Encouraging COVID-19 vaccination in pregnant women

When COVID-19 arrived in the U.S. in March 2020, I, like others, worried — not only for myself and my family, but as a perinatologist, I also feared for the health and safety of my pregnant patients. Fortunately, as we moved through 2020, my worst fears didn't materialize. Very few of my patients ended up hospitalized with COVID-19. As the vaccines began rolling out in late 2020 and early 2021, my optimism grew. It felt like the end was in sight. Then came July 2021 and the arrival of the highly contagious delta variant in our community. 
During the height of the delta surge in August 2021, 25 percent of AdventHealth Orlando's intubated COVID-19 patients were pregnant. Most were between 20 and 28 weeks. None were vaccinated, and neither were their partners. My youngest pregnant patient on a ventilator with COVID-19 was 23 years old.   
I found myself in the unfamiliar role of placing young, previously healthy women on life support and having to perform pre-term cesarean sections in an attempt to save their babies' lives. Then there were the husbands I encountered who were fraught with guilt because they had brought the virus home and had to watch their wives become intubated while also fearing that their babies, if they survived, would face lifelong health challenges. It became daunting and emotionally exhausting. The saddest part was the overarching feeling that all of this could have been avoided. 
The impact of low COVID-19 vaccination rates
In fact, the vaccination rate among pregnant people currently stands at only 31 percent, well below the overall national vaccination rate. To help prevent additional serious illness, deaths and adverse pregnancy outcomes, the CDC issued an urgent health advisory to increase COVID-19 vaccination among people who are pregnant, recently pregnant (including those who are lactating), who are trying to become pregnant now, or who might become pregnant in the future.
Reducing COVID-19 risk
Pregnant women have always been more prone to serious infections from respiratory viruses because of changes that occur in the body during pregnancy. In fact, the first American to die from H1N1 in May 2009 was a Texas woman who was 35 weeks pregnant. In addition, when flu vaccines were first developed and made widely available in the 1950s, pregnant women were prioritized to receive them.
The COVID-19 virus can be especially dangerous for those who are pregnant or recently pregnant. According to the CDC, pregnant women who contract COVID-19 are two to three times more likely to require ICU admission, invasive ventilation and ECMO than symptomatic COVID-19 patients who aren't pregnant. These women are also at a 70 percent increased risk of death and at increased risk for preterm birth (before 37 weeks).
In addition, a CDC study released Nov. 19, 2021, found that a COVID-19 diagnosis documented during a woman's delivery hospitalization was associated with an increased risk for stillbirth, with a stronger association during the period of delta variant predominance. 
The safety and effectiveness of COVID-19 vaccines for both mom and baby
Getting vaccinated is the most effective way a woman can protect herself and her baby from severe COVID-19 illness. In addition to the CDC, both the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine encourage pregnant women, women actively trying to become pregnant and those breastfeeding to get vaccinated. After reviewing several studies, I recommend my patients receive either the Pfizer or Moderna mRNA vaccines. In concurrence with ACOG, I also recommend that pregnant and recently pregnant women up to six weeks postpartum receive a COVID-19 vaccine booster shot following completion of their initial COVID-19 vaccine series. 
A recent study and a previous analysis of CDC data found no safety concerns for women in the preconception period or during pregnancy following receipt of an mRNA vaccine. In addition, we've learned COVID-19 vaccination in pregnancy or while breastfeeding actually helps to protect the baby from contracting COVID-19 because pregnant women who get mRNA vaccines pass high levels of antibodies to their babies. Finally, despite the widespread myth that the COVID-19 vaccine causes infertility, the evidence is very clear that it does not.
Despite all of this compelling research and data from our leading medical organizations, nearly 70 percent of pregnant women in the U.S. remain unvaccinated for COVID-19.
The critical role physicians play in addressing COVID-19 vaccine hesitancy
Vaccine hesitancy among pregnant patients is not new. As physicians, we have encountered it for decades with flu and DTaP vaccines. The good news is that over the years, we have learned the most effective strategies to help patients overcome their hesitancy, including the following:
1. Making simple, educational materials about vaccines widely available and prominent throughout physician offices, including waiting rooms, exam rooms and even bathrooms.
2. Talking to our patients and taking the time to listen to and address their concerns.
Our greatest challenge, by far, is debunking vaccine misinformation, and with COVID-19, that is no small feat. Our charge has been compounded by the public's growing distrust of the very medical organizations and government entities like the CDC that we as physicians have always relied upon for support. 
Admittedly, COVID-19 vaccine education can be a difficult task for physicians. Yet, given the increased risk our pregnant patients face, it is crucial. In our office, that means discussing COVID-19 vaccination with every patient, every single time we see them, if necessary. We strive to meet patients where they are, understand their reasons for hesitation, gently inform and remain nonconfrontational, even when they get defensive. 
Lessons learned from COVID-19 vaccine patient education efforts
By far, the No. 1 reason my pregnant patients provide for refusing the mRNA COVID-19 vaccines is that they are too new and not enough is known about them. In the early days of our vaccination effort, I provided patients a technical explanation of how mRNA vaccines work. However, I quickly noticed eyes glazing over and concluded that this approach was not effective. I've refined my messaging over time and now focus on a few simple points that seem to resonate most with pregnant women:
2. While the COVID-19 vaccines are new, mRNA vaccines were developed decades ago and have been safely used throughout the world to vaccinate both pregnant and non-pregnant people against Ebola.
3. The mRNA vaccines are preservative-free and additive-free.
4. The messenger RNA in the vaccines breaks down in days, so nothing remains in the body.
5. The mRNA vaccines do not enter the bloodstream, so they do not affect the baby or breast milk. Instead, the
vaccine goes into the muscle cells and lymphatic tissue of the arm.
6. The mRNA vaccines create an immune response throughout the body which also reaches the baby, protecting the baby for at least its first few weeks or months of life. This message about protecting the baby is especially compelling.
Most importantly, knowing the impact of personal stories and experiences, I share that the majority of my patients who are physicians and nurses and were pregnant in December 2020 and January 2021 received their COVID-19 vaccines and experienced no complications. They have since delivered healthy babies.  
The power of persistence and reinforcement
I had one unvaccinated patient who was a nurse and quite hesitant about getting vaccinated. Over a four-month period, I patiently listened, educated and reassured her that the COVID-19 vaccine is safe to receive during pregnancy, and her baby would be healthy. I was elated the day she told me she received her first shot. She completed both doses in pregnancy and delivered a healthy boy at term about one month after completing her series of injections. Success stories like this make the persistence worth it. 
In addition to talking to each of our patients about the importance of COVID-19 vaccines, we also posted educational material from the Society for Maternal-Fetal Medicine throughout our office in both English and Spanish.
As physicians, we must continue to champion vaccines for all of our patients, but especially for our expectant and new moms, because the more people we can convince to vaccinate, the more lives we can save.
Additional COVID-19 vaccine patient education resources
Addressing pregnant patients' concerns about COVID-19 vaccine timing 
"I want to wait until after the first trimester." — We recommend patients receive their vaccination as soon as possible. The most severe cases we have seen in our practice occurred between 20 and 28 weeks' gestation. It takes about four to six weeks to complete and receive optimal protection from the two-shot mRNA vaccines. 
"I want to get my flu shot first." — It is safe for patients to get both the flu and COVID-19 vaccines at the same time. If a patient prefers to get one at a time, we currently recommend getting the COVID-19 vaccine first due to higher transmission levels within the community. 
"I want to wait until after I deliver so the baby will gain protection through my breast milk." — We know from decades of administering flu and DTaP vaccines to pregnant patients that while breast milk can transmit a small amount of protection, receiving the vaccine during pregnancy provides more protection and also protects both mom and baby.

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