Introduction

The COVID-19 pandemic has had a profound impact on women’s access to essential health services. The inability of women to exercise their reproductive choice; inadequate availability of and access to family planning and reproductive health services; and regressive social norms which prevent women from accessing and negotiating contraception were problems well before the COVID-19 pandemic. These have been exacerbated during the pandemic. Consequently, women are at serious risk of death or disability during pregnancy and childbirth. Going forward, there is an urgent need to ensure an uninterrupted supply of and access to family planning and reproductive health services for women. In order to reach the last mile, it is important to build the capacities of frontline health workers, who are often the first and only point of contact with the public health system for rural women.

Access to Family Planning and Reproductive Health Services

Family planning, an important element of reproductive health, has rightly been at the heart of political and programmatic interventions in India and globally. Evidence across the globe reveals that investing in family planning is one of the most cost-effective public health measures and is a development ‘best buy.’ Prioritizing family planning interventions could result in manifold benefits to society including increased economic savings in government budgets and reduced expenditures on health care for households.

A study commissioned by the Population Foundation of India (PFI), titled ‘Cost of Inaction in India: An Analysis of Health and Economic Implications,’ estimated for the projected period 2015–2031 that if family planning interventions are implemented to their full potential, India could avert 2.9 million infant deaths and prevent 206 million unsafe abortions. Thus, if investments are increased in family planning, the Indian economy will benefit by an additional 13% increase in per capita gross domestic product (GDP). The government could save up to Rupees 270 billion (3.63 billion US dollars) and households could save up to Rupees 776 billion (10.4 billion US dollars) or 20% of their out-of-pocket health expenditure resulting from additional child births and child hospitalizations [1].

In contrast, inadequate investments in family planning would result in a loss to individuals, households, and the nation. This is particularly relevant currently as the COVID-19 pandemic has not just impacted people’s health but has also seriously affected people’s livelihoods and has affected the national economy.

Impact of COVID-19 on Family Planning Services

The COVID-19 pandemic and the nationwide lockdown have had a profound impact on women’s access to sexual and reproductive health and family planning services. The Population Foundation of India’s analysis of the National Health Mission’s health management information system (HMIS) data to assess the impact of the pandemic on sexual and reproductive health services during the lockdown period (April 2020 to June 2020) compared to the same period last year (April–June 2019)Footnote 1 showed a 43% drop in injectable contraceptives, 50% drop in intrauterine devices (IUDs), and 21% drop in oral contraceptive pills (OCPs). The highest decrease (59%) was for Centchroman (weekly pill). There was a decline of more than 28% in institutional deliveries. A 27% decline in ante-natal check-ups (ANC) was observed [2].

During the pandemic, maternal and child health services were also seriously impacted. These included institutional deliveries, ante-natal care, immunization, and outreach services by anganwadi workers and accredited social health activists (ASHAs). As per the government’s advisory, these services were stopped in the containment zones during the lockdown. Several regions were not visited by anganwadi workers and ASHAs after the lockdown began in March 2020. Many hospitals were converted into COVID-19 facilities, and several private nursing homes were shut down. And because of the restrictions on movement, many people including women could not visit healthcare facilities.

To assess the impact of COVID-19 on access to health services by young people, Population Foundation of India commissioned two rapid telephonic assessment surveys. The first survey included young people 15–24 years of age in three states (Bihar, Rajasthan, and Uttar Pradesh). The second survey covered frontline workers, grassroots organizations, and community members in five states (Bihar, Jharkhand, Odisha, Rajasthan, and Uttar Pradesh). The findings of these surveys showed that young people in three of India’s largest states—Uttar Pradesh, Bihar, and Rajasthan—reported an unmet need for reproductive health services and sanitary pads during the lockdown period. Contraceptives were available at the district level but because of limited access to public transportation, frontline workers were not able to collect contraceptives supplies to be delivered to their clients [3].

The long-term consequences of this disruption in reproductive and maternal health services will be severe as has been witnessed in the aftermath of past epidemics like Ebola and Zika in Africa and other countries. Experiences from past epidemics show that during an emergency, resources are often diverted from routine health services and used for containing the outbreak [4].

Projections of the Impact of Disruption of Essential Health Services

Recent projections suggest that as a result of the disruption in health services due to the pandemic, the following outcomes can be expected:

  • Twenty-six million couples in India will have no access to contraceptives due to the lockdown in 2020 [5].

  • The inability to access contraceptives during the lockdown is likely to result in an additional 2.4 million unintended pregnancies in India [6].

  • Close to 2 million Indian women will not be able to access abortion services in the near term due to COVID-19.

  • There will be a 10% decline in the use of reversible contraceptive methods in low- and middle-income countries (LMICs) due to poor access. This will result in an additional 49 million women with unmet need for modern contraceptives and an additional 15 million unintended pregnancies over the course of a year [7].

  • Countrywide lockdowns which forced clinics to close will result in an additional 3.3 million unsafe abortions in LMICs over the course of a year [8, 9].

  • COVID-19 will disrupt efforts to end child marriage which will result in an additional 13 million child marriages globally that could otherwise have been prevented [10].

Mitigating the Risk to the Family Planning Program

In the wake of the pandemic, it is important to ensure Universal Health Coverage (UHC), including universal access to family planning services. In the words of Dr. Soumya Swaminathan, Chief Scientist, World Health Organization, ‘leadership and political will will play an important role in handling this pandemic [11]. COVID-19 is a grim reminder of the government’s primary responsibility to ensure people’s health and well-being. Investing in the public health system will make a difference to the country’s response to COVID-19. It is critically important to include sexual and reproductive health and family planning services as essential components of Universal Health Coverage.’

The following interventions should be implemented to minimize risk.

Ensure Equitable Access to Essential Health Services Even During Emergency Situations

Ensuring equitable access to essential health services, including family planning, even during emergency situations is important for all, especially the most vulnerable and marginalized groups such as women, young people, and migrants. To prevent the interruption of essential commodities, it is important to ensure that adequate contraceptive stocks are available at different levels of the public healthcare system. Systems should be put in place for forecasting the need for commodities on the basis of actual consumption so that buffer contraceptive stocks can be maintained.

Social Marketing

Social marketing organizations have been an important compliment to the government’s program for ensuring an uninterrupted supply of reversible methods of contraception. Social marketing programs are centered on providing affordable access to and choice of spacing methods (condoms and pills) through commercial channels. There is a need to expand the basket of social marketing products by including newer generations of contraceptives, menstrual hygiene products, and pregnancy kits. In addition, there is a need to build more robust supply chains so that delivery time from the manufacturers and social marketing organizations can be reduced.

Self-care for Family Planning

Self-care is important for improving access and availability of contraceptives for consumers, especially women. Self-care is particularly relevant during the COVID-19 pandemic when the healthcare system is overburdened. Self-care methods of contraception like condoms, oral contraceptive pills, emergency contraceptive pills, pregnancy test kits, and sanitary pads should be made available.

Provide Family Planning Services Through Helplines and Tele-medicine

Community radios, chatbots, and mobile services have been effectively used for healthcare provision. The government should forge partnerships with non-governmental organizations (NGOs) to provide services at the time of a crisis using helplines and tele-medicines.

Strengthen the Policy Environment for Choice-Based Family Planning

The role of key stakeholders, including elected representatives and opinion leaders, in promoting and ensuring the implementation of a choice-based family planning program, is of critical importance. It is important to strategically engage with key stakeholders to create a cadre of champions who recognize the significance of choice-based family planning programs and policies and can advocate for them.

Gender Differentials in Services During the COVID-19 Pandemic

According to the UN Women’s report, as of July 2020, only 11% of total global budgets for COVID-19 and data-related projects were spent on activities with explicit gender dimensions [12]. This is not surprising as even in the past, less than one percent of funds allocated for the Ebola and Zika outbreaks focused on the gender dimensions of these emergencies [13]. Going forward, it is important to generate/collate evidence which underscores the need for quality and comprehensive choice-based family planning programs. Media is an important stakeholder that can increase the visibility of family planning issues and disseminate key messages to the people.

Role of ASHAs and Other Community Health Workers

Community health workers such as ASHAs and anganwadi workers should be supported to ensure continuous access to family planning services during emergencies. Frontline workers are often the only point of contact with the public health system for rural women and represent the foundation of India’s public health system. Investing time and resources for training and empowering them is, therefore, critical.

Critical Role of NGOs

It is important to support and ensure smooth operations of NGOs providing essential health services especially to women and children.

Increased Investments in Health Literacy and Social and Behavior Change Communication (SBCC)

Given that the implications of the COVID-19 pandemic are set for a long haul, it is critical to design national, state, and district-level strategies for behavior change communication. It is imperative to deal with COVID-19-related stigma and misinformation. Clear, unambiguous, contextually relevant, easy-to-understand messages should be communicated to the people through print, electronic, and social media.

Findings from the evaluation of the Population Foundation of India’s flagship SBCC initiative, Main Kuch Bhi Kar Sakti Hoon-I (A Woman, Can Achieve Anything) showed that there was an improvement in the knowledge and awareness around family planning and contraception as a result of this initiative. In season 1 of the program, knowledge about family planning among men and women increased from 47 to 59%. In season 2, 66% of married women and 64% of the youth said that this program had provided them with information which they had not received from any other source. In season 3, women reported an increase in knowledge of modern contraceptives—especially of injectable contraceptives—for which knowledge increased by 30%.

Concluding Comments

Disasters are never gender neutral, and COVID-19 has reaffirmed this in more ways than one. Given that COVID-19 is not a stand-alone pandemic impacting the world, there is a need to build greater resilience in India’s public health system. Gender-responsive policy-making and placing women at the center in all aspects of decision-making are paramount if we truly intend to move the needle on the status of women’s health in India.