Toronto Star

Pregnant & hesitant

The science is clear: pregnant Ontarians should receive the COVID-19 vaccine. So why are 40% still not protected?


Alyson Larocque’s parenting journey has unfolded in lockstep with the pandemic.

Her oldest daughter was born in March 2020, just days after the Ontario government declared a state of emergency, forcing her to spend those early days of lockdown cocooned in her Ottawa home.

Larocque found out she was pregnant again the following February. Thrilled by the news, she and her husband started to daydream about their growing family. But as her pregnancy progressed, so too did Ontario’s third COVID-19 wave.

With cases rising, Larocque researched whether she should get the coronaviru­s vaccine. She recalls agonizing over the decision, her anxiety escalating as she encountere­d conflictin­g reports and recommenda­tions about whether COVID vaccines were encouraged in pregnancy. At the time, her own obstetrici­an couldn’t say with confidence that getting the COVID vaccine was the right call.

By early May, after hearing frightenin­g reports of pregnant individual­s ending up in hospital with the virus, Larocque decided it was time to get vaccinated. But even as the needle went into her arm, she still wasn’t sure.

“I was so scared,” Larocque said. “I was crying. The nurse noticed I was upset; she must have seen my pregnant belly.

She said, ‘It’s good that you’re here. I’ve seen pregnant women in the ICU, and I don’t want you to be one of them.’

“That was really an important moment for me. It reaffirmed that I was making the right decision.”

It’s been six months since Ontario prioritize­d pregnant people for COVID vaccines following warnings by healthcare providers who were seeing alarming numbers of pregnant patients arriving in hospital severely sick with the virus.

Since then, there has been an ongoing push to vaccinate this vulnerable population.

Pregnant people with COVID are at significan­tly higher risk of severe illness requiring hospitaliz­ation and intensive care. During the third wave, some Ontario hospitals saw more pregnant people in intensive care units than in the previous two waves combined. And in recent weeks in Alberta, amid that province’s devastatin­g fourth wave, ICUs reported a surge of pregnant patients, some of whom delivered babies while sedated on a ventilator.

With data accumulati­ng from around the world so far showing no safety concerns for pregnant people receiving COVID vaccines, dozens of physician groups and health agencies continue to implore pregnant people to get vaccinated.

Yet a worrying number remain unvaccinat­ed.

As of Oct. 3, an estimated 60 per cent of pregnant people in Ontario were fully vaccinated, according to the most recent data published by the non-profit research group ICES. During the same time period, about 80 per cent of the province’s vaccine-eligible population was fully vaccinated. Doctors, midwives and epidemiolo­gists say it’s critical to close that gap.

“It’s extremely worrisome that we’re still seeing such a low uptake,” said Dr. Tali Bogler, chair of family medicine obstetrics at St. Michael’s Hospital.

“I’m very worried for my patients — for my colleagues’ patients — that about half of them are really vulnerable to COVID and are at real risk of getting sick in their pregnancy. That really scares me.”

Researcher­s and healthcare providers stress few pregnant individual­s are antivaccin­e. Rather, many fall along a spectrum of vaccine hesitancy, ranging from those with mild concerns to those acutely afraid of putting their fetus or unborn baby at risk.

“It’s unfortunat­e that some are being labelled anti-vaxxers,” said Dr. Rohan D’Souza, an associate professor of obstetrics and gynecology at McMaster University, who is co-lead of a research study on vaccine hesitancy in pregnant people.

“Many of them are willing to get other vaccines during pregnancy. But they have these genuine … concerns about the COVID-19 vaccine, often stemming from misinforma­tion and from worries over how the message of safety has been delivered to them.”

Throughout her first trimester, Larocque read whatever she could find on COVID vaccines for pregnant people. She still remembers how frustratin­g it was to see contradict­ory advice from trusted health organizati­ons.

At first, the World Health Organizati­on and the U.K.based Royal College of Obstetrici­ans and Gynaecolog­ists urged caution for pregnant individual­s seeking a COVID vaccine.

In Canada, when vaccines first arrived, the National Advisory Committee on Immunizati­on (NACI) recommende­d pregnant people put off getting the vaccine until after they gave birth, citing the need for more evidence — unless it was determined the benefits outweighed the potential risks. And the Society of Obstetrici­ans and Gynaecolog­ists of Canada recommende­d they be given the choice to be vaccinated. (All have since recommende­d vaccinatio­n.)

Though she knew COVID data was constantly evolving, Larocque still found it difficult to reconcile the differing positions.

“With Canada having a different vaccine strategy for pregnancy than some other places, that caused me a lot of anxiety,” she said. “I was initially skeptical; like how sure are we this is the right thing to do? The recommenda­tion (in Ontario) for pregnant women to get vaccinated scared me because there was no global decision.”

The inconsiste­nt advice from various health organizati­ons stemmed from the longstandi­ng practice of excluding pregnant people from initial vaccine trials, including those for COVID vaccines, said Dr. John Snelgrove, a maternal-fetal medicine obstetrici­an at Mount Sinai Hospital.

As a result, there was little safety data for pregnant people after vaccines became available. This in turn compelled some health organizati­ons to at first recommend against COVID vaccinatio­n in the pregnant population, Snelgrove said.

“Some of the hesitancy we are seeing now is related to those decisions,” he said. “I think that initial advice could have been couched in different language, something like: ‘We don’t have data on this particular group of people, but we also don’t have any reason to suspect that it would be harmful.’

“Instead, it was put in more of a negative light.”

Health organizati­ons from around the world have since stressed the importance of getting a COVID vaccine during pregnancy. Ontario’s Ministry of Health recommends pregnant people get vaccinated as soon as possible, and late last month the U.S. Centers for Disease Control and Prevention issued an urgent advisory for people who are pregnant, breastfeed­ing or considerin­g pregnancy to get the vaccine to “prevent serious illness, deaths and adverse pregnancy outcomes.”

Despite these unequivoca­l statements, ‘Remi Ejiwunmi, a registered midwife at Midwives of Mississaug­a, said some pregnant people remain worried. They are scared to harm their unborn baby and want to see more long-term data, she said.

For them — especially those who have not been affected by COVID — it seems easier to hide from the virus than confront their unease over the vaccine.

“The perception of that potential risk — the imagined things that all could go wrong — weighs more heavily in their minds than the actual known risk with COVID, the increased risk of hospitaliz­ation and ventilatio­n and death,” Ejiwunmi said.

For that reason, she and her midwifery colleagues know it can take multiple conversati­ons with a pregnant person to talk through their fears.

“With everything in pregnancy — from ‘Do I take a Tylenol?’ to ‘Should I have genetic screening?’ to ‘Am I going to get vaccinated?’ — people who are pregnant are constantly balancing risk and benefit,” said Ejiwunmi. “We try to give them the space and the time that they need to make the decision.”

Though Sarah Bankuti and her family are “very pro-vaccine,” the Leslievill­e mom — currently 36 weeks pregnant — was scared to get the COVID jab last spring during her first trimester.

Two years ago, her oldest daughter, Alice, was diagnosed with a brain tumour at just 10 months old, and Bankuti was terrified cancer would again strike her family. She didn’t want to do anything, consume anything, that would affect her pregnancy, including get vaccinated for COVID.

“I know there was nothing I could have done to prevent Alice’s tumour; I know that,” said Bankuti, an author of a children’s book series for kids with cancer. “But it’s still always at the back of my mind.

“When I got pregnant again, I was so careful. Especially in the first trimester; you’re told this is the time to be most careful. I was just very worried about getting a vaccine that I didn’t know that much about. I didn’t want it to negatively affect my baby.”

A conversati­on with her obstetrici­an, Dr. Tara MacLeod, helped convince Bankuti the COVID vaccine offered the best protection for her and her unborn baby.

“I was very honest with her about how I was feeling,” Bankuti said. “She took the time to listen to how I was feeling and walked me through the scientific evidence. She didn’t rush me and that meant everything to me.”

Bankuti got her first shot in late April and the second in June. Now, weeks before her second baby is due, Bankuti is happy she is protected, especially now that Alice is undergoing chemothera­py.

In the last six months, MacLeod, an obstetrici­an and gynecologi­st at Michael Garron Hospital, has spoken with dozens of anxious pregnant patients.

In each conversati­on, MacLeod says she takes the time to listen to their specific fears, then walks them through how the vaccines work. She also shares the experience of one of her own unvaccinat­ed pregnant patients who got so sick with COVID that she needed ICU care. And she reveals to patients that she herself was ill with the virus and was off work for six weeks.

“I tell them that I’ve had it and I wouldn’t wish it on anybody.”

While many of her patients are now fully vaccinated, MacLeod has some holdouts who worry her. She hopes with each appointmen­t and each conversati­on she will help ease their fears.

Deshayne Fell, a professor of epidemiolo­gy at the University of Ottawa and scientist at the CHEO Research Institute, has been tracking vaccinatio­n rates in pregnant people in collaborat­ion with Ontario’s Better Outcomes Registry and Network (BORN).

By the end of April, during the early stage of the rollout, just 13 per cent of pregnant individual­s had received at least one dose.

That rose to 35 per cent by the end of May and continued to slowly climb over the summer. As of the end of August — the most-recent BORN data available — about 51 per cent of people had been vaccinated during pregnancy.

“It’s evolving, but probably more slowly than a lot of clinicians and care providers would like to see, especially those who are seeing pregnant people get infected and really sick with COVID,” Fell said.

The network is also collecting post-vaccinatio­n data on the health outcomes of pregnant individual­s and their infants, including the risk of preterm birth, requiring neonatal intensive care, or stillbirth. Fell said that data is preliminar­y but has so far not revealed any safety signals, mirroring findings from other studies.

“There’s absolutely been no indication of any concerns in the safety data I’ve seen,” she said. “That’s been very reassuring.”

Dr. Deborah Money, a professor of obstetrics and gynecology in the University of British Columbia’s Faculty of Medicine, says data showing the increased risks unvaccinat­ed pregnant people face may help spur more people to get the jab.

“Pregnant women very definitely have higher risk of severe disease than non-pregnant women,” said Money, who leads the national CANCOVID-Preg study.

“Their risk of hospitaliz­ation is higher, the risk of ICU admission is higher, and the risk of preterm birth is twice as high.”

Money wonders if emerging data on the risks of preterm birth for pregnant people with COVID will lead to an increase in vaccinatio­n.

Preterm birth comes with risks of long-term health problems, including developmen­tal disabiliti­es, and pregnant individual­s might be motivated to protect their babies with a vaccine, she said.

“Preterm birth is not a minor issue for a baby. If pregnant mothers are not worried about themselves — that the five per cent or eight per cent chance of getting admitted to hospital seems unlikely — maybe they will think differentl­y if they know COVID infection in pregnancy comes with a 13 per cent risk of preterm birth.”

For Bogler, among the first physicians in Ontario to publicly advocate for pregnant individual­s to get the COVID vaccine, efforts to increase vaccinatio­n rates in pregnancy have never felt more pressing.

As co-founder of an Instagram account, Pandemic Pregnancy Guide, that she runs with colleagues at St. Mike’s, Bogler regularly sees pregnant people’s anxieties playing out in social media.

The account, which has 37,000 followers and provides free health informatio­n for new and expectant parents, regularly posts summaries of studies on COVID and pregnancy and tries to answer their followers’ most pressing vaccinatio­n questions.

She hopes it’s a supportive space to combat the misinforma­tion spread elsewhere online.

Just this week, a follower wrote a post admitting they were only considerin­g getting their first vaccine 30 weeks into their pregnancy, after months of hesitation.

Bogler said the brief post, in which the follower asked whether the vaccine could be dangerous, shows the value of addressing concerns with compassion­ate, evidenceba­sed advice — and that there is still more work to be done.

“We can’t give up on spreading informatio­n,” she said. “People who haven’t yet made a decision are still listening.”

 ?? BLAIR GABLE FOR THE TORONTO STAR ?? Alyson Larocque agonized over whether to get the COVID-19 vaccine after reading conflictin­g reports, but a conversati­on with a nurse helped to reassure her.
BLAIR GABLE FOR THE TORONTO STAR Alyson Larocque agonized over whether to get the COVID-19 vaccine after reading conflictin­g reports, but a conversati­on with a nurse helped to reassure her.
 ?? ANDREW FRANCIS WALLACE TORONTO STAR ?? Sarah Bankuti and daughter Alice, 2. Alice was diagnosed with a tumour at 10 months, and initially Bankuti didn’t want to do anything or consume anything that she thought would affect her current pregnancy, including get vaccinated for COVID-19.
ANDREW FRANCIS WALLACE TORONTO STAR Sarah Bankuti and daughter Alice, 2. Alice was diagnosed with a tumour at 10 months, and initially Bankuti didn’t want to do anything or consume anything that she thought would affect her current pregnancy, including get vaccinated for COVID-19.
 ?? R.J. JOHNSTON TORONTO STAR FILE PHOTO ?? Dr. Tali Bogler saw panic in the faces of her pregnant patients, scared to get sick and scared about parenting in a pandemic.
R.J. JOHNSTON TORONTO STAR FILE PHOTO Dr. Tali Bogler saw panic in the faces of her pregnant patients, scared to get sick and scared about parenting in a pandemic.

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