article/2020/03/27/covid-19-stimulus-bill-includes-broad-discretion-to-deny-loans-to-reproductive-health-groups/.) The result is a shadow pandemic of reproductive health disparities and more barriers to contraception, Viveiros says.

The pandemic disrupted women’s ability to make timely abortion decisions, at least in Canada, says Julie G. Thorne, MD, MPH, FRCS(C), assistant professor, family planning and global health, obstetrics, and gynaecology, Sinai Health Systems and University of Toronto.

Thorne’s research focused on the pandemic’s effects on women’s reproductive health worldwide, including access issues that women in Kenya and other low-resource countries face.1 But she also has seen examples of the pandemic’s effects on North American women.

“We’re seeing it borne out locally in some of the same ways and in some different ways,” Thorne explains. “As someone who focuses on family planning, I see that there has been some adverse impact for women when it comes to access to contraception and access to timely and safe abortion care during the pandemic. I’ve had a number of women referred to me for abortion care and they have parallel or familiar stories. There were a series of events, including a negative pregnancy test at home. Then they go to a doctor, but the ultrasound is canceled because of the pandemic.”

The women say they began to feel better and thought they would receive a call if they were pregnant, and the call never came. Time went on, and the women began to notice they are pregnant, Thorne adds.

These women often are disadvantaged, such as immigrants, refugees, or women who struggle with mental health issues or addiction. “They might have had any of those challenges that would impact their ability to navigate a complicated health system during the pandemic,” Thorne says. “First trimester abortions here are easier, but second trimester abortions are much harder in Canada, so there are huge access issues.”

Thorne estimates she has seen around 10 women with unintended pregnancies who made it to the second trimester because of disruption to reproductive health services.

“They’ve all had navigation issues that worsened because of the pandemic,” she says. “Universally, all of the women said that if they had known, they would have acted so much sooner.”

‘Shadow Pandemic’ Will Continue

As winter approaches, there likely will be a continuation of the shadow pandemic that intersects between COVID-19, domestic violence, and poor outcomes for women’s health and well-being, Viveiros says.

“There’s a Guttmacher Institute study that shows women’s access to contraception and reproductive health services has been constrained,” Viveiros says. “One in three reported difficulty getting to a healthcare provider to obtain birth control. The barriers were more pronounced for Black women.”

According to the study:

  • Black women were 38% more likely to encounter access issues than were white women;
  • Hispanic women were 45% more likely to encounter access issues than white women;
  • Women who identify as LGBTQ were 46% more likely to encounter access issues than straight women.2

“Nearly 40% of Black women reported delayed healthcare provider access vs. 29% of white women,” notes Amy Bonomi, PhD, professor and director of the Women’s Leadership Institute at Michigan State University.

Family planning clinics and healthcare providers could improve access during the pandemic through patient outreach. “Some of the outcomes and recommendations we made included things like being proactive and reaching out to people instead of waiting for them to contact you,” Viveiros expains.

Technology served as both a facilitator to care and a barrier, Viveiros and colleagues noted in a recent paper. Some family planning clinics found innovative ways to provide contraception access by using mail services or using an independent third party to deliver contraception. Federal and state governments should prioritize the needs of women, especially minority women, in medical, social, and legal settings. Lawmakers should pass legislation to support women, the authors noted.3

Barriers to STI Care

Another consequence of the pandemic involves barriers to diagnosing, tracing, and treating sexually transmitted infections (STIs). Since 2014, STI rates have been increasing worldwide. This follows the reverse trend where STI rates were declining through the 1990s — to the point that in 2000, the Centers for Disease Control and Prevention spoke about eliminating syphilis from the United States, says Theodore Rosen, MD, professor and vice-chair of dermatology at Baylor College of Medicine in Houston.

“This was a little pie in the sky, but it was within grasp,” Rosen says. “Then, slowly, syphilis went up. In the last five and six years, if you include 2019, the rates not only went up, but went up dramatically.”

What is happening in 2020 with STIs still is unknown. Full statistics from 2019 are not yet available, but the preliminary results showed a continuation of the trend of increased STIs, he notes.2

The increase was significant nationwide and includes every age group.4 One theory is that sex with strangers is easier now because of cellphone apps like Tinder, Rosen notes.

“Young people find new, anonymous sex partners on their cellphones,” he says. “Those things are much more prevalent now than 10 to 20 years ago.” The rise in STIs among older people could be attributed to the use of erectile dysfunction drugs, Rosen adds.

No one can say for certain what the STI trend will be for 2020, although there are solid theories about why STIs might decline during the pandemic, as well as theories why they might increase, Rosen says. Data on condom use among young people is contradictory with STI data.

“The last set of surveys suggested that condom use among that peak group of 15 to 24 had actually gone up, but at the same time sexually transmitted diseases were going up,” he explains. “Again, there is a little bit of a disconnect there.”

Some researchers have found that contraceptives have been more difficult to obtain during the pandemic because of supply chain issues and lack of access to family planning clinics during the spring of 2020 when people were asked to stay home except for emergencies. (More information is available at this link: https://www.theatlantic.com/international/archive/2020/06/coronavirus-pandemic-sex-health-condoms-reproductive-health/612298/.)

“Supply chain distribution issues are worldwide, and more pronounced in developing nations,” says Jasmine Aly, MD, staff and OB/GYN at Walter Reed National Military Medical Center and an associate professor at the Uniformed Services University of the Health Sciences in Bethesda, MD.

A chief barrier to contraception access is the shortage of contraceptives and devices because of supply chain disruption during the pandemic. This problem is worse in developing countries, according to the results of a recent study. For example, the world’s largest condom manufacturer, Karex Bhd of Malaysia, had to close in March, limiting condom exports.5

During the pandemic, the government of India limited exportation of various pharmaceuticals, including progesterone, which is used in birth control pills, Aly says.

“Because India is one of the larger exporters of progesterone, the distribution was disrupted,” she adds.

Supply chains also are affected by pandemic-related border closures and travel restrictions. Thousands of family planning clinics closed worldwide because of government edicts or the lack of healthcare staff during the crisis, Aly says.

As the pandemic continues, the World Health Organization’s advice is for clinics and countries to take key actions to secure additional suppliers so they will not experience disruptions when one supplier has to stop exports, Aly says.

“We need to stress the importance of healthcare workers and staffing of clinics,” she adds. “We should focus on making sure we’re ready to meet the needs.”

Mathematical modeling shows the pandemic could result in 3.3 million unsafe abortions and 1,000 maternal deaths worldwide.5 In the United States, several states attempted to stop abortion care during the pandemic by deeming abortion services as nonessential procedures, Aly says.

“If you deem abortion is elective, then clinics will not provide that care, and patients will have to seek later abortions,” she explains. “They will have to travel further for their care. It is difficult for them to cross the border to a different state during the pandemic, when many states have police doing border checks to screen out-of-state drivers for COVID.”

While courts have said states could not close abortion clinics, it is too early to know what the repercussions of those initial closings were because data reporting is delayed, Aly says.

Worldwide, pharmacies had limited supplies of oral contraception during the pandemic. Some might have been unwilling to give women their usual three-month supply, Thorne says.

“IUD [intrauterine device] access has been very hard with fewer [reproductive health clinics] staying open through the pandemic,” she adds. “We had to define who counts as high risk and who qualifies for an office [IUD] visit during the pandemic.”

For instance, women with high-risk medical conditions were given priority for IUD procedures, Thorne says.

“We tried to advocate to do more post-placental IUDs,” she adds. “After the placenta comes out, we have easy access to the uterus.”

REFERENCES

  1. Thorne JG, Buitendyk M, Wawuda R, et al. The reproductive health fall-out of a global pandemic. Sex Reprod Health Matters 2020;28:1763577.
  2. Lindberg LD, VandeVusse A, Mueller J, et al. Early impacts of the COVID-19 pandemic: Findings from the 2020 Guttmacher Survey of reproductive health experiences. Guttmacher Institute, June 2020. https://www.guttmacher.org/report/early-impacts-covid-19-pandemic-findings-2020-guttmacher-survey-reproductive-health
  3. Viveiros N, Bonomi AE. Novel coronavirus (COVID-19): Violence, reproductive rights and related health risks for women, opportunities for practice innovation. J Fam Violence 2020;1-5. [Online ahead of print].
  4. Wiggins CJ, Rosen T. Sexually transmitted diseases in the COVID-19 era. Skinmed 2020;18:210-212.
  5. Aly J, Haeger KO, Christy AY, et al. Contraception access during the COVID-19 pandemic. Contracept Reprod Med 2020;5:17.