When the American College of Obstetricians and Gynecologists (ACOG) published an updated immunization schedule for pregnant, lactating, and postpartum individuals this June, the organization took a major step toward normalizing vaccination as a clinical priority on par with cervical cancer screenings and prenatal care.

But the road to ownership of vaccination as a part of day-to-day ob/gyn practice has been slow and bumpy, with barriers ranging from logistical challenges with vaccine storage to time constraints in addressing patients’ vaccine concerns.

The new schedule, a culmination of over two decades worth of work from ACOG’s Immunization, Infectious Disease and Public Health Preparedness Expert Work Group, represents how far the specialty has come in helping ob/gyn clinicians discuss, promote, and provide recommended vaccines to their patients.

“When we first started the committee around immunization, it was because we were trying to convince ob/gyns that immunization should be a routine part of their practice, and in some ways, having a schedule solidifies that this is your job as an ob/gyn,” Laura E. Riley, MD, chair of ACOG’s Immunization work group, told Medscape Medical News.

Challenges remain, however, in countering post-COVID vaccine “fatigue” and hesitancy, said Riley, who is also chair of ob/gyn at Weill Cornell Medicine in New York City. ACOG is providing resources to help reproductive health clinicians discuss the benefits of vaccination during pregnancy and employ strategies to overcome vaccine hesitancy and respond to patient concerns.

As Old as Vaccination Itself

The idea that women should receive vaccines during pregnancy dates back to the very first vaccine, when medical professionals recognized the need to prevent smallpox during pregnancy since the disease could be transmitted across the placenta and increase the risk of pregnancy complications and fetal death, according to Flor Muñoz, MD, a member of ACOG’s Immunization work group and an associate professor of pediatrics and infectious disease at Baylor College of Medicine in Houston.

Then, reports from both the 1918 and 1957-1958 influenza pandemics revealed disproportionately high numbers of maternal deaths, leading public health officials to specifically target pregnant women for vaccination after the flu vaccine was developed during World War II, said Kevin Ault, MD, also a member of ACOG’s Immunization work group and a professor and chair of ob/gyn at Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan.

The introduction of the human papillomavirus vaccine in 2006 also helped move the needle in making more ob/gyns vaccinators, Ault said. But perhaps the biggest turning point for ob/gyns making immunization a routine practice was the 2009-2010 H1N1 flu pandemic, said Ault, Muñoz, and Riley.

In the early 2000s, flu immunization rates during pregnancy were “dismal,” Muñoz said, with less than one fifth of women getting the vaccine. But a big push to prioritize vaccination during pregnancy in the 2009-2010 flu season raised awareness of the importance of preventing flu during pregnancy, she said.

“That flu pandemic also crystallized the idea that we could protect newborns and that stillbirth and preterm delivery were complications due to pandemic respiratory viruses,” Ault said.

Flu vaccination rates during pregnancy climbed sharply after that flu season, eventually exceeding 50% nationally.

On the heels of that pandemic came another push for pregnancy vaccines in response to pertussis. Evidence had been building that protection provided by the two acellular pertussis vaccines (DTaP and Tdap) began waning after a few years, resulting in more transmission to infants too young to be vaccinated against the disease. Therefore, in 2012, the CDC recommended a Tdap vaccination in every pregnancy so that maternal antibodies transferred across the placenta would protect newborns after birth until they received their 2-month and 4-month DTaP vaccinations.

By the time of the COVID pandemic, then, it did not take much for clinicians to recognize the importance of vaccinating people against SARS-CoV-2 during pregnancy given the known risks of respiratory viruses during pregnancy. “I have definitely seen the progress and change over time,” Muñoz said. “What has changed is that there is now more ownership from antenatal care providers,” not only in the US but even among midwives and general providers of pregnancy care across the world.

Overcoming Barriers to Vaccination

The challenge now is improving uptake of all pregnancy vaccines — including the respiratory syncytial virus (RSV) vaccine — in the face of rising vaccine hesitancy and resistance since the pandemic.

Barriers to higher vaccination rates also include “not having the vaccine in ob/gyn offices, lack of a strong provider recommendation, and some of the mythology around these vaccines,” he said. Other barriers, Muñoz added, include time constraints during visits, the operational hurdles to storing and administering vaccines in the clinic, and clinicians’ worries about liability, Muñoz said.

Education from ACOG has helped alleviate concerns about liability, pointing to federal programs such as the Vaccine Injury Compensation Program, which is designed not only to compensate people who experience validated vaccine injuries but also to protect providers who administer vaccines.

“There’s been very clear data that suggest that if you recommend a vaccine to somebody, but you don’t offer it in your office, they are likely to leave your office and not get it,” Riley said.

Provider recommendation is more powerful in a “vaccine-friendly office,” Ault said. That means having educational materials available for patients as well as ensuring that all the staff, including nurses, medical assistants, and office staff, are educated and supportive of vaccination, he said.

Addressing Fears and Concerns

A major advantage ob/gyns have in talking with pregnant patients about vaccines is the number of routine prenatal care visits.

“Pregnancy is a little bit unique because we see people 10 times in the course of nine months, so you have multiple opportunities [to discuss vaccinations],” Riley said.

Those discussions also pave the way for easier vaccine discussions in pediatricians’ offices once children are born.

“I really appreciate my ob/gyn colleagues that work with vaccine hesitant families,” Nathan Boonstra, MD, a pediatrician practicing in Des Moines, Iowa, told Medscape Medical News. “Not only does vaccinating lead to better outcomes during the pregnancy but makes my patients healthier as well.”

Addressing vaccine hesitancy and concerns is becoming a bigger part of ob/gyn education and professional development today, but it has been a mainstay of pediatric education for decades, yielding tips that can apply in obstetric practices as well.

One of those tips is not to assume the reasons a family might be hesitant, said Jason Terk, MD, past president of the Texas Pediatric Society, past chair of the Texas Public Health Coalition, and a pediatrician in Keller, Texas.

He said it’s helpful to “introduce vaccines to expectant mothers and fathers in the context of all of the efforts that are going into having a healthy baby: a healthy diet; a safe amount of exercise; and screening and treating for hazards like gestational diabetes, gestational hypertension, fetal and placental anomalies, group B strep, genital herpes, etc.” Maternal vaccines for pertussis, influenza, and RSV serve the same purpose in trying to ensure a healthy pregnancy, delivery, and baby, he said.

And because each family has its own reasons for hesitancy, “delivering a boilerplate response to hesitancy may be counterproductive,” he added. Decades of health literacy research has shown that simply providing patients with facts on their own is insufficient in persuading them to vaccinate.

“We know that most people who have strongly held beliefs that inform their decisions will double down on those beliefs when presented with facts that create cognitive dissonance and conflict with those beliefs,” Terk said.

That includes families who have encountered false narratives on social media that suggest they are losing control of choices about their health, leading them to refuse recommended vaccines as a way of exercising more agency over their healthcare decisions, he noted.

Hesitant families may need time to process your information, said Terk. “Pressing them further at that time will be perceived as being pressured and rushed and will be unlikely to result in a favorable outcome.”

ACOG Tools

ACOG provides toolkits that explain each vaccine, its benefits, its safety and effectiveness data, how to order and store the vaccine, and how to code and bill for reimbursement, including the time spent on having a conversation about the vaccine with patients, Riley said. One of those toolkits even helps clinicians with social media messaging around vaccines.

Those efforts have borne fruit, with ob/gyns now seeing “pregnancy as an opportunity to catch people up on vaccinations” recommended more broadly to adults, Ault said. Those include the pneumococcal vaccine and the hepatitis A and B vaccines, for example, Muñoz said.

The evolution from ob/gyns not wanting to give vaccines to finding “ways to give other vaccines, not just those recommended in the pregnancy or postpartum periods,” has been a really big change, Muñoz said.

Terk reported being a speaker and advisor to Sanofi Pasteur for Beyfortus, a monoclonal antibody to protect babies from RSV. Muñoz reported consulting for Moderna, GSK, AstraZeneca, Sanofi, Novavax, and Merck; serving on the data and safety monitoring boards for Pfizer, Moderna, the National Institutes of Health (NIH), Meissa, and Dynavax; and receiving grant and research support from Pfizer, Gilead, NIH, and CDC. Boonstra, Riley, and Ault reported having no disclosures.

Tara Haelle has covered science and medicine for nearly two decades and is author of Vaccination Investigation and The Informed Parent: A Science-Based Resource for Your Child’s First Four Years. She is based in Dallas.