Trends, statistics, and policy recommendations on maternal, fetal, and infant mortality before and after COVID-19: a review of the past decade (2012-2022) based on national health information data
Article information
Abstract
Objective
To examine the impact of the coronavirus disease 2019 (COVID-19) pandemic on maternal, fetal, and infant mortality in South Korea using national statistics, in order to inform policy development and enhance maternal and child health outcomes with the provided data.
Methods
Pregnancy-related mortality in women, as well as deaths of infants, in South Korea was identified using cause-of-death statistics from Statistics Korea. Records from death certificates, cremation reports on infant and fetal deaths, and the complementary cause-of-death investigation system were reviewed for the 2012-2022 period. The classification criteria for cause of death followed the recommendations of World Health Organization and the Korean standard classification of diseases and causes of death.
Results
The maternal mortality rate decreased from 11.3 per 100,000 live births in 2018 to 9.9 in 2019, rose to 11.8 in 2020, and fell to 8.8 in 2021. The actual number of maternal deaths declined from 37 in 2018 to 23 in 2021 due to fewer births. The fetal death rate increased from 11.3 per 1,000 live births in 2018 to 11.6 in 2019, continuing to rise to 12.0 in 2021. The number of fetal deaths dropped from 3,743 in 2018 to 3,152 in 2021.
Conclusion
Despite the COVID-19 pandemic, Korea experienced a sharp decline in births as well as in maternal, infant, and fetal deaths. However, maternal, infant, and fetal mortality rates remained at similar levels.
Introduction
The global coronavirus disease 2019 (COVID-19) pandemic has had a significant and widespread impact on the healthcare sector, from access to medical services to causes of death. The World Health Organization (WHO) reports that the slow progress in reducing maternal mortality started before the COVID-19 pandemic in 2020. Although the pandemic may have worsened the situation, it is not the only reason for the lack of progress [1].
In Korea, COVID-19 spread rapidly since the first infection in January 2020 [2]. Therefore, active interventions in health policies, such as social distancing and vaccination, were implemented throughout 2020 [3,4]. As a result, health statistics indicators in 2020 differed from those of the previous year. In 2020, the use of medical services decreased by 2.1% as compared to the previous year. By type of service use, the decrease was largest in the order of emergency (-19.1%), hospitalization (-10.7%), outpatient (-2.2%), and surgery (-1.3%) services. In the case of cause of death, the mortality rate by cause of death also changed around 2020 [5].
The COVID-19 pandemic has likely altered medical care behaviors related to pregnancy and birth, and prompted stricter quarantine measures in healthcare institutions. Specifically, previous studies concluded that COVID-19 did not substantially elevate maternal mortality rates [2]. Furthermore, several hospital-based investigations into COVID-19-related maternal deaths revealed that the mortality rate for pregnant women with COVID-19 was comparable to that of non-pregnant women of reproductive age (20-45 years). Maternal mortality rates thus remained largely unchanged from pre-pandemic levels. In addition, no evidence of vertical transmission was found in COVID-19-positive pregnant women, and the severity of COVID-19 in these women did not adversely affect neonatal outcomes [2,4]. South Korea’s effective response to COVID-19 and its proactive strategies for pregnant women may explain the lower prevalence of COVID-19 infection among pregnant women than among non-pregnant women. Furthermore, no COVID-19-related deaths or severe hospitalizations among pregnant women infected with the virus were reported [4].
In this way, considering the significant impact of the pandemic on healthcare access and mortality, this study sought to analyze changes in maternal, fetal, and infant mortality rates-which are key indicators of pregnancy and childbirth health-using South Korean national statistics. Recent analyses suggested that demographic trends observed in the decades leading up to the COVID-19 pandemic, along with the reversals of those trends during the initial 2 years of the pandemic (2020-2021), can offer valuable insights into the potential long-term impacts of the pandemic [6]. Therefore, this study aimed to update previously reported data with the latest statistics and to provide trend analysis that can support research in related fields by examining changes from before to after the implementation of social distancing and lockdown measures in 2020 [7]. Ultimately, this research will provide a scientific basis for developing effective maternal and child healthcare policies.
Materials and methods
1. Study design
This descriptive study was based on the public data of Statistics Korea. It is reported according to the STROBE statement (https://www.strobe-statement.org/).
The cause-of-death statistics from Statistics Korea used in this study are compiled based on the death certificate issued by a physician at the time of death and the death notification written by the bereaved family. However, omission of infant and maternal deaths is likely to occur in the civil registration and vital statistics system. Infant deaths may be omitted without a birth or death report if the death occurs immediately after birth. In addition, in the case of maternal death, if information on pregnancy and childbirth is not known when issuing a death certificate, maternal deaths may be excluded. To make up for these shortcomings, Statistics Korea collects death reports of infants and fetuses from crematoriums. In addition, specific information on infant, maternal, and fetal deaths is collected through additional investigations into medical institutions.
In order to improve the accuracy of the cause of death, 22 types of administrative data from 16 organizations, including national health insurance data, infection-specific test information, cancer registry, police investigation records, and autopsy data, are linked for each individual to select the cause of death. The classification criteria for cause of death followed the recommendations of the WHO and the Korean standard classification of diseases and causes of death. Collection and analysis of the data were not biased. The total population of the Republic of Korea was included. No study size estimation was thus required. Descriptive statistics were applied to present the results of the data analysis.
Results
1. Maternal deaths
The number of maternal deaths in 2022 was 21, and the maternal mortality ratio was 8.4 per 100,000 live births. Compared to 2021, the number of maternal deaths decreased by 8.7% and the maternal mortality ratio decreased by 4.5%. In 2020, the maternal mortality ratio was 11.8, the highest in the past 10 years, but it has since decreased back to the previous level. The trend predated the COVID-19 pandemic: between 2018 and 2019, the ratio had decreased from 11.3 to 9.9. It then rose to 11.8 in 2020 and decreased again, to 8.8, in 2021. The number of births had declined. In terms of the actual number of maternal deaths before and after the COVID-19 pandemic, 23 maternal deaths in women under the age of 20 years had occurred, as compared with 37 in 2018. Over the past decade since 2012, the maternal mortality ratio has fluctuated slightly, consistently remaining at around 8-11 deaths per 100,000 live births (Fig. 1).
The maternal mortality ratio by age group was highest in the following order: 35-39-year age group (12.4), 40 years or older age group (12.4), and the 30-34-year age group (7.9), while the lowest maternal mortality ratio of 2.5 was found among women aged 25-29 years. Although differences were found depending on the period, the maternal mortality ratio overall increased as maternal age increased. Compared to the previous year, the maternal mortality ratio increased by 57.3% for those aged 35-39 years, and decreased by 53.3% for those aged 40 years and older. In 2020, the maternal mortality ratio for those aged 40 years and over increased significantly, remained steady until 2021, and then decreased in 2022 (Fig. 2).
In 2022, direct obstetric deaths accounted for 81.0% of all maternal deaths. The number of indirect obstetric deaths was 4, accounting for 19.0% of all maternal deaths. Eight deaths occurred due to “complications predominantly related to the puerperium (O85-O92)”, including obstetric embolism, and five deaths occurred due to “complications of labor and delivery (O60-O75)”, such as postpartum hemorrhage. In the case of “complications predominantly related to the puerperium (O85-O92)”, the maternal mortality ratio was 4.4 in 2020, which was the highest ratio in the past 10 years, and then reduced to 3.2 in 2022 (Table 1).
2. Fetal death
The number of fetal deaths after 16 weeks of pregnancy in 2022 was 3,073, a 2.5% decrease from the previous year (Fig. 3). In 2022, the number of fetal deaths after 22 weeks of pregnancy was 1,092, and the number of fetal deaths after 28 weeks of pregnancy was 429, both of which represented decreases from the previous year. The fetal mortality rate after 16 weeks of pregnancy was 12.2 per 1,000 live births and fetal deaths, which indicated an increase of 0.2 from the previous year. Since 2015, the fetal mortality rate has shown an increasing trend. The number of fetal deaths by gestational week was the highest at 16-21 weeks. The lower the gestational week, the higher the number of fetal deaths and the fetal mortality rate (Table 2).

The number of fetal deaths and fetal mortality rates for 2012-2022. *Calculated based on vfetal deaths at 16 weeks or more of pregnancy.
This trend needs to be examined from before the COVID-19 pandemic. Between 2018 and 2019, the rate of fetal deaths increased from 11.3 per 1,000 live births to 11.6. It then continued to rise, reaching 11.6 in 2020 and 12.0 in 2021. Due to the decline in the actual number of births, we investigated the actual number of fetal deaths before and after COVID-19: 3,152 fetal deaths in 2021 as compared to 3,743 in 2018.
The fetal mortality rate by maternal age was highest among women aged under 20 years at 157.7, and lowest for those in the 25-29-year age group, at 9.4. The fetal mortality rate for mothers aged under 20 years decreased to 69.9 in 2020 and then rose to 157.7 in 2022. Additionally, the fetal mortality rate among women aged 20-24 years continues to increase (Table 3).
3. Infant death
The number of infant deaths in 2022 was 565, representing a decrease of 61 from the previous year, showing a continuous downward trend. The infant mortality rate was 2.3 per 1,000 live births, a decrease of 0.1 from the previous year (Fig. 4).
In 2022, the infant mortality rate by gestational week was the highest, at 261.9, for those less than 28 weeks of gestation. Infant deaths at a gestational age of less than 28 weeks, 32-36 weeks, and 37-41 weeks have been steadily decreasing (Table 4). The infant mortality rate by maternal age was lowest for those aged 30-34 years at 1.8, and highest for those under 20 years of age, at 19.0. Compared to 2012, the infant mortality rate has increased among women under 29 years of age and has decreased among those aged 30 years and older (Table 5).
Discussion
The WHO aims to reduce the global maternal mortality rate to fewer than 70 deaths per 100,000 live births by 2030, in alignment with the targets set by the sustainable development goals [1]. The Organization for Economic Co-operation and Development (OECD) reported that the average maternal mortality ratio across its member countries was 10.9 deaths per 100,000 live births in 2020 [8]. South Korea recorded a maternal mortality ratio of 11.8 in 2020 and of 8.4 in 2022, which aligns with the global sustainable development goals (Fig. 1). In 2021, the average infant mortality rate in OECD countries was 4 deaths per 1,000 live births, a decrease from 4.7 deaths per 1,000 live births in 2011 [8]. In South Korea, the infant mortality rate was 2.5 deaths per 1,000 live births in 2020, 2.4 in 2021, and 2.3 in 2022.
As the population ages, more women are having children at older ages, leading to an increase in the average age of mothers at childbirth (Fig. 5) [9]. The average age of pregnant women has increased by about 2 years, from 31.6 years in 2012 to 33.5 years in 2022. This reflects the rise in the proportion of mothers aged 35 years and older, which grew from 40.2% in 2012 to 52.3% in 2022.
The rapid decline in the number of births in our country is reflected in the sharp decrease in the absolute numbers of maternal, infant, and fetal deaths. However, it is important to note that the mortality indicators relative to the number of births, such as the maternal mortality ratio or the infant and fetal mortality rates, have remained at comparable levels.
A more detailed analysis revealed that maternal age is a critical determinant of mortality outcomes. For maternal mortality, the mortality ratio increased with advancing maternal age [10], while in cases of infant and fetal mortality, the risk is significantly higher when maternal age is below 20 years [11]. This underscores the importance of both advanced and younger maternal age as key risk factors for pregnancy-related mortality, regardless of the COVID-19 pandemic. We believe that this should be considered in the same context as the mechanisms described by the WHO regarding the impact of the COVID-19 pandemic on maternal mortality [1,2,12]. The first mechanism involves deaths where a woman’s pregnancy condition interacted with COVID-19, resulting in her death, which is classified as an indirect obstetric death. The second mechanism refers to deaths caused by pregnancy complications that were not adequately prevented or managed due to disruptions in healthcare services during the pandemic. These service disruptions may have restricted access to essential maternal care, leading to an increase in preventable maternal deaths.
At the onset of the COVID-19 pandemic, the exact extent of the risks associated with pregnancy remained unclear.
The maternal mortality ratio for women aged 40 years and over increased during the COVID-19 pandemic [13,14]. A large-scale study found a relative risk of 1.54 for maternal morbidity and mortality, with women diagnosed with COVID-19 having a 22-fold higher risk of maternal death. Additionally, those with preexisting conditions, such as obesity, diabetes, hypertension, and chronic cardiopulmonary diseases, had a nearly four-fold increased risk of developing preeclampsia or eclampsia [15]. We showed significant increases in severe maternal morbidity, mortality, and neonatal complications in pregnant women with COVID-19. However, caution is needed when interpreting these findings, as more research is required for a full understanding of the underlying causes of the rise in maternal mortality [14,16].
In this study, in 2020, the maternal mortality ratio due to postpartum complications, such as amniotic fluid embolism and other obstetric embolisms, reached 4.4 per 100,000 live births, the highest in the past decade. It then showed little variation, with 3.1 in 2012 and 3.2 in 2022.
A previous study reported a relative risk of 2.14 for severe perinatal morbidity and mortality among women with a COVID-19 diagnosis and their newborns. That study also identified at least one severe neonatal condition listed [14].
A meta-analysis found an odds ratio of 1.71 for the occurrence of intrauterine fetal death or stillbirth in 256 women with COVID-19, as compared to 6,730 women without the virus [17].
In the Korean data in the present study, the fetal mortality rate was 12.3 in 2012, 11.6 in 2020, and 12.2 in 2022, while the infant mortality rate was 2.9 in 2012, 2.5 in 2020, and 2.3 in 2022. These figures indicate that the rates per 1,000 live births have shown little variation.
The WHO continues to highlight that maternal mortality related to pregnancy often results from severe postpartum bleeding, usually postpartum infections, pregnancy-induced hypertension, delivery complications, and unsafe abortions, which aligns with findings from our own research [18]. The WHO also emphasizes that these pregnancy-related causes of death can be prevented through high-quality care, stating that all women need access to excellent care during pregnancy, childbirth, and the postpartum period. Korea is considered to have an advanced healthcare system, as evidenced by its low maternal mortality rates [19]. It would be important to examine whether it is possible to achieve even lower maternal mortality rates through further medical and policy advancements.
In conclusion, the exact extent of pregnancy-related risks remained unclear. Despite the COVID-19 pandemic, Korea experienced a sharp decrease in the absolute numbers of maternal, infant, and fetal deaths, along with a rapid decline in the number of births. However, mortality indicators relative to the number of births, such as the maternal mortality ratio and infant and fetal mortality rates, have remained at similar levels to the past.
Notes
Conflict of interest
No potential conflict of interest relevant to this article was reported.
Ethical approval
No institutional approval was required because this was an analysis of publicly available data that were produced by Statistics Korea according to the Bioethics and Safety Act (IRB No.: NRC-2024-04-031).
Patient consent
None.
Funding information
This research was supported by the Korea Forestry Promotion Institute (grant number: RS-2024-00404406).