Changes in Pregnancy-Related Mortality Associated With the Coronavirus Disease 2019 (COVID-19) Pandemic in the United States

Abstract

OBJECTIVE: To examine pregnancy-related mortality ratios before (January 2019–March 2020) and during (April 2020–December 2020 and 2021) the coronavirus disease 2019 (COVID-19) pandemic overall, by race and ethnicity, and by rural–urban classifications using vital records data. METHODS: Mortality and natality data (2019–2021) were obtained from the Centers for Disease Control and Prevention’s WONDER database to estimate pregnancy-related mortality ratios, which correspond to any death during pregnancy or up to 1 year after the end of a pregnancy from causes related to the pregnancy per 100,000 live births. Pregnancy-related mortality ratios were determined from International Classification of Diseases, Tenth Revision codes A34, O00–O96, and O98–O99. Overall pregnancy-related mortality ratios were partitioned by whether COVID-19 was listed as a contributory cause, and quarterly estimates were compared between 2019 and 2021. Pregnancy-related mortality ratios were compared by race and ethnicity and rural–urban residence before (2019–March 2020) and during (April 2020–December 2020 and 2021) the COVID-19 pandemic. RESULTS: Pregnancy-related mortality was significantly higher in 2021 (45.5/100,000 live births) compared with during the pandemic in 2020 (36.7/100,000 live births) and before the pandemic (29.0/100,000 live births). Pregnancy-related mortality ratios increased across all race and ethnicity and rural–urban residence categories in 2021. The largest increase occurred among American Indian/Alaska Native people during 2021 compared with April–December of 2020 (pregnancy-related mortality ratio 160.8 vs 79.0/100,000 live births, 104% relative change, P=.017). Medium–small metropolitan (52.4 vs 37.7/100,000 live births, 39.0% relative change, P<.001) and rural (56.2 vs 46.5/100,000 live births, 21.0% relative change, P=.05) areas had a larger increase in 2021 compared with April–December 2020 compared with large urban areas (39.1 vs 33.7/100,000 live births, 15.9% relative change, P=.009). CONCLUSION: 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. This further exacerbated racial and ethnic disparities, especially among American Indian/Alaska Native birthing people.