key: cord-0877780-bvoyl0hb
authors: Battarbee, A.; Stockwell, M.; Varner, M.; Newes-Adey, G.; Daugherty, M.; Gyamfi-Bannerman, C.; Tita, A.; Vorwaller, K.; Vargas, C.; Subramaniam, A.; Reichle, L.; Galang, R.; Powers, E.; Lucca-Susana, M.; Parks, M.; Chen, T. J.; Razzaghi, H.; Dawood, F. S.
title: Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during August-December 2020
date: 2021-03-29
journal: nan
DOI: 10.1101/2021.03.26.21254402
sha: 1370763f87ea7819549e64d6d4c2d0fcbdaee540
doc_id: 877780
cord_uid: bvoyl0hb

ABSTRACT Objective: Evaluate pregnant women's attitudes toward COVID-19 illness and vaccination and identify factors associated with vaccine acceptability. Study Design: Cross-sectional survey among pregnant women enrolled in a prospective COVID-19 cohort study in Salt Lake City, UT, Birmingham, AL, and New York, NY, August 9-December 10, 2020. Women were eligible if they were 18-50 years old and <28 weeks of gestation. Upon enrollment, women completed surveys regarding concerns about COVID-19 illness and likelihood of getting COVID-19 vaccine if one were available during pregnancy. Vaccine acceptability was defined as a response of "very likely" or "somewhat likely" on a 4-point Likert scale. Factors associated with vaccine acceptability were assessed with multivariable logistic regression. Results: Of 939 pregnant women eligible for the main cohort study, 915 (97%) consented to participate. Among these 915 women, 39% self-identified as White, 23% Black, 33% Hispanic, and 4% Other. Sixty-two percent received an influenza vaccine last season. Seventy-two percent worried about getting sick with COVID-19. If they were to get sick, 92% worried about harm to their pregnancy and 80% about harm to themselves. Only 41% reported they would get a vaccine. Of women who were unlikely to get vaccinated, the most frequently cited concern was vaccine safety for their pregnancy (82%). Non-Hispanic Black and Hispanic women had lower odds of accepting a vaccine compared with non-Hispanic White women (adjusted odds ratios (aOR) 0.4, 95%CI 0.2-0.6 for both). Receipt of influenza vaccine during the previous season was associated with higher odds of vaccine acceptability (aOR 2.1, 95%CI 1.5-3.0). Conclusion: Although most pregnant women worried about COVID-19 illness, <50% were willing to get vaccinated during pregnancy. Racial and ethnic disparities in plans to accept COVID-19 vaccine highlight the need to prioritize strategies to address perceived barriers among groups at high risk for COVID-19.

As of March 1, 2021, there have been over 114 million cases of COVID-19 with 70 more than 2.5 million deaths worldwide (1) . Of the 1.1 million cases in the United States, 71 there have been more than 73,000 laboratory-confirmed cases of COVID-19 among 72 pregnant women(2). Based on accumulating data, pregnant women appear to be at 73 increased risk for severe COVID-19 disease (3, 4) . In a recent report that included 74 400,000 women of reproductive age, pregnant women with COVID-19 were found to be 75 more likely than non-pregnant women to be admitted to the intensive care unit, receive 76 extracorporeal membrane oxygenation, and die(5). Comparisons of rates of SARS-CoV-77 2 infection and risks for COVID-19 disease among pregnant versus non-pregnant 78 women in the United States also suggest that Hispanic women may be at increased risk 79 of infection and Hispanic and non-Hispanic Black women may be at increased risk of 80 severe disease(5, 6). At this time, the risk of transplacental transmission of COVID-19 to 81 the developing fetus appears to be low,(7, 8) and most studies have shown no 82 increased risk of spontaneous abortions or stillbirth(9, 10). However, pregnant women 83 with COVID-19 illness may be at increased risk for preterm birth(11). 84 Although social distancing, hand hygiene, and mask wearing are key non- 85 pharmaceutical interventions to slow the spread of COVID-19, widespread safe and 86 effective vaccination is ultimately necessary to control this global pandemic(12). Many 87 COVID-19 vaccine trials are currently being conducted worldwide with many vaccines in 88 Phase III testing and now a few COVID-19 vaccines approved for emergency use (14, 89 15). Pregnant women have not been included in the Phase III trials. However, both the 90 American College of Obstetricians and Gynecologists (ACOG) and the Society for 91 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 29, 2021. ; https://doi.org/10.1101/2021.03.26.21254402 doi: medRxiv preprint Maternal Fetal Medicine (SMFM) recommend that pregnant women be included in 92 vaccine trials and offered COVID-19 vaccines (16, 17) . In addition, the Centers for 93 Disease Control and Prevention recommends that pregnant women be provided the 94 opportunity to choose whether to receive COVID-19 vaccine under the current 95 Emergency Use Authorization (18, 19) . However, the willingness of pregnant women to 96 be vaccinated is unknown. 97 We evaluated pregnant women's attitudes toward Women were eligible for participation in the main cohort if they were 18-50 years   115 old and were at less than 28 weeks of gestation to allow for an average of at least 12 116 weeks of surveillance time in the cohort prior to end of pregnancy. Women without a 117 functioning telephone and those who were not willing to respond to weekly COVID-19 118 surveillance questionnaires or to self-collect nasal swabs weekly were not eligible for 119 participation, as these were key components of the ESPI Community Cohort study. 120 Additionally, women who were unable to speak and read either English or Spanish, and 121 those currently enrolled in a COVID-19 or influenza vaccine trial, were not eligible. 122 Women were not excluded based on prior suspected or confirmed COVID-19 infection. 123 Study staff attempted to approach all women who met age and gestational age criteria 124 for enrollment among those receiving prenatal care at the three participating centers 125 during the study period. Participants were recruited over the phone and in person at 126 outpatient prenatal care offices. 127 Women who consented to participate in the ESPI Community Cohort were asked is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted March 29, 2021. ; https://doi.org/10.1101/2021.03.26.21254402 doi: medRxiv preprint Using a 4-point Likert scale, pregnant women were asked "How worried are you 138 about getting sick with COVID-19?" as well as "If you were to get sick with COVID-19, 139 how worried are you that COVID-19 would harm you?" and "…how worried 140 are you that COVID-19 would harm your pregnancy?" Women were deemed concerned 141 if they answered "very worried" or "somewhat worried." Women were asked about their 142 most trusted source for receiving information about COVID-19, and women were also 143 asked "If a COVID-19 vaccine were to become available for pregnant women, how likely 144 would you be to get the vaccine for yourself during your pregnancy?" Vaccine 145 acceptability was defined as women who answered "very likely" or "somewhat likely." 146 Women were considered not willing to get a vaccine if they answered "not too likely" or 183 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 29, 2021. ; https://doi.org/10.1101/2021.03.26.21254402 doi: medRxiv preprint

The associations between: (1) women's level of concern about getting sick with 184 COVID-19 and (2) women's level of concern about harm to themselves or their 185 pregnancy from COVID-19 in the setting of SARS-CoV-2 infection and vaccine 186 acceptance were also assessed using bivariate analysis. 

During the study period, 1186 women were screened for eligibility for the main 192 cohort study, of whom 939 (79%) were eligible. Among these 939 women, 915 (97%) 193 consented to participate in the main cohort study and were fully enrolled. 194 Among the 915 women included in this analysis, 39% self-identified as White, 195 23% as Black, and 33% as Hispanic. Overall, 64% of women had more than a high 196 school education, 60% were employed, and 20% lived in households with income below 197 the local poverty line. Twenty-eight percent of women had one or more underlying 198 medical conditions. Last season 62% of women reported receiving the influenza vaccine 199 (Table 1) . 200 Seventy-two percent (95% CI: 69%-75%) of women stated they were worried 201 about getting sick with COVID-19. If they were to get sick with COVID-19, 92% (95% CI: 202 91%-94%) of women were worried that COVID-19 would harm their pregnancies, and 203 80% (95% CI: 77%-82%) were worried that COVID-19 would harm them ( Figure 1 ). 204 When asked what source of COVID-19 information women trusted the most, the most 205 common answer was their obstetrician/gynecologist (42%, 95% CI: 38%-45%), followed 206 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted March 29, 2021. ; https://doi.org/10.1101/2021.03.26.21254402 doi: medRxiv preprint by their family doctor or primary care provider (28%, 95% CI: 25%-30%), CDC (13%, 207 95% CI: 11%-15%), and other medical professionals (4%, 95% CI: 3%-5%). 208 Overall, 41% (374/915, 95% CI: 38%-44%) of women reported they would get a 209 COVID-19 vaccine if one became available during their pregnancy. When stratified by 210 enrollment month, the proportion of women willing to get a COVID-19 vaccine was 211 similar (data not shown). Among women who were willing to get a vaccine during 212 pregnancy, the most commonly cited reason for vaccine acceptability was to protect 213 their pregnancy (95%, 95% CI: 93%-98%). Other reasons included protecting 214 themselves (85%, 95% CI: 81%-89%), protecting family members (79%, 95% CI: 75%-215 83%), and protecting the community (68%, 95% CI: 63%-73%). In contrast, women who 216 were not willing to get a vaccine during pregnancy most frequently cited concerns about 217 vaccine safety for their pregnancy (82%, 95% CI: 78%-85%). Other reasons included 218 concerns about vaccine safety for themselves (68%, 95% CI: 63%-72%), vaccine 219 effectiveness (52%, 95% CI: 47%-56%), and the belief that they did not need the 220 vaccine (22%, 95% CI: 18%-26%). 221 Pregnant women's willingness to accept a COVID-19 vaccine varied by maternal 222 race and ethnicity as well as other baseline characteristics. Women who were non-223 Hispanic White were more likely to be willing to accept the vaccine than women who 224 were non-Hispanic Black or Hispanic (Figure 2 ). For example, 63% (95% CI: 58%-69%) 225 of women who were non-Hispanic White stated that they were either very likely or 226 somewhat likely to accept the vaccine whereas only 31% (95% CI: 25%-38%) of non-227 Hispanic Black and 35% (95% CI: 29%-41%) of Hispanic women were very likely or 228 somewhat likely to accept the vaccine. Stated otherwise, 69% (95% CI: 62%-75%) of 229 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) women. In addition to maternal race and ethnicity, Utah study site, having a graduate 232 school degree, and getting an influenza vaccine during the 2019-2020 influenza season 233 were also associated with COVID-19 vaccine acceptability (Table 2) In this cross-sectional study of more than 900 pregnant women from three 253 diverse centers across the U.S., three-fourths were concerned about getting sick with 254 COVID-19 and worried that COVID-19 could harm themselves and their pregnancies. 255 However, less than half of pregnant women in this study said they would be likely to get Several limitations should be considered when interpreting study findings. While 313 the study was designed to maximize diversity and generalizability, only women who had 314 access to prenatal care and who consented to participate in the prospective cohort were 315 included. Thus, our results may not be generalizable to all pregnant women. We also 316 did not enroll a non-pregnant group, and thus we cannot comment about how these 317 findings may differ from a non-pregnant population in the same communities. Given that 318 this study was conducted before a COVID-19 vaccine was available in the United 319 States, we could not assess factors associated with actual vaccine receipt and our 320 findings are based on hypothetical acceptability of a COVID-19 vaccine. In addition, as 321 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Missing/Decline to Respond/Unknown answers not included in calculations.

*Willing to get vaccine defined as survey response of "very likely" or "somewhat likely".

Not willing to get vaccine defined as "not likely" or "not at all likely." Women who responded "unknown" are not included in the analysis (n=103). † Final adjusted model includes variables for which aOR reported above. † † Includes women who are not employed. ‡ Defined as asthma, chronic lung, metabolic, hematologic, cardiovascular, renal, hepatic, neurologic, or rheumatologic disease or hypertension.

Abbreviations: OR, odds ratio; CI, confidence interval; aOR, adjusted odds ratio 435 436 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Footnote: Women whose self-reported race/ethnicity was Other, non-441 Hispanic (n=38) and women with unknown race/ethnicity (n=37) are not shown in 442 responses stratified by race and ethnicity.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted March 29, 2021. ; https://doi.org/10.1101/2021.03.26.21254402 doi: medRxiv preprint

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During