Historically, women are disproportionately impacted by pandemic illness and COVID-19 is no exception. Addressing domestic violence (DV) and access to reproductive healthcare may reduce the gendered impact of COVID-19. Before the COVID-19 pandemic, we piloted a program to enhance reproductive health literacy, Sexual Health Empowerment for Birth Control (SHE-BC). This program may offer insights to improve DV survivors’ reproductive agency during the current pandemic.
Increasing DV during the COVID-19 pandemic
The United Nations secretary-general noted a “horrifying surge in domestic violence” during the pandemic. Pre-COVID, one in four women reported sexual violence, physical violence, and/or stalking by an intimate partner. During COVID, social distancing measures have led to increased isolation and limited access to social support systems and community resources. While such measures have been critical to slow the spread of COVID-19, they have also exacerbated the staggering DV crisis. Across the nation, there has been a significant increase in DV hotline calls, website visits, police reports, and shelter occupancy.
DV survivors face unique barriers to contraception access
Amidst the pandemic, women are experiencing limited access to reproductive healthcare. Barriers include health clinics closures and limited services, fears of infection risk, and economic stress. Additionally, DV survivors may face the added barrier of reproductive coercion. Reproductive coercion is defined as a behavior that interferes with a woman’s decision-making around her reproductive health. This may include interfering with birth control, forcing a woman into a pregnancy or abortion, denying access to reproductive healthcare, or tampering with or lying about condom use. Prior to COVID, rates of reproductive coercion ranged from 8-19%, with the highest rates reported amongst DV survivors. While women have been in isolation with their partners during the pandemic, it is likely that this abuse tactic has been used with increasing frequency.
SHE-BC curriculum
Healthcare systems and DV agencies should consider expanding access to resources that address reproductive coercion. One way this can be accomplished is through critical health literacy programs, such as the SHE-BC project. Critical health literacy is more than just understanding what is written on hospital discharge sheets or prescription bottles–it requires women to have self-efficacy and health beliefs that allow them to analyze information and make their own decisions. SHE-BC is a program that aims to increase birth control critical health literacy among DV survivors so that they can recognize reproductive coercion and make informed decisions about their reproductive health.
SHE-BC was designed for small groups of female survivors in DV agencies. The curriculum consists of three 2-hour sessions with 3 core components: birth control knowledge, beliefs, and self-efficacy. The curriculum was adapted from the Sexual Health Empowerment program, which was originally designed for incarcerated women. A trained facilitator provided information, invited discussion, and created a nurturing environment to foster learning. Participants were treated as experts in their own right. The topics included for discussion were navigating healthcare systems, partner control, and reproductive desires. The facilitator encouraged participants to discuss their feelings about fertility and experiences with contraceptives, such as where they got it, and which providers, hospitals, or clinics they frequented and trusted. Finally, participants developed strategies to address reproductive coercion through discussion that focused on their experiences.
SHE-BC outcomes
In our SHE-BC pilot study, 25 women from an urban DV shelter enrolled and completed the survey. Most participants were black or white race and reported a high school degree or equivalent. 31% of women reported a history of reproductive coercion and 69% had an unplanned pregnancy.
Less than a third of participants reported using birth control in the month before arrival. The most commonly used methods were withdrawal and male condoms, and only one woman reported using hormonal birth control. None of the participants used long-acting reversible contraceptives (i.e., LARC), the most effective form of birth control. However, from pre- to post-intervention, we saw an increase in contraceptive knowledge, belief, and self-efficacy on the validated survey. These results are significant because they suggest that our intervention improved critical health literacy and provided women with a greater sense of reproductive agency.
Lessons learned
Given over 7 million COVID-19 cases in the US and no identifiable end for the pandemic, public health providers must identify unique ways to meet women’s contraceptive needs outside of typical clinic settings. SHE-BC was feasible and well-received in a DV shelter. This suggests that shelters may be an ideal venue to provide DV survivors with reproductive healthcare during the COVID-19 pandemic.
The low rates of birth control use among SHE-BC participants suggest there is an opportunity to improve contraceptive education, access, and self-efficacy for IPV victims. However, it is unclear whether low birth control use was due to access barriers, coercion by partners, or desire for pregnancy. We hope that the increased birth control knowledge, belief, and self-efficacy scores will translate to DV survivors feeling empowered to make decisions about contraception that are aligned with their reproductive goals.
Call to action
It is critical to maintain IPV survivors’ access to reproductive healthcare during the pandemic. Almost 1 in 3 SHE-BC participants reported reproductive coercion by an intimate partner. More than 2 in 3 reported an unplanned pregnancy. Even small decreases in reproductive healthcare access may result in a large number of unplanned pregnancies. The Guttmacher Institute estimates that if reproductive health care drops by 10% due to the pandemic, there will be an estimated 15 million additional unintended pregnancies and 3 million more unsafe abortions worldwide.
Healthcare systems must continue to provide essential reproductive health services to IPV survivors during the ongoing COVID-19 pandemic. Additionally, DV shelters are an important community venue for interventions to help women to achieve their reproductive health goals. In times of crisis, we must think creatively. Providing reproductive and sexual health education in DV shelters may offer a unique solution for a population at increased risk for negative reproductive health outcomes.
The SHE program is currently being piloted in an NIH-funded randomized control trial. We are happy to share untested materials and welcome comments about content and outcomes.
The authors would like to thank the entire SHE Team for their contributions to this project.
Kimberly Randell
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