We conducted a national, cross-sectional survey to explore COVID-19 vaccine uptake behaviour and intention among pregnant people. A total of 193 individuals participated in our survey from May 28 through June 7, 2021, after COVID-19 vaccination during pregnancy had been recommended by NACI.
We found that most pregnant people (57.5%) had received (48.2%) or intended to receive (9.3%) the COVID-19 vaccine while pregnant. These results are within the wide range of COVID-19 vaccine intention for pregnant people reported in the literature (28–62%), including results from the United Kingdom (62.1%; August–October 2020) (Skirrow et al., 2021), the United States (41%; August–December 2020) (Battarbee et al., 2021), Italy (28.2%; January 2021) (Carbone et al., 2021), and multinationally (61.4%; April–July 2020) (Ceulemans et al., 2021), (52.0%; October–November 2020) (Skjefte et al., 2021). Our results are somewhat higher than COVID-19 vaccine uptake results reported elsewhere. In a US study, only 16.3% of all pregnant people had received the COVID-19 vaccine between December 14 and May 8, 2021, though monthly coverage steadily increased during the study period (Razzaghi et al., 2021). Results from Ontario show a similar trend, with vaccine uptake increasing from approximately 0.02% in December 2020 to 38.1% in May 2021 (Better Outcomes Registry & Network Ontario, 2021). These studies used administrative data to determine vaccine uptake; in contrast, our study relied on self-report, which may overestimate coverage in this population (Poliquin et al., 2019).
Confidence in vaccine safety was the most significant predictor of COVID-19 vaccine acceptance among respondents in our study, and vaccine safety concerns were the most cited reason for not accepting the COVID-19 vaccine during pregnancy. Similar results have been reported in the literature (Battarbee et al., 2021; Carbone et al., 2021; Skjefte et al., 2021), with studies conducted earlier in the pandemic identifying a lack of pregnancy-specific safety information as a barrier to positive vaccine intention (Skirrow et al., 2021). Vaccine safety concerns are almost universally reported as a barrier to vaccine uptake during pregnancy, for both routine and pandemic vaccinations (Poliquin et al., 2019). Our results indicate that a majority of those who did not accept the vaccine during pregnancy disagreed with receiving a vaccine that had not been tested in pregnant people. However, over half of those who did not accept vaccination during pregnancy reported that they planned to receive the COVID-19 vaccine after giving birth, and few indicated a negative perception of vaccines in general. These findings support the necessity of pregnancy-specific safety information about the COVID-19 vaccine for optimizing vaccine uptake in this population. Notably, a lack of pregnancy-specific information also appears to be a concern among those who reported they had already received a COVID-19 vaccine dose during pregnancy. It will be important to explore whether those who received the vaccine were simply unaware of the lack of COVID-19 vaccine safety information early in vaccine rollout, or whether emerging safety information later in the pandemic informed their vaccination decision. Regardless, in an environment where safety information is evolving, it is important that pregnant people are provided with ongoing opportunities to discuss vaccine safety, and that care providers have adequate information and techniques to support and communicate individual risk-benefit assessment.
Self-protection was identified by almost 65% of respondents as their primary reason (choice 1) for accepting a COVID-19 vaccine. Motivations outside of self (protect family, protect community) were also common. Despite this, perceived personal risk was not a predictor of vaccine acceptance in the multivariate analysis, suggesting that respondents who did not accept the vaccine during pregnancy may have had a higher risk perception of the vaccine than the disease. In addition, despite the established association between chronic illness and negative COVID-19 outcomes (Public Health Agency of Canada, 2021), presence of a chronic medical condition was not associated with increased vaccine acceptance in our study. Other literature reports mixed results on the importance of personal risk in COVID-19 vaccine intentions (Battarbee et al., 2021), with one study identifying perceived personal risk as less important than general concern about COVID-19 (Skjefte et al., 2021). We did not assess whether respondents were aware of the elevated risk for negative COVID-19 outcomes during pregnancy, though given that knowledge in this area is still developing, it is likely that lack of disease risk awareness plays a role in COVID-19 vaccine acceptance. In the general adult population, risk-based messaging about COVID-19 disease appears to have little impact on those who have concerns about vaccine safety and efficacy (Motta et al., 2021). Similar results have been found regarding established vaccines in pregnant people, though messaging that emphasizes protective benefit of vaccination to the fetus may be particularly effective (Ellingson et al., 2019).
In our study, employment status was significantly related to COVID-19 vaccine acceptance. Both respondents who work in the healthcare field and those who work in other occupations at higher risk for COVID-19 exposure were more likely to report COVID-19 vaccine acceptance when compared to those who were unemployed. However, employment as a healthcare worker was not statistically significant in the multivariate model. Published literature indicates mixed results on the relationship between COVID-19 vaccine intention and healthcare employment (Battarbee et al., 2021; Ceulemans et al., 2021; Skjefte et al., 2021). It is possible that early prioritization of healthcare workers may have actually hindered COVID-19 vaccine uptake among pregnant healthcare workers, as these individuals may have made decisions about vaccination very early, when little information on COVID-19 vaccine safety during pregnancy was available. However, the specific healthcare-related professions of respondents may have also impacted our results, as significant variation between different healthcare professions has been found for both COVID-19 vaccine intention (Ciardi et al., 2021) and uptake (Dzieciolowska et al., 2021).
Respondents who self-identified as Indigenous were significantly more likely to report COVID-19 vaccine acceptance compared to those who identified as white in this study. Our results also indicate that COVID-19 vaccine acceptance among visible minorities was not significantly different from vaccine acceptance among white respondents. Minority race/ethnicity has been identified as a factor in lower COVID-19 vaccine intention among pregnant people in the UK (Skirrow et al., 2021), and both intention (Battarbee et al., 2021) and uptake (Razzaghi et al., 2021) in the USA; however, the impact of efforts to prioritize vaccine access among these communities is unknown. In Canada, national recommendations identified both Indigenous adults and adults in racialized and marginalized communities as priority groups for early access to COVID-19 vaccines, based on potential increased risk of exposure and/or negative health outcomes (Government of Canada, 2021c). Early in the pandemic, public health campaigns and education strategies developed by Indigenous communities, and grounded in Indigenous tradition, appeared to contribute to initially low COVID-19 case and mortality rates (Richardson & Crawford, 2020). The impact of these efforts on vaccine uptake, in combination with early prioritization, should be explored.
Sociodemographic factors such as age, income, and education were not significantly related to vaccine acceptance in our study. Similar results have been found regarding intention to receive COVID-19 vaccine while pregnant (Battarbee et al., 2021; Carbone et al., 2021), though results may be country-dependent (Skirrow et al., 2021; Skjefte et al., 2021). In contrast, older maternal age, higher income, and increased education have been consistently associated with higher seasonal and pandemic influenza vaccine uptake during pregnancy (Poliquin et al., 2019; Yuen & Tarrant, 2014). Reasons for these relationships have not been well explored, though vaccine access constraints are assumed to play a role (Liu et al., 2012). Efforts to facilitate vaccination during the COVID-19 vaccine rollout may have contributed to more equitable vaccination access, thus minimizing the impact of sociodemographic factors on vaccine uptake. Given this study’s small sample size, these relationships should be explored among larger samples, with a focus on understanding the impact of different vaccination strategies on equitable access.
Vaccine recommendation by a healthcare provider is extensively discussed as an important facilitator for vaccine uptake during pregnancy (Poliquin et al., 2019; Yuen & Tarrant, 2014). In our study, healthcare provider recommendation was cited as a top 3 reason for vaccine acceptance by less than 14% of respondents. Although most respondents did not identify recommendations from healthcare providers as reasons for vaccine acceptance, this may indicate that in the context of pandemic disruption, and significant public education and vaccination efforts, pregnant people who were generally positive about vaccination had less need for healthcare provider input. Evolving national recommendations and an initial lack of pregnancy-specific information on vaccine safety and effectiveness likely also impacted the willingness of maternal care providers to encourage COVID-19 vaccination for their patients (Deruelle et al., 2021). In light of the significant role vaccine safety concerns play, and indications that risk is either poorly understood or undervalued, future research should explore what patient factors determine whether healthcare provider recommendation outweighs safety concerns.
Strengths and limitations
Our study captured both COVID-19 vaccine uptake and intention among a national sample of pregnant people at a time when national guidelines recommended that COVID-19 vaccine be offered to all pregnant people. However, the small sample size and use of a pre-existing panel of individuals may limit the generalizability of our results to the broader population of pregnant women in Canada. Reliance on self-reported vaccine uptake is a potential limitation, subject to both recall and social desirability bias. However, the high-profile nature of COVID-19 vaccination means respondents were unlikely to be impacted by recall, and the online and anonymous nature of the survey likely decreases the impact of social desirability on responses. The survey excluded pregnant individuals who were vaccinated prior to pregnancy, who may have been more likely to accept the vaccine during their pregnancy. This may have resulted in an underestimation of COVID-19 vaccine acceptance, though is more likely to be a factor among groups who were prioritized very early in the vaccine rollout (e.g., healthcare workers, Indigenous peoples). Although national vaccine recommendations provide some indication of how vaccines were prioritized in Canada, program implementation decisions, including sequencing of prioritized groups, occurs at the provincial/territorial level and thus was likely subject to regional variation. Given the small sample size, we were unable to assess any regional variation in COVID-19 vaccine acceptance. Finally, the cross-sectional design of the study precludes our ability to identify any trends in vaccine acceptance with time. Given the rapidly evolving conditions of the COVID-19 pandemic, and associated vaccine information and policy, COVID-19 vaccine acceptance among this population will be subject to change.