The reason most pregnant women in South Africa will have to wait at least another month for a Covid-19 jab is that, in terms of the country’s vaccination roll-out protocols and progress, unless a pregnant woman is 35 or older and/or helping to deliver essential government services, she will only be eligible for a vaccination from September 1, when the programme opens up to people aged 18 to 35.
Dr Nicholas Crisp, national vaccination roll-out coordinator and deputy director-general in the department of health, says adding pregnant women to existing special priority groups would be too complex – and would take three weeks or longer.
“There are no priority groups for any medical conditions and adding pregnant women as a priority group would be too complicated. It’s taken this long to set up each of the public sector programmes, so it’s basically pointless adding a group that is difficult to identify,” he says.
Higher mortality risk
Spotlight interviewed three experts in obstetrics and gynaecology. They, as well as the SA Society for Obstetricians and Gynaecologists, are calling for all women of reproductive age to be vaccinated as soon as possible, and to seek proper monitoring and care in the meantime.
They cite a study of 400 000 pregnant women with Covid-19 in the US, which showed that this group had a 70% higher risk of death than pregnant women who did not have the virus. Crisp, however, questions what the risk was for their non-pregnant counterparts compared with the average 60-year-old or a patient on renal dialysis, for example.
Salome Maswime, an associate professor and head of the global surgery division at the University of Cape Town (UCT), says too many pregnant women are dying because of severe Covid-19-related disease or because they could not access care in time – or both. “There’s no clear or direct messaging for women in the public domain,” she says.
Call to prioritise pregnant women
Both Maswime and Professor Priya Soma-Pillay, the head of the department of obstetrics and gynaecology at the University of Pretoria and the Steve Biko Academic Hospital, believe Covid-19 is creating a generation of motherless children in South Africa.
They are calling for women of reproductive age to be prioritised for Covid-19 vaccinations, alongside police officers, teachers and healthcare workers, and say they are seeing ever more pregnant women in their third trimester with Covid-19 being admitted to ICU, with many dying.
“We already have a large orphan base because of Covid-19, so putting mothers at risk of dying [by not having been vaccinated] could lead to a further generation of orphans in South Africa,” says Pillay.
Crisp, however, is clear that pregnant women will not be prioritised at this point in the roll-out.
“Transplant surgeons, renal dialysis physicians and the multiple sclerosis society, among other groups, are also clamouring for early spots [for their patients],” he says.
“Pregnancy isn’t an illness – there are another 45 lobby groups pushing for us to accelerate things. It’s too complex logistically. It will be far better to open access to a younger age group than to try to select clinical priorities,” he says.
A June 11 advisory from the ministerial advisory committee on Covid-19 vaccines stated: “Covid-19 vaccination is strongly encouraged for non-pregnant women contemplating pregnancy. Covid-19 vaccines using the Pfizer or the Johnson & Johnson vaccine should be offered to all pregnant women, and pregnant women with comorbidities such as obesity, diabetes and hypertension should be prioritised for vaccination, should vaccine supplies be limited.”
Additionally, the experts to whom Spotlight spoke agreed with the following advice for women planning to fall pregnant or already pregnant:
- If a woman is thinking of getting pregnant, she should first get vaccinated, because the vaccine also confers protection on the foetus;
- Any woman of reproductive age should get the jab as soon as possible, provided she is not in the first trimester of pregnancy (the first 14 weeks); and
- If a woman is pregnant and has no health concerns or symptoms, she should get vaccinated in the third trimester.
The experts explain that this advice is no different from general guidance to pregnant women – in other words, to avoid taking all nonessential medicines in the first trimester because of the risk (although it is extremely low) of birth defects while the child is forming in the womb.
Soma-Pillay says that while no hard data exist to explain why so many women are succumbing to the virus in their third trimester, severe Covid-19-induced illness and hospitalisation of this cohort were well documented in the UK.
“If you look at our early data and the UK, women in the last trimester tend to be admitted to ICU [with Covid-19] needing ventilation,” she says.
Asked what the current hypothesis is for this, she says speculation is that the gravid uterus (the expanded womb carrying the foetus) impinges on the mother’s lung capacity.
Greater risk to mothers than to infants
Maswime stresses that all current guidelines for Covid-19 vaccines in South Africa declare them safe for pregnant women and those of reproductive age, with very little data showing any possibility of the virus being vertically transmitted to the unborn child if the mother becomes infected.
“We’re more afraid of women dying of severe disease than we are of unborn babies getting Covid-19. The emphasis should be on preventing the mother from getting the virus in the first place, which is where our call for vaccination comes in,” she adds.
Mushi Matjila, an associate professor in the department of obstetrics and gynaecology at Groote Schuur Hospital and a member of the receptor biology unit at the Institute of Infectious Disease and Molecular Medicine at UCT, says the chances of an unborn child being infected with Covid-19 are minimal, with studies estimating the rate at between 3% and 4%.
Matjila cites a major Canadian study last year comparing 348 600 births examined before the pandemic with more than 67 000 examined during the pandemic (first and second waves).
Published in the Journal of American Medicine, the study covered preterm births, stillbirths, neonatal ICU admissions and neonatal deaths, and found no difference in adverse outcomes to infants attributable to vertical transmission.
For a good overview of the evidence regarding Covid-19 and pregnancy, see this umbrella review in the journal PLoS One.
As for the potential harm of Covid-19 itself to pregnant women, Matjila cautions that one has to distinguish between the direct and indirect effects of the pandemic.
“There’s no doubt that the indirect effects on health system disruption have impacted very negatively on maternal and perinatal outcomes, especially in middle-income and low- to middle-income countries where these are much more palpable,” he says.
Matjila, who serves on the National Health Research Committee (NHRC) and the ministerial advisory committee on
research for health, and chairs the policy and strategy subcommittee of the NHRC, cites data from the district health information system. Published late last year and covering the first Covid-19 wave and the start of the second one, the statistics show an increase in maternal
deaths compared with the same period pre-Covid-19.
Research published by the SA Obstetrics and Gynaecology Forum, for which Soma-Pillay was the co-principal investigator, shows a 30% increase in maternal deaths during South Africa’s first Covid-19 surge until July last year, compared with the same period in 2019.
Stillbirths and unwanted pregnancies rose during the study period, as access to clinics and contraception was sharply reduced by the lockdown and a general fear of infection.
Plea to continue with clinic visits
Matjila pleads with pregnant women in South Africa to keep attending antenatal clinics, which are being kept open during the pandemic. “This is an absolutely essential service. You can close other nonessential services, but not maternal neonatal and child healthcare services. Sometimes patients misinterpret that, thinking they shouldn’t go to the clinic. They should. If the baby isn’t moving or you’re bleeding, don’t be afraid to go. Non-pregnant women also shouldn’t sit at home with problems. Don’t wait if you have symptoms, especially fever and respiratory symptoms, as most patients present to hospital when it’s too late,” he says.
*This article was produced by Spotlight – health journalism in the public interest