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Vaccination among the pregnant lagging despite growing evidence of safety and efficacy

Despite data showing the safety and effectiveness of the COVID-19 vaccine for pregnant women and numerous recommendations from health organizations around the world, uptake is still lagging.

Only 66 per cent of pregnant women in Ontario had been fully vaccinated against COVID by Oct. 31, compared to 82 per cent in the over-12 age group, despite the fact that the province’s COVID-19 Advisory Science Table says 7 to 15 per cent of pregnant women with COVID will experience moderate to severe disease requiring hospitalization. Alberta’s College of Physicians and Surgeons adds that pregnant patients are at a higher risk of severe disease and complications requiring ICU admission, ventilation and preterm birth. The threshold for admission is lower and they can get sick faster.

Pregnancy is a very at-risk time, says Kieran Moore, Ontario’s chief medical officer of health. “As you head into the third trimester, in many ways you can consider it an immune-suppressed state. You’re trying to not reject your baby … (which) predisposes you to severe … respiratory infections, like SARS-CoV-2.”

The Delta variant has disproportionately caused poor outcomes for pregnant women during the fourth wave, says Stephanie Cooper, a Calgary obstetrician specializing in maternal-fetal medicine and high-risk pregnancy. From July 14 to Oct. 21, 18 unvaccinated pregnant Albertans were admitted to ICU, up from seven the entire first year of the pandemic. Of the 18 cases, 10 resulted in preterm births as early as 29 weeks.

“There remains a gap and there is a percentage of pregnant people who don’t have confidence in physicians,” says Cooper. “They don’t have confidence in the health-care sector; they don’t have confidence in scientists; they have this distrust of scientific information. Many of them are doing their own research or are being influenced by family, friends or online information. And so, it very much has created this polarizing effect.”

Cooper and her colleagues in Calgary are getting information out to reassure pregnant women that the vaccine is safe and that it passes protective antibodies on to their babies. They are combating misinformation and a social media anti-vax sentiment that causes fear, guilt and stress, Cooper says.

“I am not pushing the vaccine on patients. If someone is unvaccinated, we discuss strategies for protecting oneself, such as working from home or isolating before delivery. I provide the same level of care and no judgement, whether you’re vaccinated or not,” she says, adding that she has been “fired” by a couple of her patients because she is a strong public voice in support of vaccination for pregnant women.

Fadia, a Toronto woman who gave birth to her second child in November, says she chose not to get the COVID vaccine because there was “not enough evidence to convince me that it was safe enough for me and my baby. It is just too early.”

During appointments with her obstetrician, no materials or evidence were provided about the short- or long-term safety of the vaccine during pregnancy, says Fadia. “It was all just word of mouth and the ICU scare tactics just made me angry.”

She says no one asked, “’What is your situation like?’ Or ‘Are you a front-line worker?’ I’m isolated in a bubble. I’m not going into work, not seeing the people I want to see, and not putting myself in a position to catch COVID.

“I’m not someone who will not take a vaccine,” says Fadia, who received the whooping cough (pertussis) vaccine this summer. There is ample research on the safety of the whooping cough vaccine during pregnancy, she says. “No one showed me evidence of anything to take the shot (for COVID).”

The growing body of evidence on the vaccine’s safety during pregnancy has not led to higher uptake, says epidemiologist Deshayne Fell, who studies Ontario’s pregnancy vaccination data.

“There remains a gap and there is a percentage of pregnant people who don’t have confidence in physicians,” says Cooper.

“What is starting to become apparent is that uptake is much lower among pregnant people in Ontario,” says Fell. “For instance, among people who were pregnant in September, coverage was about 60 per cent, which is about 20 to 25 per cent lower than in the general population of this age group. Coverage is also lower among those who have more recently become pregnant.

“And then on the other side of things, among those who were unvaccinated during their pregnancy and gave birth by the end of July, we aren’t seeing as much vaccination initiation in the post-partum period as we would have expected.”

Midwife Jasmin Tecson of Toronto says that while many of her pregnant clients have been vaccinated, others have not.

“Pregnant people are constantly managing the risk-benefit in everything that they do and that’s definitely heightened these days,” says Tecson, who is president of the Association of Ontario Midwives. “Those concerns around COVID and vaccination, they’re layered over an already pre-existing sense of vulnerability.”

She says midwives have the benefit of repeat visits and time with their clients.

“When we have discussions with clients … because we’ve built that trust, we have the opportunity to ask questions, to probe a little bit more, to get a sense of what is holding people back,” says Tecson. “Because when people make decisions, it’s not just the black-and-white information … People make decisions integrating their experiences – values, culture, religion, family expectations. As well, they might be incorporating biases tied to closely held beliefs that they might not be able to articulate.”

Like Cooper, Tecson says that midwives do not judge clients for their vaccine choices. However, “We’ve seen more people who might be choosing midwives because of the mistaken idea that they can avoid vaccination or avoid conversations around vaccination or COVID-19 precautions,” says Tecson. “We’re very clear on our websites and our communications what the expectations are and we very much discourage anybody making choices about their care that are driven by the need to avoid COVID-19 precautions or vaccination.”

Being pregnant during the pandemic was an isolating time for Kelsey, a Hamilton mother who gave birth to her first child in November. She was nervous getting her first COVID shot back in May, when, she says, her family physician couldn’t point to enough information about the safety of the vaccine during pregnancy.

But she “decided to put myself in the hands of science,” and then later, as pro-vaccine evidence became available, she took her second dose. At that point, in August, “when my midwife tells me that (vaccination) is the safe thing to do, then I do it.”

Says Deena Hinshaw, Alberta’s chief medical officer of health. “Anyone who is pregnant is wanting to do everything they can to protect the child that’s growing and the important thing to remember is that choosing to not receive a vaccine also carries quite significant risks if there is an exposure and an infection during that time of pregnancy.”

We don’t yet have five or 10 years’ worth of data, she says, but we can’t wait because the risk of COVID is right now.

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Mary-Kay Whittaker

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Mary-Kay Whittaker is a fellow in the Fellowship in Global Journalism at the University of Toronto focusing on health professional education and health workforce planning.

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