Updated: Sep 5, 2021
Often, we hear about women’s independence in society. According to us, it is more of inter-dependence. Both woman and man have an equal role to play, but it is the woman who embarks on the journey of giving life. Unless we ensure that a woman has access to universal healthcare, especially to prevent maternal deaths and take on the non-communicable diseases, we cannot claim that we have addressed all issues of women,” observed Dr Hema Divakar, CEO of ARTIST for Her and past president of FOGSI (1).
This mantra includes covering the broad umbrella of women’s healthcare – from the womb to tomb approach, as every health issue faced by a woman is complex (1).
Meeting women’s health needs and eliminating gender inequality are moral imperatives and fundamental human rights, and investment in women’s health should therefore not require justification (2). Although women live longer than men, they have specific unmet health needs and higher morbidity (3). Women not only provide most of the informal care in homes and communities, they also represent 70% of the global health workforce, making them central to overall population health (4).
How have women fared during the COVID-19 pandemic?
Sex-disaggregated data for COVID-19 show that there seem to be sex differences in mortality and vulnerability to the disease. Emerging evidence in the first stages of the pandemic, suggested that more men than women were dying, potentially due to sex-based immunological or gendered differences, such as patterns and prevalence of smoking (5). In Israel although mortality among men is still higher than women, women of many age groups have a higher incidence of infection than men
Source: Golbal health 50\50
Source: Global health 50\50
As with the experience from previous pandemics women are more vulnerable to infection as frontline health care workers or caregivers in the family and community (7).
Women’s burdens grow as they are often the focal point of community responses, take part in front-line service delivery or behavioural change initiatives, and women take on additional care burdens within the family. Women often embrace these roles, despite the harm to their
own health, including mental health, well-being and economic security (6). Women also face secondary health impacts in terms of increased maternal mortality and reduced access to sexual and reproductive health services
Women and the economic fragility of COVID-19
Compounded economic impacts are felt especially by women and girls who are generally earning less, saving less, and holding insecure jobs or living close to poverty (8).
Across the globe, women earn less, save less, hold less secure jobs, are more likely to be employed in the informal sector. They have less access to social protections and are the majority of single-parent households. Their capacity to absorb economic shocks is therefore less than that of men (8).
Unpaid care work has increased, with children out-of-school, heightened care needs of older persons and overwhelmed health services. All the domestic duties and responsibilities, things like childcare, preparing food for the extra youngsters who would normally be at school, and looking after sick family members, fall disproportionately on women” (9). As women take on greater care demands at home, their jobs will also be disproportionately affected by cuts and lay-offs (8).
Source: United Nations Policy Brief. The Impact of COVID-19 on Women 9 April 2020
The special role of women as front-line healthcare workers
Sustaining safe and quality care in the SARS-CoV-2 pandemic hinges on the health and mental wellbeing of frontline healthcare workers. Medical staff face exhaustion, difficult triage decisions, separation from families, stigma and the pain of losing patients and colleagues, in addition to their own risks of infection (10).
Special attention needs to be given to the health, psychosocial needs and work environment of frontline female health workers, including midwives, nurses, community health workers, as well as facility support staff. Personal Protective Equipment should be the appropriate size for women. It has been found that masks and covers that were sized using the ‘default man’ size often used in design and production leave women more exposed. It is important to include products such as essential hygiene and sanitation items (8).
Gender-based violence in COVID-19
As the COVID-19 pandemic deepens economic and social stress coupled with restricted movement and social isolation measures, gender-based violence is increasing exponentially (8).
Source: United Nations Policy Brief. The Impact of COVID-19 on Women 9 April 2020
Securing the mental wellbeing of healthcare workers
Caring for patients with COVID-19 disease causes considerable mental stress, resulting in high levels of anxiety and post-traumatic stress disorders, especially among nurses (11).
A recent systematic review and meta-analyses of 13 cross-sectional studies and a total of 33,062 participants provides early evidence that a high proportion of healthcare professionals experience significant levels of anxiety, depression and insomnia during COVID-19 pandemic. The prevalence rate of anxiety and depression appeared to be higher in females, and nursing staff exhibited higher prevalence estimates both for anxiety and depression compared to doctors. These results may be partially confounded by the fact that nurses are mostly female, but could be also attributed to the fact they may face a greater risk of exposure to COVID-19 patients as they spend more time on wards, provide direct care to patients and are responsible for the collection of sputum for virus detection. Due to their closer contact with patients, nurses may also be more exposed to witnessing patient suffering, death and ethical dilemmas (11).
The impact of COVID-19 on the pregnant mom and unborn child
Although the impact of this pandemic on maternal mental health has not yet been properly evaluated, the importance of considering the pregnant patient and unborn fetus at increased risk has been highlighted (12). The risk may be related to concerns regarding the wellbeing of the unborn child, but also exacerbated by measures, such as quarantine, physical distancing, home isolation, remote consultations with healthcare professionals, and inability to obtain expected level of support and care prenatally as well as during the intrapartum and postnatal periods (12).
Pregnant women may be at risk of having more severe disease, and maternal and neonatal mortalities have been reported (12).
Pregnant women who are infected with SARS appear to have higher morbidity and mortality compared to their non-pregnant counter-parts, though this is based on only a few small studies. Severe disease requiring hospitalization appears to develop, on average, 7 days after symptom onset1(13). Pregnant women also had longer hospital stays, were more likely to require admission to the intensive care unit, and were three times as likely to require mechanical ventilation (13). Given the novelty of COVID-19, data on the effect of COVID-19 on pregnancy, the foetus, and the newborn are so far limited to a few small case series. Nevertheless, while pregnant women do better than the population aged 80 years and above, they have twice the higher rate of PROM (premature rupture of membranes) and 3 times the higher rate of preterm births compared to the general pregnant population (14).
Many hospitals have put restrictions on visits by partners and relatives to pregnant women admitted to hospitals for delivery, therefore some women may choose to deliver at home. This could create a problem as availability of qualified birth attendants and midwives to support home deliveries is limited, even in affluent countries, and may lead to increased maternal and neonatal complication (11).
Breastfeeding could also decline. Although transmission of SARS-COV-2 through breast milk is unlikely, some infected women may choose not to breast-feed temporarily to avoid direct contact with the newborn and reduce the risk of neonatal infection. Such practices and early cessation of breastfeeding may contribute to poor health among mothers and infants (12).
Vaccination in pregnancy
Pregnant and lactating women were excluded from initial coronavirus disease 2019 vaccine trials; however, a large cohort study evaluated the immunogenicity and reactogenicity of coronavirus disease 2019 messenger RNA vaccination in pregnant and lactating women compared with: (a) nonpregnant controls and (b) natural coronavirus disease 2019 infection in pregnancy. Results showed that Coronavirus disease 2019 messenger RNA vaccines generated robust humoral immunity in pregnant and lactating women, with immunogenicity and reactogenicity similar to that observed in nonpregnant women. Vaccine-induced immune responses were statistically significantly greater than the response to natural infection. Immune transfer to neonates occurred via placenta and breastmilk (15).
Dispelling the myths of vaccination and infertility
A recent study published in Reproductive Biology and Endocrinology in 2021 showed that the mRNA SARS-CoV-2 vaccine did not affect patients’ performance or ovarian reserve in their immediate subsequent IVF cycle – indicating no impact on female or male fertility. To date, damage to the female reproductive system in COVID-19 patients has not been reported. This is the first study to demonstrate and publish that the vaccine has no effect on male or female fertility, but larger studies with longer follow-up will be needed to validate these findings (16).
The XX Chromosome and Women’s Responses To COVID-19 Infection and Their Response To COVID-19 Vaccines (17,18).
Among the many health disparities characterizing the COVID-19 pandemic, one that’s received particular attention is the difference in outcomes between men and women. As early as February last year, researchers observed that, although men and women were contracting COVID-19 at similar rates, men seemed far more likely to die from the disease.
Perhaps the most consistent result that researchers have found is that females tend to mount “stronger” immune responses to viral infections than males do (17,18).
COVID-19 is helping to shine a spotlight on an important truth in infectious disease biology: that viruses’ other pathogens don’t equally affect women (XX chromosomes) and men (XY chromosomes).
The stronger immune responses are a double-edge sword from a health perspective. On the one hand, females heightened immune activation could help limit the amount of virus in the body but on the other hand, that same biology likely also predisposes females to diseases stemming from overactive immune responses. 80% of all auto immune diseases occur in women and women are also significantly more likely to have multiple autoimmune diseases (17).
International Women’s Day 2021: Women’s health is nation's wealth – access to universal healthcare. Available from: https://newsable.asianetnews.com/health-life/international-womens-day-2021-womens-health-is-nations-wealth-access-to-universal-healthcare-dnm-qpnhdb Accessed August 9, 2021.
Remme M, Vassall A, Gernando G, Bloom DE. Investing in the health of girls and women: a best buy for sustainable development. BMJ 2020;369:m1175. doi: 10.1136/bmj.m1175: 10.1136/bmj.m1175
Crimmins EM, Shim H, Zhang YS, Kim JK. Differences between men and women in mortality and the health dimensions of the morbidity process. Clin Chem 2019; 65:135-45. 10.1373/clinchem.2018.288332
World Health Organization. Delivered by women, led by men: a gender and equity analysis of the global health and social workforce 2019. Available from: https://apps.who.int/iris/bitstream/handle/10665/311322/9789241515467-eng.pdf?ua=1. Accessed August 9,2021
Wenham C, Smith J, Morgan R, on behalf of the Gender and COVID-19 Working Group. COVID-19: the gendered impacts of the outbreak. Lancet 2020:846-847. https://doi.org/10.1016/S0140-6736(20)30526-2 Accessed August 9, 2021
Global Health 50/50. Available from: https://globalhealth5050.org/the-sex-gender-and-covid-19-project/the-data-tracker/?explore=country&country=South+Africa#search Accessed August 9, 2021.
UN WOMEN SPOTLIGHT ON GENDER, COVID-19 AND THE SDGS. WILL THE PANDEMIC DERAIL HARD-WON PROGRESS ON GENDER EQUALITY? Available from: https://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2020/spotlight-on-gender-covid-19-and-the-sdgs-en.pdf?la=en&vs=5013 Accessed August 9, 2021
United Nations Policy Brief. The Impact of COVID-19 on Women 9 April 2020. Available from: https://www.un.org/sexualviolenceinconflict/wp-content/uploads/2020/06/report/policy-brief-the-impact-of-covid-19-on-women/policy-brief-the-impact-of-covid-19-on-women-en-1.pdf Accessed August 9, 2021
Burki T. The indirect impact of COVID-19 on women. Lancet 2020; 20:904-905.
Chersich MF, Gray G, Fairlie L, Eichbaum Q, Mayhew S, Allwood B, et al. COVID-19 in Africa: care and protection for frontline healthcare workers. Globalization and Health (2020) 16:46 https://doi.org/10.1186/s12992-020-00574-3 Accessed August 9,2021
Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behavior and Immunity 2020; 88:901-907. Available from: https://www.sciencedirect.com/science/article/abs/pii/S088915912030845X?via%3Dihub Accessed August 9, 2021.
Thapa SB, Mainali A, Schwank SE, Acharya G. Maternal Mental Health in the Time of the COVID-19 Pandemic. Acta Obstetricia Et Gynecologica Scandinavica 2020 doi: 10.1111/AOGS.13894
Kucirka LM, Norton A, Sheffield JS. Severity of COVID-19 in pregnancy: A review of current evidence. Am J Reprod Immunol 2020;84: e13332. Available from: https://doi.org/10.1111/aji.13332 Accessed August 9, 2021
Akhtar H, Patel C, Abuelgasim E, Harky A. COVID-19 (SARS-CoV-2) Infection in Pregnancy: A Systematic Review. Gynecol Obstet Invest 2020; 85:295–306. DOI: 10.1159/000509290
Gray KJ, Bordt EA, Atyeo C, et al. Coronavirus disease 2019 vaccine response in pregnant and lactating women: a cohort study. Am J Obstet Gynecol 2021. Available from: https://www.ajog.org/article/S0002-9378(21)00187-3/fulltext Accessed August 9, 2021
Orvieto R, Noach-Hirsch M, Segev-Zahavi A, Haas J, Nahum R, Aizer A. Does mRNA SARS-CoV-2 vaccine influence patients' performance during IVF-ET cycle? Reproductive Biology and Endocrinology 2021; 19:69. Available from: https://doi.org/10.1186/s12958-021-00757-6 Accessed August 9, 2021
Offord C. Sex Differences in Immune Response to Viral Infection. The Scientist 2021. Available from: https://www.the-scientist.com/features/sex-differences-in-immune-responses-to-viral-infection-68466 Accessed August 9, 2021
Scully EP, Haverfield J, Ursin RL, Tannenbaum C, Klein SL. Considering how biological sex impacts immune responses and COVID-19 outcomes Nature 2020;20:442-447. Available from: https://www.nature.com/articles/s41577-020-0348-8 Accessed August 0.2021.