I read an article recently that I thought made a very profound point: “When you are thinking about a pandemic, you have to differentiate between what comes from being infected and what comes from being affected”. (Quote from Clare Wenham, Assistant Professor of Global Health Policy, London School of Economics and Political Science). As of this writing Dec 31, 2020, there have been 85.1 million cases and 1.84 million deaths worldwide. In the U.S., there are 20.6 million cases and 351,000 deaths. When you are reading this, the numbers will be greater. From March 2, 2020 to October 31, 2020, the U.S. had 84,235 new cases and in the last two months we had 231,045 new cases. In other words, it took 8 months to get to the first number and only 2 months for the last number. Things are indeed dramatically worse.
Out of the many things to learn and know, one thing that has emerged is that mortality rates appear to be higher for men than for women; however, it is women who are more likely to bear the brunt of the social and economic consequences, with lockdown measures and school closures affecting girls and women differently throughout the world, and some have long term quite negative consequences.
The UN Secretary-General António Guterres noted that “COVID-19 could reverse the limited progress that has been made on gender equality and women’s rights”.
Globally, there does not seem to be a sex or gender bias in diagnosis of COVID-19, although there may be some variations from country to country. But regarding the progression of the disease to severe cases and death, men seem to account for 57% of deaths from COVID-19 and 70% of admission to intensive care units, which is the case in the European regions. “As of December 2020, the coronavirus pandemic in the Netherlands resulted in over 527.5 thousand cases, 17.6 thousand hospital admissions, and 9.4 thousand deaths. To this day, most confirmed COVID-19 cases in the Netherlands were women. However, the distributions of hospital admissions and deaths due to the coronavirus were higher for men. Gender aside, COVID-19 figures in the Netherlands differed in terms of age. According to Dutch numbers, the coronavirus infected mostly younger age groups. However, hospital admissions were higher in older people, while the coronavirus was especially deadly for people aged over 80.” 1
According to a medical analysis based on 44,672 confirmed cases of the novel coronavirus COVID-19 in China published in February 2020, most patients were between 30 and 69 years old. Approximately 51.4 percent of the surveyed patients were males.
A study of some 44,600 people with COVID-19 from the Chinese Center for Disease Control showed the death rate among men was 2.8%, compared with 1.7% for women.
Overall, throughout the world from the data we have, men show higher death rates from confirmed cases.
What is going on? Honestly, it’s still unclear, but we do know that in general, men die earlier than women so we may be seeing that COVID-19 is worsening these underlying differences in mortality. It’s also possible that via a combination of biology and social determinants of health, women have a more robust immune response than men do. It has been noted that it is possible that the men who are dying from COVID-19 have higher rates of obesity, high blood pressure, diabetes, and lung disease. Also, men tend to go to the doctor less or later, than do women. This is more of a gender/social issue than an infection issue related to the SARS-2 corona virus.
To expand the perspective further, there is the issue of poverty and how the pandemic deepens inequalities in the social, political and economic systems in which people live. Globally, women earn less, save less, hold less secure jobs, and are more likely to be employed in jobs in which they are paid informally, or “under the table” so to speak. Women also have less governmental and cultural social protections in most societies. Women are also the majority of single-parent households creating an extra layer of economic fragility and then home security. Because of these economic disadvantages, women cannot as easily absorb economic shocks and tragedies as can men. A report by the Institute for Fiscal Studies found that mothers in the UK were 1.5 times more likely than fathers to have either quit their job or lost it during the lockdown.
It is estimated that 740 million women worldwide are employed in the informal economy. More than two thirds of female employment are a part of this informal economy in developing nations. According to the International Labour Organization, globally, women perform 76.2% of total hours of unpaid care work, more than three times as much as men. In Asia and the Pacific, it rises to 80%.
With lockdowns these jobs disappear quickly; think housecleaning and home childcare as two examples. A sudden job loss such as this means an immediate unstable household in terms of food, shelter, and clothing. Foreign domestic workers have faced travel restrictions which also puts them out of work.
As the health care system gets stretched, more sick people will be cared for at home, and this falls more to women as well, which then can also put them at increased risk of getting sick themselves. Women are also more anxious about getting sick. In a study done in March, from the Kaiser Family Foundation, more women than men worry that they or a family member will get sick from the coronavirus (68% s 56%); and more women than men worry about losing income due to closure or reduced hours of their workplace due to COVID-19 (50% vs 42%). And more women compared to men worry they would put themselves at risk of exposure to the virus because they can’t afford to miss work (39% vs 31%).
Again, a survey from the Kaiser Family Foundation, more women (16%) compared to men (11%) reported that they feel that anxiety or stress related to COVID-19 has had a major negative impact on their mental health. Nearly four in ten women (36%) and three in ten men (27%) feel that worry or stress related to coronavirus has had some impact on their mental health. This is on top of what we already know that more women than men are diagnosed with anxiety and depression.
Let’s look at one example, Liberia during the Ebola outbreak of 2013-2016, and how challenging recovering from the pandemic was for women. The majority of workers in local trading markets in Liberia are female. During the Ebola outbreak, they endured higher levels of unemployment than men and as a result, it took significantly longer for women to re-enter the labor market. And these women who survive these kinds of tough times, their risk of falling back into poverty is extremely high.
Let’s not forget another heart-wrenching issue associated with this current pandemic and the response to it. About 243 million women are thought to have experienced sexual or physical abuse by their intimate partner at some point over the last 12 months. Women are often trapped in the home with their abuser. In France, it was reported that within 1 week of their lockdown, reports of domestic violence had surged by 30%. Dozens of other countries reported the same kind of findings.
UNESCO estimated that the pandemic was preventing 1·52 billion children from attending school as of March, 2020. It is predicted that some of them will never return. In certain parts of the world, girls who are not in school face a higher risk of female genital mutilation and early marriage. Schools for girls provide feminine hygiene products, protection from abuse, and offer a better chance of prevention of teenage pregnancy and sexually transmitted infections. When not working at a job, women also face an increase in all of the unpaid domestic duties of looking after more children (who are not in school), increased food preparation, caring for sick family members and other tasks that fall more to women than to men.
Contraception and safe abortion is also under the influence of the pandemic. An international organization estimated that 9.5 million girls and women around the world will lose access to these services during the pandemic. Researchers from Aid Access, a web based provider of abortion care for U.S. women, analyzed data. When comparing before and after each state required social distancing, a 27% increase in overall requests for medications to self-manage abortion was observed.2 Typically, economic hardship does increase abortion rates, and COVID-19 is certainly in the league of economic hardship for many.
Shelter in place may raise risk for sexual violence. Two medications used in early abortion services, mifepristone and misoprostol have been recommended via telemedicine by WHO. The American College of Obstetricians and Gynecologists (ACOG) also supports mailing mifepristone after appropriate telemedicine medical consult.
Other health care impacts for impoverished nations/people are less access to health care in general and thus more malnutrition in children, less vaccinations, less prenatal care, and more. Even in the developed world, there is an increased concern about fewer children getting their vaccinations during the pandemic.
While there are people, men, women, and children worldwide who are facing a particularly fragile uncertain future, gender inequality is something that will require more attention and strategic plans so that the pandemic does not affect women even longer.
Other issues related to COVID-10 and women:
Risks during pregnancy
In the U.K. investigators assessed pregnancy outcomes. The overall risk of COVID-19 to pregnant women is low. However, pregnant women who have COVID-19 appear more likely to develop respiratory complications requiring intensive care than women who aren’t pregnant, according to the Centers for Disease Control and Prevention. In a study published in June 2020, cough and shortness of breath were equally common among all women, symptoms such as fever were less likely with pregnancy, and pregnant women were more likely to have comorbidities and be hospitalized.3 Pregnant women are also more likely to be placed on a ventilator. In addition, pregnant women who are Black or Hispanic appear to be disproportionately affected by infection with the COVID-19 virus.
It isn’t yet clear how frequently COVID-19 causes problems during pregnancy or affects the health of the baby after birth. There have been a small number of reported problems, such as premature birth, in babies born to mothers who tested positive for COVID-19 during pregnancy. But these problems might not be related to the mother’s infection. And again, black and Hispanic women may have worse COVID related pregnancy outcomes than white women.
Non COVID related co-morbid conditions are very relevant to pregnancy outcomes, as are COVID related. In one study in a large New York City cohort, a maternal BMI of >30 kg/m2 was associated with severe or critical COVID-19, which raised the risk for preterm birth.4
Two very recent studies I think there are important to pass on to others. In the first study, investigators performed a systematic review and meta-analysis of 77 studies including more than 8000 pregnant women with COVID-19. There were also many studies that also included non-pregnant women. In routine testing done on the pregnant women during hospital admission, 10% were positive for COVID-19. In COVID-19 positive women, the pregnant women were less likely than non-pregnant women to have fever and muscle pains. Pregnant women were more likely to be admitted to the intensive care unit and to require mechanical ventilation. Risk factors for more severe COVID-19 disease were the same for pregnant women and non-pregnant women, and include older age, diabetes, hypertension and obesity. The rates of preterm birth appeared to be higher in women with COVID-19.
We have known for some time that influenza has a worse outcome among pregnant women than nonpregnant women. This is likely due to the immunologic changes during pregnancy as well as alterations in respiratory physiology. Now we have learned that COVID-19 appears to have a more severe course in pregnant women and with the same preexisting conditions issues as in nonpregnant women.
Now the scientists and researchers will be moving on to the safety and efficacy of SARS-CoV-2 vaccines in pregnant women.5
The second study involved experiments done related to human breast milk and transmission of SARS-CoV-2. Human breast milk contains antibodies that offer much protection to infants however, some viruses can be transmitted through breast-feeding. An experiment was done to study 64 milk samples from 18 mothers infected with SARS-cCoV-2 both before and after a COVID-19 diagnosis. In conjunction, samples of human milk were also experimentally infected with SARS-CoV-2. Seventeen of the mothers had symptomatic COVID-19, and there were no milk samples that contained any replication-competent virus. In the experimentally infected milk samples, pasteurization of the samples, as is done in human milk banks, eliminated all viral RNA.
In this small study, reassurance is offered that COVID-19 should not disrupt breast feeding or alter the use of human milk banks. The importance of breast feeding is well known for infant health, but it also reduces the risk for breast and ovarian cancer, diabetes and cardiovascular disease. For now, we should support and encourage breast feeding even in those women who have COVID-19.6
And here’s another thing to consider. To better understand the effect of COVID-19 on the fetus, U.S. researchers examined the placentas in a case series of 16 with a SARS-CoV-2 infection during their pregnancy. Ten of them were diagnosed when presented for delivery. Six of the women were asymptomatic and 2 required supplemental oxygen. Two were symptomatic but did not require supplemental oxygen. Fourteen of the women delivered at term, one at 34 weeks and one had intrauterine fetal demise at 16 weeks gestation. This miscarriage occurred in an asymptomatic woman with retroplacental hematoma and villous edema. None of the infants born tested positive. Histopathology was done on the placentas and the results showed that placental pathology was more typical of women with hypertension and preeclampsia and the related maternal inflammation that comes with such illnesses rather than the effect of viral transfer.
The multiple thrombotic events that occur throughout the body in response to COVD-19 are likely to affect the placenta. Further determinations about the consequence of this hypercoagulability will need to be made as we learn more.7
PRENATAL CARE DURING COVID-19
In the early days of the pandemic in the U.S., there was great confusion about how to guide prenatal care providers and how to continue to provide obstetric care. Even in my community, there were great differences in how each Ob/Gyn office was conducting business. An obvious concern resulted during and after quarantines was and is that women did not seek and might still not be seeking necessary medical care in outpatient clinics, emergency departments, laboratories and imaging centers due to fears of COVID-19 infection. This study wanted to examine the actual association between OB office visits and the risk of contracting the infection in the OB population. The study included all women delivering at four hospitals in Boston between April 19 and June 27, 2020. All OB patients were tested for COVID-19 during pregnancy or on admission to labor and delivery. Patients were matched to control patients and the association between the number of in person visits and the odds of infection was assessed.
The study found no association between the number of in person prenatal care visits and the risk of COVID-19 infection.
The American College of Obstetricians and Gynecologists (ACOG) does now provide guidance to its members on how to conduct prenatal care during the pandemic. ACOG also emphasizes that decisions on care during the pandemic need to be made at the local level depending on the risk of coronavirus transmission in that area at that time. With the spacing of appointments, postponement of non-emergent appointments, social distancing, reducing prenatal care schedules and grouping components of care together (vaccinations, glucose screenings, etc.), and conducting more telehealth appointments they have now updated their guidance to say: “Emerging evidence suggests that with the appropriate precautions, in-person obstetric healthcare can be safely performed and is not likely to be an important risk factor for infection.” With appropriate precautions, in person medical care can and should be provided and many aspects of prenatal care should not be delayed and do in fact require an in person appointment. However, another approach to pre-natal care is emerging. Telehealth can have an important and satisfactory role in prenatal care. In addition, the number of prenatal visits may be able to be reduced from 12-14 visits to 8-9 visits. Number of telehealth vs in patient appointments and number of total prenatal visits can be individualized by patient need and clinical situation. Hopefully, the insurance reimbursement model will continue to support the increased role of telemedicine even after the pandemic…. and hopefully, the end of this pandemic will be in our near future.8
Perinatal Mental Health
Published data examining the effect of the pandemic on perinatal mental health are few and there are conflicting results, but also, most of the studies published prior to December 2020, occurred during the beginning of the pandemic and were outside of the U.S. with the study format generally being self-reported questionnaires rather than efficacy of interventions, the status of the symptoms throughout the pandemic period or the effect on obstetric outcomes. What the evidence does indicate is that the psychological distress caused by the pandemic leads to increased rates of depression and anxiety in perinatal patients. Whether or not one has a positive COVID 19 test has not appeared to increase the risk in at least one small study. Other life issues also matter here in that factors related to less severe anxiety/depression include more health related information, increased physical activity and improved economic, partnered (marital) and parenting support. One might add, that more education and support from obstetric providers matters in reducing the new mother’s stress and distress.
Health workers – a few facts
Women comprise the majority of health and social care workers, and are on the front lines of the fight against COVID-19.
More than half of the doctors and 90% of the nurses in Hubei, China are women, according to the Shanghai Women’s Federation, a government body.
More broadly, women make up the majority of workers in the health and social care sector – 70% in 104 countries analyzed by the World Health Organization (WHO).
- Aiken A, et al. Gynecol 2020 July 21.
- Ellington S, et al. MMWR Morb Mortal Wkly Rep 2020, June 26;69:769
- Khoury R, et al. Obstet Gynecol 2020, June 16
- Allotey J, et al. BMJ 2020 Sept 1; 370.
- Chambers C, et al. JAMA 2020 Aug 19, e-pub
- Shanes E, et al. Am J Clin Pathol 2020 July 154:23
- Reale S, et al. Association between number of in person health care visits and SARS-CoV-2 infection in obstetrical patients. JAMA 2020; Aug 14.
- Burki T. The indirect impact of COVID-19 on women. The LANCET; Infectious Diseases. 2020; 20(8): 904-905
- Wenham C, Smith J, Morgan R. COVID-10: the gendered impacts of the outbreak. The Lancet 2020; 395(10227): 846-848