Ensuring equitable patient access to family planning services, including but not limited to contraception, is critical for promoting reproductive autonomy (Holt et al., 2020; Potter et al., 2019), as these services support individuals and their partners to choose if and when to become pregnant. Family planning services are also important to prevent unintended pregnancies, which represent nearly half of all U.S. pregnancies (Finer and Zolna, 2016). Unintended pregnancies are associated with adverse maternal and infant health outcomes (Gipson et al., 2008; Qiu et al., 2020), although it is difficult to disentangle the multiple social and economic inequity factors that influence both pregnancy intention and poor maternal and infant health outcomes (Zambrano et al., 2020). Access to contraception might be especially important during public health emergencies, such as the coronavirus disease 2019 (COVID-19) pandemic, when fertility preferences might change (Lindberg et al., 2020). For example, individuals may want to postpone pregnancy during the pandemic because pregnant persons with COVID-19 are at significantly higher risk for severe outcomes compared with non-pregnant persons with COVID-19, even though the absolute risks for severe COVID-19-associated outcomes among pregnant and non-pregnant persons are low (Zambrano et al., 2020). Additionally, a survey of U.S. women examining the intersection of pandemic-related economic challenges and reproductive experiences found that those whose finances had worsened during the pandemic were more likely to want to delay childbearing or have fewer children because of the pandemic (Lindberg et al., 2020).

The COVID-19 pandemic has affected healthcare access, delivery, and utilization in the United States (Czeisler et al., 2020; Demeke et al., 2020; Koonin et al., 2020; Mehrotra et al., 2020). Healthcare systems and clinics have closed or reduced services to optimize resources and mitigate infection risks for patients and providers. Best practices and resources have been compiled to help providers continue to deliver family planning services during the pandemic (Reproductive Health National Training Center (RHNTC), 2020; University of California San Francisco (UCSF) School of Medicine, 2020). Healthcare delivery strategies include telehealth visits; curbside pickup or mail delivery of supplies; providing a 12-month supply of contraception to reduce the need for follow-up visits; preemptively giving prescriptions for or supplies of emergency contraception pills (ECPs); and proactively reviewing patient charts to identify those who will soon run out of supplies or are due for a contraceptive injection or long-acting reversible contraception (LARC, intrauterine device or implant) management (Reproductive Health National Training Center (RHNTC), 2020). Although many of these strategies reduce the need for in-person visits, clinic visits remain necessary for LARC insertion and removal, if desired by patients, and these services may be particularly impacted by the pandemic.

Nevertheless, evidence suggests the COVID-19 pandemic has disrupted access to family planning services. One survey found that one in three U.S. women reported that contraceptive or other reproductive health visits were delayed or cancelled or that they experienced challenges accessing contraception (Lindberg et al., 2020). Less is known about providers’ perspectives regarding how the COVID-19 pandemic has affected family planning service delivery. One survey of office-based obstetrician-gynecologists found that most have continued to provide reproductive health services during the pandemic, but that they have faced challenges (e.g., declines in patient volume, financial and staffing challenges) and changes (e.g., telehealth utilization) within their practices (Weigel et al., 2020). We sought to expand what is known about the effect of the pandemic on family planning service provision from the perspectives of a broad range of U.S. physicians. Using data from a web-based panel survey of primary care physicians, pediatricians, and obstetrician-gynecologists working in outpatient and inpatient settings, our objectives were to compare changes in family planning-related clinical services and healthcare delivery strategies before and during the pandemic and assess specific service provision issues experienced during the pandemic.

We analyzed cross-sectional data from the Fall 2020 DocStyles survey, a web-based panel survey of U.S. healthcare providers commissioned by Porter Novelli Public Services (http://styles.porternovelli.com) and administered September 14–October 26, 2020 by SERMO (http://www.sermo.com). The survey, which contained 135 questions, assessed healthcare provider attitudes and practices on a broad range of health topics, including family planning service provision, just before and during the COVID-19 pandemic.

Most respondents were primary care physicians (34.0% were family practitioners and 28.7% were internists) while 22.7% were obstetrician-gynecologists and 14.7% were pediatricians (Table 1). Most had practiced medicine for ≥10 years (76.3%), were aged ≥45 years (59.3%), were male (61.6%), and self-identified as non-Hispanic White (61.5%). Respondents represented all U.S. regions. Most worked in a suburban area (52.7%) and primarily in a group outpatient practice (74.6%). Family planning patient volume just before the COVID-19 pandemic (i. e., average number of female patients of reproductive age who received family planning services per week) was low (1–10 patients) for most respondents (58.6%) while 29.9% reported moderate (11–50 patients) and 11.5% reported high (≥51 patients) volume.

We found many changes in family planning clinical services when comparing service delivery before and during the pandemic and some differences by physician type. We observed slight decreases in the proportion of physicians overall whose practices provided LARC services, reflecting physicians whose practices offered LARC services before but discontinued these services during the pandemic. Approximately one in five physicians surveyed whose practices provided other key routine contraception practices just before the pandemic, reported practice-level discontinuation of these practices during the pandemic (e.g., providing or prescribing ECPs in advance and sending patient reminders about DMPA injections or LARC removal or replacement). We observed increases in the proportion of physicians whose practices used service delivery approaches that improve access and reduce the need for in-person visits (i.e., telehealth for contraception, accepted self-report of blood pressure during telehealth visits for contraception, renewed contraception prescriptions without requiring an office visit, and curbside pickup or mail delivery of contraception), reflecting physicians whose practices did not offer these services before but initiated these services during the pandemic. The physicians surveyed also experienced practice-level service provision issues during the pandemic (e.g., fewer adult females seeking care, clinic closed for in-person appointments). While a smaller proportion of physicians reported these issues in the month before survey completion compared with at any point during the pandemic, about one-third still reported fewer adult females seeking care.

We observed low availability of LARC services both before and during the pandemic. A core component of quality family planning services is patient access to a broad range of contraceptive methods, including LARC (Gavin et al., 2014). As part of providing patient-centered care and supporting individual reproductive autonomy, access to in-person visits for LARC placement and removal services is needed, if LARC services are desired by patients. Access to LARC methods, which are highly effective (Trussell et al., 2018) and have few medical contraindications for use (Curtis et al., 2016a), might be particularly important during the pandemic given possible changes in attitudes toward contraception. One study found that one in four women overall, and one in two women with concerns about reduced access to contraception, reported thinking more about getting a LARC method because of the pandemic (Lindberg et al., 2020).

Only one in three physicians surveyed reported their practices provided or prescribed ECPs in advance (both before and during the pandemic), despite evidence-based guidance supporting advance provision of ECPs so they can be taken as soon as possible after unprotected sexual intercourse (Curtis et al., 2016b). This finding may be because levonorgestrel ECPs are available over-the-counter in the United States and physicians may not perceive that they have an important role ensuring patient access to emergency contraception. However, despite over-the-counter access, barriers to ECPs remain, including stocking issues and confusion about access requirements (Upadhya, 2019). Emergency contraception is an important backup contraceptive option and might have increased salience during the COVID-19 pandemic because of potential pandemic-related contraception access barriers.

A promising finding from our analysis is use of telehealth for contraception care, in line with recommendations to offer telehealth services during the pandemic (Centers for Disease Control and Prevention (CDC), 2020). Our analysis found that more than half of physicians surveyed reported providing telehealth for both contraception initiation and continuation at some point during the pandemic, reflecting significant increases compared with just before the pandemic. These findings are similar to prior surveys of family planning providers that found increased provision of telehealth services for contraception during the COVID-19 pandemic (Stifani et al., 2020; Weigel et al., 2020). Nevertheless, recent medical claims data have shown that while telehealth services have grown rapidly during the pandemic, these services were not sufficient to offset drops in in-person visits (Cox and Amin, 2020). Moreover, providers have reported challenges with telehealth including technical difficulties, inability to conduct physical exams and diagnostic testing, and lack of guidance on telehealth best practices (Stifani et al., 2020; Weigel et al., 2020). In our survey, although physicians reported fewer practice-level telehealth issues in the month before survey completion compared with at any point during the pandemic, suggesting gained experience implementing telehealth over time, nearly one in three continued to report technical challenges with telehealth, and approximately one in five continued to report confidentiality concerns, billing challenges, and patient discomfort with telehealth. Confidentiality concerns with telehealth remained a particular issue for pediatricians. Resources are available to support family planning service delivery through telehealth, including information on providing person-centered care, workflow best practices, billing, and online pharmacies (Converge Partners in Action. Provision of Person-Centered Reproductive Health Care via Telemedicine, 2020; University of California San Francisco (UCSF) School of Medicine, 2020).

Few physicians surveyed reported their practices initiated or implemented several suggested practices to help family planning providers meet patient needs during the COVID-19 pandemic (Reproductive Health National Training Center (RHNTC), 2020) (i.e., supporting self-administration of subcutaneous injectable contraception, counseling on extending use of LARC beyond their FDA-approved duration, and sending patient reminders about DMPA injection or LARC removal or replacement). Self-administration of subcutaneous injectable contraception is safe, feasible, and improves method continuation rates (Katz et al., 2020; Kennedy et al., 2019; Lerma and Goldthwaite, 2019); it also reduces the need for in-person visits. Additionally, evidence suggests that the risk of pregnancy while using a LARC method for 1–2 years longer than prescribed is low (Ali et al., 2017; McNicholas et al., 2017; Thaxton and Lavelanet, 2019; Ti et al., 2020). For patients who desire continued LARC use, consideration of extending use beyond FDA-approved duration may provide ongoing pregnancy protection for patients having difficulty accessing LARC services (Reproductive Health National Training Center (RHNTC), 2020). Last, proactively reviewing patient charts and sending patient reminders prompts patients to schedule an appointment before a lapse in contraception protection. Low use of these strategies highlights opportunities for service delivery improvement to increase contraception access. Provider training may be needed to increase provider awareness of and confidence implementing certain strategies.

Discontinuation of key family planning services during the COVID-19 pandemic may limit contraception access, which may impede reproductive autonomy and contribute to unintended pregnancies. Implementing healthcare service delivery strategies that reduce the need for in-person visits (e.g., telehealth for contraception initiation and continuation, curbside pickup or mail delivery of contraception, providing or prescribing ECPs in advance, providing or prescribing a year’s worth of contraception) may decrease disruptions in care. Resources exist for public health and clinical efforts to ensure contraception access during the pandemic.