These are the first three things I did when I found out I was pregnant in February. I took about six more tests. Then, I called the doctor’s office to make an appointment. A few days later, I signed up for a Covid-19 vaccine. I stood in line, freezing, at a high school in Coney Island to get my shot.
Deciding to get the vaccine that same month was not easy – even as a former health reporter accustomed to deciphering medical journals. I felt a very visceral and personal responsibility toward this bean-like bundle forming in my body. There were only preliminary studies about vaccine safety – saying the vaccine was likely safe – but based on participants who didn’t know they were pregnant during trials. Gynaecologists and family physicians had not yet achieved full and public consensus on their recommendations as most have now.
Within my own family and close friends (who are largely advocates of mainstream health recommendations) there were concerns about miscarriage and long-term harm to the future baby that, at this stage of research, could not be definitively answered.
With a few more months of information, we know now that contracting Covid-19 is much riskier for pregnant women and their fetuses than the average person. August was the worst month on record in the US for pregnant people due to Covid-19, with 21 deaths. We also know that the studies published in major medical journals have not found any significant risks for those trying to conceive, those who are pregnant, or those who are breastfeeding if they take the mRNA vaccine, such as Pfizer and Moderna.
But with only 31% pregnant Americans fully inoculated as of 18 September, compared to about 52% of the average population – and with much lower rates among Black and Hispanic women – it appears that a long history of incomplete science and fear-driven medical advice about prenatal decisions has broken trust, leaving many mothers through anecdote and misinformation. For these women, condescension and fear mongering from the medical establishment or media is both unfair and ineffective.
Conflicting advice
Kim, a 34-year-old in her second trimester of pregnancy in the UK ( who asked to use only her first name for privacy) told me she hasn’t taken the vaccine because of concerns about the long-term impacts on her baby. There are no longitudinal studies available this early but she pointed out that other medicines prescribed to mothers in the past have turned out to be dangerous, for example Thalidomide, a 20th-century sedative expectant mothers took for morning sickness, which was later found to cause severe birth defects.
“Most information seems very biased towards ensuring everyone has the vaccine,” she said through email. “There are so many what-if’s. If I catch Covid that would be bad for my unborn baby, if I have bad symptoms. I’m trying to balance those against having the vaccine and then the unknowns of how that affects babies long-term.”
Earlier this year, Kim said midwives offered her leaflets with information about the vaccine and told her to make the decision that felt right for her. Now, she feels like media outlets have become “very pushy”. The only person she trusts to help her make a decision is her partner. Unvaccinated, she wears a mask and limits contact with others in the meantime to protect herself from the virus.
For Maddie, whose son was born in spring 2021, her Philadelphia doctor recommended the vaccine when it became available in her third trimester. But her husband, who has a doctorate in cellular and molecular biology and who works in pharmaceutical patent law, asked her to wait until after birth because there wasn’t enough data at that point to reassure him. She ended up waiting a few weeks after delivering to be vaccinated.
“I wanted him to feel respected and involved in decisions that impacted the baby, so I waited,” she said of her husband. “In hindsight I wish I would’ve gotten it while pregnant [after] seeing the data about antibodies passed through the placenta.” Recent studies say 99% of the babies born to fully vaccinated mothers are born with Covid-19 antibodies.
Personal health decisions often come down to a trusted messenger (such as a relative who works in healthcare), a common language around risk and fear: something that makes sense to that particular person and their cultural mores. These are the tools that drive our decisions about medical care – aggressively pushing data and scientific studies, regardless of urgency, often fall short.
What led me to sign up for a shot, for example, was not the government or the American College of Obstetricians and Gynecologists recommendation. It was talking through the mechanism of the mRNA vaccine with my husband, a physician with a public health degree well versed in epidemiology. The way in which both main US vaccines, Pfizer and Modern, work (simplistically: the vaccine triggers cells in your muscles to create a protein, then the mRNA are dismantled while your immune system begins to respond) gave me a strange sense of solace – there would be no foreign body or live virus hanging out in my body after the shot as with other vaccines, like the one for measles.
A deep loss of control
In true scientific reasoning, the piece of information that changed my mind was completely arbitrary. But to be pregnant is to face a deep loss of control on a daily basis. There is, of course, your body – new sensations arising every day, a tug here, a sharp pain there, a primal exhaustion. Then there are numerous decisions: to take an extra genetic test, choose one vitamin over another, decide whether or not to fly on an airplane.
These dilemmas are offered by clinicians and loved ones alike with a large dose of opinion and fear, and coupled with a historical dearth of research around pregnancy related choices, especially studies involving minority communities. And this doesn’t even account for those dealing with fertility issues and treatments.
Divya, a doctor in Houston has experienced almost all aspects of this process first hand. Last year, she temporarily decided to stop working as a hospitalist during her last trimester to protect herself and her baby from the virus. She delivered her son in June.
When the vaccine was offered to her in December, she and her husband – a cardiologist – debated its safety for her child, since she was breastfeeding and there was little data available about how it affected breastmilk at the time. She conferred with other mothers and decided to stop breastfeeding altogether so she could get the vaccine.
But when it came time to take a booster shot this year – which has been offered to health professionals and immunocompromised people at high risk in the past few weeks – Divya was undergoing in vitro fertilization (IVF). When she became pregnant, her doctor advised her not to get the booster shot until her second trimester, when more of the fetal anatomy was formed.
“There’s no data behind that,” she said, of the decision to wait, although she had heard of some OB-GYNS independently recommending the same thing during the first trimester. “Some doctors are confident, others are just asking people to wait a few months.”
Divya ended up having a miscarriage, and then decided to get a booster shot shortly thereafter. She said she would still recommend that any pregnant woman get the Covid-19 vaccine, given the high risk of mortality for both the mother and baby from the virus and its complications.
“It bears a lot of weight to have to think about those decisions,” she said. “Am I doing the right thing? Thinking of what you are bringing home. It feels kind of stressful.”
Iterative, at high speed
That stress is only compounded by the fact that recommendations for pregnant women change regularly. Three decades ago, for example, episiotomies (a cut to the perineum during delivery) were common and seen to prevent tearing – now they are used as a last resort. Various cultures and countries also view risks – such as drinking alcohol or forms of exercise – differently.
Studies around the vaccine have been similarly iterative at a much higher speed: updating in real time as scientists hustle to break down what we know about new variants and when protection wanes after a first dose.
One study about pregnancy and the Covid 19 vaccine was published in the New England Journal of Medicine, finding preliminary data that vaccines were safe. It was updated soon after with more context, including that there was not yet follow-up information for those vaccinated before 20 weeks of gestation. There was no change in the actual results: the people in the study who took the vaccine were similarly at risk for miscarriages and stillbirths to those pre-pandemic, but the correction left many nervous, and spurred a campaign of misinformation.
The stakes for pregnant women right now are high. Pregnancy depresses your natural immunity as a whole, and decreases lung capacity – a prime breeding ground for Covid-19 complications. Hospitals across the country have sounded the alarm this year as women and their babies have died in intensive care units. Last month, Mississippi public health officials confirmed that multiple unvaccinated pregnant women and at least one baby with Covid-19 died in a single hospital. As of 27 September, more than 125,000 cases had been confirmed in pregnant people with 22,000 hospitalizations and 161 deaths, according to the CDC – 97% of those were unvaccinated.
“It’s been very frustrating, but mostly it’s just been sad,” said Dr Jennifer Thompson, a maternal fetal health physician at Vanderbilt University, where the political divide and its public health impacts are palpable. In August alone, she said, at least 39 pregnant women had been admitted to the ICU at her facility. She has watched unvaccinated pregnant women with Covid be intubated, have stillbirths, or go on extracorporeal membrane oxygenation (ECMO), where an outside machine is used to pump and oxygenate blood, or die.
Thompson regularly sees patients who are scared to get the vaccine, or tell her they will do it postpartum. She said navigating this comes down to persistence. About three quarters of her patients are vaccinated, and if theyare not she has a discussion about it every single time they have a doctor visit.
But she attempts to address this without politics, or shame.
“I need them to understand I’m here because I care about them, and I care about their babies,” she said. For many, that could be enough. And for our broader public health system, an understanding of how messaging can be tailored, and tolerant, of pregnant people dealing with an onslaught of conflicting information could reach far more people.
It’s clear that many women like me are terrified of hurting themselves or their babies by taking the vaccine at a time when every small choice could have lifelong consequences. I decided to take the shot, and I’ve never looked back. But the truth is there is no easy decision.