On June 22, the Indonesian Obstetrics and Gynecology Association (POGI) recommended the provision of COVID-19 vaccination for pregnant women - a vulnerable group that has not been included in the national COVID-19 vaccination program - after seeing the increasing cases of pregnant women infected with the corona virus.
Until now, the Ministry of Health has not issued technical instructions for vaccination for pregnant women for health workers in the field. The Ministry of Health is still waiting for permission from the Food and Drug Supervisory Agency (BPOM).
There are thousands of pregnant health workers who cannot be vaccinated because of this policy. They are at great risk from their own pregnancies and from contracting COVID-19 through their work.
A number of data available in various studies from other countries show that pregnant women are a high-risk group in situations of the COVID-19 outbreak.
Therefore, it is time for the Ministry of Health to immediately issue a policy to vaccinate against COVID-19 for pregnant women, and to accelerate the vaccination program for pregnant women, especially for health workers.
High risk
A study involving about 91,000 women, about 8,200 of whom were pregnant), in the United States showed that if pregnant women were exposed to COVID-19, they had a 5.4-fold higher risk of being hospitalized.
In addition, they had a 50% higher risk of ICU admission and a 70% higher risk of requiring a ventilator (breathing aids) than those who were not pregnant. The risk of death from COVID-19 is the same for pregnant and non-pregnant women.
Various obstetrics and gynecology professional organizations in the world, such as the International Federation of Gynecology and Obstetrics (FIGO), have also emphasized the high risk of pregnant women if exposed to COVID-19 and recommended COVID-19 vaccination for pregnant women.
In the United States, the Center for Disease Control, the American College of Obstetricians and Gynecologists (ACOG), and the Society for Maternal-Fetal Medicine (SMFM) have recommended the COVID-19 vaccine for pregnant women. In the UK, the Royal College of Obstetrics and Gynecology (RCOG) also emphasizes this.
Data on patients with COVID-19 in pregnant women
There are several studies and recommendations from professional organizations of doctors and midwives that support the need for pregnant women to be immunized with the COVID-19 vaccine.
For example, a study from Brazil showed that 18.9% of women hospitalized for COVID-19 were pregnant, while the general birth rate for Brazil's population was only 1.3%. This may indicate the high prevalence of COVID-19 infections among pregnant women.
What is worrying is that, according to the research, only 22.6% of the number of pregnant women who died due to COVID-19 were treated in the ICU. This further underscores that pregnant women have been impacted by the health care capacity problems that are already overburdened in middle and low income countries.
In addition, a study from the UK of about 5,800 newborns showed that babies born to mothers who had COVID-19 had an almost five times greater risk of being admitted to the ICU than babies born to mothers who had not been exposed to COVID-10.
COVID-19 vaccine safety data for pregnant women
Preliminary data indicate that Pfizer/BioNTech and Moderna mRNA-based vaccines are safe to use for pregnant women.
The use of vaccines produced by Sinovac, AstraZeneca, and Johnson&Johnson/Janssen for new pregnancies has been proven safe in pregnant animal trials. WHO has issued recommendations for the use of the Sinovac vaccine for high-risk pregnant women.
In addition, all countries and regulatory agencies agree that there is no need for a pregnancy test before vaccination. They also agreed that delaying pregnancy for vaccination purposes was not necessary.
As of 3 July 2021, 23.8% of the world's population had received the vaccine. Of this number, of course, there are those who experience pregnancy after being vaccinated or do not realize that they are pregnant when they are vaccinated. So far, there have been no reports that specifically indicate safety concerns in the group who were found to be pregnant after being vaccinated.
Practice in other countries
Several developed countries and countries in Southeast Asia have opened vaccination programs for pregnant women such as the United States, Belgium, Israel, Malaysia, England, Singapore and the Philippines.
These countries have issued permits to use a wide variety of vaccines: Moderna, Pfizer, Sinovac, Bharat, AstraZeneca, CanSino, Sputnik V, and Janssen.
In its latest vaccination guidelines, the Malaysian government has decided that Pfizer/BioNTech, Sinovac, and AstraZeneca vaccines can be used for pregnant women.
Pregnancy physiology and infection susceptibility
Immunity during pregnancy undergoes changes due to the presence of the fetus and pregnancy products, including a decrease in immune cells such as Natural Killer cells, Dendritic cells and hormonal changes.
These changes in theory have the potential to increase the risk of a pregnant woman becoming infected with COVID19. During the swine flu (H1N1) outbreak in 2009, the immunity factor of pregnant women was one of the reasons why the severity rate among pregnant women was higher.
The presence of an expanding fetus will compress the chest cavity, thereby reducing respiratory capacity, and exposing pregnant women to a more severe risk of respiratory infections.
Normally, pregnant women are prone to blood clots. Meanwhile, one of the manifestations of COVID-19 is blood clots which increase the risk of death. If the two combine, then pregnant women infected with COVID19 have a doubled risk of experiencing this manifestation.
In the UK, there have been reported cases of death in pregnant women due to blood clots in the lungs due to SARS-CoV-2 infection.
Does the risk of blood clots in normal pregnancy multiply the risk of blood clots due to the AstraZeneca vaccine?
To date, there are no certain factors known to specifically increase the risk of blood clots after receiving the AstraZeneca vaccine. This means that a pregnant woman does not necessarily increase her risk of developing blood clots when she receives the AstraZeneca vaccine.
Other vaccinations for pregnant women and the need for research
Vaccination programs for pregnant women are not new.
Prior to the COVID-19 pandemic, pregnant women in various countries had received vaccine injections for various diseases that protected them from infection with pathogens that could harm their pregnancy.
So far there has never been a report that specifically says that pregnant women have a safety risk from existing vaccines.
Indonesia has a TT (tetanus toxoid) vaccination program for pregnant women). In addition, there are other vaccines recommended during pregnancy, such as the influenza vaccine and the Tdap vaccine (to prevent tetanus, diphtheria and pertussis).
To strengthen the decision to give COVID-19 vaccination to pregnant women, the Ministry of Health and universities need to immediately conduct research quickly to examine the safety data on the use of the types of COVID-19 vaccines that have been used so far in the community.
This is because, except for the Pfizer and Moderna vaccines, none of the current clinical trials of vaccines have data on their safety for use in pregnant women.
As of July 4, 2021, nearly 14 million Indonesians have received the complete two-dose vaccine and another 32 million have received one dose of the vaccine. This is a very large number to use as a research base.
Of this number, of course there are those who experience pregnancy after being vaccinated or are not aware that they are pregnant when they are vaccinated. Data from this group can provide information about the safety profile of vaccine use among pregnant women.
We don't want the delay in making a decision to vaccinate pregnant women to have a wide negative impact in the community for pregnant women and their babies, in the midst of the surge in delta variants that are currently raging in Indonesia.