COVID-19 vaccination for pregnant women in Zimbabwe: A public health challenge that needs an urgent discourse

Dear Editor

Pregnant women are a population group with distinct concerns in relation to the uptake of vaccines. Unfortunately, evidence points towards a greater risk of adverse outcomes from COVID-19 in this population [1]. Key considerations include the potential effects of vaccines on the foetus, development of pregnancy, fertility, and beyond pregnancy on aspects such as consideration with regards to breastfeeding and long-term effects on their children. Safety concerns are a key driver of vaccine hesitancy in this group, as the decision to take up the vaccine requires weighting the potential benefits versus the perceived risks to both the mother and the foetus/baby [2]. Without clear consensus or guidelines with regards to vaccination, some healthcare practitioners can also be reluctant to advise or administer vaccines to pregnant and breastfeeding women. It is therefore not surprising that in Zimbabwe there have been widespread social media reports of COVID-19 vaccine hesitancy amongst the population including pregnant and breastfeeding women, propagated by circulating myths, misconceptions and rumours regarding the safety of the vaccines in this population [3]. Currently in Zimbabwe there is no policy position on the provision of COVID-19 vaccines to pregnant and breastfeeding women, resulting in most pregnant and breastfeeding women being turned away from vaccination centres.

There is need for an urgent discussion around ways to address the challenge posed by vaccine hesitancy in pregnant and breastfeeding women, and of clear consensus and guidelines to support healthcare workers involved in vaccination. This will promote confidence in vaccines and increase their uptake, protecting this group them from the devastating effects of COVID-19 in pregnancy. In this scope, we therefore highlight some of the key issues regarding COVID-19 vaccination among pregnant and breastfeeding women in Zimbabwe, and offer recommendations to improve uptake. These relate to key challenges with vaccination and drivers of hesitancy.

Evidence regarding the safety of COVID-19 vaccines in pregnancy and during breastfeeding is scarce [1], though growing. This has raised concerns among pregnant women and healthcare providers, with some casting doubt and contributing to vaccine hesitancy. The lack of clear eligibility guidelines resulted in lack of uniform practice, with some centres turning away these clients, whilst some were vaccinating them. Several professional bodies including the Royal College of Obstetricians and Gynaecologists and the World Health Organisation have now published consensus guidelines for vaccination of pregnant women [4]. The Ministry of Health and Child Care (MoHCC) must urgently draw clear guidelines regarding this subject. This must be accompanied by extensive education for both healthcare workers and their clients to reduce confusion, increase confidence and improve vaccine uptake.

Being a vulnerable population group, pregnant women must be prioritised at the vaccination centres [5]. Long queues and lack of organisation at the point of service provision are barriers to access. We recommend the inclusion of COVID-19 vaccination as part of standard antenatal care (ANC) and baby clinics as possible solutions to issues relating to attendance at vaccination sites. Additionally, ANC clinics may offer a unique opportunity for providing targeted messages and counselling to pregnant women, as well as the opportunity to have one-on-one consultations with a clinician. This is in contrast with regular vaccination centres for the general population. Midwives, nurses and doctors working within ANC can be trained to effectively counsel and support pregnant and breastfeeding women appropriately in relation to COVID-19 vaccination.

Circulating rumours, myths, falsehoods and misconceptions regarding the origins of SARS-CoV-2 and the aims of vaccination remain a big drive of vaccine hesitancy and a significant barrier to uptake, in the general populations and in women of reproductive age [3]. Accessibility and affordability of social media platforms facilitates wide reach of negative messages which can have far reaching consequences preventing the success of public health interventions. It is critical for stakeholders in public health to provide education ahead of antivaxxers and other similar campaigners promoting false information about effectiveness and safety of vaccines. Of particular importance is to adequately address concerns relating to claimed negative effects of vaccination on pregnancy, including miscarriages, preterm deliveries and foetal abnormalities, claims which are not substantiated and for which there is no evidence.

At more than 60% of hospitals and health facilities in Zimbabwe there are maternal waiting shelters, which have provided a safe harbour for women who live far away from health facilities. During pandemic times, such shelters can become potential sources for the spread of COVID-19. Proactive public health implies taking advantage of these waiting shelters to provide COVID-19 related prevention messages, including vaccination information and COVID-19 infection prevention and control messages. These could be verbal messages during sessions, or in the form of printed information, education and communication (IEC) material in languages that are understood by local populations. Educating people to suitable levels can improve uptake of health promotion and protection interventions. Such education must also be incorporated into routine antenatal and postnatal care and baby clinics, as these settings are likely to be frequently accessed by this group. Due to an increase in other issues in women of reproductive age, such as sexual and gender-based violence (SGBV) and teenage pregnancies, reported in the COVID-19 pandemic, ANC must be made more holistic, addressing these additional issues when opportunities arise, and making them friendlier to service users.

An increase in uptake of COVID-19 vaccination by pregnant and breastfeeding women is an urgent public health priority that requires a robust and holistic approach to issues affecting this group, involving empathy in dealing with sensitive issues such as SGBV, and clearly directed messages that encourage uptake. To this end, an urgent discourse by various stakeholders involved in service planning and delivery is required. The MoHCC of Zimbabwe must prioritise drawing up clear evidence-based consensus guidelines for vaccination of pregnant and breastfeeding women in Zimbabwe. Healthcare providers involved must be adequately trained to confidently counsel women, allowing them to make informed decisions regarding vaccination, and administer the vaccines without any reluctance.

Declaration of competing interest

None to declare.