Understanding COVID 19 vaccine uptake during pregnancy

‘Hesitancy’, knowledge, and evidence-based decision-making


The global spread of coronavirus disease (COVID-19) has led to multiple vaccines becoming available and approved for use. Typically, the severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) vaccines comprise a two-dose series to generate full immunity. However, as new variants emerge, uncertainty about duration of immunity after the first two doses and possible risk of breakthrough infection led to approval of third and fourth boosters doses of the COVID-19 vaccine, and a more recent bivalent booster that targets omicron variants specifically. Since the beginning of the COVID-19 pandemic, pregnant individuals have been assigned to a high-risk group.

SARS-CoV-2 infection in pregnant women compared to non-pregnant age-matched group are more likely to have an increased risk of cesarean delivery, to deliver preterm, to die around the time of birth, or to experience serious illness from hypertensive disorders of pregnancy, postpartum hemorrhage, or from infection other than SARS-CoV-2. They were also more likely to lose the pregnancy or to have an infant die during the newborn period. This risk can be further multiplied by the presence of chronic comorbidities. Immunization against SARS-CoV-19 remains the most effective form of prevention against COVID-19-related complications.  There are two major benefits of vaccinating women in pregnancy: it protects a woman from diseases that she can be particularly susceptible to in the course of gestation, and, indirectly, protects the developing fetus. In general vaccine coverage is known to be substantially lower in pregnant women than in the general female population and gestation is a well-known factor for vaccine hesitancy despite the availability of vaccine services.

For the recently authorized COVID-19 vaccines the safety and efficacy profile were clearly demonstrated, however, some sectors of the population were not recruited such as pregnant and lactating mothers and children and were left out in early clinical trials. This created a sense of uneasiness regarding the safety of vaccines in them later on even after the safety and efficacy profiles were established. To understand why pregnant and lactating women were hesitant in receiving COVID-19 vaccines, a new study conducted by Dr. Leigh Ann Simmons, Dr. Mackenzie Whipps, Dr. Jennifer Phipps, Ms. Nikita Satish from University of California along with Dr. Geeta Swamy from the Department of Obstetrics and Gynecology at Duke University surveyed Californian pregnant women during the period of December 2020 to January 2021. The research findings were published in the Journal Vaccine.

The research team initiated their studies by raising some important questions like awareness among pregnant individuals about availability of different vaccines, identifying the proportion of eligible individuals who were ready to get vaccinated and the number of pregnant women who were hesitant. The authors also tried to identify the possible reasons for hesitancy and how knowledge and awareness had an impact on vaccination among pregnant and lactating women in California. To achieve their objectives, the authors prepared a 30-minute survey and distributed the questionnaire among eligible individuals on a web-based platform. The authors were able to collect 454 responses and after screening selected 387 responses for analysis.

The study is important because understanding factors facilitating the decision as well as the obstacles is critical for implementing prevention methods. These factors may serve as the basis for further campaigns and interventions to increase COVID-19 vaccine acceptance among pregnant women and possibly design clinical trials to address efficacy and safety of vaccines in pregnant women.  The authors found that vast majority of the pregnant Californian women were aware of the latest COVID 19 vaccines (98.7%). However, among the participants, only 43% were planning to get vaccinated and 57% of the participants were hesitant in receiving the vaccine. The authors also reported that younger pregnant females and participants from semi-urban or rural areas were more hesitant to get vaccinated. According to the authors, these findings are not surprising as people living in remote areas or less densely populated area tend to have lower chances of COVID infection. The research team findings showed that respondents who did not have a full-time job tended to be more hesitant in taking COVID-19 vaccine. The single most important reason for vaccine hesitancy according to the authors was lack of sufficient knowledge about the safety and efficacy of vaccines.  Because pregnant people were not included in initial vaccine trials, possibly it was reasonable for these respondents to be hesitant about getting vaccinated. Dr. Leigh Ann Simmons and her colleagues concluded that vaccine hesitancy can be minimized by spreading awareness about vaccines and how it can prevent COVID-19 infection. As pregnant women are at higher risk, it is important to share the essential information about vaccines and their safety in such groups, and this can be achieved by one-to-one knowledge sharing by healthcare providers.


Simmons LA, Whipps MD, Phipps JE, Satish NS, Swamy GK. Understanding COVID-19 vaccine uptake during pregnancy: ‘Hesitance’, knowledge, and evidence-based decision-making. Vaccine. 2022;40(19):2755-60.

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