Study reveals complexity of COVID-19 vaccine decision-making for pregnant people

The decision whether to vaccinate is one that many people consider routine. For others, such as people who are pregnant or interested in becoming pregnant—including those who have experienced prior pregnancy loss and/or those from racial and ethnic groups with higher rates of maternal mortality—the decision may be more complex.

An Emory University study—published in Women's Health—found that many pregnant women who delivered babies during the height of the COVID-19 pandemic were conflicted in their vaccine decision-making due to their personal risk factors and their feeling that guidance from health providers and available data were inadequate in helping them make informed decisions.

"We've had numerous studies with important information about the pandemic and navigating the pandemic, but one group in particular—pregnant people—who are particularly vulnerable to COVID-19, is a group that really did not vaccinate at the rate that public health and medical organizations were hoping," says study investigator Subasri Narasimhan, Ph.D., assistant professor in the Hubert Department of Global Health at Emory University's Rollins School of Public Health.

"And what we were trying to understand is how pregnant people were making those decisions around vaccination and what were some of their perceived barriers or issues they faced as they were pregnant at that time."

Why vaccinations are important to pregnant people: Women who are pregnant face an increased risk of severe illness, premature birth, and problems such as stillbirth and pregnancy loss if infected with COVID-19.

The study found that women who experienced prior pregnancy loss described risk aversion to vaccination in pregnancy, causing them to delay vaccination until after delivery. Even people with education, training, and careers in health care or related fields, who had high confidence in COVID-19 vaccination, had high decisional conflict about receiving a vaccine while pregnant.

The ongoing maternal mortality crisis in the United States, particularly among Black women, further complicated the decision-making process for pregnant and postpartum people.

"Pregnant people face complex immediate and long-term tradeoffs. They're making decisions not just for their own health and the health of their babies, but these tradeoffs extend to the health of other people in their household and to their social and career identities. This study is not about telling pregnant people what they 'should' do," says study co-author Subasri Narasimhan, Ph.D., assistant professor in the Hubert Department of Global Health in Emory University's Rollins School of Public Health.

"This is about identifying a need for more tailored resources that can empower pregnant people to be able to make the best decision for themselves."

"We need a deeper bench of pregnancy and postpartum support services and resources that address different concerns, including vaccination, because people are looking for multiple sources of information and often outside of the health care system," says study co-author Leslie Johnson, Ph.D., assistant professor in the Department of Family and Preventive Medicine at Emory's School of Medicine.

"This study highlights how there are shared concerns among pregnant people regarding getting the COVID-19 vaccine during pregnancy, but that there are also opportunities to create tailored public health messaging and resources that promote vaccine uptake in this population. I think this is a stepping stone to larger studies that can help better identify what those needs are among different subgroups of pregnant women."