Access to contraception during the Covid-19 pandemic: barriers and perspectives

Acesso à contracepção durante a pandemia de Covid-19: barreiras e perspectivas

Abstract

Background  The SARS-CoV-2 pandemic, which started in December 2019, was declared by the World Health Organization (WHO) as an international public health emergency in January 2020, with an impact on access to sexual and reproductive health services for women.

Objective  To discuss contraception in the pandemic context, based on current public policies and the world and Brazilian scenario.

Method  This is an opinion article, which describes the barriers and possible solutions for access to qualified sexual and reproductive health care for women.

Results  Relevant topics were explored, such as: the change in the logistics of services, the reduction in the number of consultations, the difficulty in importing contraceptives, the lack of trained professionals, and the bureaucratization of access to contraceptives methods. The use of telemedicine and the strengthening of Primary Health Care are considered strategies to guarantee access and change the reality of women.

Conclusion  In this context, it is necessary to maintain the actions of sexual and reproductive planning services to prevent injuries from unplanned pregnancies and increase maternal morbidity and mortality.

Keywords:  contraception; primary health care; Covid-19; telemedicine

Resumo

Introdução  A pandemia por SARS-CoV-2, iniciada em dezembro de 2019, foi declarada pela Organização Mundial da Saúde (OMS) como emergência de saúde pública internacional em janeiro de 2020, com impacto sobre o acesso a serviços de saúde sexual e reprodutiva para as mulheres.

Objetivo  Discutir a contracepção no contexto pandêmico, a partir das políticas públicas vigentes e do cenário mundial e brasileiro.

Método  Trata-se de um artigo de opinião, onde se descreve as barreiras e possíveis soluções para o acesso à assistência de saúde sexual e reprodutiva qualificada para as mulheres.

Resultados  Explorou-se temas relevantes como: mudança na logística dos serviços, redução do número de consultas, dificuldade na importação de contraceptivos, falta de profissionais capacitados, burocratização do acesso a métodos contraceptivos. O uso da telemedicina e o fortalecimento da Atenção Primária à Saúde são consideradas estratégias para garantia do acesso e modificação da realidade das mulheres.

Conclusão  Faz-se necessário nesse contexto, a manutenção das ações dos serviços de planejamento sexual e reprodutivo para prevenir agravos provenientes de gestações não planejadas e aumento na morbimortalidade materna.

Palavras-chave:  contracepção; atenção primária à saúde; Covid-19; telemedicina

INTRODUCTION

The Sars-Cov-2 pandemic, which started in China in December 2019 with cases described in the city of Wuhan, was declared an international public health emergency in January 2020 by the World Health Organization (WHO)¹. Currently, by November 2020, there are more than 46 million cases of Covid-19 in 216 countries, with more than five million five hundred thousand cases in Brazil, according to the most recent data². The global scenario is unpredictable, with a second wave of infection in some countries and a consequent reorganization of health assistance services.

The data demonstrate differences in COVID-19 manifestations between genders³, with men presenting more severe clinical conditions and worse outcomes⁴. However, when we assess the repercussions of the pandemic in different spheres of life, the global impact on the daily lives of women is notable. In addition to coping with increased domestic work and caring for children, together with home office in some contexts, a significant increase in domestic violence (in all its manifestations) has been observed, with damage to women’s biopsychosocial well-being⁵.

The social distancing guidelines adopted by many countries, including Brazil, were an efficient strategy to contain the spread of the virus⁶. However, they have also contributed to aggravating health inequalities due to worsening a lack of assistance, and vulnerabilities of women. Changes to mental health and sexual behavior during the pandemic were common, while family conflicts and the insecurity and fear that accompanied this period worsened domestic relationships⁷.

The effects of Covid-19 on pregnancies are still not entirely clear. The current literature presents reports of vertical transmission, abortion, premature birth and fetal distress, however, to date, no association with malformation has been identified. Pregnant and postpartum women evolve more severe cases when compared to women outside the gestational period⁸. Therefore, many women consider postponing their pregnancies. However, the greater proximity between couples due to isolation has increased levels of unprotected sex with a growth in unplanned pregnancies being expected⁹.

The health care system in Brazil is structured in levels of care according to the complexity of the services in question, aiming to achieve universality, integrality, and equity of care. The right to sexual and reproductive health has been discussed in Brazil since the creation of the Family Planning Law nº 9.263/1996. Among recent material from the Ministry of Health (MS) on the subject are materials that address international and national benchmarks. These include the National Policy on Sexual and Reproductive Rights, which reinforces the need for actions that strengthen these rights and highlights the essential role of Primary Health Care (PHC) as the gateway to this line of care^10,11.

Thus, the pandemic context demands the safeguarding of these principles, with the maintenance of sexual and reproductive planning service initiatives across all assistance levels. This involves open engagement, technical assistance and ethical respect to prevent harm from unplanned pregnancies, unsafe abortions, or an increase in maternal morbidity and mortality⁹. The Ministry of Health, in a recent technical note, stated that the right of adolescents and women to sexual and reproductive health - including access to contraception/contraceptives - is an essential service and should be maintained during the pandemic. However, the note also highlighted those measures to reduce the spread of the virus (respiratory care hand hygiene, use of personal protective equipment (PPE), physical distancing) should be observed¹². However, the note was subsequently withdrawn by presidential orientation, which weakened and threatened the guarantee of such assistance during this critical period.

BARRIERS TO ACCESSING CONTRACEPTION SERVICES

Public and private women's healthcare services were interrupted due to social distancing strategies, with elective consultations canceled and a prioritizing of the workforce to care for Covid-19 patients, which has affected the initiation and follow-up for use of contraceptive methods¹³. Financial resources were directed towards purchasing materials used to combat the pandemic, such as respirators and personal protective equipment. Sexual and reproductive planning services were not prioritized in health service organization, and misinformation regarding access has left many women in different age groups without assistance^9,14.

Many countries that produce supplies for hormone contraceptive methods and condoms are Asian, with China and India having the highest concentration of related industries^14,15. The interruption of production and the reduced working hours in factories due to the pandemic, have led to concerns about shortages of the most used contraceptive methods¹⁵. Difficulties with importing medications or supplies, a lack of knowledge of contraceptive use in health care services, and a lack of planning for adequate distribution of existing resources are factors of concern in the current global context¹⁴.

Women in Brazil routinely experience obstacles when trying to access contraceptive methods through the public health system. These include an insufficient number of trained professionals, a lack of medication and condoms in the pharmacies of basic health units, the need for a referral to another health unit, and changes to regulations for drug provision¹⁶, despite government guidelines that extend the validity of prescriptions for 90 days¹². In some services, there are usually limits on women’s autonomy in choosing contraceptive methods, restrictions on the types of methods offered, and disorganized teamwork processes, despite established Ministry of Health protocols.

The barriers to using long-acting reversible contraceptives (LARCs) such as the copper intrauterine device, levonorgestrel intrauterine system, and subdermal implants are even greater. In the Brazilian public health system, only the copper intrauterine device is offered, but availability varies between different regions. The myths and taboos associated with the LARCs and the lack of training for LARC counseling and insertion has reduced the recommendation of the method to women by health professionals, besides reinforcing young and adult women’s resistance to the method. The lack of consistent protocols between municipal health secretaries for the guarantee of the method’s availability can also lead to a disorganized work process, impairing access to insertion¹⁷.

The significant safety and effectiveness of LARCs led the WHO to recommend extending the life of the device to longer than initially recommended by manufacturers, during the period of risk caused by the pandemic, demonstrating that this could be a viable option at this time¹⁸. Accordingly, the Ministry of Health recommends maintaining the offer of IUDs in primary care and maternity wards, especially during the immediate postpartum and post-abortion period.

The path of women through these services, until starting to use a contraceptive method requires, in many instances, a doctor’s consultation, participation in talks or educational sessions, laboratory and imaging tests, and a subsequent schedule to start the chosen method^17,19. During the pandemic, due to the need to reorganize the functioning of services, several stages of this protocol could not be carried out, thereby questioning their relevance.

Moreover, some services ended up inviting women for a one-off family planning session, without continuity. This disrupted the possibility of ongoing care for the evolution and maintenance of the method¹⁶.

CURRENT POSSIBILITIES

The restructuring of services and health care regulations through technological tools to prevent Coronavirus transmission presents new possibilities for contraceptive care. Teleconsultation, via videoconference, allows anamnesis to be carried out to identify contraindications for the use of contraceptive methods¹¹, enables educational actions with the presentation of possible and available contraceptive options, and opens a channel of dialogue with the woman to clear up any doubts and assist in choosing the best contraceptive method for her^15,20.

Primary Health Care has a structuring role in this new scenario. The actions that make up the Family Health Strategy, with the work of Community Health Agents and multi-professional teams, bring the necessary capillarity to maintain the links of care with women in each territory and to approach them according to their real health needs^10,16. The information that already exists from monitoring registered families, allows an active search for women using contraceptive methods, to schedule counseling regarding their maintenance during the pandemic. Besides enabling an orderly search of the health care services, this logistical work avoids increasing exposure of patients and healthcare teams to the virus.

Access to contraceptive care for women seeking to start contraception or change their method can also be facilitated via teleconsultation. This allows for exchanging information and encourages women's autonomy in self healthcare. The use of accessibly worded digital information can be encouraged for and by health teams^9,20. The fear of using contraceptives during the pandemic, due to misinformation disseminated on social media, can be clarified during this virtual meeting, presenting reliable and reassuring data provided by WHO, health associations (FEBRASGO, SBMFC) and the Ministry of Health^19,21-23.

When analyzing the situation regarding sexual and reproductive health care during the Covid-19 pandemic some evident challenges arise. These include reducing organizational barriers, improving communication, strengthening primary health care initiatives as a gateway to healthcare, updating and offering training to teams for technological tools, and streamlining pharmaceutical logistical protocols. The establishment of intersectoral actions involving education, social assistance and civil society actors are key aspects of this process. All these elements can help facilitate the accessibility and effectiveness of sexual and reproductive planning initiatives on an ongoing basis, changing the health situation and even the socioeconomic reality of young and adult women.

• How to cite: Travassos AGA, Aquino TR, Almeida CS, Brito MB. Access to contraception during the Covid-19 pandemic: barriers and perspectives. Cad Saúde Colet, 2022; Ahead of Print. https://doi.org/10.1590/1414-462X202230020403
• Study carried out at Mestrado Profissional de Saude Coletiva, Departamento de Ciências da Vida, Universidade do Estado da Bahia (UNEB) – Salvador (BA), Brasil.
• Financial support: none.
• Ethical issues: This article did not involve research with human beings, and submission to the Ethics Committee was not required.

REFERENCES

• ¹ Yan Y, Shin WI, Pang YX, Meng Y, Lai J, You C, et al. The first 75 days of novel coronavirus (SARS-CoV-2) outbreak: recent advances, prevention, and treatment. Int J Environ Res Public Health. 2020;17(7):2323. http://dx.doi.org/10.3390/ijerph17072323 PMid:32235575.
  » http://dx.doi.org/10.3390/ijerph17072323
• ² World Health Organization. WHO coronavirus disease (COVID-19) Dashboard [Internet]. Genebra: WHO; 2020 [cited 2020 Nov 2]. Available from: https://covid19.who.int/
  » https://covid19.who.int/
• ³ Grandi G, Facchinetti F, Bitzer J. The gendered impact of coronavirus disease (COVID-19): do estrogens play a role? Eur J Contracept Reprod Health Care. 2020;25(3):233. http://dx.doi.org/10.1080/13625187.2020.1766017 PMid:32469251.
  » http://dx.doi.org/10.1080/13625187.2020.1766017
• ⁴ The Lancet. The gendered dimensions of COVID-19. Lancet. 2020;395(10231):1168. http://dx.doi.org/10.1016/S0140-6736(20)30823-0
  » http://dx.doi.org/10.1016/S0140-6736(20)30823-0
• ⁵ Gausman J, Langer A. Sex and gender disparities in the COVID-19 pandemic. J Womens Health (Larchmt). 2020;29(4):465-6. http://dx.doi.org/10.1089/jwh.2020.8472 PMid:32320331.
  » http://dx.doi.org/10.1089/jwh.2020.8472
• ⁶ Llor C, Moragas A. Coronavirus and primary care. Aten Primaria. 2020;52(5):294-6. http://dx.doi.org/10.1016/j.aprim.2020.03.002 PMid:32284192.
  » http://dx.doi.org/10.1016/j.aprim.2020.03.002
• ⁷ Silva DARD, Pimentel RFW, Merces MCD. Covid-19 and the pandemic of fear: reflections on mental health. Rev Saude Publica. 2020;54:46. http://dx.doi.org/10.11606/s1518-8787.2020054002486 PMid:32491094.
  » http://dx.doi.org/10.11606/s1518-8787.2020054002486
• ⁸ Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus disease 2019 (COVID-19) and pregnancy: what obstetricians need to know. Am J Obstet Gynecol. 2020;222(5):415-26. http://dx.doi.org/10.1016/j.ajog.2020.02.017 PMid:32105680.
  » http://dx.doi.org/10.1016/j.ajog.2020.02.017
• ⁹ Ferreira-Filho ES, de Melo NR, Sorpreso ICE, Bahamondes L, Simões RDS, Soares-Júnior JM, et al. Contraception and reproductive planning during the COVID-19 pandemic. Expert Rev Clin Pharmacol. 2020;13(6):615-22. http://dx.doi.org/10.1080/17512433.2020.1782738 PMid:32538185.
  » http://dx.doi.org/10.1080/17512433.2020.1782738
• ¹⁰ Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Saúde sexual e saúde reprodutiva [Internet]. 1. ed. Brasília: Ministério da Saúde; 2013 [cited 2020 Nov 2]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/saude_sexual_saude_reprodutiva.pdf
  » http://bvsms.saude.gov.br/bvs/publicacoes/saude_sexual_saude_reprodutiva.pdf
• ¹¹ Brasil. Ministério da Saúde. Protocolos da atenção básica: saúde das mulheres [Internet]. Brasília: Ministério da Saúde, Instituto Sírio-Libanês de Ensino e Pesquisa; 2016 [cited 2020 Nov 2]. Available from: https://bvsms.saude.gov.br/bvs/publicacoes/protocolos_atencao_basica_saude_mulheres.pdf
  » https://bvsms.saude.gov.br/bvs/publicacoes/protocolos_atencao_basica_saude_mulheres.pdf
• ¹² Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Coordenação Geral de Ciclos da Vida. Coordenação de Saúde das Mulheres. Nota técnica nº 16/2020: acesso à saúde sexual e saúde reprodutiva no contexto da pandemia da Covid-19. Brasília: Ministério da Saúde; 2020.
• ¹³ Hall KS, Samari G, Garbers S, Casey SE, Diallo DD, Orcutt M, et al. Centring sexual and reproductive health and justice in the global COVID-19 response. Lancet. 2020;395(10231):1175-7. http://dx.doi.org/10.1016/S0140-6736(20)30801-1 PMid:32278371.
  » http://dx.doi.org/10.1016/S0140-6736(20)30801-1
• ¹⁴ Purdy C. How will COVID-19 affect global access to contraceptives and what can we do about it? [Internet]. DEVEX; 2020 [cited 2020 June 25]. Available from: https://www.devex.com/news/opinion-how-will-covid-19-affect-global-access-to-contraceptives-and-what-can-we-do-about-it-96745
  » https://www.devex.com/news/opinion-how-will-covid-19-affect-global-access-to-contraceptives-and-what-can-we-do-about-it-96745
• ¹⁵ Church K, Gassner J, Elliott M. Reproductive health under Covid-19: challenges of responding in a global crisis. Sex Reprod Heal Matters. 2020;28(1):1773163. http://dx.doi.org/10.1080/26410397.2020.1773163
  » http://dx.doi.org/10.1080/26410397.2020.1773163
• ¹⁶ Moura ERF, Silva RM, Galvão MTG. Dinâmica do atendimento em planejamento familiar no Programa Saúde da Família no Brasil. Cad Saude Publica. 2007;23(4):961-70. http://dx.doi.org/10.1590/S0102-311X2007000400023 PMid:17435893.
  » http://dx.doi.org/10.1590/S0102-311X2007000400023
• ¹⁷ Gonzaga VAS, Borges ALV, Santos OA, Rosa PLFS, Gonçalves RFS. Organizational barriers to the availability and insertion of intrauterine devices in Primary Health Care Services. Rev Esc Enferm USP. 2017;51:e03270. http://dx.doi.org/10.1590/S1980-220X2016046803270 PMid:29267735.
  » http://dx.doi.org/10.1590/S1980-220X2016046803270
• ¹⁸ Bezerra EDJ, Almeida TSC, Passos NCR, Paz CT, Borges-Paluch LR. Planejamento reprodutivo na estratégia saúde da família: estudo qualitativo sobre a dinâmica do atendimento e os desafios do programa. Arq Ciênc Saúde UNIPAR. 2018;22(2):99-108. http://dx.doi.org/10.25110/arqsaude.v22i2.2018.6349
  » http://dx.doi.org/10.25110/arqsaude.v22i2.2018.6349
• ¹⁹ World Health Organization. Contraception/ family planning, and COVID-19. Q&A Detail [Internet]. Genebra: WHO; 2020 [cited 2020 June 26]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/contraception-family-planning-and-covid-19
  » https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/contraception-family-planning-and-covid-19
• ²⁰ DeNicola N, Grossman D, Marko K, Sonalkar S, Butler Tobah YS, Ganju N, et al. Telehealth interventions to improve obstetric and gynecologic health outcomes: a systematic review. Obstet Gynecol. 2020;135(2):371-82. http://dx.doi.org/10.1097/AOG.0000000000003646 PMid:31977782.
  » http://dx.doi.org/10.1097/AOG.0000000000003646
• ²¹ Brasil. Ministério da Saúde. Secretaria de Atenção Primária à Saúde. Departamento de Ações Programáticas Estratégicas. Coordenação-Geral de Ciclos da Vida. Coordenação de Saúde das Mulheres. Nota Técnica no 13/2020- COSMU/CGCIVI/DAPES/SAPS/MS: recomendações acerca da atenção puerperal, alta segura e contracepção durante a pandemia da Covid-19 [Internet]. Brasília: Ministério da Saúde; 2020 [cited 2020 June 26]. Available from: https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/nota-tecnica-no-13-2020-cosmu-cgcivi-dapes-saps-ms/
  » https://portaldeboaspraticas.iff.fiocruz.br/biblioteca/nota-tecnica-no-13-2020-cosmu-cgcivi-dapes-saps-ms/
• ²² Federação Brasileira das Associações de Ginecologia e Obstetrícia. Anticoncepção durante a pandemia por COVID-19 [Internet]. 2020 [cited 2020 June 26]. Available from: https://www.febrasgo.org.br/en/covid19/item/1002-anticoncepcao-durante-a-pandemia-por-covid-19
  » https://www.febrasgo.org.br/en/covid19/item/1002-anticoncepcao-durante-a-pandemia-por-covid-19
• ²³ Sociedade Brasileira de Medicina de Família e Comunidade. Recomendações da SBMFC para APS durante a pandemia COVID-19 [Internet]. 2020 [cited 2020 June 26]. Available from: https://www.sbmfc.org.br/noticias/recomendacoes-da-sbmfc-para-a-aps-durante-a-pandemia-de-covid-19/
  » https://www.sbmfc.org.br/noticias/recomendacoes-da-sbmfc-para-a-aps-durante-a-pandemia-de-covid-19/

Publication Dates

• Publication in this collection
  22 Aug 2022
• Date of issue
  Apr-Jun 2022

History

• Received
  11 Aug 2020
• Accepted
  09 Nov 2020