Influences on Vaccine Decision‐Making During Pregnancy

Abstract

Introduction

Pregnant people are at greater risk for vaccine‐borne illness yet are more vaccine hesitant than the general population. Hesitancy toward COVID‐19 vaccination emerged among pregnant individuals during the COVID‐19 pandemic, with vaccine hesitancy also reported in previous vaccine acceptors. With the clear benefits of vaccination for pregnant individuals and their neonates, it is essential to investigate vaccine hesitancy. Therefore, the purpose of this study was to explore the perceptions and decision‐making processes of pregnant individuals regarding COVID‐19 vaccination during pregnancy.

Methods

A qualitative descriptive design with semistructured interviews was used for the study. A convenience sample of pregnant or recently pregnant individuals who spoke English or Spanish was obtained. Interviews were conducted until data saturation was achieved, and the interviews were translated (when necessary) and transcribed. Members of the research team analyzed interview transcripts separately, coded and organized the data into themes, and then collaborated to reach a consensus on the final themes.

Results

There were 41 interviews conducted, with 10 participants self‐identifying as Spanish, Hispanic, or Latino. Influences on decision‐making included trust in health care providers, fear of complications from vaccination, fear of adverse effects from COVID‐19 infection, perceived vaccine safety and efficacy, perceptions surrounding immunity, novelty of the COVID‐19 vaccine, perceived positive health status, spiritual and religious influences, and influences from family members and friends. Information sources that participants described using in their vaccine decision‐making included information obtained from family members who were health care professionals, the Centers for Disease Control and Prevention, and internet and social media sources that participants perceived as valid.

Discussion

The findings reveal the impact of health care providers’ recommendations on the COVID‐19 vaccine decision‐making process for pregnant individuals, highlighting the crucial role health care providers play in disseminating accurate vaccine information. Safety concerns regarding the vaccine and vaccination to prevent illness were described, showing that health care providers should address these concerns when providing vaccine information.

INTRODUCTION

Pregnant individuals and their newborns are at greater risk for serious illnesses resulting from vaccine‐preventable infections. For example, influenza infection during pregnancy is associated with pneumonia, preterm birth, and fetal distress, and pregnant persons with influenza have a 7‐fold greater risk for hospitalization than their peers who are not pregnant. ¹ The recent COVID‐19 pandemic provided another illustration, as pregnant persons infected with COVID‐19 had higher rates of preeclampsia, myocardial infarctions, and venous thromboembolisms compared with those without infection. Additionally, intensive care treatment and mechanical ventilation use were increased in people with an active COVID‐19 infection who gave birth. ² COVID‐19 infection during pregnancy also showed an increased risk for adverse neonatal outcomes, including preterm birth and admission of neonates to an intensive care unit. ³

1. QUICK POINTS

• ✦In the COVID‐19 pandemic, prenatal care providers played an important role in the COVID‐19 vaccine decision‐making process for pregnant individuals, highlighting the health care provider's responsibility to provide clear and accurate vaccine information.
• ✦Other influences on a pregnant person's decision to receive the COVID‐19 vaccine included trust in the vaccine's safety and effectiveness as well as fear of negative effects from COVID‐19 illness on health, pregnancy, and the health of their fetus.
• ✦Information sources reported to influence pregnant persons’ COVID‐19 vaccine decision‐making included the Centers for Disease Control and Prevention website, other online information, and input from family and friends.
• ✦The novelty of the COVID‐19 vaccine and concerns about potential harm to the fetus from vaccination were significant contributors to vaccine hesitancy among pregnant participants.
• ✦Future research should aim to include underrepresented groups, such as non‐Latino minorities and lesbian, gay, bisexual, transgender, queer (or questioning) birthing persons, exploring vaccine perceptions in a post‐COVID‐19 pandemic context to better understand and address vaccine hesitancy.

Despite these well‐documented risks, vaccine hesitancy persists in various contexts. Vaccines given during pregnancy decrease the harmful effects of vaccine‐preventable illness and potentially eradicate the disease. For example, influenza vaccination during pregnancy decreases laboratory‐confirmed flu in pregnant people by 42% during pregnancy and 60% postpartum. ⁴ In spite of benefits, vaccine hesitancy is common in pregnant persons. Hesitancy toward seasonal influenza vaccination is seen globally, with few countries reporting immunization rates above 50%, highlighting widespread global hesitancy. ⁵

COVID‐19 vaccine hesitancy emerged among various populations during the recent pandemic, despite the potentially harmful effects of the virus, ⁶ and pregnant individuals were more vaccine hesitant than the general population. ⁷ , ⁸ Fewer than half of the pregnant people in one study reported willingness to receive a COVID‐19 vaccination during pregnancy, with vaccine hesitancy reported in previous vaccine acceptors. ⁹ Additionally, COVID‐19 vaccine acceptance among pregnant persons was lower in the United States than in other high‐income countries. ¹⁰

Despite well‐established evidence of vaccine safety and efficacy in pregnancy, ¹¹ many pregnant persons continue to experience vaccine hesitancy. A recent systematic review of barriers and enablers to vaccinations administered during pregnancy highlighted the critical influence of health care providers on vaccine uptake. The review found that a lack of health care provider recommendation was a barrier, whereas health care provider endorsement served as a primary facilitator of vaccination. Notably, only 4 of the 28 studies (14%) included in the review were conducted in the United States, ¹² underscoring a need for further research in US settings. Understanding the contextual and experiential factors shaping vaccine decisions is essential for midwives and other maternal health care providers who play a central role in vaccine education and recommendations. Therefore, the purpose of this qualitative study was to explore vaccine decisions during the COVID‐19 pandemic in an additional US population by examining the perceptions and decision‐making of pregnant persons surrounding COVID‐19 vaccination.

METHODS

Study Design

A qualitative descriptive method was used to explore the experiences of pregnant persons considering COVID‐19 vaccination during the COVID‐19 pandemic. Qualitative description summarizes participants’ experiences in their own words, minimizing theoretical interpretation by the researcher. ¹³ This approach was selected over other methods, such as phenomenology because the study sought to present participants’ perspectives in their own voices in a clear and accessible manner that could inform midwifery and women's health care practice. This study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research checklist (Supporting Information: Appendix S1).

Setting and Sample

The sample consisted of a convenience sample of English‐speaking and Spanish‐speaking individuals aged 18 to 45 years who were pregnant on or after August 11, 2021, in Salt Lake County and Utah County in Utah. These counties were chosen because they represent more than 54% of Utah's population. ¹⁴ Because 12.7% of the population of Utah County and 19.3% of Salt Lake County are classified as Latino, ¹⁵ , ¹⁶ recruitment for the study was accomplished by advertisement via flyers (in Spanish and English) incorporated with purposive and snowball sampling. People wishing to participate indicated their interest by completing a survey accessible through a quick response code on the flyer.

Ethical Considerations

Approval from Brigham Young University's Institutional Review Board was obtained prior to data collection.

Research Team and Positionality

The research team comprised individuals with diverse professional and experiential backgrounds relevant to maternal health care and qualitative inquiry. The lead researcher was a certified nurse‐midwife with a doctor of philosophy (PhD) in qualitative research, including experience conducting qualitative research in both Latin America and Tonga, a Pacific Island nation. Another team member was a Spanish‐speaking, Master‐prepared family nurse practitioner and qualitative researcher with more than 30 years of experience in labor and delivery and childbirth education. A third member was a PhD‐prepared researcher with expertise in qualitative methods and immunization research. These 3 team members supervised and mentored additional team members, including a family nurse practitioner graduate student and 3 undergraduate nursing students, one of whom was a certified medical Spanish interpreter. Varied perspectives by team members informed the study design, data interpretation, and contextual understanding of participants’ experiences.

Data Collection

Interviews were conducted using a semistructured interview guide (Supporting Information: Appendix S2). The interview guide for the study was created in accordance with the guidance from McIntosh and Morse ¹⁷ and modeled after a qualitative study on influenza vaccination in pregnant women. ¹⁸ The guide was reviewed by one doctor of nursing practice and 2 PhD experts in qualitative and/or immunization research, with their suggestions incorporated into the guide. For Spanish‐speaking individuals, all necessary materials, including the interview guide, verbal consent, demographics survey, and study qualifications survey, were translated into Spanish by a certified medical Spanish interpreter.

Participants were given the option of in‐person or Zoom interviews, with all participants choosing the Zoom option. Interviews took place between April 2022 and November 2022, with no participants declining participation at any time during or after interviews. Verbal consent was obtained for participation in the study and for Zoom recording. Participants were given time to complete demographic survey questions via a Qualtrics survey before the 20‐minute to 60‐minute interviews. All interviews were conducted by the female graduate student under the supervision of the lead researcher and continued until data saturation was reached. The certified medical Spanish interpreter/undergraduate nursing student facilitated communication with Spanish‐speaking participants, transcribed Spanish‐language interviews, and translated them into English prior to thematic analysis. No follow‐up or repeat interviews were conducted. Zoom AI‐generated interview transcripts were cleaned by one research team member and verified for accuracy by another to ensure fidelity to participants’ voices. Interview transcripts were not returned to participants for review.

Identifying information was replaced with pseudonyms chosen from a list of the top 100 girl newborn names from 1995; the pseudonyms are reflected throughout the results section. Data collection continued until saturation was reached, resulting in a sample size of 41, falling within the recommended sample size of 30 to 60 needed to obtain richness of data for qualitative analysis as identified by Morse. ¹⁹

Data Analysis

The demographic data were analyzed using descriptive statistics. Thematic analysis followed the steps outlined by Nowell et al, ²⁰ including familiarization with the data through reading observation notes and interviews. Members of the research team analyzed the data as specific statements, which were then coded and organized into themes. The research team engaged in reflexive activities, including interval reviews of qualitative findings, team updates and debriefings, and collaborative discussions on data collection, which led to activities such as purposive sampling to hear the voices of underrepresented communities. The team remained attentive to potential power imbalances, particularly in crosscultural and multilingual interactions, and took deliberate steps to provide a culturally sensitive focus on participants’ experiences while minimizing researcher bias. This reflexive approach supported a respectful and contextually grounded analysis of the data. The themes were refined by succinctly summarizing the text with a clear and identifiable distinction between themes. The research team finalized the data analysis by reaching a consensus regarding themes and how they fit into the story. The narrative results document the scope of each theme, incorporating participant quotes that substantiate the validity and merit of the analysis. ²⁰

Trustworthiness and Rigor

The research team employed strategies to boost the trustworthiness and rigor ²⁰ of the study. Credibility was enhanced through the use of established thematic analysis methods, triangulation among research team members, and reflexive practices, such as team debriefings and reflection on the researchers’ positionality. The inclusion of bilingual materials and culturally sensitive procedures contributed to the authenticity of participants’ voices. Transferability was enhanced by providing details about the study setting's context, including sample characteristics, recruitment strategies, and rich participant quotes, which allows readers to assess the applicability of the findings to similar populations. Dependability was ensured through consistent data collection by a single researcher using an expert‐reviewed interview guide, translation processes for Spanish‐speaking participants, and consensus‐building in theme development. Confirmability was supported by the verification of transcripts by researchers to minimize bias and maintain fidelity to participants’ perspectives as well as by collaborative discussions among the research team to finalize the results. Member‐checking results was not employed. ²⁰

RESULTS

Demographics

A total of 41 people participated in the study, with an average age of 28.8 years, ranging from 20 to 40 years. There were 24 participants from Utah County (58.5%) and 17 participants from Salt Lake County (41.5%). There were 10 (24%) participants who identified themselves as Spanish, Hispanic, or Latino. Most participants (n = 34; 83%) described themselves as vaccine acceptant; however, only 18 (43.9%) participants had received a COVID‐19 vaccination during pregnancy at the time of their interview. See Table 1 for additional demographic information.

Table 1.

Participant Demographic Information of Pregnant Persons Considering COVID‐19 Vaccination (N = 41)

Characteristic	n (%)
Number of Pregnancies
1	14 (34)
2	9 (22)
3	10 (24)
4	2 (5)
5	2 (5)
6	3 (7)
7	1 (2)
Number of Abortions
0	40 (98)
1	0 (0)
2	1 (2)
Number of Miscarriages
0	29 (71)
1	7 (17)
2	4 (10)
3	1 (2)
Number of Living Children
0	13 (32)
1	5 (12)
2	7 (17)
3	8 (20)
4	7 (17)
5	0 (0)
6	1 (2)
County of Residence
Utah County	24 (58.5)
Salt Lake County	17 (41.5)
Highest Degree Received
High school graduate	2 (5)
Some college but no degree	4 (10)
Associate degree	3 (7)
Bachelor's degree	22 (54)
Master's degree	9 (22)
Doctoral degree	1 (2)
Spanish, Hispanic, or Latino
Yes	10 (24)
None of these	31 (76)
Self‐Identified Race
White	30 (73)
Asian	1 (2.4)
White; Native Hawaiian/Pacific Islander	1 (2.4)
White; American Indian/Alaska Native	1 (2.4)
White; Native Hawaiian/Pacific Islander; Asian	1 (2.4)
White; other	2 (4.9)
Other	4 (9.8)
No response	1 (2.4)
Income
$10,000‐$19,999	2 (4.9)
$20,000‐$29,999	4 (9.8)
$30,000‐$39,999	3 (7.3)
$40,000‐$49,999	4 (9.8)
$50,000‐$59,999	7 (17)
$60,000‐$69,999	1 (2.4)
$70,000‐$79,999	2 (4.9)
$80,000‐$89,999	2 (4.9)
$90,000‐$99,999	5 (12.2)
$100,000‐149,999	10 (24.4)
$150,000 or more	1 (2.4)
Employment Status
Working (paid employee)	22 (53.7)
Working (self‐employed)	4 (9.8)
Not working (other)	14 (34.1)
Prefer not to answer	1 (2.4)
Routine Childhood Vaccines
Yes	39 (95.1)
Some	2 (4.9)
Self‐Identified Vaccine Stance
Vaccine acceptant	34 (83)
Vaccine hesitant	6 (14.6)
Vaccine resistant	1 (2.4)
Received COVID‐19 Vaccine
Yes, one dose	1 (2.4)
Yes, 2 doses	16 (39)
Yes, 2 doses and a booster	19 (46.4)
No	5 (12.2)
Received COVID‐19 Vaccine During Pregnancy
Yes	18 (43.9)
No	23 (56.1)
Vaccines Received During Pregnancy
COVID‐19 vaccine but no other vaccine(s)	6 (14.6)
COVID‐19 and other vaccine(s)	12 (29.3)
Other vaccine(s) but no COVID‐19 vaccine	13 (31.7)
No vaccine(s)	10 (24.4)
Interview Language of Choice
Spanish	2 (5)
English	39 (95)

Qualitative Findings: Influences on Vaccine Decision‐Making

Trust in Health Care Providers

Among vaccine acceptors, health care provider recommendations were identified as the primary factor influencing the decision to obtain a COVID‐19 vaccination during pregnancy. Sophia reflected, “His [the obstetrician's] opinion was probably the one that mattered most to me.” Hannah stated, “Hearing from a medical professional that I should get a booster made me feel safe about it.” Another participant also emphasized the importance of health care provider recommendations, expressing reluctance to receive a COVID‐19 vaccination during pregnancy, but was vaccinated after her physician advised her to do so.

Recommendations from health care providers also contributed to vaccine hesitancy, leading people to forgo the vaccine. Jessica reported, “I didn't get the booster while I was pregnant because my doctor said not to.” Victoria shared similar sentiments; she received 2 COVID‐19 vaccines prior to pregnancy and chose not to receive a booster during pregnancy after a discussion with her obstetrician, explaining, “I didn't get the booster because I talked to my doctor, [who] recommended the vaccine but not the booster…I trust his judgment.” Lack of health care provider recommendation also negatively impacted COVID‐19 vaccine uptake. Megan chose not to be vaccinated during pregnancy after discussing the option with her midwife: “There was no push one way or the other.”

Fear of Complications

Fear of adverse effects from COVID‐19 viral infection positively influenced COVID‐19 vaccination during pregnancy. A participant, Brooke, explained, “If you get infected with COVID during pregnancy, it can affect the placenta, and I hadn't known that before…so I'm pro getting the COVID vaccination just to protect myself.” Analise also expressed fears, sharing, “I don't want to have a stillbirth or…a preterm baby.”

Likewise, fear also contributed to vaccine hesitance as fear of unknown maternal and fetal complications from vaccination was often mentioned as a reason pregnant individuals chose to forgo COVID‐19 vaccination during pregnancy. Brianna explained, “I didn't want anything to happen to my baby that was growing.” Fears connected to COVID‐19 vaccination included fears of infertility and miscarriage. Morgan expressed, “I don't want to get this vaccine and then have infertility…so that was my big concern.” Maria also shared fears about her perceived link between vaccination and miscarriage: “I have felt like it would be best to avoid it [the COVID‐19 vaccine] … I have had two miscarriages before this pregnancy, so I definitely didn't want to do anything that would possibly increase my risk of miscarriage.”

Perceived Vaccine Safety and Efficacy

Positive perceptions of COVID‐19 vaccine safety and efficacy influenced pregnant participants to receive the vaccine. Emily explained, “If I get…the booster, maybe that will help my baby be safer when they're born…you obviously want to protect yourself and your baby because it's kind of a stressful time.” Lisa elaborated, “I'd do just about anything to keep the babies protected.” Likewise, positive regard for other vaccines also influenced COVID‐19 vaccine uptake. Anna commented, “My thought was that there were no vaccines up to this point that were not safe to get.”

The belief that COVID‐19 vaccines were unsafe contributed to vaccine hesitancy, leading participants to forgo vaccination. Ashley's comments illustrated her adamant opposition to COVID‐19 vaccination during pregnancy: “COVID‐19 vaccines are unsafe in general and especially during pregnancy…I'd rather not…find out later what the long‐term consequences are.”

Perceptions Surrounding Immunity

COVID‐19 vaccine acceptance was influenced by belief in vertical antibody transmission. Elena expressed, “I was really excited about being able to get the booster when I was pregnant… I wanted to give him any shot of having antibodies in his system that I could.” Madison's newborn contracted COVID‐19 during the first week of her life, but Madison's previous vaccination decision during pregnancy gave her peace of mind. Madison reflected, “I was glad that I had had the booster and that she had probably some of the antibodies from me.”

Participants chose to forgo vaccination because of their perceived immunity from previous COVID‐19 vaccines or COVID‐19 infection. Melissa explained, “I didn't choose to get the booster during my pregnancy because I already had the first and second dose, so I figured I had most of the immunity that I needed.” Jasmine's comments showed similar views: “I got COVID my third week of pregnancy…so, I don't see the necessity to get the booster.”

Novelty of the COVID‐19 Vaccine

The novelty of the COVID‐19 vaccine contributed to vaccine hesitancy, with participants reporting perceptions of insufficient research. Alyssa reported:

It is a new vaccine, and we don't have a lot of research… I know that the CDC [Centers for Disease Control and Prevention] recommends it, but just because we don't necessarily have the research to back it, I'm pretty hesitant.

Megan expressed similar views, reporting, “And then there were some studies that were coming out … It seemed like someone had a homework assignment due at 2 am, and they were writing it at 1:30…it was very condensed to me and fastly written.” Lack of confidence in the COVID‐19 vaccine, as compared with other vaccines, also produced vaccination concerns. For example, Brianna chose to forgo COVID‐19 vaccination altogether but reported:

I am pro‐vaccine…typically when you go get those [other approved vaccines during pregnancy], they have been around so long…I didn't feel like there was enough research to know how it [the COVID‐19 vaccine] affected people, let alone my unborn baby.

Perceived Positive Health Status

Some participants cited perceived personal positive health status as a reason to forgo COVID‐19 vaccination during pregnancy. For example, Rachel explained why she felt she did not need the vaccine: “We're relatively healthy people…my lifestyle has changed a lot in the last year, and I think that has just made me a little bit more confident in my immune system rather than relying on getting a booster.”

Spiritual and Faith Influences

Prayer, guidance from spiritual leaders, and faith were factors that influenced decision‐making regarding COVID‐19 vaccination during pregnancy. Isabella received a COVID‐19 vaccine during pregnancy: “[Religious leaders] can be inspired by God…my religious leaders encouraged us to get the vaccination as a way to help the world along and help our neighborhoods.” In comparison, Victoria received 2 COVID‐19 vaccines before pregnancy but chose not to receive a booster during pregnancy, explaining, “I prayed about it.” Lauren also showed the influence of her faith and received a COVID‐19 vaccination during pregnancy after her initial reluctance, explaining, “I really just went to God.”

Influences of Family Members and Friends

Trusted family members influenced COVID‐19 vaccine acceptance for many. Emily commented, “A big influence was…my in‐laws…they seem to be really supportive, and I know they did a lot of research on it.” Hannah reported similar family influence, sharing, “I asked my sister…my sister had both the primary vaccinations when she was pregnant, and…her child is very healthy and functioning.” Isabella commented on the influence of friends, discussing how she received a COVID‐19 vaccination during pregnancy, explaining, “We talked to our friends about it a lot…everybody hears about friends and acquaintances and neighbors and whatever getting COVID, and so those kinds of stories also had an impact.”

Conversely, several participants reported that family members had minimal influence on their COVID‐19 vaccine decisions apart from prompting them to seek more information about the vaccine. Sophia's mother told her of infertility risks from COVID‐19 vaccines, which catalyzed her to seek more information, explaining, “After…doing my own research, I felt like those were maybe not accurate assumptions.” Sophia ultimately chose to be vaccinated during pregnancy. Allison shared going against family opinion, stating, “My family was very reluctant…they didn't want me to get it [the COVID‐19 vaccine during pregnancy] … I chose to get it because I studied that it's better for us.”

Qualitative Findings: Information Sources

Family Members Who Are Health Care Professionals

Participants who were vaccine acceptant reported receiving COVID‐19 vaccine information from family members and friends who were health care professionals. Jennifer elaborated, “I talked to a couple of my friends who are nurses…I have a couple family members who are doctors as well, that's mainly where I've turned to as far as information.” Alexis shared similar views, explaining, “My sister…was doing med school rotations…and she said that there were quite a few pregnant women that were having pretty severe side effects to having COVID.”

CDC

Many participants referenced the CDC as a source of information for COVID‐19 vaccine decision‐making during pregnancy, explaining the influence it had on them to receive COVID‐19 vaccination. Participants expressed trust in the information provided by the CDC. Kaitlyn shared, “I do trust a lot when the CDC says that it's okay.” Allison received a COVID‐19 vaccination during pregnancy and similarly shared, “Primarily the CDC was my main [information] source.”

In comparison, some participants who considered vaccination during pregnancy expressed mistrust in the information provided by the CDC. Brianna shared, “The listing on the CDC's website…that was a pro for me—but then it actually kind of transferred to a con because I felt like some things were a little bit contradictory as…time went on.” Lauren also elaborated her mistrust: “It [the CDC] is promoted by the government. So that was really hard for me to kind of take into consideration.”

Perceived Valid Information Sources

Participants who were vaccine acceptant looked to information sources they perceived as valid and trustworthy when considering COVID‐19 vaccination during pregnancy to obtain and clarify information. Alyssa stated, “I think that [social media] just made me want to research more because there was so much conflicting information.” Jasmine also shared perceived trusted sources, explaining, “If I did ever have specific questions about specific aspects of either the vaccine or the illness itself…I usually try to stick to the more official websites.”

Participants who were vaccine hesitant also used sources they perceived as valid. Megan said, “I started researching more of the independent/right‐winged stuff, and the studies that they were publishing were a lot more non‐biased.” Mary reported, “I put a lot of faith in the evidence‐based childbirth website. I have a few other trusted sources that I find interesting … I take information from each of those sources…and then apply them to my situation.”

DISCUSSION

This qualitative descriptive study explored the experiences of pregnant individuals’ decision‐making about COVID‐19 vaccination during the pandemic. The findings revealed that health care provider recommendations were the most influential factor in vaccine decision‐making in the US population represented in this study. This is consistent with research in international settings. ²¹ , ²² , ²³ Participants emphasized the importance of trust in their health care providers, their reliance on clear and sensitive communication, and the impact of family, social networks, and information sources on their choices.

Concerns about vaccine safety and efficacy were prevalent among participants, echoing findings from other studies. ¹⁰ , ¹² , ²⁴ , ²⁵ These concerns often centered on potential harm to the fetus, the novelty of the vaccine, and the perceived lack of long‐term data. Participants also expressed a fear of COVID‐19 infection, which served as a motivator for vaccination, with the intention of providing immunity for themselves and/or their newborn, a theme also supported by previous research. ²⁶ , ²⁷ In comparison, this study found that perceived positive health status and the perception of existing immunity were barriers to COVID‐19 vaccination uptake. Similarly, Razai et al also identified perception of immunity as an impediment to vaccine acceptance during pregnancy. ¹²

Spirituality and faith influenced the decision‐making process for COVID‐19 vaccine participation among study participants. They described how advice from religious leaders served as a motivator for COVID‐19 vaccination during pregnancy and discussed the influence of personal prayer on decision‐making, which ultimately led to vaccine acceptance in most cases. This contrasts with a review on faith and vaccination, wherein faith influences were found to quite often significantly and negatively associate with the intention to vaccinate. ²⁸ The concepts of faith and spirituality have not been well studied, however, and both the findings from our study and the review indicate the need for more in‐depth exploration.

Participants reported using the CDC and internet searches as trusted sources of information. Historically, the CDC has played a central role in shaping vaccine decision‐making during pregnancy. However, recent changes in federal guidance have introduced uncertainty. In May 2025, the CDC shifted from a universal recommendation for COVID‐19 vaccination during pregnancy to a shared clinical decision‐making model, removing its explicit endorsement for routine vaccination in this population. ²⁹ This change has led to confusion among both health care providers and patients, potentially undermining vaccine confidence and access. ³⁰ Despite revisions in CDC recommendations, professional organizations such as the American College of Obstetricians and Gynecologists and the American College of Nurse‐Midwives continue to strongly recommend COVID‐19 vaccination during pregnancy. ³⁰ , ³¹ The use of internet‐based resources aligns with findings from other studies ³² , ³³ , ³⁴ and underscores the importance of health care provider‐led counseling, especially as public trust in federal health care agencies has declined. ³⁵

Implications for Clinical Practice

Study findings indicate that recommendations from health care providers contribute to increased vaccine uptake. Pregnant individuals are concerned about the safety and efficacy of vaccinations, so addressing these concerns directly is critical. ⁷ Studies have shown that clear, consistent communication about vaccine benefits and risks can alleviate fears and improve acceptance. ³⁶ Counseling should be delivered in plain language, tailored to the patient's cultural and linguistic context, and integrated into routine antenatal care. ¹²

Health care providers should also be prepared to counter misinformation, which remains a significant barrier to vaccine uptake. ¹² , ³⁰ Recognizing the influence of social networks is another important strategy. Although not widely documented in the literature, this study found that family and friends played a substantial role in vaccine decision‐making. Health care providers should explore these influences during counseling and offer support in navigating conflicting advice. ³⁶ Finally, counseling should validate patients’ emotions and support health autonomy. Participants experienced internal conflict and fear, which can be addressed through empathetic listening and shared‐decision‐making. ²⁹ , ³⁰ , ³¹ , ³⁷

Limitations

Limitations of the study include the narrow geographical region in which the study was conducted; however, the COVID‐19 vaccine acceptance (43.9%) found in the pregnant persons in our study was far less than the 76% acceptance in the Utah population found by Yasmin et al, ⁸ showing a need for exploration of this hesitancy. The voices of marginalized groups such as non‐Latino minorities and lesbian, gay, bisexual, transgender, queer (or questioning) birthing persons are not represented in this study. Another notable limitation was the timing of the interviews to the evolution of the pandemic. Vaccine acceptance or hesitance might have been influenced by interview timing in relation to pandemic events, such as the severity of illness, COVID‐19 virus transmission rates, and additional knowledge about COVID‐19 vaccine side effects, as well as CDC recommendations that evolved over time.

CONCLUSION

This study contributes to the body of knowledge regarding maternal perceptions in the US population regarding antenatal COVID‐19 vaccination, including perceived influences on vaccine acceptance and hesitancy. The influence of health care providers on vaccine decision‐making has been supported by this study, emphasizing the responsibility that health care providers have in giving correct vaccine information. Future research should explore targeted communication strategies that enhance provider‐patient trust and mitigate vaccine hesitancy across diverse populations. Safety concerns regarding the vaccine and vaccination to prevent illness were described, highlighting the need for health care providers to address these concerns when providing vaccine information and pregnancy care.

CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

Supporting information

Appendix S1: Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist

Appendix S2: SSI Guide Questions