Impact of the COVID-19 pandemic on women’s contraceptive use: a mixed-methods study in South Africa and Zambia

Ethics

All research participants gave written and verbal informed consent to participate in various aspects of the study. The main Contraceptive Use Beyond ECHO (CUBE) study, additional survey module, and in-depth interviews (IDIs) were approved by FHI 360’s Protection of Human Subjects Committee, the University of the Witwatersrand Human Research Ethics Committee (HREC), the University of North Carolina at Chapel Hill Institutional Review Board, and the University of Zambia Biomedical Research Ethics Committee (UNZABREC).

Country contexts

In 2020 and 2021, COVID-19 was spreading globally, including across the African continent. South Africa had the highest number of documented COVID-19 cases in Africa at the time and roll-out of testing and vaccine availability, was slow the true impact may not yet be known in many countries. The first cases of COVID-19 were reported in South Africa on 5^th March 2020¹⁴ and in Zambia on 18^th March 2020¹⁵. The government of Zambia enacted a series of public health measures on 13^th March 2020, and the government of South Africa declared a National State of Disaster on 15^th March 2020, implementing stringent lockdown measures designed to control the spread of COVID-19. As of 10^th March 2023, South Africa had reported over 4 million cases and 102,595 deaths, while Zambia had reported 343,135 cases and 4,057 deaths¹⁶.

Study design

To better understand the experiences of accessing contraceptive methods within the context of COVID-19 lockdowns, we conducted a mixed methods study consisting of a survey module added to the CUBE study and IDIs with participants, FP providers, and other key informants involved with FP service provision. The methods for the CUBE have been described elsewhere¹⁷. In brief, the CUBE study enrolled a subset of South African and Zambian women who had previously participated in the Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial, had agreed to be re-contacted, were using one of three contraceptive methods at ECHO trial exit, and consented to participate¹⁸. These women were recruited to participate in a prospective longitudinal study (CUBE) after their exit from ECHO to explore contraceptive use dynamics and access to LARC removal services. The ECHO trial participants received either intramuscular depot medroxyprogesterone acetate (DMPA-IM), a levonorgestrel (LNG) implant, or a copper IUD for the 18-month ECHO trial period. Participants could switch or discontinue contraceptive methods both during the study period and at the time of study completion. For CUBE, participants were recruited from three of the 12 ECHO sites: two in the KwaZulu-Natal province in South Africa (an urban site situated in eThekwini District and a peri-urban site in uMgungundlovu District) and one in Lusaka, Zambia. Phone surveys were conducted with eligible women every six months for a total of four surveys over 24 months (at 6, 12, 18, and 24 months after ECHO exit). Since the COVID-19 survey module was initiated during the 24-month follow-up period, a portion of South African participants (less than 20%) were asked during their regularly scheduled 24-month call if they would be willing to participate in an additional module of questions related to COVID-19 during the current call or in a subsequent call. Most participants had already completed their 24-month survey and were re-contacted by phone and asked if they would be willing to complete the COVID-19 survey module. Surveys were conducted in South Africa between September 2020 and March 2021 and in Zambia from November 2020 to April 2021.

For the IDIs, interviews were conducted with a subset of CUBE participants along with FP providers and other key informants. Participant IDIs were conducted between September and November 2020 in South Africa and between April and June 2021 in Zambia. Key informant IDIs were conducted between August and October 2020 in South Africa and November 2020 and January 2021 in Zambia.

Study population and sample

The main CUBE study enrolled 674 participants. For the COVID-19 survey module we sought to contact everyone who had completed the CUBE 18-month survey (n=626). Participants needed access to a phone to participate in both the CUBE study and the COVID-19 module. Written informed consent was obtained at initial CUBE enrollment and verbal consent was given to participate in the COVID-19 module. While the original eligibility criteria for the CUBE study was that participants had to be using one of the three ECHO contraceptive methods at enrollment (three-month injectable, LNG implant, or Copper IUD), there was no such restriction for participation in the COVID-19 survey module since participants could have switched from or discontinued the method they were using at CUBE enrollment. We were able to contact, consent, and interview 537 respondents for the COVID-19 survey.

A total of 39 CUBE participants (20 in South Africa and 19 in Zambia) and 36 key informants (16 in South Africa and 20 in Zambia) participated in the IDIs. IDI participants were purposefully sampled from the following four categories with an attempt to interview participants using all three contraceptive methods in each group (as applicable): 1) switched to a different method at ECHO exit; 2) discontinued their ECHO method while in CUBE; 3) continued their ECHO method into CUBE (and still using at 18 months); and 4) reported challenges getting LARC removal. For the key informant interviews, each country team created a list of FP providers, policy and program managers, and staff from FP commodity distribution centers in the public and NGO sectors, as well as other relevant stakeholders (e.g., NGOs, community advisory board (CAB) members, community advocates such as those representing sex workers, HIV-positive individuals, and youth groups). Key informant participants were purposively selected to represent local, district, provincial, and national levels.

Data collection and analysis

Phone surveys. Research assistants (RAs) called eligible women participating in the CUBE study by phone either for their regularly scheduled 24-month follow-up survey or, for those who had already completed their 24-month survey, an additional survey call. RAs described the additional COVID-19 module and obtained verbal informed consent to participate. Due to social distancing restrictions, informed consent for the additional module of COVID-19 questions was conducted over the phone. Study staff confirmed with the participant that they were free to talk and in an area that provided privacy, which was particularly important as partners may have been more likely to be home due to restrictions of movement related to the pandemic. If requested by the participant, information on COVID-19 and/or related services was provided, in line with South African Department of Health and Zambian Ministry of Health guidelines. At the end of the interviews, study staff in South Africa gave women the phone number for the South African COVID-19 hotline and staff in Zambia offered to send women a text message with all relevant contact information to get COVID-19 related updates.

The phone surveys were conducted in isiZulu or English in South Africa and Bemba, Chinyanja or English in Zambia and lasted between 5 to 114 minutes, with a median length of 20 minutes. Respondents were reimbursed in mobile money or phone credit which was sent to the mobile device of participants’ choice to offset expenditures related to use of their phones. RAs in each country entered participant responses into an online, password-protected RedCap database pre-programmed with response options to limit errors in data entry¹⁹. Research staff in both countries and a research analyst at FHI 360, an international non-governmental organization, conducted weekly data quality checks. Any errors or inconsistencies were highlighted, and participants were recontacted as needed to correct responses.

In-depth interviews. Trained female interviewers conducted the IDIs face-to-face, over the phone, or via a web-based platform such as Zoom depending on participant’s preference, distance from the study site, and social distancing/quarantine guidelines at the time of the interview. IDIs were conducted in isiZulu or English in South Africa and Bemba, Chinyanja, or English in Zambia and lasted approximately 20 and 45 minutes for CUBE participants and between 10 and 55 minutes for key informants. CUBE participants and key informants were reimbursed for their participation, with the exception of Department of Health staff in South Africa, in line with the Department of Health policy.

During the IDIs, CUBE participants were asked about issues associated with obtaining their contraceptive method of choice or any method; challenges in accessing FP services; method stock-out; gaps in use; method switching and discontinuation; and LARC removal. Key informant IDIs focused on contraceptive supply chain and procurement issues affecting method availability; effects of COVID-19 on provision of specific methods; and staffing and operational issues with FP service delivery including staff shortages, staff morale, safety concerns, and effects of social distancing. All IDIs were recorded and subsequently transcribed. If conducted in a language other than English, interviews were translated and transcribed simultaneously into English using a transcription protocol²⁰.

Survey analysis. We linked each woman’s COVID-19 module to her full CUBE survey data (6, 12, 18 and 24-month survey responses), as well as additional demographic information reported in ECHO. We produced a descriptive summary of participant sociodemographic characteristics collected from ECHO, the 24-month CUBE survey, and the COVID-19 survey, as applicable. We compared sociodemographic characteristics between those who completed the COVID-19 module and those who were lost to follow-up. Using the dates of 24-month survey and COVID-19 module completion, we confirmed the contraceptive method that the participant was using before COVID-19 restrictions in their respective country. To assess the first two study objectives related to the effect of COVID-19 on contraception access and use and LARC users’ desires and ability to remove their method, we calculated descriptive statistics overall and by country. Summary statistics are provided, including percentages for categorical variables, and means/medians, standard deviations, and ranges for continuous variables.

IDI analysis. We used applied thematic analysis to analyze data from the IDIs²¹. A codebook was developed to structurally and thematically code the transcripts using NVivo 12²². Initially three analysts each coded the same transcript and then met to assess inter-coder reliability, discuss coding discrepancies, and to revise the codebook with emerging themes and to refine code definitions and inclusion/exclusion criteria. This process was repeated until inter-coder agreement was reached. Thereafter, analysts proceeded to code all the transcripts with frequent meetings held to ensure coding decisions were made jointly. After all transcripts were coded, coding reports were generated through NVivo 12, and four analysts worked on synthesizing data from each coding report by conducting inductive thematic analysis to identify major trends and thematic domains.

IDI results

Impact of COVID-19 on access to reproductive health services. Of the 39 CUBE participants interviewed, 22 said they accessed reproductive healthcare services, including contraception and HIV/STI testing and treatment, after COVID-19 restrictions came into place. Of these, five South African participants said that they encountered challenges in accessing services, while no participant in Zambia reported challenges. As this South African participant explains, challenges included long queues at clinics and contraceptive services being deprioritized compared with other conditions:

Other challenges mentioned by South African participants (including those who did and did not attempt to access services) included limited capacity on public transport, the need to carry appointment cards or referral letters to travel during lockdown, and stock-outs of some contraceptives.

Fear of contracting COVID-19 was also mentioned by participants and led at least three women in South Africa to avoid visiting a facility for services. In general, more South African participants reported fear of infection at a clinic compared to Zambian participants; however, the concern was raised in both countries. Fear of contracting COVID-19 led this South African woman to discontinue contraceptive use:

Providers and other key informants in South Africa mentioned the same challenges that women described in accessing reproductive health services. In addition, providers and key informants also reported other challenges, including clients not able to get referral letters to other clinics because their usual clinic was closed, women desiring pregnancy termination but unable to access services, and method users finding it difficult to leave the house to get contraceptives during the lockdown because their partners did not know they were using contraceptives.

In both South Africa and Zambia, providers and key informants talked about the rise in unplanned pregnancies during lockdown. A key informant in Zambia shared how it has been particularly challenging for adolescents:

Impact of COVID-19 on family planning use. When COVID-19 restrictions were implemented in March 2020, 29 of the 39 CUBE participants who participated in IDIs were using a method, most commonly injectables, followed by implants, IUDs, condoms, and oral contraceptive pills. Those who were not using any contraceptive said that they were pregnant or that their partner was not staying with them during the lockdown. Six of the 29 method users (four in South Africa and two in Zambia) said they had switched or discontinued use after COVID-19 restrictions were implemented. Of the four South African participants, three said that they were not able to get their method because facilities were either closed or had no stock of their preferred method, or that they were afraid of going to the clinic and contracting COVID-19. The fourth switched methods due to menstrual side effects. The two participants from Zambia switched from their implants to other methods for personal reasons not influenced by the pandemic.

Of the 23 CUBE participants who had not switched methods since the start of the pandemic, about half (n=12) were using LARC. These users, especially in South Africa, said that they were glad they were on a long-acting method, so they did not need to visit a clinic. Several FP providers in South Africa also reported that women asked to switch to a LARC method during the pandemic, and others reported that women were asking for tubal ligations so that they would not have to go to a clinic, as this provider explains:

Overall, FP providers and other key informants described more negative impacts on FP use in South Africa compared to Zambia. Most Zambian key informants reported that services had largely not been interrupted and that women were not discontinuing use during the pandemic, some surmising that women did not want to become pregnant during the pandemic.

When CUBE participants were asked if COVID-19 had influenced whether they wanted to get pregnant in the next one to two years, seven out of 38 participants (two in South Africa and five in Zambia) said that COVID-19 had changed their plans about becoming pregnant. All seven said that the pandemic period was not the time to have a child because of the risk of the child getting infected with COVID-19, and that they would prefer to wait to become pregnant, as this Zambian participant explained:

Several providers/key informants in South Africa and a few in Zambia reported that they feared an increase in unintended pregnancies, having already seen a rise in antenatal care since the start of the pandemic, as this Zambian provider shared:

Impact of COVID-19 on contraceptive supplies and provision of family planning services. Providers and other key informants in both countries reported contraceptive stock-outs and other procurement issues as major challenges during the pandemic. Implants and injectables (both two-month and three-month) were the most commonly mentioned methods with procurement issues, but some also reported stock-outs for IUDs and pills. Some key informants said that procurement challenges were attributed to reduced transportation during lockdown, reduced patient flow because of restrictions, funding limitations, and competing priorities posed by the pandemic. In response to not having desired methods available, key informants noted that patients were often given another method, while less commonly noting that clients may be referred elsewhere or made to wait until their method was back in stock. A community advocate in South Africa explained how the pandemic affected method availability:

Many South African key informants also reported staff shortages, while only a few reported the same in Zambia. South African interviews described shortages due to infections among staff, time out for frequent testing, and the need to take on shifts in the COVID-19 wards. A few facilities addressed social distancing requirements by rotating staff on alternate days. Staff shortages led to the remaining staff feeling overwhelmed and increased client wait times. LARC services were sometimes not offered if trained staff were not present. Because of staff shortages in South Africa, one respondent said that they had to supplement services by bringing in Cuban doctors and referring patients to other facilities (usually in the private sector).

Providers and other key informants also reported that staff morale dropped because of the pandemic. In both countries many said staff were afraid of getting infected, with the fear causing further demoralization in their work. They also felt anxious when clients did not comply with safety guidelines, such as wearing masks:

Others felt that morale was low because providers were tired from a high influx of patients, staff shortages, having to self-isolate when infected, and practicing safe distancing at work which had been difficult as they could not shake hands, pray together, or give hugs to comfort patients/co-workers when they received bad news (e.g., the death of a family member).

Impact of COVID-19 on LARC users’ desires and ability to remove their method. A few providers reported that demand for LARC removal decreased during the pandemic, with a few surmising that women were putting up with side effects longer (rather than seeking removal) because of the pandemic-related restrictions as this provider reported:

Others, however, said they had not seen a change in requests for either LARC removal or insertion. One provider in South Africa described greater challenges to LARC service provision in the public sector compared with the private sector due to pandemic lockdown restrictions.

Limitations

One of the limitations of this study is that it constitutes a unique sample. Due to their participation in the ECHO and the CUBE studies, participants likely had more knowledge about contraceptive methods and where to obtain services. In addition, their use of LARC methods was much higher (40–45% of the sample across both countries) than the general population of women of reproductive age in either South Africa or Zambia. However, such a large number of LARC users allowed us to explore the impact of COVID-19 on method switching and discontinuation, specifically the ability to access LARC removal. Since only women were enrolled as participants in the original ECHO and CUBE study samples, we are unable to comment on how COVID-19 may have impacted men’s contraceptive use patterns. In addition, the participants were from ECHO study sites in urban and peri-urban areas. It is possible that the impact of the COVID-19 pandemic may have been more severe in rural areas.

The surveys and interviews described here were completed at slightly different points during the pandemic: between August 2020-March 2021 in South Africa and November 2020-June 2021 in Zambia. These time periods were after the initial wave of cases in Africa (particularly South Africa) and during the summer in the Southern hemisphere¹⁶, when cases were likely lower overall. The experiences shared by respondents in this study may be subject to some recall bias and they may not reflect the situation as the pandemic progressed. Finally, the impact of the restrictions on family planning services in both countries was likely dynamic and possibly changed over time as the pandemic persisted.