Most pregnant women in South Africa will have to wait at least another month for a potentially life-saving Covid-19 jab.
That is because in terms of the country’s vaccination rollout protocols and progress, unless a pregnant woman is 35 years and older, and/or helping deliver essential government services, she will only be eligible for vaccination from 1 September when the programme opens up to people aged 18 to 35.
Nicholas Crisp, the national vaccination rollout coordinator and deputy director general of the Department of Health, says adding pregnant women to existing special priority groups will be too complicated – and take three weeks or more.
“There are no priority groups for any medical conditions and adding pregnant women as a priority group would be too complicated. It’s taken that long to set up each of the public-sector programmes, so it’s basically pointless to add a group that’s difficult to identify,” he says.
Higher mortality risk
Spotlight interviewed three experts in obstetrics and gynaecology. They, plus the South African Society of 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 SARS-CoV-2 in the United States which showed that this group had a 70% higher risk of death than pregnant women without SARS-CoV-2. Crisp, however, questioned what the risk was for their non-pregnant counterparts when 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 from severe Covid-19-related disease or because they couldn’t 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 Priya Soma-Pillay, the head of department of obstetrics and gynaecology at the University of Pretoria and Steve Biko Academic Hospital, say Covid-19 is creating a generation of orphans in South Africa. They called for women of reproductive age to be prioritised for Covid-19 vaccination alongside police officers, teachers and healthcare workers. They say that they are seeing more and more pregnant women in their third trimester with Covid-19 being admitted to intensive care units (ICUs), with many dying.
“We already have a large orphan base because of Covid, so putting mothers at risk of dying, ie sans vaccination, could lead to a generation of orphans in South Africa,” says Soma-Pillay.
Crisp is however clear that pregnant women will not be prioritised at this point in the vaccine rollout. “The transplant surgeons, the renal dialysis physicians and the multiple sclerosis society, among others, are also clamouring for early spots,” he says. “Pregnancy is not 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 and select clinical priorities.”
An 11 June advisory from the ministerial advisory committee on Covid-19 vaccines says, among other things, that the “Covid-19 vaccination is strongly encouraged for non-pregnant women contemplating pregnancy, Covid-19 vaccines using the Pfizer or the J&J [Johnson & Johnson] vaccine should be offered to all pregnant women, and pregnant women with comorbidities such as obesity, diabetes and hypertension in pregnancy should be prioritised for vaccination should vaccine supplies be limited.”
Additionally, the experts Spotlight spoke to agreed with the following advice for women planning to get 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 they are not in their first trimester of pregnancy (ie, the first 14 weeks).
- If pregnant, and everything else is fine and you have no concerns or symptoms, get vaccinated in the third trimester.
They explain that the first-trimester advice is no different to general guidance, ie to avoid taking all non-essential medicines in the first trimester because of the risk, although extremely low, of birth defects while the child is forming in the womb.
Soma-Pillay says that while no hard data exists to explain why so many women were succumbing to Covid-19 in their third trimester, severe Covid-induced illness and hospitalisation of this cohort was well documented in the United Kingdom.
“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, ie the expanded womb carrying the child, impinges on the mother’s lung capacity.
Greater risk to mothers than infants
Maswime stresses that all current guidelines for Covid-19 vaccines in South Africa declare them safe for pregnant women and women 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. The emphasis should be on preventing the mother [from] getting Covid 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 chance of an unborn child being infected with Covid-19 is minimal, with studies estimating it at between 3% and 4%.
Matjila cites a major Canadian study last year comparing 348 600 births examined pre-pandemic with more than 67 000 during the pandemic (first and second waves). Published in the Journal of American Medicine, it 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 adverse effects of Covid-19 on pregnant women, he 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-and-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, it reveals an increase in maternal deaths compared with the same period pre-Covid-19.
Research published in the South African 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 coronavirus surge to July 2020 compared with the same period in 2019.
Stillbirths and unwanted pregnancies rose during the study period as access to clinics and contraception were sharply reduced by lockdown and a general fear of infection.
Plea to keep up clinic visits
Matjila pleads with women in South Africa to keep attending antenatal clinics, which are being purposely kept open during the pandemic.
“This is an absolutely essential service. You can close other non-essential 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 is not moving or you are bleeding, don’t be afraid to go.
“Non-pregnant women also shouldn’t sit at home with problems. Don’t wait with symptoms, especially fever and respiratory symptoms, as most patients present to hospital when it’s too late,” he says.
This article was first published in Spotlight.