It is that time of year again, when new student midwives are arriving at their schools, buying pinards, settling into new routines, and happily taking themselves off to be vaccinated against hepatitis B. There are, however, a few student midwives who aren’t going happily, and a few prospective midwives who will be staying at home this year. These are the people who have a philosophical or spiritual objection to vaccination yet have been told that, since the Department of Health (1992) recommend hepatitis B vaccination for all health professionals, they don’t have the right to decline it.
Inevitably, they are a minority. Most midwives prefer to be vaccinated against hepatitis B, just as most parents choose to vaccinate their children. Yet it seems slightly inconsistent that, while we champion the rights of the minority of women who want to decline treatment that they don’t feel is beneficial for themselves or their baby (especially where that treatment, like vaccination, is prophylactic), we are not equally loudly championing the rights of midwives and students to not be injected with substances against their beliefs.
The rationale for vaccination is simple enough to understand. Cafferkey et al (2001) found the overall prevalence of HBV carriage in Irish childbearing women to be 0.35% (58 women out of a total of 16,222 tested, or one woman in 280). While many infected people never have problems, and 95 per cent of those who do will recover, the consequences of infection (chronic liver disease or liver cancer) are potentially fatal. Consequently, the intention of mass vaccination is to protect both midwives and the women they attend (Ruef 2004).
As with any intervention, there are pros and cons to vaccination. On the plus side, successful vaccination can protect a midwife contracting hepatitis B, in the event that she somehow allows an infected woman’s blood to enter her own bloodstream, or sustains a ‘sharps’ injury from an infected needle or instrument. Vaccination also protects women from contracting the infection from their midwife, although I find it less easy to imagine how the midwife’s blood will enter the woman’s bloodstream.
Yet, as always, there are safety considerations. For example, while Engerix B®, one of the yeast-based vaccines used in the UK, is made without the use of human plasma and preservatives, it does contain traces of thimerosal, a mercury derivative which is a common yet potentially dangerous vaccine component. The makers of Engerix B® plainly state on their product information sheet that their product has not been evaluated for carcinogenic potential or effects on fertility, or tested for safety in pregnancy or during breastfeeding (GlaxoSmithKline 2004). The most common reason for declining vaccination among the people I have talked to is that some people simply don’t want to put this kind of product into their immune system.
If midwives were enabled to decline vaccination, itwould be simple enough to put disclaimers and procedures in place which would discharge Trusts of any liability should a midwife later contract hepatitis B, and to regularly screen non-immune midwives in order to protect women. The argument that women should have the right to be protected against hepatitis B falls down somewhat when we consider that up to fifteen per cent of people who have been vaccinated fail to seroconvert (Zuckerman et al 1997). There are a number of midwives practising without immunity, for all sorts of reasons. Ultimately, and whether we like it or not, we simply cannot protect all women (or hospital patients) from the range of infections that can be carried by humans; practitioners cannot be vaccinated against everything and we are not the only people in the hospital who have the potential to transmit infection.
As Pat Thomas, author of Your Birth Rights notes (personal correspondence 2004), the things that really put midwives at risk are questionable medical procedures such as ARM or applying fetal scalp electrodes, and the expectation that women will liedown for birth, which puts the midwife’s face right at the level of the vagina and any fluids splashing about at the time of birth. Perhaps, she suggests, we are using vaccination to compensate for the problems caused by these routine practices.
For me, the big question is whether we have the right to enforce vaccination for midwives any more than we have the right to enforce mass vitamin K or vaccine administration on new mothers? I have no problem with seeking to protect women, but is the current mass vaccination program really the only way to do this? To argue that it is acceptable to prevent midwives from entering the profession unless they agree to be vaccinated could be seen as tantamount to declining women who do not plan to vaccinate their baby the right to become pregnant, lest their child endangers another. Is the current stance on hepatitis B vaccination ethically justifiable, or unfairly prejudicial?
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