Applications of the High Impact Practices in Family Planning during COVID-19

Abstract

The COVID-19 pandemic has substantially strained health systems across the globe. In particular, documented disruptions to voluntary family planning and reproductive health care due to competing health priorities, service disruptions, stockouts, and lockdowns are significantly impacting reproductive, maternal, newborn, and child health. As governments and family planning programmes grapple with how best to respond to the direct and indirect effects of the pandemic on family planning and reproductive health (FP/RH), the implementation and adaptation of evidence-based practices is crucial. In this commentary, we outline applications of the High Impact Practices in Family Planning (HIPs) towards COVID-19 response efforts. The HIPs are a set of evidence-based family planning practices which reflect global expert consensus on what works in family planning programming. Drawing upon preliminary COVID-19 data, documented experiences from prior health emergencies, and recommended programme adaptations from a variety of global health partners, we outline situations where specific HIPs may assist family planning programme managers in developing context-specific and evidence-based responses to COVID-19-related impacts on FP/RH, with the ultimate goal of ensuring the accessibility, availability, and continuity of voluntary family planning services across the world.

Keywords:

• family planning
• reproductive health
• COVID-19
• implementation science
• health systems
• contraception

Introduction

The novel coronavirus pandemic has significantly strained the global health sector as health systems attempt to mitigate disease spread, prioritise scarce resources, and respond to increasing demand for COVID-19 testing and treatment. Competing healthcare priorities compounded by movement restrictions have further magnified disruptions in the availability and demand for essential health services. A recent World Health Organization (WHO) survey revealed that across 105 countries, 90% have experienced health service disruptions as a result of the pandemic.¹ One of the most commonly disrupted areas includes family planning (FP) services, with 68% of countries reporting service disruptions.¹ In particular, women and youth face heightened direct and indirect risks of unintended pregnancy as a result of lockdowns, service disruptions, stockouts, and financial hardships.^2,3

Estimates suggest that if a high level of FP service disruptions persist for over a year, approximately 51 million women may not be able to access modern contraceptives, leading to an estimated 15 million unintended pregnancies.⁴ Similar projections suggest that even a 10% annual reduction in access to FP and pregnancy-related care may contribute to significant increases in maternal, newborn, and child morbidity and mortality.^3,5 Furthermore, survey data indicates that COVID-19 is directly impacting women’s fertility intentions. In the United States, 34% of women reported that they wanted to get pregnant later or have fewer children due to the pandemic.⁶ Similarly, data from Kenya, Burkina Faso, and the Democratic Republic of the Congo indicates that between 9% and 14% of women have changed their minds about becoming pregnant due to COVID-19 concerns, thereby highlighting the importance of FP.⁷

The global FP community has largely responded to the pandemic with calls to ensure contraceptive services are considered essential and, as such, are continually available, accessible, and high-quality.^2,4,8–10 Guidance from many multilateral and non-governmental organisations has recommended alternative service delivery models and drawn upon preliminary data to suggest various programme and policy adaptations to mitigate service disruptions.^10–14 While the COVID-19 pandemic may impact women’s fertility intentions and contraceptive choice, it is critical to ensure that current or potential FP users continue to have access to a wide range of voluntary contraceptive information and methods, and that FP programmes continue to promote and implement evidence-based practices.^8,14

Drawing upon evidence from past epidemics and health emergencies, projected and documented disruptions due to COVID-19, and technical considerations from a range of global health partners, we suggest applications of the High Impact Practices in Family Planning (HIPs) towards mitigating and responding to FP service disruptions due to COVID-19. The HIPs are a set of evidence-based practices that reflect global expert consensus of “what works in family planning” across the service delivery landscape, enabling environment, and social and behaviour change (SBC) considerations.¹⁵ HIPs are identified by their demonstrated impact on contraceptive use and the proximate determinants of fertility, potential applicability across a wide range of settings, and high-quality scientific evidence of replicability, scalability, sustainability, and cost-effectiveness. HIP briefs are uniquely designed to be used for advocacy, strategic planning, and to inform the development of policies and guidelines for effective FP programme implementation – ultimately supporting individuals and couples to exercise their right to determine the timing and spacing of pregnancies.¹⁵

In this commentary, we outline ways in which particular HIPs may serve as useful references to global FP stakeholders as they respond to the impact of COVID-19. Beginning with service delivery practices followed by SBC and enabling environment considerations, we briefly define each high-impact practice and describe tips for implementing and adapting the practice amid COVID-19. Drawing upon documented adaptations, technical considerations from global health partners, or expert opinion, we also highlight illustrative examples of the practice’s adaptation, where available.

Community health workers

Integrating trained, equipped, and supported community health workers (CHWs) into the health system is a proven HIP that can help increase FP access by bringing services directly to clients.²⁹ Rather than requiring clients to visit health facilities, well-positioned CHWs can provide contraceptive information and services where people live or work, particularly among hard-to-reach communities.

Effective implementation of this HIP relies on CHW integration into the health system, well-defined referral and supervision structures, and comprehensive training and community engagement. Importantly, CHW programmes are most effective when they can evolve and adapt to the changing needs of the communities they serve. In response to COVID-19, the CHW HIP is particularly relevant, as CHWs may be able to both counsel and provide certain contraceptive methods, depending on national task-sharing policies.³⁰ By bringing services directly to the FP client, CHWs may help overcome access barriers due to COVID-19 mobility restrictions.^11,14 For example, The Challenge Initiative expanded training opportunities for CHWs throughout Francophone West Africa in response to the pandemic. In partnership with local facility-based health workers, CHWs are now engaged across multiple levels of the healthcare system and organise household visits, aiming to minimise large crowds at health facilities.¹⁶ Implementing this HIP can thereby expand access to FP information and promote voluntarism and informed choice, while still adhering to social distancing guidelines and limiting facility-based visits.^11,17

Evidence from the 2013 Ebola epidemic also suggests that government-organised CHWs helped to assuage community mistrust of healthcare workers and maintain access to community-based essential health services.¹⁸ Despite sharp declines in service provision, CHWs who received clear directives, support, and were well-integrated into communities more effectively responded to the outbreak.¹⁸ FP programmes may consider adapting and/or expanding existing CHWs programmes to mitigate service disruptions or dispel misinformation about COVID-19.

CHWs may also be especially pertinent in areas that do not have well-established telemedicine services wherein a client could typically receive FP information or referrals without having to visit a facility. Additionally, the WHO recommends adapting the CHW HIP by rapidly training, mobilising, and equipping community-based health cadres with FP knowledge and services alongside proper infection prevention knowledge and protocols.¹¹ However, unlike clinic-based providers, CHWs typically do not have access to personal protective equipment (PPE). Therefore, FP programmes considering implementing this HIP must also ensure CHWs have access to high-quality PPE.

Immediate postpartum and postabortion family planning

Offering contraceptive counselling and services immediately following facility-based childbirth is a proven HIP which provides women and couples the opportunity to receive FP information prior to discharge from a health facility. Similarly, proactively offering contraceptive counselling and FP services at the same time and location where women receive postabortion care is another proven HIP which can optimise contacts with the health facility.

Comprehensive immediate postpartum family planning (IPPFP)³³ and postabortion family planning (PAFP)³⁴ rely on supportive national service delivery guidelines and proper documentation to support informed choice. Additionally, IPPFP leverages antenatal care visits to educate clients on contraception and provides the opportunity for certain short- and long-acting methods to be initiated immediately after birth. By maximising a woman’s contact with the healthcare system during these sensitive periods, FP programmes may be able to prevent unintended pregnancies, while also supporting COVID-19 control by minimising the number of healthcare visits.¹⁹ Moreover, the WHO recommends optimising service delivery settings to maintain essential health services throughout the COVID-19 pandemic response, including the integration of primary care services such as IPPFP or PAFP.¹¹

However, the ability to implement facility-based HIPs like IPPFP and PAFP may be threatened by a larger proportion of home deliveries (given social distancing measures or fear of COVID-19 infection), clinic closures, and supply or service limitations. Steps to mitigate these challenges during the pandemic could include offering PAFP or IPPFP via CHWs³¹ or digital health platforms.³² Indeed, providers in Bangladesh and Nigeria have begun offering antenatal and midwifery appointments via telemedicine (e.g. phone calls, WhatsApp chats) as facility-based visits decline – thereby highlighting this as a potential adaptation for IPPFP and PAFP counselling, as well.²⁰ Providers should also ensure women are counselled on a wide range of methods in case their preferred method is temporarily unavailable¹⁹; however, FP programmes must still attempt to safely procure preferred methods to maximise choice, while taking into consideration potential supply chain disruptions during the pandemic.

Family planning and immunisation integration

Another HIP which optimises a woman’s contact with the health care system is to offer FP information and services proactively to women in the extended postpartum period during routine child immunisation visits. Child immunisation services are one of the most equitable and well-utilised health services around the world, thereby providing a unique platform to integrate FP planning and reproductive health care.²¹

As outlined in the Family Planning and Immunization Integration HIP,³⁵ implementation of this practice is particularly successful when effective referral systems via alternative platforms such as mobile outreach or CHWs are in place, a dedicated FP provider is available at the service delivery point, and when the political and community environment support service integration. However, recent data suggests that maternal, neonatal, and child health interventions – including routine immunisation services – are being paused or reduced in scale as health services are reassigned and restructured to treat COVID-19 patients.^1,14,17 Consequently, implementation of this HIP amid COVID-19 may require significant advocacy and coordination at the national and local levels to ensure these essential services for both women and children are maintained.

Mobile outreach services

Supporting mobile outreach service delivery to provide a wide range of contraceptives, including both short- and long-acting and reversible methods, is a proven HIP that allows for flexible and strategic delivery of FP services in areas with limited access to health providers.³⁷

Mobile outreach models vary greatly by the degree of resource intensity.^20,22 A classic, more resource-intensive model may include physicians, clinical assistants, nurses, and drivers who deliver both long-acting and short-acting methods at existing public or private health facilities, whereas less resource-intensive models involve provision of contraceptives by a single provider who is seconded to a community facility. Typically, mobile outreach programmes rely on community-level coordination, strong private-public partnerships, and effective referral networks. Mobile outreach services have already been encouraged and documented as a coronavirus-related adaptation across multiple contexts.¹¹ For example, in response to recent decreases in health facility attendance, the National Board for Family and Population in Tunisia implemented mobile outreach teams across multiple regions.²⁰ As many countries enforce travel restrictions to uphold social distancing protections, offering contraceptive services through mobile outreach services can limit facility-based contact while still delivering FP information and services, particularly in communities with limited access to health services.^8,11 While some regions have reported disruptions to existing mobile outreach services,²² the various models of mobile outreach as suggested in the HIP brief (organised by the degree of resource intensity) may be particularly useful as FP stakeholders aim to make context-specific adaptations.

Drug shops and pharmacies

Providing FP information, counselling, and methods including oral contraceptives, condoms, and injectable contraceptives through drug shops and pharmacies may expand FP access and availability, particularly in poor or rural areas. Drug shops and pharmacies provide easy access to information and products with their convenient locations, anonymity, and flexible working hours, and are often more acceptable among young people.³⁶

This service delivery model may help overcome systemic obstacles including staff vacancies or distance barriers in underserved areas, given that health clinics or hospitals are generally concentrated in urban areas. Throughout the COVID-19 response, FP programmes may consider drug shops and pharmacies as effective service delivery points, particularly as clinic and hospital resources are redirected towards disease control efforts. Implementation of this HIP may also align with local social marketing³⁸ or social franchising³⁹ efforts in the private sector. Indeed, many private sector programmes encourage FP users to access methods through drug shops and pharmacies, which have been emphasised by the FP community as key partners in the pandemic response.¹⁷ Furthermore, some FP methods are available without a prescription in many countries, which may further minimise burden on the health system by eliminating the need for multiple healthcare visits. For example, in response to health facility capacity reductions and closures due to the pandemic, advocacy efforts are underway between the Tanzania Ministry of Health and National Pharmacy Council to provide over-the-counter oral contraceptives in pharmacies and drug shops.²⁰ Thus, as health systems respond and adapt to COVID-19, countries may consider expanding the availability and accessibility of certain FP methods in pharmacies and drug shops.

Digital health

Using digital health technologies to support health systems and FP service delivery is a HIP enhancement that can improve data for decision-making, manage logistics, reduce contraceptive stockouts, and improve provider-client capacity by offering on-demand, yet contactless FP information and referrals.⁴⁰

To support the COVID-19 response, providers may be able to use telehealth platforms to counsel clients on FP methods, inform clients of service locations, issue prescriptions or refills, screen for medical eligibility, and help clients manage contraceptive-induced side effects.^11–14,42 Furthermore, through the DMPA-SC Access Collaborative and local Ministries of Health, provider trainings on self-injection successfully transitioned to virtual platforms in Uganda, Madagascar, Democratic Republic of Congo, and Senegal in response to the pandemic.²⁰ In contexts where infrastructure is available and accessible, integrating digital health platforms into health systems may be an effective strategy to support FP access and availability amid COVID-19.

Digital platforms are also being used to monitor disruptions in FP service provision and serve as an important resource for researching, measuring, and addressing coronavirus-related impacts on the health system.^7,23 For example, the Research for Scalable Solutions project is assessing the impact of COVID-19 on FP access and use through mobile phone-based surveys in Uganda, Nepal, Malawi, and Niger.²³ Performance Monitoring for Action (PMA) also uses mobile platforms to collect data on women’s knowledge, attitudes, and practices related to COVID-19, as well as the impact of COVID-19 on fertility intentions and contraceptive use across the Democratic Republic of Congo, Kenya, Burkina Faso, and Nigeria.⁷

Similarly, digital health adaptations may be useful enhancements to SBC efforts related to both COVID-19 and FP.⁴⁵ For example, users could receive SMS text updates or virtual counselling sessions with appropriate linkages to FP information alongside important COVID-19 messaging.^8,11,12 However, digitally-based services require access to digital resources, which may be particularly limited in underserved and more rural areas – thereby impacting the full applicability of this HIP enhancement.

Social and behaviour change

Using mass media channels to support healthy reproductive behaviors is a proven HIP that should be prioritised and adapted. Underlying any service delivery adaptation is the importance of consistent SBC strategies.^24,41

Recommended mass media programme adaptations include focusing communication towards preparedness, promoting specific local service delivery points where FP information and methods can be accessed, and in relevant contexts, modifying existing mass media and SBC content to include both coronavirus and FP-related information.^11,24,43 For example, in Côte d’Ivoire, Niger, Burkina Faso, and Togo, COVID-19 messaging has been integrated into existing FP platforms, including hotlines and radio spots which typically share information on FP access and use.²⁰ SBC strategies, as outlined in the HIP brief, should also ensure messaging is tailored to vulnerable groups, including young people.

Policy and financing

The Policy HIP of developing, implementing, and monitoring supportive government policies is aimed at improving FP access, scaling up existing health interventions, and communicating clear, up-to-date clinical guidelines.⁴⁴ Maintaining access to voluntary FP services relies on supportive and effective policies and adequate financial resource allocation.

Effective FP policies may be implemented at the national, regional, or district levels. In order to strengthen FP services at the national level amid COVID-19, FP programmes may consider classifying contraception as an essential health service and emphasising prompt port and customs clearances and distribution logistics. For example, Kenyan leaders issued a memorandum deeming family planning an essential service in order to ensure commodity supply and service continuity were not disrupted.²⁵ Similarly, due to disruptions in facility-based distribution of FP, countries may consider granting prescription waivers, permitting remote or virtual counselling for certain contraceptive methods (e.g. oral pills), shifting policies to allow for self-administration (e.g. DMPA-SC), and authorising or expanding task-sharing policies to maximise access to FP methods.^13,14

Additionally, ensuring the continuity of funding, including Domestic Public Financing (DPF), for FP services and supplies is critical.⁴⁶ Increasing the allocation and efficient use of public financing for FP at the national and sub-national levels is a pertinent HIP towards achieving sustainable financing for FP services. To promote effective DPF, FP stakeholders should ensure FP is included in strategic documents at the national and sub-national levels, set realistic goals, and invest in advocacy to galvanise commitment to FP.

Unfortunately, evidence across multiple countries suggests that resources have been diverted from essential health services towards the coronavirus pandemic response.¹ Recent data from the WHO revealed that 70% of upper-middle- and high-income countries allocated additional funding towards the maintenance of essential health services during COVID-19, whereas only roughly 42% of low- and lower-middle income countries had done so.¹ Similarly, FP clients may experience financial hardships as a result of lockdowns and distancing measures, thereby impacting their ability to afford and access contraception.¹³ In response to lockdowns and public transportation suspensions, a partnership between the Madagascar Ministry of Health and UNFPA provides free transportation for pregnant women in two major cities, thereby supporting access to prenatal, delivery, and postnatal care.²⁶ These contacts with the health system offer critical opportunities to discuss FP, particularly in the immediate postpartum period, and highlight the need for synergistic policy and financing adaptations to ensure women can access life-saving reproductive health services.⁴⁹

Along with prioritising FP as an essential health service, increasing the allocation and efficient use of DPF for FP at national and subnational levels would support the continued availability and accessibility of FP services during the COVID-19 response. Tips and toolkits for effective budget advocacy and allocation found in this HIP can serve as useful references to ensure public budgets are designed and resourced in a cost-effective manner to help mitigate financial burdens imposed as a result of COVID-19.

Supply chain management

Investing in supply chain management by increasing data visibility and use, accelerating product flow, professionalising the supply chain workforce, and capitalising on private sector capacity is a key HIP aimed at improving the availability of FP methods.⁴⁷ Well-functioning supply chains support continuous availability of a wide range of contraceptive methods and promote voluntary and informed choice.

Effective supply chain management relies on clear data, rapid product flow, a competent workforce, and partnerships with the private sector, where available. Despite these best practices, disruptions to the global contraceptive supply chain have been evident since the onset of the coronavirus pandemic. Many contraceptive manufacturers continue to operate at abbreviated capacities due to social distancing measures, thereby creating delays in both production and shipping schedules.^10,14,27 Anecdotal and systematic evidence underscores the heightened likelihood for method stockouts, such as observed stockouts of implants in Myanmar, condom shortages in Mozambique, and curtailed production of IUDs and progesterone-based methods in India.^3,16,27

Coordinated efforts by the global FP community identified countries at risk of contraceptive stock-outs and have taken action to work with suppliers, fulfil orders with partial shipments, and transfer products between countries. Implementation tips found in the Supply Chain Management HIP brief may help countries further expand on these adaptations and minimise supply disruptions.⁴⁸ For instance, closely monitoring, prepositioning commodities, and identifying alternative or interim suppliers will be critical in improving access to FP services throughout the coronavirus response and recovery.^4,27

Conclusion

Access to voluntary FP information and the ability to choose from a wide range of contraceptive methods protects reproductive, maternal, and child health by promoting healthy timing and spacing of pregnancies, advances the ability of women, young people, and couples to achieve their fertility intentions, and promotes healthier families and communities through secondary economic, social, and environmental impacts²⁸ – many of which will also be impacted by COVID-19.^4–5,9,14 Although contraceptive preferences and values may change as a result of the pandemic, health systems must maintain the availability and accessibility of FP and expand partnerships with different stakeholders and non-traditional partners to support FP users in achieving their fertility intentions. As global health systems implement context-specific responses to the COVID-19 pandemic, the utilisation and adaptation of the HIPs¹⁵ can support the continued access and availability of high-quality, essential, and life-saving voluntary FP/RH care.

Disclaimer

The contents are the sole responsibility of the authors and do not necessarily reflect the views of the United States Agency for International Development or the US Government.

Acknowledgements

The authors thank Tabitha Sripipatana, Smita Gaith, and Rabab Pettitt for reviewing drafts and providing comments. We are also grateful to the WHO/IBP COVID-19 Task Team for their assistance documenting and sharing programme adaptations.

Disclosure statement

No potential conflict of interest was reported by the author(s)