Understanding COVID-19 vaccine hesitancy and decision-making during pregnancy

In a recent study published in the journal Vaccine, researchers used a web-based survey to analyze coronavirus disease 2019 (COVID-19) vaccine-related awareness and hesitance in pregnant Californians.

Study: Understanding COVID-19 vaccine uptake during pregnancy: ‘Hesitance’, knowledge, and evidence-based decision-making. Image Credit: Marina Demidiuk/Shutterstock
Study: Understanding COVID-19 vaccine uptake during pregnancy: ‘Hesitance’, knowledge, and evidence-based decision-making. Image Credit: Marina Demidiuk/Shutterstock


The rapid development and roll-out of COVID-19 vaccines have been a key mitigation strategy against the ongoing pandemic. However, initial vaccine trials did not include pregnant and lactating people, who are thus often hesitant to receive COVID-19 vaccines, despite recommendations from the Centers for Disease Control and Prevention and the American College of Obstetrics and Gynecology.

A thorough understanding of the reasons behind this vaccine hesitancy in this population is crucial to increasing vaccine uptake.

About the study

In the present study, the team surveyed 387 pregnant women based in California between December 2020 and January 2021 to gather their understanding and decision-making regarding COVID-19 vaccination. A web-based survey was offered to the participants starting two weeks from the first COVID-19 vaccine emergency use approval (EUA). Participants were recruited using StudyPages, an online platform that uses targeted social media campaigns to solicit participants.

The surveys and recruitment materials were available in both Spanish and English. The eligibility criteria for inclusion in the study were those who were residing in California, currently pregnant, and aged between 18 and 45. A total of 454 participants completed the survey.

Participants who completed the survey in less than 10 minutes, who took the survey multiple times, or who did not complete all parts of the survey were excluded before analysis to ensure good data quality. As a result, a total of 62 participant surveys were excluded and the analytic sample comprised 387 participants.

The team used descriptive, regression-based analyses to examine rates of planned vaccine uptake and reasoning in individuals reported to have vaccine hesitancy.


The findings showed that pregnant Californians surveyed in this study were fairly aware of COVID-19 vaccines overall. Of the 387 study participants, 43% reported that they are planning to receive the vaccine as soon as they can. The remaining 57% of the participants were hesitant about receiving a COVID-19 vaccine, 27% of whom said that they do not plan to receive the vaccine.

Demographic features such as younger age and residing in less urban areas were predictors of vaccine hesitancy. Younger individuals were also less likely to engage in COVID-related healthy behaviors, including receiving a flu vaccine and mitigation strategies such as physical distancing and mask usage.

Respondents who were not in full-time employment reported more vaccine hesitancy. The reason behind these findings may be that those who stay home or live in a secluded area may perceive a lower risk of contracting COVID-19 and are more likely to delay vaccination.

In this sample, ethnicity, race, and primiparity were not linked to vaccine hesitancy. However, given the lower COVID-19 vaccination rates among pregnant women of color in general, there should be a special focus on them during vaccination efforts. Having received or intending to receive a flu vaccine was negatively linked to COVID-19 vaccine hesitancy. The most common reason provided for COVID-19 vaccine hesitancy was ‘‘I don’t know enough about the vaccine.” Low self-reported knowledge levels were also good predictors of vaccine hesitancy.

Surprisingly, essential worker status was a predictor of vaccine hesitancy, which contrasts with previous study reports suggesting that individuals perceiving themselves as more vulnerable to COVID-19 infection were less vaccine-hesitant.


According to the authors, terms such as ‘‘anti-vax” and ‘‘vaccine hesitance” do not sufficiently characterize or explain decisions related to delaying COVID-19 vaccination.

Understanding the nuance in ‘‘vaccine hesitancy” is critical for promoting vaccination uptake. Vaccine hesitancy is mostly associated with the lack of knowledge on the impact of vaccines on pregnancy and the development and wellbeing of the fetus. This gap in knowledge should be addressed by the inclusion of pregnant women and newborns in new vaccine trials and with the help of supportive and informative conversations between healthcare providers and pregnant individuals.

Future research must focus on attitudes linked to COVID-19 vaccine decision-making among pregnant individuals who were previously infected. Also, because research suggests that vaccine-induced immunity is more robust and lasts longer than infection-induced immunity, educational programs based on these findings can help improve vaccine uptake in previously infected people.

Public health agencies can collaborate with individual health care providers to help disseminate vaccine-related information to this vulnerable group of the population, by providing sample brochures and pamphlets that can be personalized to each practice and target lists.

Journal reference:
Susha Cheriyedath

Written by

Susha Cheriyedath

Susha has a Bachelor of Science (B.Sc.) degree in Chemistry and Master of Science (M.Sc) degree in Biochemistry from the University of Calicut, India. She always had a keen interest in medical and health science. As part of her masters degree, she specialized in Biochemistry, with an emphasis on Microbiology, Physiology, Biotechnology, and Nutrition. In her spare time, she loves to cook up a storm in the kitchen with her super-messy baking experiments.


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