In this review, we attempted to locate documents in the form of guidelines, consensus statements, best practice statements and standards of practice indicating directions on how contraception and safe abortion care service during COVID-19 pandemics. We searched guideline databases, PubMed, EMBASE and Google Scholar and website of international professional associations and organizations working on sexual and reproductive health.
For women already on contraception:
Telemedicine and self-care family planning methods were recommended consistently. Self-care family planning methods include contraceptive pills, self-injectables, subcutaneous depo shot, condoms, vaginal rings, and fertility awareness methods [WHO, FIGO, RCOG, RCM, SOGC, RANZOG, IPPF, UNFPA, MSI and FSRH ](3, 9-13).
There are consistent position statements that recommend combined hormonal contraception (CHC) and progesterone only pills (POP) users to continue 6-12 months without rechecking body mass index (BMI) and blood pressure. Depot medroxyprogesterone acetate (DMPA) users can switch to available progesterone only pills (POP) to avoid face to face contact(3, 9, 14, 15). For long term contraceptive user’s options of extended use to avoid face to face contact is recommended. Limited evidences show that duration of long acting contraceptive effect is 2 years beyond Food and Drug Administration(FDA)-approved duration(16). Depending on that evidences many associations and organizations practice recommendations [FIGO, RCOG, RCM, SOGC, RANZOG, IPPF, UNFPA, MSI and FSRH] advised delaying removal of implants and IUCD during the pandemic crisis unless series side effect happens or wants to get pregnant (3, 9, 12, 15, 17, 18).
New contraception starters:
Telemedicine and self-care family planning with remote assessment and prescription of CHC, POP for 6-12 month and self-injectable contraception were consistently recommended. However, administration of DMPA or insertion of implants or intrauterine device to be considered where concerns about adherence, individual intolerance of oral contraceptives or use of teratogens make longer-acting reversible contraception the only suitable option. Pre-procedure assessment and information-giving remotely to minimize face-to-face contact time (minimum contact service) with healthcare professionals were recommended [WHO, FIGO, RCOG, RCM, SOGC, RANZOG, IPPF, UNFPA, MSI and FSRH]. Optimal use of contact points, such as expanding post-partum family planning with especial focus on long acting reversible contraception were recommended [FIGO, RCOG, RCM, FSRH, MSI and UNFPA].
Emergency contraception (EC):
Remote assessment of requirement and choice of EC. Oral emergency contraception remote prescription or provision without prescription or Cu-IUD provision with minimum face to face contact is recommended [RCOG, RCM, FSRH, BSACP, FIGO].
Safe abortion service.
All records (practice recommendations and position papers or commentaries) consistently recommend screening for COVID-19 symptoms from remote before face to face contact or during remote early medication abortion without face to face contact. There were several recommendations on no-touch/no-test early medication abortion protocol (2, 3, 14, 17, 19). The no-touch protocol depicts pathways to minimize COVID-19 exposure to patient and staffs by organizing early medical abortion services to be delivered via video or teleconferencing /telemedicine and delivery of a treatment package(2, 14, 17). The treatment package includes mifepristone, misoprostol, ibuprofen and self-care family planning if patient accepted post-abortion contraception. The no-touch/no-test protocol is self-medication abortion in early pregnancy without pre-procedure ultrasound and blood testing. The guideline also indicated that for women in self-isolation because of exposure to COVID-19 no-touch early medication abortion can be arranged similarly at home. If face to face contact care is must for COVID-19 exposed women, the guideline recommends that it should be booked when the isolation period is over unless the gestation is uncertain, and the delay may result in a woman not being able to access abortion in which face to face contact must be arranged with full personal protective measures(14). There is no specific protocol recommended for second trimester medication abortion (above 12 weeks), but professional association and organizations position papers consistently recommend the utilization of telemedicine for digital patient education and counselling to reduce waiting periods and extent of face to face contact(minimal contact service)(4, 17, 19, 20).
For surgical abortion position papers and practice recommendations focus on minimum contact procedure by remote digital patient education, counselling and evaluation. The other focus practice recommendation is increasing safety during the procedure by limiting number of people in the procedure room, appropriate use of personal protective equipment’s and decontaminate area after the procedure as per the recommendation (Appendix, see included records). The practice recommendations also include surgical facemask and sanitizer or hand washing for women. Vacuum aspiration, dilatation and evacuation or dilatation and curettage are not aerosol generating procedure unless done by general anesthesia(21). Therefore, these procedures don’t require full personal protective equipment’s like N95, but abortion provides should screen all patients before the procedure and use standard precautions. Where possible and feasible it’s also highlighted to perform the procedures under local anesthesia or intravenous sedation or spinal anesthesia to avoid the need for general anesthesia(14, 17, 19, 21). Its recommended consistently that follow up visits is not required in all conditions, and where needed to be done remotely by telemedicine.