I don a gown, gloves and a mask to enter the hospital room of a new mother who is sick with COVID-19.
She lies in bed, exhausted between coughing spells; her day-old infant rests comfortably across the room. She contracted COVID-19 the week before her due date and was hospitalized when her labor began.
Given the mother’s illness and her inability to care for the newborn, we make plans for the infant to go home with his father on his second day of life. But his mother will need to remain hospitalized to recover from COVID-19 and from her delivery.
The couple’s other two children at home need care as well. The road to recovery will be long for this family, but fortunately the mother’s illness does not end up requiring intensive care or mechanical ventilation. This outcome is not what the family had imagined when they made the decision for her not to get vaccinated against COVID-19 during her pregnancy.
Unfortunately, scenarios like this have become far too common for me and other care providers during the COVID-19 pandemic. During the latest omicron surge, it was not unusual to have four or five patients with active COVID-19 infections on the labor and delivery unit at a time.
Decision-making during pregnancy
Pregnancy is often a time of sweet anticipation. But the ongoing pressure to make the right decisions for the health and well-being of both the pregnant person and the unborn child tempers this excitement. And undoubtedly, the decision-making around COVID-19 vaccination adds another layer of stress. The relative novelty of COVID-19 in our lives, fear of the unknown and abundant misinformation often complicate these decisions. Advice comes during pregnancy from many directions, including well-meaning friends and family, and sometimes even from strangers.
It’s worth noting that the decisions a person makes during pregnancy stem from the desire to avoid doing anything that could cause complications in the pregnancy or be harmful to the fetus. At the same time, it is also important that a parent do everything possible to protect the well-being of the pair.
As a family physician specializing in maternity care, I often hear of the challenges and confusion pregnant people feel in making these important decisions. My role is to respect pregnant people in their autonomy and to provide evidence-based information that may help inform their decision.
In making the decision about getting vaccinated against COVID-19, pregnant people must consider the potential risks of the vaccine, as well as any potential harm from becoming infected with SARS-CoV-2, the virus that causes COVID-19. These two sides of the same coin are important in the discussion and the ultimate decision the patient makes.
Simply avoiding action is not the answer. Each pregnant person should carefully consider the decision and not passively accept doing nothing as the safer option, since the choice to do nothing is likely a choice to accept the risk of preventable harm.
COVID-19 illness in pregnancy
COVID-19 has caused serious illness requiring hospitalization in over 30,000 pregnant people in the United States, with 292 deaths as of mid-March 2022. The risk for severe disease is higher in pregnancies that are complicated by advanced age, high body mass index, hypertension and diabetes.
Pregnant people infected by COVID-19 are three times more likely to need critical care than people who aren’t pregnant. Death is rare in pregnant people, but COVID-19 causes a significant increase in that risk.
Vaccine protection in pregnancy
Vaccinations to protect against serious illness from COVID-19 are recommended for all pregnant people or those considering pregnancy by leading health organizations, including the Centers for Disease Control and Prevention, the American Academy of Family Physicians and others.
The mRNA vaccines developed by Pfizer and Moderna are recommended for people who are pregnant in an initial two-dose series followed by a booster immunization five months later. The immunity produced has been shown to reduce severity of illness, pregnancy complications, stillbirth and maternal death.
In mid-February, 68% of pregnant people over age 18 were fully vaccinated, compared with 75% in the general adult population. Complications from the vaccine are rare and mild, similar to complications patients who aren’t pregnant. There is no increased risk of miscarriage, infertility or pregnancy complications related to the vaccine.
Additionally, vaccination during pregnancy provides important protection for newborns. Pregnant people who are vaccinated pass antibodies in blood through the umbilical cord to the fetus, and this has been shown to provide protection from serious illness from COVID-19 for the newborn for up to six months.
Research studying newborns in 20 pediatric hospitals across 17 states showed that 84% of hospitalized infants less than 6 months old were born to unvaccinated people. And infants born to people vaccinated with two doses of mRNA vaccines were 61% less likely to be hospitalized with COVID-19. Since vaccination is unlikely to be available for newborns in the foreseeable future, protecting this vulnerable population through vaccination during pregnancy is the best option.
Vaccination decision
It is natural for pregnant people to have some uncertainty about the decision to get the COVID-19 vaccine. They are likely to be unsure and to have their own conflicted feelings about it, and they may be receiving conflicting advice from family and friends. I believe it’s important to provide empathy and respect for this ambivalence while sharing information about the safety of the vaccine and the risks of COVID-19 illness.
People who are pregnant should receive the most up-to-date information based on evidence to help guide their decisions on getting vaccinated. If they decide to get vaccinated, it can be helpful for family members or others to remove any access barriers that might stand in the way. On the other hand, a pregnant person who decides against getting vaccinated needs to be provided with other additional supports such as guidance on masks and on avoiding high-risk exposures to reduce the risk of illness.
The ripple effects of COVID-19 go well beyond the person with the infection, particularly in pregnancy. It’s clear that the vaccine can help prevent serious illness in pregnant people and that it is one way to prevent newborns from going home without their mothers, either temporarily or permanently.
