Accounting for Context: Using Qualitative Methods to Model the Effects of Adaptations to Family Planning Services During COVID-19

ABSTRACT

Background: – During the first six months of the global response to Coronavirus Disease-2019 (COVID-19), multiple service delivery adaptations were suggested to maintain access to modern contraceptive methods (MCMs) and family planning (FP) services. Though these adaptations may help maintain services during COVID-19, they may also trigger mechanisms capable of fundamentally shifting MCM use and community perceptions of FP long after routine services are restored if they fail to take into account the contexts in which they are implemented. This study aimed to model the context-specific effects of suggested adaptations to FP service delivery. Methods: – A multi-step approach to modelling using qualitative methods was employed. Methods involved a targeted review of relevant literature on adaptations to FP service delivery, the development of context categories using empirical findings from five countries, and the construction of a model based on realist concepts to predict the mechanisms and outcomes likely to be triggered by adaptations to FP service delivery in specific contexts. Results: – Eleven key adaptations to FP service delivery were identified, and 19 mechanisms and their associated outcomes were predicted. The model revealed 8 negative and 11 positive effects of suggested adaptations when implemented in contexts where women’s decisions around MCM use are influenced by 1) stigma surrounding FP;2) male control of reproductive decisions;3) covert use of MCMs;4) fear of MCM side effects;and 5) concerns about long-acting reversible contraceptives. These effects were predicted to drive changes in MCM use, community perceptions of FP, and women’s trust in health services. The model also demonstrated that suggested adaptations are likely to have important long-term effects and result in changes to the prevailing contexts. Conclusions: – Though adaptations to FP service delivery are needed in response to COVID-19, the contexts in which these are implemented should be carefully considered by national and sub-national decision-makers to minimise unwanted outcomes. The model constructed in this study can be leveraged as a theorising tool to facilitate this process in different settings.