Magical Thinking


One does not have to be a bibliophile to recognize the name of Joan Didion's popular and critically acclaimed book, The Year of Magical Thinking.1 The book chronicles the sudden death of the author's husband and the year that follows. Didion's description of that year is an insightful portrayal of what women experience after the loss of a long-term partner; it is a study of bereavement and mourning. Thus, this book is enlightening for health care providers who work with women who have suffered the loss of a significant other.

Didion's book also recounts another event in her life whose lesson is also instructive for health care providers. At the time of her husband's death, Didion's daughter was critically ill with pneumonia complicated by septic shock. So, in the period surrounding her husband's sudden death, Didion also watches her young, previously healthy daughter struggle for survival. Although her daughter survives the initial illness, she experiences serious sequelae, including pulmonary emboli and a massive cerebral hemorrhage that leads to permanent brain injury. It is a tragic story of unimaginable grief. But the lesson for health care providers in this story is not only about tragedy, grief, and loss; the lesson is also about prevention. The pneumonia that led to all of the sequelae was caused by what the author described as “a case of December flu”1; it was probably influenza.

Each year, approximately 36,000 people in the United States die of influenza and its complications.2 Influenza-related illnesses account for about 226,000 hospitalizations annually, many of which are related to pneumonia.2 Although we often think about influenza affecting the elderly and the chronically ill, it also affects the young and healthy, children and adults alike. Pregnant women are at greater risk for influenza-related morbidity and mortality because of the cardiopulmonary and immunologic changes associated with pregnancy.3–5 Although the mechanisms are not fully understood, influenza during pregnancy may also be associated with an increased risk of pregnancy loss, preterm birth, congenital malformations, childhood leukemia, and an increased lifetime risk of Parkinson disease and schizophrenia.3,4,6 Therefore, influenza vaccination during pregnancy is recommended to protect both the mother and the developing fetus.2–4 Vaccination of mothers during pregnancy also protects the newborn. When mothers are vaccinated, they are significantly less likely to contract influenza and transmit the virus to their infant.2 Additionally, the antibodies that mothers develop from the vaccine cross the placenta during pregnancy and may protect the newborn during the vulnerable period immediately after birth.2,6

Despite the well-documented benefits of influenza vaccination, a recent study found that only 13.8% of pregnant women in the United States were vaccinated for influenza.7 These data suggest that health care providers are not promoting and providing influenza vaccines for pregnant women. This is unfortunate, because recent research demonstrates that pregnant women are willing to be vaccinated based on their health care provider's recommendation.8

Many health care providers not only fail to recommend vaccination to pregnant women, but also neglect to protect themselves from influenza. Recent data indicate that only 41.7% of health care workers are vaccinated for influenza.7 Unvaccinated health care providers put their patients at risk because they may unwittingly transmit influenza to their patients. Vaccination is particularly important for midwives because we work with pregnant women and infants—populations that have a higher risk for influenza-related morbidity and mortality.2 The vaccination of health care providers has become such an important component of protecting patients from influenza that provider vaccination rates are being used as a measure of quality in patient safety programs.2 The vaccination of health care providers is also an essential component of emergency preparedness for pandemic influenza.

Unfortunately, many patients and health care providers engage in magical thinking when evaluating their personal risk for influenza. People are often lulled into thinking that they will be protected from influenza by their youth, a healthy lifestyle, appropriate hand cleaning practices, previous vaccination, or having avoided the disease in previous outbreaks. Decades of data on annual influenza morbidity and mortality rates tell us otherwise.9 Although the exact rates of influenza attacks, morbidity, and mortality vary from year to year, too many women die from complications of influenza every year, including young, healthy women.9 Experts predict that in the near future the world will experience pandemic influenza.3 In previous influenza pandemics, millions of people died and pregnant women fared especially poorly.3–4

October marks the onset of the annual campaign to vaccinate the public against influenza. This year, midwives should offer vaccination to all women for whom they provide care. Reproductive health visits provide an excellent opportunity for vaccinating women.10 Ideally, midwives will provide vaccinations for their patients. If not, they should have well developed systems for recommending and referring patients for vaccinations. The guidelines for influenza vaccination are readily available from the US Centers for Disease Control and Prevention (CDC).2 Information about influenza vaccination was recently reviewed in this Journal6,10 and can also be obtained from the CDC.11 Information for patients can be downloaded from this Journal's Share with Women column12 and the CDC.11

In brief, the influenza vaccine should be offered to all pregnant patients, regardless of gestational age.2 Likewise, the influenza vaccine should be offered to postpartum and breastfeeding women.2 Influenza vaccination should also be offered to nonpregnant women, particularly women with chronic medical conditions and those age 50 and older.2 Midwives and other health care providers should be vaccinated so that we do not transmit influenza to vulnerable women and infants.2 Finally, influenza vaccination should be offered to any woman who wants to avoid the disease.2 In sum, the vaccine should be offered to all of our patients unless they have a specific contraindication to the vaccine. The attenuated virus vaccine, easily administered by nasal spray, can be offered to healthy, nonpregnant adults under 50 years of age.2 The inactivated virus vaccine, administered by intramuscular injection, should be offered to pregnant women, women 50 years of age and older, and women who have chronic medical diseases.2

Magical thinking has no place in the prevention of influenza. Vaccination is the most effective method of preventing influenza and the complications that can occur from influenza.2 Although the influenza vaccine is not magical, it does save lives, reduce morbidity, and improve the quality of life. Midwives have a tremendous opportunity to improve the health of women and infants by recommending and providing the influenza vaccine.