COVID-19 vaccine decision-making among pregnant and lactating women in Bangladesh

Abstract

Pregnant and lactating women’s vaccine decision-making process is influenced by many factors. Pregnant women were at increased risk for severe disease and poor health outcomes from COVID-19 at various time points during the pandemic. COVID-19 vaccines have been found to be safe and protective during pregnancy and while breastfeeding. In this study, we sought to examine key factors that informed the decision-making process among pregnant and lactating women in Bangladesh. We conducted 24 in-depth interviews, with 12 pregnant and 12 lactating women. These women were from three communities in Bangladesh: one urban community, and two rural communities. We used a grounded theory approach to identify emerging themes and organized emerging themes using a socio-ecological model. The socio-ecological model suggests that individuals are influenced by many levels, including individual-level influences, interpersonal-level influences, health care system-level influences, and policy-level influences. We found key factors at each socio-ecological level that influenced the decision-making process of pregnant and lactating women, including perceived benefits of vaccines and vaccine safety (individual-level), the influence of husbands and peers (interpersonal-level), health care provider recommendations and vaccine eligibility (health care system-level), and vaccine mandates (policy-level). As vaccination can reduce the effect of COVID-19 disease in mothers, infants, and unborn children, targeting critical factors that inform the decision-making process is paramount for improving vaccine acceptance. We hope the results of this study will inform vaccine acceptance efforts to ensure that pregnant and lactating women take advantage of this life-saving intervention.

1. Introduction

As of late November 2022, there have been 2,036,556 confirmed cases of COVID-19 in Bangladesh, and 29,432 COVID-19 deaths [20]. Limited information is available regarding SARS-CoV-2 infections in pregnant women, as data were not systematically collected in Bangladesh. However, a study conducted in Dhaka, Bangladesh, indicated an increased risk of preterm birth among pregnant women with SARS-CoV-2 compared to those without SARS-CoV-2 [12], in line with global findings [2], [19].

Bangladesh began COVID-19 vaccine rollout for healthcare workers on January 27, 2021, and vaccination for the rest of the population on February 7, 2021 [11], [13]. Initial postponement of vaccination efforts caused by supply issues were alleviated through support from COVAX [11]. According to the World Health Organization, as of November 2022, 89 % of the population of Bangladesh has received at least one dose of a COVID-19 vaccine, with 75 % of the population being fully vaccinated and 35 % of the population having received a booster dose [20].

In August 2021, COVID-19 vaccine eligibility in Bangladesh was expanded to include pregnant and lactating women following the recommendation of the National Immunization Technical Advisory Group and the Director General of Health Services. Prior to this decision, pregnant and lactating women were excluded from COVID-19 vaccine policy and were ineligible for vaccination. Currently, COVID-19 vaccination for pregnant women is permitted with certain qualifications and is permitted for all lactating women [7].

The socio-ecological model (SEM) is a theory-based framework for understanding the multiple layers of interactions that can influence one’s behavior [10]. The model includes four levels of influence [5] that are nested within each other: 1) individual; 2) interpersonal; 3) community; and 4) societal (policy). The individual level includes individual factors, like biological and personal history, age, education, and income. The interpersonal level looks at how close relationships, such as one’s social circle, impacts behavior. The community level focuses on community settings including health care clinics, schools, workplaces, and neighborhoods. Lastly, the societal level analyzes how policy, institutions, and other societal factors may influence behavior. SEM recognizes that individuals are embedded within larger social systems and that interactions between the various levels affect how one behaves. As vaccination programs rely on vaccination-related information for success [18], in this study, we sought to understand the most critical factors influencing the decision-making process for COVID-19 vaccines in pregnant and lactating women in Bangladesh through a socio-ecological approach.

2. Methods

This cross-sectional qualitative study interviewed 12 pregnant women and 12 lactating women for a total of 24 interviews. Participants were recruited from three different communities in Rangpur Division in northern Bangladesh: Rangpur city (urban), Damodarpur (rural), and Ramjiban (rural).

Data were collected between April-August 2022. Interview instruments included questions related to the COVID-19 vaccine decision-making process for pregnant and lactating women and were pre-tested among pregnant and lactating women living in Bangladesh. Data collectors trained in qualitative research, including transcriptions, translation, and interviews participated in a two-day training exercise on human subjects research ethics and qualitative research. Antenatal care registers were used to recruit potential participants, and participants were also recruited at health facilities across the one urban and two rural communities in Rangpur Division. After initial participants were recruited, snowball sampling was used to recruit additional participants. Oral consent was obtained from those who expressed interest in joining the study. Interviews were conducted in Bangla in semi-private settings in the health facility or at the participant’s home. All interviews were audio recorded, then later transcribed, and translated to English by members of the study team and external translators fluent in both languages. All data, including audio recordings, were stored on encrypted servers, and only members of the study team had access to the data.

A team of 7 used a grounded theory approach to analyze the data. Data were managed using Atlas.ti. The code list was developed, refined, and finalized over three rounds of open coding. Following agreement of a code list, the team coded the transcripts, holding discussions on emerging themes after coding ∼ 25 % and 50 % of the transcripts. Two members of the team conducted inter-rater reliability with ∼ 10 % of the transcripts that neither of them had coded (3 transcripts). Reliability was 93 %. The team then identified themes and sub-themes. This study received ethical approval from the Bangladesh Medical Research Council and the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

3. Results

12 pregnant women and 12 lactating women were interviewed across the 3 localities. See Table 1 for participant information.

Table 1.

Sampling by participant type and location.

	Urban (Rangpur city)	Rural (Damodarpur)	Rural (Ramjiban)	Total
Pregnant women	4	4	4	12
Lactating women	4	4	4	12
Total	8	8	8	24

We sought to identify the key factors that informed the COVID-19 vaccine decision-making process among pregnant and lactating women. We organized these key factors using the socio-ecological model.

At the individual-level, factors included perceived benefits of the vaccine and vaccine safety. At the interpersonal-level, peer influence was a factor. At the health care system-level, factors included recommendation from a health care provider and vaccine eligibility. At the policy-level, vaccine mandates were a key factor (Fig. 1 ). In the sections following, we summarize each of these factors by levels within the socio-ecological model.

Fig. 1.

Factors affecting the vaccine decision-making process among pregnant and lactating women in Bangladesh through a Socio-Ecological Model.

3.1. Perceived acceptance of COVID-19 vaccines

Before discussing each factor, it is critical to comment about vaccine acceptability. Among all pregnant and lactating women in our study, perceptions of vaccine acceptance were very high. Of the 24 participants, 18 (75 %) perceived that COVID-19 vaccine acceptance was high among pregnant and lactating women and in their broader communities. When asked about who had not yet received the COVID-19 vaccine in their households or communities, pregnant and lactating women had a hard time recalling individuals who had not yet received the vaccine: “No one is left” (Lactating woman, Damodarpur, rural). When asked about pregnant women, the sentiment was the same: “No, there is no one in this area that has not taken the vaccine. Pregnant women also (have received the vaccine)” (Lactating woman, Damodarpur, rural). In fact, the only group pregnant women could identify that had not yet received the vaccine were children: “Now, I think no one is left. If there is any, maybe like younger children” (Pregnant woman, Damodarpur, rural).

In addition, women discussed their intentions to vaccinate their children with the COVID-19 vaccine if the vaccine was available for them. Women stressed the importance of children getting COVID-19 vaccines: “The children should get the COVID-19 vaccine, as I said, if the doctors find it good for the children after research, then it is good to vaccinate the children. Because, the mothers and fathers and all the people around are vaccinated, so if the children are not vaccinated against Corona and if they become affected by Corona, it will be a problem for them” (Lactating woman, Ramjiban, rural). Women expressed their intention to get the vaccine for their children once it was recommended: “If they provide vaccines for children, then I will give it to my child. Good. It will protect from Corona” (Pregnant woman, Rangpur city, urban). Women saw the vaccine as important to keep their children healthy: “From my point of view, it would be better if children aged five to more…have it. So, they can also live long” (Lactating woman, Damodarpur, rural).

3.2. Individual-level factor: Perceived benefits of COVID-19 vaccines

When asked about why pregnant and lactating women accepted the vaccine, the primary reason was its ability to protect one against COVID-19 disease and its effects. Many women referred to the vaccine’s ability to prevent COVID disease: “No one here is attacked by Corona. They got the vaccine. They all had the vaccine” (Lactating woman, Ramjiban, rural). This woman had similar sentiments: “The vaccine is good for me. I will get the benefit. There will be no disease! Many types of diseases. Different types of diseases. Many types, different types of disease fever, cough” (Lactating woman, Ramjiban, rural). This woman suggested that individuals in her community accepted the vaccine to rid the community of COVID: “Everyone got the vaccine so that they don’t get Corona…they got it to get rid of Corona. That is why people are getting the vaccine” (Pregnant woman, Rangpur city, urban).

Women spoke about how the vaccine reduced death in their community: “When people are more affected by the Corona virus, they take the vaccines…they have seen that many people die from that disease. After hearing that they took the vaccines. They thought if they get a vaccine, they will not have the disease” (Pregnant woman, Rangpur city, urban). Specifically related to the unborn child, this woman asserted that the vaccine helped keep babies healthy: “Not taking the vaccine causes harm. The baby may have any type of problem (if they do not take the vaccine)” (Lactating woman, Damodarpur, rural). Finally, women also alluded to the importance of keeping their families and communities healthy as motivators to get the vaccine: “I want to be healthy, so I want to keep others healthy” (Lactating woman, Damodarpur, rural). They also referred to how getting the vaccine was an obligation to one’s community: “They are taking that vaccine…for that Corona will not come either. In that case they have obligations to everyone” (Lactating woman, Rangpur city, urban).

3.3. Individual-level factor: COVID-19 vaccine safety

Perceptions related to vaccine safety served as a barrier to vaccine acceptance. A key barrier as to why pregnant and lactating women had hesitations was related to the notion that the vaccine could affect breast milk: “Pregnant and lactating women are not taking (the vaccine) due to the fear as they feed baby breast milk. They are feeding baby breast milk so they are not taking the vaccine for fear” (Lactating woman, Ramjiban, rural). Women were told about the vaccine and its effects on breast milk from a variety of sources: “(At the clinic) I heard they won't give the women, the women with young children will not be given vaccines. Lest their children should not get breast milk. The children would not get breast milk” (Pregnant woman, Ramjiban, rural). Women heard this notion not only from health care providers, but also from those in their village: “Yes, they gave the vaccines to the pregnant women too. As the people say in the village, since I have a young child, they told me that if I have the vaccine, I won't have milk in my breasts. They said that young children won’t have sufficient milk. That is how they say it in the villages. Initially I didn’t take the vaccine. Later, I asked my husband to ask the doctor if a woman with a young child can have vaccines. Everyone says it will be a problem” (Lactating woman, Ramjiban, rural). Many women spoke broadly about the potential of the negative effects of the vaccine on the unborn child or baby: “The fear is about the baby. The fear is if the baby would have any problem. Vaccines are not taken for the baby. (Vaccine) is not taken due to fear. I mean, the reason for not having the vaccine is the fear of baby’s sickness” (Lactating woman, Ramjiban, rural).

Pregnant women were also told to not get the vaccine as it could affect the unborn child:

“At that time (I went to get the vaccine) I was pregnant with my baby. That is why I did not get the vaccine. The people at the clinic said that you cannot take it when you are pregnant. They said I cannot take the vaccine while pregnant” (Lactating woman, Rangpur city, urban). Other pregnant and lactating women referred to concerns about the vaccine affecting the mother and baby in a negative way: “People in the village said that pregnant women might have problems. For the baby and mother both” (Lactating woman, Rangpur city, urban). While most pregnant and lactating women stated that most people did not have concerns after the vaccine, there were some people in the community that had misperceptions about the safety of the vaccine: “There are some unaware people. They think that if they take the vaccine, it will be harmful. They are claiming that fever happens, and then you may die after the fever” (Lactating woman, Rangpur city, urban). Learning about the vaccine development process helped pregnant and lactating women to accept the vaccine: “When it was informed that there is no harm for baby or for pregnant mothers… that the vaccine is developed for everyone…I also went to have the vaccine” (Lactating woman, Damodarpur, rural).

3.4. Interpersonal-level factor: Peer influence

The biggest interpersonal influence on the decision-making process of pregnant and lactating women was a woman’s husband: “(I took the vaccine because of) my husband’s suggestion. He heard from outside about vaccines and so I got the vaccine” (Pregnant woman, Damodarpur, rural). This woman’s husband stressed the benefit of the vaccine: “My husband said that if you take the vaccine, it will be better for you. So, then I went to take that vaccine” (Lactating woman, Ramjiban, rural). This woman also was influenced by her husband: “My husband messaged me on the phone about where to get the vaccine… then I went to take the vaccine” (Pregnant woman, Damodarpur, rural). This woman said she discussed with her husband about whether to get the vaccine: “Yes, I consulted with my husband about these vaccinations…I only consult with my husband… He supports me a lot and said that it’s really good for me” (Pregnant woman, Damodarpur, rural).

Peer influence was also a factor, as women pointed to what their community members were doing to inform their own vaccine behavior: “I will do what other people will do. Everyone took the vaccine so that they don’t have Corona. I will do the same to save myself” (Lactating woman, Ramjiban, rural). This woman got the vaccine when her peers went to get it: “When it was informed that there is no harm for baby, pregnant mothers, that the vaccine is developed for everyone… When everyone went to take the vaccine, I also went to have it” (Lactating woman, Damodarpur, rural).

3.5. Health care system-level factor: Health care provider recommendation

The recommendation of health care providers was a strong influence in affecting pregnant and lactating women’s vaccine decision-making process. Many women simply followed their doctor’s advice: “If the doctor asks me to get the vaccine, I will. If any problem occurs, I will deal with it. We do so many things to survive. I asked if I could have the vaccine and that I have young children, so is it okay for me to have the vaccine? If yes, I will have the vaccine. If not, they won’t give me any vaccine, so there’s no point in going over there. Later, when asked, they said that I could have the vaccine, so I went” (Lactating woman, Ramjiban, rural). Many women followed advice from health care professionals and did not have questions about receiving the vaccine: “Yes, I was informed about the vaccine. I heard that I could receive the vaccine. So, I got it. I didn’t ask (the health care provider) anything. I was told that I need the vaccine so that’s why I received it” (Pregnant woman, Damodarpur, rural).

Some women discussed the vaccine with their provider, and after that then decided about receiving the vaccine: “I heard people were becoming ill and some even died after getting the vaccine. So, I was very afraid. Then I found everyone was well. Then after discussing it with my doctor, I took the vaccine” (Lactating woman, Ramjiban, rural). Women raised safety concerns with their doctor and after discussing them, followed the recommendation of the doctor: “I asked if there would be any problem since I breastfeed my child. The doctor said that these are nonsense, get your vaccine. If you can stay well, if your body keeps well. Later, I went there and got the vaccine. Nothing happened. I was fine. For the child, they told me to breastfeed him half or one hour later. I breast fed the child 24 h later” (Lactating woman, Ramjiban, rural).

3.6. Health care system-level factor: Eligibility

While most women in our study had no issues related to eligibility, some were not able to receive the vaccine because they were told that they were not eligible to receive the vaccine. The eligibility of pregnant and lactating women to receive the vaccine was a health care system-level factor that affected vaccine receipt. Some pregnant women explained how they were turned away when going to the clinic to get the COVID-19 vaccine while pregnant: “I went (to a local clinic), but they didn’t vaccinate me. They said I might have problems if I get the vaccine. I was four months pregnant. When I went for the vaccination, they said that I should get the vaccine after the delivery. They said that I cannot be given the vaccine (at the clinic). They said that problems might arise. They didn’t tell me that much. Just said that I can’t be vaccinated. I returned without vaccination from the community clinic” (Pregnant woman, Ramjiban, rural). Some lactating women were also told that they could not receive the vaccine: “At first, I didn’t know that those were vaccines. There is another woman of my age who had children…they went to take the vaccine and they were told that women with children cannot have the vaccine. Later one day I went to the health complex. My husband told me that I can have the vaccine too. I still went for a vaccine, if they give me one, I will have it. If not, I will come back. Later, I went there and found that I could not get vaccines” (Lactating woman, Ramjiban, rural).

3.7. Policy-level factor: Vaccine mandate

Many women discussed that the vaccine was mandated and that was the reason they accepted the vaccine. Most women alluded to the compulsory nature of the vaccine: “As this is compulsory to everyone, if I don’t take it, I will be in trouble” (Lactating woman, Rangpur city, urban). Women were worried about getting in trouble with the police if they did not take the vaccine: “I received it as people suggested I should take it otherwise there will be problems. Police will create a problem.” (Lactating woman, Ramjiban, rural). Others felt people took the vaccine or else they would not be able to access government services, including health services: “Everyone is taking it because it is needed to be taken. It’s essential and everyone has to receive it. Without having it they would be unable to use a vehicle or to visit a doctor. This is the reason why people take it” (Pregnant woman, Damodarpur, rural). This pregnant woman mentioned not being able to be admitted to a hospital if one was unvaccinated: “The doctors at the hospital… Suppose you have gone to Rangpur or any other hospital, they will first ask ‘have you got the Corona vaccine?’ If you say no, they won’t admit you. That is why out of fear, people got the vaccine” (Pregnant woman, Ramjiban, rural). Others mentioned how not getting the vaccine could also affect one’s ability to secure employment: “Everyone is saying that if you don’t take Corona vaccines you can’t move anywhere… you also will not get any kind of job. You have to show your vaccination card when you are going to travel by vehicle” (Lactating woman, Damodarpur, rural).

Others saw the mandate as a reason to not have any fear about the vaccine: “You must take the Corona vaccines. It’s a government order. You have to follow the order” (Lactating woman, Damodarpur, rural). Some women stated that a mandate is what is needed for compliance: “They take that as it is a government rule. That’s what it takes. You have to take that, there is no other way except taking that. Everyone takes that. The Government provides and women are taking that” (Lactating woman, Damodarpur, rural).

4. Discussion

To our knowledge, little is known about the vaccine decision-making process of Bangladeshi pregnant and lactating women. We identified key factors at the individual-level, interpersonal-level, health care system-level, and policy-level that informed the decision-making process.

The two primary individual-level factors identified in our study included the perceived benefits of vaccines and vaccine safety. Regarding benefits of the vaccine, women in our study overwhelmingly believed that the vaccines were able to prevent disease and the negative effects of COVID-19. This is in contrast with other studies conducted among Bangladeshi women. For example, from a 2021 study that surveyed 2,275 Bangladeshi women, a very low percentage of these women (less than 7 %) believed the vaccine to be very effective [14]. These differences may be due to timing - as data collection for our study started after the vaccine had been available for approximately a year, or could be related to the vaccines available in Bangladesh. While most women in our study did not have vaccine concerns, lactating women in our study had concerns regarding the effect of the vaccine on breast milk. In the same 2021 study that surveyed 2,275 Bangladeshi women, less than 7 % believed it safe to be vaccinated in pregnancy [14]. Additionally, a study that explored the lived experiences of pregnant women in Bangladesh during government lockdowns during the pandemic found that pregnant women were worried how COVID-19 could negatively affect their unborn children and themselves [1]. This is line with other studies from the region, for example, in a study that surveyed pregnant women in Vietnam, the most common reason for refusing vaccination was related to vaccine safety [15]. Another study that explored mothers’ experiences in Bangladesh during COVID-19 found similar feelings of worry about the negative effects of COVID-19 on their unborn child among pregnant women [8]. While this study focused on COVID-19 disease and not vaccines, perhaps worries among pregnant women related to their unborn children were eased when a vaccine became available to them.

At the interpersonal-level, women in our study pointed to the influence of their husbands and peers in vaccine decision-making. Other studies have indicated the strong influence of husbands in antenatal care (ANC) in Bangladesh; for example, a study that analyzed 2014 Demographic Health Survey (DHS) data, found that the influence of the husband was critical in the utilization of maternal healthcare services among Bangladeshi women [9]. In another study that analyzed 2014 DHS data, authors found that highly educated husbands were more likely to allow their wives to contact doctors for ANC services [6]. In our study, women went to receive the vaccine because their husbands instructed them to do so.

At the health care system-level, a health care provider’s recommendation was important to women in our study. This is in line with numerous studies that have examined the role of health care provider’s recommendations on vaccine acceptance. Specific to Bangladesh, a mixed-method study that sought to understand knowledge and acceptance of HPV vaccines identified a health care provider recommendation as a key influence in vaccine acceptance [3]. Another study that sought to identify factors that affected COVID-19 vaccine acceptance among adults in Bangladesh broadly found that perceived trust and satisfaction with health authorities was associated with vaccine acceptance [16]. Eligibility was also important. As eligibility of pregnant and lactating women have changed over time, it is not surprising that women were turned away due to eligibility.

At the policy-level, many countries have enacted vaccine mandates. Women in our study indicated that the reason they accepted the vaccine was because the Bangladeshi government required all to receive the vaccine. In a meta-analysis that sought to examine how to increase COVID-19 vaccine acceptance among pregnant women, the authors suggest that while vaccine mandates have been successful for other populations [17], using a vaccine mandate in this population could backfire, leading to less trust in health care systems [4].

Our study has limitations. This was a qualitative study, and as such, it was not designed to be generalizable. Social desirability is likely given the topic. Despite these limitations, this study is one of the first to explore how pregnant and lactating women make vaccine decisions in the context of COVID-19.

Maternal immunization is a life-saving intervention. However, to protect the health of the unborn baby, the infant, and the mother, women must have the knowledge and ability to make an evidence-based decision about whether to accept a vaccine. As seen in our study, pregnant and lactating women do not make vaccine decisions in a vacuum; rather, they are influenced by individual-, interpersonal-, health care system-, and policy-level factors. As such, interventions to improve vaccine acceptance that are multi-level and utilize approaches that increase trust in the health care system will likely be most effective.

Funding

This research was funded by the Bill & Melinda Gates Foundation, grant number INV-016977.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.