--- title: COVID-19 Vaccines and Pregnancy tags: live-v0.2, facts permalink: https://c19vax.scibeh.org/pages/pregnancy --- <!--{%hackmd FnZFg00yRhuCcufU_HBc1w %}--> {%hackmd GHtBRFZdTV-X1g8ex-NMQg %} # COVID-19 Vaccines and Pregnancy [TOC] ## Impact of COVID-19 on pregnant women During pregnancy, one’s immune system has to accommodate the developing fetus and the organs supporting it (e.g., the placenta). The adaptations to develop immune tolerance to the fetus mean that pregnant women are more susceptible to severe disease---including COVID-19 ([Ovie et al., 2021](https://www.science.org/doi/10.1126/scitranslmed.abm2070)). There is now evidence that getting infected during pregnancy yield to higher risks of developing a severe form of COVID-19 ([Zambrano et al. 2020]( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643892/); [Kadiwar et al., 2021](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00716-9/)), especially with the Delta variant ([Vousden et al., 2021](https://www.medrxiv.org/content/10.1101/2021.07.22.21261000v1)). COVID-19 can result in pregnancy complications for the mother, and there is a possibility of transmitting the disease to the child. The WHO has reviewed three possible ways transmission could occur ([WHO, 2021](https://www.who.int/publications/i/item/WHO-2019-nCoV-mother-to-child-transmission-2021.1/)): 1. In utero (i.e., in the womb) This is [possible (though rare) with COVID-19](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00716-9/fulltext), and more likely when mothers are experiencing severe disease. The evidence is still being gathered on this, but other concerns are that COVID-19 affects the mother’s organs, thereby weakening the placenta’s structure and allowing the virus to reach the fetus without entering the bloodstream. 2. Intrapartum---during labour and childbirth, when the newborn is exposed to COVID-19 from the mother’s blood, vaginal secretion, or faeces as part of the birthing process Coronavirus has been rarely detected in the vagina during pregnancy, but it is common in the faeces, which often contaminates the vaginal canal and vulva during childbirth. Droplet and aerosol transmission of the virus is also very likely during active labour. It is hard to distinguish which channel the newborn may pick up the virus (in the vagina or immediately outside the mother) but newborns will likely be exposed if the mother has an infection. 3. Post-natal, through breast-feeding This has been uncommon thus far for coronavirus; though antibodies generated by the immune system (whether through response to infection or vaccination) have been detected in breast milk. We do not yet know however if these antibodies are sufficient to protect the infant when breast-fed. Other sources of postnatal infection are similar to child and adult transmission---from infected caregivers in the environment. ## Are the COVID-19 vaccines safe for pregnant women? Vaccines boost the lowered immunity in a way that both the woman and fetus can accept, thereby protecting both ([Ovie et al., 2021](https://www.science.org/doi/10.1126/scitranslmed.abm2070)). Since the first phases of the COVID-19 vaccine roll out, the evidence has grown---both the evidence about the risks of COVID-19 for pregnant women and their babies and the evidence from observational studies and real world data on the safety and effectiveness of vaccines during pregnancy. Clinical trials on the safety and effectiveness of COVID-19 vaccines during and right after pregnancy (e.g., when breastfeeding) are [still ongoing](https://www.rcog.org.uk/en/guidelines-research-services/coronavirus-covid-19-pregnancy-and-womens-health/covid-19-vaccines-and-pregnancy/covid-19-vaccines-pregnancy-and-breastfeeding/) but data are not yet available. The initial clinical trials did not include pregnant or lactating women (as with all new drugs as a precautionary principle)---thus many scientific societies and health authorities at this point took a cautious approach and did not recommend vaccination until more evidence was available, instead advising pregnant women to discuss the individual risks and benefits, considering known individual risk factors such as risk of exposure to the virus and comorbidities. Because we now know that the risks of suffering severe disease from COVID-19 is higher for pregnant women, this shifts the risk calculus for decision-making (see our **page on [risk perception](https://c19vax.scibeh.org/pages/riskperception)** for more about understanding the different risks from COVID-19). Additionally, there is growing evidence from observational studies confirming the safety of vaccines during pregnancy ([Shimabukuro et al., 2021](https://www.nejm.org/doi/full/10.1056/NEJMoa2104983); [Wainstock et al., 2021](https://pubmed.ncbi.nlm.nih.gov/34531079/)), alongside data from safety surveillance. For example, [in the USA almost 170,000 pregnant women have been vaccinated](https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/vsafepregnancyregistry.html) (mainly with mRNA vaccines such as Pfizer and Moderna) without raising any safety concerns. At present (November 2021) many health agencies and authorities recommend pregnant women to be vaccinated at any time during pregnancy, and also people planning a pregnancy, including: - in the USA - [CDC](https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html) - the [Academy of Breastfeeding Medicine](https://www.bfmed.org), - in the UK - [NHS](https://www.nhs.uk/conditions/coronavirus-covid-19/coronavirus-vaccination/pregnancy-breastfeeding-fertility-and-coronavirus-covid-19-vaccination/) - [UK government](https://www.gov.uk/government/publications/covid-19-vaccination-women-of-childbearing-age-currently-pregnant-planning-a-pregnancy-or-breastfeeding/covid-19-vaccination-a-guide-for-women-of-childbearing-age-pregnant-planning-a-pregnancy-or-breastfeeding) - the [Royal College of Obstetricians and Gynecologists](https://www.rcog.org.uk/en/guidelines-research-services/coronavirus-covid-19-pregnancy-and-womens-health/covid-19-vaccines-and-pregnancy/covid-19-vaccines-pregnancy-and-breastfeeding/) - the [Royal College of Midwives](https://www.rcm.org.uk/news-views/news/2020/december/updated-advice-on-covid-19-vaccination-in-pregnancy-and-women-who-are-breastfeeding/) - in Australia - [Australian Government](https://www.health.gov.au/resources/publications/pregnancy-breastfeeding-and-covid-19-vaccines-english) - [Royal Australian and New Zealand College of Obstetricians and Gynecologists](https://ranzcog.edu.au/statements-guidelines/covid-19-statement/covid-19-vaccination-information) Some authorities are more cautions regarding the first trimester of prregnancy, as little data is available on women vaccinated during the first trimester of pregnancy (due to the timing of vaccine rollout, that started in December 2020). These authorities advise pregnant women to discuss risks and benefits for each individual with health professionals. These include: - [STIKO - Robert Koch Institute - Germany](https://www.rki.de/DE/Content/Kommissionen/STIKO/Empfehlungen/PM_2021-09-10.html) - [ISS - Minister of Health - Italy](https://www.epicentro.iss.it/vaccini/pdf/Aggiornamento%20indicazioni%20ISS%20su%20vaccino%20in%20grav_%20e%20allatt_2021.pdf) :::success John Hopkins University maintains a **[tracker of policies about maternal immunization](https://www.comitglobal.org).** ::: ## What about breast-feeding? Evidence is also growing on potential benefits (in terms of antibodies that are transferred) for newborns from mothers vaccinated during pregnancy and breastfed babies from mothers vaccinated while breastfeeding. Most professional societies and health authorities now (November 2021) recommend mothers to continue breastfeeding during SARS-CoV-2 infection and also after vaccination, including: - in Europe: - [WHO](https://www.euro.who.int/en/media-centre/sections/press-releases/2021/who-recommends-continuing-breastfeeding-during-covid-19-infection-and-after-vaccination) - [STIKO - Robert Koch Institute - Germany](https://www.rki.de/DE/Content/Kommissionen/STIKO/Empfehlungen/PM_2021-09-10.html); ISS - Minister of Health - Italy (https://www.epicentro.iss.it/vaccini/pdf/Aggiornamento%20indicazioni%20ISS%20su%20vaccino%20in%20grav_%20e%20allatt_2021.pdf) - in the USA: - [CDC](https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html) - [The Academy of Breastfeeding Medicine](https://www.bfmed.org) - in the UK: - [NHS](https://www.nhs.uk/conditions/coronavirus-covid-19/coronavirus-vaccination/pregnancy-breastfeeding-fertility-and-coronavirus-covid-19-vaccination/) - [UK government](https://www.gov.uk/government/publications/covid-19-vaccination-women-of-childbearing-age-currently-pregnant-planning-a-pregnancy-or-breastfeeding/covid-19-vaccination-a-guide-for-women-of-childbearing-age-pregnant-planning-a-pregnancy-or-breastfeeding) - the [Royal College of Obstetricians and Gynecologists](https://www.rcog.org.uk/en/guidelines-research-services/coronavirus-covid-19-pregnancy-and-womens-health/covid-19-vaccines-and-pregnancy/covid-19-vaccines-pregnancy-and-breastfeeding/) - the [Royal College of Midwifes](https://www.rcm.org.uk/news-views/news/2020/december/updated-advice-on-covid-19-vaccination-in-pregnancy-and-women-who-are-breastfeeding/) - in Australia: - [Australian Government](https://www.health.gov.au/resources/publications/pregnancy-breastfeeding-and-covid-19-vaccines-english) - [Royal Australian and New Zealand College of Obstetricians and Gynecologists](https://ranzcog.edu.au/statements-guidelines/covid-19-statement/covid-19-vaccination-information) Additionally, as with other maternal vaccines, a “cocoon” strategy (vaccinating other people in the family or household) is recommended to reduce the risk of infection of expectant mothers and babies. <!--## Communicating about COVID-19 vaccines to pregnant women--> <!--## Attitudes towards COVID-19 vaccines in pregnancy--> ## Facts against circulating myths about COVID-19 and pregnancy ### FACT: COVID-19 vaccines have no impact on your fertility *MYTH: "Being vaccinated could make me infertile."* The myth that a COVID-19 vaccine could cause infertility arose on a blog with a long history of promoting conspiracy theories and misinformation. It is based on the idea that the vaccine works by triggering an immune response to a [spike protein](https://www.news-medical.net/health/What-are-Spike-Proteins.aspx) on the surface of the coronavirus. It is correct that a spike protein helps the virus enter cells, and it [is also one of the ways the human body recognises a virus and knows to let its immune cells attack it](https://fullfact.org/health/vaccine-covid-fertility/). However, this has nothing to do with fertility. The [guidance published by the Association of Reproductive and Clinical Scientists and the British Fertility Society](https://www.bmj.com/content/372/bmj.n509) confirms that there is absolutely no evidence, and no theoretical reason, that any of the vaccines can affect the fertility of women or men. The myth was created based on the fact that there is overlap between a small number of component of the spike protein in the virus and in a placental protein. However, the overlap is too short to plausibly affect fertility. Indeed, if the virus was related to fertility, COVID-19 should affect the outcome of pregnancies, [which has not been observed](https://factcheck.afp.com/covid-19-vaccine-not-shown-cause-female-sterilization). Further rebuttals can be found at [Fullfact](https://fullfact.org/health/vaccine-covid-fertility/) and [Snopes](https://www.snopes.com/fact-check/covid-vaccine-female-sterilization/?mc_cid=639a39a608&mc_eid=38e9f8ee6f), and in a particularly interesting and readable [article in _The Conversation_](https://theconversation.com/covid-19-vaccines-do-not-make-women-infertile-153550). ---- <sub>Page contributors: Teresa Gavaruzzi, Dawn Holford</sub> {%hackmd GHtBRFZdTV-X1g8ex-NMQg %} {%hackmd TLvrFXK3QuCTATgnMJ2rng %} {%hackmd oTcI4lFnS12N2biKAaBP6w %}