{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T05:11:22Z","timestamp":1772169082110,"version":"3.50.1"},"update-to":[{"DOI":"10.12688\/gatesopenres.14590.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2024,7,18]],"date-time":"2024-07-18T00:00:00Z","timestamp":1721260800000}}],"reference-count":24,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2024,7,18]],"date-time":"2024-07-18T00:00:00Z","timestamp":1721260800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100001322","name":"South African Medical Research Council","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100001322","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000200","name":"United States Agency for International Development","doi-asserted-by":"publisher","award":["AID-OAA-A-15-00045"],"award-info":[{"award-number":["AID-OAA-A-15-00045"]}],"id":[{"id":"10.13039\/100000200","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000200","name":"United States Agency for International Development","doi-asserted-by":"publisher","award":["7200AA19CA00041"],"award-info":[{"award-number":["7200AA19CA00041"]}],"id":[{"id":"10.13039\/100000200","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100006661","name":"United Nations Population Fund","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100006661","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100004441","name":"Swedish International Development Cooperation Agency","doi-asserted-by":"crossref","award":["2017\/762965\u20130"],"award-info":[{"award-number":["2017\/762965\u20130"]}],"id":[{"id":"10.13039\/100004441","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["gatesopenresearch.org"],"crossmark-restriction":false},"short-container-title":["Gates Open Res"],"abstract":"<ns3:p>Background The COVID-19 pandemic affected global access to health services, including contraception We sought to explore effects of the pandemic on family planning (FP) service provision and use in South Africa and Zambia, including on implant and intrauterine device (IUD) users\u2019 desire and ability to obtain removal. Methods Between August 2020 and April 2021, we conducted surveys with 537 women participating in an ongoing longitudinal contraceptive continuation study. We also carried out in-depth interviews with 39 of the survey participants and 36 key informants involved in FP provision. We conducted descriptive analysis of survey responses and thematic analysis of interviews. Results Contraceptive use changed minimally in this sample with the emergence of COVID-19. Fewer than half of women (n=220) reported that they tried to access FP since the start of the pandemic. The vast majority of those seeking services were using short-acting methods and 95% were able to obtain their preferred method. The proportion of women not using a method before and after the start of the pandemic did not change in Zambia (31%), and increased from 8% to 10% in South Africa. Less than 7% of implant or IUD users in either country reported wanting removal. Among the 22 who sought removal, 10 in Zambia and 6 in South Africa successfully obtained removal. In qualitative interviews, those reporting challenges to service access specifically mentioned long queues, deprioritization of contraceptive services, lack of transportation, stock-outs, and fear of contracting COVID-19 at a facility. Key informants reported stock-outs, especially of injectables, and staff shortages as barriers. Conclusions We did not find a substantial impact of COVID-19 on contraceptive access and use among this sample; however, providers and others involved in service provision identified risks to continuity of care. As the COVID-19 pandemic wanes, it continues to be important to monitor people\u2019s ability to access their preferred contraceptive methods.<\/ns3:p>","DOI":"10.12688\/gatesopenres.14590.2","type":"journal-article","created":{"date-parts":[[2024,7,18]],"date-time":"2024-07-18T06:08:59Z","timestamp":1721282939000},"page":"61","update-policy":"https:\/\/doi.org\/10.12688\/gatesopenres.crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["Contraceptive access and use before and during the COVID-19 pandemic: a mixed-methods study in South Africa and Zambia"],"prefix":"10.12688","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5808-0320","authenticated-orcid":false,"given":"Rebecca L.","family":"Callahan","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1557-8062","authenticated-orcid":false,"given":"Alice F.","family":"Cartwright","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mags","family":"Beksinska","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7285-998X","authenticated-orcid":false,"given":"Margaret","family":"Kasaro","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jennifer H.","family":"Tang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0026-7560","authenticated-orcid":false,"given":"Cecilia","family":"Milford","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christina","family":"Wong","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marissa","family":"Velarde","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Virginia","family":"Maphumulo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria","family":"Fawzy","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Manze","family":"Chinyama","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Esther","family":"Chabu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mayaba","family":"Mudenda","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jennifer","family":"Smit","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2024,7,18]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2022-070085","article-title":"What is the NCD service capacity and disruptions due to COVID-19? 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Pfitzer","year":"2020","journal-title":"Glob Health Sci Pract."},{"key":"ref-5","doi-asserted-by":"publisher","DOI":"10.1080\/26410397.2021.1881210","article-title":"Applications of the high impact practices in family planning during COVID-19.","volume":"29","author":"A Mickler","year":"2021","journal-title":"Sex Reprod Health Matters."},{"key":"ref-6","doi-asserted-by":"publisher","first-page":"169-175","DOI":"10.9745\/GHSP-D-20-00171","article-title":"Doing Things differently: what it would take to ensure continued access to contraception during COVID-19.","volume":"8","author":"M Weinberger","year":"2020","journal-title":"Glob Health Sci Pract."},{"key":"ref-7","doi-asserted-by":"publisher","first-page":"102","DOI":"10.12688\/gatesopenres.13148.2","article-title":"The impact of the COVID-19 crisis on meeting needs for family planning: a global scenario by contraceptive methods used [version 2; peer review: 1 approved, 2 approved with reservations].","volume":"4","author":"A Dasgupta","year":"2020","journal-title":"Gates Open Res."},{"key":"ref-8","doi-asserted-by":"publisher","DOI":"10.1016\/j.ypmed.2021.106664","article-title":"COVID-19 and family planning service delivery: findings from a survey of U.S. physicians.","volume":"150","author":"L Zapata","year":"2021","journal-title":"Prev Med."},{"key":"ref-9","article-title":"First case of COVID-19 Coronovirus reported in SA","year":"2020"},{"key":"ref-10","doi-asserted-by":"publisher","first-page":"1547-1548","DOI":"10.15585\/mmwr.mm6942a5","article-title":"First 100 persons with COVID-19 \u2014 Zambia, March 18\u2013April 28, 2020.","volume":"69","author":"P Chipimo","year":"2020","journal-title":"MMWR Morb Mortal Wkly Rep."},{"key":"ref-11","article-title":"COVID-19 Dashboard","year":"2023"},{"key":"ref-12","doi-asserted-by":"publisher","first-page":"379-401","DOI":"10.1111\/sifp.12222","article-title":"Contraceptive continuation and experiences obtaining implant and IUD removal among women randomized to use injectable contraception, levonorgestrel implant, and copper IUD in South Africa and Zambia.","volume":"54","author":"A Cartwright","year":"2023","journal-title":"Stud Fam Plann."},{"key":"ref-13","doi-asserted-by":"publisher","first-page":"303-313","DOI":"10.1016\/S0140-6736(19)31288-7","article-title":"HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial.","volume":"394","year":"2019","journal-title":"Lancet."},{"key":"ref-14","doi-asserted-by":"publisher","DOI":"10.1016\/j.jbi.2019.103208","article-title":"The REDCap consortium: building an international community of software platform partners.","volume":"95","author":"P Harris","year":"2019","journal-title":"J Biomed Inform."},{"key":"ref-15","doi-asserted-by":"publisher","first-page":"63-84","DOI":"10.1177\/1525822X02239573","article-title":"Beyond the qualitative interview: data preparation and transcription.","volume":"15","author":"E McLellan","year":"2003","journal-title":"Field Methods."},{"key":"ref-16","doi-asserted-by":"publisher","DOI":"10.4135\/9781483384436","article-title":"Applied Thematic Analysis.","author":"G Guest","year":"2012"},{"key":"ref-17","article-title":"NVivo.","year":"2020"},{"key":"ref-18","article-title":"COVID-19\/Novel Coronavirus: About alert system."},{"key":"ref-19","doi-asserted-by":"publisher","first-page":"e793-e801","DOI":"10.1016\/S2214-109X(21)00105-4","article-title":"Need for and use of contraception by women before and during COVID-19 in four sub-Saharan African geographies: results from population-based national or regional cohort surveys.","volume":"9","author":"S Wood","year":"2021","journal-title":"Lancet Glob Health."},{"key":"ref-20","doi-asserted-by":"publisher","DOI":"10.1101\/2020.05.15.20103226","article-title":"Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: a 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perspective.","volume":"24","author":"D Govender","year":"2020","journal-title":"Afr J Reprod Health."},{"key":"ref-24","article-title":"CUBE study COVID-19 survey.","author":"A Cartwright","year":"2023"}],"container-title":["Gates Open Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v2\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v2\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v2\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,7,27]],"date-time":"2024-07-27T05:00:13Z","timestamp":1722056413000},"score":1,"resource":{"primary":{"URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,7,18]]},"references-count":24,"URL":"https:\/\/doi.org\/10.12688\/gatesopenres.14590.2","relation":{"has-version":[{"id-type":"doi","id":"10.12688\/gatesopenres.14590.1","asserted-by":"subject"}],"has-review":[{"id-type":"doi","id":"10.21956\/gatesopenres.17563.r37482","asserted-by":"subject"},{"id-type":"doi","id":"10.21956\/gatesopenres.17563.r37482","asserted-by":"object"}]},"ISSN":["2572-4754"],"issn-type":[{"value":"2572-4754","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,7,18]]},"assertion":[{"value":"Indexed","URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v2#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.21956\/gatesopenres.15906.r34939, Megan A Cohen, Division of Complex Family Planning, Department of Gynecology and Obstetrics, Emory University, Atlanta, Georgia, 28 Sep 2023, version 1, 3 approved with reservations","URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v1#referee-response-34939","order":0,"name":"referee-response-34939","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Alice Cartwright<\/b>; \n<i>Posted: 08 Jul 2024<\/i>; 1.&nbsp;To clarify \u2013 the 75 individuals in Table 2 changed or discontinued their method after COVID-19 restrictions went into place (comparing the method they were using before COVID-19 restrictions and afterward). This was true for 10 of the 20 currently pregnant respondents. We take this to mean that the other 10 pregnant respondents discontinued their methods prior to COVID-19 restrictions but became pregnant after the restrictions went into place.  Among the 10 pregnant respondents who stopped using their method after COVID-19 restrictions, only 1 South African respondent reported COVID-19 impacted their \n<i>method <\/i>use.  However, when all of the 20 pregnant respondents were asked separately about the timing of their pregnancies post-COVID-19 restrictions, 15 of the 20 pregnant respondents (75%) reported that they wanted the pregnancy at that time, 2 said they wanted another pregnancy but wanted to wait until later, and 3 said they did not want to get pregnant at all. Among the 5 with mistimed or unwanted pregnancies (4 of whom were in South Africa), only 3 (all in South Africa) reported that they felt that COVID-19 restrictions impacted their ability to avoid or delay pregnancy (all 3 reported that the method they wanted was not available and 1 reported fear of being infected with COVID-19). We have described this group in the 6th paragraph of the Results section, but we have added some additional identifiers so that it is clear that the majority of mistimed or unwanted pregnancies were in South Africa.  We acknowledge that it is challenging to align these slightly conflicting responses to different ways of asking the questions about pregnancy intention and contraceptive use, but ultimately 3 pregnant respondents, all in South Africa, reported that COVID-19 contributed to their mistimed or unwanted pregnancy. We have added a sentence addressing this to the Limitations section: \u201c\n<u>Relatedly, with many factors affecting the health systems and contraceptive supplies, it is difficult to know if respondents accurately interpreted their situations as resulting from the COVID-19 pandemic. For example, in South Africa, stock-outs of contraceptive methods are not uncommon, and therefore, respondents may not necessarily see their inability to access their preferred contraceptive method as being related to COVID-19<\/u>.\u201d  2.&nbsp;Table 1 captures the method that respondents are using at the time of the COVID-19 survey (where 95 respondents report they are not using a method). Before COVID-19 restrictions went into place, 70 respondents were already not using a method (and continued not using a method after restrictions went into place). We have added a sentence to clarify this in the second paragraph of the Results section: \u201c\n<u>Most of the participants not using contraception had discontinued method use before COVID-19 restrictions went into place (n=70)\u201d.<\/u>  Then from the time before to after COVID-19 restrictions went into place, 25 additional respondents discontinued their method (as reflected in Table 2). The 75 individuals in Table 2 either switched methods (n=50) or discontinued their method (n=25).  3.&nbsp;We have moved the number of participants from the Methods to the Results section.  We appreciate the suggestion to add an additional Figure; however, we are not sure how much additional information an additional Figure would provide to readers that could not be provided in the text. Therefore, we have added the following detail to the Methods in the &quot;Study population and sample&quot; section: \u201cThe 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; \n<u>n=390 in South Africa and n=236 in Zambia<\/u>).\u201d  We have also added the following text to the beginning of the first paragraph of the Results section: \u201cFor the COVID-19 survey module, we were able to contact, consent, and survey 537 CUBE respondents. \n<u>In South Africa, we were able to reach 87.9% of the 18-month CUBE participants, though one survey was only partially completed and excluded, resulting in a final sample of 342 respondents. In Zambia, we re-contacted 82.6% of the 18-month participants, resulting in a final sample of 195<\/u>.\u201d  All participants were enrolled into the COVID-19 module *after* country-level restrictions had gone into place. As noted in the paper, the COVID-19 survey module was conducted between September 2020-April 2021. All information about their contraceptive use at the beginning of the COVID-19 module is provided in Figure 1.  4.&nbsp;These points refer to slightly different groups. The former is those that switched or discontinued their methods *after* the date COVID-19 restrictions went into place and asks if respondents perceived that COVID-19 restrictions themselves impacted why they switched their method or discontinued. (5th paragraph in Results section and Table 2).  The group of 95 people discussed in the 8th paragraph of the Results section are all of those who reported not using contraception at the time of the COVID-19 survey module. This includes the 25 who discontinued a method, but also includes those who were not using a method before the restrictions and continued not using a method. The results described in this paragraph are specifically focused on those who were not using a method but wanted to use one (n=14) to determine whether COVID-19 impacted their ability to \n<i>re-start<\/i> using a method. We found that for the majority of those people, COVID-19 was not the main determining factor in access.  5.&nbsp;We have added mention in the Discussion that the more stringent lockdown in South Africa seemed to have a more severe impact on accessing FP services including access to LARC removal: &quot;\n<u>While overall minimal, we did find a slightly greater effect of COVID restrictions on FP access and use, including access to LARC removal, in South Africa compared to Zambia.&nbsp; This is likely because the lockdown measures in South Africa were more stringent than in Zambia, affecting access to and provision of methods<\/u>.&quot;   \n<u>Other thoughts<\/u>:  1.&nbsp;We have moved references to other studies from the Introduction to the Discussion.  2. We have combined the implant and IUD removal interest into LARC overall to align with Reviewer 2's concern about small n's and risk of disclosure. However, we have ordered Figure 3 and Table 3 such that South Africa and Zambia are presented consistently.","URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v2#referee-comment-3699","order":1,"name":"referee-comment-3699","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/gatesopenres.15906.r35216, Rebecca Geary, University of Liverpool, Liverpool, 03 Nov 2023, version 1, 3 approved with reservations","URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v1#referee-response-35216","order":2,"name":"referee-response-35216","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Alice Cartwright<\/b>; \n<i>Posted: 08 Jul 2024<\/i>; 1.&nbsp;In response to the reviewer\u2019s comment, we have included confidence intervals around the proportions in Tables 1, 2, and 3. However, we would still like to remind the reviewer that this was a descriptive study, and while we present results from South Africa and Zambia to provide some degree of comparison, the study was not designed to draw conclusions about statistically significant differences.  In response to the reviewer\u2019s second comment, we have removed specific n\u2019s from Tables 1, 2, and 3. In addition, for Figure 3 and Table 3, where the n\u2019s and proportions are very small, we have combined those seeking implant and IUD removal into overall LARC removal to avoid any risks of deductive disclosure.  2.&nbsp;For the sake of simplicity, we have not included a high level of detail about rates of participation in the ECHO and CUBE studies in this manuscript. We have acknowledged in the Notes to Table 1 the sources for the different pieces of information included. For timing of participation and other details on the methodology, we would refer the reviewer to these citations (included in the paper):  \n<u>ECHO study<\/u>: Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. Lancet Lond Engl. 2019;394: 303\u2013313. doi:10.1016\/S0140-6736(19)31288-7 \n<u>CUBE study<\/u>: Cartwright AF, Callahan RL, Beksinska M, Kasaro MP, Tang JH, Milford C, et al. Contraceptive Continuation and Experiences Obtaining Implant and IUD Removal Among Women Randomized to Use Injectable Contraception, Levonorgestrel Implant, and Copper IUD in South Africa and Zambia. Stud Fam Plann. 2023. doi:10.1111\/sifp.12222  3.&nbsp;We have added mention in the Discussion section that the more stringent lockdown in South Africa seemed to have a more severe impact on accessing FP services including access to LARC removal: &quot;\n<u>While overall minimal, we did find a slightly greater effect of COVID restrictions on FP access and use, including access to LARC removal, in South Africa compared to Zambia.&nbsp; This is likely because the lockdown measures in South Africa were more stringent than in Zambia, affecting access to and provision of methods<\/u>.&quot;","URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v2#referee-comment-3700","order":3,"name":"referee-comment-3700","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.21956\/gatesopenres.17563.r37482, Kamil Fuseini, Population Council, Accra, 27 Jul 2024, version 2, indexed","URL":"https:\/\/gatesopenresearch.org\/articles\/7-61\/v2#referee-response-37482","order":4,"name":"referee-response-37482","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This work was supported by the Bill & Melinda Gates Foundation (OPP1032115). This work was also supported by the United States Agency for International Development (USAID), provided to FHI 360 through Cooperative Agreement AID-OAA-A-15-00045 and Cooperative Agreement 7200AA19CA00041. This was also supported by the Swedish International Development Cooperation Agency (2017\/762965\u20130), the South Africa Medical Research Council, and the United Nations Population Fund. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":5,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}