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How to Combat Vaccine Hesitancy Among Pregnant People

Beth Howard
January 6, 2022

Fear of harming their unborn are keeping some expectant mothers from getting vaccinated.

A pregnant patients exposes her bare belly while the physician puts a stethoscope against the belly.

Kyndal Nipper called her second pregnancy “textbook. Ultrasounds showed that her fetus was growing normally; her glucose test was also normal.

So when the 29-year-old from Columbus, Georgia, and her husband, both unvaccinated, came down with COVID-19 in her 36th week last July, they weren’t too worried. Besides, the couple’s symptoms loss of smell and low-grade fever were mild and didn’t last long.

After the third day of being sick, though, Nipper realized that she hadn’t felt her baby move in a while. She called her obstetrician, who sent her directly to the hospital. At the hospital, where she’d checked in earlier in the day, she learned that the child that she was carrying a son the couple had already named Jack no longer had a heartbeat.

“I couldn’t grasp what they were telling me,” says Nipper, who, like many people, planned to get vaccinated after their baby’s birth.

Nipper was induced and delivered her stillborn infant hours later. But soon she was fighting for her own life.

“COVID had ravaged my body on the inside,” she says. “I had no platelets and also had hemorrhaged. It took everything they could think of to keep me from bleeding to death.”

Nipper’s experience is unfortunately not unique. A study of delivery hospitalizations between March 2020 and September 2021 found that pregnant women in the U.S. with COVID-19 were at increased risk for stillbirth compared with pregnant women without COVID-19. Another study found that pregnant women with COVID-19 were more likely to be hospitalized, deliver pre-term, and require ICU admission than non-pregnant people.  

Pregnant people with COVID-19 infection are more likely to face other complications. Studies have linked COVID infection during pregnancy to a higher risk of gestational diabetes, pre-eclampsia, C-sections, pneumonia, admission to the ICU, and death.  One study identified a higher risk of death in pregnant people with COVID-19 that was 22 times higher than for pregnant people without COVID-19. Babies born to people infected with COVID-19 were found to be more likely to be born prematurely or develop conditions such as respiratory complications.

Women of color have been hit the hardest. According to a 2020 report from an OB-GYN practice in Massachusetts, more than 80% of the practice’s COVID-19 cases were in pregnant Black or Hispanic women, even though they made up only 60% of the practice’s pregnant patient population. Pregnant Black and Hispanic women were also more likely to be hospitalized for COVID, admitted to the ICU, and put on a ventilator. The authors of the study concluded that “these findings reflect the health consequences of the social, environmental, and structural effects of racism in the United States including differences in the prevalence of underlying chronic conditions and the disproportional impact of socioeconomic determinants of health.”

Low vaccination rates aren’t helping. Just 40% of pregnant people have been vaccinated before or during their pregnancy, according to the CDC. That number rises to about 55% for pregnant Asian people and about 41% for pregnant white people, but dips to about 35% and about 23% for pregnant Latinx people and pregnant Black people, respectively.

We tell [unvaccinated] patients that if they catch COVID-19, they will be more likely to die, to be intubated, and to have preterm birth than those who have been vaccinated,” says Alyssa B. Stephenson-Famy, MD, an associate professor in the division of maternal fetal medicine at the University of Washington School of Medicine in Seattle. “No matter what we say, some patients fear that the COVID vaccine will harm them or their babies, despite the overwhelming evidence to the contrary.”

Why the virus is especially dangerous for pregnant people

Many of the changes that the body goes through during pregnancy increase the susceptibility to and severity of COVID-19. Rising progesterone levels, for instance, bring changes to the mucous membranes of the nose that make the virus more likely to adhere to the upper respiratory tract and make it difficult to be cleared.

Airway restriction as the pregnancy advances and changes in the immune system make women much more vulnerable to COVID’s effects,” adds Guiseppe Del Priore, MD, MPH, adjunct professor of obstetrics and gynecology at Morehouse School of Medicine in Atlanta.

The Delta variant has added new, deadly, risks. CDC research found that the mortality rate among pregnant women with COVID-19 in Mississippi increased from five per 1,000 infections to 25 per 1,000 during the Delta surge last summer; mothers’ mortality risk also rose fivefold during that time period.

A COVID-19 infection in pregnant people is in turn affecting the health of their unborn children.

“This version of COVID-19 is attacking the placenta as it does some people’s lungs and destroying the baby’s ability to get oxygen,” says Timothy Villegas, MD, Nipper’s OB-GYN.

Why vaccination rates lag

Some vaccine hesitation during pregnancy isn’t surprising. Pregnant people may be  appropriately reluctant to expose themselves to substances from alcohol to aspirin that are not recommended during pregnancy. Yet doing so might put their growing fetus at risk in other ways, says Stephenson-Famy.  But the science is clear that the benefits of vaccinating against COVID-19 far outweigh the risks of not vaccinating for pregnant people and their babies.

Stephenson-Famy also believes that providers and professional organizations could have done a better job of communicating the vaccines’ benefits to pregnant people.

The narrative that rolled out after the vaccine was introduced was that pregnant women were not in the clinical trials so the initial vaccine recommendations for them were less clear,” she says. “As time went on, we as health care workers missed opportunities to counsel patients proactively and to advertise how great it was going to be for everyone to get it.”

The result? Resistance to COVID vaccines was firmly established by the time the American College of Obstetricians and Gynecologists finally recommended vaccinations for pregnant woman in August — a full eight months after they first became available.

In addition, historically marginalized women face unique obstacles.

Historically, Black women had negative experiences with health care, including suboptimal care and racist providers,” says Stephenson-Famy, who sees greater vaccine hesitancy in her patients of color. “They dont feel theyve been heard, don’t have much trust in the health care system, and so they may just not be interested in new medical developments.”

Although pregnant patients are just as prone to vaccine misinformation as anyone else, clinicians are still taken aback by the attitudes they encounter in the clinic.

“Most patients say it’s about vaccine safety,” says Linda ONeal Eckert, MD, professor of obstetrics and gynecology at the University of Washington. “But maybe their real fears are that theyll be rejected from their peer group because they got a vaccine. Maybe there’s a fear that if you take it and your partner doesnt want you to that thats going to cause problems. If it’s your first decision as parents and youre not aligned that can be hard to negotiate.”

Whatever is driving vaccine refusal, caring for such patients can be both heartbreaking and frustrating when tragedy strikes.

“You always grieve with a patient when they have a stillbirth or some other bad outcome,” Eckert says. “But then to feel like, oh my gosh, it could have gone a different way. It just takes your breath away.”

Moving the needle

All this prompts the question: How can providers make a dent in the dismal uptake of vaccination among pregnant people?

“I dont think we know how to get this message across in a way that people can hear without using fear,” Eckert says.

When patients seem indifferent to facts, she finds herself looking them straight in the eyes.

I’ll say, ‘Look, I have been practicing for 30 years. I have never seen anything as scary as how this is impacting pregnant women,’” Eckert says. “‘If you as a healthy young person caught COVID and youre pregnant, thats all that’s required to send you to the intensive care unit.’”

That can sometimes inspire a few takers, she says.  

Still, many young pregnant patients come into the exam room with a sense of invincibility. One tactic that can help in such cases is showing them unconditional compassion and care.

“I tell them that I’m responsible for keeping every one of my patients safe and healthy,” says Stephenson-Famy. “‘I’m like a shepherd and Im trying to get my whole flock through this pandemic without losing anyone. This is my recommendation as your doctor but also as someone who deeply cares about you and the health of you and your family.”

Stephenson-Famy also advocates for physicians and health care personnel to meet patients where they are.

For instance, “patients have become very choosy about which vaccines they feel comfortable with during pregnancy and which ones they dont whether it’s Tdap, the flu shot, or a COVID vaccine,” she says. At the same time “people often don't want to get vaccines in the first trimester, when embryogenesis takes place, which is a reasonable time to feel the most concerned about the vaccines.”

Her strategy is to agree to delay the first shot if the patient is insistent, but then make sure the patient receives the vaccines after the first trimester. Doctors also advise wearing masks when around others, and avoiding needless trips away from home.

Stephenson-Famy says. “If you accept part of the patients conditions, sometimes you can get them to agree to something that they werent planning to agree to.”

Shifting the focus

Stephenson-Famy says it can help to underscore the other risks unvaccinated pregnant people face. These, she says, are not COVID complications although that should always be a part of the conversation but the inconvenience of vaccine mandates and the potential disruptions to care caused by quarantines, if COVID strikes.

“I’ve asked patients about their holiday plans,” Stephenson-Famy says. “I literally work through their travel itineraries or their plans to see friends and family with them, detail by detail.”

For instance, she reminds them that if they test positive before they travel home from a trip they could get stuck in a different city for a couple of weeks, or they might not be able to get on the plane back from a destination without proof of vaccination. Sometimes the unfavorable logistics — such as missing prenatal appointments — win the day.

“I’ll ask, ‘Do you think that you can go visit your grandmother in a nursing home or see the basketball game your nephew is playing in without getting vaccinated?’” Stephenson-Famy says.

When unvaccinated patients are approaching delivery, Stephenson-Famy shares with them how being in isolation during labor has been traumatizing for many mothers infected with COVID she has cared for and their families.

“If you end up with COVID when you come into labor, you cant have visitors, you have to quarantine, your baby may be taken to the nursery and you won’t be able to visit your baby or start to bond,” Stephenson-Famy tells them. “For some people there’s no more powerful a motivator to get vaccinated than to wonder, ‘Will I get to hold my baby after its born?’”

For her part, Nipper, who got her own COVID-19 vaccine as soon as she was able to following her baby’s death, hopes that sharing her experience with others will spare other families the trauma she went through.

“I just hope that when people see our story, they make the decision to protect their baby,” she says.