COVID-19 Vaccine Acceptance among Pregnant Women and Mothers of Young Children: Results of a Survey in 16 Countries

"Lessons learned from previous new vaccine roll-out including human papillomavirus (HPV) vaccine roll-out and Ebola vaccine trial field experiences have all underscored the importance of community work with sensitivity toward country-, local- and subgroup- specific culture contexts..."

Because mothers often play a key role in deciding whether their children will receive vaccinations, measuring vaccine confidence among women who are, or are soon to be, mothers and investigating the predictors for their vaccine acceptance or reluctance could help inform COVID-19 vaccination efforts. This study describes the level of acceptance, attitudes surrounding the COVID-19 vaccine, and key predictors of COVID-19 vaccine acceptance among pregnant women and mothers of young children in 16 countries.

An anonymous, online, cross-sectional survey was conducted between October 28 and November 18 2020 among 17,871 women aged 18 years or older, currently pregnant or with at least one child under 18 years of age. Fourteen countries with high cumulative incidences of COVID-19 as of October 28 2020 were included: the United States (US), India, Brazil, Russia, Spain, Argentina, Colombia, the United Kingdom (UK), Mexico, Peru, South Africa, Italy, Chile, and the Philippines. In addition, Australia and New Zealand were included for reference given that they had lower incidences of COVID-19.

To measure vaccine acceptance among three groups (pregnant women, non-pregnant women, and children), the survey posted three separate questions, each of which followed a general format: "If a COVID-19 vaccine were safe and available to (you/your child/children) for free, how likely would (you/your child/children) be to get vaccinated (during pregnancy) if the vaccine has an efficacy of [90% (in other words, it reduces the chance of getting infected by 90%)?]." Vaccine acceptance was defined as yes if a respondent answered, "very likely", "fairly likely", or "somewhat likely".

Among pregnant women, 52.0% (n=2,747) intended to receive COVID-19 vaccination during their pregnancy if an efficacy of 90% were achieved. COVID-19 vaccine acceptance level was above 80% for pregnant women in Mexico and India and below 45% for the US, Australia, and Russia. Among non-pregnant women, 73.4% (n=9,214/12,562) intended to receive vaccination. COVID-19 vaccine acceptance among non-pregnant women also varied substantially between countries (range 48.6-93.1%). Among the 17,054 women who stated their likelihood to vaccinate their children, results were very similar. COVID-19 vaccine acceptance levels among mothers for their children was above 85% in India, Mexico, Brazil, and Colombia and below 52% for Australia, US, and Russia. This country-variable pattern persisted after standardising for key demographics.

Overall, 53.0% of women were confident that a nationally approved COVID-19 vaccine would be safe, and 60.4% were confident that such a vaccine would be effective. The majority of women in the 16 countries believed that it was important for their own country to have a COVID-19 vaccine (85.8%) and for most people in their own country to get vaccinated (82.6%). Perceptions on the importance of childhood vaccinations were also positive, with 92.0% of women responding that vaccines can protect children from serious infectious diseases. In addition, 49.4% reported vaccination for influenza in the past year.

The perceived seriousness of COVID-19 and importance of prevention measures were highly variable among the 16 sampled countries - and, notably, did not correspond to the infection rate in the country. (This result underscores that a high burden of disease alone may not provide sufficient motivation for pregnant women and mothers of young children to seek vaccination for themselves or their children.) Most responders trusted health science in general and were satisfied with public health authorities in their countries for their performance in controlling the pandemic, although the trust and satisfaction level varied among countries. Though 74.2% of women felt informed on the development of a COVID-19 vaccine, 27.7% did not follow COVID-19 news in any form (TV, radio, newspaper, news websites, social media).

The top three reasons for pregnant women to decline COVID-19 vaccination during pregnancy even if the vaccine were safe and free were that they did not want to expose their developing baby to any possible harmful side effects (65.9%), were concerned that approval of the vaccine would be rushed for political reasons (44.9%), and would like to see more safety and effectiveness data among pregnant women (48.8%). The top reasons for mothers to be unwilling to have their child/children vaccinated for COVID-19 were that they are concerned that approval of the vaccine will be rushed for political reasons (39.8%), would like to see more safety and effectiveness data among children (32.7%), and believe that the vaccine is not safe (28.4%).

Only 45.9% of pregnant women and 54.6% of non-pregnant women would be more likely to have themselves/children vaccinated if recommended by healthcare providers. Strongest predictors of COVID-19 vaccine acceptance were confidence in COVID-19 vaccine safety and efficacy, belief in the importance of vaccines/mass vaccination to their own country, confidence in routine childhood vaccines, worry about COVID-19, trust in public health agencies/health science, and compliance with mask guidelines.

In light of the findings, the researchers suggest:

• Governments, especially those of countries experiencing COVID-19 denial and public distrust, should work to rebuild confidence as vaccine roll-out continues using clear and unified communication.
• In light of the finding that healthcare providers' recommendation alone will have limited effects on improving acceptance among the studied population, for those who do not follow COVID-19 news through any media and have high vaccine reluctance, alternative communication methods are needed.
• Because significant portions of pregnant women and mothers expressed safety concerns due to insufficient pregnancy- and children- related clinical evidence, it will be important to communicate data as they become available for these two groups to build trust in these vaccines.
• As reported here: "It is especially urgent for countries currently experiencing widespread public distrust during the pandemic to rebuild vaccine confidence through transparent communication and effective community engagement. COVID-19 vaccine education campaigns need to emphasize the pandemic as a whole and what's at stake for communities, instead of a limited focus of vaccine safety and effectiveness."

In conclusion: "COVID-19 vaccine acceptance and its predictors among women vary globally. Vaccination campaigns for women and children should be specific for each country in order to attain the largest impact."