Calendar year three into the pandemic, and vaccination coverage among pregnant people remains staggeringly low.
According to data from the US Centers for Disease Control and Prevention, as of January 1, just over 40 percent of pregnant people in the United States between age 18 and 49 were fully vaccinated prior to pregnancy or during their pregnancy, compared with 66 percent of the general population over the age of 5. For Black pregnant people, the figure plummets to about 25 percent. Data for the United Kingdom is a little less up to date, but in August 2021 just 22 percent of women who gave birth were fully vaccinated.
And with Omicron running rampant, this is a problem. At the end of 2021, the UK’s vaccine watchdog, the Joint Committee on Vaccination and Immunization, announced that pregnant women would be made a priority group for vaccination, after reams of research has shown just how vulnerable the group is to Covid.
But misinformation has been rife within communities of expectant parents, where viral rumors spread that the vaccines cause infertility or miscarriages, or that the spike protein found in them damages a protein found in the placenta. An investigation by The Washington Post found that not only are discussion forums on apps aimed at first-time parents riddled with bogus claims, but they include tips on how to convince doctors to delay or skip vaccines for pregnant adults and their children.
Expectant parents have traditionally tended to display more vaccine hesitancy than non-pregnant peers. “You’ve got to understand that, at baseline, people who are pregnant are terrified,” says Neel Shah, an assistant professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School and chief medical officer of Maven Clinic, a telehealth company for women’s health. “There's so much social messaging around pregnancy that makes pregnant people feel like everything around them could be a threat.” Within these communities, any whisper of potential harm to a parent or baby will spread like wildfire.
To be crystal clear: The data has resoundingly shown the vaccines to be safe. A study released this month from the CDC of more than 46,000 pregnant women showed that vaccination did not increase the risk of delivering preterm or smaller babies. Other recent studies have resoundingly shown that vaccination does not affect fertility. There’s no evidence of risk from getting the vaccine while breastfeeding; in fact, research has shown that the protective antibodies a body produces against Covid make their way into breastmilk, potentially offering a baby some protection.
On the other hand, the data has also shown that Covid can be deadly for pregnant people and their babies. A 2020 study in British Medical Journal found that if you get infected during your pregnancy, the risk of your baby being born preterm doubles; the risk of a stillbirth triples. Another study that year from the US found that the risk of death for pregnant women with Covid was 22 times higher than their counterparts without Covid. Pregnant people who are Covid-positive at time of birth are more likely to suffer from preeclampsia or require an emergency cesarean delivery.
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Clinicians have also begun to report a particular side effect of Covid during pregnancy, which they are calling Covid placentitis. Placentitis is inflammation of the placenta, typically caused by an infectious agent, and is linked to stillbirths. And, more worryingly, the cases are not appearing in patients with the most severe presentations of Covid—they’re appearing in those with mild to moderate cases.
Up until July 2021, more than 99 percent of pregnant people admitted to hospitals in the UK with symptomatic Covid-19 were unvaccinated. But poor vaccine uptake can’t be blamed on just the spread of misinformation. In fact, some of it can simply be boiled down to garbled public health messaging. Public health bodies in different parts of the world have repeatedly changed tack: First the vaccines weren’t offered to pregnant people. Then they could opt to get vaccinated, but it wasn’t actively recommended to them. It took a full eight months after vaccines first became available for them to be recommended to pregnant people in the US.
The inconsistency has meant that pregnant people were left unsure who to listen to or what the current advice was. (The term “pregnant people” includes trans and non-binary parents.) “What we weren't very good at was making sure that every time the message changed, everyone got the memo,” says Viki Male, an immunologist studying pregnancy at Imperial College London. It doesn’t matter if a public health body updates their guidance—if news of the change doesn’t reach the intended audience, it won’t help.
A survey conducted by the company at which Shah works, Maven Clinic, asked 500 nationally representative pregnant people in the US about why they were not vaccinated. Over 60 percent simply did not know that getting vaccinated was recommended during pregnancy. (Even today, the webpage concerning the UK’s Medicines and Healthcare Products Regulatory Agency’s public assessment of the Pfizer vaccine currently warns that “sufficient reassurance of safe use of the vaccine in pregnant women cannot be provided at the present time” and that women who are breastfeeding should also not be vaccinated—both untrue.)
Male points to Canada as a country that handled it better: Authorities clearly communicated any changes in policy, she says, and as a result, the percentage of fully vaccinated pregnant people is significantly higher compared to the US and the UK. In the province of Ontario, for example, almost 60 percent of people who were pregnant in September had received at least one dose.
While health authorities were keeping mum, pregnant people were told to turn to trusted experts instead: their midwives, primary care providers, and ob-gyns. But the messages they received were mixed. In the Maven Clinic survey, a third of the respondents said they had been advised against the vaccine by medical providers. Another survey of pregnant people in the UK conducted by Pregnant Then Screwed, a maternity campaign charity, found that over 40 percent said they had been made to question the safety of the vaccine by health professionals.
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“A lot of the reasons why we were so muddled with our messaging, particularly for pregnant people, and so slow, is because historically we have not prioritized people who are pregnant,” says Shah. Scientific research has a long history of forgetting women, and, specifically, women carrying fetuses. The sordid legacy of thalidomide—a deadly drug distributed in the 1950s that caused the death of thousands of babies and left many with limb deformities—has meant that medical researchers have approached pregnant people with an overabundance of caution. This pandemic has been no different: A 2021 study in The Lancet found that three-quarters of trials for Covid-19 treatments and vaccines explicitly excluded pregnant women. “The default position for all of society—for which the health care professions, including doctors, are not immune from—is to be very, very hesitant to offer pregnant people medicine,” Shah says.
This meant that the lag in waiting for data on the safety of the vaccines gave people ample time to become skeptical or fearful. In the meantime, communication from health authorities faltered, says Male, “and that's definitely a space where the people who, for whatever reason, want to spread misinformation can prey on that population.”
That we needed to prioritize pregnant people for vaccination should never have been a surprise, says Male. “We ought to have thought, this will be a group that we probably want to vaccinate. And if it's a group that we want to vaccinate, we do need to trial a vaccine in this population,” she says. After the Zika virus epidemic, a group called Prevent was set up by academics to devise guidelines for the ethical inclusion of pregnant people in vaccine trials during a public health emergency. (The acronym stands for the Pregnancy Research Ethics for Vaccines, Epidemics, and New Technologies working group.) Guidelines included clear and contextualized communication of vaccine efficacy to pregnant people, as well as evidence-based strategies to encourage vaccine confidence among this cohort.
But in this case, the guidelines weren’t applied, says Male. “If we ever end up in another situation like this, I think if we think that pregnant people are going to need to be vaccinated, then we do need to include them in the trials,” she says.
Shah believes the failure to prioritize the pregnant, and the grim repercussions of that, is something we should have foreseen and prepared for. “During every humanitarian disaster—whether it's a pandemic, a war, a weather event—the well-being of people who are pregnant suffers disproportionately,” says Shah. “And I don't know why we feel like we need to learn this lesson over and over again.”
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