Abstract
This observational analysis explores how the COVID-19 pandemic contributed to a decrease in infant vaccinations.
The COVID-19 pandemic has profoundly affected the lives of pregnant individuals and their infants, resulting in prenatal health care disruptions,1 reduced duration of postpartum hospitalization, a sharp decrease in infant vaccination rates,2 and other stressful situations. Understanding predictors of vaccination, particularly when vaccine hesitancy is increasing,3 is important to developing public health policies and preventive interventions to increase vaccine uptake.4 We prospectively investigated how maternal experiences predicted vaccination status among infants born during the COVID-19 pandemic. Specifically, we examined the contribution of COVID-19–related health care limitations (eg, prenatal telehealth care, <2 days postpartum hospitalization), perinatal experiences (eg, discrimination, birth satisfaction), COVID-19–related stress,1 and known social determinants of health to vaccination status of infants at 3 to 5 months of age.4
Methods
We analyzed data from the first and third time points of the Stony Brook COVID-19 Pregnancy Experiences (SB-COPE) Study for this report. A prospective logistic regression prediction model was used while analyzing data. Between April 25 and May 14, 2020, 4388 pregnant women across the US who were 18 years or older were recruited through social media to participate in the SB-COPE Study and completed the baseline study survey (point 1), with follow-up surveys in July 2020 (point 2) and October 2020 (point 3). A total of 1107 infants were 3 to 5 months old (12 weeks to 23 weeks) at time point 3. Study measures included validated instruments assessing sociodemographic, maternal and infant characteristics, maternal psychological stress, and health care experiences. The primary outcome measure was vaccination uptake, assessed by asking mothers whether the infant had received all, some, or none of the recommended vaccines. We categorized vaccine uptake dichotomously with 0 indicating fully vaccinated vs 1 indicating incomplete vaccination (received some/none of the recommended vaccines). We performed bivariate analyses to examine associations between predictors and vaccine uptake, followed by stepwise binary logistic regression to identify unique predictors of vaccine uptake. Waiver of documentation of consent was approved by the institutional review board of Stony Brook University. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines were used. P values were 2-sided with a .05 significance threshold.
Results
The 1107 infants in this study were born between April 27, 2020, and July 30, 2020. A total of 89 infants (8.0%) had incomplete vaccine uptake at age 3 to 5 months (51 [4.6%] received some vaccines and 38 [3.4%] did not receive any vaccines). Additional study sample characteristics can be found in Table 1. In bivariate analyses, incomplete vaccine uptake was associated with previously established predictors (eg, parity, education, health insurance) and with COVID-19– and non–COVID-19–related stress factors (eg, income loss, discrimination, receiving telehealth prenatal care, and briefer postpartum hospitalization) (Table 1). Several key predictors persisted in the multivariate analysis (Table 2). These included perinatal care limitations (telehealth prenatal care and brief postpartum hospitalization), COVID-19–related income loss, and experiencing discrimination owing to one’s race, gender, sexuality, or body size. Mothers with greater concern about perinatal infection and greater birth satisfaction had decreased risk of incomplete vaccine uptake.
Table 1. Maternal and Infant Sociodemographic Characteristics by Vaccination Status Among Infants Born During the COVID-19 Pandemic.
| Characteristic | Total | Fully vaccinated | Incomplete vaccination | χ2 | P value |
|---|---|---|---|---|---|
| Established maternal and infant characteristic | |||||
| Maternal age, mean (SD), y | 31.8 (4.4) | 31.9 (4.3) | 30.8 (5.3) | t = 1.9 | .06 |
| No. of other children, mean (SD) | 0.8 (0.3) | 0.8 (0.9) | 1.2 (1.4) | t = 2.9 | .005 |
| Racial and ethnic group | |||||
| White Non-Hispanic | 966 (87.3) | 894 (92.5) | 72 (7.5) | 3.53 | .06 |
| Minoritized groupa | 141 (12.7) | 124 (87.9) | 17 (12.1) | ||
| Relationship status | |||||
| Married/cohabiting/serious relationship | 1053 (95.1) | 972 (92.3) | 81 (7.7) | 3.53 | .06 |
| Not in stable relationship | 54 (4.9) | 46 (85.2) | 8 (14.8) | ||
| Education | |||||
| High school or some college | 200 (18.1) | 165 (82.5) | 35 (17.5) | 29.5 | < .001 |
| Academic degree | 907 (81.9) | 853 (94.0) | 54 (6.0) | ||
| Health insurance | |||||
| Private | 987 (89.2) | 920 (93.2) | 67 (6.8) | 19.3 | < .001 |
| Medicaid or uninsured | 120 (10.8) | 98 (81.7) | 22 (18.3) | ||
| Infant age at point 3, mean (SD), wk | 16.7 (2.9) | 16.7 (2.9) | 16.8 (3.0) | t = 0.5 | .63 |
| Gestational age at birth, wk | |||||
| Term birth | 1028 (92.9) | 949 (92.3) | 79 (7.7) | 2.6 | .11 |
| Preterm birth | 78 (7.1) | 68 (87.2) | 10 (12.8) | ||
| Infants with special needsb | |||||
| No | 933 (84.3) | 859 (92.1) | 74 (7.9) | 0.1 | .76 |
| Yes | 174 (15.7) | 159 (91.4) | 15 (8.6) | ||
| COVID-19–related stressors and health care experiences | |||||
| Income lossc | 9.4 | .002 | |||
| No | 655 (59.2) | 616 (94.0) | 39 (6.0) | ||
| Yes | 452 (40.8) | 402 (88.9) | 50 (11.1) | ||
| Experienced discriminationd | |||||
| No | 1013 (91.5) | 939 (92.7) | 74 (7.3) | 8.7 | .003 |
| Yes | 94 (8.5) | 79 (84.4) | 15 (16.0) | ||
| Fear of perinatal infection, mean (SD)e | 3.2 (0.9) | 3.2 (1.0) | 2.8 (1.2) | t = 0.5 | .62 |
| Birth unpreparedness stress, mean (SD)f | 3.4 (0.8) | 3.4 (0.8) | 3.35 (1.1) | t = 3.0 | .004 |
| Prenatal care disruptionsg | |||||
| No | 466 (42.1) | 426 (91.4) | 40 (8.6) | 0.35 | .57 |
| Yes | 641 (57.9) | 592 (92.4) | 49 (7.6) | ||
| Telehealth prenatal careh | |||||
| No | 772 (69.7) | 722 (93.5) | 50 (6.5) | 8.4 | .004 |
| Yes | 335 (30.3) | 296 (88.4) | 93 (11.6) | ||
| Postpartum hospital stayi | |||||
| ≥2 d | 306 (27.7) | 267 (87.3) | 39 (12.7) | 13.2 | < .001 |
| 0 or 1 d | 800 (72.3) | 751 (93.9) | 49 (6.1) | ||
| Birth satisfaction level, mean (SD)j | 3.7 (1.0) | 3.7 (1.0) | 3.6 (1.2) | t = 1.6 | .12 |
Groups included are Asian American, Black/African American, Native American, or other.
Children with Special Health Care Needs Screener.
Answers are in response to the question: Have you, or someone you rely on, lost income due to COVID-19?
Answers are in response to the question: During your pregnancy, have you experienced discrimination or harassment because of your race, sexuality, gender, or body size?
Pandemic-Related Pregnancy Stress-Perinatal infection stress subscale.
Pandemic-Related Pregnancy Stress-Preparedness stress subscale.
Answers are in response to the question: Have you had prenatal care appointments canceled or rescheduled due to the current pandemic?
Answers are in response to the question: Have you used online prenatal care? No/yes, in the past vs yes, but only since the pandemic.
Answers are in response to the question: How long did you stay at the hospital or birthing center after the delivery?
The Birth Satisfaction Scale.
Table 2. Stepwise Logistic Regression Predicting Incomplete Infant Vaccination Status Among Infants Born During the COVID-19 Pandemic From Maternal and Infant Characteristics, COVID-19–Pandemic-Related Stressors, and Health Care Experiences.
| Characteristic | AOR (95% CI) | P value |
|---|---|---|
| Established maternal and infant characteristics | ||
| Preterm birth | 2.77 (1.27-6.05) | .01 |
| No. of other children | 1.44 (1.16-1.80) | .001 |
| Attained higher education | 0.37 (0.22-0.63) | <.001 |
| Maternal age | 0.94 (0.89-1.00) | .03 |
| COVID-19–related stressors and health care experiences | ||
| Received telehealth prenatal carea | 2.60 (1.59-4.24) | .01 |
| Less than 2 d postpartum hospital stayb | 2.59 (1.54-4.36) | < .001 |
| Experienced discriminationc | 2.32 (1.19-4.54) | < .001 |
| Lost income owing to COVID-19d | 1.61 (1.59-2.60) | .05 |
| Fear of perinatal infectione | 0.61 (0.48-0.77) | < .001 |
| Birth satisfaction levelf | 0.70 (0.56-0.88) | .01 |
| Hosmer-Lemshow test, χ28g | 6.53 | .59 |
| Nagelkerke pseudo R2h | .20 | NA |
Abbreviations: AOR, adjusted odds ratio; NA, not applicable.
Answers are in response to the question: Have you used online prenatal care? No/yes, in the past vs yes, but only since the pandemic.
Answers are in response to the question: How long did you stay at the hospital or birthing center after the delivery?
Answers are in response to the question: During your pregnancy, have you experienced discrimination or harassment because of your race, sexuality, gender, or body size?
Answers are in response to the question: Have you, or someone you rely on, lost income due to COVID-19?
Pandemic-Related Pregnancy Stress-Perinatal infection stress subscale.
Birth Satisfaction Scale.
The Hosmer-Lemshow test assesses goodness of fit, with P > .05 indicating good fit.
Nagelkerke pseudo R2 ranges from 0 to 1 and represents the percent of explained variance in the outcome.
Discussion
Perinatal care limitations, experiencing discrimination during pregnancy, and preterm birth were the strongest predictors of incomplete vaccination status at age 3 to 5 months. COVID-19–related income loss was also associated with increased risk of incomplete vaccination, possibly due to limited access to health care or affordability of health care. Reliance on telehealth prenatal care and on brief postpartum hospitalization may diminish opportunities for vaccine education. While this study is limited by its self-selected sample and self-report data, it is strengthened by the prospective design and inclusion of an array of previously established and newly identified predictors.
Since vaccination status in early infancy is overwhelmingly predictive of future up-to-date vaccination status,5 strategies to address perinatal care limitations and discrimination merit serious consideration by policy makers, health care organizations, and obstetric and pediatric clinicians.4,6 To promote infant vaccination, special attention should be given to vulnerable women who experienced financial loss or discrimination or had negative health care experiences. Policies and protocols are needed to guarantee sufficient patient education about infant vaccination regimens, especially when health care is disrupted.
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