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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 2  |  Page : 98-103  

COVID-19 Vaccine hesitancy among pregnant women: A facility-based cross-sectional study in Imphal, Manipur


1 Post Graduate Trainee, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Senior Resident, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
3 Assistant Professor, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India
4 Professor and Head, Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission22-Sep-2021
Date of Decision09-Nov-2021
Date of Acceptance15-Nov-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
Jalina Laishram
Department of Community Medicine, Regional Institute of Medical Sciences, Lamphelpat, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1826_21

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   Abstract 


Background: Vaccine hesitancy has been recognized as a public health issue which needs to be addressed urgently. Pregnant women with COVID-19 are at increased risk of adverse pregnancy outcomes. An assessment of the determinants of vaccine hesitancy will aid in the acceleration of vaccine administration among pregnant women. Objectives: The present study aimed to determine COVID-19 vaccine hesitancy among pregnant women in Imphal, Manipur and assess associated factors. Methods: A cross-sectional study was conducted among pregnant women attending Obstetrics and Gynecology Department of a Tertiary Care Institute in Imphal, Manipur during August 2021. One hundred and sixty-three pregnant women were interviewed using a structured questionnaire over phone calls. Univariate analysis was carried out using the Chi-square test and multivariable logistic regression was performed to determine the factors significantly associated with vaccine acceptance. Results: The mean age of the participants was 28.3 ± 5.5 years and majority, 102 (62.6%) were multigravida and 27 (16.6%) had comorbidities. Vaccine hesitancy was found in 127 (77.9%) participants. Logistic regression analysis indicated that awareness on COVID-19 vaccine eligibility (P = 0.002), disagreement of vaccine being unsafe during pregnancy (P = 0.005), and agreement on vaccine benefiting the baby (P = 0.003) were the significant predictors of vaccine acceptance. Conclusion: Nearly four out of every five pregnant women had COVID-19 vaccine hesitancy. Pregnant women should be informed about the benefits and encouraged to take COVID-19 vaccine.

Keywords: COVID-19, India, pregnant women, vaccine hesitancy


How to cite this article:
Gupta A, Christina S, Umar A Y, Laishram J, Akoijam BS. COVID-19 Vaccine hesitancy among pregnant women: A facility-based cross-sectional study in Imphal, Manipur. Indian J Public Health 2022;66:98-103

How to cite this URL:
Gupta A, Christina S, Umar A Y, Laishram J, Akoijam BS. COVID-19 Vaccine hesitancy among pregnant women: A facility-based cross-sectional study in Imphal, Manipur. Indian J Public Health [serial online] 2022 [cited 2022 Aug 13];66:98-103. Available from: https://www.ijph.in/text.asp?2022/66/2/98/350663




   Introduction Top


Globally, COVID-19 has imposed enormous burdens of morbidity and mortality among the population. Pregnant women are among the most vulnerable population.[1] Studies have shown that pregnant women are at high risk of developing COVID-19-associated adverse pregnancy outcomes such as preeclampsia/eclampsia, severe infections, intensive care unit admission, maternal mortality, preterm birth, severe perinatal morbidity, and mortality but the evidence from India is still evolving.[2] The second wave of the COVID-19 pandemic in India killed more pregnant women and new mothers as compared to the first. Case-fatality rate in pregnant and postpartum women was 5.7% in the second wave versus 0.75% in the first wave.[3]

With the availability of effective vaccines against COVID-19, vaccination has become one of the most important strategies for controlling the pandemic. Although no clinical study had included pregnant women for efficacy documentation, on 2nd July, Union Health Ministry approved COVID-19 vaccine for pregnant women at any time during the pregnancy taking into consideration risks and benefits involved.[4]

The WHO listed vaccine hesitancy among the top ten global threats to health in 2019.[5] Vaccine hesitancy seen due to complacent behavior, lack of confidence and convenience is a major threat to the impact of vaccination in preventing severe disease and death from COVID-19.

Studies have shown variability in the acceptance of COVID-19 vaccine across countries. Globally, 52% pregnant women and 73.4% nonpregnant women had an intention to receive the vaccine.[6] Prior to launch of COVID-19 vaccination, vaccine acceptance among pregnant women was above 80% in Mexico and India and below 45% for US, Australia, and Russia.[6] In China when the COVID-19 vaccine had not started, acceptance rate was as high as 77.4% among pregnant women while in Turkey when the vaccination was about to be initiated, only 37% intended to receive the vaccine if recommended.[7],[8] According to a survey in India launched on April 23, 2020 capturing 1.5 million interviews till February 27, 2021, Kerala had the majority of general population (80%) while in Manipur, 69% were willing to get vaccinated (80%).[9]

The safety of COVID-19 vaccination during pregnancy has not been adequately documented since no clinical trial included pregnant women. However, the benefits of receiving COVID-19 vaccine outweigh any known or potential risks of vaccination during pregnancy.[10],[11],[12] Vaccination lowers the risk of infection[13] and builds antibodies that help protect the baby.[14] Miscarriage rate among those who received mRNA COVID-19 vaccine before 20 weeks of pregnancy was similar to the expected rate in the general population. Further, no safety concerns were seen for pregnant women who received vaccines in their late pregnancy.[11]

An assessment of the prevalence and determinants of vaccine hesitancy will aid in the acceleration of vaccine administration among pregnant women. No such study has been conducted in Manipur to address this issue. Thus, this study aimed to determine COVID-19 vaccine hesitancy among pregnant women in Imphal, Manipur and to assess the association between COVID-19 vaccine hesitancy and variables of interest.


   Materials and Methods Top


A cross-sectional study from July 31, 2021 to August 24, 2021 was conducted among pregnant women attending Gynecology and Obstetrics Department of a tertiary care institute in Imphal, Manipur between the duration of January 01, 2021 to August 15, 2021. Permission was sought from Research Ethics Board of the institute. Their phone numbers were accessed from antenatal care records, after taking permission from the Head of Department and interviews were done over phone calls. Participants who had already delivered had been completely vaccinated before pregnancy and who could not be contacted after three attempts of phone calls were excluded.

Sample size

Taking a COVID-19 vaccine acceptance rate of 52% among pregnant women[6] with a relative error of 15%, a sample size of 157 was required at 5% significance and 80% power. However, we enrolled all the eligible pregnant women from the antenatal care records.

Study tool: A structured questionnaire was prepared by the researchers after thorough review of literature, and it contained items on “sociodemographic characteristics,” “knowledge regarding COVID-19 vaccination,” and “vaccine hesitancy and perceptions.” Vaccine hesitancy was assessed by asking “Would you get vaccinated if provided with COVID-19 vaccine?” Those who responded “definitely no,” “probably no,” “undecided” and “probably yes” were categorized as vaccine hesitant. On the other hand, those who responded 'definitely yes' or had received at least one dose of COVID-19 vaccination during pregnancy were categorized as “vaccine acceptant” individuals. Perception of COVID-19 and COVID-19 vaccine was assessed under the three domains of “perceived susceptibility,” “perceived barriers,” and “perceived benefits” with two statements each having a binary response.

Data collection and analysis

Informed verbal consent was taken from the participants and they were allowed to leave the interview midway if they felt uncomfortable. After checking for completeness and consistency, data were entered into IBM SPSS 26 SPSS 26 for windows (IBM Corp. Chicago, U.S). It was then summarized using the descriptive statistics of mean, standard deviation, frequency, and percentage. Univariate analysis was carried out using the Chi-square test. The variables with P < 0.2 in univariate analysis were further assessed using multiple logistic regression to find out the independent predictors of vaccine acceptance. P < 0.05 was considered to be statistically significant.

Ethical issues: Ethical approval was obtained from Research Ethics Board, Regional Institute of Medical Sciences, Imphal, Manipur with Ethics No. A/REB/Prop (SP) 148/123/12/2021.


   Results Top


From the antenatal care register of Gynecology and Obstetrics Department, 288 eligible pregnant women were called, of which 163 responded (response rate of 57%). The mean age of the participants was 28.3 ± 5.5 years. Majority that is 95 (58.3%) were Hindus, 102 (62.6%) were multigravida, 80 (49.1%) were in their third trimester, 62 (38%) had one living child, and 114 (69.9%) were educated up to class twelve. Out of 27 (16.6%) participants who had comorbidities, majority had hypertension followed by diabetes mellitus. Of 13 (7.9%) participants having a history of adverse pregnancy outcomes, 8 (4.9%) had abortion followed by 5 (3.1%) having a history of preterm delivery. Eighty-eight (54%) participants had at least one known person tested positive for COVID-19.

Knowledge on COVID-19 vaccine

When asked about the eligibility of COVID-19 vaccine, 65 (39.9%) participants correctly responded that pregnant women were eligible to get vaccinated for COVID-19. Out of these participants, 28 (17.2%) responded correctly to the time of eligibility as “anytime” while 24 (14.7%) said “no idea.” Information on COVID-19 vaccine was accessed via multiple sources by 66 (40.5%) participants followed by “friends and family” in 47 (28.8%) participants.

Vaccine hesitancy

In response to likelihood of getting vaccinated with COVID-19, 26 (16.0%) responded “definitely no,” 42 (25.8%) responded “probably no,” 37 (22.7%) were undecided, 22 (13.5%) said “probably yes” and only 13 (8.0%) responded “definitely yes.” Out of total participants of 163, 23 (14.1%) were vaccinated with either a single or both doses of COVID-19 vaccine during pregnancy. In this study, 127 (77.9%) were vaccine hesitant and 36 (22.1%) were vaccine acceptant.

Univariate analysis shown in [Table 1] indicated that religion (P = 0.015) and educational status had a significant association with acceptability of COVID-19 vaccine. Those whose educational status was graduate or above, 16 (32.7) were more likely to be vaccine acceptant (P = 0.033). Age, gravida, gestational age, presence of living children, comorbidities, history of adverse pregnancy outcomes, and history of COVID-19 positive status had no significant association with vaccine acceptance.
Table 1: Association between variables of interest and vaccine acceptance (n=163)

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Univariate analysis in [Table 2] showed that participants having no knowledge on eligibility of women for COVID-19 vaccine, 93 (94.9%) participants were more likely to be vaccine hesitant (P = 0.000). Those agreeing that COVID-19 vaccine was unsafe during pregnancy, 103 (92.8%) and vaccine was ineffective to prevent a pregnant woman get COVID-19, 74 (92.5%) were more likely to be vaccine hesitant (P = 0.000). Those participants who believed that giving vaccine to pregnant woman would not benefit her baby or herself that is 90 (95.7%) and 57 (96.6%) were more likely to be vaccine hesitant (P = 0.000).
Table 2: Association between COVID.19 vaccine perception and its acceptance (n=163)

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Multiple logistic regression in [Table 3] showed that there was no significant difference in vaccine acceptance between Muslims and Christians when compared to Hindus. Those having knowledge on eligibility of COVID-19 vaccine for pregnant women had 9.56 (62.31, 39.53) times higher vaccine acceptance and it was significant (P = 0.002). The presence of comorbidities, educational status, and COVID-19 positive status were not significant predictors of vaccine acceptance in this study. In perceived barriers, those who agreed that COVID-19 vaccine was not safe during pregnancy had 91% less vaccine acceptance (P = 0.005). In perceived benefits, those who agreed that giving COVID-19 vaccine to pregnant women would benefit her baby had 18.47 (2.76, 123.52) times higher vaccine acceptance (P = 0.003).
Table 3: Multiple logistic regression for association between the variables of interest and vaccine acceptance (n=163)

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Those who were vaccine hesitant, 73 (57.5%) would get vaccinated if recommended by healthcare workers (P = 0.000) and 41 (32.3%) would get vaccinated if recommended by family members (P = 0.000). Out of 23 (14.1%) participants who were vaccinated during pregnancy, 20 (87%) would recommend COVID-19 vaccine to other pregnant women (P = 0.000).


   Discussion Top


In this facility-based study, 77.9% pregnant women were vaccine hesitant. Goncu Ayhan et al. and Helen Skirrow et al. reported similar findings in their studies.[8],[15] A survey conducted by Skjefte et al. in 16 countries showed that 52% of pregnant women and 73.4% of nonpregnant women indicated an intention to receive the vaccine which is higher than the vaccine acceptance found in our study.[6] Similarly in studies done by Tao et al. and Mose and Yeshaneh vaccine acceptance was more than 70% among pregnant women.[7],[16] The variations in the study settings could have contributed to the inconsistencies in the prevalence rates. The prevalence of vaccine hesitancy among pregnant women in our study is also much higher compared to the vaccine hesitancy of 55% in India and 31% in Manipur seen among the general population in the previous survey.[9] Further our study had strict definition for vaccine hesitancy compared to other studies which could also be reason for higher vaccine hesitancy in this study.[7] Further there is variation in the study data collection tools, approaches and definitions used across studies. The variation in time context for the studies also could have influenced the acceptance level. The local and family level COVID-19 effect could also have influenced the acceptance level.

In our study, majority of the participants had concern about the COVID-19 vaccine safety (31.9%), effectiveness (49.1%), and 57.7% disagreed that giving vaccine to them would be beneficial to their baby. These may be the probable reasons of high vaccine hesitancy seen in our study. Lack of data about COVID-19 vaccine safety in pregnant women and possibility of harm to fetus were the major concerns in Turkey which could possibly explain high vaccine hesitancy.[8] COVID-19 vaccine safety concerns were also observed in the UK.[15] In China, majority were concerned about themselves or their unborn baby getting COVID-19 and agreed that vaccine would benefit both themselves and their babies which could have explained their higher vaccine acceptance rate.[7]

In our study we saw, majority of vaccine hesitant participants were unaware about the eligibility of pregnant women for COVID-19 vaccine. Good knowledge on COVID-19 vaccine was seen to be a significant predictor of vaccine acceptance in studies done by Tao et al., Mose and Yeshaneh and Goncu Ayhan et al.[7],[8],[16] In our study, more vaccine hesitant individuals had “no” concern about contracting COVID-19 compared to vaccine acceptant. Majority of the vaccine-hesitant individuals agreed to vaccine not being safe, ineffective in preventing pregnant women to get COVID-19 and disagreed that vaccine will benefit her baby. Low perceived barriers of vaccine safety (P = 0.005) and agreeing vaccine would benefit the baby (P = 0.003) were the significant predictors of high vaccine acceptance in our study which is similar to study conducted by Tao et al. were also the acceptance was associated with high level of perceived susceptibility (adjusted odds ratio [aOR] = 2.18, 95% confidence interval [CI]: 1.36–3.49), low level of perceived barriers (aOR = 4.76, 95% CI: 2.23–10.18), high level of perceived benefit (aOR = 2.18, 95% CI: 1.36–3.49).[7] This highlights the need to empower pregnant women by providing them adequate and correct knowledge on COVID-19 and its vaccine, including its safety and benefits.

Religion has been seen as a significant predictor for vaccine acceptance, but in our study, vaccine acceptance was not significantly different between major religions (Muslims, Christians, and Hindu), but vaccine hesitancy was high among all three.[5],[6],[7] Educational status, presence of comorbidities, and history of COVID-19 infection were not seen to be significant predictors of vaccine acceptance in this study. Acceptance rate was significantly associated with educational status in studies by Tao et al. and Ceulemans et al.[7],[17] In our study, the sample size was relatively smaller and limited to pregnant women attending one facility, whereas Tao et al. conducted their study in five provinces of mainland China among 1392 pregnant women and Ceulemans et al. did a multinational study in six European countries in 16,063 participants.[7],[17] This could explain the difference in the study findings.

In this study, majority of vaccine hesitant would get vaccinated if recommended by healthcare workers. Thus, it is important to engage and educate the healthcare workers. Pregnant women should be informed about and encouraged to take COVID-19 vaccine. Awareness can be done during antenatal checkups at the facility itself and during household visits by ASHA workers. Family members can also be engaged at the COVID-19 vaccination centers by information, education and communication to encourage pregnant woman to get vaccinated.

The main limitation in this study was its small sample size. The closure of regular outpatient department for antenatal care services during the pandemic led to a sharp decline of pregnant women attendance from 250 to 300 to roughly around 50/day. Other limitation was that the exact reasons for hesitancy were not captured. This study was conducted in a single tertiary care facility which may limit the generalizability of the study. It is recommended to conduct a similar large-scale community-based study across different districts to understand the factors for vaccine hesitancy among pregnant women and address them at the earliest.


   Conclusion Top


In this study, four-fifth of the participants was vaccine hesitant. Knowledge on COVID-19 vaccine, perceived benefits of vaccine benefitting the baby, and disagreeing to perceived barriers of vaccine being unsafe were the significant predictors of vaccine acceptance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Coronavirus Disease (COVID-19): Pregnancy and Childbirth. Available from: https://www.who.int/news-room/q-a-detail/coronavirus-disease- covid-19-pregnancy-and-childbirth. [Last accessed on 2021 Sep 12].  Back to cited text no. 1
    
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17.
Ceulemans M, Foulon V, Panchaud A, Winterfeld U, Pomar L, Lambelet V, et al. Vaccine willingness and impact of the COVID-19 pandemic on women's perinatal experiences and practices – A multinational, cross-sectional study covering the first wave of the pandemic. Int J Environ Res Public Health 2021;18:1-14.  Back to cited text no. 17
    



 
 
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