The Spectrum of Hesitancy in COVID-19 Vaccine Uptake Among Pregnant Latinas on the United States–Mexico Border

Abstract

As the COVID-19 vaccine became available, pregnant people from marginalized communities disproportionately delayed vaccination. Although the urgency of vaccination has subsided, COVID-19 infection during pregnancy continues to pose maternal and fetal risks. Interviews with 45 Latinas residing on the US-Mexico border who were pregnant during the first two years of the pandemic revealed varying degrees of hesitancy related to vaccination during pregnancy. Utilizing a spectrum of hesitancy to frame the analysis revealed patterns of delayed vaccination and how varying degrees of trust in medical authority contributed to these patterns. Understanding patterns driving vaccine uptake and delays can inform clinical practice.

Introduction

As the COVID-19 vaccine became available, pregnant people, especially racial and ethnic minorities, delayed vaccination (Alcendor et al., 2022; Blakeway et al., 2022; Galanis et al., 2022; Rawal et al., 2022). This pattern persisted even after growing evidence showed that COVID-19 infection during pregnancy poses maternal and fetal risks that outweigh the risks of vaccination (Marchand et al., 2023). The maternal health risks associated with COVID-19 infection are of particular concern for Latinas in the United States (US)-Mexico border region. In the US, maternal deaths during the height of the COVID-19 pandemic increased the most among Latinas, in comparison to non-Hispanic white and Black people (Thoma & Declercq, 2022). In the border state of Texas, a majority of residents in counties adjacent to Mexico identify as Latino/a (US Census 2021). The population in this region suffered from disproportionately high hospitalization and death rates from COVID-19 prior to the widespread availability of the vaccine (Obaid et al., 2024).

As COVID-19 infection has become less deadly with a greater degree of population-level immunity and advances in therapeutic support (Murakami et al., 2022), there has been a drop in the uptake of COVID-19 boosters in the US (Jacobs et al., 2023). However, COVID-19 infection during pregnancy continues to be associated with increased risk for a range of adverse birth outcomes. While cases of maternal mortality and stillbirth among unvaccinated pregnant people have received the most attention (Khalil et al., 2022; Thoma & Declercq, 2022), a range of other adverse outcomes, such as preeclampsia, preterm birth, and placental issues remain an increased risk, even for previously vaccinated pregnant people (Karasek et al., 2021; Meyer et al., 2022; Papageorghiou et al., 2021; Thoma & Declerecq, 2022). As such, pregnant people are among the populations who may benefit the most from COVID-19 boosters (Faust et al., 2023), yet uptake of boosters remains low among previously vaccinated pregnant people (Razzaghi et al., 2022).

Given the continued increased risk of adverse events associated with COVID-19 infection for pregnant people, coupled with the lower uptake of vaccines in Black and Latina pregnant people, COVID-19 vaccination during pregnancy is an issue of health equity. Data collected through in-depth interviews with Latinas living in El Paso, Texas who were pregnant during the first two years of the pandemic is used to explore the following questions: 1) What patterns characterized vaccine uptake among pregnant Latinas as the COVID-19 vaccine became available? 2) How can women’s perceptions of the vaccine contribute to understandings of and responses to therapeutic hesitancy and therapeutic distrust?

Background

Critical Medical Anthropology frames individual experiences of health and decisions about how to act upon one’s own health in relation to broader social inequities and power dynamics (Singer, 1989). Critical Medical Anthropology also attends to how individual health practices, conditioned by one’s social position, have the potential to reinforce health inequities (Pfeiffer & Nichter, 2008; Singer & Baer, 2018). In the case of COVID-19 vaccination, high rates of vaccine refusal in a given group can amplify the disproportionate burden of harm caused by severe COVID-19 infection (Sobo et al., 2022).

Conceptually, therapeutic hesitancy and therapeutic distrust are useful for interrogating how social inequities contribute to how individuals experience medical encounters and interpret medical expertise. Therapeutic hesitancy refers to the avoidance of clinical intervention to prevent iatrogenic harm, or harm caused by medical intervention (Sharma et al., 2021; Chervanak et al., 2022; Leff & Loyal, 2021). Pregnant people and their providers have been conditioned to frame medical decisions based on not only the known potential for harm, but also the possibility of unknown harmful side effects on a fetus (Chervenak et al., 2022). A provider’s lack of familiarity with an intervention may contribute to a hesitancy to recommend that therapy (Sharma et al., 2021). Given the newness of the COVID-19 vaccine, some providers may have exercised a greater degree of hesitancy in recommending the vaccine to pregnant people (Chervanak et al., 2022). Chervenak and colleagues (2022) argue that given the significance of provider recommendations for patient decision-making, hesitancy on the part of providers may have increased the potential harm that arose from pregnant people delaying COVID-19 vaccination.

As Sobo and colleagues (2022) point out, vaccine hesitancy is an umbrella term that may result in an overgeneralization of distinct patterns. There is also a tendency to overlook the fact that people have different degrees of hesitancy, and even people who receive a vaccine may express hesitancy over doing so (Sobo et al., 2022). Leff and Loyal (2021) developed the term spectrum of refusal to account for different degrees of hesitancy. While this framing is useful, the term spectrum of hesitancy may be more descriptive of the data presented here, as “refusal” fails to account for the ways there may also be a degree of hesitancy involved in vaccine acceptance. Viewing hesitancy on a spectrum can account for both degrees of hesitancy and reasons behind this hesitancy.

Understanding patterns behind vaccine uptake requires attention to context-specific patterns in a given place and time (Laurier Decoteau & Sweet, 2024). In their study of vaccine hesitancy among the Somali immigrant community in Minneapolis, Laurier Decoteau and Sweet (2024) found an accumulation of distrust of medical experts and health institutions based on negative experiences with seeking health care. The role of distrust in factoring into medical decisions led Madorsky and colleagues (2021) to suggest therapeutic distrust as a more appropriate term than therapeutic hesitancy. A focus on therapeutic hesitancy alone may mask how structural inequities factor into a patient’s interpretation of medical recommendations (Khan et al., 2021). Therapeutic distrust emphasizes that a lack of trust in medical expertise may stem from systemic social inequities such as structural racism (Madorsky et al., 2021).

A historical legacy of abusive research practices that has harmed racialized minority populations, especially in the realm of reproductive health care, has spurred therapeutic distrust (López, 2008; Owens, 2017; Washington, 2006). Historically, US medical institutions have used Black and Brown bodies as the subject of medical experimentation. Widespread practices such as forced sterilization aimed at Latinas involved outright deception and denial of informed consent (Gutiérrez & Fuentes, 2009; López, 2008). A failure to engage with this history may lead to an oversimplification of describing what drives vaccine hesitancy (Laurier Decoteau & Sweet, 2024). Further, as Jamison, Quinn, and Freinuth (2019) point out, a passive trust in the health care establishment is a reflection of privilege. White privilege specifically grants a person the ability to trust a system that has not historically exploited white bodies.

Structural vulnerabilities also produce disproportionate burdens in attempting to access vaccines. For example, health insurance coverage is increasingly important for understanding vaccination trends in the US, as it has become more complex to navigate the programs that may offer free COVID-19 vaccines (Kates & Tolbert, 2023). Given that pregnancy is a temporary zone of inclusion, where people who otherwise lack health coverage may gain access to a publicly funded prenatal program, pregnancy may offer a limited window with enhanced access to health resources (Andaya, 2018). This may make pregnancy the only time when some individuals have easier access to COVID-19 vaccines.

El Paso is an important location for understanding patterns in COVID-19 vaccine uptake. El Paso and Ciudad Juárez, Mexico form one of the largest binational metropolitan areas in the world. Eighty-one percent of El Paso County residents identify as Latino/a or Hispanic (US Census, 2021). Prior to widespread availability of the vaccine, border counties in Texas had significantly higher death and ICU admission rates compared to non-border counties (Obaid et al., 2024). In response to the burden of COVID-19 in the region, combined with culturally and structurally competent strategies for mass vaccination, there was quick uptake of the vaccine at the local level. El Paso was among the first cities in the US to vaccinate 75% of the adult population (Ocaranza, 2023), in contrast to the trend in delayed vaccine uptake among minority populations in the US (Hildreth & Alcendor, 2021) and globally (Casubhoy et al., 2024; Hussain et al., 2022). The high degree of vaccine acceptance in El Paso also contrasts with other national patterns. In the US, a growing anti-vax movement gained momentum and fed off concerns over the perceived rushed development of the vaccine (Carpiano et al., 2023). Further, the politicization of science during the pandemic contributed to the circulation of misinformation that increased vaccine refusal, especially among political conservatives (Bolsen & Palm, 2021). These studies illustrate a range of factors that shaped perspectives on the COVID-19 vaccine. To better understand patterns of vaccine uptake, it is important to consider the standpoints and experiences of specific subgroups of people.

The relatively quick vaccine uptake locally, compared to national patterns, suggests that culturally and structurally competent approaches in vaccine rollout may have increased vaccine uptake for some sectors of the population, but not necessarily for pregnant people. Thus, there is a need to better understand the role of pregnancy in possibly exacerbating therapeutic hesitancy and therapeutic distrust within a population that otherwise had a relatively quick acceptance of the COVID-19 vaccine.

Methods

Study Design

This article draws from interviews conducted through the Maternal Health and Emotional Distress on the US-Mexico Border Project. The broader study included 176 Latinas utilizing publicly funded prenatal coverage who sought care through the obstetrics, gynecology, and midwifery practice affiliated with the county safety-net hospital between September 2020 and May 2022. Eligible participants included those who identified as Latina and had coverage under Medicaid for Pregnant Women or CHIP Perinatal, which are publicly funded programs that cover low-income populations during pregnancy. The two programs combined cover nearly half of all births annually in Texas (Kaiser Family Foundation, 2022). Potential participants were approached by a research assistant during a prenatal visit after the person had completed the first trimester of pregnancy. This strategy ensured that patients received information about the study from someone who was not one of their providers and made it more likely that the patient had already established prenatal care. These considerations reduced the risk that potential participants would feel pressured to participate as a condition of receiving care.

The 176 participants completed a sociodemographic survey and authorized access to electronic medical records. A subsample of 60 participants participated in at least one semi-structured interview; the data presented here draws exclusively from this qualitative data. Most interviews took place while the person was still pregnant, although three took place within the first three months postpartum. Fourteen of the women from the subsample of 60 participants took part in one to two additional interviews during the first year postpartum.

All participants provided written informed consent, with consent materials made available in both English and Spanish. Given that consent was initially obtained at a prenatal visit prior to survey participation, interviewers sought verbal reaffirmation of consent prior to beginning an interview. Pseudonyms are used to humanize participants without revealing their identity. The IRBs at the University of Texas at El Paso and Texas Tech University Health Science Center-El Paso approved the research protocol.

The goal of the broader study was to explore how stressors posed by border and immigration policies, the aftermath of a mass shooting, and the COVID-19 pandemic shaped pregnancy and postpartum experiences. Objectives did not initially include a focus on vaccine uptake, given a vaccine was not available when the project began. However, semi-structured interviews often result in the emergence of new topics. As the vaccine became available, conversations included reflections on vaccination intentions and factors influencing these intentions. Out of the 60 individuals interviewed, vaccine intentions were discussed with 40 women while they were still pregnant. Five women who participated in a postpartum interview gave birth prior to widespread vaccine availability, and this subset of participants was asked if they thought they would have received the vaccine while pregnant had it been available. As such, this analysis includes interview material from 45 distinct individuals, some of whom participated in multiple interviews.

Interview Process

The study’s Principle Investigator (PI) and a team of student research assistants trained by the PI conducted the interviews. All interviewers were bilingual in English and Spanish, and interviews were conducted in the participant’s preferred language. Given the constraints of the pandemic, interviews were conducted over the phone or video call at a mutually agreed upon time and typically lasted around one hour. With consent, interviews were recorded and transcribed. Transcriptions were completed in the language the interview was conducted, with only direct quotes translated for publication purposes. Translations focused on capturing the intended meaning behind a person’s words, rather than a literal translation.

Data Analysis

Interview transcripts were analyzed in multiple stages. First, the specific passages of each interview that included discussion of the COVID-19 vaccine were identified. Focusing only on these selected passages, the PI and two research assistants conducted an initial reading of the interview material. Discussion of this initial reading informed the development of a codebook aimed at analyzing two key issues: vaccination intentions and the spectrum of hesitancy guiding vaccination intentions. The following codes were applied to vaccination intentions: no intention of vaccination during pregnancy, plans vaccination during pregnancy, received vaccine during pregnancy, and vaccinated prior to pregnancy. The following codes accounted for the participants who gave birth prior to widespread vaccine availability: would have received vaccine while pregnant and would not have received the vaccine while pregnant.

An analysis of how women framed their decisions involved the development of codes that would consider degrees of hesitancy. As Sobo and colleagues (2022) emphasize, vaccine hesitancy is an umbrella term that glosses over the fact that people may display degrees of hesitancy and be more likely to receive a vaccine under certain circumstances, in spite of feeling hesitant. Thinking of hesitancy on a spectrum can attend to this variation and the specific role of pregnancy in driving decisions about vaccination. The codes developed to account for this spectrum included: vaccine enthusiasm, cautious delay during pregnancy, vaccine confusion, cautious delay beyond pregnancy, complete vaccine refusal, and vaccine apathy. Women were coded as having vaccine enthusiasm when they reported quick uptake of the vaccine and received the vaccine while pregnant. Individuals could report some degree of hesitancy, although it would not have been strong enough to significantly delay vaccination. Cautious delay during pregnancy was applied to individuals who described plans to receive the vaccine in the future, but not during pregnancy. Vaccine confusion was identified as a subtype of cautious delay during pregnancy, characterized by confusing messages as a specific factor driving delayed vaccination. Cautious delay beyond pregnancy described women with plans to delay vaccination even after the birth, but open to receiving the vaccine in the future. Complete refusal described individuals who were opposed to receiving the vaccine in the future. Women were categorized as having vaccine apathy if they delayed vaccination in the absence of outright refusal or cautious delay, but rather a lack of feeling threatened by COVID-19. Two research assistants used Atlas.ti v.23 qualitative data analysis software to code transcripts using this codebook. Both research assistants coded all interviews to ensure consistency in the application of the codes and any discrepancies that emerged were discussed and resolved.

The presentation of results draws from detailed accounts of individual participants who characterized various types within the spectrum of hesitancy. This strategy employs a case study approach that emphasizes how the contexts of people’s lives and the social meaning of their experiences can produce a rich analysis (Radley & Chamberlain, 2011).

Results

The 45 participants included in this analysis ranged in age from 19–41 years, with a mean age of 27.4 years at the time of the first interview. Thirty-one were born in the US, 13 were born in Mexico, and one was born in Chile. The woman born in Chile spent most of her childhood in Mexico prior to migrating to the US. Of the women born in the US, seven spent at least part of their childhood in Mexico. Tables 1–3 provide a summary of vaccination patterns in relation to the spectrum of hesitancy. What follows provides an analysis of what characterized each of the types on the spectrum of hesitancy, with attention to the role of therapeutic trust and distrust in driving degrees of hesitancy.

Table 1:

Vaccination Status during Pregnancy (n = 40)

Pregnancy Vaccination Status
Vaccine available during pregnancy and no intention of vaccination while pregnant	23
Actual or planned vaccination while pregnant	14
Vaccinated prior to pregnancy	3

Table 3:

Degrees of Vaccine Hesitancy (n=37)

The Spectrum of Vaccine Hesitancy
Vaccine enthusiasm	14 (37.8%)
Cautious delay during pregnancy	16 (43.2%)
Cautious delay beyond pregnancy	4 (10.8%)
Vaccine apathy	1 (2.7%)
Vaccine refusal	1 (2.7%)
Vaccine confusion (specific to pregnancy)	1 (2.7%)

The Spectrum of Hesitancy

Vaccine Enthusiasm

The women classified as vaccine enthusiasts (n = 14, 37.8%) expressed a desire to receive the vaccine as soon as it became available to them. All of these women also expressed some degree of hesitation specifically because of their pregnancy. In some cases, this hesitancy led to relatively short delays in scheduling a vaccination appointment, but a final decision to receive the vaccine before the delivery.

Crystal was among the women who sought out the vaccine as soon as it became available. Her grandmother had died from COVID-19 during the fall 2020 wave. Crystal described her grandmother’s death from COVID-19 as negatively impacting her, saying, “I think it’ll just keep affecting me, just the simple fact that I didn’t get to see her. I didn’t get to say my last goodbyes.” Of deciding to receive the vaccine early in her pregnancy in late spring of 2021, she said, “I wanted to get it right away. I just didn’t know if I could since I was pregnant…I waited to get the ok from my doctor.” Crystal’s decision-making process reflects trust that her provider would equip her with the correct recommendation. Anessa echoed this trust in her providers’ recommendation. She expressed a desire to schedule a vaccination appointment as soon as possible, but was unable to do so before she became pregnant. She said, “At my first appointment, I still had not been able to get it [the vaccine] yet, so I asked them if I should get it. They [her midwives] told me they recommended it, so a few days later, I went for it.” Both Crystal and Anessa had initial concerns about the safety of the vaccine during pregnancy. However, they both expressed trust in their provider to give them appropriate guidance, which enabled them to feel more confident about receiving the vaccine.

Liliana also scheduled a vaccination appointment as soon as possible, receiving the first dose in March 2021. At the time, she was in the second trimester of her second pandemic pregnancy. She had given birth to her first child in June 2020. Liliana reported that her prior experience of postpartum isolation contributed to her desire to receive the vaccine as soon as possible. In contrast with Crystal and Anessa, she did not rely on her provider to confirm that the vaccine would be safe. However, she still had concerns and sought information to assure herself that the vaccine would be safe during pregnancy. She said that as a former nurse, she knew how to find the information she needed: “I did my research and everything. I read the CDC website. I went to blogs, Facebook groups with moms who already got it…I believe in science. I knew I could still get sick, but I will live, you know.”

Despite Liliana’s confidence that the vaccine was safe, she expressed a desire to “check on the baby” post-vaccination. While she enthusiastically scheduled her vaccine appointment, she also made an appointment for a sonogram in Juárez the day after her vaccine. Her provider in the US only offered two sonograms – the first to confirm the viability of the pregnancy and the second full anatomy scan at 20 weeks gestation. Conversely, private providers in Mexico routinely offer more frequent sonograms, often at the demand of patients (Fleuriet, 2009). Given that Liliana grew up in Mexico and her legal residency status in the US enabled her to easily cross the border, she strategically used a provider in Mexico to “check on” her baby following vaccination.

Isabela was another vaccine enthusiast who expressed slightly more hesitancy than other vaccine enthusiasts. Prior to her third pregnancy, her entire family contracted COVID-19 in November 2020. Her own infection was mild, but it left her with lingering gastrointestinal issues that made it difficult to gain weight during pregnancy. Given this experience, she urged family members to schedule vaccination. In her own case, she waited to make an appointment until she had time to confirm the vaccine’s safety with her midwife. Also influencing Isabela’s decision was the fact that she found accessible information on the vaccine’s safety during pregnancy. Specifically, she already followed Mama Dr. Jones, an obstetrician-gynecologist (OB-GYN) with a substantial social media presence who provides information on a range of reproductive and maternal health issues. According to Isabela, “I kept watching videos and doing research and following up on people who had gotten their shots during pregnancy. After speaking to my midwives I decided, well, I already got COVID once and I don’t wanna get it again.” Isabela ultimately drew on multiple sources of information, including her provider and online resources, as she made her decision.

Like Crystal and Anessa, who exhibited vaccine enthusiasm, Liliana and Isabela sought out information with the aim of feeling confident in their decision to receive the vaccine during pregnancy. For Anessa and Crystal, provider input was significant in their final decisions. For Liliana and Isabela, searching for additional sources of trusted and accessible information helped them in their decision-making process.

It is important to reflect on the factors that promoted vaccine confidence among women who received the vaccine during pregnancy. Hearing firsthand accounts from other pregnant women who received the vaccine helped alleviate fears for some women. Others reported seeking accessible medical research. Isabela’s affinity toward Dr. Jones’s work suggests that some social media venues may be more accessible and engaging than the written material traditionally distributed in medical encounters. Given the potential for social media to promote misinformation (Hernandez et al., 2021), direction toward reputable social media sources is essential.

Overall, the women who expressed vaccine enthusiasm also expressed pregnancy-specific concerns. Either having a high degree of trust in their providers or having access to information that seriously considered pregnancy-specific concerns were important factors in enabling these women to feel like they were making the right decision about receiving the vaccine during pregnancy.

Cautious Delay during Pregnancy

Cautious delay during pregnancy was the most common pattern in this study. Sixteen women (43.2%) interviewed during pregnancy expressed definite plans to receive the vaccine in the future, but not during pregnancy. Additionally, five women who participated in postpartum interviews delivered prior to the widespread availability of the vaccine. Four of these women received the vaccine within the first three months following the delivery. These four women all reported that if the vaccine had become available while they were still pregnant, they would have likely delayed vaccination until after the birth.

Cautious delay during pregnancy was driven primarily by concerns over safety of the vaccine for the fetus and the perception that there was insufficient research on the vaccine during pregnancy. Women who expressed cautious delay during pregnancy typically expressed significant concerns over potentially contracting COVID-19 while pregnant and often reported measures such as continued isolation, masking, and limited social interactions in an effort to prevent illness. Despite their concerns surrounding COVID-19 infection, they did not view vaccination during pregnancy as a safe option for preventing infection.

Patricia succinctly explained the dominant sentiment among women exhibiting cautious delay during pregnancy, saying, “I would totally get it [the vaccine] if I wasn’t pregnant.” She went on to explain how her conversation about the vaccine with her midwife was insufficient for alleviating her pregnancy-specific concerns about the vaccine: “My provider has mentioned it to me, that the risks of getting the vaccine are minimal compared to getting COVID. But I don’t know, I still don’t feel comfortable. I know the vaccines are causing blood clots, and that’s a big factor in my family.” When the interviewer followed up with the question, “Do you think you got sufficient information from your provider?” Patricia responded, “Not really. She was supposed to provide me with a pamphlet, but I mean, she was super busy and forgot.” Rather than providing data on Patricia’s specific concern, her midwife offered her a pamphlet with general information. Given her midwife forgot to provide the pamphlet, Patricia left the encounter feeling like she had insufficient information about the risks of blood clots.

Most of the women who planned to delay vaccination because of pregnancy still expressed significant concerns over the possibility of COVID-19 infection. In such cases, they frequently reported continued isolation and use of other preventative measures to avoid exposure. Esther, for example, explained, “I really try to not go out much just because I’m not vaccinated and I don’t want to get vaccinated until after I have the baby.”

Eliana echoed these concerns. She was a home health aide who had recently completed a degree to become an occupational therapist assistant. She actively delayed seeking a higher paying job in occupational therapy while she was pregnant, given that as a home health aide she felt like she would be at lower risk of exposure by virtue of interacting with fewer patients in more isolated circumstances. Nonetheless, she was still very worried about COVID-19 exposure at work. The vaccine became widely available in the months leading up to her July 2021 delivery. However, her fear that the vaccine could harm her baby outweighed her fear over the risks of infection. Reflecting her enthusiasm for the vaccine outside the temporality of pregnancy is the fact that she scheduled the vaccine immediately following the birth, hoping the timing would allow her baby to get antibodies through breastmilk.

Both Patricia and Eliana reported concerns about COVID-19 infection during pregnancy. However, they were more concerned about unknown risks of the vaccine during pregnancy. This therapeutic distrust deterred them from receiving the vaccine during pregnancy, but caused them less hesitation over the idea of receiving the vaccine postpartum.

Eliana’s narrative also reflected a significant level of distrust in medical authorities. On multiple occasions, she referenced negative perceptions of physicians based on her experience working in health care, where she felt that doctors were often rushed and treated patients coldly. In regards to her midwife’s recommendation to receive the vaccine during her final trimester, she said, “I don’t put much faith in my midwives. I saw one study that showed that there were antibodies in the umbilical cord of the baby of a women who had the vaccine at 36 weeks. But there weren’t enough studies to say if it was good or bad for the baby.”

As Eliana’s narrative suggests, therapeutic distrust may be prevalent even among people with extensive experience in health care. Eliana’s years working in the health sector contributed to her negative perception of physicians, which perhaps limited her acceptance of medical advice at face value. More broadly, it may reflect that individuals who have had past negative experiences with providers may lack faith in their providers’ recommendations (Allen et al., 2011). This is particularly relevant for women of color, who disproportionately report negative experiences and feelings that providers overlook their concerns (Sacks, 2018).

Some women expressed the concern that if the vaccine were to harm the fetus, then the blame would rest with them. Alma described this sentiment, saying, “If for any reason something would happen to me while pregnant, my child is inside me, so I would feel like I caused something to happen to her. So that’s why I wouldn’t get it while pregnant.” Alma did not express this hesitation beyond pregnancy and scheduled a vaccination appointment postpartum. Katia came to a similar conclusion to postpone vaccination, saying, “During pregnancy, my biggest concern is what it’s going to cause to the baby. After pregnancy, I think it’s just how it’s going to affect me, but I think it’s going to be like normal. So, I’m not as concerned after pregnancy as I am right now.”

For women like Alma and Katia who delayed vaccination until after the birth, there was a perception that the vaccine had a greater risk for the baby than the possibility of contracting COVID-19 while pregnant. Although substantial research shows that COVID-19 infection during pregnancy increases the risk for a number of adverse outcomes (Karasek et al., 2021; Meyer et al., 2022; Papageorghiou et al., 2021), women who delayed vaccination often framed their decisions in relation to therapeutic distrust. They often described receiving information from their providers on the risks of COVID-19 infection during pregnancy, but they did not trust that there was enough evidence that the vaccine would not harm their developing fetus or the pregnancy. This distrust did not necessarily prevent them from ever getting the vaccine, but it did lead to persistent concerns that the vaccine may not be safe for their future child.

Vaccine Confusion

Vaccine confusion was a variation of cautious delay during pregnancy. Only one woman reported delaying vaccination primarily as the result of receiving unclear advice from her provider. Given the specifics of this case, and how provider advice contributed to hesitancy for an otherwise vaccine enthusiastic person, it merits discussion as a distinct category.

Julieta, interviewed in July 2021, had initially planned to receive the vaccine during her pregnancy. When seeking confirmation for her decision from her midwife, her midwife instead recommended that she wait until after the delivery. According to Julieta, the advice to delay vaccination seems to have been to avoid the possibility of a miscarriage. Given existing research at the time did not show an association between vaccination and miscarriage (Rimmer et al., 2023), the interviewer probed on why she thought her midwife made this recommendation. Julieta had a history of cervical insufficiency, which is a risk factor for miscarriage and preterm delivery, and was being treated with progesterone. She explained, “Since I was getting all the injections of progesterone and all those things, my [midwife] said that it could just trigger things because of all the medication I was getting.”

Given the lack of research on pregnancy-specific health issues and the vaccine at the time, Julieta’s provider may have felt the specific risks were unknown. This example shows how some providers may have exercised greater degrees of caution in recommending the vaccine, even for vaccine enthusiastic patients.

Cautious Delay beyond Pregnancy

Four women (10.8%) expressed cautious delay beyond pregnancy. The dominant pattern driving continued caution was a sentiment that the vaccine was still experimental. Continued cautious delay was not necessarily a reflection of a lack of concern over the pandemic, but rather, a feeling like the vaccine was not going to be a magic bullet.

Juliana, interviewed in August 2021, reported significant concerns over the pandemic and continued to isolate over fear of contracting COVID-19 while pregnant. However, she had little faith in the vaccine, and evidence of breakthrough infections made her reluctant to receive the vaccine when it became available prior to her pregnancy. She explained, “I don’t want to get it because it’s not a for sure thing.” Her decision came before the increased rate of breakthrough infections with Omicron and subsequent variants.

Although Juliana’s doubts stemmed from the vaccine’s efficacy, other women felt like even if the vaccine worked to prevent COVID-19, it was still experimental and may come with other long-term risks. “I don’t want to be a guinea pig,” and variations of this statement, were reported among those who had no intention of receiving the vaccine in the near future. Iris’s decision-making process captures a common sentiment. She explained, “I’m going to wait, I want to wait, until there’s more of an idea of how all of the vaccinations have affected people and there’s more studies. Like, longer-term ones, just to see‬.”

It is possible that some women who reported delaying vaccination due to pregnancy continued to delay vaccination on other grounds post-pregnancy. Among women who participated in postpartum interviews, nearly all of those who expressed cautious delay specific to pregnancy did in fact schedule their vaccination postpartum. Lina was the one exception, and the evolution of her decision-making process is telling. Lina initially reported plans to delay vaccination until after the birth. Four months postpartum, she had not yet been vaccinated and reported no immediate plans to do so, explaining, “Once I delivered, I was really scared to get that vaccine honestly.”‬ She further explained her rationale: “If it’s my time, and I don’t know, I’m a believer, so if God decides that that’s how I have to leave this world, then that’s his will.” Interestingly, the religious undertones in her later reasoning did not factor into her previous explanation of delaying the vaccine while pregnant. It is possible that pregnancy did heighten her hesitations about the vaccine and that she initially thought her hesitations would be alleviated following the delivery. However, it is also possible that as social debates emerged and evolved surrounding the vaccine, her perceptions shifted.

There was some overlap in the sentiments expressed between women who exhibited cautious delay during pregnancy and those who expressed a desire to continue to delay vaccination beyond the delivery. Women in both categories expressed safety concerns and varying degrees of trust in medical advice. The women who did opt for vaccination postpartum more often expressed lesser degrees of hesitancy – their hesitancy was enough to make them fearful over potential adverse effects for their babies, while they were less concerned if adverse events only affected themselves. Women who continued delaying vaccination often had greater degrees of therapeutic distrust and fears over the long-term ramifications of a vaccine they viewed as still experimental.

Vaccine Refusal

Only one woman, Leslie, described refusal of the vaccine. Interestingly, Leslie initially scheduled a vaccination appointment postpartum. When the pharmacy cancelled her appointment, she further contemplated the potential risks and ultimately decided she would not receive the vaccine. Her decision was far from an attitude of being opposed to the vaccine, but rather rooted in her history of having an autoimmune disorder and concerns over how the vaccine might negatively impact her. She explained, “I just read the news, and you know, how people can die from the vaccine. I don’t know, you can die or get sick or get COVID even right after the vaccine and I just don’t trust it. You know, there’s not been research enough, especially for someone who doesn’t have that great of an immune system. I’m just so scared of getting sick if I get the vaccine and passing it on to the baby. And yeah, I’d rather just stay in, and you know, I still haven’t gotten COVID, so I’m doing something right.”

Leslie’s perspective shows that vaccine refusal goes beyond opposition to the vaccine, evidenced by the fact that she initially scheduled a vaccine appointment. Rather, refusals of the vaccine may be related to an array of concerns, some of which may contribute to therapeutic distrust.

Vaccine Apathy

Vaccine apathy was characterized as delaying vaccination in the absence of expressing outright refusal or a justification for cautious delay. Further, a sentiment of therapeutic distrust did not characterize this sense of apathy, while distrust was central to other expressions of cautious delay and refusal. Although only one woman expressed apathy, this sentiment may be emerging as a more salient pattern in decisions surrounding COVID-19 boosters as the immediate crises from the pandemic have waned.

In July 2021, Angelica was unvaccinated, although not opposed to the possibility of receiving the vaccine. She expressed not knowing the process of how to get the vaccine and did not want to deal with the hassle of figuring it out, saying, “We don’t know where to go, or they say you can go to whatever place, but we haven’t looked into where we can go.” Her interpretation of her provider’s advice that “It’s not mandatory, but it’s recommended,” did little to motivate her to seek out vaccination. At the time, the vaccine was still not available at her doctor’s office, so she would have had to find a city or county vaccination site or a pharmacy with vaccination appointments.

Possibly influencing Angelica’s delay was that early during the pandemic her husband became ill from COVID-19, and despite their inability to social distance in their tight living quarters, she never contracted it. During this same time, her father-in-law also became seriously ill from COVID-19 and died. Many other women who experienced similar events felt that the death and severe infection of loved ones made it important for everyone to receive the vaccine. However, for Angelica, this experience made her feel less vulnerable. In her case, escaping infection may have led her to feel a greater sense of security that she would not become gravely ill and may have contributed to her delay in seeking vaccination.

Although the analysis has been framed in relation to the spectrum of hesitancy, the category of vaccine apathy may not fall along this spectrum. As such, while degrees of hesitancy are important for understanding vaccine uptake, there are also other dynamics to consider. For Angelica, her apathy was not so much about therapeutic distrust or concerns about the vaccine itself, but more about the accessibility of the vaccine and being able to navigate a fragmented health care system. Although Angelica was the only participant who described a sense of apathy toward the vaccine, this may be a growing sentiment worth further interrogation. The growing challenges in securing the COVID-19 vaccine as an uninsured patient (Kates & Tolbert, 2023) may contribute to increased vaccine apathy.

Discussion

Within this sample, the dominant pattern was that women received the vaccine or planned to receive the vaccine at some point, reflecting the pattern of quick vaccine uptake in the region, which provides a contrast to delayed vaccine uptake in other minority communities (Abba-Aji et al., 2022; Hildreth & Alcendor, 2021). However, pregnancy heightened the hesitations that women had, often contributing to plans to delay vaccination until after the birth. Nearly every woman cited concerns for the safety of the baby as a primary factor in deciding whether or not to receive the vaccine. While there was heightened distrust over the safety of the vaccine during pregnancy, for some women, their level of distrust contributed to vaccination delays even after the birth.

Analyzing women’s decisions in relation to a spectrum of hesitancy shows how even vaccine enthusiastic women exhibited concerns about vaccination during pregnancy. This brings up an important point for discussion: When does hesitancy translate into therapeutic distrust and a delay in vaccination? By comparing women who received the vaccine during pregnancy to those who delayed vaccination, women’s narratives suggest that hesitancy is more likely to translate into therapeutic distrust and delayed vaccination when their specific concerns about the vaccine remain unaddressed. As indicated by the dominant pattern of delaying vaccination until after the birth, this distrust is more acute during pregnancy, as this is a period when there is more at stake if there is an adverse event resulting from a therapeutic intervention (Weld at al., 2021).

The disjuncture between perceptions of vaccination risk and medical evidence reveal fault lines in health communication and lack of trust in the messages coming from medical authorities (Hildreth & Alcendor, 2021). Many women described feeling like there simply was not enough evidence available to enable them to feel confident about receiving the vaccine while pregnant. Even when women felt like they had enough information, they did not necessarily trust the medical authorities and research behind this information. Overall, therapeutic distrust was a significant factor driving delays in vaccination during pregnancy.

These findings show a need to be more attentive to the ways that temporal dimensions, such as pregnancy, factor into vaccination decisions. The low uptake of COVID-19 boosters during pregnancy among previously vaccinated individuals (Razzaghi et al., 2022) suggests that there has been insufficient emphasis on the range of effects of COVID-19 infection on pregnancy and birth, including complications such as preeclampsia and issues arising from placental abnormalities (Karasek et al., 2021; Meyer et al., 2022; Papageorghiou et al., 2021). Given that many of the adverse effects arising from COVID-19 infection during pregnancy are not variables easily extracted from birth certificates, which is one of the most common means for researching birth outcomes (Howell et al., 2021), there is a need to use other data collection techniques to better document the risks of COVID-19 during pregnancy.

While better data is an important step for enabling people to make informed decisions about vaccination, it is also important to consider the accessibility of this data. This is especially true for individuals who express a high degree of therapeutic distrust (Jarrett et al., 2015). Some women who expressed high degrees of therapeutic distrust felt less faith in provider recommendations, preferring to seek out information themselves. With a lack of access to medical journals, there may be a greater reliance on social media, where misinformation is more likely to spread (Skafle et al., 2022). This shows a need for researchers to make strategic use of social media networks to disseminate correct and accessible medical information. The COVIDLatino Project offers an important example of how this aim can be accomplished. This project involved developing tailored health communication materials that were driven by community input (Ignacio et al., 2023). As the research team identified a need for challenging misinformation to reduce vaccine hesitancy, they developed bilingual animations, art, and YouTube videos that could be easily circulated on social media (Mercado et al., 2024). This approach goes beyond relying on medical authorities, who historically marginalized populations may not trust, to do the work of health communication.

An additional challenge is that public health messaging has overwhelmingly focused on vaccination at the population-level. Overall, there has been a missed opportunity to emphasize the benefits of the vaccine during pregnancy (Durowaye et al., 2022; Manca et al., 2023), with some notable exceptions. Significantly, the One Vax Two Lives social media campaign has developed informational materials in multiple languages that can easily be disseminated on social media (Marcell et al., 2022). The development and assessment of such strategies for addressing therapeutic distrust remains an important route for future research.

Limitations

The timeframe of data collection for this research poses some limitations. While interviews captured women’s perceptions as the vaccine became available and for over a full year after it was widely available, the interviews do not indicate how perceptions may have shifted as the pandemic became less of an immediate public health threat. While these insights are relevant for understanding current patterns in uptake of COVID-19 boosters during pregnancy, it is quite possible that vaccine apathy has now become a more salient theme. Vaccine apathy may have less to do with therapeutic distrust, and instead, be a greater indication of waning concern over the risks of COVID-19.

Table 2:

Vaccination Status Postpartum (n = 5)

Postpartum Vaccination Status (Vaccine Unavailable during Pregnancy)
Vaccinated postpartum	4
Would have received vaccine if available during pregnancy	0
Would not have received vaccine if available during pregnancy	4
Unvaccinated postpartum	1

Biographies

Biographical Notes

Carina Heckert is Associate Professor of Anthropology in the Department of Sociology and Anthropology at the University of Texas at El Paso. She is the author of Fault Lines of Care: Gender, HIV, and Global Health in Bolivia (Rugters University Press, 2018) and Birth in Times of Despair: Reproductive Violence on the US-Mexico Border (New York University Press, 2024).

Kimberly Anaya completed a BS in psychology at the University of Texas at El Paso in 2022 and is currently pursuing a master’s degree in Mental Health Counseling.

Alondra Arias completed a BS in Rehabilitation Sciences at the University of Texas at El Paso in 2020 and is an entering medical student at Burrell College of Osteopathic Medicine in Las Cruces, New Mexico.

Sireesha Reddy is Professor and Chair of Obstetrics and Gynecology at Texas Tech University Health Sciences Center-El Paso. Her clinical focus is in the care of pediatric and adolescent gynecology patients understanding that this special young population has unique requirements for physicians who are skilled in the medical evaluation, surgical management, and correction of gynecologic disorders of this age group.

Data Availability Statement

Requests for access to deidentified data from the Maternal Health and Emotional Distress on the US-Mexico Border study can be made by contacting the corresponding author. Interview data will only be shared via a limited use data agreement.