A Tale of Two Times: Contraceptive Care in the COVID-19 Pandemic
Contraceptive care visits declined sharply in 2020, according to researchers. The worst period was in April 2020 during the COVID-19 shutdown.
- Long-acting reversible contraceptive use decreased by 46% in April 2020, compared to May 2019. But in December 2020, the decline was less severe — only a 6% decrease over December 2019.
- Tubal ligations declined 65% in April 2020, suggesting that hospitals and providers did not make this a priority.
- Contraceptive visits for injectables declined more than for other non-permanent contraceptives in December 2020.
Patients faced difficulties accessing contraceptive care in April 2020 and December 2020, but the steepest drop occurred during the COVID-19 shutdown in April 2020, according to researchers.1
“We compared two months in 2020 to see the sustained effect of the pandemic,” says Maria W. Steenland, SD, MPH, lead study author and assistant professor at the Population Studies and Training Center at Brown University in Providence, RI.
Investigators studied health insurance claims for 280 million patients, 1.8 million prescribers, and 16,000 health plans between May 1, 2019, and Dec. 31, 2020, from the Symphony Health claims clearinghouse.
“The idea was to account for the month-to-month seasonal differences in contraception use with comparisons from the year of the pandemic to the year prior to the pandemic,” Steenland explains.
Steenland and colleagues found steep declines in most contraceptives, including tubal ligation, in April 2020, compared to May 2019.
Tubal ligations declined 65% in April 2020 when compared with May 2019. Long-acting reversible contraceptive (LARC) care dropped by 46%; prescriptions of the pill, patch, or ring fell by 45%; and injectables fell by 16%
By December 2020, contraceptive care bounced back, but was lower than the previous year. For instance, tubal ligation declined 18% in December 2020; injectables declined 11%; LARC was down by 6%; and the pill, patch, and ring were 5% lower than the pre-pandemic period.
“We found that there were still some sustained declines in visits, although much more modest than the huge declines we saw in April 2020,” Steenland says.
The early decline in contraceptive access coincided with the shutdown of businesses and some non-urgent healthcare facilities in April 2020. Elective procedures stopped, and 54% of OB/GYNs reported seeing fewer patients between March and June 2020.1,2
OB/GYNs also said they had incorporated telehealth into their practices by June 2020. Four in five reported their practice had experienced at least one financial or staffing challenge due to the COVID-19 pandemic. Also, 60% of OB/GYNs expressed concern that patients would face delays in sexual and reproductive healthcare, including contraceptive care, abortion care, and treatment for sexually transmitted infections (STIs).2
When average monthly contraceptive visits are mapped out from May 2019 to December 2020, the line graph shows variability from month to month. For 10 months before March 2020, when COVID-19 was declared a pandemic, visits for tubal ligation, injectables, LARC, and pill/patch/ring would rise and fall, often parallel with each other.1
“We see seasonality in that,” Steenland says. “All methods are a little lower in June and then they go up in the next month.”
Healthcare visits often fluctuate throughout the year. These changes are largely predictable.
“We see visits [in 2019] are fluctuating up and down, but there’s no real change,” Steenland says. “Then, we see a very dramatic decline in visits, in particular for people who use LARC, tubal ligation, and the pill, patch, and ring visits, in April 2020.”
Tubal ligation is a different kind of service than the other contraceptives. “Most people do a tubal ligation in the hospital after childbirth,” she explains.
The sharp decline in tubal ligation suggests that hospitals, stressed during the pandemic’s early weeks, did not view tubal ligation as a priority service.
“It’s a complicated equation to figure out what is a priority,” Steenland adds. “But it seems to me that people who want a permanent contraceptive method think it’s not a minor thing to not get [tubal ligation].”
For those women, it could mean another pregnancy soon after the last one. This could occur during the pandemic, even if they did not intend to become pregnant.
“This was when a lot of people were losing their jobs, and child care is still difficult to obtain,” Steenland says.
During this same period, accessing intrauterine device (IUD) insertions was difficult, as was obtaining in-person visits for injectables and prescriptions for birth control pills, patches, and rings.
Contraceptive visits for injectables declined more than for other non-permanent contraceptives in December 2020. This possibly was the result of women’s uncertainty about when the pandemic would end or if another shutdown would occur, resulting in reduced access when the injectable was needed.
“For injectables, you might expect the situation to be a bit different,” Steenland says. “A lot of people who are continuing users may have a gap in their use, but there also [may] not be as much of a backlog of people waiting to get an appointment.”
It is possible that some women who had been using injectables switched to long-term methods like IUDs because of pandemic uncertainty.
Some providers might have offered patients a self-injectable contraceptive option, but this also would have shown up in billing codes as a healthcare encounter, Steenland says.
The data clearly show how much contraceptive care was affected in 2020 and the difficulties reproductive health providers faced.
“I’m not a provider, and I’m sympathetic to people trying to provide this care right now with all of these constraints,” Steenland says. “It’s been extremely challenging for clinics, and we haven’t been able to fully adapt.”
Positive changes during the pandemic have made contraception more accessible. These adjustments are broadly praised by healthcare groups.
“These provide best practices and include things like offering long-term supplies of oral contraception, including a 12-month supply for people to pick up at a pharmacy,” Steenland explains.
Providers could offer self-administered injectables and take advantage of new innovations in telehealth.
“Those kind of options were all theoretically possible before the pandemic, but they weren’t happening much before,” Steenland says. “Many people did just a one-month or three-month supply [of birth control pills] when they went into the pharmacy.”
Telehealth prescriptions are a great option and innovation. These should continue for people who want to access contraceptives this way.
“The takeaway is that the pandemic impacts access to contraception,” Steenland says. “This paper ends more than a year ago, so its full impact is not known, but I would suspect that especially during the periods of surges, there still are challenges that family planning providers are experiencing as they work to maintain contraceptive access for patients.”
- Steenland MW, Geiger CK, Chen L, et al. Declines in contraceptive visits in the United States during the COVID-19 pandemic. Contraception 2021;104:593-599.
- Weigel G, Frederiksen B, Ranji U, Salganicoff A. How OBGYNs adapted provision of sexual and reproductive health care during the COVID-19 pandemic. Kaiser Family Foundation. Dec. 2, 2020.
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