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Induced abortion and access to contraception in Sweden during the COVID-19 pandemic
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  1. Jenny Niemeyer Hultstrand1,
  2. Elin Törnroos1,
  3. Kristina Gemzell-Danielsson2,
  4. Margareta I Larsson1,
  5. Marlene Makenzius3,
  6. Inger Sundström-Poromaa1,
  7. Tanja Tydén1,
  8. Maria Ekstrand Ragnar1,4
  1. 1Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
  2. 2Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
  3. 3Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
  4. 4Department of Health Sciences, Lund University, Lund, Sweden
  1. Correspondence to Dr Jenny Niemeyer Hultstrand, Department of Women's and Children's Health, Uppsala University, 751 85 Uppsala, Sweden; jenny.hultstrand{at}kbh.uu.se

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The COVID-19 pandemic has impacted sexual and reproductive health and rights (SRHR) in many ways globally. In a survey conducted in 29 countries across the world, access to abortion was limited in approximately half of all countries, and 86% reported that access to contraceptive services was affected.1 In the UK, one out of four young adults reported that their access to contraception had been limited due to COVID-19.2

We investigated if the pandemic affected Swedish women’s decision to have an induced abortion and their access to contraceptive counselling. Swedish-speaking women (n=623) seeking a first-trimester abortion at seven clinics in different parts of Sweden, filled out an anonymous 39-item paper questionnaire with both multiple choice and open-ended questions on demographics, abortion and contraception between January and June 2021. The regional Ethical Review Board concluded that no formal ethical approval was needed as the questionnaire did not include any personal data (Dnr 2020–05951). The overall response rate among those invited was 92%. Percentages are presented in relation to number of women responding to specific questions.

During the previous 12 months, 43% (n=230/623) of women had experienced symptoms of COVID-19, but fewer than 19% had a verified diagnosis. Among the participating women, 4% (n=19/527) had already had a previous abortion due to COVID-19, since the pandemic started. Regarding the current abortion, approximately 13% (n=77/604) stated that the pandemic had affected their decision. Eleven percent (n=64/604) reported it had affected them somewhat and 2% (n=13/604) reported it had affected them a lot. Six percent (n=37/614) stated that COVID-19 was the main reason for their abortion (table 1).

Table 1

Impact of COVID-19 pandemic on the decision to undergo an abortion, previous abortion, and access to contraceptive counselling, among women seeking an early induced abortion (n=623)

Forty-nine women specified using free-text how the pandemic had influenced their abortion decision. A quarter of them (n=12/49) did not want to be without their partner in maternity care, including pregnancy visits and at the birth. Two women had already given birth during the pandemic and had felt alone without their partner. About 24% (n=12/49) of the women were worried about their own health and/or the health of the fetus, and 18% (n=9/49) were worried about their financial situation due to unemployment. Some mentioned they had concerns about the future, namely that they did not want to bring a child into the world during a pandemic or an unstable global economic situation, and others wanted to be vaccinated first.

Four percent (n=23/517) responded they had difficulties accessing contraceptive counselling and/or prescriptions because of COVID-19. Twelve women reported it was because of closed clinics and six because of their own illness. Most women had not used any contraceptive method around the time of conception (44%), followed by condoms (20%), withdrawal (18%) and contraceptive pills (14%).

In conclusion, we found that a minority of the women stated that the pandemic had affected their abortion decision. The finding that some women’s reproductive decisions were affected by partners not being allowed to partake in maternity care is in line with previous research.3

Few women had experienced problems accessing contraception. At a glance, this could be interpreted as if the Swedish healthcare succeeded in maintaining good access to contraception during COVID-19, even if the full magnitude of the effect may not have been reached. We believe, however, that the decision taken in Sweden, namely to avoid a total lockdown and to adapt health services as much as possible to the pandemic situation, contributed to this result. There was indeed a successful shift in providing telemedicine, and guidelines for remote prescribing were updated. However, a general decrease has been noted in the prescription of long-acting reversible contraception during the pandemic,4 and the majority of our study population used contraception methods that required little or no healthcare contact, such as condoms or withdrawal. Nevertheless, these results underline the importance of excellent and comprehensive sexual health provision within a robust healthcare system.

Ethics statements

Patient consent for publication

Ethics approval

This study involved human participants and an ethical application was sent to the regional Ethical Review Board in Sweden, but as the questionnaire did not include any personal data the study was exempted and no formal ethical approval was needed (Ref. No. 2020-05951). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors thank all the midwives, physicians and secretaries, among others, who enabled the study by being involved in the data collection. Special thanks go to Ninni Berg, Magdalena Hoveklint, Ann-Sofi Kullman-Östlund, Marianne Lindholm, Annika Lindqvist, Ulrika Nilsson, Ulrica Stråhlman, Cecilia Svedung and Kaj Wedenberg.

References

Footnotes

  • JNH and ET contributed equally.

  • Contributors The authors were involved in the study activities listed. JNH: methodology, data analysis, interpretation of results, writing manuscript and editing. ET: data collection and recruitment of participants, methodology, data analysis, interpretation of results and writing manuscript. KG-D: conceptualisation, methodology, interpretation of results, review and editing. ML: conceptualisation, methodology, interpretation of results, review and editing. MM: recruitment process, methodology, interpretation of results, review and editing. IS-P: conceptualisation, methodology, interpretation of results, review and editing. TT: conceptualisation, data collection and recruitment, methodology, interpretation of results, review and editing. MER: conceptualisation, data collection and recruitment, methodology, funding acquisition, project administration, interpretation of results, writing manuscript and editing.

  • Funding The Family Planning Fund in Uppsala, Faculty of Medicine, Lund University.

  • Competing interests KG-D has received consulting fees and/or payment or honoraria from Bayer, MSD, Gedeon Richter, Mithra, Exeltis, MedinCell, Cirqle, Natural Cycles, Exelgyn, Campus Pharma and HRA-Pharma. KG-D has been involved in data safety monitoring boards or advisory boards of Gedeon Richter and Bayer. KG-D has had reading roles (unpaid) for FIGO, WHO HRP/SRH, the European Society for Contraception and Reproductive Health, FIAPAC and FSRH/RCOG (UK). IS-P has served occasionally on advisory boards or acted as an invited speaker at scientific meetings for Asarina Pharma, Bayer Health Care, Gedeon Richter, Peptonics, Shire/Takeda and Sandoz. None of the other authors report any conflicts of interest.

  • Provenance and peer review Not commissioned; externally peer reviewed.