Looking ahead in the COVID-19 pandemic: emerging lessons learned for sexual and reproductive health services in low- and middle-income countries

Nimble adaptations to sexual and reproductive health service provision to adolescents and young people in the early phase of the COVID-19 pandemic

Early in the COVID-19 pandemic, emerging evidence showed that the provision and use of a range of health services, including sexual and reproductive health (SRH) services, were affected. Otherwise, there was little evidence on whether and how they were adapted to maintain the access of different population groups, including adolescents. The study aims to provide an overview of adaptations to adolescent sexual and reproductive health (ASRH) services carried out during the early phases of the pandemic in low- and middle-income countries (LMICs). The Human Reproduction Program (HRP) at the World Health Organization (WHO) called upon WHO and United Nations Populations Fund (UNFPA) regional offices to reach out to organisations that provided ASRH services to submit analytic case studies using a short-form survey. The study team charted information from 36 case studies and performed a content analysis. Results show that the adaptations covered a wide array of SRH services that were provided to a diverse group of adolescents. Most adaptations focused on SRH education and access to contraception in comparison to other SRH services. Over half of the case studies included mental health services, most of which were not provided before the pandemic. The adaptations varied between being face-to-face, remote, digital, and non-digital. Most adaptations complemented a pre-existing service and were nimble, feasible, and acceptable to the targeted adolescents. Lessons learned from this study could be extrapolated into other humanitarian settings and rapid responses for future public health emergencies, provided that rigorous evaluation takes place.

Family planning service disruptions in the first two years of the COVID-19 pandemic: Evidence from health facilities in seven low- and middle-income countries

Many speculated that COVID-19 would severely restrict the delivery of essential health services, including family planning (FP), but evidence of this impact is limited, partly due to data limitations. We use cross-sectional data collected from regional and national samples of health facilities (n = 2,610) offering FP across seven low- and middle-income countries (LMICs) between 2019 and 2021, with longitudinal data from four geographies, to examine reported disruptions to the FP service environment during COVID-19, assess how these disruptions varied according to health system characteristics, and evaluate how disruptions evolved throughout the first two years of the pandemic, relative to a pre-pandemic period. Findings show significant variation in the impact of COVID-19 on facility-based FP services across LMICs, with the largest disruptions to services occurring in Rajasthan, India, where COVID-19 cases were highest among geographies sampled, while in most sub-Saharan African settings there were limited disruptions impacting FP service availability, method provision, and contraceptive supplies. Facility-reported disruptions to care were not reflected in observed changes to the number of FP clients or types of stockouts experienced in the first two years of the pandemic. Public and higher-level facilities were generally less likely to experience COVID-19-related disruptions to FP services, suggesting policy mitigation measures-particularly those implemented among government-operated health facilities-may have been critical to ensuring sustained delivery of reproductive healthcare during the pandemic.

The impact of COVID-19-related restrictions on pregnancy and abortion rates in the Republic of Georgia

BACKGROUND

The Republic of Georgia implemented COVID-19-related restrictions starting on 31 March 2020, when it imposed a 1-month strict lockdown, after which the country continued with some form of restrictions for 1 year. These restrictions created barriers to healthcare access, affected healthcare services, caused severe economic degradation, and changed reproductive behavior. The aim of this study was to explore the impact of COVID-19-related restrictions on pregnancy and abortion rates in Georgia.

METHODS

Information on pregnancy, abortion, and related variables was extracted from the Georgian Birth Registry from January 2018 through April 2022. The final study sample included 232,594 pregnancies and 86,729 abortions. We used interrupted time series analysis to study the impact of COVID-19-related restrictions.

RESULTS

There were slightly decreasing trends in pregnancy and abortion rates in the pre-pandemic period (1 January 2018-31 March 2020). During the 1-month strict lockdown (1 April-30 April 2020), pregnancy and abortion rates decreased in all investigated age groups. There were no substantial differences in pregnancy or abortion rates in the pandemic period (for pregnancies: 1 April 2020-30 June 2021; for abortions: 1 April 2020-30 April 2022) compared to the pre-pandemic period. The precision of all estimates suggested that both small increases and decreases in pregnancy and abortion rates are reasonably compatible with our data.

CONCLUSIONS

Despite the 1-year-long COVID-19-related restrictions, our results did not indicate substantial long-term changes in pregnancy or abortion rates during the study period for any age group. This may indicate that the restrictions did not substantially influence access to contraception, abortion services, or reproductive behavior.

Adapting to a global pandemic: a qualitative assessment of programmatic responses to COVID-19 in the multi-country Women's Integrated Sexual Health (WISH) programme

The COVID-19 pandemic caused significant disruption to sexual and reproductive health and rights (SRHR) globally but there is little published evidence on the COVID-19 response of SRHR programmes, or lessons learned through their adaptations. To document the COVID-19 response of a global SRHR programme (the Women's Integrated Sexual Health programme), in-depth interviews were conducted between April and July 2021 with 22 key informants from implementing partners in Sierra Leone, Ethiopia and central or regional offices, the UK Foreign, Commonwealth and Development Office and the third-party monitoring partner. Framework analysis methods were used. Several rapid COVID-19 adaptations were identified: the development of crisis management and communication teams; increased partnership and engagement with government; reduced contact and risk in service delivery; reformulated community mobilisation; flexible performance management and remote methods of quality assurance; and sharing of learnings alongside the development of new guidance and tools. Throughout the pandemic, the programme was able to continue high-quality service delivery, though equity goals proved more difficult to reach. Challenges included the continually changing environment, competing pressures on governments, burdensome reporting, and staff burnout. The pandemic response was facilitated by prior experience of health emergencies, strong government relationships, a supportive workforce and some pre-existing approaches, tools, and systems. This study has identified important lessons that can inform programming in future crises, including the need for immediate recognition of SRHR as essential, sustained support for staff, use of multiple mechanisms to reach marginalised groups, adequate funding for equity goals, and a better balance between the burden of reporting and accountability needs.

The impact of the COVID-19 pandemic on the prevalence and genotype distribution of HPV infection in Beijing, China

Human papillomavirus (HPV) is one of the most common sexually transmitted infections nationwide. The COVID-19 pandemic has greatly influenced on the HPV prevention project. The objective of this study was to examine the influence of the pandemic on HPV prevalence and genotype distribution in Beijing, China. A total of 44 401 genital swabs were obtained from outpatients at Peking Union Medical College Hospital during two distinct periods: the prepandemic stage from January 2017 to December 2019 and the pandemic stage from January 2020 to December 2022. During the prepandemic and pandemic stages, a total of 33 531 and 10 870 swabs were respectively collected. Fifteen high-risk HPV (HR-HPV) DNA type and a combination of two low-risk (LR-HPV) types (6/11) of genital swabs were detected to compare the HPV infection rates and genotype distributions in two stages. The results showed that the pandemic period witnessed a decrease in the overall HPV infection rate from 33.43% (11 245/33 531) to 29.43% (5527/18 780) compared to the prepandemic. There were statistically significant differences in infection rates between females and males (p < 0.05). Single infection was the predominant type while multiple infection was more prevalent in males than females in both prepandemic and pandemic periods. HR-HPV infection constituted the majority of infections and cannot be disregarded. The distribution of HR-HPV genotypes exhibited little variation before and after the outbreak, but there were some differences between females and males. HPV 16, 52, 58, 56, and 66 were the most commonly detected genotypes in females, whereas HPV 16, 52, 51, 58, and 18 were frequently detected in males. Additionally, HPV 6/11 exhibited a higher prevalence in males than in females. Notably, the age group of 31-40 years old exhibited the highest prevalence of HPV and the lowest infection rate was detected among individuals aged ≤20 years (p < 0.05), which remained relatively consistent before and during the pandemic. These findings underscore the importance of monitoring the trend of HPV epidemic and offer valuable insights for the prevention, treatment, and scientific investigation of HPV in the post-COVID-19 era.

Syrian refugee women's access to family planning services and modern contraception during overlapping crises in Bekaa, Lebanon

BACKGROUND

Political, financial, and pandemic crises in Lebanon have affected both provision of reproductive health services including family planning and modern contraception methods as well as women's interest and ability to seek those services. This study aims to explore the impact of the compounding crises on the provision and use of family planning services including modern contraception methods for Syrian refugees in Lebanon focusing on the perspectives of Syrian refugee women.

METHODS

We carried out 12 Focus Group Discussions (FGDs) with 119 Syrian refugee women recruited from two cities in West Bekaa, Lebanon from inside and outside the informal tented settlements. We used Skype video calls to moderate the FGDs due to the limited mobility at the time of the study because of Covid-19. We used thematic analyses to analyse the data.

RESULTS

The crises seemed to exacerbate supply side barriers, which influenced provision of family planning services and women's demand for them. These included Covid-19 regulations and maltreatment by staff at public health facilities, disruption of outreach reproductive health services that provide family planning and modern contraception, and reduced supply of modern contraception methods. On the demand side, women reported financial limitations in accessing and paying for services, concern over being infected with Covid-19, and concerns about insecurity.

CONCLUSIONS

We suggest possible interventions to address these challenges and better reach these populations. These include using mobile health technology (mHealth) that may provide contraceptive counselling and/or can inform refugee women about where they may receive family planning and modern contraception. These services may also support Syrian refugees to access care they are entitled to receive and may also address disruptions in service provision due to overlapping crises, including availability and rising costs of contraceptives. These can be coupled with mobile outreach reproductive health services that provide family planning. We also suggest considering the provision of Long Acting Reversible Contraception (LARC) for Syrian refugee women, which would reduce a barrier of needing to revisit health facilities to obtain an additional supply of contraception pills.

Effects of the COVID-19 pandemic on sales of sexual and reproductive health products: an ecological study of pharmacies in Kenya

OBJECTIVES

To examine how sales of sexual and reproductive health (SRH) products varied among pharmacies in Kenya using administrative data, leveraging natural variation in the COVID-19 pandemic and accompanying policy restrictions between 2019 and 2021.

DESIGN AND SETTING

Ecological study of pharmacies in Kenya.

PARTICIPANTS

761 pharmacies using the Maisha Meds product inventory management system (capturing 572 916 products sold).

OUTCOMES

Sales quantity, price and revenue of SRH products sold per pharmacy per week.

RESULTS

COVID-19 deaths were associated with a -2.97% (95% CI -3.82%, -2.11%) decrease in sales quantity, a 1.09% (95% CI 0.44%, 1.72%) increase in sales price and a -1.89% (-1.00%, -2.79%) decrease in revenues per pharmacy per week. Results were similar when considering new COVID-19 cases (per 1000) and the Average Policy Stringency Index. Results differed substantially between individual SRH products-a large decrease in sales quantity in pregnancy tests, injectables and emergency contraception, a modest decrease in condoms and no change in oral contraception. Sales price increases were similarly varied; four of the five most sold products were revenue neutral.

CONCLUSIONS

We found a robust negative association between SRH sales at pharmacies in Kenya and COVID-19 reported cases, deaths and policy restriction. Although our data cannot definitively point to reduced access, existing evidence from Kenya regarding unchanged fertility intentions, increases in unintended pregnancies and reported reasons for non-use of contraceptives during COVID-19 suggests a prominent role of reduced access. While policymakers may have a role in sustaining access, their role may be limited by broader macroeconomic problems, such as global supply chain disruptions and inflation, during supply shocks.

Health and economic implications of the ongoing coronavirus disease (COVID-19) pandemic on women and children in Africa

The coronavirus disease (COVID-19) pandemic continues to pose major health and economic challenges for many countries worldwide. Particularly for countries in the African region, the existing precarious health status resulting from weak health systems have made the impact of the pandemic direr. Although the number of the COVID-19 infections in Africa cannot be compared to that of Europe and other parts of the world, the economic and health ramifications cannot be overstated. Significant impacts of the lockdowns during the onset of the pandemic caused disruptions in the food supply chain, and significant declines in income which decreased the affordability and consumption of healthy diets among the poor and most vulnerable. Access and utilization of essential healthcare services by women and children were also limited because of diversion of resources at the onset of the pandemic, limited healthcare capacity, fear of infection and financial constraint. The rate of domestic violence against children and women also increased, which further deepened the inequalities among these groups. While all African countries are out of lockdown, the pandemic and its consequent impacts on the health and socio-economic well-being of women and children persist. This commentary discusses the health and economic impact of the ongoing pandemic on women and children in Africa, to understand the intersectional gendered implications within socio-economic and health systems and to highlight the need for a more gender-based approach in response to the consequences of the pandemic in the Africa region.

Cervical cancer prevention program in Mexico disrupted due to COVID-19 pandemic: Challenges and opportunities

Introduction

The COVID-19 pandemic disrupted the preventive services for cervical cancer (CC) control programs in Mexico, which will result in increased mortality. This study aims to assess the impact of the pandemic on the interruption of three preventive actions in the CC prevention program in Mexico.

Methods

This study is a retrospective time series analysis based on administrative records for the uninsured population served by the Mexican Ministry of Health. Patient data were retrieved from the outpatient service information system and the hospital discharge database for the period 2017-2021. Data were aggregated by month, distinguishing a pre-pandemic and a pandemic period, considering April 2020 as the start date of the pandemic. A Poisson time series analysis was used to model seasonal and secular trends. Five process indicators were selected to assess the disruption of the CC program, these were analyzed as monthly data (N=39 pre-pandemic, N=21 during the pandemic). HPV vaccination indicators (number of doses and coverage) and diagnostic characteristics of CC cases were analyzed descriptively. The time elapsed between diagnosis and treatment initiation in CC cases was modeled using restricted cubic splines from robust regression.

Results

Annual HPV vaccination coverage declined dramatically after 2019 and was almost null in 2021. The number of positive Papanicolaou smears decreased by 67.8% (90%CI: -72.3, -61.7) in April-December 2020, compared to their expected values without the pandemic. The immediate pandemic shock (April 2020) in the number of first-time and recurrent colposcopies was -80.5% (95%CI:-83.5, -77.0) and -77.9% (95%CI: -81.0, -74.4), respectively. An increasing trend was observed in the proportion of advanced stage and metastatic CC cases. The fraction of CC cases that did not receive medical treatment or surgery increased, as well as CC cases that received late treatment after diagnosis.

Conclusions

Our analyses show significant impact of the COVID-19 pandemic with declines at all levels of CC prevention and increasing inequalities. The restarting of the preventive programs against CC in Mexico offers an opportunity to put in place actions to reduce the disparities in the burden of disease between socioeconomic levels.

Trends in fertility intentions and contraceptive practices in the context of COVID-19 in sub-Saharan Africa: insights from four national and regional population-based cohorts

OBJECTIVES

Studies in several sub-Saharan geographies conducted early in the COVID-19 pandemic suggested little impact on contraceptive behaviours. Initial results may mask widening disparities with rising poverty, and changes to women's pregnancy desires and contraceptive use amid prolonged health service disruptions. This study examined trends in contraceptive behaviours in four sub-Saharan African settings 1 year into the pandemic.

DESIGN

Nationally and regionally representative longitudinal surveys.

SETTING

Burkina Faso, Kenya, Democratic Republic of Congo (Kinshasa) and Nigeria (Lagos).

PARTICIPANTS

Women aged 15-49 years with sample size ranging from 1469 in Nigeria to 9477 in Kenya.

OUTCOME MEASURES

Fertility preferences, contraceptive use and unintended pregnancies measured before COVID-19 (November 2019 to January 2020) and during COVID-19 (November 2020 to January 2021).

ANALYSIS

We described population-level and individual-level changes by socioeconomic characteristics using generalised equation modelling. We used logistic regression models to identify factors related to contraceptive adoption and discontinuation and to experiencing an unintended pregnancy.

RESULTS

At the population level, we found no change in women's exposure to unintended pregnancy risk, alongside 5-9 percentage point increases in contraceptive prevalence in Burkina Faso, Kenya and Lagos. Reliance on provider-dependent methods dropped by 2 and 4 percentage points in Kenya and Burkina Faso, respectively, although these declines were not statistically significant. Between 1.0% and 2.8% of women across sites experienced an unintended pregnancy during COVID-19, with no significant change over time. Individual-level trajectories showed contraceptive adoption was more common than discontinuation in Burkina Faso, Kenya and Lagos, with little difference by sociodemographic characteristics. Women's COVID-19-related economic vulnerability was unrelated to unintended pregnancy across sites.

CONCLUSIONS

This study highlights the resilience of African women across diverse settings in sustaining contraceptive practices amid the COVID-19 pandemic. However, with reports of rising poverty in sub-Saharan Africa, there is continued need to monitor access to essential sexual and reproductive health services.

Impact of COVID-19 on the prescription of contraceptives in a city in São Paulo

OBJECTIVE

In the beginning of the pandemic, measures, such as social distancing, lockdown strategies, and restrictions on mobility, as well as the fear of transiting through health facilities, raised concerns about the impact of COVID-19 on women's ability to continue using contraceptives.

METHODS

This is a retrospective cohort study, which evaluated reports of medication distribution spreadsheets in Bauru - SP, from January 2019 to June 2021.

RESULTS

Our study showed that the municipal dispensation of contraceptives in the SUS was markedly impacted by the COVID-19 pandemic, suffering reductions that can impact on an increase in unplanned pregnancy rates. It is possible to note a significant decrease in the distribution of combined oral contraceptives (44.18%), combined injectable contraceptives (47.58% reduction), and medroxyprogesterone acetate (13.98%). This fact may be associated with the reduction in offers of face-to-face consultations in gynecology, due to the social isolation necessary at the time of the pandemic.

CONCLUSION

Ensuring access to contraceptives during health emergencies should be a public health policy priority. Thus, it is essential to draw up strategic plans to encourage full access to reproductive planning services even in times of health emergency, so that the occurrence of unplanned pregnancies can be adequately prevented.

Disruptions to the procurement of medical abortion medicines during COVID-19: a scoping review

OBJECTIVES

This scoping review aimed to systematically search, retrieve and map the extent and characteristics of available literature on the evidenced disruptions to medical abortion (MA) medicine procurement caused by the COVID-19 outbreak.

DESIGN

Scoping review using Arksey and O'Malley's methodology and Levac et al's methodological enhancement with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

DATA SOURCES

PubMed, Embase, PMC, Science Direct, the Cochrane Library and Google Scholar were searched from January 2020 to April 2022.

ELIGIBILITY CRITERIA

We included articles in English that: (1) contained information on MA medicines; (2) included descriptions of procurement disruptions, including those with examples, characteristics and/or statistics; (3) documented events during the COVID-19 pandemic; and (4) presented primary data.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened search results, performed a full-text review of preliminarily included articles and completed data extraction in a standard Excel spreadsheet. Extracted data from was compared for validation and synthesised qualitatively.

RESULTS

The two articles included are unpublished grey literature demonstrating evidence of short-lived disruptions in sexual and reproductive health commodity procurement, including MA medicines, in sub-Saharan Africa during the early months of the pandemic. Findings from the two included grey literature articles show that in sub-Saharan contexts, emergency preparedness, stockpiling, adaptations and flexibility of key actors, including donors, alleviated COVID-19 disruptions allowing for resumption of services within weeks.

CONCLUSION

There is a need for increased empirical evidence of MA procurement challenges to understand which barriers to MA procurement may persist and impact continuity of supply while others can fuel resilience and preparedness efforts at the country and subregional levels. The lack of evidence from social marketing organisations and their networks is a significant gap as these actors constitute a vital artery in the distribution of MA commodities in low-income and middle-income countries.

Impact of the COVID-19 pandemic on access to and utilisation of services for sexual and reproductive health: a scoping review

Introduction

The COVID-19 pandemic has negatively impacted health systems globally and widened preexisting disparities. We conducted a scoping review on the impact of the COVID-19 pandemic on women and girls’ access to and utilisation of sexual and reproductive health (SRH) services for contraception, abortion, gender-based and intimate partner violence (GBV/IPV) and sexually transmitted infections (STIs).

Methods

We systematically searched peer reviewed literature and quantitative reports, published between December 2019 and July 2021, focused on women and girls’ (15–49 years old) access to and utilisation of selected SRH services during the COVID-19 pandemic. Included studies were grouped based on setting, SRH service area, study design, population and reported impact. Qualitative data were coded, organised thematically and grouped by major findings.

Results

We included 83 of 3067 identified studies and found that access to contraception, in-person safe abortion services, in-person services for GBV/IPV and STI/HIV testing, prevention and treatment decreased. The geographical distribution of this body of research was uneven and significantly less representative of countries where COVID-19 restrictions were very strict. Access was limited by demand and supply side barriers including transportation disruptions, financial hardships, limited resources and legal restrictions. Few studies focused on marginalised groups with distinct SRH needs.

Conclusion

Reports indicated negative impacts on access to and utilisation of SRH services globally, especially for marginalised populations during the pandemic. Our findings call for strengthening of health systems preparedness and resilience to safeguard global access to essential SRH services in ongoing and future emergencies.

The impact of COVID-19 on safe abortion access in Africa: An analysis through a framework of reproductive justice and lens of structural violence

The SARS-CoV-2 virus causing the coronavirus disease (COVID-19) global pandemic heightened restrictions on sexual and reproductive health and rights (SRHR), especially concerning safe abortion access. The African region has been particularly susceptible to the impact of COVID-19 on sexual and reproductive health services. Using a framework of reproductive justice, we interviewed key informants from the Mobilizing Action around Medication Abortion (MAMA) Network regarding the impacts of structural violence and COVID-19 on SRHR programming in Africa, particularly programming on self-managed abortion. We identified themes of lacking infrastructures of support, emergent marginality, and neocolonial funding environments as facets of structural violence within the context of the MAMA Network, as heightened by the COVID-19 global pandemic.

Adaptation and Resilience: Lessons Learned From Implementing a Combination Health and Education Intervention for Adolescent Girls and Young Women in South Africa During the COVID-19 Pandemic

The COVID-19 pandemic has been associated with reduced access to health services and worsening health outcomes for HIV and sexual and reproductive health (SRH). Through the analysis of data from an evaluation study of a combination intervention for adolescent girls and young women (AGYW) in South Africa, we sought to examine the way in which implementation and service provision were impacted by the COVID-19 pandemic and related restrictions, describing the adaptation implementers made to respond to this context. The intervention was implemented from 2019 in South African districts identified as high priority, given the high rates of HIV and teenage pregnancy amongst AGYW. The South African government introduced the first COVID-19 lockdown in March 2020. We conducted in-depth interviews with 38 intervention implementers in the period from November 2020 to March 2021. Respondents described various ways in which the COVID-19 pandemic and related restrictions had limited their ability to implement the intervention and provide services as planned. As a result, AGYW intervention beneficiary access to SRH and psychosocial services was disrupted. Implementers described several ways in which they attempted to adapt to the pandemic context, such as offering services remotely or door-to-door. Despite attempts to respond to the context and adapt services, overall COVID-19 negatively affected implementation and service provision, and heightened issues around community acceptability of the programs. Our findings can help to inform efforts to reduce health service disruption, increase health system resilience, and ensure continuous SRH service provision to AGYW in times of pandemics and other crises.

Disparities in Accessing Sexual and Reproductive Health Services and Rights Among Adolescents and Young People During COVID-19 Pandemic: Culture, Economic, and Gender Perspectives

Purpose of Review

As the world grapples with the health systems' challenges during the COVID-19 pandemic, addressing the needs of the already vulnerable adolescents and young people is vital. This narrative synthesis is aimed to highlight the current gender, cultural, and socioeconomic dynamics fueling inequalities to accessing sexual, reproductive health and rights (SRHR) services among adolescents and young people in low- and middle-income countries (LMIC).

Recent Findings

The COVID-19 pandemic has in most countries exacerbated already existing inequalities due to economic, gender, cultural, and legal aspects. Strategies implemented by most governments to mitigate the spread of the virus have also had a negative impact on the access to SRHR services, some of which are long term. Few published studies have assessed the extent to which the pandemic has fueled each of these paradigms regarding access to SRHR, especially among adolescents and young people (AYP). Additionally, there is paucity in data on the same in most countries, as the systems to track such effects were not available at the inception of the pandemic.

Summary

Despite efforts to mitigate the effects of the pandemic on this population, deficits remain and a multi-stakeholder approach is needed to achieve the intended goals, especially where cultural and gender values are deeply rooted. Further research is needed to quantify how the pandemic has fueled economic, gender, and cultural aspects to influence access to SRHR services among AYP especially in LMIC.