As smoke from wildfires in Canada smothered New York City in a polluted haze in June 2023, some worried patients called the Department of Obstetrics and Gynecology at Columbia University Irving Medical Center asking if it was safe to come in for their appointments. Was the outside air so unhealthy that they should postpone their visits? Pregnant women expressed concern about how the heightened pollution might affect them and their fetuses. If they did venture outside for any reason, what masks should they wear?
The doctors understood the fears but did not want women to postpone visits, especially if the patients were pregnant. “If people cancel their appointments during pregnancy, it can put them and their baby at risk of health problems,” says Blair Wylie, MD, an obstetrician who had joined Columbia eight months prior to lead its new Collaborative for Women’s Environmental Health. The department changed some appointments to virtual.
Wildfire smoke was not the environmental risk that Wylie expected to address when she moved to New York after leading maternal-fetal medicine at Beth Israel Deaconess Medical Center in Boston. “I was thinking of heat waves. I was thinking of floods,” she says.
But the impacts of climate change are increasingly drifting across borders and miles. With Canada’s smoke parked over New York, Wylie developed basic messages for doctors to relay to patients, which included wearing N-95 masks outdoors, finding the most effective filters for home air conditioners, and looking up the city government’s daily air quality rating to decide on outdoor activities in light of specific medical conditions.
That scramble to provide health care and advice illustrates some of the particular health challenges that women face from climate change and extreme weather around the globe. By virtue of biological and social forces — including the bearing and raising of children, and the fact that they are more likely to live in poverty and therefore have less access to protective resources — women are vulnerable to these phenomena in ways that men generally are not. An analysis of more than 130 studies on climate change from around the world found that women are more likely than men to suffer health impacts associated with climate change, and more likely to suffer death or injury from extreme weather events.
“After extreme weather events, risks to women go way up, and they go up in many different ways,” says Cecilia Sorensen, MD, director of the Global Consortium on Climate and Health Education at Columbia University.
The risks come not only from immediate catastrophes (such as hurricanes and floods), but also long-term conditions (such as expanding mold and rising temperatures) that exacerbate physical, mental, and social stressors. The impacts on women include pregnancy complications that harm the mother and fetus, sexual violence, and prolonged exposure to pollution and extreme heat. Below is some of what experts are learning about the impact on women.
Reproductive health
The enormous physical changes brought on by pregnancy and giving birth leave a woman and her fetus especially vulnerable to harms from their environment.
“The physiology of a woman in pregnancy changes dramatically,” Wylie says. “That can affect [her] ability to handle exposures related to climate change.”
For example, a woman’s respiratory rate rises when she’s pregnant. If she’s living amid increased levels of air pollution — such as smoke from wildfires, windblown dust from areas of drought, and more allergens due to longer springs and summers — she is inhaling even more harmful substances than if she were not pregnant.
A research review led by medical and public health experts at The University of Texas Health Science Center at Houston (UTHealth Houston), Stanford University, and Harvard University concluded that pollution puts pregnant women and neonates at increased risk of various adverse health effects, including hypertensive disorders, postpartum depression, placental abruption, low birth weight, preterm birth, infant mortality, and lung and respiratory problems.
Other studies have linked extreme heat to low birth weight, preterm births, and stillbirths. A review of evidence about the harm of extreme heat to pregnant women, conducted by researchers from seven countries, said the reasons might include a reduction in placental blood flow and an inflammatory response that may trigger preterm birth.
Extreme heat can also increase a pregnant woman’s risk of exhaustion, heat stroke, or dehydration, according to the Centers for Disease Control and Prevention (CDC). The CDC explains that during pregnancy, women’s bodies have to work extra hard to keep themselves and their fetuses cool, but extremely hot environments stress that biological effort to the point where regular cooling mechanisms, like sweating, can be insufficient. (The CDC provides clinical guidance for handling heat during pregnancy.)
Beyond the biological stressors caused by extreme weather, the infrastructure challenges often make health care access most difficult when it’s most needed. When communities lose electrical power, when roads get blocked by downed trees and high water, and when people evacuate to shelters or other towns, women can get separated from their health care providers. Doctors’ offices and pharmacies close or reduce their hours, transportation systems shut down, and family members and friends can’t fill the gaps because they are affected as well.
“Both prenatally and postpartum, you — and subsequently your child — need consistent, frequent care and checkups,” notes Jennifer Barkin, MS, PhD, a professor who is vice chair of Community Medicine at the Mercer School of Medicine in Macon, Georgia, and interim executive director of its Center for Rural Health and Health Disparities. “You’re seeing an OB-GYN often throughout that prenatal period, then after birth, and then the pediatrician for well-child visits. But the extreme weather events can shake up that whole social support structure and the medical home.”
A literature review in the International Journal of Environmental Research and Public Health, published in 2021 and led by researchers at the University of Miami Miller School of Medicine and Case Western Reserve University in Ohio, found that limited access to health care was a main reason that pregnant women in areas affected by hurricanes were more likely to experience preterm deliveries and postpartum depression.
That study found that the lack of access to health care also affects women who are trying to avoid becoming pregnant. The reduction in access to physicians and pharmacies led to a lack of access to contraception, which “may lead to an increased frequency of unintentional pregnancy or sexually transmitted infections,” the study notes.
Sexual violence
“During and after extreme weather events, rates of domestic and sexual violence [against women] go way up,” Sorensen says.
A study after Hurricane Katrina (New Orleans, 2005) found that in areas of severe storm damage, intimate partner assaults on women increased by 5-8 times, while the National Sexual Violence Resource Center documented an increase in various types of sexual assaults, especially against women by strangers. A survey of teenagers exposed to Hurricane Ike (Galveston, Texas, 2008) found that boys who remained in the area after the storm engaged in higher rates of physical and sexual violence against their dating partners than did boys who evacuated.
What sets off the violence? A review of extreme weather events, published in The Lancet in 2022, cited increases in economic instability, food insecurity, mental stress, and disrupted infrastructure (including health services). The lead author on the Hurricane Ike study — Jeff Temple, PhD, professor and psychologist with UTHealth Houston — cited the reduced abilities of people to manage emotions in the throes of post-traumatic stress.
“Your ability to prevent yourself from escalating [conflicts], from stopping yourself from becoming violent, is diminished when you are stressed,” Temple says. The trauma of extreme weather events “taxes our coping mechanisms.”
Temple says those mechanisms are often further weakened by increased use of alcohol and other drugs (which can lower inhibitions) and less interaction with social networks that help people cope with increased stress, because family and friends are also struggling with stressors and might have even left the community.
Childcare responsibilities
Despite the slow, decades-long shifts in responsibilities among men and women in caring for their own children, in most families around the world, women remain the primary caregivers. That care includes not only direct supervision but also responsibility for the children’s out-of-home activities, from recreation to school to health care.
“Women are often the family health care CEOs — making the doctors’ appointments, remembering [to pack] the inhaler, remembering the shots they need,” Barkin says.
Even when children are in the hands of professional caregivers, most of those caregivers are women. Estimates find that women make up three-quarters of K-12 teachers and nearly 90% of daycare workers.
In the context of extreme weather, these responsibilities affect women in a couple of ways. For example, the women have to remain in the same physical environment as the children they care for. If the home, school, or daycare center is baking in extreme heat, clouded with high levels of pollution, or infested with mold from heavy rains and floods, the children and the adults often have little choice but to stay there.
The risks are particularly high in low-income communities, where many people live in old buildings and are less able to afford adequate air conditioning and the replacement of mold-infested carpets and walls. The CDC reports that women are more likely than men to be impoverished, and that the prevalence of asthma is higher among women and children living below the federal poverty level.
These dangerous environments can cause psychological strain as well. While people of all demographic groups experience what’s been called “climate anxiety,” expectant and current mothers have particular worries about how environmental conditions, such as air pollution and extreme heat, might harm their children or their pregnancies.
A literature review, led by Barkin and published in the Journal of the American Psychiatric Nurses Association in 2022, concluded that “climate change is an emerging threat to perinatal mental health,” but more research is needed to understand the precise effects and extent.
Physician awareness
The increasing environmental threats to women’s health compelled Columbia University to start the Collaborative for Women’s Environmental Health in the fall of 2022, Wylie says. The goal is to increase knowledge among OB-GYNs and other health care providers about the impact of the environment, including climate change, on women. The collaborative provides educational materials and conducts events, including a workshop this month focused on “maternal-newborn health preparedness for climate emergencies,” for health providers in the New York City area.
Wylie stresses that doctors who treat women do not have to become experts on climate change. She says providers need to know what resources they and their patients can tap into during extreme weather, such as “cooling centers” that New York City sets up during heat waves and programs that provide financial assistance to upgrade home air conditioning.
Wylie encourages doctors to be proactive as extreme weather events approach. For example, they can push out messages through their patient portals with links to local resources and information on how to protect their health and that of their families.
Barkin is proactive not only in her work but also as a mother who faces climate anxieties of her own. She recently dissuaded her teenage son from trying out for a football team this summer because of continuous extreme heat in Georgia.
She and her son are looking for another sports activity: “Something indoors, climate-controlled.”
