Am J Perinatol
DOI: 10.1055/a-2135-6704
Letter to the Editor

Associations between COVID-19 State Policies and Maternal Mortality and Morbidity

Ashley M. Williams
1   USF Health Morsani College of Medicine, Tampa, Florida
2   Department of Anesthesiology, Weill Cornell Medicine, New York, New York
Sharon Abramovitz
2   Department of Anesthesiology, Weill Cornell Medicine, New York, New York
Robert S. White
2   Department of Anesthesiology, Weill Cornell Medicine, New York, New York
› Author Affiliations
Funding R.S.W. is the recipient of FAER Grant, grant no.: MRTG-08-15-2021-White (Robert).

The exacerbation of health disparities in maternal mortality and severe maternal morbidity during the coronavirus disease 2019 (COVID-19) pandemic have been well documented.[1] Studies have shown that among pregnant individuals, COVID-19 infection was associated with elevated risk for overall mortality and serious morbidity.[2] Few studies have considered the potential impact of state-level responses and policies to the COVID-19 pandemic on maternal outcomes. Previous studies have already shown the impact that state-level policies can have on maternal health, with one study showing the association between Medicaid expansion and lower maternal mortality.[3] There have also been data highlighting the maternal health outcome disparities between restrictive versus protective states regarding abortion policies, and how the recent Supreme Court Dobbs versus Jackson ruling could further exacerbate outcomes.[4] Due to the immense variation in state COVID-19 policies and implementation dates, we examined state policy-based performance during the pandemic and its association with severe maternal morbidity and mortality, stratified by race, ethnicity, and rurality.

This was a retrospective study aiming to better understand the potential effects of state-level health care policy during the COVID-19 pandemic on maternal morbidity and mortality, using 2018 to 2020 state-level maternal mortality and birth data (ICD-10 codes: A34, O00-O95, O98-O99) queried from the Centers for Disease Control Wonder database.[5] Severe maternal morbidity data were collected from the Healthcare Cost and Utilization Project (HCUP) database.[6] Covariates of interest included state, race (White, Black, or African American), ethnicity (Hispanic or Latino, Not Hispanic or Latino), and geographic location (rural or urban). Maternal mortality rate was calculated as deaths per 100,000 live births. The Centers for Disease Control Wonder database suppresses subcategories with <10 deaths due to reliability and confidentiality restrictions. Utilizing The Commonwealth Fund 2022 State Scorecards, we stratified data into “Top-Performing States” plus the District of Columbia (26) and “Bottom-Performing States” (25), determined by seven indicators that reflect state progress in vaccinating residents, hospitalization rates, health system stress, COVID-related mortality; we also gathered data on additional factors such as mask mandates ([Supplementary Table S1], available in the online version).[7] [8] A two-tailed nonpaired t-test was conducted to measure the difference in significance between total maternal mortality and total maternal morbidity in the Top-Performing States versus the Bottom-Performing States. We analyzed data available from 2018 to 2020 given that is what was available from the CDC—while the data are mainly from the years prior to the peak of COVID-19, we predict that disparities that already existed between Top- and Bottom-Performing States prior to COVID-19 will continue forward and potentially be exacerbated.

Table 1

State mortality and severe maternal morbidity from 2018 to 2020 by state, ethnicity, race, and rurality

Top-performing states + District of Columbia (26)

Bottom-performing states (25)

Race, ethnicity, and urban status

Maternal mortality rate (per 100,000 births)

Severe maternal morbidity (per 10,000 births)

Maternal mortality rate (per 100,000 births)

Severe maternal morbidity (per 10,000 births)

Hispanic or Latino

25.6 (15.9)

89.7 (25.1)

32.5 (9.9)

76.2 (17.1)

Black or African American

60.7 (25.7)

142.4 (31.4)

85.2 (26.7)

117.7 (23.2)


16.5 (5.1)

67.0 (11.0)

27.3 (8.7)

62.9 (10.6)


19.2 (6.5)

86.8 (27.6)

26.9 (6.2)

75.8 (23.9)



82.9 (37.6)

45.4 (17.4)

68.9 (12.6)


16.6 (5.2)[a]

80.2 (15.0)

27.0 (7.0)[a]

73.5 (13.4)

a Significance at a p-value <0.05 for a two-tailed nonpaired t-test.

b Centers for Disease Control suppressed data.

Maternal mortality rate was found to be lower in Top-Performing States (16.6 [5.2]) than Bottom-Performing States (27.0 [7.0]), whereas severe maternal morbidity was higher in Top-Performing States ([Table 1]). Maternal mortality rates were higher in Black and Hispanic patients compared with White patients in both cohorts, with Black patients in Bottom-Performing States experiencing the highest rates (85.2 [26.7]). Approximately 69% of Top-Performing States implemented a vaccine mandate at some point during the pandemic, whereas only 20% of Bottom-Performing States did the same. A total of 41% of adults over age 18 in Top-Performing States were fully vaccinated against COVID-19 by March 2022, compared with 30% in Bottom-Performing States. Of note, 1 Top-Performing States and 20 Bottom-Performing States had not fully vaccinated 70% of individuals age 12+ by March 2022. Additionally, Top-Performing States had an average of 84 days of high intensive care unit (ICU) stress and 44 days of hospital staffing shortages during the pandemic, compared with 193 days of high ICU stress and 197 days of staffing shortages in Bottom-Performing States.

While the most recent maternal mortality data are not yet available, these Bottom-Performing States may show significant exacerbations of severe maternal morbidity, mortality, and racial disparities during the COVID-19 pandemic, which could be partially attributable to these policy decisions. State support of booster vaccinations remains essential, given the threat of increasingly transmissible variants and waning immunity.[9] One study found that increases in first- and second-booster vaccination rates to the rates seen in the best-performing state (Vermont) would result in improved population immunity and greater protection against severe disease.[9] The COVID-19 pandemic additionally impacted considerations for obstetric anesthesiologists. One multicenter cohort study found that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients had an increased risk for delivery prior to 37 weeks of gestation and were more likely to receive general anesthesia than neuraxial labor analgesia for cesarean delivery due to maternal respiratory failure.[10]

The incongruous relationship between maternal mortality and severe maternal morbidity may be explained in part by data collection methods. Severe maternal morbidity was calculated using HCUP data restricted to in-hospital events, whereas a large percentage of severe maternal morbidity occurs after discharge. Additionally, it is possible that more pregnant people were rescued in Top-Performing States, resulting in higher morbidity but lower mortality. Limitations to this study include data suppression and inconsistent methods states use to report maternal mortality and morbidity. Additionally, we were only able to analyze data between 2018 and 2020, which is predominantly before the peak of COVID-19. Future studies are needed to assess the impact of state policies on maternal mortality and severe maternal morbidity during the COVID-19 pandemic as new maternal mortality and morbidity data over the time course of the pandemic becomes available.

The most recent data indicate that Bottom-Performing States already show higher maternal mortality rates, which the COVID-19 pandemic may exacerbate. Racial and geographic disparities in maternal mortality will continue to widen as a result, warranting further attention to the issue. One 2022 study found that almost 85% of systematic reviews and meta-analyses related to COVID-19 maternal and pregnancy outcomes did not include measures accounting for racial or geographic disparities, with 95% not reporting race at all.[11] Considering the implications of state-level policies on existing health disparities in obstetric anesthesia and maternal morbidity and mortality is vital to improving health care for pregnant people from disadvantaged socioeconomic backgrounds and ameliorating long-term sequelae of the COVID-19 pandemic.

Supplementary Material

Publication History

Received: 28 June 2023

Accepted: 21 July 2023

Accepted Manuscript online:
24 July 2023

Article published online:
24 August 2023

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