While all persons are affected by COVID-19, this practice brief report presents considerations relevant to the unprecedented challenges and experiences of women. When referring to women in this report, we are specifically referencing cis-gender women. We acknowledge that gender-based inequities also disproportionately impact transgender women, as well as gender nonconforming and nonbinary individuals, compared with cis-gender people. More dedicated conversations are crucial to document the experiences of transgender, gender nonconforming, and nonbinary people during the COVID-19 pandemic in health inequities. Emerging evidence suggests that women are unduly burdened by inequitable access to economic, health, and social resources during the COVID-19 pandemic.1 For many women, COVID-19 has presented new challenges and illuminates systemic inequities long encountered. Women are more likely to occupy roles as primary caretakers and are key stakeholders in responding to the health and health care needs of their families.2 Reductions in childcare services and school closures pose heightened disadvantage and multiple demands (ie, caregiving, homeschooling) for women, especially who work in lower-wage positions and frontline spaces. Industries that were entirely shut down as a result of COVID-19 are disproportionately staffed by women, including restaurant, hotel service, and other service jobs.3 Resources for reproductive and sexual health being diverted to the emergency response could adversely impact the overall health and well-being of women, including maternal mortality. Considering those inequities, the pandemic has prompted an organizational response to advocate for women's human rights and respectful delivery of health care to women.4–6
The Virtual Town Hall as an Intervention
To increase dialogue around COVID-19 and its impact on women, the University of Alabama at Birmingham (UAB) School of Public Health (SOPH) convened a moderated virtual town hall on April 25, 2020, with 2 sexual and reproductive health experts. The town hall was part of a 3-part series to increase public awareness of COVID-19's impact on vulnerable populations.7–9 Two faculty members from the SOPH moderated the town hall, with an introduction provided by the SOPH dean. Two medical experts, Dr Zoë Julian, with affiliations in the Division of Women's Reproductive Healthcare, Department of Obstetrics and Gynecology, and Dr Tamara Coyne Beasley, in the Division of Adolescent Medicine, Departments of Pediatrics and Internal Medicine, from the UAB School of Medicine were invited to participate in this second discussion.
The first portion of the town hall focused on COVID-19's impact on women's health, with emphasis on mental and physical well-being, access to health care, self-care, and navigating multiple roles. The second half focused on pregnancy, birthing plans and outcomes, and structural inequities associated with pregnancy during the pandemic.
To advertise the town hall, electronic flyers were circulated through various sources, including social media platforms across several UAB units, including the SOPH, School of Medicine, Institute for Human Rights, Center for Clinical and Translational Science, local television media, national listservs, and by word of mouth. The 60-minute livestreamed discussion was recorded and uploaded to the SOPH's YouTube channel for replay 24 hours following the live discussion. Livestreaming the town hall via Facebook allowed for real-time viewer participation and questions. Approximately 400 individuals viewed the live discussion, with another 3000 views on YouTube to date (Maria White, SOPH Communications & Events Specialist, Zoom meeting, May 19, 2020).
Inequities for Women Heightened by COVID-19: Accessing Supportive Services
Pandemics can make it more difficult for women to access and receive health services. This is compounded by intersecting inequalities such as the lack of affordable housing, employment that does not pay a living wage, and inadequate health coverage. A range of issues were discussed on the basis of a moderator's guide designed to address mental and physical health and well-being, access to health care, self-care, and navigating multiple roles.
At the time of writing, Dr Coyne-Beasley emphasized that half of the world's population was in some form of quarantine.10 COVID-19 presents a new complexity regarding violence against women and girls, with abusers exploiting the inability of women to seek help or leave threatening situations. She also highlighted that stay-at-home orders can exacerbate isolation for women living in unhealthy environments and disrupt social and protective networks/services. Social distancing and stay-at-home orders do not always equate to being safer at home. Restrictions on movement can shut off avenues of escape, help-seeking, and ways of coping for vulnerable groups. Frontline and health care workers may be particularly vulnerable in these controlling environments if quarantine is required in another area of the home due to their ongoing risk for COVID-19.11–14 It is important that all response plans to COVID-19 consider both the direct and indirect health impacts on women, especially marginalized women such as low-wage frontline workers, domestic caregivers, those working in travel, tourism, restaurants, and food production, women in unstable living situations, and those who may be experiencing abuse and mental health concerns.
These and other health issues were discussed and focused on the extent to which the pandemic elevates depression and stress in times of uncertainty. Navigating multiple roles while providing for one's family can impact women's mental and physical health and capacity to seek social supports. In addition, she described how the pandemic can affect basic health care utilization such as immunizations, prenatal care, and sexually transmitted infection screenings.
Pregnancy and Birthing in the Time of COVID-19
Following the first segment of the discussion, Dr Julian addressed COVID-19's impact on pregnancy and birth outcomes. She stressed that information and recommendations are dynamic and shared decision-making in a trusted patient-provider relationship is key during this pandemic. Historically, women have often been inadequately represented in clinical trials.15 Most of what was known at the time of the town hall was derived from Chinese and other global studies focused on treatment and management of COVID-19 in the third trimester and beyond.16 According to the Centers for Disease Control and Prevention, there are insufficient data to suggest that pregnancy increases the risk for infection with novel coronavirus or infection severity.17 In a small study of pregnant women in Wuhan, China, the clinical characteristics and severity of COVID-19 appeared similar between pregnant and nonpregnant women.16 Dr Julian also discussed the impact of coronavirus at different points in pregnancy, noting that there is limited information on the impact of the virus during the first or second trimester.
The pandemic has presented emerging challenges related to birthing plans and those who choose to deliver in hospital settings. Dr Julian stressed the importance of health care system leadership investment in creating protocols and policies that mitigate exposure to coronavirus and ensure equitable access to critical resources and supportive practices.18 She spoke about how celebrations of pregnancy have moved to virtual baby showers, online group prenatal care, phone and FaceTime conversations with doulas, and how those innovations support new ways of thinking about the full system of perinatal care.
Finally, Dr Julian introduced the reproductive justice framework that was developed by 12 Black women scholars and activists, which articulates 4 basic tenets19,20:
- The right to bodily autonomy;
- The right to have children;
- The right to not have children; and
- The right to parent and raise children and families in safe and sustainable communities.
Applying the reproductive justice and other justice-oriented frameworks, panelists recommended that strategies to ensure equity in the pandemic response include disaggregating data by race and maintaining and increasing access to comprehensive, sexual, reproductive, and perinatal care services as essential health care services. Policy initiatives such as rent and mortgage freezes, paid sick leave, hazard pay for essential workers, enhanced protection for pregnant workers, and safe and affordable childcare are essential to remaining safe during this crisis. Many inequities are compounded among women, especially among those with intersecting, marginalized identities (ie, women living in poverty, sexual minority women, racial/ethnic minority women, immigrant women). For example, reports and personal narratives indicate that essential workers who are not provided with appropriate personal protective equipment at their place of business and are living in multigenerational households may not be able to practice physical distancing from family in their homes.21 The framework's application to guide an equitable pandemic response by health systems leaders, public health leaders, and elected officials must be considered in policy decision-making processes during the pandemic to minimize infectious exposure and reinforce containment.
The COVID-19 pandemic has deepened the inequities and further illuminated the gaps in workplace and social supports for women, as well as highlighted the need for affordable, accessible health care, and long-term care supports. In the absence of a long-term sustained policy response, these issues will persist long after the pandemic has passed. It is critical that special attention be given to the structural, economic, medical, and psychosocial needs of women in response planning and implementation and that women's issues are reflected in national dialogue and decision making in response to COVID-19. The use of a virtual interactive platform as a practical approach allows for dissemination of information on a specialized topic and serves as a model in creating transparent spaces for the public to directly engage with medical and public health experts. The Table lists audience questions and comments.22,23 An interdisciplinary and community-centered approach to develop and disseminate relevant and contextual messages is critical as a response strategy to the pandemic.
Questions/Comments From the Facebook Live Feed
|Impact of COVID-19 on pregnancy and birth outcomes
||Is the immune system compromised during pregnancy?
In the babies with antibodies, when was the blood drawn? At birth or further in postpartum period?
If the mother has coronavirus, does the baby have the mother's antibodies at birth? Is the baby protected from the virus?
|Stress and hardship for Black women
||Workplaces are some of the most toxic places for women of color. Do we think this discontinues as people work from home?
What are measures that can be taken to ensure the safety of woman who are working at/in this climate?
|Women navigating roles as child and adult providers
||Children are concerned and even depressed about the possibility of losing their parents. PLEASE discuss this!!! How do mothers talk to their children about this anxiety of their children?
|Health system policies during COVID-19
||What are measures that health institutions (hospitals, Dr offices, outpatient clinics) take to provide comprehensive care to Black birthing folks/reproductive care to Black people, and what are some areas they're currently failing or falling short?
|Additional resources for menstruating women
||I would love to talk more about menstruation during this time, too. Like toilet paper, people are stocking up on menstrual items like pads and tampons. What other options/resources are out there for menstruating people whose local stores may not have what they need?
“We have a lot more to learn about the possibility of vertical transmission in utero and during labor and birth.”
“This is such a great, expansive conversation about what ‘safe sex’ means. Thank you for highlighting, Dr Beasley!”
“Please emphasize that contraceptive access must continue, including by mail. Resources are available on bedsider.org.”
“Great forum Dr Allen! In these trying times we are definitely seeing an impact in the area of mental health and dealing with these added stressors.”
“Sexual harassment through cyber violence is so important to talk about.”
“I've heard from women that it's even harder because they feel the toxicity has overflown into their safe place. That's difficult.”
“I've been focusing on morbidity and mortality of all. I know people are getting frustrated, but I've neglected to consider concerns of abuse. I know abuse occurs, but I haven't thought about how abuse can escalate due to staying at home.”
“I'm so glad I turned on notifications and didn't miss this.”
“This is amazing! It never occurred to me these situations would be a huge problem during this pandemic.”
“This is great sharing of information. Thank you, glad to call you all and my colleagues. Kudos from Urology at UAB!”
“Great job Dr Tamera Coyne-Beasley! We appreciate your expert insight, explanations and excellent advice!”
“Regarding the feeding of children during this pandemic, here at the Stonewall Baptist Church, Bossier City, La, we feed youth up to the age of 18, Mon-Fri, 11:00 am-1:00 pm.”
“Grateful for the discussions and the calling of attention regarding those who take advantage of people in crisis.”
“Thank you all for this great information focusing on women. More needed. Women are much more than child bearers. PLEASE address these women. Thank you again.”
“Most valuable information 100%. All women matter and the nation depends on women in all aspects of life. Being a modern woman working, children, head of Household and married head of household or disconnected marriage partners have so much stress!!! This crisis exacerbates and exaggerates their stress.
Implications for Policy & Practice
- The virtual town hall created opportunities for dialogue with the panelists and those viewing the livestream. Technology allows for viewers to submit questions in real time, and skilled moderators can integrate these questions or themes into the discussion.
- Recording the town halls to watch later has real-world implications. Viewers were provided with additional resources at the end of the recording on comprehensive directories of health care entities, requesting supplies and equipment, along with crisis line information for those who might be living in a threatening home environment.
- Virtual town halls can inform timely and relevant content for public health coursework and forums. For example, a faculty member in the UAB SOPH has committed to using the virtual discussions as course content in a 4-week mini-term course focused on pandemics.
- Virtual town halls can result in an extensive reach to many stakeholder groups by offering compelling content, influencing research, and developing innovative solutions for special populations during and beyond this pandemic.
- Virtual town halls offer opportunities to inform the direction of local news stories and knowledge-based reporting.
1. Wenham C, Smith J, Morgan R. COVID-19
: the gendered impacts of the outbreak. Lancet. 2020;395(10227):846–848.
2. The Henry J. Kaiser Family Foundation. Women, work, and family health: key findings from the 2017 Kaiser Women's Health
. Published March 13, 2018. Accessed May 30, 2020.
4. Black Mamas Matter Alliance. Black maternal health and the U.S. COVID-19
. Accessed May 30, 2020.
5. Black Women's Health
Imperative. Home page. https://bwhi.org
. Accessed May 30, 2020.
6. Black Ladies in Public Health. Home page. https://bliph.org
. Accessed May 6, 2020.
7. Fletcher FE, Allen S, Vickers SM, et al. COVID-19
's Impact on the African American Community: a stakeholder engagement approach to increase public awareness through virtual town halls. Health Equity. 2020;4(1):320–325.
School of Public Health. COVID-19
's impact on women. https://www.youtube.com/watch?v=yCJGJUXU_8E
. Accessed May 22, 2020.
School of Public Health. COVID-19
's impact on food and shelter insecurity. https://www.youtube.com/watch?v=2v1ca1xMgFE
. Accessed May 22, 2020.
10. Medical experts discuss how COVID-19
impacts women & the challenges they face. https://abc3340.com/news/local/medical-experts-discuss-how-covid-19-impacts-women-the-challenges-they-face
. April 25, 2020. Accessed May 22, 2020.
11. Mlambo-Ngcuka P. Violence Against Women And Girls: The Shadow Pandemic. New York, NY: UN Women. https://www.unwomen.org/en/news/stories/2020/4/statement-ed-phumzile-violence-against-women-during-pandemic
. Published April 6, 2020. Accessed May 30, 2020.
12. World Health Organization. COVID-19
and violence against women: what the health sector/system can do. https://www.who.int/reproductivehealth/publications/emergencies/COVID-19-VAW-full-text.pdf
. Published March 26, 2020. Accessed May 30, 2020.
13. Bradbury-Jones C, Isham L. The pandemic paradox: the consequences of COVID-19
on domestic violence. J Clin Nurs. 2020;29:2047–2049.
14. Kukinen C. When stay-at-home orders leave victims unsafe at home: exploring the risk and consequences of intimate partner violence during the COVID-19
pandemic. Am J Crim Justice. doi:10.1007/s12103-020-09533-5.
15. Drapkin Lyerly A, Faden RR. Mothers matter: ethics and research during pregnancy. Virtual Mentor. 2013;15(9):775–778.
16. Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19
. Published February 2020. Accessed May 22, 2020.
18. McLemore M. COVID-19
is no reason to abandon pregnant people. https://blogs.scientificamerican.com/observations/covid-19-is-no-reason-to-abandon-pregnant-people/
. Published March 26, 2020. Accessed April 3, 2020.
19. Ross L, Solinger R. Reproductive Justice: An Introduction. 1st ed. Oakland, CA: University of California Press; 2017.
20. Gilliam ML, Gordon R. A call to incorporate a reproductive justice agenda into reproductive health clinical practice and policy. Contraception. 2009;79(4):243–246.
21. Centers for Disease Control and Prevention. COVID-19
in racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
. Accessed May 9, 2020.
22. How COVID-19
pandemic impacts women on the front lines. https://www.cbs42.com/news/how-covid-19-pandemic-impacts-women-on-the-front-lines
. Published April 23, 2020. Accessed May 30, 2020.
raising awareness about COVID-19
's impact on women. https://www.wsfa.com/video/2020/04/24/uab-raising-awareness-about-covid-impact-women
. Published April 24, 2020. Accessed May 30, 2020.