‘It has been the hardest decision of my life’: a mixed-methods study of pregnant women’s COVID-19 vaccination hesitancy

Figures & data

Table 1. Descriptive statistics for sample (N = 191).

		Vaccine accepting		Vaccine Hesitant		Vaccine Resist		Full sample
Variable		N	%	N	%	N	%	N	%
Marital status
	Single	0	0	1	6	6	6	7	4
	Married/living as married	78	99	17	94	87	93	182	95
	Missing	1	1			1	1	2	1
Residence
	England	60	76	17	94	81	86	158	83
	Scotland	8	10	1	6	7	7	16	8
	Wales	4	5	0	0	2	2	6	3
	N Ireland	0	0	0	0	1	1	1	.5
	Rep of Ireland	7	9	0	0	3	3	10	5.2
Ethnicity
	White	75	95	16	89	89	95	180	94
	BAME	4	5	2	11	5	5	11	6
Education
	College or below	11	14	6	33	29	31	46	24
	University	66	83	12	67	62	66	140	73
	Missing	2	3			3	3	5	3
Household income
	<£24 k	4	5	4	22	22	23	30	16
	£25 k–£44999	16	20	4	22	19	20	39	20
	£45 k–64999	24	30	5	28	30	32	59	31
	£65-849999	16	20	3	17	15	16	34	18
	>85 k	19	24	2	11	8	9	29	15
First baby
	Yes	29	37	5	28	41	44	75	39
	No	50	63	13	72	53	56	116	61
Trimester
	First	6	8	2	11	3	2	11	6
	Second	23	29	9	50	27	29	59	31
	Third	50	63	7	39	64	68	121	63
Public facing job
	Yes	24	30	7	39	40	43	71	37
	No	55	70	11	61	54	57	120	63
C-19 risk factors
	Yes	50	63	8	44	52	55	110	58
	No	28	35	10	56	42	45	80	42
	Missing	1	1					1	.5
COVID infection ever
	Yes	9	11	5	28	18	19	32	17
	No	59	75	12	67	65	69	136	71
	Not sure	11	14	1	5	11	12	23	12
Previous flu vaccine
	Yes	54	68	15	83	50	53	119	62
	No	25	32	3	17	44	47	72	38
Maternal flu vaccine
	Yes	30	38	4	22	51	54	77	40
	No	49	62	14	78	43	46	114	60
Maternal pertussis vaccine
	Yes	47	60	10	56	57	61	114	60
	No	32	40	8	44	37	39	77	40
Maternal COVID-19 vaccine
	Yes	75	95	0	0	0	0	72	38
	No	4	5	18	100	94	100	119	62
COVID-19 vaccine intention
	No	0	0	0	0	94	100
	Unsure	0	0	18	100	0	0
	Yes	6	8	0	0	0	0
	Already had it	73	92	0	0	0	0
If not pregnant how likely to have COVID-19 vaccine
	Not applicable	72	91					72	38
	Extremely unlikely	1	1			21	22	22	12
	Somewhat unlikely					4	4	4	2
	Neither likely nor unlikely			1	6	1	1	2	1
	Somewhat likely			1	6	20	21	21	11
	Extremely likely	5	6	16	89	47	50	68	36
	Missing	1	1			1	1	2	1
Partner COVID-19 vaccine
	No	2	3	0	0	25	26	27	14
	Unsure	1	1	1	5	8	9	5	5
	Yes	75	95	17	95	61	65	153	81
	Missing	1	1					1	.5
COVID-19 Information sources
	Newspaper (print or online)	43	54	6	33	25	27	74	39
	TV news	8	10	2	11	26	28	36	19
	Social media	4	5	2	11	9	10	15	8
	Word of mouth					1	1	1	.5
	Other	24	30	8	44	33	35	65	34

Table 2. Means (SD) for continuous variables for vaccine accepting, hesitant and resistant groups.

Variable	Vaccine acceptinga	Vaccine Hesitantb	Vaccine Resistantc
Age	32.89 (4.12)	30.67 (5.21)	30.68 (4.95)
C19 Susceptibility	10.98 (2.06)	9.39 (2.30)	9.31 (2.27)
C19 Severity	17.98 (2.54)	17.61 (2.36)	14.06 (4.29)
Vaccine Benefit	22.48 (2.72)	19.00 (4.09)	16.12 (6.23)
Vaccine Risk	8.00 (2.76)	11.22 (3.37)	14.60 (4.30)
Barriers to vaccination	11.32 (4.25)	16.94 (3.87)	19.05 (4.21)
Peer influences	16.61 (2.34)	14.90 (1.94)	12.66 (2.95)
Government influence	3.57 (1.05)	2.44 (.71)	1.84 (.92)
GP influence	4.28 (.93)	3.28 (.58)	2.15 (.98)
Midwife influence	4.33 (.94)	3.61 (.85)	2.32 (1.08)
Trust in authorities	68.29 (16.78)	58.44 (21.19)	47.72 (25.97)
Anticipated regret	9.22 (2.40)	6.50 (3.41)	4.20 (2.52)
Adherence to PH guidelines	57.67 (8.05)	57.11 (7.24)	55.48 (11.04)

Note.

^an = 79.

^bn = 18.

^cn = 94.

Table 3. Results of Kruskall–Wallis tests of difference with Mann–Whitney U post hoc pairwise comparisons.

	Kruskall–Wallis		VA versus VHa	VA versus VRb	VH versus VRc
Variable	H(2)	p	p	p	p
Age	11.77	.009	.091	<.001	.96
C19 Susceptibility	22.62	<.001	.009	<.001	.88
C19 Severity	49.88	<.001	.41	<.001	<.001
Vaccine Benefit	52.00	<.001	<.001	<.001	.08
Vaccine Risk	87.86	<.001	<.001	<.001	.003
Barriers to vaccination	82.58	<.001	<.001	<.001	.069
Peer influences	70.37	<.001	<.002	<.001	.008
Government influence	81.78	<.001	<.001	<.001	.005
GP influence	109.89	<.001	<.001	<.001	<.001
Midwife influence	97.59	<.001	<.001	<.001	<.001
Trust in authorities	22.78	<.001	.06	<.001	.089
Anticipated regret	93.11	<.001	<.001	<.001	<.001
Adherence to PH guidelines	.57	.75	.70	.46	.94

Note.

^aVaccine accepting vs. vaccine hesitant.

^bVaccine accepting vs. vaccine resistant.

^cVaccine hesitant vs. vaccine resistant.

Bold values are significant p-values (p < .05).

Table 4. Sociodemographic and psychological correlates of vaccine intention.

	Would you accept a COVID-19 vaccine
	Reference = vaccine acceptant
	Vaccine resistant				Vaccine hesitant
Variable	AOR	95% CI		SE	AOR	95% CI		SE
Education	0.40	.07	2.39	.91	0.57	.08	3.89	.98
Income	0.81	.14	4.75	.91	2.53	.39	16.31	.95
Partner intention	3.86	.19	77.84	1.53	0.84	.03	28.21	.01
Flu vaccine previous	0.46	.08	2.67	.90	0.17	.02	1.27	1.02
Age	0.89	.73	1.09	.10	0.93	.74	1.16	.11
Perceived susceptibility	0.75	.48	1.17	.23	0.53*	.32	.87	.26
Perceived severity	1.07	.81	1.40	.14	1.52*	1.02	2.25	.20
Perceived benefit	1.01	.76	1.33	.14	0.86	.64	1.17	.15
Perceived risk	1.39	.99	1.93	.17	1.27	.89	1.81	.18
Barriers to vaccination	1.28*	1.01	1.62	.12	1.43**	1.12	1.82	.12
Anticipated regret	0.66*	.47	.94	.18	0.86	.59	1.24	.19
Peer influences	0.78	.53	1.15	.20	1.01	.68	1.51	.20
Government influence	1.74	.55	5.33	.58	0.71	.22	2.34	.61
GP influence	0.08**	.01	.53	.99	0.14*	.02	.97	1.00
Midwife influence	1.43	.32	6.48	.77	3.56	.72	17.66	.82

Note: *p < .05 **p < .01.

Bold values indicate statistically significant variables and the note underneath the table explains the level of significance (e.g., < .05 or < .01).

Table 5. Means (SDs) for barriers to vaccinating against COVID-19.

Variable	Vaccine accepting^a	Vaccine hesitant^b	Vaccine resistant^c
Concerns about whether COVID-19 vaccines are safe for me	2.39 (1.13)	3.06 (1.35)	3.38 (1.35)
Not enough research done on COVID-19 vaccines	2.35 (1.13)	3.78 (1.31)	4.04 (1.15)
I have concerns about possible side effects of COVID-19 vaccines	2.13 (.91)	3.67 (.97)	3.54 (1.35)
Concerns about the possible effects on the wellbeing of my unborn baby	2.91 (1.23)	4.67 (.69)	4.78 (.49)
Concerns about fertility	1.53 (.96)	1.78 (.88)	3.31 (1.52)

Note.

^an = 79.

^bn = 18.

^cn = 94.

Table 6. Results of differences between groups on barriers to vaccination, including Mann–Whitney U post hoc pairwise differences.

	Kruskall–Wallis		VA versus VHa	VA versus VRb	VH versus VR^c
Variable	H(2)	p	p	p	p
Concerns about whether COVID-19 vaccines are safe for me	23.53	< .001	.04	< .001	.35
Not enough research done on COVID-19 vaccines	63.50	< .001	< .001	< .001	.41
I have concerns about possible side effects of COVID-19 vaccines	52.88	< .001	< .001	< .001	.88
Concerns about the possible effects on the wellbeing of my unborn baby	97.39	< .001	< .001	< .001	.66
Concerns about fertility	63.34	< .001	.14	< .001	< .001

^a Vaccine accepting vs. vaccine hesitant.

^b Vaccine accepting vs. vaccine resistant.

^cVaccine hesitant vs. vaccine resistant.

Bold values are significant p-values (p < .05).

Table 7. Content analysis of free-text responses to open-ended survey questions.

Category	Quotes
Concerns due to speed of vaccine development [responses to the survey question: ‘What are your concerns about COVID vaccines in pregnancy?’]	‘Not enough babies [have been] born to vaccinated mothers to fully know risks and possible consequences’ ‘This is a new vaccine. There is not enough research to show that there would be no adverse effects to my unborn baby’ ‘6 months of research is not enough data to say unborn babies will have no adverse effects’ ‘I’m a researcher with a background in infectious diseases. I know how important vaccines can be but this is too soon. ‘If studies were finished and showed it is fine, I would definitely be vaccinated’
Perceptions of virus as risky/reasons to be vaccinated [responses to survey question: ‘What are the reasons you would have a COVID vaccine in pregnancy?’]	‘I have had it [the vaccine] at 28 weeks. Risks of COVID outweigh risks of vaccine.’ ‘Benefits [of the vaccine] to myself and baby outweigh risks now that I’m in the third trimester’ ‘Extremely high new infection rates (Jan 2021 type)’ ‘To protect my baby from COVID’ ‘To prevent premature birth’
Perceptions of vaccine as risky/concerns about vaccination: [responses to the survey question: ‘What are your concerns about Covid vaccines in pregnancy?’]	I am waiting until I give birth as even the smallest risk to my baby isn’t worth it to me.’ ‘It’s my first pregnancy so I want to avoid complications where possible’ ‘I am concerned about the long term effects that vaccine could have on my baby or myself’ ‘I am being extra careful and will get the rest of my vaccine when my unborn baby is born’
Perceptions of pregnancy as risky only with additional factors [responses to survey question: ‘What are the reasons you would have a COVID vaccine in pregnancy?’]	‘If I had additional risk factors’ ‘If I was high risk outside of being pregnant’ ‘I am young fit and healthy and I just happen to be pregnant too but I am low risk’ ‘I think they are absolutely needed for mothers who are themselves high risk or living/working in high risk environments. I’ve never declined a vaccine before and I never thought I would, but I am unwilling to take risks for my baby when my risk level and likely exposure is so low’ ‘I have had the vaccine. I am Asian, overweight and public facing.’ ‘I understand that I am more at risk of serious complications from COVID as an older pregnant woman with asthma.’ ‘To hopefully ensure my older child and husband don’t lose me due to being a CEV [clinically extremely vulnerable] and now further at risk due to pregnancy.’
Advice received by healthcare professionals [responses to survey question: ‘What are the reasons you would have a Covid vaccine in pregnancy?’]	‘My GP who I trust listened to my circumstances carefully and advised me to have the vaccine. She explained that the new Delta variant was much more infectious and the risk to me and my unborn baby of catching it and becoming seriously unwell was higher than the risk of any unknown problems the vaccine could cause to the baby. She said that she would have it herself if she was pregnant.’ ‘Because [I’ve spoken to a consultant who advised me to [accept a vaccine]’ ‘Advised [to have the vaccine] by my midwife and GP after seeking advice.’ ‘I have already had the vaccine. I had this as I was advised to do so by my GP and I believe it will pass on antibodies to my unborn child’
Advice/information not received from healthcare professionals [responses to the question: ‘What are the reasons you would have a COVID-19 vaccine in pregnancy?’ or ‘Are there any other comments you wish to make about COVID-19 vaccines in pregnancy?’]	‘When I have asked for advice from medical professionals they haven’t been very helpful. Mainly just telling me it is my decision to make and not providing me with actual information about the vaccine in pregnancy’ ‘As I wasn’t actively advised by a healthcare professional to have the COVID vaccine, I have decided to wait until baby is born. My midwife said it was very much up to me whether I had it or not.’ ‘The lack of helpful advice from the government and NHS has made me decide to wait for a vaccine.’ ‘It has been the hardest decision of my life and I feel there is no right answer and no guidance from midwives’ ‘It was an incredibly difficult decision to make and I wish there had been more direction from my healthcare professionals. Sometimes saying ‘it is your choice’ is unhelpful as there is just was not enough certainty to make a choice either way’ ‘It’s a hard decision for someone who is pregnant and I constantly worry I have made the wrong decision waiting to have the vaccine. The lack of helpful advice from the government and NHS has made me decide to wait for a vaccine.’ ‘The midwives didn’t seem to have any data or information. Just said if you get offered it take it. No evidence on safety or risks of having Covid during pregnancy or labour.’ ‘The NHS midwives are giving inconsistent advice.’ ‘The midwives didn’t seem to have any data or information. Just said if you get offered it take it’ ‘If my obstetrician recommended it. But so far I have had conflicting advice.’ ‘Communication from health authorities are vague and does not give clear guidelines on pregnancy but leaves it up to women’

Data availability statement

The data that support the findings of this study are available on request from the corresponding author, SKP. The data are not publicly available due to ethical restrictions.