The COVID-19 pandemic has wreaked havoc on many aspects of life—and reproductive health and family planning are no exception. Initial lockdowns brought predictions of a baby boom, the idea that couples being stuck at home with nothing to do would lead to more pregnancy.
But soon, with widespread stress, social isolation, and financial instability—and disruptions in assisted fertility services like IVF— came predictions of a “baby bust.” And sure enough, from nine to eleven months after pandemic lockdowns began, the U.S. saw an 8% decline in births over the previous year. Some other high-income countries, including Italy, Japan, and France, also experienced sudden pandemic-related drops in birth rates.
But there’s a flip side to this story. The United Nations Population Fund released data in March showing that an estimated 12 million women in 115 low- and middle-income countries have experienced contraceptive service disruptions, leading to 1.4 million unintended pregnancies during the pandemic.
As access to contraception has increased globally, rates of unintended pregnancy have decreased. But these statistics have long varied across the globe, even before the pandemic. Women in the poorest countries are nearly three times more likely to experience an unintended pregnancy than women in the wealthiest countries, with the vast majority of unintended pregnancies in developing regions occurring among women using no contraception or a traditional method of prevention. Misinformation, cultural barriers, low levels of female autonomy, differences in fertility preferences between partners, and stigma played a role in who can access modern contraception. But this new data focuses on changes seen one year after many countries began implementing coronavirus-related lockdown measures, which have caused a host of complications along contraceptive supply chains and exacerbated existing issues within countries’ healthcare systems.
“Pregnancies don’t stop for pandemics, or any crisis,” said UNFPA Executive Director Natalia Kanem in a press release. “The devastating impact that COVID-19 has had on the lives of millions of women and girls in the past year underscores just how vital it is to ensure the continuity of reproductive health services."
The concept of a pregnancy’s “unintendedness” has been debated, but its current definition is a pregnancy that is either mistimed—occurring earlier than desired—or unwanted—occurring when no children, or no more children, were desired.
The U.N.’s findings emerge at a time when global rates of both unintended pregnancy and total fertility (the average number of children per woman) have been declining steadily. The annual rate of unintended pregnancies per 1,000 women decreased from 79 in 1990-1994 to 64 in 2015-2019. By 2017, the global fertility rate was 2.4—nearly half of what it was in 1950. And in June, CNN reported that the annual number of births in the U.S. dropped by 4% in 2020—the lowest U.S. birth rate since 1973, according to the CDC.
So what exactly is behind the U.N.’s findings of increasing unintended pregnancies? Are contraceptive service disruptions to blame, and what’s the scope of the issue?
More than two-thirds of the world has experienced some form of lockdown in the past year, resulting in health care facility closures, unavailability of medical staff, unemployment, and loss of individuals’ health insurance. People in low- and middle-income countries and marginalized groups around the world have been hit hardest.
At the start of the pandemic, already fragile global contraceptive supply chains became more and more precarious. Malaysia’s Karex Bhd, the world’s largest condom producer (which makes one in every five condoms globally) closed for a week in March of 2020, equivalent to a shortfall of 100 million condoms. Around the same time, India (one of world’s leading manufacturers of generic pharmaceuticals and inexpensive drugs) curtailed the export of any product containing progesterone, a key ingredient in many contraceptives. Substituting identical products is not always an option, as countries need to register drugs before importing them—a process that can take anywhere from six months to several years. And in the U.S., one in three women reported that they had had to delay or cancel a visit to a health care provider for sexual and reproductive care, or had had trouble getting their birth control because of the pandemic.
“All these kinds of things that you know people rely on to be able to access their contraceptive methods—all of that has been disrupted, and once you have disruptions in contraceptive continuity, that's when you can potentially have an unintended pregnancy,” says Bethany Everett, a professor of sociology at the University of Utah and expert in sexual and reproductive health outcomes among queer and cisgender women in the U.S.
One country that has seen a major pandemic “baby boom” is the Philippines. A recent study found that the country had a 42% increase in unplanned pregnancies in 2020 alone. More than 80% of Filipino citizens identify as Catholic, and the Roman Catholic Church already opposed contraceptive use before COVID-19 hit. This pushback—and the inaccessibility of reproductive health services it can create—is now being exacerbated by pandemic-induced economic and social challenges.
“It's often about equitable health and marginalized women,” says Erlidia Llamas-Clark, a practicing OB-GYN and professor at the University of the Philippines. Filipino patients are sometimes billed by hospitals for their own personal protective equipment (PPE) as well as that of their entire surgical team if they have an operation, Llamas-Clark explains. (Government hospitals are supposed to provide PPE, but it hasn’t always been readily available or completely free—especially at the height of the pandemic, she says.)
Marginalized women are again at a disadvantage when it comes to access to contraceptives: “In terms of reproductive health options, we are not talking about the sector of women who are going to be able to buy these pills over the counter, because if you are educated, you have money,” she says. “You have access.” Research also shows that reports of intimate partner violence have increased during the pandemic, creating what Everett describes as a “perfect storm” for certain groups of women.
Unintended pregnancies have also been linked to certain adverse health outcomes in women and children, with some studies suggesting that an unintended pregnancy may correlate with maternal complications like preeclampsia or hemorrhaging, and higher odds of poor infant outcomes like low birth weight and preterm birth. And postpartum depression could be more common among women who have experienced an unintended pregnancy, and may disproportionately affect racial, ethnic, and sexual minority groups, some U.S.-based studies show.
While “unintendeness” may help estimate the gravity of an unmet need for contraception, Everett, Lindberg and other experts have questioned its ability to fully encapsulate the complexity of women’s experiences, motivations, and desires. Unintendedness centers fertility reduction; the conversation should be about promoting autonomy, some researchers argue.
“How does the healthcare system not meet the needs of women at risk of unintended pregnancy?” asks Laura Lindberg of the Guttmacher Institute. “We need to think about making the system more equitable—not just changing individual women’s behaviors."
Everett also cautions against labelling all unintended pregnancies as detrimental. “It’s important for people to be able to make decisions about their bodies and their families that best suit them and their current family, whatever that looks like,” she explains. “For some people, an unplanned pregnancy is a happy accident and for other people it can really be devastating financially or relationship-wise.”
Kelsey Holt, a social and behavioral scientist at the University of California, San Francisco, has been researching “person-centered care,” a framework that puts patients’ needs and desires first. She’s one of many researchers globally who have been racing to develop creative technologies to improve women’s reproductive health in the wake of the pandemic.
Holt has been working to develop a new way to measure reproductive autonomy beyond unintendedness of a pregnancy. She’s also collaborating with teams in Sub-Saharan Africa to identify person-centered approaches to roll out a contraceptive called Sayana Press. A self-delivered injection, Sayana Press uses a needle smaller than those of other injectable contraceptives and can be administered at home. “In the context of the pandemic, there's been a lot more excitement and push towards making this method available because it doesn't require people to come back [to a clinic] as frequently,” Holt says. “It's person-controlled.”
Lindberg agrees that the movement toward reproductive justice, an idea she points out originated from the work of Black scholars and activists, is where the future lies. From technologies like Sayana Press and the creation of ride-hailing apps that deliver contraceptives, to the growth of telemedicine, there have been many promising solutions from around the world giving women the freedom of choice. “The genie is out of the bottle,” especially with regard to telemedicine, Lindberg says.
For Lindberg, listening to family providers that have innovated and shared resources with each other has been a source of hope during the pandemic. “The community of practice and of wanting to make sure that the needs of those who need contraception are met,” she says, “has truly been inspiring.”