The Impact of COVID-19 Outbreak on Family Planning Services in Indonesia: Evidence from National Routine Statistics

At the beginning of the pandemic, the policy focused on COVID-19 prevention and control. Health facilities faced disruption temporarily regarding contraceptive services. This study analysed the impacts of the COVID-19 outbreak on Family Planning services in Indonesia. Monthly routine statistics from the National Population and Family Planning Board contraceptive service were examined to determine the trends in contraceptive services in Indonesia before and during the COVID-19 Pandemic from January to December 2020. The study was secondary data analysis by utilizing monthly report data from all provinces in Indonesia. Comparison data would account for the monthly trends before and during the pandemic. There was a decrease in contraceptive services between March and April 2020. However, the trend started to increase in June when a one million acceptors campaign was conducted to provide free family planning services in 34 provinces. Injectable (54%) and pills (39%) remain the most favorable contraceptives during the pandemic. IUDs and implants peaked in June 2020 (288,503 users) and September 2020 (214,061 users). The massive campaign of contraceptive services has had a positive impact in increasing the contraceptive users. Contraceptive services are conducted following strict health protocols. Continuation of contraceptive use among reproductive couples still needs to be increased.


INTRODUCTION
The novel coronavirus disease (COVID-19) was first reported in Wuhan, China, in December 2019.Nowadays, The COVID-19 outbreak has raged worldwide since the World Health Organization (WHO) declared COVID-19 as a global pandemic in March 2020 (World Health Organization, 2020).This pandemic has led to significant challenges in human life worldwide and unpredictable conditions in daily plans and routines.
The outbreak has caused economic, health, and social disruptions such as dramatic loss of human life, improving unemployment, and labourer's informal economy lacking social protection and difficulties in accessing quality health care.To reduce the transmission of coronavirus, it is ABSTRACT At the beginning of the pandemic, the policy focused on COVID-19 prevention and control.Health facilities faced disruption temporarily regarding contraceptive services.This study analysed the impacts of the COVID-19 outbreak on Family Planning services in Indonesia.Monthly routine statistics from the National Population and Family Planning Board contraceptive service were examined to determine the trends in contraceptive services in Indonesia before and during the COVID-19 Pandemic from January to December 2020.The study was secondary data analysis by utilizing monthly report data from all provinces in Indonesia.Comparison data would account for the monthly trends before and during the pandemic.There was a decrease in contraceptive services between March and April 2020.However, the trend started to increase in June when a one million acceptors campaign was conducted to provide free family planning services in 34 provinces.Injectable (54%) and pills (39%) remain the most favorable contraceptives during the pandemic.IUDs and implants peaked in June 2020 (288,503 users) and September 2020 (214,061 users).The massive campaign of contraceptive services has had a positive impact in increasing the contraceptive users.Contraceptive services are conducted following strict health protocols.Continuation of contraceptive use among reproductive couples still needs to be increased.
recommended that people work from home, attend school from home, and maintain physical distance.
Indonesia is the world's fourth most populous country with the largest archipelago.The President of Indonesia announced the first two confirmed positive for COVID-19 cases in Indonesia at the beginning of March 2020 (Djalante et al., 2020).On the last day of March 2020, the President of the Republic Indonesia announced Presidential Decree Number 11 of 2020, stating that the COVID-19 pandemic is a public health emergency, and implemented a large-scale social restriction.Then, the COVID-19 pandemic in Indonesia is declared a non-natural national disaster in Indonesia.The government advises the society to stay at home and maintain social distancing.
At the beginning of the pandemic, the policy focused on COVID-19 prevention and control.In Indonesia, the COVID-19 outbreak has highlighted significant changes, especially in health and economic consequences, to protect vulnerable populations with urgent action.Strengthening public health systems is needed in this pandemic time.Family planning program improves maternal and child health by increasing the birth interval, reducing the number of pregnancies, reducing the high-risk pregnancies, and improving planned pregnancies (Utomo et al., 2021).Unintended pregnancy and its potential risk may result in unsafe abortion and many adverse health effects or complications for babies and their mothers (Gayatri & Fajarningtiyas, 2023).Therefore, family planning services must continue to be offered in order to prevent the problem associated with unintended pregnancy, especially during the COVID-19 pandemic.
Health facilities faced disruption temporarily regarding contraceptive services.At the beginning of the pandemic, some strategies were implemented to prevent the spread of the virus, such as social distancing, mobility restrictions, closure of schools and public places, and stay at home (Gayatri & Irawaty, 2021a).The fear of being exposed to the virus has changed people's travel behaviour.Travel fear during pandemics may impact women and couples to access health facilities to meet their contraceptive needs.Family planning services are assumed to be impacted by the disruption of supply chain management of modern contraceptive methods, pharmacy closures, economic difficulties, and the fear of going to health facilities (Fuseini et al., 2022).The ability of women to go to health facilities will influence their behaviour in using and continuing their contraceptive methods to protect those women from unintended pregnancy.Unhindered access to family planning services is an essential solution to improve sexual and reproductive health services during the pandemic.Therefore, this study analysed the impacts of the COVID-19 outbreak on Family Planning services in Indonesia.

MATERIAL AND METHODS
This study is a secondary data analysis.Using routine statistics, this study examines the number of contraceptive users before and during the Pandemic of COVID-19.The routine statistical data were monthly collected data on family planning and family welfare that be used for program evaluation.The National Population and Family Planning Board (NPFPB) of the Republic of Indonesia gather this data monthly from all municipalities and provinces in Indonesia.There are monthly and annual reports on contraceptive services and field control.The contraceptive services reports collect data on contraceptive services carried out by public and private health facilities such as family planning clinics, private doctors, or midwives in accordance with the established system.Field control reports collect data on various aspects of the coordination and activities of the population, family planning, and family welfare implementation in the field.The data were collected by a web-based application developed by the institution.
Monthly routine statistics from the National Population and Family Planning Board contraceptive services were examined to determine the trends in contraceptive services in Indonesia before and during the COVID-19 Pandemic from January to December 2020.The study utilized monthly report data from all provinces in Indonesia.Comparison data would be used to account for the monthly trends before and during the pandemic.The study used variables such as monthly contraceptive prevalence and mixed-contraceptive in health facilities.

RESULTS AND DISCUSSION
Figure 1 shows the number of current (active) contraceptive users in Indonesia in 2020.At the start of the pandemic, between March and April 2020, there was a decrease in the number of contraceptive users from 36.7 million to 35.3 million.The contraceptive user's bar chart in Figure 1 shows all reproductive-aged couples currently using modern contraceptive methods: intrauterine device (IUD), female sterilization, male sterilization, condoms, implants, injectable, and oral contraception.Modern contraceptive users increased gradually from 36.1 million in May to 37.2 million in November 2020.

Figure 1. The number of current contraceptive users in Indonesia in 2020 (in a million)
Figure 2 shows the number of women who received contraceptive services in health facilities.These numbers are the total number of new users, women who switch their contraceptive methods, and those women who return to visit for contraceptive services.Based on the trend, there is a decrease in contraceptive services monthly between the first five months of 2019 and 2020.The trend of contraceptive services in health facilities in 2020 shows that contraceptive services decreased at the beginning of the pandemic between March and April 2020.However, the trend started to increase in June when a one million acceptors campaign was conducted to provide free family planning services in 34 provinces (Figure 2). Figure 3 shows the contraceptive method-mix of women who received contraceptive services in public or private health facilities.Based on the pie chart, it can be known that injectable (54%) and pills (39%) still became the most favourable contraceptives during the pandemic in 2020.The implementation of physical and social distancing during the COVID-19 pandemic has caused couples to stay at home and spend much time together at home.This situation may increase the possibility of occurring pregnancies.Therefore, couples needing to delay or limit their pregnancies must use effective contraceptives to prevent unintended pregnancies.Unintended pregnancy, especially due to not using contraceptive methods consistently, has a risk factor for unsafe abortion, maternal morbidity, and adverse infant health outcomes (Gayatri & Irawaty, 2021b).
The impact of the pandemic cannot be seen clearly through the cumulative number of contraceptive users in Indonesia (Figure 1), because long-acting and permanent contraceptive users do not need to return visits to switch their contraception.Moreover, the discontinuation rates among long-acting and permanent contraceptive users are lower than for short-acting contraceptive users.However, the impact of the pandemic can be seen in the monthly report on the number of women who received contraceptive services in health facilities (Figure 2).At the beginning of the pandemic, the fear of being infected by COVID-19 and the government's advice to stay at home unless for emergency matters become challenges for women to access contraceptive services directly in health facilities.Therefore, at the start of the outbreak, there was a disruption in family planning services.The previous study based on qualitative and quantitative research in 62 countries showed that the pandemic is causing changes in how healthcare services are delivered and how people seek out healthcare services that are generally detrimental to reproductive health services (Endler et al., 2021).A study in India reveals that the decline of family planning services during the pandemic is caused by the healthcare workers and field workers being sent to community health centers to provide COVID-19-related services, including treatments and medications (Vora et al., 2020).
The lockdown policy implemented in some countries has prevented women from using and accessing services related to fear, decreased income, and disrupted transportation.Health services, which were frequently the concomitant effects that deterred women (Endler et al., 2021).Moreover, the COVID-19 lockdown policy in India has reduced access to family planning services by preventing the distribution of contraceptive social marketing (Vora et al., 2020).
A study of family planning services among reproductive women aged 15-49 years during the outbreak in Bangladesh shows that the contraceptive prevalence rate dropped by roughly 23% (Roy et al., 2021).During the pandemic, some women decided not to use contraception because of fear of side effects or health concerns and disapproval from families.Another study demonstrated a sharp fall in oral contraceptive use caused by family planning workers' visits to the oral contraceptive users, stock outs of the contraceptive methods, and the disruptions in contraceptive security due to the changes in functioning supply chain during the pandemic.
The massive campaign of contraceptive services has positive impacts on increasing contraceptive users.Reproductive women need to have better access to family planning information from various media, whether online media (such as social media) or offline media (such as newspapers, magazines, television, radio, and outdoor media).Contraceptive services are conducted following strict health protocols.It is still needed to increase contraceptive continuation among reproductive couples.Due to social distancing, some eligible couples must postpone seeking contraceptive services at health facilities.The fear of being contaminated has been a severe challenge for couples accessing family planning services.Previous studies demonstarted that women regularly visited by family planning workers were more likely to use contraception (Roy et al., 2021).The frequent visitation of family planning workers has a significant role in preventing contraceptive discontinuation.
At the start of the pandemic, contraceptive services dropped significantly.A survey conducted by NPFPB reveals that the reasons couples do not use any contraceptive methods during the pandemic include wanting to become pregnant (34%), side effects/health concerns (30%), infrequent sex (7.4%), access to health services (2.4%) (Badan Kependudukan dan Keluarga Berencana Nasional, 2020c).
National Population and Family Planning Board (NPFPB), the government agency responsible for managing family welfare, population, and family planning programs in Indonesia, has developed and implemented some strategies to deal with the problem of accessing contraceptive services during the COVID-19 pandemic.Some strategies stated in the NPFPB Head Regulation No. 8 of 2020 include (1) promoting family planning by using various media, especially through online platforms, (2) under the supervision of a primary healthcare facility/doctor/midwife, family planning field workers may distribute oral contraceptives and condoms, (3) family planning field workers continue to promote family planning and conduct the programs of information, education, and communication (IEC) by using online platforms, social media of field visit with keep maintaining safe physical distancing (BKKBN, 2020).Moreover, online contraceptive counseling by family planning providers is needed for couples to access contraceptive information during the pandemic.
Contraceptive mix-method increased significantly in June 2020 when NPFPB conducted "one day, one million contraceptive users" as a massive movement on National Family Day (June 29 th , 2020).The movement, through massive contraceptive services in 34 provinces in Indonesia, reports 1,355,294 contraceptive users in only 24 hours (Badan Kependudukan dan Keluarga Berencana Nasional, 2020b).These services were conducted in primary health care facilities, private midwives' services, and clinics/hospitals.All modern contraceptive services were provided, such as female sterilization, male sterilization, IUDs, implants, injectable, oral contraceptives, and condoms.Due to the movements conducted during the COVID-19 outbreak, strict health protocols are implemented during the contraceptive services.The movement provides contraceptive services for postpartum women, women who want to switch contraceptive methods or women who return to visit to continue their contraceptive methods.
Furthermore, another movement was conducted on World Contraception Day, September 26 th , 2020 to improve the long-acting prevalence rate..The movement provides contraceptive services, especially long-acting and permanent contraceptive services.The contraceptive services were only for IUDs, implants, female sterilization, and male sterilization.On the movement, it was targeted to reach 250,000 long-acting and permanent contraceptive users.The movement has reported 287,991 long-acting and permanent users during the day (Badan Kependudukan dan Keluarga Berencana Nasional, 2020a).The partnership program between the public and private sectors has encouraged the success of the massive movement on contraceptive services during the pandemic.

CONCLUSION AND SUGGESTION
The massive campaign of contraceptive services has positive impacts on increasing contraceptive users.Contraceptive services are conducted following strict health protocols.It is still needed to increase contraceptive continuation among reproductive couples.Moreover, increasing spousal communication in their reproductive health goals will increase the contraceptive continuation that protects the couples from unintended pregnancy during the COVID-19 Pandemic.

CONFLICT OF INTEREST
The author has declared that no competing interests exist.

Figure 3 .
Figure 3. Contraceptive method-mix of women who received contraceptive services in health facilities in 2020

Figure 4 .
Figure 4. Contraceptive services in health facilities in Indonesia in 2020