Opinion | The Onus Is on Us to Get Our Pregnant Patients Vaccinated

Amid the buzz of excitement and relief with the COVID-19 vaccine rollout in December 2020, there was uncertainty. I was 31 weeks pregnant and found myself immediately eligible for vaccination as a high-risk obstetrician. At the time, those of us who were pregnant didn’t have any data on vaccine efficacy or safety to inform our decision. But we had experienced the devastation firsthand, and were desperate to finally have some internal PPE — for ourselves and for our babies. We also got vaccinated knowing that our actions would provide others with the data and peace of mind we didn’t have.

The decision to get vaccinated during pregnancy has been validated by study after study. As data on the myriad maternal and perinatal complications of COVID-19 have accumulated, so have data reassuring us the vaccines are safe and effective. The primary reason for vaccination is to prevent severe maternal disease, which in turn protects the baby. But maternal vaccination results in tangible benefits for babies too because maternal antibodies pass to the baby through the placenta. Importantly, vaccination results in higher antibody titers and longer lasting immune protection for the baby than natural infection. This passive immunity translates into a reduction in infant hospitalization. At the same time, disturbing increases in stillbirth (fetal death) and maternal morbidity and mortality occurred following the arrival of the Delta variant. A recent international case series of COVID-related stillbirths and neonatal deaths showed that SARS-CoV-2 can infect and effectively destroy the placenta — a nightmare scenario.

With two lives on the line and the ongoing threat of new variants, getting pregnant people vaccinated ASAP is a public health priority. Clearly, efforts to address low vaccination rates and vaccine hesitancy in pregnancy are urgently needed.

Confusion and Fear Among Pregnant Individuals

Pregnancy leads many to question decisions they wouldn’t normally think twice about (e.g. coffee consumption). Inconsistent advice from clinicians is common (see medication use and bedrest). Many pregnant individuals, understandably, become risk-averse, as they weigh the potential risks for the baby. A big part of my job is helping patients understand that maternal health and well-being are paramount and inextricably linked to fetal health. With COVID-19, this message has never been more critical. As some like to point out, the fetus tolerates maternal death poorly.

From the outset, messaging on COVID-19 vaccination during pregnancy has been confusing, uncoordinated, and muddied by misinformation. The data void that resulted from default “protection by exclusion” policies and underfunding of pregnancy and women’s health research was quickly filled with misinformation and fearmongering directed at women and people of reproductive age. Harmful and false narratives linking the vaccines to infertility, miscarriage, and fetal harm have been amplified in social media echo chambers. It’s no wonder patients question our confidence in the vaccines. As one patient put it plainly, “I can’t take over-the-counter medications during pregnancy but you’re telling me it’s safe to put a new vaccine into my body?”

Pregnant people are also judged — all the time. Questions from loved ones or strangers can easily insert doubt: “You’re not getting the vaccine while you’re pregnant, are you? Aren’t you worried about the baby?” Pregnant people desiring vaccination have been turned away from vaccine clinics and dissuaded by people administering the shots. Even prenatal care providers offered inconsistent advice before clear recommendations for vaccination in pregnancy were issued by professional medical organizations and the CDC in July and August 2021. Mom shaming has gotten worse during the pandemic, and the COVID-19 vaccines are yet another target.

Remember there are many reasons people are unvaccinated other than deeply held anti-vaccine beliefs. Many personal circumstances contribute to vaccine hesitancy. People who have experienced infertility, loss, or trauma in a previous pregnancy may be especially worried about doing something that “might hurt the baby.” Many pregnant people, especially women of color, experience mistreatment and discrimination when they interact with the healthcare system, which has likely contributed to racial-ethnic disparities in vaccination. A person may belong to a family or community that stigmatizes vaccination. Logistics (childcare or transportation issues) and lack of up-to-date information (e.g. current consensus guidelines recommending vaccination in any trimester) are also common reasons.

Getting More Pregnant Patients Vaccinated

We have a collective responsibility to amplify evidence-based messages and combat misinformation about the COVID-19 vaccine in pregnancy. The onus is on each of us. Do not underestimate your potential impact. You might be the first person to take the time to listen and clearly communicate the proven benefits and safety of the vaccines. I know clinicians have grown weary of vaccine conversations. But the key is to operate from the baseline assumption that all people want a healthy pregnancy and healthy baby. Use patience, empathy, and credibility as a healthcare professional to get your message across.

Here is my approach:

• Listen without judgment. Identify specific concerns and barriers, then tailor your approach. Take the time to build rapport and trust.
• Validate concerns and empathize: “You’re right. We didn’t have data in pregnancy when the vaccines came out and it’s normal to have questions. It’s a tough decision and I want you to feel comfortable and confident. Luckily, we now have more than a year’s worth of experience showing the vaccines are safe and effective in pregnancy.”
• Normalize and reassure. Some people don’t know anyone who was vaccinated during pregnancy, so sharing stories can be a very effective strategy. I often share my personal story so patients know I’ve been in their shoes. Also remind people that immunization during pregnancy is not a new practice — it’s an essential part of good prenatal care. Normalizing vaccination can extinguish uncertainty and guilt.
• Keep your messages clear and simple. Decisions are often driven by emotions rather than logic. An appeal to a person’s emotions is often more effective than a well-constructed argument with a lot of clinical data. We know that people are overestimating the risks of the vaccines and underestimating the benefits, so focus on the numerous benefits.
• Remind patients that protecting moms protects babies. “Did you know you have the power to help protect your baby from COVID-19? If you get vaccinated while you’re pregnant, your antibodies will pass through the placenta to the baby’s blood to provide a layer of protection in the first months of life. Your baby also needs you to be healthy to thrive.”
• Don’t give up. You will not be successful every time, but you can keep the conversation going. Follow up with vaccine- and booster-eligible patients. Remove all barriers to vaccination by providing information for walk-in vaccine clinics and written materials that reinforce your key vaccine messages. If you sense the conversation is not going well or your patient is on the defensive, take a step back and remind them you’re on the same team.

Example responses to common concerns:

• I’ve already had COVID-19 so I have natural immunity. Vaccination is still recommended because the vaccines produce a strong immune response that provides more protection for you and baby. And reinfection is possible.
• I’m staying home and taking all the precautions. I’m glad to hear you’re being so careful. But most patients I’ve cared for with COVID-19 don’t know where they got it and were also being really careful. They regret not getting the vaccine, and I don’t want you to be in that situation.
• I’m going to wait until after I have the baby. I’m planning to breastfeed so the baby will get antibodies through my breast milk and will be protected. If you decide to wait, neither you nor baby will get the maximum benefits. You will continue to be at risk for COVID-19. And breast milk antibodies are not the same as the antibodies that would pass from your blood stream to the baby while you are pregnant. Breast milk antibodies don’t last long and don’t enter the baby’s blood so they don’t provide the same degree of protection. They also have to be replenished constantly by feeding. The best way to protect your baby is to get vaccinated during pregnancy so the baby can get dual protection from the antibodies in your bloodstream and breast milk.

Remember, don’t underestimate the impact you can have and don’t give up. Let’s get our pregnant patients vaccinated.

Jacqueline Parchem, MD, is a maternal-fetal medicine subspecialist and researcher at McGovern Medical School at The University of Texas Health Science Center at Houston. She is an advocate for COVID-19 vaccination during pregnancy and protecting pregnant people through research.