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Hospitals have had to reckon with decisions over whether or not to provide COVID-19 vaccine exemptions -- or temporary deferrals -- to pregnant employees.

Those decisions, which continue to be polarizing for many pregnant women in the workforce, have to be made at a time when guidelines, legislation, and healthcare staffing demands can all be at odds.

New York State has in requiring COVID-19 vaccines for all healthcare workers. In a to state healthcare facilities on August 23, New York State Health Commissioner Howard Zucker, MD, JD, wrote that "pregnancy alone is not a valid 'health condition' upon which to base a medical exemption."

In the weeks following the state's revised restrictions to vaccine exemptions, at least one New York hospital reported being in danger of certain clinical services due to staffing shortages caused by healthcare workers' refusal to get vaccinated.

Outside of New York, though, many hospitals continue to hold pregnancy exemptions in place for employees until further notice. They are left to navigate available legislation, urging pregnant people and those hoping to get pregnant to get the COVID-19 vaccine, the local threat of the pandemic, and a potential worsening of their staffing shortages.

The Biden administration has yet to issue more specifics on where pregnancy fits into the list of medical exemptions. Employers must follow , which, according to the U.S. Equal Employment Opportunity Commission (EEOC) and Title VII as amended by the Pregnancy Discrimination Act, asserts that pregnant workers must be "treated the same as others who are similar in their ability or inability to work."

At the same time, the EEOC also states that "employees who are not vaccinated because of pregnancy may be entitled (under Title VII) to adjustments to keep working, if the employer makes modifications or exceptions for other employees."

Right now, hospitals are required to provide employees with the option to seek vaccine exemptions if they are experiencing a pregnancy-related medical condition or disability, just like any other employee who has a medical condition or disability. Yet some hospitals, despite opposing legal perspectives, have decided that pregnancy itself counts as an eligible medical reason to avert or postpone vaccination.

At Yale Medicine, and with the approval of their physician, healthcare workers at various stages of pregnancy are eligible to defer the COVID-19 vaccine. Infectious disease and pediatrics expert Richard Martinello, MD, of Yale Medicine, told MedPage Today that, beyond those who are currently pregnant, people trying to get pregnant and those who are breastfeeding have the option to seek deferment.

Less than 1% of Yale Medicine healthcare workers are seeking exemptions under this policy, Martinello said. In Connecticut, he noted, vaccine hesitancy isn't as it is in other parts of the country.

"We're pretty comfortable with where we are and we're going to sit tight with our current policies," Martinello said of their pregnancy exemption rules. "We do continually try to ensure that our physicians and physicians in the community are aware of what the latest guidelines are, so that's part of our active discussion."

Yale Medicine's vaccination deadline is September 30. After that, those who are exempt are required to get tested weekly; getting a test at one of Yale Medicine's COVID-19 testing sites is free for staff regardless of vaccination status, Martinello added.

Michael Leonardi, MD, a maternal and fetal medicine physician who specializes in high-risk pregnancies at OSF Healthcare in Illinois, echoed the notion that concerns about staffing shortages likely have an influence over exemption policies.

"Healthcare systems don't exist in a vacuum, and prior to the federal mandate, they've got to staff their hospitals," Leonardi told MedPage Today. "So if they are short-staffed already, that influences how strongly they can push their staff. If you're in an area that has a lot of vaccine hesitancy, you're going to have a steeper hill to climb than if you're in an area like Vermont that has embraced vaccination."

At OSF, an employee may still seek exemption due to pregnancy. Those looking to get pregnant, however, cannot, according to Leonardi. Unlike other hospital systems, which may allow employees to use individual physician approval to apply for vaccine exemption, a pregnant healthcare worker at OSF seeking exemption from the COVID-19 vaccine may only do so through the Occupational Safety and Health Administration.

"I think that was smart because it avoids physicians injecting their own bias into it, or being willing to write notes for patients without making any effort to counsel them about ACOG [American College of Obstetricians and Gynecologists] and AAP [American Academy of Pediatrics] and CDC recommendations," Leonardi said.

Leonardi, who hopes that OSF's pregnancy exemption policies can change to follow a stricter model such as New York's, added that, at OSF, those who get a deferral are logistically and financially responsible for their required weekly COVID-19 testing.

On the department level, members of hospital staff are finding their own ways not to aid employees seeking exemption due to pregnancy.

"As a department, we've decided that we're not going to provide exemptions," said Darla Berry, MSN, CNM, head of the nurse-midwife team at Indiana University's School of Medicine. "We can provide documentation that you are pregnant, and then what the institution decides to do with that is up to them."

Berry noted that her department right now is seeing an unprecedented number of COVID-positive pregnant patients. Caring for otherwise healthy women who have had to be put on ventilators and deliver their babies extremely preterm due to COVID, has possibly contributed to her staff's willingness to get vaccinated despite their own pregnancy status.

"We have women who are delivering babies and then being put on transplant lists for lungs because their disease has become so severe," Berry said. "So if the science and organizational recommendation is not enough, then maybe seeing what it can do would be enough of a motivator to help people make that decision," Berry told MedPage Today.

When it comes to the topic of losing staff members due to stricter exemption policies, Berry has a different view.

"The one thing that would really impact and preserve staffing levels would be increasing vaccination rates," Berry said. "If you increase vaccination rates, then you would decrease hospitalizations with severe disease, which would then decrease the strain and the stress on the system and the staff."

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