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Comparison of Pregnancy and Birth Outcomes Before vs During the COVID-19 Pandemic

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To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Was the COVID-19 pandemic associated with changes in pregnancy-related outcomes?

Findings  In a cohort of more than 1.6 million pregnant patients across 463 US hospitals, the number of live births decreased by 5.2% during the COVID-19 pandemic (March 2020 to April 2021) compared with the 14 months prior. While live-birth outcomes and mode of delivery remained stable, small but significant increases in pregnancy-related complications and maternal death during delivery hospitalization were observed.

Meaning  In this study, the COVID-19 pandemic was associated with increases in pregnancy-related complications and maternal deaths during delivery hospitalization.

Abstract

Importance  Little is known about changes in obstetric outcomes during the COVID-19 pandemic.

Objective  To assess whether obstetric outcomes and pregnancy-related complications changed during the COVID-19 pandemic.

Design, Setting, and Participants  This retrospective cohort study included pregnant patients receiving care at 463 US hospitals whose information appeared in the PINC AI Healthcare Database. The relative differences in birth outcomes, pregnancy-related complications, and length of stay (LOS) during the pandemic period (March 1, 2020, to April 31, 2021) were compared with the prepandemic period (January 1, 2019, to February 28, 2020) using logistic and Poisson models, adjusting for patients’ characteristics, and comorbidities and with month and hospital fixed effects.

Exposures  COVID-19 pandemic period.

Main Outcomes and Measures  The 3 primary outcomes were the relative change in preterm vs term births, mortality outcomes, and mode of delivery. Secondary outcomes included the relative change in pregnancy-related complications and LOS.

Results  There were 849 544 and 805 324 pregnant patients in the prepandemic and COVID-19 pandemic periods, respectively, and there were no significant differences in patient characteristics between periods, including age (≥35 years: 153 606 [18.1%] vs 148 274 [18.4%]), race and ethnicity (eg, Hispanic patients: 145 475 [17.1%] vs 143 905 [17.9%]; White patients: 456 014 [53.7%] vs 433 668 [53.9%]), insurance type (Medicaid: 366 233 [43.1%] vs 346 331 [43.0%]), and comorbidities (all standardized mean differences <0.10). There was a 5.2% decrease in live births during the pandemic. Maternal death during delivery hospitalization increased from 5.17 to 8.69 deaths per 100 000 pregnant patients (odds ratio [OR], 1.75; 95% CI, 1.19-2.58). There were minimal changes in mode of delivery (vaginal: OR, 1.01; 95% CI, 0.996-1.02; primary cesarean: OR, 1.02; 95% CI, 1.01-1.04; vaginal birth after cesarean: OR, 0.98; 95% CI, 0.95-1.00; repeated cesarean: OR, 0.96; 95% CI, 0.95-0.97). LOS during delivery hospitalization decreased by 7% (rate ratio, 0.931; 95% CI, 0.928-0.933). Lastly, the adjusted odds of gestational hypertension (OR, 1.08; 95% CI, 1.06-1.11), obstetric hemorrhage (OR, 1.07; 95% CI, 1.04-1.10), preeclampsia (OR, 1.04; 95% CI, 1.02-1.06), and preexisting chronic hypertension (OR, 1.06; 95% CI, 1.03-1.09) increased. No significant changes in preexisting racial and ethnic disparities were observed.

Conclusions and Relevance  During the COVID-19 pandemic, there were increased odds of maternal death during delivery hospitalization, cardiovascular disorders, and obstetric hemorrhage. Further efforts are needed to ensure risks potentially associated with the COVID-19 pandemic do not persist beyond the current state of the pandemic.

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Article Information

Accepted for Publication: June 26, 2022.

Published: August 12, 2022. doi:10.1001/jamanetworkopen.2022.26531

Correction: This article was corrected on September 2, 2022, to fix errors in the Abstract, Results, and Figure 1.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Molina RL et al. JAMA Network Open.

Corresponding Author: Rose L. Molina, MD, MPH, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215 (rmolina@bidmc.harvard.edu).

Author Contributions: Dr Tsai and Mr Soto had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Molina, Tsai, Dai, Rosenthal, Figueroa.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Molina, Tsai, Dai, Rosenthal.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Tsai, Soto, Rosenthal, Orav.

Obtained funding: Tsai, Figueroa.

Administrative, technical, or material support: Molina, Dai, Rosenthal, Figueroa.

Supervision: Molina, Tsai, Rosenthal, Figueroa.

Conflict of Interest Disclosures: Dr Tsai reported receiving grants from Massachusetts Consortium on Pathogen Readiness underwritten by the Massachusetts Life Sciences Center during the conduct of the study and grants from the Commonwealth Fund, the William F. Milton Fund of Harvard University, and Arnold Ventures outside the submitted work. Dr Figueroa reported receiving grants from Arnold Ventures, and The Commonwealth Fund and Robert Wood Johnson Foundation during the conduct of the study as well as grants the Robert Wood Johnson Foundation, Arnold Ventures, the National Institute of Aging, the Episcopal Health Foundation, the Commonwealth Fund, and the Harvard Center for AIDS Research and personal fees from Humana outside the submitted work. No other disclosures were reported.

Funding/Support: This project was supported by a research grant from The Commonwealth Fund.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: This manuscript was written and submitted for publication prior to an author’s government service. Any views or opinions expressed are those of those authors and are not on behalf of the federal government or Harvard University.

References
1.
Al-Jabir  A , Kerwan  A , Nicola  M ,  et al.  Impact of the Coronavirus (COVID-19) pandemic on surgical practice - Part 1.   Int J Surg. 2020;79:168-179. doi:10.1016/j.ijsu.2020.05.022PubMedGoogle ScholarCrossref
2.
Kendzerska  T , Zhu  DT , Gershon  AS ,  et al.  The effects of the health system response to the COVID-19 pandemic on chronic disease management: a narrative review.   Risk Manag Healthc Policy. 2021;14:575-584. doi:10.2147/RMHP.S293471PubMedGoogle ScholarCrossref
3.
Núñez  A , Sreeganga  SD , Ramaprasad  A .  Access to healthcare during COVID-19.   Int J Environ Res Public Health. 2021;18(6):2980. doi:10.3390/ijerph18062980PubMedGoogle ScholarCrossref
4.
Søreide  K , Hallet  J , Matthews  JB ,  et al.  Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services.   Br J Surg. 2020;107(10):1250-1261. doi:10.1002/bjs.11670PubMedGoogle ScholarCrossref
5.
Aranda  Z , Binde  T , Tashman  K ,  et al; Cross-site COVID-19 Syndromic Surveillance Working Group.  Disruptions in maternal health service use during the COVID-19 pandemic in 2020: experiences from 37 health facilities in low-income and middle-income countries.   BMJ Glob Health. 2022;7(1):e007247. doi:10.1136/bmjgh-2021-007247PubMedGoogle ScholarCrossref
6.
Chmielewska  B , Barratt  I , Townsend  R ,  et al.  Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis.   Lancet Glob Health. 2021;9(6):e759-e772. doi:10.1016/S2214-109X(21)00079-6PubMedGoogle ScholarCrossref
7.
Czeisler  MÉ , Marynak  K , Clarke  KEN ,  et al.  Delay or avoidance of medical care because of COVID-19-related concerns—United States, June 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(36):1250-1257. doi:10.15585/mmwr.mm6936a4PubMedGoogle ScholarCrossref
8.
Petersen  EE , Davis  NL , Goodman  D ,  et al.  Racial/ethnic disparities in pregnancy-related deaths—United States, 2007-2016.   MMWR Morb Mortal Wkly Rep. 2019;68(35):762-765. doi:10.15585/mmwr.mm6835a3PubMedGoogle ScholarCrossref
9.
Artiga  S , Pham  O , Orgera  K , Ranji  U . Racial disparities in maternal and infant health: an overview. KFF. November 10, 2020. Accessed January 24, 2022. https://www.kff.org/report-section/racial-disparities-in-maternal-and-infant-health-an-overview-issue-brief/
10.
Mackey  K , Ayers  CK , Kondo  KK ,  et al.  Racial and ethnic disparities in COVID-19-related infections, hospitalizations, and deaths : a systematic review.   Ann Intern Med. 2021;174(3):362-373. doi:10.7326/M20-6306PubMedGoogle ScholarCrossref
11.
TRACIE. COVID-19 healthcare delivery impacts. 2021. Accessed January 23, 2022. https://files.asprtracie.hhs.gov/documents/covid-19-healthcare-delivery-impacts-quick-sheet.pdf
12.
Xiong  J , Lipsitz  O , Nasri  F ,  et al.  Impact of COVID-19 pandemic on mental health in the general population: a systematic review.   J Affect Disord. 2020;277:55-64. doi:10.1016/j.jad.2020.08.001PubMedGoogle ScholarCrossref
13.
Kaur  H , Singh  T , Arya  YK , Mittal  S .  Physical fitness and exercise during the COVID-19 pandemic: a qualitative enquiry.   Front Psychol. 2020;11:590172-590172. doi:10.3389/fpsyg.2020.590172PubMedGoogle ScholarCrossref
14.
Coulthard  H , Sharps  M , Cunliffe  L , van den Tol  A .  Eating in the lockdown during the COVID 19 pandemic; self-reported changes in eating behaviour, and associations with BMI, eating style, coping and health anxiety.   Appetite. 2021;161:105082. doi:10.1016/j.appet.2020.105082PubMedGoogle ScholarCrossref
15.
Wilke  J , Mohr  L , Tenforde  AS ,  et al.  A pandemic within the pandemic? physical activity levels substantially decreased in countries affected by COVID-19.   Int J Environ Res Public Health. 2021;18(5):2235. doi:10.3390/ijerph18052235PubMedGoogle ScholarCrossref
16.
Chowdhury  P , Paul  SK , Kaisar  S , Moktadir  MA .  COVID-19 pandemic related supply chain studies: a systematic review.   Transp Res E Logist Transp Rev. 2021;148:102271-102271. doi:10.1016/j.tre.2021.102271PubMedGoogle ScholarCrossref
17.
Hoyert  D . Maternal Mortality Rates in the United States, 2020. US Centers for Disease Control and Prevention. Accessed July 11, 2022. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2020/maternal-mortality-rates-2020.htm
18.
Gemmill  A , Casey  JA , Catalano  R , Karasek  D , Margerison  CE , Bruckner  T .  Changes in preterm birth and caesarean deliveries in the United States during the SARS-CoV-2 pandemic.   Paediatr Perinat Epidemiol. 2022;36(4):485-489. doi:10.1111/ppe.12811PubMedGoogle ScholarCrossref
19.
Son  M , Gallagher  K , Lo  JY ,  et al.  Coronavirus disease 2019 (COVID-19) pandemic and pregnancy outcomes in a U.S. population.   Obstet Gynecol. 2021;138(4):542-551. doi:10.1097/AOG.0000000000004547PubMedGoogle ScholarCrossref
20.
Harvey  EM , McNeer  E , McDonald  MF ,  et al.  Association of preterm birth rate with COVID-19 statewide stay-at-home orders in Tennessee.   JAMA Pediatr. 2021;175(6):635-637. doi:10.1001/jamapediatrics.2020.6512PubMedGoogle ScholarCrossref
21.
Berghella  V , Boelig  R , Roman  A , Burd  J , Anderson  K .  Decreased incidence of preterm birth during coronavirus disease 2019 pandemic.   Am J Obstet Gynecol MFM. 2020;2(4):100258. doi:10.1016/j.ajogmf.2020.100258PubMedGoogle ScholarCrossref
22.
Wood  R , Sinnott  C , Goldfarb  I , Clapp  M , McElrath  T , Little  S .  Preterm birth during the coronavirus disease 2019 (COVID-19) pandemic in a large hospital system in the United States.   Obstet Gynecol. 2021;137(3):403-404. doi:10.1097/AOG.0000000000004237PubMedGoogle ScholarCrossref
23.
Main  EK , Chang  SC , Carpenter  AM ,  et al.  Singleton preterm birth rates for racial and ethnic groups during the coronavirus disease 2019 pandemic in California.   Am J Obstet Gynecol. 2021;224(2):239-241. doi:10.1016/j.ajog.2020.10.033PubMedGoogle ScholarCrossref
24.
Handley  SC , Mullin  AM , Elovitz  MA ,  et al.  Changes in preterm birth phenotypes and stillbirth at 2 Philadelphia hospitals during the SARS-CoV-2 pandemic, March-June 2020.   JAMA. 2021;325(1):87-89. doi:10.1001/jama.2020.20991PubMedGoogle ScholarCrossref
25.
Bunnell  ME , Koenigs  KJ , Roberts  DJ , Quade  BJ , Hornick  JL , Goldfarb  IT .  Third trimester stillbirth during the first wave of the SARS-CoV-2 pandemic: similar rates with increase in placental vasculopathic pathology.   Placenta. 2021;109:72-74. doi:10.1016/j.placenta.2021.04.003PubMedGoogle ScholarCrossref
26.
Malhotra  Y , Miller  R , Bajaj  K , Sloma  A , Wieland  D , Wilcox  W .  No change in cesarean section rate during COVID-19 pandemic in New York City.   Eur J Obstet Gynecol Reprod Biol. 2020;253:328-329. doi:10.1016/j.ejogrb.2020.06.010PubMedGoogle ScholarCrossref
27.
Sinnott  CM , Freret  TS , Clapp  MA , Reiff  E , Little  SE .  Investigating decreased rates of nulliparous cesarean deliveries during the COVID-19 pandemic.   Am J Perinatol. 2021;38(12):1231-1235. doi:10.1055/s-0041-1732449PubMedGoogle ScholarCrossref
28.
Mattingly  AS , Rose  L , Eddington  HS ,  et al.  Trends in US surgical procedures and health care system response to policies curtailing elective surgical operations during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(12):e2138038-e2138038. doi:10.1001/jamanetworkopen.2021.38038PubMedGoogle ScholarCrossref
29.
Sun  S , Savitz  DA , Wellenius  GA .  Changes in adverse pregnancy outcomes associated with the COVID-19 pandemic in the United States.   JAMA Netw Open. 2021;4(10):e2129560. doi:10.1001/jamanetworkopen.2021.29560PubMedGoogle ScholarCrossref
30.
Janevic  T , Glazer  KB , Vieira  L ,  et al.  Racial/ethnic disparities in very preterm birth and preterm birth before and during the COVID-19 pandemic.   JAMA Netw Open. 2021;4(3):e211816. doi:10.1001/jamanetworkopen.2021.1816PubMedGoogle ScholarCrossref
31.
Lemon  L , Edwards  RP , Simhan  HN .  What is driving the decreased incidence of preterm birth during the coronavirus disease 2019 pandemic?   Am J Obstet Gynecol MFM. 2021;3(3):100330. doi:10.1016/j.ajogmf.2021.100330PubMedGoogle ScholarCrossref
32.
Premier. Premier Healthcare Database white paper: data that informs and performs. March 2, 2020. Accessed July 11, 2022. https://products.premierinc.com/downloads/PremierHealthcareDatabaseWhitepaper.pdf
33.
Kadri  SS , Gundrum  J , Warner  S ,  et al.  Uptake and accuracy of the diagnosis code for COVID-19 among US hospitalizations.   JAMA. 2020;324(24):2553-2554. doi:10.1001/jama.2020.20323PubMedGoogle ScholarCrossref
34.
Rosenthal  N , Cao  Z , Gundrum  J , Sianis  J , Safo  S .  Risk factors associated with in-hospital mortality in a US national sample of patients with COVID-19.   JAMA Netw Open. 2020;3(12):e2029058-e2029058. doi:10.1001/jamanetworkopen.2020.29058PubMedGoogle ScholarCrossref
35.
Cunningham  JW , Vaduganathan  M , Claggett  BL ,  et al.  Clinical outcomes in young US adults hospitalized with COVID-19.   JAMA Intern Med. 2020;181(3):379-381. doi:10.1001/jamainternmed.2020.5313PubMedGoogle ScholarCrossref
36.
Tsai  TC , Bryan  AF , Rosenthal  N ,  et al.  Variation in use of surgical care during the COVID-19 pandemic by surgical urgency and race and ethnicity.   JAMA Health Forum. 2021;2(12):e214214. doi:10.1001/jamahealthforum.2021.4214Google ScholarCrossref
37.
Agency for Healthcare Research and Quality. Elixhauser Comorbidity Software Refined for ICD-10-CM. Accessed July 11, 2022. https://www.hcup-us.ahrq.gov/toolssoftware/comorbidityicd10/comorbidity_icd10.jsp
38.
Darrow  LA , Strickland  MJ , Klein  M ,  et al.  Seasonality of birth and implications for temporal studies of preterm birth.   Epidemiology. 2009;20(5):699-706. doi:10.1097/EDE.0b013e3181a66e96PubMedGoogle ScholarCrossref
39.
Gregory  E , Osterman  M , Valenzuela  C . Changes in home births by race and Hispanic origin and state of residence of mother: United States, 2018–2019 and 2019–2020. National Vital Statistics Report. December 9, 2021. Accessed March 4, 2022. https://www.cdc.gov/nchs/data/nvsr/nvsr70/NVSR70-15.pdf
40.
Metz  TD , Clifton  RG , Hughes  BL ,  et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (MFMU) Network.  Association of SARS-CoV-2 infection with serious maternal morbidity and mortality from obstetric complications.   JAMA. 2022;327(8):748-759. doi:10.1001/jama.2022.1190PubMedGoogle ScholarCrossref
41.
Ramirez Biermann  C , Choo  MS , Carman  K , Siden  JY , Minns  A , Peahl  A .  Stay home, stay connected: a virtual model for enhanced prenatal support during the COVID-19 pandemic and beyond.   Int J Gynaecol Obstet. 2021;153(3):549-550. doi:10.1002/ijgo.13676PubMedGoogle ScholarCrossref
42.
Peahl  AF , Smith  RD , Moniz  MH .  Prenatal care redesign: creating flexible maternity care models through virtual care.   Am J Obstet Gynecol. 2020;223(3):389.e1-389.e10. doi:10.1016/j.ajog.2020.05.029PubMedGoogle ScholarCrossref
43.
Bornstein  E , Gulersen  M , Husk  G ,  et al.  Early postpartum discharge during the COVID-19 pandemic.   J Perinat Med. 2020;48(9):1008-1012. doi:10.1515/jpm-2020-0337PubMedGoogle ScholarCrossref
44.
Greene  NH , Kilpatrick  SJ , Wong  MS , Ozimek  JA , Naqvi  M .  Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the coronavirus disease 2019 pandemic.   Am J Obstet Gynecol MFM. 2020;2(4):100234. doi:10.1016/j.ajogmf.2020.100234PubMedGoogle ScholarCrossref
45.
Arora  KS , Mauch  JT , Gibson  KS .  Labor and delivery visitor policies during the COVID-19 pandemic: balancing risks and benefits.   JAMA. 2020;323(24):2468-2469. doi:10.1001/jama.2020.7563PubMedGoogle ScholarCrossref
46.
Cronin  S , Piacquadio  M , Brendel  K ,  et al.  Perceptions of patients and providers regarding restriction of labor and delivery support people in the early stages of the coronavirus disease 2019 pandemic.   Am J Obstet Gynecol MFM. 2020;2(4):100196. doi:10.1016/j.ajogmf.2020.100196PubMedGoogle ScholarCrossref
47.
Adams  C .  Pregnancy and birth in the United States during the COVID-19 pandemic: the views of doulas.   Birth. 2022;49(1):116-122. doi:10.1111/birt.12580PubMedGoogle ScholarCrossref
48.
Aksoy Derya  Y , Altiparmak  S , Akça  E , Gökbulut  N , Yilmaz  AN .  Pregnancy and birth planning during COVID-19: the effects of tele-education offered to pregnant women on prenatal distress and pregnancy-related anxiety.   Midwifery. 2021;92:102877. doi:10.1016/j.midw.2020.102877PubMedGoogle ScholarCrossref
49.
Ajayi  KV , Harvey  IS , Panjwani  S , Uwak  I , Garney  W , Page  RL .  Narrative analysis of childbearing experiences during the COVID-19 pandemic.   MCN Am J Matern Child Nurs. 2021;46(5):284-292. doi:10.1097/NMC.0000000000000742PubMedGoogle ScholarCrossref
50.
Breman  RB , Neerland  C , Bradley  D , Burgess  A , Barr  E , Burcher  P .  Giving birth during the COVID-19 pandemic, perspectives from a sample of the United States birthing persons during the first wave: March-June 2020.   Birth. 2021;48(4):524-533. doi:10.1111/birt.12559PubMedGoogle ScholarCrossref
51.
Janevic  T , Maru  S , Nowlin  S ,  et al.  Pandemic birthing: childbirth satisfaction, perceived health care bias, and postpartum health during the COVID-19 pandemic.   Matern Child Health J. 2021;25(6):860-869. doi:10.1007/s10995-021-03158-8PubMedGoogle ScholarCrossref
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