This is the first longitudinal study to assess the incidence of reproductive outcomes during the COVID-19 pandemic. More specially, it assessed how changes in women’s health and economic conditions impacted their reproductive behaviors over one year period in Burkina Faso. We found that, over one-year period before and during COVID-19 outbreak, 52% of women of reproductive age neither got pregnant nor adopted contraceptive method. However, childbearing occurred among 29% of women while 19% adopted contraception. Moreover, we also found that, relative to women with no reproductive event, greater exposure to family planning promotion increased both the likelihood of childbearing and contraception while greater healthcare utilization increased the likelihood of childbearing only. In addition, relative to women with no reproductive event, being employed without cash paid and having experienced household income loss reduced the likelihood of childbearing, while being concerned about getting COVID-19 infection has the same effect on contraception. Furthermore, relative to women with no reproductive event, childbearing was less likely among women aged 35–49 but more likely among those with primary education. Whereas, relative to women with no reproductive event, contraception was more likely among women with at least secondary education.
Changes in women’s reproductive status during COVID-19 pandemic
The COVID-19 pandemic restrictions significantly affected women’s reproductive outcomes in Burkina Faso, during a year before, during and after the pandemic outbreak. We found an 19% and 17.7% increase in contraceptive adoption nationally and in rural setting, respectively. Although previous research found 25.4% and 17.4% contraceptive adoption at national level and in rural Burkina Faso, in a shorter study period [3, 11]. It is possible that the increase in contraceptive adoption decelerated or stalled overtime. Similar trend was observed during the 2013–2016 West African Ebola outbreak in Liberia and in Sierra Leone [22]. The pandemic may not have led to widespread or lasting changes in fertility intentions, especially in poor countries [12]. Nevertheless, the most vulnerable women may attempt to accelerate their childbirth period for greater support and marital stability [4]. We found relatively high rates of childbirth as 29% of women became pregnant over one-year period. In 2010, the Demographic and Health survey in Burkina Faso found that only 20.6% of women aged 15–49 had live births over three-year period [23]. Increased stress and financial insecurity may have led to sexual coercion, inability to negotiate contraception and unintended pregnancies. In Ethiopia, the magnitude of unintended pregnancy was found to be higher during COVID-19 pandemic, especially in disadvantaged communities [24]. In addition, limited access to contraception may have also given rise to unplanned pregnancies during the pandemic. Conversely, in high income countries, women had forgone their immediate fertility intentions and avoid getting pregnant after the COVID-19 outbreak. For instance, fewer women who were mothers of young children in New York (U.S.) were planning or attempting to become pregnant [25]. In Catania (Italy), all married women continued the use of contraceptive method while unmarried women reported unplanned pregnancies due to contraceptive discontinuation [26]. Moreover, a study found that women sought parenthood during COVID-19 pandemic so as to bring some positivity in their lives and to increase family bound [27]. The effects of the pandemic on women’s reproduction may be context-dependent. In high income countries, most women may have the means to revise their immediate fertility intentions, whereas in LMICs, vulnerable women struggled taking similar decision. As an example, a panel survey in four rural health districts of Burkina Faso found a higher desire to stop or postpone pregnancy, including a higher contraceptive use, over one-year period before and during the pandemic among women aged 15–49 [28]. Yet, unwanted pregnancy and self-reported history of miscarriages, abortions, or stillbirths had reportedly increased during the same period. Fear of COVID-19 infection, unavailability of the preferred method or of providers and lack of money may explain unintended pregnancies and limited contraceptive access during our study period [6]. Eventually, socioeconomic effects of the COVID-19 pandemic exacerbate access to contraception, especially for the disadvantaged populations [29]. In Kenya, adolescent secondary schoolgirls who remained out of school for 6 months due to the COVID-19 lockdown had twice the risk of becoming pregnant [30]. Globally, economic loss and food insecurity did not affect women’s fertility intentions in the early months of the COVID-19 pandemic. However, those in low income countries experienced more strain in healthcare system and economic hardship [4, 26, 31].
The effects of changes in health and economic conditions
Similar to previous studies, we found that family planning promotion during COVID-19 pandemic increased access to contraceptive services [8]. Experiences from Kenya, Nigeria, and Zimbabwe showed that innovative approaches to ensure continuity of care during the COVID-19 pandemic can decrease the need for in-person visits, improved services and increase contraceptive uptake [7, 32]. In Burkina Faso, community mobilization helped introduce and expand self-administered subcutaneous injectables before and during the pandemic [33]. Such community-based service delivery allows the availability of contraceptives without impending on the access of critical health services. Despite experiencing major disruptions in the early stage, family planning services have adapted to COVID restrictions [34]. However, it is possible that this resilience has not been enough or timely to avoid an upsurge in childbearing [4]. Women who experienced childbearing may have been lately informed on the continuity of family planning services. Another explanation may be that those who wanted to access contraception experienced restrictions either at home or at the health facility. For instance, fear of infection at health facilities was the most frequently reported COVID-19-related reason associated with non-usage of contraceptive in Burkina Faso and Kenya, respectively [3]. In fact, we found that women who visited a health facility in the last 12 months experienced childbirth. This finding may be a case of reverse causation in which women who got pregnant attended ante-, delivery and post-natal care or post-abortion treatment. In 2016, Burkina Faso has introduced exemption policy for maternal and child healthcare services, including family planning [35]. Literature shows that this policy significantly increase healthcare utilization for pregnant women [36]. Yet, in terms of contraceptive use, it only facilitates the negotiation processes without changing social norms and gender inequalities that still limit women’s decision-making power [37]. In line with previous researches, we found that women who were concerned about getting infected were less likely to use contraception [3, 6]. This may be an indirect impact of epidemics on sexual and reproductive health service utilization [38]. Women may be avoiding those services due to stigma, fear of testing positive, and misconceptions about service denial or unavailability. In Kenya, a research found that government restrictions on movement have heightened the fear and anxiety surrounding COVID-19, leading people to non-usage of health services for other health matters [39]. This finding raised several concerns, including how authorities and the media informed the public during the pandemic. Fear of going to the facility for contraceptive services during COVID-19 has been noted among patients and health workers [40]. In Egypt, it was reported that women stopped using contraception during the pandemic for a variety of reasons, including fear of contracting COVID 19 during a visit to the primary health care centers [41]. The same reason may play out among those who wish to adopt contraception. As a result, unintended pregnancy may increase along with its negative effects on maternal and newborn health, especially in poor resource countries [42]. Inevitably, the economic shocks following COVID-19 outbreak has affected women’s fertility intentions and behaviors. Our results imply that economic instability in the form of women’s employment without cash paid and household income loss was associated with greater birth control in Burkina Faso. Similarly, Karp et al, found that household income loss or food insecurity was associated with greater contraceptive protection in Burkina Faso, but not in Kenya [3]. Shifts in fertility timing preferences often occur in response to changes in life circumstances, including income loss [43]. In Burkina Faso, it is possible that women living in rural areas expressed stronger intentions to postpone or limit childbearing in the COVID-19 context. In fact, a study suggested that those women may have benefited from lighter COVID-19 restrictions, targeted outreach programs and free contraceptive provision [11]. In addition, evidence shows that disadvantaged populations kept using contraception, despite difficulties accessing their preferred method [29]. It is possible that disadvantaged women postponed childbearing to allow time for the household to recover financially. Another reason may be that the pandemic had reduced couples’ sexual functioning and activity. A systemic review and meta-analysis demonstrates that COVID-19 related restrictions were correlated with lower rates of sexual desire and reduced sexual activity, especially among women [44]. Stress, anxiety, and depression following COVID-19 restrictions may be the psychological factors that negatively affect couples sexual function in general and that of women in particular [41]. Besides, during the COVID-19 outbreak, quarantine and self-isolation with children and extended family may limit the opportunity for couples to have privacy for intimacy. But, the relationship between COVID-19 restrictions and childbearing may be context-dependent. In contrast however, a study in Malawi found that changes in economic circumstances did not predict the direction of fertility’s timing and quantum [43].
The role of women’s background characteristics
In line with previous research, we found that during COVID-19 pandemic older women had lower childbirth events while we observed opposite effect among those with primary education level. The plausible explanation may be that older women were less subjected to sexual abuse, less pressure to bear a child, and freer to access family planning services. In Nigeria, a study found that younger age increased the odds of experiencing intimate partners violence during the pandemic [45]. In this study, older women may hold reproductive decision-making power in their relationships due to negotiation skills, greater autonomy, and financial independence. In fact, despite being statistically insignificant, we found that women who lack financial independence were also more likely to bear a child during COVID-19 pandemic. This finding is significant as it may depict increase vulnerability to unintended pregnancies during COVID-19 pandemic. In Nigeria, a study found that amidst the pandemic, younger and less educated women had lower disposition of being unhappy towards pregnancy [10]. While older women are culturally allowed to control birth after proving their fertility, those with lower formal education use high fertility to gain better social position in their households and communities. In Ethiopia, a study related the increase in the proportion of teenage girls who got unintended pregnancy and used abortion care services to school closures during the pandemic [46]. It is possible that women with primary education lacked awareness about contraception and safe abortion services and its availability during COVID-19 pandemic. Curiously, a research found that younger women and those with higher education had an increase in the need for contraception in urban Nigeria (Lagos), but not in three other SSA countries [11]. In most rural areas and among younger women, sociocultural hurdles may prevent the translation of inherent desire to delay pregnancy into effective birth control. It is also possible that older women have less sexual desire and sexual activity leading to lower childbirths. Surprisingly, our results contradict that of a previous research comparing two cross-sectional surveys. That research found a decline in pregnancy rates and an increase in modern contraceptive prevalence among younger women and those without formal education in Burkina Faso, one-year apart before and during COVID-19 outbreak [47]. Yet, we expected that the economic downturn triggered by the pandemic would activate channels toward higher fertility, especially in vulnerable population [14]. Since, the evidence presented in this study came from a longitudinal survey. Differences may arise as our study does not account for the history of pregnancy at the start of the study, but uniquely, followed the not pregnant, fecund women during the study period. Expectedly, we found that women with higher education were more likely to adopt a contraceptive method during the pandemic, a trend that has been observed in previous research [11]. It is also possible that highly educated women had increased need for contraception and more access to reliable information about family planning services availability [48, 49]. Amidst the pandemic, they may desire to delay childbearing, given the uncertainty of the pandemic. Highly educated women may be aware of substantial costs associated with childrearing as well as the risks of unemployment and loss of income associated with the long-term effects of COVID-19 restrictions. In fact, in the early months of the pandemic, some research found no association between women’s education and contraceptive adoption [3, 10]. Our study accounted for a much longer time needed for women to adapt their fertility intentions to the health and economic repercussions of COVID-19 pandemic. Further research on the time lapse and women’s ability to translate fertility intentions into actual behavior is required to better capture the impact of COVID-19 pandemic on reproductive health.
Our study is not without limitations. First, misclassification is possible as women with history of contraceptive use may be unaccounted for. Some women may start and stop contraception during the study period. However, they largely remain at risk of unintended pregnancies due to inconsistent use of contraception. Second, we lacked data on family planning service delivery during the pandemic. Therefore, we cannot rule out the effects of service functionality, provider’s attitudes and commodity availability on reproductive outcomes. Instead, we used women’s exposure to family planning promotion and their health care utilization in the last 12 months to capture the level of care during the study period. Finally, COVID-19 outbreak emerged as Burkina Faso is facing serious security and humanitarian crisis following terrorist activities and insurgency. It is possible that terrorist attacks contributed to reduce or limit access to contraceptive services. In fact, research found that these attacks changed delivery practices by reducing the number of antenatal care visits, assisted deliveries and cesarean sections in the country [50].