What COVID-19 means for the global provision of sexual and reproductive healthcare

Dr Annabel Sowemimo, member of FSRH’s International Committee, reflects on the impact of COVID-19 on global sexual health provision.

This post was written and first published on April 16th on the website of the Faculty of Sexual and Reproductive Healthcare of the Royal College of Obstetricians and Gynaecologists and republished with permission.

The novel coronavirus pandemic (COVID-19) was announced by the WHO Director-General as a Public Health Emergency of International Concern under International Health Regulation on 30 January. The pandemic continues to sweep across continents, at the time of writing, 208 countries or territories are affected with Europe and the US being the latest hotspots. COVID-19 presents an unprecedented challenge to sexual and reproductive healthcare (SRH) and the protection of SRH rights. Despite WHO declaring that the continued provision of SRH is essential there still has been numerous challenges to maintaining safe and accessible services.

Many of those working in SRH have been task shifted and redeployed to provide acute services causing some services to close or limit access. As more healthcare providers become unwell and have to self-isolate, it is likely that SRH services will face further closures and come under further duress.

As a member of the FSRH International Committee I wanted to reflect on what some of these changes may mean globally.

Marginalised groups

Poor SRH often affects the most marginalised groups within our society including those living with disabilities, those living with HIV, the transgender community, sex workers and migrant communities who will likely have their livelihoods severely disrupted by the economic downturn resulting from this pandemic.

These groups will not only be adversely affected by the disease itself, but also by the public health measures utilised to combat its spread; greater restrictions in freedom of movement, increased policing and reduced income when working from home.

Early data from the US indicates that Black Americans are already dying at a higher rate from COVID-19 which may be due to unequal health insurance coverage and greater economic hardship amongst this community however, similar trends are now being reported in the UK with 35% of those affected with COVID-19 coming from black or minority backgrounds.

Lessons from the HIV epidemic teach us the importance of placing the most affected communities at the centre of our interventions. Generally, public health measures should be intersectional – acknowledging that whilst some may benefit, others from the most marginalised communities are at risk of worsening mental health and a rise in gender-based violence due to the impacts of social isolation.

Young people and other vulnerable groups will be greatly affected by the lack of face-to-face services which provide an invaluable safeguarding opportunity. The WHO states that about 1 in 3 women have experienced intimate partner violence and attendance at school, work or health care appointments is often a time to identify those at risk of various forms of abuse.

There has already been a significant rise in gender based violence (GBV) being reported in some countries and the domestic violence charity sector in the UK has called for greater efforts to house those at risk of GBV. In Spain and Italy, campaigners have encouraged the use of code words to raise concern when survivors access essential services such as pharmacies. It is crucial that each country devises strategies to avoid greater fatalities due to intimate partner violence.

Pregnancy

New restrictions are likely to take a significant toll on pregnant people who have been advised to self-isolate; pregnancy increases the risk of intimate partner violence and coercive control.

The adaptations within several medical facilities have also caused severe disruption to maternity services including no birth partners, a change in the birth facility and fewer staff being available.

We could see similar effects to that of the Ebola pandemic where maternal mortality rose as well as a reduction in neonatal vaccination programmes, especially in lower income countries. The UNFPA have emphasised that standards of maternity care should be prioritised by all Governments alongside COVID-19 measures, or many countries risk reverting the progress made in their maternal mortality statistics.

Abortion

There have been unprecedented challenges to abortion care providers including reduced clinical staff, stock outs of essential medications, the reduction in surgical abortion under general anaesthetic and having to limit face-to-face consultation times.

In the US, anti-choice politicians have exploited the chaos created by this pandemic, with abortion providers in Alabama, Iowa, Ohio, Oklahoma and Texas having been told told to stop the provision of abortion care unless it endangers a women’s life.

This is despite evidence showing that without adequate abortion provision, maternal mortality increases substantially due to unsafe measures taken to end a pregnancy. Ohio and Alabama’s decisions have since been overturned in court, with the other states being challenged too. Chris Purdy, President of DKT International (one of the largest suppliers of SRH related pharmaceuticals) remarked that in India there has already been a shortage of mifepristone and misoprostol due to supply chain disruption from their main manufacturers in China.

Here in the UK, England, Scotland and Wales have introduced temporary laws to allow for telemedicine prescribing and the home use of mifepristone. This is a really important step forward, but even so there maybe vulnerable individuals who will still find access difficult as they might not have access to a phone, or computer, they might not have a fixed address or they might need to self-isolate.

Contraception and other hormonal medication

Stock outs of contraceptives are already a problem encountered in global SRH programmes particularly in low resource settings; the prolonged reduction in manufacturing and border closures are likely to amplify this problem.

Many of the world’s contraceptives and condoms are produced in Asia where factories have closed; when production does recommence, it is likely goods will spend longer in quarantine and there will be significant delays in reaching their destination.

Whilst many people are abiding by social distancing it is likely that the lack of access to adequate contraception and condom provision will lead to a rise in both unplanned pregnancy and untreated sexually transmitted infections (STIs). Whilst globally SRH organisations have tried to make adequate adaptations including extension to LARCs methods, telemedicine consultations and postal orders; an inevitable consequence of the COVID-19 pandemic is restriction to contraceptive choice.

Those requiring hormonal medications for a variety of reasons including those undergoing gender transition or accessing menopause services will also be impacted, and providers should act quickly to ensure patients have adequate supplies of essential medication. The consequences of medication shortages may be far-reaching and it is likely we will not know the full extent until we weather the worst of this pandemic.

HIV and antiretroviral medication

The COVID-19 pandemic will bring new challenges for those living with HIV – whilst those on antiretrovirals with an undetectable viral load are not considered at increased risk of COVID-19, they do suffer discrimination when accessing healthcare. Although several countries including the UK, Netherlands, Botswana have achieved the UNAIDs 90-90-90 target there are still many countries in Africa and Asia that have not.

It is imperative that we continue to encourage frontline health professionals to test those who are admitted with COVID-19 for HIV, so that they can be commenced on antiretroviral medication and have the best chance of survival. Those utilising pre-exposure prophylaxis (PrEP) treatment may choose to stop their medication or switch to an event based regime; however, others may have a need to continue.

A prolonged lockdown may lead to supply chain issues and inadequate distribution of anti-retroviral medication; we must encourage patients to check their supply regularly and professionals should start contingency planning early.

The future

How long it will take to beat COVID-19 and how long new regulations restricting movement will be in place isn’t always clear, but the effects of this pandemic will be long lasting. Acting rapidly to safeguard SRH services over the next three months will likely determine the health inequalities that our sector will be addressing for years to come.

The key to beating this pandemic will be through excellent public health measures; however, it is vital that preservation of human rights including SRH rights lie at the centre. There is a need for a united, global strategy towards SRH now, more than ever before.

 

 

Source of cover image

Popularity of apps like Natural Cycles highlights serious issues with contraceptives today

Natural Cycles

Many women have made a dramatic change in their use of contraceptives of late. Specifically, use of “contraceptive apps” such as Natural Cycles, a smartphone app that predicts the days on which a woman is fertile and can be used for contraception (as well as planning pregnancy), is on the rise. By closely tracking a woman’s cycle and temperature, such apps designate unprotected sex safe or unsafe each day. When unsafe, the use of barrier methods of protection is advised.

Natural Cycles was developed by CERN scientist Elina Berglund and her husband, Raoul Scherwitzl, whose scientific background has lent the app a certain kudos. And as “the only app certified for contraception” in Europe and, as of August 10, the US, women who might otherwise be suspicious of the method, which is at the end of the day simply jazzed up natural family planning, have taken the plunge.

The fact that many women are spurning more “medical” kinds of contraception, such as the pill or IUD, in favour of such apps, along with discussion in some cases of their failures, are once again drawing public attention to the hazards of being a pre-menopausal, heterosexual, sexually active woman. The risks of contraceptives range from milder side effects to rare but potentially serious complications. These, of course, come alongside the ever present risk of unintended pregnancy through contraceptive failure.

Many women report side effects with the contraceptive pill, but often aren’t listened to.
Suriyachan/Shutterstock

Understated side effects

When choosing a method of contraception, women routinely have to balance the impacts of each method against its likely effectiveness. Most of the evidence suggests that it is common for women to choose the least bad option in terms of side effects, rather than something they are really comfortable with. Consequently, it’s not surprising that a technology that promises to overcome many of these difficulties would prove to be popular.

Being able to control fertility is essential for women’s equality, yet the means to do this are currently all imperfect. Side effects are a common experience and are a major cause of women stopping using particular birth control methods. In contraceptive consultations, the frequency and severity of side effects and other more serious health risks are often understated.

Research suggests that health professionals seek to avoid mentioning issues they believe would cause undue concerns. This reluctance to disclose may be linked to historic ideas that women are not fully capable of rational decision making. The assumption that women are not to be trusted with contraception is most clearly seen in the promotion of long-acting reversible contraception (LARC): the injection, implant, and hormonal and copper coils. The evidence shows that some women who encounter difficulties sometimes struggle to get health professionals to remove their LARC. Women are expected to put up with side effects rather than taking a bigger risk of unintended pregnancy.

A perfect woman

Culturally speaking, unintended pregnancies are usually frowned upon. This is particularly the case for younger women and those in marginalised circumstances. This denigration links to ideas about irresponsibility more generally. Popular stereotypes of “feckless” families who have babies for benefits are commonplace, but are rarely accurate. In the US for example, the idea of the “welfare queen” has been shown to be false.

In the UK, it is government policy to limit the number of children claimants can receive benefits for. As in-work poverty means increasing numbers of families are reliant on benefits, more and more women will have their fertility judged.

Stereotypes of who would be or not be a “good” mother can be seen in healthcare providers’ assumptions of who would particularly benefit from LARC. It is also important to remember that the stigma surrounding abortion builds on assumptions of irresponsible women failing to successfully control their fertility. This is despite the evidence that contraceptive failure is a significant reason for needing abortion.

Failed contraceptives are a major cause of unwanted pregnancy.
Vadim Zakharishchev/Shutterstock

The cultural notions that women fail, rather than the fault being with contraceptive technologies, has even become standardised within health information. Many contraceptive information pages have institutionalised notions of women’s irresponsibility by including statistics on effectiveness reporting “perfect” and “typical” use. Given that “perfect” use for some methods is actually beyond women’s control (for example, the impact of a stomach upset on the pill), just showing “typical” use would ensure women were informed properly but without being judgemental.

Although women are largely held responsible for failure, that does not necessarily mean they are seen as responsible enough to make decisions over which birth control method to use. Although in other parts of the world, emergency hormonal contraception is available in supermarkets or even vending machines, in the UK and Australia, women wanting access need to have a consultation, even if this just takes place in a pharmacy. This is not necessarily to access them medically, but so they can be “advised” to avoid future “mistakes”.

Gendered inequality

In an age where relationships are supposed to be equal partnerships, contraception raises equality issues. To date, the “male pill” still has not materialised, leaving men with few options. Condoms are often not seen as “proper” contraception for ongoing relationships. The protection they provide against sexually transmitted infections means that they are associated with casual partners.

Condoms tend not to be used by those in ongoing relationships.
BORIMAT PRAOKAEW / Shutterstock.com

Meanwhile the idea of vasectomy (which should obviously only be undertaken if a decision of no future children is made) is popular with women for equality reasons. It allows couples to take turns over contraceptive responsibility over time. But many men do not seem to be that keen.

It’s also important to remember that pregnancy carries some risks for women alone. Even if they are supportive partners, men do not face the same biological issues of either continuing or ending a pregnancy. While there are now challenges to the expectations that women should always be the primary carer of children, changes in attitude cannot overcome this biological reality of pregnancy.

So it’s unsurprising that such apps are popular. Avoiding the health difficulties that many women experience with other contraceptive methods is appealing. But women are still waiting for better contraceptive solutions. In the meantime, reducing the stigma and costs of unintended pregnancy and abortion would an extremely useful step in recalibrating the understanding of the difficult balance women make between embodied impacts and the effectiveness of the current options.

Pam Lowe, Senior Lecturer in Sociology, Aston University

This article is republished from The Conversation under a Creative Commons license. Read the original article.