Impact of COVID-19 pandemic on maternal and neonatal morbidities in the United States

Abstract

Although SARS-CoV-2 infection in pregnancy is associated with several adverse pregnancy outcomes,1Metz TD Clifton RG Hughes BL et al.Disease severity and perinatal outcomes of pregnant patients with coronavirus disease 2019 (COVID-19).Obstet Gynecol. 2021; 137: 571-580Crossref PubMed Scopus (100) Google Scholar,2Metz TD Clifton RG Hughes BL et al.Association of SARS-CoV-2 infection with serious maternal morbidity and mortality from obstetric complications.JAMA. 2022; 327: 748-759Crossref PubMed Scopus (19) Google Scholar data exploring the impact of the COVID-19 pandemic on maternal and neonatal morbidities in the United States have been limited. Therefore, we set out to evaluate whether the COVID-19 pandemic had an impact on the overall rates of preterm birth and maternal and neonatal complications in the United States. This retrospective cohort study used the US Department of Health and Human Services, the Centers for Disease Control and Prevention, the National Center for Health Statistics (NCHS), and the Division of Vital Statistics Natality online database. The study group included all singleton live births from April 1, 2020, to December 31, 2020 (ie, pandemic group), whereas the comparison group included similar births from January 1, 2016, to February 29, 2020 (ie, prepandemic group). March 2020, when the COVID-19 outbreak was declared a global pandemic,3World Health Organization. Coronavirus disease 2019 (COVID-19): situation report –51. 2020. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10. Accessed May 14, 2020.Google Scholar was considered a washout period and excluded from our analysis. In addition, cases with missing data were excluded. Baseline characteristics, incidences of preterm birth (<24, 28, 34, and 37 weeks of gestation), and several maternal and neonatal complications were compared between the 2 groups using the Pearson chi-squared test with statistical significance set at P<.05. Multivariable logistic regression was used to adjust for the following potential confounders: maternal age, body mass index, race or ethnic group, chronic hypertension, pregestational diabetes mellitus, history of preterm birth, and tobacco use. Data were presented as unadjusted odds ratios (ORs) and adjusted ORs (aORs) with 95% confidence intervals (CIs). An institutional review board approval was not required as the reported deidentified data are publicly available through a data use agreement with the NCHS.4Centers for Disease Control and Prevention. Data use restrictions. 2020. Available at: https://wonder.cdc.gov/DataUse.html. Accessed December 20, 2021.Google Scholar Overall, 18,071,658 live births were included, of which 2,641,746 (14.6%) were in the pandemic group and 15,429,912 (85.4%) were in the prepandemic group. The pandemic group had higher rates of chronic hypertension, gestational hypertension or preeclampsia, pregestational diabetes mellitus, and previous preterm birth, and lower rates of tobacco use than the prepandemic group (Table 1). The rates of preterm birth were nearly identical between the 2 groups, conferring no clinical difference in this outcome during the COVID-19 pandemic (Table 2). The pandemic group had slightly higher odds of several complications, such as maternal transfusion (aOR, 1.17; 95% CI, 1.15–1.19), uterine rupture (aOR, 1.16; 95% CI, 1.08–1.22), and immediate and prolonged neonatal assisted ventilations (aORs, 1.18 [95% CI, 1.17–1.19] and 1.15 [95% CI, 1.13–1.17], respectively) (Table 2).Table 1Baseline characteristics compared between the 2 groupsGulersen. Impact of COVID-19 on maternal and neonatal morbidities. Am J Obstet Gynecol MFM 2022.CharacteristicPre-COVID-19 (Jan. 1, 2016, to Feb. 29, 2020; n=15,429,912)COVID-19 (April 1, 2020, to Dec. 31, 2020; n=2,641,746)P valueMaternal age (y)28.9±5.829.2±5.8<.001Body mass index (kg/m2)28.8±13.128.9±12.0<.001Race or ethnic group Non-Hispanic White7,926,922 (51.8)1,345,279 (51.4)<.001 Non-Hispanic Black2,213,816 (14.5)381,258 (14.6) American Indian or Alaskan Native120,137 (0.8)19,750 (0.8) Asian or Pacific Islander1,030,471 (6.7)166,163 (6.4) Non-Hispanic multiracial332,954 (2.2)61,921 (2.4) Hispanic3,667,846 (24.0)642,235 (24.5)Chronic hypertension300,433 (1.9)66,933 (2.5)<.001Gestational hypertension or preeclampsia1,027,175 (6.7)217,641 (8.2)<.001Eclampsia39,280 (0.3)6994 (0.3)<.001Pregestational diabetes mellitus141,945 (0.9)28,294 (1.1)<.001History of preterm birth511,938 (3.3)95,518 (3.6)<.001Tobacco use1,016,627 (6.6)143,367 (5.4)<.001Chorioamnionitis246,957 (1.6)42,221 (1.6)<.001Data are presented as mean±standard deviation or number (percentage), unless otherwise specified. Open table in a new tab Table 2Adverse maternal and neonatal outcomes compared between the 2 groupsGulersen. Impact of COVID-19 on maternal and neonatal morbidities. Am J Obstet Gynecol MFM 2022.OutcomePre-COVID-19 (Jan. 1, 2016, to Feb. 29, 2020; n=15,429,912)COVID-19 (April 1, 2020, to Dec. 31, 2020; n=2,641,746)Unadjusted OR (95% CI)Adjusted OR (95% CI)aModels were adjusted for maternal age, body mass index, race or ethnic group, chronic hypertension, pregestational diabetes mellitus, history of preterm birth, and tobacco use.Preterm birth at <37 wk1,268,316 (8.2)221,074 (8.4)1.02 (1.02–1.03)0.99 (0.98–0.99)Preterm birth at <34 wk326,868 (2.1)55,635 (2.1)0.99 (0.99–1.00)0.95 (0.95–0.96)Preterm birth at <28 wk82,904 (0.5)13,834 (0.5)0.97 (0.96–0.99)0.95 (0.93–0.96)Preterm birth at <24 wk27,185 (0.2)4455 (0.2)0.96 (0.93–0.99)0.93 (0.90–0.96)Cesarean delivery4,688,227 (30.4)805,296 (30.5)1.00 (1.00–1.01)0.97 (0.96–0.97)Maternal transfusion54,044 (0.4)11,034 (0.4)1.19 (1.17–1.22)1.17 (1.15–1.19)Uterine rupture4779 (0.04)974 (0.03)1.19 (1.11–1.28)1.16 (1.08–1.22)Unplanned hysterectomy6400 (0.04)1117 (0.04)1.02 (0.96–1.09)0.96 (0.90–1.02)ICU admission22,631 (0.1)4172 (0.2)1.08 (1.04–1.11)1.02 (0.99–1.05)Immediate assisted ventilation613,572 (4.0)126,757 (4.8)1.22 (1.21–1.23)1.18 (1.17–1.19)Prolonged assisted ventilation198,522 (1.3)40,754 (1.5)1.20 (1.19–1.221.15 (1.13–1.17)Surfactant replacement therapy60,027 (0.4)10,503 (0.4)1.02 (1.00–1.04)0.96 (0.93–0.98)Antibiotics for suspected neonatal sepsis310,594 (2.0)46,986 (1.8)0.88 (0.87–0.89)0.87 (0.86–0.88)Seizures5343 (0.04)902 (0.03)0.99 (0.92–1.06)0.99 (0.92–1.06)Data are presented as number (percentage), unless otherwise specified.CI, confidence interval; ICU, intensive care unit; OR, odds ratio.a Models were adjusted for maternal age, body mass index, race or ethnic group, chronic hypertension, pregestational diabetes mellitus, history of preterm birth, and tobacco use. Open table in a new tab Data are presented as mean±standard deviation or number (percentage), unless otherwise specified. Data are presented as number (percentage), unless otherwise specified. CI, confidence interval; ICU, intensive care unit; OR, odds ratio. Based on a large US population database, we reported several characteristics and pregnancy complications that increased during the COVID-19 pandemic. Specifically, we detected higher rates of chronic hypertension, gestational hypertension or preeclampsia, pregestational diabetes mellitus, and previous preterm birth, and lower rates of tobacco use. In addition, pregnancies in the pandemic group had slightly higher odds of maternal transfusion, uterine rupture, and immediate and prolonged neonatal assisted ventilations. Despite previous data suggesting that COVID-19 in pregnancy is associated with an increased risk of preterm birth,1Metz TD Clifton RG Hughes BL et al.Disease severity and perinatal outcomes of pregnant patients with coronavirus disease 2019 (COVID-19).Obstet Gynecol. 2021; 137: 571-580Crossref PubMed Scopus (100) Google Scholar,5Lai J Romero R Tarca AL et al.SARS-CoV-2 and the subsequent development of preeclampsia and preterm birth: evidence of a dose-response relationship supporting causality.Am J Obstet Gynecol. 2021; 225 (e1): 689-693Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar we did not detect a difference in overall preterm birth rates in the US population during the pandemic. Given that preterm birth is more common in symptomatic patients with COVID-19, which represent a minority of pregnancies during the pandemic,1Metz TD Clifton RG Hughes BL et al.Disease severity and perinatal outcomes of pregnant patients with coronavirus disease 2019 (COVID-19).Obstet Gynecol. 2021; 137: 571-580Crossref PubMed Scopus (100) Google Scholar,5Lai J Romero R Tarca AL et al.SARS-CoV-2 and the subsequent development of preeclampsia and preterm birth: evidence of a dose-response relationship supporting causality.Am J Obstet Gynecol. 2021; 225 (e1): 689-693Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar this did not translate to a clinically significant difference in preterm birth rates on a national level. It is unclear why the COVID-19 pandemic was associated with higher odds of immediate and prolonged neonatal assisted ventilations despite similar preterm birth rates and adjustments for potential confounders, such as pregestational diabetes mellitus. Unmeasured confounders may have contributed to these findings.