Epidemiological data in COVID-19 mortality indicate that men are more prone to die of SARS-CoV2 infection than women, but biologic causes for this sexual dimorphism are unknown. We discuss the prospective behavioral and biological differences between the sexes that could be attributed to this gender-based differentiation. The female sex hormones and the immune stimulatory genes including toll-like receptors, interleukins, micro-RNAs present on X-chromosome may impart lesser infectivity and mortality of the SARS-CoV-2 in females over males. The sex hormone estrogen interacts with the Renin-Angiotensin-Aldosterone System, one of the most critical pathways in COVID-19 infectivity, and modulate the vasomotor homeostasis. Testosterone on the contrary enhances the levels of the two most critical molecules angiotensin converting enzyme 2 (ACE2) and the transmembrane protease, serine-type 2 (TMPRSS2), transcriptionally and post-translationally, thereby increasing viral load and delaying viral clearance in men as compared to women. We propose that modulating sex hormones, either by increasing estrogen or anti-androgen, may be a therapeutic option to reduce mortality from SARS-CoV-2.

Background Poor patient experiences during delivery in Uttar Pradesh, India is a common problem. It delays presentation at facilities after the onset of labor and contributes to poor maternal health outcomes. Patient-centered maternity care (PCMC) is recognized by the World Health Organization as critical to overall quality. Changing PCMC requires changing the process of care, and is therefore especially challenging. Methods We used a matched case-control design to evaluate a quality improvement process directed at PCMC and based on widely established team-based methods used in many OECD countries. The intervention was introduced into three government facilities and teams supported to brainstorm and test improvements over 12 months. Progress was measured through pre-post interviews with new mothers, scored using a validated PCMC scale. Analysis included chi-squared and difference-in-difference tests. Findings On a scale to 100, the PCMC score of the intervention group increased 22.9 points compared to controls. Deliveries attended by midwives, dais, ASHAs or non-skilled providers resulted in significantly higher PCMC scores than those attended to by nurses or doctors. The intervention was associated with one additional visit from a doctor and over two additional visits from nurses per day, compared to the control group. Interpretation This study has demonstrated the effectiveness of a team-based quality improvement intervention to ameliorate women’s childbirth experiences. These improvements were locally designed and led, and offer a model for potential replication.

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