Disrupted Contraceptive Care Hurt Disadvantaged Patients the Most
The COVID-19 pandemic affected most women seeking contraceptive care — but those who already are disadvantaged by structural inequities were hit the hardest. The problem worsened as the pandemic continued.1
The pandemic made reproductive health access disparities worse, creating economic hardship for many women and disproportionately affecting Black, indigenous, and people of color (BIPOC). Recently, researchers found that people were less happy with their ability to access contraceptive care in January 2021 than in July 2020.1
Patients Are More Dissatisfied
Investigators recruited thousands of women, ages 18 to 45 years, through Facebook and Instagram ads. They asked participants if they experienced barriers to switching, discontinuing, or starting a new contraceptive method during the pandemic. They collected sociodemographic data and asked if respondents had lost income or a job during the pandemic, or whether someone in their house went hungry because of a lack of money for food during any day in the previous three months.
“People reported more barriers for everything, more dissatisfaction, and more job and income loss in January 2021,” says Nadia Diamond-Smith, PhD, MSc, lead study author and assistant professor in epidemiology and biostatistics with the Institute for Global Health Services at the University of California, San Francisco.
This was unexpected. “We thought there would be more barrier issues in July 2020 because the pandemic still was new and people were freaked out, and healthcare systems were minimally providing care,” Diamond-Smith explains. “We thought that maybe by January 2021, health systems would be better [at handling the pandemic], and they could provide care.”
But when Diamond-Smith and colleagues asked respondents about their experiences, they found more dissatisfaction than expected. It is possible respondents’ answers reflect those two distinct points in time and not what people had been experiencing in the months leading up to July 2020 and January 2021.
“January 2021 was a time point that was pretty bad for COVID because of a winter surge,” Diamond-Smith explains. “Even though the healthcare system had shifted in a lot of ways, when we collected that data, it had been a bad time again.”
Diamond-Smith and colleagues found that women faced COVID-19-associated barriers to care in both the early and mid-pandemic periods. About half of contraception users reported at least one barrier to obtaining contraceptive care. Barriers included lack of support persons to attend healthcare visits, facility closures, fear of COVID-19, and household burdens and responsibilities.
The researchers did not find much of a difference in respondents’ ability to schedule contraceptive appointments between July 2020 and January 2021. But there was a change in respondents’ fear of going out.
“The proportion of people who said they were not able to go to their appointments because the facility was closed had gone down between July 2020 and January 2021,” Diamond-Smith explains. “COVID was bad [in the winter of 2021], and people were staying in their houses.”
Money and Time Constraints
Money was the biggest barrier to accessing contraceptive care in January 2021. “It was not a healthcare system issue, but more of a burden on people,” she says. “They said they couldn’t go because they didn’t have enough money.”
Respondents also reported time constraints, such as homeschooling their children and shouldering more household responsibilities.
Nine months of the pandemic took a toll on women, making it more challenging for them to think about their own healthcare, including reproductive services.
“The impact of losing income had a strong effect,” Diamond-Smith says. Women who experienced income loss and some food insecurity and hunger were more likely to report not using the contraceptive method they wanted to use, she adds.
One hypothesis for why income loss and hunger mattered is that women without sufficient income might have more trouble visiting a provider. For instance, they might have taken a lower-paying job with less flexibility, leaving them without time to receive reproductive healthcare.
Twenty-two percent of respondents indicated they would be using a different method if not for COVID-19-related barriers. “We found the proportion of women increased from 14% to 22%,” Diamond-Smith says. “They weren’t using the method they wanted to use.”
These findings suggest women were not satisfied with the availability of their choices, and this problem compounded as the pandemic continued and clinics dealt with the winter surge of COVID-19 cases, which may have led to more restrictions on available care.
It would be helpful to know how women’s experiences changed by mid-2021 or even in January 2022, but Diamond-Smith and colleagues stopped data collection after early 2021.
“We wish we had done another survey in July 2021, but we thought vaccination was coming,” Diamond-Smith says. “We got a small, short-term grant to work on it, and this was an easy way to collect a large sample.”
- Diamond-Smith N, Logan R, Marshall C, et al. COVID-19’s impact on contraception experiences: Exacerbation of structural inequities in women’s health. Contraception 2021;104:600-605.
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