EXCUTIVE SUMMARY
The COVID-19 pandemic caused disruptions and barriers to contraceptive care in its first year. Reproductive health providers have navigated conflicting and confusing messages about vaccine mandates.
- Keeping facilities fully staffed during the pandemic — particularly in the omicron surge — has been one of the biggest challenges.
- Infection prevention is challenging when some states outlaw vaccine mandates, but the federal government requires vaccination for all staff in facilities that receive Medicaid/Medicare funding.
- Staffing issues could ease when facilities no longer require asymptomatic staff to stay home after a COVID-19 exposure.
Women’s access to most contraceptives dropped precipitously in 2020. This may continue as clinics limit in-person visits because of staffing shortages and other issues.1,2
“I think the health system has really struggled to fully adapt to the stressors of the pandemic,” says Maria W. Steenland, SD, MPH, assistant professor at the Population Studies and Training Center at Brown University in Providence, RI.
Staff reductions from nursing burnout and COVID-19 omicron infections have affected all healthcare providers, including those working in reproductive health, she notes. (See story on contraceptive barriers during the pandemic in this issue.)
“We’re seeing not just people quitting, but people sick and having to stay home sick, which reduces the amount of patients you can schedule in a day,” Steenland says.
Many healthcare facilities and businesses faced staffing shortages due to exposure to or illness with omicron in the winter of 2022.
The ferocity of omicron’s transmissibility caught everyone by surprise. “It’s way more transmissible than the original one, and more than delta was,” says Stephen Colodny, MD, FIDSA, FACP, chief of infection control and prevention at St. Clair Health in Pittsburgh.
Based on the trajectories of previous pandemics, the hope is that enough people will be fully vaccinated and/or develop some immunity after infection that the nation will achieve herd immunity before a new COVID-19 variant emerges.
“If you remember, two years ago, we were talking about herd immunity in the context of the number of people vaccinated and those who had illness. If we had done things correctly, we’d now have herd immunity,” Colodny says.
Barriers to Care Increased
The results of a recent survey showed 51.2% of women who sought contraception in July 2020 reported barriers to care. In January 2021, 55.3% reported barriers to contraceptive care.2
“Initially, when we proposed doing two rounds [of surveys], we framed it as the second one would be post-pandemic. Unfortunately, that was not the case, although they were very different times,” says Nadia Diamond-Smith, PhD, MSc, assistant professor in epidemiology and biostatistics in the Institute for Global Health Services at the University of California, San Francisco (UCSF). (See the story in this issue on what caused barriers during the pandemic.)
Women reported barriers to filling prescriptions for contraceptives, starting new methods, and seeking insertion or removal of intrauterine devices (IUDs) and contraceptive implants.2
“Someone who had been on the pill when COVID happened might not have been able to get the pill again, so now they were using condoms,” Diamond-Smith explains. “Or maybe they wanted their implant removed and couldn’t get it removed.”
Staffing Is an Issue
The ever-constant threat of COVID-19 infection and surges also affected family planning centers, provider offices, and clinics. Healthcare providers struggled to maintain capacity when staff were out sick with COVID-19. Omicron tore through the country in December 2021, causing some healthcare facilities to triage patients as the winter surge continued into 2022.
With COVID-19 turning endemic, family planning clinics and provider offices should prepare for surges, just as they do for the annual influenza outbreaks. For example, they could increase staffing during the winter months, planning for employees who may be out sick.
Staffing during the pandemic has been particularly challenging, because staff must stay home after exposure to the virus, even if they are asymptomatic. But asymptomatic testing probably will end after the omicron surge, says Monica Gandhi, MD, MPH, director of the UCSF Center for AIDS Research and professor of medicine and associate chief of the division of HIV, infectious diseases, and global medicine at UCSF.
Another tactic would be to increase pay during the winter months to incentivize employees to work overtime, if asked.
“Our case numbers of people being exposed to omicron are astronomical,” Gandhi says. “A population of people who’ve been infected, including those who were not vaccinated, and even those who were vaccinated, is a lot of exposure. It builds immunity.”
Vaccine Mandates
The challenge is for healthcare organizations and providers to protect their staff and patients while dealing with conflicting laws and rules about what they can require of their employees. These mixed messages about vaccines and masking are coming from state elected officials, public health authorities, and from the federal government.
Reproductive health providers, clinics, and public health departments across the United States may find the current legal environment surrounding vaccine mandates challenging. If some staff members refuse vaccination, can leadership suspend them, fire them, or require daily or weekly COVID-19 tests? What should they do when state law prohibits the mandates, but the federal government requires them?
On Jan. 13, the U.S. Supreme Court decided the federal government could enforce a vaccine mandate for healthcare facilities that receive federal funding, such as Medicaid and Medicare. The Supreme Court’s decision states that the U.S. Department of Health and Human Services’ rule regarding vaccination of hospital staff “fits neatly within the language of the statute. After all, ensuring that providers take steps to avoid transmitting a dangerous virus to their patients is consistent with the fundamental principle of the medical profession: First, do no harm.”3
While the provision pertains only to hospitals, the secretary has similar statutory powers with respect to most other categories of healthcare facilities.3
But, at the same time, some states continued to enforce their anti-vaccine mandate laws, passed in 2021. For example, in January, the Florida Department of Health put Raul Pino, MD, director of the Florida Department of Health in Orange County, on leave after he encouraged employees to take the vaccine. Pino sent employees information about how too few of them had been vaccinated or received booster shots. His email did not say employees were mandated to receive the shots, but he called it irresponsible to not take the vaccine. State officials are investigating whether Pino violated a state law, signed in the fall, that would prohibit state government agencies from implementing vaccine mandates.4
The federal government holds one big cudgel it could use to stop states from obstructing vaccine mandates: a threat of taking away federal funding, says Herschel Nachlis, PhD, research assistant professor of government and policy fellow in the Rockefeller Center for Public Policy and Social Sciences at Dartmouth College in Hanover, NH.
“The threat alone is enough to induce compliant behavior at the state and local level,” Nachlis says. “There’s a long tradition related to when federal law conflicts with state law, the federal government threatens to take away funding, and, in most cases, that scares states enough to get them to comply.”
For healthcare facilities, the Supreme Court’s ruling allows them to require employee vaccinations, Nachlis says. Any state action against a health facility that requires mandates would be challenged in court and would, presumably, fail.
“When local and state officials complain, they can refer to the Supreme Court decision instead of their own preferences, saying, ‘If the Supreme Court says to do it, we have no choice,’” Nachlis explains.
The risk of healthcare facilities losing staff because of a vaccine mandate is low. “It seems to me that staff shortages are mainly due to the virus exposure itself and are not because of people quitting over vaccine mandates,” he says.
The biggest risk for reproductive health providers as the pandemic trudges into its third year is that some fast-spreading COVID-19 variant will pick up where omicron left off and cause more breakthrough infections and continued staff shortages.
By the end of January, many large cities reported that their COVID-19 cases had plateaued and were decreasing. The Centers for Disease Control and Prevention showed an overall decrease.5
Widespread healthcare staffing shortages affected access to care, but early data suggest that the most dramatic effect on outpatient clinics occurred during the early part of the pandemic in 2020, when some clinics closed and some stopped IUD insertions for a while.
“There were extreme changes,” Steenland explains. “There were different hours, longer times to get in and out, and some OB/GYNs might have had to prioritize by patient types, such as seeing pregnant patients vs. routine care.”
REFERENCES
- Steenland MW, Geiger CK, Chen L, et al. Declines in contraceptive visits in the United States during the COVID-19 pandemic. Contraception 2021;104:593-599.
- Diamond-Smith N, Logan R, Marshall C, et al. COVID-19’s impact on contraception experiences: Exacerbation of structural inequities in women’s health. Contraception 2021;104:600-605.
- Phillips A. READ: Supreme Court rulings on nationwide vaccine and testing mandate for large businesses, health care vaccine mandate. CNN. Jan. 13, 2022.
- Bella T. Florida health official placed on leave after encouraging employees to get vaccinated. The Washington Post. Jan. 19, 2022.
- Centers for Disease Control and Prevention. COVID Data Tracker Weekly Review. Updated Jan. 28, 2022.
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