<scp>COVID</scp>‐19 Vaccination Rates and Vaccine Hesitancy in Pregnant Women in Seven Low‐ and Middle‐Income Countries Through May 2023: An Observational Study From the Global Network

COVID-19 infection, a severe acute respiratory syndrome, was declared a global pandemic by the World Health Organization (WHO) in March 2020. During the pandemic, millions of people died and countless others suffered from severe illness [1]. COVID-19 vaccination has shown > 90% effectiveness in preventing severe disease and death [2]. While COVID-19 vaccination was initially not approved during pregnancy in many low- and middle-income countries (LMICs), the recommendations evolved by 2022 so that the WHO and most countries approved this indication [3]. Worldwide, more than 70% of adults have received at least one COVID-19 vaccine and widespread vaccination programmes are ongoing. Challenges to COVID-19 vaccination include vaccine refusal, even when vaccination is available and approved [4]. Maternal vaccination remains an important public health strategy to reach women and their foetus or newborn in LMICs but rates in this period are lower than the general public. To address COVID-19 in pregnancy in LMICs, from February 2021 through May 2023, the National Institute of Child Health and Human Development's (NICHD) Global Network's Maternal Newborn Health Registry collected prospective, population-based data on COVID-19 and COVID-19 vaccination status in pregnant women in Global Network sites. We published data through December 2022 [5]. This letter updates our findings through May 2023. The Global Network study included pregnant people living in defined areas in seven LMICs including: Bangladesh, India (two sites), Pakistan, Guatemala, the Democratic Republic of the Congo (DRC), Kenya and Zambia who were enrolled in a prospective, geographic-based pregnancy registry. The study was approved by all ethics committees and women provided informed consent [5]. From February 2021 through May 2023, we surveyed pregnant participants regarding COVID-19 vaccine knowledge, attitudes and practices (KAP) and vaccination status administered through face-to-face interviews. To analyse trends, we examined three time-periods: February 2021–October 2021, November 2021–December 2022 and January 2023–May 2023. The main outcome measures for the vaccination studies included COVID-19 vaccination rates; KAP regarding COVID-19 vaccination; and reasons for vaccine acceptance and hesitancy. Altogether 58 468 participants were interviewed. The figure presents the vaccination rates by sites in the three time-periods. In the first time-period, overall few women were vaccinated (2.9% altogether), including Pakistan (0.7%), Guatemala (5.2%), India (11.4%) and ≤ 0.2% in the other sites. During the second time-period, vaccination rates increased substantially so that the overall COVID-19 vaccination rate was 45.2%. From January 2023 through May 2023, the overall vaccination rate among pregnant women in the Global Network increased to 71.4%. In the most recent time-period, the lowest vaccination rates (approximately 50%) occurred in the DRC, Kenya and Pakistan, while the highest vaccination rates (approximately 90%) occurred in the Indian and Bangladeshi sites. By the third time-period, vaccine hesitancy was much reduced together with considerable increases in the proportion of women who believed that COVID-19 vaccines were effective and safe for pregnant women. Of those who would not get vaccinated, concerns about safety, effectiveness and fear of side effects were associated with refusal. Younger women and those with less education were less willing to be vaccinated. Family members and health professionals were the most trusted source of information regarding COVID-19 vaccination. Knowledge about COVID-19 vaccination was relatively limited and highly variable among pregnant women in the Global Network sites. The COVID-19 vaccine study conducted in pregnant women during the pandemic showed a considerable increase in COVID-19 vaccination rates across Global Network sites. These increases were correlated with increased beliefs in the vaccine effectiveness and safety. Of those women who would not get vaccinated, concerns about safety, effectiveness and fear of side effects were associated with refusal. Thus, these concerns are important targets for educational efforts to increase vaccination rates among pregnant women. To improve coverage of the COVID-19 vaccines, it is critical that pregnant women have sufficient knowledge about effectiveness and safety. Positive messaging from health authorities also will likely be important. R.L.G. wrote first draft with E.M.M. S.N., S.S., M.K.-T. and E.M.M. reviewed and edited. R.L.G., S.N., S.S. and E.M.M. contributed to protocol development and study monitoring. All authors reviewed and approved final version. The authors declare no conflicts of interest. The data that support the findings of this study are openly available in NICHD Data & Specimen Hub (N-DASH) at https://dash.nichd.nih.gov/.