Exploring COVID-19 vaccination behavior: A cross-country study among pregnant and postpartum women in Brazil, Ghana, Kenya, and Pakistan

Pregnant women infected with SARS-CoV2 are more likely to be hospitalized and require ventilation, compared to non-pregnant women. Although the development of the COVID-19 vaccine was regarded as a scientific breakthrough among many, the pace of development in combination with delayed and unclear recommendations for maternal vaccination led to slower vaccine uptake among this population. We explored the decision-making process for COVID-19 vaccination among pregnant and postpartum women in four countries: Brazil, Ghana, Kenya, and Pakistan through 201 in-depth interviews. A grounded theory approach was used for analysis, and a socio-ecological framework was used to synthesize emerging themes. Four levels of influence on vaccine-related attitudes and behaviors were identified: individual, interpersonal, community, and policy. Risk perception and beliefs about vaccines safety were the primary individual-level factors identified. Risk perception of the disease was a common reason for vaccine acceptance, whereas lower risk perception emerged as a reason to not vaccinate. Vaccine safety concerns, for the pregnant woman herself, her pregnancy, and her baby were common across all countries. At the interpersonal level, the influence of the male partner and peers emerged across all countries. While participants identified the partner or spouse was most influential, they also discussed the limited impact the male partner had on decision-making, particularly in Ghana, Kenya, and Pakistan. At the community-level, healthcare providers helped in allaying vaccine safety concerns, and women looked to them for their health expertise and recommendations. At the policy-level, the requirement — real or perceived — of vaccination to access services, travel, work, and education was an important factor in all countries. Vaccine decision-making is complex, multi-faceted, and context-specific. When promoting vaccination among pregnant and postpartum women, engaging influential individuals can support the successful uptake of maternal vaccination.