For National Women’s Health Week, a Look Ahead at the Coming Pandemic-Induced Challenges

The combined physical, economic, and mental toll of COVID-19 on women in the United States has resulted in acute short-term health consequences and likely long-term ramifications. As the nation recognizes National Women’s Health Week, new issues wrought by the pandemic and existing ones amplified by the crisis come into sharp focus.

Not only have a quarter of women reported they are financially worse off 1 year into the crisis—due in part to being shut out of the work force—but rising rates of violence against women exacerbate an already challenging time.

Women are already twice as likely as men to develop depression and anxiety, while postpartum depression remains the number one complication of childbirth—roughly 20% of women experience depression after they deliver.

Throughout the crisis, increased substance use and overdose deaths have been documented, while research indicates psychological stress related to COVID-19 was associated with greater alcohol intake for women, but not for men. Alcohol use alone can negatively affect mental health, contributes to intimate partner violence, and is linked to an increased risk of breast cancer in women.

The emotional pain we experience drives us towards increased use of drugs and alcohol, explained Nazanin Silver, MD, MPH, FACOG, a gynecologic psychiatrist and co-director of UPMC Pinnacle Women’s Behavioral Health Specialists, in an interview with The American Journal of Managed Care® (AJMC®). “And we want to mitigate and decrease that emotional pain,” she said.

For those who previously abused drugs and alcohol and were in recovery, the pandemic was a stressor for them and potential trigger of relapse, Silver said. “For those who actually didn't have problems in the past utilizing these things and now have a problem, they have used it as a method to cope. It's not a healthy coping mechanism, but unfortunately, when your entire life just plummets downward people resort to very creative ways of mitigating their emotional pain,” she said.

Rising food and rent costs, in addition to the burden of concurrent childcare, online school monitoring, and remote work, have stretched many American women to the breaking point. Fathers are also involved in these household management activities, but oftentimes women are the ones handling them more, while single-parent families are more often headed by women than by men, said Ivy M. Alexander, PhD, APRN, ANP-BC, FAANP, FAAN, a co-chair of the Expert Panel on Women’s Health at the American Academy of Nursing. Alexander is also a clinical professor and director of the Adult-Gerontology Primary Care Nurse Practitioner Track at the University of Connecticut.

At the pandemic’s outset, women and workers of color were more likely to lose their jobs as these populations account for large segments of service-sector jobs in restaurants, hotels, spas, salons, and non-urgent health care.

“We just came to this amazing grinding halt,” Alexander said. “We have now a significant portion of our workforce that is a little bit stranded because of the pandemic and the circumstances that have come out of that.”

As restaurants and service positions slowly start to open back up, owners are not going to be able to hire back the workforce that was there before the pandemic, Alexander explained, noting employers will tend to be more cautious about spending money in the absence of demand for dining and shopping services.

One survey conducted by The Washington Post and ABC News revealed 29% of women younger than 65 reported their financial situation is worse today than a year ago compared with 10% of those 65 and older. Women also reported quitting their jobs to take care of their children throughout the crisis.

But more time at home could also mean more exposure to domestic abuse. For Indigenous women in particular, cases of domestic violence and instances of sexual assault have increased over the past year.

Victim advocates who testified at a recent summit focusing on ending violence against Indigenous women and children highlighted the role lockdowns and stay-at-home orders played in their plight. Not only were victims confined to their homes with abusers, but advocates faced challenges connecting with victims and sharing resources.

“Child abuse, domestic violence rates have all gone up,” said Silver, noting the difficult situation the pandemic has inflicted on women. “It's either you get COVID-19 with a very real possibility of dying, versus you endure the mental strains of being at home.”

She continued, “You're living with a partner who is abusive, add economic crisis to that, you lose your job, you have to go on food stamps, it's like a volcano erupting. This in itself, because it is a traumatic stressor, can cause depression, can cause anxiety, and in some cases can cause post-traumatic stress disorder (PTSD).”

More stress can lead to increased substance use, and those already diagnosed with substance use disorder (SUD) are more likely to get COVID-19 and experience more severe outcomes, including hospitalization and mortality.

New claims data from Blue Cross Blue Shield (BCBS) of Massachusetts reflect the massive increase in demand for telehealth mental health services. “Women have been hit harder by the pandemic in some key ways,” said Ken Duckworth, MD, senior medical director for behavioral health and BCBS of Massachusetts. But they are also, in general, more willing to get help.

The data, collected between March and December of 2020 and compared with the same time frame in 2019, showed that in 2020 females accounted for 65% of telehealth utilization within the system, compared with 35% for males. Top mental health diagnoses made via telehealth included anxiety (60%) and depression (20%). In addition, the system’s spending on SUD treatment increased by 10% in 2020.

“We had never seen anxiety numbers that high,” said Duckworth, “but it’s not surprising [given] the amount of uncertainty people have faced.”

Rates of depression and anxiety in women have risen across the board, Silver said, "whether it's women who are pregnant, postpartum, perimenopausal," or in their 20s and 30s.

Looking Long Term

Economic worries, personal stress, and mental struggles can all lead to increased use of sometimes harmful coping mechanisms. And these mechanisms could result in consequences years down the road.

For example, women who drink 3 alcoholic beverages per week have a 15% higher risk of developing breast cancer compared with women who don’t drink, while that risk increases by 10% for each additional drink women regularly have each day. Should current trends of greater alcohol intake among women continue, increased rates of cancer could contribute to more stress placed on already strained hospitals and health systems.

Although it’s impossible to know if these projections will play out, “I do know that a lot of cancer patients have stopped their care during the pandemic,” said Silver. “All of those potential cancer cases have not gotten care. So those will be added long term.”

Compounding the issue, projections from February 2021 estimate employment rates for women may not recover to pre-pandemic levels until 2024, or 2 years after a recovery for men. According to McKinsey & Company, women accounted for 56% of workforce exits since the pandemic’s onset despite accounting for 48% of the total workforce. Minorities, younger workers, and workers with low educational attainment will also face a challenging road to recovery.

Female workforce participation has dropped to the lowest level since 1988 at 57%, while a lack of significant action could result in the steepest sustained decline since World War II. Taken together, these factors underscore the need for more a robust psychiatric care infrastructure in the United States.

“I can tell you that we are going to be, in the next several years to come, facing significant mental health crises—more depression, anxiety, much more PTSD, more cancer cases. We really have to be ready for it because it's going to come flooding,” said Silver.

Currently, there aren’t many psychiatrists in the United States, and for some patients it can take between 3 and 6 months to see one.

“We have a supply-demand mismatch now. More people are seeking help than we have professionals,” said Duckworth. Utilizing alternative treatment specialists like peer recovery coaches and taking advantage of large-scale interventions like support groups or collaborative care between psychiatrists and primary care doctors can help meet this demand, Duckworth explained.

“We need to figure out how to approach this from a public health point of view,” he said, “We still have a very slow pipeline to develop practitioners.”

However, advances in telehealth made throughout the pandemic have helped jumpstart this effort, marking a silver lining for some providers. For BCBS of Massachusetts, the number of telehealth visits rose by 9500% in 2020. This transformation in care delivery can help reach more patients and limit no-show rates.

In addition to this shift, young people in general are more open to speaking about their mental health, Duckworth explained. “I think that generation is going to do a lot for us in terms of changing the conversation.”

Going forward, the country should also focus on processes that improve access to good public health for everyone, said Alexander. Using preschool access as an example, she noted children who attend these programs do better socially, are less likely to go to jail, are less likely to get into trouble, and are more likely to graduate high school.

“They don't necessarily get better grades, but they're more likely to move on in life and get to the next step and succeed. Those are things that can help people to get employment that's more sustainable down the road and have access to health care,” Alexander said.

Overall, increased emphasis on women’s care in general can help mitigate the looming consequences of the COVID-19 pandemic. As pregnancy rates are up due to women staying at home, Silver urges those experiencing post-delivery depression to seek help, and not to refrain from doing so out of shame. “Without a healthy mother, there is no healthy baby, and there is no healthy family unit,” she said.

As some women who need access to gynecological care, birth control or other services are unable to reach them during the pandemic, the disproportionate reduction in access to care for women’s health issues needs to be addressed, Alexander stressed. “That's really making the situation for women worse,” Alexander said. “And when it’s not good for women, it’s not good for families.”