RESUMEN
BackgroundReproductive health services were significantly disrupted during the COVID-19 pandemic in Britain. We investigated contraception-related health inequalities in the first year of the pandemic. MethodsNatsal-COVID Wave 2 surveyed 6,658 adults aged 18-59 between March-April 2021, using quotas and weighting to achieve quasi-representativeness. Our analysis included sexually active participants aged 18-44, described as female at birth. We analysed contraception use and switching, contraceptive service access, and pregnancy plannedness in the year from March 2020. FindingsAmongst all participants (n=1,488), 14.3% (12.5%-16.3%) reported switching or stopping contraception due to the pandemic. Of participants at risk of unplanned pregnancy (n=1,169), 54.1% (51.0%-57.1%) reported routinely using effective contraception in the past year. 3.2% (2.0%-5.1%) of those using effective methods pre-pandemic switched to less effective methods, while 3.8% (2.5%-5.9%) stopped. Stopping/switching was more likely amongst participants of younger age, non-white ethnicity, and lower social grade. 29.3% of at-risk participants (26.9%-31.8%) reported trying to access contraceptive services; of whom 16.4% (13.0%-20.4%) reported their needs went unmet. Unmet need was associated with younger age, diverse sexual identities and anxiety symptoms. Of 199 pregnancies, 6.6% (3.9%-11.1%) were scored as unplanned; less planning was associated with younger age, lower social grade and unemployment. InterpretationAlthough many participants reported accessing contraceptive services during the pandemic, one-in-six of these reported an unmet need. Inequalities in unmet need and risk of unplanned pregnancy - related to age, ethnicity, social disadvantage and mental health - potentially exacerbated existing reproductive health inequalities. These should be addressed in the post-pandemic period and beyond. FundingWellcome Trust, The Economic and Social Research Council, The National Institute for Health Research, Medical Research Council/Chief Scientist Office Social and Public Health Sciences Unit, and UCL Coronavirus Response Fund. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIThe COVID-19 pandemic likely impacted reproductive outcomes in diverse ways; such impacts may have been unequally distributed. C_LIO_LIPrevious studies reported adaptations to health service delivery and difficulties experienced in accessing reproductive health services, with switching and stopping of contraceptive methods and potentially greater risk of unplanned pregnancy. C_LI What this study addsO_LIWe examined differences in contraceptive use and pregnancy planning in a sample of women, trans and non-binary people able to become pregnant who were quasi-representative of the British general population. C_LIO_LIWe found that key markers of inequality and vulnerability, related to age, ethnicity, social disadvantage and mental health, were associated with increased contraceptive method switching, unmet need of contraceptive services and less-planned pregnancies. C_LI How this study might affect research, practice or policyO_LIOngoing efforts to ease the health impacts of the pandemic should aim to improve equality of access to contraceptive services. C_LI
RESUMEN
ObjectivesAccess to quality sexual and reproductive health (SRH) services remains imperative, even during a pandemic. Our objective was to understand experiences of delayed or unsuccessful access to SRH services in Britain during the early stages of COVID-19 pandemic. DesignSemi-structured qualitative follow-up interviews were conducted in October-November 2020 (six months after the first UK lockdown) with participants of Natsal-COVID, a quasi-representative web-panel survey of sexual health and behaviour during COVID-19 (n=6654). Inductive thematic analysis was used to identify lessons for future SRH service access and quality. SettingTelephone interviews with participants from the general population. Participants14 women and 6 men (24-47-years-old) reporting unmet need for SRH services and agreeing to recontact (n=311) were selected for interview using socio-demographic quotas. ResultsParticipant experiences spanned ten different SRH services, including contraception and antenatal/maternity services. At interview, ten participants still experienced unmet need. Participants reported hesitancy and self-censorship of need. Accessing services required tenacity. Challenges included navigating inconsistent information and changing procedures; perceptions of gatekeepers as obstructing access; and inflexible appointment systems. Concerns about reconfigured services included reduced privacy; decreased quality of interactions with professionals; reduced informal support due to lone attendance; and fewer routine physical checks. However, participants also described examples of more streamlined services and staff efforts to compensate for disruptions. Many viewed the blending of telemedicine with in-person care as a positive development. ConclusionCOVID-19 impacted access and quality of SRH services. The accounts of those who struggled to access services revealed self-censorship of need, difficulty navigating shifting service configurations, and perceived reduction in quality due to a socially-distanced service model. Telemedicine offers potential for greater efficiency if blended intelligently with in-person care. We offer some initial data-based recommendations for promoting equitable access and quality in restoration and future adaption of SRH services. SUMMARY BOXO_ST_ABSWhat is already known on this topicC_ST_ABSAccess to quality sexual and reproductive health (SRH) services remains imperative, even during a pandemic. In response to the threat of COVID-19, SRH services limited in-person provision, introduced social distancing and mask wearing, and expanded remote consultations and postal services. There are no published qualitative community studies in Britain exploring service-user experiences of the rapid adaption and scaling-down of SRH services in response to COVID-19. What this study addsThis study provides important insights into how rapid contraction and adaptation of sexual and reproductive health services was experienced by service users. It adds the patient perspective to formal and informal learning and sharing of knowledge been practitioners and policy makers. The study highlights that difficulty accessing services, decreased quality of SRH interactions, reduced opportunity to receive informal support, and fewer routine physical checks were difficult for patients. Our data-driven recommendations - including cautious adoption of telemedicine and improving collaboration across services - have relevance across SRH services and may be useful to other primary and secondary care providers.
