By Anita Raj, Jay Silverman, Rebecka Lundgren, Nandita Bhan, and Meredith Pierce

May 4, 2020

This blog originally appeared on Knowledge Success

The rapid growth of the COVID-19 pandemic has raised global awareness of inadequacies in our public health systems across high-, middle-, and low-income nations. As health care systems are stretched to capacity dealing with the pandemic, many of us are worried that delivery of essential health services—including family planning—is being severely compromised. Earlier this month, Marie Stopes International reported that up to 9.5 million women and girls may not get vital family planning services this year because of COVID-19, due to issues both in supply and demand, resulting in tens of thousands of maternal deaths. On the supply side, there are worries that reduced manufacturing and delivery may affect contraceptive access, and inadequate health care availability due to COVID-19 burdens on health systems may impede access to more effective contraceptives such as IUD and tubal ligation. Still, on the supply side, we may be able to monitor availability of family counselors and contraceptives to meet needs. But what of the demand side? How can we monitor shifts in women’s family planning needs and preferences in light of the social and economic shocks they are facing due to the pandemic?

Why Measure Demand for Family Planning During the COVID-19 Pandemic?

First, we must clarify why we need ongoing measurement to better understand demand for family planning. Obviously, the issue is important, as there is extensive research, including our own study released this month, documenting the negative health consequences of unintended pregnancy, including risk for maternal and neonatal death. This study among women who had given birth in the past year in Uttar Pradesh, India found that those with an unintended pregnancy were twice as likely to experience pre-eclampsia in pregnancy and post-partum and almost 50% more likely to have experienced post-partum hemorrhage, relative to those reporting a planned pregnancy. While the importance of family planning is widely recognized, we do not understand how the pandemic will exacerbate inequalities in demand and how health and economic fears may affect pregnancy desire and contraceptive preferences. Additionally, not only do the contexts of lockdowns affect women’s ability to obtain and use contraception due to the supply issues noted above, but family influence and control over them may also be greater at this time.

Globally, we are seeing an increase in reports of domestic violence since the establishing of national lockdowns. As social, health, and financial stresses increase as a consequence of the pandemic and lockdowns, we can expect elevation in both the frequency and severity of these abuses. Domestic violence has been associated with greater reproductive control and coercion of women and impeding access to and use of contraceptives. Importantly, there is also increasing evidence that women experiencing violence or reproductive coercion  are more likely to use women-controlled reversible contraceptives (e.g., IUDs), with some findings from ongoing analyses indicating that this is often occurring as covert use. Thus, access to methods such as IUDs, which require little ongoing contact with a provider (apart from addressing potential unwanted side effects), may be particularly useful and preferred by women during the pandemic.

A field investigator in the midst of data collection as part of the CHARM2 trial. Photo: Mr. Gopinath Shinde; CHARM2 Project in Maharashtra, India.

As we consider how best to monitor and track women’s family planning needs, considerations of violence, reproductive autonomy, and female control of contraceptive methods will be important, emphasizing the need to focus on women’s agency in our measurement. Our conceptualization of women’s agency in health focuses on the Can-Act-Resist constructs of agency, beginning with an emphasis on women’s choice and goals for family planning. In this time of pandemic, where people are feeling less control over their lives, measuring family planning agency is even more important to include in our efforts to monitor demand. Hence, measurement of family planning demand among women should include:

• What family planning methods do they want to use, and feel that they can use in their current situation? [Choice and Can]
• What actions have they taken to meet their family planning needs (e.g., using covertly)? [Act]
• Who if anyone has impeded or influenced their access to or use of contraceptives, and how have they overcome these impediments? [Resist]

A married couple attending their third CHARM2 session, discussing issues of gender equity including marital communication and gender based violence, and family planning uptake with a trained provider. Photo: Mr. Gopinath Shinde; CHARM2 Project in Maharashtra, India.

What Promising Quantitative Measures Can Assess Women’s Agency in Family Planning?

To assess these questions quantitatively, a growing body of evidence-based measures of gender equity and health speaks to a broad range of needs, constructs, and cultural contexts. GEH’s EMERGE platform is an open-access, one-stop shop where researchers and survey implementers can find and draw from over 300+ gender measures in the areas of health, politics, economics, and other social spheres, including family planning and household/family dynamics. In the coming months, we plan to launch a special webpage that focuses on gender measures in family planning. In the interim, we have selected a few measures of agency in family planning from our website that demonstrate strong measurement science and ease of use:

• Interpersonal Quality of Family Planning Scale (Facilitator for Choice)
• Fertility Preferences for Future (Choice)
• Self-Efficacy to Discuss and Use Family Planning (Can)
• Reproductive Decision-Making Agency (Act)
• Reproductive Coercion Scale¹ (Need for Resistance) [Note that the measure linked here has been adapted specifically for COVID-19. You can find all our COVID-19 and Gender measures on EMERGE.]

The EMERGE site includes additional details on the context and science of the measures, as well as their citations.

While there is much advancement on the science and validation of promising measures, we continue to face many gaps, requiring further research to improve our measures. For example, we often ask questions about contraceptives used, but not about contraception preferred or not preferred and reasons for this (Choice and Can). We assess family planning communication and decision-making but not negotiation, where women navigate compromise to achieve their family planning goals (Act and Resist). We assess barriers to family planning use, including reproductive coercion, but not the ways women are able to ensure they can have their needs met despite these barriers, such as via covert use (Resist). Certainly, beyond these issues, we need to ensure that the measures we have can be adapted and tested for use in more diverse contexts. To that end, more research is needed in the area of measurement science. For those interested in this line of inquiry, please review our guidance on measurement development.

A mother, who had recently completed a CHARM2 session, and her child. Photo: Mr. Gopinath Shinde; CHARM2 Project in Maharashtra, India.

Where Do We Go from Here?

While we promote and offer guidance to get measures into the field to ensure we understand changes in family planning demand and unmet need as the COVID-19 pandemic continues to grow, it is with an understanding that most surveys in the field have ceased at this time. Once we are able to return to the field and assessment opportunities arise to identify health needs beyond COVID-19, it is likely we’ll find that women’s reproductive health needs and agency have been substantially affected by this pandemic. Now is the time to prepare our surveys, including those that are rapid and those that are deep, as both will be needed. Rapid assessments will likely roll out first, with early health assessments to capture health needs, particularly in our lowest resourced and most marginalized groups. Deeper assessments are likely to follow, as we not only assess immediate needs but help understand the health damage and losses that occur as a consequence of the pandemic. We must be forward thinking in our approach, and include family planning considerations with a lens of women’s agency as we move forward.

^{1. See also: Silverman JG, Boyce SC, Dehingia N, Rao N, Chandurkar D, Nanda P, Hay K, Atmavilas Y, Saggurti N, Raj A. Reproductive coercion in Uttar Pradesh, India: Prevalence and associations with partner violence and reproductive health. SSM Popul Health. 2019 Dec; 9:100484. PMID: 31998826.}