Opinion: COVID-19 vaccination and pregnancy — an afterthought?

The evidence is abundantly clear: nearly everyone should receive the COVID-19 vaccine and booster when eligible, including those who are pregnant and breastfeeding.

Yet the path to inclusion for pregnant people remains fraught. Most clinical trials exclude pregnant people, which raises unnecessary concerns about the use of the vaccine, although all other evidence — animal studies and past use of the core vaccine technology, for example — points to safety.

Despite early endorsements from obstetric and midwifery authorities in the United States and United Kingdom, many governments, policymakers, and health workers have been reluctant to officially recommend COVID-19 vaccines during pregnancy or lactation.

Reluctance to vaccinate during pregnancy is not playing it safe. On the contrary, it is putting pregnant people at high risk. There is now clear evidence that an unvaccinated person who becomes infected with COVID-19 during pregnancy has, compared to nonpregnant peers, a higher risk of hospitalization, admission to an intensive care unit, need for ventilator support, stillbirth or premature delivery, and even death.

This is an equity issue. For years, bioethicists and researchers have argued that ethical inclusion of pregnant people in clinical trials is good practice, but no major COVID-19 vaccine trial did so until recently. Default exclusion has led to many gaps in evidence on the safety of prevention and treatment strategies across a range of illnesses that impact people during pregnancy.

With five decades of global experience in maternal health, Jhpiego’s experts have seen time and again lives and opportunities lost when we don’t invest, adapt, innovate, and focus on serving families amid crises.

We see firsthand the stringency of the evidence review that the World Health Organization’s immunization advisory body applies to recommendations for COVID-19 vaccine use in pregnancy.

An inclusive model of vaccine care

The question is not whether people should receive the COVID-19 vaccine during pregnancy, but how they should receive it. As you might imagine, prenatal care looks very different from country to country, and we want to give everyone the best opportunity to receive a vaccine without negatively impacting prenatal care or vaccination services — for clients and providers — in the process.

Imagine a prenatal care visit in which your provider first sends you to another area of the facility where the COVID-19 vaccine is delivered. The line is long and outdoors. It’s shaded, but sweltering, and there’s nowhere to sit. You’re in your third trimester, tired and uncomfortable, and everyone in line is frustrated at the delay. These conditions might lead a meaningful number of people to avoid the vaccine altogether.

There are tremendous barriers to improving COVID-19 vaccination coverage globally: vaccine supply, misinformation, providers biased against the vaccine, gender bias across social and health arenas, and service delivery barriers. Major gaps in global vaccine equity exacerbate these challenges.

We should be asking, how are vaccines currently being delivered? Are they located in places where prenatal care is provided? Are they provided elsewhere? Are those places pregnancy-friendly? Should we figure out how to bring pregnant people to the vaccine or how to bring the vaccine to pregnant patients? Can we open up priority lanes or special appointments?

Jhpiego has decades of experience in countries from Afghanistan to Zambia integrating new services into prenatal care. For example, we know from tetanus, whooping cough, and flu vaccines that including the vaccine in prenatal care can increase their coverage. Measuring a handful of key metrics for COVID-19 maternal vaccination and adapting programs to meet goals will be vital as efforts are ramped up worldwide.

Jhpiego is working with health ministries around the world to look at how the integration of new health interventions in prenatal care may impact a patient’s experience of care, and whether key elements of care are still retained in prenatal care services. Partnering with professional organizations, such as midwifery and nursing associations, will advance these efforts.

Person-centered approaches that listen to pregnant clients and health workers, and innovate to meet their needs, are one of the most important steps to achieve success.

Looking beyond COVID-19

As we strengthen delivery of COVID-19 vaccines during pregnancy, we’re also laying the groundwork for other life-saving maternal vaccines that will be available soon. New vaccines against newborn illnesses will include those against respiratory syncytial virus and group B streptococcus. Both will need to be delivered in a specific later stage of prenatal care to provide babies with the best chance of protective immunity, which means that in the near future, prenatal care providers will need to counsel patients on new vaccines; have immunization supplies, skills, and capacity; assess gestational age accurately; and assess other key criteria for vaccination accurately.

When people feel confident about receiving vaccines, and have convenient access to vaccination services, they are in a better place to support their own health and launch the newest members of their families into a healthier life.

We can’t leave anyone behind in this vaccination effort against COVID-19. Ensuring that we focus on, invest in, and pioneer the best ways to reach everyone will help grow healthier families and stronger communities across the world today and far into the future.