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The prevalence of COVID vaccine acceptance among pregnant women: A systematic review and meta-analysis

Open AccessPublished:September 11, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101144

      Abstract

      COVID pandemic has massively hit every nook of the world. Millions of people were infected and lost their lives to the deadly pandemic. This novel virus destroyed the essential healthcare service globally. Mass vaccination is the only option to halt the virus transmission. This study aimed to estimate the acceptance of the COVID vaccine among pregnant women and breastfeeding mothers. Method: We followed Cochrane collaboration guidelines and the PRISMA reporting system. Studies were identified through a systematic search of indexed articles in Medline (PubMed), Clinical key, Google Scholar, Cochrane Library, and CINAHL databases until March 10, 2022, 26,995 articles were identified in the initial search and 24 articles were included in the review. Result: Twenty four studies comprise 22,947 pregnant and 11,022 breastfeeding women. About 54% of pregnant women and 59% of breastfeeding mothers intended to take the COVID vaccination. Among the pregnant mothers, 21% with comorbidities, 14% in the first trimester, 34% in the second trimester, and 51% in the third trimester were willing to take the COVID vaccine. Risks of infections and comorbidities were the reasons for acceptance of the COVID vaccine in pregnant women. Similarly, adverse effects and safety concerns were top indicators for the rejection of the COVID vaccine. Conclusion: The acceptance of COVID vaccination among pregnant women and breastfeeding mothers are not satisfactory. Therefore, timely guidance would help to address the negative perceptions of vaccines among pregnant women.

      Keywords

      1. Introduction

      The healthcare authority of China has identified a rare respiratory illness in late 2019 in Wuhan province. Signs and symptoms of novel infection appeared to be most contagious and transmissible among human beings.

      WHO. Co V, I D - 19 Strategy up Date. Covid-19 Strateg Updat. 2020;3(April):18.

      Meanwhile, the intensity of viral load increased in people with this novel infection. Subsequently, the health authority of China had identified the source of the mysterious respiratory infection and named it a Novel coronavirus registered within and outside the Republic of China. Novel COVID-19 cases were being spread like wildfire all over the world by the first quarter of the year 2020. Considering this spread, on March 11, 2020, the World Health Organization (WHO) announced COVID-19 a pandemic and emerging contagious infectious disease worldwide.

      WHO. WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19 - 11 March 2020. 2020.

      On April 22, 2022, 505.81 million people were infected with Coronavirus and 46.19 million people succumbed to the deadly virus.

      WHO. Coronavirus Disease (COVID-19) pandemicNo Title. Coronavirus Disease (COVID-19) Pandemic. 2021;1.

      Covid-19 pandemic has had a catastrophic effect on the world's economy and disturbed the smooth functioning of healthcare services, worldwide. As a result, vulnerable populations such as pregnant women, lactating mothers, elder people, and children appear to be at higher risk and increased risk of hospitalization. In this context, the COVID pandemic affected the essential services that are needed for pregnant women, children, and heighten psychological threats in pregnant women.
      • Nguyen L.H.
      • Hoang M.T.
      • Nguyen L.D.
      • et al.
      Acceptance and willingness to pay for COVID-19 vaccines among pregnant women in Vietnam.
      In pregnant women, the effect of the pandemic increased hospital admission threefold and the death rate by 1.5 times. Unfortunately, pregnant women who contracted COVID infections are at high risk of other advanced infections.
      • Soemari Y.B.
      • Sapri
      • Maghfiroh F.
      • Yuniarti
      • et al.
      Coronavirus disease 2019 vaccine response in pregnant and lactating women: a cohort study.
      ,
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • et al.
      Covid - 19 vaccine acceptance among pregnant women and mothers of young children : results of a survey in 16 countries United States of America.
      COVID 19 has provided several opportunities to develop appropriate vaccines against deadly pandemics. However, some countries used their own designed vaccine on their citizens excluding children and pregnant mothers. Subsequently, some nations insist on approval from WHO for universal vaccination against deadly viruses. Nevertheless, mass vaccination against COVID-19 is one of the best options to control the COVID pandemic.
      Previous research articles have reported the incidence of COVID vaccine acceptance among pregnant and lactating women.
      • Pairat K.
      • Phaloprakarn C.
      Acceptance of COVID-19 vaccination during pregnancy among Thai pregnant women and their spouses: a prospective survey.
      ,
      • Ghamri Ranya
      • Alshahrani A.
      Acceptance of COVID-19 Vaccine and Associated Factors Among Pregnant Women in Saudi Arabia.
      Though a meta-analysis was reported with a few primary studies, there is dearth of evidence to understand the acceptance level among these populations.
      • Carbone L.
      • Di Girolamo R.
      • Mappa I.
      • et al.
      Worldwide beliefs among pregnant women on SARS-CoV-2 vaccine: a systematic review.
      ,
      • Nikpour M.
      • Sepidarkish M.
      • Omidvar S.
      • Firouzbakht M.
      Global prevalence of acceptance of COVID-19 vaccines and associated factors in pregnant women: a systematic review and meta-analysis.
      Therefore, we aimed to conduct a systematic review and meta-analysis to understand the psychological phenomenon of pregnant and lactation women towards COVID vaccination. Further, our review compared COVID vaccine acceptance with different trimesters of pregnancy, Influenza vaccination, and education level of pregnant women which are not published in the previous reviews.

      2. Review methods

      2.1 Protocol and registration

      This systematic review and meta-analysis adopted Cochrane Collaboration guidelines
      • Green Jph and S.
      and reported using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • et al.
      The review protocol was prospectively registered with PROSPERO (CRD42021282462).

      2.2 Search strategy and study selection

      The search strategy was designed based on MeSH terms (pregnan* OR “pregnant women” OR “antenatal mother*” OR “nursing mother*” OR “primi mother*” OR “pregnant mother*”) AND (vaccine” OR “COVID vaccine” OR vaccination OR “SARS-COV vaccine”) AND (willingness OR acceptance OR receive OR hesitancy). Articles published between November 01, 2021 and March 10, 2022 were searched in different databases namely Medline (PubMed), The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase and Google Scholar.
      Two authors (KH & SD) independently screened the titles, abstracts, and full text of the original identified articles. We also hand-searched the references of the included studies. Any disagreements between the first two authors on the screening discrepancies were referred to the third (LT), and dissimilarity was resolved in discussion with the third reviewer. All included articles were selected based on the following criteria i) study population comprised of pregnant women ii) Cross-sectional studies published in the English language and, iii) Pregnant women seeking COVID vaccine. The extracted data were summarized in tables under headings of author/s’ name, year of publication, the country in which the study was conducted, sample size, age of the participants, education level, and the study outcomes.

      2.3 Search outcome

      The initial electronic search strategy has identified 26,992 studies and additional 3 studies were obtained from hand searches (Fig. 1 A total of 1298 duplicate records were removed. After a thorough screening of title, abstracts and full text against inclusion criteria, 24 studies were found to be eligible.Table-1 Therefore, these 24 studies were included for quantitative synthesis figure-2.
      Table 1Characteristics of included studies.
      Author name,yearCountrySample sizeStudy's designAge in yearsEducation > (HS)Inclusion criteriaStudies outcome
      Stuckelberger,2021SwitzerlandT-1551

      P-515

      BF-1036
      Multi center survey33 (median)721Pregnant women or lactation mother(0–12 weeks) at least 18 years and above age at time data collectionAfter the first pandemic wave, Switzerland had a low SARS-CoV-2 vaccination acceptance rate, emphasizing the need to identify and reduce barriers for immunization in pregnant and breastfeeding women, particularly among the youngest and those with a lower educational level
      Nguyen et al., 2021VietnamP-651CS29.4 ± 5.4403Age above 18 years of Pregnant women or just given birth.Implementing COVID- 19 vaccination and resource mobilization among pregnant women in Vietnam is feasible, although communication programs to improve risk perception and awareness about vaccine should be developed for facilitating acceptance of the vaccine
      Skjefte et al., 2021USA5282CS<35= 4156

      >35 = 1125
      4565Women currently pregnant or with at least one child under 18 years of ageAbout 52% of pregnant women ready to take COVID-19 vaccine, when efficacy more than 90%.Prediction of vaccine acceptance different vary globally. However vaccine acceptance among women and children should be specific for each country in order to attain the largest impact.
      Goncu et al., 2021Turkey300CS27.99 ± 5.672Pregnant mother who were attending prenatal care centers.About 37% (111) pregnant women ready o take COVID vaccine. Lack of knowledge on COVID-19, concern to fetal harm were major reason for vaccine rejection in pregnancy population.
      Hoque et al., 2020South Africa346CS26.7 ± 6.8145Pregnant women attending antenatal clinic during COVID pandemicThe rate of COVID vaccine acceptance higher among younger pregnant women (93%).Similarly 75.3% of pregnancy women who had one or two children likely to accept COVID vaccine.
      Hailemariam et al., 2021Ethiopia412CS30.6 ± 5.9159Pregnant women more than 18 years residing at least 6 months in the area.Approximately 217 (52.6%) pregnant women positive perception towards COVID vaccine. Participants with good knowledge likely receive three times COVID vaccine.
      Ceulemans et al., 2021IE,

      NO, CH, NL &UK
      T-16,063

      P-6661

      BF-9402
      Multinational CS<35=1168

      >35 = 4375
      10,688Age >18 years of pregnant & lactation mother(0–3 months)First trimester women and lactation mother more likely received the COVID vaccine. Low family income and health care workers are less interested to receive COVID vaccine
      Tao et al., 2021China1392Multi center CS<35=1231

      >35 = 161
      1154Pregnant >18 years those attending antenatal clinicOverall 77.4% of participants were intended to take COVID vaccine. In contract age inversely proportional to COVID vaccine acceptance among pregnant women.
      Desmond Sutton et al., 2021USAT-338

      P-216

      BF-122
      CSP-34 ± 6

      BF-35 ± 7
      NRPregnant women and breast feeding mothers those.Overall 656 participants, 318 (64.8%) were non pregnant, 216 (21.3%) were pregnant, and 122 (12.1%) were breastfeeding. Pregnant women likely accept COVID vaccine ((76.2%), breast feeding mother (55.2%).and pregnant women (44.3%).Working with care center was not influence the vaccine acceptance.
      Sznajder et al., 2022USA196Multi center CS<35=157

      >35 = 39
      M-137

      F-109
      The pregnant women age >18 yearsEducation and history of Influenza vaccine increases COVID vaccine acceptance among pregnant women. Timely health teaching will improve future pandemic responses and current vaccination efforts.
      Mappa et al., 2021Italy161CS33
      • Battarbee A.N.
      • Stockwell M.S.
      • Varner M.
      • et al.
      Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during august-december 2020.
      • Levy A.T.
      • Singh S.
      • Riley L.E.
      • Prabhu M.
      • Hosokawa Y.
      • Okawa S.
      • Hori A.
      • et al.
      The prevalence of COVID-19 vaccination and vaccine hesitancy in pregnant women: an internet-based cross-sectional study in Japan.
      • Tao L.
      • Wang R.
      • Han N.
      • et al.
      Acceptance of a COVID-19 Vaccine and Associated Factors Among Pregnant Women in China : A Multi-Center Cross-Sectional Study Based on Health Belief Model Acceptance of a COVID-19 Vaccine and Associated Factors Among Pregnant Women in China : a Multi-Cente.
      • Goncu S.
      • Deniz A.
      • Aysegul O.
      • et al.
      19 vaccine acceptance in pregnant women.
      • Hoque A.M.
      • Buckus S.
      • Hoque M.
      • Hoque M.E.
      • Hal G Van
      COVID-19 vaccine acceptability among pregnant women at a primary health care facility in durban , South Africa.
      156Pregnant women visit antenatal care in last 2 weeksAbout 136 (84.5%) pregnant women in favor to COVID vaccine. Education and unemployment inversely propositional to COVID vaccine.
      Mohan et al., 2021Qatar341CS30NRPregnant and breast feeding mothersApproximately 75% of participants disinterest in COVID vaccine. Further 18.3% participants were not recommending COVID vaccine to their family.
      Skirrow et al., 2022UKT-1181

      P-803

      BF-378
      Multi center survey<35=461

      >35 = 720
      NRResidents in UK and over 16 yearsAbout (62.1%) of pregnancy women are willing to accept COVID vaccine. Standard intervention required to justify the efficacy of COVID vaccine.
      Riad et al., 2021EuropeT-362

      P-278

      BF-84
      CS>31 = 183

      <31 = 172
      T-205

      P-155

      BF-50
      Pregnant or lactation women (last 6 months of delivery) age 15–44 years.About pregnancy (76.6%) and lactating (48.8%) women ready to take COVID vaccine. Although overall 70.2% participants in favor immediate and delayed vaccination.
      Egloff et al., 2022France664Multi center Survey>35 = 32

      <35 = 132
      522All pregnant women attending French obstructive department.Of the 664 participants, 29.5% of pregnancy women willing to accept COVID vaccine. Following reasons for accepting COVID vaccine to protect themselves (84.7%), to protect relations (79.6%) or to protect the newborn (62.2%).The reason for vaccine avoidance about (76.9 fear to fetal and (33.8%) themselves transmission.
      Kumari et al., 2022India313CS28.32 ± 4.62256All pregnant women attending in-patient and out patients departmentThe future effect on fetus was a major reason for vaccine unacceptance (58.6%) among pregnant women. The safety was major concern for hesitancy of COVID vaccine.
      Carbone et al., 2020Italia142Multi centers survey3421Pregnant women attending outpatient department and post-operative womenThe majority of pregnant women and lactating mother not willing to take COVID vaccine. Further there were no significance between COVID acceptance and marital status, employment, marital status, pregnancy etc.
      Desai, 2021India124CS29.9 ± 2.8961Pregnancy women older than 18 years,Participants who received annual Influenza vaccine more likely receive COVID 19 vaccine.
      Geoghegan et al., 2021Ireland300CS<35=131

      >35 = 56
      163Pregnant womenAbout 113(38%) of pregnant women are score >8, as they likely take COVID vaccine in concern of their unborn fetus.
      Kiefer et al., 2022USA456CS29.3 ± 5.38324Pregnant women and post-operative womenAbout 46% vaccine participants were not willing to take COVID vaccine. Barrier of government services major reason for COVID vaccine hesitancy among pregnant women.
      Mose & Yeshaneh, 2021Ethiopia396Multi center survey<35=354

      >35 = 42
      82All pregnant women visit antenatal care follow-upThere was 70.7% of pregnant willingness COVID vaccine. Education, knowledge and good practice are major factors for acceptance.
      Battarbee et al., 2022USA915Multi center survey<35=741

      >35 = 172
      591Participants age from 18 to 50 years old and were at less than 28 weeks gestation.Only 41% of participants were ready to take COVID vaccine. About 72% worried to sick if take COVID vaccine, Although most pregnant women worried about COVID-19 illness, <50% were willing to get vaccinated during pregnancy.
      Levy et al., 2021USA662CS<35=415

      >35 = 237
      565Participants above >18 yearsAbout 381/653 (58.3%) of pregnant women in favor to COVID vaccine. The risk of fetal transmission (45.8%) and side effects45.8%) were major reason for vaccine rejection among pregnant women.
      Hosokawa et al., 2022Japan1621Multi center survey<35=1206

      >35 = 415
      1369Pregnant womenThe prevalence of vaccination and vaccine hesitancy among pregnant women was 13.4% (n = 217) and 50.9% (n = 825), respectively. Adverse effect and fetal side effects were major concerns.Vaccine hesitancy was significantly associated with the lack of trust in the government.
      CS- Cross sectional studies, NR: Not reported, HS-High school, P-Pregnant, BF-Breastfeeding, IE- Ireland, NO- Norway,CH- Switzerland, NL- the Netherlands,UK- the United Kingdom.
      Fig. 2
      Fig. 2Acceptance of COVID vaccine among pregnant women.

      2.4 Quality evaluation

      The qualities of the included studies were assessed using the modified Newcastle-Ottawa Scale (NOS),

      PA Modesti et al. Panethnic Differences in Blood Pressure in Europe: A Systematic Review and Meta-Analysis. S1 Text S1 Text NEWCASTLE-OTTAWA QUALITY ASSESSMENT SCALE (Adapted for Cross Sectional Studies).

      Each of the individual studies was appraised against selection, comparability, and study outcomes. Fig. 3 and Fig. 4 The assessment tool scores ranged between zero and five. Those studies scored three and above are considered low risk of bias or high-quality study. The appraisal of the included studies is presented in Table 2.
      Fig. 3
      Fig. 3Acceptance of COVID vaccine among pregnant women.B.Previous influenza vaccination increases the acceptance of COVID vaccine among pregnant women.
      Fig. 4
      Fig. 4Education level(>Higher secondary) vs acceptance of COVID vaccine among pregnant women.
      Table 2Quality appraisal of the included studies using modified Newcastle-Ottawa scale.
      AuthorSample size >200Representativeness of samples >70%Response rate

      >80%
      Valid toolNot required further statistical calculationsStudy quality
      Stuckelberger,2021*****Low risk
      Nguyen et al., 2021*****Low risk
      Skjefte et al., 2021*****Low risk
      Goncu et al., 2021*****Low risk
      Hoque et al., 2020*****Low risk
      Hailemariam et al., 2021*****Low risk
      Ceulemans et al., 2021*****Low risk
      Tao et al., 2021*****Low risk
      Desmond et al., 2021*****Low risk
      Sznajder et al., 2022*****Low risk
      Mappa et al., 2021*****Low risk
      Mohan et al., 2021*****Low risk
      Skirrow et al., 2022*****Low risk
      Riad et al., 2021*****Low risk
      Egloff et al., 2022*****Low risk
      Kumari et al., 2022*****Low risk
      Carbone et al., 2020*****Low risk
      Desai, 2021****Low risk
      Geoghegan et al., 2021*****Low risk
      Kiefer et al., 2022*****Low risk
      Mose & Yeshaneh, 2021*****Low risk
      Battarbee et al., 2022*****Low risk
      Levy et al., 2021*****Low risk
      Hosokawa et al., 2022*****Low risk

      2.5 Statistical analysis

      We manually calculated the pooled prevalence of individual studies using Microsoft excel. The Pooled data with a 95% confidence interval was estimated using the inverse-variance weighted method. Meta-analysis was performed using Poisson distribution under the Metaprop function of Stata software version 16 (Stata Corp LP, College station USA).Table-3 The pooled prevalence of COVID vaccine acceptance of pregnant women and lactating mothers among included studies was calculated using a random-effect model in proportion with a 95% confidence interval. The heterogeneity of studies was evaluated through the I2 test. The heterogeneity was categorized based on I2 value as high >75, medium 50–75 and low <50 percentages.
      • Halemani K.
      • Issac A.
      • Mishra P.
      • Mathias E.
      The impact of exercise on fatigue among patients undergoing adjuvant the impact of exercise on fatigue among patients undergoing adjuvant radiation therapy : a systematic review and meta-analysis.
      Table 3Participants’ characteristics of included studies.
      Studies outcomeNumber of studiesSamplesPrevalence(95% CI)I2 in percentages
      Participants' age<35 years242630477(0.76, 0.78)99.9
      >35 years12766522(0.21,0.23)
      COVID vaccine acceptance during pregnancy1st trimester8147314(0.13,0.15)99.8
      2nd trimester9388534(0.32,0.36)

      51(0.50,0.54)
      3rd trimester105848
      Comorbidity during pregnancyOne or more chronic disease11147421(0.20,0.22)
      Literacy rate vs COVID acceptance>High school14747164(0.55,0.73)98.9
      Study settingSouth & North America7458948(0.47,0.49)99.1
      Europe71158861(0.60,0.62)
      Asia7234449(0.47,0.51)
      Africa371662(0.59,0.65)
      Number of childrenNo child11516521(0.20,0.22)99.8
      One child12967839(0.38,0.40)
      One child6930644(0.43,0.645)
      Acceptance of COVID vaccine among studies' participantsPregnancy231206854(0.46,0.61)99.2
      Breast feeding5693959(0.47,0.70)98.2
      History of previous vaccination influences COVID vaccine acceptanceInfluenza vaccine8220667(0.53,0.80)99.01

      3. Result

      The extracted data were cross-checked and summarized in the tables and figures. A total of 24 studies comprised 22,947 pregnant women and 11,022 breastfeeding mothers. Among these studies, six studies had both pregnant women and lactating mothers as their samples.
      • Ceulemans M.
      • Foulon V.
      • Panchaud A.
      • 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.
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave.
      • Desmond Sutton M.
      • Mary D'Alton M.
      • Zhang Yijia
      • et al.
      COVID-19 vaccine acceptance among pregnant, breastfeeding, and nonpregnant reproductive-aged women.
      • Skirrow H.
      • Barnett S.
      • Bell S.
      • et al.
      Women's views on accepting COVID-19 vaccination during and after pregnancy, and for their babies: a multi-methods study in the UK.
      • Riad A.
      • Jouzová A.
      • Üstün B.
      • et al.
      COVID-19 vaccine acceptance of pregnant and lactating women (PLW) in Czechia: an analytical cross-sectional study.
      • Kumari A.
      • Mahey R.
      • Kachhawa G.
      • Kumari R.
      • Bhatla N.
      Since January 2020 Elsevier Has Created a COVID-19 Resource Centre with Free Information in English and Mandarin on the Novel Coronavirus COVID- 19 . The COVID-19 Resource Centre Is Hosted.
      Further, we noticed that participants were different in trimesters; 10,225 participants were in the first trimester, 11021 participants were in the second trimester and the remaining 11685 participants were in the third trimester. Also, 5165 participants were in primigravida, 9678 participants had one child and 9306 participants had more than one child [Table 1].

      3.1 Demographic variables Vs COVID vaccine acceptance among pregnant women

      Table 1 summarized the overall data of included studies. On assessment, 26,304 (76%) participants' age was less than 35 years and 7665 (23%) participants' age was above 35 years. COVID vaccine acceptance during pregnancy was as follows: 1473 (14%) participants' in the first trimester, 3885 (34%) participants' in the second trimester and 5848 (51%) participants’ in the third trimester. A total of 1474 pregnant women reported comorbidity. The studies were conducted in different countries; seven studies in South & North America (N = 4589), seven studies in Asia (N = 2344), seven studies in Europe (N = 11,588) and three studies conducted in Africa (N = 1312). About 54% of pregnant women and 59% of lactating mothers preferred COVID vaccination. Similarly, 67% of pregnant women with a history of previous influenza vaccinations were willing to accept the existing COVID vaccine. [Table 3]

      3.2 The prevalence rate of COVID Vaccine acceptance among pregnant and laction women

      Overall, 54% of pregnant women [0.54(0.46, 0.61), I2 = 99.27%, P = 0.001] intended to take COVID vaccine.
      • Nguyen L.H.
      • Hoang M.T.
      • Nguyen L.D.
      • et al.
      Acceptance and willingness to pay for COVID-19 vaccines among pregnant women in Vietnam.
      ,
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • et al.
      Covid - 19 vaccine acceptance among pregnant women and mothers of young children : results of a survey in 16 countries United States of America.
      ,
      • Ceulemans M.
      • Foulon V.
      • Panchaud A.
      • 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.
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave.
      • Desmond Sutton M.
      • Mary D'Alton M.
      • Zhang Yijia
      • et al.
      COVID-19 vaccine acceptance among pregnant, breastfeeding, and nonpregnant reproductive-aged women.
      • Skirrow H.
      • Barnett S.
      • Bell S.
      • et al.
      Women's views on accepting COVID-19 vaccination during and after pregnancy, and for their babies: a multi-methods study in the UK.
      • Riad A.
      • Jouzová A.
      • Üstün B.
      • et al.
      COVID-19 vaccine acceptance of pregnant and lactating women (PLW) in Czechia: an analytical cross-sectional study.
      • Kumari A.
      • Mahey R.
      • Kachhawa G.
      • Kumari R.
      • Bhatla N.
      Since January 2020 Elsevier Has Created a COVID-19 Resource Centre with Free Information in English and Mandarin on the Novel Coronavirus COVID- 19 . The COVID-19 Resource Centre Is Hosted.
      • Hailemariam S.
      • Mekonnen B.
      • Shifera N.
      • et al.
      • Sznajder K.K.
      • Kjerulff K.H.
      • Wang M.
      • Hwang W.
      • Ramirez S.I.
      • Gandhi C.K.
      Covid-19 vaccine acceptance and associated factors among pregnant women in Pennsylvania 2020.
      • Mappa I.
      • Luviso M.
      • Distefano F.A.
      • Carbone L.
      • Maruotti G.M.
      • Rizzo G.
      Women perception of SARS-CoV-2 vaccination during pregnancy and subsequent maternal anxiety: a prospective observational study.
      • Mohan S.
      • Reagu S.
      • Lindow S.
      • Alabdulla M.
      COVID-19 vaccine hesitancy in perinatal women: a cross sectional survey.
      • Egloff C.
      • Couffignal C.
      • Cordier A.G.
      • et al.
      Pregnant women's perceptions of the COVID-19 vaccine: a French survey.
      • Carbone L.
      • Di R.
      • Mappa I.
      • et al.
      Since January 2020 Elsevier Has Created a COVID-19 Resource Centre with Free Information in English and Mandarin on the Novel Coronavirus COVID- 19 . The COVID-19 Resource Centre Is Hosted.
      • Desai P.K.
      COVID-19 vaccine acceptance in pregnancy.
      • 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.
      • Kiefer M.K.
      • Mehl R.
      • Costantine M.M.
      • et al.
      Characteristics and perceptions associated with COVID-19 vaccination hesitancy among pregnant and postpartum individuals: a cross-sectional study.
      • Mose A.
      • Yeshaneh A.
      COVID-19 vaccine acceptance and its associated factors among pregnant women attending antenatal care clinic in southwest Ethiopia: institutional-based cross-sectional study.
      • Battarbee A.N.
      • Stockwell M.S.
      • Varner M.
      • et al.
      Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during august-december 2020.
      • Levy A.T.
      • Singh S.
      • Riley L.E.
      • Prabhu M.
      • Hosokawa Y.
      • Okawa S.
      • Hori A.
      • et al.
      The prevalence of COVID-19 vaccination and vaccine hesitancy in pregnant women: an internet-based cross-sectional study in Japan.
      • Tao L.
      • Wang R.
      • Han N.
      • et al.
      Acceptance of a COVID-19 Vaccine and Associated Factors Among Pregnant Women in China : A Multi-Center Cross-Sectional Study Based on Health Belief Model Acceptance of a COVID-19 Vaccine and Associated Factors Among Pregnant Women in China : a Multi-Cente.
      • Goncu S.
      • Deniz A.
      • Aysegul O.
      • et al.
      19 vaccine acceptance in pregnant women.
      • Hoque A.M.
      • Buckus S.
      • Hoque M.
      • Hoque M.E.
      • Hal G Van
      COVID-19 vaccine acceptability among pregnant women at a primary health care facility in durban , South Africa.
      Of which, prevalence of acceptance was reported highest (93%)
      • 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.
      by Geoghegan and lowest (31%)
      • Egloff C.
      • Couffignal C.
      • Cordier A.G.
      • et al.
      Pregnant women's perceptions of the COVID-19 vaccine: a French survey.
      by Egloff [Fig. 2].
      A total of six studies were involved for estimating acceptance of COVID among lactating mothers. On the other hand, 59% of breastfeeding mothers [0.59(0.47, 0.70, I2 = 98.20%, P = 0.001)] were willing to take the COVID vaccine. Among existing studies, the prevalence of COVID vaccine acceptance was reported highest (74%)
      • Kumari A.
      • Mahey R.
      • Kachhawa G.
      • Kumari R.
      • Bhatla N.
      Since January 2020 Elsevier Has Created a COVID-19 Resource Centre with Free Information in English and Mandarin on the Novel Coronavirus COVID- 19 . The COVID-19 Resource Centre Is Hosted.
      highest by Kumari 74% and lowest (38%)
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave.
      by Stuckelberger [Fig. 3]
      Prevalence of COVID vaccine acceptance among Influenza vaccinated pregnant mothers.
      • Sixty seven percent of pregnant women with previous history of influenza vaccine were anticipated to take COVID vaccine [0.67(0.53, 0.80), I2 = 99.01%, P = 0.00].
        • Stuckelberger S.
        • Favre G.
        • Ceulemans M.
        • et al.
        SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave.
        ,
        • Sznajder K.K.
        • Kjerulff K.H.
        • Wang M.
        • Hwang W.
        • Ramirez S.I.
        • Gandhi C.K.
        Covid-19 vaccine acceptance and associated factors among pregnant women in Pennsylvania 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.
        ,
        • Kiefer M.K.
        • Mehl R.
        • Costantine M.M.
        • et al.
        Characteristics and perceptions associated with COVID-19 vaccination hesitancy among pregnant and postpartum individuals: a cross-sectional study.
        ,
        • Battarbee A.N.
        • Stockwell M.S.
        • Varner M.
        • et al.
        Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during august-december 2020.
        ,
        • Levy A.T.
        • Singh S.
        • Riley L.E.
        • Prabhu M.
        ,
        • Tao L.
        • Wang R.
        • Han N.
        • et al.
        Acceptance of a COVID-19 Vaccine and Associated Factors Among Pregnant Women in China : A Multi-Center Cross-Sectional Study Based on Health Belief Model Acceptance of a COVID-19 Vaccine and Associated Factors Among Pregnant Women in China : a Multi-Cente.
        ,
        • Goncu S.
        • Deniz A.
        • Aysegul O.
        • et al.
        19 vaccine acceptance in pregnant women.
      Among eight studies Geoghegan reported the highest (98%)
      • 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.
      and Stuckelberge lowest (35%)
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave.
      COVID vaccine acceptance among pregnant women with previous influenza vaccination [Fig. 3].

      3.3 Prevalence of COVID vaccine acceptance with a literacy level of pregnant women

      Pregnant mothers (64%) completed high school and above education were ready for the COVID vaccine [0.64(0.55, 0.73, I2 = 98.90%, P = 0.001]. From the 15 studies estimated
      • Nguyen L.H.
      • Hoang M.T.
      • Nguyen L.D.
      • et al.
      Acceptance and willingness to pay for COVID-19 vaccines among pregnant women in Vietnam.
      ,
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • et al.
      Covid - 19 vaccine acceptance among pregnant women and mothers of young children : results of a survey in 16 countries United States of America.
      ,
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave.
      ,
      • Riad A.
      • Jouzová A.
      • Üstün B.
      • et al.
      COVID-19 vaccine acceptance of pregnant and lactating women (PLW) in Czechia: an analytical cross-sectional study.
      ,
      • Hailemariam S.
      • Mekonnen B.
      • Shifera N.
      • et al.
      ,
      • Sznajder K.K.
      • Kjerulff K.H.
      • Wang M.
      • Hwang W.
      • Ramirez S.I.
      • Gandhi C.K.
      Covid-19 vaccine acceptance and associated factors among pregnant women in Pennsylvania 2020.
      ,
      • Egloff C.
      • Couffignal C.
      • Cordier A.G.
      • et al.
      Pregnant women's perceptions of the COVID-19 vaccine: a French survey.
      ,
      • Desai P.K.
      COVID-19 vaccine acceptance in pregnancy.
      • 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.
      • Kiefer M.K.
      • Mehl R.
      • Costantine M.M.
      • et al.
      Characteristics and perceptions associated with COVID-19 vaccination hesitancy among pregnant and postpartum individuals: a cross-sectional study.
      • Mose A.
      • Yeshaneh A.
      COVID-19 vaccine acceptance and its associated factors among pregnant women attending antenatal care clinic in southwest Ethiopia: institutional-based cross-sectional study.
      • Battarbee A.N.
      • Stockwell M.S.
      • Varner M.
      • et al.
      Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during august-december 2020.
      • Levy A.T.
      • Singh S.
      • Riley L.E.
      • Prabhu M.
      • Hosokawa Y.
      • Okawa S.
      • Hori A.
      • et al.
      The prevalence of COVID-19 vaccination and vaccine hesitancy in pregnant women: an internet-based cross-sectional study in Japan.
      • Tao L.
      • Wang R.
      • Han N.
      • et al.
      Acceptance of a COVID-19 Vaccine and Associated Factors Among Pregnant Women in China : A Multi-Center Cross-Sectional Study Based on Health Belief Model Acceptance of a COVID-19 Vaccine and Associated Factors Among Pregnant Women in China : a Multi-Cente.
      the prevalence of COVID vaccine acceptance among educated pregnant women was reported highest (93%)
      • 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.
      by Geoghegan and lowest (31%)
      • Egloff C.
      • Couffignal C.
      • Cordier A.G.
      • et al.
      Pregnant women's perceptions of the COVID-19 vaccine: a French survey.
      by Egloff. [Fig. 4].

      4. Discussion

      The COVID pandemic has seriously changed the way people live and work. Globally, most people experienced a new viral menace. The way of routine and essential healthcare services were interrupted. Meanwhile, a number of vaccines are developed and tested worldwide. According to history, vaccine development takes 10–15 years. However, vaccines for coronavirus were the quickest to develop. This short duration in the development of the vaccine created mixed opinions in the mindset of people and it has resulted in doubting the efficacy of the novel vaccine.
      • Solis-Moreira J.
      How did we develop a COVID-19 vaccine so quickly?.
      Vaccines are boosting natural immunity and saving millions of lives from many infectious diseases. Vaccines are essential in children and pregnant women for fighting against specific microbes.
      • Visanth V.S.
      • Halemani K.
      A study assess the knowledge and attitude of mothers of under-five children regarding immunization in selected ruralareas of Uttar Pradesh.
      According to WHO's Strategic Advisory Group Experts (SAGE) Pfizer/BionTec COVID vaccines are safe in children above 12 years. Globally, several vaccine trials for children are undergoing. The mortality rate is likely to increase among comorbid patients such as lung cancer, diabetic mellitus and immune suppressant patients.
      • Erener S.
      Diabetes, infection risk and COVID-19.
      ,
      • Zachreson C.
      • Chang S.L.
      • Cliff O.M.
      • Prokopenko M.
      How will mass-vaccination change COVID-19 lockdown requirements in Australia?.
      The findings of our review confirmed that the acceptance rate of the COVID vaccine among pregnant and breastfeeding women is consistent with previous studies conducted on influenza.
      • Raut S.
      • Apte A.
      • Srinivasan M.
      • et al.
      Determinants of maternal influenza vaccination in the context of low- and middle-income countries: a systematic review.
      However developed countries reported the highest acceptance rate of influenza vaccine among pregnancy women.
      • Raut S.
      • Apte A.
      • Srinivasan M.
      • et al.
      Determinants of maternal influenza vaccination in the context of low- and middle-income countries: a systematic review.
      On the other hand COVID vaccine has not reported much difference between high-income and middle or low-income courtiers.
      The acceptance of the COVID vaccine among women of reproductive age was higher than the acceptance of influenza vaccine.
      • Tao L.
      • Wang R.
      • Liu J.
      Comparison of vaccine acceptance between COVID-19 and seasonal influenza among women in China: a national online survey based on health belief model.
      The readiness of various populations to receive COVID vaccine has also been explored. For example, according to a survey among healthcare professionals in the Asia-Pacific countries, the majority of healthcare workers in Asia are eager to receive COVID-19 vaccine. The key motivators include perceived COVID-19 vulnerability, minimal possible risk of side effects due to vaccination, and pro-sociality.
      • Chew N.W.S.
      • Cheong C.
      • Kong G.
      • et al.
      International Journal of Infectious Diseases an Asia-Paci fi c study on healthcare workers ’ perceptions of , and willingness to receive , the COVID-19 vaccination.
      A multicenter comparative study was carried out among patients suffering from depression and anxiety disorders as well as healthy people to determine their attitudes regarding COVID vaccination and readiness to pay. Based on the study, people with mental illnesses are more likely to accept vaccination.
      • Hao F.
      • Wang B.
      • Tan W.
      • et al.
      There is no clear evidence for the timing and side effects of COVID vaccination in pregnant women.
      CDC
      COVID-19 Vaccines while Pregnant or Breastfeeding.
      Therefore, for safety concerns, pregnant women, lactation mothers, and children were excluded from the COVID vaccine worldwide. Our review findings showed that approximately 59% of comorbid pregnant women were willing to take the COVID vaccine. However, many studies reported that the COVID-19 vaccine provides the same effects among individuals with comorbidities and those without any underlying chronic diseases.
      • Zambrano L.D.
      • Ellington S.
      • Strid P.
      • et al.
      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.
      In addition, the WHO recommended COVID vaccination for patients with comorbidities.
      The higher literacy rate of pregnant women (60%) was likely to have a better acceptance of the COVID vaccination. Similar results were found during influenza vaccination in pregnant women.
      • Alzeer A.A.
      • Alfantoukh L.A.
      • Theneyan A.
      • et al.
      The influence of demographics on influenza vaccine awareness and hesitancy among adults visiting educational hospital in Saudi Arabia.
      Therefore, it is important for the government or health agencies to campaign and medical recommend vaccination to mitigate the misperception of the COVID vaccine among pregnant women.
      • Kfouri R. de Á.
      • Richtmann R.
      Influenza vaccine in pregnant women: immunization coverage and associated factors.

      4.1 Strength and limitation

      This study has some limitations. First, we could not find a sound and acceptable method for pooling reported medians and interquartile ranges in the literature. The second, the vaccine acceptance was measured using different questionnaires. The bias in collecting the subjective data may exist. Nevertheless, this study has major strengths. This included a meta-analysis of proportions for estimating the pooled prevalence of underlying comorbidities, education level and history of vaccination against the influenza virus. This study also offers an updated summary of existing evidence of vaccine acceptance among pregnant and lactating mothers.

      5. Conclusion

      About 54% of pregnant women and 59% of breastfeeding mothers anticipated of taking the COVID vaccine. The safety and fetal side effect was a major concern for vaccine hesitancy among pregnant mothers as the initial vaccine trials excluded these vulnerable groups from testing. Therefore, it's creating mixed opinions in the mindset of pregnant women and resulting in doubting the efficacy of the novel vaccine. Therefore, the health teaching on COVID vaccination may be ascertained to improve the acceptance ratio.

      Ethical issues

      This project being a systematic review and meta-analysis, didn't require ethical approval.

      Funding Details

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Ethical Consideration

      Ethical approval was not required.

      Authors’ Contribution

      Conceptualization: KH, SD; Data curation: KH, SD, LT; Visualization: LT, PM; Writing original draft: KH, SD; Writing – review & editing: LT, PM. All authors have read and agreed on the final version of the manuscript.

      Declaration of competing interest

      The authors declare no conflict of interest.

      Acknowledgment

      Our sincere thanks to library staff of Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow for their contribution in searching.

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