COVID19 vaccine hesitancy among perinatal women at risk for health disparities

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Abstract Despite safety data supporting use of COVID-19 vaccines among pregnant and lactating women, COVID-19 vaccine coverage among perinatal women in the United States is very low, with uptake even lower among some racial and ethnic groups such as Black/African American and Latina women. Concerningly, pregnancy is associated with more severe outcomes associated with COVID-19 infection: pregnant women with COVID-19 have higher rates of ICU admission, mechanical ventilation, and mortality compared to women with COVID-19 who are not pregnant. Further, infants born to women with COVID-19 are more likely to be born preterm, potentially leading to numerous downstream negative consequences for the child’s health and development. In spite of the high stakes of infection for women and their offspring, little is known about factors contributing to COVID-19 vaccine hesitancy (VH) and refusal among perinatal women, particularly those at highest risk for health disparities. Identifying factors contributing to VH among this vulnerable group of women is crucial to the development of effective interventions to promote vaccine uptake. Further, little is known about factors relating to prenatal care provider behavior and recommendations regarding COVID-19 vaccination during pregnancy and postpartum. Our experienced, interdisciplinary team proposes a 2-year, mixed methods R21 investigation that includes both a patient component and a provider component in order to identify key factors contributing to COVID-19 vaccine uptake and refusal in the perinatal period. In the patient component, we will recruit 120 English and Spanish-speaking financially-disadvantaged pregnant and postpartum women, including half who were vaccinated in pregnancy and half who are unvaccinated. Guided by the Theory of Planned Behavior and the Five C’s model of Vaccine Hesitancy, and with input from a diverse group of community stakeholders, we will assess cognitive and affective factors, psychological symptoms, medical mistrust, and other contributors to vaccine decision-making. We will conduct qualitative interviews with a subset of women (n=30) to augment our understanding of factors driving vaccine reluctance and refusal. In the provider component, we will recruit 60 prenatal care providers who work with financially disadvantaged women (OBs, family medicine, midwives, nurses) to take part in an in-depth survey regarding factors contributing to VH, refusal and uptake during the perinatal period; a subset of 30 providers will take part in qualitative interviews to explore these issues further. Our analytic plan involves generalized linear models to examine predictors of patient vaccination outcomes, and qualitative thematic analysis to identify key themes women and providers endorse regarding COVID-19 vaccine hesitancy. Findings will inform provider education and services innovations, as well as intervention development to target increased vaccination uptake this vulnerable patient group.