Transactional sex in the wake of COVID-19: sexual and reproductive health and rights of the forcibly displaced

Factors associated with adolescent pregnancy in Maharashtra, India: a mixed-methods study

Reducing the adolescent birth rate is paramount in achieving the health-related Sustainable Development Goals, given that pregnancy and childbirth are the leading cause of mortality among young women aged 15-19. This study aimed to explore predictors of adolescent pregnancy among girls aged 13-18 years in Maharashtra, India, during the COVID-19 pandemic. Using a mixed-methods approach, primary data were gathered from two regions in Maharashtra between February and April 2022. Quantitative data from face-to-face interviews with 3049 adolescent girls assessed various household, social, and behavioural factors, as well as the socioeconomic and health impacts of COVID-19. Qualitative data from seven in-depth interviews were analysed thematically. The findings reveal that girls from low socioeconomic backgrounds face a higher likelihood of adolescent pregnancy. Multivariable analysis identified several factors associated with increased risk, including older age, being married, having more sexual partners, and experiencing COVID-19-related economic vulnerability. On the other hand, rural residence, secondary and higher secondary education of the participants, and higher maternal education were associated with a decreased likelihood of adolescent pregnancy. In the sub-sample of 565 partnered girls, partner's emotional abuse also correlated with higher rates of adolescent pregnancy. Thematic analysis of qualitative data identified four potential pathways leading to adolescent pregnancy: economic hardships and early marriage; personal safety, social norms, and early marriage; social expectations; and lack of knowledge on contraceptives. The findings underscore the significance of social position and behavioural factors and the impact of external shocks like the COVID-19 pandemic in predicting adolescent pregnancy in Maharashtra, India.Plain Language Summary: Adolescent pregnancy is an important health issue for young girls. In South Asia, one out of every five adolescent girls becomes a mother before turning 18, and in India, around 9% of girls aged 15-19 get pregnant yearly. This study focused on understanding the factors associated with adolescent pregnancy in Maharashtra, India, especially after the COVID-19 pandemic. We collected information from both urban and rural areas in Maharashtra. A total of 3049 adolescent girls participated in a survey, and seven girls participated in detailed interviews. Our analysis showed that factors like older age, being married, having multiple sexual partners, and experiencing economic difficulties due to COVID-19 increased the chances of adolescent pregnancy. On the other hand, living in rural areas, higher education for both the girls and their mothers reduced the likelihood of adolescent pregnancy. Qualitative analysis revealed that economic challenges, concerns about safety and societal norms, early marriage, societal expectations, and lack of knowledge about contraceptives could contribute to adolescent pregnancy in Maharashtra.

A systematic review of the indirect impacts of COVID-19 on sexual and reproductive health services and outcomes in humanitarian settings

BACKGROUND

Humanitarian settings, particularly those in low-income and middle-income countries (LMICs), present increased sexual and reproductive health (SRH) challenges for individuals and health systems. Previous infectious disease outbreaks in such settings have negatively impacted SRH services and outcomes, as fragmented health systems are further overstretched. The COVID-19 pandemic has magnified the SRH challenges in LMIC humanitarian settings on an unprecedented scale. However, understanding of the impacts of COVID-19 is lacking. This review aimed to understand how the COVID-19 pandemic has impacted SRH service coverage, utilisation and outcomes in LMIC humanitarian settings, to inform current and future humanitarian research, programming and practice.

METHODS

A systematic review methodology was followed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting standards. Three search fields related to humanitarian settings, SRH and COVID-19 were applied, and limited to LMIC settings only. Three bibliographic databases and nine grey literature sources were searched. Articles meeting inclusion criteria at full-text screening were critically appraised using standardised tools. Data extraction was undertaken on included articles and analysed through narrative synthesis.

RESULTS

In total, 7742 citations were screened and 42 were included in the review. All included studies were cross-sectional. The quality was mostly medium to high. Narrative synthesis identified the reduced provision of, and access to, SRH services, and increased morbidity including sexual and gender-based violence and unplanned pregnancies. Impacts on service uptake varied across and within settings. Adaptations to improve SRH service access including telemedicine were reported; however, implementation was hindered by resource constraints.

CONCLUSIONS

The COVID-19 pandemic has indirectly negatively impacted SRH at the individual and health system levels in LMIC humanitarian settings. Further research on the impacts on service uptake is required. SRH programmers should target interventions to meet the increased SRH needs identified. Policy-makers must incorporate SRH into emergency preparedness and response planning to mitigate indirect impacts on SRH in future outbreaks.

Struggling, Forgotten, and Under Pressure: A Scoping Review of Experiences of Sex Workers During the COVID-19 Pandemic

The COVID-19 pandemic profoundly affected physical, mental, and economic well-being across the globe and has disproportionately affected certain vulnerable groups. This paper provides a scoping review of literature on the impact of the COVID-19 pandemic on sex workers, published between December 2019 and December 2022. Six databases were systematically searched, identifying 1009 citations; 63 studies were included in the review. Thematic analysis revealed eight main themes: financial issues; exposure to harm; alternate ways of working; COVID-19 knowledge, protective behaviors, fear, and risk; well-being, mental health, and coping; access to support; access to health care; and the impact of COVID-19 on research with sex workers. COVID-associated restrictions led to reduced work and income, leaving many sex workers struggling to cover basic needs; additionally, government protections excluded those working in the informal economy. Fearing the loss of their already reduced number of clients, many felt compelled to compromise both prices and protective measures. Although some engaged in online sex work, this raised concerns about visibility and was impossible for those without technological access or skills. Many feared COVID-19, but felt pressure to continue working, often with clients who refused to wear masks or share exposure history. Other negative impacts on well-being related to the pandemic included reduced access to financial support or health care. Marginalized populations (and especially those in professions which require close contact like sex workers) need further support and capacity-building within the community to recover from the impact of COVID-19.

Social determinants of mental health among older adolescent girls living in urban informal settlements in Kenya and Nigeria during the COVID-19 pandemic

The health burden due to mental health has historically been underestimated with focus on communicable diseases and deaths and little consideration of disability and comorbidity effects of poor mental health. Recent data show increasing trends of mental health disorders as a share of global health burdens and vulnerability of adolescents. This paper aims to explore social determinants of mental health as experienced by adolescent girls, drawing attention to gendered risks during the COVID-19 pandemic. Semi-structured interviews with twenty-two adolescent girls in urban informal settlements in Kenya and Nigeria reveal unique environmental, socio-cultural, economic and educational factors that threatened their mental wellbeing. The pandemic exacerbated these determinants. An equitable recovery will require a consideration of not only disproportional mental health outcomes, but also social determinants that contribute to these outcomes. As more than half of the urban population in sub-Saharan Africa reside in informal settlements, this study has implications for youth-focused mental health interventions in these and similar settings.

Health system resilience during COVID-19 understanding SRH service adaptation in North Kivu

Background

There is often collateral damage to health systems during epidemics, affecting women and girls the most, with reduced access to non-outbreak related services, particularly in humanitarian settings. This rapid case study examines sexual and reproductive health (SRH) services in the Democratic Republic of the Congo when the COVID-19 hit, towards the end of an Ebola Virus Disease (EVD) outbreak, and in a context of protracted insecurity.

Methods

This study draws on quantitative analysis of routine data from four health zones, a document review of policies and protocols, and 13 key-informant interviews with staff from the Ministry of Public Health, United Nations agencies, international and national non-governmental organizations, and civil society organizations.

Results

Utilization of SRH services decreased initially but recovered by August 2020. Significant fluctuations remained across areas, due to the end of free care once Ebola funding ceased, insecurity, number of COVID-19 cases, and funding levels. The response to COVID-19 was top-down, focused on infection and prevention control measures, with a lack of funding, technical expertise and overall momentum that characterized the EVD response. Communities and civil society did not play an active role for the planning of the COVID-19 response. While health zone and facility staff showed resilience, developing adaptations to maintain SRH provision, these adaptations were short-lived and inconsistent without external support and funding.

Conclusion

The EVD outbreak was an opportunity for health system strengthening that was not sustained during COVID-19. This had consequences for access to SRH services, with limited-resources available and deprioritization of SRH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01443-5.

Women and girls often face increased challenges to accessing healthcare during epidemics on top of pre-existing health disparities. There is emerging evidence that COVID-19 has had negative impacts on the health of women and girls in sub-Saharan Africa due to diverted funding, reduced services, negative socioeconomic impacts, and increased or new barriers to access. In the DRC, COVID-19 hit shortly after the end of an Ebola epidemic within a context of protracted insecurity. This study used mixed methods and drew upon 13 interviews to examine the effects of COVID-19 on SRH services in North Kivu and how the health system did or did not adapt to ensure continued access and utilization of SRH services. There was limited prioritization of SRH during COVID-19. Although the government issued policies on how to adapt SRH services, these were developed centrally, without much guidance on how to operationalize these policies in different contexts. Consequently, healthcare providers and civil society actors developed their own ways to continue activities at local levels, not necessarily in a systematic way. There was limited longer-term strengthening of the health system that could adapt to the subsequent COVID-19 pandemic aside from increased capacity of healthcare providers to manage infection prevention and control measures. However, this was hampered by the lack of personal protective equipment that received no external support. Therefore, donors need to consider how resources can be leveraged to support sustained strengthening of the health system to be able to adapt to shocks even when resources are limited.

Prioritising women's and girls' health in disaster settings: Lessons from the COVID-19 pandemic and the overlapping crises affecting Beirut, Lebanon

The COVID-19 pandemic has placed strain on healthcare systems across the world; however, countries experiencing overlapping crises such as economic or political unrest face immense pressure in ensuring routine healthcare services can continue to operate. Despite being less likely suffer severe disease or die from COVID-19, data suggest women have experienced poorer mental health, higher rates of unemployment, and more social isolation during the pandemic. In general, we know women and girls experience multiple forms of disadvantage in disaster contexts including being more likely to become homeless, work as an unpaid carer, and to experience poverty. Research from previous disaster contexts has demonstrated that women's healthcare services tend to be deprioritised in the emergency response, and reports suggest this has been the case during the COVID-19 pandemic. This paper highlights key priorities for safeguarding women's and girls' health in disaster contexts, especially during the COVID-19 pandemic, by drawing on learning from the multiple crises facing Beirut, including responding to the pandemic, economic collapse, and the Beirut Port Explosion in 2020.

Socioeconomic Burdens of the COVID-19 Pandemic on LMIC Populations with Increased HIV Vulnerabilities

Purpose of Review

To review the impact of the COVID-19 pandemic and its public health response on key populations at risk of HIV infection, with a focus on sex workers.

Recent Findings

Since last year several groups have documented how the COVID-19 pandemic has impacted the livelihoods and health of sex workers. We focus on case studies from Kenya, Ukraine, and India and place these in the broader global context of sex worker communities, drawing on common themes that span geographies.

Summary

COVID-19-associated lockdowns have significantly disrupted sex work, leading to economic and health challenges for sex workers, ranging from HIV-related services to mental health and exposure to violence. Several adaptations have been undertaken by sex workers and frontline workers, including migration, a move to mobile services, and struggling to find economic supports. Strengthening community-based responses for future pandemics and other shocks is critical to safeguard the health of marginalized populations.