Last week, three pregnant women with severe COVID checked into a rural hospital in Pennsylvania.  Two required intubation and ventilation, and then were quickly transferred to the ICU. These patients were first evaluated in the ER by the hospitalist group of doctors including Laszlo Madaras, MD, MPH, Migrant Clinicians Network’s Chief Medical Officer, and a hospitalist. He has been working in his rural hospital’s COVID-19 floor since the beginning of the pandemic. He has treated patients of all ages, but his age range has shifted in the last year, from mostly older patients in 2020 to younger patients since mid-2021.  But three pregnant women in quick succession were the most his hospital has seen thus far. 

“All three are in their mid-20s, and they got very hypoxic,” Dr. Madaras noted. “They couldn’t get enough oxygen for themselves, which means it’s hard on the developing baby also.”

Two of the women required intubation; the third was given a BiPap, a mask linked to a machine to force air into the lungs without intubation. It’s unknown what the effect of low oxygen or COVID infection will be on their babies.

Typically, he said, obstetricians don’t work in the ICU, except for emergency C-sections which may require a short stay in the ICU. The ICU staff for their part aren’t specialists in caring for both mother and fetus in a typical rural hospital. Of course, no one is a long-term expert in COVID, he added: “I’ve been a general doctor for 25 years, but my experience with COVID is for less than two,” he said.

His hospital chose to fly the three women out to a high-level tertiary care center, better equipped to serve pregnant patients. “Hopefully, the pregnant moms won’t have to be intubated for too long – but we just don’t know what this ultimately means for the child,” Dr. Madaras said.

Right as Dr. Madaras flew out his patients, the Centers for Disease Control and Prevention (CDC) released an emergency health advisory specific to pregnant people, where they called for “urgent action” to increase COVID vaccination among people who are pregnant, recently pregnant, who are trying to become pregnant now, or who might become pregnant in the future. The advisory is responding to the data. While the risk of severe illness remains low, pregnant and recently pregnant people with COVID-19 are at increased risk for severe illness from COVID-19 compared to non-pregnant people. The highest number of COVID-19-related deaths in pregnant people in a single month occurred in August – 22 deaths. Those who survive may have adverse pregnancy outcomes.

The urgency of the message is perhaps intended to overcome earlier clinician messaging that encouraged pregnant people to hold off on vaccination due to a lack of data. Although new data are now available to strongly support the recommendation to get vaccinated, pregnant people still appear highly complacent or hesitant. At present, just 31% of pregnant women are fully vaccinated, and the percentage drops even lower among pregnant people of color. Data indicate that 97% of pregnant people hospitalized with COVID-19 were unvaccinated.

Dr. Madaras believes it’s critical for clinicians to strongly encourage women who are pregnant or who may wish to get pregnant to get vaccinated. “Women are concerned it may affect the child’s development, but that has not been the case,” he noted. “Basically, infection from the virus is much worse than any temporary side effects of the vaccine.” The good news is that, as of this week, the two pregnant patients who required intubation were extubated. They appear to be recovering. But their traumatic emergency care could have been avoided with the COVID-19 vaccine, coupled with recommended prevention measures like mask-wearing.

Increasing outreach efforts, particularly to women of childbearing age in hard-to-reach communities, can save lives. CDC’s Health Advisory, COVID-19 Vaccination for Pregnant People to Prevent Serious Illness, Deaths, and Adverse Pregnancy Outcomes from COVID-19, includes the most recent and relevant data, and a list of recommendations for health care providers.  Here, we reprint the CDC’s recommendations for health care providers in full:

• Ensure all clinical staff are aware of the recommendation for vaccination of people before and during pregnancy and the serious risks of COVID-19 to pregnant and recently pregnant people and their fetuses/infants.
  
  
• Increase outreach efforts to encourage, recommend, and offer vaccination to people who are pregnant, recently pregnant (including those who are lactating), who are trying to get pregnant now, or who might become pregnant in the future. A strong recommendation from a healthcare provider is a critical factor in COVID-19 vaccine acceptance and can make a meaningful difference to protect the health of pregnant and recently pregnant people and their fetuses/infants from COVID-19.
  
  
• For healthcare providers who see patients who are pregnant, recently pregnant (including those who are lactating), who are trying to get pregnant now, or who might become pregnant in the future:
  
  
  • Review patients’ COVID-19 vaccination status at each pre- and post-natal visit and discuss COVID-19 vaccination with those who are unvaccinated.
    
    
  • Reach out to your patients with messages encouraging and recommending the critical need for vaccination.
    
    
  • Remind patients that vaccination is recommended even for those with prior COVID-19 infections. Studies have shown that vaccination provides increased protection in people who have recovered from COVID-19.
    
    
  • Support efforts to ensure people receiving the first dose of an mRNA COVID-19 vaccine (i.e., Pfizer-BioNTech, Moderna) return for their second dose to complete the series as close as possible to the recommended interval.
    
    
    • Consider a booster dose in eligible pregnant persons.
      
      
  • Communicate accurate information about COVID-19 vaccines and confront misinformation with evidence-based messaging from credible sources. For example, there is currently no evidence that any vaccines, including COVID-19 vaccines, cause fertility problems in women or men.
    
    
• Become a COVID-19 vaccine provider and vaccinate patients during their visit.  More information can be found at How to Enroll as a COVID-19 Vaccination Provider.

Here are some additional resources that may assist communities in reaching out to pregnant refugees, immigrants and migrants:

• NRC-RIM’s Conversation Guide: Fertility + Parenthood relating to COVID-19 vaccines
  
  
• The Society for Maternal-Fetal Medicine (SMFM) - COVID-19 Vaccination During Pregnancy: Get the Facts and Get Vaccinated! - English and Spanish
  
  
• The Society for Maternal-Fetal Medicine (SMFM) - COVID-19 Vaccination if You Are Pregnant or Breastfeeding - English and Spanish
  
  
• CDC- COVID-19 Vaccines While Pregnant or Breastfeeding
  
  
• Hesperian Health Guides - COVID-19: Vaccines
  
  
• CDC - V-safe After Vaccination Health Checker
  
  
• National Center for Farmworker Health (NCFH) - COVID-19 Educational Resources for Agricultural Workers

MCN offers numerous materials and customizable campaigns to get the word out.

• “Vaccination is…” campaign features numerous customizable materials for print-out and social media, in English, Spanish, and Haitian Creole. Created in partnership with the National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM) with IDEO.org.
  
  
• #YoMeLaPuse campaign to encourage vaccination with this short multigenerational video and customizable and downloadable posters.
  
  
• What to Expect When Getting the COVID-19 Vaccine is a colorful and customizable low-literacy flyer/poster, in English, Spanish, and Haitian Creole. An accompanying video guides users on how to customize it.

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