Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage

Publication date: 2020

Interim Technical Note Information as of 27 April 2020 1 Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage Pandemic threatens achievement of the Transformative Results committed to by UNFPA By UNFPA, with contributions from Avenir Health, Johns Hopkins University (USA) and Victoria University (Australia) UNFPA aims to achieve three world-changing results by 2030, the deadline for achieving the Sustainable Development Goals. These are: Ending unmet need for family planning, ending gender-based violence including harmful practices such as female genital mutilation and child marriage, and ending all preventable maternal deaths. This analysis shows how the COVID-19 pandemic could critically undermine progress made towards achieving these goals. Key points The impact of COVID-19 on ending unmet need for family planning ● COVID-19 is already causing disruptions in meeting family planning needs: ○ Clinical staff occupied with the COVID-19 response may not have time to provide services, or may lack personal protective equipment to provide services safely ○ Health facilities in many places are closing or limiting services ○ Women are refraining from visiting health facilities due to fears about COVID-19 exposure or due to movement restrictions ○ Supply chain disruptions are limiting availability of contraceptives in many places, and stock-outs of many contraceptive methods are anticipated within the next 6 months in more than a dozen lowest- income countries ○ Product shortages and lack of access to trained providers or clinics mean that women may be unable to use their preferred method of contraception, may instead use a less effective short-term method, or may discontinue contraceptive use entirely ● Some 47 million women in 114 low- and middle-income countries are projected to be unable to use modern contraceptives if the average lockdown, or COVID-19-related disruption, continues for 6 months with major disruptions to services ● For every 3 months the lockdown continues, assuming high levels of disruption, up to 2 million additional women may be unable to use modern contraceptives ● If the lockdown continues for 6 months and there are major service disruptions due to COVID-19, an additional 7 million unintended pregnancies are expected to occur ● The number of unintended pregnancies will increase as the lockdown continues and services disruptions are extended The impact of COVID-19 on ending gender-based violence ● The COVID-19 pandemic is likely to undermine efforts to end gender-based violence through two pathways: ○ Reducing prevention and protection efforts, social services and care ○ Increasing the incidence of violence ● COVID-19 pandemic is likely to cause a one-third reduction in progress towards ending gender-based violence by 2030 Interim Technical Note Information as of 27 April 2020 2 Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage ● If the lockdown continues for 6 months, 31 million additional gender-based violence cases can be expected ● For every 3 months the lockdown continues, an additional 15 million additional cases of gender-based violence are expected The impact of COVID-19 on ending female genital mutilation ● COVID-19 could have far-reaching impacts on the effort to end female genital mutilation ● Due to COVID-19 disruptions, we anticipate a 1/3 reduction in the progress towards ending FGM by 2030 ● Due to pandemic-related disruptions in prevention programmes, 2 million FGM cases could occur over the next decade that would otherwise have been averted The impact of COVID-19 on ending child marriage ● COVID-19 will disrupt planned efforts to end child marriage and cause wide-reaching economic consequences ● Together, these factors are expected to result in an additional total 13 million child marriages taking place that otherwise would not have occurred between 2020 and 2030 Impact of the COVID-19 Pandemic on Achieving the Transformative Results The COVID-19 pandemic has been the fastest-moving global public health crisis in a century, causing significant mortality and morbidity and giving rise to daunting health and socioeconomic challenges. Governments are taking unprecedented measures to limit the spread of the virus, while health and social systems are struggling to cope with rising caseloads, supply chain bottlenecks, movement restrictions and economic strains. In humanitarian and fragile settings and low-income countries, where these systems are already weak, the pandemic is disrupting access to life- saving sexual and reproductive health services. It is also compounding existing gender and social inequalities. UNFPA embraces the vision set forth in the 2030 Agenda for Sustainable Development and the targets contained in the 17 Sustainable Development Goals (SDGs). UNFPA is also rolling out a Global Response Plan in support of the United Nations Secretary-General’s strategy to respond to the devastating socioeconomic impacts of COVID-19. These efforts are not in conflict: The 2030 Agenda aims to ensure the health, rights and dignity of all people; its achievement must not be derailed by the current global public health crisis. To this end, UNFPA’s operations are focused on three strategic priorities including: continuing sexual and reproductive health services and interventions, including protection of the health workforce; addressing gender-based violence; and ensuring the supply of modern contraceptives and reproductive health commodities. The COVID-19 pandemic will have a negative effect on the three transformative results UNFPA aims to achieve by 2030: the ending of preventable maternal deaths, the ending of unmet need for family planning, and the ending of gender-based violence and all harmful practices. UNFPA and its partners, Avenir Health, Johns Hopkins University (USA) and Victoria University (Australia), have estimated the impact of the pandemic and related challenges on these transformative goals. This work builds on a global impact and cost analyses published in January 2020. Impact of COVID-19 on ending unmet need for family planning There is global consensus on the importance of making voluntary family planning available to all women. Not only is access to family planning a human right, but it saves lives and promotes healthier populations, more efficient health systems and stronger economies. Much progress has been made in the last 25 years to make family planning methods available, with the number of women using modern contraceptive methods almost doubling from 470 million in 1990 to 840 million in 2018. https://www.unfpa.org/resources/coronavirus-disease-covid-19-pandemic-unfpa-global-response-plan https://www.unfpa.org/featured-publication/costing-three-transformative-results Interim Technical Note Information as of 27 April 2020 3 Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage As of March 2020, there were an estimated 450 million women using modern contraceptives across 114 priority low- and middle-income countries. The COVID-19 pandemic as well as social distancing and other strategies to reduce transmission are anticipated to impact the ability of these women to continue using contraception. These factors may also stall increases in contraceptive use that were previously anticipated. Disruptions to global manufacturing and supply chains may also reduce the availability of contraceptive commodities. The closure of health facilities, unavailability of medical staff to provide family planning services, and women themselves being hesitant to visit health facilities due to concerns about COVID-19 exposure are additionally anticipated to impact women’s access to, and continued use of, contraception. Avenir Health estimated the impact of different lengths of disruption (e.g., 3-, 6-, 9- and 12-months) with different levels of service reductions (i.e., ranging from 5 per cent to 40 per cent in the public sector, with higher disruption of injectables than other short-term methods; half of these levels were estimated in the private sector). Without mitigation strategies, depending on the degree that health services are disrupted and the duration of these disruptions, it is estimated that between 13 million and 51 million women who otherwise would have used modern contraceptives will be unable to (see Table 1). This reduction in contraceptive use could have dire consequences for women, from 325,000 unintended pregnancies, the estimate for minimal disruptions for 3 months, up to a staggering 15 million unintended pregnancies if high disruptions are seen for a period of 12 months. Table 1 Estimated number of women not able to use modern contraceptives Estimated number of unintended pregnancies Low health service disruptions 3-month lockdown 13 million 325,000 6-month lockdown 15 million 2 million 9-month lockdown 18 million 4 million 12-month lockdown 20 million 6 million Medium health service disruptions 3-month lockdown 23 million 600,000 6-month lockdown 26 million 4 million 9-month lockdown 28 million 6 million 12-month lockdown 30 million 9 million High health service disruptions 3-month lockdown 44 million 1 million 6-month lockdown 47 million 7 million 9-month lockdown 49 million 11 million 12-month lockdown 51 million 15 million Impact of COVID-19 on ending gender-based violence Gender-based violence occurs in all countries and economic and social groups. It undermines the health, dignity, security and autonomy of its victims. Yet global resources to find solutions and implement programs to end gender-based violence have been limited. Interim Technical Note Information as of 27 April 2020 4 Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage To estimate the impact of the COVID-19 pandemic on efforts to end gender-based violence, Avenir Health modelled a delay in the scale-up of prevention efforts as attention and resources are devoted to COVID-19, and an increase in violence during the period of lockdown. Assuming a slow start to the scale-up of prevention programmes (i.e., a 2-year delay in 2020 and 2021), followed by a rapid expansion of prevention programs in the middle of the decade, an estimated 2 million additional instances of intimate partner violence in 2020-2021 are expected. This translates to almost 200 million fewer cases of violence being averted by 2030, a reduction of about one third in progress in ending gender-based violence. The COVID-19 pandemic is also expected to increase levels of violence. In the immediate term, the largest contributor is likely to come from the effects of stay-at-home orders and movement restrictions, which could increase women’s exposure to violent partners. Mounting household tensions and economic stresses could also play a role. There are already indications that violence incidence is indeed growing, including increases in calls to violence prevention hotlines and media reports of rising domestic abuse and homicide. Projections show that if violence increases by 20 per cent during periods of lockdown, there would be an additional 15 million cases of intimate partner violence in 2020 for an average lockdown duration of 3 months, 31 million cases for an average lockdown of 6 months, 45 million for an average lockdown of 9 months, and 61 million if the average lockdown period were to be as long as one year. These projections are global -- inclusive of all 193 United Nations member states -- and account for the high levels of underreporting seen with gender-based violence. Together, they amount to an additional 15 million cases of gender- based violence for every 3 months the lockdown continues. Resources to provide support, counselling and post-rape care during the pandemic will also be strained. Impact of COVID-19 on ending female genital mutilation An estimated 200 million women alive today have undergone FGM, which is a violation of girls’ human rights and is often a precursor to child, early and forced marriage, which usually ends a girl’s education and dims her economic prospects. Programmes that promote the abandonment of FGM have proved successful in communities around the world. These, together with growing urbanization, education and other dynamics, were expected to avert 46.5 million cases of FGM between 2020 and 2050. At the same time, due to population growth in countries where the practice is prevalent, an additional 68 million girls are at risk of undergoing this harmful practice between 2015 and 2030. But the situation today is in flux, as the COVID-19 pandemic could postpone the deployment of programmes to eliminate FGM. Social distancing precludes some of the most effective prevention programming such as community empowerment programmes and abandonment proclamations, which are typically implemented in group settings. It is additionally possible that economic uncertainty and school closures could cause an uptick in the incidence of FGM, although this requires investigation. Avenir Health previously projected that scaling up FGM prevention programmes would reduce new cases of FGM by around 5.3 million cases between 2020 and 2030. The COVID-19 pandemic could affect those estimates by delaying the scale-up of prevention efforts due to lockdown terms, and by diverting the attention and efforts of health and social programmes instead to COVID-19 control. Assuming a later start of programmes (i.e., using a 2-year delay in 2020 and 2021) in many countries as a result of these factors, and a resulting lower programme coverage achievements by 2030, it is anticipated that 2 million cases of FGM will occur between 2020 and 2030 that could have been averted, resulting in a 33 per cent reduction in the progress toward ending this harmful practice. Interim Technical Note Information as of 27 April 2020 5 Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage Impact of COVID-19 on ending child marriage COVID-19 is likely to have a significant impact on the implementation of interventions to reduce child marriage, in particular as a result of the social distancing requirements implemented in many countries. Not all interventions are expected to be equally affected, but on average a delay of one year could be regarded as conservative. Researchers had previously projected that a well-defined package of interventions to reduce child marriage -- which both address social and cultural norms around early marriage and keep girls in school -- would reduce the number of child marriages by almost 60 million in the period between 2020 and to 2030. Deferring the implementation of this package by just one year, on average, will reduce the number of child marriages averted by an estimated 7.4 million. In addition to reducing the efficacy and reach of such planned interventions, the pandemic is expected to cause a severe worldwide economic recession. This economic downturn will likely have a large impact on poverty levels in low-income countries where child marriage is most prevalent. Because poverty is a key driver of child marriage, these economic impacts are anticipated to increase rates of child marriage in vulnerable communities. While the ultimate size of the economic impact is still impossible to predict, a paper published by the United Nations University has placed the reduction in GDP per capita in the range of 5 to 20 per cent. Should the reduction in GDP per capita be 10 per cent, then an estimated 5.6 million additional child marriages are likely to take place between 2020 and 2030. The total effect of the COVID-19 pandemic is therefore projected to result in 13 million additional child marriages. Notes on Methodology To estimate the impact of the COVID-19 pandemic on gender-based violence, researchers modelled a delay in the scale- up of prevention efforts and an increase in violence during the period of lockdown. These projections attempt to account for the known underreporting of gender-based violence. They build on estimates of the occurrence of violence rather than reported rates of violence. To estimate the impact of the pandemic on contraceptive use, researchers modelled a range of scenarios showing an unmitigated impact in 114 countries covering 93 per cent of users in low- and middle-income countries. Assumptions of service disruption (i.e., percent reduction in service utilization, Table 2) were based on disruptions to service provision seen during Ebola Virus Disease outbreaks and expert opinion. It was assumed that: (1) injectables would see the most disruption since they require an interaction with a health-care provider, and (2) the public sector would see more disruption than the private sector since it was more likely to be overwhelmed by COVID-19. These percentages were applied to estimates of current modern contraceptive users (as of March 2020) by method and sector.1,2 Estimates of additional unintended pregnancies as a result of reduced family planning use for 3, 6, 9 and 12 months were made based on an average rate of 0.3 unintended pregnancies averted per user (Table 3). 1 Based on RHSC’s Commodity Gap Analysis 2019; annual data converted to monthly projections to estimate users as of March 2020 2 Current long-acting and permanent method users were assumed to continue to use their method throughout the disruption (due to limited access to removals and re-insertion of long-acting reversible contraceptive) Interim Technical Note Information as of 27 April 2020 6 Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage Table 2 Public sector Private sector Injectable Pill Condom Other Injectable Pill Condom Other Low 10% 5% 5% 5% 5% 3% 3% 3% Medium 20% 10% 10% 10% 10% 5% 5% 5% High 40% 20% 20% 20% 20% 10% 10% 10% Table 3 Average unintended pregnancy averted per user 3-month lockdown 0.025 6-month lockdown 0.15 9-month lockdown 0.225 12-month lockdown 0.3 To estimate the impact of the pandemic on FGM, researchers built on an earlier analysis of the cost of eliminating FGM by 2030. This assessment assumed that all communities with majority approval for FGM in the 31 high-incidence countries are reached with direct or indirect community empowerment programming to promote abandonment of this practice. In the analysis on meeting this transformative result, researchers projected that scaling up FGM prevention programmes would reduce new cases of FGM by around 5 million cases between 2020 and 2030. The COVID-19 pandemic could affect those estimates by delaying the scale-up of prevention efforts and diverting the attention and efforts of health and social programmes instead to pandemic control. As such, a 2-year delay in 2020 and 2021 in the start of FGM prevention programs was assumed due to COVID-19. This in turn reduces the achievements previously anticipated between 2020 and 2030. https://www.unfpa.org/featured-publication/costing-three-transformative-results Interim Technical Note Information as of 27 April 2020 7 Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence, Female Genital Mutilation and Child Marriage To estimate the impact of the pandemic on child marriage, researchers estimated two effects: delay in the implementation of a package of interventions and economic impacts. The delay in the implementation of interventions is attributed to a range of reasons including social distancing requirements and restrictions on domestic and international travel, which will limit the availability of technical staff to conduct teaching and training programmes. These effects could vary between interventions, e.g., the physical construction of schools may be less affected, but the implementation of life-skills education could be seriously delayed. Researchers assumed a one-year average delay across all programmes and interventions. Researchers also undertook a literature review of current commentary on the projected economic impact of the pandemic on low-income countries. Sumner et al.3 provided estimates of increased poverty by major region for three scenarios of GDP per capita reduction: 5 per cent, 10 per cent and 20 per cent. The mid-range of 10 per cent estimated an increase in poverty of 7 per cent (World Bank measures), which was estimated to represent about 50 per cent of the global population. The economic downturn is therefore likely to have a large impact on poverty levels in low-income countries, where child marriage is most prevalent. Because poverty is a key driver of child marriage – representing one of the ways poor families lighten the perceived burden of dependent daughters – this is projected to have a significant impact on the prevalence of child marriage. Paul4 has undertaken econometric work to indicate that family income has a 32 per cent impact on child marriage for the poorer quintiles, and a 5 per cent impact on richer income quintiles. Researchers used these parameters to estimate that a 7 per cent increase in poverty for half the population would increase child marriage for that segment by 2.2 per cent, while for the richer segment, a 10 per cent reduction in per capita income would have an effect of perhaps 0.5 per cent. On average across the population, based on these assumptions, the child marriage rate would increase by 1.4 per cent. This interim note contains preliminary data released as pandemic conditions are rapidly evolving. Updates will be released as more information becomes available and the data are further refined. Additionally, estimates on the impact of COVID-19 on maternal mortality are forthcoming. 3 Sumner, Andy, Chris Hoy, and Eduardo Ortiz-Juarez. Estimates Of The Impact Of Covid-19 On Global Poverty, WIDER Working Paper 2020/43 Helsinki: UNU-WIDER, 2020. 4 Paul, Pintu, 2019. "Effects of education and poverty on the prevalence of girl child marriage in India: A district–level analysis," Children and Youth Services Review, Elsevier, vol. 100(C), pages 16-21.

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