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

The initial rollout of COVID-19 vaccines was marked by inconsistencies in recommendations for vaccination during pregnancy, varying across different countries. While recommendations have since become more consistent, the initial disparities highlight a larger issue: the inconsistent messaging around vaccine safety and efficacy in pregnancy. This inconsistency stems from several factors, including differences in evaluation criteria used by various national and international organizations (NITAGs, medical societies, and regulatory bodies), gaps in data, and differing purposes of information dissemination (vaccine product labels vs. public health recommendations). These inconsistencies result in a shifting of responsibility from vaccine manufacturers and regulators onto pregnant women and their healthcare providers (HCPs). The study uses Canada as a case study to investigate how the discrepancies in discourse concerning COVID-19 vaccines during pregnancy impact decision-making and the allocation of responsibility. Specifically, it explores how cultural perceptions of motherhood shape decision-making, the consistency of public health messaging during the early stages of vaccine deployment when evidence was rapidly emerging, and how the discrepancies between discourses, recommendations and evidence influence the distribution of responsibility and governance around vaccination in pregnancy.

The paper reviews existing literature on vaccine hesitancy in pregnancy, highlighting inconsistencies in recommendations for vaccines such as influenza and Tdap across high-income countries (HICs) and low- and middle-income countries (LMICs). It notes that differences in national resources, cultural norms, and disease risk influence vaccine recommendations. The authors also discuss previous research illustrating inconsistencies in discourses and recommendations within countries, arising from differences between NITAGs and national medical organizations. These inconsistencies often lead to a deferral of responsibility from manufacturers and regulators onto pregnant individuals and their HCPs. The literature also highlights how HCP hesitancy can be influenced by factors such as inadequate information and reimbursement issues, as well as the impact of centralized vs. decentralized vaccine administration on vaccination uptake.

The researchers employed a qualitative discourse analysis approach to examine online expert texts related to COVID-19 vaccination in pregnancy between May 4th and 12th, 2021. This period was chosen as it followed the Society of Obstetricians and Gynaecologists of Canada's (SOGC) recommendation to prioritize pregnant women for vaccination. A Google.ca search was conducted using 16 combinations of search terms, including "vaccination pregnancy" with "Canada" and each province/territory. Inclusion criteria were met if the texts contained expert discourses intended for policymakers, HCPs, or pregnant persons. A total of 52 texts were included in the analysis. Using MaxQDA software, the researchers coded and analyzed the texts, focusing on contradictions between recommendations, intertextual relationships (references to other texts), and gendered power relations. The analysis employed critical feminist and governmentality approaches to understand how texts (re)produce gendered power relations and responsibilities related to vaccination in pregnancy. The analysis focuses on intertextual relationships (how different texts relate to each other and reproduce discrepancies), maternal responsibility (how discourses about risk and uncertainty place responsibility on mothers), and individualized responsibility for preventative practices (how non-pharmacological measures are presented alongside vaccination).

The analysis revealed significant discrepancies and contradictions in discourses and recommendations across the analyzed texts. Intertextual relationships showed that provincial/territorial (P/T) texts often reproduced inconsistencies present in national recommendations, highlighting a lack of harmonization. National-level texts displayed differences between the SOGC (strongly recommending vaccination) and NACI (suggesting vaccination on a case-by-case basis, requiring risk assessments). Vaccine manufacturer discourses emphasized the lack of established safety and efficacy in pregnant women, further contributing to uncertainty. P/T texts demonstrated a range of recommendations, from strongly recommending vaccination to stating that pregnant individuals could not receive it. Many emphasized the right of pregnant individuals to decide, but simultaneously highlighted "unknown risks", thereby fostering uncertainty and implicitly positioning pregnant people to bear the primary responsibility of assessing and mitigating those risks. The study also found that discourses around non-pharmacological public health measures were often presented as alternatives or additional measures for pregnant individuals to take, reinforcing the responsibility placed on them to protect fetal health. The inconsistency in recommendations related to vaccination timing during pregnancy also contributed to uncertainty.

The findings demonstrate that the discrepancies in expert health discourses around COVID-19 vaccination in pregnancy created confusion and deferred responsibility to individuals and HCPs. The inconsistent use of language (e.g., "may offer" vs. "should offer") contributed to this ambiguity. The emphasis on "unknown risks" despite existing evidence of the increased risk of severe COVID-19 in pregnant individuals highlighted a cultural tendency to overemphasize potential risks to fetuses and infants. This deferral of responsibility to pregnant individuals perpetuates existing gender norms. The study suggests the need for better collaboration between national and provincial/territorial advisory groups to harmonize discourses and recommendations, mirroring the model employed in Australia and New Zealand. Improving the consistency of messaging, especially during public health emergencies, requires addressing gaps in data through prioritized research and ensuring timely updates to public information. Addressing the gendered deferral of responsibility requires acknowledging the systemic inequities in evidence related to women's and pregnant persons' use of health technologies.

The study highlights the critical public health implications of inconsistent messaging around COVID-19 vaccination in pregnancy. The discrepancies in recommendations and messaging contribute to confusion and place undue burden on pregnant individuals and HCPs. Harmonizing discourses and creating clear, consistent, and evidence-based messaging are essential to improve vaccine uptake and ensure equitable access to healthcare. Future research should focus on understanding how these discrepancies affect diverse pregnant populations and how to improve data collection and sharing to inform vaccine recommendations prior to and during vaccine rollout.

The study's analysis was limited to English language texts and focused primarily on discourses surrounding vaccination in pregnancy, with limited attention to breastfeeding. The study did not examine how individuals utilize these texts alongside other information sources (news, social media), or the influence of public health measures. Further research is needed to understand how the identified inconsistencies affect diverse pregnant populations.