COVID-19 vaccination uptake in 441 socially and ethnically diverse pregnant women.

Pregnant women are at greater risk of severe COVID-19 disease compared to their non-pregnant counterparts [ 1 – 3 ]. Rates of admission to intensive care are three times greater in pregnant women compared to non-pregnant women, with a 25% greater likelihood of death [ 4 ]. The risk is higher in pregnant women with health conditions and complications during pregnancy [ 1 , 2 , 5 ]. In addition, women who contract COVID-19 during pregnancy have a higher risk of pre-eclampsia, preterm birth, stillbirth and early neonatal death [ 5 ]. Whilst initial advice from the UK’s Joint Committee on Vaccination and Immunisation (JCVI) stated in December 2020 there was insufficient evidence to vaccinate during pregnancy routinely [ 6 ], it is now known that COVID-19 vaccination during pregnancy can reduce the risk of severe infection and resultant complications [ 7 , 8 ]. In April 2021, the JCVI made a specific recommendation that pregnant women should be offered a COVID-19 vaccine [ 8 ]. To date, observational data have not identified any safety issues with COVID-19 vaccination in pregnancy [ 9 ], with similar side-effects reported between vaccinated and non-vaccinated pregnant women [ 7 , 9 – 11 ]. However, COVID-19 vaccine uptake and intent to vaccinate remain low amongst pregnant women [ 3 , 5 , 7 ]. A recent UK cohort study found that less than one-third of 1328 eligible pregnant women accepted the COVID-19 vaccination [ 7 ]. A prospective cohort study of 131,000 pregnant women in Scotland suggested that less than half of those who gave birth in October 2021 had received any COVID-19 vaccination, and less than a third were fully vaccinated [ 5 ]. These vaccination rates are significantly lower than that in the general population, where 77% of non-pregnant women of child-bearing age had been vaccinated with two doses over the same period [ 5 ]. Additionally, high rates of vaccine hesitancy [ 12 ] (a delay or refusal of safe vaccines despite availability of vaccine services) have resulted in adverse consequences in pregnancy [ 1 ]. Data from England show that between February and September 2021, over 98% of 742 pregnant women admitted to hospital with symptomatic COVID-19 were unvaccinated [ 1 ]. Even more recent data from November 2021 to January 2022 show about 46% (n = 56,461) of pregnant women remained unvaccinated at delivery, with the highest number of unvaccinated in Black (69.5%, n = 4,164) and mixed ethnicities (56%, n = 1694) [ 13 ]. A further study found hospitalisation (n = 748/823, 91%) and intensive care admissions (n = 102/104, 98%) due to COVID-19 were disproportionately high among unvaccinated pregnant women [ 5 ]. Vaccine hesitancy is higher in women who are younger [ 7 ], have higher levels of socio-economic deprivation [ 3 , 7 ] and are of Afro-Caribbean or Asian ethnicities [ 3 , 7 , 14 ]. These ethnic groups have also been found to be at greater risk of COVID-19 associated morbidity and mortality [ 2 , 15 , 16 ]. Recent studies have shown reasons for vaccine hesitancy include poor communication of vaccine safety and benefits, lack of recommendations from trusted sources, lack of long-term safety data and mistrust of healthcare providers [ 17 – 21 ]. However, local factors that lead to low vaccine uptake amongst ethnically diverse pregnant women are not well known. This quality improvement survey aimed to explore uptake, facilitators, and barriers to COVID-19 vaccination amongst pregnant women presenting to the antenatal units of two district general hospitals in Berkshire and Surrey and provide recommendations for improving vaccine uptake.

There were 441 respondents to the survey in Frimley Park and Wexham Park hospitals (212 and 229 participants, respectively). Due to the nature of the survey, an overall response rate could not be calculated. However, the estimated response rate in women who were actively invited by the healthcare staff in Wexham Park Hospital was 63% (n = 190/300), with a further 39 women completing the survey in response to posters about the survey in clinics. A similar estimated response was received in Frimley Park Hospital. Table 1 presents the baseline characteristics of the participants. Their mean age was 32 years (range 17–44). Most survey respondents were White British 63.6% (n = 271) and 85.4% (n = 364) of respondents reported English as their main language. About 12% of participants (n = 52) reported a different main language, including Urdu, Punjabi, Pushto, Somali, Swahili, Romanian, Arabic, Amharic, Portuguese, Spanish, Italian and French. Most participants (n = 299, 68.7%) did not report any underlying health condition. Asthma was the most commonly reported condition (8.7%) followed by diabetes (4.1%) and hypertension (2%). Other conditions included arthritis, idiopathic intracranial hypertension, chronic fatigue syndrome, polycystic ovary syndrome, Crohn’s disease, cystic fibrosis, eczema, alopecia, endometriosis, epilepsy, migraines, factor V Leiden, fibromyalgia, lupus, hypothyroidism, irritable bowel syndrome, multiple sclerosis, stroke, ulcerative colitis, and joint hypermobility syndrome. Most women either reported nulliparity or one previous delivery (n = 306, 76.5%) and most survey participants were in their third trimester of pregnancy (n = 222, 66.2%). Fourteen percent of women (n = 60) reported having had COVID-19, predominantly during the second wave of the current pandemic (September 2020 –April 2021) [ 23 ]. A third of these (n = 20) were pregnant at the time of infection. Most survey respondents (n = 292, 66.2%) chose to have a COVID-19 vaccine. Of those vaccinated, 87.6% received two doses, and most were Pfizer-BioNTech vaccine (75.3%) ( Table 2 ) . Respondents not receiving the vaccine were most concerned about the effect of the vaccine on the baby and future pregnancies. In addition, they felt that there was insufficient information known about the vaccine to make a decision ( Table 2 and Fig 1 ). *Multiple answers allowed; thus, percentages can sum to greater than 100. Vaccination uptake was 72% in White British women, 68% in Asian or Asian British women and 64% in White Other ( Table 2 ). Only 33% of Black/African/Caribbean/Black British women were vaccinated; however, numbers were small. Differences were not statistically significant (χ 2 (5 n = 422) = 4.63, p<0.46). Fifty-one participants cited further reasons for refusal to take up the COVID-19 vaccine in the free text box ( S1 Fig ). Thematic analysis revealed the following themes: Nearly all who responded to the question mentioned concerns about vaccine safety, side effects, and unknown long-term effects on the health of the unborn baby and/or mother. Most participants were worried about the effect of the vaccine on the foetus and its development. Some said they would consider having the vaccine once the baby was born but not whilst they were pregnant. “There is no actual facts on how safe this vaccine is during pregnancy . One minute your told pregnant women should not take it then they should . Who knows how safe it really is . Issues will arise in time to come . ” 29 years, White Other “We have no idea what the long term consequences of this vaccine will be for mother or baby . This is a trial drug . ” 39 years, White British “I’m concerned mainly about the impact on the baby currently when pregnant . Don’t know long term impact . ” 33 years, Asian or Asian British Most respondents mentioned a lack of data and information on the effect of the vaccine during pregnancy as the reason for their refusal. Further, they believed that the vaccine has not been around for long enough to have an adequate understanding of its safety and long term effects in pregnancy. “No proof that the vaccine is safe for the newborn—it hasn’t been out long enough . I strongly believe it shouldn’t be advertised as safe as they don’t know that yet ! ” 33 years, White British “There is no long term data to show any adverse effects on a foetus or adult . The unvaccinated are being told that they must be vaccinated to be protected but the vaccinated are being told that they are not fully protected and need a "booster" . For this reason , at this moment in time I choose not to have the vaccine as I have no faith . ” 25 years, White British “It is still a new vaccine with limited data on side effects and if it works . ” 34 years, Asian or Asian British Some women were concerned about the lack of clarity and the changing nature of advice. “ I wanted it but then got pregnant . In that time , they keep moving the goal posts . Plus it’s too soon to have a great understanding and statistics .” 40 years, White British “ When I was pregnant—at the start it wasn’t advised for pregnant women to have . Then half way through that was changed to we should . In a matter of months with little evidence as to why . I chose to decline it . I worked through the pandemic as a funeral coordinator and on private ambulance . Covid was sadly wiping out like flu does but earlier . I personally did not see people my age . Or middle aged passing of covid . So I am not happy to take a vaccine that could put myself and my baby at risk or my future . ” 30 years, White British Many women mentioned that they did not trust the vaccine or had any confidence in its necessity, safety or effectiveness. Some women believed that the vaccines did not prevent people from contracting or spreading the infection. Further, a few women had lower perception of risk from COVID-19 due to being younger and healthier. “I don’t trust . ” Age and ethnicity not disclosed “The infections have now risen so high when so many people are jabbed . It does not seem to be working . ” 32 years, White British “It doesn’t stop you catching it or spreading it—it only potentially reduces the symptoms and as a young fit healthy woman , I’d rather not take the risk of injecting the unknown into my body . If the vaccine prevented you getting it or spreading then I’d reconsider as it’s helping others but right now , the only person it’s helping is me and weighing up the risks , I’m happy not getting it for now . ” 28 years, White Other “ I trust the NHS information however I think the governments’ message is wrong and misleading . Forcing young healthy people to get a vaccine when they probably wouldn’t end up on hospital and they can still spread it is so wrong ! Right now , as the vaccine stands , it’s a personal choice which only affects the person getting the dose and nobody else . If I chose not to get it , I’m not putting anyone else at a greater risk then someone who is vaccinated as we can both spread it . ” 28 years, White Other Some women specifically mentioned the effect of the vaccine on their fertility. “Most concerns are around the impact on fertility . ” 39 years, White British “My doctor initially advised against and after a miscarriage last year I’ve been too scared to have it . ” 40 years, White Other “It is still in a trial phase therefore it is not known what side effects can happen to me or baby.” White British Common sources of information included patients’ GPs and midwives, health-related websites, mainstream news organisations, patients’ families and friends and social media respectively Table 2 . The single most trusted sources of information were the patients’ local GP or Midwife (n = 186, 42.8%) and specific health related websites (n = 170, 39.3%) Table 2 and Fig 2 . Other sources of information included Google searches, workplace, research and news from outside the UK, health websites such as Royal College of Obstetrics and Gynaecology, other healthcare professionals such as an obstetrician, nurse or hospital doctor and information directly from vaccine manufacturers. Some patients responded that they did not trust any source and relied on their own opinion/gut instinct or ‘independent search’ and some reported that it was a “guessing game”.

This large quality improvement survey amongst a diverse group of pregnant women highlights barriers and facilitators to COVID-19 vaccination in pregnancy. As a result, we have already appointed vaccine champions at our hospital. The recommendations based on this study could improve both COVID-19 vaccination uptake and other routine immunisations, such as pertussis and influenza vaccines, during pregnancy.

Pregnant women booked for antenatal clinics at Wexham Park and Frimley Park Hospitals (District General Hospitals of Frimley Health NHS Foundation Trust) were invited to participate in an anonymous, voluntary quality improvement survey between 1 September 2021 and 28 February 2022. The two suburban hospitals serve a diverse population group in terms of socio-economic status and ethnicity. The survey was conducted in English. The survey instrument was initially developed based on our current understanding of the influencing factors in COVID-19 vaccination [ 17 , 18 ]. The final multiple-choice survey questionnaire was modified based on a pilot in five pregnant women ( S1 Fig ). Participants were asked to provide demographic data on age, ethnicity, main spoken language, parity, gestation, and pre-existing health conditions. Participants were also asked about previous COVID-19 infection and their COVID-19 vaccination status. Those who had not received a COVID-19 vaccine were asked the reasons (barriers). We also asked participants to identify where they received information about COVID-19 vaccines and which single source of information they trusted the most (facilitators). Participants were also asked open-ended questions about COVID-19 vaccination. According to Frimley Health NHS Trust, this work met the criteria for operational improvement activities exempt from ethics review. (We also applied the Medical Research Council (MRC) Criteria.) Accordingly, it was registered as a Quality Improvement Project (QIP FXP-49) with the Frimley Excellence. Participants were given information about the study and advised that they could choose whether or not to take part without affecting their treatment, and that completing the survey denoted consent to participate. Pregnant women presenting for routine appointments at antenatal clinics of the two hospitals were invited to participate. Pregnant women were given information about the survey and encouraged to ask questions. They were provided with a paper copy of the survey by the clinic receptionist or clinical staff (consultant, specialty registrar or midwife) or directed to a QR code link where they could complete the survey online using their smartphone. Additionally, posters advertising the survey with the QR code were placed in the antenatal waiting room and toilet facilities. Most women had a relatively high-risk pregnancy, defined as anyone referred to secondary care for specialist management due to underlying health conditions, maternal age, previous pregnancy-related complications, and other risk factors [ 22 ]. Online versions were collected on Microsoft Forms (MS Forms). Paper versions of the survey were manually inputted into MS Forms, and the data was collated on Microsoft Excel Version 16.58. Statistical analysis was performed by (LPG) using Stata 15.1 (Stata Corp (2017) Stata Statistical Software: Release 15. College Station, TX.) Descriptive data were summarised. The Pearson Chi-squared test excluding groups with expected counts of less than five was used to test for differences in categorical data. Analysis of patient free text responses was informed by thematic analysis, conducted by MSR and approved by other team members.

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