“This choice does not just affect me.” Attitudes of pregnant women toward COVID-19 vaccines: a mixed-methods study

ABSTRACT

Public health experts agree that pregnant women who fall into priority groups may be offered a Coronavirus Disease 2019 (COVID-19) vaccine. However, little is known about attitudes of pregnant women toward COVID-19 vaccination. We surveyed 300 pregnant women during the roll out of the Pfizer-BioNTech vaccine in Ireland. Women rated likelihood of receipt of a vaccine during pregnancy, on a 1–10 scale (1 = very unlikely, 10 = very likely). One hundred and thirteen (38%) women responded with a score of ≥8, while a similar proportion (36%) selected a score of ≤2. Safety of their unborn infant was the primary driver of decision making among survey participants, but specific safety concerns differed according to likely acceptance of a vaccine. Communication about COVID-19 vaccines to pregnant women must explicitly address safety. Pregnant women and their health-care providers should be supported with accessible interpretations of data so that they can make the best choice for their individual risk profile.

Introduction

Coronavirus Disease 2019 (COVID-19) vaccines are being rolled out throughout the world. The World Health Organization (WHO), Center for Disease Control (CDC), the American College of Obstetricians and Gynecologists (ACOG), and multiple national immunization advisory committees state that pregnant women, who are part of a high-risk group (i.e., a health-care worker), may be offered vaccination.^1,2 Since early in the pandemic, experts have consistently advocated for inclusion of pregnant women in trials of therapeutics and vaccines.^3–5 However, vaccine trials completed to date did not enroll pregnant women. Pregnant women now face a more difficult choice around vaccination than the general population. Data from the CDC, released in October 2020, showed that pregnant women with COVID-19 are more likely to be admitted to intensive care, to require mechanical ventilation, and to die than non-pregnant women.⁶ Additionally, an increase in pre-term delivery has been seen among pregnant women with COVID-19.^7,8 There is an increasing amount of data available on the acceptability of COVID-19 vaccines among the general population.^9–11 However, very little is known about the viewpoints of pregnant women. It is important to investigate the attitudes of pregnant women toward COVID-19 vaccines, so that women may be supported to make the best decision for their individual risk profiles. We present the results of a mixed-methods study of 300 pregnant women who were surveyed during the initial role out of the Pfizer-BioNTech vaccine in Ireland.

Methods

Study setting

The study took place in a busy maternity hospital in Dublin, Ireland. The first COVID-19 vaccine was administered in the Republic of Ireland on the 29th of December 2020. Vaccination rollout commenced with those over 65 y of age living in long-term care facilities and front-line health-care workers. The Pfizer-BioNTech vaccine was available first, and the Moderna vaccine was introduced shortly after approval from the European Medicines Agency on the 6th of January 2021. The AstraZeneca vaccine was introduced on the 29th of January 2021 and was recommended for use in those under 65 y of age. In February 2021, the vaccination program expanded to include all those aged 70 y or older and those aged 16–69 with specified severe underlying medical conditions.¹² In early January, the Irish National Immunization Advisory Committee recommended that pregnant women who were otherwise eligible for COVID-19 immunization either due profession or underlying health conditions should be offered a COVID-19 vaccine.¹³

Study population and survey development

The study population were pregnant women presenting for care at the Rotunda Hospital, the busiest maternity hospital in Ireland (>8000 deliveries per year). A 25-question survey was developed and piloted for readability among a convenience sample of women of childbearing age. This survey is part of a multicentre discrete choice experiment, which examines factors that impact a decision to receive a hypothetical vaccine against Group B Streptococcus. Survey items included demographic information, obstetric factors, and prior vaccination experience. Women rated their likelihood of receipt of a COVID-19 vaccine, when pregnant and when not pregnant, and their likelihood of receipt of routinely recommended vaccines in pregnancy. Likelihood was measured on a 10-point scale where 1 represented “very unlikely” and 10 “very likely.” An open-ended question, “What do you think would most affect your choice about receiving or not receiving a COVID-19 vaccine during pregnancy?” accompanied the scale question. Women completed the survey between the 4th of December 2020 and the 14th of January 2021. The survey instrument was developed and hosted online using Sawtooth software.

Participant recruitment

Participants were recruited both in person and via online platforms. The Rotunda Hospital delivers prenatal care in hospital-based public, private, and semi-private clinics, and in community-based midwife-lead clinics. A mixture of in-person and online recruitment allowed for the enrollment of women from all these settings. Obstetricians and midwives working in the Rotunda hospital distributed study information leaflets with a link to the survey to women attending for clinic appointments. Women completed the survey at home on their own device as restricted waiting times (due to COVID-19 era measures) did not permit “in the moment” completion of the survey. Additionally, a short video that explained the purpose of the research and provided a link to the survey appeared on the hospital’s Instagram and Twitter accounts. A member of the research team also recruited women in-person during oral glucose tolerance testing. In this setting, women completed the survey on study tablets while awaiting blood testing.

Data analysis

For both the quantitative and qualitative analysis, we grouped respondents in two groups according to their self-rated likelihood score for receipt of a COVID-19 vaccine during pregnancy, using a cut-off score of 8. Analysis of distribution of the scores determined selection of this this cut-off value. The median score in those with a score of <8 was 2 with an interquartile range of 1–4 (Table 1). Descriptive statistics summarized responses to closed-ended questions. Multivariable logistic regression performed post-hoc examined potential factors associated with likelihood of COVID-19 vaccine receipt during pregnancy. The dependent variable was a self-rated likelihood score of ≥8. Variables with a p-value of < .2 on bivariate analysis were entered into the final model.

Table 1.

Characteristics of participants according to likelihood of COVID-19 vaccine in pregnancy (1–10, 10 = very likely, 1 = very unlikely)*

	Score <8	Score ≥8
	N = 187	N = 113	p-value
Age			0.006
18–24	5% (10)	1% (1)
25–30	26% (49)	15% (17)
31–35	39% (72)	60% (68)
36–40	26% (49)	19% (22)
41–45	3% (6)	4% (4)
>45	1% (1)	1% (1)
Birthplace			0.37
Ireland	82% (153)	86% (97)
Outside of Ireland	18% (34)	14% (16)
Race			0.46
Asian	3% (6)	3% (3)
Black	3% (5)	1% (1)
White	90% (169)	96% (108)
Other	3% (6)	1% (1)
Prefer not to answer	1% (1)	0% (0)
Education**			0.042
Some secondary school, no leaving certificate	4% (7)	2% (2)
Secondary school, complete	9% (17)	4% (5)
Third level education: certificate or diploma	22% (42)	13% (15)
Third level education: bachelor’s degree	37% (69)	40% (45)
Master’s, professional, or doctorates degree	28% (52)	41% (46)
Household income			0.026
€0–24,999	5% (9)	3% (3)
€25,000–44,999	8% (15)	9% (10)
€45,000–64,999	17% (31)	13% (15)
€65,000–99,999	28% (53)	33% (37)
€100,000 +	30% (57)	41% (46)
Prefer not to answer	12% (22)	2% (2)
Pregnancy care			0.11
Community midwife	16% (30)	16% (18)
Public clinic	46% (86)	34% (38)
Semi-private clinic	13% (24)	13% (15)
Private clinic	25% (47)	37% (42)
Gestational age (weeks)			0.008
<12	9% (16)	3% (3)
12–16	9% (17)	8% (9)
17–20	10% (19)	5% (6)
21–30	48% (90)	41% (46)
31–36	18% (33)	29% (33)
37+	6% (12)	14% (16)
Parity			0.74
≥1 previous pregnancy	66% (124)	68% (77)
First pregnancy	34% (63)	32% (36)
Received or intend to receive pertussis and or Flu vaccine			0.006
No	10% (19)	2% (2)
Yes	90% (168)	98% (111)
Likely receipt of recommended vaccines during pregnancy (1–10 scale) §	8 (6–9)	10 (10–10)	<0.001
Likely receipt of COVID-19 vaccine during pregnancy (1–10 scale) §	2 (1–4)	10 (9–10)
Likely receipt of COVID-19 vaccine if not pregnant (1–10 scale) §	7 (2–10)	10 (10–10)	<0.001

*Women responded to the following question: “If a COVID-19 vaccine was available and was recommended for pregnant women how likely is it that you would receive the vaccine during this pregnancy?”

**Highest level of education completed.

§Results presented as median and interquartile ranges.

Two authors coded free text responses using NVivo software. The SAGE working group determinants of vaccine hesitancy informed the initial codebook development.¹⁴ Coders met regularly to discuss interpretation of codes and to make refinements to the codebook. Assessment of inter-coder reliability used Cohen’s kappa coefficient. Incomplete surveys were excluded from analysis. STATA version 16 was used for all statistical analyses. The Research Ethics Committee of the Rotunda Hospital approved this study.

Results

In total, 342 women consented to participation, and 300 women fully completed the survey. Response rate was 83/94 (88%) for those recruited in person. Language proficiency inhibited participation in 8/11 women who chose not to complete the survey. Response rate for those recruited online could not be calculated as denominator is not known. Table 1 summarizes the characteristics of the study participants. One hundred and thirteen (38%) women rated likelihood of receipt of a COVID-19 vaccine during pregnancy as 8 or higher, while 108 (36%) respond with a score of ≤2. On the other hand, 63% of women rated their likelihood of receipt of a COVID-19 vaccine if not pregnant as ≥8 and 75% of women rated their likelihood of receipt of routine vaccines during pregnancy as ≥8 (Figure 1). On bivariate analysis having a college degree (OR 2.26, 95% CI 1.30–2.93), attending private or semi-private clinic (OR 1.66, 95% CI 1.04–2.67), being aged 30–35 y (OR 3.1, 95% CI 1.66–5.77), and gestational age greater than 31 weeks (OR 2.99, 95% CI 1.38–6.50) were associated with a score of ≥8. However, only later gestational age (OR 3.74, 95% CI 1.64–8.53) and being aged 30–35 y (OR 2.43, 95% CI 1.25–4.75) remained associated with increased likelihood of a COVID-19 vaccine receipt on multivariable logistic regression.

Figure 1.

(a) Scale responses to the question “If a COVID-19 vaccine was available and was recommended for pregnant women how likely is it that you would receive the vaccine during this pregnancy?” (b) Scale responses to the question “If a COVID-19 vaccine became available and was recommended for everyone, how likely is it that you would receive this vaccine if not pregnant?” (c) Scale responses to the question “In general how likely are you to accept recommended vaccines during pregnancy?”

Qualitative analysis of free text responses found that safety concern for the unborn infant was the primary driver for decision making among women regardless of stated likelihood of receipt of COVID-19 vaccine during pregnancy. However, there were some clear differences in the nature of the safety concerns raised by women who rated a likelihood of receipt of COVID-19 vaccine as 8 or above compared with those who rated their likelihood as <8. While women in both groups emphasized the importance of research in pregnant women, those with higher likelihood of acceptance tended to discuss the existing data while concerns about unknown “long-term effects” and how new the vaccine was were cited by those with likelihood scores of <8. Additionally, this group expressed more fear and anxiety around receiving a COVID-19 vaccine during pregnancy (Table 2). Women with a higher likelihood score mentioned a reliance on advice from health-care providers or policymakers, citing a recommendation from their obstetrician, GP or public health officials as an important influencing factor.

Table 2.

Themes and illustrative quotations from analysis of free text responses

Likelihood of COVID-19 vaccine receipt ≥8/10	Likelihood of COVID-19 vaccine receipt <8/10
Vaccine safety concerns and emphasis on research
Inclusion of pregnant women in clinical trials “Clinical Trials on Pregnant women and clinical research on babies born to women who had the vaccine whilst pregnant.” “Further testing for pregnant cohort.” “Medical studies on pregnancy and covid vaccines. I would like a bit of scientific reassurance.” “Amount of pregnant women in the clinical trials.” Demonstrating safety through data “I would want to wait until more testing was done to understand the effect of the vaccine on pregnant women and their unborn children. However, once more was known and it was recommended, I would definitely want to receive the vaccine in the same way as I receive the flu vaccine, to ensure mine and my unborn child’s safety.” “Supporting data proving safety in pregnant women. If shown to be safe, I would absolutely get it, I am very pro vaccine and work in healthcare.” “If it was proven to protect pregnant women without any harmful side effects on their unborn baby, I would take it.” “If it helps protect both my child, partner(transmission) & myself from covid-19 I see no reason not to get it as extensive clinical testing has been done.”	Introduction of a new vaccine “Because it is brand new and not much is known about it in terms of long-term side effects or any harm it may cause my baby.” “I wouldn’t take it as it is a new vaccine, and no one knows the effects of it yet.” “The results of a brand-new vaccine for such a new illness on an unborn baby can’t be known yet.” “It’s so new and thinking of the baby and not just me. Would be very likely to get if not pregnant.” Fear and anxiety “I would be so scared about the effects it could cause to my unborn son.” “My fear of putting my unborn baby at risk.” “It’s so new. Would be afraid of the effect it would have on the baby.” “Well, I feel it takes years of research to get the right vaccine, and I will like to see more sides effects before risking my baby’s life.” “I’ll be afraid for my baby.” “ … this choice does not just affect me. For example, (nonsmoker) I’ve cut alcohol, pate, cheesecake, coffee, soft serve ice cream and google pretty much everything I’ve put into my mouth for the last 6 months to protect my unborn child … given the above are minor low risk sacrifices I feel the C19 vaccine is too high of a risk, given the nature of the ‘unknowns’.” Concern about long- term effects “Insufficient scientific and medical evidence that the vaccine doesn’t harm the unborn baby or have long term implications to mother and child.” “If I wasn’t pregnant, I would get it. But not while I’m pregnant as I would be more worried about unknown long term side effects on my unborn child.” “I’d want to see robust data confirming that it did not result in any defects or have any long-term impact on the infant.”
The role of provider recommendation
“What the professionals say about it. If they say it is safe during pregnancy, I would question it but trust their professional knowledge.” “Public health guidance and advice from my medical team. I would be very happy to get a vaccine if it were recommended during pregnancy.” “The advice received by my consultant and GP. I trust their judgment and that they are placed to advise me on best practices during pregnancy.” “Advice from my midwife/doctors. I trust in what they tell me is important for me and my baby.” “The communicated risks would be a consideration but overall I trust my consultant and if it is being recommended by my consultant I would 100% take it as I trust her.” “What the professionals say about it. If they say it is safe during pregnancy I would question it but trust their professional knowledge.”	“The vaccine has been created in such a short time frame, so would just be a bit unsure about getting it. Will take GP and hospital advice as what is best for me and baby.” “Depending on whether my consultant advises me to get it.” “Obstetrician recommendation based on RCOG recommendation.”

Women responded to the question “What do you think would most affect your choice about receiving or not receiving a COVID-19 vaccine during pregnancy?”

Discussion

The results of this study show a divergence in attitudes toward COVID-19 vaccination in a sample of pregnant women who were otherwise highly inclined toward prenatal immunization. Safety of their unborn infant was the primary concern of women, regardless of stated likelihood of vaccine receipt. Later gestational age was independently associated with likelihood of vaccine receipt. This aligns with concerns about potential long-term effects on the infant, which emerged from the qualitative data, among those less likely to take the vaccine. Research on influenza and pertussis vaccine uptake during pregnancy demonstrates that concern about vaccine safety is one of the most important factors impacting the decision to receive a recommended vaccine during pregnancy.^15,16

Women in this study placed significant emphasis on scientific data, which may reflect the current media environment. The qualitative results provide insight into the nature of safety concerns and suggest that the interpretation of scientific data differs among women. Concerns about long-term effects, and general anxiety around how new the vaccine is were more commonly cited by women with a lower likelihood of vaccine receipt. Whereas those with higher stated likelihood of COVID-19 vaccine receipt spoke more about demonstrating safety through data. Such differences emphasize the importance of providing clear and easy to understand interpretations of the science so that women have an equal opportunity to make the best decision for their risk profile, guided by available data rather than fear.

An important finding of this study was the strong emphasis placed on safety. Recruitment coincided with the third wave of COVID-19 in Ireland; however, perceptions of susceptibility or severity of disease were rarely mentioned by the women surveyed. This finding is in keeping with results of a recent systematic review and meta-analysis of studies of pregnant women conducted during the HINI pandemic that could not find clear evidence that belief of susceptibility to pandemic influenza was associated with increased vaccine uptake during the H1N1 pandemic. On the other hand, the authors found that beliefs that the vaccine could cause birth defects or harm was a strong barrier to vaccination.¹⁶ This has important implications for public health messaging around the COVID-19 vaccine in pregnancy, emphasizing the importance of explicit communication about safety.

The importance of a health-care provider recommendation was more frequently cited by women who were more likely to receive the COVID-19 vaccine. Three systematic reviews demonstrate that a strong provider recommendation is one of the most important factors impacting uptake of vaccines during pregnancy.^15,17,18 A recent meta-analysis demonstrated that during the 2009 influenza pandemic a recommendation from a health-care provider increased the odds of H1N1 vaccine uptake during pregnancy six times (OR 6.76, 95% CI 3.12–14.64, I2 = 92.00%).¹⁶ Health-care providers play a central role in encouraging vaccine uptake during this pandemic. However, on this occasion prenatal care providers are facing more challenging and more nuanced discussions with their patients due to the paucity of data in pregnant women. Moreover, perception of risk and benefit may differ between individual providers. It is thus important that both pre-natal care providers and their patients have access to clear and up-to-date decision support material.

This study has some limitations. Firstly, as a single-center study findings may not be generalizable, and though a broad demographic was included, we believe online recruitment resulted in a selection bias toward those more inclined toward immunizations. Additionally, national recommendations around COVID-19 vaccination during pregnancy are likely to impact opinion. In Ireland, the National Immunization Advisory Committee issued guidance in early January that pregnant women who are at high risk should be offered vaccination if potential benefits of the vaccine outweigh theoretical or unknown risks. These recommendations received media coverage on 14th og January as the Institute of Obstetricians and Gynecologists in Ireland together with the Irish Medicines in Pregnancy Service released decision aid for pregnant women and their providers.¹³ Secondly, women who were born outside of Ireland were under-represented in this study compared with available population data for the hospital. We believe this was due to language barriers and the impact of online recruitment. It has been demonstrated in many countries, including Ireland that there is a decrease in uptake of maternal immunizations in women whose birthplace differs from their country of residence.^19–21 In this study, there was no difference in likelihood of vaccine receipt seen among women who were Irish born versus women who were born outside of Ireland; however, there were insufficient numbers to detect such a difference. Previous research in Ireland demonstrated regional differences in uptake, with women from Eastern European countries being less likely to receive vaccines during pregnancy than women from other parts of the world.²¹

The results of this study suggest that safety of their unborn infant will be the major driver for pregnant women when deciding whether to receive a COVID-19 vaccine. The exclusion of pregnant women from COVID-19 vaccine trials leaves at-risk pregnant women facing a more complex decision than that facing their non-pregnant peers. Women should be supported with clear explanations from trusted health-care providers so that they may make an informed choice guided by expert interpretations of available data.

Funding Statement

Sarah Geoghegan is supported by a clinical research fellowship award from the National Children’s Research Centre, Crumlin, Dublin. Grant number: [D/19/6].

Disclosure of potential conflicts of interest

In accordance with Taylor & Francis policy and our ethical obligations as researchers, we report that KA Feemster is currently employed as global director in medical affairs at Merck & Co Inc.