Have pregnant women been neglected as an at-risk group during the pandemic?

Statistics this week from both Scotland and England have highlighted concerns over the numbers of unvaccinated mothers-to-be ending up in critical care, particularly since the Delta strain became dominant.

Yet despite growing evidence about the dangers posed by Covid during pregnancy - including increased risks of miscarriage and stillbirth - expectant mothers are not, and never have been, prioritised for vaccination.

Instead, mixed messages have fuelled uncertainty over the vaccines' safety, with mothers-to-be initially advised not to get it due to a lack of clinical trial data (pregnant women, understandably, having been excluded as participants).

HeraldScotland: The third wave, which began in May, coincided with the rise of the Delta variant and with first dose vaccines being offered to people in their 30s and, mostly from June onwards, to people aged 18 to 29The third wave, which began in May, coincided with the rise of the Delta variant and with first dose vaccines being offered to people in their 30s and, mostly from June onwards, to people aged 18 to 29

Yet even after official guidance changed in April, making clear the vaccines were safe, effective and should be offered to women at any stage of pregnancy, reports surfaced on social media of women being given contradictory information, often by midwives, ranging from vague and non-committal "we can't advise you what to do" to cautions that they should delay.

One mother - who wanted the jag - told the iPaper in July that her midwife had urged her "not to be a guinea pig", while another said she had caught Covid after being told "not to risk the vaccine".

The consequences of this confusion are crystal clear in figures showing uptake rates which are around a third of that compared to the general population of the same age.

READ MORE: One in four intensive care Covid patients under-40 in third wave

In Scotland, two separate reports published over the past ten days have shed some light on the patterns of Covid infection and serious illness among pregnant women and those who had recently given birth.

For instance, we now know for the first time - thanks to a Public Health Scotland (PHS) report - that a total of 4,248 cases of Covid were detected in pregnancies between March 1 and August 31.

Meanwhile, analysis by the Scottish Intensive Care Society Audit Group (SICSAG) has revealed that between March 1 and September 19 a total of 67 women were admitted to intensive care with Covid who were either pregnant on admission (70 per cent) or had given birth in the six weeks prior (30%).

HeraldScotland: From Scottish Intensive Care Society Audit GroupFrom Scottish Intensive Care Society Audit Group

From this it is possible to conclude that roughly 1.6% of expectant and new mothers who contracted Covid in Scotland have ended up in ICU (with the caveats that many asymptomatic infections go undetected; community testing availability is much higher now than earlier in the pandemic; and that not all patients who have tested positive for the coronavirus are necessarily in hospital for that reason).

However, given that these caveats apply to everyone - not just pregnant women - how do these figures compare to the general population?

Well, according to PHS there have been 155,831 confirmed cases and 213 ICU admissions to date in females aged 15 to 44.

On that basis, the infection to intensive care conversion among young women in general is approximately 0.14% - a tenth of the rate compared to those linked to pregnancies.

HeraldScotland: The number of cases being confirmed in pregnancy has increased over time, in line with the pattern of the pandemic in generalThe number of cases being confirmed in pregnancy has increased over time, in line with the pattern of the pandemic in general

Another cause for concern is how the pattern of ICU admissions has changed for pregnant women over time.

In the course of the first two waves combined - covering the period from March 1 2020 to May 17 2021 - a total of 25 pregnant, or recently pregnant, women were admitted to ICU with Covid out of a total of 630 female Covid admissions. In other words, just 4% were classed as 'obstetric' patients.

In the third wave, from May 18 to September 19, there were 189 female ICU admissions with Covid, but this time 42 of them - 22% - were obstetric patients.

None of these 42 women had been vaccinated, even with a single dose, despite appointments having opened to 30 to 39-year-olds in early May and 18 to 29-year-olds in late May.

READ MORE: What Israel tells us about boosters, waning immunity and Covid deaths

Uptake has been "substantially lower", as PHS put it, among pregnant women compared to the general population: of all the women who gave birth in August, just 25% had had a single vaccination compared, at the time, to around 80% of 30 to 39-year-olds and more than 70% of 18 to 29-year-olds.

Some evidence from around the world has also pointed to increasingly severe illness in pregnant women as the virus has mutated - a pattern which appears to be borne out by the data in Scotland where the Alpha variant dominated during wave two before being overtaken by Delta in wave three.

HeraldScotland: The third wave was associated with a steeper rise in Covid ICU admissions among people aged 16 to 49The third wave was associated with a steeper rise in Covid ICU admissions among people aged 16 to 49

As SICSAG notes there "were very few critical care admissions" for obstetric patients during wave one - very probably fewer than five, in fact.

By wave three, however, Scotland had seen "increased numbers of pregnant women being admitted to hospital with moderate to severe Covid-19 symptoms requiring critical care".

Of these wave three mothers, 17% were of non-white ethnicity (in a Scottish population where 96% of people are white) and 34% came from the most deprived areas.

Groups, coincidentally, known to have lower vaccine coverage.

On Monday, data for England revealed 20 of the 118 most critically ill Covid patients given extra corporeal membrane oxygenation (Ecmo) between July and September were mothers-to-be, of whom 19 were unvaccinated and one had had a single dose.

ECMO is administered when a patient's lungs are so badly damaged that a ventilator cannot maintain oxygen levels.

READ MORE: Almost 400 fully-vaccinated Scots died from Covid after restrictions lifted

According to Dr Sarah Stock, a consultant in maternal and foetal medicine who is co-leading a study into Covid-19 in pregnancy at Edinburgh University, being pregnant affects how the body responds to infections and "this is probably what we're seeing with Covid-19".

Thankfully, no pregnant women in Scotland have died from Covid.

But it seems clear that they have been let down by a toxic combination of confusion and misinformation which has understandably increased their hesitancy and left them under-protected as Delta - combined with a lifting of restrictions - fuelled a surge in infections over summer.

At the very least, much more needs to be done now to drive up coverage among expectant mothers, particularly as winter - and flu season - approaches.