Short-term effects of the COVID-19 state of emergency on contraceptive access and utilization in Mozambique

Abstract

The COVID-19 pandemic has increasingly disrupted the global delivery of preventive health care services, as a large number of governments have issued state of emergency orders halting service delivery. However, there is limited evidence on the realized effects of the pandemic and associated emergency orders on access to services in low-income country contexts to date. To address this gap, this paper analyzes administrative data on utilization of contraceptive health services by women referred via community health promoters in two large urban and peri-urban areas of Mozambique. We focus on the period immediately surrounding the national state of emergency declaration linked to the COVID-19 pandemic on March 31, 2020. Data reported for 109,129 women served by 132 unique promoters and 192 unique public health facilities is analyzed using logistic regression, interrupted time series analysis and hazard analysis. The results demonstrate that the imposition of the state of emergency is associated with a modest short-term drop in both service provision and utilization, followed by a relatively rapid rebound. We conclude that in this context, the accessibility of reproductive health services was not dramatically reduced during the first phase of the pandemic-related emergency.

Fig 1. Daily sessions per promoter.

Count of promoter sessions includes the sum of sessions with referrals, sessions without referrals, and reminder sessions by date conducted between January 21 and May 20, excluding weekends and public holidays (3-Feb, 7-Apr, and 1-May). These are normalized by the number of active promoters (i.e. promoters with at least one session) each day. Vertical lines denote the initial state of emergency declaration (1-Apr) and subsequent extension announcement (29-Apr). Trends are smoothed using a uniformly weighted moving average by week, taking into account the three days before and after in conjunction with the given date.

Fig 2. Referral rate by day of promoter visit.

The referral rate is defined as the number of sessions in which referrals were issued as a proportion of sessions with and without referrals each day. The referral rate is reported for January 21 through May 20, excluding weekends and public holidays (3-Feb, 7-Apr, and 1-May). Vertical lines denote the initial state of emergency declaration (1-Apr) and subsequent extension announcement (29-Apr). Trends are smoothed using a uniformly weighted moving average by week, taking into account the three days before and after in conjunction with the given date.

Fig 3. Contraceptive receipt rate.

The contraceptive receipt rate is defined as the number of referred women who access a contraceptive method within 14 days of receiving the referral from a promoter as a proportion of all women who receive referrals from promoters that day. The uptake rate is reported according to the date of promoter visit between January 21 and May 20, excluding weekends and public holidays (3-Feb, 7-Apr, and 1-May). Vertical lines denote the initial state of emergency declaration (1-Apr) and subsequent extension announcement (29-Apr). Trends are smoothed using a uniformly weighted moving average by week, taking into account the three days before and after in conjunction with the given date.

Fig 4

Predicted probabilities of contraceptive referral (4a) and contraceptive receipt (4b). These graphs show the predicted probabilities of contraceptive referral (Fig 4A) and contraceptive receipt (Fig 4B) corresponding to the logistic regressions presented in Table 2. Each graph presents the predicted probabilities for six subsamples of women: women who do and do not report access to a phone; women who are and are not current contraceptive users; and women under age 25 and over age 25. Predicted probabilities in the pre and post period are shown, in conjunction with 95% confidence intervals.