COVID-19 and Sexual and Reproductive Health Care: Findings From Primary Care Providers Who Serve Adolescents

Innovations produced in Primary Health Care during the COVID-19 pandemic: an integrative literature review

Primary Health Care (PHC) proved to be an important part of the prevention, control and treatment measures against COVID-19, a situation in which it was challenged to keep up its provision of regular services as well. This article identifies the main arrangements made to provide PHC care in the context of the COVID-19 pandemic. An integrative literature review of articles found in PubMed, SciELO and LILACS databases was performed using the descriptors "Primary Health Care" and "COVID-19". Findings were analyzed considering three questions: Information and Communication Technologies (ICT), Organizations of Work Processes and Non-COVID Chronic Diseases. The use of different forms of ICT to provide PHC is highlighted regarding patients with respiratory symptoms and chronic patients. Changes in team composition, service flows, physical spaces and working hours were also introduced. Although strategies aimed at monitoring chronic patients and at remote care may have helped minimize deterioration of their health, the decrease in the number of visits performed during this period could have resulted in an increased demand for PHC in post-pandemic years.

The role of school-based health centers in providing long-active reversible contraceptive care to adolescents in New York City

Long-acting reversible contraceptives (LARCs) are effective contraceptive methods for adolescents. This study describes the initiation and continuation of LARC care to adolescents at school-based health centers (SBHCs) during the COVID-19 pandemic. Participants received contraceptive care in New York City SBHCs from April 2021-June 2022. LARC initiation, LARC discontinuation, and total contraceptive visits were measured monthly. During the study period, the SBHCs provided 1,303 contraceptive visits, including 77 LARC initiations. Among LARC initiations, six-month continuation probability was 79.3 % (95 %CI: 69.0-91.1). SBHCs play an important role in providing adolescents contraceptive services, particularly LARC care, when other health care systems are disrupted.

Implementing digital sexual and reproductive health care services in youth clinics: a qualitative study on perceived barriers and facilitators among midwives in Stockholm, Sweden

BACKGROUND

Digital health care services have the potential to improve access to sexual and reproductive health care for youth but require substantial implementation efforts to translate into individual and public health gains. Health care providers are influential both regarding implementation and utilization of the services, and hence, their perceptions of digital health care services and the implementation process are essential to identify and address. The aim of this study was to explore midwives' perception of digital sexual and reproductive health care services for youth, and to identify perceived barriers and facilitators of the implementation of digital health care provision in youth clinics.

METHODS

We performed semi-structured interviews with midwives (n = 16) working at youth clinics providing both on-site and digital sexual and reproductive health care services to youth in Stockholm, Sweden. Interview data were analyzed using a content analysis approach guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Midwives acknowledged that the implementation of digital health care improved the overall access and timeliness of the services at youth clinics. The ability to accommodate the needs of youth regarding their preferred meeting environment (digital or on-site) and easy access to follow-up consultations were identified as benefits of digital health care. Challenges to provide digital health care included communication barriers, privacy and confidentiality concerns, time constraints, inability to offer digital appointments for social counselling, and midwives' preference for in person consultations. Experiencing organizational support during the implementation was appreciated but varied between the respondents.

CONCLUSION

Digital sexual and reproductive health care services could increase access and are valuable complements to on-site services in youth clinics. Sufficient training for midwives and organizational support are crucial to ensure high quality health care. Privacy and safety concerns for the youth might aggravate implementation of digital health care. Future research could focus on equitable access and youth' perceptions of digital health care services for sexual and reproductive health.

Lasting Impact of the COVID-19 Pandemic on Care and Prevention of Sexually Transmitted Infections in the Midwest

BACKGROUND

The COVID-19 pandemic reduced the general accessibility of health services. Many sexually transmitted infection (STI) testing and treatment sites modified services (e.g., reduced hours, limited walk-in availability, decreased testing capacity), changes that may result in permanent change in STI service availability. At the same time, systems were driven to innovate in ways that could benefit patients. This study aimed to describe how the COVID-19 pandemic changed STI clinical services, with a focus on long-term impacts.

METHODS

In July 2022, a phone survey was designed to assess services for STIs at the 105 STI testing and treatment providers in the St. Louis metropolitan statistical area. Sexually transmitted infection testing providers included STI clinics, primary care clinics that cater to a broad population, and community-based organizations, and excluded emergency departments and urgent care centers. In most cases, the survey was completed by a clinic manager, medical director, or nursing staff member.

RESULTS

Of the 75 locations that were interviewed, 12 (16%) had not returned to prepandemic capacity and operations as of July 2022. Five sites had closed completely since the pandemic began, 3 of which are in the northwestern region of the metropolitan statistical area. Most (58.6%) of the open clinics had added telehealth appointments.

CONCLUSIONS

Sexually transmitted infection testing sites decreased during the pandemic with lasting impact in one area of the Midwest. Resources to support STI infrastructure should be expanded. Maintaining updated information on STI care providers in the region can aid future assessments.

Disparities in Unmet Health Care Needs Among US Children During the COVID-19 Pandemic

PURPOSE

The COVID-19 pandemic disrupted pediatric health care in the United States, and this disruption layered on existing barriers to health care. We sought to characterize disparities in unmet pediatric health care needs during this period.

METHODS

We analyzed data from Wave 1 (October through November 2020) and Wave 2 (March through May 2021) of the COVID Experiences Survey, a national longitudinal survey delivered online or via telephone to parents of children aged 5 through 12 years using a probability-based sample representative of the US household population. We examined 3 indicators of unmet pediatric health care needs as outcomes: forgone care and forgone well-child visits during fall 2020 through spring 2021, and no well-child visit in the past year as of spring 2021. Multivariate models examined relationships of child-, parent-, household-, and county-level characteristics with these indicators, adjusting for child's age, sex, and race/ethnicity.

RESULTS

On the basis of parent report, 16.3% of children aged 5 through 12 years had forgone care, 10.9% had forgone well-child visits, and 30.1% had no well-child visit in the past year. Adjusted analyses identified disparities in indicators of pediatric health care access by characteristics at the level of the child (eg, race/ethnicity, existing health conditions, mode of school instruction), parent (eg, childcare challenges), household (eg, income), and county (eg, urban-rural classification, availability of primary care physicians). Both child and parent experiences of racism were also associated with specific indicators of unmet health care needs.

CONCLUSIONS

Our findings highlight the need for continued research examining unmet health care needs and for continued efforts to optimize the clinical experience to be culturally inclusive.

Sexual and Reproductive Health Outcomes Among Adolescent Females During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Coronavirus disease 2019 (COVID-19) posed a significant threat to adolescents' sexual and reproductive health. In this study, we examined population-level pregnancy and sexual health-related care utilization among adolescent females in Ontario, Canada during the pandemic and evaluated relationships between these outcomes and key sociodemographic characteristics.

METHODS

This was a population-based, repeated cross-sectional study of >630 000 female adolescents (12-19 years) during the prepandemic (January 1, 2018-February 29, 2020) and COVID-19 pandemic (March 1, 2020-December 31, 2022) periods. Primary outcome was pregnancy; secondary outcomes were contraceptive management visits, contraception prescription uptake, and sexually transmitted infection (STI) management visits. Poisson models with generalized estimating equations for clustered count data were used to model pre-COVID-19 trends and forecast expected rates during the COVID-19 period. Absolute rate differences between observed and expected outcome rates for each pandemic month were calculated overall and by urbanicity, neighborhood income, immigration status, and region.

RESULTS

During the pandemic, lower-than-expected population-level rates of adolescent pregnancy (rate ratio 0.87; 95% confidence interval [CI]:0.85-0.88), and encounters for contraceptive (rate ratio 0.82; 95% CI:0.77-0.88) and STI management (rate ratio 0.52; 95% CI:0.51-0.53) were observed. Encounter rates did not return to pre-pandemic rates by study period end, despite health system reopening. Pregnancy rates among adolescent subpopulations with the highest pre-pandemic pregnancy rates changed least during the pandemic.

CONCLUSIONS

Population-level rates of adolescent pregnancy and sexual health-related care utilization were lower than expected during the COVID-19 pandemic, and below-expected care utilization rates persist. Pregnancy rates among more structurally vulnerable adolescents demonstrated less decline, suggesting exacerbation of preexisting inequities.

Changes in Commercial Insurance Claims for Contraceptive Services During the Beginning of the COVID-19 Pandemic-United States, January 2019-September 2020

OBJECTIVE

We describe changes in commercial insurance claims for contraceptive services during the beginning of the COVID-19 pandemic.

METHODS

We analyzed commercial insurance claims using IQVIA PharMetrics Plus data from more than 9 million U.S. females aged 15-49 years, enrolled during any month, January 2019 through September 2020. We calculated monthly rates of outpatient claims for intrauterine devices (IUDs), implants, and injectable contraception and monthly rates of pharmacy claims for contraceptive pills, patches, and rings. We used Joinpoint regression analysis to identify when statistically significant changes occurred in trends of monthly claims rates for each contraceptive method. We calculated monthly percentages of claims for contraceptive counseling via telehealth.

RESULTS

Monthly claims rates decreased for IUDs (-50%) and implants (-43%) comparing February 2020 with April 2020 but rebounded by June 2020. Monthly claims rates for injectables decreased (-19%) comparing January 2019 with September 2020, and monthly claims rates for pills, patches, and rings decreased (-22%) comparing July 2019 with September 2020. The percentage of claims for contraceptive counseling occurring via telehealth was low (<1%) in 2019, increased to 34% in April 2020, and decreased to 9-12% in June-September 2020.

CONCLUSIONS

Substantial changes in commercial insurance claims for contraceptive services occurred during the beginning of the COVID-19 pandemic, including transient decreases in IUD and implant claims and increases in telehealth contraceptive counseling claims. Contraceptive claims data can be used by decision makers to identify service gaps and evaluate use of interventions like telehealth to improve contraceptive access, including during public health emergencies.

Single-Visit Long-Acting Reversible Contraception Initiation Among Adolescents Before and During COVID-19

PURPOSE

Single-visit long-acting reversible contraception (LARC) is cost-effective and convenient. Our objective was to compare incidence of single-visit LARC placement and associated factors during the year before the COVID-19 pandemic (March 15, 2020) and the first year of the pandemic.

METHODS

This retrospective cohort study analyzed electronic health records from a large healthcare system. Eligible adolescents were aged 10-19 years and received outpatient LARC from March 15, 2019 to March 14, 2021. Logistic regression models determined the relationship of patient and provider characteristics on single-visit LARC before and during COVID-19.

RESULTS

One thousand six adolescents initiated LARC during the study period. Fewer adolescents received single-visit LARC during COVID-19 (289/506, 57.1%) compared to before (315/500, 63.0%), although changes in odds of single-visit LARC were not statistically significant. Concordance between county of patient residence and the location of the LARC placement facility was associated with single-visit LARC before (adjusted odds ratio [aOR] = 2.75) and during (aOR = 1.74) the pandemic (both p < .05). During the pandemic, a few factors were associated with reduced odds of single-visit LARC: (1) public insurance (aOR = 0.49, p < .01), (2) nonobstetricians/nongynecologists providers (pediatrics [aOR = 0.35, p < .01], family medicine [aOR = 0.53, p < .01], or internal medicine [aOR = 0.14, p < .05]), and (3) advanced practice practitioners (aOR = 0.49, p < .01).

DISCUSSION

Incidence of single-visit LARC was similar before and during the pandemic. Certain factors were associated with lower odds of single-visit LARC insertion, suggesting differential access during the pandemic for subgroups of adolescents. Our findings may guide policy and programmatic interventions to improve access to single-visit LARC for all adolescent populations.

Confidentiality and privacy considerations for adolescents receiving contraceptive health services via telemedicine: A narrative review

Confidential medical care for adolescent patients is essential as they are likely to forgo needed care if privacy cannot be maintained. The use of telemedicine for adolescent health has rapidly expanded due to the COVID-19 pandemic and can increase access to important services like reproductive care; however, it has raised challenges for providers, patients, and their parents/guardians related to confidentiality and privacy. Health care providers are often uncertain about the laws and regulations that govern confidential services including the 21st Century Cures Act. Through a narrative review of studies on confidentiality and telemedicine, this article seeks to summarize the available evidence and provide recommendations on maintaining privacy during virtual encounters and identify current best practices for prescribing contraception via telemedicine.

Sexually Transmitted Infection Diagnoses at Children's Hospitals During COVID-19

OBJECTIVES

COVID-19 mitigation strategies resulted in changes in health care access and utilization, which could negatively impact adolescents at risk for sexually transmitted infections (STIs). We evaluated changes in STI diagnoses during adolescent visits at children's hospitals during COVID-19.

METHODS

We conducted a retrospective cohort study using the Pediatric Health Information System database comparing adolescent (11-18 years) hospital visits with an STI diagnosis by International Classification of Diseases, 10th revision, code during COVID-19 (2020) to pre-COVID-19 (2017-2019). Data were divided into spring (March 15-May 31), summer (June 1-August 31), and fall (September 1-December 31). Median weekly visits and patient characteristics were compared using median regression.

RESULTS

Of 2 747 135 adolescent encounters, there were 10 941 encounters with an STI diagnosis from 44 children's hospitals in 2020. There was a decrease in overall median weekly visits for STIs in spring during COVID-19 (n = -18.6%, P = .001) and an increase in overall visits in summer (11%, P = .002) during COVID-19. There were significant increases in inpatient median weekly visits for STIs in summer (30%, P = .001) and fall (27%, P = .003) during COVID-19. We found increases in Neisseria gonorrhoeae (50%, P < .001) and other STI diagnoses (defined as other or unspecified STI by International Classification of Diseases, 10th revision, code; 38%, P = .040) in fall COVID-19 (2020), and a decrease in pelvic inflammatory disease (-28%, P = .032) in spring COVID-19 (2020).

CONCLUSIONS

We found increases in median weekly adolescent inpatient visits with an STI diagnosis in summer and fall COVID-19 (2020). These findings were likely partially driven by changes in behaviors or health care access. Further work is needed to improve STI care and thus potentially improve related health outcomes.

Assessing changes in adolescent girls' and young women's sexual and reproductive health service utilisation following a COVID-19 lockdown in eSwatini

The effects of COVID-19-associated restrictions on youth sexual and reproductive health (SRH) care during the pandemic remain unclear, particularly in sub-Saharan Africa. This study uses interrupted time series analyses to assess changes in SRH care utilisation (including visits for HIV testing and treatment, family planning, and antenatal care) adolescent girls' and young women's (AGYW; aged 15-24 years old) in eSwatini following COVID-19 lockdown beginning in March 2020. SRH utilisation data from 32 clinics in the Manzini region that remained open throughout the 2020 COVID-19 period were extracted from eSwatini's electronic health record system. We tabulated and graphed monthly visits (both overall and by visit type) by AGYW during the two-year period between January 2019 and December 2020. Despite the March to September 2020 lockdown, we did not detect significant changes in monthly visit trends from 2019 to 2020. Our findings suggest little change to AGYW's SRH utilisation in eSwatini during the 2020 COVID-19 lockdown period.

Impact of the COVID-19 pandemic on the sexual and reproductive health of adolescents in Alberta, Canada

PURPOSE

The COVID-19 pandemic led to major service disruptions in the healthcare sector, especially regarding sexual and reproductive health services. However, the impact of the pandemic on Canadian adolescents is relatively unknown. This study aimed to investigate the impacts of the COVID-19 pandemic and associated public health measures on the sexual and reproductive health (SRH) of adolescents in Alberta, Canada.

METHODS

A qualitative study using an interpretive description (ID) approach and community-based participatory research principles was conducted to capture the subjective experience and perceptions of adolescents and service providers. With the collaboration of the Adolescent Advisory Group and community partners, 18 adolescents and 15 service providers were recruited for the study through purposive sampling. Findings from the qualitative interviews were analyzed using thematic analysis.

RESULTS

Three major themes emerged from the analysis: (1) COVID-19 SRH experience, (2) barriers to SRH, and (3) adolescent SRH strategies. Our findings highlight numerous barriers and challenges that prevented adolescents from accessing SRH education, products, and services.

CONCLUSION

The COVID-19 pandemic had a profound impact on the SRH and the well-being of adolescents. Our study reflects the need for diverse SRH strategies to maintain continued access to SRH resources during disruptive events, such as the pandemic.

Effects of the COVID-19 pandemic on publicly supported clinics providing contraceptive services in four US states

Objectives

The COVID-19 pandemic has disrupted contraceptive service provision in the United States (US). We aimed to explore the impact of COVID-19 on the publicly supported family planning network at the provider level. This study adds to the literature documenting the challenges of the pandemic as well as how telehealth provision compares across timepoints.

Study design

We conducted a survey among sexual and reproductive health (SRH) providers at 96 publicly supported clinics in four US states asking about two timepoints-one early in the pandemic and one later in the pandemic. We used descriptive statistics to summarize the data.

Results

We found that almost one-third of sites reduced contraceptive services because of the pandemic, with a few temporarily stopping contraceptive services altogether. More sites stopped provision of long-acting reversible contraception (LARC), Pap tests, and Human papillomavirus (HPV) vaccinations than other methods or services. We also found that sites expanded some practices to make them more accessible to patients, such as extending existing contraceptive prescriptions without consultations for established patients and expanding telehealth visits for contraceptive counseling. In addition, sites reported high utilization of telehealth to provide contraceptive services.

Conclusions

Understanding how service delivery changed due to the pandemic and how telehealth can be used to provide SRH services sheds light on how these networks can best support providers and patients in the face of unprecedented crises such as the COVID-19 pandemic.

Implications

This study demonstrates that providers increased provision of telehealth for sexual and reproductive health care during the COVID-19 pandemic; policymakers in the US should support continued reimbursement of telehealth care as well as resources to expand telehealth infrastructure. In addition, this study highlights the need for more research on telehealth quality.

Adapting Family Planning Service Delivery in Title X and School-Based Settings during COVID-19: Provider and Staff Experiences

The COVID-19 pandemic introduced urgent and unique challenges to family planning providers and staff in ensuring continued access to high-quality services, particularly for groups who experience greater barriers to accessing services, such as women with systemically marginalized identities and adolescents and young adults (AYA). While research has documented key adaptations made to service delivery during the early phase of the pandemic, limited studies have used qualitative methods. This paper draws on qualitative interview data from family planning providers and staff in Title-X-funded clinics and school-based clinics-two settings that serve populations that experience greater barriers to accessing care-to (a) describe the adaptations made to service delivery during the first year of the pandemic and (b) explore provider and staff experiences and impressions implementing these adaptations. In-depth interviews were conducted with 75 providers and staff between February 2020 and February 2021. Verbatim transcripts were analyzed via inductive content analysis followed by thematic analysis. Four key themes were identified: (1) Title-X- and school-based staff made multiple, concurrent adaptations to continue family planning services; (2) providers embraced flexibility for patient-centered care; (3) school-based staff faced unique challenges to reaching and serving youth; and (4) COVID-19 created key opportunities for innovation. The findings suggest several lasting changes to family planning service delivery and provider mindsets at clinics serving populations hardest hit by the pandemic. Future studies should evaluate promising practices in family planning service delivery-including telehealth and streamlined administrative procedures-and explore how these are experienced by diverse patient populations, particularly AYA and those in areas where privacy or internet access are limited.

Is the COVID-19 Pandemic Continuing to Impact Sexual and Reproductive Health Services for Adolescents? Findings From a 2021 Survey of US Physicians

PURPOSE

We examined the impact of the COVID-19 pandemic in Fall 2021 on sexual and reproductive health (SRH) services among physicians whose practice provided these services to adolescents just before the pandemic.

METHODS

Data were from the DocStyles online panel survey administered September-November 2021 to US physicians who reported their practice provided SRH services to adolescent patients before the pandemic (n = 948). We calculated prevalence of service delivery challenges (e.g., limited long-acting reversible contraception services) and use of strategies to support access (e.g., telehealth) in the month prior to survey completion, compared these estimates with prevalence "at any point during the COVID-19 pandemic", and examined differences by physician specialty and adolescent patient volume.

RESULTS

Fewer physicians reported their practice experienced service delivery challenges in the month prior to survey completion than at any point during the pandemic. About 10% indicated limited long-acting reversible contraception and sexually transmitted infection testing services in the prior month overall; prevalence varied by physician specialty (e.g., 26% and 17%, respectively by service, among internists). Overall, about 25% of physicians reported reductions in walk-in hours, weekend/evening hours, and adolescents seeking care in the prior month. While most practices that initiated strategies supporting access to services during the pandemic used such strategies in the prior month, some practices (22%-37% depending on the strategy) did not.

DISCUSSION

Findings suggest some physicians who serve adolescents continued to experience challenges providing SRH services in the Fall 2021, and some discontinued strategies to support access that had been initiated during the pandemic.

Gender Differences in Routine Health Maintenance Examinations Before and During the COVID-19 Pandemic

PURPOSE

Adolescent and young adult (AYA) males historically have lower healthcare utilization than their female peers.

METHODS

Electronic health record data from an Adolescent/Young Adult Medicine outpatient practice were reviewed to assess gender differences in routine health maintenance examinations before and during the COVID-19 pandemic.

RESULTS

Routine health maintenance examinations decreased for both males and females during the pandemic. However, a two-proportion z-test demonstrated that established male patients were statistically less likely (p < .01) to have a routine health maintenance examination from December 2020 to December 2021 than their female counterparts.

DISCUSSION

AYA males are at a higher risk for persistent disengagement in healthcare and exacerbates future gender gaps in healthcare utilization. Primary care providers need to focus efforts on re-engaging all young people in preventive care, with specific efforts tailored to AYA males.

Telehealth for Women's Preventive Services for Reproductive Health and Intimate Partner Violence: a Comparative Effectiveness Review

BACKGROUND

Telehealth delivery of preventive health services may improve access to care; however, its effectiveness and adverse effects are unknown. We conducted a comparative effectiveness review on the effectiveness and harms of telehealth interventions for women's reproductive health and intimate partner violence (IPV) services.

METHODS

We searched MEDLINE, Cochrane Library, CINAHL, and Scopus for English-language studies (July 2016 to May 2022) for randomized controlled trials (RCTs) and observational studies of telehealth strategies for women's reproductive health and IPV versus usual care. Two investigators identified studies and abstracted data using a predefined protocol. Study quality was assessed using study design-specific standardized methods; disagreements were resolved through consensus.

RESULTS

Eight RCTs, 1 nonrandomized trial, and 7 observational studies (n=10 731) were included (7 studies of contraceptive care and 9 of IPV services). Telehealth interventions to supplement contraceptive care demonstrated similar rates as usual care for contraceptive use, sexually transmitted infections, and pregnancy (low strength of evidence [SOE]); evidence on abortion was insufficient. Outcomes were also similar between telehealth interventions to replace or supplement IPV services and comparators for repeat IPV, depression, posttraumatic stress disorder, fear of partner, coercive control, self-efficacy, and safety behaviors (low SOE). In these studies, telehealth barriers included limited internet access, digital literacy, technical challenges, and confidentiality concerns. Strategies to ensure safety increased telehealth use for IPV services. Evidence on access, health equity, or harms was lacking.

DISCUSSION

Telehealth interventions for contraceptive care and IPV services demonstrate equivalent clinical and patient-reported outcomes versus in-person care, although few studies are available. Effective approaches for delivering these services and how to best mobilize telehealth, particularly for women facing barriers to care remain uncertain.

TRIAL REGISTRATION

PROSPERO CRD42021282298.

Trends in Pregnancy Rates in an Urban Adolescent Clinic Before and During the COVID-19 Pandemic

We examined COVID-19 pandemic-related changes on reproductive health care delivery and pregnancy rates in an adolescent clinic. Through a retrospective data collection as part of quality improvement project, we compared the number of pregnancies, visit percentages for newly diagnosed pregnancies, and number/percentage of long acting reversible contraception (LARC) visits. The percentage of visits for newly diagnosed pregnancies during the first 3 months of the COVID-19 pandemic (April-June 2020) increased significantly relative to pre-pandemic percentages while the absolute number of new pregnancies only trended upward. Over the same timeframe, the total number of LARC visits decreased, although they consisted of a higher percentage of all in-person visits than pre-pandemic. After the first few months of the pandemic, these values returned to pre-pandemic levels. The substantial increase in the rate of new pregnancies during the first 3 to 6 months of the COVID-19 pandemic demonstrates the importance of prioritizing access to reproductive health care services for adolescents and young adults.

Factors affecting delayed and non-receipt of healthcare during the COVID-19 pandemic for women in rural Maharashtra, India: Evidence from a cross-sectional study

Background

Pathways to low healthcare utilisation under the COVID-19 pandemic are not well understood. This study aims to understand women's concerns about the health system's priorities and their increased burden of domestic responsibilities during COVID-19 as predictors of delayed or non-receipt of needed care for themselves or their children.

Methods

We surveyed married women in rural Maharashtra, India (N = 1021) on their health and economic concerns between Feb 1 and March 26, 2021. This study period was when India emerged from the first wave of the pandemic, which had severely impacted the health systems, and before the second-even more devastating wave had started. We captured if women were concerned about access to non-COVID health services due to healthcare being directed solely to COVID-19) (exposure 1) and whether their domestic responsibilities increased during the pandemic (exposure 2). Our outcomes included women's reports on whether they delayed healthcare seeking (secondary outcome and mediator) and whether they received healthcare for themselves or their children when needed (primary outcome). We conducted adjusted regression models on our predictor variables with each outcome and assessed the mediation effects of delayed healthcare seeking for each of the exposure variables.

Findings

We found that women who were concerned that healthcare was directed solely towards COVID-19 were more likely not to receive healthcare when needed (Adjusted Risk Ratio [ARR] = 1.49, 95% CI = 1.14, 1.95). We also found that women whose domestic care burden increased under the pandemic were more likely to delay healthcare seeking (ARR = 1.84, 95% CI = 1.05, 3.21). Delayed healthcare seeking mediated the associations between each of our exposure variables with our outcome variable, non-receipt of needed healthcare.

Interpretation

Our findings suggested that women's perceptions of healthcare systems and their domestic labour burdens affected healthcare seeking during the pandemic in India, even before the second wave of COVID-19 incapacitated the health system. Support for women and health systems is needed to ensure healthcare uptake during crises.

Funding

Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, USA (grant numbers: R01HD084453- 01A1 and RO1HD61115); Department of Biotechnology, Government of India (grant #BT/IN/US/01/BD/2010); the EMERGE project (Bill and Melinda Gates Foundation Grants: OPP1163682 and INV018007; PI Anita Raj), and Bill and Melinda Gates Foundation Grant number INV-002967.

Providing Contraceptive Health Services to Adolescents and Young Adults by Telemedicine: A Scoping Review of Patient and Provider Perspectives

OBJECTIVE

The objective of this scoping review is to synthesize and identify gaps in existing research on accessibility of telemedicine-delivered contraceptive health services to female adolescents and young adults (AYAs) and acceptability of these services to AYA patients and their medical providers.

METHODS

We searched the PubMed, Scopus, Embase, and CINAHL databases to extract relevant studies on telemedicine and provision of contraceptive services among non-institutionalized, non-chronically ill female AYAs, ages 10 through 24 years.

RESULTS

We screened 154 articles, and 6 articles representing 5 studies met the full inclusion criteria. Three studies assessed telemedicine acceptability and accessibility from the perspective of providers, and 3 described patients' perceived accessibility and acceptability of a theoretical telemedicine visit. No studies directly assessed AYA patients' satisfaction with actual telemedicine visits for contraceptive services. Providers viewed telemedicine-delivered sexual and reproductive health (SRH) services as acceptable to themselves and AYA patients. Most AYAs reported that they would use telemedicine for SRH services, although they would prefer in-person care. All articles identified concerns about privacy and confidentiality as a barrier to SRH telemedicine care.

CONCLUSIONS

Telemedicine-delivered contraceptive health services for AYAs were perceived as acceptable and accessible by providers and by most AYA patients, although patients reported a preference for in-person care. However, none of these findings are based on patients' actual experiences with SRH telemedicine. Further research is needed to directly assess the accessibility and acceptability of telemedicine-delivered contraceptive health services for female AYA patients.

Interrupted Access to and Use of Family Planning Among Youth in a Community-Based Service in Zimbabwe During the First Year of the COVID-19 Pandemic

The COVID-19 pandemic has had serious impacts on economic, social, and health systems, and fragile public health systems have become overburdened in many countries, exacerbating existing service delivery challenges. This study describes the impact of the COVID-19 pandemic on family planning services within a community-based integrated HIV and sexual and reproductive health intervention for youth aged 16-24 years being trialled in Zimbabwe (CHIEDZA). It examines the experiences of health providers and clients in relation to how the first year of the pandemic affected access to and use of contraceptives.

Contraceptive care service provision via telehealth early in the COVID-19 pandemic at rural and urban federally qualified health centers in 2 southeastern states

PURPOSE

To investigate telehealth use for contraceptive service provision among rural and urban federally qualified health centers (FQHCs) in Alabama (AL) and South Carolina (SC) during the initial months of the COVID-19 pandemic.

METHODS

This is a mixed-methods study using data from the FQHC Contraceptive Care Survey and key informant interviews with FQHC staff in AL and SC conducted in 2020. Differences between rural and urban clinics in telehealth use for contraceptive service provision were assessed with a chi-square test of independence. Interviews were audio recorded, transcribed, and coded to identify facilitators and barriers to telehealth.

FINDINGS

Telehealth for contraceptive care increased during the early months of the pandemic relative to prepandemic. Fewer rural clinics than urban clinics provided telehealth for contraceptive counseling (16.3% vs 50.6%) (P = .0002), emergency contraception (0.0% vs 16.1%) (P = .004), and sexually transmitted infection care (16.3% vs 34.6%) (P = .031). Key facilitators of telehealth were reimbursement policy, electronic infrastructure and technology, and funding for technology. Barriers included challenges with funding for telehealth, limited electronic infrastructure, and reduced staffing capacity.

CONCLUSIONS

Differences in telehealth service provision for contraceptive care between rural and urban FQHCs highlight the need for supportive strategies to increase access to care for low-income rural populations, particularly in AL and SC. It is essential for public and private entities to support the implementation and continuation of telehealth among rural clinics, particularly, investing in widespread and clinic-level electronic infrastructure and technology for telehealth, such as broadband and electronic health record systems compatible with telehealth technology.

Comparison of Pregnancy Preferences Preceding vs Year 1 of the COVID-19 Pandemic

Importance

Understanding how the COVID-19 pandemic affected people's desire to avoid pregnancy is essential for interpreting the pandemic's associations with access to reproductive health care and reproductive autonomy. Early research is largely cross-sectional and relies on people's own evaluations of how their desires changed.

Objective

To investigate longitudinal changes in pregnancy desires during the year before and the first year of the COVID-19 pandemic.

Design, Setting, and Participants

In this cohort study, participants reported their pregnancy preferences at baseline and quarterly for up to 18 months between March 2019 and March 2021. An interrupted time series analysis with mixed-effects segmented linear regression was used to examine population-averaged time trends. People were recruited from 7 primary and reproductive health care facilities in Arizona, New Mexico, and Texas. Participants were sexually active, pregnancy-capable people aged 15 to 34 years who were not pregnant or sterilized. Data analysis was performed from September 2021 to January 2022.

Exposures

Continuous time, with knots at the onset of the first (July 1, 2020, summer surge) and second (November 1, 2020, fall surge) COVID-19 cases surges in the Southwest.

Main Outcomes and Measures

Preferences around potential pregnancy in the next 3 months, measured using the validated Desire to Avoid Pregnancy (DAP) scale (range, 0-4, with 4 indicating a higher desire to avoid pregnancy).

Results

The 627 participants in the analytical sample had a mean (SD) age of 24.9 (4.9) years; 320 (51.0%) identified as Latinx and 180 (28.7%) as White. Over the year before the first case surge in the US Southwest in summer 2020, population-averaged DAP scores decreased steadily over time (-0.06 point per quarter; 95% CI, -0.07 to -0.04 point per quarter; P < .001). During the summer 2020 surge, DAP scores stopped declining (0.05 point per quarter; 95% CI, -0.03 to 0.13 point per quarter; change in slope, P < .001). During the fall 2020 surge, however, DAP scores declined again at -0.11 point per quarter (95% CI, -0.26 to 0.04 point per quarter; change in slope, P = .10). Participants aged 15 to 24 years and those who were nulliparous and primiparous experienced greater declines in DAP score before the summer surge, and greater reversals of decline between summer and fall 2020, than did those who were aged 25 to 34 years and multiparous.

Conclusions and Relevance

These findings suggest that the COVID-19 pandemic onset was associated with the stalling of a prior trend toward greater desire for pregnancy over time, particularly for people earlier in their reproductive lives.

Perceptions of Good Health and Impact of COVID-19 Among Adolescents in a Low-Income Urban Agglomerate in Delhi, India: A Qualitative Study

Adolescents constitute 16% of the global population and are susceptible to adverse health and illness from substance abuse, unhealthy diet, physical inactivity, and high-risk sexual behaviors. We conducted this study to assess the perceptions of good health, health-seeking behavior, and health service utilization among adolescents living in a low-income urban neighborhood after the second wave of the COVID-19 pandemic. A total of 23 adolescents, including 12 males and 11 females, were interviewed. Adolescents' perceived body image and size considerations apart from functioning at an optimum physical capacity as the principal attributes of good health, which was possible through the intake of a healthy diet and exercise. Adolescents were likely to be aware of the addiction potential and risk of cancer from using tobacco and alcohol, but attitudes towards eschewing their use were ambivalent. Adolescents perceived themselves as lacking access to reliable, adequate, and validated sources of sexual and reproductive health information. Knowledge and utilization of adolescent health services in this area were negligible, suggestive of the need to strengthen these services and improve the program outreach.