COVID-19 Vaccination in Pregnancy

The resurgence of high levels of Covid-19 infections and hospitalizations, driven in large part by the highly contagious Delta variant, has raised the question of Covid-19 vaccination in pregnancy to a greater level of urgency.

The decision to get vaccinated or the decision to not get vaccinated against Covid-19 is a complicated and stressful one for many soon-to-be parents. It is, effectively, the first major healthcare decision new parents are being asked to make for their unborn children—and they are being asked to do it in the context of a constantly changing pandemic, rapidly evolving data, changing recommendations, and a slew of misinformation and (at times) outright fear-mongering with a poorly-concealed political agenda.

Like almost all decisions you will make about the health of your pregnancy and the health of your future child, the decision to be vaccinated while pregnant or not should check two major boxes: it should be driven by available scientific evidence, and it should feel like the right choice for you, your child, and your family as a whole.

What are the Facts?

Covid-19 Risks to Pregnant Women

Covid-19 poses a greater risk to pregnant women than their non-pregnant peers of a similar age and medical background. Any decision you make regarding vaccination needs to start with this basic premise. While the mechanism for the increased risk is still being studied, most scientists believe that the changes to a woman’s immune system which occur during pregnancy may put them at greater risk for severe Covid-19 infection, much in the same way we see pregnant women being at greater risk for poorer outcomes with other respiratory viruses, including the flu and respiratory syncytial virus (RSV). Overall, pregnant women who experience infection with Covid-19 are 3x more likely to require admission to an intensive care unit (ICU), and 2.5x more likely to require mechanical ventilation through intubation or some form of bypass support relative to their non-pregnant peers. According to a study published in JAMA Pediatrics in April 2021, pregnant women infected with Covid-19 at the time of delivery are 22x more likely to die during or immediately after childbirth than their non-infected, pregnant peers. (Yes, you read that number correctly: 22x.) Pregnant women who experience Covid-19 infection are also at greater risk of preeclampsia, preterm labor, gestational hypertension, and are more likely to require an unplanned or emergency c-section than their non-infected, pregnant peers. Women with a Covid-19 infection at the time of labor and delivery stay in the hospital, on average, nearly four days longer than those without infection at the time of delivery. An important note to caveat nearly all available data which is relevant to the conversation surrounding Covid-19’s impact on pregnant women: these numbers are drawn from studies which ended in the early part of 2021—prior to the widespread prevalence of the Delta variant, which we know to be more contagious and associated with more severe infections and poorer outcomes across all population groups, pregnant women and young children included.

Covid-19 Risks to Newborns

The newborn babies of mothers whose pregnancies were complicated by Covid-19 infection are also at risk for several morbidities relative to their peer group. Babies born to mothers who experience Covid-19 infection are at greater risk of preterm birth (prior to 37 weeks), which by itself subsequently puts children at greater risk for a myriad of long-term complications including cerebral palsy, developmental delay, impaired learning, and problems with vision, hearing, and behavior. Babies born to mothers infected with Covid-19 are also at greater risk of low birth weight, and are significantly more likely to require an admission to the neonatal intensive care unit (NICU)—an important factor which can increase the likelihood of maternal postpartum depression and decrease the likelihood of a successful breastfeeding relationship.

 Risks of the Covid-19 Vaccine to Pregnant Women and their Unborn Children

What is the flip-side of this cost-benefit analysis? Reported side effects of Covid-19 vaccines in women do not appear different, more severe, or more likely to occur in pregnant women versus their non-pregnant peers. Among these potential side effects, the potential to develop a severe allergic reaction or a fever are the standouts which some pregnant women worry about, and which definitely warrant consideration.

Fevers of any cause in pregnancy, including as a side effect of Covid-19 vaccination or Covid-19 infection, are associated with risks to the fetus. This is particularly true if the fever is greater than 101 degrees, lasts for a significant duration of time, or occurs in the first trimester—when some studies have suggested it may be more likely to cause certain birth defects, though evidence regarding this is highly disputed (such studies failed to consider the root cause of the fever as the true cause of resulting defects).  Even prior to Covid-19 entering the discussion, fevers are generally experienced by roughly 20-33% of all women during the course of pregnancy, the vast majority of whom go on to deliver healthy babies. Fever is a reported side effect in approximately 3-4% of all Covid-19 vaccinations in the United States to date. While a percentage cannot be calculated for the frequency of fever experienced during Covid-19 infections on the whole due to the significant amount of completely asymptomatic cases, fevers are reported in approximately 80% of all adults infected with Covid-19 who require hospital admission. All-in-all, while the risk of fever to pregnancies is an important consideration, fever is unlikely to negatively impact a pregnancy or unborn baby, and fever is unlikely to occur as a vaccine side effect. Those who do experience fever during pregnancy as a result of Covid-19 vaccination (or any cause) should speak with their care provider about an appropriate antipyretic, such as acetaminophen, to mitigate any potential risks.

The risk of severe allergic reaction in response to a Covid-19 vaccine, while small, would be a potentially life-threatening scenario for both Mom and baby. Any individual, pregnant or not, with a history of a severe or anaphylactic allergic reaction to an ingredient in a Covid-19 vaccine should not be vaccinated with the corresponding formula, and should discuss vaccination alternatives, risks, and benefits with their provider.   

Other reported risks or concerns regarding the Covid-19 vaccine in pregnant women or their babies are, in a word, untrue. All available data indicates there is no increased risk of miscarriage, stillbirth, or fetal demise associated with Covid-19 vaccination in pregnancy. Furthermore, there is no scientific basis for previous concerns and claims that vaccinations could impact female or male fertility, or fertility of an unborn child. There are no currently approved Covid-19 vaccines in the United States or Canada which contain a live virus—meaning that no available vaccine is biologically capable of inducing a Covid-19 infection.

Weighing the Risks

While the risk of adverse side effects to Covid-19 vaccination does exist, the simple truth is the risk of these side effects pales in comparison to the potential risks—to both Mom and baby—of contracting Covid-19 during pregnancy. Much of parenting can be boiled down to a giant, continuous cost-benefit analysis: exclusive breastfeeding vs improved quality of sleep for mom; sleep training vs mommy shaming; baby-led weaning vs risk of choking; private elementary school vs a more robust college savings account—on and on it goes. While the decisions parents weigh over the course of a child’s life will be innumerable, few may feel as urgent or come with as much anxiety as the decision to get vaccinated for Covid-19 while pregnant, particularly in the current climate of new variants, increased infection rates, and rising hospitalizations. Many families have recently told me they simply felt like there was “no good option” regarding vaccination—that the idea of getting vaccinated and the idea of remaining unvaccinated both feel very scary. If you feel this way, I encourage you to lean on your care providers. Have frank conversations with your nurses, obstetricians, and midwives regarding risks, benefits, and all your available options. And, as always, in the face of uncertainty: go where the evidence takes you. You’ve got this, Mama.

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