Women's Mental Health and Lessons Learnt from the COVID-19 Pandemic

Abstract

Women are at the highest risk of pandemic adversities as they represent the majority of health and frontline workers in addition to their essential roles at home. We review gender differences during the COVID-19 pandemic by demonstrating risk-exposure during specific situations such as pregnancy, women's mental health fallouts, COVID-19 disease itself and exposure to different forms of violence. We discuss the particularities that women face in developing countries with depicted examples from some countries in Africa and the Middle East. Women mental health care service stands out as an essential component of the national response to pandemics. Women’s integration and leadership in the national pandemic response planning is crucial.

Key points

• •Most pregnant women have asymptomatic or midly symptomatic COVID-19 disease but about 10% of them may present with severe disease. Preterm delivery, low birth weight may be observed in COVID + women. All these uncertainties have increased the risk of anxiety and/or depression or even PTSD in pregnant women. Prescription of contraception and medical abortions should be maintained during pandemics.
• •Even if men were at higher risk of death and severe COVID-19 disease, the risk of long COVID is two times higher in women as compared to men.
• •Anxiety, depression, and PTSD are more prevalent in women (especially in health care professionals), however, longitudinal studies will be necessary to conclude if there was only a transient increase of psychological symptoms due to a particularly stressful situation or if this will last in the long term.
• •Females, young aged, and low- and middle-income countries have been the most affected by COVID 19-related mental health fallouts and economic crisis.

Introduction

The COVID-19 pandemic is an unprecedented health crisis that rapidly impacted every country around the globe in a matter of few weeks. Initially, the United Nations (UN) Director General drew attention to certain populations who will be the most impacted by the pandemic adversities namely, those living in poverty and in conflict zones, the elderly, children, and importantly frontline health workforce. The former UN Women Executive Director emphasized that women are at the highest risk as they represent the majority of health workers, in addition to being already burdened by their essential roles as parents and caregivers to other family members.¹ Developing countries were hit the hardest with the pandemic and its related fallouts, which extended to impact every sphere of lives. Importantly, the pandemic is not just a health crisis; it also brings drastic social and economic costs. The pandemic and its adverse impact continue to hit hard, and it is projected to drive up to 40 million people into extreme poverty across sub-Saharan Africa, with African women and girls being hit the hardest.² Our article will review the specific impact of COVID-19 pandemic on women and also the consequences of COVID-19 pandemic on women in different parts of the world capturing experiences from developed and developing countries.

The specific situation of pregnancy

The pandemic has been particularly distressing to pregnant women. Most pregnant women with SARS-CoV-2 infection are asymptomatic or mildly symptomatic. They often present with fever and cough and less often with myalgia and chill. Ma and colleagues³ have conducted a metaanalysis in 19,884 individuals with confirmed COVID-19. The pooled percentage of asymptomatic infections was 54.1% in pregnant women as compared to 40.5% in the general population. Yet, Vouga and colleagues⁴ reported 9.9% of severe COVID-19 disease in a cohort of 926 pregnant women positive for SARS-CoV-2. In these pregnant women, risk factors for severe COVID-19 were pulmonary comorbidities, hypertension, and diabetes. Symptomatic COVID-19 pregnant women were also more likely to experience hospitalization (RR 5.4), intensive care unit admission (RR 1.5), intubation and mechanical ventilation (RR 1.7), and even death.⁵ Maternal death due to all causes was 11.3% in pregnant women as compared with 6.4% in non-pregnant hospitalized women.⁶

The adverse outcomes most often reported in pregnant women with SARS-CoV-2 infection were preterm delivery and low birth weight.⁷ Other obstetric complications include stillbirth, miscarriage, preeclampsia-like syndrome, fetal growth restriction, coagulopathy, premature rupture of membranes and postpartum hemorrhage, all of which remained rare.^{7 , 8} The severity of maternal disease was associated with a higher risk of cesarean section, preterm delivery and requirement of neonatal intensive care unit.

Maternal–fetal transmission was considered low during SARS-CoV-2 maternal infection; rate of SARS-CoV2 positive test in neonates born to mothers with COVID-19 was 8% in⁶; 2.9% in⁴ and 6% in⁹ respectively and two neonates died. Respiratory symptoms were observed in these COVID-positive neonates. Vivanti and colleagues¹⁰ described a case of congenital COVID-19 infection associated with neurological symptoms following neonatal viremia and transplacental transmission. Magnetic resonance imaging showed bilateral lesions of the neonate brain white matter. The risk of bipolar disorders or schizophrenia during adolescence remains unknown after exposure to SARS-CoV2 during pregnancy.

The transmission of SARS-CoV-2 through breast milk remains unclear. The World Health Organization (WHO) considers that the benefit of breastfeeding is higher than the potential risk of maternal transmission whereas the Centers for Disease Control and Prevention recommends temporary separation of the newborn from a mother with confirmed or suspected COVID-19.⁷

All these uncertainties may have contributed to increased levels of stress which may in turn increase the risk of mental health problems in pregnant women and, of pregnancy terminations. Indeed, high levels of posttraumatic stress (43%), anxiety and depression (31%), were reported in 6894 pregnant women from 64 countries,¹¹ while 86% were somewhat or very worried about medical care and their future babies. A pooled prevalence of 25% to 30% for depression and 34% to 42% for anxiety was reported in pregnant women during the pandemic¹² (prevalence two times higher in pregnant vs nonpregnant women).^{13 , 14}; Berthelot and colleagues¹⁵ have compared 1258 women recruited online during the pandemic with 496 pre–COVID-19 pregnant women and reported higher levels of depressive and anxiety symptoms (OR:1.94). Previous psychiatric diagnosis or low income were risk factors for elevated distress and psychiatric symptoms during the COVID-19 pandemic.^{15 , 16} In contrast, several studies have reported a lower prevalence of anxiety, depression, insomnia, or PTSD in pregnant woman during the first lockdown compared to nonpregnant women or prepandemic rates.^{17 , 18}

It is also of upmost importance to note that the COVID-19 pandemic was associated with major disruptions in access to essential health services including family planning, mental health services, and perinatal health services.¹⁹ Furthermore, the notable limited access to women-specific critical services may have resulted in riskier home births and an increase in maternal mortality.²⁰ In addition, it is reported that institutional deliveries dropped below prepandemic levels in 6 out of 10 sub-Saharan African countries.²¹

Even before the COVID-19 pandemic, several countries had limited access to sexual and reproductive health services, and social stigma on sexuality was observed in certain communities. During the pandemic, the United Nations Population Fund estimated that 12 million women in 115 countries have lost access to birth control and 1.4 million unplanned pregnancies might have occurred during the pandemic. Moreover, abortion was considered as non-essential in many countries during the lockdown periods.²² These social factors have increased the risk of psychiatric symptoms in women.

Women at Increased Risk of Psychiatric Symptoms During the COVID-19 Pandemic?

COVID-19 disease was associated with a significant increase in the prevalence of both anxiety and depressive symptoms in the general population. Most studies have reported a gender effect in the increased prevalence of psychological distress, anxiety, and depressive symptoms or loneliness during the lockdowns but most studies were conducted in Europe, China, and North America, were cross-sectional and based on self reports²³(female gender was a risk factor)²⁴; (OR 1.48 for women and anxiety).25, 26, 27; Finally, in a review of 2020 Western European and North American studies, females were more affected than males for major depressive and anxiety disorders respectively (29.8% vs 24% and 27.9% vs 21.7%).²⁸ In contrast several studies did not report any gender effect.²⁹

In developing countries, mental ill-being has been, and continues to be a major fallout of the pandemic. This comes as a result of the direct pandemic-related adversities, which challenges human coping and adaptation, and heightens the sense of threat, uncertainty, and negative expectations. The World Health Organization (WHO) provided evidence that females, young aged and low- and middle-income countries (LMICs) were the most affected by COVID 19-related mental health fallouts.³⁰ A study of the mental health impact of COVID-19 in 7 Arab countries reveals that COVID-19 traumatic stress significantly contributes to increased mental distress. This effect correlates with population density and economic status.³¹ Ethiopia’s Amhara reported high levels of anxiety and depression with a three-fold increase compared to prepandemic levels.³² Similarly, there are heightened levels of depression and anxiety among women when comparing pre to postpandemic studies in Pakistan.^{32 , 33}

A significantly higher prevalence of posttraumatic stress disorder was observed in women (7%–53.8%).²³

Suicide rate in Japan increased by 16% especially in females and younger individuals after the first lockdown.³⁴ Dubé and colleagues³⁵ have reported increased rates for suicide ideation (10.8%), suicide attempts (4.7%), and self-harm (9.6%) during the COVID-19 pandemic as compared to prepandemic studies. Women and ethnic minorities were at higher risk of suicide ideation during the pandemic.

Women at Increased Risk of Addictive Disorders During the COVID-19 Pandemic?

Historically, women have used tobacco, alcohol, or illicit drugs less often than men. The gradual change of societal role of women over time and lessening of social taboos have led to a gradual increase in the frequency and amount of psychoactive substance use in women, particularly in Europe and North America.³⁶ Even if 50% of adults did not report any change in alcohol and/or tobacco consumption during the COVID-19 pandemic, women and past-year harmful alcohol users had a higher risk of change in alcohol and/or tobacco use.³⁷ In most studies, women reported more emotional distress38, 39, 40 and a higher risk of drinking prevalence was observed in women in some studies.^{38 , 39 , 41 , 42} In contrast several studies did not report any gender effect or even higher risk in men.^{40 , 43 , 44} Currie⁴⁵ reported a slight increase in illicit substance use (13.4%) while Malandain and colleagues⁴³ reported a decrease in 27.8% of cases without any gender effect.

Malandain and colleagues⁴³ reported an increase in internet use (gambling, cybersex (4%–24%), creation of new social networks) in 14.4% of cases without any gender effect as well as an increased risk of behavioral addictions. In contrast, Huang and colleagues⁴⁶ have reported a higher increase in internet use in women as compared to men. Grubbs and colleagues⁴⁷ reported a trend downwards for problematic pornography use in men without any change in women (already low users). Furthermore, women were 1.6 times more likely than men to lose control on diet and 2.3 times more likely to increase smartphone use. No gender effect was reported for videogaming.⁴⁸

Gender Inequalities

The pandemic has increased the inequality between men and women. The constraints, lockdowns, and other measures enforced in order to contain the spread of the disease have drastically impacted all aspects of human lives and livelihoods, education, domestic life, economic wellbeing, traditional gender roles and overall health, interlocking life spheres which are inevitably affecting mental wellbeing directly and indirectly as discussed in Fig. 1 .⁴⁹ Women were more likely to take care of children because of closed schools and adapt their job with reduced working hours and lower income. They have more often insecure jobs and jobs with lower social security coverage. They were also more affected by lockdown-related closures, reduced work and job losses in the hotels, restaurants, services, and retail. According to the U.S. Bureau of Labor Statistics,⁵⁰ women accounted for 55% of the 20.5 million jobs lost and at a faster rate than men in April 2020. Notably, the limited access to health services and increased partner violence were also contributing factors.^{51 , 52}

Fig. 1.

Impact of Interlocking life spheres on Mental Health.

It is noteworthy that 85% of women in Africa (58% of self-employed population in Africa) are employed informally with no employment security or benefits, which makes women the most vulnerable sector to be laid off by employers.⁵³ Lessons learnt from previous epidemics, such as the Ebola outbreak in West Africa in 2014 showed that women suffered more income losses as a result of such crisis. The direct effect of the crisis, in addition to the preventive measures (which included travel restrictions), severely impacted women’s livelihoods and economic security. In Yemen 1:5 people live in conflict zones and express high need for mental health and psychosocial support.^{54 , 55} On the other hand, in South Sudan, it was estimated that around 5 million people were affected by the ongoing prepandemic humanitarian emergency in the country representing one of the largest mental health gaps in the world, which got even worse with the COVID outbreak.⁵⁶ The UN urged for mental health care to be incorporated into all Governments’ COVID- 19 national response.

COVID-19 Disease and Gender Differences

Interestingly, a study based on health records from US hospitals reported that a recent diagnosis of mental disorder increased the risk for COVID-19 infection. The strongest effects were observed for depression (OR 7.6) and schizophrenia (OR 7.34), especially in women and African-Americans.⁵⁷

In Western Europe and North America, men represented a slight majority of coronavirus deaths (52%–58%). The largest proportion of deaths (male-to-female ratio) in confirmed cases was observed in Taiwan, Denmark, Thailand, Tunisia, and Albania (ratio>2).⁵⁸ For every 10 female intensive care admissions (ICU) there were 17 male ICU admissions and 15 male confirmed deaths. The highest death ratio observed in men could be partly explained by pre-existing cardio-vascular or metabolic diseases, a higher prevalence of alcohol abuse, or tobacco smoking. Women are also more likely to follow hand hygiene practices, which may decrease infection risk.⁵⁹ Finally, sex chromosomes, sex hormones may contribute to the differences in the immune responses observed between males and females.⁶⁰

Long COVID occurred in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset of COVID-19 (symptoms may appear following initial recovery from an acute infection or persist from the initial infection). Symptoms last for at least 2 months and cannot be explained by another diagnosis. The most common symptoms are fatigue, shortness of breath, and cognitive dysfunction. Being a female is a risk factor for long COVID. Approximately 10% to 20% of patients with COVID-19 experience persistent symptoms following an acute SARS-CoV-2 infection.⁶¹ Long COVID was more frequently observed in women (10.6%) as compared to men (5.4%).⁶² An estimated 15.1% continued to experience symptoms at 12 months. Huang and colleagues⁶³ reported that 3/4 of patients with SARS-CoV-2 positive had at least one symptom at 6 months of follow-up, the percentage was higher in women (fatigue, muscle weakness, and sleep difficulties, OR 1.33; anxiety and/or depression, OR 1.80).

Health Care Professionals

Worldwide, more than 70% of front-line health workers and essential service staff are women (including nurses, midwives, social workers, employees in pharmacies, cleaning, canteens, child or elderly care, grocery retail, laundry, and so forth). Women were, therefore, more exposed to SARS-CoV-2 infection, sustained distress, and higher workload levels as compared to the general population.^{64 , 65} In Italy and Spain, 66% and 72% of health workers SARS-CoV-2 positive were women vs. 34% and 28% men respectively.³² Many women required smaller-sized N95 masks than those made available to them, which was a matter of safety and put them at higher risk of SARS CoV-2 infection.⁶⁶ Shortages of personal protective equipment was also observed in many sectors and increased the infectious risk in women.

Health care professionals were at higher risk of psychological distress compared to the general population. Higher risk of insomnia, PTSD, depression, anxiety and burn out were observed during and after the pandemic peak^{64 , 67}; especially in female frontline workers (47.1% for insomnia, 33% for depression, and 16.3% for PTSD respectively).⁶⁸ Risk factors were lack of rest (for insomnia), death of friends or relatives (for depression) and personal COVID-19 status (for PTSD). In a survey conducted in Pakistan among healthcare workers, more than 35% and around 50% showed substantial symptoms of depression and anxiety respectively, notably young women.⁶⁹

The societal norms and structures stating that women assume caregiving roles are increased during pandemics.⁷⁰ This resulted in a high workload level in female health care professionals. Health care professionals had also encountered higher social isolation and discrimination.⁷¹ In addition there were insufficient specialized services to detect and manage anxiety, depression, suicidal ideation and to give advice to health workers without stigmatization. Yet, longitudinal studies will be necessary to conclude if there was only a transient increase of psychological symptoms due to a particularly stressful situation or if this will last in the long term.

Increased Violence Against Women

An increase of 25% to 30% in intimate partner violence was observed during the COVID-19 pandemic.^{72 , 73} Like many parts of the world, the Arab States and Sub Saharian Africa witnessed a staggering surge of domestic violence in different parts of both regions including Tunisia, South Africa, Jordan, Egypt, Kenya, Uganda, Nigeria and many more as compared to pre-pandemic figures. Kenya, Yemen, Morocco, Egypt, and Tunisia have reported an increase in domestic violence (Fig. 2 ).⁷⁴

Fig. 2.

The surge in domestic violence in different developing countries.

All male psychiatric diagnoses were associated with an increased risk of domestic violence against women (alcohol and mostly substance use disorders were associated with the highest risk).^{75 , 76}

Likewise, increased verbal and physical aggression was reported toward caregivers in China, Italy, France, and Singapore.⁷⁷ Violence during pandemics is even more complex including prevent women from accessing health or social services, inability for women to escape or call social services, increased risk of being put on the streets without shelters.⁷⁸

According to estimates by the UNFPA,²² the COVID-19 pandemic may result in two million cases of female genital mutilation.

Gendered adversities extended to become a witnessed gender-based violence with reported incidences of online violence faced by many women when they used smartphones, the Internet, social media platforms, and emails. This type of gendered violence took several forms as for instance: cyberbullying, sexual harassment, zoom bombing, social media harassment, threats, and so forth. The negative consequences of this escalating form of gendered violence are expected to impact women and girls negatively in several ways limiting their access to online services, use of helplines and other information systems, hindering their education and employment opportunities, and minimizing women’s participation as active digital citizens.⁷⁹ Sixty percent of women across nine Arab states reported experiencing online violence during the pandemic. Moreover, two-thirds of 100 East African women journalists reported that online harassment had increased during the pandemic.⁵³ Importantly, health services provided to survivors of gender-based violence continued to be disrupted, with health facilities repurposed into quarantine centers.

Impact on Education

Over a 100 million girls in developing countries struggle to access proper education. In the wake of COVID-19, the closure of thousands of schools was part of confinement measures taken to limit the spread of the coronavirus, there are deep concerns that this will exacerbate gender gaps in education and lead to increased risk of sexual exploitation, early and unintended pregnancy, child abuse, child labor, and forced early marriage in some societies. In Kenya, the dropout of girls has tripled (3.2% to 9.4%).²¹ This will result in a rollback on previous preemptive measures taken during the previous years to narrow the gender disparity in education.

Summary

It is quite obvious that women and girls are facing multiple challenges as a result of the pandemic, a situation which requires a multipronged response. In order to achieve this, women’s participation and leadership in pandemic response planning is critical. Unfortunately, data compiled by⁵³ monitoring women’s representation and leadership in COVID-19 taskforces, showed that women are significantly underrepresented or notably excluded from the assemblies assigned to this purpose, even at the national levels. The adversity of the COVID-19 pandemic is not a thing of the past, it continues to teach us lessons as we witness the red flags of long-haul COVID; with a long list of somatic, cognitive, and neuropsychiatric manifestations. The pandemic remains a public health emergency of international concern and it is yet too early to cease efforts on combating it as declared by the COVID-19 Emergency Committee of the WHO. Telehealth services, insurance coverage should be increased. Prescription of contraception and medical abortions should be maintained during pandemics. The development of novel vaccines and therapies must include pregnant and breastfeeding women. Emergency aid should be gender-based as proposed by the World Health Organization to take into account existing economic gender disparities.¹⁹ Countries national preparedness and response to this pandemic is now stemming from an enhanced understanding of the impact of a global crisis on mental health, and how this impact is gender-specific. We need to turn our lens to mental health. It is quite obvious that women mental health care service stands out as an essential component of the national preparedness and response to disease outbreaks. Mental wellbeing and effective coping with crisis now being recognized as an integral part of the immediate, short-term and long-term of national public health strategy, which yet need to be gender-responsive.

We learnt a lesson: Women Mental Health matters-this is what we learnt. Putting women first in mental health support should be part of the holistic approach aiming to curb the post-pandemic adversities. As front-liners and key mobilizers in the community, fostering women mental well-being is a way to empower them to pursue their roles and improve their lives.

Disclosure

The authors have nothing to disclose.