COVID-19 and the Changing Landscape of Perinatal Mortality

The COVID-19 pandemic disrupted pregnancy and newborn care at a scale rarely seen in modern medicine. Hospitals had to reorganize services, families faced travel restrictions, and health workers worked under infection-control pressures. These disruptions affected outcomes even when pregnant people and newborns were never infected with SARS-CoV-2.

Perinatal mortality generally refers to stillbirths and deaths during the first seven days after birth, although definitions vary between countries and research studies. That variation matters when comparing global data. Some reports measure late fetal deaths and early neonatal deaths separately, while others use broader periods that include the first 28 days of life.

The pandemic also exposed the importance of the systems that surround specialist care: antenatal appointments, referral transport, skilled birth attendance, neonatal intensive care, laboratory testing, and social support. The official FAOPS 2020 congress site reflects the international clinical and research community that was preparing to discuss perinatal and neonatal medicine in Tokyo before the meeting was canceled in April 2020.

Why Mortality Rose Even Without Widespread Infection

Direct infection contributed to some severe maternal and neonatal outcomes, especially during later waves and among pregnant people with underlying health conditions. However, indirect effects often played a larger role in the early phase of the pandemic. Lockdowns, fear of infection, reduced public transportation, and overwhelmed facilities delayed routine and emergency care.

A missed antenatal appointment can mean that hypertension, fetal growth restriction, diabetes, or placental complications remain undetected. Delayed presentation during labor can reduce the opportunity for timely cesarean delivery or management of fetal distress. In low-resource settings, a shortage of oxygen, blood products, personal protective equipment, and trained staff intensified these risks.

Stillbirths were particularly sensitive to disruptions in pregnancy surveillance. Fetal movement concerns, abnormal ultrasound findings, and maternal warning signs require rapid assessment. When referral pathways became uncertain or families postponed hospital visits, preventable complications could progress beyond the point at which treatment was effective.

Neonatal deaths were affected by similar pressures after delivery. Premature infants depend on reliable thermal care, respiratory support, feeding assistance, infection prevention, and follow-up. Interruptions in these services can be fatal, especially for babies born in facilities without a fully equipped neonatal unit.

The Global Pattern Was Uneven

The effect on perinatal mortality was not uniform across countries, regions, or hospitals. Wealthier health systems often maintained emergency obstetric services but still experienced increases in stillbirth or neonatal complications in particular areas. Lower-income settings faced more severe threats because routine maternity services were already operating with limited staff and equipment.

Urban hospitals could be overwhelmed during infection peaks, while rural communities faced long journeys and transport restrictions. In some places, maternity wards were converted for COVID-19 care or separated into designated infection areas. These changes protected staff and patients from transmission, yet they sometimes reduced access to ultrasound, fetal monitoring, operating rooms, or neonatal beds.

Differences in reporting also complicate global estimates. A fall in recorded perinatal deaths may reflect weaker registration rather than improved survival. Conversely, a rise in hospital-based mortality may occur because high-risk patients were concentrated in referral centers after smaller facilities closed or restricted services.

Research published during and after the first pandemic waves has therefore produced varied estimates. Some studies found a clear increase in stillbirth, while others reported little change in neonatal mortality. The most consistent finding is that service disruption and social inequality shaped risk, with the greatest harm concentrated among families already facing barriers to care.

Maternal Health Was Closely Connected

Perinatal survival cannot be separated from maternal health. Pregnant people with severe COVID-19 were more likely to require intensive care, and severe respiratory illness could increase the risk of preterm birth or medically indicated delivery. Yet maternal mortality and morbidity also rose through indirect pathways, including untreated preeclampsia, delayed management of hemorrhage, and reduced access to mental-health support.

The pressure was especially intense for high-risk pregnancies. People with multiple gestations, placental disorders, previous cesarean births, fetal anomalies, or chronic disease required individualized surveillance. Social-distancing policies made some clinical encounters safer but could also weaken continuity of care when remote consultations replaced examinations that could not be performed virtually.

Guidance developed rapidly and differed between health systems. Some hospitals limited birth companions, changed visiting rules, or separated mothers and newborns when infection was suspected. These measures were designed to reduce transmission, but unnecessary separation and poor communication could interfere with breastfeeding, bonding, and parental participation in care.

Practical guidance on high-risk pregnancy care illustrates why pandemic planning must balance infection prevention with timely monitoring and emotional support. A safe system needs clear criteria for in-person assessment, dependable escalation routes, and communication that families can understand.

Low-Resource Settings Faced Compounded Risk

Many low- and middle-income countries entered the pandemic with shortages of midwives, obstetricians, neonatal nurses, medicines, and functioning referral networks. When COVID-19 added travel restrictions and supply-chain problems, the margin for managing complications became even smaller.

A facility may have remained open yet become practically inaccessible. Public transport interruptions, fuel costs, checkpoints, and fear of exposure all influenced whether a pregnant person could reach care. Families who lost income also faced difficult decisions about transport, food, and medical expenses. These factors can contribute to delays at home, delays reaching a facility, and delays receiving treatment after arrival.

Community health workers and local birth attendants played a critical role in identifying danger signs and directing families to care. Where outreach programs continued, they helped preserve vaccination, antenatal counseling, and newborn follow-up. Where programs were suspended, the loss of trusted local support widened the gap between formal health services and households.

The pandemic also threatened essential newborn interventions. Kangaroo mother care, breastfeeding support, and skin-to-skin contact were sometimes restricted because of infection concerns, even though evidence increasingly supported maintaining these practices with appropriate precautions. Policies that rely on separation can create new risks for premature and low-birth-weight infants when alternatives are not available.

Measuring the Long-Term Impact

Researchers assess pandemic effects through stillbirth rates, early neonatal mortality, neonatal mortality, preterm birth, maternal deaths, and service-use indicators. Each measure captures a different part of the story. A stable neonatal death rate does not prove that the system was unaffected if stillbirths increased or if care shifted away from vulnerable populations.

Comparisons before and during the pandemic can be distorted by seasonal variation, changes in referral patterns, incomplete reporting, and differences in testing. Hospital studies may overrepresent severe cases, while national statistics may take years to become complete. Researchers therefore need linked data from birth registers, mortality records, facility reports, and household surveys.

Long-term monitoring is also necessary because the consequences may continue after restrictions end. Missed vaccinations, untreated maternal disease, interrupted developmental follow-up, and accumulated economic hardship can affect children beyond the perinatal period. Health systems may appear operational while still carrying a backlog of high-risk pregnancies and delayed neonatal reviews.

Future studies should distinguish direct viral effects from the consequences of service disruption. They should examine which groups experienced the greatest increase in risk, how quickly services recovered, and whether telemedicine improved access or excluded families without reliable connectivity. Transparent definitions and consistent reporting will make international comparisons more useful.

Building More Resilient Perinatal Services

The pandemic showed that maintaining maternity and newborn care requires more than issuing infection-control instructions. Essential services must be identified in advance, protected during emergency planning, and supported with staff, transport, equipment, and reliable communication.

Hospitals also need flexible models that can expand without removing routine obstetric and neonatal capacity. Separate infection pathways, rapid testing, appropriate ventilation, and clear triage can reduce transmission while keeping urgent care available. Regional networks should make it possible to transfer patients and newborns when a local unit reaches capacity.

Practical priorities include:

• Preserve antenatal appointments for hypertension, fetal growth, diabetes, and other high-risk conditions, using remote care only when physical assessment is unnecessary.
• Guarantee emergency transport and referral communication across urban, rural, and cross-border areas.
• Protect neonatal essentials such as oxygen, thermal care, breast milk support, antibiotics, and kangaroo mother care.
• Give families clear instructions about warning signs, hospital safety measures, and when immediate assessment is required.
• Track stillbirths, early neonatal deaths, near misses, and missed appointments in real time to identify service failures quickly.

Training should include emergency triage, respectful maternity care, infection prevention, bereavement support, and communication with families during isolation. Staff wellbeing also matters: exhausted or unsupported clinicians are more likely to experience errors, absenteeism, and burnout.

Recovery plans should include parents and community organizations. Families can help identify barriers that do not appear in hospital statistics, such as unaffordable transport, language differences, fear of stigma, or confusion about changing rules. Their experience should inform preparedness plans before the next public-health emergency occurs.

Turning Evidence Into Safer Care

The pandemic’s effect on perinatal mortality was shaped by a combination of viral disease, delayed care, disrupted services, inequality, and policy choices. It cannot be reduced to a single worldwide percentage. Some systems protected survival effectively, while others saw preventable losses rise when routine and emergency pathways became fragile.

Perinatal professionals, health administrators, researchers, and policymakers can use this evidence to strengthen surveillance and protect essential care. Reviewing local stillbirth and neonatal death data, identifying referral bottlenecks, and restoring trusted community links are practical steps toward a safer future.

The next public-health emergency will test whether these lessons were applied. Use the available evidence to audit maternity and newborn services, prioritize families at greatest risk, and make continuity of perinatal care a core part of emergency preparedness.