Knowledge, attitudes, and practices of pregnant women regarding COVID-19 vaccination in pregnancy in 7 low- and middle-income countries: An observational trial from the Global Network for Women and Children's Health Research

Maternal and perinatal health research during emerging and ongoing epidemic threats: a landscape analysis and expert consultation

INTRODUCTION

Pregnant women and their offspring are often at increased direct and indirect risks of adverse outcomes during epidemics and pandemics. A coordinated research response is paramount to ensure that this group is offered at least the same level of disease prevention, diagnosis, and care as the general population. We conducted a landscape analysis and held expert consultations to identify research efforts relevant to pregnant women affected by disease outbreaks, highlight gaps and challenges, and propose solutions to addressing them in a coordinated manner.

METHODS

Literature searches were conducted from 1 January 2015 to 22 March 2022 using Web of Science, Google Scholar and PubMed augmented by key informant interviews. Findings were reviewed and Quid analysis was performed to identify clusters and connectors across research networks followed by two expert consultations. These formed the basis for the development of an operational framework for maternal and perinatal research during epidemics.

RESULTS

Ninety-four relevant research efforts were identified. Although well suited to generating epidemiological data, the entire infrastructure to support a robust research response remains insufficient, particularly for use of medical products in pregnancy. Limitations in global governance, coordination, funding and data-gathering systems have slowed down research responses.

CONCLUSION

Leveraging current research efforts while engaging multinational and regional networks may be the most effective way to scale up maternal and perinatal research preparedness and response. The findings of this landscape analysis and proposed operational framework will pave the way for developing a roadmap to guide coordination efforts, facilitate collaboration and ultimately promote rapid access to countermeasures and clinical care for pregnant women and their offspring in future epidemics.

Myths Pertaining to COVID-19 Vaccination in Pregnant Women Attending a Rural Tertiary Care Hospital

Background The outbreak of the COVID-19 pandemic led to the rise of various social issues apart from medical ones. Several myths regarding COVID-19 vaccination were found worldwide, and some of the common ones identified were abortions, birth defects, bad pregnancy outcomes such as abortions, ectopic pregnancy, risk of infertility, and irregular menstrual cycles. Although no scientific theories or data backed those myths, pregnancy was still omitted from trials for a long time as any drug/vaccine given during pregnancy may affect the fetus. Objective The objective of this study was to evaluate the vaccination status of pregnant women (PW) regarding COVID-19 and explore the factors influencing those who chose not to get the initial dose, second dose, or booster dose. Methodology A total of 747 PW were enrolled in the current study. Information related to sociodemographic data, clinical data, COVID-19 vaccine status, and rationale for choosing not to receive the COVID-19 vaccination was analyzed using a prestructured and validated Performa. Results The mean age and gestational age of the women enrolled for the study was 27.39 ± 3.75 years and 30.21 ± 7.30 weeks, respectively. The first dose of the COVID-19 vaccine was not received by 40 (5.4%) subjects, and the second dose was pending in 142 (19%) women, and none of them received booster dose. The prevalent cause for abstaining from receiving the COVID-19 vaccination was the fear of abortion in 179 (24%) subjects, followed by the fear of vaccine-related side effects in 142 (19%) subjects. There was a significant correlation between acceptance of COVID-19 vaccination and education and employment. Conclusion The present study indicated that most women have taken the COVID-19 vaccine before conception and that none received the first, second, or booster dose during pregnancy, even if it was due. Women need to be educated about the benefits of vaccination to enhance the compliance rate of COVID-19 vaccination and reduce COVID-19-related morbidity and mortality during pregnancy.

Knowledge, Attitudes, and Subjective Norms Associated with COVID-19 Vaccination among Pregnant Women in Kenya: An Online Cross-Sectional Pilot Study Using WhatsApp

COVID-19 vaccination during pregnancy has been recommended, but the perceptions related to uptake remain unexplored. This pilot study aimed to explore how perceptions influence COVID-19 vaccine uptake among a sample of 115 pregnant women in Kenya, recruited via WhatsApp. Data were collected using an adapted online questionnaire between May and October 2022. Logistic analyses assessed the relationship between COVID-19 vaccination uptake and the Theory of Reasoned Action (TRA) constructs: attitudes and subjective norms. COVID-19 vaccination coverage was 73%, with vaccine hesitancy estimated at 41.4% among the unvaccinated group. Most participants had completed college education and had good knowledge of COVID-19 vaccines. There was no significant effect of enrollment in WhatsApp pregnancy groups on attitudes toward COVID-19 vaccination. Pregnant women were concerned about vaccine effectiveness (31.1%), and almost one-half (47.3%) were discouraged from receiving COVID-19 vaccines. Positive attitudes towards vaccination were associated with COVID-19 vaccination (aOR 2.81; 95% CI 1.12-7.04; p = 0.027), but no significant relationship was found between COVID-19 vaccination and strong subjective norms (influences to get COVID-19 vaccines). Our findings suggest that strategies to improve vaccination should consider targeting attitudes and proximal social networks (friends/family) to facilitate vaccination decision-making. WhatsApp can be used for research distribution and enhance the dissemination of accurate information.

Vaccine inequity: a threat to Africa's recovery from COVID-19

BACKGROUND

Vaccine inequity is a reality facing the Sub-Saharan Africa region as vaccine nationalism from high-income countries (HICs) leads to limited access to the lifesaving vaccines needed to end the pandemic. In Africa, a significant portion of the population has yet to be vaccinated against Covid-19; however, the barriers to accessing such vaccines, including capacity challenges, still persist despite the implementation of the COVAX facility meant to support the lower- and middle-income countries (LMICs) to boost vaccination.

METHODS

This study involved a systemic narrative review where literature search was conducted using the NCBI's PMC and BMC databases based on defined keywords. Three authors were involved in the literature search and consensus was applied to settle disagreements and validate the findings.

RESULTS

In this systematic narrative review, we report that vaccine nationalism remains a challenge for LMICs as HICs still hoard vaccines and even bypass COVAX to procure doses directly from the manufacturers. Factors that promote vaccine hesitancy in Africa include misinformation regarding the Covid-19 vaccine, a lack of trust in politicians and the pharmaceutical industry, and concerns about vaccine safety and efficacy. The policies implemented to enhance vaccine coverage in Africa, such as mandates, community engagement, and partnerships, all seek to promote equity of vaccination and ending Covid-19.

CONCLUSION

Covid-19 vaccine inequity persists and contributes to prolonged pandemic in LMICs. In response, African governments have taken certain measures to enhance vaccine uptake but more needs to be done to address resistance to vaccines.

COVID-19 vaccine hesitancy among pregnant women attending public antenatal clinics in Dar es Salaam, Tanzania

The COVID-19 pandemic has claimed over six million lives and caused significant morbidities globally. The development and use of COVID-19 vaccines is a key strategy in ending this. There is a general public hesitancy on vaccine uptake, including pregnant women who are at high risk of severe forms of the disease and death when infected with the virus. To determine the magnitude of hesitancy toward COVID-19 vaccines and the associated factors among pregnant women attending public antenatal clinics in Dar es Salaam‬. This was a cross-sectional analytical study conducted among 896 pregnant women attending antenatal clinics at public health facilities in Dar es Salaam. A structured interviewer-based questionnaire, in an electronic form, was used. The analysis was done by a multivariable linear regression model using STATA 16 to obtain factors associated with vaccine hesitancy, and P < .05 was considered significant. The proportion of pregnant women with vaccine hesitancy was 45%. Hesitancy was higher among unemployed pregnant women (AOR 2.16 (95% CI 1.36-3.42) and the self-employed group (AOR 1.62 (95% CI 1.07-2.44). It was also higher among pregnant women with poor attitudes to COVID-19 vaccines (AOR 2.44 (95% CI 1.75-3.39) and women who had low perceived benefits of the vaccines (AOR 2.57 (95% CI 1.83-3.60). COVID-19 vaccine-targeted interventions should aim at the provision of knowledge on COVID-19 and the COVID-19 vaccine and address poor attitudes and perceptions that pregnant women have on these vaccines.

"I'd do it for my baby": Lessons learned from qualitative research on COVID-19 vaccination among pregnant women in Côte d'Ivoire

In January 2023, almost two years after the COVID-19 vaccines were authorized for the general Ivorian population, the Government of Côte d'Ivoire authorized the Pfizer vaccine for pregnant women. Qualitative research with 214 adults (including pregnant women) in three Ivorian cities in November 2022 revealed that most participants knew that the COVID-19 vaccine had not been recommended for pregnant women. Some participants felt that the policy change alone would be enough to motivate pregnant women to get vaccinated, but others felt that it would be difficult to convince pregnant women that the vaccine is safe for them and their babies. Pregnant women who participated in the study expressed a preference for waiting until after giving birth to get vaccinated against COVID-19, to be safe. They viewed the COVID-19 vaccine as risky during pregnancy but seemed unaware of the heightened risks that COVID-19 illness poses to pregnant women and babies. Pregnant participants stated that if they believed that the COVID-19 vaccine was good for the baby they would put aside their fears and get vaccinated. Reframing the conversation around the dangers of COVID-19 for pregnant women and their babies and positioning the COVID-19 vaccine as safe during pregnancy and protective, both during pregnancy and afterwards, could encourage uptake among this important segment of the population. Potential strategies to reinforce perceptions of COVID-19 vaccine safety for pregnant women include frequent and consistent messaging through both interpersonal and mass media channels; leveraging prenatal consultations and the relationship between health workers and pregnant women for both counseling and vaccination; and engaging influential others to support pregnant women in the decision to accept vaccination against COVID-19. Positive testimonials may help combat rumors that the vaccine negatively affects fertility and reproductive health, which could help to foster positive attitudes towards the vaccine before a woman even becomes pregnant and encourage broad vaccination among women of reproductive age.

An investigation of the relationship between the general vaccination attitudes of pregnant women and their attitudes toward the COVID-19 vaccine

This study aimed to investigate the relationship between the attitudes of pregnant women toward general vaccines based on the Health Belief Model and their attitudes toward the COVID-19 vaccine. The study, which was designed as a descriptive, cross-sectional, and correlational study, was conducted with 348 pregnant women in three public hospitals in Northern Cyprus between June 24 and November 28, 2022. Data were collected using the "Participant Information Form," "Public Attitude Toward Vaccination Scale-Health Belief Model" (PAVS-HBM), and "Attitudes Toward the COVID-19 Vaccine" (ATV-COVID-19). The COVID-19 vaccination rate among pregnant women was quite high. Pregnant women have a high perception of sensitivity, importance, benefit, and health responsibility for routine vaccines and vaccination programs based on the HBM, and a low perception of barriers to vaccination. These results showed that pregnant women have a determined and positive attitude toward the acceptance of vaccines in general. On the other hand, the attitude of pregnant women toward the COVID-19 vaccine was moderately negative. Despite the reservations about the COVID-19 vaccine, a determined and positive attitude toward vaccines in general has increased acceptance of the COVID-19 vaccine.

COVID-19 vaccine acceptance and hesitancy in Indian context: a systematic review and meta-analysis

Vaccination against COVID-19 is vital for achieving herd immunity, and the Government of India has adopted several strategies to achieve coverage. Vaccine hesitancy was identified as a potential obstacle in combating COVID-19. This study aimed to review the COVID-19 vaccine acceptance and hesitancy, and factors associated with vaccine hesitancy based on studies conducted in Indian populations. The data sources (PubMed, Scopus, and Google Scholar) were searched by following PRISMA guidelines, and the search was done in September 2022. We performed a meta-analysis through a random effect model to estimate pooled hesitancy rate with 95% confidence intervals (CI). A total of 3,339 records were searched, of which 46 studies were found to be eligible for inclusion in the review. The included studies covered 65,551 respondents, 55% were female. Studies reported COVID-19 vaccine acceptance rate of 65.7% in January-February 2021, which increased to 92.8% in May-August 2021. Likewise, the rate of vaccine hesitancy in December 2020 was 37%, dropping to 12.1% through November 2021. The estimated pooled COVID-19 vaccine hesitancy was 31% [95% CI: 27% - 36%, I2 = 99.3%]. Most studies highlighted that fear of the vaccine's side effects, efficacy, and safety were major barriers to vaccine acceptance. However, as the review indicates, it is important to consider and address all factors contributing to vaccine hesitancy.

COVID-19 Vaccination Booster Dose: Knowledge, Practices, and Intention among Pregnant/Planning to Get Pregnant and Lactating Women

Pregnant women are at higher risk of developing severe COVID-19 symptoms. Therefore, booster dose against COVID-19 was recommended for this special population in Jordan. However, vaccine hesitancy/refusal remains the main obstacle to providing immunity against the spread of COVID-19. Thus, the aim of this study is to examine the intention of pregnant/planning to get pregnant and lactating women towards receiving a booster dose against COVID-19 and its associated factors. A questionnaire was given to Jordanian pregnant/planning to get pregnant and lactating females. A total of 695 females were enrolled in the study. Older age, having a chronic disease, high education, high income, and high perceived risk of COVID-19 were significantly associated with higher knowledge about COVID-19. High perceived risk of COVID-19 was significantly associated with better practice. Participants who anticipated they might contract COVID-19 in the next six months, had high perceived risk of COVID-19, had high knowledge, had received the COVID-19 vaccine based on conviction, and smokers had higher intention to receive a booster dose of the COVID-19 vaccination. In order to increase pregnant and lactating women's intention to receive a booster dose of the COVID-19 vaccine, public health organizations should consider developing comprehensive health education campaigns.

Determinants of COVID-19 Vaccination Decision-Making Behaviors among Pregnant Women in Sub-Saharan Africa: A Scoping Review

Despite the availability of the coronavirus disease 2019 (COVID-19) vaccination, uptake among pregnant women in Sub-Saharan Africa has been low. This scoping review aimed to identify and characterize determinants influencing COVID-19 vaccination decision-making behaviors among pregnant women in Sub-Saharan Africa. We searched five online databases for articles on COVID-19 vaccination among pregnant women in Sub-Saharan Africa. We identified studies published in English between March 2020 and April 2023 that assessed vaccine-specific issues, psychosocial constructs, and contextual factors associated with COVID-19 vaccination decision-making behaviors. Of the fourteen studies identified, over half (57.1%) were cross-sectional; three used qualitative research methods; and three involved multi-country participants. Most studies assessed COVID-19 vaccination acceptability and willingness. Overall, 85.7% of the publications examined knowledge, attitudes, or both as critical factors associated with COVID-19 vaccination. The prevalence of COVID-19 vaccine uptake during pregnancy was low in Sub-Saharan Africa (14.4-28%). While most current studies assess COVID-19 vaccination knowledge, research on maternal vaccination in Sub-Saharan Africa would benefit from the inclusion of theory-informed and driven studies that measure additional psychosocial factors and contextual constructs. Future studies should also employ study designs that can determine causal pathways of vaccination determinants and vaccination uptake.

Global Cross-Sectional Study Evaluating the Attitudes towards a COVID-19 Vaccine in Pregnant and Postpartum Women

Pregnant and postpartum women have an increased risk of severe complications from COVID-19. Many clinical guidelines recommend vaccination of these populations, and it is therefore critical to understand their attitudes toward COVID-19 vaccines. We conducted a cross-sectional online survey in November 2020 of currently pregnant and ≤1-year postpartum women in Brazil, India, the United Kingdom (UK), and the United States (US) that assessed their openness to COVID-19 vaccines and reasons for vaccine hesitancy. Logistic regression analyses were conducted to evaluate openness to receiving a vaccine. Out of 2010 respondents, 67% were open to receiving a COVID-19 vaccine themselves. Among pregnant and postpartum participants, 72% and 57% were willing to receive a vaccine, respectively. Vaccine openness varied significantly by country: India (87%), Brazil (71%), UK (59%), and US (52%). Across all participants, among the 33% who were unsure/not open to receiving a COVID-19 vaccine, the most common reason cited was safety/side effect concerns (51%). Participants were similarly open to their children/other family members receiving a COVID-19 vaccine. Presence of a comorbidity, a positive COVID-19 test result, and pregnancy were all significantly associated with positive vaccine acceptance. Targeted outreach to address pregnant and postpartum women's concerns about the COVID-19 vaccine is needed.

Maternal COVID-19 vaccine acceptance among Malaysian pregnant women: A multicenter cross-sectional study

Introduction

The coronavirus disease 2019 (COVID-19) caused a global pandemic that resulted in devastating health, economic and social disruption. Pregnant mothers are susceptible to COVID-19 complications due to physiological and immunity changes in pregnancy. We aimed to assess the maternal vaccine acceptance of the COVID-19 vaccine.

Methods

A multi-center study across four teaching hospitals in the Klang Valley, Malaysia was conducted between September 2021 and May 2022. A survey was conducted using a self-administered electronic questionnaire. The survey instruments included; (1) maternal perception and attitude toward COVID-19 vaccination, (2) COVID-19 pregnancy-related anxiety, and 3) generalized anxiety disorder.

Results

The response rate was 96.6%, with a final number for analysis of 1,272. The majority of our women were Malays (89.5%), with a mean age (standard deviation, SD) of 32.2 (4.6). The maternal vaccine acceptance in our study was 77.1%. Household income (p < 0.001), employment status (p = 0.011), and health sector worker (p = 0.001) were independent predictors of maternal willingness to be vaccinated. COVID-19 infection to self or among social contact and greater COVID-19 pregnancy-related anxiety were associated with increased odds of accepting the SARS-CoV-2 vaccine. Women who rely on the internet and social media as a source of vaccine information were more likely to be receptive to vaccination (adjusted odd ratio, AOR 1.63; 95% CI 1.14-2.33). Strong correlations were observed between maternal vaccine acceptance and the positive perception of (1) vaccine information (p < 0.001), (2) protective effects of vaccine (p < 0.001), and (3) getting vaccinated as a societal responsibility (p < 0.001).

Discussion

The high maternal vaccine acceptance rate among urban pregnant women in Malaysia is most likely related to their high socio-economic status. Responsible use of the internet and social media, alongside appropriate counseling by health professionals, is essential in reducing vaccine hesitancy among pregnant women.

Lack of clear national policy guidance on COVID-19 vaccines influences behaviors in pregnant and lactating women in Kenya

SARS-CoV-2 infection in pregnancy is associated with a greater risk of maternal and newborn morbidity and maternal death. In Kenya, pregnant and lactating women (PLW) were ineligible to receive COVID-19 vaccines until August 2021. How shifts in policy influence vaccine behaviors, such as health worker recommendations and vaccine uptake, is not well documented. We conducted qualitative interviews with PLW, health workers, and policymakers in Kenya to understand how different stakeholders' perceptions of national policy regarding COVID-19 vaccination in pregnancy shaped vaccine behaviors and decision-making. Policymakers and health workers described pervasive uncertainty and lack of communication about the national policy, cited vaccine safety as their primary concern for administering COVID-19 vaccines to PLW, and expressed that PLW were inadequately prioritized in the COVID-19 vaccine program. PLW perceived the restrictive policy as indicative of a safety risk, resulting in vaccine hesitancy and potentially exacerbated inequities in vaccine access. These findings support the need for the development and dissemination of effective vaccine communication guidelines and the prioritization of PLW in COVID-19 vaccination policies and campaigns. To ensure PLW do not face the same inequities in future epidemics, data on infectious disease burdens and vaccine uptake should be collected systematically among pregnant women, and PLW should be included in future vaccine trials.