By Emma Rezel-Potts, Melissa J Palmer, Caroline Free, Paula Baraitser
The lockdown measures issued by the UK government in response to the COVID-19 pandemic have transformed all aspects of healthcare delivery, including sexual and reproductive health (SRH). Remote and online solutions, that were already developing as alternative options to some traditional, face-to-face SRH services, have rapidly expanded, in some cases as the only way to provide care. The temporary deregulation of abortion services epitomises this shift, with the Department of Health (DoH) in England announcing updated guidance allowing women who are unable to access clinic services to use abortion pills at home. Whilst the DoH stresses the short-term nature of these changes, for many this signifies an important recognition of women’s reproductive rights. It also resurfaces debates about the extent to which approaches to aspects of women’s reproductive health have been paternalistic and over-medicalised.
The difficulty with such rapid changes is that the evidence base to support decision making can be limited. In recent years, the literature on telemedicine more broadly, and specifically on online services for sexually-transmitted infection testing and treatment, has continued to grow (see here, here and here). However, contraception, like abortion pills, has largely been considered a service that required in-person consultation, particularly for first-time prescriptions. Our paper in BMJ SRH examines an innovative online sexual health service that delivers oral contraceptive pills (OCPs), free-of-charge to women’s homes, following an online consultation process and, where required, remote contact with an OCP prescriber. We present the first findings on online and remote delivery of OCPs, including the following key messages:
- Uptake of a free, online contraceptive service in two inner-London boroughs was high among residents of the most deprived areas according to Index of Multiple Deprivation quintile.
- Two-thirds of the service-users were aged between 20 and 29 years and 58.8% were of white ethnic group, reflecting the ethnic diversity of the area.
- Black and minority ethnic (BME) service-users had lower odds of repeat access. This warrants further investigation into potential barriers to online contraception for these groups.
We considered these findings reassuring about the capacity for innovative health services to be accessible to an ethnically and socio-economically diverse population. Uptake was high among BME groups and those residing in more deprived areas, helping to allay concerns that bringing elements of such services online may serve to exacerbate existing inequalities in access. Black and minority ethnic service-users had lower odds of repeat online OCP orders and are known to experience poorer contraceptive continuation within traditional services. We make recommendations for researchers and developers to investigate the reasons for these differences in repeat use and seek to improve online services to better meet the needs of these groups.
There has been much media coverage on the health inequalities that have been exposed thus far in the COVID-19 crisis, with BME groups bearing a disproportionate burden of severe disease and mortality. This suggests that face-to-face services overall may be failing to meet the needs of these populations. The development of new, online platforms represents a unique opportunity to be conscious of the potential for such inequalities from the outset; a chance to build systems from the ground up which do not replicate the inadequacies of the past.
Having said this, we recognise that regardless of their strengths and capacity to drive change, online and remote health services are unlikely to be a panacea, both during this time of crisis and beyond. Women’s SRH needs will continue to include those which must be met within face-to-face, traditional providers, including abortion services at later stages of pregnancy and long-acting reversible contraception (LARC). Even those women who prefer OCPs may still wish to consult with their providers face-to-face depending on timing and circumstances. Young people, with their additional safeguarding needs, are still likely to benefit from physical attendance at specialist SRH clinics.
We hope that our study will contribute to the growing literature on online and remote SRH services and highlight its potential to expand options for women’s access to a safe and effective method of contraception. In this current pandemic context, online and remote services are indispensable and may be the only way to avoid detrimental reproductive health consequences. Post-lockdown we must continue to ensure that robust research underpins innovation and ask ourselves how we can better integrate online options with traditional, face-to-face care, to ease pressure on over-stretched services and provide a wider array of options for access so women can better meet their reproductive health needs.
A Cohort Study of the Service-users of Online Contraception was published in BMJ Sexual and Reproductive Health. Read the full manuscript here.
Emma Rezel-Potts: School of Population Health & Environmental Sciences, King’s College London, Addison House, London, SE1 1UL, UK
Melissa J Palmer, Caroline Free, and Paula Baraitser: Department for Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK