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Cited by 555Sex and Gender in HealthcareGender, Health, and Social InequalityCOVID-19 Clinical Research Studies

Health risks and outcomes that disproportionately affect women during the Covid-19 pandemic: A review

Open access
Connor, Jade, Madhavan, Sarina, Mokashi, Mugdha, Amanuel, Hanna, Johnson, Natasha R., Pace, Lydia E., Bartz, Deborah·2020·Social Science & Medicine
DOI 10.1016/j.socscimed.2020.113364PMC PMC7487147
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Abstract

Background The Covid-19 pandemic is straining healthcare systems in the US and globally, which has wide-reaching implications for health. Women experience unique health risks and outcomes influenced by their gender, and this narrative review aims to outline how these differences are exacerbated in the Covid-19 pandemic. Observations It has been well described that men suffer from greater morbidity and mortality once infected with SARS-CoV-2. This review analyzed the health, economic, and social systems that result in gender-based differences in the areas healthcare workforce, reproductive health, drug development, gender-based violence, and mental health during the Covid-19 pandemic. The increased risk of certain negative health outcomes and reduced healthcare access experienced by many women are typically exacerbated during pandemics. We assess data from previous disease outbreaks coupled with literature from the Covid-19 pandemic to examine the impact of gender on women’s SARS-CoV-2 exposure and disease risks and overall health status during the Covid-19 pandemic. Conclusions Gender differences in health risks and implications are likely to be expanded during the Covid-19 pandemic. Efforts to foster equity in health, social, and economic systems during and in the aftermath of Covid-19 may mitigate the inequitable risks posed by pandemics and other times of healthcare stress.

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Crossref · 10.1016/j.socscimed.2020.113364

Cites

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Claims the paper makes

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  • Premisecitation

    The US's poor obstetric and neonatal indicators are largely driven by worse maternal morbidity and mortality among Black and Native populations.

    “Outside of the current pandemic, the US's poor obstetric and neonatal healthcare indicators are largely driven by worse rates of maternal morbidity and mortality within Black and Native populations (Petersen et al., 2019).”
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  • Premisecitation

    65% of informal family caregivers in the US are women.

    “Beyond the paid workforce, 65% of informal family caregivers in the US are women (Feinberg et al., 2011).”
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  • Premisecitation

    Women are concentrated in healthcare roles that require the most close and prolonged contact with patients.

    “Women are concentrated in roles requiring the most close, prolonged contact with patients (Fig. 1) (US Census Bureau, 2020).”
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  • Interpretationcitation

    These changes likely worsen maternal and neonatal outcomes.

    “These changes likely negatively impact maternal and neonatal outcomes (Elmir et al., 2010; Goodman et al., 2004).”
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    There is no difference in death between pregnant and non-pregnant women with SARS-CoV-2.

    “This study found no difference in death among pregnant and non-pregnant women.”
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    • cites Ellington et al., 2020

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    Premisecitation

    Healthcare workers have a higher risk of contracting SARS-CoV-2 because of close contact with many patients and visitors and because of PPE shortages.

    “Reports from the CDC emphasize healthcare workers’ increased risk of contracting SARS-CoV-2 given the close interaction with high concentrations of patients and visitors amidst shortages of personal protective equipment (PPE) (CDC, 2020a).”
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    Pregnant people have had their autonomy limited during the pandemic through visitor restrictions during labor, forced separation of SARS-CoV-2-positive mothers and infants, and reduced anesthesia options due to limited respiratory support resources.

    “In an effort to mitigate SARS-CoV-2 infection, pregnant people have had their autonomy limited during this pandemic, including visitor restrictions during labor (CDC, 2020b), forced separation of SARS-CoV-2-positive mothers and infants (CDC, 2020b), and the potential for reduced options for anesthesia due to limited resources for respiratory support (Society for Obstetric Anesthesia and Perinat”
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    Premisecitation

    Some states are threatening to halt abortion services and inaccurately label these procedures as elective and delayable.

    “Despite this potential increase in unintended pregnancies and financial strain of the pandemic's economic fall-out, some states are threating to halt abortion services (Ollstein, 2020), inaccurately denoting these procedures as elective and able to be delayed (Smith et al., 2018; Watson, 2018; Bayefsky et al., 2020).”
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    Premisecitation

    Women in the US report more physical and mental unhealthy days per year than men on average, even though they use more preventive care.

    “Outside of the pandemic, women on average report more physical and mental unhealthy days per year than men despite utilizing more preventive care services (Centers for Disease Control and Prevention [CDC], 2013).”
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    Study design and conductcitation

    The Ellington et al. study was limited by missing data on pregnancy status for nearly 75% of participants and on medical comorbidities for close to 80% of cases.

    “However, this study was limited by missing data points among its participants including pregnancy status (missing for nearly 75% of participants) and medical comorbidities (missing in close to 80% of cases).”
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    Women, especially women of color and immigrants, are the majority of US domestic workers and caregivers paid outside formal channels, and many legal protections for formal caregivers exclude domestic caregivers, particularly undocumented ones.

    “Outside of the healthcare workforce, women, particularly women of color and immigrants, constitute the majority of US domestic workers and caregivers that are paid outside of formal channels (Diaz-Ordaz, 2010). Although these workers play critical roles in the care of children, the sick, and the elderly, many legal protections afforded to formal caregivers (including health insurance, overtime pay”
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    One-third of US women reported delays or cancellations in sexual and reproductive healthcare, with higher proportions among Black, Latinx, LGBTQIA, and low-income women, who also reported more concern about accessing contraception.

    “One-third of US women reported delays or cancellations in sexual and reproductive healthcare, with a higher proportion of reports from Black, Latinx, LGBTQIA, and low-income women. Women in these groups also report more concern about their ability to access sexual and reproductive healthcare services, particularly contraception (Lindberg et al., 2020).”
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    Premisecitation

    Pregnant women infected with SARS-CoV-2 have a greater risk of severe illness than non-pregnant women with SARS-CoV-2, including higher risks of hospitalization, ICU admission, and mechanical ventilation.

    “According to Ellington et al. (2020), pregnant women infected with SARS-CoV-2 are at greater risk for severe illness when compared to non-pregnant women with SARS-CoV-2, including increased risk of hospitalization (aRR = 5.4, 95% CI 5.1–5.6), intensive care unit admission (aRR = 1.5, 95% CI 1.2–1.8) and mechanical ventilation (aRR = 1.7, 95% CI 1.2–2.4).”
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    Premisecitation

    Gender is a social determinant of health that is distinct from but intertwined with sex differences.

    “Gender is a social determinant of health, unique from but entangled with sex differences (Springer et al., 2012; Rich-Edwards et al., 2018)”
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    Premisecitation

    Working women lose about $5000 annually in income because of caregiving wage penalties and reduced hours, while male informal caregivers do not experience an income difference for these responsibilities.

    “Due to their personal caregiving responsibilities, working women lose roughly $5000 annually in income from wage penalties and reduced hours (Van Houtven et al., 2013). Conversely, male informal caregivers do not experience any difference in income for these responsibilities (Van Houtven et al., 2013).”
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    Premisecitation

    Racial disparities in healthcare access and utilization, along with provider and institutional bias, contribute to poor obstetric outcomes and may worsen during pandemic-related health system stress.

    “Racial disparities in access to and utilization of healthcare services and provider and institutional bias contribute to these outcomes, all of which may worsen during the health system stress of pandemics (Moaddab et al., 2018; American College of Obstetrics and Gynecologists [ACOG], 2015; Rosenthal and Lobel, 2011).”
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    Women have worse outcomes for common conditions such as asthma, diabetes, and myocardial infarction.

    “Women also have worse outcomes for prevalent health conditions including asthma (CDC, 2013), diabetes (Roche and Wang, 2013), and myocardial infarctions (Mehta et al., 2016).”
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    Premisecitation

    PPE is often marketed as unisex but is manufactured to traditional male proportions, leading some women to wear ill-fitting PPE that may reduce protection.

    “although PPE is often marketed as “unisex,” findings show that they are manufactured according to traditional male proportions (Trades Union Congress, 2017). This has led to some women wearing ill-fitting PPE, potentially compromising their degree of protection (Pugh, 2020).”
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    Premisecitation

    Cesarean section rates have increased among SARS-CoV-2-positive patients, often before term, raising complication risks for both mother and neonate.

    “Additionally, there have been increased cesarean section rates among SARS-CoV-2 positive patients, which are often performed before term, increasing the risk of complications for both the mother and neonate (Della Gatta et al., 2020; Matar et al., 2020).”
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    Interpretationcitation

    Many women work part-time across multiple healthcare facilities without paid sick leave, which raises their risk of SARS-CoV-2 exposure and transmission.

    “With increased job loss due to the pandemic (Nicola et al., 2020), many women are forced to work part-time in multiple healthcare facilities without paid sick leave, thereby increasing their risk of SARS-CoV-2 exposure and transmission to others (Pichler et al., 2020).”
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    Interpretationreasoning

    Women are likely experiencing more caregiver burden during the pandemic while being isolated from the social supports that reduce it.

    “Consequently, it is likely that women are experiencing more caregiver burden during the pandemic while being isolated from the social supports needed to reduce this burden.”
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    Interpretationcitation

    Even though women wanted to delay or avoid pregnancy, they faced logistical and political barriers to contraception and abortion during the Covid-19 pandemic.

    “Despite the decreased desire to become pregnant, women have experienced logistical and political threats to contraception and abortion access during the Covid-19 pandemic.”
    Quote in the paperSubstantial claim

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    Premisecitation

    Outside disease outbreaks, female caregivers are more likely to experience caregiver burden, and perceived lack of agency, financial stress, and social isolation are associated with higher burden.

    “Outside of disease outbreaks, female caregivers are more likely to experience a specific stress termed “caregiver burden,” the multidimensional toll that caregivers experience to their social, emotional, spiritual, financial, and physical wellbeing (Adelman et al., 2014). Perceived lack of agency in choosing the role, financial stress, and social isolation are associated with higher caregiver”
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    Interpretationnone given

    Many women face increased risk of negative health outcomes and reduced healthcare access, and these problems are typically worsened during pandemics.

    “The increased risk of certain negative health outcomes and reduced healthcare access experienced by many women are typically exacerbated during pandemics.”
    Quote in the paperSubstantial claim

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    Interpretationcitation

    Differences in screening, testing, and hospitalization indications between pregnant and non-pregnant people may obscure the reported conclusions, and it is unclear whether the increased risks come from obstetric or SARS-CoV-2 complications.

    “More broadly, differences in screening, testing, and indications for hospitalization for SARS-CoV-2 among pregnant and non-pregnant people may cloud the reported conclusions, and it is unclear if the increased risks seen among pregnant people are from obstetric or SARS-CoV-2 related complications (Ellington et al., 2020).”
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    Premisecitation

    A multinational survey found that women without social support are more vulnerable to negative mental health outcomes than men without social connections, because women rely more on social support.

    “A multinational survey found that women without social support are more vulnerable to negative mental health outcomes than men without social connections, due to women's greater reliance on social support (Dalgard et al., 2006).”
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    Premisecitation

    Incidents of IPV and gender-based violence increased globally during the Ebola (2014) and Zika (2016) outbreaks and are escalating during Covid-19.

    “Incidents of IPV and gender-based violence (GBV) increased globally during the Ebola (2014) and Zika (2016) outbreaks (Davies and Bennett, 2016) and are escalating during Covid-19 (North, 2020).”
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    Premisecitation

    IPV is a social determinant of health and is associated with higher morbidity and mortality from co-occurring diseases.

    “Beyond its direct implications for physical and mental health, IPV is a social determinant of health and is associated with higher morbidity and mortality for co-occurring diseases (Miller and Mccaw, 2019).”
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    Interpretationcitation

    The Covid-19 pandemic creates a perfect storm for female informal caregivers to experience increased burden, which has demonstrated negative outcomes such as poor self-care, depression, and anxiety.

    “The Covid-19 pandemic also presents a perfect storm for female informal caregivers to experience increased burden, as mentioned above, which has demonstrated negative outcomes such as poor self-care, depression, and anxiety (Adelman et al., 2014).”
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    Interpretationcitation

    Shelter-in-place isolation combined with the pandemic's mental and economic strains is likely initiating and worsening IPV and GBV.

    “This, coupled with the mental and economic strains of the pandemic, is likely initiating and exacerbating IPV and GBV (Van Gelder et al., 2020).”
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    Interpretationreasoning

    These issues will both contribute to mental health disorders and limit access to mental health resources for women during and after the pandemic.

    “These issues will both contribute to the development of mental health disorders and limit access to mental health resources for women during and after the pandemic.”
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    Premisecitation

    Gendered differences in mental health disorders outside outbreaks exist largely because of structurally imposed strains on women, with disproportionate impacts on Black, Latinx, Native, and immigrant populations partly due to discrimination.

    “Previous work suggests that gendered differences in mental health disorders outside of the disease outbreaks exist largely due to structurally imposed strains on women (Afifi, 2007), with disproportionate impacts on Black, Latinx, Native, and immigrant populations, partially due to discrimination (American Psychiatric Association, 2007; Greenwood et al., 2017).”
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    Premisecitation

    Despite using more mental health resources, US women are twice as likely as men to have unmet mental health service needs, often because of inadequate insurance and stigma.

    “Despite greater utilization of mental health resources, women in the US are twice as likely to have unmet needs for mental health services as men, often because of inadequate insurance coverage and stigma associated with seeking care (US Department of Health and Human Services, 2010).”
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    Premisecitation

    Medication abortion via telemedicine is prohibited in eighteen US states, and mifepristone is subject to REMS restrictions that effectively bar retail pharmacy provision, forcing people to clinics or hospitals and increasing SARS-CoV-2 exposure and access barriers.

    “Despite the challenges in access to family planning in a pandemic, medication abortion facilitated by telemedicine is prohibited in eighteen US states (Guttmacher Institute, 2020). Even if pregnant people obtain prescriptions for medication abortions, mifepristone—one of the drugs used—is subject to Risk Evaluation and Mitigation Strategy (REMS) restrictions (Mifeprex REMS Study Group, 2017). The”
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    Interpretationreasoning

    Continued abortion restrictions will inevitably increase the number of pregnant people needing obstetric care during and after the pandemic, burdening an already under-resourced healthcare system.

    “Continued restrictions on abortion will inevitably increase the number of pregnant people needing obstetric care during and in the aftermath of this pandemic, burdening an already under-resourced healthcare system.”
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    Premisecitation

    Women are underrepresented in drug development trials; many researchers fail to design studies with adequate samples of women, and even fewer analyze results by gender and sex.

    “Women are underrepresented in drug development trials; many researchers fail to design studies with adequate samples of women, and even fewer analyze results according to gender and sex (Liu and Mager, 2016; Nowogrodzki, 2017).”
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    Interpretationreasoning

    Together, the increased IPV, strained survivor resources, shelter crowding, and reliance on closed institutions represent dangerous public health emergencies that disproportionately affect women.

    “Together, these circumstances represent dangerous, often tragic, public health emergencies that disproportionately affect women.”
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  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Although these mental health risk factors affect all populations during Covid-19, there is likely a differential impact on women.

    “While these risk factors can affect the mental health of all populations during the Covid-19 pandemic, there is likely a differential impact on women.”
    Quote in the paperNot a substantial claim

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    Interpretationcitation

    Gender roles tend to be reinforced during disease outbreaks, which likely increases stress, dissatisfaction, and lack of autonomy among women as they reconcile self-identity with imposed roles.

    “Gender roles tend to be reinforced during times of disease outbreak (Smith, 2019; Davies and Bennett, 2016). This likely increases feelings of stress, dissatisfaction, and lack of autonomy among women as they try to reconcile their self-identity with their imposed roles.”
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    • cites Davies and Bennett, 2016

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    Interpretationreasoning

    Covid-19 will affect women's health both immediately and over the long term.

    “The pandemic will have immediate and long-term effects on women's health, highlighting the importance of gender analysis in its planning and response.”
    Quote in the paperSubstantial claim

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    Premisecitation

    Gender blindness can produce health interventions that are at best less effective for women and at worst directly harmful to their wellbeing.

    “Gender blindness leads to health interventions that may be less effective for women at best and directly harmful to their wellbeing at worst—outcomes demonstrated in previous disease outbreaks (Smith, 2019; Davies and Bennett, 2016).”
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    • cites Davies and Bennett, 2016

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  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductnone given

    The existing literature focuses overwhelmingly on gender differences that harm women.

    “Additionally, the current body of knowledge overwhelmingly focuses on differences among genders that are detrimental to women.”
    Quote in the paperNot a substantial claim

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    Premisecitation

    In outbreaks, gender blindness-a systemic failure to recognize gender differences in health-is widespread and obstructs response efforts.

    “During disease outbreaks, “gender blindness”—the systemic failure to acknowledge gender differences in health—pervades and hinders response efforts (Smith, 2019).”
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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The review's coverage of potentially beneficial aspects of women's pandemic experiences is constrained by a negativity bias in the literature.

    “There may be aspects of women's experiences during the Covid-19 pandemic and other disease outbreaks that are beneficial to women's health, but our discussion of those topics is limited by the negativity bias of reporting in the literature.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Much of the literature cited in this review on gender and disease outbreaks comes from the SARS, Ebola, and Zika outbreaks.

    “Much of the literature cited here regarding gender and disease outbreaks come from the SARS, Ebola, and Zika outbreaks.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductnone given

    Gender is often framed through ethnocentrism, classism, and heteronormativity, which limits the review's description of the literature.

    “Furthermore, we recognize that gender is often framed through a lens of ethnocentrism, classism, and heteronormativity, which limits our description of the literature.”
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  • The paper relies on this without support.

    Health inequities are compounded in women who have intersecting identities such as non-white race, low socioeconomic status, immigrant status, lower education, older age, rural location, disability, and LGBTQIA identity.

    “These health inequities are compounded in women with intersecting identities such as non-white race, low socioeconomic status (SES), immigrant status, lower education, older age, rural geographic location, disability, and LGBTQIA identity.”

  • The paper relies on this without support.

    The societal effects of the Covid-19 pandemic disproportionately impact marginalized populations.

    “Much as the SARS-CoV-2 virus confers disproportionate morbidity to individuals on the periphery of health—the elderly and those with chronic medical conditions—the societal effects of the pandemic disproportionately impact marginalized populations.”
2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • For migrant women with young children, especially single mothers, the risk for mental health issues, including depression, is high due to accumulation of risk factors (e.g., caregiving roles, economic insecurity).

    “For migrant women with young children, especially single mothers, the risk for mental health issues, including depression, is high due to the accumulation of risk factors (e.g., caregiving roles, economic insecurity) (44, 46).”

    From Social Isolation, Loneliness and Health: A Descriptive Study of the Experiences of Migrant Mothers With Young Children (0–5 Years Old) at La Maison Bleue (2022) · cites this paper as [44]

    The paper’s “Psychological response to stress” section links caregiving burden and economic hardship to women’s mental-health risks, including depression, and identifies immigrant women as facing particular resource barriers. Its “Caregiver workforce” section also describes increased childcare demands. Neither section establishes the claimed risk specifically for migrant women with young children or says it is especially high for single mothers; page numbers were not available in our copy. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Our results and emerging literature highlight the vulnerability and potential severe and long-term effects that the pandemic may have for certain groups.

    “Our results, as well as the emerging literature on the COVID-19 pandemic' impacts on wellbeing and mental health, highlight the vulnerability and the potential severe and long-term effects that the pandemic may have for certain groups (21, 44, 45).”

    From Social Isolation, Loneliness and Health: A Descriptive Study of the Experiences of Migrant Mothers With Young Children (0–5 Years Old) at La Maison Bleue (2022) · cites this paper as [44]

Cites

Flagged first, then by citations

4 of the 75 references couldn’t be matched to a known paper.

Research works printed but not linked: 4

  1. Ollstein, 2020, Judges block 3 states from enforcing abortion bans pegged to pandemic, Politico
  2. Purdie, 2020, Sex, gender and COVID-19: disaggregated data and health disparities, BMJ Global Health Blog
  3. Rasmussen, 2019, Ebola vaccine for pregnant women: one step closer but more to go, STAT
  4. Townsend, 2020, Revealed: surge in domestic violence during Covid-19 crisis, Observer

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Related

Authors
Connor, J., Madhavan, S., Mokashi, M., Amanuel, H., Johnson, N. R., Pace, L. E., & Bartz, D.
Affiliations
  • Harvard University (US)
  • Brigham and Women's Hospital (US)
Corresponding author
Connor, Jade
ORCID
Venue
Social Science & Medicine
Publisher
Elsevier BV
Published
2020-12
Volume
266
Pages
113364
ISSN
0277-9536 (ISSN-L)
DOI
10.1016/j.socscimed.2020.113364
PMC
PMC7487147
OpenAlex
W3085791039
Semantic Scholar
5f91593e262883768d4fad93c4f7e87d1b18ba14
Cited by
555
References
75
Citations by year
2026: 24 · 2025: 44 · 2024: 92 · 2023: 115 · 2022: 152 · 2021: 120 · 2020: 8
FWCI
16.48
Type
journal article
Language
en
Open access
Licence
Locations
  • Social Science & Medicine (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • RePEc: Research Papers in Economics (submittedVersion)
Funders
National Institute of General Medical Sciences (T32GM007753)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Sex and Gender in Healthcare
  • Social Sciences › Sociology and Political Science › Gender, Health, and Social Inequality
  • Health Sciences › Medicine › Infectious Diseases › COVID-19 Clinical Research Studies
Keywords
COVID-19 pandemic, SARS-CoV-2, gender differences in health, women's health, healthcare workforce, reproductive health, drug development, gender-based violence, mental health, health care access, health equity, economic impact of pandemic
MeSH terms
Intimate Partner Violence, Drug Development, COVID-19, SARS-CoV-2, Female, Health Status, Humans, Maternal Health Services, Mental Health, Risk Factors, Stress, Psychological, Women's Health, Caregivers, Workplace, Pregnant People, Racial Groups, Pandemics

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-07.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-07.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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