Q+A: COVID-19's effect on maternal mortality and prevention priorities with Maegan Ashworth Dirac, MD, PhD

A systematic analysis of the Global Burden of Disease (GBD) 2023 study, published in The Lancet Obstetrics, Gynaecology, & Women's Health, found that global maternal mortality declined substantially between 1990 and 2023, with the maternal mortality ratio (MMR) falling from 321.0 to 190.5 deaths per 100,000 livebirths. Despite that progress, 240,000 women died from maternal causes in 2023, and 120 of 204 countries and territories saw progress slow or reverse between 2015 and 2023 compared with 2000 to 2015. A total of 104 countries have not yet met the United Nations Sustainable Development Goal target of fewer than 70 maternal deaths per 100,000 livebirths.^1,2

Contemporary OB/GYN previously spoke with Maegan Ashworth Dirac, MD, PhD, assistant professor of Health Metrics Sciences and Family Medicine and a senior author of the study, about the overall findings driving the global slowdown.² In this follow-up Q&A, Dirac expands on the specific role COVID-19 played in maternal mortality trends and outlines where prevention efforts should be concentrated in low- and high-resource settings alike.

Contemporary OB/GYN:
How did the COVID-19 pandemic influence maternal mortality globally, and were certain regions disproportionately affected?

Dirac:
In the countries where we have quite a bit of good data through the pandemic years, we did not see massive disruption of care for the traditional common causes of maternal mortality. That is not where we saw the bump. What we saw was a lot of indirect maternal mortality due to COVID infection. We have seen in cohort studies that were adequately matched and controlled for confounding that pregnant women, compared to women of the same age and comparable levels of health, experienced much higher mortality if they were infected with COVID due to the physiologic changes impacting their immune system, respiratory function, [etc]. Despite that higher risk, we know that, at least early on when vaccination became available, uptake among pregnant women was lower than among other women, particularly for younger pregnant women.

Recognizing the vulnerability of pregnancy, including women who are pregnant in studies of vaccine efficacy, and including them in vaccine recommendations are incredibly important when there is a new disease that is killing pregnant women. We need to take that seriously and address it, not say ‘we just do not know.’ There is a lot of hesitancy around vaccines in general and vaccines in pregnancy in particular, but it is clear that COVID was a big threat to pregnant women who would otherwise be able to handle those infections. That is where we saw the bump in mortality in some of the middle- and high-income countries that had intense COVID pandemics and were able to record and report that.

Contemporary OB/GYN:
For clinicians and health systems, what do these findings reinforce about priorities in preventing maternal deaths, particularly in both high- and low-resource settings?

Dirac:
Twofold. Looking at low-income settings, we see that the predominant causes of maternal mortality, despite huge improvements, are still maternal hemorrhage and maternal hypertensive disorders. We have known interventions, and we know they are not being delivered at scale in places that have a lot of births. Strengthening core systems, meaning the core interventions we know work to reduce deaths associated with severe preeclampsia, eclampsia, and hemorrhage, could take us really far, and most of those interventions are needed right around the time of labor and delivery. There is postpartum hemorrhage, there is delayed severe preeclampsia, but you could get really far with effective delivery of known interventions around the time of labor and delivery and in the immediate postpartum period.

In high-income countries, that is not what we are seeing. [There] we see a lot more indirect maternal deaths and a lot more late maternal deaths, and a good portion, though not all, of the increasing maternal mortality ratio is due to shifts to delayed childbearing, which brings different risks coming into pregnancy for women in different age groups. With indirect maternal deaths, we are talking about other conditions that are harder to manage when someone is also pregnant. With late maternal deaths, we are talking about people who are past their 6-week postpartum visit, and in high-income countries, we really need to start thinking longitudinally about women's health across the life course, recognizing the postpartum year as a vulnerable time for mental health, cardiovascular health, and other reasons.

We need the systems in place and the expertise to care for women well beyond that immediate postpartum period, and to integrate systems so that what midwives or obstetricians observe and know about their patients' health is effectively passed on to primary care providers, so women do not drop out of the health care system shortly after they deliver.

This is particularly true in the United States, where women may have very good coverage and relatively good access to care during and immediately following their pregnancy and then lose coverage after, leaving them without access to care during that postpartum year. But it is interesting to note we are still seeing these increases in indirect deaths and late maternal deaths even in high-income countries that have better access to care. We see more subtle increases in maternal mortality ratio in Canada as well, so even when people do have access to primary care, we really need to account for that year being a high-risk period and think about what care we deliver, how patients access that care, and shoring up support for women for the full postpartum year, even when they nominally have access and could see a doctor if they felt so motivated.

References:

1. GBD 2023 Maternal Mortality Collaborators. Global, regional, and national trends in maternal mortality, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet Obstet Gynaecol Womens Health. 2026. https://www.thelancet.com/journals/lanogw/article/PIIS3050-5038(26)00047-6/fulltext
2. Fitch J. Maegan Ashworth Dirac, MD, PhD, discusses slowed global maternal mortality progress. Contemporary OB/GYN. Published July 7, 2026. Accessed July 8, 2026. https://www.contemporaryobgyn.net/view/maegan-ashworth-dirac-md-slowed-global-maternal-mortality-progress