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Table 2 Study characteristics

From: Reproductive justice in the time of COVID-19: a systematic review of the indirect impacts of COVID-19 on sexual and reproductive health

Author(s) Methods Sample Epidemic SRH outcome Major findings
Aiken et al. [32] Quantitative; Quasi-experimental Individuals seeking online abortion telemedicine services in the US between Jan 1, 2019 and April 11, 2020 (n = 49,935) COVID-19 Abortion • From March 20–April 11, 2020 ('after' COVID-19), there was a 27% increase in requests for self-managed medication abortion across the US
• States with significant increases in requests had higher rates of stay-at-home-behaviors, especially high rates of COVID-19, and/or more severe COVID-19 related restriction on in-clinic abortion access
Aryal et al. [39] Quantitative; Cross-sectional Women provided with safe abortion services between April—June 2020 (lockdown period) and July–September 2020 (lockdown eased) in western Nepal (n = 52) COVID-19 Abortion • COVID-19 pandemic related lockdowns reduced the number of women coming in for abortions by 25.7%. Additionally, 47.1% more women came in for an abortion later in the pandemic, when pandemic related restrictions eased, compared to earlier in the pandemic, with strict lockdowns
• Women who came in for an abortion earlier in the pandemic had a later period of gestation compared to women who came in when restrictions eased (9.5 weeks vs 7.5 weeks; p = 0.049). Distance from health facility was also significantly associated with accessibility to the health facility, with women who lived more than 5 h from the facility not seeking an abortion early in the pandemic (p = 0.021)
• Finally, 48% of all women enrolled in the study reported an increased need for contraception, with 23% of women not using contraceptives due to inaccessibility due to lockdowns
Caruso et al. [43] Quantitative; Cross-sectional Women who use hormonal contraceptives and were registered at a family planning clinic in Italy (n = 317) COVID-19 Contraceptive utilization • Two-thirds of participants used short-acting reversible contraceptives (SARC; oral contraceptive pill = 53.3%; vaginal ring = 14.2%) and one-third of participants used long-acting reversible contraceptives (LARC; subdermal implant = 19.2%); IUD = 13.2%)
• 70% of women used contraceptives to avoid unplanned pregnancies; 30% used contraceptives for additional non-contraceptive benefits
• Women who married or co-habiting continued to use contraceptives and had no unplanned pregnancies
• Half of all women (n = 51) who were not co-habiting discontinued SARC; half continued to engage in sexual activity (n = 47) and 15% (n = 15) had an unplanned pregnancy, for which they sought abortion
Coombe et al. [46] Mixed methods; Cross-sectional Australian women of reproductive age (18–49 years) (n = 518) COVID-19 Pregnancy intentions & access to contraceptives • Most participants (76%) indicated that they were trying to avoid pregnancy
• Nearly 20% of women were not using any contraception. Of those that were, the oral contraceptive pill was the most common (21%) method
• When asked about SRH access during lockdown, only 9% reporting difficulties accessing contraception. For some this was due to shortages in their preferred method, difficulty obtaining a doctor’s appointment, fear of leaving the house due to COVID-19, or privacy concerns. Women that were unemployed reported greater difficulty accessing contraceptives (OR: 2.5 (1.1- 5.0)). Nearly a quarter (22%) of women reported needing to access SRH-related healthcare, with little difference by socio-demographics
• Most participants indicated that the COVID-19 pandemic had not changed their pregnancy intentions, however, some women indicated that they had actively stopped trying during the pandemic, or that they were unable to continue trying to conceive due to cancellations of IVF or other reproductive services
Dell'Utri et al. [50] Quantitative; Retrospective cohort Medical records data of women admitted for obstetric and gynecological emergency services at the largest maternity clinic in Milan, Italy between Feb 23-June 24 in 2019 and 2020 (N = 9291) COVID-19 Obstetric and gynecological service provision • Compared to the reference year (2019), registered admissions during stay-in-place measures in 2020 decreased by 35.4% (34.1 to 36.6), with the highest reduction corresponding to the maximum increase of newly infected cases
• The decrease was nearly double among Italians, compared to foreign women, with no decrease observed among African women
• There was a 63.5% (60.5 to 66.5) reduction in gynecological complaints, particularly for admissions for vulvovaginal infections, urogynecological conditions and/or cystitis (− 75.7% (71.4 to 80.1); menorrhagia/atypical blood loss (− 41.4% (− 31.7 to 51.1); and pelvic inflammatory disease (− 61.5% (− 35.1 to 88.0)
Endler et al. [38] Quantitative; Cross-sectional SRH-related clinicians, researchers and practitioners from 29 countries (n = 51) COVID-19 Contraceptive access & abortion • Nearly all (86%) reported that access to contraceptives decreased during the COVID-19 pandemic, whereas 62% and 46% of respondents reported decreases in surgical and medical abortion, respectively
• The highest perceived barriers to abortion access were fear of COVID-19 infection, lack of transportation, and closed pharmacies. Most respondents indicated that SRHR services decreased due to the prioritization of the COVID-19 pandemic response, or that the pandemic was an excuse to pause, ignore or dismantle any progress made toward advancing SRHR. A few exceptions were made in high-income countries, where the pandemic provided an opportunity to advance access to SRHR
• Compared to countries with mildly restrictive abortion policies, countries with severely restrictive abortion policies reported less women accessing SRH-related services (69% vs 23%; p = 0.026); no abortion policy changes (69% vs 0%); p < 0.001); and decreased contraceptive policy changes (88% vs 46%; p = 0.023)
Fuchs et al. [53] Quantitative; Longitudinal Sexually active women between the ages of 18–40 years (n = 764) in Poland COVID-19 Sexual behavior • Total sexual function as measured by the Female Sexual Function Index (FSFI) significantly decreased (30.1 (4.4) vs 25.8 (9.7)) during the COVID-19 pandemic. Decreases were seen across every FSFI domain (desire, arousal, lubrication, orgasm, satisfaction, and pain)
• Sexual dysfunction (FSFI score < 26) increased during COVID-19 control measures (15.3% vs 34.3%)
• Frequency of sexual intercourse declined due to isolation, conflict with partner and mental health (stress, anxiety, depression)
• Less educated women, those with worse living conditions, women who did not work, women living with their parents or those in informal relationships experienced lowest sexual functioning
Kerestes et al. [34] Quantitative; Retrospective cohort Patients who had medication abortion up to 77 days gestation between April and November 2020 in Hawaii (n = 334) COVID-19 Abortion • A total of 334 patients received medication abortion, of which 149 (45%) received telemedicine with in-person pickup of medications, 75 (23%) received telemedicine with medications mailed, and 110 (33%) received traditional in person visits
• The rate of complete medication abortion without surgical intervention was 96%, with success rates of 97%, 97%, and 94% for the clinic pickup, mail, and clinic visit groups, respectively
• Success rate for those with and without an ultrasound prior were similar (96% vs 97%), and 88% of patients returned for follow up care. Very few women (17; 5%) experienced any complications
Leight et al. [42] Quantitative; Quasi-experimental n = 109,129 women served by n = 132 unique promoters (community healthcare workers) and 192 unique public health facilities in Nampula and Sofala, Mozambique between January 21—May 20, 2020 COVID-19 Access to contraceptives • COVID-19 related lockdowns and disruptions were associated with a decrease in contraceptive receipt (OR 0.798, 95% CI [0.701–0.908], p = 0.001)
• Easing lockdown restrictions was associated with an increase in contraceptive referrals (OR 1.187, 95% CI [1.034, 1.354], p = 0.015), especially amongst women who were not currently using contraceptives (OR 1.490, 95% CI [1.203, 1.841], p < 0.001); and in contraceptive receipt (OR 0.777, 95% CI [0.660, 0.913], p = 0.002), especially among women with phone access (OR 1.800, 95% CI [1.469, 2.205], p < 0.001)
Li et al. [45] Quantitative; Cross-sectional Young citizens between the ages of 18–35 years who reported having sexual intercourse in the 6 months prior (n = 967) in China COVID-19 Sexual behavior & service provision • COVID-19 control measures resulted decrease in sexual desire (20%), frequency of sex (41%), alcohol consumption before or during sexual activities (20%), and risky sexual behavior (10%), partner deterioration (31%)
• Partner relationships were influenced by housing (aOR: 0.59; 95% CI 0.30–0.86), exclusivity (aOR 0.44; 95% CI 0.27–0.73); sexual desire (aOR 2.01; 95% CI 1.38–2.97); and sexual satisfaction (aOR 1.92; 95% CI 1.54–2.50)
• Although the numbers were small, participants reported difficulties in accessing reproductive health services:
 Women with recent abortions described difficulties making appointments
 Participants with STIs described difficulties obtaining a doctor’s appointment and in accessing medications
 8.9% reported experiencing a shortage of contraceptives
Lin et al. [47] Quantitative; Cross-sectional Women between the ages of 18–49 year who reside in the US between May 16 and June 16, 2020 (n = 554) COVID-19 Pregnancy intentions & access to contraceptives • Compared to White respondents, Latinx (OR 4.01 (2.25–7.15)), Black/African Americans (OR 3.92 (1.81–8.50)) and Multiracial (OR 2.12 (1.10–4.07)) respondents reported higher odds of inability to afford food, transportation, and/or housing during the pandemic; and Hispanics/Latinx [1.95 (1.12–3.40)] reported higher odds of food insecurity
• Inability to afford food, transportation, and/or housing was associated with a decreased desire for pregnancy [OR 2.13 (1.32–3.43)], and greater difficulty accessing contraceptives (OR 1.86 (1.06–3.24)
Luetke et al. [54] Quantitative; Cross-sectional Nationally representative weighted sample of partnered men and women (n = 742) in the US COVID-19 Sexual behaviors • One-third of participants (34%) reported some degree of COVID-related conflict with their romantic partners
• Compared to those experiencing no conflict, those with any conflict reported decreased odds of intimate behavior: hugging, kissing, holding hands, cuddling (aOR: 2.35, 95% CI 1.58–3.50); giving/receiving oral sex (aOR: 2.34, 95% CI 1.36–4.02); intercourse (aOR: 2.28, 95% CI 1.40, 3.73)
• There was a dose–response curve between conflict and intimate/sexual behaviors; and those that reported more conflict exhibited less sexual behaviors
Mello et al. [37] Mixed methods; Policy analysis & Cross-sectional quantitative survey Abortion health facilities in Ohio, Kentucky & West Virginia (n = 14) COVID-19 Abortion • Despite federal regulations encouraging the utilization of medication abortions in the US, state laws governing medication and telemedicine abortion in Ohio, Kentucky and West Virginia remained in effect throughout 2020 and barred patients from receiving medication abortions by mail
• Surveys with abortion facilities indicate that an average of 2107 abortions were performed monthly between December 2019 and December 2020, 42% (n = 893) of which were medication abortions
• Coinciding COVID-19 pandemic related disruptions and executive orders, the number of total (n = 2306) and medication abortions (n = 1613; 70%) peaked in April 2020 and returned to pre-pandemic levels by June 2020. The peak is most stark for Ohio (72%, vs 40% average) and West Virginia (87%, vs 49% average); whereas Kentucky sees only a slight increase (55% vs 50% average)
Micelli et al. [55] Quantitative; Cross-sectional Italian men and women in long-term relationships between the ages of 18–46 years (n = 1482; nwomen = 944, nmen = 538) COVID-19 Pregnancy intentions • Of the 18% participants who were planning to have a child before the pandemic, 37% abandoned the intention because of worries about future economic difficulties (58%) and consequences on pregnancy (58%)
• Of 82% who did not intend to conceive, 12% revealed a desire for parenthood during quarantine than before (p < 0.01), related to will for change (50%) and need for positivity (40%). 4.3% of these tried to get pregnant
• Stratifying by age, a trend toward older ages was found in the desire for parenthood before and during the COVID-19 pandemic (p < 0.05)
Nagendra et al. [49] Quantitative; Cross-sectional Convenience sample of individuals on the NYC STD PTC educational mailing list and key partners from state and local health department (N = 73, nNew York = 61, n = 12 from Indiana, Ohio, Michigan, New Jersey, Puerto Rico, or United States Virgin Islands) COVID-19 Service provision • Majority of clinics providing sexual health services indicated a significant decrease in the regular services they were able to provide, except for expansion in telehealth services
• Only 25% of the clinics that offered pregnancy termination and 18% of clinics (n = 11) that offered STI testing services before March 1, 2020, could do so as of April 1, 2020
• 80% of clinics have resorted to treating STIs presumptively based on symptomology, before testing, due to the COVID-19 outbreak in the US
• As of April 1, 2020, only 25% of respondents located in NYS and 26% outside of NYS are able to offer HIV testing
Phelan et al. [48] Quantitative; Cross-sectional Women of reproductive age, globally (n = 1031) COVID-19 Menstruation • Nearly a quarter (23%) of respondents were using hormonal contraception
• Almost half (46%) reported a change in menstrual cycle since the beginning of the pandemic, with 53% reported worsening premenstrual symptoms, 18% reporting new menorrhagia and 30% new dysmenorrhea compared to before the pandemic (p < 0.05)
• A small number of respondents (9%) reported missed periods whereas they previously did not (p = 0.003), with a median number of 2 (1–3) missed periods. 21% of those who “occasionally” missed periods pre-pandemic missed periods “often” during pandemic
• Nearly half of all women (45%) reported a reduced libido
• There was no change in the median cycle length (28 days) or days of bleeding (5) but there was a wider variability of cycle length (p = 0.01) and a 1-day median decrease in the minimum and maximum cycle length (p < 0.05)
Rimmer et al. [51] Quantitative; Cross-sectional Junior obstetrics and gynecology doctors across training units in the UK National Health Service UK (n = 148) COVID-19 Obstetrics and gynecology service provision • Majority of units (60%) completed training drills for managing obstetrics and gynecology emergencies during COVID-19, nearly all (88%) implemented COVID-19 specific protocols, had adequate PPE (91%), operated dedicated COVID-19 obstetric emergency theatres (71%)
• Most had to reduce in-person antenatal clinics (79%), but offered telehealth services (71%) and dedicated clinic areas for pregnant women with confirmed or suspected COVID-19 (78%)
• Elective gynecological services (fertility and urogynaecology) were mostly suspended (89%); 40% implemented protocols to reduce inpatient stays, including medical management as the first line of treatment for miscarriage (59%) or ectopic pregnancies (28%) in order to reduce inpatient stays
• Oncological referral pathways were unaffected in half (51%) of all units, with planned reductions in oncology surgery in half (55%) of all units
• Rapidly changing protocols and lack of clarity led to confusion among doctors
Roberts et al. [35] Quantitative; Cross-sectional Providers at independent abortion clinics across the US (nclinics = 103) COVID-19 Abortion • Clinics in all regions of the US were represented: Northeast (21%), Midwest (25%), South (31%), and West (22%)
• Over half of all clinics (51%) had to clinicians/staff who were unable to work because of the pandemic. Clinicians were unable to provide care because they were quarantined (23%), part of a high-risk group (21%), sick with possible COVID-19 (20%), subject to COVID-19 related travel restrictions (15%, re-assigned to other COVID-19 related responsibilities (13%), or had childcare (12%) or other caregiving (5%) responsibilities
• Non-clinical staff reported being unable to work because of childcare responsibilities (50%), being sick with possible COVID-19 (45%), quarantine (44%), belonging to a high-risk group (33%) and having caregiving responsibilities (18%). 40% of respondents reported that they had to cancel or postpone appointments because patients had COVID-19 symptoms or had been exposed, and 13% had patients who were subject to COVID-related restrictions on travel
• Most clinics had had to cancel or postpone some clinical services, including gynecologic services (59%), contraceptive visits (55%) and STI tests (45%)
• More than 60% of respondents in the Northeast, Midwest and West reported that their state had declared abortion essential, compared to just 14% in the South. 38% of clinics had canceled or postponed first-trimester aspiration abortions, 27% second-trimester or later abortions and 25% medication abortions
• The proportion of clinics that had canceled or postponed first-trimester aspiration abortions was highest in the South (66%) and Midwest (38%), compared to 9% Northeast and 26% in the West
• 19% reported having to close their clinic temporarily, especially in the Midwest (21%) and South (35%)
Roland et al. [41] Quantitative; Longitudinal National Health Data System insurance claims of all pharmacy dispensations of residents of France between January 1, 2018–June 7, 2018, 2019 and 2020 COVID-19 Contraceptive utilization • Oral contraceptive dispensation increased during the first two weeks of lockdown by 47% and 16%, but thereafter decreased
• Overall, the number of prescriptions of oral contraceptives, emergency contraception, intrauterine devices (IUDs), and ovulation indicators decreased over the course of the 8-week lockdown by 46,603; 38, 429; 21,250; and 44,510 respectively
• In the 4-weeks post-lockdown, prescriptions continued to decrease, and the number of prescriptions of oral contraceptives, emergency contraception, intrauterine devices (IUDs), and ovulation indicators decreased by 70,021; 11,226; 1,807; and 17,431, respectively
Stifani et al. [40] Quantitative; Cross-sectional Family planning providers in the US (n = 172) COVID-19 Access to contraceptives • 91% of surveyed providers provided telemedicine services during the COVID-19 pandemic. About half of providers (53%) referred less than a quarter of telemedicine patients to in-person visits, with the most common reason being LARC insertion (53%)
• Almost all providers reported that the following services were available to their patients even at the height of the COVID-19 pandemic: LARC insertions (88%); LARC removals (90%); depot-medroxyprogesterone acetate injections (88%), and visits for other contraception-related issues (85%)
• Most providers (80%) agreed that telemedicine is an effective way to conduct contraceptive counseling, and that the role of telemedicine for contraceptive counseling should be expanded after the pandemic (84%)
Tao et al. [52] Quantitative; Retrospective cohort All patients presenting for care at a major STI clinic in Rhode Island between September 1, 2019—May 13, 2020 (n = 2347) COVID-19 Service provision • Compared to pre-COVID-19, there was a 55% (95% CI 45–63%; p < 0.001) reduction in the total number of STI clinic visits overall during COVID-19 lockdowns. More specifically, the number of screening visits were reduced by 60% (95% CI 46–71%; p < 0.001), provider visits by 50% (95% CI 35–62%; p < 0.001) and treatment visits by 62% (95% CI 40–75%; p < 0.001, when compared with the pre-COVID-19
• After lockdowns eased, there was an 84% (95% CI 68–88%, p < 0.001) reduction in total clinic visits, 100% reduction in screening visits, 68% (95% CI 56–77%, p < 0.001) reduction in provider visits, and 77% (95% CI 61–86%, p < 0.001) reduction in treatment visits compared to pre-COVID-19 phase
Tschann et al. [33] Quantitative; Longitudinal Health facilities that provide medication abortion across the US between April -October 2020 (n = 74) COVID-19 Abortion • In February 2020, 71% required 2 or more patient visits for a medication abortion. By April 2020, 35% reported reducing the total number of in-person visits associated with a medication abortion, and as of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits
White et al. [36] Quantitative; Retrospective cohort Abortion clinics in Texas (n = 18) COVID-19 Abortion • The number of abortions decreased by 38.0% (95% CI − 40.8% to − 35.1%) in April 2020, compared to April 2019
• The number of medication abortions increased accounting for 39% of all abortions in April 2019 to 80% in April 2020
• Texas residents receiving care at out-of-state facilities increased from 157 in February 2020 to 947 in April 2020
• After the COVID-19 related executive order was lifted in May 2020, the number of procedural abortions increased by 82.6% (95% CI 46.7%-127.4%)
Yuksel et al. [44] Quantitative; Cross-sectional Married patients who were older than 18 years and not menopausal (n = 58) in Turkey COVID-19 Sexual behavior • Sexual desire and frequency of intercourse significantly increased during the COVID‐19 pandemic, whereas quality of sexual life significantly decreased
• Compared with 6–12 months, the pandemic is associated with increased sexual intercourse (2.4% vs 1.9%), decreased desire for pregnancy (32.7% vs 5.1%), decreased female contraceptive use (24% vs 10%), increased menstrual disorders (27.6% vs 12.1%) and lower FSFI (sexual function) scores (20.5 vs 17.6)
  1. COVID-19 coronavirus disease 2019, STI sexually transmitted infection; FSFI Female Sexual Functioning Index; SARC short-acting reversable contraceptive; LARC long-acting reversible contraceptive