In a variety of ways that suit their contexts, countries around the world have adapted international guidance on providing voluntary family planning and related reproductive health care during the COVID-19 pandemic. Tracking the extent to which these new policies are successful in maintaining women’s access to safe, high-quality care will provide valuable lessons for responses to future public health emergencies.
In late January 2020, the World Health Organization (WHO) declared COVID-19 a Public Health Emergency of International Concern, a formal declaration that triggered governments to mandate that only “essential” health care be provided during the pandemic. Though well-intentioned, this directive is also ambiguous. While health care workers scramble to manage waves of highly infectious and often critically ill patients, who decides what type of health care is essential?
Amid an inconsistent designation of “essential” services, overburdened health facilities, lockdowns, supply chain interruptions, and travel restrictions, without decisive action, provision of voluntary family planning will inevitably decline, with potentially devastating effects. The Guttmacher Institute estimated the impact of a 10% proportional decline in the use of short- and long-acting reversible contraceptive methods in 132 low- and middle-income countries. By their calculations, this would result in an additional 49 million women with an unmet need for modern contraceptives and an additional 15 million unintended pregnancies over the course of a year.
Fortunately, governments have taken steps to help ensure that voluntary family planning care remains essential and accessible. Below, we highlight actions taken by five countries in East and Southern Africa and compare their guidance to the following WHO recommendations:
|Country||Substitution||Relaxing Prescription Requirements||Task Sharing|
|Kenya||X||3-month refills for pills||Community-based distribution (CBD) of pills and condoms
Offered guidance for continued provision of injectables and other methods allowable in private-sector pharmacies and drug shops
|Uganda||X||3-month refills for pills||Allowed for community health workers (CHWs), but no clear emphasis on the private sector|
|Tanzania||Emergency contraceptive pills (ECPs) recommended||3-month refills for pills||Recommend ECPs be provided at all pharmacies and drug shops|
|Zambia||X||3-month refills for pills||X
(Did not disallow, but offered no clear guidance)
|Zimbabwe||Fertility awareness methods (FAMs)||3-month refills for pills||X
(Did not disallow, but offered no clear guidance)
Kenya released a guidance document, Practical Guide for the Provision of Maternal, Newborn and Family Planning Care and Services during the Context of COVID-19, that officially designated voluntary family planning as an essential service. Recommendations include:
Kenya’s openness to task sharing sets it apart from some neighboring countries. In general, the government’s guidance encourages a balance between innovation and fidelity to established recommendations in order to maintain women’s access to safe, high-quality family planning care.
The Global Financing Facility estimated that due to current COVID-related disruptions, the percentage of married women using modern and traditional family planning methods could drop from the current level of 44% to 26% in a year, without intervention. To help ward off the damaging results of an estimated 941,800 fewer women receiving family planning care, the Government of Uganda released an interim guidance document, Sustained Delivery of Essential Health Services in the Context of COVID-19 in Uganda, prioritizing voluntary family planning as an essential service. Subsequently, the Ministry of Health (MOH) prepared specific guidelines on reproductive health care in the context of the pandemic. The approach focuses on:
It is interesting to note that despite some successful pilot programs, Uganda’s COVID guidance does not recommend task sharing via provision of injectables in private-sector clinics or by drug shops. However, Uganda’s plan to review medical records to identify women in need of refills and engage trusted motorcycle taxi drivers to contact these clients is a novel approach that could be easily replicated if successful.
During a webinar in June, Dr. Alfred Mukuwani, Tanzania’s Assistant Director for Reproductive and Child Health, explained that Tanzania’s approach to COVID-19 differs from that of some neighboring countries. The country never fully locked down, but rather emphasized infection prevention, mainly through handwashing. Tanzania’s New Practical Guidelines for Maternal Nutrition and Child Health and Family Planning Services during COVID-19 focuses on the following measures:
Provision of ECPs is unique to Tanzania among the countries discussed here, and their ready accessibility is especially important.
The Government of Zambia developed General Guidelines for Continuation of Essential Public Health Services, which notes that the likelihood of increased unintended pregnancies during the pandemic necessitates women’s continued access to voluntary family planning information and care. Zambia’s strategy for maintaining continuity of voluntary family planning relies on:
However, injectable contraceptives are the most popular method among Zambian women, and the guidelines do not emphasize task sharing (such as provision by drug shops) to increase access or reduce the burden on facilities. Also, outreach services were suspended, and the guidelines defer the removal of long-term methods, provision of IUDs, and elective surgeries like vasectomy and tubal ligations. As a result, practically speaking, many women will have few options beyond condoms and OCPs, which may result in decreased use of voluntary family planning.
Some family planning clinics in Zimbabwe have closed because of COVID-19, and others have suspended outreach services. Even where clinics remain open and provide a full range of contraceptive care, attendance has dropped precipitously; one nongovernmental organization (NGO) reported that the number of clients fell by 70% in April 2020. Zimbabwe’s MOH developed guidance which, similar to those of the other countries, asserts that voluntary family planning is an essential service and its provision will continue during the pandemic. However, unlike Zambia and Kenya—whose main strategy is provision of short-acting methods—Zimbabwe is promoting fertility awareness methods (FAMs), such as lactational amenorrhea and the Standard Days Method. This emphasis on FAMs is unique; they are a viable option, especially given that access to facilities is limited. However, the effectiveness of FAMs varies widely, and intensive counseling will be required to successfully shift clients currently using other methods.
|Country||Implications of guidelines for continued contraceptive access|
|Kenya||The guidelines generally have positive implications for continued access to short-term methods. Task sharing through CBD (pills and condoms) and the private sector is highlighted, including through innovative means such as motorcycle taxi operators. Long-term methods are available for women to start and/or continue if they are able to visit a facility.|
|Uganda||The guidelines generally have positive implications for contraceptive access for people who are comfortable receiving care through CBD and health facilities. Women who are far from facilities have less access, because the guidelines do not emphasize provision through private-sector clinics or drug shops. Access is even more limited for clients who are not able or willing to leave their homes. No emphasis on FAMs, which could be a substitute method for clients stuck at home.|
|Tanzania||The guidelines offer some continuity for people who are willing and able to visit a facility or drug shop (of the countries reviewed here, only Tanzania did not lock down). Otherwise, access is limited because clinical community outreach and CBD are suspended. The guidelines do recommend that drug shops and pharmacies stock ECPs.|
|Zambia||The guidelines offer some continuity of family planning, particularly for clients who prefer pills or condoms, but offer very few options for women who prefer long-acting methods.|
|Zimbabwe||With clinical outreach care suspended and CHWs advised to stay home, contraceptive options are limited for women who are unable or unwilling to visit a facility. The guidelines recommend substituting with FAMs, but the effectiveness of these methods is limited if women and couples are not properly counseled on their use and the importance of adherence.|
While WHO guidance provided a generic platform for responses to COVID-19, the countries discussed here customized according to their own goals, policies, and political contexts. The most commonly adopted WHO recommendation is to relax requirements to allow easier access to short-acting methods for up to three months. However, as for the recommendation that substitutions be made when the preferred method is not available, countries’ guidance varies quite a bit. For instance, Zimbabwe prioritizes FAMs, while Tanzania prioritizes emergency contraception. There is also significant variation in the level of flexibility: While Uganda and Kenya have more open approaches that encourage innovation, Tanzania and Zambia seem to be more restrictive.
The pandemic has caused countries to rapidly adjust their policies and adopt measures that, under normal circumstances, could take years to implement. When the emergency lifts, there will be rich opportunities to study what worked, what did not, and what measures might be applied not only to future pandemics but also to everyday family planning guidance. Illustrative programmatic and research questions include:
It remains to be seen whether any country’s response will be more successful than others. Going forward, it will be important to track all the key metrics of reproductive health/family planning to learn valuable lessons from the experiences of women and couples using voluntary family planning during these extraordinary times.
The USAID-funded Research for Scalable Solutions (R4S) Project, with technical assistance from the USAID-funded EnvisionFP Project, developed a series of survey questions that can be added to ongoing studies and activities to systematically capture the effects of the COVID-19 pandemic and recovery process on voluntary family planning access and use.