Pregnant women are at increased risk for severe COVID-19–related illness, and COVID-19
is associated with an increased risk for adverse pregnancy outcomes and maternal and
neonatal complications (
1
–
3
). To date, studies assessing whether COVID-19 during pregnancy is associated with
increased risk for stillbirth have yielded mixed results (
2
–
4
). Since the B.1.617.2 (Delta) variant of SARS-CoV-2 (the virus that causes COVID-19)
became the predominant circulating variant,* there have been anecdotal reports of
increasing rates of stillbirths in women with COVID-19.
†
CDC used the Premier Healthcare Database Special COVID-19 Release (PHD-SR), a large
hospital-based administrative database,
§
to assess whether a maternal COVID-19 diagnosis documented at delivery hospitalization
was associated with stillbirth during March 2020–September 2021 as well as before
and during the period of Delta variant predominance in the United States (March 2020–June
2021 and July–September 2021, respectively). Among 1,249,634 deliveries during March
2020–September 2021, stillbirths were rare (8,154; 0.65%): 273 (1.26%) occurred among
21,653 deliveries to women with COVID-19 documented at the delivery hospitalization,
and 7,881 (0.64%) occurred among 1,227,981 deliveries without COVID-19. The adjusted
risk for stillbirth was higher in deliveries with COVID-19 compared with deliveries
without COVID-19 during March 2020–September 2021 (adjusted relative risk [aRR] = 1.90;
95% CI = 1.69–2.15), including during the pre-Delta (aRR = 1.47; 95% CI = 1.27–1.71)
and Delta periods (aRR = 4.04; 95% CI = 3.28–4.97). COVID-19 documented at delivery
was associated with increased risk for stillbirth, with a stronger association during
the period of Delta variant predominance. Implementing evidence-based COVID-19 prevention
strategies, including vaccination before or during pregnancy, is critical to reducing
the impact of COVID-19 on stillbirths.
Delivery hospitalizations were identified from PHD-SR using International Classification
of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic and procedure
codes pertaining to obstetric delivery and diagnosis-related group delivery codes.
¶
Deliveries with discharge dates during March 2020–September 2021 were included. Stillbirths,
defined as fetal deaths at ≥20 weeks’ gestation, were identified using maternal ICD-10-CM
diagnosis codes.** Hospitalizations without ICD-10-CM codes indicating gestational
age or with ICD-10-CM codes indicating gestational age <20 weeks were excluded to
reduce misclassification of fetal deaths at <20 weeks’ gestation as stillbirths (1.5%
of the overall sample).
Maternal demographic variables assessed included age, race/ethnicity (i.e., Hispanic,
non-Hispanic Black, non-Hispanic White, non-Hispanic Asian, and non-Hispanic other),
and primary payor (i.e., Medicaid, private insurance, self-pay, and other). Assessed
hospital characteristics included urban or rural location and U.S. Census division.
COVID-19
††
and selected underlying medical conditions (i.e., obesity, smoking,
§§
any diabetes,
¶¶
any hypertension,*** and multiple-gestation pregnancy) were included if the relevant
ICD-10-CM diagnosis code was documented during the delivery hospitalization (
3
). In addition, among deliveries with documented COVID-19, indicators of severe illness
(i.e., adverse cardiac event/outcome,
†††
placental abruption, sepsis, shock, acute respiratory distress syndrome, mechanical
ventilation, and intensive care unit [ICU] admission) were considered present if the
relevant ICD-10-CM diagnosis code was documented during the delivery hospitalization
(
3
). Vaccination status was unable to be assessed in this analysis.
Poisson regression models with robust standard errors were used to calculate overall
unadjusted and adjusted
§§§
relative risks for stillbirth among deliveries with COVID-19 versus deliveries without
COVID-19, accounting for within-hospital and within-woman correlation. To better understand
the potential biologic mechanism for stillbirth among women with COVID-19 at delivery,
Poisson regression models with robust SEs were used to calculate unadjusted and adjusted
¶¶¶
prevalence ratios for stillbirth for each underlying medical condition and indicator
of severe illness among deliveries with documented COVID-19. Relative risks and prevalence
ratios were calculated overall as well as during the pre-Delta and Delta periods.
Effect modification by period was assessed using adjusted models with interaction
terms. For all models, p-values <0.05 were considered statistically significant. All
analyses were performed using SAS software (version 9.4; SAS Institute). This activity
was reviewed by CDC and was conducted consistent with applicable federal law and CDC
policy.****
Among 1,249,634 deliveries at 736 hospitals during March 2020–September 2021, 53.7%
of women were non-Hispanic White, and 50.6% had private insurance as the primary payor
(Table 1). Overall, 15.4% had obesity, 11.2% had diabetes, 17.2% had a hypertensive
disorder, 1.8% had a multiple-gestation pregnancy, and 4.9% had smoking (tobacco)
documented on the delivery hospitalization record. Overall, 21,653 (1.73%) delivery
hospitalizations had COVID-19 documented.
TABLE 1
Maternal demographic and health characteristics and hospital characteristics among
delivery hospitalizations with and without a documented COVID-19 diagnosis — Premier
Healthcare Database Special COVID-19 Release, United States, March 2020–September
2021
Characteristic
No. (%)
Overall
N = 1,249,634
Pre-Delta* (Mar 2020–Jun 2021)
n = 1,076,745
Delta* (Jul–Sep 2021)
n = 172,889
Total
N = 1,249,634
No COVID-19
n = 1,227,981
COVID-19
n = 21,653
No COVID-19
n = 1,058,651
COVID-19
n = 18,094
No COVID-19
n = 169,330
COVID-19
n = 3,559
Maternal age, median (SD)
29.0 (5.8)
29.0 (5.8)
28.0 (6.0)
29.0 (5.8)
28.0 (6.0)
29.0 (5.7)
28.0 (5.8)
Maternal race/ethnicity
White, non-Hispanic
671,392 (53.7)
663,136 (54.0)
8,256 (38.1)
574,368 (54.3)
6,660 (36.8)
88,768 (52.4)
1,596 (44.8)
Hispanic
230,836 (18.5)
223,784 (18.2)
7,052 (32.6)
188,114 (17.8)
6,164 (34.1)
35,670 (21.1)
888 (25.0)
Black, non-Hispanic
181,143 (14.5)
177,508 (14.5)
3,635 (16.8)
153,408 (14.5)
2,947 (16.3)
24,100 (14.2)
688 (19.3)
Asian
57,535 (4.6)
56,855 (4.6)
680 (3.1)
49,583 (4.7)
604 (3.3)
7,272 (4.3)
76 (2.1)
Other/Unknown, non-Hispanic
108,728 (8.7)
106,698 (8.7)
2,030 (9.4)
93,178 (8.8)
1,719 (9.5)
13,520 (8.0)
311 (8.7)
Primary payor
Private
631,894 (50.6)
624,069 (50.8)
7,825 (36.1)
537,957 (50.8)
6,367 (35.2)
86,112 (50.9)
1,458 (41.0)
Medicaid
534,139 (42.7)
521,739 (42.5)
12,400 (57.3)
450,813 (42.6)
10,548 (58.3)
70,926 (41.9)
1,852 (52.0)
Self-pay
21,022 (1.7)
20,557 (1.7)
465 (2.1)
17,351 (1.6)
386 (2.1)
3,206 (1.9)
79 (2.2)
Other
62,579 (5.0)
61,616 (5.0)
963 (4.4)
52,530 (5.0)
793 (4.4)
9,086 (5.4)
170 (4.8)
Hospital location
Rural
159,634 (12.8)
157,006 (12.8)
2,628 (12.1)
134,615 (12.7)
2,014 (11.1)
22,391 (13.2)
614 (17.3)
Urban
1,090,000 (87.2)
1,070,975 (87.2)
19,025 (87.9)
924,036 (87.3)
16,080 (88.9)
146,939 (86.8)
2,945 (82.7)
U.S. Census division
East North Central
200,701 (16.1)
198,061 (16.1)
2,640 (12.2)
169,631 (16.0)
2,259 (12.5)
28,430 (16.8)
381 (10.7)
East South Central
94,224 (7.5)
92,902 (7.6)
1,322 (6.1)
80,335 (7.6)
1,018 (5.6)
12,567 (7.4)
304 (8.5)
Middle Atlantic
147,774 (11.8)
144,423 (11.8)
3,351 (15.5)
124,755 (11.8)
3,123 (17.3)
19,668 (11.6)
228 (6.4)
Mountain
91,554 (7.3)
90,458 (7.4)
1,096 (5.1)
77,393 (7.3)
939 (5.2)
13,065 (7.7)
157 (4.4)
New England
25,158 (2.0)
24,892 (2.0)
266 (1.2)
21,463 (2.0)
246 (1.4)
3,429 (2.0)
20 (0.6)
Pacific
126,615 (10.1)
124,277 (10.1)
2,338 (10.8)
107,760 (10.2)
1,890 (10.4)
16,517 (9.8)
448 (12.6)
South Atlantic
332,317 (26.6)
326,419 (26.6)
5,898 (27.2)
283,595 (26.8)
4,683 (25.9)
42,824 (25.3)
1,215 (34.1)
West North Central
80,263 (6.4)
78,710 (6.4)
1,553 (7.2)
66,326 (6.3)
1,310 (7.2)
12,384 (7.3)
243 (6.8)
West South Central
151,028 (12.1)
147,839 (12.0)
3,189 (14.7)
127,393 (12.0)
2,626 (14.5)
20,446 (12.1)
563 (15.8)
Obesity
No
1,057,646 (84.6)
1,039,849 (84.7)
17,797 (82.2)
897,069 (84.7)
14,881 (82.2)
142,780 (84.3)
2,916 (81.9)
Yes
191,988 (15.4)
188,132 (15.3)
3,856 (17.8)
161,582 (15.3)
3,213 (17.8)
26,550 (15.7)
643 (18.1)
Diabetes (any)†
No
1,109,053 (88.8)
1,090,087 (88.8)
18,966 (87.6)
940,575 (88.8)
15,803 (87.3)
149,512 (88.3)
3,163 (88.9)
Yes
140,581 (11.2)
137,894 (11.2)
2,687 (12.4)
118,076 (11.2)
2,291 (12.7)
19,818 (11.7)
396 (11.1)
Hypertensive disorders of pregnancy (any)§
No
1,034,519 (82.8)
1,016,918 (82.8)
17,601 (81.3)
877,063 (82.8)
14,678 (81.1)
139,855 (82.6)
2,923 (82.1)
Yes
215,115 (17.2)
211,063 (17.2)
4,052 (18.7)
181,588 (17.2)
3,416 (18.9)
29,475 (17.4)
636 (17.9)
Multiple-gestation pregnancy
No
1,226,534 (98.2)
1,205,299 (98.2)
21,235 (98.1)
1,039,095 (98.2)
17,751 (98.1)
166,204 (98.2)
3,484 (97.9)
Yes
23,100 (1.8)
22,682 (1.8)
418 (1.9)
19,556 (1.8)
343 (1.9)
3,126 (1.8)
75 (2.1)
Smoking¶
No
1,187,831 (95.1)
1,166,855 (95.0)
20,976 (96.9)
1,005,234 (95.0)
17,598 (97.3)
161,621 (95.4)
3,378 (94.9)
Yes
61,803 (4.9)
61,126 (5.0)
677 (3.1)
53,417 (5.0)
496 (2.7)
7,709 (4.6)
181 (5.1)
Stillbirth
No
1,241,480 (99.3)
1,220,100 (99.4)
21,380 (98.7)
1,051,845 (99.4)
17,917 (99.0)
168,255 (99.4)
3,463 (97.3)
Yes
8,154 (0.7)
7,881 (0.6)
273 (1.3)
6,806 (0.6)
177 (1.0)
1,075 (0.6)
96 (2.7)
Timing of stillbirth, wks (trimester)**
20–27 (2nd)
3,607 (44.2)
3,498 (44.4)
109 (39.9)
3,058 (44.9)
77 (43.5)
440 (40.9)
32 (33.3)
28–42 (3rd)
4,547 (55.8)
4,383 (55.6)
164 (60.1)
3,748 (55.1)
100 (56.5)
635 (59.1)
64 (66.7)
Gestational age at stillbirth, wks, median (SD)
29.0 (6.8)
29.0 (6.8)
29.0 (6.2)
29.0 (6.8)
29.0 (6.5)
30.0 (6.7)
30.0 (5.7)
Abbreviation: HELLP = hemolysis, elevated liver enzymes, low platelet count.
* Deliveries with discharge dates during March 2020–June 2021 were considered to have
occurred during the pre-Delta period, whereas deliveries with discharge dates during
July–September 2021 were considered to have occurred during the period of Delta predominance.
† Includes prepregnancy diabetes and gestational diabetes.
§ Includes chronic hypertension, gestational hypertension, chronic hypertension with
superimposed preeclampsia, preeclampsia, HELLP syndrome, and eclampsia.
¶ Includes smoking (tobacco) complicating pregnancy, childbirth, or the puerperium.
** Only among deliveries with a stillbirth.
During March 2020–September 2021, a total of 8,154 stillbirths were documented, affecting
0.64% and 1.26% of deliveries without COVID-19 and with COVID-19, respectively (aRR = 1.90;
95% CI = 1.69–2.15) (Figure). During the pre-Delta period (March 2020–June 2021),
6,983 stillbirths were documented, involving 0.98% of deliveries with COVID-19 compared
with 0.64% of deliveries without COVID-19 (aRR = 1.47; 95% CI = 1.27–1.71). During
the Delta period (July–September 2021), 1,171 stillbirths were documented, involving
2.70% of deliveries with COVID-19 compared with 0.63% of deliveries without COVID-19
(aRR = 4.04; 95% CI = 3.28–4.97).†††† Effect modification was present in the model;
the risk for stillbirth was significantly higher during the period of Delta predominance
than during the pre-Delta period (p<0.001).
FIGURE
Relative risk for stillbirth among women with COVID-19 at delivery hospitalization
compared with those without COVID-19 at delivery hospitalization — Premier Healthcare
Database Special COVID-19 Release, United States, March 2020–September 2021*
,†,
§
Abbreviation: RR = relative risk.
* Deliveries with discharge dates during March 2020–June 2021 were considered to have
occurred during the period preceding SARS-CoV-2 B.1.617.2 (Delta) variant predominance,
whereas those with discharge dates during July–September 2021 were considered to have
occurred during the period of Delta predominance.
† Overall: unadjusted RR = 1.96 (95% CI = 1.74–2.21); adjusted RR = 1.90 (95% CI =
1.69–2.15); pre-Delta: unadjusted RR = 1.52 (95% CI = 1.31–1.77); adjusted RR = 1.47
(95% CI = 1.27–1.71); Delta: unadjusted RR = 4.25 (95% CI = 3.46–5.22); adjusted RR
= 4.04 (95% CI = 3.28–4.97); p-value for effect modification by period (pre-Delta
period versus period of Delta predominance): <0.001.
§ Models accounted for within-facility and within-woman correlation, and were adjusted
for maternal age, race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White,
and non-Hispanic other), primary payor (Medicaid, private insurance, and other), obesity,
smoking, any diabetes, any hypertension, and multiple-gestation pregnancy.
Figure is a chart showing relative risk for stillbirth among women with COVID-19 at
delivery hospitalization compared with those without COVID-19 at delivery hospitalization
in the United States during March 2020–September 2021 according to the Premier Healthcare
Database Special COVID-19 Release.
Among deliveries with COVID-19, chronic hypertension, multiple-gestation pregnancy,
adverse cardiac event/outcome, placental abruption, sepsis, shock, acute respiratory
distress syndrome, mechanical ventilation, and ICU admission were associated with
a higher prevalence of stillbirth (Table 2). The associations for adverse cardiac
event/outcome and ICU admission varied significantly between the periods before and
during Delta predominance (p = 0.03 and p = 0.003, respectively); for each of these,
the associations were stronger during the period of Delta predominance.
TABLE 2
Risk for stillbirth by maternal health characteristics and indicators of severe illness
among delivery hospitalizations with a documented COVID-19 diagnosis — Premier Healthcare
Database Special COVID-19 Release, United States, March 2020–September 2021
Characteristic
Overall
N = 21,653
Pre-Delta* (Mar 2020–Jun 2021)
n = 18,094
Delta* (Jul–Sep 2021)
n = 3,559
p-value§
Outcome No. (%)
RR (95% CI)
Outcome No. (%)
RR (95% CI)
Outcome No. (%)
RR (95% CI)
No stillbirth
Stillbirth
Unadjusted
Adjusted†
No stillbirth
Stillbirth
Unadjusted
Adjusted†
No stillbirth
Stillbirth
Unadjusted
Adjusted†
Hypertensive disorders of pregnancy (any)¶
3,995 (18.7)
57 (20.9)
1.15 (0.86–1.53)
1.08 (0.81–1.44)
3,379 (18.9)
37 (20.9)
1.14 (0.79–1.63)
1.05 (0.73–1.50)
616 (17.8)
20 (20.8)
1.21 (0.74–1.96)
1.19 (0.74–1.92)
<0.001
Chronic hypertension
515 (2.4)
13 (4.8)
2.00 (1.15–3.47)
1.79 (1.03–3.11)
418 (2.3)
7 (4.0)
1.71 (0.81–3.62)
1.49 (0.70–3.19)
97 (2.8)
6 (6.3)
2.24 (1.00–4.99)
2.11 (0.94–4.74)
0.02
Pregnancy-associated hypertension**
3,480 (16.3)
44 (16.1)
0.99 (0.72–1.36)
0.94 (0.68–1.29)
2,961 (16.5)
30 (16.9)
1.03 (0.70–1.52)
0.97 (0.66–1.43)
519 (15.0)
14 (14.6)
0.97 (0.66–1.43)
0.96 (0.55–1.69)
0.005
Obesity
3,810 (17.8)
46 (16.8)
0.94 (0.68–1.28)
0.90 (0.66–1.23)
3,181 (17.8)
32 (18.1)
1.02 (0.70–1.50)
0.97 (0.66–1.42)
629 (18.2)
14 (14.6)
0.77 (0.44–1.36)
0.78 (0.44–1.37)
0.02
Diabetes (any)††
2,659 (12.4)
28 (10.3)
0.81 (0.55–1.19)
0.80 (0.53–1.18)
2,273 (12.7)
18 (10.2)
0.78 (0.48–1.27)
0.78 (0.47–1.30)
386 (11.1)
10 (10.4)
0.93 (0.49–1.77)
0.88 (0.46–1.67)
0.005
Smoking§§
663 (3.1)
14 (5.1)
1.67 (0.98–2.85)
1.56 (0.91–2.68)
488 (2.7)
8 (4.5)
1.68 (0.83–3.39)
1.60 (0.79–3.27)
175 (5.1)
6 (6.3)
1.24 (0.55–2.80)
1.09 (0.47–2.52)
0.18
Multiple-gestation pregnancy
399 (1.9)
19 (7.0)
3.80 (2.41–6.00)
3.54 (2.24–5.59)
330 (1.8)
13 (7.3)
4.10 (2.36–7.14)
3.76 (2.16–6.57)
69 (2.0)
6 (6.3)
3.10 (1.40–6.85)
3.04 (1.35–6.82)
0.11
Adverse cardiac event/outcome¶¶
160 (0.7)
10 (3.7)
4.81 (2.60–8.87)
4.44 (2.38–8.29)
120 (0.7)
4 (2.3)
3.35 (1.26–8.89)
3.09 (1.15–8.34)
40 (1.2)
6 (6.3)
5.09 (2.35–11.03)
5.18 (2.34–11.48)
0.03
Placental abruption
273 (1.3)
36 (13.2)
10.49 (7.53–14.63)
10.12 (7.28–14.08)
206 (1.1)
22 (12.4)
11.12 (7.26–17.05)
10.63 (6.96–16.22)
67 (1.9)
14 (14.6)
7.33 (4.35–12.36)
7.53 (4.47–12.66)
0.07
Sepsis
306 (1.4)
10 (3.7)
2.57 (1.38–4.78)
2.55 (1.37–4.76)
211 (1.2)
6 (3.4)
2.89 (1.30–6.45)
2.83 (1.27–6.31)
95 (2.7)
4 (4.2)
1.52 (0.57–4.05)
1.58 (0.59–4.21)
0.56
Shock
121 (0.6)
15 (5.5)
9.20 (5.62–15.05)
9.31 (5.65–15.35)
91 (0.5)
8 (4.5)
8.60 (4.35–17.00)
8.70 (4.35–17.39)
30 (0.9)
7 (7.3)
7.49 (3.73–15.04)
7.95 (3.95–16.00)
0.07
Acute respiratory distress syndrome
915 (4.3)
25 (9.2)
2.22 (1.48–3.33)
2.16 (1.44–3.23)
601 (3.4)
12 (6.8)
2.07 (1.16–3.71)
2.01 (1.13–3.59)
314 (9.1)
13 (13.5)
1.55 (0.87–2.75)
1.53 (0.87–2.70)
0.09
Mechanical ventilation
379 (1.8)
20 (7.3)
4.21 (2.70–6.57)
4.12 (2.62–6.48)
257 (1.4)
12 (6.8)
4.82 (2.72–8.55)
4.79 (2.67–8.61)
122 (3.5)
8 (8.3)
2.40 (1.19–4.84)
2.41 (1.17–4.95)
0.57
ICU admission
1,074 (5.0)
36 (13.2)
2.81 (1.99–3.97)
2.74 (1.93–3.89)
800 (4.5)
18 (10.2)
2.39 (1.48–3.87)
2.31 (1.42–3.76)
274 (7.9)
18 (18.8)
2.58 (1.57–4.25)
2.57 (1.54–4.28)
0.003
Abbreviations: HELLP = hemolysis, elevated liver enzymes, low platelet count; ICU = intensive
care unit; RR = relative risk.
* Deliveries with discharge dates during March 2020–June 2021 were considered to occur
during the pre-Delta period, whereas deliveries with discharges dates during July–September
2021 were considered to occur during the period of Delta predominance.
† Models accounted for within-facility and within-woman correlation, and were adjusted
for maternal age, race/ethnicity (Hispanic, non-Hispanic Black, non-Hispanic White,
and non-Hispanic other), and primary payor (Medicaid, private insurance, and other).
§ Assessing for effect modification by period (pre-Delta versus period of Delta predominance),
based on interaction term added to adjusted model.
¶ Includes chronic hypertension, gestational hypertension, chronic hypertension with
superimposed preeclampsia, preeclampsia, HELLP syndrome, and eclampsia.
** Includes gestational hypertension, chronic hypertension with superimposed preeclampsia,
preeclampsia, HELLP syndrome, and eclampsia.
†† Includes prepregnancy diabetes and gestational diabetes.
§§ Includes smoking (tobacco) complicating pregnancy, childbirth, or the puerperium.
¶¶ Includes acute myocardial infarction, cardiomyopathy, heart failure/arrest during
surgery or procedure, cardiac arrest/ventricular fibrillation, conversion of cardiac
rhythm, incident ventricular tachycardia, ischemia, pulmonary edema/acute heart failure,
and atrial fibrillation/atrial flutter/supraventricular tachycardia.
Discussion
Although stillbirth was a rare outcome overall, a COVID-19 diagnosis documented during
the delivery hospitalization was associated with an increased risk for stillbirth
in the United States, with a stronger association during the period of Delta variant
predominance. A previous study of pregnancies complicated by SARS-CoV-2 infection
identified placental histopathologic abnormalities, suggesting that placental hypoperfusion
and inflammation might occur with maternal COVID-19 infection (
5
); these findings might, in part, explain the association between COVID-19 and stillbirth.
Among deliveries with COVID-19 documented during the delivery hospitalization, certain
underlying medical conditions and markers of maternal morbidity, including the need
for intensive care, were associated with stillbirth. Additional studies are warranted
to investigate the role of maternal complications from COVID-19 on the risk for stillbirth.
Further, given the differences observed before and during the period of Delta variant
predominance, comparisons of placental findings might improve understanding of biologic
reasons for the observed differences.
The rates of stillbirth in women without COVID-19 at delivery in this analysis (0.64%
overall) were similar to the known prepandemic stillbirth rate of 0.59% (
6
). However, 0.98% of COVID-19–affected deliveries pre-Delta and 2.70% during the Delta
period resulted in stillbirth. Data on the association between COVID-19 in pregnancy
and stillbirth are emerging. Two metaanalyses found an association between COVID-19
during pregnancy and stillbirth but were unable to adjust for potential confounders
(
2
,
4
). In a previous analysis of the PHD-SR data, comparing women with and without COVID-19
documented at the delivery hospitalization during March–September 2020, the risk for
stillbirth was not significantly increased after adjusting for confounders (
3
). The current analysis includes an additional year of data, adding to the growing
evidence that COVID-19 is associated with an increased risk for stillbirth.
Delta became the predominant variant of SARS-CoV-2 in the United States in July 2021.§§§§
The Delta variant is more infectious and is associated with increased risk for hospitalization
compared with previous variants (
7
,
8
); however, nonpregnant patients are not more likely to have severe outcomes during
hospitalization (
9
). In this analysis, the association between COVID-19 and stillbirth was stronger
during the period of Delta predominance. Further studies that examine the effect of
SARS-CoV-2 infection, including with the Delta variant, on fetal well-being are warranted.
The findings in this report are subject to at least seven limitations. First, the
analysis relied on administrative data from hospital discharge ICD-10-CM codes; thus,
identification of COVID-19 status, underlying medical conditions, gestational age,
and stillbirths might be misclassified. Second, gestational age at SARS-CoV-2 infection
was not available, and it is unknown whether COVID-19 diagnoses documented during
the delivery hospitalization represented current or past infection. Third, many hospitals
implemented universal SARS-CoV-2 testing among pregnant women assessed in labor and
delivery units during spring 2020 (
10
), which would increase the detection of asymptomatic COVID-19. Laboratory information
was unavailable for most hospitals in PHD-SR and therefore not used in this analysis;
if participating hospitals had different screening practices, some patients with SARS-CoV-2
infection might have been missed or misclassified. In hospitals not conducting universal
SARS-CoV-2 testing, women experiencing adverse outcomes during the delivery hospitalization,
including stillbirth, might have been more likely to be tested for SARS-CoV-2 infection.
Fourth, because outpatient records were not universally available, and linkage across
different hospital systems was not possible, the analysis was restricted to codes
included during the delivery hospitalization and did not examine COVID-19 diagnoses
or underlying medical conditions recorded before the delivery hospitalization (i.e.,
during a prenatal visit). Fifth, whole genome sequencing data were not available to
confirm the variant of SARS-CoV-2 for this analysis, and period was used as a proxy;
however, the Delta variant accounted for >90% of U.S. COVID-19 cases during July–September
2021.¶¶¶¶ Sixth, it was not possible to assess vaccination status in this analysis.
However, because COVID-19 vaccines are highly effective,***** and COVID-19 vaccination
coverage among pregnant women was approximately 30% as of July 2021,††††† most women
with COVID-19 at delivery were likely unvaccinated. Finally, although the PHD-SR included
a large population across U.S. Census divisions, it represents delivery hospitalizations
from a convenience sample of reporting hospitals, limiting generalizability of results
to the U.S. population.
This analysis adds to growing evidence of an association between COVID-19 in pregnancy
and stillbirth, highlights that the risk for stillbirth associated with COVID-19 is
affected by maternal morbidity, and demonstrates that the risk has increased during
the Delta period. Further investigation from prospective studies is warranted to confirm
these findings, identify the biologic mechanism for the observed increased risk for
stillbirth with maternal COVID-19, and assess differences in risks relative to the
timing and severity of infection and the contribution of maternal risk factors. In
addition, further investigation of vaccine effectiveness during pregnancy, including
prevention of stillbirth, is warranted. Most importantly, these findings underscore
the importance of COVID-19 prevention strategies, including vaccination before or
during pregnancy.
Summary
What is already known about this topic?
Pregnant women are at increased risk for severe disease from COVID-19, and COVID-19
is associated with an increased risk for adverse perinatal outcomes.
What is added by this report?
Among 1,249,634 delivery hospitalizations during March 2020–September 2021, U.S. women
with COVID-19 were at increased risk for stillbirth compared with women without COVID-19
(adjusted relative risk [aRR] = 1.90; 95% CI = 1.69–2.15). The magnitude of association
was higher during the period of SARS-CoV-2 B.1.617.2 (Delta) variant predominance
than during the pre-Delta period.
What are the implications for public health practice?
Implementing evidence-based COVID-19 prevention strategies, including vaccination
before or during pregnancy, is critical to reduce the impact of COVID-19 on stillbirths.