Across the U.S., vaccination numbers have been slowly climbing, protecting more and more of the population and bringing the country closer to getting the coronavirus under control. But despite this success, some high-risk groups have lagged behind. In particular, rates among pregnant people are discouragingly low.
Although more than three-quarters of all eligible adults have gotten at least one COVID-19 shot, only about 25 percent of mothers-to-be have gotten one during their pregnancy. Rates are even lower for Latina and Black expectant mothers, at 22 and 15 percent, respectively, compared with 27 percent of white and 35 percent of Asian expectant moms. The vaccines are safe for use during pregnancy—a CDC study on the Pfizer and Moderna mRNA shots found that they did not increase miscarriages, and the agency has urged pregnant people to get vaccinated. And though infants and small children are not yet able to get the immunizations themselves, nursing babies may be able to receive some protection from antibodies in breast milk.
The consequences of remaining unvaccinated can be dire. At least 200 pregnant people have died of COVID-19, including 22 in August alone; nearly 23,000 have been hospitalized. Newborns are suffering too. The American Academy of Pediatrics has reported links between infection during pregnancy and preterm birth, and according to the CDC, babies born to patients with COVID-19 are at increased risk of admission to the neonatal intensive-care unit.
So why aren’t more expectant mothers getting shots that could be lifesaving for both them and their future children? Many assume that all unvaccinated people are conspiracy-minded anti-vaxxers, but as my colleague Ed Yong has written, the reasons for not getting COVID-19 shots are more complicated than that. Pregnancy adds another layer of complexity. The vaccine-skeptical women I spoke with told me that they believe the pandemic is real and that they are pro-science, but they were also overwhelmingly concerned about their own and their baby’s safety because of what they saw as a dearth of research on long-term outcomes. Given the high stakes of protecting their unborn child, and amid an often confusing information landscape, many opted for what felt safe, rather than what was safe.
The doctors I interviewed also found that a perceived shortage of data is what concerned most of their unvaccinated pregnant patients. Some had been spooked by anecdotes they’d heard about family members and friends with kids on the way reporting negative vaccine side effects. Others were simply worried about putting something unfamiliar in their body. All were trying to make the best choice for themselves and their child. Jennifer Thompson, a maternal-fetal-medicine specialist at Vanderbilt University Medical Center, said that some of those who declined to get a COVID-19 shot asked her about other ways they could protect themselves from the virus. Regan Theiler, an obstetrician at the Mayo Clinic, in Minnesota, told me that her patients “routinely get their flu shots. These are women who are health-care workers vaccinated against hepatitis B. They get their TDAP boosters in pregnancy to protect their baby.” Indeed, pregnant people have been more likely to take more familiar vaccines: 61 percent got a flu shot during the 2019–20 flu season, for example.
Convincing a historically marginalized population about the value of a new treatment is challenging in the best of times. Medical researchers have generally understudied how a lot of drugs affect pregnancy, and doctors too often dismiss pregnant patients’ worries—especially Black people’s. In the case of COVID-19 vaccines, early mixed messaging about the shots’ safety during pregnancy created a lasting anxiety that some health-care providers fueled. (In Mississippi, some pregnant people were reportedly wrongly turned away from clinics.) In the absence of clear guidance, misinformation masquerading under the guise of “wellness” and coordinated anti-vax campaigns targeting expectant mothers took root. Even for those who didn’t subscribe to any conspiracy theories, the confusion may have felt overwhelming.
Kirsy Vasquez, a pregnant woman from outside Boston, is vaccinated only because her workplace mandated it. She told me she would have willingly gotten the shot after giving birth, but doing so while she was expecting terrified her. She hasn’t experienced any major side effects—just fatigue and a sore arm—but that hasn’t quelled her fear. “I might be okay right now, but nobody knows,” she said, sharing that she’s most worried about what this decision will mean for her baby. Indeed, vaccination is typically thought of as a medical decision, but during pregnancy it’s also a parenting one. For many, it’s the first big decision they’re making on behalf of a new child, Lynn O’Brien Hallstein, a professor studying motherhood at Boston University, told me. Vaccination then becomes a test of whether you’re a good parent; both those in favor and those against have loud, strong opinions, and the stakes of failure feel monumental.
Of course, a COVID-19 vaccine is recommended for anyone eligible, and the clear medical consensus is that getting vaccinated is in the best interest of pregnant women and their babies. The reasons that refraining still feels safer to so many are likely informed by historical theories about pregnancy that emphasized the danger a mother’s actions—and even thoughts—posed to an unborn baby. Quill Kukla, a philosophy professor at Georgetown and the author of Mass Hysteria: Medicine, Culture, and Mothers’ Bodies, points to the early-modern theory of the maternal imagination, which posited that “if pregnant women so much as had a feeling or saw something that was disturbing, that would translate itself directly onto the body of the fetus.” The theory was often used for blatantly racist purposes—such as suggesting that a white woman lusting after a Black man might change the race of her baby—but its effects are still felt today.
Culturally, pregnant bodies are seen as fragile entities that must be kept pure from pollution. And while, practically, women do have to take into account that what they do affects the health of their fetus, assessing and weighing the risks can be confusing. They often have to sort through long lists of what to avoid in pregnancy, such as sushi and certain sleeping positions; while many of these things carry some risk, some advice books might lead new parents to believe the danger is greater than it is. “You can’t even take an ibuprofen when you’re pregnant, so it’s definitely scary to think about taking a brand-new vaccine,” Kristina, who works in finance in Dallas, told me. (The FDA recommends avoiding the drug if you’re pregnant, especially after 20 weeks.) It’s no wonder that expectant mothers have favored inaction on the vaccine, Kukla told me. “The whole history of pregnancy advice has been organized around pregnant women somehow keeping out outside influences.”
While some anti-vaxxers are actively spreading fear and misinformation, a lot of unvaccinated pregnant people are safety-minded, but have been understandably influenced by this overarching cultural attitude around pregnancy. “I do hear from lots of patients that ‘I just don’t like putting things in my body when I’m pregnant. I want this to be as natural as possible, and maybe I’ll consider it after delivery,’” Thompson, the maternal-fetal-medicine doctor, told me.
Kristina, who asked to be referred to by first name only, given that she was discussing private medical information, decided to wait out her pregnancy. She said her doctor waffled when giving her advice, emphasizing that there were no safety guarantees and ultimately telling her the choice was hers. “Honestly, it’s probably not what a pregnant woman needs to hear, because obviously, they’re not gonna go forward if you tell them that,” she told me. Instead of getting a shot, she took strict precautions, because she knew the risks of COVID-19. She was working from home, getting groceries delivered, and rarely leaving her house. To her, this scenario was “the best of both worlds”—she could avoid both infection and the stress of getting a vaccine that felt scary to her. Still, she emphasized that she’s not an anti-vaxxer. She encouraged her relatives to get vaccinated, and eagerly got her shots too—after she gave birth over the summer.
Although Kristina made it through her pregnancy without getting COVID-19, this bias toward inaction can have wide-ranging harms, pandemic or no pandemic. When nonintervention is a default, patients with conditions that actually require treatment can be endangered. There’s also a lack of research on the effects of many medicines during pregnancy. Though pregnant people were excluded from the initial COVID-19 vaccine trials, researchers did study the shots’ effects on them later on. However, according to one report, almost 75 percent of drugs approved between 2000 and 2010 don’t have any data on how they influence pregnancy. Without adequate evidence, many feel stuck when making decisions about their health. “It’s not just my body now. I’m thinking about my child’s body as well,” Jasmine Fortescue, an insurance representative from Florida who hasn’t gotten vaccinated, told me. “The information helps. But information can also be so overwhelming that sometimes you just have to stop and think about what you want to do and what you really believe.” As O’Brien Hallstein, the Boston University professor, said, while the power of choice can be empowering, it can also be a terrible burden, because it comes with being the target of blame if anything goes wrong.
An obvious exception to the preference for nonintervention is the racist history of researchers unethically testing treatments on pregnant women of color. The entire modern field of gynecology, for example, is indebted to experiments that a man named James Marion Sims performed on enslaved Black women without their consent and without anesthesia. In the 20th century, the influential obstetrician Fred Adair standardized a blueprint for prenatal care that was rooted in eugenics. As Dána-Ain Davis, a professor at the City University of New York studying Black maternal health and medical racism, told me, these “afterlives of slavery” permeate obstetric care to this day. “From that kind of relationship, you want to have trust that I’m supposed to take this vaccine?” Davis asked. “That is irrational. It is irrational on the part of the medical community and the public-health community, knowing what they know about how Black people’s bodies had been treated during reproduction and pregnancy. It is irrational for them to think that people are going to embrace all of a sudden the recommendations of somebody who they feel has not paid attention to them.”
To improve vaccination rates, the experts I spoke with all pointed to the importance of community-based care that both eases problems of access and builds trust. “When I have these conversations, I ... acknowledge that you’re not crazy for feeling like this,” Ndidiamaka Amutah-Onukagha, a public-health professor at Tufts University School of Medicine and the director of the MOTHER Lab, which studies maternal-health disparities, told me. “Then you back it up with science.”
Erika R. Cheng, a researcher at the Indiana University School of Medicine who has studied communication between patients and obstetricians, says that in the exam room, the gold standard for provider-patient communications is a process called shared decision making. In it, the two work together to reach an informed medical decision based on both the available evidence and the patients’ own values. But that process works only when the provider takes the patient’s concerns seriously, devotes adequate time to the conversation, and encourages the patient’s autonomy—conditions that many medical conversations don’t meet. Her research has shown that many pregnant people don’t always feel comfortable raising questions with their doctors at all.
If patients are uncomfortable with their doctors during normal times, it’s no wonder things go awry when information changes as quickly as it has during the pandemic. Confusion among patients was a natural response to uncertainty in earlier months among providers, who were still waiting on research. Many I spoke with were hopeful that more available data on the vaccines might convince the skeptical and get more shots in pregnant patients’ arms. Jennifer Thompson has started to notice this play out already. She says some women who were initially mistrustful have shared with her that they eventually chose to get vaccinated not in spite of their pregnancy, but because of it—making a choice that both felt and was safe.