Women are most affected by pandemics — lessons from past outbreaks

Women are affected more than men by the social and economic effects of infectious-disease outbreaks. They bear the brunt of care responsibilities as schools close and family members fall ill^1,2. They are at greater risk of domestic violence³ and are disproportionately disadvantaged by reduced access to sexual- and reproductive-health services. Because women are more likely than men to have fewer hours of employed work and be on insecure or zero-hour contracts, they are more affected by job losses in times of economic instability².

There has been a “horrifying global surge in domestic violence” since the start of the COVID-19 lockdowns, said United Nations secretary-general António Guterres in early April. Malaysia, for example, reported 57% more calls to domestic-abuse helplines between 18 March and 26 March. Moreover, sexual- and reproductive-health clinics are closing worldwide. Some US states have restricted access to abortions⁴.

It is all too familiar. During outbreaks of Ebola and Zika viruses in the past few years, women’s socio-economic security was upended², and for longer than men’s¹. During the West African Ebola outbreak of 2014–16, for example, quarantines closed markets for food and other items. This destroyed the livelihoods of traders in Sierra Leone and Liberia, 85% of whom were women⁵. Men lost jobs, too, but 63% had returned to work 13 months after the first case was detected. For women, the proportion was 17%².

At the same time, too little is known about the differential impacts of outbreaks on men and women. And that can leave political and policy responses flying blind. Only a minority of governments collect and share basic, disaggregated sex and gender data on cases of infectious disease and the socio-economic impacts of the response to outbreaks. Analysis remains high level, often conducted after the fact and with incomplete information (go.nature.com/2a9gtja). This time, gaps must be plugged.

Here, we call for COVID-19 research, response and recovery efforts that are tailored to support women (see ‘How to minimize the gendered impact of COVID-19’). The three priorities are to tackle domestic violence; ensure access to sexual- and reproductive-health services; and support women’s livelihoods.

We recognize that gender is neither binary nor fixed; that the pandemic differentially affects non-binary and transgender people (go.nature.com/2zym8jc); and that gender in global health intersects with other social stratifiers such as ethnicity and race, religion, location, disability and class⁶. Therefore, beyond what we set out here, efforts to reduce the differential effects of COVID-19 must explore these intersections of marginalization and vulnerability.

Domestic violence

Domestic abuse has increased around the world since social isolation and lockdown measures for COVID-19 began⁷, affecting women and girls more than men⁸. In March, the media reported that a woman was killed at the hands of a partner every 29 hours in Argentina — that’s around 4 more women than the monthly average (go.nature.com/3evkopw). The official statistics are yet to be reported, and are often unreliable because reports tend to omit the victim–perpetrator relationship and motive⁹. With isolation measures restricting the movement of women and their privacy, many will be struggling to access help. Cases of domestic abuse are likely to increase as COVID-19 continues and data are collected³.

Similar patterns emerged in previous health crises. During the 2014 Ebola outbreak in Guinea, sexual and gender-based violence rose by 4.5% compared with pre-outbreak levels, according to the country’s minister of social action, women and children. Last year, a study in Ebola-affected regions of the Democratic Republic of the Congo (DRC) showed that women and girls reported increases in sexual and domestic violence after the outbreak started in 2018 (go.nature.com/3duubsx).

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Countries’ efforts on the issue in the current pandemic vary widely. In some, it has not been addressed at all — in Kazakhstan, for example, where domestic violence is not a criminal offence¹⁰. And Hungary declared in May that it would not ratify the Istanbul Convention targeting violence against women, leaving women without protection from domestic abusers (go.nature.com/3ewmmpg).

By contrast, other nations braced for the onslaught. Italy increased the number of domestic-abuse helplines and set up clandestine notification protocols at pharmacies (go.nature.com/2vfxj5f). Australia boosted funding for anti-violence organizations, including those that offer safe accommodation. Kenya bolstered telephone counselling services for those facing domestic violence or the threat of it (go.nature.com/3dbvubn).

To identify where such interventions can prevent most harm, there is an urgent need to collect data using a variety of methods. This should be done during and after the outbreak, and should focus on what causes violence and where. Because domestic violence is widely under-reported, innovative methods are required.

Data gathering poses many challenges, particularly during a crisis such as COVID-19. Governments and researchers must work with survivor organizations to understand trends and impacts, changes in contexts and the socio-political dynamics. For example, how are levels of violence changing in response to lockdown or unemployment? To capture the stories of women affected by violence, whose experiences might not be apparent in official statistics, researchers will need to use qualitative methods such as interviews with community leaders, health-care providers and the women themselves¹¹. Examples of best practices should be identified and shared to inform future responses to outbreaks.

Sexual and reproductive health

Global health emergencies limit and disrupt sexual- and reproductive-health services; COVID-19 is no different. This dangerous curtailment of women’s rights and well-being slows progress towards achieving the UN Sustainable Development Goal on gender equality. Yet, as of 9 June, the World Health Organization’s COVID-19 Strategic Preparedness and Response Plan had provided no recommendation on how resources should be channelled to provide safe abortion and ensure the supply of contraceptives.

With governments left to chart their own paths, the consequences have been grim. Contraceptives are still out of stock in Indonesia, Mozambique and many other countries. Abortions in Italy were cancelled, and are still not happening in some hospitals. Coupled with the increase in sexual violence and domestic abuse that happens in outbreaks, these problems reduce the autonomy and self-determination of women and girls, and can damage their health and well-being.

After the Ebola outbreak in Sierra Leone in 2014, some studies estimated that teenage pregnancies were 23% higher than in the previous year¹². Restrictions on abortions do not necessarily limit demand¹³. Driven underground, these services become unsafe. During the 2016 Zika outbreak — a virus that affects fetal development, manifesting in babies with abnormally small heads, or microcephaly — no national policy changed to increase access to reproductive-health services¹⁴. As a consequence, women in the Zika epicentre — in Brazil, Colombia and El Salvador — told us, in work currently under peer review, that they sought unsafe abortions through providers they found online, feminist groups and the black market. Because abortion is illegal in most states where Zika was prevalent, there are no official statistics on it.

Government policies on abortion during the current pandemic differ widely, and will lead to different outcomes for women. For example, England changed its legislation in March to permit medical abortion at home through the use of pills (mifepristone and misoprostol) to terminate pregnancy after online consultation with a physician. Conversely, the states of Texas, Ohio, Iowa, Oklahoma and Alabama have further restricted access to abortion, deeming it a non-essential service⁴.

The family-planning organization Marie Stopes International estimates that there could be up to 2.7 million extra unsafe abortions performed as a consequence of COVID-19.

In the short term, policymakers should take three urgent steps. First, they should make contraceptives freely available at pharmacies. Second, they should permit medical abortions at home, in consultation online with a health professional. Third, policymakers should develop a minimum initial service package for sexual and reproductive health to be implemented at the start of every humanitarian crisis. It should ensure access to contraception, obstetric and newborn care, and safe abortion care.

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The package should be implemented at the start of every humanitarian crisis. The increases in sexual and domestic violence during the DRC Ebola outbreak reveals the difficulties of prioritizing sexual and reproductive health during emergencies, when health-care systems are already strained. The Inter-Agency Working Group on Reproductive Health in Crises in New York City details what governments and donor organizations should provide to women and girls to meet reproductive-health needs. For example, women are more likely to use services in locations that are less risk-prone, such as in community centres, rather than in hospitals, which are often seen as disease hotspots.

In the longer term, researchers should consider the effects of reduced access to sexual- and reproductive-health services during the pandemic. Comparing how women engage with services during a crisis and normal periods can help to analyse fertility rates or barriers to health care. For example, women changed their reproductive decisions because of the risks posed by Congenital Zika Syndrome, but this was not uniform across society. Fertility declined more in higher socio-economic groups than in low-income groups¹⁵. Such insights allow governments to target programmes to where they are most needed.

Livelihoods

COVID-19 is decimating livelihoods across the world. The Organisation for Economic Co-operation and Development, the African Union and the International Monetary Fund all predict potentially frightening consequences for national, regional and global economies.

By 27 March, 84 countries had adopted fiscal measures to mitigate the economic effect on households¹⁶. By 12 June, the number had risen to 195. Most governments increased either the coverage or payout amounts from existing social-protection schemes. Forty-seven countries have made cash-transfer programmes more flexible by waiving conditions such as the requirement for children to attend school and for women to attend ante- and postnatal appointments (such as in the Philippines). Some, such as Armenia, have provided home delivery of payments for elderly people. And 64 governments have amended unemployment benefits; 49 have adopted paid sick-leave interventions¹⁶.

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So far, only 16 countries have reported new or amended social-protection measures that make reference to women. Pakistan, for example, has increased cash transfers to women who are already receiving financial assistance from the state. Algeria has introduced paid leave for women who are pregnant, have chronic diseases or are taking care of children. Togo is providing women with US$21 per month, whereas men receive $17: President Faure Gnassingbé specified in April that this was because women are “more directly involved in nurturing the entire household”. Canada has increased its national childcare benefit, which is directed to mothers unless otherwise requested. These policies recognize the specific and increased burden that COVID-19 is having on women because of social expectations around caring responsibilities.

Yet, most countries’ interventions overlook the fact that the economic consequences are likely to be worse for women.

Measures do not sufficiently cover workers in the gig or informal economy, such as street vendors or those on zero-hour contracts. They are at particular risk, because they lack the social protections of those who are formally employed. In particular, in low- and middle-income countries, 92% of women and 87% of men work in the informal economy¹⁷. Although the difference between these proportions is small, women tend to work in positions that leave them more open to exploitation and abuse, such as in domestic work, home-based work or by contributing to family businesses¹⁷. High-income countries are not immune to these trends: data from the European Institute for Gender Equality suggest that 26.5% of women employees in the European Union work in precarious employment, compared with 15.1% of men (go.nature.com/3eaabbt).

Women have higher representation in the sectors that are now laying off employees, such as hospitality, travel, education and retail (see, for example, go.nature.com/2zalzme). Many women have had to stop any casual work to meet care duties during lockdown.

Much broader measures are urgently needed for these workers and their families. By 22 May, just 29 of the 190 countries or regions for which information was available had reported commitments to support informal workers financially, leaving millions at risk¹⁶. Spain has committed to a universal basic income that will protect all workers. By contrast, Hong Kong gives universal payments only to permanent residents. This will not cover the 5% of the city’s population who are migrant domestic workers — mainly women¹⁸. Australia’s JobKeeper programme pays wage subsidies to salaried employees during the pandemic, but not to casual workers — who are more often women (go.nature.com/2zalzme).

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In the short term, governments should focus on help for informal and casual workers. For example, removing requirements that a person must have had previous taxable income to benefit from COVID-19-related relief, and ensuring that unemployment benefits and statutory sick pay meet basic needs.

This is also a time for innovation. New Zealand, for example, is suggesting a four-day working week to mitigate rising unemployment, to support a better work–life balance and to boost local tourism. The idea comes from a well-being budget that it introduced last year (go.nature.com/2bjt1qa).

To inform the long road out of this global depression, we need to monitor the real-world impact of policies on the hardest hit in real time, so that strategies can be adjusted if necessary. Such research requires sex-disaggregated data on the workforce. The UK government, for example, suspended collection of data on the gender pay gap during the pandemic because it was deemed non-essential. Such information is more crucial now than ever.

Context is key

Broad-brush comparisons of vulnerabilities to COVID-19 responses are to be treated with caution. Gender and its impacts are context-specific, and vary between and within countries. The data collected in other health emergencies in Liberia, Yemen or Brazil can suggest trends. But data sets are often incomplete, and the nuances are highly dependent on race, religion, ethnicity, location, disability and class⁶. Addressing some of the issues that women face in outbreaks highlights a broader landscape of inequalities. Policymakers must consider and support all those at the margins.

Our critics might advocate for other priorities. We’re calling on governments to use evidence to ensure that all their citizens have an equal chance of safety, shelter and security. And when the pandemic ends, addressing gender inequality must be at the heart of the broader programme to ‘build back better’.