Global Excess Maternal Mortality During the COVID-19 Pandemic: Country-Level Counterfactual Estimates and Associated Factors
- 1Georgia State University School of Public Health
Abstract
SynopsisO_ST_ABSStudy questionC_ST_ABSHow did maternal deaths and MMR during 2020-2023 depart from pre-pandemic country trajectories, and were those departures associated with reported disruptions in antenatal, facility-based delivery, or postnatal care?
What is already knownMaternal mortality was changing before COVID-19; infection and service disruption increased maternal risk, but simple pre/post comparisons cannot separate these influences from underlying trends.
What this study addsAcross 195 countries and territories, we estimated 68,489 cumulative excess maternal deaths, with statistically detectable excess in 113. In 39 self-selected countries, broad national disruption measures were not clearly associated with signed MMR deviations, highlighting heterogeneity and the need for more granular measures of access and quality.
BackgroundCOVID-19 increased maternal risk through infection and disruption of essential services, but maternal mortality was already changing before 2020, making simple pre-pandemic comparisons difficult.
ObjectivesTo estimate country-level departures in maternal deaths and maternal mortality ratios (MMR) during 2020-2023 from projected pre-pandemic trajectories and examine whether maternal health-service disruptions were associated with MMR deviations.
MethodsWe fitted country-specific counterfactual models to WHO/UN MMEIG estimates from 2000-2019 and projected maternal deaths and MMR through 2023 under a no-pandemic scenario. Excess was defined as the positive difference between the MMEIG estimate and counterfactual value. In a self-selected subset of 39 countries (63 country-year observations), we modelled log(MMEIG-estimated MMR/counterfactual MMR) as a function of three service-disruption measures and four baseline or year covariates.
ResultsAcross 195 countries and territories, cumulative excess maternal deaths were estimated at 68,489 (95% UI 34,706, 147,118); 113 had statistically detectable cumulative excess. The largest regional burdens were in South-East Asia, the Eastern Mediterranean, and Africa. In the 39-country subset, antenatal care, facility-based delivery, and postnatal care disruption were not clearly associated with signed MMR deviation in the full or separate models. No single country materially changed the estimated coefficients in leave-one-country-out analyses, and excluding Namibia, which had the two most unusual observations, did not alter the conclusions.
ConclusionsMaternal mortality departed substantially but unevenly from pre-pandemic trajectories. The absence of associations with broad national disruption measures should not be interpreted as evidence that service disruption was unimportant; it instead highlights the need for more detailed measures of service access and quality, alongside protection of the maternal-care continuum during emergencies.
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BibTeX
@misc{gajjar2026global,
title = {{Global Excess Maternal Mortality During the COVID-19 Pandemic: Country-Level Counterfactual Estimates and Associated Factors}},
author = {J. H. Gajjar and H. Karami and H. A. Hayes and M. A. Dixon and G. M. Massetti and G. Chowell},
howpublished = {medRxiv},
year = {2026},
month = jun,
doi = {10.64898/2026.06.30.26356947},
url = {https://www.medrxiv.org/content/10.64898/2026.06.30.26356947v2},
note = {CC BY-NC-ND},
}
RIS
TY - UNPB
TI - Global Excess Maternal Mortality During the COVID-19 Pandemic: Country-Level Counterfactual Estimates and Associated Factors
AU - J. H. Gajjar
AU - H. Karami
AU - H. A. Hayes
AU - M. A. Dixon
AU - G. M. Massetti
AU - G. Chowell
PY - 2026
DA - 2026/06/30
PB - medRxiv
DO - 10.64898/2026.06.30.26356947
UR - https://www.medrxiv.org/content/10.64898/2026.06.30.26356947v2
AB - SynopsisO_ST_ABSStudy questionC_ST_ABSHow did maternal deaths and MMR during 2020-2023 depart from pre-pandemic country trajectories, and were those departures associated with reported disruptions in antenatal, facility-based delivery, or postnatal care? What is already knownMaternal mortality was changing before COVID-19; infection and service disruption increased maternal risk, but simple pre/post comparisons cannot separate these influences from underlying trends. What this study addsAcross 195 countries and territories, we estimated 68,489 cumulative excess maternal deaths, with statistically detectable excess in 113. In 39 self-selected countries, broad national disruption measures were not clearly associated with signed MMR deviations, highlighting heterogeneity and the need for more granular measures of access and quality. BackgroundCOVID-19 increased maternal risk through infection and disruption of essential services, but maternal mortality was already changing before 2020, making simple pre-pandemic comparisons difficult. ObjectivesTo estimate country-level departures in maternal deaths and maternal mortality ratios (MMR) during 2020-2023 from projected pre-pandemic trajectories and examine whether maternal health-service disruptions were associated with MMR deviations. MethodsWe fitted country-specific counterfactual models to WHO/UN MMEIG estimates from 2000-2019 and projected maternal deaths and MMR through 2023 under a no-pandemic scenario. Excess was defined as the positive difference between the MMEIG estimate and counterfactual value. In a self-selected subset of 39 countries (63 country-year observations), we modelled log(MMEIG-estimated MMR/counterfactual MMR) as a function of three service-disruption measures and four baseline or year covariates. ResultsAcross 195 countries and territories, cumulative excess maternal deaths were estimated at 68,489 (95% UI 34,706, 147,118); 113 had statistically detectable cumulative excess. The largest regional burdens were in South-East Asia, the Eastern Mediterranean, and Africa. In the 39-country subset, antenatal care, facility-based delivery, and postnatal care disruption were not clearly associated with signed MMR deviation in the full or separate models. No single country materially changed the estimated coefficients in leave-one-country-out analyses, and excluding Namibia, which had the two most unusual observations, did not alter the conclusions. ConclusionsMaternal mortality departed substantially but unevenly from pre-pandemic trajectories. The absence of associations with broad national disruption measures should not be interpreted as evidence that service disruption was unimportant; it instead highlights the need for more detailed measures of service access and quality, alongside protection of the maternal-care continuum during emergencies.
ER -