Study participants
Among 17,871 respondents, 29.6% (n = 5294) were pregnant at the time of taking the survey. Among pregnant women, 49.7% (n = 2629) had at least one child (Table 1). For those who were pregnant, the mean gestational age was 20.0 weeks (SD = 9.4). The mean age of all respondents, both pregnant and non-pregnant, was 34.4 years (SD = 7.3). A summary of respondent demographics is included in Table 1. Country-specific demographics are summarized in Table 1S. Overall distributions of age were homogenous across countries. India, Italy, Australia and New Zealand had higher than overall proportions of high-income respondents; US, South Africa, UK, India, Australia and New Zealand had higher than overall proportions of highly educated respondents; US, Russia and India had higher than overall proportions of married respondents.
Table 1 Baseline characteristics among pregnant women and mothers of young children (n = 17,871) Global vaccine acceptance and confidence
Among pregnant women, 52.0% (n = 2747) intended to receive COVID-19 vaccination during their pregnancy if an efficacy of 90% were achieved. Responses among pregnant women varied substantially by country (range: 28.8–84.4%). COVID-19 vaccine acceptance level was above 80% for pregnant women in Mexico and India; and below 45% for US, Australia and Russia (Fig. 2a). Among non-pregnant women, 73.4% (n = 9214/12,562) intended to receive vaccination. COVID-19 vaccine acceptance among non-pregnant women also varied substantially between countries (range 48.6–93.1%). COVID-19 vaccine acceptance level was above 90% for non-pregnant mothers in India, Brazil and Mexico; and below 56% for Australia, US and Russia (Fig. 2b). 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 (Fig. 2c). This country-variable pattern persisted after standardizing for key demographics including age, education, income and marital status.
Overall, 53.0% of women were confident that a nationally approved COVID-19 vaccine would be safe, with no harmful side effects (Fig. 3a), and 60.4% were confident that such a vaccine would be effective, protecting most people who receive the vaccine (Fig. 3b).
Perceptions on the COVID-19 pandemic
The perceived seriousness of COVID-19 and importance of prevention measures were also highly variable among the 16 sampled countries, and it did not correspond to the infection rate in the country. Women’s level of worry about COVID-19 in the US and Russia was comparable to that in lower incidence countries (Australia and New Zealand) (Fig. 4a). Despite this variation in concern, self-reported compliance with local mask-wearing regulations was above 75% in all countries (Fig. 4b). Most responders trusted health science in general (Figure S2a) and were satisfied with public health authorities in their countries for their performance in controlling the pandemic (Figure S3a); although the trust and satisfaction level varied among countries (Figures S2b, S3b, 5a, b). Though 74.2% of women felt informed on the development of a COVID-19 vaccine (Figure S4), 27.7% did not follow COVID-19 news in any form (TV, radio, newspaper, news websites, social media).
Attitudes towards vaccines
The majority of women in the 16 countries believed it was important for their own country to have a COVID-19 vaccine (85.8%) (Figure S1a), and for most people in their own country to get vaccinated (82.6%) (Figure S1b). 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 (Figure S5b). In addition, 49.4%, reported vaccination for influenza in the past year.
Top reasons for COVID-19 vaccine reluctance
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 and could have harmful side effects (28.4%). Health care providers had a limited impact: 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 health care providers.
Overall women indicated higher likelihoods to get vaccinated with higher vaccine efficacies. A sensitivity analysis was conducted to see if there was any difference in vaccine acceptance within-country before and after November 9th, 2020, the day in which Pfizer-BioNTech announced news of the first COVID-19 vaccine efficacy results. No significant difference was found in vaccine acceptance outcomes from this test.
Predictors of COVID-19 vaccine acceptance
Crude-level associations between women’s COVID-19 vaccine acceptance and potential predictors are shown in Table 2. Demographic factors, such as younger age, lower income, lower education level, non-married and no health insurance were slightly linked to COVID-19 vaccine non-acceptance. 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, worried about COVID-19, trust of public health agencies/health science, as well as compliance to mask guidelines (Figure S6). Although some of these determinants were correlated and their odds ratios diminished in multivariate regression models, they remained the strongest predictors (Table 3). These predictors were similar for pregnant and non-pregnant women, for self-vaccination and for child vaccination acceptance. The AUC was 0.84, 0.94 and 0.92 for the models of pregnant women, non-pregnant women self-vaccination and child vaccination acceptance, respectively.
Table 2 Univariate analysis for predictors of COVID-19 vaccine acceptance among pregnant women and mothers of young children Table 3 Multivariate analysis for predictors of COVID-19 vaccine acceptance among pregnant women and mothers of young children, with adjustment for all countries These findings persist in all within-country analyses (Table 2S), so we present the pooled analysis only. The correlation between the top predictors and vaccine acceptance found at the individual level is also reflected at the ecologic level (e.g., countries with higher trust in public health agencies tend to have higher acceptance).