Trends in Utilization of Contraceptive and Pregnancy-Related Services around COVID-19 Pandemic through Public Health Facilities: A Secondary Data Analysis

Abstract

Essential health services that by no means suffered due to the unprecedented COVID-19 pandemic of which family planning was one of them. World Health Organization (WHO) initiated a multi-country study (India, Nigeria, and Tanzania) in 2021 to assess the impact of the COVID-19 pandemic on the public health system to deliver family planning (FP) services and the trends in the uptake of contraceptive services in health facilities. As a part of major mixed-method study, secondary data from India’s Health Management Information System (HMIS) was analyzed to assess the trends in contraceptive and pregnancy-related services during the pre-and post-COVID-19 phases. During the first wave, the suspension of elective surgery including sterilization camps, Migration, and fear of visiting health facilities were some of the reasons that indirectly affected the trends in utilization of family planning services causing unintended pregnancies and increased ANC registration. Health system should continue providing family planning and abortion services during the pandemic as essential health services. Promotion and advocacy of Long-Acting Reversible Contraceptives could help in future health emergencies that can prevent the beneficiary from frequent visits to a health facility.

BACKGROUND

The World Health Organization (WHO) declared the outbreak of the SARS-COV-2 to be a public health emergency of international concern (PHEIC) on 31^st January 2020.[1] COVID-19 presented a significant public health threat worldwide with the surge in demand for health systems, necessitating the allocation of various resources, especially medical resources, towards the response which led to disruptions in the provision of essential health services, including sexual and reproductive health (SRH) services. Ending unmet need for Family planning (FP) by 2030 has been one of the priorities set by Sustainable Development Goals. However, United Nations Population Fund (UNFPA) estimated it that the pandemic had disrupted contraceptive use for about 12 million women with a consequence of nearly 1.4 million unintended pregnancies during 2020 across 115 low- and middle-income (LMIC) countries.[2]

Literature evidence exists as to how services got disrupted in the initial phase of the pandemic in India.[3] However, little is known about how the country coped with the pandemic to deliver SRH services including contraceptives. Thus, a study was undertaken to compare how contraceptive utilization through public health system in India differed prior, during and post-COVID-19 pandemic. Secondary data was analyzed at the country level, at the level of a selected state, at the level of a district within the and at two selected blocks within the district, representing urban and rural population.

MATERIALS AND METHODS

As part of a larger WHO supported multi country study,[4] secondary data from India’s Health Management Information System (HMIS) was compiled to assess the trends in utilization of family planning services for three consecutive financial years, 2019-20, 2020-21 and 2021-22 which represented pre COVID-19, 1^st wave COVID-19 and 2^nd wave COVID-19 years respectively. HMIS data is an open-access online website (https://hmis.mohfw.gov.in/#!/). Data from the blocks were retrieved physically, while visiting the health facilities during qualitative data collection. Permissions were also taken from the state and district officials for this study. State of Maharashtra being one of the populous states in India was purposively selected and Thane district being one of the severely affected districts with a COVID-19 Case fatality rate during the first wave of 1.9 (https://www.mygov.in/covid-19) was also purposively selected. Two blocks within the district representing urban (Navi Mumbai) and rural (Ambernath) were selected randomly.

There were five primary health care facilities in the urban block and four in the rural block. In addition, there was a referral secondary level of care sub- district hospitals at both sites. Data on monthly utilization of various contraceptives available in the national family planning program of India, ANC and abortion services was analyzed over three years and trend analysis was performed.

RESULTS

The trend analysis of contraceptive utilization is presented in comparison to the pre-COVID-19 year. During the first wave of COVID-19 pandemic, utilization of almost all the family planning services was affected. At the country level, beneficiaries for sterilization reduced by 33% with almost similar reduction (40%) at the state and district level compared to pre-COVID-19 phase. This significant change was due to suspension of elective surgeries including sterilization camps [Figure 1]. At the block level, it was more affected in urban in comparison with rural sites. Urban block level data showed a prominent decline by 82.5% during first lockdown phase which however increased gradually during second wave by 72.4% but did not reach pre-pandemic levels. On the contrary, at the rural site it increased by 10.4% in first wave followed by 45.6% increase during the second wave. During second wave, due to strict COVID-19 protocols and mandatory COVID-19 testing prior to surgeries, the uptake of permanent method was low. However, these eligible couples were provided alternative method of contraceptives.

Figure 1.

Trends in contraceptive utilization at Country, State, and district and study sites

In comparison to pre-COVID-19, the uptake of Long-Acting Reversible Contraceptives (IUCD and Injectable contraceptives) minimally decreased by 6.3% at country level during the 1^st COVID-19 wave, however at the state and district level it showed 50.4% and 29.3% reduction respectively due to interruption in the supply chain. IUCD services at the urban site significantly reduced by 66.3% in the 1^st wave of COVID-19 unlike pre-COVID-19 [Figure 1].

Centchroman (non-hormonal oral contraceptive by the name “Saheli”) showed impressive uptake during pandemic at the country and district level by 40% and 70.2%, respectively, and state by only 12.9%. However, site specific data could not demonstrate the same trend. These changes could be due to poor awareness in community about the availability of such type of contraceptives since centchroman is a relatively new commodity in the program.

While the other family planning services were disrupted, demand for Emergency Contraceptive pills increased by 17.4% at country level during 1^st wave of COVID-19 than the pre-pandemic phase. However, at state level this was not observed. A small increase by 7.3% was seen in the overall Thane district followed by 54.3% increase in Urban site and Rural by 53% where the study was undertaken.

Distribution of spacing methods mainly Oral contraceptive (OC) pills and Condoms at the household level through community health workers greatly maintained the utilization of these methods. It reduced by only 5% at country and district level compared to pre-COVID-19 year [Figure 1]. OC pills utilization increased by 10.8% among the rural sites but markedly reduced by 40.2% than the pre-COVID-19 phase at urban site. [Figure 1] Similarly during the first wave of COVID-19, service utilization for condoms increased by 30%, among the rural sites in first wave and by 70% during the second wave. However, it showed a decline by 16.2% in urban than pre-COVID-19.

Disruptions in Family planning services at country level during the first wave of COVID-19 showed significant impact on ANC registration and abortion services (Medical Termination of Pregnancy up to 12 weeks of gestation) as it increased by 14.1% and 7% respectively [Supplementary Figure 1 ^{(218.8KB, tif)} ] with a gradual decline in these services as the FP services resumed and were getting normalized in the recovery phase of second wave. ANC registration did not show significant change in services at state and district level but abortion rates increased by 47.4% in state during both 1^st and 2^nd wave of pandemic and similar trend was seen Thane district [Supplementary Figure 1 ^{(218.8KB, tif)} ].

ANC utilization increased by 23.5% in rural and decreased by 19.5% in urban. Matching this trend, the abortion rates dropped by 79.5% in urban with negligible change in numbers seeking abortion and this could possibly be because of poor access to abortion services in rural compared to urban or felt need to continue pregnancy despite it being unintended. [Supplementary Figure 1 ^{(218.8KB, tif)} ].

DISCUSSION

The trends in contraceptive use assessed from the HMIS data reflects low utilization of almost all family planning methods mainly in the 1^st wave of COVID-19. As is evident from data, among spacing methods during pre-COVID-19, the commonest contraceptive used was IUCD. However, during COVID-19 the commonly used contraceptives were condoms and OC pills. Overall, the trends were similar across all levels at national state, district, and block but some variations were noted in the urban and rural uptake of family planning, ANC, and abortion services. Reduced interactions with health care providers for contraceptive advise at facilities, fear of getting tested and isolated and travel inconveniences could be some of the reasons for the declining trends in use of long-acting contraceptives. Moreover, reduced demand for contraceptives, migration, and suspension of sterilization camps along with other elective surgeries directly and indirectly resulted in reduced utilization of family planning services. The demand for contraceptives could have been ensured and encouraged by utilizing the tele consultation and other digital pathways which was overlooked during the upsurge of COVID-19 pandemic

This would have been expected to be the case in every developing world where systems were not geared up to immediately cope with the challenges of providing ongoing services. Similar observations were made in the South African study during first 5 weeks of COVID-19 lockdown.[5] Unwanted pregnancy was reported by few clients in the study due to shortage of FP methods as reported by Brunie A et al.[6]

This had direct reflections on the trends observed nationally in number of abortions along with ANC registrations reflecting probably a lot of unintended pregnancies during pandemic due to the unavailability of contraceptives.

CONCLUSION

These lessons could pave way for good strategic planning to ensure adequate preparedness of providing FP and other essential SRH services. Provision of abortion services both medical and surgical procedures also need to be prioritized in rural areas that can help in preventing unwanted births along with easy availability of Emergency contraception in such future health emergencies.

Ethical approval

The generic research protocol was approved by WHO RP2 and WHO Ethics and Research Committee to conduct the research. (Project no. A66007).

The study proposal was approved by the Institutional Ethical Committee (IEC) of ICMR.

NIRRCH, Mumbai (D/ICEC/Sci-166/175/2021) on 28^th September 2021.

Conflicts of interest

There are no conflicts of interest.

Supplementary Figure 1

Trends in ANC registration and Abortion services at Country, state, district and study sites

Funding Statement

This work was supported by World Health Organization (WHO), Geneva.