Intended for healthcare professionals

Analysis Women’s Health and Gender Inequalities

Women’s wellbeing and the burden of unpaid work

BMJ 2021; 374 doi: (Published 31 August 2021) Cite this as: BMJ 2021;374:n1972

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  1. Soraya Seedat, executive head1,
  2. Marta Rondon, consultant in psychiatry2
  1. 1Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
  2. 2Instituto Nacional Materno Perintal, Lima, Peru
  3. Correspondence to: S Seedat sseedat{at}

Soraya Seedat and Marta Rondon examine how gender inequities in the time allocated to unpaid work, exacerbated by covid-19, are affecting women’s mental health

Women spend a disproportionate amount of their time carrying out three quarters of the world’s unpaid work: 11 billion hours a day.1 Globally women undertake three times more care and domestic work than men, with women in low and middle income countries devoting more time to unpaid work than women in high income countries, although income related differences within countries also exist.2

Unpaid care work is often perceived as low value and is invisible in mainstream economics, underpinned by entrenched patriarchal institutions and national accounting systems that fail to factor in women’s total contributions. Unpaid domestic and care work is associated with greater mental health burden and negative effects on quality of life,34 although most of the evidence comes from high income countries. Internationally, during the covid-19 pandemic, time spent on care and domestic work has increased for both men and women, but the increase and intensity of this work has been far greater for women. The risk of mental illness among women engaged in unpaid work can be expected to rise during the crisis with exposure to greater and more stressful workloads. Urgent action is needed to protect women’s mental health.

Unpaid work, stress, and mental health

Unpaid work refers to services provided within a household for its members, including personal care and housework.5 Because of the gendered nature of domestic and reproductive roles, women and girls are often expected to assume unpaid domestic work and care.6 Unpaid care work is a major factor in determining both whether women enter and stay in paid employment and the quality of their work.7 Although evidence is limited in the context of unpaid work on the effect of individual level factors (eg, perceptions of distress, cumulative stress load, past mental health problems) and ecological factors (eg, household conditions, space constraints, noise) on stress and mental health, the contributions of drudgery and the physical demands of unpaid work need to be considered.

Women’s experience of unpaid domestic work and care, and the drudgery associated with these activities, varies a great deal not only between those in high income countries and lower income countries but also between different income groups within countries.2 Higher earning women in all countries are able to give more attention to and spend more quality time with their children by outsourcing more onerous household tasks—for example, by using care services and domestic help. By contrast, women who lack the financial means are often burdened by repetitive, time consuming, and physically demanding domestic tasks.2 This drudgery component, which makes up the largest share of poorer women’s total unpaid work burden, may cause substantial fatigue and stress, whereas the relational component of unpaid work, such as playing with children, may be stress reducing and fulfilling.2

Stress activates the release of neurohormones, including cortisol. Women who experience household tasks and childcare as highly stressful have been shown to have higher cortisol levels and slower recovery of cortisol than women who report low stress from this type of unpaid work.8 This underscores the importance of women’s subjective experience of unpaid work, as sustained high cortisol levels may partially explain some adverse mental health outcomes, including depression, in women doing unpaid care work.9 For women, higher levels of objective stress may also translate into higher levels of perceived stress (burden and role strain) compared with men.10 Moreover, the cognitive and emotional involvement and the lack of respite (eg, time for leisure, communication with partners or friends, and self-care) from unpaid work can eventually lead to physical and emotional distress, depression, and anxiety.11

The “double burden” of paid and unpaid work has differential effects, with household stress seeming to affect women more than men.12 For example, a US study13 found that inequities in the division of housework and women’s disproportionate share contributed substantially to sex differences in depression. A four wave study that mapped depression trajectories in the Swedish working population between 2008 and 2014 found that women generally worked longer hours overall and spent more time doing unpaid work than men.14 The link between more unpaid work hours and a higher depression symptom trajectory was stronger for women than men. There was also an association in women (not men) between more total work hours and a “high stable” depression trajectory. Both trajectories are associated with poorer outcomes, underscoring the need for targeted interventions to reduce women’s work hours, especially unpaid work hours.

Unpaid work also has other unfavourable deleterious effects. The Korean Longitudinal Study of Ageing (2006–18) showed that middle aged, full time homemakers had five times the risk of cognitive impairments compared with women in other occupations.15

Furthermore, providing long term or high intensity care for a sick or elderly relative has been associated with an excess of psychiatric morbidity in women (eg, depression, anxiety, and lower life satisfaction).16 Analysis of three waves of the UK Household Longitudinal Study to compare employment, earnings, and health effects in young people providing unpaid care found that young unpaid care givers for elderly, sick, and disabled people were mostly women, uneducated, living with a partner, and living in social housing.17 Compared with young people without caring responsibilities, they had worse physical and mental health, earnt less, paid fewer taxes, received more welfare, and spent more on health services.

These findings contribute to our understanding of causal associations between unpaid work and longer term individual and societal outcomes. If we consider that women and girls make up 49.5% of the global population, the direct and indirect costs are staggering.

Although evidence on the adverse mental health consequences of unpaid work in women from high income countries is growing, sex disaggregated data on the mental health effects of unpaid work in low and middle income countries are sparse. This is concerning given that the costs to physical and mental health from unpaid care giving may be even higher in these countries. A systematic review and meta-analysis comparing health outcomes of unpaid care givers and non-care givers from Africa, Asia, and South America found that unpaid care givers had higher levels of anxiety and depressive symptoms than non-care givers.18 Women comprised the majority of caregivers in 12 of the 14 included studies, and they included those caring for individuals with chronic health problems (eg, HIV, cancer, diabetes mellitus), disabled family members, or individuals without any apparent medical condition.

Unpaid work during the covid-19 crisis

The gendered nature of unpaid work has become more apparent during the covid-19 pandemic.19 A rapid assessment survey by UN Women in April 2020 found that among women surveyed in Pakistan, 49% reported spending more time on domestic chores compared with 33% of men. In Bangladesh and the Maldives, 55% and 68% of women surveyed reported spending more time on unpaid domestic work, compared with 44% and 55% of men in these countries.20 In the US and the UK, real time surveys in March and April 2020 found that more women than men had lost paid jobs.21

Gender asymmetries during the pandemic have extended to childcare, with mothers doing a greater share of childcare than fathers in response to closure of schools and day care facilities and the unavailability of home help. A UK survey of 4915 parents from two parent mixed sex households conducted early in the pandemic (April-May 2020) found that compared with 2014-15, women were spending substantially longer on childcare and housework than their male partners. Women’s paid work had also shrunk disproportionately compared with men’s, and their work productivity (measured in interrupted hours) had more steeply declined when working from home. For example, mothers and fathers doing paid work used to be interrupted during the same proportion of their work hours before the pandemic. However, the survey found mothers were being interrupted 57% more during their paid work hours than fathers.22

A nationally representative household study in the UK during the first covid-19 lockdown (April-May 2020) found that not only did women do about two thirds of the housework and childcare but they were more likely than men to reduce working hours and adapt employment schedules because of spending increased time on unpaid care.23 Increased hours spent on childcare and home schooling were associated with greater levels of psychological distress among women than men. One limitation is that the study did not assess change in unpaid care work due to lockdown and how this may have affected levels of psychological distress.

Several other studies, including from Australia, China, the UK and US, have documented a greater rise in psychological distress in women than in men during lockdown. In Australia, for example, a population based study during the first month of covid-19 restrictions to establish the population prevalence of clinically significant symptoms of depression and anxiety among adults aged 18 years and older, showed that women had a greater propensity to develop symptoms of anxiety and depression and were also more likely to be taking care of children and dependent people. These findings suggest that the disproportionate burden of unpaid care giving may be a risk factor for psychopathology.19 Other factors such as social isolation, decreased access to health and social services, and increased exposure to intimate partner violence have also been shown to disproportionately affect women’s mental health and quality of life during covid-19 restrictions.2425

Reducing the burden

Gendered social norms construct women as care givers and providers, yet unpaid work is clearly associated with poorer mental health for women. The pandemic has magnified these inequities and placed women at an even greater risk of depression, anxiety, and other common mental disorders.

Longitudinal research is needed to improve our understanding of the implications of unpaid care giving for mental health outcomes on a global level, in both pandemic and post-pandemic times. This should include in-depth exploration of the duration, type, and intensity of unpaid domestic work and care giving, the interaction with paid work, and the contribution to mental health outcomes. The interplay between individual level factors and ecological factors in shaping mental health problems also requires further examination. The pandemic has reinforced the need to generate national robust time-use survey data on the gender distribution of unpaid care and domestic work across countries as evidence for policy makers. The UN Women’s global programme, Making Every Woman and Girl Count has spearheaded such an initiative,26 and concerted efforts must be made to ensure the data are prioritised.

From a policy perspective we urgently need to drive transformative change, especially because the prolonged pandemic and recurring lockdowns in many parts of the world have entrenched gender asymmetries in unpaid work. The increase in unpaid work responsibilities during the covid-19 crisis will also make it more difficult for women who have lost their jobs to find alternative employment and income streams, as well as making it more challenging to reduce their unpaid work to the level that existed before the pandemic.

We can start to address this by prioritising the continued safe operation of childcare facilities and schools. Social protection measures, such as paid leave for workers who need to care for children or sick or elderly family members, and subsidies for people with care responsibilities must be established—or continued in countries where these measures exist. For example, a covid-19 related measure implemented in Austria grants employees three weeks of exceptional leave at full pay for childcare responsibilities for children under 14 years.27 Peru is another example where women are the default household recipients of a covid-19 stimulus cash transfer scheme that seeks to affirm women as central to families’ wellbeing.28

Providing a more extensive menu of flexible working options (eg, teleworking, staggered work hours, flexi hours) that account for women’s care responsibilities during the pandemic and beyond is another strategy to support women. Although many low and middle income countries may not have the resources to implement some of these measures, other strategies are feasible. For example, a UN Women analysis using country level data showed that if a middle income country such as South Africa made childcare services available for children under the age of 5 years, two to three million new jobs would be created and unemployment rates would go down by 10 percentage points.29 This is a compelling case for investing in free universal childcare services of high quality to reduce gender inequality in earnings and employment.30

Adopting a life cycle perspective to the more equitable distribution of unpaid care work, starting with policies that grant fathers longer paternity leave, has also consistently been associated with better infant and child health outcomes and reduced mortality.29

The covid-19 pandemic has highlighted the urgency of integrating service delivery and improved access for women to mental and physical health services, income and employee support, social welfare, and legal and justice systems. Access to legal systems needs particular strengthening to protect and support women increasingly vulnerable to intimate partner violence.

Transformative change for women requires policy that recognises, reduces, and redistributes unpaid care work. Government incentives can support this change, such as through “cash for care” subsidies to compensate parents affected by school and daycare closures and for employers that provide workers with paid leave. Ultimately, whole communities and local governments need to be involved in the provision of care. This will free up women to contribute more to the paid work economy, to engage in voluntary and leisure activities, to have more time for themselves, and to safeguard their careers with arguably less compromise to, and negative effect on, their mental health and general wellbeing.

Key messages

  • Women have historically carried a disproportionate burden of unpaid domestic and home care responsibilities

  • The response to covid-19 has widened the inequality gap and highlighted women’s escalating burden of unpaid care work

  • The higher risk of depressive and anxiety symptoms among women may be partially explained by this disproportionate burden

  • Innovative research is needed to identify policies to reduce inequalities in the unpaid economy


  • Contributors and sources: SS holds the South African Research Chair in Post-Traumatic Stress Disorder and is director of the South African Medical Research Council Genomics of Brain Disorders Research Unit at Stellenbosch University. MR is a psychiatrist with a master’s degree on policy and services for mental health. She has done research on women’s mental health, violence against women and the interface between sexual and reproductive rights and health and mental health.

  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • This article is part of a series commissioned by The BMJ, based on an idea from the United Nations University-International Institute for Global Health and the World Health Organization, to mark the 25th anniversary of the adoption of the 1995 Beijing Declaration and platform for action. The BMJ retained full editorial control over external peer review, editing, and decision to publish. Open access fees for this collection were paid by the United Nations University-International Institute for Global Health and WHO. The authors alone are responsible for the views expressed, and they do not necessarily represent the views, decisions or policies of UNU, UNU-IIGH, or WHO.

This is an Open Access article distributed under the terms of the Creative Commons Attribution IGO License (, which permits use, distribution, and reproduction for non-commercial purposes in any medium, provided the original work is properly cited.