Reproductive health and rights in the COVID-19 era: Why and how are rights and choices still the answer?

Md. Anwer Hossain

Department of Population Sciences, Faculty of Social Sciences, University of Dhaka, Dhaka-1000, Bangladesh

Amidst the coronavirus disease 2019 (COVID-19) pandemic, the concern over the potential ‘baby boom’ or ‘baby bust’ had drawn renewed attention across the globe[1-3]. However, historically alarmism over fertility rates gave rise to restrictive and coercive policies with an aim of ‘controlling the population’ that violated people’s sexual and reproductive health and rights (SRHR). In this perspective, the author argued that whether countries of the world face a COVID-19-induced short-term baby boom or bust,the solution lies in prioritizing the rights and choices of all people,especially their SRHR; not in adopting target-oriented population policies or coercive family planning programs.

What was the impact of COVID-19 that led to population alarmism? Firstly, in low and middle-income countries, COVID-19 had evidently disrupted sexual and reproductive health services such as access to and availability of family planning methods[4]; such that there would be 60 million fewer users of modern contraceptives in 2020[5]. Moreover, the pandemic had enabled fertility promoting environment such as school closure and resultant dropping out of girls leading to an increase in child marriage. The United Nations Population Fund (UNFPA) predicted that COVID-19-induced disruptions would result in an additional 13 million child marriage between 2020 and 2030 that could otherwise have been averted[6].Besides, non-therapeutic measures such as ‘lockdown’ were expected to increase couples’ exposure to sexual activity, which in concert with limited family planning services would increasingly contribute to unintended pregnancies. In fact, an expected 15 million additional unintended pregnancies would occur in 132 low and middle-income countries[7]. Altogether, these were expected to result in a ‘baby boom’ as a short-term demographic consequence in low and middle-income countries, especially in their rural areas[2].

In a second scenario, fertility was expected to decrease resulting in a ‘baby bust’ in the high-income countries where the pre-pandemic total fertility rates were already below the replacement level, i.e.,less than 2.1 children per woman. Data from the USA, nineteen European and two East Asian countries revealed sharp declines in births starting in October 2020, compared to the same months of 2019[7,8]. Several explanations were put forward. For example,economic losses, reduced income, and uncertainty about the future due to the pandemic might reduce fertility aspirations for the parents, given the irreversible nature of childbearing and substantial costs associated with childrearing in high-income countries. This was the experience after the Great Recession in 2008[9]. Besides,as maternal age remains high in high-income countries, the use of assisted reproductive technology is widespread among parents which is likely to be suspended or canceled due to the COVID-19-induced mobility restrictions and lockdown[2].

Historically, the concern of population growth, specifically the fear of over-population, led to various population control measures that aimed to reduce the fertility rate at any cost, even if at the cost of individual’s rights and choices[10]. However, a paradigm shift occurred in 1994 when 179 countries reached a global consensus that the focus should not be on population, per se, but rather on people. The groundbreaking International Conference on Population and Development (ICPD) heralded a shift in focus from ‘human numbers’ to ‘human rights’ and mandated governments to ensure SRHR for all people[11].

In the era of COVID-19, how are rights and choices still the answer? Here, the author focuses on two countries: Bangladesh and the USA. The hypothesis of COVID-19 induced baby boom in Bangladesh is yet to be empirically tested given the fact that a change in fertility occurs after a 9-month lag in pregnancy, and also there are limited opportunities to conduct nationally representative surveys amidst the pandemic. Still, the available shreds of evidence provide enough basis for arguments that a baby boom is more likely. On one hand, COVID-19 has increased the incidence of child marriage in Bangladesh amounting to the highest rate in the last 25 years[12] while the country already had the fourth-highest rate of child marriage in the world (51.4%), only out-numbered by three African countries: Mali (53.7%), Chad (60.6%), and Niger(76.3%). On the other hand, the pandemic has disrupted the sexual and reproductive health services[4,13]. An impact assessment study found that COVID-19 had a statistically significant negative effect on the utilization of maternal health, family planning, outpatient,and childhood vaccination services in Bangladesh, with the highest decline between March and May 2020[14].

Thus, SRHR should be prioritized with a renewed commitment that is being side-tracked while responding to the pandemic[13,15]. As recognized globally, Bangladesh has brought down the national total fertility rate from 6.7 in 1974 to 2.3 in 2018[16], which is considered a paradoxical decline[17]. It was possible through a successful family planning program that enabled Bangladeshis to decide freely and responsibly the number and spacing of their children while the door-to-door family planning services provided the information and means to exercise couple’s reproductive rights, ensured informed choices, and made available a full range of safe and effective family planning methods[18,19]. Therefore, now the focus should be on how to reduce the unmet needs for sexual and reproductive health services, especially among the currently married adolescents (15-19 years) where the unmet need for family planning services is highest(15.5% vs. national estimate of 12%)[16]. Moreover, the wanted total fertility rate in Bangladesh is 1.7 while the actual total fertility rate is stagnant at 2.3 for about a decade[16]. Thus, there is ample room for prioritizing sexual and reproductive health in Bangladesh rather than concerning about the COVID-19-induced short-term demographic implications. Moreover, prioritizing sexual and reproductive health services as essential health services for all during the pandemic period would significantly diminish the chances of a baby boom as well as foster the pace of consecutive rebounds[13].

In 2020, Americans gave birth to 3.6 million babies which were the lowest total annual births since 1979[20]. Under this circumstance,concerns had been raised that the pandemic would push 2021’s birth rates down even further resulting in a baby bust. Data from 32 out of the 50 US states demonstrated that the nation's birth rate in 2020 fell by more than 4%[21]. However, the case of the baby bust in the USA, as well as in other developed countries, during the pandemic is largely parental aspirations-driven as well as the outcome of their conscious decision-making. Because ‘having- and raising- a kid in America is too hard’[20]. On top of that, the pandemic-driven economic losses, reduced income, and uncertainty about the future might have reduced fertility aspirations among the parents[9].

In this context of a baby bust too, the rights and choices of individuals are the answer to shifting fertility rates in an increasing direction. It must be acknowledged that the choice of couples or individuals that they would remain childless or would just take one child is determined by the environment in which they live[20,22].Therefore, population policies and programs should focus on how to create an enabling environment where parents would not feel burdened having two/three kids, rather they will be incentivized in terms of ‘baby bonuses’, tax incentives, maternity capital and paid leave, subsidized child care, flexible working hours for mothers, job protections to parents who opt into part-time work and so on[20,23,24].Following these strategies, countries such as Germany, Estonia, the Czech Republic, Russia, and others have seen upticks in their birth rates for the longer term[20,23,24]. In that way, the focus was still on upholding the rights and choices of individuals or couples while the population policies created an enabling environment for parents to voluntarily opt to have a higher total fertility rate. That is why it is rightly mentioned in the ICPD program of action that “individuals everywhere- when supported and offered choices- can and will act responsibly in the light of their own needs and those of their families and communities”[11]. However, on the contrary, recent ruling of the Supreme Court overturning Roe v. Wade ends 50 years of federal abortion rights in the USA and poses significant threats to women's reproductive rights[25].

In conclusion, though the global population has been growing for hundreds of years at a rate that increased or decreased with unprecedented booms or busts and consecutive rebounds, the ongoing COVID-19 pandemic has led to population alarmism that might put individual or couples’ rights and choices at stake.This paper draws on historical as well as contemporary shreds of evidence and argues that whether the countries of the world face a COVID-19-induced short-term baby boom or baby bust, the solution lies in prioritizing the reproductive health and rights of all people,and thereby, calls for a global recognition that there is no effective alternative other than upholding the rights and the choices of individuals in shifting fertility rates as per the need of each country.

Conflict of interest statement

The author declares there is no conflict of interest.

Funding

The study received no extramural funding.

AcknowledgmentsThe author Md. Anwer Hossain would like to thank Professor Dr.Mohammad Bellal Hossain, Department of Population Sciences,University of Dhaka for his emphasis on the often-overlooked principle of responsibility in the paradigm of SRHR while conceptualizing the manuscript. The author also conveys his thanks to the editors for their input in streamlining the manuscript.

Author’s contributions

The author wrote the manuscript and proofread the final version.