SARS-CoV-2 vaccination in pregnancy: a unique opportunity for equity
Authors: Erkan Kalafat, Laura A Magee, Peter von Dadelszen, Pat O’Brien, Asma Khalil
Journal: The Lancet (2021)

We read the Comment by Bollyky and colleagues1Bollyky TJ Murray CJL Reiner Jr, RC Epidemiology, not geopolitics, should guide COVID-19 vaccine donations.Lancet. 2021; 398: 97-99Summary Full Text Full Text PDF PubMed Scopus (20) Google Scholar with great interest and wanted to echo the sentiment from the maternal health-care perspective. Pregnant women and their babies in under-resourced settings bear the greatest burden of mortality and morbidity related to pregnancy complications, so it is unsurprising that this is also true of COVID-19.2Chmielewska B Barratt I Townsend R et al.Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis.Lancet Glob Health. 2021; 9: e759-72Summary Full Text Full Text PDF PubMed Scopus (627) Google Scholar Maternal mortality due to COVID-19 is 149 per 10 000 infections in Mexico, compared with 15 per 10 000 symptomatic infections in the USA.3Zambrano LD Ellington S Strid P et al.Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22–October 3, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1641-1647Crossref PubMed Google Scholar, 4Martinez-Portilla RJ Sotiriadis A Chatzakis C et al.Pregnant women with SARS-CoV-2 infection are at higher risk of death and pneumonia: propensity score matched analysis of a nationwide prospective cohort (COV19Mx).Ultrasound Obstet Gynecol. 2021; 57: 224-231Crossref PubMed Scopus (115) Google Scholar However, although solutions to the leading causes of maternal mortality (hypertension, haemorrhage, and sepsis) are complex and involve improving weaker health systems, the solution to COVID-19-related mortality is not. Vaccines are highly effective at reducing severe COVID-19 and death, with the number needed to vaccinate to avoid one maternal death being substantially lower in low-income and middle-income countries (LMICs) than in high-income countries. For example, assuming that vaccination is at least 95% effective in preventing maternal mortality, one maternal death could be prevented by approximately 70 immunisations in Mexico or at least 700 immunisations in the USA.3Zambrano LD Ellington S Strid P et al.Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, January 22–October 3, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1641-1647Crossref PubMed Google Scholar, 4Martinez-Portilla RJ Sotiriadis A Chatzakis C et al.Pregnant women with SARS-CoV-2 infection are at higher risk of death and pneumonia: propensity score matched analysis of a nationwide prospective cohort (COV19Mx).Ultrasound Obstet Gynecol. 2021; 57: 224-231Crossref PubMed Scopus (115) Google Scholar Because vaccine hesitancy is lower among women in LMICs than in high-income countries,5Skjefte M Ngirbabul M Akeju O et al.COVID-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries.Eur J Epidemiol. 2021; 36: 197-211Crossref PubMed Scopus (355) Google Scholar there is a huge potential for public good if the poor availability of the vaccine can be rectified, particularly in Africa; this is shown in the proportion of people who have received at least one dose of the COVID-19 vaccine in different regions of the world (appendix). Unless pregnant women receive protection through immunisation or shielding strategies, the absolute increase in maternal morbidity and mortality will be staggering in LMICs given their high baseline morbidity and mortality rates, the greater proportional effect of the pandemic, and the already strained health-care resources. We call for urgent action to ensure equitable access to immunisation for pregnant women in LMICs who are particularly willing to be vaccinated, are at an increased risk of death from COVID-19, and live where fewer vaccines are needed to save each life compared with high-income countries. The COVID-19 vaccine is a unique opportunity for the global health community to provide health-care equity. AK is an unpaid member of the COVAX Maternal Immunisation Committee. PO'B is the co-Chair of the Royal College of Obstetricians and Gynaecologists COVID-19 Vaccination Committee. All other authors declare no competing interests. Download .pdf (.07 MB) Help with pdf files Supplementary appendix