Science, Art and Religion

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Related articles

VOLUME 1 , ISSUE 2-4 ( April-December, 2022 ) > List of Articles

REVIEW ARTICLE

Ethical Lessons Learned from the COVID-19 Pandemic in Perinatal Medicine

Keywords : Coronavirus disease of 2019 vaccine, Maternal mortality, Neonatal morbidity, Neonatal mortality, Patient rights, Preterm birth, Stillbirth, Therapeutic nihilism, Vaccine counseling

Citation Information : Ethical Lessons Learned from the COVID-19 Pandemic in Perinatal Medicine. 2022; 1 (2-4):203-209.

DOI: 10.5005/jp-journals-11005-0039

License: CC BY-NC 4.0

Published Online: 20-03-2023

Copyright Statement:  Copyright © 2022; The Author(s).


Abstract

Professional ethics in obstetrics is based on the ethical principles of beneficence, respect for autonomy, and justice and the professional virtues of integrity, humility, compassion, self-effacement, and self-sacrifice. The ethical principle of beneficence and the professional virtue of integrity are directly applicable tools for addressing the question posed in this paper. The Coronavirus disease of 2019 (COVID-19) pandemic is unprecedented in our lifetime, especially in perinatology. In this publication, we will discuss important clinical ethical lessons we learned during the pandemic, including COVID-19 vaccination and physician hesitancy, ringfencing, and frameshifting. The gold standard is to strongly recommend COVID-19 vaccinations to those trying to get pregnant, to those who are pregnant, and to those who are postpartum. The three root causes of physician hesitancy—misapplication of therapeutic nihilism, misapplication of shared decision-making, and misapplication of respect for autonomy should not be ignored and need to be addressed. It is important that we heed Brent's insightful recommendations. Doing nothing with respect to vaccination is not an option, whether it applies to COVID-19 vaccines or to future pandemics. Physician hesitation is not an option. When there is sufficient evidence of vaccine safety and effectiveness without documented risks, vaccine recommendations before, during, and after pregnancy should be explicitly made to prevent maternal, fetal, and neonatal morbidity and mortality.


HTML PDF Share
  1. COVID Data Tracker. https://covid.cdc.gov/covid-data-tracker. Accessed 12/31/2022.
  2. Maternal Health: Outcomes Worsened and Disparities Persisted During the Pandemic. https://www.gao.gov/products/gao-23-105871. Accessed 12/31/2022.
  3. McCullough LB, Coverdale JH, Chervenak FA. Professional ethics in obstetrics and gynecology. Cambridge and New York: Cambridge University Press, 2020.
  4. Chervenak FA, McCullough LB. The Professional Responsibility Model of Perinatal Ethics. Berlin: Walter de Gruyter, 2014.
  5. Chervenak FA, McCullough LB, Brent RL. The professional responsibilitymodel of obstetrical ethics: avoiding the perils of clashing rights. Am J Obstet Gynecol 2011;205(4):315.e1–315.e5. DOI: 10.1016/j.ajog.2011.06.006
  6. Metz TD, Clifton RG, Hughes BL, et al. Disease severity and perinatal outcomes of pregnant patients with coronavirus disease 2019 (COVID-19). Obstet Gynecol 2021;137(4):571–580. DOI: 10.1097/AOG.0000000000004339
  7. Wei SQ, Bilodeau-Bertrand M, Liu S, et al. The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis. CMAJ 2021;193(16): E540–E548. DOI: 10.1503/cmaj.202604
  8. Villar J, Ariff S, Gunier RB, et al. Maternal and neonatal morbidity and mortality among pregnant patients with and without covid-19 infection: the intercovid multinational cohort study. JAMA PediatrJAMA Pediatr 2021;175(8):817–826. DOI: 10.1001/jamapediatrics.2021.1050. Erratum in: 2022;176(1):104.
  9. DeSisto CL, Wallace B, Simeone RM, et al. Risk for stillbirth among patients with and without covid-19 at delivery hospitalization - United States, March 2020-September 2021. MMWR Morb Mortal Wkly Rep 2021;70(47):1640–1645. DOI: 10.15585/mmwr.mm7047e1
  10. Badell ML, Dude CM, Rasmussen SA, et al. COVID-19 vaccination in pregnancy. BMJ 2022;378:e069741. DOI: 10.1136/bmj-2021-069741
  11. Aslam J, Masroor M, Mehmood QU, et al. Maternal mortality with SARS-COV-2 during its 4th wave in Pakistan: the vaccine paradox and pregnancy. J Coll Physicians Surg Pak 2022;32(1):119–121. DOI: 10.29271/jcpsp.2022.01.119
  12. Atak Z, Rahimli Ocakoglu S, Topal S, et al. Increased maternal mortality in unvaccinated SARS-CoV-2 infected pregnant patients. J Obstet Gynaecol 2022;42(7):2709–2714. DOI: 10.1080/01443615.2022.2099255
  13. Covid-19 vaccines have saved more than 3 million lives in US, study says, but the fight isn't over. By Jen Christensen, CNN. https://www.cnn.com/2022/12/13/health/covid-19-vaccines-study/index.html accessed 12/31/2022.
  14. Ma Y, Deng J, Liu Q, et al. Effectiveness and safety of COVID-19 vaccine among pregnant patients in real-world studies: a systematic review and meta-analysis. Vaccines (Basel) 2022;10(2):246. DOI: 10.3390/vaccines10020246
  15. Effectiveness of Maternal Vaccination with mRNA COVID-19 Vaccine During Pregnancy Against COVID-19–Associated. Hospitalization in Infants Aged 6 Months — 17 States, July 2021–January 2022. https://www.cdc.gov/mmwr/volumes/71/wr/mm7107e3.htm. Accessed 12/31/2022.
  16. COVID-19. Vaccines for People Who Would Like to Have a Baby. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/planning-for-pregnancy.html. Accessed 12/31/2022.
  17. Drugs and Lactation Database (LactMed) [Internet]. Bethesda (MD): National Library of Medicine (US); 2006–. COVID-19 vaccines. 2022 20th February. PMID:33355732
  18. USA Today. Should pregnant patients get the COVID-19 vaccine? Dr. Anthony Fauci sees ’no red flags’ in safety datahttps://www.usatoday.com/story/news/health/2021/02/01/covid-vaccine-pregnant-patients-dr-fauci-says-no-red-flags-so-far/4335747001/. Accessed 12/31/2022.
  19. Chervenak FA, McCullough LB, Bornstein E, et al. Professionally responsible coronavirus disease 2019 vaccination counseling of obstetrical and gynecologic patients. Am J Obstet Gynecol 2021;224(5):470–478. DOI: 10.1016/j.ajog.2021.01.027
  20. Hsu AL, Johnson T, Phillips L, et al. Sources of vaccine hesitancy: pregnancy, infertility, minority concerns, and general skepticism. Open Forum Infect Dis 2021;9(3):ofab433. DOI: 10.1093/ofid/ofab433
  21. Chervenak FA, McCullough LB, Grünebaum A. Reversing physician hesitancy to recommend COVID-19 vaccination for pregnant patients. Am J Obstet Gynecol 2021;226(6):805–812. DOI: 10.1016/j.ajog.2021.11.017
  22. CDC Statement on Pregnancy. Health Advisory. https://www.cdc.gov/media/releases/2021/s0929-pregnancy-health-advisory.html. Accessed 12/31/2022.
  23. Wilson RJ, Paterson P, Jarrett C, et al. Understanding factors influencing vaccination acceptance during pregnancy globally: a literature review. Vaccine 2015;33(47):6420–6249. DOI: 10.1016/j.vaccine.2015.08.046
  24. Myers KL. Predictors of maternal vaccination in the United States: an integrative review of the literature. Vaccine 2016;34(34):3942–3949. DOI: 10.1016/j.vaccine.2016.06.042
  25. Lutz CS, Carr W, Cohn A, et al. Understanding barriers and predictors of maternal immunization: identifying gaps through an exploratory literature review. Vaccine 2018;36(49):7445–7455. DOI: 10.1016/j.vaccine.2018.10.046
  26. Poliquin V, Greyson D, Castillo E. A systematic review of barriers to vaccination during pregnancy in the Canadian context. J Obstet Gynaecol Can 2019;41(9):1344–1355. DOI: 10.1016/j.jogc.2018.05.042
  27. Yuen CYS, Tarrant M. Determinants of uptake of influenza vaccination among pregnant patients - a systematic review. Vaccine 2014;32(36):4602–4613. DOI: 10.1016/j.vaccine.2014.06.067
  28. Ellingson MK, Dudley MZ, Limaye RJ, et al. Enhancing uptake of influenza maternal vaccine. Expert Rev Vaccines 2019;18(2):191–204. DOI: 10.1080/14760584.2019.1562907
  29. Carson SL, Casillas A, Castellon-Lopez Y, et al. COVID-19 vaccine decision-making factors in racial and ethnic minority communities in Los Angeles, California. JAMA Netw Open 2021;4(9):e2127582. DOI: 10.1001/jamanetworkopen.2021.27582
  30. Dubé E, Laberge C, Guay M, et al. Vaccine hesitancy: an overview. Hum Vaccin Immunother 2013;9(8):1763–1773. DOI: 10.4161/hv.24657
  31. Centers for Disease Control and Prevention.Influenza and Tdap Vaccination Coverage Among Pregnant. Patients — United States, April 2020https://www.cdc.gov/mmwr/volumes/69/wr/mm6939a2.htm. Accessed 10/5/2021.
  32. Blatt DB, Blatt SD, Dennehy PH. It's not only vaccine hesitancy; it's also physician hesitancy. R I Med J (2013) 2020;103(6):47–48.
  33. Paterson P, Meurice F, Stanberry LR, et al. Vaccine hesitancy and healthcare providers. Vaccine 2016;34(52):6700–6706. DOI: 10.1016/j.vaccine.2016.10.042
  34. Centers for Disease Control and Prevention. Interim clinical considerations for use of mRNA COVID-19 vaccines currently authorized in the United States. 2021. Available at: https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html. Accessed 7th January, 2021.
  35. The American College of Obstetricians and Gynecologists. Vaccinating pregnant and lactating patients against COVID-19. 2020. Available at: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-pregnant-and-lactating-patients-against-covid-19. Accessed 7th January, 2021.
  36. Centers for Disease Control and Prevention.Vaccination considerations for people who are pregnant or breastfeeding. 2021. Available at: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/pregnancy.html. Accessed 7th January, 2021.
  37. Society for Maternal-Fetal Medicine. Society for Maternal-Fetal Medicine (SMFM) Statement: SARS-CoV-2 Vaccination in Pregnancy. 2020. Available at:https://s3.amazonaws.com/cdn.smfm.org/media/2591/SMFM_Vaccine_Statement_12-1-20_(final).pdf. Accessed 10/6/2021.
  38. Society of Obstetricians and Gynaecologists of Canada. SOGC Statement on COVID-19 Vaccination in Pregnancy
  39. Minkoff H, Ecker J. Balancing risks: making decisions for maternal treatment without data on fetal safety. Am J Obstet Gynecol 2021;224(5):479–483. DOI: 10.1016/j.ajog.2021.01.025
  40. Zipursky JS, Greenberg RA, Maxwell C, et al. Pregnancy, breastfeeding and the SARS-CoV-2 vaccine: an ethics-based framework for shared decision-making. CMAJ 2021;193(9):E312–E314. DOI: 10.1503/cmaj.202833
  41. Ontario Ministry of Health COVID-19 Vaccination Recommendations for Special Populations. https://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/vaccine/COVID-19_vaccination_rec_special_populations.pdf Accessed: 9/30/2021
  42. Royal College of Obstetricians & Gynaecologists. Coronavirus (COVID-19) Vaccination in Pregnancy. Published 30th June, 2021. https://www.rcog.org.uk/globalassets/documents/guidelines/2021-06-30-coronavirus-covid-19-vaccination-in-pregnancy.pdf. Accessed 9/30/2021. [Shared decision for Covid vaccination]
  43. Australian Government Department of Health. COVID-19 vaccination – Shared decision making guide for patients who are pregnant, breastfeeding or planning pregnancy. https://www.health.gov.au/resources/publications/covid-19-vaccination-shared-decision-making-guide-for-patients-who-are-pregnant-breastfeeding-or-planning-pregnancy. Accessed 9/30/2021.
  44. Rasmussen SA, Jamieson DJ. COVID-19 vaccination during pregnancy - two for the price of one. N Engl J Med 2022;387(2):178–179. DOI: 10.1056/NEJMe2206730
  45. Razzaghi H, Meghani M, Pingali C, et al. COVID-19 vaccination coverage among pregnant patients during pregnancy—eight integrated health care organizations, United States, 14th December, 2020-May 8, 2021. MMWR Morb Mortal Wkly Rep 2021;70(24):895–899. DOI: 10.15585/mmwr.mm7024e2
  46. American Society for Reproductive Medicine (ASRM). Patient Management and Clinical Recommendations During the Coronavirus (COVID-19) Pandemic.(2022)Accessible at:)https://www.asrm.org/covid-update-16. Date accessed 24th August, 2022.
  47. Merriam-Webster. Therapeutic nihilism. https://www.merriam-webster.com/medical/therapeutic%20nihilism Accessed: 10/2/2021.
  48. Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician's obligation. N Engl J Med 1986;315(21):1347–1351. DOI: 10.1056/NEJM198611203152109
  49. Brent RL. Immunization of pregnant patients: reproductive, medical and societal risks. Vaccine 2003;21(24):3413–3421. DOI: 10.1016/s0264-410x(03)00396-7
  50. Brent RL. Risks and benefits of immunizing pregnant patients: the risk of doing nothing. Reprod Toxicol 2006;21(4):383–389. DOI: 10.1016/j.reprotox.2005.09.009
  51. Grunebaum A, Chervenak FA. Physician hesitancy to recommend COVID-19 vaccination in pregnancy as a cause of maternal deaths - Robert Brent was prescient. Birth Defects Res 2022. DOI: 10.1002/bdr2.2136
  52. Grünebaum A, Dudenhausen J, McCullough LB, et al. Women and children first: the need for ringfencing during the COVID-19 pandemic. J Perinat Med 2020. DOI: 10.1515/jpm-2020-0149
  53. Chervenak FA, McCullough LB, Grünebaum A, et al. Professionally responsible advocacy for women and children first during the COVID-19 pandemic: guidance from World Association of Perinatal Medicine and International Academy of Perinatal Medicine. J Perinat Med 2020;48(9):867–873. DOI: 10.1515/jpm-2020-0329
  54. Chervenak FA, Grünebaum A, Bornstein E, et al. Expanding the concept of the professional integrity of obstetrics during a public health emergency. J Perinat Med 2020;48(5):435–437. DOI: 10.1515/jpm-2020-0174
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.