LETTER | Pregnant women left behind in the fight against Covid-19

LETTER | In the rush to get vaccines into the arms of as many people as possible, pregnant and recently postnatal women have been left to navigate the vaccination system by themselves with little to no indication that they are being considered and supported by the government. These women are currently not being screened and identified by the vaccine booking system, and the guidance surrounding suitable vaccines for this group have not been updated.

This issue is even more pertinent now that Malaysia is starting to vaccinate women of childbearing age under the opt-in AstraZeneca (AZ) vaccination programme and pregnant and breastfeeding women are forced to make a choice between getting an AZ vaccine now, or face the unknown of what will happen in Phase 3 of the national Covid-19 Immunisation Programme (Pick).

It is this unknown that needs to be addressed by the Health Ministry, and it is irresponsible for the authorities to avoid rolling out a specific implementation strategy for this group of women in light of the latest data surrounding the impact of Covid-19 infections and vaccine suitability.

Pregnant women have a unique set of circumstances in which we are increasingly being recognised to be at higher risk of being severely ill if infected with Covid-19 and yet we are not being prioritised under Phase 2 of Pick. In the third trimester, emerging data indicates an increased need for ventilation support, premature birth risk, and increased likelihood of neonatal ICU admissions. Brazil is currently experiencing devastating levels of maternal deaths from Covid-19, with 432 deaths recorded this year alone.

In Phase 3, we are not being differentiated from the non-pregnant population with regards to the urgency of vaccination. The MySejahtera app does not allow for women to declare if they are pregnant or breastfeeding. This is assuming that pregnant women will be eligible for a vaccine in this phase.

JKJAV’s literature on the different groups eligible for vaccinations under the mainstream PICK have also conveniently left this group of women out, only choosing to highlight pregnant women with co-morbidities as a high-risk group. MOH’s latest list of priority groups states that pregnant women are not being routinely vaccinated due to insufficient data, and any “vaccination during pregnancy should be done after counselling through a process of shared decision making”.

With all the uncertainty surrounding vaccinations for pregnant women, I suspect many have signed up for JKJAV’s opt-in AZ programme, with the belief that any vaccine is better than none. However, this decision goes against what many of us have been told by our obstetricians or have read through our own research on guidelines in the UK, where AZ vaccines have been rolled out extensively.

To date, there have been no clinical trials carried out on pregnant women by any vaccine manufacturers. Because of this, the WHO only recommends the AZ vaccine if the benefits of receiving it outweighs the risks – i.e those with comorbidities or risk of exposure to Covid-19 due to being a healthcare worker. Data on the effects of the Sinovac vaccine on pregnant women are also woefully insufficient.

Updated guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) recommends that pregnant and recently postnatal women should have the option to avoid vaccination with AstraZeneca and request for Pfizer or Moderna instead. This is based on real-world data gleaned from the vaccination of some 90,000 pregnant women in the US using Pfizer/Moderna vaccines.

Based on this data, the Joint Committee on Vaccination and Immunisation (JCVI) in the UK have advised that it is preferable for pregnant women in the UK to be offered the Pfizer or Moderna vaccines where available. Canada’s NACI have also recently recommended the same, stating that treating vaccine-induced thrombotic thrombocytopenia (VITT), a side effect of the AZ vaccine, in pregnant people is more complicated than treating it in those who are not pregnant.

Although many aspects of the opt-in AZ programme can be commended, the lack of clarity on AZ’s suitability for pregnant women is glaring. In trying to solve the issue of supposed AZ vaccine hesitancy, JKJAV has failed to address legitimate concerns from mothers with regards to confusing guidance and emerging data surrounding vaccines and what Malaysia’s implementation strategy is for this group of the population.

When asked regarding this (on Twitter) they advised individuals to consult with their gynaecologist. Based on updated guidance in other countries, many in Malaysia have been, understandably, advised by their obgyns to wait and forgo the AZ programme. But what is the alternative being offered to pregnant women?

The issue at hand is not so much the lack of data on the safety of vaccines for pregnant and breastfeeding women, but rather the lack of a strategy by the MOH to protect this vulnerable group of women. If the only data we can rely on is real-world data on Pfizer for pregnant women, should we not be prioritising pregnant women for this vaccine and incorporating this within Pick?

If pregnant women decide to forgo AZ now, what guarantee will they have that the MOH will implement screening procedures for Phase 3 to identify pregnant women and offer them a suitable vaccine? Will we reach our turn under Phase 3 months later only to find out that we are faced with the same dilemma of being offered a potentially unsuitable vaccine or remain unvaccinated?

The waiting period for Phase 3 is riddled with risks, increasing as the pregnancy enters the third trimester. The number of Covid cases looks set to increase further, and to make matters worse, the latest news also indicates that Phase 3 is likely to be delayed due to supply issues.

As JKJAV starts to expand the opt-in AZ programme to other states, they will encounter many more pregnant women faced with the same dilemma. Malaysia cannot afford to ignore this group any longer and urgently needs a clear plan and infrastructure in place to identify and support the implementation of vaccines for pregnant and breastfeeding women.

This needs to be communicated clearly so that women in this group, and their obgyns, can make a more informed risk-benefit analysis to come to a shared decision. Mothers can then be assured that if they decide to forgo the AZ vaccine, they will not have risked theirs and their babies lives only to be let down in Phase 3.

The views expressed here are those of the author/contributor and do not necessarily represent the views of Malaysiakini.