The impact of the COVID-19 crisis on meeting needs for family planning: a global scenario by contraceptive methods used

Abstract

The COVID-19 crisis could leave significant numbers of women and couples without access to essential sexual and reproductive health care. This research note analyses differences in contraceptive method mix across Sustainable Development Goal regions and applies assumed method-specific declines in use to produce an illustrative scenario of the potential impact of COVID-19 on contraceptive use and on the proportion of the need for family planning satisfied by modern methods. Globally, it had been estimated that 77 per cent of women of reproductive age (15-49 years) would have their need for family planning satisfied with modern contraceptive methods in 2020. However, taking into account the potential impact of COVID-19 on method-specific use, this could fall to 71 per cent, resulting in around 60 million fewer users of modern contraception worldwide in 2020. Overall declines in contraceptive use will depend on the methods used by women and their partners and on the types of disruptions experienced. The analysis concludes with the recommendation that countries should include family planning and reproductive health services in the package of essential services and develop strategies to ensure that women and couples are able to exercise their reproductive rights during the COVID-19 crisis.

Disclaimer

The views expressed herein are entirely those of the authors and do not necessarily reflect the views of the United Nations.

Introduction

Declared a global pandemic in March 2020, COVID-19 has come to affect the lives of billions of people around the world. It is the largest global public health emergency since the Spanish flu pandemic of 1918–1919 and has put many countries’ health-care systems under severe stress. Most governments have responded by introducing far-reaching policies, including behavioural changes aimed at limiting transmission and saving human lives. This has impacted a multitude of sectors, including sexual and reproductive health care, for which an essential component is the provision of safe, effective, affordable and acceptable methods of contraception. The COVID-19 crisis could leave significant numbers of women and couples without access to essential sexual and reproductive health care.

COVID-19 is impacting women’s ability to use contraception in a number of ways: disruptions to the supply chain are limiting the production, distribution and availability of contraceptive commodities, resulting in stock-outs ( Purdy, 2020); some health-care facilities are reducing services ( IPPF, 2020; MSI, 2020a); health-care providers are redirected from providing family planning services towards responding to COVID-19 ( Santoshini, 2020); and many women are unable to visit health-care facilities due to lockdowns or fear of exposure to COVID-19 ( UNFPA, 2020). When women’s and couple’s needs for family planning are not met, the number of unintended pregnancies is certain to rise, with life-long impacts on women and their families.

Riley et al. (2020) produced a scenario of 10 per cent decline in the use of short- and long-acting reversible contraception in low- and middle-income countries due to COVID-19, which resulted in an additional 49 million women with unmet need for modern contraception and an additional 15 million unintended pregnancies over the course of the year in low and middle-income countries. United Nations Population Fund ( UNFPA, 2020) and Avenir Health modelled a range of scenarios of unmitigated impact in 114 countries covering 93 per cent of users in low- and middle-income countries and projected 47 million women to be unable to use modern contraceptives due to the COVID-19 disruptions continuing for six months. It is possible that these scenarios provide conservative estimates of the global impact, since service providers have suggested even larger disruptions to services in 2020 ( MSI, 2020b). These scenarios were produced for a selection of countries and limited to estimates of contraceptive use changes and their impact on a range of outcomes, such as unintended pregnancies, unsafe abortions and maternal deaths.

This research note presents a scenario of the impact of COVID-19 on the Sustainable Development Goals (SDG) indicator 3.7.1., the proportion of women who have their need for family planning satisfied by modern methods. The indicator is monitored annually by the United Nations Population Division. Globally, it was estimated that the proportion of women of reproductive age (15–49 years) who had their need for family planning satisfied with modern contraceptive methods increased slightly, from 74 per cent in 2000 to 77 per cent in 2020 ( United Nations, 2020a) ( Figure 1). It is projected to reach 78 per cent in 2030, with a 95 per cent uncertainty interval of 74 per cent to 81 per cent. Just half of the need is satisfied with modern methods in sub-Saharan Africa today.

Figure 1. Trends in the proportion of women of reproductive age (15–49 years) who have their need for family planning satisfied with modern methods.

Source: United Nations, Department of Economic and Social Affairs, Population Division (2020). Estimates and Projections of Family Planning Indicators 2020. This figure is reproduced here under a Creative Commons Attribution 3.0 IGO license.

The impact of the COVID-19 pandemic on meeting the demand for family planning will be influenced by many factors, one of them being the types of contraceptive methods used by women in each country. Individual contraceptive methods differ in terms of the need for contact with health-care providers, the periodicity of renewal, the susceptibility to stock-outs and global supply chains disruptions, and their effectiveness in preventing unintended pregnancies.

Estimates of contraceptive use by individual methods are available at the national, regional and global levels ( United Nations, 2019). The prevalence of use of different contraceptive methods varies widely by region ( Figure 2). For example, in Central and Southern Asia the most common method is female sterilisation (22 per cent of women of reproductive age rely on this method), while injectables are the dominant method in sub-Saharan Africa, with a prevalence of 9 per cent among women of reproductive age.

Figure 2. Contraceptive use by method among women of reproductive age (15–49 years), by region, in 2019.

Source: United Nations, Department of Economic and Social Affairs, Population Division (2019). Contraceptive use by method 2019. Note: In this figure, Oceania includes Australia and New Zealand. Abbreviations: IUD, intrauterine device. This figure is reproduced here under a Creative Commons Attribution 3.0 IGO license.

Methods

This research note analyses the differences in contraceptive method mix across regions and applies method-specific declines in use to produce an illustrative scenario of potential impact of COVID-19 on contraceptive use and the proportion of need for family planning satisfied by modern methods. The scenario is implemented in Microsoft Excel and is provided as Underlying data ( Dasgupta et al., 2020).

Contraceptive prevalence is the percentage of women who report themselves or their partners as currently using at least one contraceptive method. Unmet need for family planning is the percentage of women who want to stop or delay childbearing for at least two years but are not using any contraceptive method. Demand for family planning satisfied by modern methods (SDG indicator 3.7.1.) is modern contraceptive prevalence divided by total demand, which is the sum of contraceptive prevalence and unmet need.

The methods for national, regional and global estimates and projections of family planning indicators among women of reproductive age (15–49 years) used in this research note are described in Kantorová et al., 2020. The estimates and projections are available from 1990 to 2030 for all women of reproductive age (15–49) for 186 countries or areas with a total population of 90,000 people or more and with at least one observation of contraceptive prevalence, as well as for aggregate geographic regions ( United Nations, 2020a). They are weighted by population and take into account changes in marital status. The survey data underlying the model-based estimates and projections are publicly available as a comprehensive data set of 1,317 survey-based observations for 196 countries or areas for the period 1950 to 2019 ( United Nations, 2020b).

The scenario assumes no change in sexual activity, fertility intentions, or total demand for family planning, as was also assumed by Riley et al. (2020), and no difference in the impact of COVID-19 disruptions on married/in-union versus unmarried women.

The assumed percentage decline in use for each method is presented in Table 1. Where possible, we followed the UNFPA (2020) assumptions of service disruption according to their public sector medium scenario. Broadly, we assume a 10 per cent decline for commodities that can be sourced from a range of distribution channels (e.g. condoms and oral contraceptive pill), and a 20 per cent decline for methods that require a service provision from a health care provider (e.g. injectables). For long-acting and permanent methods, all of which require a service from a health care provider, we use the metric couple years of protection (CYP) ( USAID, 2019) to estimate the number of users requiring a service over the course of the year to maintain the existing number of users, and apply the 20 per cent decline to that portion. No decline was assumed for methods that do not require any commodity or contact with a service provider. Because of the lack of country-specific data, we assume no differences in method-specific decline across countries and regions, despite the fact that some countries and regions may be better prepared to handle the crisis than others. We also make no assumptions about switches between modern methods of contraception (e.g. from injectables to oral contraceptive pills or condoms).

Table 1. Scenario assuming declines in use by method, with justification.

Method	Assumed percentage decline in use	Justification
Female sterilization	2%	Some existing female sterilization users age-out and are not replaced by adopters of sterilization. We applied the 20% decline to this fraction, estimated as 1/10, because the CYP for female sterilization is 10.
Male sterilization	2%	Some wives/parters of existing male sterilization users age-out and are not replaced by adopters of sterilization. We applied the 20% decline to this fraction, estimated as 1/10, because the CYP for male sterilization is 10.
IUD	4.3%	Some existing IUD users age-out or discontinue their use because the commodity expires. We applied the 20% decline to this fraction, estimated as 1/4.6, because the CYP for Copper T IUD is 4.6. The assumed decline is an overestimate, since existing users who require a resupply are likely to still be somewhat protected by their expired IUD.
Implant	5.3%	Some existing implant users age-out or discontinue their use because the commodity expires. We applied the 20% decline to this fraction, estimated as 1/3.8, because the CYP for Jadelle implant is 3.8. The assumed decline is an overestimate, since existing users who require a resupply are likely to still be somewhat protected by their expired implant.
Oral contraceptive pills	10%	Pills can be accessed from a variety of sources (e.g. pharmacies) with limited interaction with health care system. The 10% decline is consistent with UNFPA (2020) medium public sector scenario.
Condoms	10%	Condoms can be accessed from a variety of sources and distribution channels. Access does not require interaction with health care system. The 10% decline is consistent with UNFPA (2020) medium public sector scenario.
Injectables	20%	With the exception of self-injectables (e.g. Sayana press), the majority of injectable users require interaction with a service provider. This interaction is typically required every three months, so discontinuation is likely to be more heavily impacted by COVID-19. The 20% reduction is consistent with UNFPA (2020) medium public sector scenario.
Other modern methods (including vaginal barrier methods, emergency contraception)	10%	Consistent with UNFPA (2020) medium public sector scenario.
Lactational amenorrhea method	0%	No decline assumed since women can use this method without contraceptive commodity / service provision
Traditional methods including rhythm, withdrawal	0%	No decline assumed since women can use this method without contraceptive commodity / service provision. Any change in traditional use does not affect SDG 3.7.1. since the indicator is concerned with demand satisfied by modern methods.

CYP, couple years of protection; IUD, intrauterine device; UNFPA, United Nations Population Fund; SDG, Sustainable Development Goal.

Regarding the time-frame of our analysis, we assume the disruptions take place over the year 2020 and calculate the estimates for this year. While the disruptions might not be equally spaced through 2020, we assume the impact is averaged over the year.

As a sensitivity test, we also prepared a separate scenario using an assumed 10 per cent decline in short-term and long-acting reversible contraception (the scenario is included in Underlying data) ( Dasgupta et al., 2020). This replicates the Riley et al. (2020) approach, but extends their analysis to the global level, and to the indicator demand for family planning satisfied by modern methods.

Results

In the scenario of method-specific declines presented above, the proportion of women who have their need for family planning satisfied with modern methods could fall to 71 per cent in 2020 ¹ ( Figure 3), which would be a regression to levels not seen at the global level since 1995. The largest declines would be in Latin America and the Caribbean (6.7 per cent) and sub-Saharan Africa (6.8 per cent), because these regions have a method-mix skewed towards short-term methods. Central and Southern Asia would experience a smaller average decline (3.7 per cent), because this region has a high proportion of women using female sterilization, which is least affected by short term disruptions.

Under this scenario, the impact of the pandemic could be around 60 million fewer users of modern contraception worldwide in 2020. Overall declines in contraceptive use will depend on the methods used by women and their partners, and the types of disruptions experienced (availability of commodities, health care service provision). For example, countries with a high prevalence of long-acting and permanent methods (LAPM) would likely experience little change, as many LAPM users will continue to be protected. On the other hand, countries that rely more heavily on short-term methods such as injectables, requiring repeated contact with a service provider, would likely see a decline in use.

Figure 3. Proportion of women of reproductive age (15–49 years) who have their need for family planning satisfied with modern methods in 2020.

Conclusions

This scenario is intended to be illustrative of the potential impacts during 2020 of continued disruptions due to COVID-19. Although we applied simplified assumptions across all countries, not all countries will experience the same level of disruptions due to COVID-19. We have assumed that such disruptions could last for a full year, but a shorter disruption would obviously have less impact. For example, a six-month disruption would result in half the impact (the demand for family planning satisfied by modern methods in 2020 would be 74 per cent).

To understand the impacts of COVID-19 disruptions on contraceptive services and use, countries and family planning service providers need to continue data collection through health management information systems, focusing on data quality and completeness during the crisis. This is especially needed because major survey programmes paused the data collection field work. By the time surveys have resumed, some of the gaps in contraceptive use may have recovered, as shown by research on contraceptive use during and after the West African Ebola crisis ( Bietsch et al., 2020), and so the decline in use during the crisis might not be observed in future surveys. The data from health management information systems and information about supply chains will also help to inform projections for year 2030.

While we do not yet know how fertility preferences will change in response to the COVID-19 crisis, it is likely that as a result of the economic downturn and increasing uncertainties, some women and couples who were planning a pregnancy may decide to postpone childbearing to a later period. These changes in childbearing preferences increase the need for family planning methods, and therefore our scenario could underestimate the potential impact of COVID-19.

Countries should include family planning and reproductive health services in the package of essential services and develop strategies to ensure that women and couples are able to exercise their reproductive rights during the COVID-19 crisis. Countries should plan for adequate stocks of commodities. Family planning programmes could also increase availability of some less common self-care methods such as diaphragm, female condom, emergency contraception, and provide information about fertility awareness-based methods, which do not require resupply or do not require commodity. The experience gained during the present pandemic should be used to develop preparedness and contingency plans for any future disruptions. For example, countries could improve access to long acting methods because existing users of these methods are less impacted when there are disruptions to services.

Data availability

Source data

Contraceptive prevalence data was retrieved from the United Nations, Department of Economic and Social Affairs, Population Division Estimates and Projections of Family Planning Indicators 2020 ( https://www.un.org/development/desa/pd/node/3288) and United Nations, Department of Economic and Social Affairs, Population Division Contraceptive Use by Method 2019: Data Booklet ( https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_contraceptiveusebymethod_databooklet.pdf).

Source data are available under the terms of the Creative Commons Attribution 3.0 IGO license (CC BY 3.0 IGO).

Underlying data

Harvard Dataverse: Supplementary material to "The impact of the COVID-19 crisis on meeting needs for family planning: A global scenario by contraceptive methods used". https://doi.org/10.7910/DVN/C6V7PN ( Dasgupta et al., 2020).

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

Notes

¹Under the separate scenario where we assumed a 10 per cent decline in all short-term and long-acting reversible contraception in line with the approach taken by Riley et al., 2020, the estimate of the need for family planning satisfied with modern methods in 2020 is 72 per cent. There are not large differences between the two scenarios at the global level.

Funding Statement

This work was supported by the Bill and Melinda Gates Foundation [OPP1183453].

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.