Contraception during Disaster and Pandemic Periods: Challenges and Strategies (2024)

3.1 Logistical barriers: Supply chain disruptions, medication and material shortages

Disaster and epidemic situations significantly restrict access to healthcare services. Supply chain disruptions, along with shortages of materials and personnel, pose logistical challenges that hinder the provision of sexual and reproductive health services. Interruptions in access to essential healthcare, particularly concerning contraceptive and pregnancy-related emergency services, increase the risk of unwanted pregnancies and health complications.

The COVID-19 pandemic impacted access to healthcare services, including contraceptive services. A study conducted in South Africa and Zambia involved a survey of 537 women and in-depth interviews with 39 participants. The findings indicated that while there was no significant change in contraceptive use among the participants, barriers to access were reported, including long wait times, shortages of supplies, and fears related to COVID-19 [29].

The World Health Organization defines inequities in access to reproductive health services as unjust differences both within and between groups [30]. Access to contraceptive services is particularly crucial for disadvantaged groups, such as migrants. Research in Europe has shown that immigrant and refugee women experience higher rates of unwanted pregnancies and abortions compared to their non-immigrant counterparts [31, 32].

Displacements following disasters and epidemics are fraught with various logistical barriers that significantly affect immigrants’ access to sexual and reproductive health services. Disruptions in the supply chain, along with shortages of medications and materials, complicate the delivery of these essential services. In migrant camps, healthcare is often constrained by inadequate infrastructure and limited resources. Delays in procuring necessary contraceptive supplies during emergencies increase the risk of unwanted pregnancies and associated health complications. A study conducted in Oslo, Norway, revealed that the contraceptive needs of Somali immigrant women are not adequately met, with knowledge gaps regarding the safety and accessibility of modern contraceptive methods identified as significant barriers [33]. This situation is considered one of the contributing factors to the high rates of unwanted pregnancies and abortions among immigrant women in Europe.

Zika virus infection is associated with adverse pregnancy outcomes, including miscarriage, intrauterine growth restriction, and congenital brain abnormalities. As of 2016, Puerto Rico reported the highest number of Zika virus cases among the United States and its territories, highlighting the need for effective and accessible contraceptive methods for women living in these areas who do not wish to become pregnant. Reports indicate that approximately two-thirds of women of reproductive age in Puerto Rico experience unintended pregnancies, with significant restrictions in access to contraceptive methods [34].

In environments with limited financial resources, providing healthcare services during disaster periods becomes significantly more challenging. The inherent burden that disasters place on healthcare systems is compounded by financial pressures, adversely affecting the capacity to deliver essential services. Among the groups most impacted by these challenges are women and children [14]. For instance, a study examining the effects of the 2010 Haiti earthquake on women’s reproductive health found that increased earthquake intensity led to a decrease in the use of injections, the most common modern contraceptive method in Haiti, resulting in a rise in unwanted pregnancies. Furthermore, the study noted that the severity of the earthquake intensified the unmet need for family planning among women and reduced their access to condoms [35].

3.2 Shortage of healthcare workers and services: Interruptions in healthcare personnel and clinical services

During disasters and pandemics, there is often a widespread lack of information and education regarding sexual health and contraceptive methods. Disruptions in educational and informational activities can hinder individuals from acquiring sufficient knowledge about contraceptive options. This limitation can subsequently restrict both the demand for contraceptive services and their effective utilization.

For instance, during the Ebola outbreak, nurses and midwives in Sierra Leone continued to provide care driven by various motivations, including their professional responsibilities, community obligations, and religious beliefs. This situation serves as a significant example of the continuity of healthcare services [36]. Similarly, a study examining access to contraceptives and changes in contraceptive methods before and after the 2006 earthquake in Indonesia found a decrease in the use of injections and implants within a year following the disaster, alongside an increase in the use of oral contraceptives. Additionally, the prevalence of coitus interruptus as a contraceptive method significantly rose post-disaster, and participants facing difficulties accessing contraceptive methods exhibited higher rates of unintended pregnancies. The extensive damage to healthcare facilities in Yogyakarta is believed to have restricted the abilities of nurses and midwives to perform intrauterine device insertions, implant placements, or administer injections, contributing to the observed outcomes [11].

These examples illustrate how the challenges faced by healthcare workers during disasters and pandemics affect access to sexual health and contraceptive services. A notable critical factor that emerges is the lack of education, which poses a significant threat to the continuity of these services.

3.3 Cultural and social barriers: Increased societal pressures, security concerns, and misinformation during crises

Socio-cultural barriers encompass various factors that hinder women’s use of modern contraceptive methods, including religious beliefs, societal norms, social pressures, and opposition from partners to the use of such methods [33].

Studies conducted in Europe indicate that unwanted pregnancy and abortion rates are notably higher among immigrant and refugee women, many of whom do not utilize modern contraceptive methods. For instance, a study involving Somali immigrant women in Oslo identified systemic and socio-cultural barriers, such as language difficulties, inadequate information, religious beliefs, gender roles, and social pressures, that complicate access to contraceptive methods for these women. The research highlighted that although a significant portion of Somali women expressed a willingness to maintain their desired birth spacing, these barriers impede their ability to use modern contraceptive methods [33].

Religion is a significant component of the socio-cultural fabric in many societies, with religious leaders playing a crucial role in either facilitating or hindering the adoption of contraceptive methods. For instance, in Nigeria, the prevalence of modern contraceptive use remains alarmingly low at 9.8%. A study assessing the impact of exposure to family planning messages from religious leaders found that women exposed to these messages were 70% more likely to utilize modern contraceptive methods (odds ratio=1.70; 95% confidence interval, 1.54–1.87; P<0.001) [37].

The widespread sexual violence directed at women and girls displaced due to disasters, coupled with inadequate gender-sensitive health services and unsafe living conditions, has been documented as creating camp environments that expose women to an increased risk of harassment by undermining cultural norms [21].

3.4 Psychological and social factors

Disasters and pandemics can profoundly impact individuals’ psychosocial well-being. Psychological factors such as stress, trauma, and anxiety can indirectly lead to adverse outcomes in sexual and reproductive health. In particular, Post-Traumatic Stress Disorder (PTSD) and other psychiatric conditions can significantly influence sexual health behaviors and the use of contraceptives during these periods. The pressures created by psychosocial issues negatively shape attitudes toward and access to contraceptive services.

During periods of disaster and pandemics, women’s fertility preferences are influenced by psychosocial factors such as heightened anxiety and uncertainty. A study conducted in Turkey examined how COVID-19 affected women’s pregnancy plans; it found that some women postponed their plans due to the anxiety generated by the pandemic, while others decided to pursue pregnancy due to increased free time and a desire for closeness with their partners. This indicates that pandemics can influence not only fertility preferences but also decisions regarding contraception [18].

During disaster periods, although there is a general decline in quality of life, cultural norms supporting extended family structures persist. This situation emerges as a deterrent factor in the use of contraception. Women, in particular, experience peer pressure from other women and mothers, leading to encouragement for those with fewer children to have more. These social norms and peer pressure are significant contributors to the low utilization of contraceptive methods [33].

Male partners’ resistance to family planning also presents a significant barrier to contraceptive use. For instance, studies conducted with refugees have revealed that women often fear their husbands may seek another partner if they do not bear a sufficient number of children [33]. Similarly, a study conducted in Tanzania found that women who used contraception without their husbands’ consent faced the risk of violence or divorce [38].

During the COVID-19 pandemic, migrant women faced structural barriers to accessing healthcare, compounded by fears of discrimination. Concerns about health and safety became significant factors influencing their contraception and pregnancy choices. A study conducted in New York revealed how economic hardships and health anxieties during the pandemic shaped migrant women’s reproductive health decisions [39].

3.5 Political and economic factors: Changes in government policies and lack of funding

Disasters and pandemics can significantly exacerbate economic challenges, which in turn restrict individuals’ access to contraceptive products. Loss of income and economic crises can limit personal health expenditures, reducing the allocation of resources to essential healthcare services such as contraception. Low-income individuals and communities are particularly vulnerable to these adverse effects.

The high cost of modern contraceptive methods has been reported as a major barrier to their use. For instance, a study by Gele et al. on Somali immigrant women in Oslo identified the high cost of modern contraception as a key obstacle to contraceptive use [33].

4.1 Telemedicine: The use of remote health services

Pandemics and disasters often lead to interruptions in access to healthcare services. In this context, telemedicine has emerged as an effective strategy to ensure the continuity of contraceptive services. The COVID-19 pandemic, in particular, posed significant challenges to young people’s timely access to sexual and reproductive health (SRH) services, highlighting the need for telemedicine solutions. A study by Sturgiss et al. (2022) found that international innovations aimed at improving SRH access for young people, and services provided through telemedicine, have been instrumental in raising awareness about gender-based violence [40].

During the COVID-19 pandemic, the use of telemedicine for contraceptive services rapidly increased. In a study conducted with open-ended responses from 546 contraceptive providers in the United States, it was noted that telemedicine facilitated continuous access and overcame challenges posed by in-person visits. Providers emphasized the importance of telemedicine in reaching young people, especially when schools were closed. However, challenges such as lack of awareness about available services and limited access to technology were also reported. Additionally, concerns were raised about reduced personal connection and privacy issues during virtual consultations [41].

In conclusion, while telemedicine is a vital tool, it is essential to address the challenges encountered during crises and develop hybrid care models to ensure effective service delivery.

4.2 International collaboration and support: The role of international organizations and non-governmental organizations

Access to SRH services becomes crucial for saving women’s lives during periods of crisis and disaster. In this context, international and non-governmental organizations play a vital role in ensuring the continuity of SRH services, particularly in the face of emergencies such as pandemics and natural disasters. These entities provide essential guidelines and standards for maintaining SRH services in times of crisis, supporting women’s access to critical healthcare, including safe childbirth and family planning services, and facilitating the uninterrupted delivery of these essential services.

The 1978, Alma-Ata Declaration emphasized that access to healthcare is a fundamental human right, which can be achieved through primary healthcare (PHC) systems [42]. Sexual and reproductive health (SRH) services represent a core component of both primary and secondary healthcare, and their continuity in disaster-affected regions is of paramount importance, especially through international collaboration and support. The World Health Organization (WHO) and other global actors actively promote the preservation of these critical services and develop policies and programs to ensure sustained access at the PHC level.

To underscore the significance of these efforts, it is important to note that the United Nations Population Fund (UNFPA) projected in 2015 that two-thirds of maternal deaths worldwide occur in countries affected by humanitarian crises or vulnerable conditions [43]. The Global Strategy for Women’s and Children’s Health, implemented by the United Nations between 2010 and 2015, has saved millions of lives and made progress toward achieving the Millennium Development Goals (MDGs). However, by the end of this period, women, children, and adolescents in disaster and crisis-affected areas continued to face significant challenges in accessing essential healthcare services. To address this issue, the Global Strategy for Women’s, Children’s, and Adolescents’ Health for the period 2016–2030 was developed, aiming to ensure access to health services for women and children, even in the context of humanitarian crises and challenging environments [44].

In this regard, it is crucial for national governments to strengthen the resilience of their health systems to reduce maternal mortality and ensure access to universal health services. The European Sexual and Reproductive Health Action Plan emphasizes the importance of improving access to contraception services for disadvantaged groups, such as migrants [45].

In addition to efforts conducted by international organizations, numerous local initiatives are also ongoing. For instance, a research project supported by the Government of Bangladesh’s National Institute of Population Research and Training (NIPORT) includes operational research aimed at improving sexual and reproductive health services in remote and disaster-prone areas. This project seeks to identify feasible interventions for Menstrual Regulation (MR) and Post-Abortion Care (PAC) that can be implemented in hard-to-reach healthcare facilities in the Barisal and Sylhet regions [46].

5.1 Successful strategies

Strategies that have been effectively implemented during pandemics and disaster periods play a critical role in ensuring the continuity of sexual and reproductive health services. One notable example is the Z-CAN (Zika Contraception Access Network) program, which was launched in Puerto Rico during the Zika virus outbreak. This initiative provided a comprehensive approach to preventing unintended pregnancies by offering a variety of contraceptive methods, including long-acting reversible contraceptives (LARC), at no cost. The program was a collaborative effort involving federal and local health agencies, the private sector, and non-governmental organizations. Between 2016 and 2017, Z-CAN served over 21,000 women, enabling them to access their chosen contraceptive methods on the same day. This resulted in a significant increase in the utilization of LARC methods. The Z-CAN model is regarded as an effective solution for enhancing access to contraceptive services in future outbreaks and disasters [47].

5.2 Regional and global experiences

Another successful initiative involves postpartum family planning (FP) strategies. Emergency postpartum family planning (EPPFP) interventions can contribute to the prevention of over 30% of maternal deaths and hold significant importance during humanitarian crises. In 2014, Save the Children incorporated postpartum intrauterine devices (IUDs) into their emergency family planning package, followed by the inclusion of implants in 2017. Countries with high-intensity EPPFP implementations have reported a notable increase in the adoption of IUDs or implants among women within the first 48hours post-delivery. These findings indicate a strong demand for long-acting reversible contraceptives (LARC) in humanitarian settings [48].

During epidemics and disaster periods, the significance of self-administered contraceptive methods for women increases. The World Health Organization’s (WHO) “Family Planning: A Global Handbook for Providers,” specifically in the “Providing Family Planning Services During an Epidemic” section, highlights that various contraceptive methods can be safely and effectively used without direct support from healthcare providers. Table 2 provides essential information regarding these self-administered methods [49].

Enhancing the accessibility of these methods will help protect women’s health and facilitate their access to necessary services. It is crucial to remember that the self-administration of contraceptives is a vital strategy for ensuring women’s access to health services.