COVID-19 vaccination in pregnancy: How discrepant public health discourses shape responsibility for fetal health

The paper examines how early-pandemic inconsistencies in public health guidance about COVID-19 vaccination in pregnancy shaped decision-making and responsibility for fetal health in Canada. During initial vaccine rollout, national and subnational recommendations varied widely, creating uncertainty for pregnant people and health care providers. The authors investigate expert discourses across national organizations and provincial/territorial authorities to address three questions: how cultural understandings of motherhood influence governance of vaccine decisions in pregnancy; how consistent public health messaging was in early 2021; and how discrepancies in discourse and evidence shape responsibility and governance. Set within Canada’s multilevel vaccine policy context (NACI nationally; provinces/territories for programs/funding), the study highlights the importance of clear, harmonized communication when evidence is rapidly evolving and pregnant people are historically underrepresented in clinical trials.

The authors draw on feminist and governmentality theories to analyze health discourses as instruments of self-governance and external regulation, particularly of pregnant bodies perceived as risky to fetal health (Foucault; Lupton; Weir). They review how expert discourses moralize and responsibilize mothers/pregnant persons to minimize risks to fetuses/infants, often amid contradictory guidance. Vaccine research historically excludes pregnant/breastfeeding people, leaving product labels and recommendations built on limited evidence (animal reproductive studies; inadvertent trial pregnancies; early observational data), which fosters discrepancies between manufacturer labeling and public health recommendations. Prior work shows misalignment between NITAGs, professional societies, and product labels can defer responsibility onto individuals and clinicians, amplify perceived risk, and fuel hesitancy. The review situates COVID-19 within broader patterns of uneven maternal immunization recommendations across countries (e.g., influenza, Tdap) and highlights ongoing global disparities, especially in LMICs, due to evidence gaps and differing products/access.

Design: Critical feminist discourse analysis with governmentality lens. Data sources: Publicly available Canadian online texts (national, provincial/territorial, local health authorities; professional societies; expert advisory panels; vaccine manufacturers’ product labels) addressing COVID-19 vaccination in pregnancy. Search strategy: Google.ca, May 4–12, 2021, shortly after SOGC (Apr 15, 2021) recommended prioritizing pregnant women for vaccination. Sixteen search term combinations (e.g., vaccination pregnancy + Canada + each province/territory). Inclusion: Texts offering expert discourse intended to inform policymakers, HCPs, and/or pregnant persons. Data handling and analysis: Texts were imported into MaxQDA and coded abductively for contradictions/inconsistencies, intertextual relationships (how texts cite/reproduce others), and gendered power relations. The analysis iteratively applied and challenged feminist/governmentality/risk theories to interpret how discourses governed vaccine decision-making and allocated responsibility. Timeframe context: Captures the period when evidence and recommendations were changing rapidly; many P/Ts had just updated guidance and eligibility.

- Corpus: 52 texts analyzed; discrepancies and contradictions were common across and within jurisdictions. - Intertextuality and national-level discrepancies: - SOGC texts consistently stated from Dec 2020 that pregnant persons should be offered/eligible for vaccination, emphasizing emerging evidence, theoretical safety, and autonomy. - NACI (May 3, 2021) advised pregnant persons may be offered vaccination following a risk assessment and informed consent, without clear assignment of who conducts the assessment; later (May 13, 2021) updated to a strong recommendation that mRNA vaccines should be offered to pregnant/breastfeeding persons. - Manufacturer product monographs uniformly stated safety/efficacy in pregnancy not established; three cited no adverse findings in animal reproductive studies; all deferred to HCP consultation. - Provincial/territorial (P/T) reproduction of discrepancies: - P/T texts variably stated vaccines should be offered (n≈5), may be offered (n≈10), recommended (n≈3), eligible (n≈9), or prioritized (n≈5). Some listed national recommendations without stating a clear P/T stance (n≈5). A few required HCP consultation/letters (n≈3) or initially listed pregnancy/breastfeeding as unable to receive the vaccine (e.g., early Northwest Territories). - Within-jurisdiction contradictions occurred (e.g., Ontario and British Columbia had concurrent texts ranging from unequivocal recommendation to conditional/consultation-based language). - “Unknown risk” framing and responsibilization: - 19 P/T texts (45%) emphasized individual choice; 4 explicitly referenced personal values/anxieties as decision criteria. - Several texts highlighted unknowns (e.g., miscarriage, fetal anomalies), risk-benefit checklists, or enhanced consent forms requiring acknowledgment of absent fetal/infant risk data (e.g., Manitoba). - Timing guidance varied: 12 stated vaccination could occur in any trimester; 23 did not comment/said no evidence; 4 advised considering delaying until after first trimester (e.g., due to post-vaccination fever). - Some texts suggested delaying second dose until after pregnancy unless high risk and informed consent obtained. - Non-pharmacologic measures and individualized prevention: - 14 texts mentioned non-pharmacologic measures: 5 as alternatives to vaccination; 7 as additional measures even after vaccination; 2 applied to everyone. - 30 texts did not add public health measures or only advised risk assessment. Guidance often responsibilized pregnant persons to negotiate workplace risks and personal exposure. - Overall pattern: One-way intertextuality from national bodies and manufacturers to P/T outputs reproduced inconsistency, shifting responsibility for decisions and perceived risks onto pregnant persons and HCPs amid rapidly evolving evidence.

The analysis shows that inconsistent national recommendations (e.g., NACI’s neutral “may be offered” versus SOGC’s directive “should be offered”) and product label caveats were propagated into P/T communications, producing unclear and sometimes contradictory guidance. In a cultural context where mothers/pregnant persons are responsibilized to protect fetal health, such discrepancies intensified scrutiny of uncertain risks from vaccination while underemphasizing the documented risks of COVID-19 in pregnancy, potentially restricting autonomy and access when HCPs act as gatekeepers. Discourses around “unknown risk,” timing, and continued non-pharmacologic measures encouraged individualized risk calculation and acceptance of the risks of inaction over action. The findings underscore the need for coordinated, harmonized guidance across advisory bodies and alignment with labeling, as well as earlier and ongoing research in pregnant/breastfeeding populations to reduce uncertainty and deferral of risk onto individuals and clinicians, especially during public health emergencies. Global disparities, particularly in LMICs with different vaccine products and longer delays in evidence generation, further emphasize the necessity of context-specific data and recommendations.

Discrepant discourses about COVID-19 vaccination in pregnancy created confusion and deferred responsibility for decision-making to individuals and HCPs, undermining public health efforts during a pandemic. In Canada’s decentralized system, misalignment across national bodies (NACI, SOGC), manufacturers, and P/T authorities compounded inconsistent messaging. The authors recommend harmonizing discourses across centralized national institutions and P/Ts, ensuring recommendations are clear, regularly updated, and transparent about evidence and gaps. Crucially, research on safety, effectiveness, timing, and outcomes of vaccination in pregnant/breastfeeding populations must be prioritized before and during rollout to support evidence-based, consistent communications and reduce gendered deferral of risk. Future work should examine impacts across diverse populations and settings, and improve alignment between product labeling and public health recommendations through interprofessional collaboration.

- Scope: Focused on English-language, publicly available Canadian texts during early general population rollout; primarily pregnancy with some attention to breastfeeding. - Generalizability: Findings reflect a specific time window with rapidly evolving evidence/guidance and may not capture all updates or non-public communications. - Populations: Did not analyze implications for diverse groups (e.g., sex/gender minorities, racialized and Indigenous communities, low-income, disabled persons). - Media ecosystem: Did not assess how individuals integrate these texts with other sources (news, social media) or broader public health guidance.