COVID-19 vaccination patterns and attitudes among American pregnant individuals

Abstract

OBJECTIVE: Recent investigations have provided reassuring data on the use of COVID-19 vaccines in pregnant populations,1Shimabukuro TT Kim SY Myers TR et al.Preliminary findings of mRNA Covid-19 vaccine safety in pregnant persons.N Engl J Med. 2021; 384: 2273-2282Crossref PubMed Scopus (401) Google Scholar. Vaccination during pregnancy has now been endorsed by key organizations, including the American College of Obstetrician Gynecologists (ACOG) and the Society of Maternal Fetal Medicine (SMFM).2The American College of Obstetricians and GynecologistsACOG and SMFM recommend COVID-19 vaccination for pregnant individuals.2021https://www.acog.org/news/news-releases/2021/07/acog-smfm-recommend-covid-19-vaccination-for-pregnant-individualsGoogle Scholar Yet, with respect to vaccine acceptance, the United States (US) ranked near the bottom in a list of 16 countries in a recent international survey.3Skjefte M Ngirbabul M Akeju O et al.COVID-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries.Eur J Epidemiol. 2021; 36: 197-211Crossref PubMed Scopus (216) Google Scholar Granular information regarding the predictors of acceptance is lacking. To optimize vaccine acceptance in people during pregnancy in the United States, the data on current patterns and attitudes toward vaccination are needed. As of May 2021, just 16% of pregnant persons in a centers for disease control and prevention (CDC) database had received at least one dose of a COVID-19 vaccine.4Razzaghi H Meghani M Pingali C et al.COVID-19 vaccination coverage among pregnant women during pregnancy - eight integrated health care organizations, United States, December 14, 2020-May 8, 2021.MMWR Morb Mortal Wkly Rep. 2021; 70: 895-899Crossref PubMed Scopus (77) Google Scholar In this report, we utilized a nationwide prospective study of pregnant persons, recruited before 10 weeks of gestation, to characterize the vaccination rates and acceptance during the first 6 months of vaccine rollout. STUDY DESIGN: Institutional Review Board approval was obtained through the University of California, San Francisco. We analyzed the survey data from the participants in the assessing the safety of pregnancy in the coronavirus pandemic (ASPIRE) study, which is a nationwide prospective cohort of pregnant individuals recruited early in the first trimester. The study was launched in April 2020, with participant recruitment accomplished through social media and web-based communications. Inclusion required pregnancy at <10 weeks’ gestation and a lack of vaccination before pregnancy. The current analysis considers respondents who completed at least one vaccine-specific questionnaire between April 1, 2021, and June 30, 2021, with the most recently completed questionnaire being utilized. Unvaccinated respondents who indicated a willingness to be vaccinated in the future were defined as indicating vaccine acceptance. The Wilcoxon rank sum or Fisher's exact tests were used to test for bivariable associations with the vaccine status and acceptance. Those significant at the P<.1 level were included in multivariable logistic regression models. RESULTS: A total of 2506 community ASPIRE respondents completed at least 1 vaccine questionnaire as of June 30, 2021, with 57.4% getting vaccinated during pregnancy (Table). In an adjusted model, the predictors of lower odds of vaccination were being of the Black race compared with White race and being counseled by a provider not to vaccinate compared with no counseling. The predictors of higher odds of vaccination were increasing education and income, living in a metropolitan area, and worry over COVID-19. In addition, being counseled about vaccination by a provider was a strong predictor of getting vaccinated compared with receiving no counseling (Figure, A).TableParticipant characteristics by vaccination statusHuddleston. COVID-19 vaccination patterns and attitudes among American pregnant individuals. Am J Obstet Gynecol MFM 2021.Characteristic or GroupOverall Mean (SD) or N (%) of cohortUnvaccinated Mean (SD) or % of groupVaccinated Mean (SD) or % of groupP valueAge at enrollment (y)32.3 (3.9)31.8 (4.5)32.7 (3.7)<.001Race White2100 (83.8)41.858.2<.001 Black78 (3.1)78.221.8 Asian91 (3.6)20.979.1 Native American19 (0.8)36.863.2 Mixed/Other127 (5.1)47.252.8Ethnicity Not Hispanic2135 (85.2)41.958.1.054 Hispanic273 (10.9)48.052.0Education Less than bachelor's degree579 (23.1)66.833.2<.001 Bachelor's degree903 (36.0)42.457.6 Graduate degree985 (39.3)29.570.5Household income <$50,000391 (15.6)68.531.5<.001 $50,000–$99,000730 (29.1)50.749.3 $100,000–$250,0001078 (43.0)33.666.4 >$250,000266 (10.6)22.277.8Work status Unemployed137 (5.5)61.338.7<.001 Full-time homemaker366 (14.6)55.544.5 Part-time employment316 (12.6)45.654.4 Full-time employment1648 (65.8)38.261.8Employed in a healthcare field No1824 (72.8)42.657.4.476 Yes640 (25.5)44.255.8Region of residence South718 (28.7)47.952.1.011 Midwest596 (23.8)43.356.7 West706 (28.2)39.960.1 Northeast405 (16.2)39.860.2Lives in a metropolitan area No978 (39.0)51.448.6<.001 Yes1448 (57.8)37.462.6COVID-19 anxiety/worry (baseline) Anxiety about pregnancy (1–100)50.3 (25.8)44.8 (28.9)54.3 (24.5)<.001 Anxiety about giving birth (1–100)53.4 (26.0)50.7 (30.1)55.4 (25.0).004 Worry about self/loved ones being affected A little/not at all796 (31.8)56.943.1<.001 Somewhat933 (37.2)37.862.2 Extremely/very700 (27.9)32.667.4General anxiety/worry (baseline) GAD-7 score (0–21)4.5 (4.2)4.7 (4.6)4.3 (4.1).246 Minimal (GAD-7 score 0–4)1445 (57.7)40.959.1.064 Mild-Severe (GAD-7 score 5-21)941 (37.5)44.755.3Provider counseling/advice Counseled by provider No1000 (39.9)61.538.5<.001 Yes1501 (59.9)30.669.4 Advice given (if counseled) No given clear direction278 (11.1)40.359.7<.001 Discussed pros and cons603 (24.1)33.266.8 Told not to vaccinate39 (1.6)89.710.3 Told to vaccinate579 (23.1)19.380.7Planning Planning to get vaccinated336 (13.4)31.2 Reasons for not planning to get vaccinated693 (27.7) May experience side effects or get sick195 (7.8)28.1 Does not think it will work80 (3.2)11.5 Does not need - had COVID-19 infection94 (3.8)13.6 Does not need - not at risk107 (4.3)15.4 Does not think it's good for them136 (5.4)19.6 Not sure if vaccine is safe in pregnancy566 (22.6)81.7 Allergic to the vaccine/other medical reason22 (0.9)3.2 Other reasonaOf those reporting other reasons, 67.7% also cited at least one of the other listed reasons.136 (5.4)19.6Timing Gestational weeks at enrollment6.9 (1.3)6.9 (1.3)6.9 (1.3).312 Gestational weeks at data collection19.9 (10.4)18.2 (12.0)21.2 (9.5)<.001 Weeks between data collection and analysis5.8 (4.1)4.7 (3.9)6.5 (4.1)<.001 Gestational weeks at vaccination16.8 (8.4)16.8 (8.4) Month of vaccination1416 (56.5) Dec 202059 (2.4)4.2 Jan 2021115 (4.6)8.1 Feb 2021123 (4.9)8.7 March 2021630 (25.1)44.5 April 2021316 (12.6)22.3 May 2021140 (5.6)9.9 June 202135 (1.4)2.5P values by Wilcoxon rank sum (continuous), or Fisher's exact test (categorical).Region of residence and zip code variables are based on US Census Bureau data.GAD-7: minimal: 0–4; Mild-Severe: 5–21.GAD-7, general anxiety disorder scale; SD, standard deviation.a Of those reporting other reasons, 67.7% also cited at least one of the other listed reasons. Open table in a new tab P values by Wilcoxon rank sum (continuous), or Fisher's exact test (categorical). Region of residence and zip code variables are based on US Census Bureau data. GAD-7: minimal: 0–4; Mild-Severe: 5–21. GAD-7, general anxiety disorder scale; SD, standard deviation. Among the unvaccinated, only 35.7% reported vaccine acceptance. Being advised by a provider not to vaccinate negatively predicted vaccine acceptance. The predictors of higher odds of vaccine acceptance were the following: some or extreme COVID-19 worry compared with little or none and being counseled about vaccination (Figure, B). Over time, provider information was a consistent predictor of vaccination and vaccine acceptance (Figure, C). CONCLUSION: Using data from an ongoing, nationwide study launched in the beginning of the COVID-19 pandemic, we found that while a slight majority of the pregnant respondents had been vaccinated as of June 2021, there remained substantial vaccine hesitancy, with most of the currently unvaccinated individuals indicating no plans to get vaccinated. Race, education, living in a metropolitan area, and income were strong predictors of vaccination status, but they did not predict vaccine acceptance among those currently unvaccinated. The initial roll-out of the COVID-19 vaccine to pregnant persons was complicated by a lack of phase 3 trial data, and there continues to be a need for rigorous investigations on vaccine safety in pregnancy. We found that the respondents who reported having any vaccine discussion with their provider, even when no advice was given, were more likely to get vaccinated; this suggests that providers can play an important role in improving vaccination rates. Public health strategies should prioritize provider and public education regarding the adverse effects of COVID-19 in pregnancy and evolving safety data for vaccines in this group.5Villar J Ariff S Gunier RB et al.Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: the INTERCOVID multinational cohort study.JAMA Pediatr. 2021; 175: 817-826Crossref PubMed Scopus (446) Google Scholar Critically, authorities including the CDC, ACOG and SMFM now recommend vaccination for all pregnant individuals. Encouragingly, we found that the decision to vaccinate evolved, with many participants reporting a shift in attitude from no acceptance to acceptance on the final survey. Our sample size is large and distributed across diverse regions and backgrounds, but it also represents those who chose to participate in a longitudinal cohort study focused on COVID-19. Therefore, as with any observational study, the limitations include generalizability to the larger population. Overall, our data characterize the current landscape of COVID-19 vaccination during pregnancy in the United States, highlighting opportunities for improving vaccination rates in this high-risk group. The ASPIRE Study was funded by the following: The Start Small Foundation, California Breast Cancer Research Program (CBCRP), Covid Catalyst Award, Abbvie, Ferring Pharmaceuticals, and individual philanthropists.