Pregnant and Unvaccinated: Delta’s Deadly Toll

The number of pregnant people suffering from severe COVID is preventable tragedy

Scientific American, By Carolyn Barber on October 1, 2021


She was having trouble getting a full breath. That was the first thing. The day before, Autumn Carver, seven months pregnant with her third child, had enjoyed a CrossFit class. Now a simple cough was compounded by the breathing issues, which rapidly worsened. It wasn’t long before her husband, Zach Carver, took Autumn to Community Hospital South in the couple’s hometown of Indianapolis and then began a series of heartbreaking Facebook updates.

As COVID-19 began to ravage Autumn’s system, the 34-year-old’s condition deteriorated with dizzying speed. The physicians started her on life-supporting oxygenation therapy, then placed her on a ventilator and admitted her to the intensive care unit (ICU). She was flown by helicopter to Indiana University Health Methodist Hospital, where a crash C-section delivered Huxley Elias Carver safely, albeit two months premature.

Within a week of being admitted, Autumn was under sedation and paralyzed as physicians worked to relieve the pneumonia filling her lungs with fluid. “Please pray her lungs begin to heal,” Zach wrote on Facebook on September 9. “She is fighting so hard, and I am so proud of her,” he wrote two days later. Not long after, doctors told Zach that a double lung transplant might be his wife ’s only chance for survival. The couple is still hoping for that “miracle,” Zach wrote on September 18. More than a month into her ICU stay, Autumn has still not met her newborn son.

When Autumn became pregnant earlier this year, she and Zach considered their options. The couple had experienced three prior miscarriages. After talks with their physician, they both decided to wait on the COVID-19 vaccine. With that decision, Autumn became part of a growing and dangerous trend in the U.S.

“The Delta variant in unvaccinated pregnant patients is one of the most horrifying disease processes I’ve ever seen,” says Danielle Jones, an obstetric hospitalist who works at several centers in Austin, Tex. “My heart is broken. My patients are suffering. Families are grieving. Moms are never meeting their babies.”

Although it will take some time for corroborating data to be compiled, anecdotal and preliminary reports from the field are staggering. Some unvaccinated pregnant people are suffering far worse courses of COVID than those who have been inoculated, and the consequences can be severe. According to the Centers for Disease Control and Prevention, 22,000 pregnant people have been hospitalized, and 161 have died, because of COVID as of September 27.

Between the end of June and end of August, cases among pregnant people in the U.S. doubled from more than 500 to more than 1,000 per week, “and these numbers are likely an underestimate,” says Scott Pauley, a press officer at the CDC. Meanwhile the 22 COVID-related deaths among pregnant people recorded in August marked the highest one-month total since the pandemic hit—and shocked some obstetric doctors and nurses, who might normally see “zero to two” maternal deaths over a full career, Jones suggests. And Pauley notes that after months of decline, “we now see an increased number of pregnant people admitted to the ICU in July and August.”

Experts expect many pregnant people will be hospitalized largely because so many remain unvaccinated even as the Delta variant surges across the country. Among people who are pregnant in the U.S., only 32 percent of those aged 18 to 49 are fully vaccinated, according to CDC data from September 25. That figure stands in stark contrast to the 65 percent of people aged 12 and older who are fully inoculated and the more than 75 percent of that age group who have had at least one shot.

Simply put, pregnant people have been avoiding the vaccine, and the toll may be enormous. “The number of maternal deaths in the United States in a typical year is around 700,” Jones says. “I don’t know what the counts are going to be this year, but they are going to be astronomically higher than that.”

The road to this point is filled with misinformation but also with fears and concerns about the COVID vaccines’ impact on fertility and pregnancy, which many physicians find understandable, if mostly unsupported. These factors, combined with the inconsistent guidance patients received from their obstetricians and the delays in endorsing vaccines for expectant mothers from the CDC and key medical organizations, have left many pregnant people uncertain about receiving a shot.

“Vaccine hesitancy is not new,” says J. Martin Tucker, president of the American College of Obstetricians and Gynecologists (ACOG) and chair of the department of obstetrics and gynecology at the University of Mississippi Medical Center (UMMC). “We see vaccine hesitancy with the influenza vaccine and Tdap (tetanus, diphtheria and acellular pertussis) vaccine, which are routinely recommended in pregnancy.”

Health care professionals need to “answer questions, dispel myths and make strong recommendations for indicated vaccinations, especially the COVID vaccine,” Tucker says. But as the wild politicization of the coronavirus vaccine has demonstrated, that ’s much easier said than done.

Autumn Carver ’s case, progressing from one serious event to another, may sound extreme. And without a doubt, the overwhelming majority of pregnant people do well with COVID-19. In fact, in a study of more than 1,200 pregnant people who tested positive for COVID before vaccines became available and before the advent of the Delta variant, nearly 75 percent either had no symptoms or only mild disease.

But in my conversations with experts around the country, scenarios similar to Carver’s difficult experience are becoming more and more frequent among symptomatic, unvaccinated pregnant people.

Thomas Dobbs, Mississippi’s state health officer, says that at least eight pregnant women in Mississippi have died from COVID-19 since July. None of them were fully vaccinated. Physicians at the University of Alabama at Birmingham (UAB) Hospital have been seeing record numbers of pregnant people hospitalized: among 39 unvaccinated pregnant women with COVID admitted there in August, 10 were in the ICU, and were placed on a ventilator. Two of the 39 women died, and nine lost their babies. Tucker says that at UMMC, 12 pregnant women have died of COVID overall—five of them since August. All were unvaccinated.

“To see pregnant individuals so sick, some of whom will never see their baby, dying from a vaccine-preventable illness is absolutely tragic and traumatic,” says Linda Eckert, a professor of obstetrics and gynecology with an infectious disease fellowship at the University of Washington.

Pregnant people tend to be more susceptible to viral diseases in general, Tucker says, which may be because of “the mechanical effects of the advancing pregnancy, especially for pulmonary infections or changes in one ’s immune system.” Being pregnant may weaken one ’s immune system and render it susceptible to the highly contagious Delta variant. Delta now represents more than 99 percent of cases of COVID tracked in the country.

A CDC study of 400,000 women aged 15 to 44 who were diagnosed with symptomatic COVID-19 found that, although the absolute risk of severe outcomes was low, the pregnant women had a higher risk of severe disease and death than the nonpregnant ones. Likewise, a study of about 870,000 women found that, compared with those who did not give birth with COVID-19, those who did so had a nearly one-and-a-half-fold increase in preterm births, a sixfold increase in ICU admissions, a 14-fold increase in mechanical ventilation and a 15-fold increase in death.

Early clinical trials for COVID vaccines, though, did not include those who were pregnant. In hindsight, the exclusion “led to confusing messaging about the safety and effectiveness of the vaccines,” says Geeta Swamy, vice dean of scientific integrity and an obstetrics and gynecology professor at the Duke University School of Medicine. While that oversight has now been rectified—data from studies, such as one involving more than 2,000 pregnant and vaccinated people, show the vaccines do not raise risks for pregnancies—the misgivings linger.

“This is actually a group of vaccine-hesitant people that I very much understand,” Jones says. “People have this deep fear of performing some action that causes harm to their baby… Although we have lots of data now [supporting vaccination for pregnant people], it’s hard to not be worried when these patients were left out of the studies intentionally.”

There is another component to this story: age. As the pandemic has progressed, younger people have become sick and been hospitalized at increasing rates, according to William Grobman, vice chair of clinical operations in the department of obstetrics and gynecology at the Ohio State University College of Medicine and president of the Society for Maternal-Fetal Medicine (SMFM). “Pregnant individuals, being in a younger age category, have been part of this trend,” he says. Vaccination numbers for younger Americans are lower across the board than for the population at large, and recent data show that approximately 97 percent of pregnant people who are hospitalized with COVID are unvaccinated.

The acute progression of COVID-19 in patients like Carver can be stunning. The process “impacts families greatly,” Jones says. “Patients get sick very quickly and are often blindsided by how they walked into the hospital, were just feeling a little sick and then rapidly deteriorated.” The obstetricians themselves, far more accustomed to dealing with tragedies such as fetal and newborn deaths, have been affected, too. “Maternal deaths—it’s hard to walk a family through that,” Jones says. “It’s hard to feel helpless, like you’ve done everything that you can.”

The ACOG, SMFM and CDC have all strongly endorsed the use of vaccines by those who are pregnant, based on evidence demonstrating their safety and effectiveness in tens of thousands of pregnant people. On September 29 the CDC issued an urgent alert, recommending that pregnant people and nursing parents get vaccinated because “the benefits of vaccination outweigh known or potential risks.”

Data from eight health systems, which included more than 100,000 pregnancies, found that people who experienced miscarriages were not more likely to have received a COVID vaccine. As of September 27, more than 160,000 people have reported they were vaccinated for the disease while pregnant.

Beyond that, a recent study shows that pregnant people who received mRNA vaccines passed high levels of protective antibodies against COVID-19 to their babies. Out of 36 newborns tested at birth, 100 percent of the infants had protective antibodies—a strong endorsement for the added value of the vaccine.

“The increased circulation of the highly contagious Delta variant, the low vaccine uptake among pregnant people, and the increased risk of severe illness and pregnancy complications related to COVID-19 infection among pregnant people make vaccination for this population more urgent than ever”, the CDC’s Pauley says.

The argument for vaccines is both real and grounded in scientific evidence. The stakes, meanwhile, are neither academic nor political. They’re human, as Zach Carver’s near-daily Facebook updates make all too real. Zach and Autumn Carver met in high school, dated for a decade, married nine years ago and now have three children. The couple’s anniversary was September 15. “Autumn I love you very much, and am very proud of you,” Zach wrote on Facebook. “We will celebrate when we get you out of here.”

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