ABSTRACT

Objectives.

To estimate inequalities in demand for family planning satisfied with modern methods among women in Latin America and the Caribbean, with an emphasis on Brazil and Mexico, and to calculate the scenario for recovery of modern contraceptive coverage by expanding access to long-acting contraceptives (LARC) after the COVID-19 pandemic.

Methods.

National health surveys from 2006 to 2018 were used to estimate the demand for family planning satisfied with modern methods and how it was affected by the COVID-19 pandemic. The scenario included three variables: coverage, health outcomes, and costs. Considering coverage, United Nations Population Fund data were used to estimate the impact of COVID-19 on access to contraception in Latin America and the Caribbean. Health outcomes were assessed with the Impact 2 tool. Direct investment was used to evaluate cost-effectiveness.

Results.

Substantial inequalities were found in the use of modern contraceptive methods before the pandemic. We showed the potential cost-effectiveness of avoiding maternal deaths by introducing LARCs.

Conclusions.

In the scenario predicted for Brazil and Mexico, the costs of modern family planning and averted disability-adjusted life years are modest. Governments in Latin America and the Caribbean should consider promoting LARCs as a highly efficient and cost-effective intervention.

Keywords
Long-acting reversible contraception; health services accessibility; COVID-19; Latin America; Caribbean region; Brazil; Mexico

RESUMEN

Objetivos.

Estimar las desigualdades en la demanda de planificación familiar satisfecha con métodos anticonceptivos modernos entre las mujeres de América Latina y el Caribe, especialmente en Brasil y México, y analizar el escenario de recuperación de la cobertura de los anticonceptivos modernos mediante la ampliación del acceso a los anticonceptivos de acción prolongada tras la pandemia de COVID-19.

Métodos.

Se emplearon encuestas nacionales de salud desde el año 2006 hasta el año 2018 para estimar la demanda de planificación familiar satisfecha con métodos modernos y el impacto de la pandemia de COVID-19. El escenario comprendía tres variables: cobertura, resultados en materia de salud y costos. En lo respectivo a la cobertura, se emplearon datos del Fondo de Población de las Naciones Unidas para evaluar la repercusión de la COVID-19 en el acceso a los anticonceptivos en América Latina y el Caribe. Los resultados en materia de salud se examinaron con la herramienta Impact 2. Se empleó la inversión directa para evaluar la costo-efectividad.

Resultados.

Se encontraron desigualdades sustanciales en el uso de métodos anticonceptivos modernos antes de la pandemia. Se demostró la posible costo-efectividad de evitar muertes maternas mediante la introducción de anticonceptivos de acción prolongada.

Conclusiones.

De acuerdo con el escenario previsto para Brasil y México, los costos de la planificación familiar moderna y los años de vida ajustados en función de la discapacidad evitados son moderados. Los gobiernos de América Latina y el Caribe deberían considerar la posibilidad de promover los anticonceptivos de acción prolongada como intervención sumamente eficiente y costo-efectiva.

Palabras clave
Anticoncepción reversible de larga duración; accesibilidad a los servicios de salud; COVID-19; América Latina; región del Caribe; Brasil; México

RESUMO

Objetivos.

Estimar as desigualdades na demanda por planejamento familiar atendida por métodos contraceptivos modernos em mulheres da América Latina e do Caribe, com ênfase no Brasil e no México, e calcular o cenário de recuperação da cobertura por métodos contraceptivos modernos por meio da ampliação do acesso a métodos contraceptivos reversíveis de longa duração (LARC) após a pandemia de COVID-19.

Métodos.

Foram usadas pesquisas nacionais de saúde de 2006 a 2018 para estimar a demanda por planejamento familiar atendida por métodos contraceptivos modernos e como ela foi afetada pela pandemia de COVID-19. O cenário incluiu três variáveis: cobertura, desfechos de saúde e custos. Para cobertura, os dados do Fundo de População das Nações Unidas foram usados para estimar o impacto da COVID-19 no acesso à contracepção na América Latina e no Caribe. Desfechos de saúde foram avaliados com a ferramenta Impact 2. O investimento direto foi usado para avaliar a relação custo-benefício.

Resultados.

Foram constatadas desigualdades importantes no uso de métodos contraceptivos modernos antes da pandemia. Demonstramos a potencial relação custo-benefício de evitar mortes maternas mediante a introdução de LARC.

Conclusões.

No cenário previsto para o Brasil e o México, os custos do planejamento familiar moderno e dos anos de vida ajustados por incapacidade por ele evitados são modestos. Os governos da América Latina e do Caribe devem considerar a promoção dos LARC como uma intervenção altamente eficiente e custo-efetiva.

Palavras-chave
Contracepção reversível de longo prazo; acesso aos serviços de saúde; COVID-19; América Latina; região do Caribe; Brasil; México

According to 2020 estimates by the United Nations, to achieve further reductions in total fertility rates in countries where fertility levels remain high, it is crucial to continue working toward gender equality and female empowerment (¹1. United Nations, Department of Economic and Social Affairs. World fertility and family planning 2020: highlights [Internet]. New York: UN; 2020 [cited 2020 Dec 15]. Available from: https://www.un.org/en/development/desa/population/publications/pdf/family/World_Fertility_and_Family_Planning_2020_Highlights.pdf
https://www.un.org/en/development/desa/p... , ²2. United Nations, Department of Economic and Social Affairs [Internet]. New York: UN; 2019 [cited 2020 Dec 15]. World population prospects 2019. Available from: https://population.un.org/wpp/.
https://population.un.org/wpp/... ). Since the 1994 International Conference on Population and Development Programme of Action, and through to the 2030 Agenda for Sustainable Development, governments have made commitments to promoting access to sexual and reproductive health and rights (³3. United Nations [Internet]. New York: UN; 2020 [cited 2020 Dec 15]. SDG Integration. Integrated solutions for sustainable development. Available from: https://sdgintegration.undp.org
https://sdgintegration.undp.org... ). Meeting the demand for modern contraceptives by investing in sexual and reproductive health (SRH) and providing access to SRH services is crucial to ensuring universal health coverage (⁴4. Holtz H, Intissar S. Integrating family planning into universal health coverage efforts [Internet]. Bethesda, MD: Sustaining Health Outcomes through the Private Sector Plus Project, Abt Associates; 2018 [cited 2020 Dec 15]. Available from: https://www.shopsplusproject.org/sites/default/files/resources/Integrating%20Family%20Planning%20into%20Universal%20Health%20Coverage%20Efforts.pdf
https://www.shopsplusproject.org/sites/d... ).

Health inequities are driven by social determinants, and significant wealth-related inequalities in contraceptive coverage have been identified in countries of Latin America and the Caribbean (LAC) (⁵5. Ponce de Leon RG, Ewerling F, Serruya SJ, Silveira MF, Sanhueza A, Moazzam A, et al. Contraceptive use in Latin America and the Caribbean with a focus on long-acting reversible contraceptives: prevalence and inequalities in 23 countries. Lancet Glob Health. 2019;7(2):e227–e35.). The global COVID-19 pandemic, which has struck the LAC region particularly hard, threatens to exacerbate these inequalities (⁵5. Ponce de Leon RG, Ewerling F, Serruya SJ, Silveira MF, Sanhueza A, Moazzam A, et al. Contraceptive use in Latin America and the Caribbean with a focus on long-acting reversible contraceptives: prevalence and inequalities in 23 countries. Lancet Glob Health. 2019;7(2):e227–e35., ⁶6. Pan American Health Organization. 58th Directing Council of the Pan American Health Organization. COVID-19 Pandemic in the Region of the Americas [Internet]. Washington, DC: PAHO; 2020 [cited 2020 Dec 15]. Available from: https://www.paho.org/en/documents/cd58-r9-e-covid-19
https://www.paho.org/en/documents/cd58-r... ) and set back decades of progress (⁶6. Pan American Health Organization. 58th Directing Council of the Pan American Health Organization. COVID-19 Pandemic in the Region of the Americas [Internet]. Washington, DC: PAHO; 2020 [cited 2020 Dec 15]. Available from: https://www.paho.org/en/documents/cd58-r9-e-covid-19
https://www.paho.org/en/documents/cd58-r... , ⁷7. Riley T, Sully E, Ahmed Z, Biddlecom A. Estimates of the potential impact of the COVID-19 pandemic on sexual and reproductive health in low- and middle-income countries. Int Perspect Sex Reprod Health. 2020;46:73–6.).

Universal access to modern contraceptives (⁸8. Hubacher D, Trussell J. A definition of modern contraceptive methods. Contraception. 2015;92(5):420–1.) is one of the most cost-effective investments a country can make to improve its future (⁹9. Starbird E, Norton M, Marcus R. Investing in family planning: key to achieving the Sustainable Development Goals. Glob Health Sci Pract. 2016;4(2):191–210.) and increase population health and development (¹⁰10. World Health Organization. Contraception. Evidence brief [Internet]. Geneva: WHO; 2019 [cited 2020 Dec 15]. Available from: https://apps.who.int/iris/bitstream/handle/10665/329884/WHO-RHR-19.18-eng.pdf
https://apps.who.int/iris/bitstream/hand... ). Contraceptive use rates exceed 70% in Europe, LAC, and North America (¹¹11. United Nations, Department of Economic and Social Affairs. World family planning 2017 [Internet]. New York: UN; 2017 [cited 2020 Dec 15]. Available from: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2017_worldfamilyplanning_highlights.pdf
https://www.un.org/development/desa/pd/s... ). However, estimates for 2019 showed that SRH services fell well short of meeting the needs of the population in low- and middle-income countries (LMICs). Approximately 218 million women in these countries have an unmet need for modern contraception—that is, they want to avoid pregnancy but are not using a modern method—and 49% of pregnancies in LMICs, some 111 million annually, are unintended (¹⁰10. World Health Organization. Contraception. Evidence brief [Internet]. Geneva: WHO; 2019 [cited 2020 Dec 15]. Available from: https://apps.who.int/iris/bitstream/handle/10665/329884/WHO-RHR-19.18-eng.pdf
https://apps.who.int/iris/bitstream/hand... –¹²12. Sully EA, Biddlecom A, Darroch JE, Riley T, Ashford LS, Lince-Deroche N, et al. Adding it up: investing in sexual and reproductive health 2019 [Internet]. New York: Guttmacher Institute; 2020 [cited 2020 Dec 15]. Available from: https://www.guttmacher.org/sites/default/files/report_pdf/adding-it-up-investing-in-sexual-reproductive-health-2019.pdf
https://www.guttmacher.org/sites/default... ). Sexual and reproductive health and rights have far-reaching implications for individuals, families, and society (⁴4. Holtz H, Intissar S. Integrating family planning into universal health coverage efforts [Internet]. Bethesda, MD: Sustaining Health Outcomes through the Private Sector Plus Project, Abt Associates; 2018 [cited 2020 Dec 15]. Available from: https://www.shopsplusproject.org/sites/default/files/resources/Integrating%20Family%20Planning%20into%20Universal%20Health%20Coverage%20Efforts.pdf
https://www.shopsplusproject.org/sites/d... ).

There is limited evidence of the impact of the COVID-19 pandemic on SRH (¹³13. Tang K, Gaoshan J, Ahonsi B, Ali M, Bonet M, Broutet N, et al. Sexual and reproductive health (SRH): a key issue in the emergency response to the coronavirus disease (COVID- 19) outbreak. Reprod Health. 2020;17(1):59. Available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-020-0900-9 Correction available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-020-00926-7
https://reproductive-health-journal.biom... ). The United Nations Population Fund (UNFPA) has determined that, if no action is taken, up to 19.7 million women in the LAC region—which has the second-highest rate of unsafe abortion worldwide due to unplanned pregnancies (¹⁴14. United Nations Population Fund. Impact of COVID-19 on access to contraceptives in the LAC region [Internet]. New York: UNFPA; 2020 [cited 2020 Dec 15]. Available from: https://lac.unfpa.org/sites/default/files/pub-pdf/technical_report_impact_of_covid_19_in_the_access_to_contraceptives_in_lac_1_2.pdf
https://lac.unfpa.org/sites/default/file... )—could have an unmet need for contraception.

Long-acting reversible contraceptives (LARC) are the most effective and cost-effective contraceptives, especially after disasters and pandemics. Based on predicted estimates currently available, home isolation and the fear of contracting COVID-19 appear to have led to a decrease in utilization of SRH services, increased reports of intimate partner violence, and, in some settings, reduced access to counseling and modern contraceptive methods, especially LARCs (⁷7. Riley T, Sully E, Ahmed Z, Biddlecom A. Estimates of the potential impact of the COVID-19 pandemic on sexual and reproductive health in low- and middle-income countries. Int Perspect Sex Reprod Health. 2020;46:73–6., ¹⁵15. International Planned Parenthood Federation [Internet]. London: IPPF; 2021 [cited 2020 Dec 15]. COVID-19 impact. Available from: https://www.ippf.org/blogs/contraception-and-covid-19-disrupted-supply-and-access
https://www.ippf.org/blogs/contraception... ). The Guttmacher Institute estimates that a 10% decrease in the use of short-acting and LARC methods in LMICs due to COVID-19 would lead to 49 million additional women with an unmet need for modern contraceptives and 15 million unintended pregnancies over the course of a year (¹⁶16. Bradley SE, Casterline JB. Understanding unmet need: history, theory, and measurement. Stud Fam Plann. 2014;45(2):123–50.). If no action is taken, this could result in 1.7 million unintended pregnancies, almost 800 000 abortions, 29 000 maternal deaths, and almost 39 000 infant deaths (¹⁴14. United Nations Population Fund. Impact of COVID-19 on access to contraceptives in the LAC region [Internet]. New York: UNFPA; 2020 [cited 2020 Dec 15]. Available from: https://lac.unfpa.org/sites/default/files/pub-pdf/technical_report_impact_of_covid_19_in_the_access_to_contraceptives_in_lac_1_2.pdf
https://lac.unfpa.org/sites/default/file... ).

Within this context, our report aimed to estimate inequalities in demand for family planning satisfied with modern methods (mDFPS) among women in the LAC region, with an emphasis on Brazil and Mexico, and to calculate the scenario for recovery of modern contraceptive coverage by expanding access to LARCs after the COVID-19 pandemic.

MATERIALS AND METHODS

A cross-sectional study was conducted using data from national health surveys performed between 2006 and 2018. The mDFPS was estimated, defined as the proportion of women of reproductive age (15–49 years) in need of contraception whose need is currently being satisfied with a modern contraceptive method (¹⁵15. International Planned Parenthood Federation [Internet]. London: IPPF; 2021 [cited 2020 Dec 15]. COVID-19 impact. Available from: https://www.ippf.org/blogs/contraception-and-covid-19-disrupted-supply-and-access
https://www.ippf.org/blogs/contraception... ).

Brazil and Mexico represent 54% of women of reproductive age in the region, and half of the women who potentially would discontinue use of contraceptives due to the COVID-19 pandemic.

We estimated mDFPS using publicly available data from Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and Reproductive Health Surveys carried out between 2006 and 2018. These surveys have a focus on reproductive, maternal, and child health and nutrition, and are highly comparable in terms of methods. To include the most recent estimates, we used the 2013 Brazilian Pesquisa Nacional de Saúde and the 2012 Encuesta Nacional de Salud y Nutrición from Ecuador. We used standard definitions for all indicators to ensure comparable results across surveys, and all estimates were calculated from survey microdata.

These were assessed in terms of wealth, women’s education, area of residence, and ethnicity (¹⁷17. Filmer D, Pritchett LH. Estimating wealth effects without expenditure data--or tears: an application to educational enrollments in states of India. Demography. 2001;38(1):115–32.–²⁰20. Stover J, Bertrand JT, Shelton JD. Empirically based conversion factors for calculating couple-years of protection. Eval Rev. 2000;24(1):3–46.). For Argentina, Brazil, Ecuador, Nicaragua, and Peru, information regarding women in need of contraception was not available. Given the high correlation between mDFPS and prevalence of contraceptive use, we estimated mDFPS using the predictive equation proposed previously (²¹21. Barros AJ, Boerma T, Hosseinpoor AR, Restrepo-Méndez MC, Wong KL, Victora CG. Estimating family planning coverage from contraceptive prevalence using national household surveys. Glob Health Action. 2015;8(1):10.), which has been shown to provide fairly accurate predicted values of DFPS from contraceptive use estimates:

logit(mDFPS) = 0.61+0.68log(mCPR) + 3.57mCPR²

where mDFPS is the demand for contraception satisfied by modern methods, and mCPR is the prevalence of modern contraceptive use.

The analyzed scenario includes three variables: coverage, health outcomes, and costs. Coverage analysis was based on United Nations Department of Economic and Social Affairs projections (²²22. United Nations, Department of Economic and Social Affairs [Internet]. New York: UN; 2020 [cited 2021 Apr 28]. Estimates and projections of family planning indicators 2020. Available from: https://www.un.org/en/development/desa/population/theme/family-planning/cp_model.asp
https://www.un.org/en/development/desa/p... ) and the assessment made by UNFPA for estimating the impact of COVID-19 on access to contraceptives in LAC (¹⁴14. United Nations Population Fund. Impact of COVID-19 on access to contraceptives in the LAC region [Internet]. New York: UNFPA; 2020 [cited 2020 Dec 15]. Available from: https://lac.unfpa.org/sites/default/files/pub-pdf/technical_report_impact_of_covid_19_in_the_access_to_contraceptives_in_lac_1_2.pdf
https://lac.unfpa.org/sites/default/file... ). Further, we used Impact 2, which is a model developed by Marie Stopes International that allows construction of counterfactual scenarios (²³23. MSI Reproductive Choices [Internet]. London: MST; 2020 [cited 2020 Nov 19]. Impact 2 – An innovative tool for measuring the impact of reproductive health program. Available from: https://www.msichoices.org/who-we-are/our-technical-expertise/impact-2/#
https://www.msichoices.org/who-we-are/ou... ). Taking the couple-years of protection (CYP) provided by each modern contraceptive method as the independent variable, Impact 2 estimates unintended pregnancies, abortions, unsafe abortions, and maternal deaths avoided. In addition, years of life lost and disability-adjusted life years (DALYs) averted are forecasted based on their elasticity to mCPR and adjusted by vital statistics.

To calculate the total users of modern contraceptives, we added the number of users before the proposed intervention and the number of users considered for post-pandemic recovery of mCPR. Impact 2 then provided the rest of the parameters of interest (CYP, unintended pregnancies, abortions, maternal deaths avoided, and DALYs). The cost of LARCs was obtained from the UNFPA Procurement Catalogue according to the corresponding Incoterm (²⁴24. United Nations Population Fund [Internet]. New York: UNFPA; 2021 [cited 2021 Apr 28]. Available from: https://www.unfpa.org/.
https://www.unfpa.org/... , ²⁵25. United Nations, Department of Economic and Social Affairs. Contraceptive use by method 2019 [Internet]. New York; UN: 2019 [cited 2021 Apr 28]. Available from: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Jan/un_2019_contraceptiveusebymethod_databooklet.pdf
https://www.un.org/development/desa/pd/s... ). The COVID-19 pandemic can disrupt the progress that has been made to end unmet family planning needs by 2030 in the LAC region, and we measure this disturbance through information on 12 LAC countries. For the public sector, data were collected from surveys conducted by the ministries of health; for the private sector, estimations were made using results from the publicly available sales data during a five-year period. A simulation of the impact of an increase in LARC use in Brazil and Mexico was performed using this model.

RESULTS

Table 1 shows the countries included in our analysis, sources of data, mDFPS at the national level and among the poorest 20%, and sample sizes. Almost all countries presented high levels of coverage. Among the poorest 20%, coverage was lower in all included countries.

The mDFPS at a national level and among the poorest 20% and the share of each method used by women are presented in Figure 1. Short-acting contraceptives (SARC) are the most-used method in the region. Colombia, Dominican Republic, Ecuador, El Salvador, and Mexico had different patterns, with sterilization accounting for the highest share among modern contraceptive methods. The LARC methods were highly prevalent in Cuba, Mexico, Bolivia, and Guyana. Figure 2 presents differences between proportions of modern methods used in the two selected countries, Brazil and Mexico. In Mexico, the share of each contraceptive method was similar between different groups, considering wealth, education, area of residence, and ethnicity, with a smaller share of SARCs and a high prevalence of sterilization. In Brazil, SARCs were the most-used methods among all population subgroups, but LARC use increased with wealth and women’s education.

Among the poorest Brazilian women, LARCs were not used at all on average, while they accounted for 6% of mDFPS among the richest women. In terms of education, the highest share of LARC use was observed among those with at least a secondary education (4%), while it was only 1% among those with primary-level education and 0% among those with no formal education. Furthermore, LARCs accounted for 3% of mDFPS among women living in urban areas and 1% for those living in rural areas. According to ethnicity, LARCs accounted for 4% of mDFPS among women of the reference group but only 1% among Indigenous and Afro-descendant women.

In terms of decline in CYP, access to contraceptive methods dropped in the private sector, with a CYP estimated for LAC, per thousand, of 2 621.7 (95% confidence interval 1 369.0–3 887.3); Argentina (321.3 [167.8–476.4]), Brazil (1 024.8 [535.1–1 519.6]), and Mexico (518.3 [270.6–768.5]) together represented almost three-fourths of this loss. When analyzing the public sector, the estimated CYP for LAC was 2 532.1, where Brazil accounted for two-thirds of this loss in CYP (1 582.5).

Recovery of lost modern family planning coverage by expanding LARC use in Brazil and Mexico

The situation in Brazil and Mexico, including comparisons with the LAC region, is shown in Table 2. Further, Table 3 shows results for Brazil and Mexico considering the recovery of that coverage lost due to the COVID-19 pandemic, exclusively through LARCs, in a scenario where half of women use intrauterine devices (IUDs) and half receive a levonorgestrel implant. We observed that 47 776 women would have access to modern family planning methods. The resulting increase in LARC use (from 5 731 users to 15 874 if the need for modern family planning methods was to be met exclusively via LARCs) would result in averting 2 452 unplanned pregnancies and 1 167 abortions (of which 874 would have been unsafe abortions) and preventing 214 maternal deaths (163 in Brazil and 51 in Mexico), with a low cost of US$ 34 681.00 for Brazil and US$ 10 635.00 for Mexico, being highly cost-effective.

DISCUSSION

Our study showed that most LAC countries have high levels of mDFPS. Short-acting contraceptives are the most widely used form of contraception in the region; LARCs were more prevalent in Cuba, Mexico, Bolivia, and Guyana. Out of all LAC countries, Brazil and Mexico had the highest family planning coverage and account for almost half of the women of reproductive age in the LAC region. Our findings indicated inequalities in both countries; however, these were greater in Brazil, were the richest women had more access to LARCs and the general population used more SARCs. Furthermore, the distribution of the use of contraceptives was similar across different sociodemographic strata of wealth in Mexico, where a high prevalence of sterilization was observed and LARC use was more prevalent in urban than in rural areas.

SRH services were severely affected in previous health crises (²⁶26. Bietsch K, Williamson J, Reeves M. Family planning during and after the West African Ebola crisis. Stud Fam Plann. 2020;51(1):71–86., ²⁷27. Camara BS, Delamou A, Diro E, Beavogui AH, El Ayadi AM, Sidibe S, et al. Effect of the 2014/2015 Ebola outbreak on reproductive health services in a rural district of Guinea: an ecological study. Trans R Soc Trop Med Hyg. 2017;111(1):22–9.), and the COVID-19 pandemic was no different. In several LAC countries, efforts and achievements in this field are at serious risk, with the potential to return to a 1990–1998 scenario (¹⁴14. United Nations Population Fund. Impact of COVID-19 on access to contraceptives in the LAC region [Internet]. New York: UNFPA; 2020 [cited 2020 Dec 15]. Available from: https://lac.unfpa.org/sites/default/files/pub-pdf/technical_report_impact_of_covid_19_in_the_access_to_contraceptives_in_lac_1_2.pdf
https://lac.unfpa.org/sites/default/file... ). Achieving universal health coverage and the realization of SRH services are essential to fulfilling the pledge of the 2030 Agenda for Sustainable Development that “no one will be left behind” (²⁸28. World Health Organization [Internet]. Geneva: WHO; 2021 [cited 2020 Nov 19]. Universal health coverage (UHC). Available from: https://www.who.int/health-topics/universal-health-coverage#tab=tab_1
https://www.who.int/health-topics/univer... ). This will require intensified support for contraceptive services, including the implementation of effective government policies and programs. Universal access to modern contraception is a highly cost-effective intervention (¹⁴14. United Nations Population Fund. Impact of COVID-19 on access to contraceptives in the LAC region [Internet]. New York: UNFPA; 2020 [cited 2020 Dec 15]. Available from: https://lac.unfpa.org/sites/default/files/pub-pdf/technical_report_impact_of_covid_19_in_the_access_to_contraceptives_in_lac_1_2.pdf
https://lac.unfpa.org/sites/default/file... , ²⁸28. World Health Organization [Internet]. Geneva: WHO; 2021 [cited 2020 Nov 19]. Universal health coverage (UHC). Available from: https://www.who.int/health-topics/universal-health-coverage#tab=tab_1
https://www.who.int/health-topics/univer... ).

The Family Planning 2030 partnership is one of the new significant possibilities for the LAC region (²⁹29. Family Planning 2030 [Internet]. Washington, DC: FP2030; 2020 [cited 2020 Nov 19]. Building FP2030: a collective vision for family planning post-2020 Available from: https://fp2030.org/Building2030
https://fp2030.org/Building2030... ). Starting in 2021, countries and partners in the LAC region will have the opportunity to make commitments to the next global Family Planning partnership and to engage in shaping the movement for the upcoming decade and beyond. LARCs convey many other characteristics other than avoiding unintended pregnancy; that is, non-contraceptive benefits (³⁰30. Bahamondes L, Valeria Bahamondes M, Shulman LP. Non-contraceptive benefits of hormonal and intrauterine reversible contraceptive methods. Hum Reprod Update. 2015;21(5):640–51.). When media strategies are used to promote modern contraceptive methods, a 5%–27% greater positive effect is achieved when compared with those who were not exposed to these strategies. Once the demand for contraceptive use is created, the availability and accessibility of contraceptive methods should be ensured (³¹31. High Impact Practices [Internet]. Baltimore, MD: HIP; 2017 [cited 2021 Apr 28]. Mass media: reaching audiences far and wide with messages to support healthy reproductive behaviors. Available from: https://www.fphighimpactpractices.org/briefs/mass-media
https://www.fphighimpactpractices.org/br... ).

According to United Nations Population Division estimates, as of early 2020, 19.72 million women had an unmet need for modern contraceptive methods in the LAC region (¹⁴14. United Nations Population Fund. Impact of COVID-19 on access to contraceptives in the LAC region [Internet]. New York: UNFPA; 2020 [cited 2020 Dec 15]. Available from: https://lac.unfpa.org/sites/default/files/pub-pdf/technical_report_impact_of_covid_19_in_the_access_to_contraceptives_in_lac_1_2.pdf
https://lac.unfpa.org/sites/default/file... ). If the drop in contraception due to the COVID-19 pandemic is included in this estimate, 20 million women will have discontinued use of contraceptives in the region. The unmet need for modern family planning methods is expected to have increased from 11.4% to 17.7% by the end of 2020, which reflects the situation seen in 1998—representing over 20 years of lost progress (¹⁴14. United Nations Population Fund. Impact of COVID-19 on access to contraceptives in the LAC region [Internet]. New York: UNFPA; 2020 [cited 2020 Dec 15]. Available from: https://lac.unfpa.org/sites/default/files/pub-pdf/technical_report_impact_of_covid_19_in_the_access_to_contraceptives_in_lac_1_2.pdf
https://lac.unfpa.org/sites/default/file... ).

Regarding the understanding of the impact of COVID-19 on access to contraception, several important recommendations could be made. Health systems should consider dispensing multi-month supplies of SARCs, thereby reducing the need for travel to health facilities; offering subcutaneous depot medroxyprogesterone acetate (DMPA-SC) to women who desire injectable contraception; and massively informing providers and women about the possibility of the extended use of LARCs during the pandemic (³²32. Nanda K, Lebetkin E, Steiner MJ, Yacobson I, Dorflinger LJ. Contraception in the Era of COVID-19. Glob Health Sci Pract. 2020;8(2):166–8.).

Our findings would help governments in the LAC region make informed decisions to minimize the impact of the COVID-19 pandemic on SRH and maternal health, using evidence-based interventions to provide modern family planning. Our study has strengths including the use of a validated method to simulate recovery scenarios based on innovative actions to support modern contraceptive services, with effective government policies and programs, as a cost-effective intervention. However, one of the limitations is that although shortages were observed for some contraceptives, women may have substituted other methods, or even changed their sexual behaviors, moving them out of the need-for-contraception group. Even when SRH services were shut down due to pandemic-related lockdowns, few governments implemented innovative outreach strategies to continue providing contraceptive services. Finally, failure to acquire contraceptives does not always translate directly to unavailability of methods, given that countries may have small preexisting stocks. Due to these and other limitations, we were unable to assess all inequalities in the region.

Conclusion

In the scenario predicted for Brazil and Mexico, the costs of modern family planning and averted DALYs are modest, allowing governments to consider LARC promotion in LAC as a highly efficient and cost-effective intervention. Inaction by governments in this area will cost not only more lives but also many more resources, leaving many women and their families behind.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or those of the Pan American Health Organization, nor of the institutions with which they are affiliated.

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