COVID-19 affects men and women differently both in terms of the outcome of infection and the effect of the disease upon society. The mortality due to COVID-19 is higher in men. Slightly more men than women contract COVID with a ratio of 10:9.

School closures, lockdowns and reduced access to healthcare following the COVID-19 pandemic may differentially affect the genders and possibly exaggerate existing gender disparities.

Sex differences in mortality More men than women die after being affected by COVID-19. In Italy, the greater risk for men starts in their 50s, with the gap between men and women closing only at 90. In China, the death rate was 2.8 percent for men and 1.7 percent for women. However, in a few countries like India, Nepal, Vietnam, and Slovenia the fatality cases are higher in women than men.

The higher mortality rate in men is consistent with other respiratory diseases, which show a similar disparity. Genetic, social, and behavioral factors may play a part. Sex-based immunological differences, lesser prevalence of smoking in women and men developing co-morbid conditions such as hypertension at a younger age than women could have contributed to the higher mortality in men. However, since both professional and home care affairs are traditionally linked to women, they may have had a higher infection rate than men in some places. For example, in Spain since the sanitary crisis began, healthcare workers have been more affected than anyone else. Almost 50,000 of them have been affected, of whom 66% are women.

As of April 2020, the US government was not tracking sex-related data of COVID-19 infections. However, researchers and expert organizations such as UN Women have argued that data on COVID-19 infection should be sex-disaggregated. This would allow to develop solutions to the pandemic from a gender-equitable perspective, since sex-differences in fatality rates have been identified. Also, it would allow experts to deliver high-quality data separately to men and women.

Data has changed throughout the course of the pandemic, as much within as between countries. However, what has remained constant is the prevalence of women affected by COVID-19 in contrast to men, although the fatalities have not been as high as theirs. This was especially so at the beginning of the pandemic. This might be due to the fact that both professional and home care affairs have been an area relegated to women in history. These are obviously closer to the virus than other areas of work. Regarding age and sex, in India, for instance, COVID-19 cases between men and women did not represent a uniform ratio among different age groups. Mortality rates were higher in women, especially in the 40-49 year age group. Research has shown that other viral illnesses like Ebola, HIV, influenza and SARS affect men and women differently. For example, according to a report by the WHO in 2007, more than half the SARS cases at the beginning of 2000 were women.

Impact on health Women in medical roles

Globally, women make up 70 percent of workers in the health and social sector. 90% of the healthcare workers in China's Hubei province (where the disease originated) were women and 78% of the healthcare workers in the USA are women. Women are playing a disproportionate role in responding to the disease, including as front line healthcare workers (as well as caregivers at home and community leaders and mobilisers). In some countries, COVID-19 infections among female health workers are twice that of their male counterparts. Women are still paid much less than their male counterparts in almost all countries and hold fewer leadership positions in the health sector. Masks and other protective equipment designed and sized for men leave women at greater risk of exposure.

As of 14 August 2020, the number of nurse deaths reported by COVID-19 was 1,097 in 44 countries. According to the Conselho Federal de Enfermagem (COFEN Brasil, the Brazilian Nursing Association), as of 11 August 2020, 351 deaths related to COVID-19 had been registered among nurses in Brazil, which is the highest number of deaths of nurses in the entire data set.

Women as students College students are a vulnerable group and this community is among those most affected by the impact of COVID-19, especially women. More than ten studies conducted in the United States identify women as being at the greatest risk for psychological distress during the COVID-19 pandemic.

They are generally prone to depression and anxiety disorders and appear to be more strongly affected by the long-term psychological impacts of the pandemic. One study attributed these gender differences to greater emotional expression, lower tolerance for uncertainty, and less effective coping strategies among female students. In addition, these studies highlight certain factors that make women more likely to experience these problems, such as being of Asian origin, being in fair to poor health, having a lower than average family or personal income, and knowing someone in their community who has been infected with COVID-19.

Access to healthcare Women and girls, who already faced health and safety implications in managing their sexual and reproductive health and menstrual hygiene without access to clean water and private toilets before the crisis, are particularly in danger. When healthcare systems are overburdened and resources are reallocated to respond to the pandemic, this can further disrupt health services unique to the well-being of women and girls. This includes pre- and post-natal healthcare, access to quality sexual and reproductive health services, and life-saving care and support for survivors of gender-based violence. Women are also refraining from visiting health facilities due to fears about COVID-19 exposure or due to movement restrictions.

The health impacts can be catastrophic, especially in rural, marginalized and low-literacy communities, where women are less likely to have access to quality, culturally-accessible health services, essential medicines or insurance coverage. Before the pandemic, around 810 women died every day from preventable causes related to pregnancy and childbirth—94 per cent of these deaths occurred in low and lower middle-income countries. Past pandemics have shown increased rates of maternal mortality and morbidity, adolescent pregnancies, and HIV and other sexually transmitted diseases. Multiple and intersecting inequalities, such as ethnicity, socioeconomic status, disability, age, race, geographic location and sexual orientation, among others, can further compound these impacts. It is essential to mention the age structure of the countries' populations. For example, the case fatality rate for COVID-19 is lower in India than in the US since India's younger population represents a larger percentage than in the US.

Reproductive health

During an outbreak, healthcare resources are diverted to combat the disease, which results in down-prioritizing reproductive health of women. The physiological changes in pregnancy puts women at an increased risk for some infections, although evidence is lacking particularly about COVID-19. Women had a higher risk of developing severe illness when affected with influenza virus (which belongs to the same family as COVID-19), so it is important to protect pregnant women from being infected with COVID-19. Women nurses were reported to have decreased access to tampons and sanitary pads while also working overtime without adequate personal protective equipment during the COVID-19 pandemic in mainland China. Moreover, the confinement measures themselves hinder access to health services, including sexual, reproductive and/or maternal health. Various researchers have speculated that coronavirus may harm male fertility, either from direct viral effects or from the immune response inflammation.

Pregnant women in the pandemic

Social perspective The specialized medical journal BMJ sheds light on the risk COVID-19 poses to pregnant women and their babies. The article indicates that pregnant women with COVID-19 suspected or confirmed to have been cared for in hospital are often less likely to experience fever or muscle aches, but if they get a serious illness, they are more likely to need intensive care than non-pregnant women with COVID-19.

According to the ISGlobal (Barcelona Institute for Global Health), pregnant women are one of the groups most vulnerable to COVID-19 due to their morbidity and mortality in epidemics. During pregnancy, physiological changes in the lungs and adaptation of immunity may increase the susceptibility and clinical severity of COVID-19 pneumonia, so pregnant women are at increased risk of severe COVID-19 problems.

The Spanish Society of Gynaecology and Obstetrics (SEGO) presented a document based on experience during several epidemics where the close association of these infections with severe respiratory problems and even risk of death during pregnancy is exposed. There is increasing evidence that the mother can transmit the virus to the fetus, especially during the last months of pregnancy.

Another factor that has had a major influence on care for pregnant women during the pandemic is access to reproductive health programmes. There has been a marked reduction in face-to-face antenatal visits, which have been replaced by telephone consultations. Yet, in low-income countries, even these have not been replaced, putting prenatal and child health at greater risk.

In terms of reproductive health, there are two types of situations depending on the economy of the society and the country: in low-income countries, unwanted pregnancies have increased due to less access to family planning services and an increase in gender-based violence. Not only that, but there is also a marked increase in maternal mortality associated with unsafe abortions and girls and women dropping out of school. The impact on maternal and child health in low-income countries is therefore of great concern, as their resilience during COVID-19 and beyond is very difficult.

In contrast to low-income countries, we observe that, in high-income countries, there has been a decline in birth rates due to a decline in assisted reproduction due to a deterioration in family finances and changes in reproductive priorities.

Assistance and recovery In research:

It is necessary to promote the inclusion of women in clinical trials of pharmaceutical products for the treatment and prevention of COVID-19, in addition to including disaggregated data (sex, age, pregnancy status in epidemiological studies...). It is worth mentioning that answering key questions and conducting qualitative studies to understand the effects of COVID-19 on emotional health and social impact during pregnancy would help to improve the management and prevention of infection.

In public health:

COVID-19 prevention guidelines should be established for pregnant women and their entourage, including that, following hygiene and safety protocol, they can attend antenatal visits and childbirth accompanied. In addition to adapting the frequency of face-to-face prenatal visits and complementing them with telematic monitoring. In order to identify pregnant women exposed to the virus in advance, it is advisable to record pregnancy status in contact tracing and prioritise them for COVID-19 diagnostic testing.

In communication

It would be supportive to publish COVID-19 news concerning pregnancy to improve reproductive health knowledge in the general population and thus provide an adequate risk perception with reality, including its corresponding dissemination for specific groups (pregnant women). Promoting an open dialogue, such as interviews, with people specialised in topics such as childbirth, obstetrics, paediatrics..., helps to provide families and/or pregnant women with quality information.

Medical perspective