When "Recommendations" Fail: Why We Need a New Playbook for Maternal Health
With all our medical authority, evidence-based guidelines, recommendations, and professional consensus, we reached barely one in seven pregnant patients to accept the COVID-19 vaccine.
The numbers are stark and undeniable: despite years of official recommendations from the CDC, ACOG, and every major medical organization, 85.6% of pregnant women did not receive the 2024-25 COVID-19 vaccine. Let that sink in. With all our medical authority, evidence-based guidelines, and professional consensus, we reached barely one in seven pregnant patients.
Now, adding insult to injury, the CDC has stepped back from even making strong recommendations. The federal Advisory Committee on Immunization Practices (ACIP) hasn't issued updated guidance for the 2025-26 COVID vaccine and isn't scheduled to meet until late September. This has left states scrambling—New York's Governor Hochul had to sign an emergency executive order just to ensure vaccine access, declaring that "science and health care are under attack by the federal government."
But here's the uncomfortable truth: even when the CDC was making strong, clear recommendations, they weren't working anyway. The 85.6% non-vaccination rate among pregnant women happened during the height of federal recommendations, not in their absence.
This isn't just a COVID problem. This is a wake-up call about how we communicate medical advice in an era where trust in institutions has eroded and information travels faster than evidence. We are likely at a point where well over 50% of Americans are either actively anti-vaccine or simply don't prioritize vaccination—and our current approach of issuing recommendations from ivory towers clearly isn't cutting it.
The Recommendation Trap
The medical establishment built its communication strategy around the concept of "recommendations." We study the data, convene expert panels, publish guidelines, and expect compliance. But recommendations assume several things that may no longer be true: that patients trust medical authority, that they have access to reliable information, and that they view their physician as their primary source of health guidance.
The recent federal retreat from vaccine guidance has exposed another flaw in the recommendation model: its fragility. When political winds shift, recommendations can disappear overnight, leaving healthcare providers and patients in limbo. If our entire public health strategy depends on consistent federal messaging, what happens when that messaging becomes politically inconvenient?
The reality is messier. Physicians have been trained to be increasingly neutral in their language—partly from malpractice concerns, partly from a misguided interpretation of patient autonomy. Many doctors now say things like "the CDC recommends" or "studies suggest" rather than "I think you should." This creates distance between the physician and the advice, making it feel less personal and urgent.
Add to this the political polarization that has infected healthcare. A significant percentage of physicians voted for a president who has been openly skeptical of vaccines and public health measures. How enthusiastic can we expect these providers to be about promoting vaccination? And even for those who strongly support vaccination, they're operating within seven-minute appointment slots where vaccine counseling competes with blood pressure checks, fetal heart monitoring, and discussions about nutrition.
When the System Fails, States Step In
The current federal vacuum has forced states to become their own public health authorities. New York, Massachusetts, Connecticut, and other states have formed the Northeast Public Health Collaborative to issue their own vaccine guidance. But this patchwork approach means patients in different states receive different messages—hardly the consistent, authoritative communication that the recommendation model supposedly provides.
More troubling is what this reveals about the recommendation system itself. If recommendations only work when backed by consistent federal authority, and that authority can be withdrawn at any moment, then we've built our entire public health communication strategy on quicksand.
The Disparity Crisis
The vaccination data reveals another uncomfortable truth: our approach is failing some communities more than others. While 23.6% of non-Hispanic Asian pregnant women received the vaccine, only 7.2% of non-Hispanic Black pregnant women did. This isn't just about access—it's about trust, historical context, and the fact that generic recommendations don't account for the very real reasons different communities might be skeptical of medical advice.
Black women have legitimate reasons to distrust medical recommendations. From the Tuskegee experiments to current maternal mortality disparities, the medical system has not always served Black communities well. A recommendation from a medical establishment that has historically failed them—and that can apparently change its tune based on political pressure—may actually be counterproductive.
What Actually Works
Instead of doubling down on recommendations, we need to acknowledge that behavior change is complex and requires different tools. The examples I've used successfully with patients illustrate this:
Rather than saying "the CDC recommends the COVID vaccine," try: "You're already doing everything right for your baby—taking vitamins, avoiding alcohol, coming to all your appointments. COVID vaccination is just one more way to give your baby the best start, like getting a head start on their immune system before they're even born. What questions do you have about it?"
This approach does several things differently. It acknowledges the patient's existing good choices, frames vaccination as part of their existing care routine, doesn't rely on external authority, and immediately opens space for dialogue rather than compliance.
For patients who need more urgency: "COVID poses serious risks to you and your baby during pregnancy—it increases your chances of severe illness, ICU admission, preterm birth, and stillbirth. The vaccine prevents these complications and gives your baby protective antibodies for their first six months when they're most vulnerable. Let's get you protected today."
And for those who respond to personal stories: "I just delivered a baby last week whose mom had COVID at 34 weeks—the baby spent three weeks in the NICU, and mom was on a ventilator missing those crucial first days. The moms I see who get vaccinated? Their babies come home with them, healthy and protected. Your choice, but I've seen what happens both ways, and I know which outcome I want for your family."
A New Framework for an Unreliable World
What we need is a complete shift from recommendation-based to relationship-based communication that doesn't depend on federal consistency or institutional authority. This means:
Provider training that goes beyond clinical facts to include motivational interviewing, cultural competency, and understanding vaccine hesitancy. Doctors need tools to address concerns personally, not hide behind changing federal guidelines.
Community-based education that meets people where they are, delivered by trusted community members rather than distant medical authorities who may reverse course based on political pressure.
Personalized approaches that acknowledge individual circumstances, concerns, and values rather than applying one-size-fits-all messaging that can disappear overnight.
Honest acknowledgment of uncertainties and the political realities affecting healthcare guidance, rather than presenting medical advice as infallible pronouncements from institutions that may not be reliable.
Local resilience that doesn't depend on federal coordination. If New York can issue its own vaccine guidance when federal authorities step back, individual practices and healthcare systems can develop their own evidence-based communication strategies.
The traditional model of medical authority issuing recommendations and expecting compliance is broken—and recent events show it's not just ineffective, it's unreliable. Federal guidance can be withdrawn, recommendations can be politically influenced, and institutional authority can evaporate based on electoral outcomes.
We can either continue repeating failed strategies and watch vaccination rates stagnate while hoping for consistent federal messaging, or we can adapt our approach to meet patients where they actually are—skeptical, overwhelmed, and in need of authentic connection rather than recommendations that may change with the political winds. The health of mothers and babies depends on our willingness to abandon what's comfortable for what actually works, regardless of what Washington decides to recommend this week.