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Maternal mortality before and during COVID pandemic

Maternal deaths in the United States rose by a staggering 33% after the onset of the COVID-19 pandemic in March 2020, which is a significantly higher percentage than the 22% overall excess death estimate linked to the pandemic, according to a research letter published in JAMA Network Open.

The increases were highest for Hispanic and non-Hispanic Black women.

“We are very familiar with the potential and limitations of current data on maternal death,” said co-author Eugene Declercq, PhD, a professor of community health sciences at Boston University School of Public Health in Massachusetts. “Hence, we thought it relevant to use that experience to explore the potential impact of COVID on maternal deaths.”

The study, which used data from the National Center for Health Statistics (NCHS), stratified deaths by month or year: deaths before COVID (2018, 2019, and January to March 2020) and deaths during the pandemic (April to December 2020).

A total of 1,588 maternal deaths (18.8 per 100,000 live births) occurred before the pandemic versus 684 deaths (25.1 per 100,000 live births) during the pandemic, for a relative increase of 33.3%.

Late maternal mortality (between 43 and 365 days after birth) increased by 41%.

Absolute and relative changes were highest for Hispanic (increases of 8.9 per 100,000 live births and 74.2%, respectively) and non-Hispanic Black women (16.8 per 100,000 live births and 40.2%) compared to non-Hispanic White women (2.9 per 100 000 live births and 17.2%).

For underlying cause-of-death codes, the largest relative increase was among indirect causes (56.9%), specifically other viral diseases, diseases of the respiratory system and diseases of the circulatory system.

Relative increases in direct causes (27.7%) were mostly linked to diabetes in pregnancy (95.9%), hypertensive disorders (39.0%) and other specified pregnancy-related conditions (48.0%).

COVID-19 was also commonly listed as a secondary condition with other viral diseases and diseases of the respiratory system.

“The somewhat surprising finding was the high rate of COVID cases (32%) among Hispanic mothers and the 74% increase in maternal deaths in this population,” Declercq told Contemporary OB/GYN. “For a number of years, Hispanic mothers have had a maternal mortality rate lower than non-Hispanic White mothers. However, during the 9 months of the pandemic, Hispanic maternal deaths rose so quickly that their maternal mortality ratio slightly exceeded that for non-Hispanic Whites.”

The study focused on public health rather than clinical concerns. “Our findings suggest that the notable efforts that maternity care providers have engaged in to improve hospital outcomes need to be extended to community-level care for prevention of not only COVID infections, but future infectious diseases as they arise,” Declercq said.

The expansion of women’s health services to reduce what the March of Dimes has described as “maternity care deserts” and allow for a more robust response to subsequent outbreaks can help reduce racial and ethnic disparities, according to Declercq, who noted that the pandemic exacerbated existing disparities.

“Mortality ratios for non-Hispanic Black mothers rose to an astonishing 59 per 100,000 during the first 9 months of the pandemic, a ratio that would rank close to 100th in the world,” he said. “While some of that increase appears related to COVID cases, the proportion of COVID cases as a multiple cause of death among Black women (13%) was not particularly high and therefore the jump in maternal mortality may be related to the continued limitations of care for women of color.”

The critical question is the degree to which clinicians can learn from the pandemic and “establish robust, integrated healthcare systems that serve women at the community and hospital levels, and provide needed supports throughout the lifespan,” Declercq said.

Reference

Thomas ME, Declercq ER. All-cause maternal mortality in the US before vs during the COVID-19 pandemic. JAMA Netw Open. Published online June 28, 2022. doi:10.1001/jamanetworkopen.2022.19133