The Association of the COVID-19 Pandemic With Disparities in Maternal Outcomes

BACKGROUND: In the United States, Black and Hispanic patients have substantially worse maternal outcomes than non-Hispanic White patients. The goals of this study were to evaluate the association between the coronavirus disease-2019 (COVID-19) pandemic and maternal outcomes, and whether Black and Hispanic patients were disproportionately affected by the pandemic compared to White patients. METHODS: Multivariable logistic regression was used to examine in the United States the association between maternal outcomes (severe maternal morbidity, mortality, failure-to-rescue, and cesarean delivery) and the weekly hospital proportion of COVID-19 patients, and the interaction between race, ethnicity, payer status, and the hospital COVID-19 burden using US national data from the Vizient Clinical Database between 2017 and 2022. RESULTS: Among 2484,895 admissions for delivery, 457,992 (18.4%) were non-Hispanic Black (hereafter referred to as Black), 537,867 (21.7% were Hispanic), and 1489,036 (59.9%) were non-Hispanic White (hereafter referred to as White); mean (standard deviation [SD]) age, 29.9 (5.8). Mortality (adjusted odds ratio [AOR], 2.72; 95% confidence interval [CI], 1.28–5.8; P = .01) and failure-to-rescue (AOR, 2.89; 95% CI, 1.36–6.13, P = .01), increased during weeks with a COVID-19 burden of 10.1% to 20.0%, while rates of severe maternal morbidity and cesarean delivery were unchanged. Compared to White patients, Black and Hispanic patients had higher rates of severe maternal morbidity ([Black: OR, 1.97; 95% CI, 1.85–2.11, P < .001]; [Hispanic: OR, 1.37;95% CI, 1.28–1.48, P < .001]), mortality ([Black: OR, 1.92; 95% CI, 1.29–2.86, P < .001]; [Hispanic: OR, 1.51;95% CI, 1.01–2.24, P = .04]), and cesarean delivery ([Black: OR, 1.58; 95% CI, 1.54–1.63, P < .001]; [Hispanic: OR, 1.09;95% CI, 1.05–1.13, P < .001]), but not failure-to-rescue. Except for Black patients without insurance (1.3% of the patients), the pandemic was not associated with increases in maternal disparities. Odds of mortality (AOR, 1.96; 95% CI, 1.22–3.16, P = .01) and failure-to-rescue (AOR, 3.67; 95% CI, 1.67–8.07, P = .001) increased 2.0 and 3.7-fold, respectively, in Black patients without insurance compared to White patients with private insurance for each 10% increase in the weekly hospital COVID-19 burden. CONCLUSIONS: In this national study of 2.5 million deliveries in the United States, the COVID-19 pandemic was associated with increases in maternal mortality and failure-to-rescue but not in severe maternal morbidity or cesarean deliveries. While the pandemic did not exacerbate disparities for Black and Hispanic patients with private or Medicaid insurance, uninsured Black patients experienced greater increases in mortality and failure-to-rescue compared to insured White patients.