The global epidemic of COVID-19 is wreaking havoc on a wide array of health, economic, social and personal decisions. However, what may be lost in the chaos among other effects and dangers is the specific impact on sexual and reproductive health and rights, both for people in the United States and around the world. Policymakers, providers and advocates must be aware of the broad links between the global outbreak response and sexual and reproductive health and rights in order to prepare to mitigate the impact.
Unlike the Zika virus outbreak, where sexual and mother-to-infant transmission were well-established, much less is known today about these potential transmission routes for COVID-19. In addition, the specific risk to pregnant women and their infants is not yet clear, but these groups are often particularly vulnerable to infectious disease threats. Therefore, many experts say an enhanced focus on primary prevention for pregnant women is warranted.
Health Care Systems
At the health system level, we may see shortages of medications—such as contraceptives, antiretrovirals for HIV/AIDS and antibiotics to treat STIs—due to disruptions in supply chains overall. China, the second-largest exporter of pharmaceutical products in the world, has shut down several drug-manufacturing plants, which has in turn caused delays at Indian factories that produce generic medicines.
Health care providers are being diverted to help address the epidemic while also being most at risk of acquiring the disease. This may create a shortage of clinicians who can provide sexual and reproductive health services and increase wait times for patients in need. In places that already have a limited number of providers, this will put an extreme strain on capacity to serve patients, especially for non-emergency care.
These impacts may be compounded by the diversion of financial resources to COVID-19 response, which would take funding away from reproductive health programs and decrease access for patients who rely on free or subsidized care. Likewise, the need for new precautionary equipment, training and protocols will further draw time and resources away from other work, including projects and programs related to sexual and reproductive health. This burden may not be distributed equally across the health care system, as certain facilities or geographic areas may be most impacted by the outbreak and need to take more focused action.
Economic Barriers to Care
In addition to barriers like waiting times and supply shortages, many people seeking sexual and reproductive health care may be stymied by broader economic and social hurdles. First, people may have reasonable fears of taking public transportation in the midst of an epidemic, and in serious situations, local authorities might suspend transit services. That could be a major obstacle to seeking reproductive health care for people without a car, particularly many low-income people.
Second, many people already face barriers to seeking health care if they cannot find or afford child care. In an epidemic, that situation may be worse: School and daycare closures might eliminate child care options, child care workers might become sick themselves, and many parents may not feel comfortable bringing a child to a health care appointment and risk exposure to the virus.
Third, and more generally, COVID-19 outbreaks may lead many workplaces to close, potentially affecting employees’ income. Particularly in countries that do not guarantee paid sick leave, like the United States and many in the developing world, people with low incomes may be unable to afford sexual and reproductive health care.
Reproductive Behavior
A major outbreak like this one has implications for people’s reproductive priorities and actions. For example, health authorities have recommended that people stock up on any needed prescription drugs and other crucial health care supplies, in case they have to stay home for an extended period. For many people, items like oral contraceptives, the contraceptive patch and ring, condoms, spermicide and lubrication will be important items on that list. However, building that stockpile might be difficult because of supply shortages and insurance practices that often limit reimbursement to just one month of prescription drugs at a time.
These sorts of barriers might lead some people to switch to a long-acting contraceptive, such as an IUD or implant. In the United States, there is clear recent precedent for this: There was a measurable surge in demand for IUDs in the wake of the 2016 presidential election, when many people feared that a repeal of the Affordable Care Act (ACA) and its contraceptive coverage guarantee was imminent.
Moreover, if pregnant women and infants are found to be at heightened risk from COVID-19—or if a large proportion of the public fears that may be the case—that may prompt some people to avoid having children and could lead to increased demand for contraceptive and abortion services. That was the case in many countries hit hard by the Zika virus in 2015 and 2016.
Ideological Attacks
The Trump administration has exacerbated this wide array of existing challenges by consistently pushing for reductions to domestic and international public health programs. While Congress has largely rejected these draconian cuts, legislators have also not scaled up funding to meet the demand for services or addressed the substantial unmet need left by decades of underfunded programs.
The administration’s policies on sexual and reproductive health and rights also intersect dangerously with an epidemic. For example, the domestic "gag rule" has reduced the Title X family planning system’s capacity to provide women with contraceptive services by at least 46%, with about one thousand clinic sites having left the network because of the policy’s restrictions on abortion referral and other abortion-related activities. Health centers no longer participating in Title X have reduced funding to deal with a crisis, and many of those still receiving Title X funding are struggling to fill the gap in family planning care.
Similarly, the global gag rule hampers the ability of foreign nongovernmental organizations to partner with the U.S. government to fill in gaps in sexual and reproductive health services created by the COVID-19 response. These organizations are vital to addressing the wide-ranging socioeconomic and health needs of women in other countries during the response and recovery, as well as to addressing the unique challenges of preventing and containing an outbreak in humanitarian settings.
More broadly, the Trump administration’s ongoing attempts to undermine the ACA and reshape Medicaid to better fit its conservative ideology have put the entire U.S. health insurance system on shaky footing in ways that may hamper the COVID-19 response. And the administration’s broadly discriminatory and xenophobic policies—including policies targeting people with low incomes, people of color, LGBTQ+ people and immigrants—will heighten the challenges of combatting an epidemic for communities that are already marginalized. In fact, given this administration’s coercive track record, advocates will need to guard against the possibility that it will seize the opportunity of COVID-19 to further restrict people’s fundamental rights and access to health care.