The SARS-CoV-2 (COVID-19) pandemic has had- and continues to have- a tremendous impact on individuals, societies, and health-care systems. Apart from the morbidity and mortality directly caused by the virus, the COVID-19 pandemic has had adverse effects on maternal and perinatal health and fertility (1, 2). Due to disruptions in access to family planning (FP) and reproductive health (RH) services, approximately 1.4 million unplanned pregnancies occurred during the pandemic in low-and middle-income countries qw(2). Recent evidence also suggests an increase in stillbirth and maternal deaths as a result of the pandemic (1)
Global evidence suggests that women’s access to family planning and reproductive health services may have been significantly affected as a result of the outbreak of the COVID-19 virus, especially in LMIC (3, 2). The World Health Organization (WHO) estimates that approximately 44% of countries worldwide have experienced disruptions in access to family planning and contraception services (4). Lockdown measures may have resulted in interruptions at factories of key pharmaceutical components and transportation delays of contraceptive commodities. Some RH/FP services may have been suspended as a result of diversion of equipment, resources, and supplies to the direct management of COVID-19 cases. Moreover, utilization of health services may have been reduced due to fear of contracting the virus when visiting healthcare facilities, restrictions of mobility, and/or reductions in household incomes due to the economic burden of COVID-19 on individuals and families (3).
Most of the available literature and evidence of the impact of COVID-19 on RH/FP services have been derived from high income countries or LMIC in Sub-Saharan Africa, Asia, and Latin America. There is a paucity of studies on the challenges that women in the Arab region face in accessing FP/RH services during COVID-19 pandemic. This exploratory study aims to understand the impact of the COVID-19 pandemic on women's access to RH/FP services during the first wave of the pandemic in Port Said and Souhag governorates in Egypt. Specific objectives of the study are to: (1) examine challenges women in Port Said and Souhag may have faced in accessing RH/FP services during the first wave of the pandemic, (2) identify coping mechanisms that women followed to address challenges in accessing RH/FP services, and (3) to understand the impact of the above challenges and coping mechanisms on women and their families. The study was conducted within a larger USAID- funded project that aimed to expand the role of the private sector in addressing family planning needs of young people in the Port Said and Souhag governorates in Egypt (5). The above project will be referred thereafter as Youth Health Project.
Egypt is a middle-income country with a population of about 103 million people and an annual population growth rate of 1.9% (6). The Ministry of Health and Population (MOHP) runs an extensive network of more than 5,000 primary health care (PHC) facilities which provide FP, antenatal care, immunization and child care services free of charge (7). Alongside these services, MOHP offers secondary and tertiary care through nearly 690 governmental hospitals, while the private sector offers health services through more than 1,000 private hospitals, 30,000 private clinics and 60,000 pharmacies (8, 9).
Egypt has made remarkable improvements in maternal and child health over the last 20 years. In 2019, the maternal mortality ratio was estimated at 37 maternal deaths per 100,000 live births, while neonatal mortality was estimated at 11.0 neonatal deaths per 1,000 live births (10). In 2014, 83 percent of women received four or more antenatal care visits during their last pregnancy and more than four fifths of deliveries took place in a health facility while 61 percent took place in a private health facility (11).
With regard to FP, Egypt has witnessed a steady decline in fertility until 2010. This was followed by a reversal of fertility trends as a result of political, economic and programmatic changes that took place between 2008 and 2014 (12). The 2014 Egypt Demographic and Health Survey found that approximately 59% of married (or previously married) women in Egypt used a family planning method. Of those women, 57% obtained their FP method from a public facility while 43% obtained their method from a private facility (i.e. a private clinic or pharmacy) (11).
Port Said, one of the two governorates where the present study was conducted, is an urban governorate that lies in the northeast of Egypt and has a population of nearly 750,000 people (13). Port Said is a relatively affluent city with many of its residents working in trade. In 2014, 57% of married women aged 15–49 in Port Said used a modern FP method. Of those FP users, 43% obtained their FP method from a public facility (11). Antenatal care coverage in Port Said is almost universal with 97% of women reporting receiving four or more ANC visits prior to the last childbirth. Additionally, nearly all deliveries were attended by a skilled birth attendant (99.6%). When considering access to healthcare in Port Said, 71% of women in 2014 reported at least one problem in accessing health care, compared to the national average of 68% at the time.
Port Said is the first governorate in Egypt where the social health insurance program is being piloted, with plans for nationwide rollout by 2032. Under the SHI program, patients seeking RH/FP services can either contact the designated Call Center to book an appointment or head directly to one of the primary service centers (healthcare unit or health center). For delivery care, patients are referred to hospitals that are affiliated with the SHI scheme where services are offered free of charge.
The second governorate in which the present study was conducted is Souhag governorate which is located in the southern region of Egypt, most commonly known as Upper Egypt. Souhag has a population of nearly 4.9 million people (13). Predominantly a rural governorate, Souhag is one of the poorest governorates in Egypt. Contraceptive use is significantly lower in Souhag with only 29% of married women aged 15 to 49 having used any FP method in 2014, as compared to the national contraceptive prevalence rate of 59%. Maternal health indicators in Souhag are relatively low, 70% women reported receiving regular antenatal care prior to the last childbirth and 87% reported that the last childbirth was attended by a skilled provider (national average is 93%). Access to health services is fairly limited in Souhag, where 93% of women reported at least one problem in accessing health care in 2014, compared to the national average of 68%.
With regard to COVID-19, the first case was declared in Egypt in February 2020. As of November 2021, Egypt has recorded a total of about 350,000 COVID-19 cases and approximately 20,000 deaths (14). Egypt ranks at 80 with regard to the number of COVID-19 detected cases.
Public life in Egypt has been affected dramatically by COVID-19 pandemic. A partial lockdown was implemented between March 2020 and June 2020 to limit the spread of the virus. Schools, universities and places of worship were closed; most commercial and entertainment activities were suspended, with many workplaces requiring their staff to work from home. A curfew was enforced from 8 PM until 6 AM during lockdown months (15).
The pandemic has placed significant pressure on the health sector in Egypt, as a result of diverting public resources towards management of COVID-19 cases and limiting the spread of the virus. Several public hospitals were turned to quarantine hospitals for the isolation and treatment of COVID-19 cases (16). In addition, many private doctors temporarily closed their clinics for fear of contracting the virus and several pharmacists reported stock outs of some brands of contraceptives (17). Reports from health care providers suggest a decrease in the demand for family planning and reproductive health services between March and June 2020, during the first wave of the pandemic outbreak of COVID-19. However, service statistics from public or private health facilities are not readily accessible, emphasizing the need for and importance of this exploratory study.