EIGE-2021 Gender Equality Index 2021 Report: Health
The COVID-19 pandemic aggravates and brings forth health inequalities
In the early summer of 2021, most EU countries were simultaneously battling a third wave of COVID-19 and aggressively rolling out large-scale vaccination programmes. Various levels of restrictions were in place and progressively being lifted. At the time of writing, the EU had reported more than 33 million cases and at least 730 000 direct COVID-19-related deaths. France, Germany, Italy, Spain and Poland have had the highest number of cases – from nearly 3 million in Poland to more than 5.7 million in France. If, overall, about 7 % of the EU population has been infected, the highest shares of cases by population are in less populated countries – Czechia, Slovakia, Slovenia and Luxembourg – with rates ranging from 11 % in Luxembourg to 16 % in Czechia. The shock of such a staggering loss of life in little more than a year and the ramifications of many people suffering long-term effects from COVID-19 will be felt for years to come.
The pandemic’s impact has been very unequal across the EU and over time. Western and southern European Member States were more affected than central European countries during the first wave in spring 2020. In contrast, the second and third pandemic waves have seen central and eastern European countries such as the Baltic states, Czechia, Poland and Romania more affected (OECD/European Union, 2020).
The pandemic has impacted different groups of people differently, and to different degrees, depending on a varitey of factors including the level of exposure to the virus and prior health status. many authors, such as Bambra et al. (2020b), have pointed out, differences in COVID-19 infection rates and mortality have highlighted pre-existing socioeconomic inequalities and the unequal burden of chronic disease across the population. Some authors have described the current situation as a ‘syndemic’ – in which the interaction of a pandemic and a NCD, each exacerbating the effect of the other, against the backdrop of significant social and economic disparity, has led to adverse outcomes for large segments of the population (Bambra et al., 2020b; Horton, 2020).
This section presents data gathered during the pandemic on mortality, morbidity, and vaccine uptake and hesitancy. Analysis is also provided on three specific gendered impacts of the pandemic on health: poor mental health, a rise in gender-based violence and the provision of SRH services in a crisis.
COVID-19 deadlier for men, ‘long COVID’ more likely for women
There are considerable variations in how data is provided across countries. For example, the number of people tested differs greatly between countries. Some countries test individuals more than once and provide data on the number of tests, some countries provide data on the number of individuals tested, and other countries test only people who are severely ill or hospitalised (Rozenberg et al., 2020). In addition, data on testing, prevalence and mortality is not always separated by sex, with evidence showing no progress, or even a decline, in the number of countries reporting sex-disaggregated data over time. According to the Global Health 50/50 initiative, which tracks sex-disaggregated data on COVID-19 from 119 countries, the most frequently reported data relates to confirmed cases (68 % of countries) and deaths (55 % of countries) (Global Health 50/50, 2020).
Early in the pandemic, women were more likely to get tested than men, as priority was given to healthcare and residential care workers – both groups mostly composed of women. At the time of writing, data on COVID-19 cases disaggregated by sex and age is unavailable for all Member States, hindering a comprehensive gender analysis of the pandemic’s toll.
Men are more likely to have severe outcomes
Early in the pandemic, overall infection rates appeared to be similar among women and men across EU countries (Rozenberg et al., 2020). Likewise, at the time of writing, women accounted for just over half of all cases in EU countries for which data is available (52 %) (Figure 42). In only three Member States (Greece, Malta and Finland) were COVID-19 rates higher among men.
When age is taken to account, large gender differences are revealed in the number of cases. A study of 10 European countries, including seven EU Member States, found that, among those of working age (i.e. up until about the age of 60), infections in women far outnumber those among men; at older ages, infection is more common in men. The highest rates of infection among men are among those aged between 70 and 79 years. Higher rates of infection among women have been linked to their presence in caring professions, especially healthcare (Tomáš Sobotka et al., 2020). This is consistent with reports that poor working conditions, including a lack of appropriate occupational health and safety measures and precarious employment, contribute to high infection levels in women-dominated frontline sectors (OECD, 2020b; Pelling, 2021; Shallcross et al., 2021).
Evidence shows that men are more likely than women to become severely ill or die from COVID-19 complications, with gender differences often quite large (Parra-Bracamonte et al., 2020; Rozenberg et al., 2020). In spring 2020, the mortality rate related to COVID-19 infections was significantly higher among European men than among European women (Pérez-López et al., 2020). The rates of all-cause mortality within 30 days of COVID-19 diagnosis and of intensive care unit admission were also higher among men (Kragholm et al., 2020).
Across the world, the Global Health 50/50 data for April 2021 shows clear gender differences in health outcomes. Although women are more likely to be tested – women account for 57 % of COVID-19 tests overall – women and men are similarly affected. Of confirmed cases, women accounted for 51 % and men for 49 % globally. However, men are more likely to be hospitalised and to be admitted to an intensive care unit, accounting for 53 % of hospitalised patients and 64 % of those requiring intensive care.
Data from the ECDC for 10 EU Member States reflects similar trends, that is that men are at higher risks of severe disease (as measured by the need to hospitalise) and death from COVID-19, with gender differences increasing with age (Figure 43). Overall, 8 % of women and 10 % of men infected with COVID-19 were hospitalised as a result; however, among those aged 70–79 years who contracted COVID-19, 24 % of women and 33 % of men were hospitalised. For those aged 80 years or older, the rate of hospitalisation reached 31 % for women and 45 % for men.
Similarly, data on fatality from COVID-19 shows that, in the 10 EU Member States reporting data disaggregated by age and sex, about 2 % of women and girls who tested positive for COVID-19 died from the disease, compared with 3 % of boys and men. Disaggregating by age group shows that overall fatality rates, as well as gender differences, are considerably higher among patients aged 70–79 years (6 % of women and 12 % of men) and among patients aged 80 years and older (17 % of women and 28 % of men dying) (Figure 44).
Overall in the EU, men account for 55 % of COVID-19 deaths. Their increased risk of dying is reflected in almost all EU countries for which data is available, with the exception of Lithuania and Slovenia (Figure 45).
Figure 44 presents for each group the case fatality rate, that is the number of deaths divided by the number of COVID-19 cases confirmed by testing. It indicates the severity of infection among different population groups. However, it can be misleading, as values for both the number of cases and the number of deaths are likely to be underestimated, for example because of insufficient testing. It has been recommended that fatality rates (Figure 44) and data on COVID-19 deaths (Figure 45) be read in conjunction with excess mortality to best capture the toll (Hantrais, 2021; Islam et al., 2021).
In the EU, men’s mortality in 2020/2021 was, on average, 17 % higher than in an average week in previous years, and 14 % higher for women (Figure 46). The excess mortality among men in 2020/2021 was highest in Czechia, Poland and Slovakia, at 30 %, 26 % and 25 %, respectively. The same three countries accounted for the highest excess mortality among women in the EU: 22 %, 22% and 23 %, respectively (Figure 46).
These findings confirms WHO data showing that analyses of numbers of registered COVID-19 deaths underestimate the full toll of the pandemic. A similar analysis of 29 high-income countries concluded that estimated excess mortality substantially exceeded the number of reported deaths from COVID-19 in many countries. The highest excess death rates (per 100 000) for men were in Hungary, Italy, Lithuania, Poland and Spain; the highest rates for women were in Belgium, Hungary, Lithuania, Slovenia and Spain (Islam et al., 2021).
The COVID-19 pandemic has been particularly devastating for nursing home residents. Miralles et al. (2021) found that the highest COVID-19 mortality rates in nursing homes in six EU countries ranged from 26 % to 66 %.
Gender differences in severe COVID-19 infections and associated mortality are often attributed to comorbidities, behavioural habits and biology, including differences in immune systems (Kragholm et al., 2020; Rozenberg et al., 2020). Health behaviours such as smoking, and comorbidities such as cardiovascular disease, hypertension and diabetes, which are more common among men, are linked to increased COVID-19 mortality rates. This may explain some gender differences (Franklin et al., 2021; OECD, 2020a; Rozenberg et al., 2020). Evidence shows that women are more likely than men to follow hand hygiene practices (Baker, 2019), to adhere to social distancing and other public health recommendations, such as mask wearing (Capraro and Barcelo, 2020; Galasso et al., 2020), and to seek preventive care (Sharma et al., 2020), all of which can reduce infection rates and improve health outcomes.
Beyond sex and age, understanding the full impact of the pandemic requires analysis of the other groups who have been most affected.
Gender intersects with occupation, age, and migration status to increase vulnerability to infection
The COVID-19 outbreak has led to an unprecedented shift in remote working to help slow spread of the virus (ILO, 2020). However, teleworking has not been equally accessible to all workers. Key gender differences exist between those who are able to follow ‘stay at home’ orders and those whose physical presence is still required at work (EIGE, 2021c). Most governments in the EU established lists of occupations deemed ‘critical’, ‘essential’ or ‘key’ (EIGE, 2021c). In most cases, they involved roles considered necessary for national socioeconomic functioning and which could not be carried out remotely. These jobs are mostly in health and care, victim support services, law enforcement, education, agro-industry, supermarkets, pharmacies and banks.
Women are over-represented among essential workers. Eurostat data shows that women account for 88 % of personal care workers, 84 % of cleaners and helpers, 73 % of education workers and 72 % of health professionals in EU countries. Fasani and Mazza (2020) estimated that migrant workers constitute 13 % of all key workers and are also over-represented in some low-skill essential jobs, for example personal care workers, drivers, transport and storage labourers, and food-processing workers. As highlighted by the International Organization for Migration, some EU countries with the highest COVID-19 numbers on 1 March 2021 also have some of the highest numbers of foreign-born workers in healthcare – Czechia, Germany, Spain, France and Italy.
Workers on the frontline of the pandemic response are likely to have more contact with the general public, including those who are possibly infected (OECD, 2020b; Pelling, 2021; Shallcross et al., 2021). This both increases their risk of infection and magnifies the physical and psychological pressure they experience (King et al., 2020). An index of social distancing risks identified accommodation, food services, wholesale and retail trade, and social and personal services as the sectors whose workers face the greatest risk of COVID-19 exposure as a result of regular interpersonal communication, teamwork and customer service tasks (Pouliakas and Branka, 2020). It also estimated that vulnerable workforce groups, such as women, older employees, foreigners and those with a lower level of education, are disproportionately exposed to infection risk at work. Also at increased risk are those working longer hours, on multiple sites or in micro-sized workplaces (Pouliakas and Branka, 2020).
In Germany, Italy, Spain and the United States, around 70 % of confirmed infections among health workers have occurred in women (Rozenberg et al., 2020). Globally, women accounted for an estimated 72 % of COVID-19 cases among healthcare workers, as of April 2021. Preliminary EU-OSHA data reveals a stark increase in psychosocial risks in the health and social care sectors. Workforce shortages, partly due to healthcare staff being off sick or in self-isolation, have led to busy schedules, long working days, failure to take time off work and constant struggles with work–life balance (EU-OSHA, forthcoming 2022). These findings support the hypothesis of higher levels of infection and psychosocial risks among working-age women being linked to occupational risks (Tomáš Sobotka et al., 2020).
Migrant workers, especially women, are particularly vulnerable to COVID-19 infection because of their over-representation in care and domestic work and lower socioeconomic status. Structural inequalities affecting ethnic minorities and people of low socioeconomic status aggravate infection risk already experienced at work through crowded housing and long commuting times, making physical distancing and self-isolation difficult (Bhala et al., 2020).
Women are more likely to have ‘long COVID’
Emerging evidence points to significant numbers of people with COVID-19 continuing to have symptoms weeks or even months after contracting the virus (Dennis et al., 2020). The intensity of symptoms does not always mirror the severity of the initial infection. Symptoms can linger, appear for the first time or become worse (Gousseff et al., 2020). Although the prevalence and risk factors remain unclear, this syndrome, termed ‘long COVID’ or ‘post-COVID-19 syndrome’, can affect multiple organs and lead to long-lasting health issues such as diabetes (Nalbandian et al., 2021).
More than 1 year into the pandemic, estimates of the prevalence of long COVID are emerging, with some studies finding that the phenomenon could affect half of COVID-19 survivors after 14 weeks (Moreno-Pérez et al., 2021), with three quarters of COVID-19 patients showing at least one ongoing symptom after 6 months (Huang et al., 2021). Long COVID has been referred to as a major public health crisis in waiting. Figures from the UK Office for National Statistics show that 1 million people have self-symptoms 4 weeks after first being infected, and nearly 400 000 people still report symptoms after a year (Ayoubkhani, 2021). Women of working age, people with disabilities, those living in deprived areas and people working in care professions are most likely to be affected with long COVID (Ayoubkhani, 2021). Most respondents report that symptoms adversely impact their day-to-day activities.
A study in the United Kingdom found that women younger than 50 years are five times less likely than men and older women to report feeling fully recovered from infection. They are twice as likely as men of the same age to report greater fatigue, seven times more likely to be breathless and generally more likely to have increased difficulties or new disabilities. More than half of COVID-19 patients report not being fully recovered 7 months after having the first symptoms, with younger women most affected. Long-term outcomes are more frequent among individuals who were previously healthy (Sigfrid et al., 2021).
Another study in the United Kingdom has highlighted that the majority of hospitalised patients are not fully recovered after 5 months, with white middle-aged women among those experiencing more than nine persistent symptoms.
Patients’ associations point to a lack of recognition by health and social protection systems of some severe health limitations associated with long COVID, particularly when it concerns classifying long COVID as an occupational disease.
Vaccine uptake and hesitancy
In the EU, vaccination roll-outs organised by national governments have prioritised health professionals and age groups most at risk of severe outcomes. Studies from various countries show broad public support for such approaches (Duch et al., 2021; Persad et al., 2021), possibly acknowledging healthcare workers’ essential role in the pandemic response. High vaccination rates are considered essential to end the pandemic. So too is vaccine uptake among high-priority groups (Zintel et al., 2021).
As mentioned previously, women and men have been affected differently by the infection – if only to a degree – depending on age, comorbidities and occupational exposure. While infections among women of working age outnumber those among men, many more men have died from COVID-19.
A systematic review of gender differences in vaccination intentions conducted in January 2021 pointed to men being much more likely than women to report that they wanted a vaccination (Zintel et al., 2021). In contrast, the February/March 2021 Eurofound COVID-19 e-survey reported 29 % of male respondents as vaccine hesitant, compared with 25 % of female respondents (Eurofound, 2021c). Results by country show a significant east–west divide. Vaccination intentions were above 60 % in most western European Member States. Among eastern European countries, the rate was much lower – ranging from 59 % in Romania to 33 % in Bulgaria. These figures reveal significant vaccine hesitancy in the EU, particularly in sparsely populated areas, among the self-employed or unemployed, among those with an illness or disability and among those using social media as their main information sources or who spend a lot of time on social media (Eurofound, 2021c). A Eurobarometer survey from May 2021 confirms the east–west divide in vaccine hesitancy: the proportion of respondents who reported that they would not like to be vaccinated ranged from 23 % in Bulgaria to just 4 % in Spain and Portugal. However, the gender gap is small: overall in the EU with 9 % of women said that they would never want to receive a vaccine, while 8 % of men responded the same (European Commission, 2021e).
In terms of actual uptake in the EU, in June 2021, women were more likely than men to be fully vaccinated in all Member States for which data was available (Figure 47), accounting for 70 % in Lithuania, 59 % in Sweden and Latvia, 57 % in Belgium, Denmark and France, 56 % in Estonia, 55 % in Austria and 53 % in Slovenia.
A pandemic in hand with a mental health crisis
As the Index domain chapters show, the full effects of the COVID-19 pandemic may still be unfolding, but preliminary findings point to profoundly unequal social and economic consequences across the EU. Social isolation, fear of infection for oneself and loved ones, grief and financial distress are enormous stressors. Evidence of the impact of these consequences on mental well-being is emerging, with multiple accounts of different population groups showing increased signs of distress such as PTSD, suicidality, eating disorders and burnout. These manifestations are likely to exacerbate pre-existing levels of poor mental health and its gender-specific impacts, as discussed in Section 9.1.1. This section mainly focuses on the mental health of the general public and of healthcare professionals.
Mental well-being levels are at their lowest since pandemic outbreak
Pandemic lockdown measures have led to a rise in loneliness, recognised as a major public health concern globally. Groups at most risk before and during the pandemic are near identical – young adults, women, people with lower education or income, the unemployed, people living alone and urban residents (Bu et al., 2020).
Lockdowns and other social distancing measures are known to have had a significant impact on opportunities for physical activity, as discussed in Section 9.1.2. A study on social distancing among UK adults found that those who were physically active had better overall mental health, that is they had fewer depressive and anxiety symptoms and more positive mental well-being (Jacob et al., 2020). In Italy, total physical activity has significantly decreased during the pandemic in all age groups, especially among men. This fall in total physical activity has had a profoundly negative impact on psychological health and well-being (Maugeri et al., 2020).
A recent Eurofound survey on COVID-19 effects measured the level of mental well-being across three pandemic waves – April 2020, July 2020 and February/March 2021 (Eurofound, 2021c). Mental well-being, as measured using the WHO-5, was significantly lower than in 2016 in both women and men and across all age groups (Figure 29 and Figure 30). While the results are not directly comparable because of different methodological approaches, they do indicate a worrying deterioration of mental well-being in the EU, with large segments of the population at risk of depression (Figure 48).
On average, mental well-being across the EU-27 fell between e-survey rounds 2 and 3 in summer 2020 and spring 2021, despite having improved earlier in the pandemic. Women consistently had lower mental well-being across the three pandemic waves (Figure 48), with the lowest levels during the third wave being in women aged 18–34 years (42 points) and 35–49 years (41 points). This could be due both to social isolation and to the increased unpaid workload from school closures or movement restrictions (EIGE, 2021c). As highlighted in the domain of time, people with care responsibilities, especially lone parents, have faced acute tensions from balancing the demands of paid and unpaid work when support services and social networks have been profoundly disrupted.
People aged 50 years or older had better mental well-being scores in round 3 of the e-survey than younger people. However, this older group also saw a large drop in average mental well-being from summer 2020 to spring 2021.
Eurofound (2021c) highlights an overall increase in negative feelings in spring 2021, including tension, anxiety, loneliness and depression, across most social groups in the EU. Among both young men and women, there was a 13-p.p. increase. The greatest jump in loneliness was recorded among women older than 50 years – an increase of 13 p.p. compared with summer 2020 findings. For young women, the findings also reveal an increase in pre-existing levels of anxiety and depressive disorders (see Section 9.1.1.), including a spike in hospital referrals for eating disorders (Solmi et al., 2021). Almeida et al. (2020) discovered that pregnant women and women who are experiencing postpartum or miscarriage are more likely to endure mental health problems during the pandemic. Such alarming accounts of mental well-being, especially among young people, may result in more people resorting to unhealthy coping mechanisms, including substance abuse, which is already common among young men. Studies also warn that the mental health consequences of the crisis are likely to be felt for a long time, peaking only after the pandemic has subsided (Costanza et al., 2020; European Commission, 2021h; Meherali et al., 2021; Standish, 2021).
Care workers face acute distress
Evidence is mounting on the profound mental health toll of the pandemic on frontline workers, particularly in the care sector. Scholars note that health workers are already at higher risk of poor mental health in normal times. That risk increased with COVID-19 and the stress of poor pandemic preparedness of health systems (Mortier et al., 2021), trauma from having to prioritise care and seeing patients suffer or die (Greenberg et al., 2020), insufficient rest and overwork, and the fear of infection or infecting others.
Psychological symptoms include high rates of stress, depression, anxiety and insomnia. Healthcare workers and those directly engaged with affected patients report PTSD and psychological distress (Kisely et al., 2020). Systematic reviews show that frontline healthcare workers and those with pre-existing mental health issues are at higher risk of poor mental health than others (Bekele and Hajure, 2021).
In Spain, where the health system was under enormous strain during the first wave, data from a 30-day period shows that about 8 % of hospital workers – mostly men – had suicidal thoughts and behaviours (Mortier et al., 2021). Evidence from France shows that half of the staff in the social care sector, facing the death of residents, experienced post-traumatic stress (EU-OSHA, forthcoming 2022).
The high level of distress experienced by health workers increased because of staff attrition in the medical field, especially in female-dominated professions. Women make up the majority of medical staff in low-level positions, such as nurses, and occupational segregation is a key reason why women nurses leave the profession (WHO, 2019c). With significant exposure to infected patients, fewer social support systems and different coping mechanisms, women are at greater risk than men of developing PTSD as a result of the pandemic (Carmassi et al., 2020).
According to the International Council of Nurses (ICN), there was already a global shortage of nursing staff before the COVID-19 pandemic, amounting to a deficit of 6 million worldwide. The pandemic exacerbates the attrition of nursing staff. Women nurses report occupational hazards, such as ill-fitting personal protective equipment (PPE), more often than men (Regenold and Vindrola-Padros, 2021). According to EU-OSHA, ‘almost half of carers did not have adequate PPE in April 2020 and one in five care workers … considered quitting over the lack of PPE’ (European Commission, 2021h). Surveys in Sweden show that 7 % of nurses considered leaving the profession altogether (ICN Policy Brief, 2021). In Denmark, a survey among nurses working in regions and municipalities found that 88 % of respondents were considering looking for a new job, with 37 % wanting a job outside the nursing profession (DSR, 2020). The ICN argues that the pandemic-induced health crisis is worsening the gender inequalities, gender-based violence and social stigmatisation that nurses experience generally (ICN, 2021).
An epidemic of gender-based violence
Governments in 142 countries around the world imposed lockdown measures in early 2020 (Hale and Webster, 2020), which contributed to the global surge in intimate partner violence (Graham-Harrison et al., 2020; WHO, 2020b), causing a ‘shadow pandemic’ (UN Women, 2020). Forced cohabitation and economic and labour instability are stressors known to be associated with an increase in intimate partner violence (Buller et al., 2018; Buttell and Ferreira, 2020; Jarnecke and Flanagan, 2020); these factors have been exacerbated by the pandemic and this, combined with the increased psychological distress resulting from lockdown (S. K. Brooks et al., 2020; Gillespie et al., 2021), has led to an increased risk of intimate partner violence (Clemens et al., 2019; Curtis et al., 2019; Straus and Douglas, 2019).
For example, in Spain the incidence of intimate partner violence increased by 24 % during the 3 months of lockdown. This increase can be explained by the lockdown itself as well as by economic stress, health concerns, working under pressure, closure of schools and increased caring demands (Arenas-Arroyo et al., 2020). The stressors arising from the quarantine and having to live with an aggressor without options to escape can aggravate violent dynamics between members of a couple (Hsu and Henke, 2020; Hussein, 2020). As discussed in the domain of violence chapter, lockdown restrictions make it more difficult to find help arise , thereby increasing tensions and leading to a rise in violence (Hsu and Henke, 2020), including femicide (Townsend, 2020; Vagianos, 2020). It is broadly recognised that the end of the lockdown will not lead to a decline in intimate partner violence; the consequent economic instability is highly likely to aggravate already high levels of violence (Arenas-Arroyo et al., 2020).
Researchers have also noted that new forms of control have emerged as a result of the pandemic (Peterman et al., 2020). Perpetrators use the ‘fear of contracting COVID-19’ as an excuse to control a partner’s movements and prevent them from having contact with their support networks (Gearing, 2020) and from accessing services, family or friends (Smyth et al., 2021). This constant control impairs victims’ autonomy, and leads to fear and loss of control over their own lives (Weil, 2020). As a result, many cases of intimate partner violence remain unreported (UN Women and WHO, 2020).
Lockdown measures may have compounded the risks of violence against vulnerable groups such as women with disabilities, homeless women, undocumented migrants or migrants with temporary visa, families with low socioeconomic status, families with children and LGBTIQ* couples (Arenas-Arroyo et al., 2020; De Schrijver et al., 2021; Flatau et al., 2020; Pleace et al., 2021; Segrave and Pfitzner, 2020; Zero and Geary, 2020). While evidence is still scarce, lockdown measures leading to the closure of temporary shelters are likely to have exposed homeless women to greater risks of violence. Even before the pandemic, homeless shelters were not fully able to address the complex issues of women suffering gender-based violence (Bretherton and Mayock, 2021). More evidence is available on the impact of COVID-19 on sexual minorities (ILGA Europe, 2020; Phillips et al., 2020). Stressors such as the lack of social support (Song et al., 2020), specifically for those who did not share their sexual orientation/identity with their family or are part of a family that rejects their orientation/identity (ILGA Europe, 2020), may increase the likelihood of intimate partner violence. Research in Belgium shows that a third of the LGBTIQ* community experienced some form of violence at home during the first 6 weeks of the lockdown (De Schrijver et al., 2021).
The COVID-19 pandemic challenges the quality of sexual and reproductive health services
There is increasing evidence of the pandemic’s severe toll on the SRHR of women, girls and other marginalised groups.
With abortion banned in Malta and pandemic-related travel restrictions preventing women from travelling abroad for an abortion, imports of abortion pills in Malta surged (Caruana-Finkel, 2020). During the pandemic, Poland passed additional restrictive legislation, while Hungary was the only Member State to suspend surgical abortions because of pandemic pressure on public hospitals. Belgium, Germany, Latvia, Luxembourg and Slovenia introduced longer waiting periods for abortions for those who tested positive for COVID-19 or were symptomatic (Moreau et al., 2020).
Lockdown led to isolation of pregnant women, during childbirth, as fathers and birth partners were not allowed to attend. This could have long-term consequences for parent–child bonding and increase post-partum depression. Elsewhere, it has been estimated that disruptions to counselling programmes will lead to an increase in FGM of 2 million cases over the next decade (UNFPA, 2020), while school closures have generally curtailed access to SRHR information for young people.
More positively for SRH, the COVID-19 pandemic has made telemedicine more common (Porter et al., 2020). The option to receive sexual and reproductive healthcare online or through messenger apps has made healthcare more accessible and available for people with limited mobility or who are unable to leave home because of care responsibilities.