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

Educational Objective
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.


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 30, 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, and on May 3, 2023, to fix errors in the Results, Discussion, Table 1, and Supplement.

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.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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