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Q&A Reading Time: 7 minutes

Postabortion Care and Postpartum Family Planning During COVID-19

Opportunities and Challenges: An Interview with GHSP Journal Authors

Preserving voluntary family planning as an essential service amid the COVID-19 pandemic has been the clarion call for global actors in the family planning and reproductive health field. How do we also ensure that women seeking postpartum or postabortion care don’t fall in the gaps?

A Global Health: Science and Practice article highlights both the challenges in balancing the prevention measures and risks of infection with opportunities to create innovative ways to meet postpartum and postabortion care for women, including postpartum family planning. Sonia Abraham, GHSP Journal’s Scientific Editor, spoke with article authors Anne Pfitzer, Eva Lathrop, and Saumya RamaRao to understand how providing voluntary family planning and reproductive health care can be adapted. This interview has been edited for brevity and clarity.

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Q: At the start of the COVID-19 pandemic, a lot of information was coming out on maintaining access to health care services and maintaining family planning as an essential service. Why did you feel it was important to write the article to address the needs of postpartum and postabortion women in particular?

Saumya: This resonated with all of us in the urgency of the need to respond. We were at a moment in time when most [program] activities [in low- and middle-income countries] had already stopped or were on the verge of being stopped. With our different perspectives from service delivery, programs, research, and donors, we thought about how we could call upon the strengths and different orientations that each one of us has.

Eva: I agree. The urgency drove our ability to write because we felt passionate. If we can reach women when they’re making health care decisions and seeking care otherwise in the context of this pandemic, maybe we can make a difference.

Q: What did you feel was missing in the information that was already available that you needed to include in this article?

Anne: I kept looking through the World Health Organization guidance and hoping that they would call out postpartum family planning and postabortion care more clearly. And it didn’t. We felt this area needed attention before the pandemic and doubly needs it now.

Saumya: We wanted to be action-oriented, and we wanted something that could be practical and useful.

Eva: My favorite parts of the article are the table and the box because they can help a provider or an implementer in facilities or communities. They can look at those tools to know, “This is what I can do, and I can do it tomorrow in my clinic or in my hospital to make a difference—to adapt and pivot quickly to make sure these services are still protected in the context of COVID.” That’s what’s missing in “generic” guidelines that tell someone, “That’s what I’m supposed to do, but I don’t know how to do it.”

Q: Your two overarching recommendations center on task-sharing and integrating voluntary postpartum and postabortion care counseling and services into existing routine points of contact. What have been the barriers in the past and that still exist now in implementing these recommendations?

Eva: This catastrophe has accelerated the need to recognize that we already have the ability to do these things: integrate, task-share, move to digital, and move to a more self-managed care spectrum. COVID-19 is forcing us to get policy changed, get these prioritized by ministries, and get these prioritized by funders and policy makers. It [the pandemic] has sparked innovation, but it has also sparked this need to accelerate what we already know works to mitigate the risk of COVID and still protect access to these services. Just making policy decisions to lift regulations has opened up this ability to actually do something that we already knew how to do but didn’t do because of policy regulations.

Anne: I think for postpartum family planning and postabortion family planning, we were trying to avoid it getting lost in the shuffle. There is a need for leadership and for recognizing this as a critical opportunity. This has the potential to increase resilience and strengthen the health system. But the operationalizing of it is not that easy, right? It does require change, and change is hard. It’s changing what providers do daily. Now that they are in the process of change because of COVID-19, maybe there’s more receptivity to that change when change is part of their daily reality.

Saumya: I’m glad you brought up the resilience argument, Anne. When I first thought of resilience in the months before COVID-19, we were dealing with it from the financial point of view. Most of the programs in low- and middle-income countries were going to be seeing a reduction in development assistance, and there was this trend toward making countries rely on their own resources. Countries were already beginning to struggle with which aspect of domestic resource mobilization they should be focusing on. When this pandemic hit, the question was how do you then build resiliency when there are these multiple shocks and these shocks come in various forms such as the pandemic? At the end of the day, you want a health system that can continue to provide services and not wither away.

Anne: We assume that integrating [health care] services and reducing visits will be cost-saving, but we don’t have a ton of evidence for it. We have evidence that it saves women costs for time and transport, but for the health systems side, I think they’re some assumptions that are being made that I don’t think have been fully tested. We were also thinking of it in terms of reducing the number of visits that women have to make, and therefore their exposure to high-risk contact in the context of the pandemic. If these changes outlived the pandemic, they would be a good habit formed.

Now that we’re well into the pandemic, do you see some of these recommendations being realized in low- and middle-income country settings?

Eva: That’s the hardest thing to know. What we do know is that at PSI, for example, we have documented all of the quick pivot adaptations to all of our services across all health areas, including our postabortion care work. What we don’t know is how that’s affected service delivery numbers and whether or not those things would be “successful.” If I had my way, we would collectively, as several organizations working together, do an evaluation of program adaptations to protect essential services in family planning and postabortion care so that we know what needs to be integrated into programming going forward. We’ve probably uncovered some best practices in the context of COVID that should carry forward outside of the context of the pandemic, but we’re not going to know that unless we can study that. I think that the findings as a collective will be much more powerful and resonate globally than if we do so as organizations on our own.

Anne: Right. It’s a bit of a challenge as systems are adapting and trying to react and manage a crisis. I agree with you, Eva, that it would be great to collectively think about what are the adaptations that have been done, what has worked well, and what’s not worked well. How can we be better partners to the health systems, but we also have to be doing it with a light touch so that it doesn’t burden people who are trying to fix the gaps.

Q: In the article, you mention the unique features of COVID-19 that can influence care differently than other past epidemics and list questions on knowledge gaps around COVID-19. What can individuals do to explore these learning gaps?

Eva: The learning questions [in the article] were a start to all the things that we have to learn about this pandemic while we’re still in it and what the post-effects will be and for how long. I think we’re looking at a number of years of trying to recover from this in terms of the health systems and the ability to get families back to accessing services. The questions are a reminder that we need to prioritize a learning agenda over the next couple of years so we don’t squander the learning opportunities in all the tragedy.

Anne: The International Conference on Family Planning is coming up next year. We hope to still gather as a [family planning] community. And maybe we should think ahead about using that as an opportunity to gather those learnings collectively as you were saying, Eva, across our postpartum family planning and postabortion care champions, implementers, researchers, and advocates, etc. I’m wondering if there is a way to sort of “crowdsource” some of the learning at that time.

Q: You talk about the substantial losses in this pandemic and how the outlook is gloomy. What encouragement can be offered as the world continues to navigate the pandemic and issues that arise around it?

Anne: We want to have empathy with the difficulties that the providers are dealing with in this situation and context in which these [family planning] services are being provided. If those opportunities for more client-centered comprehensive care are seized, it has a multiplier effect in terms of peace of mind that a woman’s voluntary family planning needs are met. It’s time well-invested for both the mother and the baby in terms of postpartum family planning. In terms of postabortion care, it’s time well-invested in terms of reducing a woman’s risk of having another unintended pregnancy. So the idea that effort now pays dividends later and reduces more closely spaced pregnancies that add more burden to the health system and the health worker.

Eva: I second that. Effort now and dividends later. If we’re trying to inspire a younger person who’s new to this field, whether it’s a provider or someone working in our groups, I say, if you have a creative solution, now is the time to put it forth. We’re so open to hearing innovation and creativity right now because this is unprecedented. And we need to play the long game in the sense that the big dividends are not going to be tomorrow but are going to come.

Saumya: It’s an innovation mindset that we’re creating. When we wrote this paper, we came from a place of optimism of “how to build back better.”

Eva: Yes! We’re always going to be in the midst of pregnant women and delivering women and women who need miscarriage management and postabortion care. So, let’s harness the creativity and innovation now.

Anne: I would agree with you on optimism in the sense of let’s seize that window of opportunity. But operationally, it’s not necessarily easy especially at scale, so I don’t want to underappreciate that it will take leadership at the facility level, district level, and in the private sector. I think there’s a slew of challenges. The innovation that needs to be applied to those problems is fully welcome now perhaps more so than in normal times.

Saumya: The second thing we learned is the agility of health systems to move and pivot. Even in those weak health systems that we’ve always thought of, some of them are beginning to show that they can pivot pretty quickly. I think that might have come from those investments in the past around health systems strengthening or around epidemic response that’s paying off. It validates the assumption that we’re making in this paper that the investments you make at one point, you’ll reap the dividends later on. Both as individuals in the public health space and institutions and systems, we’re at a moment in time when we’re required to be very agile and pivot.

Sonia Abraham

Scientific Editor, Global Health: Science and Practice Journal

Sonia Abraham is the scientific editor for the Global Health: Science and Practice Journal and has been writing and editing for over 25 years. She holds a Bachelor’s in Biological Sciences from the University of Maryland and a Master’s in Writing from Johns Hopkins.