Mukherjee et al.

Reproductive Health (2021) 18:252

https://doi.org/10.1186/s12978-021-01286-6

REVIEW Open Access

Reproductive justice in the time

of COVID‑19: a systematic review
of the indirect impacts of COVID‑19 on sexual
and reproductive health
Trena I. Mukherjee1* , Angubeen G. Khan2, Anindita Dasgupta3 and Goleen Samari4

Abstract
Objective: Despite gendered dimensions of COVID-19 becoming increasingly apparent, the impact of COVID-19 and
other respiratory epidemics on women and girls’ sexual and reproductive health (SRH) have yet to be synthesized. This
review uses a reproductive justice framework to systematically review empirical evidence of the indirect impacts of
respiratory epidemics on SRH.
Methods: We searched MEDLINE and CINAHL for original, peer-reviewed articles related to respiratory epidemics
and women and girls’ SRH through May 31, 2021. Studies focusing on various SRH outcomes were included, however
those exclusively examining pregnancy, perinatal-related outcomes, and gender-based violence were excluded due
to previously published systematic reviews on these topics. The review consisted of title and abstract screening, full-
text screening, and data abstraction.
Results: Twenty-four studies met all eligibility criteria. These studies emphasized that COVID-19 resulted in service
disruptions that effected access to abortion, contraceptives, HIV/STI testing, and changes in sexual behaviors, men-
struation, and pregnancy intentions.
Conclusions: These findings highlight the need to enact policies that ensure equitable, timely access to quality SRH
services for women and girls, despite quarantine and distancing policies. Research gaps include understanding how
COVID-19 disruptions in SRH service provision, access and/or utilization have impacted underserved populations and
those with intersectional identities, who faced SRH inequities notwithstanding an epidemic. More robust research is
also needed to understand the indirect impact of COVID-19 and epidemic control measures on a wider range of SRH
outcomes (e.g., menstrual disorders, fertility services, gynecologic oncology) in the long-term.
Keywords: COVID-19, Reproductive health, Sexual health, Gender, Health inequity, Abortion, Contraceptives

Plain English summary

The impact of respiratory epidemics, like COVID-19 on women and girls’ sexual and reproductive health (SRH) is not
yet known. This review applies a reproductive justice framework, to systematically review the impact of respiratory

*Correspondence: [email protected]
1
Department of Epidemiology, Mailman School of Public Health,
Columbia University, New York, NY, USA
Full list of author information is available at the end of the article

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Mukherjee et al. Reproductive Health (2021) 18:252 Page 2 of 25

epidemics on SRH, in order to examine the impact of COVID-19 on equitable, sustained access to quality SRH services
for all populations. This framework highlights the right to reproductive autonomy, including the right to have an abor-
tion, conceive, bear and raise children; and is inclusive of the intersectionality of race, class and gender. This review
includes original, peer-reviewed research related to COVID-19 and women and girls’ SRH through May 31, 2021, and
consisted of title and abstract screening, full-text screening, and data abstraction. Overall, twenty-four studies met eli-
gibility criteria. Results emphasize that the COVID-19 pandemic resulted in service disruptions that effected access to
abortion, contraceptives, HIV/STI testing, and changes in changes in sexual behaviors, menstruation, and pregnancy
intentions. These findings highlight the urgent need to enact policies that ensure equitable, timely access to quality
SRH services for women and girls, despite pandemic response policies. This review also highlights opportunities to
better understand how COVID-19 related disruptions in SRH service provision, access and/or utilization have impacted
underserved populations and those with intersectional identities, who faced SRH inequities prior to the COVID-19
pandemic. More research is needed to understand the indirect impact of COVID-19 and epidemic control measures
on a wider range of SRH outcomes (e.g., menstrual disorders, fertility services, gynecologic oncology) in the long-term.

Background will result in declines in short- and long-acting reversible

As the COVID-19 pandemic continues to take lives contraceptive use, and increases in unintended pregnan-
worldwide, an understanding of the short- and long-term cies and unsafe abortions [14]. Conservative estimates of
consequences of the pandemic on women’s and girls’ sex- the impact of service disruptions at Marie Stopes Interna-
ual and reproductive health (SRH) is critical [1, 2]. Global tional-affiliated health facilities across 37 countries suggest
responses, lockdowns, and travel restrictions converge that the COVID-19 pandemic could result in 1.3 million
with pervasive, existing health inequities and injustices unintended pregnancies, 1.2 million unsafe abortions, and
to disproportionately impact the health, wellbeing, and 5000 pregnancy-related deaths [6]. Therefore, it is crucial to
economic stability of women and girls [3]. The indirect apply a reproductive justice framework to ensure equitable,
consequences of COVID-19 control may be overlooked sustained access to quality SRH services for all populations
in the immediate need to mitigate transmission, and throughout the duration of the COVID-19 pandemic. This
SRH-related morbidity and mortality will not become framework highlights the right to reproductive autonomy,
apparent for years to come. Several commentaries have including the right to have an abortion, and to conceive,
discussed the disruptions to SRH care provision that pro- bear and raise children; and is inclusive of the intersection-
viders and family planning clinics experienced [1, 2, 4, ality of race, class and gender [15, 16].
5]; including interruptions to the supply and provision of Despite hypothesized impacts, empirical evidence of the
contraception, abortion and post-abortion care, a decline indirect impacts of the COVID-19 pandemic on women
in the number of patients served due to inaccessibility, and girls SRH have yet to be synthesized. We apply a
and reduced client engagement as lockdowns and travel reproductive justice framework to systematically review
restrictions went into effect [6]. empirical evidence on the indirect impacts of the COVID-
In light of the efforts to exclude SRH from essential health 19 pandemic on women and girls’ SRH, in order to iden-
services during COVID-19 [1–3, 7], an understanding of the tify the observed effects of COVID-19 and the pandemic
impact of the COVID-19 pandemic on SRH is critical for response on SRH; and to highlight SRH disparities for mar-
informing future actions and policies that prevent adverse ginalized women and girls who are all too often overlooked
SRH outcomes and comorbidities. Evidence from the SARS, and underserved.
MERS and Ebola pandemics envisage that the populations
for whom human rights are least protected and most vio- Main text
lated (e.g. women/girls, youth, poor people, immigrants,
racial/ethnic minorities) will experience severe, unique dif- Methods
ficulties and differentially die from COVID-19 [8, 9]. Even A protocol with search terms was developed in consul-
prior to the COVID-19 pandemic, African American/Black, tation with and approved by a trained systematic review
Latinx, immigrant, and women and girls with lower socio- specialist at Columbia University. Respiratory illness
economic status experienced greater SRH disparities [10– related search terms included “pandemic, epidemic, out-
13]. The restrictions on movement disproportionately affect break, influenza, COVID-19, coronavirus, 1918 Flu, Mid-
marginalized populations, and simulation studies estimate dle Eastern Respiratory Syndrome, MERS, Severe Acute
that COVID-19 related disruptions in essential SRH care Respiratory Syndrome, SARS, Swine Flu, and H1N1.”
Mukherjee et al. Reproductive Health (2021) 18:252 Page 3 of 25

Outlined by the reproductive justice framework [15, 16], criteria were assessed for methodological quality and
with a focus on reproductive autonomy, including the risk of bias using the Quality Assessment Tool for Stud-
right to have an abortion, and to conceive, bear and raise ies with Diverse Designs (QATSDD) as it enables review
children, SRH search terms included “preventative and of studies with similar research questions, but different
curative care related to pregnancy, fertility, contracep- study designs. The QATSSD has shown good reliability
tion, sexually transmitted infection (STI), reproductive and validity for quantitative and qualitative study designs
cancers and other reproductive morbidities, gender- [29, 30]. The QATSDD consists of 16-items (4-items are
based, gender inequities, women’s health, sexual health, for quantitative or qualitative studies only) that are rated
reproductive health, obstetric, gynecol*, pregnancy, fer- on a 4-point Likert Scale. Total scores range from 0 to
tility, contracepti*, abortion, family planning, STI/STD, 42, with higher scores indicating higher quality research.
sexual violence, maternal health, reproductive coercion, Scores were converted into a percentage, and those scor-
maternal mortality, reproductive justice, menstrual ing > 60% were rated as high-quality studies, whereas
hygiene, and reproductive tract infection.” those scoring ≤ 60% were rated as lower quality studies
Peer-reviewed studies published until May 31, 2021 [31]. TM and AK independently reviewed and rated each
were included from journals across MEDLINE via Pub- study for risk of bias. Any disagreements were discussed
Med and CINAHL (PsychINFO, Gender Studies Data- until an agreement was reached.
base, Violence & Abuse, Women’s Studies International).
Inclusion criteria included respiratory illness epidemic Results
and an outcome explicit to women and girls’ SRH. Popu- The search returned 2913 unique articles for title and
lations could have been diagnosed with, exposed to, or abstract review, of which 88 met eligibility criteria and
impacted by public health responses (i.e., service disrup- were included for full text review (Fig. 1). Twenty-
tions, lockdowns, etc.) to respiratory epidemics or pan- four articles met all eligibility criteria after full review
demics. Studies also had to have abstracts, full-texts and (Tables 1, 2). Most (n = 22, 92%) were quantitative,
be published in a peer-reviewed journal. Articles without with over half using cross-sectional (n = 13, 55%) study
English translation, opinion pieces, commentaries, guide- designs. The majority of studies were published in the
lines and simulation/modelling studies were excluded. global North (n = 16, 67%), and all examined the impact
Those addressing non-respiratory epidemics (i.e., obe- of COVID-19. No studies examined the impact of the
sity, opioid, HIV, etc.) and those that failed to examine 1918 Flu, H1N1 and SARS or Middle Eastern Respira-
SRH outcomes beyond vaccine interest and/or the psy- tory Syndrome (MERS) on non-pregnancy related SRH
chological and emotional impact of the pandemic among outcomes. One-third of studies examined SRH outcomes
pregnant women were excluded. Although pregnancy related to abortion (n = 8, 33%), one-quarter examined
and birth-related outcomes, gender-based violence, changes in service provision (n = 6, 25%), while oth-
and maternal and child health fall within the realm of ers examined contraceptive access or utilization (n = 5,
reproductive justice, studies exclusively examining these 21%), sexual behavior (n = 4, 17%), pregnancy intentions
outcomes were excluded, as systematic reviews includ- (n = 3, 13%), and menstrual cycle changes (n = 2, 8%).
ing these topics have been recently published elsewhere The majority (n = 14, 58%) of studies were rated as having
[17–28]. Studies could have been published in any coun- low methodological quality based on the total QATSDD
try including low, middle, and high-income settings, and score, with total scores ranging from 31 to 88%.
there was no restriction on study publication dates.
The review consisted of screening: (1) titles, (2) Abortion
abstracts, (3) full-texts, (4) data abstraction, and (5) criti- The majority of abortion-related studies report results
cal appraisal of study bias. Each phase was completed exclusively from the US (n = 6, 75%). Across the US,
independently by study authors. Title, abstract, and full the overall number of abortions decreased, how-
text screening of eligible articles were completed by TM, ever, demand for self-managed medication abortions
AK, AD, and GS. Study data (author, study type, epi- increased during pandemic-related lockdowns and in
demic, SRH outcome and major findings) were abstracted the period immediately following lockdown. This was
by AK and TM. Data-screening procedures were applied especially pronounced in states with greater stay-at-
according to the eligibility criteria. At the data abstrac- home orders, or in states with more restrictive abortion
tion stage, reviewers used data collection forms to policies [32]. The need for in-person visits for medica-
capture the primary epidemic and primary outcome tion abortion decreased from two visits among most
measure(s), in addition to supplementary information providers (71%) to no in-person visits among 50% of
on study design, sampling/data sources, analytical meth- abortion providers surveyed across the US [33]. Tel-
ods, and effect estimates. Studies that met all eligibility emedicine, with in-person medication pick up or mail
Mukherjee et al. Reproductive Health (2021) 18:252 Page 4 of 25

Records identified through database Additional records identified

searching through other sources
n = 4106 n = 37

Records after duplicates removed

n = 2913

Records screened Records excluded

n = 2913 n = 2825

Full-text articles assessed Full-text articles excluded

for eligibility n = 64
n = 88
No SRH outcome (n=29)
No respiratory epidemic (n=18)
No methods (n=17)

Studies included in
qualitative synthesis
n = 24

Fig. 1 Study selection process

order was found to be acceptable during the pandemic reported fewer women accessing abortion services,
in Hawaii, and was found to have high rates of suc- and fewer policy changes deeming SRH as essential to
cess, follow-up retention and very little complications increase access to abortion or contraceptives during the
[34]. In a separate study of 103 abortion clinics across pandemic [38]. A study in Nepal reported decreased
the US, several providers reported having to postpone, demand for abortions during COVID-19 lockdown,
cancel or temporarily close their clinics due to staff which later increased once lockdowns were eased.
being sick with probable COVID-19, COVID-19 related Women who did receive abortions came in at a later
travel restrictions, or caregiving responsibilities, espe- gestational period and reported living closer to a health
cially in the Southern states [35]. In Texas, an executive facility [39].
order postponing all unnecessary medical procedures
(including abortion) prohibited most abortion proce- Contraceptive access & utilization
dures. Consequently, the total number of abortions fell All studies examining the impact of the COVID-19
by 38%, the number of out of state abortions increased pandemic and associated lockdowns on contraceptive
by over 500%, and medication abortions increased by access and utilization reported substantial decreases.
41% [36]. Similarly, the number of medication abor- Nearly all SRH-related clinicians, researchers and prac-
tions peaked at the height of COVID-19 in other states titioners surveyed from 29 different countries reported
with restrictive abortion policies (Ohio, Kentucky & that access to contraceptives and other SRH-related
West Virginia) [37]. services decreased, primarily due to the prioritization
Similarly, the number of surgical and medication of the pandemic response over SRH. A few respond-
abortions decreased globally, due to fear of COVID- ents from high-income countries reported that the
19, lack of transportation and access to pharmacies. pandemic provided an opportunity to expand access
Moreover, countries with restrictive abortion policies to medication abortion, through telehealth services
Mukherjee et al. Reproductive Health (2021) 18:252 Page 5 of 25

Table 1 Summary of studies included (N = 24) decreased. The decrease was sustained in the 4-weeks
Characteristic n (%)
post-lockdown [41]. Pandemic related lockdowns con-
tributed to a 20% decrease in contraceptive uptake in
Study design rural Mozambique. Once the lockdown was eased,
Quantitative 22 (91.7) however, contraceptive referrals by community health
Cross-sectional 13 (54.2) workers increased by 18%. Moreover, uptake increased
Longitudinal 3 (12.5) by 47% among women who were not currently using
Quasi-experimental 2 (8.3) contraceptives, and by 80% by women who did not have
Retrospective 4 (16.7) phone access, and were likely of lower socioeconomic
Mixed methods 2 (8.3) status [42].
Sample size In Northern Italy, where the majority of respondents
None given 1 (4.2) reported using short-acting reversible contraceptives
1–100 7 (29.2) (SARC), half of all women who were not married/co-
101–1000 10 (41.6) habiting discontinued their SARC during COVID-19
> 1000 6 (25.0) [43]. Of these, one-third reported an unintended preg-
Region (as defined by WHO) nancy and sought an abortion. In Turkey, respondents
Africa 1 (4.2) reported a 14% decrease in contraceptive use, despite
Americas 11 (45.8) decreased desire for pregnancy, and increased sexual
South-East Asia 1 (4.2) intercourse and menstrual disorders during COVID-
Europe 5 (20.8) 19 [44]. In China, 9% of young women reported expe-
Eastern Mediterranean 0 (0.0) riencing a shortage in contraceptives [45]. Similarly,
Western Pacific 2 (8.3) few women (9%) reported difficulties accessing contra-
Global 2 (8.3) ceptives in Australia, however, nearly a quarter (22%)
Respiratory epidemic reported unmet SRH-related needs, which include
COVID-19 24 (100) needing to access general practice, SRH specialist pro-
­ utcomea
Primary SRH o viders, pharmacies, hospitals, or counseling services
Abortion 8 (33.3) [46]. In Nepal, 48% of women seeking safe abortion
Contraceptive access/utilization 5 (20.8) services reported an increased need for contraception,
Menstruation 2 (8.3) with 23% not using contraceptives due to inaccessibility
Service provision 6 (25.0) because of lockdowns [39]. The type of contraceptive
Sexual behavior 4 (16.7) was not noted in these studies, however.
Pregnancy intentions 3 (12.5) Only one study reported racial/ethnic disparities in
QATSDD contraceptive access. In the US, Black/African Ameri-
High 10 (41.7) can, Latinx and Multi-racial respondents reported
Low 14 (58.3) experiencing greater housing, transportation and food
SRH sexual and reproductive health; COVID-19 coronavirus disease 2019,
insecurity, when compared to White respondents. Pov-
WHO World Health Organization; QATSDD Quality Assessment Tool for Studies erty related factors of housing, transportation and food
with Diverse Designs insecurity were found to be associated with an 86%
a
May not equate to 100% due to multiple outcomes
greater difficulty in accessing contraceptives [47].

[38]. In the US, most family planning providers (91%)

Menstruation
reported providing telemedicine services for contra-
Only one study explicitly examined menstrual cycle
ceptive counseling and prescriptions throughout the
changes [48], with almost half of all respondents report-
pandemic, with over half (53%) making referrals to a
ing missed periods, with decreases and higher vari-
minority of patients for in-person services for LARC
ability in cycle length. Yuksel et al. similarly report a
insertion/removal, Depo-Provera injections or other
16% increase in menstrual disorders among survey
contraceptive-related issues [40]. An ecological study
respondents in Turkey [44]. The reason for menstrual
using insurance data from a national database in France
cycle changes was not reported in either study, and it is
found that prescriptions of contraceptives and of ovu-
not clear whether these changes were due to pandemic
lation indicators initially increased by 47% and 16% in
related lockdowns or COVID-19 infection.
the first 2-weeks of lockdown, but then substantially
Table 2 Study characteristics
Author(s) Methods Sample Epidemic SRH outcome Major findings

Aiken et al. [32] Quantitative; Quasi-experimental Individuals seeking online abortion tele- COVID-19 Abortion • From March 20–April 11, 2020 (’after’
medicine services in the US between Jan COVID-19), there was a 27% increase in
1, 2019 and April 11, 2020 (n = 49,935) requests for self-managed medication
abortion across the US
• States with significant increases in
requests had higher rates of stay-at-home-
behaviors, especially high rates of COVID-
19, and/or more severe COVID-19 related
restriction on in-clinic abortion access
Mukherjee et al. Reproductive Health

Aryal et al. [39] Quantitative; Cross-sectional Women provided with safe abortion COVID-19 Abortion • COVID-19 pandemic related lockdowns
services between April—June 2020 reduced the number of women coming in
(lockdown period) and July–September for abortions by 25.7%. Additionally, 47.1%
2020 (lockdown eased) in western Nepal more women came in for an abortion later
(n = 52) in the pandemic, when pandemic related
restrictions eased, compared to earlier in
(2021) 18:252

the pandemic, with strict lockdowns

• Women who came in for an abortion ear-
lier in the pandemic had a later period of
gestation compared to women who came
in when restrictions eased (9.5 weeks vs
7.5 weeks; p = 0.049). Distance from health
facility was also significantly associated
with accessibility to the health facility, with
women who lived more than 5 h from the
facility not seeking an abortion early in the
pandemic (p = 0.021)
• Finally, 48% of all women enrolled in
the study reported an increased need for
contraception, with 23% of women not
using contraceptives due to inaccessibility
due to lockdowns
Caruso et al. [43] Quantitative; Cross-sectional Women who use hormonal contracep- COVID-19 Contraceptive utilization • Two-thirds of participants used short-
tives and were registered at a family acting reversible contraceptives (SARC;
planning clinic in Italy (n = 317) oral contraceptive pill = 53.3%; vaginal
ring = 14.2%) and one-third of participants
used long-acting reversible contracep-
tives (LARC; subdermal implant = 19.2%);
IUD = 13.2%)
• 70% of women used contraceptives to
avoid unplanned pregnancies; 30% used
contraceptives for additional non-contra-
ceptive benefits
• Women who married or co-habiting
continued to use contraceptives and had
no unplanned pregnancies
• Half of all women (n = 51) who were not
co-habiting discontinued SARC; half con-
tinued to engage in sexual activity (n = 47)
and 15% (n = 15) had an unplanned preg-
nancy, for which they sought abortion
Page 6 of 25
Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings

Coombe et al. [46] Mixed methods; Cross-sectional Australian women of reproductive age COVID-19 Pregnancy intentions & access to • Most participants (76%) indicated that
(18–49 years) (n = 518) contraceptives they were trying to avoid pregnancy
• Nearly 20% of women were not using
any contraception. Of those that were, the
oral contraceptive pill was the most com-
mon (21%) method
• When asked about SRH access during
lockdown, only 9% reporting difficulties
Mukherjee et al. Reproductive Health

accessing contraception. For some this

was due to shortages in their preferred
method, difficulty obtaining a doctor’s
appointment, fear of leaving the house
due to COVID-19, or privacy concerns.
Women that were unemployed reported
greater difficulty accessing contraceptives
(2021) 18:252

(OR: 2.5 (1.1- 5.0)). Nearly a quarter (22%) of

women reported needing to access SRH-
related healthcare, with little difference by
socio-demographics
• Most participants indicated that the
COVID-19 pandemic had not changed
their pregnancy intentions, however, some
women indicated that they had actively
stopped trying during the pandemic, or
that they were unable to continue trying
to conceive due to cancellations of IVF or
other reproductive services
Dell’Utri et al. [50] Quantitative; Retrospective cohort Medical records data of women admit- COVID-19 Obstetric and gynecological service • Compared to the reference year (2019),
ted for obstetric and gynecological provision registered admissions during stay-in-place
emergency services at the largest mater- measures in 2020 decreased by 35.4%
nity clinic in Milan, Italy between Feb (34.1 to 36.6), with the highest reduction
23-June 24 in 2019 and 2020 (N = 9291) corresponding to the maximum increase
of newly infected cases
• The decrease was nearly double among
Italians, compared to foreign women, with
no decrease observed among African
women
• There was a 63.5% (60.5 to 66.5)
reduction in gynecological complaints,
particularly for admissions for vulvovaginal
infections, urogynecological conditions
and/or cystitis (− 75.7% (71.4 to 80.1);
menorrhagia/atypical blood loss (− 41.4%
(− 31.7 to 51.1); and pelvic inflammatory
disease (− 61.5% (− 35.1 to 88.0)
Page 7 of 25
Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings

Endler et al. [38] Quantitative; Cross-sectional SRH-related clinicians, researchers and COVID-19 Contraceptive access & abortion • Nearly all (86%) reported that access
practitioners from 29 countries (n = 51) to contraceptives decreased during the
COVID-19 pandemic, whereas 62% and
46% of respondents reported decreases in
surgical and medical abortion, respectively
• The highest perceived barriers to abor-
Mukherjee et al. Reproductive Health

tion access were fear of COVID-19 infec-

tion, lack of transportation, and closed
pharmacies. Most respondents indicated
that SRHR services decreased due to the
prioritization of the COVID-19 pandemic
response, or that the pandemic was an
(2021) 18:252

excuse to pause, ignore or dismantle any

progress made toward advancing SRHR.
A few exceptions were made in high-
income countries, where the pandemic
provided an opportunity to advance
access to SRHR
• Compared to countries with mildly
restrictive abortion policies, countries
with severely restrictive abortion policies
reported less women accessing SRH-
related services (69% vs 23%; p = 0.026);
no abortion policy changes (69% vs 0%);
p < 0.001); and decreased contraceptive
policy changes (88% vs 46%; p = 0.023)
Fuchs et al. [53] Quantitative; Longitudinal Sexually active women between the COVID-19 Sexual behavior • Total sexual function as measured by
ages of 18–40 years (n = 764) in Poland the Female Sexual Function Index (FSFI)
significantly decreased (30.1 (4.4) vs 25.8
(9.7)) during the COVID-19 pandemic.
Decreases were seen across every FSFI
domain (desire, arousal, lubrication,
orgasm, satisfaction, and pain)
• Sexual dysfunction (FSFI score < 26)
increased during COVID-19 control meas-
ures (15.3% vs 34.3%)
• Frequency of sexual intercourse declined
due to isolation, conflict with partner and
mental health (stress, anxiety, depression)
• Less educated women, those with worse
living conditions, women who did not
work, women living with their parents
or those in informal relationships experi-
enced lowest sexual functioning
Page 8 of 25
Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings
Mukherjee et al. Reproductive Health

Kerestes et al. [34] Quantitative; Retrospective cohort Patients who had medication abortion COVID-19 Abortion • A total of 334 patients received medica-
up to 77 days gestation between April tion abortion, of which 149 (45%) received
and November 2020 in Hawaii (n = 334) telemedicine with in-person pickup of
medications, 75 (23%) received telemedi-
cine with medications mailed, and 110
(33%) received traditional in person visits
(2021) 18:252

• The rate of complete medication abor-

tion without surgical intervention was
96%, with success rates of 97%, 97%, and
94% for the clinic pickup, mail, and clinic
visit groups, respectively
• Success rate for those with and without
an ultrasound prior were similar (96% vs
97%), and 88% of patients returned for
follow up care. Very few women (17; 5%)
experienced any complications
Leight et al. [42] Quantitative; Quasi-experimental n = 109,129 women served by n = 132 COVID-19 Access to contraceptives • COVID-19 related lockdowns and disrup-
unique promoters (community health- tions were associated with a decrease in
care workers) and 192 unique public contraceptive receipt (OR 0.798, 95% CI
health facilities in Nampula and Sofala, [0.701–0.908], p = 0.001)
Mozambique between January 21—May • Easing lockdown restrictions was associ-
20, 2020 ated with an increase in contraceptive
referrals (OR 1.187, 95% CI [1.034, 1.354],
p = 0.015), especially amongst women
who were not currently using contracep-
tives (OR 1.490, 95% CI [1.203, 1.841],
p < 0.001); and in contraceptive receipt
(OR 0.777, 95% CI [0.660, 0.913], p = 0.002),
especially among women with phone
access (OR 1.800, 95% CI [1.469, 2.205],
p < 0.001)
Page 9 of 25
Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings

Li et al. [45] Quantitative; Cross-sectional Young citizens between the ages of COVID-19 Sexual behavior & service provision • COVID-19 control measures resulted
18–35 years who reported having decrease in sexual desire (20%), frequency
Mukherjee et al. Reproductive Health

sexual intercourse in the 6 months prior of sex (41%), alcohol consumption before
(n = 967) in China or during sexual activities (20%), and risky
sexual behavior (10%), partner deteriora-
tion (31%)
• Partner relationships were influenced
by housing (aOR: 0.59; 95% CI 0.30–0.86),
(2021) 18:252

exclusivity (aOR 0.44; 95% CI 0.27–0.73);

sexual desire (aOR 2.01; 95% CI 1.38–2.97);
and sexual satisfaction (aOR 1.92; 95% CI
1.54–2.50)
• Although the numbers were small, par-
ticipants reported difficulties in accessing
reproductive health services:
Women with recent abortions described
difficulties making appointments
Participants with STIs described difficul-
ties obtaining a doctor’s appointment and
in accessing medications
8.9% reported experiencing a shortage of
contraceptives
Lin et al. [47] Quantitative; Cross-sectional Women between the ages of 18–49 year COVID-19 Pregnancy intentions & access to • Compared to White respondents, Latinx
who reside in the US between May 16 contraceptives (OR 4.01 (2.25–7.15)), Black/African Ameri-
and June 16, 2020 (n = 554) cans (OR 3.92 (1.81–8.50)) and Multiracial
(OR 2.12 (1.10–4.07)) respondents reported
higher odds of inability to afford food,
transportation, and/or housing during
the pandemic; and Hispanics/Latinx [1.95
(1.12–3.40)] reported higher odds of food
insecurity
• Inability to afford food, transportation,
and/or housing was associated with a
decreased desire for pregnancy [OR 2.13
(1.32–3.43)], and greater difficulty access-
ing contraceptives (OR 1.86 (1.06–3.24)
Page 10 of 25
Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings

Luetke et al. [54] Quantitative; Cross-sectional Nationally representative weighted COVID-19 Sexual behaviors • One-third of participants (34%) reported
sample of partnered men and women some degree of COVID-related conflict
with their romantic partners
Mukherjee et al. Reproductive Health

(n = 742) in the US
• Compared to those experiencing no
conflict, those with any conflict reported
decreased odds of intimate behavior:
hugging, kissing, holding hands, cuddling
(aOR: 2.35, 95% CI 1.58–3.50); giving/
receiving oral sex (aOR: 2.34, 95% CI
(2021) 18:252

1.36–4.02); intercourse (aOR: 2.28, 95% CI

1.40, 3.73)
• There was a dose–response curve
between conflict and intimate/sexual
behaviors; and those that reported more
conflict exhibited less sexual behaviors
Mello et al. [37] Mixed methods; Policy analysis & Cross- Abortion health facilities in Ohio, Ken- COVID-19 Abortion • Despite federal regulations encouraging
sectional quantitative survey tucky & West Virginia (n = 14) the utilization of medication abortions in
the US, state laws governing medication
and telemedicine abortion in Ohio, Ken-
tucky and West Virginia remained in effect
throughout 2020 and barred patients from
receiving medication abortions by mail
• Surveys with abortion facilities indicate
that an average of 2107 abortions were
performed monthly between December
2019 and December 2020, 42% (n = 893)
of which were medication abortions
• Coinciding COVID-19 pandemic related
disruptions and executive orders, the
number of total (n = 2306) and medica-
tion abortions (n = 1613; 70%) peaked in
April 2020 and returned to pre-pandemic
levels by June 2020. The peak is most stark
for Ohio (72%, vs 40% average) and West
Virginia (87%, vs 49% average); whereas
Kentucky sees only a slight increase (55%
vs 50% average)
Page 11 of 25
Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings
Mukherjee et al. Reproductive Health

Micelli et al. [55] Quantitative; Cross-sectional Italian men and women in long-term COVID-19 Pregnancy intentions • Of the 18% participants who were plan-
relationships between the ages of ning to have a child before the pandemic,
18–46 years (n = 1482; ­nwomen = 944, 37% abandoned the intention because of
­nmen = 538) worries about future economic difficulties
(58%) and consequences on pregnancy
(58%)
• Of 82% who did not intend to conceive,
(2021) 18:252

12% revealed a desire for parenthood

during quarantine than before (p < 0.01),
related to will for change (50%) and need
for positivity (40%). 4.3% of these tried to
get pregnant
• Stratifying by age, a trend toward older
ages was found in the desire for parent-
hood before and during the COVID-19
pandemic (p < 0.05)
Nagendra et al. [49] Quantitative; Cross-sectional Convenience sample of individuals on COVID-19 Service provision • Majority of clinics providing sexual health
the NYC STD PTC educational mailing services indicated a significant decrease
list and key partners from state and local in the regular services they were able to
health department (N = 73, ­nNew York = 61, provide, except for expansion in telehealth
n = 12 from Indiana, Ohio, Michigan, services
New Jersey, Puerto Rico, or United States • Only 25% of the clinics that offered
Virgin Islands) pregnancy termination and 18% of clinics
(n = 11) that offered STI testing services
before March 1, 2020, could do so as of
April 1, 2020
• 80% of clinics have resorted to treating
STIs presumptively based on symptomol-
ogy, before testing, due to the COVID-19
outbreak in the US
• As of April 1, 2020, only 25% of respond-
ents located in NYS and 26% outside of
NYS are able to offer HIV testing
Page 12 of 25
 Mukherjee et al. Reproductive Health

Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings

Phelan et al. [48] Quantitative; Cross-sectional Women of reproductive age, globally COVID-19 Menstruation • Nearly a quarter (23%) of respondents
(n = 1031) were using hormonal contraception
(2021) 18:252

• Almost half (46%) reported a change in

menstrual cycle since the beginning of the
pandemic, with 53% reported worsening
premenstrual symptoms, 18% reporting
new menorrhagia and 30% new dysmen-
orrhea compared to before the pandemic
(p < 0.05)
• A small number of respondents (9%)
reported missed periods whereas they
previously did not (p = 0.003), with a
median number of 2 (1–3) missed periods.
21% of those who “occasionally” missed
periods pre-pandemic missed periods
“often” during pandemic
• Nearly half of all women (45%) reported a
reduced libido
• There was no change in the median cycle
length (28 days) or days of bleeding (5)
but there was a wider variability of cycle
length (p = 0.01) and a 1-day median
decrease in the minimum and maximum
cycle length (p < 0.05)
Page 13 of 25
 Mukherjee et al. Reproductive Health

Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings

Rimmer et al. [51] Quantitative; Cross-sectional Junior obstetrics and gynecology COVID-19 Obstetrics and gynecology service • Majority of units (60%) completed
doctors across training units in the UK provision training drills for managing obstetrics
National Health Service UK (n = 148) and gynecology emergencies during
(2021) 18:252

COVID-19, nearly all (88%) implemented

COVID-19 specific protocols, had adequate
PPE (91%), operated dedicated COVID-19
obstetric emergency theatres (71%)
• Most had to reduce in-person antenatal
clinics (79%), but offered telehealth
services (71%) and dedicated clinic areas
for pregnant women with confirmed or
suspected COVID-19 (78%)
• Elective gynecological services (fertil-
ity and urogynaecology) were mostly
suspended (89%); 40% implemented pro-
tocols to reduce inpatient stays, including
medical management as the first line of
treatment for miscarriage (59%) or ectopic
pregnancies (28%) in order to reduce
inpatient stays
• Oncological referral pathways were
unaffected in half (51%) of all units, with
planned reductions in oncology surgery in
half (55%) of all units
• Rapidly changing protocols and lack of
clarity led to confusion among doctors
Page 14 of 25
Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings

Roberts et al. [35] Quantitative; Cross-sectional Providers at independent abortion clinics COVID-19 Abortion • Clinics in all regions of the US were rep-
across the US (­ nclinics = 103) resented: Northeast (21%), Midwest (25%),
South (31%), and West (22%)
• Over half of all clinics (51%) had to
clinicians/staff who were unable to work
because of the pandemic. Clinicians were
Mukherjee et al. Reproductive Health

unable to provide care because they were

quarantined (23%), part of a high-risk
group (21%), sick with possible COVID-19
(20%), subject to COVID-19 related travel
restrictions (15%, re-assigned to other
COVID-19 related responsibilities (13%),
or had childcare (12%) or other caregiving
(2021) 18:252

(5%) responsibilities
• Non-clinical staff reported being unable
to work because of childcare responsi-
bilities (50%), being sick with possible
COVID-19 (45%), quarantine (44%),
belonging to a high-risk group (33%) and
having caregiving responsibilities (18%).
40% of respondents reported that they
had to cancel or postpone appoint-
ments because patients had COVID-19
symptoms or had been exposed, and 13%
had patients who were subject to COVID-
related restrictions on travel
• Most clinics had had to cancel or
postpone some clinical services, including
gynecologic services (59%), contraceptive
visits (55%) and STI tests (45%)
• More than 60% of respondents in the
Northeast, Midwest and West reported
that their state had declared abortion
essential, compared to just 14% in the
South. 38% of clinics had canceled or
postponed first-trimester aspiration abor-
tions, 27% second-trimester or later abor-
tions and 25% medication abortions
• The proportion of clinics that had
canceled or postponed first-trimester aspi-
ration abortions was highest in the South
(66%) and Midwest (38%), compared to
9% Northeast and 26% in the West
• 19% reported having to close their clinic
temporarily, especially in the Midwest
(21%) and South (35%)
Page 15 of 25
Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings

Roland et al. [41] Quantitative; Longitudinal National Health Data System insurance COVID-19 Contraceptive utilization • Oral contraceptive dispensation
claims of all pharmacy dispensations of increased during the first two weeks of
Mukherjee et al. Reproductive Health

residents of France between January 1, lockdown by 47% and 16%, but thereafter
2018–June 7, 2018, 2019 and 2020 decreased
• Overall, the number of prescriptions of
oral contraceptives, emergency contra-
ception, intrauterine devices (IUDs), and
ovulation indicators decreased over the
course of the 8-week lockdown by 46,603;
(2021) 18:252

38, 429; 21,250; and 44,510 respectively

• In the 4-weeks post-lockdown, prescrip-
tions continued to decrease, and the num-
ber of prescriptions of oral contraceptives,
emergency contraception, intrauterine
devices (IUDs), and ovulation indicators
decreased by 70,021; 11,226; 1,807; and
17,431, respectively
Stifani et al. [40] Quantitative; Cross-sectional Family planning providers in the US COVID-19 Access to contraceptives • 91% of surveyed providers provided tel-
(n = 172) emedicine services during the COVID-19
pandemic. About half of providers (53%)
referred less than a quarter of telemedi-
cine patients to in-person visits, with
the most common reason being LARC
insertion (53%)
• Almost all providers reported that the
following services were available to their
patients even at the height of the COVID-
19 pandemic: LARC insertions (88%); LARC
removals (90%); depot-medroxyprogester-
one acetate injections (88%), and visits for
other contraception-related issues (85%)
• Most providers (80%) agreed that tel-
emedicine is an effective way to conduct
contraceptive counseling, and that the
role of telemedicine for contraceptive
counseling should be expanded after the
pandemic (84%)
Page 16 of 25
Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings

Tao et al. [52] Quantitative; Retrospective cohort All patients presenting for care at a COVID-19 Service provision • Compared to pre-COVID-19, there was a
major STI clinic in Rhode Island between 55% (95% CI 45–63%; p < 0.001) reduction
September 1, 2019—May 13, 2020 in the total number of STI clinic visits
Mukherjee et al. Reproductive Health

(n = 2347) overall during COVID-19 lockdowns. More

specifically, the number of screening visits
were reduced by 60% (95% CI 46–71%;
p < 0.001), provider visits by 50% (95% CI
35–62%; p < 0.001) and treatment visits
by 62% (95% CI 40–75%; p < 0.001, when
compared with the pre-COVID-19
(2021) 18:252

• After lockdowns eased, there was an 84%

(95% CI 68–88%, p < 0.001) reduction in
total clinic visits, 100% reduction in screen-
ing visits, 68% (95% CI 56–77%, p < 0.001)
reduction in provider visits, and 77% (95%
CI 61–86%, p < 0.001) reduction in treat-
ment visits compared to pre-COVID-19
phase
Tschann et al. [33] Quantitative; Longitudinal Health facilities that provide medication COVID-19 Abortion • In February 2020, 71% required 2 or more
abortion across the US between April patient visits for a medication abortion.
-October 2020 (n = 74) By April 2020, 35% reported reducing the
total number of in-person visits associated
with a medication abortion, and as of
October 2020, 37 sites indicated newly
adopting a practice of offering medication
abortion follow-up with no in-person visits
White et al. [36] Quantitative; Retrospective cohort Abortion clinics in Texas (n = 18) COVID-19 Abortion • The number of abortions decreased by
38.0% (95% CI − 40.8% to − 35.1%) in April
2020, compared to April 2019
• The number of medication abortions
increased accounting for 39% of all abor-
tions in April 2019 to 80% in April 2020
• Texas residents receiving care at out-
of-state facilities increased from 157 in
February 2020 to 947 in April 2020
• After the COVID-19 related executive
order was lifted in May 2020, the number
of procedural abortions increased by
82.6% (95% CI 46.7%-127.4%)
Page 17 of 25
 Mukherjee et al. Reproductive Health
(2021) 18:252

Table 2 (continued)
Author(s) Methods Sample Epidemic SRH outcome Major findings
Yuksel et al. [44] Quantitative; Cross-sectional Married patients who were older than COVID-19 Sexual behavior • Sexual desire and frequency of inter-
18 years and not menopausal (n = 58) course significantly increased during the
in Turkey COVID‐19 pandemic, whereas quality of
sexual life significantly decreased
• Compared with 6–12 months, the pan-
demic is associated with increased sexual
intercourse (2.4% vs 1.9%), decreased
desire for pregnancy (32.7% vs 5.1%),
decreased female contraceptive use (24%
vs 10%), increased menstrual disorders
(27.6% vs 12.1%) and lower FSFI (sexual
function) scores (20.5 vs 17.6)

COVID-19 coronavirus disease 2019, STI sexually transmitted infection; FSFI Female Sexual Functioning Index; SARC​short-acting reversable contraceptive; LARC​long-acting reversible contraceptive
Page 18 of 25
Mukherjee et al. Reproductive Health (2021) 18:252 Page 19 of 25

Service provision and quality of sexual life based on the Female Sexual
All studies noted that COVID-19 control measures Function Index (FSFI) [44]. Fuchs et al. [53] also used
resulted in decreased service provision and/or utilization. the FSFI to examine sexual functioning among women
A study of providers from sexual health clinics across the of reproductive age in Poland and found that overall sex-
US indicated that abortion services, HIV and STI testing ual functioning and each FSFI domain (desire, arousal,
decreased by 76%, 75% and 82%, respectively [49]. Con- lubrication, orgasm, satisfaction, and pain) decreased
sequently, telehealth services expanded, and provided significantly, and sexual dysfunction doubled. In this
greater access to services such as STI treatment based study, women of lower socioeconomic status experi-
on symptomology and self-managed abortion. Using enced lowest sexual functioning. Moreover, frequency
difference-in-difference analyses, Aiken et al. [32] found of sexual activity declined due to isolation, conflict with
that requests for self-managed abortions increased dur- partners and mental health. Decreases in sexual activity
ing COVID-19, especially in states with greater stay-at- also included decreases in risky sexual behaviors in China
home behaviors, restrictions on in-clinic abortions, and/ [45]. Partner conflict was explicitly examined in the US,
or those with especially high rates of COVID-19 inci- where one-third (34%) of all participants reported some
dence. Dell’Utri et al. compared obstetric and gynecolog- degree of COVID-19 related conflict. An inverse dose–
ical (OB/GYN) emergency service admissions during the response relationship was observed between relationship
COVID-19 pandemic, to the same period the year prior conflict, sexual activity and other intimate behaviors [54].
and found that overall admissions decreased by over 35%
[50]. This translated to reduced admissions for compli- Pregnancy intentions
cations related to pregnancy and gynecology. Similarly, In examining pregnancy intentions, a study in Tur-
Rimmer et al. (2020) reported changes to OB/GYN ser- key reported a 28% decline in pregnancy desire among
vice provision in response to the COVID-19 pandemic women of reproductive age as result of the COVID-19
in the UK [51]. These changes included reduced in-per- pandemic [44]. In Italy, 18% of respondents intended
son antenatal care, elective procedures (such as fertil- on getting pregnant before the pandemic, however,
ity treatments or urogynecology), and inpatient stays. over one-third abandoned their intention due to future
Patient-level outcomes were not reported, however. In economic difficulties and further straining the health-
China, women reported difficulties in accessing antena- care system. In contrast, some respondents who did not
tal and/or maternal care; and obtaining appointments intend to conceive reported doing so because of a need
or medications for abortion services and STI testing for positivity [55]. In Australia, most women surveyed
[45]. Compared to pre-COVID-19 related lockdowns, indicated that they were trying to avoid pregnancy, and
the total number of clinic visits for STI screening, pro- that the pandemic had not changed their pregnancy
vider appointments and treatment decreased by 55%, and intentions. In the US, survey respondents indicated that
84%, respectively at a STI clinic in Rhode Island during the pandemic exacerbated housing and food insecurity
and after COVID-19 lockdown [52]. It is unclear how among racial/ethnic minorities, which was associated
much of this decrease is attributed to pandemic-related with a decreased desire for pregnancy by over twofold
lockdowns, fear of exposure, or decreased incidence of [47].
STIs due to decreased sexual activity. Disparities in ser-
vice provision and/or utilization are unknown, however, Risk of bias
as results are not described by sociodemographic status. Overall studies were of low quality with scores ranging
Moreover, little is known about the impact of COVID- from 13 to 37 (40–88%) and averaging 23 (56%) points
19 on fertility treatments and gynecological cancer across all 24 eligible studies (Table 3). Of the 16 QATSDD
screenings and treatment. Only one study, from Aus- items, the highest scoring items were a specific state-
tralia, reported that several women trying to conceive ment of aims/objectives (item 2); a clear description of
had actively stopped trying or were unable to continue the research setting (item 3), and fit between research
because their in-vitro fertilization appointments had question and analysis method (item 12). On average,
been cancelled [46]. lowest scoring items included the use of an explicit theo-
retical framework (item 1), statistical assessment of reli-
ability and validity of measurement tool(s) (item 9), and
Sexual behavior evidence of user involvement in design (e.g., pilot study,
Several studies examined changes in sexual behaviors and informed by persons with lived experience, etc.; item
functioning during the COVID-19 pandemic. Married 15). Although theoretical frameworks were not explicitly
women in Turkey reported increased sexual desire and included, most authors stated why their research ques-
frequency of intercourse, but lower sexual functioning tion was important within their given context. Items that
Table 3 Quality assessment of eligible studies
Author Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Item 12 Item 13 Item 14 Item 15 Item 16 Total score % Rating

Aiken et al. [32] 0 3 3 0 3 3 2 2 1 3 N/A 3 3 N/A 0 1 27 64 High

Mukherjee et al. Reproductive Health

Aryal et al. [39] 0 2 3 0 1 3 3 1 0 2 N/A 2 2 N/A 0 2 21 50 Low

Coombe et al. [46] 0 3 2 0 1 1 1 1 0 1 N/A 2 2 N/A 0 3 17 40 Low
Endler et al. [38] 0 2 1 0 1 1 1 1 0 2 N/A 1 1 N/A 1 1 13 31 Low
Fuchs et al. [53] 1 2 2 0 3 2 3 1 0 1 N/A 2 1 N/A 1 2 21 50 Low
Leight et al. [42] 0 3 3 1 3 3 3 1 0 3 N/A 3 3 N/A 0 3 29 69 High
(2021) 18:252

Li et al. [45] 1 3 1 0 3 1 3 1 0 1 N/A 2 2 N/A 0 3 21 50 Low

Luetke et al. [54] 1 3 3 0 3 3 3 3 0 3 N/A 3 3 N/A 0 3 31 74 High
Nagendra et al. [49] 0 3 3 0 2 3 2 3 0 3 N/A 2 1 N/A 1 1 24 57 Low
Phelan et al. [48] 0 2 1 0 1 2 1 1 0 1 N/A 2 2 N/A 0 3 16 38 Low
Rimmer et al. [51] 0 3 3 0 1 3 3 3 0 3 N/A 3 2 N/A 2 3 29 69 High
Roberts et al. [35] 0 3 3 0 2 2 2 2 0 2 N/A 3 2 N/A 0 3 24 57 Low
Roland et al. [41] 0 3 3 3 3 3 3 1 0 3 N/A 3 3 N/A 0 0 28 67 High
Stifani et al. [40] 0 3 2 0 1 2 2 2 0 1 N/A 2 2 N/A 0 3 20 48 Low
Tao et al. [52] 0 3 3 0 3 2 3 1 2 3 N/A 2 2 N/A 0 3 27 64 High
Tschann et al. [33] 0 3 1 0 1 2 2 1 0 2 N/A 2 2 N/A 0 2 18 43 Low
White et al. [36] 1 3 2 2 3 2 3 1 2 3 N/A 3 3 N/A 0 2 30 71 High
Yuksel et al. [44] 1 3 3 3 3 3 3 3 3 3 N/A 3 3 N/A 0 3 37 88 High
Aiken et al. [32] 0 3 3 0 3 3 2 2 1 3 N/A 3 3 N/A 0 1 27 64 High
Aryal et al. [39] 0 2 3 0 1 3 3 1 0 2 N/A 2 2 N/A 0 2 21 50 Low
Caruso et al. [43] 1 3 3 0 3 1 1 3 0 2 N/A 1 0 N/A 0 1 19 45 Low
Coombe et al. [46] 0 3 2 0 1 1 1 1 0 1 N/A 2 2 N/A 0 3 17 40 Low
Dell’Utri et al. [50] 1 2 3 0 3 3 3 3 0 3 N/A 2 1 N/A 1 1 26 62 High
Endler et al. [38] 0 2 1 0 1 1 1 1 0 2 N/A 1 1 N/A 1 1 13 31 Low
Page 20 of 25
 Mukherjee et al. Reproductive Health

Table 3 (Continued)
Quality Assessment Tool for Studies with Diverse Designs [29]
Item 1: Explicit theoretical framework
Item 2: Statement of aims/objectives in main report
(2021) 18:252

Item 3: Clear description of research setting

Item 4: Evidence of sample size considered in terms of analysis
Item 5: Representative sample of target group of a reasonable size
Item 6: Description of procedure for data collection
Item 7: Rationale for choice of data collection tool(s)
Item 8: Detailed recruitment data
Item 9: Statistical assessment of reliability and validity of measurement tool(s) (Quantitative studies only)*
Item 10: Fit between research question and method of data collection (Quantitative studies only)*
Item 11: Fit between research question and format and content of data collection tool e.g., interview schedule (Qualitative studies only)*
Item 12: Fit between research question and method of analysis
Item 13: Good justification for analytic method selected
Item 14: Assessment of reliability of analytic process (Qualitative studies only)*
Item 15: Evidence of user involvement in design
Item 16: Strengths and limitations critically discussed
Scores: 0 = not at all; 1 = very slightly; 2 = moderately; 3 = complete
Total scores > 60% = High quality; scores ≤ 60% = Low quality [31]
Page 21 of 25
Mukherjee et al. Reproductive Health (2021) 18:252 Page 22 of 25

did not score well may have been due to study design especially among women who were not using contracep-
(e.g., observational vs randomized control trials). Simi- tives previously and women of lower socio-economic sta-
larly, statistical assessment of reliability and validity of tus [42]. Only one study examined how poverty related
measurement tool(s) may not have been considered due factors are negatively associated with contraceptive
to lack of time for test re-test sampling, or the lack of access in the US [47].
validated tools measuring SRH-related outcomes. Finally, Our search returned no studies on the impact of other
user involvement may not have been feasible or ethical respiratory epidemics on women and girls SRH out-
during an epidemic. comes (not including pregnancy and birth-related out-
comes, gender-based violence, and maternal and child
Discussion health). This may be because the prioritization of epi-
Beyond COVID-19 morbidity and mortality, all women demic response has overshadowed SRH, the historic lack
and girls, including underserved populations, racial/ of investment in SRH, or the dismissal of SRH as rooted
ethnic or sexual minorities, immigrants and those with in structural gender inequities. However, given the rise
intersectional identities, will experience immediate and in emerging infectious diseases [59] and increasing calls
long-term consequences to their sexual and reproduc- for attention to SRH during pandemics/epidemics [2, 12,
tive health [2, 12, 13]. Results from this review suggest 13], this finding emphasizes the need to examine the full
that the indirect impact of the COVID-19 pandemic on range of SRH outcomes, that is inclusive of HIV/STIs;
SRH include significant reductions in access to abortion, comprehensive sexuality education; safe abortion; pre-
contraceptives, and OB/GYN service provision. All stud- vention, detection, and counselling for gender-based vio-
ies reported in this review indicate that the total number lence; prevention, screening and treatment of infertility
of abortions decreased during the pandemic, but it is not and gynecological cancers; and counseling and care for
clear whether this is due to decreased access because of sexual health and well-being [60]. High quality evidence
pandemic-related lockdowns and SRH not being deemed of the indirect, downstream consequences of epidemics is
an essential service, or due to decreases in sexual activ- needed to inform future policy and planning, ensure SRH
ity and changes in pregnancy intentions, as reported by equity, and generate equitable access to the full range
some studies. Among women receiving abortions, the of SRH services. Moreover, few studies included in this
number of medication abortions increased, whereas sur- review examined the indirect impact of COVID-19 and
gical abortions decreased. Studies reported innovations the pandemic response on SRH outcomes among under-
such as telemedicine with or without in-person follow served populations, racial/ethnic or sexual minorities,
up visits for medication abortions, which were deemed immigrants, or those with intersectional identities. The
safe, accessible and without complications [56]. The stud- pandemic has been found to exacerbate poverty, dispro-
ies include in this review did not examine abortion access portionately impact people of lower socioeconomic sta-
by sociodemographic characteristic or socioeconomic tus, and aggravate existing health issues, including those
status, and disparities or inequities are unknown. The related to SRH [61]. Interventions are critically needed
lack of unified abortion or epidemic control policies in to sustain adequate access to abortion, family planning,
response to COVID-19, however, likely widened existing STI/HIV testing and treatment, ensure continuity of fer-
health inequities [57]. tility treatments, gynecological cancer screenings and
Based on this review, COVID-19 pandemic related treatment, and other SRH service provision, especially
disruptions to family planning services were reported among women of lower socioeconomic status, to reduce
to decrease access to contraceptives, prescriptions, and/ the number of unintended pregnancies, unsafe abortions,
or uptake globally. This may be an unintended conse- STI/HIV transmission, and halt the decades of progress
quence of prioritizing COVID-19 response over SRH made on health and development [62].
needs, and it is unclear how changes in sexual behavior SRH is a human right that is vital for sustainable
and pregnancy intentions impact contraception uptake. development, and should be among the least restrictive
Most studies included in this review did not report con- solutions in the context of epidemic control [2, 13, 63].
traception method. The limited number of studies that Historically, restrictive SRH policies have perpetuated
did report contraception method suggest that service inequities among Black, Latinx, and immigrant women,
disruptions disproportionately impact women who rely and are expected to widen as a result of COVID-19 and
on SARCs, as LARCS have been proven to be effective related policies for epidemic control. Few studies of res-
past their intended duration [58]. Of concern is that piratory epidemics and SRH explicitly examined out-
the reduction in contraceptive use was sustained, even comes among women with diverse lived experiences,
once lockdowns were eased in some places [41]. On the despite the accumulating evidence that indicate that
other hand, some places showed a promising rebound, COVID-19 disproportionately impacts racial/ethnic
Mukherjee et al. Reproductive Health (2021) 18:252 Page 23 of 25

minorities, immigrants, and people with lower socio- impact of interventions and/or policy changes (e.g., tel-
economic status [12, 64]. This review highlights a gap emedicine with in-person versus mail order medication
in research of SRH service provision, access and utiliza- abortion, executive orders that did not deem SRH as an
tion among marginalized groups of women and girls and essential service, etc.) on SRH-related outcomes.
those with intersectional identities, including adolescent By being aware of the impacts of COVID-19 on SRH,
and young girls, those with disabilities, sexual or eth- policy makers can be better prepared to enact guidelines
nic/racial minorities, refugees and immigrants, many of and policies that promote reproductive justice and access
whom experience difficulties in accessing SRH services to equitable, timely SRH, despite lockdowns. Given
notwithstanding an epidemic [10, 11, 13]. Several stud- the service disruptions evident in this review, provid-
ies noted the expansion of telehealth services, offers an ers should prioritize education and provision of various
opportunity to reach more women and girls, including contraceptive methods, and when appropriate, should
those traditionally underserved. Yet, little research on counsel and allow patients to consider switching meth-
how telehealth has improved or constrained SRH access ods. Patient education on the range of contraceptive
for underserved populations has been published. This methods, protocols for switching methods, at-home use
review highlights the need to understand the indirect of contraceptive methods (including injectables [66]) and
impact of COVID-19 and its control measures on the self-managed abortion can be completed via telehealth,
wider range of SRH outcomes and populations of women which may provide an opportunity to reach more women
and girls in the long-term. and girls. Although not included in this review, COVID-
This study is not without limitations. Given the rapid 19 has resulted in notable increases in gender-based vio-
timeline of this review and the constantly evolving lence and reproductive coercion [28, 67], making access
research on COVID-19, we included readily available to contraceptives and abortion services vital for ensuring
studies on COVID-19 impacts on SRH at the time of access to care and reproductive justice.
review, but new findings emerge on a weekly basis. More- Changes to service provision, in response to COVID-
over, there were no restrictions on location, and gener- 19, must consider historical inequities in access to SRH
alizability of results may be inadequate due to variations services. Clear and consistent guidelines for changes to
in epidemic control policies. Non-respiratory epidem- service provision that ensure access to quality SRH ser-
ics (e.g., Ebola, HIV, Zika, etc.) have also impacted SRH vices are needed. Moreover, increased efforts should be
outcomes; however, these were not included as modes made to collect sociodemographic information to better
of transmission and infection control measures varied understand the indirect and downstream impact of the
too greatly. Although we apply a reproductive justice COVID-19 pandemic on SRH for diverse groups. Finally,
lens, we excluded maternal and child health outcomes while the expansion of telehealth services provides an
beyond pregnancy, childbirth and violence. While these opportunity to reach underserved populations, privacy
are an important aspect of reproductive justice, this lit- concerns, disparities in access to technology, and long-
erature seemed to be its own body of work and dedi- standing impacts of racism on care uptake must also be
cated systematic reviews have been published elsewhere considered.
[17–28]. Finally, the majority of studies included in this
review were of low quality; possibly because the major- Conclusion
ity of studies reported in this review were observational, As COVID-19 presents new challenges to accessing
and more rigorous research on the impact of pandem- essential SRH services, the application of a reproduc-
ics on SRH is needed. Randomized-control trials are the tive justice lens is crucial to ensure SRH inequities do
gold-standard for high-quality studies, however, they are not continue to widen. Evidence suggests that COVID-
not always feasible, practical or ethical within the context 19, and its control measures disproportionately impact
of an infectious disease epidemic, and studies without a women’s SRH outcomes. Results indicate that OB/GYN
comparison group should be interpreted with caution. and SRH service provision, pregnancy intentions and
Conversely, quasi-experimental designs are useful in sexual behavior, access to family planning, contracep-
determining causal relationships when randomized con- tives and abortion markedly decreased, as an indirect
trol trials cannot be used for practical or ethical reasons consequence of the COVID-19 pandemic response.
[65]. The COVID-19 pandemic provides an opportunity Accumulating evidence indicates that COVID-19 dis-
to use quasi-experimental designs to better understand proportionately impacts marginalized and underserved
the indirect impact of COVID-19 and the pandemic populations directly, yet these are the groups least rep-
response on SRH outcomes among marginalized women resented in the research. More research dedicated to the
and girls. Future research using quasi-experimental diverse lived experiences of women and higher quality
designs are needed to provide robust evidence of the evidence is needed to prevent and mitigate the indirect
Mukherjee et al. Reproductive Health (2021) 18:252 Page 24 of 25

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