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Contraception prescribing in England during the COVID-19 pandemic
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  1. Tanha Begum1,
  2. Emer Cullen2,
  3. Malcolm Moffat2,
  4. Judith Rankin2
  1. 1School of Pharmacy, Newcastle University, Newcastle upon Tyne, UK
  2. 2Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
  1. Correspondence to Dr Malcolm Moffat, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK; Malcolm.Moffat{at}newcastle.ac.uk

Abstract

Background National lockdowns in England due to COVID-19 resulted in rapid shifts in healthcare provision, including in primary care where most contraceptive prescriptions are issued. This study aimed to investigate contraception prescribing trends in primary care during the pandemic and the impact of socioeconomic deprivation.

Methods Prescribing data were accessed from the English Prescribing Dataset for the first year of the COVID-19 pandemic (1 March 2020–28 February 2021) and the year prior (1 March 2019–29 February 2020). Data were analysed by geographical region (London, Midlands and East of England, North of England, South of England) and contraceptive type (progestogen-only pill (POP), combined oral contraception (COC), emergency hormonal contraception (EHC) and contraceptive injections). Differences in prescribing rates were calculated using Poisson regression. Pearson correlation coefficients were calculated for the Index of Multiple Deprivation (IMD) scores for each Clinical Commissioning Group (CCG) in the North East and North Cumbria (NENC).

Results Contraception prescribing rates decreased overall during the COVID-19 pandemic in England (Poisson regression coefficient (β)=−0.035), with a statistically significant (p<0.01) decrease in all four regions. Prescriptions decreased for COC (β=−0.978), contraceptive injections (β=−0.161) and EHC (β=−0.2005), while POP (β=0.050) prescribing rates increased. There was a weak positive correlation between IMD and prescribing rates in NENC (p>0.05).

Conclusions Contraception provision was impacted by COVID-19 with an overall decrease in prescribing rates. The deprivation results suggest that this may not be a significant contributing factor to this decrease. Further research is recommended to better understand these changes, and to ensure that services respond appropriately to population needs.

  • COVID-19
  • family planning services
  • contraceptives, oral
  • contraceptives, postcoital
  • hormonal contraception

Data availability statement

Data are available in a public, open access repository. All the data used in these analyses are available at https://www.nhsbsa.nhs.uk/prescription-data/prescribing-data/english-prescribing-data-epd.

https://doi.org/10.1136/bmjsrh-2023-201856

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • The COVID-19 pandemic, and in particular its associated national lockdowns, had a significant impact on healthcare provision in England.

    WHAT THIS STUDY ADDS

    • Contraception prescribing in primary care decreased significantly during the first year of the pandemic in all four English regions, and decreased to a greater extent during months when lockdown restrictions were in place. Reductions in prescriptions for the contraceptive injection, the emergency hormonal contraceptive pill, and the combined oral contraceptive pill were only partially mitigated by an increase in prescriptions for the progestogen-only pill.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Contraception provision is vital healthcare, and services should be prepared to respond more effectively to the need for ongoing contraception availability during future crisis situations. The downstream consequences of reduced access to contraception care during the first year of the pandemic, and the effects of health inequalities on variation in access, require further investigation.

    Introduction

    The COVID-19 pandemic necessitated three national lockdowns in England,1 resulting in a rapid shift in healthcare service provision. Although contraception provision was considered essential, capacity within primary care was reduced, with a drop in overall consultations and a rapid move to remote consultations.2 3 In sexual health drop-in services, the siting of long-acting reversible contraceptives (LARCs) and some sexually transmitted infection (STI) testing were also temporarily suspended.4 Other changes, recommended by the Faculty of Sexual and Reproductive Health (FSRH), included temporarily suspending certain checks prior to prescribing combined oral contraception (COC) and recommending a switch from injectable contraceptives to the progestogen-only pill (POP).5 Lockdown rules may also have restricted access to pharmacies,6 and worldwide shortages in the supply of contraceptive medication and devices are likely to have resulted in additional unmet need.7 Barriers to accessing sexual healthcare were recognised prior to the pandemic,8 and service reconfigurations made in response to COVID-19 had the potential to worsen inequalities.6

    A reduction in contraception-related contacts with sexual and reproductive health services in 2020/2021 has been reported,9 while abortion statistics showed a 4% increase in 2020 compared with 2019.10 Previous research examining overall prescribing trends11 and in the first 3 months of the pandemic12 suggests that contraception prescriptions reduced during the pandemic. However, there is a paucity of published evidence specifically exploring the wider impact of the COVID-19 pandemic on contraception prescriptions issued in England. The aim of this study was to investigate contraception prescribing trends in England during the COVID-19 pandemic.

    Methods

    The English Prescribing Dataset (EPD) collates National Health Service (NHS) primary care prescriptions issued in England.13 NHS England redefined their geographical regions in April 2020, changing from four to seven regions. For the purposes of this study, four geographical regions are used: London, Midlands and East of England, South of England, and North of England.13 The EPD does not include prescriptions issued outside of primary care. However, given its comprehensive coverage of general practitioner (GP)-issued prescriptions, which comprises the vast majority of contraception prescriptions in the UK,14 the EPD was considered the most relevant data source to assess changes in contraception prescribing in England.

    A retrospective database analysis was conducted using EPD data for the period 1 March 2019 to 28 February 2021, during which a total of 15 428 874 prescriptions were issued and dispensed. The period 1 March 2020 to 28 February 2021 represented the first full year of the pandemic, while the period 1 March 2019 to 29 February 2020 represented the pre-pandemic comparator year. National lockdown periods were defined as April to May 2020, November 2020, and January to February 2021.1 For the purposes of this study, contraception prescriptions were limited to COC, POP, contraceptive injections and emergency hormonal contraception (EHC), with all other forms of contraception excluded.

    Data were organised into the four NHS England regions and sorted by contraceptive type, to calculate the number of prescription items by region. In order to investigate the potential impact of deprivation on prescribing rates within a region at a more local footprint, this was repeated for Clinical Commissioning Groups (CCGs) in the North East of England and North Cumbria (NENC), using the Index of Multiple Deprivation (IMD) measure. Relative deprivation in England is officially measured using the IMD, with a higher score indicating a higher level of deprivation.15

    All analyses were undertaken using Stata (StataSE 17). Poisson regression, a relatively simple regression model used for modelling count data, was used to explore differences in prescription rates in relation to pre-pandemic and COVID-19 time periods, and in relation to lockdown and non-lockdown months within those periods. The Pearson correlation coefficient was used to measure linear correlation between the percentage change in prescriptions issued during the pandemic, pre-pandemic, lockdown and non-lockdown months, and IMD score in NENC CCGs. Statistical significance was set at the p<0.05 level.16

    Patient and public involvement

    There was no patient or public involvement in this study.

    Results

    All of England results

    There was variation in prescription rates by month in both time periods, both overall and by contraceptive type, with more significant fluctuations in rates seen between months during the pandemic (figure 1). Overall, there was a 3.6% reduction in prescribing rates during the first year of the COVID-19 pandemic compared with the pre-pandemic year. This reduction was found to be statistically significant across the whole year (Poisson regression coefficient (β) = −0.035 (p<0.01)), with the most noticeable reduction seen in May 2020. There was also a reduction in prescribing during lockdown months compared with non-lockdown months during the pandemic period (β = −0.064 and −0.0073 (p<0.01), respectively).

    Figure 1
    Figure 1

    Number of contraceptive prescriptions issued in England pre- and during the COVID-19 pandemic. The circles signify the periods of lockdown. The black line signifies prescribing rates during the pandemic (March 2020 to February 2021) and the grey line signifies prescribing rates pre-pandemic (March 2019 to February 2020).

    Contraceptive type

    There was a reduction in prescribing in the first 3 months of the pandemic year for all four contraceptive types, with significant variation subsequently (figure 2). There was a steep increase in prescriptions for EHC between April and July 2020, although rates did not return to pre-pandemic levels. Contraceptive injection prescribing rates remained below pre-pandemic levels across the whole year, with an overall reduction of 14.89% (β = −0.161 (p<0.01)). Rates of POP prescribing exceeded pre-pandemic levels over the whole year (percentage increase 5.15%, β = 0.050 (p<0.01)), while rates of COC remained below pre-pandemic levels (8.41% reduction, β = −0.098 (p<0.01)).

    Figure 2
    Figure 2

    (A) Prescribing trends for combined oral contraception (COC) pre- and during the COVID-19 pandemic in England. The black line signifies prescribing rates during the pandemic (March 2020 to February 2021) and the grey line signifies prescribing rates pre-pandemic (March 2019 to February 2020). (B) Prescribing trends for the progestogen-only pill (POP) pre- and during the COVID-19 pandemic in England. The black line signifies prescribing rates during the pandemic (March 2020 to February 2021) and the grey line signifies prescribing rates pre-pandemic (March 2019 to February 2020). (C) Prescribing trends for emergency hormonal contraception (EHC) pre- and during the COVID-19 pandemic in England. The black line signifies prescribing rates during the pandemic (March 2020 to February 2021) and the grey line signifies prescribing rates pre-pandemic (March 2019 to February 2020). (D) Prescribing trends for the contraceptive injection pre- and during the COVID-19 pandemic in England. The black line signifies prescribing rates during the pandemic (March 2020 to February 2021) and the grey line signifies prescribing rates pre-pandemic (March 2019 to February 2020).

    Regions

    An overall reduction in contraceptive prescribing was seen in each of the four regions, with the largest percentage reduction seen in London (−5.43%, β = −0.053 (p<0.01))) and the lowest in North of England (−2.23%, β = −0.022 (p<0.01)). The most noticeable decrease in prescribing rates for England and for all four regions was early in the pandemic. However, the North of England showed a small increase in prescribing rates during the non-lockdown months in the pandemic period compared with pre-pandemic levels.

    Across the four regions, prescribing rates by contraceptive type showed similar trends to England, and were broadly similar across the four regions (see online supplemental material). London showed higher rates of EHC prescribing in June and July, and September to November 2020 compared with pre-pandemic. Poisson regression coefficients and incidence rate ratios for changes in prescribing rates for each region and contraceptive type were statistically significant (table 1).

    Supplemental material

    View this table:
    Table 1

    Percentage change in prescription rate, Poisson regression coefficient and incidence rate ratio for England, each region and contraceptive type across the 2 years, during the lockdown and non-lockdown periods

    Contraceptive prescriptions by CCGs in the North East and North Cumbria (NENC)

    Changes in contraception prescribing in NENC CCGs are described in table 2. Six of the eight CCGs showed a decrease in prescribing rates during the pandemic compared with before the pandemic. However, South Tyneside and Sunderland showed a 3.47% increase and a 3.99% increase in prescribing rates, respectively. For those CCGs with a lower rate across the year, this reduction was greater during the lockdown months compared with non-lockdown months.

    View this table:
    Table 2

    Percentage change in prescribing rates comparing pandemic and pre-pandemic months; lockdown months (April–June 2019, November 2019, January–February 2020) compared with pre-pandemic; and non-lockdown months (March 2020, July–October 2020, December 2020) compared with pre-pandemic, for each Clinical Commissioning Group in the North East and North Cumbria, with Index of Multiple Deprivation scores

    The Pearson correlation coefficient (R2) for percentage change in contraception prescribing against IMD was 0.53, indicating a moderately positive linear relationship. However, this was not found to be statistically significant (p=0.18). During lockdown months only, the R2 of 0.29 expresses a weak positive correlation between the level of IMD and percentage change in contraception prescriptions during the lockdown periods, but this was also not statistically significant (p=0.48). During non-lockdown months, the R2 of 0.56 describes a moderate to strong positive correlation between deprivation and prescribing rates, but this did not reach statistical significance (p=0.15).

    Discussion

    This study investigated contraception prescribing rates during the COVID-19 pandemic compared with pre-pandemic rates. Overall, contraception prescribing rates declined during the pandemic across England as a whole and within the four geographical regions studied, and these decreases were statistically significant. A statistically significant decrease in prescribing rates during lockdown periods compared with non-lockdown periods was also observed across England. The North of England showed a small increase in prescribing during non-lockdown months compared with pre-pandemic levels. Rates of prescribing for all four contraceptive types reduced at the beginning of the pandemic, and rates of prescribing for EHC, COC and contraceptive injections remained below pre-pandemic levels across England and within the four regions. The largest reduction was seen in prescriptions for contraceptive injections. However, rates of prescribing of POP were higher during the pandemic. Although all results were statistically significant, some of the effect sizes as indicated by the incidence rate ratio are potentially too small to have an impact on population level outcomes. No statistically significant correlation between prescription rates and deprivation rates was observed on examination of prescriptions issued in NENC CCGs. However, two CCG areas showed higher rates of prescribing during the pandemic.

    The observed decrease in contraception prescriptions is in line with other UK research that has shown a reduction in contraceptive and other prescribing rates in 2020.11 Several factors may have contributed to this reduction. Access to GP appointments was limited due to reconfiguration of services.2 4 6 This resulted in fewer consultations and thus a reduction in the number of prescriptions issued. This reduction in access may have also resulted in longer-length prescriptions being issued, thus under-quantifying overall contraception use. Despite changes in service provision, research suggests that most people could access the healthcare they needed.17 18

    Patient behaviour may also have affected access. Published research identified fear of contracting the coronavirus or putting loved ones at risk, fear of breaking rules, and a belief that personal medical concerns were not significant as barriers to accessing healthcare.18 19 Two UK studies revealed that the public was unclear if contraception services were considered essential, and highlighted other barriers to access including hesitation in interacting with healthcare professionals remotely, a lack of privacy when accessing services from home, and confusion around health service messaging.6 19 For example, the change away from mandatory blood pressure and body mass index checks prior to COC prescription caused concern.6 It is of note that while an 11% drop in contraception prescribing in England is observed in these data during the first lockdown period (April–June 2020), a smaller decrease of 4% is observed in the lockdown in early 2021, and a 1% increase in contraception prescriptions occurred during the shorter lockdown in November 2020. Provider and patient behaviours are likely to have evolved during the course of the pandemic.

    Changes in sexual activity levels can also influence contraception behaviours. A UK-based survey identified pandemic-related changes in sexual desire/activity, with a bigger impact noted in women and those who did not live with a partner.20 21 Lockdown rules placed legal restrictions on contact with people from other households,20 while social disruption resulted in psychological, financial and work-related stress, negatively impacting well-being,22 and potentially impacting sexual desire. The lack of easily accessible contraceptive care may also have resulted in reduced sexual activity.6

    Changes in prescribing rates varied by contraception type. The increase in overall prescribing of the POP may have compensated for the decrease in COC prescriptions. Prescriptions for the POP do not require blood pressure or weight measurements, and can be issued without a face-to-face appointment.23 Although the FSRH5 issued advice on suspending these measurements for COC, prescribers and patients may have felt more comfortable with POP. The Medicines and Healthcare products Regulatory Agency (MHRA) made the decision to declassify the POP from prescription-only to a pharmacy medicine in July 2021.24

    Prescription rates for contraceptive injections showed a consistent decline throughout the pandemic, likely due to the reduction in face-to-face appointments. Although self-administration of contraceptive injections is possible,5 these data suggest that this is not well-established. EHC prescribing rates in primary care also decreased significantly during the pandemic. However, EHC is also available through pharmacies without the need for a prescription, and these would not be included in the EPD. However, pharmacies struggled to provide facilities to conduct pre-EHC consultations in a confidential or COVID-secure manner during the pandemic,25 and there has been a push for declassification of EHC26 to make it accessible without a pharmacist consultation.

    From January to June, there was a 4.07% increase in the rate of abortions in 2020 compared with 2019.10 This increase may reflect a lack of access to contraception care.27 However, the increase in the number of abortions by 4500 in April 2020 compared with April 2019,10 which would include women who became pregnant prior to when lockdown restrictions were introduced, suggests a more complex explanation, including a reluctance to be pregnant during the pandemic.27

    Despite the influence of economic insecurity on family planning, this research found no correlation between deprivation and contraceptive-prescribing rates at the level of CCGs in the North East of England. Similarly, when the authors examined data for individual GP practices within Newcastle upon Tyne, they found no correlation between IMD for each practice and changes in prescription rates. Two areas within the North East, Sunderland and South Tyneside, showed an increase in prescribing rates during the pandemic. Discussion with the Local Authority partners in those areas, who are responsible for the commissioning of sexual health services, revealed that a new online service, provided by SH:24, had been introduced shortly before the first lockdown.28

    The use of the EPD, a large national dataset, is a major strength of this study. To the authors’ knowledge, this is the first study to analyse contraceptive prescribing trends over a full year of the pandemic by contraception type, geography and deprivation. However, analysis was limited by what was available within the EPD, which does not include demographics or indications for prescriptions, or any information on compliance. Therefore, some prescriptions included in this dataset could have been prescribed for non-contraceptive reasons. Only one database was used, and so the analysis does not include those medications dispensed by other means, including through private practice and secondary care. Only two years of contraceptive data were analysed; examining across a longer timeframe in an interrupted time series analysis would add further insights. This study did not include devices and implants but focused on items that together make up the larger part of primary care contraception prescriptions.

    The COVID-19 pandemic resulted in significant changes to contraceptive prescribing trends in England. In future crisis situations, there is a need for contraception’s status as an essential medicine to be effectively communicated to the public. The pandemic has presented opportunities to trial new approaches to healthcare provision that could help address shortcomings in sexual health provision. Improved accessibility is already happening with trials piloting pharmacy-led COC services.29

    Due to the nature of this study, it was not possible to investigate barriers to accessing contraception, which should be the focus of future qualitative research. Additionally, further research could also explore the quantity of the prescriptions supplied, to assess whether there were changes in prescription length.

    This retrospective database analysis demonstrated that the COVID-19 pandemic had a profound impact on contraception prescribing rates across England. A reduction in prescriptions of COC, EHC and contraceptive injections were consistently identified compared with pre-pandemic levels, while an increase in POP was shown. Although we did not find a relationship between deprivation and prescribing trends, this requires further investigation. Further qualitative research is recommended to better understand these changes, to ensure that services respond appropriately to population need in crisis situations.

    Data availability statement

    Data are available in a public, open access repository. All the data used in these analyses are available at https://www.nhsbsa.nhs.uk/prescription-data/prescribing-data/english-prescribing-data-epd.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

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    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • Contributors TB, MM and JR contributed to the conception and design of the work. All authors contributed to the analysis and interpretation of the work. TB and EC drafted the manuscript and all authors revised it for important intellectual content. All authors gave final approval of the version to be published. MM is responsible for the content overall as guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. JR is part-funded by the National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) North East and North Cumbria (NENC).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.