Recently published data demonstrate that vaccination against coronavirus disease 2019 (COVID-19) in pregnancy is safe and effective, with antibody transfer through the umbilical cord blood and breast milk.1–4 However, pregnant individuals are less likely than nonpregnant individuals to accept COVID-19 vaccination.5 Research on vaccine acceptance among obstetric populations has shown two factors increase vaccination rates: 1) vaccine availability in the obstetric health care setting, and 2) vaccine counseling from an obstetric clinician.6 We assessed the feasibility of inpatient COVID-19 vaccination among obstetric patients admitted for delivery and compared the characteristics of those who were vaccinated while inpatient with those who were vaccinated before admission.
We performed a retrospective cohort study of all patients admitted for delivery in the first 36 days after Pfizer/BioNTech (BNT162b2) COVID-19 vaccine availability at a single institution to describe rates of eligibility, vaccination counseling, and uptake in the obstetric unit. The COVID-19 vaccine was available to hospitalized obstetric patients if they had not received a COVID-19 vaccination and did not have active COVID-19. Eligible patients were offered vaccination and counseled by obstetricians. Pharmacy staff administered vaccinations in the postpartum unit on weekdays (vaccination was not available on weekends). Second-dose appointments were scheduled before discharge. Characteristics of patients vaccinated before admission, including Area Deprivation Index, were compared with those of patients vaccinated during their admission using χ2, Fisher exact, and Mann-Whitney U tests as appropriate. We included race as a demographic variable in our analysis because of underlying racial disparities in vaccination.7 Area Deprivation Index is a measure of socioeconomic disadvantage in Census block groups; this analysis used the 2019 Area Deprivation Index.8,9 This project was deemed exempt by the Washington University in St. Louis Human Research Protection Office.
From June 1 to July 6, 2021, there were 329 deliveries: 75 (22.8%) individuals had been vaccinated before admission, and five (1.5%) were not eligible for vaccination due to active COVID-19, resulting in 249 eligible patients (75.7% of deliveries, Fig. 1). From medical record abstraction, we confirmed that 221(88.8%) eligible patients were offered vaccination and underwent counseling. Of the 221, 169 (76.5%) declined and 52 (23.5%) accepted. The vaccine was successfully administered to 43 (82.7%) patients. Six of the nine patients who desired vaccination but did not receive it were discharged over the weekend, when vaccination was not available. There was no explanation in the medical record for the other three patients.
Compared with those vaccinated before admission, patients who received inpatient vaccination were more likely to be Black, have public insurance, have a hypertensive disorder of pregnancy, and reside in areas with a higher Area Deprivation Index (median [interquartile range]) 87 [65–94] vs 57 [38–80], P<.001 (Fig. 2). They were less likely to be nulliparous and exclusively breastfeeding at discharge (Table 1).
More than three quarters of patients admitted to our obstetric service for delivery were eligible for vaccination, and most of them were offered vaccination and underwent counseling with an obstetrician. Although vaccine uptake during hospitalization was low, the proportion of patients vaccinated at discharge was 50% higher than at admission. Importantly, inpatient vaccination may improve the health equity of obstetric patients. Patients vaccinated during admission were more likely to be from groups with higher health disparities in both COVID-19 acquisition and vaccination access, in addition to having higher rates of comorbidities that increase risk of severe disease.10,11 Availability of COVID-19 vaccination during obstetric hospitalization presents a feasible opportunity for counseling by obstetric clinicians and convenient timing for first-dose administration. However, given persistently low vaccination rates, strategies to optimize COVID-19 vaccination acceptance among obstetric patients are needed.
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7. Ndugga NPO, Hill L, Artiga S, Parker N. Latest data on COVID-19 vaccinations by race/ethnicity. Accessed August 19, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity/
8. Kind AJH, Buckingham WR. Making neighborhood-disadvantage metrics accessible - the neighborhood atlas. N Engl J Med 2018;378:2456–8. doi:10.1056/NEJMp1802313
9. Department of Medicine, University of Wisconsin School of Medicine and Public Health. Area deprivation index v2.0. Accessed July 14, 2021. https://www.neighborhoodatlas.medicine.wisc.edu/
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