It's hard for pregnant women to escape the message: You're at extra risk from the H1N1 flu — it could trigger premature labor, hospitalize you for weeks, even kill you — so be among the first in line for vaccine next month. But only about one in seven pregnant women gets a flu shot each winter.
While federal health officials are working hard to raise that number this year, repeated swine flu warnings won't automatically overcome a key obstacle: Many obstetricians don't vaccinate. And not only are many women reluctant to go hunting for flu shots elsewhere, historically some pharmacists and other providers have been wary of vaccinating them.
"Maybe this year we can change that culture," says Dr. Anne Schuchat of the Centers for Disease Control and Prevention. "It's not supposed to happen that you, when you are pregnant, are fighting for your life on a respirator."
Yet getting simple vaccine information took Charla Bason of Washington, D.C., repeated requests, as she was bounced between her obstetrician's office and her primary care doctor a few weeks ago.
"I feel like if I hadn't brought it up, they never would have mentioned it to me," says Bason, 30, who is seven months pregnant with her first child.
Bason decided to seek vaccination after watching a CDC Webcast about pregnant women and talking with a physician in the family. But she still has no clear answer about where to get one.
"It's been incredibly frustrating. There's a terrible disconnect between the message that was getting out and, once you decide you want it, how do you get it?" she says.
Any kind of flu is risky during pregnancy, and pregnant women have been on the get-a-flu-shot priority list for years. Their reluctance to take any medication during pregnancy is part of the reason for the low vaccination rates.
With swine flu, what doctors call the 2009 H1N1 strain, pregnant women seem at particular risk for complications. Pregnant women make up 6 percent of H1N1-confirmed deaths even though they account for only 1 percent of the population, according to the CDC. They're at least four times as likely to be hospitalized as other flu sufferers.
Vaccine is a two-for-one deal during pregnancy: It can protect not just mom but the baby, too, for the first few months after birth. The mother's body makes flu-fighting antibodies that easily cross the placenta to be carried by the fetus, explains Dr. Neil Silverman of the University of California, Los Angeles. That's important because flu can easily kill newborns, yet babies can't be vaccinated until they're 6 months old.
Once women get that vaccine advice, where do they get the shot?
The American College of Obstetricians and Gynecologists has no count of how many OBs offer flu vaccine. It's still considered a minority although recent surveys suggest many more may be starting this year, especially in large cities.
An extra complication: Each state's health department ultimately will decide who gets to offer the H1N1 vaccine, aiming for locations that vaccinate the most people. Those decisions haven't been made public yet. Even if your OB requested swine flu shots, he or she may not get any, at least from initial shipments.
So the CDC and ACOG are urging obstetricians to partner with a nearby site — a hospital or drugstore, for example — to guarantee their patients a flu-shot source, a message the government will reiterate Tuesday in a swine flu training seminar for obstetricians nationwide.
Yet providers who don't routinely treat pregnant women may not understand flu's risk and the shot's safety record, says Silverman, who helps set ACOG practice guidelines.
Take pharmacists, expected to be key H1N1 vaccinators. Silverman gets occasional phone calls from women who say a pharmacist won't fill the flu-shot prescription he wrote.
"They act like the doctor who prescribed it didn't know what he or she was doing," says Silverman, who settles the standoff by getting the pharmacist on the phone. For every patient who calls, "I know there are at least two who just say, 'Well, OK, I'm not going to do this,' and just walk away."
The American Pharmacists Association is urging its members to follow the CDC's pregnancy guidelines but can't mandate that, and a few stores may still balk, says association chief of staff Mitchel Rothholz.
But some are embracing the potential customers. The large Walgreen's drugstore chain told states that if picked as an H1N1 shot site, it might put get-vaccinated-here signs next to the pregnancy tests, or print vaccine reminders for people who bought prenatal vitamins.
And Louisiana this month lifted its requirement that pharmacists vaccinate by prescription only, making it easier for everyone to get a drugstore flu shot.
Why don't more OBs vaccinate? Largely it's the expense and hassle, but it's not part of routine obstetrician training, says Dr. Stanley Gall of the University of Louisville, an OB and longtime vaccine provider. That's changing as more stock a different vaccine — against the virus that causes cervical cancer — and decide they might as well offer flu vaccine, too.
Because so few pregnant women even have another doctor, "the OB office should be a one-stop shop," he says.