Recovery of Pregnancy-Related Death Ratios After the Coronavirus Disease 2019 (COVID-19) Pandemic

OBJECTIVE: To describe trends in pregnancy-related death ratios from 2018 to 2024, assess the contribution of coronavirus disease 2019 (COVID-19) to these trends, and evaluate whether pregnancy-related death ratios have recovered to prepandemic levels. METHODS: We conducted an observational study that used vital statistics data to calculate the annual pregnancy-related death ratio (the number of pregnancy-related deaths per 100,000 live births) for female individuals aged 15-49 years between 2018 and 2024. We compared the pregnancy-related death ratios across prepandemic (2018-2019) pandemic (2020-2022), and postpandemic (2023-2024) periods; to assess the contribution of COVID-19, we calculated the pregnancy-related death ratio including and excluding COVID-associated deaths (ie, those with ICD-10 U07.1 listed as a cause). Pregnancy-related deaths were identified using International Statistical Classification of Diseases, Tenth Revision codes (A34, O00-O99), and the total pregnancy-related death ratio was decomposed into the early pregnancy-related death ratio (deaths during pregnancy or within 42 days after pregnancy) and the late pregnancy-related death ratio (deaths 43-365 days postpartum). We conducted subgroup analyses by maternal age, race and ethnicity, or geographic region. RESULTS: From 2018 to 2024, there were 8,298 pregnancy-related deaths (32.3/100,000 live births). From the prepandemic period to the pandemic period, the early pregnancy-related death ratio increased by 7.5 deaths per 100,000 live births (95% CI, 6.1-8.8) and the late pregnancy-related death ratio increased by 3.7 deaths per 100,000 live births (95% CI, 2.7-4.6). Most of this increase (76% for the early pregnancy-related death ratio, 50% for the late pregnancy-related death ratio) was COVID-associated deaths. By 2023-2024, the early pregnancy-related death ratio had returned to prepandemic levels, but the late pregnancy-related death ratio remained elevated (1.4 additional deaths/100,000 live births; 95% CI, 0.4-2.4). Most subgroups experienced an increase in early and late pregnancy-related death ratios during the pandemic, but recovery varied. Notably, both early and late pregnancy-related death ratios remained substantially elevated among non-Hispanic Black mothers in 2023-2024 compared with the prepandemic period (early pregnancy-related deaths increased by 7.0/100,000 live births [95% CI, 1.3-12.8]; late pregnancy-related deaths increased by 5.4 /100,000 live births [95% CI, 1.3-9.5]). CONCLUSION: Pregnancy-related death ratios increased dramatically during the COVID-19 pandemic, and by 2023-2024, recovery differed by the timing of death relative to pregnancy and across sociodemographic subgroups. Additional efforts are needed to identify drivers of differential recovery from the COVID-19 pandemic and inform clinical and policy initiatives to reduce pregnancy-related deaths, improve maternal health, and promote health equity.