EXECUTIVE SUMMARY
Reproductive health providers handled many challenges during the COVID-19 pandemic, including maintaining access to contraceptives.
- Some clinics discontinued or reduced services for placing long-acting reversible contraception and also stopped prescribing emergency contraceptive pills in advance, but telehealth increased.
- Abortion providers could briefly mail abortion pills directly to patients, but the U.S. Supreme Court stopped that expansion to abortion access in January.
- In March 2021, the Food and Drug Administration allowed mailing of abortion pills to patients, restarting the telehealth medication abortion program.
New research highlights the challenges many reproductive health providers and family planning clinics faced during the COVID-19 pandemic. These include discontinuation of services, such as placing long-acting reversible contraception (LARC) and prescribing emergency contraceptive pills in advance.1
Abortion care also was affected. “We saw a dramatic increase in people seeking no-test medication abortion,” says Karen Meckstroth, MD, MPH, medical director of University of California, San Francisco (UCSF) Family Planning and clinical professor of obstetrics, gynecology, and reproductive sciences. Meckstroth answered questions via email. “At UCSF, we were not able to mail the medications, so it still required that patients stopped by or drove by to see the clinician in person, briefly, when they would get medications and sign the consent. Still, many people preferred this to coming into the clinic.”
There was a brief period in 2020 when providers were permitted to mail abortion pills directly to patients, since the pandemic reduced access to in-person medication abortion services. This ended in January with a U.S. Supreme Court decision. Then, when President Biden took office, the Food and Drug Administration (FDA) decided in March to resume mailing of medication abortion pills, says Ushma Upadhyay, PhD, MPH, associate professor in residence at UCSF.
“With the COVID pandemic and changes that the FDA began to allow providers to mail abortion pills directly to patients or to use mail order to send abortion pills, it was a great opportunity to jump in there and evaluate the service,” Upadhyay says. “We thought it was important to document outcomes during this window of opportunity that could inform subsequent decisions on whether the change should be permanent.”
Upadhyay and colleagues collected data on 141 patients and outcomes on 120 from October 2020 to January 2021.2
“We are collecting data again because they restarted in March, and we started our data collection in April 2021,” she says.
Investigators found that 95% of telehealth medication abortions were successful with no complications. “That was consistent with in-clinic care,” Upadhyay adds. “We saw the same rates as we see where people go in to pick up their medication.”
The results also showed that providing medication abortion without an ultrasound was helpful. “It has helped many providers think about how we can provide person-centered care rather than recommending the same evaluation for all patients,” Meckstroth says. “I’m glad we were able to obtain some preliminary evidence on the safety and efficacy of telehealth abortion with an asynchronous, mailing model. It’s encouraging that this appears to be a safe option for people who qualify by their history and symptoms. I hope to be able to offer this at UCSF.”
Although reproductive health providers found new ways to maintain access to services, there was a definite effect on access for many patients. The results of a survey conducted between September and October 2020 revealed that one-fifth of physicians who provided reproductive health services before the pandemic discontinued them during the pandemic. Twenty percent stopped reminding patients about contraception injections or LARC removal or placement. LARC removal as a service was discontinued by 17% of those surveyed, and 16% discontinued LARC placement. Also, 18% stopped prescribing emergency contraceptive pills in advance.1
Investigators also found that the pandemic ushered in new reproductive health services, such as telehealth for contraception initiation — reported by 43% of respondents. Forty-eight percent started telehealth for contraception continuation services.
“We used survey data from 1,063 physicians who provided family planning services just before the pandemic to compare reported changes in family planning-related clinical services and healthcare delivery strategies before and during the pandemic,” says Lauren B. Zapata, PhD, MSPH, epidemiologist with the Centers for Disease Control and Prevention (CDC). Zapata also is a research scientist in the division of reproductive health with the CDC’s National Center for Chronic Disease Prevention and Health Promotion. Zapata answered questions via email.
Surveyed physicians reported significant changes in the provision of family planning-related clinical services and healthcare delivery tactics. Compared with the period just before the COVID-19 pandemic, many physicians discontinued services during the pandemic. Survey data did not capture reasons why certain services were discontinued. But there were some differences in discontinuation of services and tactics by type of physician.
“For example, discontinuation of LARC placement and LARC removal services differed significantly by physician type,” Zapata adds. The highest discontinuation of LARC services was among pediatricians, and the lowest was among OB/GYNs.
The highest discontinuation of emergency contraception was among primary care providers. The lowest was among pediatricians.
“One promising finding from this analysis was the use of telehealth for contraception care in accordance with recommendations to offer telehealth services during the pandemic,” Zapata explains. “More than half of the physicians surveyed reported providing telehealth for both contraception initiation and continuation at some point during the pandemic, reflecting significant increases compared with just before the pandemic.”
When providers implement healthcare service delivery methods that reduce the need for in-person visits, such as telehealth, it can decrease disruptions in care.
“We also found that many practices [that were] not providing certain services or strategies just before the pandemic initiated those services during the pandemic, like telehealth services for contraception and renewing contraception prescriptions without requiring an office visit,” Zapata says.
Implementing remote healthcare service delivery techniques can reduce the need for in-person visits and decrease disruptions in care.1
The pandemic fostered innovation among abortion providers as well.
“This COVID [pandemic] provided an opportunity to test a new service delivery method that some patients prefer because it works in their lives, and they didn’t have to risk COVID infection,” Upadhyay says.
Researchers found that abortion providers changed their protocols in response to the pandemic. Abortion clinics provided more telehealth services, including pre-abortion counseling on the phone or videoconferencing, and text message or phone follow-up, Upadhyay explains.
“Healthcare delivery strategies that reduce the need for in-person visits can limit disruptions in family planning care,” Zapata says. “Strategies that were increasingly employed or implemented during the pandemic included telehealth for contraception care, acceptance of self-report of blood pressure during telehealth visits for contraception, renewal of contraception prescriptions without requiring an office visit, and allowing curbside pickup or mail delivery of contraception. The survey did not address provider comfort with implementing these healthcare delivery strategies.”
While some family planning-related healthcare delivery strategies could reduce the need for in-person visits, Zapata and colleagues observed no significant changes for the following:
- supporting self-administration of subcutaneous injectable contraception;
- counseling on extending use of LARC beyond their FDA-approved duration;
- providing or prescribing emergency contraceptive pills in advance;
- providing or prescribing a year’s worth of oral contraceptives;
- sending patients reminders about contraceptive injections or LARC removal or replacement.
The study results confirm what family planning providers said in 2020 about the disruption in services and increases in telehealth for contraceptive care.
“We know that discontinuing key family planning services during the COVID-19 pandemic may limit access to contraception and impede reproductive autonomy, or the ability to decide and control contraceptive use, pregnancy, and childbearing,” Zapata says. “It is critical that access to family planning services remains available while keeping healthcare providers and their patients safe.”
It helps to prevent service disruption when providers implement healthcare service delivery methods such as telehealth for contraception, curbside pickup or mail delivery of contraception, providing or prescribing emergency contraceptive pills in advance, or providing or prescribing a year’s worth of contraception.
“Healthcare providers and public health professionals should be aware that resources exist to ensure continued access to contraception during the COVID-19 pandemic,” Zapata says.
Delays in contraceptive care and abortion care can have significant consequences for patients.
“I regularly see patients with unplanned pregnancies who have stories of not being able to obtain their contraception, the pharmacy not filling their prescription as expected,” Meckstroth explains.
Patients say they became pregnant while waiting for a visit to place an IUD. Others say they were told they should stop their contraceptive method, but were not offered an alternative. “All of these increased during COVID. I think COVID has reinforced the importance of removing structural barriers to obtaining contraception and abortion,” Meckstroth says.
Barriers include only providing one month of birth control pills at a time, requiring clinic visits that are unrelated to their contraceptive care, or requiring a subsequent visit for an implant or IUD.
“All of these became 10 times more challenging for patients during COVID,” Meckstroth says. “The increase in telehealth during COVID will continue to provide more options for patients.”
REFERENCES
- Zapata LB, Curtis KM, Steiner RJ, et al. COVID-19 and family planning service delivery: Findings from a survey of U.S. physicians. Prev Med 2021 Sep;150:106664. doi: 10.1016/j.ypmed.2021.106664. Epub 2021 Jun 1.
- Upadhyay UD, Koenig LR, Meckstroth KR. Safety and efficacy of telehealth medication abortions in the US during the COVID-19 pandemic. JAMA Netw Open 2021;4:e2122320.
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