Global Excess Burden of Pregnancy-Related Adverse Outcomes Among Women of Reproductive Age During the COVID-19 Pandemic.

PURPOSE: Infectious disease emergencies may affect pregnancy-related health through biological vulnerability, disrupted obstetric and reproductive care, and health-system shocks. We estimated excess incidence of pregnancy-related adverse outcomes during 2020-2021 relative to a no-pandemic counterfactual. METHODS: We conducted a counterfactual time-series modelling study using data from the Global Burden of Disease Study 2021. Incidence data for pregnancy-related adverse outcomes from 1990 to 2021 were extracted. Five forecasting approaches were trained on 1990-2016 data and validated against 2017-2019 data. For each outcome and location, the best-performing model was selected primarily based on validation mean absolute error (MAE), with root mean square error (RMSE) used as a secondary criterion, to prioritize average out-of-sample prediction accuracy. The best-performing model was used to estimate expected age-standardised incidence rates (ASIRs) for 2020-2021 under a no-pandemic scenario. Observed and expected ASIRs were compared using population-weighted absolute rate differences and relative percentage changes. RESULTS: Globally, observed ASIRs for most pregnancy-related adverse outcomes exceeded counterfactual expectations, except for ectopic pregnancy. The largest absolute excesses were observed for maternal sepsis and other maternal infections (32.21 per 100,000 women; +3.40%) and abortion and miscarriage (30.92; +1.58%), followed by maternal hypertensive disorders (3.79; +0.41%), maternal hemorrhage (2.61; +0.36%), and obstructed labor and uterine rupture (1.06; +0.15%). Excess in abortion and miscarriage was most pronounced among women aged 15-19 and 25-44 years, whereas excess maternal sepsis and other maternal infections was greatest among women aged 20-24 years. Significant national-level excess increases were observed in 26 countries and territories for maternal sepsis and other maternal infections, 42 for maternal hemorrhage, 41 for maternal hypertensive disorders, 35 for obstructed labor and uterine rupture, 56 for abortion and miscarriage, and 11 for ectopic pregnancy. CONCLUSION: Several pregnancy-related adverse outcomes exceeded expected no-pandemic levels during 2020-2021, with substantial variation by age and country. These findings underscore the need to safeguard essential obstetric and reproductive health services and strengthen equity-oriented surveillance and health-system resilience for future infectious disease emergencies, including Disease X.