Although most international trips, including students’ study abroad programs, were put on hold in 2020, these might resume this year after the COVID-19 vaccine reaches student populations. Reproductive health providers can help young women prepare for the contraceptive needs and uncertainties of travel.

A new study revealed that young female travelers overwhelmingly say they will be abstinent during their travels, but their actual experience is the opposite.1

“Women who returned from travel told me they left with no intention of having a new sex partner, but that was not how it turned out,” says Summer Martins, PhD, MPH, postdoctoral associate in the department of obstetrics, gynecology, and women’s health at University of Minnesota Medical School. “Women in the pre-travel group thought they would not be sexually active, so that expectation lowers their level of alertness.”

For instance, a women might think, “I might be a month late with my contraceptive shot, but I’ll just get it when I come back,” she explains.

From a clinician’s viewpoint, it would be worthwhile to say, “Maybe you’ll be abstinent, but just in case, let’s renew your shot right now before you go, and then we won’t have to worry about it,” she adds. “Some of those risks can be mitigated. It’s a clinician’s job to help patients anticipate where those potential risks are.”

In 2016 and 2017, Martins and co-investigators recruited female students who had either completed an international trip in the previous three months or who had plans for international travel in the next three months.

“It was important in this study to gather data in both the pre-travel period to know what are the risks they’re preparing for, and also after they travel, to see what their experiences are when they traveled,” Martins says.

While travel is not universally risky from a reproductive health perspective, some women in the study found themselves in situations that posed risk. “In the pre-travel period, when I asked women if they had ever used emergency contraception, they were very experienced with it, but very few of them were planning on bringing it with them,” Martins says.

The reality is that international travel is a situation in which someone might not have access to emergency contraception when its needed. “You need that backup, Plan B, and they were not bringing it with them,” she says.

Researchers found that 17% of women who had recently traveled internationally formed new sexual partnerships with men during their travel period. Overall, 29% experienced a contraceptive lapse. Contraceptive lapse was highest (50%) among pill users. The pill was the most commonly reported contraceptive method.2,3

Researchers were motivated to identify potentially vulnerable points in women’s travel and reproductive health and safety. Knowing that women might underestimate their potential for sexual experiences abroad, providers and counselors can make suggestions and educate them on those risks.

“Someone could say, ‘You’re traveling internationally, and you’ll face risks, and here’s a dose to bring with you. You might not need it, but here it is, just in case,’” Martins says. “Providers and counselors can raise awareness of the different types of risks women may face when they’re traveling.”

Providers also can help women access emergency contraception in areas where it might be difficult to find over the counter. Providers can write a prescription before the woman travels.

Doctors give travelers prescriptions of antibiotics to take in the event of foodborne illnesses, and they vaccinate travelers to prevent infectious diseases. Giving travelers an emergency contraceptive to take with them is similar, Martins notes.

“If we do it for diarrhea, we can do it for unplanned pregnancy,” she adds.

Another issue that young women travelers might experience is running out of contraception during their overseas stay. During in-depth interviews with study participants, researchers found that women often were unable to get enough contraception to cover their entire travel period.

“Either there were insurance rules that limited the number of pill packs dispensed at one time so they couldn’t get an entire semester of pills, or there were other logistics,” Martins explains.

For instance, some women did not expect to have sex while they traveled, so contraceptives were a low priority. They expected to let their patch or injection lapse. “Some, at the last minute, got their pills refilled, but the timing was wrong, and they ended up traveling to another country without a continuation of their preferred method,” Martins explains.

Even women who traveled with enough contraception faced problems. They found the time differences and new and hectic traveling schedule would throw off their timing in taking a daily birth control pill.

“They would have contraceptive lapse because they were traveling across time zones, and all of their routines were ended with a completely new country, different experiences, and a disruption in all those things that helped them keep on schedule with their daily pill,” Martins says.

Qualitative interviews of participants revealed that young women had an overall positive response to questions about intrauterine devices (IUDs) and whether these are appropriate for longer-term travelers. They acknowledged that IUDs were maintenance-free when compared with taking a pill every day, Martins says.

“But a lot of women expressed concern about adjusting to a new method like that,” she adds. “What if something went wrong and they needed to manage it in a clinician’s office? Would they have access to care if they had it inserted and then needed it removed?”

Clinicians could keep in mind the same guiding principles of patient autonomy when counseling women travelers on contraceptive options and strategies. “Patients should choose the method that’s most well-suited for them,” Martins says.

Clinicians can guide patients in their choices by noting that not all methods will be available during their international travel, so they might want to plan ahead. Also, they could point out that it is difficult to maintain their pill schedule when traveling across time zones. “They need to have a plan, but not necessarily change their methods,” Martins says.

For example, some women interviewed by researchers said they anticipated that their contraceptive ring would need to be replaced while they were traveling. They replaced it right before their trip, which made it effective during a several-week travel schedule, she explains. Women also could get a contraceptive shot right before they leave.

“They could bring emergency contraception or condoms with them,” Martins says. “Clinicians can help them, saying, ‘I’ll give you this dose and six condoms, to make sure you’re set.’”

Women returning from trips often were resourceful and accessed contraception while abroad. One participant even obtained a medical abortion during her travels, she notes.

“Some of those travelers will have partners who have their own condoms, or they can find condoms in their destination,” Martins says.

But the important thing is for clinicians and counselors to help patients troubleshoot their potential obstacles and options before they leave the United States.

“If they’re going on a long trip, do they have enough supply of contraceptives? If not, help them get it,” Martins says.

Other issues that clinicians should discuss include the problems with language barriers and cultural miscommunication, which could affect contraception discussions with potential sexual partners. Also, there is potential for sexual assault and becoming infected with HIV or sexually transmitted infections (STIs). Women need consistent advice on STI/HIV prevention, and they should be offered condoms to take with them in case their sexual partners do not have condoms.

“Equip them to the best extent you can, literally with supplies,” Martins says.

Also, clinicians could ask women to return for a visit after their trip, to rescreen them for STIs in the event they had a new partner while traveling, she adds.

“Close physical and emotional relationships that lead to sexual intercourse and unintended pregnancies also expose women and men to COVID-19 infection,” explains Robert A. Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board. “Once exposed to the risk of becoming pregnant from unprotected sex, a woman may know she has the option of using an emergency contraceptive. There is no postcoital treatment that can lower a woman’s risk for COVID-19 infection.”

REFERENCES

  1. Martins SL, Hellerstedt WL, Brady SS, et al. Sexual and reproductive health during international travel: Expectations and experiences among female university students. J Am Coll Health 2020;1-8.
  2. Martins SL, Mason, SM, Hellerstedt WL, et al. Risk of contraceptive lapse and new sexual partnership among female university students traveling internationally. Persp Sex Reprod Health 2018;50:173-180.
  3. Martins SL, Hellerstedt WL, Mason SM, et al. Pregnancy prevention on the fly: An exploratory study of contraceptive lapse among young women traveling internationally. J Women’s Health 2019;28:951-960.