Purpose COVID-19 vaccine uptake among pregnant women has been low, particularly in younger and ethnic minority mothers. We performed a ‘snapshot’ survey to explore vaccine uptake and factors which influence this, as well as underlying beliefs regarding COVID-19 vaccination among pregnant women in a North London hospital.
Study design Pregnant women were invited to complete an anonymised survey, where data were collected on demographics, personal and household vaccination status, and beliefs about the vaccine. Free-text comments were analysed thematically.
Results Two hundred and two women completed the survey, of whom 56.9% (n=115) were unvaccinated and 43.1% (n=87) had received at least one dose of COVID-19 vaccine, with 35.6% (n=72) having received two doses. Factors associated with acceptance of vaccination included: (a) age over 25 years (57.6% vaccinated vs 17.2% under 25 years); (b) Asian ethnicity (69.4% vaccinated vs 41.2% white ethnicity, 27.5% black/Caribbean/African/black-British ethnicity and 12.5% mixed ethnicity) and (c) living in a vaccinated household (63.7% vaccinated vs 9.7% living in an unvaccinated household) (all p<0.001). Vaccine uptake was higher in women who had relied on formal medical advice as their main source of information compared with other sources (59.0% vs 37.5% friends and family, 30.4% news and 21.4% social media). Qualitative data revealed concerns about a lack of information regarding the safety of COVID-19 vaccination in pregnancy.
Conclusion Age, ethnicity, household vaccination status and information source influenced vaccination status in our pregnant population. These findings highlight the urgent need to tackle vaccine mistrust and disseminate pregnancy-specific vaccine safety data to pregnant women.
Trial registration number 5467.
Data availability statement
Data are available on reasonable request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Vaccination is of crucial importance in reducing the prevalence and severity of COVID-19 infection in pregnant women; however, the actual uptake in this group has been poor and particularly low acceptance has been observed in pregnant women from black and mixed ethnic minorities, low-income households and younger age groups.
WHAT THIS STUDY ADDS
Our data suggest that vaccine uptake by pregnant women may be influenced by one or more of members from the same household being vaccinated.
Pregnant women who accessed formal healthcare-based resources as their primary basis of vaccine information were more likely to be vaccinated compared with those using less regulated information sources such as friends/ family and Facebook and social media.
Free-text comments from unvaccinated pregnant women indicated they mainly declined due to vaccine novelty and concerns about potential effects on the fetus.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Vaccine hesitancy should be judiciously but firmly addressed.
Vaccine uptake in pregnant women living in unvaccinated households should be encouraged by involving individuals in their support bubbles in information sharing and discussions.
Staff training in counselling and specialised antenatal clinics offering unbiased counselling and easy access to vaccination have reported uptakes.
Tackling ethnicity-based disparities in vaccine uptake would include engagement with trusted sources within the target community and endorsement by community leaders.
In the UK from May to October 2021 (the ‘Delta’ wave), 1436 pregnant women were admitted to hospital with symptomatic COVID-19: 33% needed respiratory support, 16% required care in intensive care unit and 17 women died. Over 96% of these women were unvaccinated.1 At the start of the pandemic, advice from the Joint Committee on Vaccination and Immunisation (JCVI) was for pregnant women to avoid vaccination unless clinically vulnerable, as there was limited evidence of COVID-19 vaccine safety in pregnancy due to the exclusion of pregnant women from phase III clinical trials. However, with subsequent encouraging safety data, the JCVI endorsed vaccination for all pregnant women regardless of risk group from April 2021, and by December 2021 pregnant women were recognised as a priority group for vaccination.2
Maternal mortality is 22 times greater in pregnant women with COVID-19 and the affected are five times more likely to require admission to intensive care than other pregnant women.3 While vaccination is a key strategy in pregnant women to reduce COVID-19 prevalence and severity, the actual uptake in this group has been poor: as of May 2020, only 2.8% of women giving birth in the UK had received one or more doses of the vaccine.4 This increased to 22.2% in the subsequent 3 months but remained significantly lower than the proportion of vaccinated non-pregnant individuals aged 18–44 years, which ranged from 70% to 90%.4 5 Particularly low vaccine uptake has been observed in pregnant women from ethnic minorities, low-income households and younger age groups.4 6
The aim of our study was to explore vaccine uptake, factors associated with vaccination acceptance and underlying beliefs regarding COVID-19 vaccination among pregnant women in our multi-ethnic North London borough.
In a 4-week period between October and November 2021, pregnant women attending North Middlesex University Hospital maternity department (antenatal clinics, maternity triage and maternity day unit) were invited to complete an anonymised electronic survey. Professional interpreters were available to all pregnant women through a telephone interpretation service (Big Word) or in-house advocacy systems for non-English speakers. Informed consent was obtained and the women were made aware that non-participation did not prejudice their subsequent treatment in the hospital.
The survey questionnaire was based on previous studies assessing attitudes towards the COVID-19 vaccine in pregnancy.7 Basic demographic data regarding age, gestation, ethnicity and occupation were collected. Participants were questioned about their vaccination status, future vaccination plans, whether other household members were vaccinated, information given in antenatal appointments and what they had used as their main information source. The women were also asked their level of agreement with particular statements regarding their decision to accept or decline the vaccine, scored on a 5-point Likert scale: (1) ‘strongly disagree’, (2) ‘disagree’, (3) ‘neutral’, (4) ‘agree’, (5) ‘strongly agree’. At the end of the survey, participants were given the opportunity to make free-text comments on the COVID-19 vaccine.
Basic descriptive statistics were used to analyse the data which were normally distributed and t-test and χ2 test were employed to compare means and distributions. Free-text responses were analysed thematically by AMD using data familiarisation, coding, theme identification and refinement,8 following discussion between AMD, DD and WY. This study was registered as a service improvement project with the North Middlesex University Hospital Clinical Effectiveness Unit (ID number 5467).
Two hundred and two women completed the survey, of whom 56.9% (n=115) were unvaccinated. Overall, 43.1% (n=87) had received at least one dose of the COVID-19 vaccine while 35.6% (n=72) had received two doses. Of those vaccinated, 41.4% (n=36) had been vaccinated prior to their current pregnancy, while the remaining 58.6% (n=51) had received the vaccine during pregnancy. Worryingly, only 2.6% (n=3) of the unvaccinated women were planning on receiving the vaccine during their pregnancy, and approximately one-third (n=39) had no intention of being vaccinated in the future.
Factors associated with positive vaccination status are as follows:
Age: vaccination rates generally increased with age, and particularly high uptake was observed in the 25–29 age group (table 1). Women under the age of 25 years were less likely to be vaccinated compared with those aged >25 years (17.2% vaccinated vs 57.6%; p<0.0001, χ2 test).
Ethnicity: women of Asian/Asian British ethnicity and ‘other’ ethnic groups (this included ‘Afghanistan’, ‘Brazilian’, ‘Hispanic’, ‘Mauritian’) had the highest vaccination rates (69.4% and 75.0%, respectively). Women from black ethnic groups or of mixed ethnicity reported the lowest rates of vaccination (27.5% and 12.5%, respectively), while 41.2% of women from the white/‘other white’ group had been vaccinated (table 1). Asian women (69.4%) were more likely to have been vaccinated compared with white (41.2%), black (27.5%) or mixed (12.5%) ethnicity (p<0.001).
Household vaccination status: of the 202 participants, 61.4% lived in a household where at least one other household member had been vaccinated. Women residing in households where at least one member had been vaccinated were much more likely to have been vaccinated themselves compared with those living in households with no vaccinated members (63.7% vs 9.7%; p<0.0001, χ2 test) (table 1).
Information sources: 59.0% of women who accessed formal healthcare-based resources as their primary basis of vaccine information had received at least one dose of the vaccine. In contrast, those using less regulated information sources such as friends/family and Facebook and social media had lower rates of vaccination of 37.5% and 21.4%, respectively (both p<0.0001, χ2 test) (table 1).
Information given at antenatal appointments: only 35.1% of women reported that they had received information about the vaccine at booking. Receiving information at the booking appointment was associated with a higher rate of vaccination (57.7%) compared with not receiving information at booking or being unsure whether information was given (36.2% and 30.8%, respectively) (both p<0.001, χ2 test) (table 1). Less than half of women (45.0%) were given opportunities to discuss COVID-19 vaccination at subsequent antenatal appointments.
Fluency in English language: fluency was rated from 1 (needs interpreter) to 5 (fluent) based on the Employee Language Skills Self-Assessment Tool. Patients with lowest fluency level (level 1) had the lowest vaccination rates (25%), while the highest percentages of acceptance occurred in pregnant women rated as having fluency levels 2 (not fluent) (50%) and 5 (fluent) (47.7%), respectively. There is therefore not a clear trend between proficiency in English and vaccination status among the patients in our study.
Beliefs of vaccinated and unvaccinated women
Most vaccinated women agreed or strongly agreed that they had decided to receive the vaccine to protect their personal health (85.1%), their family (80.5%) and their baby (75.9%) (table 2). Paradoxically, 80.9% of unvaccinated women agreed or strongly agreed with the statement that they did not have the vaccine due to concerns about its potential effects on the baby. Approximately half the unvaccinated women (49.6%) stated that they declined vaccination because of concerns about the effects of the vaccine on their own health (table 2).
Free-text comments (122 responses) were analysed thematically and were broadly categorised as ‘positive comments’, ‘negative comments’, ‘neutral comments’, ‘concerns regarding safety in pregnancy’, ‘concerns regarding effectiveness’, ‘comments regarding advice given’, ‘further information required’ and ‘uncertain’. Examples of the most common themes are given in box 1.
Safety in pregnancy
“I’m not sure if it works or not, but I definitely don’t want to take it in pregnancy in case it affects my baby”.
“It’s a good thing, but I’m concerned about the effects on my baby”.
“I am worried the vaccine causes infertility”.
“Information was woefully lacking. A lot of ‘it’s up to you’… Our first midwife simply said that she couldn’t advise”.
“I think more information should be provided by midwives…was not asked at all by my midwife about my thoughts/feelings about being vaccinated…”
“Was difficult to get advice on what to do early on…. Midwife said she wouldn’t get it”.
“… found it a hard decision as midwife not advising to get it. But I’m so pleased I did to protect me and baby”.
“My midwife told me not to get it. GP also said no and pharmacy…”
“I don’t feel a vaccine created in such a short period can have an effect or reduce the chances of getting COVID-19”.
“Not sure whether effective or not, I know people have had it and still fallen ill”.
“Worth doing as it seems to be much more dangerous to get COVID-19 while pregnant”.
“I think it’s a good way to protect myself and my baby”.
Unvaccinated women were specifically given the opportunity in free text to expand on their reasons for not receiving the vaccine, and the most common themes were pregnancy concerns (15/35) followed by safety concerns (6/35), particularly around vaccine novelty (box 2). About one-third of unvaccinated women (n=39) stated they had no plans to be vaccinated in the future. In this subgroup, 64.1% of women were from white ethnic groups, 79.5% lived in an unvaccinated household (vs 35.6% in whole study group) and 59.0% had received no information about the vaccine at booking (table 3).
Reasons for non-vaccination
“I know the vaccine is effective but I am worried about the effects on baby”.
“There is not enough research on taking the vaccine whilst pregnant”.
“I was strongly advised not to take the vaccine in my early pregnancy by a medical professional”.
“It’s an experimental drug”.
“We are guinea pigs in the process. We won’t know the effect of it until 3+ years”.
This observational study provides further evidence of the association between age and ethnicity with COVID-19 vaccine uptake in pregnancy. It has also brought to attention other factors previously not identified that may influence vaccine acceptance, such as household vaccination status and patient access to vaccine information. We provide a ‘snapshot’ view as to why some patients decline the vaccine, thus allowing healthcare professionals to formulate strategies to manage vaccine hesitancy. Earlier studies in 2020 and 2021 had assessed hypothetical acceptance by pregnant mothers of COVID-19 vaccines then in development,7 9 while more recent studies looked at the actual uptake of existing vaccines.6 10 Overall, our data showed a higher rate of COVID-19 vaccination compared with the London-based study by Blakeway et al 6 (conducted between March and July 2021) but a similar vaccination rate to the study by Stock et al,10 which was conducted in October 2021 among a population of Scottish pregnant women. It is feasible that the higher vaccine uptake in the later studies reflects rapidly changing attitudes towards the COVID-19 vaccine following the updated advice from the JCVI, and the publication of endorsement statements and patient decision aids from professional bodies including the Royal Colleges of Obstetricians and Gynaecologists and Midwifery.
Age has previously been linked to vaccine uptake, with greater coverage as age increases.4 6 At the time of the survey, individuals over the age of 12 years were eligible for COVID-19 vaccination in the UK, although a ‘catch-up’ effect following the age-based vaccine rollout may have contributed to the lower rates seen in young women. Risk perception may also play a role. Younger people, in general, have a lower perception of risk compared with older individuals11 and that this appears to apply in the context of COVID-19.12 13 Although pregnancy constitutes a significant risk factor for severe COVID-19 infection, younger women may still perceive themselves as lower risk, particularly as an age-based vaccine invitation system was employed. A Dutch study exploring low COVID-19 vaccine uptake in young adults noted that perceived necessity of the vaccine and greater perceived consequences of COVID-19 infection was linked to greater vaccine uptake.14
Vaccine hesitancy among women of black and mixed ethnicities is well established4 6 7 9 and our data further corroborate this finding. Women from black and mixed ethnic groups had less than half and one-fifth (respectively) the vaccination rate of Asian/British Asian pregnant women (table 1). Potential reasons for this are complex and multifactorial but include historical and contemporary experiences of racism, under-representation in health research with concerns that immunisation research is not ethnically heterogenous15 and higher levels of medical mistrust.16 Racial inequalities in maternity care have been previously documented in Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK reports.17 The high vaccination rate in Asian women has not been previously reported and requires further exploration. It is unclear if language barrier itself contributes to this and so far, very few studies have assessed the issue of language fluency in isolation. Tankwanchi et al 18 believed that vaccine hesitancy among migrant communities is determined more by cultural barriers, religious beliefs, access to vaccines and trust rather than language per se. Interestingly, Geipel et al 19 found that Hong Kong Chinese patients (n=611) were more likely to accept COVID-19 immunisation when information was presented in English rather than their native Chinese and suggested that material in English somehow increased patient confidence in the safety and effectiveness of the vaccine; however, this may represent an underlying protest against the Chinese government by Hong Kongers rather than a preference for the English language! Abba-Aji et al 20 reviewed 31 studies on vaccine access among migrants and ethnic minorities and suggested that these groups may experience barriers related to trust, cultural issues and language but many of the studies reported here pertained more to issues of vaccine access rather than any reluctance to immunisation. In relation to our own study, the association between English fluency and vaccine acceptance is tenous, as all our non-English speaking women have access to either face-to-face or telephone interpretation in the course of their pregnancy.
Our data suggest that household vaccination status may be one of the key factors associated with vaccine uptake in our pregnant population, which has been hitherto unrecognised. This association was maintained within different age and ethnic groups, with a vaccination rate of around 10% for women under 25 years old and those from black ethnic backgrounds living in unvaccinated households. Furthermore, nearly 80% of women with no plans to be vaccinated lived in unvaccinated households. These findings imply a wider social and cultural environment significantly influencing women’s decision to be vaccinated.
Decisions may also be subject to influence by social media, as nearly 45% of UK adults use media platforms such as Facebook, Instagram and Twitter for news access.21 Young people are especially likely to rely on social media to inform decisions, including those regarding healthcare.22 Misinformation can be disseminated on unregulated social media platforms, and incorrect or biased information around the COVID-19 vaccine has been found to be associated with a lower vaccine uptake.23 One misinformation theme that has been consistently highlighted is that the vaccine could impact on fertility.23 24 Despite long-term safety data now being available, these concerns remain evident according to the free-text comments made by our participants (Boxes 1–2). It is likely that concerns about fertility would disproportionately affect younger women who had not completed their families, compared with older, multiparous women. Compared with women primarily using these informal information sources, pregnant women in our study citing formal medical advice as their main information source had higher vaccination rates.
With this in view, the antenatal booking appointment provides a key opportunity to inform women with accurate medical information so that they can make positive health-conscious decisions in pregnancy. However only about a third of women in our study reported that they had received information about the vaccine at booking, and over half of women indicated they were not given the opportunity to discuss the vaccine at subsequent appointments. Although the safety of the vaccine has now been well established, the exclusion of pregnant women from the initial clinical trials resulted in extreme caution among pregnant women, and healthcare professionals. The rapidly changing landscape of information on COVID-19, fear of medicolegal repercussions and the lack of explicit classification of pregnant women as a high priority group at the time of survey may have contributed to a systemic failure in provision of up-to-date information about the vaccine at appointments.
Addressing vaccine hesitancy
While not a new phenomenon, vaccine hesitancy in the context of the ongoing COVID-19 pandemic poses a major current public health concern: this is distinct, for example, from a small minority of parents declining the measles, mumps and rubella vaccine on behalf of their children. Improving COVID-19 vaccine uptake in pregnancy requires the dissemination of contemporaneous, accurate information in accessible formats regarding vaccine safety and the dangers of COVID-19 infection, starting from the antenatal booking appointment and continuing throughout the pregnancy. Groups where uptake is low should be judiciously but firmly targeted. For instance, an effective way to encourage vaccine uptake in women living in unvaccinated households would be to involve family members or individuals in women’s immediate support bubbles in information sharing and discussions around the vaccine. Staff training to counsel women for COVID-19 vaccination is required, and specific safety concerns, such as the impact on fertility must be addressed. Specialised antenatal clinics in Manchester offering unbiased counselling and easy access to vaccination have reported uptakes of >60%.25 Tackling ethnicity-based disparities in vaccine uptake requires culturally responsible strategies. In groups where vaccine uptake is low, community focus groups may be beneficial, including engagement with trusted sources within the target community and endorsement by community leaders. Furthermore, in order to ensure that lack of language proficiency does not become a barrier, access to telephone or face-to-face translation service is crucial.
Finally, we acknowledge the limitations of our study which include a small sample size, self-selection bias and likely under-representation of non-English speakers. In addition, the demographic characteristics of participants including ethnicity were categorised as per the hospital maternity booking systems and did not allow for meaningful analysis of specific ethnic or cultural groups. However, the main strengths of this study are the range of ethnicities and age groups surveyed, and the inclusion of patient perspectives and future vaccination plans. Prior to this survey, there had been little published data on vaccine hesitancy specific to COVID-19 and pregnancy in the UK with the vaccine widely available.
This study has provided an insight into the factors associated with COVID-19 vaccine uptake in pregnancy and patient perspectives in a multi-ethnic setting. Very few unvaccinated women planned on receiving the vaccine during the pregnancy and a significant proportion of unvaccinated women had no plans to be vaccinated in the future. As vaccine acceptance is key to the success of the COVID-19 immunisation programme, these findings highlight the urgent need to tackle vaccine mistrust and disseminate pregnancy-specific vaccine safety data among the pregnant population and healthcare providers.
Data availability statement
Data are available on reasonable request.
Patient consent for publication
Ethics approval was exempted by Dr Deborah McCartney, Governance lead, the Research Department of the hospital (letter of exemption available). Participants gave informed consent to participate in the study before taking part.
We would like to thank all patients who participated in the trial. We also acknowledge Dr Adhavan Sugumar, Dr Natasha Harringman, Dr Nicola Morrison and Midwifery student Anna Vallis for helping to recruit patients into the study.
Contributors DD collected and analysed the data, performed the literature search and co-wrote the article. AMD initiated the study protocol and co-wrote the article. AP collected the data and co-wrote the paper. VS initiated the study protocol and peer reviewed the manuscript. WY analysed the data, performed the literature search and co-wrote the article. WY is the guarantor of the study.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.