Over video calls from her bed in a Texas intensive care unit, Paige Ruiz gazed at the newborn girl who had gone home without her.
Taking in baby Celeste’s round cheeks, brown eyes and fine hair, she sometimes became so overcome with longing that she started crying, recalled her mother, Robin Zinsou. Then crying would turn to coughing, and Ruiz would have to hang up.
Those calls, painful as they could be, were “how she got to be a mom to Celeste,” Zinsou said. Ruiz, a 32-year-old wife and mother of two, died of coronavirus complications on Aug. 15, within days of giving birth on a ventilator.
She spent some of her final days urging others to get the vaccine she was waiting to receive out of concern for the baby she never got to hold.
Ruiz’s death came as the delta variant sent infections soaring in the United States and as hospitals reported a spike in critically ill patients like her: young, pregnant and unvaccinated. In a tragic paradox, those who are pregnant are simultaneously more likely to experience severe illness and death from COVID-19 and less likely to get the shot capable of preventing such suffering. At least 171 have died, including 22 in August alone, the Centers for Disease Control and Prevention reported this week and in an urgent health advisory recommending vaccination.
Just 25 percent of Americans have received at least one dose of the coronavirus vaccine while pregnant, according to CDC data, a figure that places them among the nation’s most hesitant populations. The number remains low — 31 percent — even when women who were vaccinated before becoming pregnant are included. Their reluctance appears to be driven partly by months of unclear guidance and a lack of data for the expectant, both of which persisted until this summer — a consequence of their exclusion from early coronavirus vaccine trials.
Into that vacuum of information flowed misinformation about infertility and miscarriage, causing further confusion for those trying to make decisions for themselves and their babies.
“I have to say that I haven’t had a single pregnant woman tell me that she didn’t get the vaccine because she’s opposed to vaccination,” said Nida Qadir, associate director of the medical ICU at the Ronald Reagan UCLA Medical Center. “It was usually more along the lines of, ‘Well, I wasn’t sure if it was safe for me to take in pregnancy,’ ‘I thought it might be better to wait until later on,’ ‘My OB/GYN told me I could take it if I wanted to but it’s not clear yet if I should.'”
She added: “I really can’t blame these women for being confused and not feeling comfortable taking the vaccine.”
The medical establishment has now fully endorsed receiving the coronavirus vaccine during pregnancy. The CDC formally recommended it on Aug. 11, after long-awaited studies showed no increased risk of miscarriage. Leading obstetrics and gynecology organizations unequivocally backed vaccination in late July.
Also adding their voices to the current push: those who have faced devastating consequences as a result of hesitation. In interviews and social media posts, they have shared stories of emergency Caesarean sections, premature deliveries, lost mothers and lost babies, hoping to reach others who are unsure about the shots.
Kayleigh Fox, a 27-year-old nurse in Walkerville, Mich., wiped away tears while describing her ordeal in a commercial for her state’s health department. She contracted the virus in late March at 39 weeks pregnant, coming down initially with body aches and cold-like symptoms. After delivering a healthy baby boy, plunging oxygen levels landed her in intensive care. Her condition continued to deteriorate: A blood clot developed her lungs, then sent her into right-sided heart failure. She feared she wouldn’t make it.
“I was constantly worrying about my kids, my new baby, my husband,” Fox said in an interview. “What would they do without me? Would they be OK?”
The ad, shot in black and white, ends with her bouncing her baby and kissing his cheek. In a voice-over, she says, “Being 27 and a mom and a wife and almost having that all taken away from me — it’s scary. And if a vaccine can prevent that from happening, why not?”
Ruiz’s loved ones think of encouraging vaccination as honoring one of her last wishes, and they’ve been heartened to see the stepped-up effort aimed at those who are pregnant. They just wish it came a couple of months earlier. Maybe then, she would still be here.
Left out of earliest testing
Within the first few months of the pandemic, research suggested COVID-19 could be particularly devastating in pregnancy, leading to higher chances of hospitalization and use of a ventilator. Yet in the race to develop vaccines that could vanquish the virus, pregnancy was a disqualifier for early trials — meaning data on vaccine safety and efficacy in pregnant women and other pregnant individuals could not be fully evaluated until the shots were publicly available.
The exclusion of pregnant participants is common in clinical research, historically intended to protect against potential harm. It stems in part from the tragedy that followed the prescribing of a sedative, thalidomide, to treat morning sickness in pregnant women in countries around the world during the 1950s. Within a few years of the drug hitting the market, severe birth defects had emerged in thousands of children, and it was pulled.
Although it was not approved by the Food and Drug Administration, thalidomide was given to Americans in trials. That led to stricter regulations for testing new pharmaceuticals, including barring pregnant women from most clinical trials.
The exclusionary approach has come into question in recent years, however, because it has left pregnant women in the dark about whether a wide range of vaccines and treatments are safe for them. Almost three-quarters of drugs approved by the FDA since 2000 have no data on their impact on human pregnancy, one study found.
“Our starting point has often been excluding pregnant women and then addressing the pregnancy issue later,” said Denise Jamieson, chair of the department of gynecology and obstetrics at the Emory University School of Medicine and a member of the American College of Obstetrics and Gynecology’s (ACOG) COVID expert group.
More than 20 organizations signed a March 2020 letter urging federal regulators to include pregnant and lactating women in coronavirus vaccine research. Three months later, the FDA encouraged vaccine makers to consider their inclusion in prelicensure trials following animal studies, but they were not included.
Pfizer, Moderna and Johnson & Johnson now have trials underway examining the effects of their vaccines on pregnancy, but they come months after the shots were authorized for emergency use. Pfizer’s vaccine has been fully approved by the FDA.
Pfizer spokeswoman Jerica Pitts said pregnant women were left out initially “to understand the safety and efficacy in healthy volunteers at the forefront before moving into other populations.” A Johnson & Johnson spokesperson said it was “important to establish the safety profile of vaccines before being expanded into vulnerable populations, such as pregnant women.” Moderna representatives did not respond to a request for comment.
Conflicting advice from medical authorities
The lack of data specific to pregnancy as the vaccines were made available led to varying — and sometimes conflicting — advice from medical authorities. In the early rollout of the shots, there were scattered reports of pharmacies and clinics turning away pregnant women, even though they have been eligible for vaccination from the start.
CDC director Rochelle Walensky said in April that vaccine surveillance systems showed “no safety concerns” for 35,000 vaccinated pregnant women or their babies. But until August, the agency’s formal guidance stated that those who were expecting “can receive a COVID-19 vaccine,” stopping short of endorsing it. The American College of Obstetricians and Gynecologists said for months that the shot “should not be withheld.” The World Health Organization recommended immunization only in pregnant women who were at high risk of exposure or had comorbidities. As a result, advice from OB/GYNs varied.
“We know that when providers counsel patients about the importance of vaccination that people are more likely to get vaccinated,” said Brenna Hughes, vice chair for obstetrics and quality at Duke University’s department of obstetrics and gynecology. “And since providers were unsure of the best approach or how to offer it or how to counsel patients up until this point, it’s made it fairly difficult to make those recommendations.”
The CDC and ACOG now endorse vaccination for all who are pregnant; the WHO recommends it when the benefits “outweigh the potential risks.” Jamieson, of ACOG, said the organization was able to strengthen its stance once data emerged. The WHO did not directly address a question on why its stance differs but noted that the data, while promising, has been limited. The CDC did not return multiple requests for comment.
In the absence of consistent information, many pregnant women decided to wait. Ruiz, a newly minted school district administrator in the Fort Worth area, came from a family of educators, all of whom got the shot. She believed in the vaccine and planned to get it, too — just as soon as the baby was born.
Two years earlier, Ruiz had endured a difficult delivery with her firstborn, Joanna. She was anxious heading into her second time giving birth and, without more information about the injection’s impact on pregnancy, worried about the potential effect on her child.
“My sister did tell me, when I was home in May, that if she got the vaccine and something happened to her unborn baby, she’d never be able to forgive herself,” recalled her older brother, Cameron Zinsou.
She made it, just barely: ‘I thought I was going to die’
Katie Pederson, a 33-year-old Los Alamitos, Calif., mother who was pregnant with her second child, talked to her doctor about getting vaccinated. But she, too, worried about the lack of information on the shot’s impact during pregnancy. She was mostly staying home, she reasoned, and had an extra layer of protection: The rest of her family had already rolled up their sleeves.
“I was like, ‘OK, I feel comfortable in waiting until the third trimester when the baby is much more cooked. Maybe there will be more studies,'” Pederson recalled. “Unfortunately, I never made it to the third trimester. When I got COVID, I was just 25 weeks pregnant.”
She checked in to an Orange County emergency room on July 6, struggling to breathe. Even on a ventilator, her oxygen levels remained perilously low and, the Sunday morning after she arrived, a medical team transported her to UCLA Health for a more advanced form of life support, called ECMO, or extracorporeal membrane oxygenation. The therapy performs the job of the heart and lungs, with a machine removing blood from the body, adding oxygen to it and then pumping it back through. It is a last resort for COVID-19 patients.
Alone in critical care, Pederson felt terror set in: “I thought I was going to die,” she said. “I was, like, actually sure of it.” But 3½ weeks after she walked into the hospital, she got to go home. Even into September, she still hadn’t fully recovered: She was using an oxygen machine at night and attending therapy. She and her husband and son moved into her mother’s house for extra support.
And yet, she said, her doctors call her a miracle. She survived — and her baby did, too. Her family is whole again.
“Just being home and reunited with my son, it was everything I thought about when I was in the ICU,” said Pederson, who has since received her first vaccine dose. “It was like, this is everything I want to do — just sit on the couch and have a meal with my family.”
Others were not as lucky. When vaccines became available, Haley Mulkey Richardson, 32, of Theodore, Ala., had recently learned she was pregnant with a second daughter. It was, said her husband Jordan, “exactly what we wanted: two little girls.”
Because of her job as a labor and delivery nurse, Richardson was immediately eligible for the shot. But because of her pregnancy, she held off. Then, in late July, she tested positive for the coronavirus. Her condition worsening, she was admitted to a hospital, where an ultrasound of the baby revealed a heart defect and other problems “that were not there on any previous testing or scans,” her husband said. She was seven months along and devastated.
“Here in the dark, in the wee hours of the morning, it is so easy to pretend that all of this was just a nightmare or that I’m just here in this hospital bed due to my own issues with Covid,” Richardson wrote on Facebook. “Not for anything being wrong with my sweet baby girl whom I thought I was protecting in my own womb.”
The baby, already named Ryleigh Beth, died on Aug. 18. The tragedy was compounded two days later, when her mother followed. Richardson’s husband, Jordan, suddenly a widower and single father to their 2-year-old, Katie, has been clinging to faith as he tries to navigate the dual losses.
“I believe those two are up there and me and Katie are still here,” he said. “And it’s — you don’t have a choice but to go on.”
Christine and Tate Ezzi, of Sherwood, Ark., considered vaccination, but heard a false rumor that the shot could cause miscarriage. She was pregnant with their sixth child and decided to wait. He did, too. Both came down with COVID, but it was worse for her, then 23 weeks pregnant. She had “everything, every symptom you can think of,” her husband said.
Shortly after midnight on May 15, Christine’s 39th birthday, she was put on a ventilator at the University of Arkansas for Medical Sciences medical center. The baby had to be delivered prematurely via C-section. Tate, who was also hospitalized for respiratory support, struggles with his memories of that day.
“The baby was stillborn. They brought the baby up to me, and I got to hold her for a little while. It was awful, especially knowing my wife was still asleep, that she couldn’t … that she wasn’t going to know what was going on,” he recalled.
Christine was on life support for 5½ weeks and regained much of her physical strength quickly, although she still struggles with what may be nerve damage to her fingers. The emotional and mental pain is taking more time.
“She’s having a little bit of PTSD, almost, from everything that has happened,” Tate said.
How many families are grappling with similar tragedies is unclear. The CDC said only about a third of case report forms include information on pregnancy status, warning that its numbers “must be interpreted with caution.” The agency has recorded more than 127,000 cases in the pregnant population over the duration of the pandemic, along with more than 22,000 hospitalizations.
Health-care workers have been reporting alarming details from the front lines in recent weeks. Qadir, the associate ICU director at the Ronald Reagan UCLA Medical Center, said most of the critically ill female COVID patients she’s treated have been pregnant, and they make up a large proportion of those on ECMO machines. Pregnant patients used to be rare in the ICU, she added, but “now it feels like kind of a constant.”
“These are young, healthy people. You’re not supposed to see them in the ICU,” Qadir said. “Everybody’s life is of course extraordinarily valuable, but the impact of a pregnant woman dying, or even going through this near-death experience but surviving and going through a very, very long recovery — it impacts so many people.”
In Tennessee, Vanderbilt University Hospital reported a spike in critically ill, unvaccinated pregnant women over the month of August, with 39 hospitalized and 10 in intensive care. At least three had emergency C-sections due to the severity of their conditions. Todd Rice, a critical care physician and director of the ICU, told a hospital publication that “these patients get very sick very quickly” and “a significant proportion of them end up losing their pregnancies.”
But the virus’ toll on mothers and babies is perhaps most clear in Mississippi, one of the nation’s least-vaccinated states and an epicenter of the delta-driven surge. There, eight unvaccinated pregnant women died from late July to September, State Health Officer Thomas Dobbs said. That’s more than half the total the state has reported over the course of the pandemic. Stillbirths have also doubled amid the pandemic, with 72 such cases reported statewide.
During a September news conference, Dobbs pleaded with pregnant Mississippians to get the shot, describing it as “phenomenally safe.”
“Please get vaccinated,” he said. “I mean, you got to protect yourself, you got to protect your baby, you got to protect your family.”
In interviews and public statements, some physicians treating this wave of severely ill pregnant women expressed frustration at the previous lack of clarity in vaccination advice.
Christina Han, a maternal/fetal medicine specialist at UCLA Health, said the professional societies that advise OB/GYNs acted on the right timeline, “because the last thing we wanted was for the organizations to rush into a recommendation and then have to withdraw it based on some subsequent data.” Before data became available, she said, she asked patients to get the shot based on decades of research on other vaccines — “to take a leap of faith.”
But in Texas, Ruiz wanted more solid evidence that the vaccine was safe.
She had always longed for children, said her mother, noting that “from an early age, she wanted to take care of others.” After becoming a mom, she said, “she just lit up every time she thought about Joanna.”
Ruiz and her husband, Daniel, who had been college sweethearts at Texas Christian University, were thrilled to find out they were having a second daughter — a little sister for Joanna. Robin Zinsou was thrilled, too. But all through the pregnancy, she worried about COVID. After every prenatal appointment, she asked her daughter if she was going to get the vaccine.
“Every time, every time, every time,” she said. “I knew what the answer was going to be, but I continued to ask.”
The virus struck at the end of July, days before Ruiz’s due date. Cameron Zinsou had booked a plane ticket from Greensboro, N.C. to be home that week, expecting he’d meet his new niece and spend time with the growing Ruiz family. Instead, he found himself waving at his sick sister through a window at her house. By Aug. 1, she was in the emergency room.
She delivered Celeste by emergency Caesarean section the next day, nurses whisking the baby away before she awoke. Her husband and family cared for the healthy newborn while awaiting her release from the hospital, where Ruiz implored people to get vaccinated.
“You know anyone who’s not vaccinated?” her mom recalled her asking. “Beg them to get vaccinated.”
Ruiz was always joking about “breaking out of jail” and getting home, and that’s what they all hoped for up until Aug. 15. Robin Zinsou was on baby duty early that morning when she noticed missed calls from the hospital. Ruiz’s heart rate was dropping, a nurse said. Her family should come right away.
Weeks after her death and burial, they were still in shock; her husband, who has not spoken publicly about his loss, is trying to adjust to life without the only woman he had ever dated.
“I’m not done with my sister,” Cameron Zinsou said. “I still have 50 years of nonsense to get in with her. I have a lifetime of annoyance and big brother things to do with my sister.”
They’ve shared her story with several news outlets, with her mother saying she “didn’t want other people to go through this.” She was also speaking out for Joanna and Celeste, she said: “These little girls are not going to remember their mommy, but I want their mother’s legacy to be a good one, and that she made a difference.”
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The Washington Post’s Ariana Eunjung Cha contributed to this report.