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Covid-19: US maternal mortality rose during pandemic

BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p659 (Published 20 March 2023) Cite this as: BMJ 2023;380:p659
  1. Janice Hopkins Tanne
  1. New York

Two studies show that maternal mortality in the US dramatically increased during the covid-19 pandemic and was especially severe among racial and ethnic minorities and in rural areas and small cities.12

The US already has the worst maternal mortality rate among industrialised countries. The World Health Organization defines maternal mortality as a death during pregnancy or within 42 days of the end of pregnancy from any cause related to or aggravated by pregnancy or its management.

Before the pandemic the US ranked last of 10 industrial countries, with 17.4 deaths per 100 000 live births, which compares with 1.7 in New Zealand, 3.2 in Germany, 4.8 in Australia, and 6.5 in the UK.3

The new study from the US Centers for Disease Control and Prevention showed that, in 2021, there were 1205 deaths from maternal causes in the US, up from 861 in 2020—a 40% increase—and 754 in 2019.1 The maternal mortality rate for 2021 was 32.9 deaths per 100 000 live births, up from 23.8 in 2020 and 20.1 in 2019.

Maternal mortality rose from 2020 to 2021 in all racial and ethnic groups. It was much worse in black groups, with 69.9 deaths per 100 000 live births, more than two and a half times the rate in white groups (26.6). Maternal mortality rates also increased in all age groups from 2018 (before the pandemic) to 2021. Among under 25s the rate increased from 10.6 deaths per 100 000 live births in 2018 to 20.4 in 2021. In the 25-39 years age group the rate increased from 16.6 to 31.3, and among those aged 40 or over the rate rose from 81.9 to 138.5.

Most of the people who died in pregnancy were not vaccinated against covid-19. It was not until August 2021 that vaccinations were recommended for pregnant women.

A study from the Schools of Public Health at the University of Maryland and Boston University looked at pregnancy related deaths that occurred up to one year after the end of pregnancy. It found that pregnancy related deaths were significantly higher in 2021, at 45.5 per 100 000 live births, than during the pandemic in 2020 (36.7 deaths per 100 000 live births) and before the pandemic (29.0 per 100 000 live births).2

The researchers said that pregnancy related deaths increased across all race and ethnicity and rural-urban categories in 2021. The largest increase was seen in American Indian/Alaska Native groups. Maternal mortality increased more in small and medium metropolitan areas (39% relative change) and in rural areas (21% relative change) than in large urban areas (15.9% relative change).

A 2022 report on maternal health from the General Accountability Office found that the covid-19 pandemic “exacerbated the effects of social determinants of health—factors such as access to care, transportation, or technology; living environment; and employment—on maternal health disparities. For example, service reductions in public transportation and child care worsened existing barriers to accessing care . . . In addition, the pandemic highlighted the effect racism has on maternal health. For example, physiological changes caused by chronic stress can increase the risk of maternal death, as well as severe illness from covid-19.”4

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