U.S. maternal mortality rates rose during COVID-19 pandemic

By Dr. Liji Thomas, MDReviewed by Benedette Cuffari, M.Sc.Mar 23 2023

A new study published in the journal Obstetrics and Gynecology examines mortality related to pregnancy during the coronavirus disease 2019 (COVID-19) pandemic and compares these rates to pre-pandemic rates.

Study: Changes in pregnancy-related mortality associated with the coronavirus disease 2019 (COVID-19) pandemic in the United States. Image Credit: cristinarosepix / Shutterstock.com

What did the study show?

There were rises in maternal mortality and late maternal deaths in 2021, the second year after the pandemic began, as compared to before its onset in 2020.

In 2020, maternal mortality specific to the pandemic hovered around 25, with late maternal deaths amounting to almost 12 per 100,000 live births. This was an increase of one-third and 40%, respectively, over the corresponding rates before COVID-19.

Between January 2019 to March 2020, there were 29 maternal deaths per 100,000 live births. Over the course of the next nine months, this rate rose to almost 38 per 100,000, peaking at 45 in 2021.

This increase occurred across all races and ethnicities, irrespective of locality, rural or urban. However, there were differences in the degree of rise.

The worst-hit in terms of pregnancy-related mortality in the United States appeared to be the Native Americans and Alaska Natives in 2021. These populations suffered over 160 maternal deaths per 100,000 live births that year, more than doubling the previous year’s rate of 79 per 100,000. Black and Hispanic pregnant women showed an increase by 20% and 55%, respectively.

Smaller but significant rises were seen in small-to-medium metropolitan areas, which were associated with an increase of about 40% in 2021 from the 2020 rate of 37.7 per 100,000. In rural areas, maternal death rates increased by 21% in 2021 from the rate of 46.5 per 100,000 in 2020.

The greatest increases were seen in large urban areas, both in absolute and relative terms, from pre-pandemic to early pandemic periods. Small-to-medium metros reported greater increases later in the pandemic during the Delta wave.

Most maternal deaths occurred during pregnancy or the early postpartum period within 42 days as compared to late maternal deaths.

These increases were likely due to multiple causes. First, pregnancy was a high-risk time for unvaccinated women during the pandemic, as they were more likely to develop a severe form of the disease if infected.

Moreover, the imposition of social distancing and isolation rules could have affected antenatal care. This included the availability of this care, as healthcare personnel was directed to other areas under stress, as well as its utilization, as many women were unable to gain access to transportation or other help required to visit a clinic or hospital for routine care.

Birthing partners were often refused admission to labor suites during this period. Many pregnant women were often cut off from family and friends, thus losing their social support and potential caretakers during and after pregnancy and childbirth.

After the widespread distribution of COVID-19 vaccines, more transmissible variants of the virus began to arise in rapid succession. The emergence of these strains appears to have further increased the already rising maternal mortality rates in the U.S.

What are the implications?

Beginning at 30 per 100,000 in the first quarter of 2020, the overall mortality ratio in pregnancy rose to and then remained at around 38 from the second quarter of 2020 to the corresponding point in 2021.

However, by this point, the maternal mortality rate rose steeply to 60 per 100,000 in the third quarter and remained at about 50 in the final quarter of 2021. As compared to the same time point in 2020, with a rate hovering around 35 per 100,000, this was a significant increase.

As the pandemic progressed, the mortality rates related to pregnancy shifted toward American Indians, Native Alaskans, and those residing in more rural areas as compared with 2020.

Non-COVID-19-related mortality among pregnant women and new mothers remained significantly unchanged from the second quarter of 2020 to the third of 2021, at 30-33 per 100,000. This reflected the general increase in COVID-19 mortality rates among women in the reproductive age group, coinciding with the start of the Delta wave in the U.S.

Pregnancy-related mortality ratios increased more rapidly in 2021 than in 2020, consistent with rising rates of COVID-19–associated mortality among women of reproductive age.”

The increases in maternal mortality rates were greatest among women from disadvantaged backgrounds, especially American Indians and Native Alaskans, thus worsening their health status. This continued and exacerbated disparities in maternal health that were already being observed early in the pandemic.

Continued surveillance in 2022 and focused intervention to mitigate concerning trends in pregnancy-related mortality are needed.”