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

Abstract

Objective

To explore psychological factors influencing decision-making regarding COVID-19 vaccination among pregnant women.

Design

Cross-sectional mixed-methods online survey comprising sociodemographic factors, health beliefs, trust and anticipated regret, and open-ended qualitative questions. Pregnant respondents living in the UK or Ireland (n = 191) completed the online survey during June and July 2021.

Main outcome measures

Intention to vaccinate against COVID-19 during pregnancy, with response options yes (vaccine accepting), no (vaccine resistant), unsure (vaccine hesitant). Qualitative questions about perceived benefits and risks of COVID-19 vaccination during pregnancy.

Results

Multivariate analysis of correlates of vaccine hesitancy and resistance revealed independent associations for perceived barriers to the COVID-19 vaccine, anticipated regret, and social influences. Most respondents described making a decision regarding COVID-19 vaccination in the absence of satisfactory information or guidance from a health care professional. Vaccine hesitant and resistant respondents reported significantly greater barriers to the COVID-19 vaccination than vaccine accepting respondents. Concerns about the vaccine focussed on the speed of its development and roll-out and lack of evidence regarding its safe use in pregnancy.

Conclusion

Participants who did not intend to be vaccinated against COVID-19 in pregnancy focused on vaccine fears as opposed to virus fears. Results indicate that pregnant women need balanced vaccine information and unequivocal health care provider recommendation to aid maternal vaccination decision-making.

Keywords:

• COVID-19
• vaccines
• vaccine hesitancy
• pregnancy
• women’s experiences

Introduction

The outbreak of COVID-19, a disease caused by coronavirus SARS-CoV-2, in December 2019 prompted the rapid development of vaccinations using a range of vaccine platforms (Hodgson et al., 2021). By early January 2021 three authorised COVID-19 vaccines were available in the UK and Ireland, and the most recent figures show that, 75.2% of the population in the UK and 80.9% of the population in Ireland has been fully vaccinated (i.e. received all recommended doses of an approved COVID-19 vaccine) (Mathieu et al., 2020). The World Health Organisation (WHO) state there is good evidence of an increased risk of experiencing adverse outcomes of COVID-19 infection during pregnancy, particularly in the third trimester (WHO, 2021), and according to the UK Obstetric Surveillance System (UKOSS) there is now clear evidence of the real-world effectiveness of vaccination against COVID-19 in pregnancy (UKOSS, 2021) . Ninety-eight percent of pregnant women who were admitted to hospital with symptomatic COVID-19 in the UK between February and September 2021 were unvaccinated (UKOSS, 2021), indicating a high level of vaccine protection against particularly adverse consequences of COVID-19 in pregnancy. Furthermore, a recent systematic review of COVID-19 vaccines among pregnant people concluded that COVID-19 vaccines are safe and effective for pregnant people, their foetuses, and newborns. COVID-19 vaccination in pregnancy confer protective effects similar to those observed in the general population. The vaccines trigger a robust immune response and confer protective immunity to newborns through breastmilk and placental transfer (Rawal et al., 2022).

In April 2021 pregnant women were offered a COVID-19 vaccine in line with the vaccine rollout plan for the UK, which was based on age and clinical risk. In July 2021, the UK’s Royal College of Obstetricians and Gynaecologists (RCOG) changed their guidance to strongly recommend all pregnant women to accept a COVID-19 vaccination, however, many pregnant women in the UK remain unvaccinated (RCOG, 2021). Statistics from the UK Health Security Agency (UKHSA) show that 65.8% of UK women who gave birth in February 2022 had received at least one dose of the COVID-19 vaccine (UKHSA, 2022). Pregnant women are at increased risk of severe disease from COVID-19 and COVID-19 infection is associated with increased risk of preterm birth, stillbirth, preeclampsia and caesarean birth (Zayyan & Frise, 2022). Given the continued high number of cases and the known increased risk of COVID-19 in pregnant women, a high vaccination coverage in this vulnerable population is essential to reduce adverse outcomes, morbidity and mortality (Galanis et al., 2022). Understanding the factors related to COVID-19 vaccine acceptance in pregnant women is paramount to increase vaccine literacy and uptake.

Several studies of pregnant women assessing intention to vaccinate against COVID-19 were conducted before the rollout of national vaccination programmes. An international cross-sectional survey conducted across 16 countries found that 52% of women intended to receive COVID-19 vaccination during pregnancy if vaccine efficacy of 90% was achieved, although vaccine acceptance rates varied substantially between countries (29–84%) (Skjefte et al., 2021). Further, when exploring correlates of vaccine intention, the strongest predictors of vaccine acceptance included confidence in vaccine safety or effectiveness, worrying about COVID-19, belief in the importance of vaccines to their own country, compliance with mask guidelines, trust of public health agencies/health science, as well as attitudes towards routine vaccines (Skjefte et al., 2021). A UK study investigating pregnant women’s views on COVID-19 vaccine acceptability surveyed 1181 women aged over 16 years in autumn 2020, and ten women were followed up with a qualitative interview. Of survey respondents, 62% indicated they would be willing to have a COVID-19 vaccine while pregnant. This study found differences in vaccination intention depending on sociodemographic variables. Specifically, lower income and minority ethnic background were associated with less willingness to vaccinate against COVID-19 while pregnant (Skirrow et al., 2022). The quantitative survey did not explore any psychological factors associated with vaccination intention, but qualitative free-text comments solicited as part of the survey and the qualitative interviews revealed that vaccine safety concerns and trust in vaccines and health care system were important considerations for women.

A range of health behaviour theories attempt to explain psychological and behavioural factors associated with various health protective behaviours. The Health Belief Model (HBM; (Rosenstock, 1974)) has been widely used to predict preventative health behaviour, including getting vaccinated. It is focused on how beliefs about a personal threat of illness or disease along with beliefs in the effectiveness of a health behaviour will predict the likelihood of a person engaging in that behaviour (Rosenstock, 1974). The HBM includes four main constructs: perceived susceptibility and perceived severity to a disease, and perceived benefits and perceived barriers of preventative behaviour or action against a disease.

Research studies focused on maternal flu and pertussis vaccinations have found that perceived benefits of vaccination and perceived susceptibility these illnesses during pregnancy are important predictors of vaccination intent (Frew et al., 2014a). Pregnant women have greater intention to receive a vaccine if they perceive themselves susceptible to infection and believe infection could have serious consequences for their health or the health of their baby (Frew et al., 2014b). This provides support for the use of the HBM within this population. Furthermore, the HBM has been used to predict intention to have newly developed pandemic vaccines. For example, during the H1N1 influenza pandemic of 2009/2010, Byrne et al. (2012) used health beliefs and additional variables (developed from Zijtregtop et al., 2009, and included subjective social norms, social influence, and trust in authorities) to predict university students’ intention to accept the H1N1 swine flu vaccine. The results showed that negative attitudes and perceived barriers to vaccination was associated with non-intention to vaccinate. There were also differences in specific attitudes between those intending to vaccinate and those not intending to vaccinate. In particular, non-intenders reported less social influence to vaccinate, and more negative attitudes towards mandatory H1N1 vaccinations.

More recently, Chu and Liu (2021) integrated constructs from the HBM, the theory of planned behaviour, and the extended parallel process model in an attempt to identify psychosocial factors associated with US adults’ COVID-19 vaccine intentions. The study was conducted before any vaccines were available, and so provided insights about a hypothetical vaccine. The key constructs under study included the social and psychological contexts (e.g. cues to action, subjective norms, past vaccination behaviour), COVID-19 risk perception and fear (i.e. perceived susceptibility, perceived severity, fear of COVID-19), attitudes and beliefs about COVID-19 vaccines (e.g. perceived benefits and perceived barriers), self-efficacy and demographic variables (i.e. age, gender, ethnicity, education, income). The results showed that intention to vaccinate was associated with positive vaccine attitudes, previous vaccination history, higher fear of COVID-19, perceived community benefits, and fewer perceived barriers. Additionally, anticipated regret has been found to influence intention (Abraham & Sheeran, 2003) and behaviour (Brewer et al., 2016). It refers to affective responses to decision-making, specifically beliefs about whether action or inaction would result in feelings of regret or upset (Abraham & Sheeran, 2003). A recent meta-analysis revealed that anticipated action regret (e.g. having a vaccination) has weaker associations with intentions and behaviour than anticipated inaction regret (Brewer et al., 2016). In other words, action regret is associated with lower behavioural intentions and being less likely to engage in health-protective behaviours, such as getting vaccinated. Finally, due to the mainstream and social media interest in COVID-19, the influence of COVID-19 information-seeking on vaccine attitudes and behaviour is of importance. Social media use has been associated with general vaccine hesitancy due to the spread of anti-vaccination misinformation (Wilson & Wiysonge, 2020), and COVID-19 information-seeking has been associated with greater perceptions of COVID-19 severity (Oosterhoff & Palmer, 2020).

This paper uses the extended HBM framework to explore the extent to which pregnant women’s health beliefs, past vaccination behaviour, anticipated regret, and information seeking influence intentions to vaccinate against COVID-19 while pregnant. Understanding the extent to which personal beliefs and previous vaccination behaviour influence COVID-19 vaccination uptake in pregnancy is fundamental to designing, trialling and deploying interventions aimed at improving vaccine acceptance (Kilich et al., 2020). Additionally, we used open-ended questions to further explore pregnant women’s self-reported reasons for having a COVID-19 vaccination during pregnancy and also to explore any self-reported concerns about having a COVID-19 vaccination during pregnancy. We use the term ‘women’ or ‘respondents’ to mean service users who are gestational parents.

Methods

Participants and design

Between June and July 2021, we conducted a cross-sectional internet-based survey in the UK and Ireland. Participant inclusion criteria included being pregnant, aged > 18 years, and living in the UK or Ireland. A sample of 191 participants from the UK and Ireland (mean age 31.59, SD = 4.75) was recruited using a number of convenience sampling strategies, including internet and social media, for example, posts on Twitter, Facebook (open posts plus specific maternity-related groups) and Mumsnet outlining purpose, inclusion criteria, and a request to share with eligible contacts. Participants completed an anonymous, self-administered mixed-methods 15-min online survey hosted by Qualtrics in self-selected locations. All procedures were reviewed and approved by the host universities’ ethics committees.

Procedure

Participants accessed the anonymous survey link and were presented with study information and were required to indicate consent before starting the survey. Confidentiality and the voluntary nature of participation was assured and participants informed of their right to withdraw from the survey at any time. A debrief including sources of support and advice regarding COVID-19 was presented on completing the survey.

Measures

The questionnaire incorporated elements of the protocol used by Byrne et al. (2012) and assessed demographic and psychological determinants of intention to vaccinate based on components of the HBM and other relevant variables of interest, details of which are provided below.

Intention to vaccinate

The primary outcome was the intention to vaccinate against COVID-19 which was measured by a single item; “If the NHS/HSE advised you to take an available COVID-19 vaccine would you comply?” Respondents had the choice of three options: yes (vaccine accepting), no (vaccine resistant), and unsure (vaccine hesitant).

Demographic information: The background self-report information included country of residence, age, marital status, parity, ethnicity, education, and household income. In addition, respondents self-reported how many weeks pregnant they were (subsequently converted to first, second, or third trimester) and whether they had received any vaccinations in pregnancy (including flu, pertussis, or COVID-19), and whether they had received the flu vaccination in previous years. COVID-19 specific information was also collected, including self-reported vulnerability (consisting of a checklist of risk factors for COVID-related serious illness in pregnancy [UKHSA, 2022]), public facing jobs, previous COVID-19 infection (Sherman et al., 2021), and likelihood of having the COVID-19 vaccination if not pregnant. We also asked “Has your partner had or does your partner intend to have a COVID-19 vaccination?” with the following response options: yes/no/They are unsure/I don’t know. See Table 1 for sample demographic information.

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

Psychological variables

The items relating to the HBM were based on previous influenza and COVID-19 vaccination research (Byrne et al., 2012; Chu & Liu, 2021; Zijtregtop et al., 2009), and additional variables measuring attitudes and social normative influences were also adopted from these sources and modified to relate to COVID-19. Unless otherwise stated, responses for the below variables were on a five-point Likert scale from strongly disagree (1) to strongly agree (5), where a higher score indicates greater endorsement of that variable.

Perceived susceptibility (α =.72) explored respondents’ perceived likelihood of contracting COVID-19 and was measured with three items, including ‘It is likely that I will get COVID-19’.

Perceived severity (α =.92) comprised four items to explore the dangers perceived by the respondent if they were to contract COVID-19 and included dangers to self and to baby, for example, ‘I believe that COVID-19 has serious negative consequences’.

Vaccine benefit (α=.94) consisted of five items exploring perceived personal and wider social benefits of getting the COVID-19 vaccination including “If I get the vaccines I will be less likely to get COVID-19”.

Vaccine risk (α=.82) contained five items relating to perceived risks of vaccination for oneself and for the baby, including ‘I believe the COVID-19 vaccine is riskier to my baby than the COVID-19 disease’.

Barriers to vaccination (α=.87) comprised five items asking the extent to which a specific concern would prevent vaccination, including ‘Concerns about whether COVID-19 vaccines are safe for me’. The responses were on a five-point Likert scale from not at all (1) to a great deal (5).

Social influences were measured by three individual items which explored perceived external influences. Respondents rated how likely they would be to have the vaccination if advised by the government, GP, or midwife. Responses were made on a five-point Likert scale from very unlikely (1) to very likely (5).

Peer Influences (α = .70) were assessed by four items to determine the impact of others on one’s vaccination intentions, including ‘Most people who are important to me will get vaccinated for COVID-19’.

Anticipated regret (α = .90) was measured by two items including ‘If I didn’t have a COVID-19 vaccine I would feel regret’ and were adapted from Abraham and Sheeran (2003). The responses were made on a six-point Likert scale from Definitely no (1) to Definitely yes (6).

Trust in authorities (α = .77) was assessed by two items of trust in the government and in the national health service in providing ‘the best possible advice regarding my health’. Respondents rated their level of agreement with each of the two statements on a scale from 0 (never) to 100 (always).

Adherence to COVID-19 guidelines (α = .89) was assessed using 14 items that explored respondent’s participation in and general compliance with the COVID-19 guidelines during the pandemic, for example, ‘Wear a facemask’. Responses were given on a five-point Likert scale ranging from never (1) to always (5).

Information sourcing: Due to the mainstream and social media interest in the COVID-19 pandemic, we developed questions from Byrne et al. (2012) and Oosterhoff and Palmer (2020). Respondents were asked ‘Do you actively seek out information regarding COVID-19’ (yes/no/I actively avoid information regarding COVID-19) and included the selection of sources of information from a closed set of questions (e.g. paper-based, social media, TV news).

Open-ended questions

To solicit qualitative responses, we asked three open-ended questions: ‘What are the reasons you would have a COVID-19 vaccine during pregnancy?’, ‘What are your concerns about COVID-19 vaccines during pregnancy, if any?’, and ‘Any other comments you wish to make about COVID-19 vaccines in pregnancy?’

Statistical analyses

All statistical analyses were conducted using IBM SPSS 27. Differences in continuous variables were analysed using Kruskal–Wallis with a Mann–Whitney U post hoc analysis. Associations between vaccination intention and categorical variables were analysed using chi-square tests of independence. Some categorical variables were collapsed to allow for this. Specifically, education (college or below/degree level), income (less than 44999/over 45 k), marital status (single/married or living as married), ethnicity (white/BAME), partner’s vaccination intention (yes/no or they are unsure). A multinomial logistic regression was then performed to assess the influence of beliefs on vaccination hesitancy and acceptance, adjusting for other variables in the model, thereby giving an insight into the relative importance of each individual correlate.

Qualitative data analysis

The findings from the responses to the three open-ended questions were analysed using qualitative content analysis. The data were coded following an inductive process of preparation and organising (Elo & Kyngäs, 2008), using open coding and then grouping these under higher order headings to create categories (Vaismoradi et al., 2016). These were further refined by discussion of initial codes and categories between two authors, with the resulting categories then discussed further with the team. We report here the key categories that were relevant across all respondents’ beliefs, intentions and decision-making.

Results

Completion rate

The total number of respondents accessing the survey was 252, but 61 responses were removed due to being incomplete. Data for 191 respondents were analysed, giving a completion rate of 76%.

Vaccination intentions

Thirty eight percent of respondents in our sample (n = 72) had already received a COVID-19 vaccination during pregnancy, and 4% (n = 7) said they intended to have the vaccination in pregnancy. Forty nine percent of respondents (n = 94) said they would not have the vaccination, while 9% (n = 18) were unsure. Among respondents who were unvaccinated at the time of participating (thus excluding the 72 respondents who had already received the COVID-19 vaccination in pregnancy), vaccination intention percentages were as follows: five percent (n = 7) intending to vaccinate, 15% (n = 18) unsure of whether to vaccinate, and 80% (n = 94) not intending to vaccinate during pregnancy. In addition, vaccine resistance in a majority of respondents appeared due to their pregnant status, with 76% of unvaccinated respondents (n = 89) reporting they would be somewhat likely or extremely likely to have the COVID-19 vaccination if they were not pregnant, 22% (n = 26) saying they would be somewhat unlikely or extremely unlikely to have a COVID-19 vaccination if not pregnant, and two percent (n = 2) were unsure. See Table 1 for demographic information.

Univariate analyses of vaccination intentions

In the analyses which follow, the ‘vaccine accepting’ group comprise respondents who indicated they already had a COVID-19 vaccination in pregnancy and respondents who indicated they were willing to have a COVID-19 vaccine in pregnancy. The ‘vaccine hesitant’ group consists of respondents who indicated they were unsure about having a COVID-19 vaccine during pregnancy, and the ‘vaccine resistant’ group consists of the respondents who said they would not have the vaccination during pregnancy. Table 2 details the mean continuous variables (SDs) across the three vaccination intention groups. Only statistically significant pairwise comparisons have been reported in text, Table 3 summarises the results of all the post hoc pairwise comparisons.

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).

Sociodemographic variables

There were significant differences in age between vaccine intention groups, H(2) = 11.77, p = .009, and post hoc analyses revealed that vaccine accepting respondents were older than vaccine resistant respondents.

The relationship between education and vaccination intention was significant, χ²(2) = 7.72, p = .021 with college education or below associated with lower vaccine acceptance and higher vaccine resistance. There was a significant relationship between vaccination intention and annual income with income less than £44 999 associated with lower vaccine acceptance, χ² (2) = 6.83, p = .033. There were no statistically significant associations between vaccination intention and ethnicity χ² (2) = 1.05, p = .590 or between intentions and marital status χ² (2) = 5.14, p = .076. There was a significant association between vaccination intention and partner’s vaccination intention, χ² (4) = 30.04, p < .001, with no or unsure partners associated with less vaccine acceptance and more vaccine resistance.

Pregnancy-related variables

There were no significant associations between vaccination intention and trimester χ² (4) = 6.82, p = .146, nor any significant associations between intention and whether it is the first baby χ² (2) = 1.96, p = .376. There were no significant associations between COVID-19 vaccination intention and other vaccinations in pregnancy, that is whether respondents had the flu vaccine in pregnancy χ² (2) = 3.78, p = .151, or pertussis vaccine in pregnancy χ² (2) = .16, p = .921.

Health-related variables

There was no significant association between vaccination intention and the presence of an additional risk factor for COVID-19, χ² (2) = 2.83, p = .244. There was also no significant association between vaccination intention and previous COVID-19 infection, χ² (2) = .84, p = .657. There was a significant association between vaccination intentions and having accepted previous flu vaccinations, χ² (2) = 7.94, p = .019, with vaccine hesitant and resistant respondents less likely to have had the flu vaccine in previous years.

Psychological variables

Vaccine accepting respondents differed from the vaccine hesitant and resistant respondents on the following psychological variables: higher perceived COVID-19 susceptibility, greater perceived vaccine benefit, lower vaccine risk perceptions, fewer barriers to vaccination, higher levels of peer and social influences, and greater anticipated regret. Vaccine accepting respondents also reported significantly higher COVID-19 severity and higher levels of trust in authorities than vaccine resistant respondents. Vaccine hesitant respondents differed from the vaccine resistant respondents on the following psychological variables: higher COVID-19 severity perceptions, lower vaccine risk perceptions, higher levels of peer and social influences, and greater anticipated regret. See Tables 2 and 3 for full statistical reporting of these results.

There were no statistically significant difference in adherence to public health guidance during the pandemic, H(2) = .57, p = .75, and there were no significant associations between vaccination intention and sources of COVID-19 information seeking, χ² (4) = 4.07, p = .396.

Multinomial regression analysis

Relative to those who were vaccine accepting, vaccine resistant respondents were significantly more likely to report a greater number of barriers to getting the COVID-19 vaccine, less anticipated regret and less likely to be influenced by GP to have the vaccine. Relative to those who were vaccine accepting, vaccine hesitant respondents were less likely to perceive themselves susceptible to COVID-19, but more likely to perceive greater severity from COVID-19. They were also more likely to report a greater number of barriers to getting the COVID-19 vaccine and less likely to be influenced by GP to have the vaccine. No other variables made statistically significant contributions to the outcomes. See Table 4 for summary.

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).

Comparisons between groups on individual barriers and attitudes to intention to vaccinate

Given the importance of vaccine barriers, we took a closer look at the individual barriers to further elucidate their influence on vaccination intention, see Tables 5 and 6 for summary descriptive and inferential statistics.

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).

The vaccine hesitant and vaccine resistant groups reported significantly higher concerns about vaccine safety and side effects compared to the vaccine accepting group. Vaccine resistant respondents have significantly greater fertility concerns than vaccine accepting or vaccine hesitant respondents. No other specific barrier to vaccination distinguished the vaccine hesitant or vaccine resistant respondents.

Qualitative content analysis

The analysis from the free text question responses identified four themes: concerns about the speed of vaccine development; fear of the virus versus fear of the vaccine; perception of risks posed by COVID-19 in pregnancy; and a lack of information and guidance from healthcare professionals. The results are presented below; see Table 7 for a summary.

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’

‘Six months of research is not enough’: the speed of vaccine development

The reasons underpinning respondent’s vaccine hesitancy or resistance were further highlighted within the qualitative data. Of those respondents who stated they would not have a vaccination in pregnancy, but would if they were not pregnant, the perceived speed of development of the COVID-19 vaccines caused particular fear and resistance, as well as a lack of longitudinal follow-up data, due to the novel nature of COVID-19 vaccines. One hundred and thirty respondents referred to having concerns about the speed of vaccine development. One respondent stated, ‘6 months of ‘research’ is not enough data to say unborn babies will have no long-term effects. The vaccine is still in trials’ and another, ‘This is a new vaccine, there is not enough research to show that there would be no adverse effects to my unborn baby. A high number of respondents (n = 102) referred to the potential for as-yet unknown adverse effects on the unborn child specifically as a reason for waiting until after pregnancy to accept vaccination, expressed via comments such as, ‘I am concerned that there could be future risks to my child’ and ‘I’m due in a month, I will get vaccine after but don’t believe it is worth the risk on unborn baby after such a short testing period’.

‘To protect my baby’: fear of the virus versus fear of the vaccine

What was clear across all responses, regardless of vaccine intention, was that a desire to protect the safety of the fetus/baby was paramount for respondents. When asked to state reasons why they would accept vaccination, some respondents (n = 34) who had either had the vaccine in pregnancy, or intended to do so during their current pregnancy, indicated that they had concerns about risks associated with the vaccine, but that they perceived these as less of a threat to their health and pregnancy than those posed by the virus. One respondent said she had the vaccine ‘Because it appears that the risks of COVID in late pregnancy are much more severe than the possible risks of the vaccine’ while another responded with ‘I have had it [vaccine] at 28 wk, risk of COVID outweigh risks of vaccine. Trust science’

However, the majority of those respondents who did not intend to have a vaccine in pregnancy did not refer to the threat posed by the virus, but only those they perceived were posed by the vaccine. Those who referred to the virus threat perceived their risk of exposure to be low and indicated their belief they were clinically ‘low-risk’ in pregnancy. This was expressed in comments such as ‘if I as serious risk for my health from COVID-19′ and ‘if I was at very high risk of contracting the disease and becoming very ill because of it’. This indicated that many respondents did not perceive pregnancy to be a factor that increased the risks associated with contracting COVID-19 in pregnancy, which is discussed below.

‘If I had additional risk factors’: perceptions of risk posed by COVID-19 in pregnancy

Many respondents did not regard pregnancy as increasing risk sufficiently enough to accept a COVID-19 vaccine. Related to this, further respondents reported that their additional risk factors had led to their decision to have a COVID-19 vaccine. One woman said ‘I have had the vaccine. I am Asian, overweight and public-facing’. Another respondent said, ‘I have long COVID and my breathing has been affected’. It appeared therefore, that pregnancy itself was not accepted by many as increasing the risks of severe illness and adverse pregnancy outcomes, but rather that pregnancy in addition to the presence of another, more widely accepted risk factor was perceived as significantly increasing risk.

‘Mainly just telling me it is my decision to make’: a lack of information and guidance from healthcare professionals

A small number of respondents (n = 14) cited the advice they received from a health professional as having helped them to come to a positive decision about the vaccine in pregnancy, with comments such as, ‘my GP who I trust listened to my circumstances carefully and advised me to have the vaccine’. However, many more respondents (n = 83) described receiving little or no information or advice from formal healthcare sources. It is notable that these comments came in response to an open question inviting any other comments about COVID-19 vaccination in pregnancy, while other questions asked specifically for reasons and concerns related to vaccination in pregnancy. These included comments such as ‘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’ and ‘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 emergence of this theme in response to an open question about respondents concerns indicates the importance to participants of the lack of information and guidance that they received.

Discussion

This mixed-methods survey provides insight into the experiences, perceptions and beliefs of pregnant respondents regarding the COVID-19 vaccine. These data were collected in the UK and Ireland at a time when pregnant women were being offered the COVID-19 vaccination based on age and clinical risk.

Eighty percent of unvaccinated respondents we surveyed did not intend to vaccinate against COVID-19 while pregnant, while 76% of unvaccinated respondents said they would be extremely likely or somewhat likely to have the vaccination if they were not currently pregnant. Overwhelmingly then, pregnant participants in this survey who did not intend to have a COVID-19 vaccine during pregnancy had concerns associated specifically with the COVID-19 vaccine and specifically in pregnancy, rather than general vaccination concerns. These concerns were related to the speed of vaccine development and rollout, and the lack of evidence regarding the safety of the vaccine. Importantly, most respondents described making a decision regarding the vaccine in the absence of information or guidance from a health care professional (HCP). We discuss this below.

Our study discovered that 76% of participants would be willing to receive a COVID-19 vaccine if not pregnant, a result that is comparable to that of another UK-based survey which found that 81% of pregnant respondents were likely to accept a COVID-19 vaccine when not pregnant (Skirrow et al., 2022). Our study found a lower rate of antenatal COVID-19 vaccination acceptance (42%) than Skirrow et al. (62%). Although other studies have reported higher intentions to vaccinate (Goncu Ayhan et al., 2021; Skjefte et al., 2021) it is important to note that the current study examined actual behaviour rather than hypothetical or future behaviour, which may account for differences in results. Our study was conducted when the vaccination programme was extended to include pregnant women in the UK and Ireland, and women were making real-life decisions about whether to vaccinate against COVID-19. This is likely the reason for the lower vaccination acceptance rates found in our sample, relative to most other studies conducted before vaccine roll-out.

Sociodemographic factors appear to distinguish vaccination intentions. Our study found vaccine resistant respondents were more likely to be younger, with fewer years spent in formal education, and with lower household income, when compared to vaccine accepting respondents, consistent with findings of studies conducted before the availability of COVID-19 vaccines (e.g. Skirrow et al., 2022; Skjefte et al., 2021). However, it is worth noting that in our survey, none of the sociodemographic variables emerged as independent correlates of vaccine intention in the multivariate analyses. This may suggest that psychological or behavioural factors, such as perceptions and attitudes towards vaccination, are more influential in determining vaccination intentions than sociodemographic variables. These findings have important implications for public health campaigns, which may need to tailor their messaging to address the unique psychological and behavioural factors that underlie vaccine hesitancy.

The components of the extended HBM provided insights to the psychological determinants of respondents’ reluctance to get vaccinated against COVID-19 during pregnancy. Specifically, vaccine hesitancy was related to perceived barriers to the COVID-19 vaccination, along with less anticipated regret, and less perceived influence from GP to get vaccinated. Additionally, perceived COVID-19 risk (perceived susceptibility and severity) distinguished between vaccine accepting and vaccine hesitant respondents. In the univariate analyses, general vaccine risk beliefs as well as barriers to the COVID-19 vaccine differed between vaccine intention groups, with vaccine accepting respondents perceiving the least risk and the fewest barriers. In the multivariate analysis, barriers to COVID-19 vaccination emerged as an independent correlate of vaccination intention. The results of the follow-up analyses suggest that women’s concerns about vaccine safety in terms of perceived lack of research, possible side effects for woman or baby, and fertility-related concerns should be addressed to increase vaccination acceptance. These findings are in line studies conducted prior to the rollout of COVID-19 vaccination programmes (Goncu Ayhan et al., 2021; Skjefte et al., 2021; Skirrow et al., 2022). Furthermore, a recent meta-analysis on maternal vaccination uptake concluded that vaccine-specific factors have a strong influence on general vaccine acceptance (Kilich et al., 2020), and our findings strongly support this for the COVID-19 vaccine. Importantly, the current findings are consistent with the HBM’s emphasis on perceived threat and perceived barriers as key factors in preventive health behaviour. Therefore, the HBM can be used to understand and address vaccine hesitancy by targeting the specific components that influence individuals’ decision-making regarding vaccines.

In our sample, pregnant respondents who were vaccine accepting reported higher anticipated regret for vaccination inaction than vaccine hesitant or vaccine resistant respondents. This finding is consistent with prior vaccination research and extends this finding to pregnant women making decisions about having the COVID-19 vaccine. For example, a large survey of Norwegian adults conducted before vaccination approval found anticipated regret was the strongest predictor of COVID-19 vaccination intention (Wolff, 2021), followed by positive attitudes to vaccination, subjective norm and perceived behavioural control. Similarly, anticipated inaction regret has emerged as the strongest predictor of HPV vaccination intentions (Ziarnowski et al., 2009), and HPV and flu vaccination intentions, followed by cognitive factors (Penţa et al., 2020). Along cognitive evaluations of the COVID-19 vaccine (i.e. safety beliefs), affective processes are important determinants of vaccination intentions. According to Brewer et al. (2016) engaging in health-protective behaviour (e.g. getting vaccinated) result in less anticipated regret than behavioural inaction (e.g. not getting vaccinated). Anticipated regret is a modifiable variable, and interventions that emphasise the consequences of inaction (i.e. highlighting the risks of COVID-19 in pregnancy) may increase vaccinations uptake. However, this should be carefully considered alongside our other findings.

Qualitative data showed the rapid development and rollout of the vaccine caused reported anxiety for many of our respondents, specifically regarding the lack of safety data and the potential for unknown effects on the pregnancy and future child. This echoes findings from studies with the pregnant population and parents conducted prior to the vaccine being available (Anderson et al., 2021; Bell et al., 2020; Skirrow et al., 2022). For some of our survey respondents, the decision-making process about accepting the vaccine during pregnancy was one of considering the perceived risks posed by the virus during pregnancy alongside the perceived risks and benefits of accepting a new vaccine. It has been observed elsewhere that pregnant women who do not accept vaccination may perceive the risks associated with a new vaccine as greater than those posed by COVID-19 itself (Anderson et al., 2021: Kilich et al; 2021), and the responses of vaccine-hesitant participants in our survey regarding perceived vaccine-associated risks concur with this. As Meharry et al. (2013) observed in their study on decision-making about the influenza vaccine in pregnancy, women can experience fear related to different perceived risks during pregnancy. In our study, some women feared complications from COVID-19, some from the vaccine, and some from both. It appears that vaccine-specific factors were stronger predictors of maternal vaccination intention than disease-specific factors (Kilich et al., 2020). We suggest this warrant further investigation in the context of COVID-19 vaccination in pregnancy.

A very high number of respondents reported having received either no information and guidance, or insufficient or conflicting information and guidance from HCPs. It is notable too that a high number of respondents reported this when answering the open question: ‘Any other comments you wish to make about COVID-19 vaccines in pregnancy?’. Our survey did not include an open-ended question specifically about maternity care and vaccine information; thus, this finding indicates this was an important factor in respondents’ decision-making. The multinomial regression analysis in our study revealed differences in likelihood of vaccinating if recommended by a GP between vaccine accepting and vaccine hesitant or resistant respondents, with vaccine accepting respondents more likely to have a vaccine if recommended by a GP. It is well-evidenced that a clear recommendation from a HCP to vaccinate can be decisive in pregnant women having antenatal vaccinations (Kilich et al., 2020; Meharry et al., 2013; Wilson et al., 2015) and indeed, some participants in our study indicated that a recommendation from a health professional had led them to accept a vaccine, while others indicated that a lack of such information and guidance had led to their decision to wait.

For vaccine-resistant respondents, answers to open-ended questions indicated a lack of acknowledgement of the increased risks associated with COVID-19 infection in pregnancy. This may relate to the lack of information respondents received from HCPS, meaning their vaccine concerns remained unanswered, but also that they were potentially unaware of the possible hazards of remaining unvaccinated during pregnancy. This is further evidenced by the high number of respondents who cited additional risk factors (such as asthma, maternal age, maternal weight, ethnicity) as increasing risk, but not pregnancy. Healthcare workers’ knowledge of and attitude towards vaccinations are essential for maternal vaccination uptake (Meharry et al., 2013) and inconsistent messages from healthcare workers are a barrier to vaccination (Bettinger et al., 2016). We suggest it is critical to investigate the knowledge, beliefs and education needs of maternity HCPs regarding COVID-19 and vaccination, in order to inform future training and to develop maternity care interventions to improve vaccine uptake. This is particularly needed at this point in the pandemic, but would provide important evidence for future planning and strategic approaches, during the ongoing COVID-19 pandemic and indeed for future pandemic response planning.

Limitations

Our study results should be considered with the following limitations in mind. Our sample consisted of primarily white, English respondents with a high education level and from relatively affluent households. Consequently, our findings may not generalise to the wider population of pregnant people and the results may underestimate the influence of sociodemographic factors on vaccination intention. Nevertheless, previous research on COVID-19 vaccination hesitancy has concluded that psychological and behavioural factors are more consistently related to hesitancy than sociodemographic factors (Schmid et al., 2017). Additionally, this study used a cross-sectional survey design, and the findings are correlational. These findings require corroboration through further research employing prospective designs, which can establish causality.

Conclusion

Our study concludes that intention to vaccinate against COVID-19 during pregnancy is associated with behavioural determinants that go beyond one theoretical model of behaviour. Perceived susceptibility, perceived severity and perceived barriers to vaccination emerged from the HBM as correlates of vaccination intent. Anticipated regret and social influences (specifically, GP influences) also emerged as important. In our sample, the reluctance to vaccinate against COVID-19 was driven primarily by vaccine-specific concerns, and it would appear women were largely unaware of the risks of COVID-19 in pregnancy. Therefore, future research should explore the utility of disease-focused communication strategies alongside vaccine-centred communication strategies. Finally, the safety of the unborn baby was paramount from all respondents to our survey, whether they had been vaccinated, intended to be vaccinated during pregnancy, did not intend to be vaccinated during pregnancy, or did not intend to be vaccinated at all. This universal factor can potentially be used as a starting point for effective communication approaches on the part of maternity HCPs. It is imperative that this is then underpinned by up-to-date knowledge of the evidence regarding COVID-19 risks in pregnancy and the risks and benefits of vaccination in pregnancy.

Ethical approval

Granted by the University of Huddersfield SREIC panel number SREIC/2021/061.

Disclosure statement

The authors declare no conflicts of interest.

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.

Additional information

Funding

The entire study was conducted without external funding.