How resilient were family planning programs during the COVID-19 pandemic?  Evidence from 70 countries

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Evidence from 70 countries", "datePublished": "2023-09-28T15:15:05", "dateModified": "2024-03-25T10:06:43", "author": [ { "@type": "Person", "name": "Karen Hardee" }, { "@type": "Person", "name": "Rebecca Rosenberg" }, { "@type": "Person", "name": "John Ross" }, { "@type": "Person", "name": "Imelda Zosa-Feranil" } ], "publisher": { "@type": "Organization", "name": "Gates Open Research", "logo": { "@type": "ImageObject", "url": "https://gatesopenresearch.org/img/AMP/Gates_image.png", "height": 600, "width": 47 } }, "image": { "@type": "ImageObject", "url": "https://gatesopenresearch.org/img/AMP/Gates_image.png", "height": 1200, "width": 94 }, "description": " Background At the beginning of the COVID-19 pandemic fears of severe disruptions to family planning (FP) and access to services abounded. This paper uses a unique data source, a special Supplement added to the 2021 round of the National Composite Index for Family Planning (NCIFP), to assess in depth the resilience of FP programs in the face of the COVID-19 pandemic across 70 countries spanning six regions. Methods The 2021 NCIFP included 961 key informants who were asked questions to assess interference in the countries’ ability to achieve objectives, ability to maintain commitment to FP, and availability of information and services. Open ended responses added context. Results All programs were affected; the magnitude of effects varies by region and country. While the average resilience score, at 47 out of 100, implies middling levels of resilience, further analysis showed that despite interference in many components of programming, with some exceptions, the COVID-19 pandemic generally did not diminish government commitment to FP and programs remained resilient in providing access to services. Common themes mentioned by 178 respondents (18.5% of respondents) included: fear of infection; disruption of services / difficulty with lockdown and travel restrictions; staff / facilities diverted to COVID-19; access to reproductive health services and contraceptive methods affected; shifts in services / outreach; interference with logistics & supplies, training & supervision, and M&E; lack of attention to FP/sexual reproductive health; financing reduced or diverted; and effects on existing partnerships. A strong enabling environment for FP, which the NCIFP is designed to measure, was positively correlated with continued government commitment and access to contraceptive methods during COVID-19. Conclusion These findings are instructive for programming: it will face challenges and ‘interference’ when unanticipated shocks like COVID-19 occur, with strong FP programs best prepared to exhibit resilience. 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Gates Open Res 2024, 7 :121 ( https://doi.org/10.12688/gatesopenres.14856.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] Karen Hardee https://orcid.org/0000-0003-2545-6269 1 , Rebecca Rosenberg https://orcid.org/0000-0003-2183-3098 2 , John Ross https://orcid.org/0000-0003-3748-4128 3 , Imelda Zosa-Feranil https://orcid.org/0000-0002-9786-554X 2 Karen Hardee https://orcid.org/0000-0003-2545-6269 1 , Rebecca Rosenberg https://orcid.org/0000-0003-2183-3098 2 , John Ross https://orcid.org/0000-0003-3748-4128 3 , Imelda Zosa-Feranil https://orcid.org/0000-0002-9786-554X 2 PUBLISHED 25 Mar 2024 Author details Author details 1 Hardee Associates, Arlington, VA, 22207, USA 2 Avenir Health, Glastonbury, Connecticut, 06033, USA 3 Independent demographic consultant, New Paltz, NY, 12561, USA Karen Hardee Roles: Conceptualization, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Rebecca Rosenberg Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Software, Visualization, Writing – Review & Editing John Ross Roles: Conceptualization, Writing – Review & Editing Imelda Zosa-Feranil Roles: Conceptualization, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background At the beginning of the COVID-19 pandemic fears of severe disruptions to family planning (FP) and access to services abounded. This paper uses a unique data source, a special Supplement added to the 2021 round of the National Composite Index for Family Planning (NCIFP), to assess in depth the resilience of FP programs in the face of the COVID-19 pandemic across 70 countries spanning six regions. Methods The 2021 NCIFP included 961 key informants who were asked questions to assess interference in the countries’ ability to achieve objectives, ability to maintain commitment to FP, and availability of information and services. Open ended responses added context. Results All programs were affected; the magnitude of effects varies by region and country. While the average resilience score, at 47 out of 100, implies middling levels of resilience, further analysis showed that despite interference in many components of programming, with some exceptions, the COVID-19 pandemic generally did not diminish government commitment to FP and programs remained resilient in providing access to services. Common themes mentioned by 178 respondents (18.5% of respondents) included: fear of infection; disruption of services / difficulty with lockdown and travel restrictions; staff / facilities diverted to COVID-19; access to reproductive health services and contraceptive methods affected; shifts in services / outreach; interference with logistics & supplies, training & supervision, and M&E; lack of attention to FP/sexual reproductive health; financing reduced or diverted; and effects on existing partnerships. A strong enabling environment for FP, which the NCIFP is designed to measure, was positively correlated with continued government commitment and access to contraceptive methods during COVID-19. Conclusion These findings are instructive for programming: it will face challenges and ‘interference’ when unanticipated shocks like COVID-19 occur, with strong FP programs best prepared to exhibit resilience. READ ALL READ LESS Keywords Family planning, COVID-19, national composite index of family planning, NCIFP Corresponding Author(s) Karen Hardee ( [email protected] ) Close Corresponding author: Karen Hardee Competing interests: No competing interests were disclosed. Grant information: This work was supported by the Gates Foundation [INV-007530]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2024 Hardee K et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Hardee K, Rosenberg R, Ross J and Zosa-Feranil I. How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.12688/gatesopenres.14856.2 ) First published: 28 Sep 2023, 7 :121 ( https://doi.org/10.12688/gatesopenres.14856.1 ) Latest published: 25 Mar 2024, 7 :121 ( https://doi.org/10.12688/gatesopenres.14856.2 ) Revised Amendments from Version 1 This version of the paper includes more detail on the purpose, methodology, and limitations of the analysis in the paper. This version of the paper includes more detail on the purpose, methodology, and limitations of the analysis in the paper. See the authors' detailed response to the review by Philip Anglewicz See the authors' detailed response to the review by Nadia Diamond-Smith READ REVIEWER RESPONSES Background In 2020, when the global COVID-19 pandemic was unfolding and was taking a toll on health systems, communities and individuals, questions arose about how family planning programs and contraceptive services would fare in the face of COVID-19 ( Brunie et al. , 2022 ; GEH et al. , 2021 ; UNFPA, 2021 ). One estimate suggested that 15 million unintended pregnancies over a year could result from a 10 percent reduction in use of contraception in lower- and middle-income countries ( Riley et al. , 2020 ), raising dire warnings of strong negative consequences associated with anticipated disruption of access to contraceptives. WHO conducted pulse surveys on disruptions to essential sexual reproductive maternal neonatal children and adolescent health services, once in mid-2020 and twice in 2021. These pulse surveys show widespread disruptions to family planning services early in the pandemic, diminishing over time ( WHO, 2021b ). In the first pulse survey in May-July, 2020, 68 percent of the 102 states that responded noted disruptions in family planning and contraceptive services, compared to 44 percent of the 104 countries responding in January-March 2021 ( WHO, 2020 ; WHO, 2021a ). By November-December 2021, 35 percent of the countries responding noted disruptions ( WHO, 2021b ). A multi-country study of COVID-19 and resilience of health systems found large declines in family planning services in two countries (Chile and Mexico), a small decline in one country (Nepal) and no decline in four countries (Haiti, Lao PDR, Ethiopia and Ghana) ( Arsenault et al. , 2022 ). Country respondents reported that most effects to the health systems, including related to family planning, had been addressed by the end of 2020, with more lasting effects in Chile and Mexico. Evidence from country-level studies suggest mixed findings on effects of the COVID-19 pandemic on contraceptive use ( Bietsch et al. , 2022 ; Brunie et al. , 2022 ; Karp et al. , 2021 ; Wood et al. , 2021 ). A voice response survey to gain insight into women’s contraceptive access and use in Malawi, Nepal, Niger, and Uganda one year into the pandemic, found less reported use of contraception than before the pandemic in three of the four countries (Niger was the exception) ( Brunie et al. , 2022 ). The sample in the Brunie et al. study was primarily younger women ages 18 to 24. Temporary service closures, product shortages, and fear of COVID-19 infections were reported to affect access and use. Using multiple rounds of Performance Monitoring and Action (PMA) data from Kenya, Burkina Faso, Lagos State Nigeria and Kinshasa, DRC, Wood et al. (2021) reported some increases in women’s need for contraception. However, results also showed continued increases in contraceptive use. Assessing contraceptive use in 15 countries using service statistics data from 2019 and 2020, Bietsch et al. (2022) found that contraceptive use was higher in 12 of the countries in 2020 than in 2019. Most studies that have asked about family planning program disruptions have not delved deeply into what aspects of the program have been disrupted (e.g., the WHO pulse surveys ask only one question), and the more in-depth evidence that is available covers a handful of the countries around the world, or is summarized without specific country information ( Global Health Supply Chain Program, n.d. ). This paper uses a unique data source, a special Supplement added to the 2021 round of the National Composite Index for Family Planning (NCIFP), to assess in depth the resilience of family planning programs in the face of the COVID-19 pandemic across 70 countries spanning six regions: Francophone sub-Saharan Africa; Anglophone sub-Saharan Africa; Asia; Latin America and the Caribbean; Middle East and North Africa, and Eastern Europe and Central Asia. In this paper, we first explain the NCIFP then present findings from the Supplement added to assess the effects of COVID-19 and thus the resilience of the family planning program during COVID-19, set in the context of the findings of the general NCIFP in 2021. Results are intended to serve as a starting point for policy and program managers to delve deeper into the root causes of resiliency in their respective countries and for researchers to gain a more nuanced picture of resiliency of family planning programing during the COVID-19 pandemic. Methods The National Composite Index of Family Planning Building on the Family Planning Program Effort Score measured since the 1970s ( Kuang & Brodsky, 2016 ; Lapham & Mauldin, 1984 ; Mauldin & Ross, 1991 ; Ross & Stover, 2001 ), the NCIFP was developed after 2012 to support FP2020’s efforts to improve the enabling policy and program environment for family planning, by examining the levels and types of effort for a range of family planning policy and programmatic indicators, including indicators to measure rights-based programming. The NCIFP includes 41 items related to five dimensions of family planning programs, namely, Strategy, Data, Quality, Equity and Accountability, with scores summing to a total possible score of 100 1 ( Box 1 ). For more information about development of the NCIFP, see Weinberger & Ross (2016) . Three rounds of the NCIFP have been completed: 2014, 2017 and 2021. To see scores from the first three rounds of the NCIFP, or to compare country scores over time, see Rosenberg (2020) or visit the Track20 website at Track20.org. Box 1. The 5 NCIFP Dimensions + 2021 COVID-19 Supplement ■ Strategy: Includes questions on topics such as what plans are in place, whether they include important elements (e.g. quantified objectives), government support for family planning, etc. ■ Data: Focuses on both data collection (service statistics, monitoring sub-groups, etc.), and data use to inform decisions. ■ Quality: Measures whether services meet WHO standards, whether quality of care indicators are monitored, whether there are structures are in place to support quality services. ■ Equity: Focuses on policies and programs related to discrimination, efforts to reach under-served groups, and wide-spread access to contraceptive methods. ■ Accountability : Focuses on monitoring and addressing issues related to informed choice, lack of coercion and absence of denial of services. ■ COVID-19 Supplement (questions included in the 2021 round): Asks to what extent COVID-19 affected various components of the family planning program. A ‘COVID-19 Supplement’ was added to the 2021 round, which includes results from 70 countries in six regions ( Rosenberg et al. , 2022 ). The regional representativeness of the sample for 2021 is 64 percent of countries for both Anglophone and Francophone sub-Saharan Africa regions (SSAF-A and SSAF-F), 52 percent of countries for Asia, 18 percent of countries for Latin America and the Caribbean (LAC), 21 percent of countries for the Middle East and North Africa (MENA), and 53 percent of countries for Eastern Europe and Central Asia (EECA). The total number of respondents in 2021 was 961. The NCIFP is administered through a key informant approach, with the key informants comprising 10–15 respondents in each country who know the family planning program, from the public sector and private sectors; from civil society and nongovernmental organizations; from academic/research organizations; and from development and implementation partners. Country-level NCIFP data collection was managed by either Track20 monitoring and evaluation officers (MEO) assigned to work with the MOH or by a consultant selected based on familiarity with the FP/RH policy and program environment. The MEO or consultant selected respondents who are known to have at least 5 years’ experience with the family planning program, ensuring at least two respondents from each of the categories listed above. While the same respondents were identified for the 2021 round that had participated in the 2017 round, their inclusion was not always possible given turnover in relevant positions. The approach uses a rating system based on opinion of “the extent to which” with 1–10 as responses (1 = non-existent; 10 = extremely strong effort) for each item in the NCIFP. The 2021 round was administered in eight languages online using Google Form, with an offline option available. The questionnaire included informed consent for respondents. While the NCIFP does not measure how women were actually impacted by the pandemic with regards to contraceptive access and use, NCIFP country managers (selected because of their known familiarity of the FP environment in their own countries) were instructed to ensure inclusion of FP advocates, gender-oriented NGOs, women’s groups working on FP/RH—who are likely to get feedback from constituents about problems accessing FP during the pandemic. We have included qualitative comments from respondents about key barriers in each country. COVID-19-specific questions added to the 2021 NCIFP as a Supplement The Supplemental questions on COVID-19 came at the end of the regular NCIFP questionnaire and respondents were told that this final set of questions was unique to the 2021 NCIFP and was meant to capture the resiliency of the health system. The questions on COVID-19, shown in Box 2 , covered four main aspects of family planning program resiliency: 1) the extent to which COVID-19 interfered with the country’s ability to achieve its objectives related to seven issues (shown in Box 2 ), with space to add additional issues; 2) the extent to which the government maintained commitment to family planning; 3) the extent to which the family planning program was able to maintain availability of contraceptive information and services; and 4) extent to which clients were able to access contraceptive counseling and methods during lockdowns associated with COVID-19. Taken together, these results give an indication of the resiliency of family planning programs in the face of the COVID-19 pandemic from the perspective of stakeholders who know the programs well. Box 2. COVID-19 Supplement Items in the 2021 NCIFP to Measure Resilience of the Family Planning Program During COVID-19 Extent to which COVID-19 interfered with the country's ability to reach its family planning objectives. (1 = not at all; 10 = extremely interfered) • Financing for family planning • Advocacy or community mobilization efforts • Supply of contraceptives, including transport and logistics systems • Recording and reporting of services (routine data) • Restrictions to movement/transport that interfered with the population’s access to short-term FP methods (STM) • Restrictions to movement/transport that interfered with the population’s access to long-term and permanent family planning methods (LAPM) • Other (please specify) Extent to which the government maintained its commitment to family planning during COVID-19. (1 = not at all; 10 = maintained commitment) Extent to which the family planning program was able to maintain availability of contraceptive information and services, including contraceptive methods during COVID-19. (1 = not at all; 10 = availability maintained) Extent to which clients were able to access contraceptive counseling and methods during lockdowns associated with COVID-19. (1 = no access; 10 = easy access) Analysis of the NCIFP Data from the google forms questionnaires were exported to Excel for analysis. The authors, led by RR, calculated scores for each item by averaging across individual items in each dimension of the NCIFP and across the COVID-19 Supplement questions. Total scores are an average across all 41 items in the NCIFP. Dimension scores are an average of the individual items in each dimension. Country scores were generated by taking the average for all respondents within that country and converting to a score from 1-100. Regional scores are the average of all country scores within that region. Scoring on responses to COVID-19 questions about ‘interference’ was reversed for analysis for consistency with scoring of the five dimensions of the NCIFP. Thus, a high score indicates little interference to the program from COVID-19 and thus higher resilience of the program and a low score indicates a great deal of interference and lower resilience. Analysis also included correlations between the NCIFP total score (an average of the five dimensions (excluding the COVID-19 Supplement) and three COVID-19 Supplement indicators: 1) the total Supplement score; 2) the Supplement item on whether government commitment was maintained; and 3) the Supplement item on whether access to contraception was maintained. Respondents had the opportunity to provide a short answer to ‘COVID Other’ following the questions about COVID-19 interference. The authors, led by KH, analyzed the responses to this open-ended question to highlight common and unique themes across the regions. We started with a list of all of the open-ended responses, grouped by country and region. Starting with the themes represented by the items in the COVID-19 Supplement, we let the comments ‘speak for themselves’ and represent the voices of the respondents in terms of themes that emerged. Ethical approval and consent Since the first round in 2014, the NCIFP has been conducted within a monitoring and evaluation framework focused on family planning programs, rather than under a research protocol. Still, written informed consent was obtained to take part in the NCIFP and all data has been anonymized. Findings Regional variation in family planning program resilience during COVID-19 Regions show variations in the resilience of their family planning programs during the COVID-19 pandemic ( Figure 1 ). Keeping in mind that a high score indicates higher resilience and a low score indicates lower reliance, the average score across all 70 countries was 47 out of 100. SSAF-F had the highest score (55), indicating that that region’s family planning programs were affected by COVID-19, but still may have been most resilient during the pandemic. LAC has the lowest overall score (35), meaning that COVID-19 was considered to affect family planning programs to a greater extent in that region. Figure 1 also shows that respondents gave higher scores overall for the five standard dimensions of the NCIFP in 2021 (described in Box 1 ) compared to their assessments of the resilience of the program in the face of COVID-19. Figure 1. Resilience of the FP Program during COVID-19 and NCIFP Score, by Region. No region or country was immune to effects of COVID-19 on the family planning program. Regions showed variation in the resilience of their programs, ranging from a high of 55 in Francophone sub-Saharan Africa (out of 100 indicating fully resilient) to a low of 35 in Latin America and the Caribbean, with an average across the six regions of 47. Turning to the components of resilience of the family planning program to COVID-19 ( Box 2 and Figure 2 ), respondents in four of the six regions were positive about their governments’ continued commitment to family planning and ability to maintain access to contraceptives in the face of COVID-19. LAC (yellow line) and EECA (green line) were the exceptions, with less positive views on government commitment and access to contraceptives during COVID-19 ( Figure 2 ). Regarding interference, across the regions, COVID-19 was considered to have the most effect on advocacy and community mobilization efforts and on supply and logistics. Restrictions to movement and/or transport were considered to have had more effect on access to long acting and permanent methods (LAPM) than on access to short term methods (STM) across all regions except SSAF-F (orange line). SSAF-F had equal levels of interference to access to both types of methods related to restrictions to movement and/or transport. Figure 2. Components of resilience, by Region. Note: The wording for each component of resilience in Figure 2 is found in Box 2 . Respondents in four of six regions were positive about government commitment to family planning and access to contraceptives during COVID-19 although all regions reported interference with logistics and supply and, relatedly, access to both types of methods due to restrictions on movement and/or transportation. Country variation in family planning program resilience during COVID-19 Country scores for resilience vary widely, with Turkmenistan reporting the highest resilience (78) and Bolivia the lowest (22) ( Figure 3 ). Within regions, there is considerable variation in the country scores for resilience. The largest difference is 52 points in EECA, from the high of 78 for Turkmenistan and a low of 26 for Armenia. The smallest difference is 19 points in MENA (from a high of 54 in Djibouti to a low of 35 in Palestine. Table 1 provides the component scores for the items in the COVID-19 Supplement for each country, grouped within regions. The scores across countries reinforce that for most countries, with some exceptions, while the government maintained commitment to family planning, the programs faced interference. Among the 70 countries, around half (36) had similar scores related to the government maintaining commitment to family planning and the country maintaining availability of contraceptives (scores for those two items were within 5 points of each other in those 36 countries). In eight countries, the scores for those items differed by 10 or more points. Figure 3. Resilience of the FP Program During COVID-19, for Countries Grouped Within Regions. Table 1. Resilience of the FP Program During COVID-19, Component Scores by Country within Region. COVID-19 interfered with… Government maintained commitment to FP Maintained availability of contraceptives Access during lockdowns Average score Region and Country financing advocacy logistics and supply routine data access to STMs access to LAPM SSAF-F 40 38 46 55 52 53 71 73 65 55 Mozambique 26 24 24 47 29 31 67 64 61 42 Sao Tome and Principe 16 17 29 31 33 36 79 86 64 44 Madagascar 32 29 38 43 44 46 50 76 71 48 Cameroon 36 30 38 56 46 50 61 63 53 48 Tchad 42 40 44 44 53 56 47 58 48 48 Togo 40 35 39 55 48 45 73 75 58 52 DRC 46 51 44 61 52 54 56 65 45 53 Guinea 44 44 46 58 51 50 74 69 64 56 Mali 36 26 52 54 58 55 82 81 76 58 Burkina Faso 48 44 50 59 57 53 79 79 70 60 Niger 33 37 59 64 65 66 78 77 69 61 Cote d'Ivoire 51 42 50 63 63 63 78 71 70 61 Guinea-Bissau 56 52 67 69 61 62 81 84 79 68 Burundi 58 51 56 70 67 67 84 79 79 68 SSAF-A 33 30 33 47 41 40 65 63 47 45 Eswatini 12 16 22 39 15 21 60 47 21 28 Lesotho 21 30 30 36 35 32 42 49 32 34 Liberia 21 22 24 31 27 29 61 57 41 35 Botswana 24 22 20 37 28 30 76 58 43 38 Nigeria 31 29 32 42 36 33 50 55 41 39 The Gambia 20 22 26 37 27 29 67 74 49 39 Somalia 35 32 27 50 57 54 38 41 29 40 Malawi 28 32 27 51 40 36 60 61 45 42 Zimbabwe 35 31 31 43 29 25 86 81 57 47 Kenya * 43 43 43 43 43 43 62 60 41 47 Sierra Leone 34 36 36 49 41 42 69 71 45 47 Uganda 41 32 33 55 44 41 75 63 45 48 South Africa 43 33 42 46 44 36 66 69 52 48 Zambia 46 32 48 46 32 45 69 54 61 48 Ghana 32 33 43 61 50 49 67 60 46 49 Ethiopia 32 31 33 54 52 43 83 82 66 53 South Sudan 48 33 43 57 74 66 67 74 60 58 Tanzania 52 46 44 72 73 67 80 79 75 65 Asia 42 37 42 49 43 37 68 65 49 48 Philippines 19 20 21 22 22 8 71 66 53 34 Papua New Guinea 27 25 31 52 31 31 38 44 38 35 Malaysia 36 29 42 51 33 34 51 54 43 41 Indonesia 31 30 29 34 31 26 79 74 66 44 India 58 46 46 44 42 35 57 45 35 45 Viet Nam 23 28 36 39 42 38 78 73 65 47 Lao PDR 34 35 30 33 48 47 73 66 56 47 Nepal 43 33 39 54 44 31 69 68 52 48 Pakistan 42 52 36 55 44 34 73 57 44 49 Mongolia 49 57 34 58 47 50 53 59 48 51 Cambodia 41 36 52 67 52 43 69 68 35 51 Bhutan 49 27 50 56 44 37 87 79 57 54 Bangladesh 56 43 69 59 52 43 77 66 44 57 China 59 46 57 65 59 47 72 75 48 59 Timor-Leste 60 50 59 50 52 47 81 75 52 58 LAC 33 25 28 39 30 28 48 47 37 35 Bolivia 16 14 15 37 16 18 27 31 25 22 Peru 22 10 16 17 18 18 49 40 24 24 Ecuador 18 19 23 24 25 21 36 37 27 26 El Salvador 29 31 30 34 27 25 29 35 28 30 Dominican Republic 32 12 18 26 17 16 64 48 35 30 Guatemala 46 19 21 41 10 11 41 44 38 30 Honduras 28 22 24 45 30 28 52 54 40 36 Haiti 48 47 55 63 63 59 55 61 47 55 Jamaica 53 53 54 63 60 56 84 76 64 62 MENA 46 38 43 47 41 40 61 62 43 47 Palestine 35 37 29 31 26 26 47 45 37 35 Jordan 39 34 46 54 40 27 47 57 31 41 Morocco 45 39 50 41 40 42 71 73 44 49 Egypt 62 39 41 58 43 46 72 70 52 54 Djibouti 48 42 47 49 59 57 70 66 50 54 EECA 42 42 46 56 49 44 49 49 43 47 Armenia 13 19 16 29 38 38 26 30 28 26 Kyrgyz Republic 18 21 24 28 20 20 46 37 33 27 Romania 42 30 51 62 39 29 18 32 27 37 Georgia 38 42 49 54 42 39 27 36 29 39 Uzbekistan 35 37 33 51 42 36 47 50 37 41 Azerbaijan 38 51 40 47 53 52 56 47 47 48 Kazakhstan 33 36 60 57 51 49 66 65 60 53 Tajikistan 68 67 64 79 76 63 73 73 66 70 Turkmenistan 87 80 77 94 81 73 78 75 62 78 *Note that for Kenya, respondents were asked if COVID-19 interfered with the family planning program but not about how specifically it interfered; thus the same score is given for the six components related to interference. Country scores for resilience vary widely, with Turkmenistan reporting the highest resilience (78 out of 100) and Bolivia the lowest (22). Even within regions, countries show considerable variation in their resilience score, and in the components of resilience that affect each country. Correlations between Total NCIFP Scores and COVID-19 Supplement Scores To assess links between the strength of the overall enabling environment for family planning in programs and resilience to COVID-19, we measured correlations between total scores on the five dimensions of the NCIFP (Strategy, Data, Quality, Accountability and Equity) and the Total COVID-19 Supplement score. The connection was positive with a correlation coefficient (R 2 ) of 0.26 ( Figure 4 ). The correlation between the total NCIFP Score and the Supplement item on whether government commitment was maintained was R 2 = 0.59 ( Figure 5 ) compared to R 2 = 0.50 for the Supplement item on whether access was maintained ( Figure 6 ). The relationships for government commitment and access were strong, implying that maintaining government commitment to family planning and access to contraceptives during COVID-19 were both bolstered by a robust overall enabling environment for family planning. Figure 4. Correlation: Total NCIFP and Total COVID-19 Supplement. Figure 5. Correlation: Total NCIFP and Maintained Government Commitment During COVID-19. Figure 6. Correlation: Total NCIFP and Maintained Access During COVID-19 Family planning programs with a strong enabling environment, as measured by the NCIFP, were more likely than those with weaker enabling environments to exhibit continued government commitment and access to contraceptive methods during COVID-19. Self-reported challenges related to the effects of COVID-19 Respondents were given the opportunity to provide open-ended responses about the effects of COVID-19 on family planning programming. Comments from 178 respondents from 63 of the 70 countries, representing around 18.5% of all respondents, provide a narrative snapshot and reinforcement of the challenges that family planning programs faced in the context of COVID-19 across the regions ( Table 2 ). Comments can be grouped into seven themes. Fear of infection was mentioned in 5 of 6 regions, disruption of services / difficulty with lockdown and travel restrictions was mentioned in all six regions and staff / facilities diverted to COVID-19 was mentioned in 4 of 6 regions. Five of six regions mentioned: access to reproductive health services and contraceptive methods affected; shifts in services / outreach affected; interfered with logistics & supplies, training & supervision, and M&E; and lack of attention to FP/SRH, financing reduced or diverted, and partnerships affected. Table 2. Summary of comments, by Region * . Theme SSA-F SSA-A Asia LAC MENA EECA Fear of infection Fear of going to health care settings (7) Affected access to FP, most people were scared to go to the facilities (2) Misinformation and misconception interfered with access due to COVID-19 Health worker hesitancy and misinformation; fear of unknown disease; lack of PPE Fear of infection reduced demand for FP services (4) Fear of infection Disruption of services / difficulty with lockdown & travel restrictions Services never stopped; little effect; no particular problem Lockdown restricted access (2) Service reductions affected access (2) Transportation issues disrupted health care workers Elective (permanent methods) postponed Low attendance at health centers (2) Impact of COVID-19 mostly at national level Declined overall performance of the program All services put on hold during lockdown (2), with restrictions greatest during partial lockdown (3) Mobility to health facilities and personnel was interfered with During intense lockdown, mainly pregnant women moved easily to health facilities, not routine FP services Lockdown exacerbated challenges related to access to contraception for almost 2 years Disruptions were temporary (3) Restrictions short lived - deliberate initiative to continue essential health service delivery Access to services disrupted; counseling affected; management of side effects and concerns (3) Discouraged discontinuation due to limited access Difficulties with lockdown (2) Issues at first, then improved (2) Health facilities functioning ok; some local effects Some services hours reduced (2) Travel restrictions limited access Remote areas most affected Service providers out on quarantine Lack of clarity on what services are deemed essential Elective services suspended (2) E.g. IUD, BTL, NSV, etc.) Services closed due to lockdown (7) Closings initially then progressive opening Services limited (6) Comprehensive health care units for adolescents suspended Lockdowns made access to FP difficult; reduced demand Restrictions at the beginning; better now Lack of health facilities Difficulties with lockdowns (2); clinics closed Travel restrictions limited access Restriction to abortion during COVID (2) Staff, facilities diverted to COVID-19 Health workers focused on COVID-19 (2) Focus and attention directed to COVID-19 prevention, thus neglecting FP services Service providers occupied with COVID services (3) Hospitals converted for COVID-19 Service provider shortages (2) Staff diverted to COVID-19 (2) Access to RH services & contraceptive methods affected Limited access to removal of IUD Lack of some methods (implants and injections) LARC access/removal (3) Difficulty getting resupply methods Shifts in services/ outreach affected Community outreach affected (4) Clinics were ok; outreach was affected Moved to private services Lack of transportation for motivators Tried a digital health program (pilot) for clients during and after COVID-19 Shift in services; home delivery, remote consultations Interfered with logistics & Supplies, training & supervision; M&E Stockouts; logistics and supplies; shortage of supplies (7) Interstate lockdown interfered with supplies Interfered with training (3) and supportive supervision Monitoring was challenging (2) Difficulties with logistics and supplies (2) Interfered with M&E Stockouts/import difficulties Lack of attention to FP/SRH; financing reduced; diverted; partnerships affected Diversion of resources meant for FP to combat COVID-19 SRH services not prioritized during COVID-19 Health partners involvement in FP services Coordination meetings with all stakeholders were affected Financing – government moved funding to COVID-19 (2) Lack of government attention to FP FP not a priority in the country, even before COVID-19 (2) * Summary includes analysis of 178 responses from 63 countries (15 responses from 7 countries in EECA; 27 responses from 12 countries in Asia; 32 responses from 9 countries in LAC, 12 comments from 5 countries in MENA; 41 comments from 13 countries in SSA-F; and 51 responses from 17 countries in SSA-A). No comments were received from 7 countries. Numbers in parenthesis indicate multiple respondents gave the same/similar responses. A respondent from Morocco reaffirmed the diversion of providers, saying, “Access to FP services has been affected due to the mobilization of FP health professionals in the context of the COVID 19 pandemic” (Morocco) A respondent from Bangladesh explained, “Long national lockdown had a role in receiving services from facilities. This created challenges in travel and provider contact mostly. Discontinuation of advocacy and counseling made disruption of services and increased the threat of unwanted pregnancy” (Bangladesh) Also in Asia, a respondent from Pakistan reflected, “Lock downs and smart lock downs have had its toll on both the providers and the users besides interrupted supply chain” (Pakistan) In line with findings shown in Table 1 , the comments mostly indicated more issues with long acting and permanent methods than with short term methods. A respondent in Eswatini noted that, “Procurement of family planning commodities was greatly affected which led to serious shortages of all methods, due to international lockdowns which affected the supply chain” (Eswatini) Another respondent from Eswatini added that the shortages especially affected rural areas. The comments showed varying views, even within regions and countries, on how severe and how long-lasting the effects of COVID-19 were and the interactions of COVID-19 with other underlying issues affecting the family planning program. For example, one respondent from Uganda said, “The COVID-19 impact on FP services was most severe in April-May 2020 but the program recovered from June 2020 onwards quite well, due to a deliberate initiative to continue essential health service delivery” (Uganda) In contrast, another respondent from Uganda described the situation differently, saying, “Lock down exacerbated the challenges related to access to contraception in Uganda for almost 2 years” (Uganda) A respondent from Burkina Faso noted the effect of COVID-19 on partnerships that were implementing programming, explaining that the pandemic interacted with other stressors to affect family planning: “With COVID, many partnerships have been suspended, jeopardizing the progress of community interventions, especially in the context of insecurity with restrictions on movement in certain localities and the massive internal displacement of populations” (Burkina Faso) A respondent from El Salvador explained that family planning got lost with COVID-19, saying, “The priority of the government has been almost absolutely to care for COVID and a new maternal and childcare program which has been much publicized, but that leaves the family planning program abandoned” (El Salvador) A respondent from Vietnam reflected on issues of equity, noting that, “Those most affected by the COVID pandemic are those living in isolation and lockdown…through… the end of the third quarter of 2021 due to the Government’s Zero COVID strategy….Nearly half of the provinces live in a state of social distancing. The supply of essential goods is greatly affected because the list of essential goods is not clear…. in mountainous areas, economic conditions are difficult, the point of providing contraceptives is also limited compared to urban areas, they have fewer opportunities and choices” (Vietnam) Not all respondents thought COVID-19 had adversely affected contraceptive use, although they did say that the family planning program had adapted to the pandemic conditions. A respondent from Tajikistan said, “There was no decrease in contraceptive use during the Corona virus pandemic. More work was possibly done on the side of the healthcare professionals such as home delivery to patients who had COVID, etc., as well as provision of consultation remotely.” Likewise, a respondent from Guinea explained that the effect was short-lived, saying, “The COVID - 19 pandemic has hardly affected the use of FP services in Guinea. A 10% drop in use was recorded during the first month after the outbreak of the pandemic and immediately after, with the measures taken to maintain essential services including FP, usage gradually increased continuously and stabilized.” Comments across the regions paint a picture of fear of COVID-19, along with lockdowns of varying durations, keeping people from accessing services, along with providers being diverted to COVID-19 services or being out sick themselves with COVID-19. Discussion These findings from the 2021 NCIFP and its Supplement on COVID-19 provide a broad view from 70 counties across six regions of the resilience of family planning programs during COVID-19 into the second year of the pandemic. Our analysis shows that programs in all regions were affected by the COVID-19 pandemic. The magnitude of the effects varies by region and country, and by component of resilience. Comments across the regions paint a picture of fear of infection, with lockdowns of varying durations, travel restrictions keeping people from accessing services, and providers being diverted to COVID-19 services or being out sick themselves with COVID-19. While comments mostly implied that the effects were strongest early in the pandemic, that view was not uniform, with some respondents noting long periods of lockdown, for example, related to zero-COVID-19 policies. Similarly, respondents across four countries in a study by Brunie et al. (2022) reported that temporary service closures, product shortages, and fear of COVID-19 infections affected their access to and use of contraception. The comments in our study show differing views on the effects of COVID-19 for the same country, with respondents in one country reporting ‘no effect’ to a ‘lasting effect’. These comments illustrate the uncertainty based on the unknown with COVID-19: how long it would last; how severely it would affect different countries; and what services, including family planning and reproductive health, would be deemed essential and thus maintained throughout the pandemic. While the average score for resilience, at 47 out of 100, implies middling levels of resilience, further analysis suggests that, for the most part, family planning programs were able to maintain government commitment and provide access to contraception despite facing challenges to financing; advocacy and community mobilization efforts; supply of contraceptives; routine data recording and reporting; and restrictions to movement/transport that interfered with the population’s access to short term methods and to long acting and permanent methods. Programs in Francophone Sub-Saharan Africa appeared to have been the most resilient, while programs in Latin America and the Caribbean appeared to have been most severely affected by, and thus least resilient to, COVID-19. Arsenault et al. (2022) found large declines in family planning services in the two LAC countries included in their study. The differences between LAC and SSAF-F may be due to the relatively high use of contraception in LAC compared to SSAF-F, with less government focus on family planning programming in countries in LAC than in SSAF-F, which was possibly shored up by more donor funding. Across the regions, COVID-19 had the largest negative impact on advocacy and community mobilization efforts. This could have been due partly to lockdowns that restricted external movements, shifting attention to COVID-19 related behaviors including wearing masks, keeping distance, and washing hands, among others. This paper finds that despite ‘interference’ in many components of family planning programming, with some exceptions, respondents said that the COVID-19 pandemic generally did not diminish government commitment to family planning. Overall, programs remained resilient in providing access to services. Strong global attention to commodities and related supplies likely bolstered countries’ ability to provide access to services ( Weinberger et al. , 2023 ). Some countries that did not score highly on resilience reported indifferent commitment from governments even before COVID-19. This paper shows that a strong enabling environment for family planning, which the NCIFP is designed to measure, was positively correlated with continued government commitment and access to contraceptive methods during COVID-19, despite noted disruptions to services. This finding is supported by evidence from 15 countries that contraceptive use mostly increased over the years of the pandemic ( Bietsch et al. , 2022 ), and from analysis of successive waves of PMA ( https://www.pmadata.org/ ) data from four countries in sub-Saharan Africa ( Wood et al. , 2021 ). Limitations This paper has limitations in that the findings from the countries are based on self-reports from respondents on their perceptions of the effects of COVID-19 on the family planning program. Still, the findings represent expert opinion from respondents in each country who were familiar with the family planning program and were in a unique position to observe program features and effects. The questions on COVID-19 were added as a Supplement to take advantage of the timing of the 2021 NCIFP, which limited the number of questions that could be added. That is, the respondents answered the questions on COVID-19 in the context of earlier items on the enabling environment for family planning. While a strength of the data is that they were collected in late 2021 and thus provide a broad perspective over the period of the pandemic from 70 countries across six regions, they do not capture any periodicity of the effects (e.g., effects of lockdowns with easing over time). The qualitative findings do indicate a gradation of effect, with the most intensive effects early in the pandemic. Furthermore, characteristics of the family planning program before the onset of COVID-19 may have impacted resilience of the program including the strength of the health system, presence of donor support and funding, and socio-cultural factors. Beyond different levels of contraceptive use, method mix could also have an impact on resilience as countries with higher levels of long-acting method use may have had less interruption, since women wouldn’t have to come to the facility regularly for resupply. Many factors may impact a country’s resiliency, and to varying degrees. The purpose of this analysis was to present the findings from the COVID-19 Supplement of the 2021 NCIFP and to provide a broad overview of the impacts of COVID-19 on national FP programs. Additional analyses exploring these and other factors would add to our understanding of FP program resilience and the characteristics that may lead to more or less reliance in the face of widespread disruptions. An in-depth analysis of these causes for individual countries is beyond the scope of this paper, however, we urge others to undertake further analysis. Further in-depth studies to examine the challenges faced by the programs and how they were overcome, or not, would add to our understanding of the resilience of family planning programs. Conclusion The 2021 round of the NCIFP provides a unique view of the effects of the COVID-19 pandemic on family planning programming in 70 countries across six regions over two years of the pandemic. The questions added as a ‘COVID-19 Supplement’ to the standard questions in the NCIFP, an ongoing survey on the enabling environment for family planning, gauged both interference with various components of family planning and the extent to which governments maintained their program commitments and public access to services. Together, the questions measured the resilience of family planning programs in the face of COVID-19. The findings in this paper are instructive for family planning programming moving forward: it will face challenges and ‘interference’ when unanticipated shocks like COVID-19 occur, and strong programs will be best prepared to exhibit resilience during unexpected times. Data availability Underlying data Zenodo: 2021 National Composite Index for Family Planning (NCIFP): Data File and Questionnaire. https://doi.org/10.5281/zenodo.8264220 ( Rosenberg et al. , 2022 ) This project contains the following underlying data: 2021 NCIFP Data File.xlsx (The data file includes the final, cleaned data for the 2021 round of the NCIFP, as well as a codebook identifying the variable names with their corresponding questions. Underlying country data are available from the authors upon reasonable request.) Extended data 2021 Questionnaire_English.pdf (The questionnaire is the full questionnaire for the 2021 round of the NCIFP, in English). Data are available under the terms of the Creative Commons Attribution 4.0 International . Footnotes 1 NCIFP data, reports, and country briefs are available at: http://www.track20.org/pages/data_analysis/policy/NCIFP.php Faculty Opinions recommended References Arsenault C, Gage A, Kim MK, et al. : COVID-19 and resilience of healthcare systems in ten countries. Nat Med. 2022; 28 (6): 1314–1324. PubMed Abstract | Publisher Full Text | Free Full Text Bietsch K, Emmart P, Parks J, et al. : The Impact of COVID-19 on Family Planning Programs in 15 Low and Lower-Middle Income Countries. Presentation at the International Conference on Family Planning. Pattaya, Thailand, November, 14–17, 2022. Brunie A, Austin G, Arkin J, et al. : Women’s experiences with family planning under COVID-19: a cross-sectional, interactive voice response survey in Malawi, Nepal, Niger, and Uganda. Glob Health Sci Pract. 2022; 10 (4): e2200063. PubMed Abstract | Publisher Full Text | Free Full Text Center on Gender Equity and Health (GEH) - UC San Diego (UCSD) and International Union for the Scientific Study of Population (IUSSP): Family Planning and COVID-19; Cross-National Experiences from Burkina Faso, India, Nigeria, and Uganda. GEH-US San Diego, 2021. Reference Source Global Health Supply Chain Program (GHSCP): Impact of COVID-19 Pandemic Operational practices to facilitate access to FP services. Brief 6_Impact of COVID-19 on FP - Operational Practices_Dec2022.pdf (ghsupplychain.org), n.d. Karp C, Wood SN, Guiella G, et al. : Contraceptive dynamics during COVID-19 in sub-Saharan Africa: longitudinal evidence from Burkina Faso and Kenya. BMJ Sex Reprod Health. 2021; 47 (4): 252–260. PubMed Abstract | Publisher Full Text | Free Full Text Kuang B, Brodsky I: Global trends in family planning programs, 1999-2014. Int Perspect Sex Reprod Health. 2016; 42 (1): 33–44. PubMed Abstract | Publisher Full Text Lapham RJ, Mauldin WP: Family planning program effort and birthrate decline in developing countries. Int Fam Plan Perspect. 1984; 10 (4): 109–118. Publisher Full Text Mauldin WP, Ross JA: Family planning programs: efforts and results, 1982-89. Stud Fam Plann. 1991; 22 (6): 350–367. PubMed Abstract | Publisher Full Text Riley T, Sully E, Ahmed Z, et al. : Estimates of the potential impact of the COVID-19 pandemic on sexual and reproductive health in low- and middle-income countries. Int Perspect Sex Reprod Health. 2020; 46 : 73–76. PubMed Abstract | Publisher Full Text Rosenberg R: The National Composite Index for Family Planning (NCIFP): 2017 Global Report. Avenir Health: Track20, 2020. Reference Source Rosenberg R, Hardee K, Zosa-Feranil I: The National Composite Index for Family Planning (NCIFP): 2021 Global Report. Avenir Health: Track20, 2022. Reference Source Ross J, Stover J: The Family Planning Program Effort Index: 1999 cycle. Int Fam Plan Perspect. 2001; 27 (3): 119–129. Publisher Full Text UNFPA: Impact of COVID-19 on Family Planning: What we know one year into the pandemic. Technical Note. New York: UNFPA, 2021. Reference Source Weinberger M, Ross J: The National Composite Index for Family Planning (NCIFP). Avenir Health: Track20, 2016. Weinberger M, Eva G, Gold J: Contraceptive Commodity Funding During the COVID-19 Pandemic: Analysis of funding trends and potential pandemic impacts in low and middle income countries. Reproductive Health Supplies Coalition, 2023. Reference Source Wood SN, Karp C, OlaOlorun F, et al. : Need for and use of contraception by women before and during COVID-19 in four sub-Saharan African geographies: results from population-based national or regional cohort surveys. Lancet Glob Health. Burkina Faso, Kenya, Kinshasa, Democratic Republic of the Congo and Lagos, Nigeria, 2021; 9 (6): e793–801. PubMed Abstract | Publisher Full Text | Free Full Text World Health Organization (WHO): Pulse survey on continuity of essential health services during the COVID-19 pandemic. Interim report. 2020. Reference Source WHO: Second round of the national pulse survey on continuity of essential health services during the COVID-19 pandemic. Interim report, 2021a. Reference Source WHO: Third Round of the National Pulse Survey on Continuity of Essential Health Services During the COVID-19 Pandemic. Nov-Dec 2021, 2021b. Reference Source Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 28 Sep 2023 ADD YOUR COMMENT Comment Author details Author details 1 Hardee Associates, Arlington, VA, 22207, USA 2 Avenir Health, Glastonbury, Connecticut, 06033, USA 3 Independent demographic consultant, New Paltz, NY, 12561, USA Karen Hardee Roles: Conceptualization, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Rebecca Rosenberg Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Software, Visualization, Writing – Review & Editing John Ross Roles: Conceptualization, Writing – Review & Editing Imelda Zosa-Feranil Roles: Conceptualization, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This work was supported by the Gates Foundation [INV-007530]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 25 Mar 2024, 7:121 https://doi.org/10.12688/gatesopenres.14856.2 version 1 Published: 28 Sep 2023, 7:121 https://doi.org/10.12688/gatesopenres.14856.1 Copyright © 2024 Hardee K et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads Gates Open Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Hardee K, Rosenberg R, Ross J and Zosa-Feranil I. How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.12688/gatesopenres.14856.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 25 Mar 2024 Revised Views 0 Cite How to cite this report: Cheney K. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16858.r36839 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v2#referee-response-36839 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 23 Jul 2024 Kate Cheney , The Sydney School of Nursing and Midwifery, The University of Sydney, Sydney, Australia Approved VIEWS 0 https://doi.org/10.21956/gatesopenres.16858.r36839 Thank you for submitting your manuscript; How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries What an interesting question, from a planning perspective. Abstract: - “…fears of severe ... Continue reading READ ALL Thank you for submitting your manuscript; How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries What an interesting question, from a planning perspective. Abstract: - “…fears of severe disruptions to family planning (FP) and …” – fear by whom? You might not have enough words to include a response but it raised the question for this reader. - Can the National Composite Index for Family Planning (NCIFP) DATA be briefly introduced as understanding who you are asking to respond is important to understand. Background Should you write out WHO in full first? What do you mean by 102’ states’ that responded, do you mean countries? You use both words “ Temporary service closures, product shortages, and fear of COVID-19 infections were reported to affect access and use. Using multiple rounds of Performance Monitoring and Action (PMA) data from Kenya, Burkina Faso, Lagos State Nigeria and Kinshasa, DRC, Wood et al. (2021) [Ref-1] reported some increases in women’s need for contraception" - why was the need increasing because of COVID? Do you mean there was an unmet need? Or maybe that more women were asking for contraception for some reason related to the situation. ‘Most studies that have asked…’ ….can you provide some references? Again, what is the National Composite Index for Family Planning – a brief earlier introduction might be useful but I see you move to explain it in methods. Methods Does the representation include Oceania? Just a comment , Asia has included some quite different countries grouped as one area. Discussion This paragraph is key “This paper finds that despite ‘interference’ in many components of family planning programming, with some exceptions, respondents said that the COVID-19 pandemic generally did not diminish government commitment to family planning.” Limitations “This paper has limitations in that the findings from the countries are based on self-reports from respondents on their perceptions of the effects of COVID-19 on the family planning program” SO , could it be that the NCIFP uses who they consider experts in FP programming to answer this survey so those ‘experts’ may have political biases about governments who were in power over this time? They may have had their own COVID response biases? - just a thought and not a criticism or additional comment needed. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Wood SN, Karp C, OlaOlorun F, Pierre AZ, et al.: Need for and use of contraception by women before and during COVID-19 in four sub-Saharan African geographies: results from population-based national or regional cohort surveys. Lancet Glob Health . 2021; 9 (6): e793-e801 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: I am an academic midwife and nurse working around the area of contraception, with an interest in postpartum contraception. I was awarded a PhD around pregnancy planning and contraception, and have published in peer review journals and am a current peer reviewer. My current project is in a project about postpartum contraception and training in PNG, Samoa, Kiribati and Fiji. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Cheney K. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16858.r36839 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v2#referee-response-36839 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Diamond-Smith N. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16858.r36260 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v2#referee-response-36260 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 23 Jul 2024 Nadia Diamond-Smith , Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA Approved VIEWS 0 https://doi.org/10.21956/gatesopenres.16858.r36260 The authors responded to some of ... Continue reading READ ALL The authors responded to some of the comments from my prior review. Competing Interests: No competing interests were disclosed. Reviewer Expertise: reproductive and maternal health, demography I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Diamond-Smith N. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16858.r36260 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v2#referee-response-36260 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Anglewicz P. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16858.r36259 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v2#referee-response-36259 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 01 Apr 2024 Philip Anglewicz , Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health,, Baltimore,, MD,, USA Approved VIEWS 0 https://doi.org/10.21956/gatesopenres.16858.r36259 The authors have adequately ... Continue reading READ ALL The authors have adequately addressed my previous comments. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Demography, family planning, survey methods. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Anglewicz P. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16858.r36259 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v2#referee-response-36259 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 28 Sep 2023 Views 0 Cite How to cite this report: Bahamondes L and Bahamondes MV. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16184.r35589 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v1#referee-response-35589 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 22 May 2024 Luis Bahamondes , Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences, Campinas,, SP, Brazil M. Valeria Bahamondes , Independent consultant, Austin, tx, USA Approved VIEWS 0 https://doi.org/10.21956/gatesopenres.16184.r35589 Thank you for the opportunity to review the manuscript: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries. Background: “At the beginning of the COVID-19…” Please rephrased as: At the beginning of the SARS-CoV-2 (COVID-19)… ... Continue reading READ ALL Thank you for the opportunity to review the manuscript: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries. Background: “At the beginning of the COVID-19…” Please rephrased as: At the beginning of the SARS-CoV-2 (COVID-19)… Also at introduction for the first time. What means “M&E”? Please don´t use acronyms without explanation. There are no doubts that the COVID-19 pandemic affected in major or minor severity the FP services and access of women and men not only for services but also for contraceptive methods and it was affected different countries. One of the main limitations is that in LAC the authors did not evaluate large countries like Brazil, Mexico and Argentina with severe lockdown and negationist perspectives about COVID-19 from the governments of the two largest countries. I suggest visiting the paper (Charles et al, 2022) 1 About the sales of contraceptive methods in Brazil. In conclusion, the manuscript is well writing, and the study was well conducted. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Charles CM, Munezero A, Bahamondes LG, Pacagnella RC: Comparison of contraceptive sales before and during the COVID-19 pandemic in Brazil. Eur J Contracept Reprod Health Care . 2022; 27 (2): 115-120 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Contraception We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Bahamondes L and Bahamondes MV. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16184.r35589 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v1#referee-response-35589 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Anglewicz P. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16184.r35588 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v1#referee-response-35588 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 04 Mar 2024 Philip Anglewicz , Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health,, Baltimore,, MD,, USA Approved with Reservations VIEWS 0 https://doi.org/10.21956/gatesopenres.16184.r35588 This study addresses a worthwhile point, that not much is known about exactly what aspects of FP programs may have been disrupted by COVID, and how this varies across countries. This research uses data from key informants in 70 countries ... Continue reading READ ALL This study addresses a worthwhile point, that not much is known about exactly what aspects of FP programs may have been disrupted by COVID, and how this varies across countries. This research uses data from key informants in 70 countries to estimate the impact of COVID, compare across and within regions, and provide more details on the impact. Some strengths of this research include the consistent categorization of COVID-19 impacts, which permits a comparison across countries; the ability to identify what feature of the program was impacted; and the accompanying open-ended responses that provide more details. So overall, this provides a high-level overview of COVID-19’s impact across settings, which has not been done to date. That said, a limitation of the approach is that it doesn’t measure the impact of COVID-19 directly, by asking women about their experience with accessing services, for example, but instead asks key informants who know the FP programs in their geography. The disadvantage of this is that the key informants could be wrong, or at least inaccurate (in some or all sections)- just as many experts were in predicting the impact of COVID-19 at the beginning of the pandemic. Was there any way to assess the validity of the responses? Similarly, the NCIFP might be vulnerable to response bias, in which areas that were more affected by COVID-19 were less likely to respond. Overall, this research provides valuable insight overall, but might benefit from a bit more information about the survey methods. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Demography, family planning, survey methods. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Anglewicz P. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16184.r35588 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v1#referee-response-35588 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 31 May 2024 Karen Hardee , Hardee Associates, Arlington, 22207, USA 31 May 2024 Author Response You raise a valid point that a limitation of our study is that it does not directly measure how women were actually impacted by the pandemic. We have added a ... Continue reading You raise a valid point that a limitation of our study is that it does not directly measure how women were actually impacted by the pandemic. We have added a point in the methodology section on this, and have added text in the discussion about the need for further analysis, where data are available, linking NCIFP findings with data on use of family planning during the pandemic: “While the NCIFP does not measure how women were actually impacted by the pandemic with regards to contraceptive access and use, NCIFP country managers (selected because of their known familiarity of the FP environment in their own countries) were instructed to ensure inclusion of FP advocates, gender-oriented NGOs, women’s groups working on FP/RH—who are likely to get feedback from constituents about problems accessing FP during the pandemic. We have included qualitative comments from respondents about key barriers in each country. You raise a valid point that a limitation of our study is that it does not directly measure how women were actually impacted by the pandemic. We have added a point in the methodology section on this, and have added text in the discussion about the need for further analysis, where data are available, linking NCIFP findings with data on use of family planning during the pandemic: “While the NCIFP does not measure how women were actually impacted by the pandemic with regards to contraceptive access and use, NCIFP country managers (selected because of their known familiarity of the FP environment in their own countries) were instructed to ensure inclusion of FP advocates, gender-oriented NGOs, women’s groups working on FP/RH—who are likely to get feedback from constituents about problems accessing FP during the pandemic. We have included qualitative comments from respondents about key barriers in each country. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 31 May 2024 Karen Hardee , Hardee Associates, Arlington, 22207, USA 31 May 2024 Author Response You raise a valid point that a limitation of our study is that it does not directly measure how women were actually impacted by the pandemic. We have added a ... Continue reading You raise a valid point that a limitation of our study is that it does not directly measure how women were actually impacted by the pandemic. We have added a point in the methodology section on this, and have added text in the discussion about the need for further analysis, where data are available, linking NCIFP findings with data on use of family planning during the pandemic: “While the NCIFP does not measure how women were actually impacted by the pandemic with regards to contraceptive access and use, NCIFP country managers (selected because of their known familiarity of the FP environment in their own countries) were instructed to ensure inclusion of FP advocates, gender-oriented NGOs, women’s groups working on FP/RH—who are likely to get feedback from constituents about problems accessing FP during the pandemic. We have included qualitative comments from respondents about key barriers in each country. You raise a valid point that a limitation of our study is that it does not directly measure how women were actually impacted by the pandemic. We have added a point in the methodology section on this, and have added text in the discussion about the need for further analysis, where data are available, linking NCIFP findings with data on use of family planning during the pandemic: “While the NCIFP does not measure how women were actually impacted by the pandemic with regards to contraceptive access and use, NCIFP country managers (selected because of their known familiarity of the FP environment in their own countries) were instructed to ensure inclusion of FP advocates, gender-oriented NGOs, women’s groups working on FP/RH—who are likely to get feedback from constituents about problems accessing FP during the pandemic. We have included qualitative comments from respondents about key barriers in each country. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Diamond-Smith N. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16184.r35241 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v1#referee-response-35241 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 14 Nov 2023 Nadia Diamond-Smith , Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA Approved with Reservations VIEWS 0 https://doi.org/10.21956/gatesopenres.16184.r35241 Thank you for the opportunity to read this paper, entitled "How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries". This paper presents data from surveys of experts in 70 countries about how COVID had impacted ... Continue reading READ ALL Thank you for the opportunity to read this paper, entitled "How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries". This paper presents data from surveys of experts in 70 countries about how COVID had impacted various components of FP and also the overall gov commitment to FP. Overall the paper is clearly written and has an interesting finding that there actually wasn't as huge of a disruption as many had feared. This paper does not involve very complicated analysis, but I think that the findings will be interesting to program and policy makers if the authors are able to better delve into more about why they think that some countries had more resiliency than others, there is a little in there, but I think this really needs to be fleshed out. The differences are the interesting part and help us know what to do to improve things. Saying that stronger programs with more commitment did better doesn't really help us that much and we probably would have known without this study. More detailed comments below. Methods: A little more detail about how respondents are selected would be helpful, is it word of mouth/connections? Is it the same people who have answered across all years? The methods make it seem like you will be presenting longitudinal data, but I dont think that you actually do at all, so you might not want to focus on that as much. Results/Discussion: One thing that I kept struggling with is that these countries have different baseline levels of use of FP. I see you discuss this some in the discussion, but I think that you could discuss this even more and possibly do some analysis in the results of how baseline FP use is associated with resilience. Same could be said for donor $, I kept thinking about how countries that rely a lot on donor money probably would have different levels of resiliency, and again, you briefly mention this in the discussion, but is there a way to graph resiliency and donor $ % or something? Also relatedly, the distribution of where the funding comes from seems important to discuss and how differences between countries might explain your findings. I think you are only measuring gov commitment and resilience, but some of these countries must get more or less $ from gov vs donors? The r2 is pretty weak, the way it is presented/worded makes it sound stronger than it is. Hard to follow the acronyms ("with LAPM than with STM"), can you just write out? I'm not sure the write in findings are that insightful (or at least not all of them) - you could potentially shorten this section. I think more of the analysis suggested above could help us really situate these findings in the broader context and help us know how to prepare for the next disruption (what really works to help resiliency?) Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: reproductive and maternal health, demography I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Diamond-Smith N. Reviewer Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16184.r35241 ) The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v1#referee-response-35241 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 31 May 2024 Karen Hardee , Hardee Associates, Arlington, 22207, USA 31 May 2024 Author Response Thank you for your comments on the paper. We have incorporated responses as follows. We have added more detail about how the respondents were identified for the survey, ... Continue reading Thank you for your comments on the paper. We have incorporated responses as follows. We have added more detail about how the respondents were identified for the survey, including the criteria for inclusion, and ensuring a range of perspectives on each country program, namely that respondents have at least 5 years’ experience with the FP program, and ensuring at least two respondents from each of the listed groups. We have added a sentence to explain that the same respondents were identified for the 2021 round of the NCIFP, but their inclusion was not always possible given turnover in relevant positions. We have revised the methods section to clarify that we are not presenting longitudinal data. The COVID-19 questions were only asked in the 2021 round and the paper focuses only on that round. It is true that the countries have different baseline levels of contraceptive use. We have added to the limitations: Characteristics of the family planning program before the onset of COVID-19 may have impacted resilience of the program including the strength of the health system, presence of donor support and funding, and socio-cultural factors. Beyond different levels of contraceptive use, method mix could also have an impact on resilience as countries with higher levels of long-acting method use may have had less interruption, since women wouldn’t have to come to the facility regularly for resupply. Many factors may impact a country’s resiliency, and to varying degrees. The purpose of this analysis was to present the findings from the COVID-19 Supplement of the 2021 NCIFP and to provide a broad overview of the impacts of COVID-19 on national FP programs. Additional analyses exploring these and other factors would add to our understanding of FP program resilience and the characteristics that may lead to more or less reliance in the face of widespread disruptions. An in-depth analysis of these causes for individual countries is beyond the scope of this paper, however, we urge others to undertake further analysis. We have added to purpose: Results are meant to serve as a starting point for policy and program managers to delve deeper into the root causes of resiliency in their respective countries and for researchers to gain a more nuanced picture of resiliency of family planning programing during the COVID-19 pandemic. Financing is an important topic and warrants a separate paper that includes countries for which data on tracking of sources of funding is available. We agree with the comment that one of the three r2 should not be characterized as strong. We have modified the sentence: The relationships for government commitment and access were strong, implying that maintaining government commitment to family planning and access to contraceptives during COVID-19 were both bolstered by a robust overall enabling environment for family planning. We have written out long acting and permanent methods and short term methods, with use of the acronyms in figures and tables. We think the qualitative findings from regions add some depth to the findings and provide examples from various countries across the regions. We anticipate that readers will be interested in the insights from countries across the regions. We agree that further investigation and analysis would add insight into resilience, we believe this sentence in the limitations section covers the point: “Further in-depth studies to examine the challenges faced by the programs and how they were overcome, or not, would add to our understanding of the resilience of family planning programs.” Thank you for your comments on the paper. We have incorporated responses as follows. We have added more detail about how the respondents were identified for the survey, including the criteria for inclusion, and ensuring a range of perspectives on each country program, namely that respondents have at least 5 years’ experience with the FP program, and ensuring at least two respondents from each of the listed groups. We have added a sentence to explain that the same respondents were identified for the 2021 round of the NCIFP, but their inclusion was not always possible given turnover in relevant positions. We have revised the methods section to clarify that we are not presenting longitudinal data. The COVID-19 questions were only asked in the 2021 round and the paper focuses only on that round. It is true that the countries have different baseline levels of contraceptive use. We have added to the limitations: Characteristics of the family planning program before the onset of COVID-19 may have impacted resilience of the program including the strength of the health system, presence of donor support and funding, and socio-cultural factors. Beyond different levels of contraceptive use, method mix could also have an impact on resilience as countries with higher levels of long-acting method use may have had less interruption, since women wouldn’t have to come to the facility regularly for resupply. Many factors may impact a country’s resiliency, and to varying degrees. The purpose of this analysis was to present the findings from the COVID-19 Supplement of the 2021 NCIFP and to provide a broad overview of the impacts of COVID-19 on national FP programs. Additional analyses exploring these and other factors would add to our understanding of FP program resilience and the characteristics that may lead to more or less reliance in the face of widespread disruptions. An in-depth analysis of these causes for individual countries is beyond the scope of this paper, however, we urge others to undertake further analysis. We have added to purpose: Results are meant to serve as a starting point for policy and program managers to delve deeper into the root causes of resiliency in their respective countries and for researchers to gain a more nuanced picture of resiliency of family planning programing during the COVID-19 pandemic. Financing is an important topic and warrants a separate paper that includes countries for which data on tracking of sources of funding is available. We agree with the comment that one of the three r2 should not be characterized as strong. We have modified the sentence: The relationships for government commitment and access were strong, implying that maintaining government commitment to family planning and access to contraceptives during COVID-19 were both bolstered by a robust overall enabling environment for family planning. We have written out long acting and permanent methods and short term methods, with use of the acronyms in figures and tables. We think the qualitative findings from regions add some depth to the findings and provide examples from various countries across the regions. We anticipate that readers will be interested in the insights from countries across the regions. We agree that further investigation and analysis would add insight into resilience, we believe this sentence in the limitations section covers the point: “Further in-depth studies to examine the challenges faced by the programs and how they were overcome, or not, would add to our understanding of the resilience of family planning programs.” Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 31 May 2024 Karen Hardee , Hardee Associates, Arlington, 22207, USA 31 May 2024 Author Response Thank you for your comments on the paper. We have incorporated responses as follows. We have added more detail about how the respondents were identified for the survey, ... Continue reading Thank you for your comments on the paper. We have incorporated responses as follows. We have added more detail about how the respondents were identified for the survey, including the criteria for inclusion, and ensuring a range of perspectives on each country program, namely that respondents have at least 5 years’ experience with the FP program, and ensuring at least two respondents from each of the listed groups. We have added a sentence to explain that the same respondents were identified for the 2021 round of the NCIFP, but their inclusion was not always possible given turnover in relevant positions. We have revised the methods section to clarify that we are not presenting longitudinal data. The COVID-19 questions were only asked in the 2021 round and the paper focuses only on that round. It is true that the countries have different baseline levels of contraceptive use. We have added to the limitations: Characteristics of the family planning program before the onset of COVID-19 may have impacted resilience of the program including the strength of the health system, presence of donor support and funding, and socio-cultural factors. Beyond different levels of contraceptive use, method mix could also have an impact on resilience as countries with higher levels of long-acting method use may have had less interruption, since women wouldn’t have to come to the facility regularly for resupply. Many factors may impact a country’s resiliency, and to varying degrees. The purpose of this analysis was to present the findings from the COVID-19 Supplement of the 2021 NCIFP and to provide a broad overview of the impacts of COVID-19 on national FP programs. Additional analyses exploring these and other factors would add to our understanding of FP program resilience and the characteristics that may lead to more or less reliance in the face of widespread disruptions. An in-depth analysis of these causes for individual countries is beyond the scope of this paper, however, we urge others to undertake further analysis. We have added to purpose: Results are meant to serve as a starting point for policy and program managers to delve deeper into the root causes of resiliency in their respective countries and for researchers to gain a more nuanced picture of resiliency of family planning programing during the COVID-19 pandemic. Financing is an important topic and warrants a separate paper that includes countries for which data on tracking of sources of funding is available. We agree with the comment that one of the three r2 should not be characterized as strong. We have modified the sentence: The relationships for government commitment and access were strong, implying that maintaining government commitment to family planning and access to contraceptives during COVID-19 were both bolstered by a robust overall enabling environment for family planning. We have written out long acting and permanent methods and short term methods, with use of the acronyms in figures and tables. We think the qualitative findings from regions add some depth to the findings and provide examples from various countries across the regions. We anticipate that readers will be interested in the insights from countries across the regions. We agree that further investigation and analysis would add insight into resilience, we believe this sentence in the limitations section covers the point: “Further in-depth studies to examine the challenges faced by the programs and how they were overcome, or not, would add to our understanding of the resilience of family planning programs.” Thank you for your comments on the paper. We have incorporated responses as follows. We have added more detail about how the respondents were identified for the survey, including the criteria for inclusion, and ensuring a range of perspectives on each country program, namely that respondents have at least 5 years’ experience with the FP program, and ensuring at least two respondents from each of the listed groups. We have added a sentence to explain that the same respondents were identified for the 2021 round of the NCIFP, but their inclusion was not always possible given turnover in relevant positions. We have revised the methods section to clarify that we are not presenting longitudinal data. The COVID-19 questions were only asked in the 2021 round and the paper focuses only on that round. It is true that the countries have different baseline levels of contraceptive use. We have added to the limitations: Characteristics of the family planning program before the onset of COVID-19 may have impacted resilience of the program including the strength of the health system, presence of donor support and funding, and socio-cultural factors. Beyond different levels of contraceptive use, method mix could also have an impact on resilience as countries with higher levels of long-acting method use may have had less interruption, since women wouldn’t have to come to the facility regularly for resupply. Many factors may impact a country’s resiliency, and to varying degrees. The purpose of this analysis was to present the findings from the COVID-19 Supplement of the 2021 NCIFP and to provide a broad overview of the impacts of COVID-19 on national FP programs. Additional analyses exploring these and other factors would add to our understanding of FP program resilience and the characteristics that may lead to more or less reliance in the face of widespread disruptions. An in-depth analysis of these causes for individual countries is beyond the scope of this paper, however, we urge others to undertake further analysis. We have added to purpose: Results are meant to serve as a starting point for policy and program managers to delve deeper into the root causes of resiliency in their respective countries and for researchers to gain a more nuanced picture of resiliency of family planning programing during the COVID-19 pandemic. Financing is an important topic and warrants a separate paper that includes countries for which data on tracking of sources of funding is available. We agree with the comment that one of the three r2 should not be characterized as strong. We have modified the sentence: The relationships for government commitment and access were strong, implying that maintaining government commitment to family planning and access to contraceptives during COVID-19 were both bolstered by a robust overall enabling environment for family planning. We have written out long acting and permanent methods and short term methods, with use of the acronyms in figures and tables. We think the qualitative findings from regions add some depth to the findings and provide examples from various countries across the regions. We anticipate that readers will be interested in the insights from countries across the regions. We agree that further investigation and analysis would add insight into resilience, we believe this sentence in the limitations section covers the point: “Further in-depth studies to examine the challenges faced by the programs and how they were overcome, or not, would add to our understanding of the resilience of family planning programs.” Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 28 Sep 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 4 Version 2 (revision) 25 Mar 24 read read read Version 1 28 Sep 23 read read read Nadia Diamond-Smith , University of California San Francisco, San Francisco, USA Philip Anglewicz , Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health,, Baltimore,, USA Luis Bahamondes , Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences, Campinas,, SP, Brazil M. Valeria Bahamondes , Independent consultant, Austin, USA Kate Cheney , The University of Sydney, Sydney, Australia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Cheney K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 23 Jul 2024 | for Version 2 Kate Cheney , The Sydney School of Nursing and Midwifery, The University of Sydney, Sydney, Australia 0 Views copyright © 2024 Cheney K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for submitting your manuscript; How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries What an interesting question, from a planning perspective. Abstract: - “…fears of severe disruptions to family planning (FP) and …” – fear by whom? You might not have enough words to include a response but it raised the question for this reader. - Can the National Composite Index for Family Planning (NCIFP) DATA be briefly introduced as understanding who you are asking to respond is important to understand. Background Should you write out WHO in full first? What do you mean by 102’ states’ that responded, do you mean countries? You use both words “ Temporary service closures, product shortages, and fear of COVID-19 infections were reported to affect access and use. Using multiple rounds of Performance Monitoring and Action (PMA) data from Kenya, Burkina Faso, Lagos State Nigeria and Kinshasa, DRC, Wood et al. (2021) [Ref-1] reported some increases in women’s need for contraception" - why was the need increasing because of COVID? Do you mean there was an unmet need? Or maybe that more women were asking for contraception for some reason related to the situation. ‘Most studies that have asked…’ ….can you provide some references? Again, what is the National Composite Index for Family Planning – a brief earlier introduction might be useful but I see you move to explain it in methods. Methods Does the representation include Oceania? Just a comment , Asia has included some quite different countries grouped as one area. Discussion This paragraph is key “This paper finds that despite ‘interference’ in many components of family planning programming, with some exceptions, respondents said that the COVID-19 pandemic generally did not diminish government commitment to family planning.” Limitations “This paper has limitations in that the findings from the countries are based on self-reports from respondents on their perceptions of the effects of COVID-19 on the family planning program” SO , could it be that the NCIFP uses who they consider experts in FP programming to answer this survey so those ‘experts’ may have political biases about governments who were in power over this time? They may have had their own COVID response biases? - just a thought and not a criticism or additional comment needed. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Wood SN, Karp C, OlaOlorun F, Pierre AZ, et al.: Need for and use of contraception by women before and during COVID-19 in four sub-Saharan African geographies: results from population-based national or regional cohort surveys. Lancet Glob Health . 2021; 9 (6): e793-e801 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise I am an academic midwife and nurse working around the area of contraception, with an interest in postpartum contraception. I was awarded a PhD around pregnancy planning and contraception, and have published in peer review journals and am a current peer reviewer. My current project is in a project about postpartum contraception and training in PNG, Samoa, Kiribati and Fiji. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Cheney K. Peer Review Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16858.r36839) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v2#referee-response-36839 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Diamond-Smith N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 23 Jul 2024 | for Version 2 Nadia Diamond-Smith , Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA 0 Views copyright © 2024 Diamond-Smith N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors responded to some of the comments from my prior review. Competing Interests No competing interests were disclosed. Reviewer Expertise reproductive and maternal health, demography I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Diamond-Smith N. Peer Review Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16858.r36260) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v2#referee-response-36260 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Anglewicz P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 01 Apr 2024 | for Version 2 Philip Anglewicz , Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health,, Baltimore,, MD,, USA 0 Views copyright © 2024 Anglewicz P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors have adequately addressed my previous comments. Competing Interests No competing interests were disclosed. Reviewer Expertise Demography, family planning, survey methods. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Anglewicz P. Peer Review Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16858.r36259) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v2#referee-response-36259 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Bahamondes L et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22 May 2024 | for Version 1 Luis Bahamondes , Department of Obstetrics and Gynecology, University of Campinas Faculty of Medical Sciences, Campinas,, SP, Brazil M. Valeria Bahamondes , Independent consultant, Austin, tx, USA 0 Views copyright © 2024 Bahamondes L et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the opportunity to review the manuscript: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries. Background: “At the beginning of the COVID-19…” Please rephrased as: At the beginning of the SARS-CoV-2 (COVID-19)… Also at introduction for the first time. What means “M&E”? Please don´t use acronyms without explanation. There are no doubts that the COVID-19 pandemic affected in major or minor severity the FP services and access of women and men not only for services but also for contraceptive methods and it was affected different countries. One of the main limitations is that in LAC the authors did not evaluate large countries like Brazil, Mexico and Argentina with severe lockdown and negationist perspectives about COVID-19 from the governments of the two largest countries. I suggest visiting the paper (Charles et al, 2022) 1 About the sales of contraceptive methods in Brazil. In conclusion, the manuscript is well writing, and the study was well conducted. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes References 1. Charles CM, Munezero A, Bahamondes LG, Pacagnella RC: Comparison of contraceptive sales before and during the COVID-19 pandemic in Brazil. Eur J Contracept Reprod Health Care . 2022; 27 (2): 115-120 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Contraception We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Bahamondes L and Bahamondes MV. Peer Review Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16184.r35589) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v1#referee-response-35589 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Anglewicz P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 04 Mar 2024 | for Version 1 Philip Anglewicz , Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health,, Baltimore,, MD,, USA 0 Views copyright © 2024 Anglewicz P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This study addresses a worthwhile point, that not much is known about exactly what aspects of FP programs may have been disrupted by COVID, and how this varies across countries. This research uses data from key informants in 70 countries to estimate the impact of COVID, compare across and within regions, and provide more details on the impact. Some strengths of this research include the consistent categorization of COVID-19 impacts, which permits a comparison across countries; the ability to identify what feature of the program was impacted; and the accompanying open-ended responses that provide more details. So overall, this provides a high-level overview of COVID-19’s impact across settings, which has not been done to date. That said, a limitation of the approach is that it doesn’t measure the impact of COVID-19 directly, by asking women about their experience with accessing services, for example, but instead asks key informants who know the FP programs in their geography. The disadvantage of this is that the key informants could be wrong, or at least inaccurate (in some or all sections)- just as many experts were in predicting the impact of COVID-19 at the beginning of the pandemic. Was there any way to assess the validity of the responses? Similarly, the NCIFP might be vulnerable to response bias, in which areas that were more affected by COVID-19 were less likely to respond. Overall, this research provides valuable insight overall, but might benefit from a bit more information about the survey methods. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Demography, family planning, survey methods. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 31 May 2024 Karen Hardee, Hardee Associates, Arlington, 22207, USA You raise a valid point that a limitation of our study is that it does not directly measure how women were actually impacted by the pandemic. We have added a point in the methodology section on this, and have added text in the discussion about the need for further analysis, where data are available, linking NCIFP findings with data on use of family planning during the pandemic: “While the NCIFP does not measure how women were actually impacted by the pandemic with regards to contraceptive access and use, NCIFP country managers (selected because of their known familiarity of the FP environment in their own countries) were instructed to ensure inclusion of FP advocates, gender-oriented NGOs, women’s groups working on FP/RH—who are likely to get feedback from constituents about problems accessing FP during the pandemic. We have included qualitative comments from respondents about key barriers in each country. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Anglewicz P. Peer Review Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . Gates Open Res 2024, 7 :121 ( https://doi.org/10.21956/gatesopenres.16184.r35588) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://gatesopenresearch.org/articles/7-121/v1#referee-response-35588 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2023 Diamond-Smith N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 14 Nov 2023 | for Version 1 Nadia Diamond-Smith , Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA 0 Views copyright © 2023 Diamond-Smith N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for the opportunity to read this paper, entitled "How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries". This paper presents data from surveys of experts in 70 countries about how COVID had impacted various components of FP and also the overall gov commitment to FP. Overall the paper is clearly written and has an interesting finding that there actually wasn't as huge of a disruption as many had feared. This paper does not involve very complicated analysis, but I think that the findings will be interesting to program and policy makers if the authors are able to better delve into more about why they think that some countries had more resiliency than others, there is a little in there, but I think this really needs to be fleshed out. The differences are the interesting part and help us know what to do to improve things. Saying that stronger programs with more commitment did better doesn't really help us that much and we probably would have known without this study. More detailed comments below. Methods: A little more detail about how respondents are selected would be helpful, is it word of mouth/connections? Is it the same people who have answered across all years? The methods make it seem like you will be presenting longitudinal data, but I dont think that you actually do at all, so you might not want to focus on that as much. Results/Discussion: One thing that I kept struggling with is that these countries have different baseline levels of use of FP. I see you discuss this some in the discussion, but I think that you could discuss this even more and possibly do some analysis in the results of how baseline FP use is associated with resilience. Same could be said for donor $, I kept thinking about how countries that rely a lot on donor money probably would have different levels of resiliency, and again, you briefly mention this in the discussion, but is there a way to graph resiliency and donor $ % or something? Also relatedly, the distribution of where the funding comes from seems important to discuss and how differences between countries might explain your findings. I think you are only measuring gov commitment and resilience, but some of these countries must get more or less $ from gov vs donors? The r2 is pretty weak, the way it is presented/worded makes it sound stronger than it is. Hard to follow the acronyms ("with LAPM than with STM"), can you just write out? I'm not sure the write in findings are that insightful (or at least not all of them) - you could potentially shorten this section. I think more of the analysis suggested above could help us really situate these findings in the broader context and help us know how to prepare for the next disruption (what really works to help resiliency?) Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise reproductive and maternal health, demography I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 31 May 2024 Karen Hardee, Hardee Associates, Arlington, 22207, USA Thank you for your comments on the paper. We have incorporated responses as follows. We have added more detail about how the respondents were identified for the survey, including the criteria for inclusion, and ensuring a range of perspectives on each country program, namely that respondents have at least 5 years’ experience with the FP program, and ensuring at least two respondents from each of the listed groups. We have added a sentence to explain that the same respondents were identified for the 2021 round of the NCIFP, but their inclusion was not always possible given turnover in relevant positions. We have revised the methods section to clarify that we are not presenting longitudinal data. The COVID-19 questions were only asked in the 2021 round and the paper focuses only on that round. It is true that the countries have different baseline levels of contraceptive use. We have added to the limitations: Characteristics of the family planning program before the onset of COVID-19 may have impacted resilience of the program including the strength of the health system, presence of donor support and funding, and socio-cultural factors. Beyond different levels of contraceptive use, method mix could also have an impact on resilience as countries with higher levels of long-acting method use may have had less interruption, since women wouldn’t have to come to the facility regularly for resupply. Many factors may impact a country’s resiliency, and to varying degrees. The purpose of this analysis was to present the findings from the COVID-19 Supplement of the 2021 NCIFP and to provide a broad overview of the impacts of COVID-19 on national FP programs. Additional analyses exploring these and other factors would add to our understanding of FP program resilience and the characteristics that may lead to more or less reliance in the face of widespread disruptions. An in-depth analysis of these causes for individual countries is beyond the scope of this paper, however, we urge others to undertake further analysis. We have added to purpose: Results are meant to serve as a starting point for policy and program managers to delve deeper into the root causes of resiliency in their respective countries and for researchers to gain a more nuanced picture of resiliency of family planning programing during the COVID-19 pandemic. Financing is an important topic and warrants a separate paper that includes countries for which data on tracking of sources of funding is available. We agree with the comment that one of the three r2 should not be characterized as strong. We have modified the sentence: The relationships for government commitment and access were strong, implying that maintaining government commitment to family planning and access to contraceptives during COVID-19 were both bolstered by a robust overall enabling environment for family planning. We have written out long acting and permanent methods and short term methods, with use of the acronyms in figures and tables. We think the qualitative findings from regions add some depth to the findings and provide examples from various countries across the regions. We anticipate that readers will be interested in the insights from countries across the regions. We agree that further investigation and analysis would add insight into resilience, we believe this sentence in the limitations section covers the point: “Further in-depth studies to examine the challenges faced by the programs and how they were overcome, or not, would add to our understanding of the resilience of family planning programs.” View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Diamond-Smith N. Peer Review Report For: How resilient were family planning programs during the COVID-19 pandemic? Evidence from 70 countries [version 2; peer review: 4 approved] . 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