Publication date: May 28, 2025

In this paper, we test the hypothesis that SARS-CoV-2 infection and the COVID-19 pandemic period had stronger adverse implications for perinatal outcomes among marginalized racial and ethnic groups in California. We used California birth certificate and hospital data from 2019-2021 to estimate marginal risk differences for SARS-CoV-2 infection and the COVID-19 pandemic period in relation to perinatal outcomes for Asian, Black, Hispanic, Multiracial, and White pregnant people using targeted maximum likelihood estimation. Among 849,401 deliveries, there were racial and ethnic disparities in the burden of SARS-CoV-2 infection and perinatal outcomes, and in the magnitudes of risk associated with SARS-CoV-2 infection and the COVID-19 pandemic. Hispanic pregnant people had the highest incidence of SARS-CoV-2 infection. Asian and Black pregnant people had the greatest marginal risk differences for multiple outcomes, particularly outcomes already disproportionately experienced by these groups. Risks from SARS-CoV-2 infection and the COVID-19 pandemic period on perinatal outcomes were disproportionately experienced by marginalized racial and ethnic groups. Differential burdens of infection and larger risks experienced with pandemic exposures were associated with worse perinatal outcomes for Asian, Black, and Hispanic pregnant people in California compared with those for White pregnant people.

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