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Fertility and contraception among women of reproductive age following a disaster: a scoping review
Reproductive Health volume 19, Article number: 147 (2022)
The prevalence and severity of disasters triggered by natural hazards has increased over the last 20 years. Women of reproductive age may encounter unique reproductive health challenges following a disaster. In this scoping review we identify gaps in literature to inform future research and search for potential associations between disasters by natural hazards and post-disaster fertility and contraception among women of reproductive age.
Medline (OVID), Embase (OVID), PsycInfo (OVID), CINAHL (Ebsco), Scopus, Environmental Science Collection (ProQuest Central), and Sociological Abstracts (ProQuest Central) were searched for articles published from 1980 through March 3, 2022 in English or Spanish language. Search terms were related to fertility, contraception, and disasters. We included original research that described a discrete natural hazard exposure, a population of women of reproductive age (15–49 years), and outcomes of fertility or contraception use or access, with pre- and post-disaster measures.
Among 9788 citations, after initial exclusion 5121 remained for title and abstract review. One hundred and eighteen citations underwent full-text review and 26 articles met the inclusion criteria. Following critical appraisal, 20 articles were included in this review. Eighteen articles described outcomes related to fertility, five articles described contraception access, and three articles described contraception use.
Clearly defined exposure measures, robust analyses, and methodical post-disaster assessment periods, may address the current gaps within disaster research on fertility and contraception among women of reproductive age. Consistent patterns in fertility following a disaster triggered by natural hazards were not identified between or within disaster types. Studies that assessed contraception found no change in use, while some studies found a decrease in contraceptive access overall.
Plain English Summary
Natural disasters are becoming more frequent and severe. In this scoping review, we explore published literature from 1980 to March 3, 2022 on the impacts of natural disasters for women of reproductive age, 15–49 years. We assess gaps in the literature and search for possible trends in fertility and contraception use and access after a disaster. A targeted literature search in multiple databases resulted in 9,788 citations. Systematic methods were used to identify relevant articles for this scoping review. Of the 20 articles included, we identify several gaps. Future research may benefit from improved disaster exposure measurements, comparing exposed samples to a similar unexposed sample, and measuring outcomes at purposeful post-disaster time points. No consistent patterns were identified among studies assessing post-disaster fertility. Contraception use did not appear to change following disasters, while contraception access generally decreased.
Disasters can be triggered by natural hazards such as earthquakes, hurricanes, floods, tsunamis, and wildfires threatening substantial damage to property and human health. The frequency and severity of these types of disasters have increased over the last 20 years, affecting more than three billion people worldwide . While challenges for whole communities may vary by disaster hazard type and severity, women of reproductive age (WRA), 15–49 years, are at unique risk for negative impacts to their reproductive health following a disaster .
A 2012 systematic literature review  examined reproductive health outcomes among WRA following disasters in the United States and identified three studies describing fertility after a natural hazard disaster. Results were mixed; disaster exposure was associated with increased fertility in one study  and decreased fertility in two studies [4, 5]. Additional studies have since been published using various data sources and report changes in fertility associated with disasters [6,7,8]. Factors affecting fertility after a disaster are unclear, but may include increased interpersonal conflict, uncertain economic conditions, changes in pregnancy desires and plans, as well as changes in access to and use of contraception [3, 6, 8, 9]. After a disaster, changes in contraception use may vary based on accessibility, supply, and demand [7, 10]. For example, changes to contraception access may result in couples changing to a less effective method and lead to unintended pregnancies . Contraception use may be altered if fiscal and economic resources are impacted following the disaster, and post-disaster stress may alter contraceptive use adherence, decreasing efficacy [3, 12]. During emergency relief in the post-disaster period, the prioritization of contraceptives may be lacking [12, 13]. Understanding fertility and contraception use and access in the post-disaster setting can inform emergency preparedness and response planning and better support people in their reproductive life plans following a disaster.
Our scoping review updates and expands upon the search criteria used by Zotti et al.  in their 2012 review. We summarize available literature regarding the impacts of disaster caused by a natural hazard for WRA on fertility and contraception use and access. We identified gaps in the literature to inform future research and searched for potential associations between exposure to disasters and the outcomes of fertility and contraception use and access.
This review was developed according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses Scoping Review extension checklist . Preliminary searches showed no evidence of literature available on these topics in the context of natural hazard disasters prior to 1980. Medline (OVID), Embase (OVID), PsycInfo (OVID), CINAHL (Ebsco), Scopus, Environmental Science Collection (ProQuest Central), and Sociological Abstracts (ProQuest Central) were systematically searched for articles published from 1980 through March 3, 2022 in English or Spanish. Search terms were related to fertility, contraception, and disasters (Table 1). Citations of all articles selected for study inclusion were reviewed for additional relevant articles.
An initial review removed duplicate citations and citations with a non-human population, an infectious disease outbreak, or an exposure of humanitarian crisis related to conflict. Two blinded reviewers screened the title and abstract of remaining citations using RAYYAN software (Qatar Computing Research Institute) . Discordant review determinations were reconciled by a third reviewer. Citations meeting the following inclusion criteria were included for full-text review: non-review article and had an exposure of a disaster or extreme weather event, a population of WRA, and outcomes related to pregnancy or contraception.
During full-text review, articles were assessed for: an exposure limited to disasters describing a discrete event, excluding periods of extreme weather (e.g., drought); a population of WRA; and outcomes related to fertility and contraception use or access. Articles published in journals as original research were included while other publication types including abstracts, commentaries, conference proceedings, dissertations, opinion pieces, and reviews were excluded. Studies without pre- and post-disaster measurements were excluded, as this review aimed to describe patterns of association between the disaster and outcomes.
Data were abstracted using a Microsoft Access 2016 form created for this scoping review (Additional file 1). Full-text review and data abstraction methods were standardized across reviewers using a 10% sample of randomly selected citations, which underwent full-text review and group discussion by the entire author group. Full-text review and data abstraction were performed in duplicate. Discrepancies between the two full-text reviewers were resolved by the entire author group. The study design for all citations undergoing full-text review was recorded, along with a decision to include or exclude. Exclusion reason was assigned using the following hierarchy: wrong exposure, wrong population, wrong publication type, wrong outcome, or wrong study design. The following information was abstracted from included articles: location of disaster, study population, sample size, length of follow-up, type of disaster (e.g., earthquake, hurricane, flooding, tsunami), fertility outcomes (e.g., birth rate, total fertility rate, monthly hospital births), and contraception outcomes (i.e., access and use). When birth and population counts were available, birth rates per 1000 population per year were calculated.
All included articles underwent a critical appraisal by two reviewers using the National Heart, Lung, and Blood Institute quality assessment tool for observational cohort and cross-sectional studies . Definitions for quality ratings of good, fair, or poor were agreed upon by all authors prior to conducting critical appraisal. Articles deemed poor quality were excluded from further analysis (Additional file 2).
Database searches yielded 9788 citations (Fig. 1). After an initial exclusion, 5121 citations remained for title and abstract review. We completed full-text review on 118 citations. Ninety-two citations were further excluded. Thirty-seven citations were excluded due to wrong exposure (e.g., the study exposure was not a discrete disaster of natural hazard). Four citations were excluded due to wrong population (e.g., the study population was not WRA). Fourteen citations were excluded due to wrong publication type, and 31 citations were excluded due to wrong outcome (e.g., the studies did not assess fertility or contraception). Five citations did not describe pre- and post-disaster measurements and were therefore excluded. One citation was excluded for duplicate information as it described a sub-set of data included in another report . Twenty-six articles remained for critical appraisal. Six articles received a quality rating of poor, leaving 20 articles for inclusion in this scoping review.
Among the 20 articles included in this scoping review, the studies included exposure to disasters (earthquake, n = 10; hurricanes, n = 7; tsunami, n = 2; and flood, n = 1) occurring between 1989 and 2012. The number of years from disaster event occurrence to study publication varied from one to 19 years. Multiple disasters were described by two articles; the 2004 Indian Ocean Tsunami [8, 18], hurricanes occurring in Florida in 2004 [19, 20], Hurricane Katrina in 2005 [5, 6], the 2010 Chile Earthquake [21, 22], and the 2011 Great East Japan Earthquake [23, 24]. Ten studies used a cohort study design, eight studies performed an analysis of longitudinal administrative data, and two used mixed methods including interview. Thirteen articles described a disaster occurring outside of the United States (i.e., Chile, China, Haiti, India, Indonesia, Iran, Japan, Nicaragua) and seven described exposure to a disaster occurring within the United States (i.e., Alabama, Florida, Louisiana, Mississippi, North Dakota, South Carolina). Exposure to disaster events were generally defined by the affected geographical area, and in some cases measured by rainfall, wind speed, storm advisories, and federal disaster declarations. Hurricane exposure was categorized by wind speed, distance from storm path, storm advisories and warnings, and Federal Emergency Management Agency disaster declarations. Grabich et al.  compared results using two exposure measures, wind speed and storm path, and came to similar conclusions. Evans et al.  used storm advisories and warnings, suggesting behaviors change when storm projections are released, regardless of the storm’s actual path. Eighteen of the included articles described outcomes related to fertility (e.g., birth count, birth rate, fertility rate), five described outcomes related to contraception use or access (e.g., report of contraception use, report of unmet need for contraception, access to condoms, and change in contraceptive method), and three described outcomes related to both fertility and contraception use or access (Table 2).
Among the 18 articles describing outcomes related to fertility, five report an increase in the birth rate or fertility rate between the pre- and post-disaster study periods [3, 8, 18, 26, 27], nine reported a decrease [4, 5, 7, 9, 21,22,23,24, 28], four reported varied associations [5, 6, 19, 25], and two reported no change [20, 28]. The association varied by disaster type. Eight articles described fertility in the context of earthquakes. Most (n = 5) reported a decrease, while two described an increase, and one reported no change. In the post-disaster period, Scapini et al.  observed an overall decrease in birth rate compared to the pre-disaster period. However, in the post-disaster period, compared to the unaffected regions, the affected regions showed an increase in birth rate . The association between fertility and hurricanes was assessed in seven articles; one reported an increase, one reported a decrease, four reported varied outcomes, and one reported no association. Both articles with an exposure of tsunami described an increase in fertility, while the article describing a flood noted a decrease. Results of the seven articles describing fertility within the United States did not show a consistent association.
Five studies described contraception access associated with exposure to an earthquake occurring from 2006 to 2012; three of these studies also described contraceptive use. Contraceptive access generally decreased. Bahmanjanbeh et al.  noted a change in annual contraception coverage from 66.9% in the year before to 64.9% in the year after the disaster. Behrman et al.  reported a statistically significant unmet need for contraceptives in the post-disaster period, while Djafri et al.  described a 20% decline in client’s self-reported perceptions of contraceptive access in the one to three months after the disaster. Hapsari et al.  reported 11% of pre-disaster contraceptive users had a difficult time obtaining contraceptives in the post-disaster period, while Oyarzo et al.  described no change in the post-disaster period. Among the three articles describing contraceptive use, two reported no change [11, 27] and one reported 3% of study participants stopped using contraception after the disaster .
In this scoping review, findings across studies varied and consistent trends in fertility following a disaster were not identified between or within disaster types. Generally, no change in contraceptive use was observed, while a general decrease in contraception access was identified. Following a disaster, infrastructure may be damaged, fuel or transportation may be unavailable, medical supplies may be depleted, and trained medical staff may be unavailable to offer provider-administered contraceptives making access to contraception difficult . Results from included studies may not be comparable due to heterogeneity in study designs. This includes differences in measurement of exposure, data analysis, and study time frame relative to the disaster. Variation in results may also be attributable to differences in local, regional, and national healthcare delivery practices, and potential cultural and geographical differences in attitudes towards fertility and contraception between study settings. Future use of established reporting checklists, such as the Strengthening and Reporting of Observational Studies in Epidemiology  are encouraged to promote transparency in reporting and will aid in future comparisons among articles.
The measure of exposure within each disaster type was varied and future research may benefit from detailed description of how disaster exposure was measured. Disaster exposure can include the actual disaster, in addition to the threat of a disaster . Additionally, consideration should be given to direct and residual disaster exposure. Therefore, multiple exposure measures can be beneficial to understanding a disaster’s impact. Exposure measures that accurately capture the populations most impacted by a disaster are needed. The misclassification of exposure measures and underreporting of disaster exposure can dampen observed associations or suggest spurious associations.
Great heterogeneity of data analysis was observed among the studies included in this review. Prediction modeling may require different parameters or alternative covariates by region. While results may not be generalizable due to regional differences, the development and application of consistent data analysis methods for disaster research may improve the comparability of studies. Research describing fertility is enhanced when potential socio-demographic events and trends are accounted for, such as pre-disaster fertility decline. Disregarding the seasonality of births may mask subtle changes by month as seen in Hamamatsu et al. . International evidence suggests fertility declines with an economic recession, therefore changes in the economy and migratory patterns can influence reproductive health outcomes and are important factors to consider in data analysis and interpretation [6, 24, 25]. For example, in the models developed by Evans et al.  standard population growth and county fixed effects were controlled for. Multiple authors used difference-in-differences models to control for county level measures and possible unmeasured ecological bias [11, 19, 21, 26]. Grabich et al.  compared difference-in-differences models and generalized linear models, and the resulting associations differed.
In this review, multiple studies used population data and did not have a contemporaneous non-disaster affected comparison group. Without comparing outcomes between similar exposed and unexposed populations we cannot determine if reported changes are meaningfully related to the disaster. Future research that accounts for confounders, clearly describes methodological challenges, and includes comparison groups may address these identified gaps in the literature.
Study time frames
An appropriate post-disaster time frame is crucial for the interpretation of a study’s findings. Measuring outcomes soon after the disaster may capture immediate changes, but may not inform long-term, population level changes in fertility . Oyarzo et al.  described birth admissions in the year prior to and 0–10 months after an earthquake. A majority of the post-disaster births were conceived prior to the disaster, therefore this short post-disaster follow-up period limits interpretation of findings for women with disaster exposure before or early in pregnancy . There are analytic complexities related to disaster exposure and the timing of pregnancy (i.e., pre-pregnancy, conception, or in utero exposure) . Therefore, disaster researchers, particularly those describing fertility, may consider multiple post-disaster assessment periods. In contrast, long-term post-disaster assessment periods may not be necessary in contraceptive use and access research. Among included articles, contraception use was determined by availability and access [12, 27]. Extending contraceptive use assessment period slightly beyond the return of contraceptive services to pre-disaster coverage may be most informative. Determining the short- and long-term changes in reproductive health following a disaster may help inform preparedness, response, and recovery interventions that better support people’s reproductive life plans.
Overall challenges in disaster research
This scoping review included studies on natural hazard disasters worldwide to better understand the available research on the impacts to fertility and contraception. The field of disaster research is challenging due to the aforementioned heterogeneity in study design. Additionally, variations in disaster type, location, and available resources can make comparative studies difficult. The mechanisms of association between reproductive health outcomes and disasters have been difficult to determine [2, 19, 30]. Disaster literature is primarily comprised of single case studies . Post-disaster research can be methodologically challenging to conduct. Studies that limit the sample to individuals in an affected geographic area may not capture outcomes among persons who are displaced due to pre-disaster evacuation or post-disaster migration [6, 11]. Data collection can be logistically difficult in a post-disaster setting and resources may be limited; delaying the timeliness of findings to inform policies and interventions. Analyses using surveillance or administrative data not originally designed for post-disaster research may be subject to unmeasured confounding and bias . Articles excluded from this review for poor quality lacked clear descriptions or had poor sampling methods (Additional file 2). A convenience sample and cross-sectional study may allow for the rapid collection of data, however generalized conclusions and the direction of association become difficult to ascertain. The association between disasters and fertility is likely multifactorial, and many articles included in this review offer theoretical models to explain changes in fertility, and possibly contraception use. Examples include economic security, attachment theory, stress theory, replacement theory, and risk insurance hypothesis [3, 7, 11, 25].
Additionally, consideration may be given to the benefits and limitations of individual and aggregate level data. Individual level data may be more useful for studying behavioral changes, while aggregate data can be used to identify trends. Aggregate data are more readily available and allow for larger sample sizes but can result in exposure misclassification and suggest null results when meaningful differences are present [3, 25].
There are several limitations to this scoping review. Multiple studies assessed the same disaster and outcome, so study populations may have overlapped. Methods for measuring reproductive health outcomes following a disaster were not standardized. For example, across studies measuring fertility, fertility was reported as: birth rate per 1000 population, birth rate per 1000 population per month, fertility rate per 1000 women 15–44, total fertility rate, and marriage fertility rate. Few studies included unexposed comparison groups, so it is unclear if changes observed were a result of the disaster or other factors. Studies on contraception were limited by small sample sizes and post-disaster follow-up was limited to individuals using contraceptives before the disaster.
This scoping review describes fertility and contraception among WRA following a disaster of natural hazards between 1989 and 2012. Among 20 articles included, variations in fertility trends and contraception use and access were observed. Based on the heterogeneity of study designs, disaster type, location, and available resources across studies the direction and magnitude of association between disasters of natural hazards and fertility remains unclear. The few studies that assessed contraception use found no change, and studies assessing contraception access generally found an overall decrease in access. This scoping review illustrates the need for more standardized research to understand the potential impacts of disasters triggered by natural hazards on fertility and contraception among WRA. Future research may benefit from clearly defined exposure measures, more robust analyses, including the exploration of factors that may influence observed associations, comparing the exposed population to a similar unexposed population, and assessing outcomes at methodical post-disaster time points.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.
Women of reproductive age
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The authors would like to acknowledge Joanna Taliano, MS, MLS for her assistance with the literature search.
This study was performed as regular work of the Centers for Disease Control and Prevention. It used no additional funding. The authors do not have any financial involvement that could represent potential conflicts of interest.
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Strid, P., Snead, M.C., Galang, R.R. et al. Fertility and contraception among women of reproductive age following a disaster: a scoping review. Reprod Health 19, 147 (2022). https://doi.org/10.1186/s12978-022-01436-4