Women’s Health and COVID-19
Indeed, the COVID-19 pandemic disrupted health care delivery as we know it, often restricting access to routine health services. Women’s health was not immune to this disruption. In this month’s review, we discuss recent literature on inequities in women’s health during the COVID-19 pandemic.
The COVID-19 pandemic created substantial access barriers to office administered contraceptives such as the depot medroxyprogesterone acetate (DMPA)-intramuscular injection (IM). DMPA-subcutaneous could potentially serve as a more accessible alternative contraceptive as, although off label, it can be self-administered at home. Burlando and colleagues reviewed evidence on acceptability, safety, and continuation rates of DMPA-subcutaneous and disparities and implicit bias in contraceptive provision. Their review indicated DMPA-subcutaneous is safe and acceptable and has a 20% higher continuation rate compared to the in-office IM administration formulation. However, authors note pandemic-related pharmacy distribution supply chain issues often resulted in delayed or no access to the DMPA-subcutaneous formulation. Black women continue to be the primary audience for long-acting reversible contraceptives (LARC)-centered contraceptive counseling and the literature indicates that Black women often face resistance and barriers when attempting to discontinue LARC. Although these practices may be “unintended,” they can lead to inequities in care delivery. Authors’ experience-based recommendations for implementing DMPA-subcutaneous prescribing are provided in this month’s “Tools for the Toolkit.”
Tools for the Toolkit
|Recommendations for Implementing DMPA-Subcutaneous Prescribing|
|ALLIED HEALTH EDUCATION: Incorporate comprehensive contraceptive education, promote implicit bias awareness and teach the importance of shared decision making in all aspects of patient care.|
|PATIENT EDUCATION: Organize patient education materials to support clinical staff in teaching self-injection (in person and virtually).|
|PHARMACIST AWARENESS: Given that pharmacists may be unfamiliar with DMPA-subcutaneous, prescribers should consider including a prescription note clarifying rationale for prescribing DMPA-subcutaneous vs. IM, as well as written assurance the patient was educated in safe product use.|
|CONTRACEPTIVE ACCESS: 1. Providers should offer DMPA-subcutaneous as an alternative to DMPA-IM when discussing options with patients, prescribe it when chosen and provide support and education for ongoing use, 2. Professionals and staff should familiarize themselves with their patients’ most commonly used insurance plans and DMPA coverage and identify and use pharmacies that reliably stock this medication and 3. If the patient is present at the time of prescription, administer DMPA-IM during visit, allowing pharmacies a 3-month lead time to obtain the subcutaneous product.|
|ADVOCATE: Petition state-level insurance coverage of the subcutaneous formulation, support efforts to change U.S. FDA labeling of DMPA-subcutaneous for home administration.|
Given the observed disproportionate impact of COVID-19 on groups that have been historically marginalized and the known socioeconomic disparities in infertility care, Zhou and colleagues evaluated trends in infertility and assisted reproductive technology (ART) service utilization rates during the pandemic and whether patterns differed by age, income, or race and ethnicity. This evaluation applied a cross-sectional, interrupted times series study design and utilized OptumLabs Data Warehouse administrative claims data, which includes more than 200 million commercially-insured beneficiary data. Majority (73%) of beneficiaries’ socioeconomic data were obtained from public information. To evaluate the COVID-19 pandemic impact on infertility outcomes and estimate group effects while accounting for time trends and confounding, an interrupted time-series design with linear spline regression was used. To assess group differences, female age, race and ethnicity, and household income were analyzed using interaction terms. Analyses included data from 8,755,271 eligible women in the US. The decline and recovery in infertility care utilization rates varied by age. Recovery rates adjusted for race, ethnicity and income were not significantly different for women aged 35 to 37 and those aged 38 to 40 years (55.2 vs 46.8 per 10,000/y; P for interaction = .60). However, recovery rates were significantly higher when compared with women aged 18 to 34, 41 to 42, and 43 to 50 years (19.2, 28.8, and 8.4 per 10,000/y, respectively; P for interaction < .001 for ages 18 to 34 years and ages 43 to 50 years, P for interaction = .005 for ages 41 to 42 years). Pre-COVID-19 pandemic, ART utilization rate was highest among Asian women (19.1 per 10,000), followed by White, Black, and Hispanic women (9.2, 5.3, and 4.5 per 10,000, respectively; P < .001). The recovery rate post-recommended infertility care suspension (April 2020) was faster for Asian women compared with White women (105.6 vs 40.8 per 10,000/y; P for interaction < .001). ART utilization rate pre-COVID-19 pandemic was positively associated with income, however, changes in utilization rates over time did not vary by group.
Pregnancy and Childbirth
Karasek and colleagues examined 1) the prevalence of COVID-19 diagnosis in pregnancy, 2) the association of COVID-19 diagnosis with very preterm birth (VPTB), preterm birth (PTB), early term birth, and 3) differences in these outcomes by socioeconomic status, and 4) whether additional risk for adverse outcomes is conferred by comorbidities, including preexisting and gestational hypertension, diabetes, and obesity. California Vital Statistics birth certificates were used to determine gestational age and COVID-19 diagnosis. Best obstetric estimate of gestational age was used to classify births VPTB (<32 weeks), PTB (< 37 weeks), early term (37 and 38 weeks), and term (39-44 weeks). This retrospective cohort study used the Cochrane-Armitage test for trend to identify significant changes in COVID-19 diagnosis rates over time. Relative risks (RRs) were modeled using log-link binary regression with robust standard errors. Descriptive statistics were reported for cell sizes of 5 or greater for people with versus without SARS COV-2 infection. Joint effects of COVID-19 diagnosis, and comorbidities of hypertension, diabetes, and obesity on VPTB, PTB and early term birth were computed. Findings indicated increase in COVID-19 diagnosis from July 2020 – January 2021 was highest for American Indian/Alaska Native (12.9%), Native Hawaiian/Pacific Islander (11.4%), and Latinx (10.3%) birthing people. COVID-19 diagnosis was associated with an increased risk of VPTB (aRR 1.6, 95% CI [1.4, 1.9]), PTB (aRR 1.4, 95% CI [1.3, 1.4]), and early term birth (aRR 1.1, 95% CI [1.1, 1.2]). No effect modification was observed for overall association by race/ethnicity or insurance status (proxies for socioeconomic status). COVID-19 diagnosis was associated with elevated risk of PTB in people with hypertension, diabetes, and/or obesity.
The authors conclude with emphasizing the need to adopt equitable strategies to address systemic and structural barriers that exclude groups that have been historically marginalized from optimum access to and utilization of care. The authors recommend prioritizing efforts such as policy protections, prioritized vaccination, rent control, and economic supports to reduce the impact of the COVID-19 pandemic and risk of infection amongst these groups.