The role of telehealth in sexual and reproductive health services in the response to COVID-19

This opinion article brings considerations about advantages and challenges with the use of telehealth in sexual and reproductive health services aiming family planning in the face of COVID-19 pandemic new scenario.


Introduction
Since March 2020, when the World Health Organization (WHO) declared COVID-19, disease caused by the new coronavirus (SARS -CoV2), as a pandemic, the global population needed to adapt to this new condition and started to adopt several changes in lifestyle. Overload in health services, as well as socioeconomic and behavioral readjustments turned out to be the new challenges that the contemporary society needed to face. 1,2 Among various preventive measures used to mitigate COVID-19 dissemination, including compulsory quarantine, lockdown and restriction to access to health services, the use of telehealth presents itself as an adequate care alternative, since it does not demand personal contact, which may decrease the pandemic impact. Although telehealth use had increased globally in the last years, the current pandemic moment came to make it a reality for several developing countries and many services had been able to confirm its effectiveness. [1][2][3] World regarded organizations such as Centers for Disease Control and Prevention (CDC) and American College of Obstetrics and Gynecology (ACOG) reinforced the expanded use of the telehealth system in this pandemic context. 4,5 Several studies have already demonstrating many advantages in the use of telehealth due to the possibility of its application by health professionals in risk groups, as well as extinguishing geographic barriers and reducing waiting time to access health services. 2,6,7 Telehealth also works as an important tool for information exchange and better inter-professional collaboration, generating alternatives of continuous learning and improvement of professional skills. 5 Among various benefits the use of telehealth brings, a review study found high rates of satisfaction of uses, decreasing of anxiety in patients with virtual meetings and a lower number of lost consultations. 8 Although patients accept this way of healthcare, managers of health services need to be alert for some obstacles that may occur during the implementation of this new technological tool. Among these obstacles, it is observed that even in an emergency scenario, people tend to use telehealth services in the way they did before the pandemic, and search for treatment with the same professional they already know, not accepting to be treated by a new professional, which may hinder telehealth. The lack of knowledge related to the use of this technology as well as the access to it are also factors that may limit the process of telehealth implementation. 2 Another important aspect that must be consi-dered during telehealth adoption regards the moment in which the telehealth services are being provided, as they can be executed in synchronous and asynchronous methods. The first one is on live streaming, with communication in two sides, in which healthcare providers and patients see and listen to each other. The asynchronous method is based in storage and forwarding of patient's information (system user) and posterior visualization and review by health service professionals (providers). [3][4][5] Due to the increasing use of telehealth systems, many studies have demonstrated the unwanted consequences of different telehealth projects. [9][10][11][12][13] These unwanted consequences (UCs) would be the results that are not expected by managers that planned the implementation. 9 Examples of some of these negative consequences or side effects have been documented, as the increase of stress and anxiety with the use of the new technology, demanded by the training of health professionals, changes in workflow, besides the dependence of the technology itself. [9][10][11][12][13] The telehealth initiative applied to sexual and reproductive health services, which are considered essential, occurred in a largely reasonable way and was encouraged by governments, health authorities and non-governmental organizations, once they couldn't be interrupt during this emergency moment in public health. 2,4,14 We understand that any service related to reproductive health that uses electronic communication technologyto provide contraception services or counselling constitutes a safe option positive costeffectiveness. 4,14,15 Concomitant to the incentive to the use of telehealth in reproductive planning services, some medical associations started to adopt new recommendation based on scientific evidences in response to threats that the pandemic brought to women's sexual and reproductive health and their family's wellbeing. The postponing of surgical sterilization, the expanded off-label use of long-acting reversible contraceptives (LARC), such as Intra Uterine Devices (IUD) and implants, are some guidelines that have been orientating in a largely prudent way some reproductive and sexual health services. 7,[16][17][18] We support the expansion of family planning postpartum services recommended by FIGO (International Federation of Gynecology and Obstetrics) through its Contraception and Family Planning Committee, emphasizing the supply of LARC methods. [16][17][18] Innovations in several contraceptive practices were implemented in different situations. The United Ferreira ALCG, Souza AI S321 Telehealth, reproductive health services and COVID-19

Kingdom Faculty of Sexual & Reproductive
Healthcare and the Society of Obstetricians and Gynecologists of Canada preconize the remote prescription of progesterone pills, isolated or combined to estrogen, during the pandemics, for up to one year, [15][16][17] besides recommending women who want injectable contraception to search for tutorial videos about DMPA auto injection (Depot Medroxyprogesterone). 19 In California, USA, drivethrough services for injectable contraceptives, as well as the supply of injectable contraceptives for self-administration directly in drugstores have been one of the offered services that deserve to be highlighted. 15 Countless visits for counselling and follow-up of the use of contraceptive methods have been globally executed by means of tele-support, where the health providers that work in region with scarce inputs such as many Brazilian cities, perform an approach aiming individual needs of each user, trying to use the available technological resources in an effective way.
Even in services in which the infrastructure of technology for telehealth is possible, there may be situations that requires personal assistance, and in these cases, the assurance of all procedures of sanitary safety should be observed. In this way, it is yet recommended the scheduling of consultations, organization of waiting rooms following all the social distancing procedures and the use of adequate equipment of personal protection. 15 In that perspective, we support the access to services of high quality reproductive planning which use telehealth and offer a broad variety of contraceptive methods, always respecting the autonomy, dignity and confidentiality principles of the user, which are independent of the pandemic context. 7,15 Users of telehealth services capable of planning their reproductive future, who can have the option of prevent a unwanted gestation in a safe manner, deciding about when and how many children they want to have, choosing the timespan between the gestations, as well as the moment to limit their families in a safe and healthy manner, are confident and socially included users.
During the process of implementation and adoption of telehealth services in the reproductive planning care, besides respecting the user's autonomy and dignity precepts, the health service need to plan issues related to funding, logistics and human resources. In addition, the engagement and satisfaction of the user, which are also important tools in the implementation process. A detailed understanding about legal and regulatory changes which rule the telehealth services, coexistence of predatory services and sustainability of these implemented services are challenges that still persist. 1,5,9 Finally, we highlight the relevance and necessity of further studies of research and assessment of telehealth services, considering circumstances and environments where the service is implemented, the complexity of its implementation process, and the manner the service is perceived by the community and its potential to engage users and providers in the process. 9,20 In this way, we believe that the development, implementation and usage of telehealth services should not be limited to a merely technical process, in which only effects and expected benefits of the technology are evaluated. We highlight the importance of further studies that assess continuously the incorporation and management of telehealth services in sexual and reproductive healthcare. Continuous evaluations that consider interdependence of human, technological, economic, ethical and socio-cultural factors that may influence the implementation and use of telehealth services are relevant and must be thought beyond the COVID-19 pandemic.

Author's contribution
Ferreira ALCG and Souza AI participated in the conception, literature review, writing and approval of the article.