Sandra Fyfe is a freelance writer for Contemporary OB/GYN.
Diverse Voices: COVID-19 and the Health of Women, a virtual speaker series run by the NIH Office of Research on Women’s Health (ORWH), presented compiled research on sex and gender disparities during the COVID-19 pandemic. In addition to identifying issues of concern, the webinar offered actions to improve women’s health despite sex and gender disadvantages.
Ana Langer, MD, director, and Jewel Gausman, MHS, ScD, research associate, both from the Women & Health Initiative at the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health in Boston, Massachusetts, presented the inaugural webinar for the Diverse Voices series, entitled “Sex and Gender Disparities in the COVID-19 Pandemic.”
Key Concepts in Sex and Gender
Gausman clarified the terms sex and gender: that sex is the biological, genetic differences between females and males. She said these differences begin at conception, are based on the combinations of X and Y chromosomes, and that all cells in the human body have a sex. There is a range of sex categories: male, female, and intersex bodies. These genetic and hormonal differences create variation in disease predisposition, disease manifestation, and treatment response, she said.
Gausman said gender is a social construction consisting of norms that place expectations on relationships, roles, and positional power for people across the life span. It is a fluid concept, and masculine and feminine traits can exist together, may be shown in different degrees, and are independent of biological sex. While gender norms vary among cultures, Gausman said, “everywhere women are in disadvantaged situations when compared to men.”
Like sex, there is a range of gender identities and sexual orientations. People who do not fit into traditional gender norms are vulnerable because policy is often targeted towards binary male/female gender norms, Gausman said. Gender is a culture-bound convention that impacts behavior that can influence health, including patterns in smoking, alcohol, lifestyle, stress, nutrition, exercise, decision making, disease perception, and use of healthcare. Gender affects COVID-19 infection and outcomes due to the perception of risk of the disease, treatment seeking, occupational exposure, and other factors, Gausman stressed.
Gausman noted how most health research and treatment testing is conducted on male subjects, which puts women at a disadvantage. She said providers may also discount correct diagnoses due to assumptions made based on sex and gender.
Gausman also emphasized the intersectionality between sex, gender, sexual orientation, race, and economic status in the healthcare setting. She noted that women make up 70% of the world’s poor, which exacerbates sex and gender disparities. She said that multiple factors determine vulnerabilities in disease mortality rates.
Specific Data on Sex, Gender, and COVID-19
Langer presented a wealth of data from a literature review compiled from various sources on the effects of sex and gender on COVID-19. She said there is a significant collection of data at this point in the pandemic.
Langer began with the disparities for COVID-19 outcomes that seem to favor women: for every 10 COVID cases in women, there are 10 cases in men. However, for every 10 women in the same circumstances, 12 men are hospitalized, 19 men are in the ICU, 13 men die, and 15 men with confirmed cases die. Explanations for this include sex and gender differences such as poorer health status among men, hormones, genetics, immune response, smoking, drinking, occupation, and health seeking behaviors.
Despite men having higher risk factors, disparities still threaten women’s health in the pandemic, Langer said.
In a follow-up interview with Contemporary OB/GYNÒ, Langer discussed her perspective about whether telehealth has played a role in addressing any of the disparities.
“Women who mostly benefit from telehealth are those with access to the technology and the knowledge and experience on to use it, i.e., more educated and better off women,” she said. “Telehealth is a great resource, but it has made socioeconomic and other disparities deeper.”
Maternal and Perinatal Health
Langer explained that while pregnant women are not at higher risk for COVID-19 infection, they are high risk for severe disease, preeclampsia, eclampsia, HELLP syndrome, ICU admission, infections that need antibiotics, and maternal mortality. It is not yet clear if COVID-19 shows up in pregnancy with a preeclampsia-like syndrome or just increases the risk for preeclampsia, she said. COVID also contributes to higher rates of stillbirth, prematurity, and low birth weight. Langer noted that while asymptomatic women did not show an increased risk of complications, women with shortness of breath and fever are at a higher risk of negative outcomes. In addition, pregnant women and new mothers have an increased risk of economic difficulties, anxiety, and depression, Langer said. At particular risk are women of color due to racial and ethnic disparities, especially rates of poverty and poor housing. Women of color are also more likely to suffer from chronic conditions and worse maternal health outcomes, she said.
Perinatal Care and COVID-19
Langer noted an 18-50% reduction in antenatal care visits because of the pandemic. This is due to fear of the virus, pressure from family to isolate, lack of understanding about service availability, and transportation issues. She also noted an unequal distribution of telehealth availability due to technology and economic barriers.
Delivery and Post-Partum Care and COVID-19
Langer said there has been an increase in the medicalization of childbirth, such as unnecessary inductions, the use of forceps, and caesarean section. Pregnant patients have been refused ambulances and turned away from hospitals due to pandemic strain. Another issue is shortened postpartum hospital stays due to occupancy limits in hospital rooms because of COVID-19. She also noted that providers lack training in the virus and Personal Protective Equipment (PPE), in addition to breakdowns in supply chains. She also explained how the pandemic is causing disrespectful care of pregnant people, mothers, and babies, with limitations on companions, separation of mother and baby after birth, and limits on breastfeeding. Langer said there is a false narrative that to protect healthcare workers, these restrictions are necessary when in fact they are not.
Vertical Transmission of COVID-19
While to date studies are inconclusive, Langer said that vaginal transmission of SARS-CoV-2 during childbirth is unlikely because the virus has not been detected in vaginal fluid in severe cases. Some evidence exists of transmission due to blood contamination for caesarean births. In addition, the virus has not been detected in breast milk, so women should still be encouraged to breastfeed. Langer noted that the benefits of breastfeeding outweigh the risks of transmission.
Perinatal Mental Health
Langer said COVID-19 is having a profound effect on perinatal mental health, including increased distress, depression, thoughts of self-harm, and anxiety. These issues are associated with women fearing exposure in healthcare settings and while giving birth, limited access to antenatal care, a lack of social support, and social distancing, isolation, and quarantine procedures.
SARS-CoV-2 Vaccination in Pregnancy and Breastfeeding Individuals
Langer said that while pregnant women were not included in SARS-CoV-2 vaccine trials, vaccines without live virus are safe and considered routine care in pregnancy. She noted that vaccine trials in pregnant animals did not cause complications, and that both CDC and the American College of Obstetrics and Gynecology (ACOG) recommend vaccination. Pregnant patients should consult with their providers based on their individual circumstances when deciding whether or not to vaccinate. While there is no data on the vaccine and breastfeeding individuals, Langer said that digestion most likely inactivates the vaccine. She noted that COVID-19 antibodies may be passed to the infant through breastmilk, and that breastfeeding individuals will be offered the vaccine.
Spending more time at home and reduced access to services has caused an increase in domestic violence risk for girls and women, Langer said, citing the United Nations Secretary General’s Office. This is reflected in the number of calls to domestic violence hotlines, Langer noted. She emphasized that this is a small view into the reality of the situation due to underreporting.
Domestic Effects and COVID
“At the domestic level, COVID magnifies the existing inequities between women and men,” Langer said. Women have seen an increased burden in domestic responsibilities during the pandemic. Regardless of employment status, women do the bulk of the cooking, cleaning, and school instruction assistance for children in homes shared by couples - up to three times more often, she noted.
COVID-19 Infection in Healthcare Workers and Women in Academic Medicine
Women are more at risk for contracting COVID-19 in the healthcare setting since they make up the majority of workers in the US and globally, Langer said. A CDC study as of April 2020 showed 70% of infections were female healthcare workers: 6,776 women were infected of 9,282 healthcare workers studied. Langer said a study from China showed that female healthcare workers reported high stress, anxiety, and depression. Women in academic medicine also are severely affected. Non-COVID manuscripts submitted for publication by women fell significantly, and only 1/3 of COVID publications were by women authors, she said. “This will result in fewer women in leadership positions,” Langer added, based on academic culture’s requirement for publication.
Women Policy Makers and COVID-19
While women make up a smaller percentage of policy makers, countries led by women had fewer deaths by a significant margin, including New Zealand, Germany, and Bangladesh, when compared with countries of similar population and development. “Women leaders consistently prioritize health,” Langer noted.
To ease health disparities for women during the pandemic, Langer listed a range of actionable items. She said evidence-based policies should be introduced and enforced, and that addressing structural racism would result in better health outcomes. Pandemic preparedness and response efforts should incorporate gender analysis so that women are better served, Langer said. In addition, women’s voices and knowledge need to be included for effective pandemic response efforts, she noted.
“Policies need to be established that support women, workers, and families with caring responsibilities,” Langer said. She added that gender disparities in bodies that make decisions need to also be addressed. Understanding the interconnectedness of sex, gender, and health should be promoted, and rigorous research to measure COVID-19’s impact on men and women and what factors contribute to these results should be conducted, Langer said. She also emphasized the need to look at the intersectionality of race, sex, and gender on COVID-19’s impact using data that is disaggregated. She stressed that scientific evidence on the pandemic needs to be translated into actionable practice, and supportive policies and programs for women in academia need to be strengthened.
Langer told Contemporary OB/GYN® that the most important thing for ob/gyn providers to understand about the pandemic was that COVID-positive pregnant patients are at risk of poor maternal and/or perinatal health outcomes. She said that third trimester symptomatic patients are particularly at risk. For COVID-positive pregnant patients, “providers should stay vigilant and advise them about danger signs and the need to contact their providers immediately if they have an issue,” Langer said. To protect maternal rights, including keeping mothers and babies together, ob/gyns should ensure access to PPE. Finally, Langer said that practical strategies providers can use to help their patients include informing them about the COVID-19 and its impact on women and pregnant people, base counseling and practice on evidence, reassure patients, and encourage good levels of psychosocial support.
Gausman J, Langer A. Sex and gender disparities in the COVID-19 pandemic. NIH Office of Research on Women’s Health (ORWH) webinar. January 27, 2021. Accessed January 27, 2021.