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COVID-19 Vaccine Hesitancy during the Perinatal Period: Understanding Psychological and Cultural Factors to Improve Care and Address Racial/Ethnic Health Inequities

  • Micheline R. Anderson
    Correspondence
    Correspondence to: Micheline R. Anderson, PhD, Clinical Psychology Training Program, Warren Alpert Medical School of Brown University, Box G-BH, Providence, RI 02912. Phone: (401) 444-1929.
    Affiliations
    Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island

    Women and Infants' Hospital of Rhode Island, Providence, Rhode Island
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  • Erica J. Hardy
    Affiliations
    Women and Infants' Hospital of Rhode Island, Providence, Rhode Island

    Departments of Medicine and Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island

    Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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  • Cynthia L. Battle
    Affiliations
    Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island

    Women and Infants' Hospital of Rhode Island, Providence, Rhode Island

    Butler Hospital, Providence, Rhode Island
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Published:April 12, 2022DOI:https://doi.org/10.1016/j.whi.2022.04.001
      From the beginning of the COVID-19 pandemic until December 2021, more than 24,400 pregnant people have been hospitalized with COVID-19 in the United States; however, perinatal vaccination against COVID-19 remains disproportionately low, placing pregnant and postpartum individuals at greater risk for morbidity and mortality from COVID-19. Strikingly low rates of vaccination among pregnant individuals from some racial/ethnic groups highlight pre-existing health care disparities and potentially the presence of unique vaccination concerns among some groups. Despite its significance to public health, an evidence-based understanding of how and why pregnant and postpartum individuals decide to accept the COVID-19 vaccine is lacking. Further, COVID-19 vaccine hesitancy may be related to a larger, concerning presence of medical mistrust that has been magnified in an age of misinformation. Accelerating and prioritizing research that can inform targeted and effective campaigns to increase COVID-19 vaccination among perinatal populations is essential.

      Perinatal COVID-19 Infection Risk and Vaccination

      It is now known that pregnant and postpartum women with COVID-19 are at increased risk of severe disease, in comparison with women with COVID-19 who are not pregnant. Further, infants of women with COVID-19 infections may experience poor neonatal outcomes (
      • Allotey J.
      • Stallings E.
      • Bonet M.
      • Yap M.
      • Chatterjee S.
      • Kew T.
      • Zhou D.
      Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: Living systematic review and meta-analysis.
      ;
      • Angelidou A.
      • Sullivan K.
      • Melvin P.R.
      • Shui J.E.
      • Goldfarb I.T.
      • Bartolome R.
      • Singh R.
      Association of maternal perinatal SARS-CoV-2 infection with neonatal outcomes during the COVID-19 pandemic in Massachusetts.
      ;
      • Chinn J.
      • Sedighim S.
      • Kirby K.A.
      • Hohmann S.
      • Hameed A.B.
      • Jolley J.
      • Nguyen N.T.
      Characteristics and outcomes of women with COVID-19 giving birth at US academic centers during the COVID-19 pandemic.
      ;
      • Metz T.D.
      • Clifton R.G.
      • Hughes B.L.
      • Sandoval G.
      • Saade G.R.
      • Grobman W.A.
      • Clark K.
      Disease severity and perinatal outcomes of pregnant patients with coronavirus disease 2019 (COVID-19).
      ;
      • Villar J.
      • Ariff S.
      • Gunier R.B.
      • Thiruvengadam R.
      • Rauch S.
      • Kholin A.
      • Cardona-Perez J.A.
      Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: The INTERCOVID multinational cohort study.
      ;
      • Wei S.Q.
      • Bilodeau-Bertrand M.
      • Liu S.
      • Auger N.
      The impact of COVID-19 on pregnancy outcomes: A systematic review and meta-analysis.
      ;
      • Zambrano L.D.
      • Ellington S.
      • Strid P.
      • Galang R.R.
      • Oduyebo T.
      • Tong V.T.
      • Gilboa S.M.
      Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status—United States, January 22–October 3, 2020.
      ). For example, pregnant women with COVID-19 experience almost four times the rate of intensive care unit admission and mechanical ventilation, and almost twice the rate of death as nonpregnant women with COVID-19 (
      • Zambrano L.D.
      • Ellington S.
      • Strid P.
      • Galang R.R.
      • Oduyebo T.
      • Tong V.T.
      • Gilboa S.M.
      Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status—United States, January 22–October 3, 2020.
      ). As compared with pregnant women without COVID-19, those with COVID-19 are also significantly more likely to experience preterm birth and the neonatal morbidity that is associated with preterm birth (
      • Allotey J.
      • Stallings E.
      • Bonet M.
      • Yap M.
      • Chatterjee S.
      • Kew T.
      • Zhou D.
      Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: Living systematic review and meta-analysis.
      ;
      • Chinn J.
      • Sedighim S.
      • Kirby K.A.
      • Hohmann S.
      • Hameed A.B.
      • Jolley J.
      • Nguyen N.T.
      Characteristics and outcomes of women with COVID-19 giving birth at US academic centers during the COVID-19 pandemic.
      ;
      • Metz T.D.
      • Clifton R.G.
      • Hughes B.L.
      • Sandoval G.
      • Saade G.R.
      • Grobman W.A.
      • Clark K.
      Disease severity and perinatal outcomes of pregnant patients with coronavirus disease 2019 (COVID-19).
      ;
      • Villar J.
      • Ariff S.
      • Gunier R.B.
      • Thiruvengadam R.
      • Rauch S.
      • Kholin A.
      • Cardona-Perez J.A.
      Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: The INTERCOVID multinational cohort study.
      ). Mitigation efforts, including the widespread uptake of COVID-19 vaccination, are imperative to prevent loss of life and other negative maternal–infant outcomes.
      COVID-19 vaccinations have been successful at preventing COVID-19 transmission, hospitalization, severe infection, and COVID-related deaths; moreover, safety data suggest that the vaccine is safe and effective in pregnant and lactating people (
      • Blakeway H.
      • Prasad S.
      • Kalafat E.
      • Heath P.T.
      • Ladhani S.N.
      • Le Doare K.
      • Khalil A.
      COVID-19 vaccination during pregnancy: Coverage and safety.
      ;
      • Gray K.J.
      • Bordt E.A.
      • Atyeo C.
      • Deriso E.
      • Akinwunmi B.
      • Young N.
      • Edlow A.G.
      Coronavirus disease 2019 vaccine response in pregnant and lactating women: A cohort study.
      ;
      • Kachikis A.
      • Englund J.A.
      • Singleton M.
      • Covelli I.
      • Drake A.L.
      • Eckert L.O.
      Short-term reactions among pregnant and lactating individuals in the first wave of the COVID-19 vaccine rollout.
      ;
      • Shimabukuro T.T.
      • Kim S.Y.
      • Myers T.R.
      • Moro P.L.
      • Oduyebo T.
      • Panagiotakopoulos L.
      • Meaney-Delman D.M.
      Preliminary findings of mRNA Covid-19 vaccine safety in pregnant persons.
      ). Studies evidencing vaccine-triggered immune response among pregnant people and neonatal transfer of antibodies (
      • Gray K.J.
      • Bordt E.A.
      • Atyeo C.
      • Deriso E.
      • Akinwunmi B.
      • Young N.
      • Edlow A.G.
      Coronavirus disease 2019 vaccine response in pregnant and lactating women: A cohort study.
      ;
      • Trostle M.E.
      • Aguero-Rosenfeld M.E.
      • Roman A.S.
      • Jennifer L.
      High antibody levels in cord blood from pregnant women vaccinated against COVID-19.
      ), alongside data illustrating no increased risks for miscarriage, preterm birth, or stillbirth associated with vaccination (
      • Trostle M.E.
      • Limaye M.A.
      • Avtushka V.
      • Lighter J.L.
      • Penfield C.A.
      • Roman A.S.
      COVID-19 vaccination in pregnancy: early experience from a single institution.
      ), have propelled strong recommendations by the American College of Obstetricians and Gynecologists, the Society for Maternal Fetal Medicine, and the Centers for Disease Control and Prevention (CDC) that pregnant individuals and those attempting to become pregnant receive COVID-19 vaccines. However, recent data suggest that pregnant individuals are much more likely to be hesitant about and to refuse the COVID-19 vaccine compared with the rest of the adult population (
      • Murphy J.
      • Vallières F.
      • Bentall R.P.
      • Shevlin M.
      • McBride O.
      • Hartman T.K.
      • Hyland P.
      Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom.
      ). As of December 2021, data from the CDC Vaccine Safety Datalink estimated that only 24% of pregnant individuals in the United States had received at least one dose of a COVID-19 vaccine either during or before pregnancy (in comparison with 84% of U.S. adults;
      Centers for Disease Control and Prevention (CDC)
      COVID data tracker weekly review.
      ), with rates varying significantly across ethnic/racial group (Asian, 33%; White, 24%; Hispanic, 22%; Black, 17%). Low maternal COVID-19 vaccine coverage may not resolve after birth. Postpartum women also report lower rates of intention to accept the COVID-19 vaccine than nonpregnant women (
      • Sutton D.
      • D’Alton M.
      • Zhang Y.
      • Kahe K.
      • Cepin A.
      • Goffman D.
      • Coletta J.
      COVID-19 vaccine acceptance among pregnant, breastfeeding and non-pregnant reproductive aged women.
      ), citing similar reasons for COVID-19 vaccine refusal as those reported during pregnancy, such as concerns over safety and efficacy (
      • Goncu Ayhan S.
      • Oluklu D.
      • Atalay A.
      • Menekse Beser D.
      • Tanacan A.
      • Moraloglu Tekin O.
      • Sahin D.
      COVID-19 vaccine acceptance in pregnant women.
      ;
      • Oluklu D.
      • Goncu Ayhan S.
      • Menekse Beser D.
      • Uyan Hendem D.
      • Ozden Tokalioglu E.
      • Turgut E.
      • Sahin D.
      Factors affecting the acceptability of COVID-19 vaccine in the postpartum period.
      ). With the significant risk of severe COVID-19 in both pregnant and recently postpartum individuals, as well as the maternal–infant benefits of vaccination, it is crucial to understand psychological contributors to perinatal COVID vaccine uptake.

      COVID-19 Vaccine Hesitancy among Perinatal Populations

      Vaccine hesitancy is a leading contributor to low vaccination coverage across a range of diseases (
      • Dubé E.
      • Laberge C.
      • Guay M.
      • Bramadat P.
      • Roy R.
      • Bettinger J.A.
      Vaccine hesitancy: An overview.
      ), contributing to as many as 1.5 million deaths worldwide. Health care decision-making models, such as the theory of planned behavior (
      • Ajzen I.
      The theory of planned behavior.
      ), the health belief model (
      • Rosenstock I.M.
      The health belief model and preventive health behavior.
      ), and the behavioral model for vulnerable populations (
      • Gelberg L.
      • Andersen R.M.
      • Leake B.D.
      The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people.
      ) include environmental, cultural, and systems-level factors that inform the engagement or rejection of various health behaviors, including vaccination. Theoretically guided research focused specifically on vaccination decisions during pregnancy and postpartum, using these and other vaccination-specific models of health behavior (e.g., the five Cs;
      • Betsch C.
      • Schmid P.
      • Heinemeier D.
      • Korn L.
      • Holtmann C.
      • Bo hm R.
      Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination.
      ), could help to clarify the reasons for vaccination decisions among perinatal women. Importantly, vaccine hesitancy research with other vaccines (before the COVID-19 pandemic) suggests that pregnant and postpartum individuals’ vaccine-specific and disease-specific beliefs, attitudes, and other psychological characteristics represent critical factors in predicting vaccine hesitancy (
      • Kilich E.
      • Dada S.
      • Francis M.R.
      • Tazare J.
      • Chico R.M.
      • Paterson P.
      • Larson H.J.
      Factors that influence vaccination decision-making among pregnant women: A systematic review and meta-analysis.
      ). However, despite the recognition of the important role of vaccine hesitancy in determining final behaviors regarding uptake and refusal, little is known about the psychological determinants of COVID-19 vaccine hesitancy among perinatal populations. Recent reviews examining determinants of recommended vaccinations during pregnancy (e.g., pertussis, influenza) have found that perceived maternal–infant risk, questions regarding vaccine efficacy, susceptibility to illness, and lack of knowledge are commonly reported concerns (
      • Adeyanju G.C.
      • Engel E.
      • Koch L.
      • Ranzinger T.
      • Shahid I.B.M.
      • Head M.G.
      • Betsch C.
      Determinants of influenza vaccine hesitancy among pregnant women in Europe: A systematic review.
      ;
      • Kilich E.
      • Dada S.
      • Francis M.R.
      • Tazare J.
      • Chico R.M.
      • Paterson P.
      • Larson H.J.
      Factors that influence vaccination decision-making among pregnant women: A systematic review and meta-analysis.
      ;
      • Qiu X.
      • Bailey H.
      • Thorne C.
      Barriers and facilitators associated with vaccine acceptance and uptake among pregnant women in high income countries: A mini-review.
      ).
      The current research on perinatal COVID-19 vaccine hesitancy suggests that it is complex and that some vaccine-related attitudes and beliefs may even lead to seemingly inconsistent behavioral choices (
      • Truong J.
      • Bakshi S.
      • Wasim A.
      • Ahmad M.
      • Majid U.
      What factors promote vaccine hesitancy or acceptance during pandemics? A systematic review and thematic analysis.
      ). For example, although most pregnant individuals report fears of COVID-19 infection and an overwhelming desire to protect one's unborn child, these sentiments can result in either acceptance or refusal of COVID-19 vaccination (
      • Battarbee A.
      • Stockwell M.
      • Varner M.
      • Newes-Adey G.
      • Daugherty M.
      • Gyamfi-Bannerman C.
      • Subramaniam A.
      Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: A cross-sectional multicenter study during August-December 2020.
      ;
      • Geoghegan S.
      • Stephens L.C.
      • Feemster K.A.
      • Drew R.J.
      • Eogan M.
      • Butler K.M.
      “This choice does not just affect me.” Attitudes of pregnant women toward COVID-19 vaccines: A mixed-methods study.
      ). Of relevance to inquiry on this topic are reports of concerns regarding lack of confidence or mistrust in the development and dissemination of the COVID-19 vaccine that are not accounted for by previous vaccine attitudes or behaviors (
      • Ceulemans M.
      • Foulon V.
      • Panchaud A.
      • Winterfeld U.
      • Pomar L.
      • Lambelet V.
      • Richardson J.L.
      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.
      ;
      • Goncu Ayhan S.
      • Oluklu D.
      • Atalay A.
      • Menekse Beser D.
      • Tanacan A.
      • Moraloglu Tekin O.
      • Sahin D.
      COVID-19 vaccine acceptance in pregnant women.
      ;
      • Palamenghi L.
      • Barello S.
      • Boccia S.
      • Graffigna G.
      Mistrust in biomedical research and vaccine hesitancy: The forefront challenge in the battle against COVID-19 in Italy.
      ;
      • Tram K.H.
      • Saeed S.
      • Bradley C.
      • Fox B.
      • Eshun-Wilson I.
      • Mody A.
      • Geng E.
      Deliberation, dissent, and distrust: Understanding distinct drivers of coronavirus disease 2019 vaccine hesitancy in the United States.
      ;
      • Walker K.K.
      • Head K.J.
      • Owens H.
      • Zimet G.D.
      A qualitative study exploring the relationship between mothers’ vaccine hesitancy and health beliefs with COVID-19 vaccination intention and prevention during the early pandemic months.
      ). Medical mistrust among perinatal samples has been observed regarding medical interventions believed to be understudied and may contribute to health care decisions that run counter to provider-based recommendations (
      • Denton L.K.
      • Creeley C.E.
      • Stavola B.
      • Hall K.
      • Foltz B.D.
      An analysis of online pregnancy message boards: Mother-to-mother advice on medication use.
      ). For example, there is a longstanding history of the exclusion of pregnant people from vaccine clinical trials, despite numerous calls from within academic medicine and obstetric providers and researchers for the inclusion of pregnant participants in early COVID-19 vaccine trials and accountability in the case of vaccine-related injuries (
      • Bardají A.
      • Sevene E.
      • Cutland C.
      • Menéndez C.
      • Omer S.B.
      • Aguado T.
      • Muñoz F.M.
      The need for a global COVID-19 maternal immunisation research plan.
      ;
      • Beigi R.H.
      • Krubiner C.
      • Jamieson D.J.
      • Lyerly A.D.
      • Hughes B.
      • Riley L.
      • Karron R.
      The need for inclusion of pregnant women in COVID-19 vaccine trials.
      ;
      • Halabi S.
      • Heinrich A.
      • Omer S.B.
      No-fault compensation for vaccine injury—The other side of equitable access to COVID-19 vaccines.
      ). Thus, beliefs about the legitimacy and transparency of medical research may perpetuate maternal distrust of conventional medicine (
      • Hornsey M.J.
      • Lobera J.
      • Díaz-Catalán C.
      Vaccine hesitancy is strongly associated with distrust of conventional medicine, and only weakly associated with trust in alternative medicine.
      ). Further, there is evidence that vaccine refusal and hesitancy during pregnancy may predict pediatric vaccine hesitancy (
      • Cunningham R.M.
      • Minard C.G.
      • Guffey D.
      • Swaim L.S.
      • Opel D.J.
      • Boom J.A.
      Prevalence of vaccine hesitancy among expectant mothers in Houston, Texas.
      ;
      • Fuchs E.L.
      Self-reported prenatal influenza vaccination and early childhood vaccine series completion.
      ). Therefore, it is essential to understand beliefs and attitudes about the COVID-19 vaccine during the perinatal period, because these may potentially extend to concerns regarding the vaccination of one's child and the subsequent associated health outcomes related to vaccine-preventable disease.

      Vaccine Hesitancy and Racial/Ethnic Health Disparities in Perinatal Populations

      Understanding mistrust and barriers to COVID-19 vaccination may be particularly salient for people of color, who have historically faced discriminatory medical treatment, subsequently influencing health care decision-making and creating greater risk for poor health outcomes (
      • Gerend M.A.
      • Pai M.
      Social determinants of Black-White disparities in breast cancer mortality: A review.
      ;
      • Richard-Davis G.
      The pipeline problem: Barriers to access of Black patients and providers in reproductive medicine.
      ). In the United States, health disparities are perhaps most pronounced during the perinatal period, where Black and American Indian women are two to three more times likely to die from pregnancy-related complications as compared with non-Hispanic White women (
      • Petersen E.E.
      • Davis N.L.
      • Goodman D.
      • Cox S.
      • Syverson C.
      • Seed K.
      • Shapiro-Mendoza C.
      • Barfield W.
      Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016.
      ). These disparities take on greater urgency in the context of the COVID-19 pandemic, during which higher proportions of Black and Hispanic pregnant individuals have tested positive for COVID-19 in comparison with those who are White (
      • Ellington S.
      • Strid P.
      • Tong V.T.
      • Woodworth K.
      • Galang R.R.
      • Zambrano L.D.
      • Gilboa S.M.
      Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status—United States, January 22–June 7, 2020.
      ;
      • Jering K.S.
      • Claggett B.L.
      • Cunningham J.W.
      • Rosenthal N.
      • Vardeny O.
      • Greene M.F.
      • Solomon S.D.
      Clinical characteristics and outcomes of hospitalized women giving birth with and without COVID-19.
      ). In one Southern U.S. state, for example, a recent report found that Black and Hispanic women accounted for 80% of COVID-19–related deaths among pregnant women, all of whom were unvaccinated (
      • Kasehagen L.
      • Byers P.
      • Taylor K.
      • Kittle T.
      • Roberts C.
      • Collier C.
      • Dobbs T.
      COVID-19–associated deaths after SARS-CoV-2 infection during pregnancy—Mississippi, March 1, 2020–October 6, 2021.
      ).
      Beliefs about vaccinations can vary significantly across racial groups (
      • Wooten K.G.
      • Wortley P.M.
      • Singleton J.A.
      • Euler G.L.
      Perceptions matter: Beliefs about influenza vaccine and vaccination behavior among elderly White, Black and Hispanic Americans.
      ), and it is possible that safety concerns about vaccines and/or medical distrust may disproportionately contribute to COVID-19 vaccine hesitancy among perinatal women of color in comparison with White women. Specific to the COVID-19 vaccines, one study found that Black Americans in general were more likely to believe that the vaccines are unsafe and endorse mistrust of the vaccine than other racial groups (
      • Kricorian K.
      • Civen R.
      • Equils O.
      COVID-19 vaccine hesitancy: Misinformation and perceptions of vaccine safety.
      ). There is also evidence that greater medical mistrust is associated with greater COVID-19 vaccine hesitancy among Black immune-compromised individuals (
      • Bogart L.M.
      • Ojikutu B.O.
      • Tyagi K.
      • Klein D.J.
      • Mutchler M.G.
      • Dong L.
      • Kellman S.
      COVID-19 related medical mistrust, health impacts, and potential vaccine hesitancy among Black Americans living with HIV.
      ).
      Additionally, racial inequities in health care could potentially influence health care decision-making among some perinatal groups. For example, women of color are more likely to report awareness of provider biases that contribute to increased maternal mortality or childbirth related trauma and, in turn, seek alternatives to medical interventions during pregnancy (
      • Proujansky A.
      Why Black women are rejecting hospitals in search of better births. The New York Times.
      ). To date, there have been no published studies examining the psychological determinants of COVID-19 vaccine hesitancy among perinatal people, nor any that examined specific factors that may drive vaccine hesitancy or behavior among perinatal individuals from racial/ethnic groups with higher rates of nonvaccination. Without a greater understanding of the drivers of vaccine hesitancy and refusal among perinatal populations, creating sensitive and effective approaches to addressing these issues will be challenging.

      Strategies for Developing Acceptable and Effective Vaccine-Related Interventions

      Although the first step in improving the rates of vaccine uptake is conducting research to identify factors influencing vaccine hesitancy among perinatal women—including factors that may be particularly salient for women of color—the ultimate challenge will be developing and implementing evidence-based interventions that lead to vaccine uptake. Interventions to promote vaccine acceptance across the perinatal period would be most effective when using empirically informed targets; that is, psychological factors that are specific to perinatal COVID-19 vaccine hesitancy. Before the COVID-19 pandemic, strategies developed to increase vaccination uptake among perinatal groups have included provider-based communications, education, bedside vaccine administration after childbirth, and evidence-based interviewing techniques; results have been mixed (
      • Brewer S.E.
      • Cataldi J.R.
      • Fisher M.
      • Glasgow R.E.
      • Garrett K.
      • O’Leary S.T.
      Motivational Interviewing for Maternal Immunisation (MI4MI) study: A protocol for an implementation study of a clinician vaccine communication intervention for prenatal care settings.
      ;
      • Cheng P.-J.
      • Huang S.-Y.
      • Su S.-Y.
      • Peng H.-H.
      • Chang C.-L.
      Increasing postpartum rate of vaccination with tetanus, diphtheria, and acellular pertussis vaccine by incorporating pertussis cocooning information into prenatal education for group B streptococcus prevention.
      ;
      • Gagneur A.
      • Lemaître T.
      • Gosselin V.
      • Farrands A.
      • Carrier N.
      • Petit G.
      • de Wals P.
      A postpartum vaccination promotion intervention using motivational interviewing techniques improves short-term vaccine coverage: PromoVac study.
      ;
      • Hutchinson A.F.
      • Smith S.M.
      Effectiveness of strategies to increase uptake of pertussis vaccination by new parents and family caregivers: A systematic review.
      ;
      • Mohammed H.
      • McMillan M.
      • Roberts C.T.
      • Marshall H.S.
      A systematic review of interventions to improve uptake of pertussis vaccination in pregnancy.
      ;
      • Wong V.W.Y.
      • Lok K.Y.W.
      • Tarrant M.
      Interventions to increase the uptake of seasonal influenza vaccination among pregnant women: A systematic review.
      ). Provider-delivered vaccine recommendations are consistently cited as significant drivers of vaccine behavior (
      • Beel E.R.
      • Rench M.A.
      • Montesinos D.P.
      • Mayes B.
      • Healy C.M.
      Knowledge and attitudes of postpartum women toward immunization during pregnancy and the peripartum period.
      ;
      • Castillo E.
      • Patey A.
      • MacDonald N.
      Vaccination in pregnancy: Challenges & evidence-based solutions.
      ;
      • Wiley K.E.
      • Cooper S.C.
      • Wood N.
      • Leask J.
      Understanding pregnant women’s attitudes and behavior toward influenza and pertussis vaccination.
      ). However, there is at least one report of failed intervention efforts to increase COVID-19 vaccination via provider counseling and onsite vaccine access (
      • Hirshberg J.S.
      • Huysman B.C.
      • Oakes M.C.
      • Cater E.B.
      • Odibo A.O.
      • Raghuraman N.
      • Kelly J.C.
      Offering onsite COVID-19 vaccination to high-risk obstetrical patients: Initial findings.
      ), suggesting other individual factors likely contribute to COVID-19 vaccine behaviors. Thus, there is a great need for understanding determinants of COVID-19 vaccine hesitancy in the perinatal population to develop efficacious interventions specific to COVID-19 vaccination. Further, understanding perinatal care providers’ perspectives regarding helpful versus unhelpful communication strategies—and effective models for integrating vaccine education and communication as well as COVID-19 vaccination into routine clinical care—will provide a critical angle as the field seeks to improve vaccination uptake.
      Although major models of behavior and existing studies on COVID-19 vaccine hesitancy take into account individual factors, few studies have used community-based participatory research approaches to investigate psychological determinants that may vary widely across underserved communities. Intervention acceptability and efficacy among marginalized and understudied populations can be improved by using community-engaged, patient-centered research that includes key stakeholders in health care (
      • Collins S.E.
      • Clifasefi S.L.
      • Stanton J.
      • Straits K.J.
      • Gil-Kashiwabara E.
      • Rodriguez Espinosa P.
      • Wallerstein N.
      Community-based participatory research (CBPR): Towards equitable involvement of community in psychology research.
      ;
      • Gonzalez C.
      • Ramirez M.
      • Diaz A.
      • Duran M.
      • Areàn P.
      Expanding virtual postpartum mental health care for latina women: a participatory research and policy agenda.
      ). Across health care consumers and providers, there is evidence of trends in COVID-19 vaccine hesitancy that are associated with sociodemographic characteristics (
      • Momplaisir F.M.
      • Kuter B.J.
      • Ghadimi F.
      • Browne S.
      • Nkwihoreze H.
      • Feemster K.A.
      • Green-McKenzie J.
      Racial/ethnic differences in COVID-19 vaccine hesitancy among health care workers in 2 large academic hospitals.
      ;
      • Waring M.E.
      • Pagoto S.L.
      • Rudin L.R.
      • Ho C.
      • Horkachuck A.
      • Kapoor I.A.
      • Foye Q.
      Factors associated with mothers’ hesitancy to receive a COVID-19 vaccine.
      ). Traditional psychology designs, while controlling for sample characteristics, may be enhanced by the input of community members, to fine tune the characteristics that are accounted for in the study design. Specifically, including patients, health care providers, and other stakeholders with representative views across a range of ethnic/racial groups in all phases of the research process can inform equitable and effective culturally adaptable interventions and health care policy. Further, using narrative and qualitative approaches to data collection can provide expanded and nuanced insight/understanding into complex and often understudied phenomena. Finally, the iterative co-creation of interventions through formative qualitative work and community-based participatory research may provide much-needed flexibility when conducting research within the rapidly changing landscape of COVID-19 prevention, mitigation, and treatment. As such, research that directly engages community members and stakeholders may improve the typically sluggish lines of communication that can exist between bench science and the community at large. More streamlined communication can ultimately result in a deeper understanding and prioritization of community needs, which can increase trust and improve care.

      Addressing COVID-19 Vaccine Hesitancy to Promote More Equitable Health Care Use

      To develop a robust and effective health care system that provides equitable care to all perinatal patients, it is essential to understand how trust and other psychological determinants of COVID-19 vaccine hesitancy may shape pregnant individuals' vaccination intentions and behavior—which could potentially impact future vaccination decisions with their children. Listening to and understanding patient concerns and provider insights—both in the clinical realm and through dedicated research—will help to uncover patient's experiences and attitudes that may shape care decisions in the era of COVID-19, including any specific concerns, fears, or misinformation that could serve as barriers to vaccination. Such research is essential to improve the care for all perinatal people, and we believe it may be particularly critical in strengthening systems of care for women of color who face greatest risk for poor outcomes due to COVID-19.

      References

        • Adeyanju G.C.
        • Engel E.
        • Koch L.
        • Ranzinger T.
        • Shahid I.B.M.
        • Head M.G.
        • Betsch C.
        Determinants of influenza vaccine hesitancy among pregnant women in Europe: A systematic review.
        European Journal of Medical Research. 2021; 26: 116
        • Ajzen I.
        The theory of planned behavior.
        Organizational Behavior and Human Decision Processes. 1991; 50: 179-211
        • Allotey J.
        • Stallings E.
        • Bonet M.
        • Yap M.
        • Chatterjee S.
        • Kew T.
        • Zhou D.
        Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: Living systematic review and meta-analysis.
        BMJ. 2020; 370: m33220
        • Angelidou A.
        • Sullivan K.
        • Melvin P.R.
        • Shui J.E.
        • Goldfarb I.T.
        • Bartolome R.
        • Singh R.
        Association of maternal perinatal SARS-CoV-2 infection with neonatal outcomes during the COVID-19 pandemic in Massachusetts.
        JAMA Network Open. 2021; 4: e217523
        • Bardají A.
        • Sevene E.
        • Cutland C.
        • Menéndez C.
        • Omer S.B.
        • Aguado T.
        • Muñoz F.M.
        The need for a global COVID-19 maternal immunisation research plan.
        Lancet. 2021; 397: e17-e18
        • Battarbee A.
        • Stockwell M.
        • Varner M.
        • Newes-Adey G.
        • Daugherty M.
        • Gyamfi-Bannerman C.
        • Subramaniam A.
        Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: A cross-sectional multicenter study during August-December 2020.
        American Journal of Perinatology. 2021; 39: 75-83
        • Beel E.R.
        • Rench M.A.
        • Montesinos D.P.
        • Mayes B.
        • Healy C.M.
        Knowledge and attitudes of postpartum women toward immunization during pregnancy and the peripartum period.
        Human Vaccines & Immunotherapeutics. 2013; 9: 1926-1931
        • Beigi R.H.
        • Krubiner C.
        • Jamieson D.J.
        • Lyerly A.D.
        • Hughes B.
        • Riley L.
        • Karron R.
        The need for inclusion of pregnant women in COVID-19 vaccine trials.
        Vaccine. 2021; 39: 868
        • Betsch C.
        • Schmid P.
        • Heinemeier D.
        • Korn L.
        • Holtmann C.
        • Bo hm R.
        Beyond confidence: Development of a measure assessing the 5C psychological antecedents of vaccination.
        PLoS ONE. 2018; 13: e0208601
        • Blakeway H.
        • Prasad S.
        • Kalafat E.
        • Heath P.T.
        • Ladhani S.N.
        • Le Doare K.
        • Khalil A.
        COVID-19 vaccination during pregnancy: Coverage and safety.
        American Journal of Obstetrics and Gynecology. 2021; 226: 236.e1-236.e14
        • Bogart L.M.
        • Ojikutu B.O.
        • Tyagi K.
        • Klein D.J.
        • Mutchler M.G.
        • Dong L.
        • Kellman S.
        COVID-19 related medical mistrust, health impacts, and potential vaccine hesitancy among Black Americans living with HIV.
        Journal of Acquired Immune Deficiency Syndromes. 2021; 86: 200
        • Brewer S.E.
        • Cataldi J.R.
        • Fisher M.
        • Glasgow R.E.
        • Garrett K.
        • O’Leary S.T.
        Motivational Interviewing for Maternal Immunisation (MI4MI) study: A protocol for an implementation study of a clinician vaccine communication intervention for prenatal care settings.
        BMJ Open. 2020; 10: e040226
        • Castillo E.
        • Patey A.
        • MacDonald N.
        Vaccination in pregnancy: Challenges & evidence-based solutions.
        Best Practice & Research Clinical Obstetrics & Gynaecology. 2021; 76: 83-95
        • Centers for Disease Control and Prevention (CDC)
        COVID data tracker weekly review.
        (Available:)
        • Ceulemans M.
        • Foulon V.
        • Panchaud A.
        • Winterfeld U.
        • Pomar L.
        • Lambelet V.
        • Richardson J.L.
        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.
        International Journal of Environmental Research and Public Health. 2021; 18: 3367
        • Cheng P.-J.
        • Huang S.-Y.
        • Su S.-Y.
        • Peng H.-H.
        • Chang C.-L.
        Increasing postpartum rate of vaccination with tetanus, diphtheria, and acellular pertussis vaccine by incorporating pertussis cocooning information into prenatal education for group B streptococcus prevention.
        Vaccine. 2015; 33: 7225-7231
        • Chinn J.
        • Sedighim S.
        • Kirby K.A.
        • Hohmann S.
        • Hameed A.B.
        • Jolley J.
        • Nguyen N.T.
        Characteristics and outcomes of women with COVID-19 giving birth at US academic centers during the COVID-19 pandemic.
        JAMA Network Open. 2021; 4: e2120456
        • Collins S.E.
        • Clifasefi S.L.
        • Stanton J.
        • Straits K.J.
        • Gil-Kashiwabara E.
        • Rodriguez Espinosa P.
        • Wallerstein N.
        Community-based participatory research (CBPR): Towards equitable involvement of community in psychology research.
        American Psychologist. 2018; 73: 884
        • Cunningham R.M.
        • Minard C.G.
        • Guffey D.
        • Swaim L.S.
        • Opel D.J.
        • Boom J.A.
        Prevalence of vaccine hesitancy among expectant mothers in Houston, Texas.
        Academic Pediatrics. 2018; 18: 154-160
        • Denton L.K.
        • Creeley C.E.
        • Stavola B.
        • Hall K.
        • Foltz B.D.
        An analysis of online pregnancy message boards: Mother-to-mother advice on medication use.
        Women and Birth. 2020; 33: e48-e58
        • Dubé E.
        • Laberge C.
        • Guay M.
        • Bramadat P.
        • Roy R.
        • Bettinger J.A.
        Vaccine hesitancy: An overview.
        Human Vaccines & Immunotherapeutics. 2013; 9: 1763-1773
        • Ellington S.
        • Strid P.
        • Tong V.T.
        • Woodworth K.
        • Galang R.R.
        • Zambrano L.D.
        • Gilboa S.M.
        Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status—United States, January 22–June 7, 2020.
        Morbidity and Mortality Weekly Report. 2020; 69: 769
        • Fuchs E.L.
        Self-reported prenatal influenza vaccination and early childhood vaccine series completion.
        Preventive Medicine. 2016; 88: 8-12
        • Gagneur A.
        • Lemaître T.
        • Gosselin V.
        • Farrands A.
        • Carrier N.
        • Petit G.
        • de Wals P.
        A postpartum vaccination promotion intervention using motivational interviewing techniques improves short-term vaccine coverage: PromoVac study.
        BMC Public Health. 2018; 18: 811
        • Gelberg L.
        • Andersen R.M.
        • Leake B.D.
        The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people.
        Health Services Research. 2000; 34: 1273-1302
        • Geoghegan S.
        • Stephens L.C.
        • Feemster K.A.
        • Drew R.J.
        • Eogan M.
        • Butler K.M.
        “This choice does not just affect me.” Attitudes of pregnant women toward COVID-19 vaccines: A mixed-methods study.
        Human Vaccines & Immunotherapeutics. 2021; 17: 1-6
        • Gerend M.A.
        • Pai M.
        Social determinants of Black-White disparities in breast cancer mortality: A review.
        Cancer Epidemiology and Prevention Biomarkers. 2008; 17: 2913-2923
        • Goncu Ayhan S.
        • Oluklu D.
        • Atalay A.
        • Menekse Beser D.
        • Tanacan A.
        • Moraloglu Tekin O.
        • Sahin D.
        COVID-19 vaccine acceptance in pregnant women.
        International Journal of Gynecology & Obstetrics. 2021; 154: 291-296
        • Gonzalez C.
        • Ramirez M.
        • Diaz A.
        • Duran M.
        • Areàn P.
        Expanding virtual postpartum mental health care for latina women: a participatory research and policy agenda.
        Womens Health Issues. 2021; 31: 96-99
        • Gray K.J.
        • Bordt E.A.
        • Atyeo C.
        • Deriso E.
        • Akinwunmi B.
        • Young N.
        • Edlow A.G.
        Coronavirus disease 2019 vaccine response in pregnant and lactating women: A cohort study.
        American Journal of Obstetrics and Gynecology. 2021; 225: 303.e1-303.e17
        • Halabi S.
        • Heinrich A.
        • Omer S.B.
        No-fault compensation for vaccine injury—The other side of equitable access to COVID-19 vaccines.
        New England Journal of Medicine. 2020; 383: e125
        • Hirshberg J.S.
        • Huysman B.C.
        • Oakes M.C.
        • Cater E.B.
        • Odibo A.O.
        • Raghuraman N.
        • Kelly J.C.
        Offering onsite COVID-19 vaccination to high-risk obstetrical patients: Initial findings.
        American Journal of Obstetrics & Gynecology MFM. 2021; 3: 100478
        • Hornsey M.J.
        • Lobera J.
        • Díaz-Catalán C.
        Vaccine hesitancy is strongly associated with distrust of conventional medicine, and only weakly associated with trust in alternative medicine.
        Social Science & Medicine. 2020; 255: 113019
        • Hutchinson A.F.
        • Smith S.M.
        Effectiveness of strategies to increase uptake of pertussis vaccination by new parents and family caregivers: A systematic review.
        Midwifery. 2020; 87: 102734
        • Jering K.S.
        • Claggett B.L.
        • Cunningham J.W.
        • Rosenthal N.
        • Vardeny O.
        • Greene M.F.
        • Solomon S.D.
        Clinical characteristics and outcomes of hospitalized women giving birth with and without COVID-19.
        JAMA Internal Medicine. 2021; 181: 714-717
        • Kachikis A.
        • Englund J.A.
        • Singleton M.
        • Covelli I.
        • Drake A.L.
        • Eckert L.O.
        Short-term reactions among pregnant and lactating individuals in the first wave of the COVID-19 vaccine rollout.
        JAMA Network Open. 2021; 4: e2121310
        • Kasehagen L.
        • Byers P.
        • Taylor K.
        • Kittle T.
        • Roberts C.
        • Collier C.
        • Dobbs T.
        COVID-19–associated deaths after SARS-CoV-2 infection during pregnancy—Mississippi, March 1, 2020–October 6, 2021.
        Morbidity and Mortality Weekly Report. 2021; 70: 1646
        • Kilich E.
        • Dada S.
        • Francis M.R.
        • Tazare J.
        • Chico R.M.
        • Paterson P.
        • Larson H.J.
        Factors that influence vaccination decision-making among pregnant women: A systematic review and meta-analysis.
        PLoS One. 2020; 15: e0234827
        • Kricorian K.
        • Civen R.
        • Equils O.
        COVID-19 vaccine hesitancy: Misinformation and perceptions of vaccine safety.
        Human Vaccines & Immunotherapeutics. 2021; 18: 1950504
        • Metz T.D.
        • Clifton R.G.
        • Hughes B.L.
        • Sandoval G.
        • Saade G.R.
        • Grobman W.A.
        • Clark K.
        Disease severity and perinatal outcomes of pregnant patients with coronavirus disease 2019 (COVID-19).
        Obstetrics and Gynecology. 2021; 137: 571
        • Mohammed H.
        • McMillan M.
        • Roberts C.T.
        • Marshall H.S.
        A systematic review of interventions to improve uptake of pertussis vaccination in pregnancy.
        PLoS One. 2019; 14: e0214538
        • Momplaisir F.M.
        • Kuter B.J.
        • Ghadimi F.
        • Browne S.
        • Nkwihoreze H.
        • Feemster K.A.
        • Green-McKenzie J.
        Racial/ethnic differences in COVID-19 vaccine hesitancy among health care workers in 2 large academic hospitals.
        JAMA Network Open. 2021; 4: e2121931
        • Murphy J.
        • Vallières F.
        • Bentall R.P.
        • Shevlin M.
        • McBride O.
        • Hartman T.K.
        • Hyland P.
        Psychological characteristics associated with COVID-19 vaccine hesitancy and resistance in Ireland and the United Kingdom.
        Nature Communications. 2021; 12: 29
        • Oluklu D.
        • Goncu Ayhan S.
        • Menekse Beser D.
        • Uyan Hendem D.
        • Ozden Tokalioglu E.
        • Turgut E.
        • Sahin D.
        Factors affecting the acceptability of COVID-19 vaccine in the postpartum period.
        Human Vaccines & Immunotherapeutics. 2021; 17: 4043-4047
        • Palamenghi L.
        • Barello S.
        • Boccia S.
        • Graffigna G.
        Mistrust in biomedical research and vaccine hesitancy: The forefront challenge in the battle against COVID-19 in Italy.
        European Journal of Epidemiology. 2020; 35: 785-788
        • Petersen E.E.
        • Davis N.L.
        • Goodman D.
        • Cox S.
        • Syverson C.
        • Seed K.
        • Shapiro-Mendoza C.
        • Barfield W.
        Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016.
        MMWR. Morbidity and Mortality Weekly Report. 2019; 68: 762-765
        • Proujansky A.
        Why Black women are rejecting hospitals in search of better births. The New York Times.
        (Available:)
        • Qiu X.
        • Bailey H.
        • Thorne C.
        Barriers and facilitators associated with vaccine acceptance and uptake among pregnant women in high income countries: A mini-review.
        Frontiers in Immunology. 2021; 12: 1246
        • Richard-Davis G.
        The pipeline problem: Barriers to access of Black patients and providers in reproductive medicine.
        Fertility and Sterility. 2021; 116: 292-295
        • Rosenstock I.M.
        The health belief model and preventive health behavior.
        Health Education Monographs. 1974; 2: 354-386
        • Shimabukuro T.T.
        • Kim S.Y.
        • Myers T.R.
        • Moro P.L.
        • Oduyebo T.
        • Panagiotakopoulos L.
        • Meaney-Delman D.M.
        Preliminary findings of mRNA Covid-19 vaccine safety in pregnant persons.
        New England Journal of Medicine. 2021; 384: 2273-2282
        • Sutton D.
        • D’Alton M.
        • Zhang Y.
        • Kahe K.
        • Cepin A.
        • Goffman D.
        • Coletta J.
        COVID-19 vaccine acceptance among pregnant, breastfeeding and non-pregnant reproductive aged women.
        American Journal of Obstetrics & Gynecology MFM. 2021; 3: 100403
        • Tram K.H.
        • Saeed S.
        • Bradley C.
        • Fox B.
        • Eshun-Wilson I.
        • Mody A.
        • Geng E.
        Deliberation, dissent, and distrust: Understanding distinct drivers of coronavirus disease 2019 vaccine hesitancy in the United States.
        Clinical Infectious Diseases. 2021; 16: ciab633
        • Trostle M.E.
        • Aguero-Rosenfeld M.E.
        • Roman A.S.
        • Jennifer L.
        High antibody levels in cord blood from pregnant women vaccinated against COVID-19.
        American Journal of Obstetrics & Gynecology MFM. 2021; 3: 100481
        • Trostle M.E.
        • Limaye M.A.
        • Avtushka V.
        • Lighter J.L.
        • Penfield C.A.
        • Roman A.S.
        COVID-19 vaccination in pregnancy: early experience from a single institution.
        American Journal of Obstetrics & Gynecology MFM. 2021; 3: 100464
        • Truong J.
        • Bakshi S.
        • Wasim A.
        • Ahmad M.
        • Majid U.
        What factors promote vaccine hesitancy or acceptance during pandemics? A systematic review and thematic analysis.
        Health Promotion International. 2021; 37: daab105
        • Villar J.
        • Ariff S.
        • Gunier R.B.
        • Thiruvengadam R.
        • Rauch S.
        • Kholin A.
        • Cardona-Perez J.A.
        Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection: The INTERCOVID multinational cohort study.
        JAMA Pediatrics. 2021; 175: 817-826
        • Walker K.K.
        • Head K.J.
        • Owens H.
        • Zimet G.D.
        A qualitative study exploring the relationship between mothers’ vaccine hesitancy and health beliefs with COVID-19 vaccination intention and prevention during the early pandemic months.
        Human Vaccines & Immunotherapeutics. 2021; 17: 3355-3364
        • Waring M.E.
        • Pagoto S.L.
        • Rudin L.R.
        • Ho C.
        • Horkachuck A.
        • Kapoor I.A.
        • Foye Q.
        Factors associated with mothers’ hesitancy to receive a COVID-19 vaccine.
        Journal of Behavioral Medicine. 2022; : 1-6
        • Wei S.Q.
        • Bilodeau-Bertrand M.
        • Liu S.
        • Auger N.
        The impact of COVID-19 on pregnancy outcomes: A systematic review and meta-analysis.
        CMAJ. 2021; 193: E540-E548
        • Wiley K.E.
        • Cooper S.C.
        • Wood N.
        • Leask J.
        Understanding pregnant women’s attitudes and behavior toward influenza and pertussis vaccination.
        Qualitative Health Research. 2015; 25: 360-370
        • Wooten K.G.
        • Wortley P.M.
        • Singleton J.A.
        • Euler G.L.
        Perceptions matter: Beliefs about influenza vaccine and vaccination behavior among elderly White, Black and Hispanic Americans.
        Vaccine. 2012; 30: 6927-6934
        • Wong V.W.Y.
        • Lok K.Y.W.
        • Tarrant M.
        Interventions to increase the uptake of seasonal influenza vaccination among pregnant women: A systematic review.
        Vaccine. 2016; 34: 20-32
        • Zambrano L.D.
        • Ellington S.
        • Strid P.
        • Galang R.R.
        • Oduyebo T.
        • Tong V.T.
        • Gilboa S.M.
        Update: characteristics of symptomatic women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status—United States, January 22–October 3, 2020.
        Morbidity and Mortality Weekly Report. 2020; 69: 1641

      Biography

      Micheline R. Anderson, PhD, is a postdoctoral fellow in the Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University and the Postpartum Day Hospital, Women & Infants Hospital. Her research interests include perinatal stress, coping, and related intervention development.

      Biography

      Erica J. Hardy, MD, MMSc, is a Clinical Assistant Professor of Medicine and OBGYN, Alpert Medical School of Brown University and Director of Infectious Disease, Women & Infants Hospital. Her research interests include infectious disease and trauma-informed care in pregnancy.

      Biography

      Cynthia L. Battle, PhD, is a clinical psychologist and Professor of Psychiatry & Human Behavior, Alpert Medical School of Brown University. Her research is focused on women's perinatal mental health, including development of novel, behavioral intervention approaches.