Excess maternal deaths and maternal mortality ratios during the COVID-19 pandemic period: a global country-level counterfactual modelling study

Background: Maternal mortality remains uneven globally, and the COVID-19 pandemic disrupted maternal health services through direct infection-related risks and indirect health-system pathways. We estimated country-level deviations in maternal deaths and maternal mortality ratios (MMR) during 2020-2023 relative to pre-pandemic trends. Methods: We used WHO/UN MMEIG model-based country-level estimates of maternal deaths and MMR from 2000-2019 to fit an ensemble n-sub-epidemic forecasting model. We generated no-pandemic counterfactual projections for 2020-2023 and compared them with WHO/UN MMEIG estimates for the same years. Excess was defined as the positive difference between the WHO/UN MMEIG estimate and the counterfactual prediction; uncertainty was quantified using bootstrap-based prediction intervals. Results: Globally, estimated cumulative excess maternal deaths were 68,489 (95% UI 34,706-147,118) during 2020-2023, and the aggregate excess MMR was 10,154 (95% UI 4,568-23,744). The largest regional excess death burdens were observed in the South-East Asia Region, Eastern Mediterranean Region, and African Region. Among the eight illustrative high-burden countries, Afghanistan and Somalia had statistically detectable excess maternal deaths, with totals of 2,335 (95% UI 1,148-4,350) and 1,815 (639-3,401), respectively. Liberia had a positive median estimate of 265 excess maternal deaths, but its interval included zero (0-990). Nigeria, Chad, and South Sudan had median totals of zero, although uncertainty intervals indicated that nonzero excess could not be excluded in Chad and South Sudan. Conclusion: Pandemic-period WHO/UN MMEIG estimates deviated heterogeneously from pre-pandemic counterfactual trends. These findings should be interpreted as modeled excess relative to a no-pandemic baseline and may reflect pandemic-related disruptions together with other contemporaneous health-system, political, and social shocks, rather than directly observed deaths or causal effects attributable solely to COVID-19.