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\title{COVID-19 vaccination and pregnancy: getting the word out}



\author[1]{Victoria Male}%
\affil[1]{Imperial College London}%


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  \date{March 14, 2025}


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\textbf{COVID-19 vaccination and pregnancy: getting the word out}

Victoria Male, Senior Lecturer in Reproductive Immunology, Imperial
College London

Pregnancy is a risk factor for severe COVID-19, doubling the likelihood
that an unvaccinated individual requires intensive care, invasive
ventilation, or ECMO. Between March 2020 and December 2021 in the UK,
COVID-19 emerged as the leading cause of death during pregnancy: among
the 33 women who succumbed to the virus, none had been fully vaccinated
(Knight et al, ISBN: 978-1-7392619-4-8). Furthermore, in unvaccinated
individuals, SARS-CoV-2 during pregnancy can adversely affect infants,
increasing the odds of preterm birth by 1.5-fold and those of stillbirth
or neonatal death by approximately 3-fold (Male, Nat Rev Immunol, 2022,
22:277-82).

In the face of these concerning statistics, COVID-19 vaccination in
pregnancy seems a sensible precaution. Clinical trials and subsequent
observational studies demonstrated that COVID-19 vaccination is safe and
effective in the general population, but expectant parents naturally
have an important additional question: is it safe for my baby?

In the clinical trials of the COVID-19 vaccines, pregnancy was an
exclusion criterion but nonetheless 102 participants became pregnant
during mRNA vaccine trials, with miscarriage rates no different between
the vaccinated and control groups. Early observational studies focussed
on outcomes at birth which, during the pandemic, have been somewhat
better in vaccinated individuals, particularly with respect to outcomes
influenced by SARS-CoV2 infection (Prasad, Nat Comms, 2022, 13:2412*). A
population-based cohort study published in this issue of BJOG (please
add reference) is the latest in a mounting number of observational
studies that examine the risk of early pregnancy loss following COVID-19
vaccination, controlling for gestational age and relevant medical and
social confounders. This is the first to formally consider termination
of pregnancy at the patient's request as a competing risk, but whether
or not this was including in the analysis, the authors found no
increased risk of miscarriage associated with COVID-19 vaccination
either during or before pregnancy.

The evidence is now clear: COVID-19 vaccination is safe in pregnancy,
but infection is not. Despite this, COVID-19 booster uptake among those
eligible due to pregnancy remains low, peaking at 19\% in the 2022-23
booster season. Some people are not aware their pregnancy makes them
eligible for a booster and, among those who are, not all are informed of
the extensive evidence on the safety and benefits of COVID-19
vaccination in pregnancy. Others believe their primary course of
vaccination, or a previous infection, is sufficient to protect them.
Although a primary course of vaccination continues to protect against
severe disease, evidence on how long protection lasts, particularly in
the face of new variants, is not yet available: as time elapses the
benefit of a booster is expected to increase. Pertinently, people
continue to die of flu during and shortly after pregnancy, despite
having been exposed to the virus throughout their lives. In the UK, two
women recently died this way: neither had received the recommended flu
booster during pregnancy (Knight et al, ISBN: 978-1-7392619-4-8).

While ongoing research remains important for confirming the safety of
COVID-19 vaccination during pregnancy, it is unlikely that any new study
will overturn the wealth of evidence we have already amassed. The
challenge now is to get the word out.

* For a regularly updated list of studies concerning the safety of
COVID-19 vaccination in pregnancy, please see
http://bit.ly/pregnancysafety

\textbf{Conflict of interests}

The author has no conflicts of interest to declare.

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