Policy responses to Covid 19 such as lockdown measures, social distancing, containment zones, travelling restrictions, and Covid testing procedures before admission in hospitals or clinics have created new challenges for women to practice safe, timely, and appropriate contraceptive use. The pandemic has exacerbated the existing vulnerabilities of women and further resulted in exploitation of sexual and reproductive rights. Contraceptive use is a complex and dynamic public health issue, and each year, approximately 50 million of the 190 million women who become pregnant undergo abortions to terminate unwanted pregnancies, and about 13% of maternal deaths are caused by complications of abortion[1]. Globally, 146 million women worldwide aged 15- 49 years who were married or in a union had an unmet need (not using any contraceptives) for family planning in 2010[2]. Due to negligence of their own needs, the condition is worst among low income women as they are particularly vulnerable to reproductive health risks[3] due to poverty, lack of access to health centres, and unawareness of health facilities. Numbers of unwanted pregnancies and unmet contraceptive need are still high in many developing countries[4] .
The Covid 19 pandemic which emerged as a public health emergency has disrupted the existing sexual and reproductive health services at all levels. It has threatened human lives and caused breakdown of infrastructure, health systems, and social security systems in all the affected countries. Consequently, the resources meant for sexual and reproductive services are diverted to respond to the pandemic emergencies. The lockdown measures halted manufacturing of contraceptives and disrupted supply chains[5]. Currently, although the production and delivery of contraceptives have been resumed, the access to information, services and social support system has been limited. Riley at al[6] estimate that a 10% decline in the use of short and long acting reversible contraceptive measures due to reduced access would result in an additional 59 million women with unmet need for contraception and an additional 15 million unintended pregnancies in developing countries over the course of one year. The impact of these figures manifests beyond sexual and reproductive health of women.
Contraception provision is considered to be a non-essential activity by policy makers and medical institutions[7] and it is often overlooked in policy responses, especially during the Covid 19 pandemic. While many international bodies and governments have provided guidelines to focus sexual and reproductive health in Covid policy responses, no specific sustainable interventions are evident in the overall health policy responses. India’s National Health Mission is a case in point. Under this programme, the accredited social health activists (ASHA), auxiliary nurse midwife (ANM), and anganwadi workers, posted at the village/local level across the country, provide contraceptives and counselling services. Even with the inclusion of local level workers, 31 million of India’s population do not use any contraception in pre covid times and 14 million use unreliable traditional methods that carry a three times higher risk of pregnancy compared to using modern methods[8] . During the covid 19 pandemic, it is estimated that 63 million couples did not have access to contraceptives from March to September 2020 due to restricted mobility and lack of supply due to lockdowns, and the fear of getting the infection, preventing people from accessing over-the-counter OCPs, condoms, and emergency pills at local markets[9]. This means witnessing increased unwanted pregnancies, unsafe or illegal abortion practices, childbirths and higher risk of sexually transmitted diseases in the next few months. It is a challenging task to address these multiple dimensions of reproductive health and hence, need a comprehensive response not only during covid 19 but beyond. Vora, Saiyed and Natesan (2020) suggest a comprehensive, rights-based health system response to address family planning services provision during pandemics to avoid unwanted pregnancies and prevent additional mortality and morbidity of women.
However, a need assessment of age, gender and diversity, and a rights-based intervention coupled with an understanding of the cultural beliefs in the framing of contraceptive use would be more effective in addressing the family planning issues both during covid 19 and beyond. This response can leverage the vulnerable communities, women’s reproductive rights and local knowledge. ASHA, ANM, and Anganwadi workers are skilled female healthcare providers and can play a crucial role in mobilising the community, conducting the needs assessment, intervention, and providing local understanding of contraception and reproduction. Including female local workers in the response team makes an effective two-way communication between the response team and the women. The need assessment should be disaggregated by sex, social group, age, and ability so that special needs and the potential for social exclusion can be identified[10]. This can be integrated in the overall need assessment conducted for gender analysis. The government, non-government and local stakeholders can scrutinise the needs and priorities of women and then strategize the programme. During the pandemic, there has been abuse of women’s sexual and reproductive rights. Women were not getting the basic and safe sexual and reproductive services, their bodily autonomy to abort or continue the pregnancy and the freedom to exercise to use contraceptives- terminal or non-terminal[11]. Over and above this, many women who are victims of sexual violence are locked up with their abusers during the pandemic. This worsens their sexual and reproductive health. Identifying the reproductive needs, rights and vulnerabilities will reduce the negative impact of the pandemic and gender norms. Understanding the gendered use of contraceptives of a particular community will increase the effectiveness of the programme. Gender norms and sexual scripts are not static and vary across communities and respond to the changing socioeconomic and political landscape, according to social constructions[12]. In many cultures, use of contraception is influenced by unequal power within the family and society. Brown[13] found that men assume that women will take care of unwanted pregnancies by using contraceptives. Avoidance of responsibility is due to the understanding that if women do not prevent pregnancy, they are the ones who would have to face the negative consequences (ibid). Women were observed to have lack of control over their reproductive health[14]. Women’s sexual and reproductive decisions are influenced by gender norms. Integrating these understanding on how gender norms are played out in framing the use of contraceptives will help stakeholders to prioritise and focus on specific needs and vulnerabilities of women.
A sexual and reproductive intervention implemented based on needs assessment, rights-based health care system, both clinical and non-clinical that is informed by the practiced gender norms of a particular community must be at the centre of Covid 19 response. As the lockdown measures and travelling restrictions are loosened, the scattered response by the National Health Mission can be re-examined and intensified with the deployment of ASHA, ANM, Anganwadi workers and in partnership with non-government bodies.
[1] WHO. 2011. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Geneva: World Health Organization.
[2] Alkema K, Menozzi, and Biddlecom. National, regional, and global rates and trends in contraceptive prevalence and unmet need for family planning between 1990 and 2015: a systematic and comprehensive analysis. Lancet. 2013; 381: 1642-1652.
[3] Hunter de Bessa, Gina (2006) Ethnophysiology and Contraceptive Use Among Low-Income Women in Urban Brazil. Health Care for Women International 2006;27:428-452, DOI: 10.1080/07399330600629617 .
[4] Ahmed S, Li Q, Liu Li and Tsui A. Maternal deaths averted by contraceptive use: an analysis of 172 countries. The Lancet 2012; 380: 111-125.
[5] Vora, Kranti Suresh; Saiyed, Shahin and Natesan, Senthilkumar. Impact of COVID-19 on family planning services in India. Sexual and Reproductive Health Matters 2020; 28:1, DOI: 10.1080/26410397.2020.1785378.
[6] Riley T, et al. Estimates of the potential impact of the COVID-19 pandemic on sexual and reproductive health in low- and middle-income countries. Int Perspect Sex Reprod Health. 2020; 46:73-6.
[7] Aly, J., Haeger, K.O., Christy, A. et al. Contraception access during the COVID-19 pandemic. Contracept Reprod Med 2020; l-17 (2020). https://doi.org/10.1186/s40834-020-00114-9.
[8] Hindustan Times. India’s young shun use of modern day contraceptives, 2017. https://www.hindustantimes.com/india-news/india-s-young-shun-use-of-modern-day-contraceptives/story-mC1ygeasvyHeBxHP6L7mlM.html
[9] Gupta, Medhavi and Chhetri, Deepshikha. Reducing unwanted pregnancies during COVID-19: Rights-based, system-level response need of the hour. 2020. https://www.firstpost.com/india/reducing-unwanted-pregnancies-during-covid-19-rights-based-system-level-response-need-of-the-hour-9098361.html.
[10] UNDP. 2013. Livelihoods and Economics Recovery in Crisis Situations.
[11] Gupta, Aarushi and Singh, Hardeep. Reproductive Rights amid Covid 19, London School of Economics (LSE) 2020. https://blogs.lse.ac.uk/gender/2020/08/03/reproductive-rights-amid-covid-19/
[12] Strebel, A., M. Crawford, T. Shefer, A. Cloete, N. Henda, M. Kaufman, L. Simbayi, K. Magome, and S. Kalichman. Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa, Journal of Social Aspects of HIV/AIDS 2006;3: 516–28.
[13] Brown, S. 2015. ‘They Think It’s All up to the Girls’: Gender, Risk and Responsibility for Contraception. Culture, Health & Sexuality 2015; 17: 312–325.
[14] Amuchastegui, Ana. 1999. Dialogue and the negotiation of meaning: Constructions of virginity in Mexico. Culture Health and Sexuality 1999; 1: 79 – 93.
Photo Coutesy: Lubo Minar
