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ORIGINAL ARTICLE
Open Access

Women’s Experiences With Family Planning Under COVID-19: A Cross-Sectional, Interactive Voice Response Survey in Malawi, Nepal, Niger, and Uganda

Aurélie Brunie, Gwyneth Austin, Jamie Arkin, Samantha Archie, Dinah Amongin, Rawlance Ndejjo, Saujanya Acharya, Basant Thapa, Sarah Brittingham, Grace McLain, Philip Mkandawire, Maimouna Hallidou Doudou and Ndola Prata
Global Health: Science and Practice August 2022, 10(4):e2200063; https://doi.org/10.9745/GHSP-D-22-00063
Aurélie Brunie
aFHI 360, Washington DC, USA.
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  • For correspondence: ABrunie@fhi360.org
Gwyneth Austin
bFHI 360, Durham, NC, USA.
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Jamie Arkin
cViamo, Nairobi, Kenya; Now with AInfluence Inc, Nairobi, Kenya.
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Samantha Archie
bFHI 360, Durham, NC, USA.
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Dinah Amongin
dMakerere University School of Public Health, Kampala, Uganda.
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Rawlance Ndejjo
dMakerere University School of Public Health, Kampala, Uganda.
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Saujanya Acharya
eViamo, Kathmandu, Nepal.
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Basant Thapa
fFHI 360, Kathmandu, Nepal.
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Sarah Brittingham
bFHI 360, Durham, NC, USA.
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Grace McLain
bFHI 360, Durham, NC, USA.
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Philip Mkandawire
gPSI, Lilongwe, Malawi.
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Maimouna Hallidou Doudou
hEvidence for Sustainable Human Development Systems in Africa, and Université Africaine Privée pour le Développement, Niamey, Niger.
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Ndola Prata
iEvidence for Sustainable Human Development Systems in Africa, University of California, Berkeley, CA, USA.
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    FIGURE

    Study Design Summary Examining Behaviors Related to Contraceptive Access and Use During the COVID-19 Pandemic in 4 Countries

    Abbreviation: COVID-19, coronavirus disease.

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    TABLE 1.

    Key Outcome Measures and Associated Data Sources

    OutcomeMeasuresData Source
    Unintended pregnancyProportion of pregnant women reporting that their pregnancy was planned at a later time (mistimed) or not planned at all (unplanned)3-2-1 survey
    Contribution of COVID-19 pandemic to unintended pregnancyProportion of women with an unintended pregnancy who responded “yes” when asked if the COVID-19 pandemic and the coronavirus social restrictions had affected their ability to avoid or delay getting pregnant3-2-1 survey
    Pre-pandemic modern contraceptive useProportion of women who reported they were using an implant, IUD, injectables, pills, emergency contraception, condoms, Standard Days Method, or Lactational Amenorrhea Method when the COVID-19 restrictions began in March 2020 (Malawi, Niger, Uganda) or April/May 2020 (Nepal)Outbound survey
    Current modern contraceptive useProportion of women who reported they were using an implant, IUD, injectables, pills, emergency contraception, condoms, Standard Days Method, or Lactational Amenorrhea Method at the time of the survey3-2-1 survey
    Method choiceProportion of current modern method users who said “yes” when asked if their current method was the method that they wanted to use. The question was only asked of current method users who were using a short-term method (injectables, pills, emergency contraception, condoms, Standard Days Method, or Lactational Amenorrhea Method) and current LARC users who said their method had been inserted after the COVID-19 restrictions began in March 2020 (Malawi, Niger, Uganda) or April/May 2020 (Nepal)Outbound survey
    Barriers to useProportion of nonusers of modern contraception who said “yes” when asked if they had wanted to obtain a method since the COVID-19 restrictions began in March 2020 (Malawi, Niger, Uganda) or April/May 2020 (Nepal) and who said “yes” when asked if they had tried to obtain a methodOutbound survey
    • Abbreviations: COVID-19, coronavirus disease; IUD, intrauterine contraceptive device; LARC, long-acting reversible contraception.

    • View popup
    TABLE 2.

    Characteristics, Contraceptive Use, and Pregnancies Among 3-2-1 Survey Participants

    Malawi, %(N=4,936)Nepal, %(N=6,776)Niger, %(N=2,602)Uganda, %(N=7,378)
    Age, years
     18–2477.970.079.976.7
     25–3421.922.813.319.1
     35–490.27.26.84.2
    Current pregnancy and contraceptive use statusa
     Pregnant25.225.538.324.6
     Nonpermanent modern method37.529.418.128.9
     Traditional method0.11.02.82.0
     Permanent or any other method0.22.67.32.7
     Nonuser not wanting to get pregnant within 2 years27.429.421.930.3
     Nonuser wanting to get pregnant within 2 years9.512.011.711.7
    Pregnancies by pregnancy intentionbn=1,245n=1,731n=996n=1,812
     Planned49.269.158.745.3
     Mistimed, not COVID-19-related5.52.45.24.9
     Unplanned, not COVID-19-related5.91.65.45.9
     Mistimed, COVID-19-related23.820.917.728.4
     Unplanned, COVID-19-related15.76.013.015.5
    n=633n=535n=411n=992
    COVID-19-related unintended pregnanciesc77.687.174.280.2
    Main reason for COVID-19-related unintended pregnanciesdn=491n=466n=305n=796
     Family planning services closed22.412.925.819.8
     Preferred method unavailable77.687.174.280.2
     Afraid of getting COVID-199.019.25.022.8
     Family would not allow going to get a method due to COVID-1918.127.614.820.7
     Government restrictions1.40.61.62.4
     Other family planning access reason4.11.14.32.0
     Other reason not related to accessing contraception34.033.540.744.3
    • Abbreviations: COVID-19, coronavirus disease; IUD, intrauterine contraceptive device; LAM, lactational amenorrhea method; SDM, standard days method.

    • ↵a Nonpermanent modern methods include implants, IUD, injectables, pills, emergency contraception, condoms, SDM, and LAM. Traditional methods include withdrawal, rhythm method, or folk methods like herbs.

    • ↵b Among pregnant women.

    • ↵c Among pregnant women with an unplanned or mistimed pregnancy.

    • ↵d Among pregnant women with an unplanned or mistimed pregnancy who reported that COVID-19 affected their ability to avoid or delay pregnancy.

    • View popup
    TABLE 3.

    Characteristics of Participants in the Outbound Survey, by Country

    Malawi, %(N=1,694)Nepal, %(N=1,468)Niger, %(N=458)Uganda, %(N=1,504)
    Age, years
     18–2472.762.379.974.5
     25–4927.337.720.125.5
     Married, %73.887.376.468.2
    Parity, %
     011.716.325.119.4
     138.139.427.735.0
     222.729.520.123.3
     3+27.414.827.122.3
    Highest education
     None8.512.241.98.5
     Some primary44.033.032.834.7
     Finished primary22.113.38.527.5
     Finished secondary22.822.010.721.3
     More than secondary2.519.66.18.0
    Concern about getting infected with COVID-19
     A little/not concerned or has/had COVID-1949.158.828.622.5
     Concerned19.318.328.823.9
     Very concerned31.623.042.653.5
    Household income loss during COVID-19
     None16.319.426.913.9
     Small part56.633.853.342.6
     Moderate part9.019.25.022.8
     Large part/all18.127.614.820.7
    • Abbreviation: COVID-19, coronavirus disease.

    • View popup
    TABLE 4.

    Contraceptive Use Dynamics Among Outbound Survey Participants,a by Country

    Malawi, %(N=1,694)Nepal, %(N=1,468)Niger, %(N=458)Uganda, %(N=1,504)
    Pre-pandemic contraceptive use
     Pre-pandemic contraceptive use, including traditional methods78.457.446.566.4
     Pre-pandemic modern contraceptive use75.054.740.459.8
     Pre-pandemic modern method mixbn=1,271n=803n=185n=900
      Implant54.832.848.136.9
      IUD8.38.618.915.0
      Injectable22.323.013.521.7
      Pill4.32.113.54.1
      Emergency contraception2.110.32.74.0
      Condoms7.822.80.014.7
      SDM/cycle beads or LAM0.40.43.23.7
     Pre-pandemic source of supplycn=1,268n=800n=182n=887
      Public sector facility83.576.665.965.5
      Private sector facility8.615.815.420.3
      Community health worker or outreach event6.73.311.08.0
      Pharmacy, chemical, or drug shop1.24.14.95.2
      Ordered on a website, app, or phone0.00.32.71.0
    Current contraceptive use
     Current contraceptive use, including traditional methods58.150.749.653.9
     Current modern contraceptive use58.048.242.148.8
     Current modern method mixdn=982n=708n=193n=734
      Implant44.528.433.732.8
      IUD5.98.510.910.6
      Injectable30.225.121.223.7
      Pill3.411.223.36.7
      Emergency contraception4.33.15.73.4
      Condoms8.823.21.017.3
      SDM/cycle beads or LAM3.00.64.15.4
     Current source of supplyen=622n=573n=159n=592
      Public sector facility77.874.562.366.2
      Private sector facility10.514.815.121.8
      Community health worker or outreach event9.83.512.66.1
      Pharmacy, chemical, or drug shop1.46.82.54.6
      Ordered on a website, app, or phone0.50.37.51.4
     Main reason for choosing current source of supplyen=622n=573n=159n=592
      Family planning services closed elsewhere87.526.929.621.6
      Preferred method unavailable elsewhere11.723.928.918.8
      Afraid of getting COVID-19 elsewhere0.325.118.945.8
      Family would not allow going elsewhere due to COVID-190.33.76.94.7
      Government restrictions0.25.89.47.4
      Other0.014.76.31.7
    Changes in contraceptive use
     Change in modern contraceptive statusn=1,694n=1,468n=458n=1,504
      Consistent user50.040.123.439.6
      Discontinuer25.014.617.020.2
      Adopter8.08.118.89.2
      Consistent nonuser17.037.240.831.0
     Change in contraceptive methodsfn=847n=589n=107n=596
      Less effective method18.211.230.816.6
      Method as effective77.174.561.777.3
      More effective method4.714.37.56.0
    • Abbreviations: COVID-19, coronavirus disease; EC, emergency contraception; IUD, intrauterine device; LAM, lactational amenorrhea method; SDM, standard days method.

    • ↵a Outbound survey participants include (1) nonpregnant women using nonpermanent, modern contraception and (2) nonpregnant women who do not want to get pregnant within the next two years and are not using modern contraception. Due to study design, in this table, modern methods refer to nonpermanent, modern contraceptive methods including implants, IUDs, injectables, pills, emergency contraception, condoms, SDM, and LAM.

    • ↵b Among pre-pandemic modern method users.

    • ↵c Among pre-pandemic users of modern contraception other than LAM.

    • ↵d Among current users of modern, nonpermanent contraception (implants, IUDs, injectables,, pills, EC, condoms, SDM, or LAM).

    • ↵e Among current users of modern contraception other than LAM who obtained/resupplied during COVID-19.

    • ↵f Among consistent users of modern contraception.

    • View popup
    TABLE 5

    Adjusted Odds Ratio Estimates and 95% Confidence Intervals for Factors Associated With Adoption and Discontinuation of Modern Contraception During the COVID-19 Pandemic, by Country

    MalawiNepalNigerUganda
    FactorAdoption AmongNonusers,a AOR(95% CI)(n=423)DiscontinuationAmong Users, AOR(95% CI)(n=1,268)Adoption AmongNonusers,aAOR(95% CI)(n=665)DiscontinuationAmong Users, AOR(95% CI)(n=800)Adoption AmongNonusers,aAOR(95% CI)(n=273)DiscontinuationAmong Users, AOR(95% CI)(n=182)Adoption AmongNonusers,aAOR(95% CI)(n=604)DiscontinuationAmong Users, AOR(95% CI)(n=887)
    Age (25–49 vs. 18–24b)0.80 (0.47, 1.35)0.74 (0.55, 1.00)0.51 (0.31, 0.84)c0.76 (0.53, 1.10)1.12 (0.57, 2.18)0.66 (0.29, 1.47)0.91 (0.56, 1.49)1.10 (0.79, 1.53)
    Married2.23 (1.40, 3.54)c0.70 (0.52, 0.93)3.06 (1.53, 6.10)c0.73 (0.41, 1.29)1.74 (0.93, 3.25)0.94 (0.40, 2.21)1.02 (0.67, 1.54)0.87 (0.63, 1.18)
    Parity (2+ vs. 0–1b)1.13 (0.69, 1.84)0.97 (0.74, 1.27)1.36 (0.87, 2.13)0.86 (0.61, 1.23)1.31 (0.75, 2.27)0.82 (0.42, 1.60)2.00 (1.31, 3.06)c1.10 (0.81, 1.49)
    Education (higher vs. lowerb,d)0.98 (0.62, 1.53)1.34 (1.04, 1.71)c0.71 (0.46, 1.10)0.92 (0.66, 1.28)1.22 (0.71, 2.10)0.44 (0.24, 0.84)c0.79 (0.53, 1.18)0.89 (0.66, 1.19)
    Concern about COVID-19 infection (little/not concerned or has/had COVID-19b)
     Concerned1.18 (0.67, 2.07)0.86 (0.62, 1.20)0.76 (0.41, 1.42)1.00 (0.66, 1.51)0.55 (0.27, 1.10)1.10 (0.49, 2.51)0.46 (0.26, 0.81)c0.74 (0.49, 1.14)
     Very concerned0.85 (0.52, 1.40)1.34 (1.02, 1.75)c1.47 (0.91, 2.37)0.92 (0.61, 1.37)0.93 (0.51, 1.69)0.60 (0.27, 1.33)0.60 (0.38, 0.96)c0.93 (0.65, 1.33)
    Household income loss due to COVID-19 (noneb)
     Smalln/an/a1.80 (0.98, 3.30)0.97 (0.62, 1.52)n/an/a1.39 (0.75, 2.58)0.83 (0.53, 1.30)
     Moderate/large/alln/an/a1.51 (0.82, 2.76)0.90 (0.58, 1.40)n/an/a1.32 (0.72, 2.44)1.09 (0.70, 1.70)
     Any0.96 (0.53, 1.74)1.37 (0.97, 1.91)n/an/a1.09 (0.57, 2.09)0.86 (0.42, 1.74)n/an/a
    Pre-pandemic method (long-acting vs. short-actingb)n/a0.85 (0.66, 1.09)n/a0.89 (0.64, 1.25)n/a0.66 (0.34, 1.27)n/a0.84 (0.63, 1.13)
    Pre-pandemic source of supply (public facilityb)
     Private facilityn/a1.02 (0.67, 1.56)n/a1.49 (0.98, 2.27)n/a1.31 (0.54, 3.21)n/a1.35 (0.94, 1.94)
     CHW/outreach/pharmacy/onlinen/a0.89 (0.57, 1.40)n/a0.89 (0.47, 1.68)n/a1.18 (0.52, 2.66)n/a2.08 (1.38, 3.12)c
    • Abbreviations: AOR, adjusted odds ratio; CHW, community health worker; CI, confidence interval; COVID-19, coronavirus disease.

    • ↵a Nonusers are nonpregnant women who reported using a traditional method or not using any form of contraception, and also reported that they did not want to get pregnant in the next 2 years. Users include current users of nonpermanent, modern contraception.

    • ↵b Reference.

    • ↵c Statistically significant (P ≤ .05).

    • d In Malawi, Nepal and Uganda, lower includes none and some primary, and higher includes finished primary, finished secondary, and higher. In Niger, lower includes none, and higher includes all other categories.

    • View popup
    TABLE 6.

    Method Choicea Among Current Nonpermanent Method Users and LARC Removals Among LARC Users, by Country

    MalawiNepalNigerUganda
    n=635n=575n=165n=606
    Obtained preferred method, % (95% CI)83.9 (80.8, 86.7)87.8 (84.9, 90.4)79.4 (72.4, 85.3)84.2 (81.0, 87.0)
    Main reason for not obtaining preferred method, %bn=78n=44n=26n=65
     Preferred method unavailable34.652.330.830.8
     Provider unable to provide preferred method20.515.946.224.6
     Provider recommended another method/not eligible17.920.515.44.6
     Not enough money11.56.87.715.4
     Afraid of getting COVID-196.44.50.021.5
     Other9.00.00.03.1
    LARC removalscn=495n=261n=86n=319
     Tried to get LARC removed, %45.736.854.717.6
     Main reason for not being able to have LARC removed, %dn=226n=96n=47n=56
      No provider available/place closed35.867.746.821.4
      No equipment/supplies for removal23.010.421.325.0
      Provider advised to keep method20.89.410.623.2
      Not enough money11.17.312.821.4
      Other9.35.28.58.9
    • Abbreviations: CI, confidence interval; COVID-19, coronavirus disease; IUD, intrauterine device; LAM, lactational amenorrhea method; LARC, long-acting reversible contraception.

    • ↵a At last episode of use: calculated for current modern method users who last obtained/resupplied their method during COVID-19 or who use LAM.

    • ↵b Among current modern method users who last obtained their method during COVID-19 and are not using their preferred method.

    • ↵c Among current implant and IUD users.

    • ↵d Among current implant and IUD users who tried to have their method removed.

    • View popup
    TABLE 7.

    Barriers to Use Among Current Nonusersa of Modern Contraception, by Country

    Malawi, %Nepal, %Niger, %Uganda, %
    n=712n=760n=265n=770
    Intention to get modern method
     Did not want method34.162.150.934.4
     Wanted method, did not try obtaining one13.69.312.112.5
     Tried obtaining a method52.228.637.053.1
    Reasons for not trying to obtain a methodbn=97n=71n=32n=96
     Family planning services closed20.621.118.816.7
     Afraid of getting COVID-1948.552.150.049.0
     Family would not allow going to get a method due to COVID-192.17.012.512.5
     Government restrictions15.57.09.49.4
     Other13.412.79.412.5
    Reasons for not obtaining a method among those who triedcn=372n=217n=98n=409
     Preferred method unavailable31.260.432.729.3
     Provider unable to provide preferred method25.812.922.413.0
     Provider recommended another method11.88.810.215.6
     Not enough money12.47.431.630.8
     Other18.810.63.111.2
    • Abbreviation: COVID-19, coronavirus disease.

    • ↵a Nonusers include nonpregnant women who reported using a traditional method or not using any form of contraception but did not want to get pregnant in the next two years.

    • ↵b Among current nonusers of modern contraception who wanted a method but did not try obtaining one.

    • ↵c Among current nonusers of modern contraception who tried obtaining a method.

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Global Health: Science and Practice: 10 (4)
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Women’s Experiences With Family Planning Under COVID-19: A Cross-Sectional, Interactive Voice Response Survey in Malawi, Nepal, Niger, and Uganda
Aurélie Brunie, Gwyneth Austin, Jamie Arkin, Samantha Archie, Dinah Amongin, Rawlance Ndejjo, Saujanya Acharya, Basant Thapa, Sarah Brittingham, Grace McLain, Philip Mkandawire, Maimouna Hallidou Doudou, Ndola Prata
Global Health: Science and Practice Aug 2022, 10 (4) e2200063; DOI: 10.9745/GHSP-D-22-00063

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Women’s Experiences With Family Planning Under COVID-19: A Cross-Sectional, Interactive Voice Response Survey in Malawi, Nepal, Niger, and Uganda
Aurélie Brunie, Gwyneth Austin, Jamie Arkin, Samantha Archie, Dinah Amongin, Rawlance Ndejjo, Saujanya Acharya, Basant Thapa, Sarah Brittingham, Grace McLain, Philip Mkandawire, Maimouna Hallidou Doudou, Ndola Prata
Global Health: Science and Practice Aug 2022, 10 (4) e2200063; DOI: 10.9745/GHSP-D-22-00063
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