A strategy is needed to make up for lost time, training opportunities, and the confidence of pregnant doctors and new parents, argue these authors
On 16 April 2021, the UK’s Joint Committee on Vaccination and Immunisation (JCVI) announced that pregnant women will now be encouraged to get a covid-19 vaccine. This has been made possible because 90,000 pregnant women in the US have been vaccinated—predominantly using mRNA-based Pfizer and Moderna vaccines—with no specific adverse outcomes recorded. Many of these women are healthcare workers. They have been forced to make tough decisions about their own safety and that of their baby in an environment hostile to their choices. The pharmaceutical companies excluded pregnant women from covid-19 vaccine clinical trials—a controlled and relatively safe setting—therefore preventing reassuring data reaching pregnant women in the community who urgently require protection from the virus. The UK government’s latest recommendation that those who are pregnant be vaccinated “promptly,” fails to acknowledge how confusing the previous messaging has been to women in this situation. Pregnant healthcare workers have been part of a real-world experiment during the vaccine rollout, and through responses to the covid-19 pandemic more broadly, in which they have been unable to give meaningful informed consent.
There is never a good time to have a baby when you’re a doctor. At least it can feel that way. Women in training must advocate for themselves to be relieved from night shifts in the third trimester, to limit on-call duties, to protect their maternity leave, and to cope with the change in their professional identity that can result from time away from work. Covid-19 has put further pressure on the existing tensions between professional roles and parental choices. The pandemic’s looming unknowns have been worsened by a lack of occupational, research, and governmental efforts to provide answers.
“Solutions” for pregnant doctors in the NHS over the past year have varied by location, resulting in a deanery lottery. We heard from women whose NHS trusts pushed a “better safe than sorry” agenda, insisting from March 2020 that pregnant women be redeployed to non-patient facing roles or work from home. Some employees were pleased with this approach (“it’s definitely possible to have a positive experience!”), while others had reasons to be critical, citing “mental health (hate staying at home, where I cannot support with much) and training (particularly surgery)”. After the first peak of cases, some trusts took a different stance and refused to accommodate women who wanted to be non-patient facing, because pregnancy had been removed from the government’s “extremely vulnerable” list. Individual risk assessments were advised by the Royal College of Obstetricians and Gynaecologists (RCOG), rather than automatic shielding from 28 weeks. Meanwhile, the government recommended non-patient facing work in the third trimester. This divergence in guidance meant some women were pushed to continue clinical work beyond 28 weeks, while others were encouraged to work from home. As cases increased in December 2020 and new variants of concern were identified, trusts updated their policies in an ad hoc manner, some very strongly advising pregnant women to leave frontline roles at 28 weeks, while others doubled down on continued frontline work with individual risk assessments as clinical pressures increased. Deaneries seemed to assume that all of their pregnant doctors felt the same way, denying individual autonomy to make risk-benefit decisions, even though the scientific evidence to support different recommendations was far from certain.
The professional and financial penalties of trusts’ differing policies will cast long shadows. While few doctors have suffered immediate pay implications from amended duties, they will have missed out on competencies from patient interaction as well as surgical and procedural experience. This risks prolonging their training and delaying their CCT date. Doctors in junior stages of training face greater interruption, as they were more likely to be re-deployed to unrelated specialties for service provision and in many cases may not have been sufficiently experienced to run teleclinics or engage in training activities from home, further limiting their remote working options. Women who faced no other option but to continue working in an environment that felt unsafe may find returning to work after maternity leave an even more painful process than it can be ordinarily.
Confusion in the workplace has been worsened by confusion about vaccination. The MHRA changed its guidance on 30 December 2020, finally allowing pregnant women at high risk of sequelae from SARS-CoV-2 infection to be vaccinated, having previously prevented all pregnant and breastfeeding women from receiving a vaccine. Guidance was further relaxed two weeks ago to include all pregnant women, regardless of medical history. This broadening of eligibility was welcome news after intense online campaigning, but has also created new problems. The initial prohibition of the innovative mRNA Pfizer vaccine led to online speculation that the older technology of the AstraZeneca vaccine was safer in pregnancy and breastfeeding. Concerned by erratic government and research messaging, women wanted to choose, but were told to accept whichever vaccine was offered at their appointment.
The JCVI’s advice that pregnant women discuss vaccination with an obstetrician was a further stumbling block. We heard from pregnant employees who were turned away from hospital vaccination clinics because they did not have a letter from an obstetric consultant. In other cases, women were advised that permission would be at the discretion of vaccinators on the day, and that neither occupational health nor clinical directors could ensure an appointment would result in vaccination. “Everyone including the consultant in clinic declined to sign the form as they didn’t feel comfortable doing so”, said one trainee, who relied on a supportive GP to help her get a vaccine, echoed by another who said, “my trust and obstetricians made things very difficult for me which was incredibly infuriating…[I was] made to feel like I’m incapable of making decisions for myself after reading the guidance!” Another said she is “still fighting for vaccine 10 weeks and counting…Incredibly frustrating.” Exasperation was a common theme, with comments that “I’ve been made to feel my concerns were not significant and my fully informed medical decision was irrelevant.” There was often no clear pathway, team, or person responsible for supporting pregnant women, nor with whom they could engage in vaccine risk-benefit discussions.
Frequently, pregnant women felt they were in a “lose-lose” situation. Women who were prevented from getting vaccinated still faced pressure to keep working despite being at risk from the virus. “I feel I need to work on…If I’d been vaccinated in January and just getting my second dose, I’d be much more comfortable about doing so…I do care about my patients and, with no registrars etc, I see them all on my own so I feel fully responsible for them,” a consultant told us. For others who chose not to be vaccinated during pregnancy and would have preferred to work in a non-patient facing role from 28 weeks, many faced pressures to get vaccinated and continue work through the third trimester. We even heard from one trainee (and there are surely many more), who has delayed trying to conceive because telling her colleagues she was pregnant during the pandemic would have “let down the team.” Individual women are bearing the pressures of a system that has been badly coordinated and, in many cases, neglectful.
In the stories we’ve heard, sympathetic and energetic senior champions who went out of their way to support pregnant women, whether educational supervisors or heads of department, have been pivotal. From a line manager who “emailed me every day to keep me in the loop”, to “a supportive supervisor who’s encouraging plenty of activity for my portfolio, and dialing me into clinics virtually”, positive experiences all mentioned excellent local leaders. These colleagues were not exclusively women, though tended to be. However, a culture which supports pregnant women must be supportive through structures as well as individuals. Too often pregnant women rely on the luck of their circumstances and goodwill of their seniors rather than NHS-wide protective systems. Covid-19 has exposed the gaping flaws of this haphazard approach which needs urgent modernisation.
As we move from the acute phase of the pandemic to a period of recovery, reparation, and the prospect of long-term responses to chronic waves of disease, a strategy is needed to make up for lost time, training opportunities, and the confidence of pregnant doctors and new parents. Senior NHS management should improve support for pregnant women, and empower them to make autonomous choices in an environment of risk. Meanwhile, the detrimental impact already felt by thousands women must be proactively corrected.
Kate Womersley, Academic FY2 doctor, University of Edinburgh, NHS Lothian; Research Associate, The George Institute for Global Health, Imperial College London, UK.
Katherine Ripullone, Academic Clinical Fellow and ST1 Obstetrics and Gynaecology, Oxford University Hospitals; Research Associate, The George Institute for Global Health, Imperial College London, UK.
Helen Hare, Acute Medicine CT2, NHS Lothian.
Competing interests: None declared.