When the world ground to a halt a year ago, millions of women saw their contraceptive supplies dry up and their routes to replenish them cut off.
New research by the United Nations Population Fund (UNFPA) found that 12 million women couldn’t get the family planning services they needed, leading to an estimated 1.4 million unintended pregnancies.
Stellah Bosire, co-executive director at UHAI: East African Sexual Health & Rights Initiative, said she saw this play out firsthand in Nairobi, where she’s based. According to Bosire, a combination of global supply chain disruptions, strict lockdown measures (which, in Kenya, included an evening curfew) and the fact that medical professionals had to suddenly pivot their time and resources toward coronavirus prevention meant that sexual and reproductive health services were often left by the wayside.
At her clinic, people missed appointments, medications used to manage HIV were out of stock, immunizations were halted, and many patients struggled to get their basic medications, including contraceptives, filled, Bosire said.
“A service provision that has been heavily and negatively affected is reproductive health,” said Bosire, adding that during the pandemic, many of her clinic’s partner organizations have approached UHAI looking for condoms and medications used to manage HIV because their supplies, normally provided by the Kenyan government, had run out.
“There was a lot of disruption for our patients,” she said. “People were afraid, and it really negatively affected our patients’ ability to be healthy.”
In May, the international family planning organization Marie Stopes reported having to suspend its outreach services in Kenya because of coronavirus restrictions, telling Foreign Policy that they received 300 WhatsApp messages in one day from women asking about clinic access. By June, the Kenyan government and public health-care workers were reporting that thousands of teenage girls, out of school as a result of the pandemic and unable to leave home to access services (and potentially escape abusers), had become pregnant during lockdowns.
In April, the International Planned Parenthood Federation said that 5,633 of its locations, or 14 percent of its service points, had closed around the world as a result of the outbreak. Clinics on almost every continent were affected, but South Asia was hit worst with more than 1,872 closures. Marie Stopes warned that the pandemic could result in 1.5 million unsafe abortions, including for the estimated 920,000 Indian women who could no longer access safe abortion services because of the country’s strict lockdown. Meanwhile, manufacturers were sounding the alarm about a potential worldwide condom shortage because factories in Asian manufacturing hubs had to shut down to stop the spread of the virus.
Stephanie Musho, a human rights lawyer specializing in sexual and reproductive health, described the choices many young women with unintended pregnancies are facing now: “You either have to go through an unsafe abortion because you’re very scared of what society is going to think of you and the stigma you’ll deal with, or you’re forced into a marriage you’re not ready for.”
The consequences of unintended pregnancies
Like many other issues, the pandemic has shone a light on previously existing inequalities. Some 270 million women around the world had unmet needs for modern contraceptives before the pandemic. Poverty and stigma are major factors in this and are exacerbated by geopolitics. The United States’ “Mexico City Policy,” known by critics as the “global gag rule” and recently overturned by President Biden, for years also blocked organizations that receive U.S. funding from providing abortion services or information related to abortion. Research shows that stricter contraceptive laws under French colonial rule mean that today, people in former French colonies have a harder time accessing contraception than those living in former British colonies, which had looser regulations.
Women who didn’t mean to get pregnant face a host of elevated risk factors, including increased maternal health complications like postpartum hemorrhage and preeclampsia, fewer prenatal care appointments and a higher incidence of mental health problems.
Women are three times as likely to have an unintended pregnancy in low-income countries, where 94 percent of maternal deaths occur (the majority in sub-Saharan Africa).
Although unintended pregnancies have fallen worldwide since the 1990s as access to contraceptives have increased, global health professionals worry that as the pandemic cleaves the global wealth gap wider, those gains could evaporate.
“The estimates we have don’t tell the full story of what will happen with long-term economic changes the pandemic has caused,” said Jennie Greaney, a technical specialist at UNFPA. “Many women are paying out of pocket [for contraceptives] and whether they can afford that long term as economies are shrinking will be another question.”
Some 495 million people, predominantly in poor countries, lost their jobs as a result of the pandemic, and global food prices have risen 20 percent. The question for many, according to Musho, becomes: “Am I going to spend money on reproductive health services or am I going to spend money on food if my family is starving and I don’t have a job?”
Innovation in a crisis
Creative distribution methods and increased access to flexible birth control options has been a bright spot in an otherwise dire situation. UNFPA found that there were actually smaller and shorter disruptions in family planning services than initially projected in March 2020.
A relatively new method that has helped bridge gaps during the pandemic, particularly in far-flung rural areas, are contraceptives that women can inject themselves. UNFPA has trained hundreds of health-care workers in Lesotho on this method.
In Uganda, public-health workers delivered free condoms and government-subsidized reproductive health products through a ride-hailing app called SafeBoda. The Indonesian government sent health-care workers door to door, delivering condoms and the pill along with emergency food aid.
In Colombia, the health-care organization Fundacion Oriéntame started offering medical abortion services via telemedicine. Patients can video-chat with a doctor to determine whether they’re eligible. If they decide to move forward, doctors will then monitor them for complications through video chats and WhatsApp messages. Reproductive health experts hope the ripple effects of these innovations will carry beyond the pandemic to help make a dent in long-standing gaps in access.
Greaney, the UNFPA technical specialist, attributes the number of unintended pregnancies being lower than originally predicted in part to “incredibly inventive efforts. … People are finding ways to make it happen.”
Still, inequality and lack of access are challenges for women around the world. In the United States, 36 percent of low-income women have experienced delays or an inability to get contraceptive or reproductive health care as a result of the pandemic. While 23 percent of higher-income American women say they worry more than they used to about being able to afford or obtain contraception, 32 percent of lower-income women do.
In response, California and several other states approved drive-through contraceptive services and allowed pharmacies to provide self-injectable contraceptives. Telemedicine has also played a crucial role, with 24 percent of women who use the pill having switched to a virtual appointment to refill their prescriptions. The number of states where people can get a birth control prescription from a pharmacist instead of exclusively a doctor also expanded.
Vaccine rollout has made health-care providers hopeful across the United States and Europe. But in poorer countries most affected by unintended pregnancies, hopes of the pandemic waning are remote.
Bosire points out that in many ways, access to the vaccine, as well as contraception, presents a conversation about equity: “I hope that for the first time the global leadership will speak about health care as a critical component of security, as a critical component of economic development, as a critical component of human rights.”