Opinion

Pandemic recovery plans must address gaps in reproductive health

The widespread economic and social disruptions precipitated by the COVID-19 pandemic have had far-reaching negative implications for reproductive health in multiple domains. Even as much of Canada turns toward pandemic recovery plans, we must ensure that these plans, and any mitigation strategies in response to future COVID-19 waves, address reproductive health for all of Canada.

Sexual and reproductive health. The pandemic has been a significant threat to sexual and reproductive health and rights globally. In Canada, reports throughout the pandemic suggest increased numbers of unintended pregnancies; restricted access to contraception and abortion resulting from reduced clinic hours; medication shortages; and travel-related barriers for individuals seeking care. Given additional barriers experienced by Indigenous and rural/remote communities to sexual and reproductive health care, COVID-19 related inequities have been exacerbated in these groups.

Pregnancy-related health. With the ongoing emergence of new variants, risks of severe COVID-19 in pregnancy have risen, with pregnant individuals experiencing higher risks of hospitalization, admission to intensive care units requiring ventilation and death compared to non-pregnant individuals. Fears about risks of COVID-19 to mothers and babies have also led to significant distress among pregnant individuals, with as many as 37 per cent of Canadians reporting depressive symptoms and 57 per cent reporting anxiety symptoms during pregnancy. While the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends that all pregnant individuals receive the COVID-19 vaccine, widespread disinformation continues to make decisions about COVID-19 vaccinations difficult for many pregnant and postpartum individuals.

Pregnancy and birth-related care. During much of the pandemic, a large proportion of in-person prenatal care visits transitioned to different modalities, including telephone and video-based care. Many individuals do not have the resources to access this type of care, particularly individuals experiencing poverty or homelessness, those living in rural/remote communities with inadequate internet infrastructure, d/Deaf individuals, and those who are non-English speakers. Anecdotally, many prenatal, postpartum and early parenting supports have been paused or have had a reduction in capacity, leaving families further isolated from critical supports. Pregnant individuals are faced with additional stressors during labour and birth, including the possible need to wear a mask during labour and limited access to support persons during the postpartum stay, particularly in regions with high COVID-19 incidence. Continuous labour support plays a critical role in promoting agency throughout labour, birth and the postpartum period and their absence may disadvantage already under-served groups.

Postpartum mental health. The postpartum period is a high-risk time for mental illness, impacting up to 1 in 5 women. COVID-19 response measures have restricted access to social support networks and key community programs, such as breastfeeding clinics, support groups and home visiting public health nurses that are essential for protecting against postpartum mental illness. In recent Canadian surveys, 33 per cent of women with infants under 18 months of age reported depressive symptoms and 36 per cent reported anxiety symptoms. Substance use has also been impacted, with 39 per cent of Canadian parents of young children reporting increases in their substance use during the pandemic.

Family and child health. Reproductive health includes supporting families to parent children in safe and sustainable communities, including meeting families’ economic, housing, food and other social needs. When a provincial state of emergency was declared, most child protection agencies across Ontario suspended all in-person family access for children in care. While not the case for children with shared custody between parents, families separated due to child protection concerns faced further isolation. Similar family separations were imposed on children living in congregate care settings. Socioeconomic vulnerability puts children and their families at higher risk of being involved with child protection systems. Child protection agencies across Canada highlight a marked decrease in reporting, raising concerns that many child protection needs may have been exacerbated by pandemic restrictions but under-reported due to decreased interaction between support agencies and families. At the same time, there are signs that children and families need increased support. The Kids Help Phone reported a 350 per cent increase in the number of young people contacting the help line about COVID-19 in the first two weeks of March 2020. Given the disproportionate rate of child welfare interventions experienced by Indigenous and Black communities, the lack of stable, accessible and community-based supports may exacerbate existing inequities in child and family outcomes.

Intimate partner violence. In March 2020, the United Nations issued a statement warning about a potential increase in rates of intimate partner violence during the pandemic, in parallel with rising economic uncertainty, social isolation and other stressors. The predicted increase in intimate partner violence has been observed in Canada; Canada’s Assaulted Women’s Helpline received 20,334 calls between Oct. 1 and Dec. 31, 2020, compared to 12,352 calls over the same period the previous year. A survey of more than 250 Indigenous women by the Native Women’s Association of Canada found that one in five women had experienced physical or psychological violence during the pandemic.

There is evidence of inequitable distribution of harms brought on by both the COVID-19 pandemic and policy interventions in response. This requires that equity and social justice perspectives be central to pandemic responses, including with respect to reproductive health.

The pandemic has required shifts and innovations in all aspects of health and social care.

Many communities living with economic and social vulnerability experienced poorer maternal and newborn outcomes prior to the pandemic while simultaneously being under-served by reproductive health supports; the impacts of the pandemic and the province’s response have exacerbated inequities, particularly for Indigenous, Black and other racialized communities. Other under-served communities, including individuals with disabilities, immigrants and refugees and those living in rural/remote communities are also disproportionately impacted, given pre-existing inequities in reproductive health.

The pandemic has required shifts and innovations in all aspects of health and social care. As Ontario and Canada turn toward pandemic recovery plans, this is an opportune moment to re-evaluate how the provision of sexual, reproductive, pregnancy and postpartum care can centre equity and evidence-based approaches, balancing our evolving understanding of the ongoing risks created by COVID-19 and what works best to support reproductive health. Our COVID-19 response and recovery must leverage innovations born out of necessity and address long-term reproductive health needs within communities across Canada.

  1. Leverage innovative approaches to supporting access to critical outpatient reproductive health services such as at-home medication-assisted abortion and access to contraception outside of hospital and clinic settings.
  2. Provide clear, accessible information about the risks and benefits of COVID-19 vaccination to all individuals of reproductive age, including non-pregnant, pregnant and parenting families.
  3. Adapt postpartum mental health supports to community needs, including culturally and community-specific needs, leveraging innovations in telehealth while also considering alternative solutions for those unable to access telehealth.
  4. Protect and promote significant family and cultural connections for all children, youth and pregnant and parenting families, paying particular attention to communities overrepresented in care, namely First Nations, Métis, Inuit, Black and LGBTQ2S+ Canadians.
  5. Integrate opportunities to proactively offer reproductive health services, including intimate partner violence screening and supports and preconception health consultations, into community-based service delivery.
  6. Address social determinants of health that impact all aspects of reproductive health and have been exacerbated by the pandemic, including economic stability, housing and food security.
  7. Sustain and/or increase support to community-based, regional and provincial organizations contributing to accessible and equitable reproductive health services and supports across Ontario.

Underlying all these efforts is the need to involve communities and community organizations, particularly from historically under-served populations, in policy and program decisions related to COVID-19 response, recovery and reproductive health.

As we continue to respond to the pandemic and move toward recovery efforts, we must address upstream contributors to reproductive health. This is an opportunity to reduce the burden of unmet social determinants of health on reproductive health outcomes while building a better future for all.

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Authors

The Ontario Public Health Association’s Reproductive Health Working Group addresses the many facets encompassing reproductive health with an eye toward impacting provincial systems to enhance reproductive health for Ontarians.

Hilary Brown

Cynthia Montanaro

Deanna Stirling

Joanne Enders

Joelle Chartrand

Mary Ann Gatbonton

Melissa Stewart

Michelle McDonald

Rachel McDougall

Pegeen Walsh

Anna Dion

Pegeen Walsh is the Executive Director of the OPHA. The other authors are members of the working group.

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