Podcast: Pregnant women, new moms and vaccines

Jim Dryden (host): Hello, and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri, the Show-Me State. As we continue to detail Washington University’s response to the COVID-19 pandemic, we look in this episode at some of the effects of the virus on pregnant women, new moms, their babies, and the physicians who care for them. Dr. Ebony Carter works with women who have high-risk pregnancies. She’s also the director of the Division of Clinical Research in the Department of Obstetrics and Gynecology. And for months now, she’s been dealing with pregnant women who aren’t sure whether it’s safe to get vaccinated.

Ebony Carter, MD: I think we’re all kind of traumatized. And so pregnant patients with COVID are three times as likely to end up in the intensive care unit, three times as likely to need a machine to breathe for them, twice as likely to die. It’s really serious in pregnancy. And I always tell patients, “I’m not trying to scare you, because the absolute numbers of people that happens to are relatively low, but your risk is much higher. So when you take that known huge risk versus the small theoretical risk associated with a vaccine, I would take my chances with a vaccine any day.”

Dryden: One new mom who has been vaccinated is Dr. Heather Jones. She’s a Washington University dermatologist.

Heather Jones, MD: My husband is an infectious disease doctor, and we believe in vaccines. When the time came for us to get vaccinated, I was just a few weeks postpartum, and I immediately jumped at that opportunity.

Dryden: Both Jones and Carter have young children at home, and both have spent more than a year worrying about what it would mean for their kids if they happened to catch the virus from a patient — patients who, in Carter’s case, tend to be pregnant women who normally have fairly high levels of stress. But she says stress has been exponentially greater during the pandemic.

Carter: The stress level has been high, but for various reasons throughout the pandemic. So last March, it was the fear of the unknown. Patients didn’t want to come into the clinic to see us for their prenatal care. Even if they had a problem, they were terrified to come to the hospital. That fear of the unknown was universal. So we had very limited infrastructure for remote visits or telemedicine. And suddenly, within three weeks, we did what we hadn’t been able to do in three years and shifted almost everything that we could to being remote. But if you’re seeing people remotely, there’s certain things that you pick up on exams or with ultrasounds of babies that you’re not going to pick up. So I think it was the fear of not knowing what coming into the hospital was going to do to you. In addition to that, what we started to see in the months after that is if you had limited resources, the stress of life was high. And we’re not seeing patients as much. So you’re also having to deal with it without a lot of those support services that we would have had normally. So people who were losing their jobs or their partner lost their job, they suddenly have children at home that they have to care for. And so that’s limiting. So I think all of the stresses of life exponentially increased, yet the support and care we were able to provide was not at the same level that it would have been pre-pandemic, because we had sent many of our people home as well. For example, some of the social workers were gone.

Dryden: A pretty good portion of your practice involves caring for patients with high-risk pregnancies. And much of your research involves promoting health equity for pregnant women and their babies. I’m guessing that during this pandemic that exposed so many inequities, you must have seen a lot of that firsthand.

Carter: Most certainly. So the thing is, the people who most needed the help seemed least likely to receive it. So I can give you a really good example that ties all of these things together. We rolled out universal COVID testing on our labor and delivery floor. And we were really excited about it, because back in those (early) days of the pandemic, it was impossible to get a test if you needed it, and so we thought this was a great service. I think the thing that we probably didn’t anticipate as well as we should have is people were terrified to be tested because there’s consequences to a test. So when we rolled the testing out, I happened to be on a 24-hour call on the labor floor that Saturday, and I very quickly noticed a pattern that patients who tended to have either Medicaid insurance or were patients of color were saying no versus patients who had private insurance or were white in general were saying yes to testing. It was stark. I saw it clear as day just on those 24 hours. So we decided to just look into it because we realized that universal testing doesn’t mean it’s universally acceptable. So for a week, we just looked to see who is accepting testing. And sure enough, 90% of white patients were, and only 50-something% of black patients were accepting it. The next week we asked patients why. “Why did you say no?” And we got some really interesting answers. But those answers allowed us to inform kind of an intervention, where we went and said, “Look, we’re doing testing. And the reason we’re testing is to protect you, to protect your baby, to protect all of the other moms on the floor, and to protect our staff. And we assure you that unless it’s 100% necessary for your own health, because you need to go to an ICU or your baby needs to go to an ICU, we will not separate you from your little one.” And so with this intervention, the rates of testing uptake increase for everyone. So they were universally greater than 90% for all patients, and everybody benefited from it. So that’s just one kind of small example of where we saw a huge health inequity because people were scared. And with asking patients why and some changes in behavior on our part, we were able to make it acceptable to everyone and the safety of our floor so much greater because we knew people’s status.

Dryden: That’s testing. Vaccination — lots of misinformation around that. Has there been a similar sort of divide in terms of pregnant women or women who just delivered willing to be vaccinated?

Carter: Yes, there has. And I feel like that more universally cuts across — everyone who’s pregnant tends to be scared, and it’s because of the unknown. And in December, that was a little bit demoralizing because in my heart of hearts, I felt like vaccination was probably the right thing. But I have to be data-driven, and there wasn’t any data at that point. The other thing that I said, though, is, “What are the risks of vaccination versus COVID?” Because people act like, “I’m just not going to get vaccinated, and I’ll be fine.” But there are but two choices to personally exit the pandemic. You either get COVID, or you get the vaccine, right? Those are your choices. And when you put it that way, pregnant patients have much worse outcomes with COVID. We have seen it. I think we’re all kind of traumatized. We have seen people who have been so sick. And so pregnant patients with COVID are three times as likely to end up in the intensive care unit, three times as likely to need a machine to breathe for them, twice as likely to die. It’s really serious in pregnancy. And I always tell patients, “I’m not trying to scare you because the absolute numbers of people that happens to are relatively low, but your risk is much higher. So when you take that known huge risk with COVID versus the small theoretical risk associated with a vaccine, I would take my chances with a vaccine any day.” And the nice thing in my counseling now is that we have 40,000 patients who are pregnant who have gotten the vaccine since December. And we have studied those patients, and there’s not really a signal we’re seeing for harm for the patient or the baby. So I think we have a lot more to go on now than we did in December. I try to be very balanced in my counseling, but still, in my personal opinion, I would take the vaccine over COVID.

Dryden: What about your perspective during these months, working with these women and knowing that you sort of have a job that social distancing is not necessarily always a possibility? And you’re going into wards where your patients may not have been tested. You’re putting yourself at risk, as are many of your colleagues. What was it like coming home from work before you were vaccinated?

Carter: So I almost — this is going to sound dramatic. I almost feel like I have PTSD from the early days of the pandemic, because I have largely blocked out how terrified I was. I am immunosuppressed and take an immunosuppressant. My husband has asthma. So we were both in high-risk groups for badness, and we have three beautiful little girls. And I was just thinking, “If I bring this stuff home to my husband and both of us end up dying, who’s going to take care of these little kids?” I was absolutely terrified. And as a physician, I don’t have a problem going in and taking care of people with infectious diseases. I am trained in universal precautions, and I don’t have an issue with that. But I do have an issue with the fact that there wasn’t adequate protection for health-care workers, and our country at large very quickly went toward, “We’re not wearing masks, we’re not doing this, we’re not doing that.” It’s like, “So don’t expect me to put my family in harm’s way when society as a whole is not going to do the very basic things to make sure that we minimize this catastrophe.” So I was furious. I was mad going to work every day, just feeling like I’m making this sacrifice and the country as a whole is not honoring it by doing their part. So we had a little contamination routine. So I have a little side porch on my house that opens to the outside. And so I would go to the side porch. I would strip. I stopped taking my typical stuff to — I used to have a cute little work bag and all of that stuff. I’d stop taking my purse. I took nothing but the bare essentials. I would strip naked on our side porch, would not bring anything that had touched the hospital. I mean, shoes, everything went on the side porch. I would streak across our house naked, hoping not to see my baby because if she saw me, she would want to run into my arms, and I didn’t feel safe. I didn’t want to harm her. Right? So I also felt like a horrible mother when she would happen to see me and was running toward me and I’m, like, running away from her. And I would go to the shower and basically shower away all of the germs and unknown COVID and everything else before I would see my family. So it added a good like 30 minutes to the routine every day. And then I would go to that side porch and pick up my stuff before I left in the morning. But that was our routine. In the summer, I was on a 24-hour call on the labor floor. It was a great call. I had so much fun. Everybody was excited to learn. The chief, I was so proud of her. It was her first day as a chief. She nailed it, did a great job. We did a ton of vaginal deliveries. So I was feeling really good about the day. Went to sleep around 2 a.m. in my call room. When I came out at 6 a.m., the second-year (resident) was like, “Dr. Carter, they all have COVID.” So this was a month after we had started doing universal testing, but it was taking a while for the test to come back. So oftentimes you had done the delivery before you knew the test results. And we had worn our masks and everything else. But N95s were still in short supply at that point, so it’s not like I had an N95 on for the whole 24 hours. And the majority of the patients we had delivered in that shift had COVID. And I knew that we did not have adequate protection. I should have had an N95, for all of these patients had COVID. And in particular, I thought about a patient who came in, breech, fully dilated. And we all ran to take care of her because that’s kind of an emergency. For a breeched baby, you need to do a C-section. And she was too far along. We couldn’t do it. So we were all in the room taking care of this patient, telling her to push. I’m holding her hand. My chief is sitting there getting ready to do the delivery. Right? So this woman is huffing and puffing like this far from my face. And she had COVID. And so I just remember driving home that morning thinking, “What have I done?” And Dedric (Carter’s husband) and I had talked in March about whether we should separate for a time, whether I should go stay in other housing or do something else, just because we didn’t want that burden for our family. And it just wasn’t practical, right? We both have crazy jobs. We have little kids. Somebody has to take care of them. It just wasn’t practical to do. But I called him on my way home kind of panicked. And I was like, “I just had a horrible COVID — several COVID exposures over the last 24 hours. We didn’t do it in March. If there was going to be a time to do it … I don’t even want to set foot in the house.” And he was like, “You’re stressed out. You’re tired. Just come home and shower, and we can talk about it.” So I get home. I go to the side porch. I do my decontamination routine. I streak to the shower. I take the shower, and I’m just feeling so dejected. From the height of times, like such a good call and I had so much fun and we took great care of patients, to like, crap. And I feel something on my leg. And I look down, and it’s my 4-year-old, who has slipped into the shower with me. I was shampooing my hair with my eyes closed. She was so proud of herself that she had slipped in. And I’m like, so much for keeping separate from the kid, right? The kids kind of made the decision for us. And I just kind of had to laugh in that moment. I mean, she kind of helped make our decision. We’re not going to do everything. And thank God I didn’t have COVID, and everything was fine. But yeah, I feel like those are the kind of stressful moments that I have just kind of blocked from the pandemic.

Jones: I am Heather Jones. I am a dermatologist at Washington University in St. Louis. I’m also the new associate program director for the Division of Dermatology, as well as a Gateway coach for Washington University School of Medicine.

Dryden: Heather Jones learned she was pregnant at just about the same time that various places around the U.S. began to shut down.

Jones: My family was very lucky during all of this. Right before the pandemic hit, my parents bought a condo here so that they could help with child care now that we were having two children. To maintain our level of work at the university, we had to get my 65-plus-years-old parents across the country during the middle of a pandemic to provide care for my child. People with parents that live in other countries have to navigate all of this. As a dermatologist, for each of our visits with our patients, we are within inches of their faces, unmasked. We were not using N95s, and we were reusing surgical masks. So there was always a fear that you would walk in, and even though we’ve done the screening tests, you would be in a closed, poorly ventilated room with that patient who is unmasked, multiple times a day.

Dryden: You are my dermatologist. So I have had the experience of being examined. It is not, as you said, a socially distant thing. How have your patients reacted?

Jones: Some of my most meaningful experiences as a dermatologist came in the early wave of getting patients back into the clinic. So I had an older patient who I was seeing with my resident whose significant other died a few months ago before COVID hit. And they had been stuck alone in their apartment that whole time. They looked at me and said, “This is the first time anyone has touched me.” One of my patients actually felt so badly for me that she — she was also a young mom with kids — she had an N95 sitting in her home that she came to personally deliver to me in the clinic because it was disturbing for her to see her pregnant doctor with just a surgical mask on.

Dryden: It’s last summer, and you’re pregnant. You’re a little ways along. What are you thinking?

Jones: I’m thinking, did we make a mistake? Should we have done this? Should we have done this now? Obviously, we don’t have a crystal ball, and when we very meticulously planned out our family, we were reading about the virus being in other countries. I don’t think we had any real idea of the significance that it would have on us here in the U.S. when we decided to ultimately continue to try to conceive. But I think the biggest thought was, “Oh goodness, we might have made a mistake.”

Dryden: When it came as an opportunity for you to potentially be vaccinated, what were you thinking then?

Jones: My husband is an infectious disease doctor, and we believe in vaccines. When the time came for us to get vaccinated, I was just a few weeks postpartum, and I immediately jumped at that opportunity because I believe that vaccines are safe.

Dryden: Once I was a few weeks out from the second shot, my stress levels went way down. Was that your experience here? Was it a different experience being a doctor after the vaccination than it was before the vaccination?

Jones: So it was not a different experience for me because I have a 4-year-old at home that’s not vaccinated. It was actually very stressful because I was vaccinated. I was passing the antibody through breast milk to my infant. My younger child was not vaccinated. And because of the way the vaccines were rolled out in Missouri, his teachers did not get access to the vaccine right away, which I think there might have been ways to potentially include teachers in that first wave. So he continued to go to school and continued to be with his friends because we needed child care. But there was always that question: Am I bringing something back to my child? Is my child getting exposed at school? It’s not over for parents of young kids. We are still very much in the deep end.

Dryden: I guess when I ticked down the list of specialties that would be affected by a virus, dermatology is not the first one that comes to mind.

Jones: And I think that is reasonable. I think we were affected but maybe in different ways, when you compare it to, like, emergency medicine or OB. The number of women either leaving work or leaving academics has been staggering. So I actually think that’s the thing that I’m probably struggling with most right now, how to manage this potential next wave with the Delta variant. The fact that I — residents are in my clinic now with new babies saying they’ve called five different daycare centers across the St. Louis area, and there are hundreds of dollars, $200 deposits to hold a spot with no guarantee of child care. Seeing women leave academics because they don’t have the resources. The onslaught daily, it’s like death by a thousand cuts. It has been hard watching many of my friends who are in similar situations who didn’t have the same level of resources that we did.

Dryden: As the pandemic has dragged on and with cases rising again in St. Louis and Missouri, Jones says she doesn’t expect that sensation of death by a thousand cuts to end any time soon. Meanwhile, Carter is trying to cut through the rumors and the untruths on social media as she works to keep women and their new babies healthy in these uncertain times.

“Show Me the Science” is a production of the Office of Medical Public Affairs at Washington University School of Medicine in St. Louis. The goal of this project is to keep you informed and maybe teach you some things that will give you hope. If you’ve enjoyed what you’ve heard, please remember to subscribe and tell your friends. Thank you for tuning in. I’m Jim Dryden. Stay safe.