New research explores how the COVID-19 pandemic has affected the emotional and mental health of reproductive healthcare workers.

  • Investigators surveyed reproductive health providers, including nurses, physicians, administrative staff, and others. Two-thirds of respondents reported feelings of stress, and one-third experienced increased feelings of anxiety and depression.
  • Previous studies have revealed that health crises can cause high levels of severe psychiatric distress.
  • One stressor for reproductive health workers was being redeployed to provide COVID-19 testing.

Reproductive health providers are at increased risk of depression, anxiety, and stress as the COVID-19 crisis continues, according to researchers.1

Researchers studying frontline healthcare staff around the world consistently show that crises, like the COVID-19 pandemic, take a heavy toll on healthcare workers’ mental health and can lead to increases in serious mental illness, as well as post-traumatic stress disorder (PTSD).2,3

But there is less evidence about the toll the pandemic has taken on other healthcare professionals. Investigators wanted to explore how outpatient reproductive healthcare workers have been affected by the stress and changed work conditions.

“I feel like this is something that needs to be talked about, and it’s not addressed enough,” says Alison B. Comfort, PhD, health economist at the Bixby Center for Global Reproductive Health at the University of California, San Francisco (UCSF).

A recent study revealed high levels of stress and mental health issues among reproductive health providers. “Two-thirds of the sample said they had been having increased feelings of stress during the pandemic, and one-third had increased feelings of anxiety and depression,” Comfort says.1

The study’s purpose was to draw attention to this issue. “The gap we’re trying to fill is there is more attention given to the impact of the COVID-19 pandemic on healthcare workers on the frontlines — the emergency room and hospital settings,” she explains. “We thought these [outpatient] providers may be affected, even if they’re not on the frontlines.”

“Research from previous epidemics has shown a high prevalence of severe psychological distress and mental health problems among healthcare workers, with some 50% to 60% having some severe psychological distress syndrome,” says Alexander Tsai, MD, PhD, a psychiatrist at Massachusetts General Hospital and associate professor of psychiatry at Harvard Medical School. 2

Severe psychiatric distress includes a positive screen for major depression, he adds. (See story on moral injury and psychological distress during the pandemic in this issue.)

“If you do structured interviews, you find major depressive disorder is around 5% to 6% in the overall population, so it’s 10 times as many people [working in healthcare] with these disorders,” Tsai explains.

These previous studies were centered around the severe acute respiratory syndrome outbreak in East Asia and the Ebola epidemic in Africa, he adds. For example, one review of 44 studies revealed that up to 73% of healthcare workers, including nurses, physicians, and auxiliary staff, reported PTSD symptoms during previous infectious disease outbreaks. Their symptoms lasted for more than three years in up to 40% of reported cases. The same review showed evidence of depressive symptoms in up to half of healthcare workers, and insomnia symptoms in more than one-third.2

If the experience in these 44 studies of previous epidemics/pandemics is comparable in the COVID-19 pandemic, we can anticipate extensive, long-term psychiatric problems in the months and years following current COVID-19 infections.

Emotional and Mental Health Toll

In the new COVID-19 study, researchers surveyed U.S. reproductive health providers, including physicians, nurses, advanced practice providers, administrative staff, health educators, and anyone who worked in a reproductive health setting, across different practice settings, from April 21, 2020, to June 24, 2020.1

“This population is interesting because reproductive healthcare providers practice in a variety of settings, including clinics, departments of health, family clinics, school-based health centers, outpatient hospital settings, and college-based health centers,” says Cynthia Harper, PhD, professor of obstetrics, gynecology, and reproductive sciences and director of the UCSF-Kaiser Permanente Building Interdisciplinary Research Careers in Women’s Health at UCSF. “The findings were similar in the different care settings. It was broad-based how the pandemic affected different types of clinics throughout the U.S. and the people working there.”

The emotional/mental health toll can include PTSD and psychological distress disorders. Healthcare leaders should prepare for these problems to continue even as the nation becomes vaccinated. (See story on helping staff cope with emotional/mental health in this issue.)

The survey included open-ended questions about their experiences during the early part of the pandemic. Respondents talked about some of the obstacles and problems they faced.1

“We found that a lot of them mentioned concerns about quality of patient care and access to services,” Comfort says. “They worried about whether their patients were avoiding coming into the clinic if they thought they couldn’t get services, and what would that do to their other health conditions if they avoided coming in.”

Stressors also included the quick job changes and constantly changing protocols, especially at the beginning of the pandemic. “Some people were responsible for running testing sites,” Comfort says. “They had new responsibilities, and some mentioned the challenges of switching to telehealth visits that they were not used to doing.”

For example, one reproductive health nurse told researchers that most of their staff assisted at COVID-19 drive-through testing centers, testing about 300 people within four hours in high temperatures. Then, they had to call all of the people who tested positive and perform contact tracing, mailing out both positive and negative results. They did not have volunteer help and had to perform this work in addition to their normal daily routines, including telemedicine visits with patients.

Other issues involved their colleagues’ stress. “One provider mentioned the challenge of presenting a calm and supportive environment to patients and staff,” Comfort says. This provider wrote, “This is exhausting … I have depleted my emotional reserves calming others.”1

Reproductive healthcare professionals worried about becoming infected with the virus and potentially bringing it home to their families. “Some talked about the challenges of homeschooling and taking care of people in their homes,” Comfort says. “There were financial concerns and [fears of] being fired.”

Redeployment led to additional stress. “A lot of providers were redeployed outside of their own specialties to support the acute care response, especially during big surges,” Tsai says.

Or they were asked to work with fewer staff members as patient visits declined and the economy collapsed. “It’s like our healthcare workforce at large really kicked into high gear to help with things like testing,” Harper explains. “There was so much to be done with the pandemic.”

Preventive Care Is a Challenge

It was harder to provide preventive care and testing and treatment for sexually transmitted infections (STIs) during the pandemic. Plus, reproductive health providers’ administrative responsibilities went through the roof as guidelines changed overnight.

“Things shut down, and they had to learn different ways to do reimbursement and interact with patients,” Harper says. “They had to give high-quality counseling over the phone and use resources in a smart way.”

For instance, clinics had to triage patients for in-person care. Those who could be counseled via telemedicine were handled remotely, leaving the clinic safer for those necessary in-person visits.

Telemedicine had shortcomings because not all patients had reliable internet connections, smartphones, or privacy in their households. “For reproductive health, privacy makes a big difference,” Harper explains. “Maybe if you’re calling a doctor for something not as stigmatized or private, you can do that with other family members around. But, generally, privacy and confidentiality are important.”

According to survey respondents, this was particularly true of adolescent patients, who did not have the privacy in their households for telemedicine visits, Harper says.

The researchers also pointed to obstacles such as a lack of supplies, including personal protective equipment (PPE). The worldwide PPE supply chain was disrupted, making day-to-day operations more difficult, Harper says.

Reproductive health staff also coped with the anxiety and depression of their patients. “You have patients arriving with depression, and healthcare providers are suffering, too,” Harper says.

It is important for healthcare providers and leaders to acknowledge the sacrifices everyone has made during the pandemic, Tsai notes.

“Acknowledge the loss people experienced, perhaps in the kind of way that doesn’t make people feel you are just papering over whatever difficulties they have encountered,” he says.


  1. Comfort AB, Krezanoski PJ, Rao L, et al. Mental health among outpatient reproductive health care providers during the US COVID-19 epidemic. Reprod Health 2021;18:49.
  2. Preti E, Di Mattei V, Perego G, et al. The psychological impact of epidemic and pandemic outbreaks on healthcare workers: Rapid review of the evidence. Curr Psychiatry Rep 2020;22:43.
  3. Chew QH, Wei KC, Vasoo S, et al. Psychological and coping responses of health care workers toward emerging infectious disease outbreaks: A rapid review and practical implications for the COVID-19 pandemic. J Clin Psychiatry 2020;81:20r13450.