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The COVID-19 pandemic has presented obstacles for providers and patients in the maternal health care setting, causing changes to many pregnant women’s birth plans, as well as abrupt changes in hospital labor and delivery policies and procedures. Few data exist on the effects of the COVID-19 pandemic on the maternal health care landscape at the national level in the United States.
The aim of this study is to assess the incidence of key obstetrics outcomes (preterm delivery, Cesarean sections, and home births) and length of hospital stay during the COVID-19 pandemic as compared to the 6 months prior.
We conducted a retrospective cohort study of women aged 18-44 years in the United States who delivered between October 1, 2019, and September 30, 2020, had singleton deliveries, and completed a birth report in the Ovia Pregnancy mobile app. Women were assigned to the prepandemic cohort if they delivered between October 2019 and March 2020, and the pandemic cohort if they delivered between April and September 2020. Gestational age at delivery, delivery method, delivery facility type, and length of hospital stay were compared.
A total of 304,023 birth reports were collected, with 152,832 (50.26%) in the prepandemic cohort and 151,191 (49.73%) in the pandemic cohort. Compared to the prepandemic cohort, principal findings indicate a 5.67% decrease in preterm delivery rates in the pandemic cohort (
Results suggest a need for continuous monitoring of maternal health trends as the COVID-19 pandemic progresses and underline the important role of digital data collection, particularly during the pandemic.
The first confirmed case of COVID-19 in a pregnant woman in the United States was during the week of January 19, 2020. By March 8, there were over 100 confirmed cases in pregnant women per day, increasing to over 2000 cases per day by the first peak in early July [
Several studies have explored the effects of COVID-19 infection in pregnant women and on their birth outcomes, but there remains a lack of data (particularly at the national level) describing the effects of the pandemic itself—including infections and policy and lifestyle adjustments—on birth outcomes. Early studies on potential pandemic effects show decreases in preterm deliveries [
Using user-reported data from the Ovia Pregnancy mobile app, we assessed key obstetrics outcomes throughout the COVID-19 pandemic and compared them to outcomes in the 6 months prior to the pandemic. This short paper focuses on the incidence of preterm delivery, Cesarean sections, and home births, as well as the length of hospital stays postdelivery during the first 6 months of the pandemic and the preceding 6 months.
We conducted a retrospective cohort study of women aged 18-44 years residing in the United States who had singleton deliveries between October 1, 2019, and September 30, 2020, and completed a birth report in a pregnancy mobile app. The birth report collected delivery date, delivery method, delivery facility type, and hospital admission and discharge dates. We assigned women to the prepandemic cohort if they delivered between October 1, 2019, and March 30, 2020, and to the pandemic cohort if they delivered between April 1, 2020, and September 30, 2020. We compared gestational age at delivery, delivery method, delivery facility type, and hospital length of stay. Preterm delivery was defined as a baby born before 37 weeks of pregnancy. Delivery method options were vaginal, planned and unplanned Cesarean sections, and vaginal birth after Cesarean (VBAC). Delivery facility type options included hospital, birthing center, home birth, or other. Hospital length of stay was equal to the difference in days between hospital admission date and discharge date and was limited to those who reported stays ≤14 days. Demographic data were collected via Ovia Pregnancy app questions delivered to users as part of their app experience. With the exception of age, all demographic questions were optional.
All analyses were conducted in R Studio (version 1.3.959; R Foundation for Statistical Computing). Descriptive statistics were calculated using the
All of the data used in the study were collected from US resident users. All of the personal information collected by Ovia is processed in accordance with Ovia’s Privacy Policy [
A total of 304,023 pregnant women in the United States between the ages of 18 and 44 years completed a birth report via the Ovia Pregnancy app and were thus eligible for the study. Among those, 152,832 (50.26%) women delivered between October 2019 and March 2020 and were assigned to the prepandemic cohort and 151,191 (49.73%) delivered between April 2020 and September 2020 and were assigned to the pandemic cohort. Women who reported their births represented 30.37% (prepandemic) and 31.10% (pandemic) of all women who used the app and also were expected to deliver during the respective time periods based on their logged last menstrual period date. The sample used in this study represents approximately 8.11% of annual births in the United States [
Among all users in the sample, 14.9% (n=45,530) completed questions about their race, 20.4% (n=61,886) completed questions about their education, 58.3% (n=177,359) completed questions about their employment status, and 21.7% (n=65,957) completed questions about their income. The majority identified as White (n=32,477, 71.33%), college-educated (n=23,085, 37.30%), and employed (n=131,420, 74.09%), and had annual household incomes over $100,000 (n=15,997, 24.25%). The average age at delivery was 28.31 years, and users in the pandemic cohort were, on average, slightly older. Demographic stratifications by cohort are shown in
Sample demographics prepandemic and during the pandemic.
Variables | Prepandemic (October 2019-March 2020; n=152,832) | Pandemic (April-September 2020; n=151,191) | |
Age at delivery (years), mean (SD) | 28.2 (5.28) | 28.5 (5.23) | |
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<20 | 5775 (3.78) | 4848 (3.21) |
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20-24 | 36,323 (23.77) | 33,658 (22.26) |
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25-29 | 48,026 (31.42) | 47,258 (31.26) |
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30-34 | 43,682 (28.58) | 45, 687 (30.22) |
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35-39 | 15,474 (10.78) | 17,152 (11.34) |
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40-44 | 2552 (1.67) | 2588 (1.71) |
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White (non-Hispanic) | 16,571 (71.04) | 15,906 (71.63) |
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Black (non-Hispanic) | 1584 (6.79) | 1467 (6.61) |
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Asian American/Pacific Islander | 415 (1.78) | 372 (1.68) |
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Hispanic/Latinx | 1782 (7.64) | 1704 (7.67) |
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Multiracial | 2973 (12.75) | 2756 (12.41) |
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<25,000 | 5370 (15.87) | 4655 (14.49) |
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25,000-50,000 | 8047 (23.78) | 7436 (23.15) |
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50,000-75,000 | 6311 (18.65) | 6181 (19.24) |
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75,000-100,000 | 6034 (17.83) | 5926 (18.45) |
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>100,000 | 8072 (23.86) | 7925 (24.67) |
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Some high school | 917 (2.91) | 900 (2.96) |
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High school degree/equivalent | 4123 (13.10) | 3689 (12.13) |
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Some college | 7711 (24.50) | 7331 (24.10) |
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College degree | 11,670 (37.08) | 11,415 (37.53) |
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Some postgraduate studies | 1446 (4.59) | 1463 (4.81) |
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Postgraduate degree | 5604 (17.81) | 5617 (18.47) |
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Employed | 65,619 (73.53) | 65,801 (74.67) |
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Not employed | 23,619 (26.47) | 22,320 (25.33) |
A total of 272,686 (89.69%) users in the sample had valid gestational ages at delivery based on the last menstrual period date. Overall preterm delivery rates had a relative decrease of 5.67%, from 8.46% (n=11,192) in the prepandemic cohort to 7.98% (n=11,216) in the pandemic cohort (
Comparison of birth outcomes prepandemic and during the pandemic.
Birth outcomes | Value, n (%) | Relative change, % | Odds ratio (95% CI) | |||
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Prepandemic | During the pandemic |
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Reported births, n (%) | 152,832 (50.26) | 151,191 (49.73) | –1.05 | N/Aa | N/A | |
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Full-term births | 121,113 (91.54) | 129,165 (92.01) | 0.51 | <.001b | 0.94 (0.91-0.96) |
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Preterm births (<37 weeks) | 11,192 (8.46) | 11,216 (7.98) | –5.67 | <.001b | 0.94 (0.91-0.96) |
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Vaginal | 103,808 (67.98) | 102,717 (67.95) | –0.04 | .79 | 1 (0.98-1.01) |
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Cesarean section | 46,923 (30.73) | 46,381 (30.68) | –0.16 | .79 | 0.99 (0.98-1.01) |
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Vaginal birth after Cesarean | 1981 (1.30) | 2072 (1.37) | 5.38 | .29 | 0.96 (0.91-1.02) |
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Hospital | 141,267 (91.76) | 141,173 (90.97) | –0.86 | <.001b | 0.90 (0.87-0.93) |
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Birthing center | 4812 (3.13) | 4985 (3.21) | 2.56 | .11 | 1 (99.2-1.07) |
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Home | 1535 (1.00) | 2019 (1.30) | 30.00 | <.001b | 1.3 (1.23-1.4) |
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Total out-of-hospital (birthing center + home) | 6347 (4.12) | 7004 (4.51) | 9.47 | <.001b | 1.1 (1.06-1.14) |
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All deliveries | 2.69 (1.39) | 2.48 (1.35) | –7.81 | <.001b | N/A |
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Vaginal + vaginal birth after Cesarean | 2.42 (1.19) | 2.24 (1.16) | –7.44 | <.001b | N/A |
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Cesarean section | 3.46 (1.62) | 3.17 (1.59) | –8.38 | <.001b | N/A |
aN/A: not applicable.
b5% statistical significance cutoff.
Relative change in reported birth outcomes by month, compared to reference period (October 2019).
Comparison of birth outcomes (preterm or full-term) prepandemic and during the pandemic by age group at delivery.
Age group (years), n (%) | Prepandemic, n (%) | Pandemic, n (%) | Relative change, % | Odds ratio (95% CI) | |||
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Preterm | Full-term | Preterm | Full-term | Preterm |
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|
<20 | 474 (9.25) | 4648 (90.75) | 411 (9.27) | 4022 (90.73) | 0.19 | 1 | 1 (0.87-1.15) |
20-24 | 2587 (8.15) | 29,153 (91.85) | 2572 (8.36) | 28,190 (91.64) | 2.58 | .35 | 1.02 (0.97-1.08) |
25-29 | 3422 (8.36) | 37,498 (91.64) | 3286 (7.55) | 40,231 (92.45) | –9.70 | <.001a | 0.90 (0.85-0.94) |
30-34 | 3036 (8.10) | 34,427 (91.90) | 3223 (7.52) | 39,653 (92.48) | –7.24 | .002a | 0.92 (0.87-0.97) |
35-39 | 1363 (9.29) | 13,307 (90.71) | 1424 (8.74) | 14,873 (91.26) | –5.95 | .09 | 0.93 (0.86-1.01) |
40-44 | 310 (12.97) | 2080 (87.03) | 300 (12.02) | 2196 (87.98) | –7.34 | .34 | 0.91 (0.77-1.09) |
a5% statistical significance cutoff.
Comparison of birth outcomes (preterm versus full-term) prepandemic and during the pandemic by race and ethnicity.
Race and ethnicity | Prepandemic, n (%) | Pandemic, n (%) | Relative change, % | Odds ratio (95% CI) | |||
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Preterm | Full-term | Preterm | Full-term | Preterm |
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White (non-Hispanic) | 1069 (7.74) | 12,751 (92.26) | 1069 (7.25) | 13,677 (92.75) | –6.28 | <.001a | 0.85 (0.78-0.94) |
Black (non-Hispanic) | 160 (11.28) | 1259 (88.72) | 170 (12.59) | 1180 (87.41) | 0.13 | .31 | 1.13 (0.90-1.43) |
Asian American/Pacific Islander | 30 (8.19) | 336 (91.81) | 33 (9.42) | 317 (90.58) | 15.03 | .65 | 1.16 (0.69-1.97) |
Hispanic/Latinx | 154 (9.91) | 1399 (90.09) | 146 (9.24) | 1433 (90.76) | –6.76 | .85 | 1.03 (0.81-1.30) |
Multiracial | 241 (9.62) | 2262 (90.38) | 237 (9.47) | 2265 (90.53) | –1.62 | .88 | 0.98 (0.81-1.18) |
a5% statistical significance cutoff.
Among the total sample, 303,882 (99.9%) users completed the delivery method field of the app’s birth report form. Overall Cesarean section rates did not change significantly in the pandemic cohort compared to the prepandemic cohort (
Comparison of birth outcomes (delivery method) prepandemic and during the pandemic by age group at delivery.
Age group (years), n (%) | Prepandemic, n (%) | Pandemic, n (%) | Relative change, % | Odds ratio (95% CI) | |||
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Cesarean section | Vaginal/vaginal birth after Cesarean | Cesarean section | Vaginal/vaginal birth after Cesarean | Cesarean section |
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<20 | 1105 (19.13) | 4670 (80.87) | 1036 (21.37) | 3812 (78.63) | 11.68 | .004a | 1.15 (1.04-1.26) |
20-24 | 9124 (25.13) | 27,187 (74.87) | 8598 (25.55) | 25,059 (74.45) | 1.67 | .20 | 1.02 (0.98-1.06) |
25-29 | 14,103 (29.38) | 33,903 (70.62) | 13,664 (28.92) | 33,589 (71.08) | –1.57 | .12 | 0.97 (0.95-1.00) |
30-34 | 14,563 (33.39) | 29,052 (66.61) | 14,930 (32.68) | 30,749 (67.32) | –2.11 | .025a | 0.96 (0.94-0.99) |
35-39 | 6774 (41.16) | 9684 (58.84) | 6899 (40.24) | 10,247 (59.76) | –2.24 | .08 | 0.96 (0.92-1.00) |
40-44 | 1254 (49.23) | 1293 (50.77) | 1254 (48.47) | 1333 (51.53) | –1.55 | .60 | 0.97 (0.86-1.08) |
a5% statistical significance cutoff.
Comparison of birth outcomes (delivery method) prepandemic and during the pandemic by race and ethnicity.
Race and ethnicity | Prepandemic, n (%) | Pandemic, n (%) | Relative change, % | Odds ratio (95% CI) | |||
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Cesarean section | Vaginal/vaginal birth after Cesarean | Cesarean section | Vaginal/vaginal birth after Cesarean | Cesarean section |
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White (non-Hispanic) | 5070 (30.60) | 11,494 (69.40) | 4849 (30.49) | 11,053 (69.51) | –0.38 | .83 | 0.99 (0.94-1.04) |
Black (non-Hispanic) | 578 (36.48) | 1006 (63.52) | 590 (40.21) | 877 (59.79) | 10.22 | .03a | 1.17 (1.01-1.35) |
Asian American/Pacific Islander | 133 (32.04) | 282 (67.96) | 124 (33.33) | 248 (66.67) | 4.01 | .75 | 1.06 (0.78-1.42) |
Hispanic/Latinx | 578 (32.45) | 1203 (67.55) | 550 (32.27) | 1154 (67.73) | –0.54 | .94 | 0.99 (0.86-1.14) |
Multiracial | 928 (31.21) | 2045 (68.79) | 839 (30.44) | 1917 (69.56) | –2.47 | .54 | 0.96 (0.86-1.07) |
a5% statistical significance cutoff.
Among the sample, 295,791 (97.29%) users provided their birth facility type in the app. Total out-of-hospital birth rates increased by 9.47%, from 4.12% (n=6347) to 4.51% (n=7004;
Comparison of birth outcomes (delivery location) prepandemic and during the pandemic by age group at delivery.
Age group (years), n (%) | Prepandemic, n (%) | Pandemic, n (%) | Relative change, % | Odds ratio (95% CI) | |||
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Home birth | Other | Home birth | Other | Home birth |
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<20 | 33 (0.58) | 5621 (99.42) | 31 (0.65) | 4756 (99.35) | 10.95 | .77 | 1.11 (0.67-1.82) |
20-24 | 291 (0.83) | 34,892 (99.17) | 338 (1.02) | 32,653 (98.98) | 23.87 | .007a | 1.24 (1.06-1.45) |
25-29 | 509 (1.10) | 45,885 (98.90) | 669 (1.45) | 45,587 (98.55) | 31.83 | <.001a | 1.32 (1.18-1.49) |
30-34 | 486 (1.16) | 41,508 (98.84) | 672 (1.50) | 44,087 (98.50) | 29.73 | <.001a | 1.30 (1.16-1.46) |
35-39 | 186 (1.17) | 15,731 (98.83) | 270 (1.60) | 16,573 (98.40) | 37.18 | <.001a | 1.37 (1.14-1.66) |
40-44 | 30 (1.21) | 2442 (98.79) | 39 (1.53) | 2502 (98.47) | 26.47 | .39 | 1.26 (0.78-2.06) |
a5% statistical significance cutoff.
Comparison of birth outcomes (delivery location) prepandemic and during the pandemic by race and ethnicity.
Race and ethnicity | Prepandemic, n (%) | Pandemic, n (%) | Relative change, % | Odds ratio (95% CI) | |||
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Home birth | Other | Home birth | Other | Home birth |
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White (non-Hispanic) | 249 (1.54) | 15,824 (98.46) | 281 (1.80) | 15,319 (98.20) | 16.27 | .08 | 1.16 (0.98-1.34) |
Black (non-Hispanic) | 14 (0.90) | 1527 (99.10) | 20 (1.38) | 1422 (98.62) | 52.66 | .29 | 1.52 (0.77-3.11) |
Asian American/Pacific Islander | 3 (0.75) | 396 (99.25) | 4 (1.08) | 364 (98.92) | 44.57 | .71 | 1.44 (0.23-9.96) |
Hispanic/Latinx | 10 (0.58) | 1713 (99.42) | 12 (0.71) | 1665 (99.29) | 23.29 | .78 | 1.23 (0.52-2.95) |
Multiracial | 52 (1.80) | 2822 (98.20) | 69 (2.56) | 2617 (97.44) | 41.98 | .06 | 1.42 (0.99-2.06) |
A total of 122,613 (40.33%) users who delivered in a hospital provided their admittance and discharge dates in the app. Average hospital length of stay decreased by 7.81% in the pandemic cohort (mean 2.48 days, SD 1.35) as compared to the prepandemic cohort (mean 2.69, SD 1.39;
Comparison of hospital length of stay after delivery prepandemic and during the pandemic, by age group at delivery.
Age groups by delivery type | Hospital length of stay (days), mean (SD) | Relative change, % | |||
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Prepandemic | Pandemic |
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<20 | 2.73 (1.32) | 2.56 (1.24) | –6.23 | <.001a |
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20-24 | 2.65 (1.33) | 2.48(1.33) | –6.42 | <.001a |
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25-29 | 2.66 (1.4) | 2.66 (1.32) | 0.38 | <.001a |
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30-34 | 2.7 (1.41) | 2.48 (1.36) | –6.77 | <.001a |
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35-39 | 2.84 (1.51) | 2.58 (1.43) | –9.15 | <.001a |
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40-44 | 3.08 (1.62) | 2.77 (1.65) | –10.06 | <.001a |
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<20 | 3.47 (1.52) | 3.3 (1.42) | –4.90 | .05 |
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20-24 | 3.42 (1.57) | 3.19 (1.62) | –6.73 | <.001a |
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25-29 | 3.47 (1.67) | 3.13 (1.52) | –9.80 | <.001a |
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30-34 | 3.44 (1.59) | 3.18 (1.63) | –7.56 | <.001a |
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35-39 | 3.52 (1.60) | 3.19 (1.58) | –9.38 | <.001a |
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40-44 | 3.84 (1.83) | 3.27 (1.78) | –14.84 | <.001a |
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<20 | 2.57 (1.22) | 2.38 (1.13) | –7.39 | <.001a |
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20-24 | 2.44 (1.16) | 2.28 (1.16) | –6.56 | <.001a |
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25-29 | 2.38 (1.18) | 2.21 (1.15) | –7.14 | <.001a |
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30-34 | 2.40 (1.20) | 2.21 (1.13) | –7.92 | <.001a |
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35-39 | 2.46 (1.32) | 2.27 (1.23) | –7.72 | <.001a |
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40-44 | 2.50 (1.15) | 2.41 (1.44) | –3.60 | .26 |
a5% statistical significance cutoff.
Comparison of hospital length of stay prepandemic and during the pandemic, by race and ethnicity.
Race/ethnicity by delivery type | Hospital length of stay (days), mean (SD) | Relative change, % | ||||
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Prepandemic | Pandemic |
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White (non-Hispanic) | 2.58 (1.36) | 2.32 (1.24) | –10.47 | <.001a | |
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Black (non-Hispanic) | 2.84 (1.45) | 2.57 (1.43) | –9.51 | <.001a | |
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Asian American/Pacific Islander | 2.74 (1.57) | 2.46 (1.15) | –10.22 | <.001a | |
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Hispanic/Latinx | 2.44 (1.21) | 2.33 (1.29) | –4.51 | .07 | |
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Multiracial | 2.63 (1.41) | 2.33 (1.24) | –11.41 | <.001a | |
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White (non-Hispanic) | 3.47 (1.52) | 3.3 (1.42) | –4.90 | .05 | |
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Black (non-Hispanic) | 3.42 (1.57) | 3.19 (1.62) | –6.73 | <.001a | |
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Asian American/Pacific Islander | 3.47 (1.67) | 3.13 (1.52) | –9.80 | <.001a | |
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Hispanic/Latinx | 3.44 (1.59) | 3.18 (1.63) | –7.56 | <.001a | |
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Multiracial | 3.52 (1.6) | 3.19 (1.58) | –9.38 | <.001a | |
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White (non-Hispanic) | 2.57 (1.22) | 2.38 (1.13) | –7.39 | <.001a | |
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Black (non-Hispanic) | 2.44 (1.16) | 2.28 (1.16) | –6.56 | <.001a | |
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Asian American/Pacific Islander | 2.38 (1.18) | 2.21 (1.15) | –7.14 | <.001a | |
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Hispanic/Latinx | 2.4 (1.2) | 2.21 (1.13) | –7.92 | <.001a | |
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Multiracial | 2.46 (1.32) | 2.27 (1.23) | –7.72 | <.001a |
a5% statistical significance cutoff.
This paper describes key birth outcomes during the COVID-19 pandemic. Our results indicate a decline in preterm births, a contrast to recent trends in the United States reflecting data from nonpandemic years [
Overall results indicated no change in Cesarean section rates between the two cohorts, but age-specific results showed increases in Cesarean section rates among those under 20 years and decreases in those aged 30-34 years. When comparing race and ethnicity, Black non-Hispanic users had a significant increase in Cesareans compared to all other race groups. Special attention and further research should be conducted to address age-specific differences, as well as social determinants of health that disproportionately affect Black pregnant women, particularly during the COVID-19 pandemic.
We also found a significant increase in home births in just 6 months, compared to national reports indicating no change in home birth rates between 2018 and 2019 [
Our study also shows a decreased average length of stay after delivery among those who delivered in a hospital, particularly among those aged 40-44 years and those who are multiracial. Reduced hospital length of stay has both positive and negative implications: decreased hospital stay length could lead to increased readmission rates and costs, and poorer postpartum and neonatal outcomes [
Our study is limited in that those who choose to report the details of their deliveries in an app may differ from those who do not. We are also reliant on user-reported data, which we recognize can present additional biases. Relatedly, while we do present some demographic data in this paper, we are largely restrained by demographic data completeness for this population, as most demographic fields in the Ovia Pregnancy app are not required or collected in the sign-up process. As such, sample sizes were limited when performing stratified analyses, and in-app questions, such as household income, education level, and employment status may have been completed and unchanged outside of the study time period.
We also know that SARS-CoV-2 infection may play a significant role in the birth outcomes described here [
As the pandemic progresses, continuous monitoring of these trends and others is necessary to evaluate long-term effects on birth outcomes. The use of digital data collection is paramount to monitoring these trends in real time, particularly during a time when there are increased limitations regarding access to care.
odds ratio
vaginal birth after Cesarean
We would like to thank the users of the Ovia Pregnancy mobile app for being part of the Ovia community and contributing to this important research.
None declared.