How has the COVID-19 pandemic affected access to contraception?

The COVID-19 pandemic has created a significant barrier to many UK women wanting to take control of their sexual health by using long-acting reversible contraceptives (LARC).

What are long-acting reversible contraceptives (LARC)?

A LARC defined by the National Institute for Health and Care Excellence (NICE) is a form of contraception that doesn't require you to do anything to prevent pregnancy every day or every time you have sex. As the name suggests, LARCs are long-lasting methods that are completely reversible, and they include implants, injections, the coil (also known as intrauterine devices, or IUDs) and the intrauterine system, or IUS.

In contrast to other methods of contraception, like the oral contraceptive pill or barrier methods like condoms, the effectiveness of LARCs does not depend on your ability to use them correctly and consistently. This is a key reason why LARCs are so highly effective (with a success rate of over 99%) and why NICE believes they play a crucial role in reducing unwanted pregnancy in the UK.

The impact of COVID-19 on access to contraception

A new report has found that amid the pandemic, 29% of women were unable to access LARCs through sexual health and contraceptive services.

The report comes from a survey carried out in August 2021 on behalf of Preventx, the largest provider of sexual health testing in the UK. Of the 500 women surveyed who tried to access LARCs, 68% found accessing sexual health services more stressful than before the COVID-19 pandemic, and 27% reported stress and anxiety caused by poor access to long-acting reversible contraception.

These findings back up and provide more insight into official data that show a large drop in women using LARC methods since the pandemic. In 2019/20, there were 343,000 women using LARCs at sexual and reproductive health services, compared to only 214,100 women in 2020/21. This drop of 38% is significant, and the reasons behind it need addressing.

How has COVID-19 prevented access to contraception?

The impact of multiple COVID-19 lockdowns has meant that sexual health clinics have been closed for long periods at a time, with 41% of women in the survey citing this reduced access as the main barrier to long-acting reversible contraception. A further 35% also flagged full-up appointment schedules as another blockade. Here, a combination of the backlog of demand these clinics have been facing due to lockdown closures and restrictions on capacity and emergency-only services is to blame.

However, it is worth noting that 36% of respondents reported that they felt embarrassed to visit a sexual health clinic. This barrier to contraception is not a direct impact of the pandemic, but it should be considered by healthcare professionals who wish to encourage higher uptake of the most effective contraceptive methods.

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What has reduced access to contraception meant for women?

"Lack of access to both LARC and sexual health testing services has had a significant impact on people and will result in a negative impact on health inequalities," says Ruth Poole, Preventx CEO.

Second-choice contraception

One fifth of women said that as a result of the difficulties in accessing LARCs, they were forced to try alternative contraception they felt less comfortable with.

Although contraceptives such as the birth control pill and condoms are also effective, they depend on correct and consistent use. This means there is often a significant gap between theoretical and real-life effectiveness for these methods.

NICE is very clear that providing women with access to the full range of contraception methods could reduce the number of unintended pregnancies. Solutions need to be found to put women back in full control of what methods they use. There are side-effects and risks to consider with all contraceptive options, and a woman's ability to choose what's right for her will improve health equality.

The morning after pill

Of those who had unwanted pregnancies as a result of having no access to LARCs, 13% reported having to take the morning after pill (also known as the emergency contraceptive pill). It can be taken up to three days (or, for ellaOne®, up to five days) after unprotected sex.

While this contraceptive method can reduce the risk of becoming pregnant after unprotected sex, its effectiveness depends on several factors, depending on when in the cycle it is taken. It is not as reliable as regular preventative contraception and it it cannot replace it.

The morning after pill is not recommended as a long-term contraceptive option, as the user would experience repeated higher levels of hormones. Side-effects can include headaches, tummy aches, feeling sick, and disturbances to your menstrual cycle.

In fact, fitting of a coil within five days of unprotected sex is more effective than using the emergency contraceptive pill, and also provides ongoing protection against pregnancy. But with women struggling to access LARCs even routinely, access at short notice has been even more challenging.

Abortion services

The report also found that 7% of women accessed abortion services as a direct result of being denied access to LARCs. While healthcare professionals recommend always using some form of protection if you don't wish to fall pregnant, lack of access to sexual health services does increase the risk of unwanted pregnancies.

It is every women's right to use abortion services. This said, the emotional and physical impacts of abortions mean that the decision should be carefully considered.

Stress and anxiety

Over one quarter of women suffered from stress and anxiety after struggling to access LARCs. For some women who could get LARCs, attending appointments alone - although necessary to control COVID-19 - has also been a source of stress.

Laura Domegan, assistant head of nursing at sexual health charity Brook, explains that "people need to be able to access sexual and reproductive healthcare in ways that best suit them.

"One person who visited our clinic in Cornwall to have an IUD fitted, told us: 'I was very nervous for my appointment. But this was even worse when I was told that my partner could not be with me due to COVID-19 restrictions, although I fully understand and respect this as the room was tiny. However, both nurses did their best to comfort me throughout.'"

How can the backlog of demand for LARCs be addressed?

The huge backlog of demand for long-acting reversible contraception needs to be addressed in order to put women back in control of their health and bodies. The findings of the report suggest that online sexual health testing can play a key part in clearing the NHS backlog by freeing up capacity in sexual health clinics.

"By creating wider access to online sexual health testing, with more immediate access to treatment and care, we have been able to support the NHS to free up space in their clinics and give patients the in-person help they desperately need," explains Poole.

Innovative digital healthcare platforms such as Preventx have already been relieving some of the pressure that COVID-19 has placed on the NHS. Domegan describes the benefits this has had for charity Brook:

"During the pandemic Brook rapidly mobilised remote contraception and STI provision, allowing people who were able to, and wanted to, manage their sexual health online.

"In line with the recommendations in this latest report, we found that improving our digital access protected our appointments for those who needed safeguarding support or face-to-face interventions (such as LARC).

"Our journey over the last 18 months is proof that a blended model is the way forward, and we have seen a shift in commissioning to reflect this. The biggest challenge we face as a sector is continuing to innovate and adapt to meet demand while operating under the constraints of further public health cuts."