COVID-19 vaccination when pregnant or breastfeeding and for those planning pregnancy

Pregnant women have a higher risk of severe illness from COVID-19.

RANZCOG

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) acknowledges the risk posed to the community, healthcare workers, and all patients, due to the COVID-19 (coronavirus) pandemic. RANZCOG also recognises our responsibility to respond to this situation as a large organisation, and also as a medical college, and health leader.

The College respects the role of governments, health departments and health administrators in coordinating a national response in Australia and New Zealand, respectively. The purpose of this communiqué is to provide updated advice on the issue of vaccination for pregnant and breastfeeding women, and those planning pregnancy in Australia, in line with updated advice from The Australian Technical Advisory Group on Immunisation (ATAGI) and the Ministry of Health and Immunisation Advisory Centre in New Zealand.

RANZCOG advice aligns with that issued by ATAGI and the New Zealand Ministry of Health.

Key points

Pregnant women have a higher risk of severe illness from COVID-19. Their babies also have a higher risk of being born prematurely. 

COVID-19 vaccination significantly reduces the risk of becoming infected with COVID-19. Vaccination also reduces your risk of transmitting the virus to others, including to infants.

COVID-19 vaccination may provide indirect protection to babies by transferring antibodies through the placenta (for pregnant women) or through breastmilk (for breastfeeding women).

Pregnant women in Australia are a priority group for COVID-19 vaccination and should be routinely offered up to 3 doses of the Pfizer vaccine (Comirnaty) or Moderna (Spikevax) at any stage of pregnancy. 

Pregnant women in Aotearoa New Zealand are a priority group for COVID-19 vaccination and should be routinely offered up to 3 doses the Pfizer vaccine (Comirnaty) as this is the preferred vaccine for pregnant women in New Zealand. 

Pfizer (Comirnaty) and Moderna (Spikevax) are mRNA vaccines. Global evidence has shown that the Pfizer and Moderna vaccines are safe for pregnant women. 

Novavax COVID-19 vaccine, a protein-based vaccine, can also be used in pregnancy (but is not currently approved for use in third or fourth doses). While there are no immunogenicity or safety data, there are no theoretical safety concerns relating to its use in pregnancy, since the Novavax COVID-19 vaccine, like other COVID-19 vaccines, is not a live vaccine.

There is no evidence of increased risk of miscarriage or teratogenic risk with mRNA or viral vector vaccines (e.g. AstraZeneca (Vaxzevria).

Women who are trying to become pregnant do not need to delay vaccination or avoid becoming pregnant after vaccination. 

Third doses for pregnant women are recommended 3 months after the second dose and are vital for protection against the Omicron strains BA.1 and BA.2.

All healthcare workers, including midwives and doctors, are encouraged to be vaccinated, to protect themselves, pregnant women, and their babies.

What are the current recommendations for the COVID-19 vaccine in pregnant women? 

Pregnant women are a priority group for COVID-19 vaccination and should be routinely offered Pfizer mRNA vaccine (Cominarty) [or Moderna (Spikevax) in Australia] at any stage of pregnancy. 

Pregnant women with COVID-19 have a higher risk of severe illness compared to non-pregnant women with COVID-19 of the same age. This includes an increased risk of:

hospitalisation

admission to an intensive care unit

invasive ventilation

COVID-19 during pregnancy also increases the risk of complications for the baby including a higher risk of stillbirth and of being born prematurely.

Vaccination is the best way to reduce these risks.

Pregnant women should get vaccinated and continue to follow the current guidelines to prevent the spread of COVID-19 after they are vaccinated. Vaccination significantly reduces the risk of becoming infected with COVID-19. Vaccination also reduces your risk of transmitting the virus to others, including your baby. Everyone should continue with hand hygiene, wearing masks where social distancing cannot be maintained, testing when symptoms are present and isolation, when appropriate.

When is the best time to have a COVID-19 vaccine if I am pregnant?

It is recommended to have a COVID-19 vaccine as soon as you are offered one.

Pfizer (Cominarty) and Moderna (Spikevax) are mRNA vaccines and can be given at any stage of pregnancy. Two doses of Pfizer mRNA [or Moderna mRNA vaccine in Australia], 3-6 weeks apart, provides good protection against COVID-19, including against the Delta strain.

With the advent of the Omicron strain it is recommended that a third dose is administered 3 months after the second dose of the vaccine. Current approved COVID-19 vaccines have been shown to be similarly effective against both Omicron BA.1 and BA.2 when a third dose has been administered.

With newer Omicron variants having emerged:

in Australia, a fourth dose of COVID-19 vaccination is now available to all people aged 30 years and over and recommended to all people aged 50 years and over, to be given three months after the third dose. This fourth dose is also recommended for people with certain conditions including immunocompromise, cancer, chronic inflammatory conditions, chronic lung disease, chronic kidney disease, chronic neurological disease, diabetes requiring treatment, people with disability with significant health needs, severe obesity (BMI > 40kg/m2), and severe underweight (BMI < 16.5 kg/m2). People with medical conditions should discuss vaccination with their care providers.

in Aotearoa New Zealand, a fourth dose of COVID-19 vaccination is available to all people aged 50 years and over, and health, aged care and disability workers aged 30 years and over. As a priority, a fourth dose is recommended for people aged 16 years and over who have a medical condition that increases the risk of severe COVID-19 illness, or live with disability with significant or complex health needs or multiple comorbidities.

At this stage, pregnancy is not considered a specific indication for a fourth dose in healthy women under 50 years of age, who do not have additional risk factors. RANZCOG recommends that pregnant people discuss this with their maternity care provider, or doctor.

Covid-19 vaccines can be given at the same time as an influenza vaccine. The administration of other types of vaccines (whooping cough vaccine, etc.) with a COVID-19 vaccine is not recommended. The minimum interval time between a COVID-19 vaccine and any vaccine other than the influenza vaccine, is 7 days.

All medical advice should be patient-centred and take into account each individual’s personal considerations and preferences. 

Please note: Eligibility for vaccination is determined by the Australian Government and the New Zealand Ministry of Health, and local jurisdictions, and is not within the authority of RANZCOG. 

Aotearoa New Zealand advice:

Three (3) COVID-19 vaccines are currently available in New Zealand: Pfizer (Comirnaty); AstraZeneca (Vaxzevria) and Novavax (Nuvaxovid).

Pregnant women in Aotearoa New Zealand are a priority group for COVID-19 vaccination and should be routinely offered up to 3 doses of the Pfizer vaccine (Comirnaty) as the preferred vaccine for pregnant women in New Zealand.

Australian advice:

Four (4) COVID-19 vaccines are approved in Australia: Pfizer (Comirnaty); Moderna (Spikevax); AstraZeneca (Vaxzevria) and Novavax (Nuvaxovid).

Pregnant women in Australia are a priority group for COVID-19 vaccination and should be routinely offered up to 3 doses of the Pfizer vaccine (Comirnaty) or Moderna (Spikevax) at any stage of pregnancy.

Everyone in Australia aged 5 years and over is eligible for a free COVID-19 vaccination. Use  the Australian Government Eligibility Checker to arrange an appointment. A national COVID-19 Hotline (1800 020 080) is available to find relevant vaccination clinics.

Please note: When using the eligibility checker, pregnant women should tick ‘no’ to AstraZeneca and progress to the end.

Recommendations for women who have already received a dose of AstraZeneca (Vaxzevria) vaccine.

Pregnant women who have already received a first dose of AstraZeneca vaccine can receive either the Pfizer vaccine or Moderna or the AstraZeneca vaccine for their second dose within the recommended time periods.

Research has shown that mRNA vaccines (e.g. Pfizer or Moderna) are safe for pregnant women.

There is less available data on the safety of viral vector vaccines (e.g. AstraZeneca (Vaxzevria)) in pregnancy, hence the current recommendation for pregnant women to receive mRNA vaccines (Pfizer (Comirnaty); Moderna (Spikevax)).

There is currently no immunogenicity or safety data for these groups with the Novavax (Nuvaxovid) vaccine.

Other treatments in pregnancy

Pregnant women should continue to receive pertussis and influenza vaccination during pregnancy, noting the advice to space these two vaccine injections by at least one week.

The administration of Anti-D should continue as per usual indications and timing is not affected by vaccination.

What are the recommendations for women planning pregnancy?

Women who are trying to become pregnant can receive COVID-19 vaccination (Pfizer, Moderna, AstraZeneca or Novavax), as approved within their country. They do not need to delay vaccination or avoid becoming pregnant after vaccination.

There is currently no immunogenicity or safety data for these groups with the Novavax (Nuvaxovid) vaccine.

What are the recommendations for breastfeeding women? 

Vaccination is recommended for breastfeeding women, as approved within their country. They do not need to stop breastfeeding before or after vaccination.

Either Pfizer (Comirnaty) and Moderna (Spikevax) or AstraZeneca (Vaxzevria) are considered safe for breastfeeding women.

There are substantial data on the safe use of the Pfizer (Comirnaty) and Moderna (Spikevax) vaccines in breastfeeding women. The mRNA in Pfizer or Moderna is rapidly broken down in the body and does not appear to pass into breastmilk. The viral vector in AstraZeneca (Vaxzevria) vaccines cannot cause infection.

There is currently no immunogenicity or safety data for these groups with the Novavax (Nuvaxovid) vaccine. 

Further information

New Zealand Ministry of Health COVID-19 vaccine: Boosters, available at:

Australian Government Department of Health: Shared decision making guide for women who are pregnant, breastfeeding or planning pregnancy, available at:

ATAGI statement 7th July 2022, available at:

ATAGI statement 25th May 2022, available at:

RANZCOG will continue to monitor available data and issue updated advice as evidence emerges. 

Multicultural communities

RANZCOG recognises the importance of ensuring multicultural communities have the information they need about the COVID-19 vaccination program, and would recommend members encourage their patients to access information available through:

Ministry of Health New Zealand information packs on COVID-19 for specific communities available at:

Migration Council Australia: MyAus COVID-19 app — a multilingual app for Australia’s culturally and linguistically diverse communities about COVID-19, available throughout Australia. Supported by the Australian Government, the app is currently available in 29 community languages. Available for iPhones and Android devices.

Further research

The circumstances of the COVID-19 pandemic are unprecedented and knowledge is continually evolving. RANZCOG emphasises the importance of inclusion of pregnant and breastfeeding women in clinical trials of COVID-19 vaccines to develop evidence-based advice regarding safety and efficacy.

Disclaimer

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) is the lead body for women’s health in Australia and New Zealand and carries the responsibility for advice, dissemination of information and support of our members, our patients and the community during the Covid-19 pandemic.

The College respects the role of government, health departments and health administrators in coordinating a national response. Our public statements are made following consultation with officials, and medical experts, and with the understanding that the impacts of the pandemic are evolving, multifactorial and that action in one area will have intended, and unintended, effects on other areas.

RANZCOG will continue to provide information and advice that is the best available, to our knowledge. Given the recency of COVID-19 and the paucity of data, particularly in pregnancy, the accuracy of any advice may be rapidly superseded. We will endeavour to regularly update our communication as new information becomes available. Furthermore, RANZCOG will not comment on areas beyond our remit.

RANZCOG commentary on COVID-19 should be considered advisory, and not proscriptive, and all health workers, and the general public, should heed the advice of government and health authorities.

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