By Dr. Celia Karp, Assistant Scientist, Dr. Linnea Zimmerman, Assistant Professor, Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, Dr. Elizabeth Gummerson, Executive Director of the Performance Monitoring for Action project, Bill & Melinda Gates Institute
Restricted access to quality healthcare during COVID-19 threatened reproductive autonomy. Health facility closures and restrictions on movement threatened to limit the ability of women and girls to avoid unwanted pregnancies, switch their contraceptive methods, stop using contraception to become pregnant, and receive critical and timely reproductive healthcare. Projections from early in the pandemic estimated an additional 15 million unintended pregnancies worldwide due to reduced access to and use of reproductive health services.
Understanding barriers to reproductive healthcare amidst the evolving pandemic primed us to support people today—and prepare for the challenges of tomorrow.
Our capacity to measure the pandemic’s impact on sexual and reproductive health and rights (SRHR), however, was limited because of scarce empirical evidence on SRHR needs, particularly in low- and middle-income countries. Fortunately, the Performance Monitoring for Action (PMA) project was well situated to fill this data gap.
The PMA project of the Bill & Melinda Gates Institute for Population and Reproductive Health collects nationally and regionally representative data on a range of reproductive health indicators from women in eight countries in sub-Saharan Africa and South Asia to guide family planning policies and programs. When COVID-19 hit, PMA quickly adapted to collect data on the pandemic’s impact on SRHR.
Leveraging its existing cohorts of survey participants, PMA project partners adapted the in-person survey design to capture COVID-19-related outcomes via phone-based follow-up interviews six months into the pandemic. To understand how COVID-19 was likely to impact reproductive health, interviews focused on understanding changes in women’s fertility desires, availability of reproductive services, and contraceptive use.
Data from the phone-based surveys were some of the first population-based evidence generated from sub-Saharan Africa during this period, offering critical insights into women’s SRHR needs. As the pandemic conditions improved, PMA resumed its in-person surveys, following safety protocols, collecting data two years into the pandemic.
So, what did the PMA project learn?
A recent study using PMA’s longitudinal data from Kenya found that women were overwhelmingly consistent in their fertility intentions before and during the first year of the pandemic, despite widespread economic loss during this time. Data also revealed that the most vulnerable women—those who reported food insecurity before and during the pandemic—were more likely to accelerate their childbearing desires, wanting children earlier than when they were asked just before the pandemic. While many people feared that COVID-19 would lead to drastic increases in unintended pregnancy and associated increases with maternal and newborn morbidity and mortality, due in part to increased desires to avoid pregnancy, PMA found little evidence of this at the population level.
Concerns of rising unintended pregnancies were also informed by the anticipated negative impacts of the pandemic on health services. Data collected from public and private health facilities revealed wide variations in COVID-19’s impact across different PMA geographies. Disruption to available family planning services was highest in Rajasthan, India—where COVID-19 cases rose quickly—and was lowest in Cote d’Ivoire.
Despite differences in case numbers and service availability, PMA observed large reductions in the number family planning clients across geographies. This may have reflected people’s apprehension about seeking care, suggesting declines in demand for facility-based services. Overall, data showed health services were largely resilient during the pandemic, overcoming significant barriers to ensure continuity of reproductive healthcare.
PMA also explored how demand for and use of contraception changed during the pandemic. Study results from Burkina Faso and Kenya indicated that most women did not change their contraceptive status—that is, discontinuing contraception altogether or newly adopting contraception—during the first six months of the pandemic. Those who did change, however, were more like to adopt a method than discontinue.
Similarly, research from Burkina Faso, Kenya, and Nigeria found evidence that a greater number of women were using contraception within the first six months into the pandemic, relative to before COVID-19 began. While these findings suggested continued coverage of reproductive health services, the impact of COVID-19 on reproductive health was not uniform. Researchers also found an increase in need for contraception among women who had never given birth, underscoring the importance of ensuring sustained availability and accessibility of family planning services for all women and girls amid health emergencies.
The story of PMA’s pivot is just one example of how health programs, surveys, and services transformed to meet global health needs. Rapid data collection and analysis demonstrated some of the ways that the expectations of researchers and advocates did not necessarily match women’s lived experiences. At least in the early stage of COVID-19, women’s fertility desires, contraceptive use, and access to reproductive health services were less impacted than initially expected. We will continue to learn about the pandemic’s long-term impact on SRHR with further data collection and triangulation of key data sources, like DHIS2 and DHS, over time.
As the public health community prepares for future health emergencies, the ability of data systems to adapt quickly will enable the global health community to better anticipate and address women’s health needs in dynamic environments.
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This article is a part of PSI’s ICFP 2022 Impact Magazine. Explore the magazine here.