Mishkin K. Perceptions of the COVID-19 vaccines and rationale surrounding the decision to vaccinate among pregnant women of color in the United States: Lessons learned from four focus groups. HPHR. 2021;36.10.54111/0001/JJ6
Prior to the COVID-19 pandemic, the United States was facing a maternal health crisis grounded in health disparities. People of color have been disproportionately burdened by COVID-19. Simultaneously, maternity patients are at higher risk of severe complications and death due to COVID-19 infection. In spite of this, COVID-19 vaccination rates among pregnant women are low, and they are lowest among non-Hispanic Black women. To understand barriers and inform public health actions, this paper describes knowledge about COVID-19 infection in pregnancy, perceived infection risk, and reasons for vaccinating or not vaccinating against COVID-19 among pregnant women of color.
Four virtual focus group discussions were held with 32 participants in the United States. Two groups included women who had received at least one COVID-19 vaccine dose and two included those who stated they had not been vaccinated, but were considering it.
Findings showed that both unvaccinated and vaccinated participants were knowledgeable about the risks of COVID-19 infection in pregnancy and were taking prevention precautions. Perceived benefits of vaccination included having a healthy pregnancy and baby, reduced stress about COVID-19 infection, and resuming social activities. All vaccinated participants reported having conversations with providers about vaccination, but the same provider engagement was not found among the unvaccinated. Concerns about the vaccines centered on bias in health care and vaccine safety.
Since vaccination benefits included having a healthy pregnancy and delivery, information about how the vaccines improve maternal and infant outcomes should be incorporated into health messaging. Addressing the historical and current racist practices in healthcare is critical to improve care and to improve trust in the health care system. Because health care provider engagement appears to be important for patient vaccination decisions, efforts should be made to support providers to talk to pregnant patients in culturally-sensitive ways about COVID-19 vaccines in pregnancy.
The United States has the highest maternal mortality rate among all industrialized countries and the data show significant racial disparities since Black women are three times as likely to die in pregnancy and the postpartum period compared to White counterparts. 1 Social determinants of maternal mortality are described in the literature and researchers have called for increased support for historically marginalized communities in order to improve outcomes.2
The COVID-19 pandemic has provided new examples of the ways that people of color are disproportionately burdened by poor health outcomes. People of color, meaning people who do not identify as White, are at higher risk of both severe illness and death due to COVID-19 infection 3; communities of color are more likely to work in situations that may have a greater likelihood of exposure to SARS CoV-2; and their living environment is more likely to expose them to others who are sick.4 Further, individuals of color report being less trusting of institutional health care compared to White people, citing concerns about bias in health care.5
Pregnant people are at elevated risk of severe illness due to COVID-19 when compared to non-pregnant people. Research analyzing COVID-19 related hospital admission rates of female patients found that pregnant women, compared to non-pregnant women, were more likely to be hospitalized (60.5% vs. 17.0%, P < 0.001), have a longer length of hospital stay (0.15 day vs. 0.08 day, P < 0.001), and were more likely to be placed on moderate ventilation (1.7% vs. 0.7%, P < 0.001). 6 Risk of preterm birth among pregnant women with COVID-19 is also higher than among pregnant women not infected with COVID-19.7–9
A critical method to prevent COVID-19 infection is vaccination. Prior to distribution, the three COVID-19 vaccines authorized by the U.S. Food and Drug Administration including Pfizer-BioNTech, Moderna, and Johnson & Johnson’s Janssen, were tested for safety. As is common for clinical trials of new vaccines, pregnant people were excluded due to theoretical risks to the fetus. The manufacturers of the COVID-19 vaccines conducted animal developmental and reproductive toxicity studies to identify effects of the COVID-19 vaccine on fetal development of animals. 10 No safety concerns were demonstrated.11–13
Since the COVID-19 vaccines were made available, pregnant people have been eligible to receive the vaccines. Considerations include risk of exposure to COVID-19, risks of severe infection, known benefits of vaccination, and limited but growing evidence about safety of COVID-19 vaccination during pregnancy.14 Preliminary findings on the safety of the COVID-19 vaccines in pregnancy and the postpartum period have been reassuring. Early data did not find any vaccine-related safety concerns for pregnant people vaccinated in the third trimester or for their babies.15 Data suggest mRNA COVID-19 vaccines during pregnancy are effective. Maternal antibodies following COVID-19 vaccination during pregnancy have been demonstrated in the cord blood.16,17
In July and August 2021, the Centers for Disease Control and Prevention (CDC), American College of Obstetricians and Gynecologists, and Society of Maternal-Fetal Medicine formally released statements recommending that pregnant people receive a COVID-19 vaccine. 18,19
In spite of the availability of the vaccine, vaccination uptake among pregnant women is low at 23% as of August 1, 2021; and just 10% of non-Hispanic Black women have been vaccinated. 20
Limited research exploring opinions of the COVID-19 vaccines among pregnant women has been published. One pre-print cross-sectional study has examined perceptions and attitudes toward COVID-19 and the COVID-19 vaccinations among pregnant women, using data collected in 2020, prior to the authorization of any COVID-19 vaccines. 21 This study surveyed 915 women in Utah, Alabama, and New York and found that 41% of women reported that they would be willing to get the COVID-19 vaccine, their primary concern centered on vaccine safety, and that non-Hispanic Black and Hispanic women were less likely to choose vaccination. 21 Qualitative responses were not collected in this research.
Because of the evolving nature of the COVID-19 pandemic and the gap in timely research centered on the diversity of and rationale behind pregnant women’s perceptions of the COVID-19 vaccines, this paper provides qualitative findings describing awareness of risks of COVID-19 infection in pregnancy, perceived infection risk, and reasons for vaccinating or not vaccinating against COVID-19 among pregnant women of color in June 2021.
Four virtual focus group discussions were held with pregnant persons who self-identified as being women of color. Two groups included individuals who had received at least one dose of the COVID-19 vaccines and two included individuals who have not yet received any dose of the COVID-19 vaccines but were considering receiving it.
The discussion guide was developed by March of Dimes and reviewed by multiple teams working on vaccine efforts at CDC to support complementary and timely work undertaken by CDC. The discussion guide was also reviewed by the third-party moderator who guided the focus group discussions for ease of use and content prior to finalization. Because of the evolving nature of information available about the COVID-19 pandemic and engagement with multiple partners, this review process occurred over multiple months. The discussion guide was adapted to collect relevant perspectives as new information about COVID-19 and the COVID-19 vaccines was made available.
Recruitment of participants was through a third-party recruiter using a national strategy to capture diverse perspectives. Candidates were invited to complete an online intake survey to determine if they met inclusion criteria for participation, including being currently pregnant and expected to be pregnant at the time of the focus groups, self-reported non-White race, self-identified as being a person of color, 18 years of age or older, and living in the United States. Eligible participants had either received at least one dose of the COVID-19 vaccine or had not received any dose, but indicated that they were considering receiving the COVID-19 vaccine.
In addition, candidates provided responses to demographic questions including race, ethnicity, age, education level, healthcare insurance status, type of health insurance (public vs. private), whether they are a single parent or double parent household, if they live in an urban or rural area, occupation, trimester of pregnancy, and pre-existing health conditions.
Participants were compensated for their time with a gift card after the focus groups. All participants completed a written informed consent form prior to participation.
The four virtual focus group discussions occurred in early June 2021 for a duration of 90 minutes each. The discussions were led
by a woman of color. A HIPAA-compliant Zoom meeting was used and discussions were recorded and transcribed verbatim by the third-party contractor.
The project leaders were invited to attend the discussions as silent observers to view participant reactions in real-time. A separate discussion board was set up to facilitate internal conversations with project organizers and the moderator to suggest additional clarifying questions for the moderator to pose to the group for additional probing.
Thematic and content analyses were performed. An analytic team reviewed the transcript and developed a preliminary codebook. The codes were applied to the transcripts, verifying code meaning throughout the analytic process. Qualitative data analysis software, MaxQDA 2020, was used for coding (VERBI Software, Berlin, Germany, 2019). Relevant codes included: knowledge about the effects of COVID-19 in pregnancy; perceived risk of COVID-19 infection; reasons for receiving or not receiving the COVID-19 vaccines; benefits of vaccination; and trusted sources of information about the COVID-19 vaccines.
The project was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy. 22–26 This project was designated by the CDC review as non-research and as a quality assurance effort for communications/message improvement to targeted populations (Project ID: 0900f3eb81c83d65)
Each of four focus groups included eight participants. Participant ages ranged from 21-41 years, the majority (81%) lived in an urban area, and 16% had underlying health conditions which put them at increased risk for severe illness from COVID-19. Among those selected to participate who were vaccinated, average gestational age was 22 weeks, 30% were Black, average age was 31 years, and the majority had private insurance (78%) and did not have other children (69%). Among those selected to participate who were not vaccinated, average gestational age was 21 weeks, 58% were Black, average age was 22 years, and the majority had private insurance (59%) and did not have other children (76%). Among those selected to participate who were not vaccinated, while all reported considering receiving the COVID-19 vaccine in the future, 21% reported definitely going to receive it, 42% were undecided, and 37% reported that they probably would receive it.
Table 1 : Description of the participants in the
Not vaccinated (n=8)
Both vaccinated and unvaccinated participants reported accurate knowledge about the effects of COVID-19 on both pregnant women and newborns. The symptoms described demonstrate that participants had heard that COVID-19 is a serious disease, particularly during pregnancy.
“The effects it’s having on pregnant women are some of the worst effects that has happened on people.” (vaccinated)
“I’ve just heard that being pregnant…[COVID-19] just affects you that much worse. And I can’t even imagine, it’s hard to call as it is, being pregnant…I can only imagine how much harder [it would be].” (unvaccinated)
“I’ve heard that the symptoms last way longer than if you weren’t pregnant. Like even up to even three months.” (vaccinated)
“I heard it was worse If you were pregnant… I guess you could be hospitalized.” (vaccinated)
Women in the vaccinated and unvaccinated groups expressed similar concerns about infection with COVID-19. The majority of concerns related to infant health and having their own health affected negatively by COVID-19 symptoms. There were also concerns about the efficacy of vaccines against future variants and concerns about getting infected while in labor at the hospital.
“Everything you’ve heard about COVID and how you feel, how bad it is, it’s true…I would be terrified for a newborn to go through that.” (unvaccinated)
“Are their lungs developed, their breathing? That’s my major concern. Going into early labor and [my infant] having any possible breathing issues”. (unvaccinated)
“It’s got to have some effect on my baby, right? If eating a sandwich will affect my baby potentially, then getting COVID certainly will too.” (vaccinated)
“I’m not saying that when you walk in the hospital, you’re going to catch COVID but it is a worry. And if you have a long labor…there’s multiple people that have to come in because they’re changing shifts.” (unvaccinated)
“Even though I’m vaccinated and everybody else around me for the most part is vaccinated. I’m nervous that one day the CDC comes out and says that it’s safe…but then there’s all these other strains in different countries.” (vaccinated)
Participants were asked to describe their perception of risk of COVID-19 infection. Various responses about risk level and reasons for their risk were given by both unvaccinated and vaccinated groups as presented in Table 2. Reasons for lower perceived risk included receiving the vaccines and reasons for higher perceived risk included uncertainty about others’ vaccination status and concerns about risk in pregnancy.
Table 2: Perceived risk of COVID-19 infection among focus group participants
Low perceived risk
Medium perceived risk
High perceived risk
Most vaccinated participants learned more about the COVID-19 vaccines through discussions with their health care provider and friends and family, and through the news. Most unvaccinated participants learned about the vaccine through social media and the news. Both groups talked about performing their own literature review and reading or watching testimonials to learn about timely information.
While both groups stated that a significant reason to get vaccinated related to protecting their health and the health of their baby, there were differences between the two groups. The majority of the vaccinated participants stated that they had conversations about COVID-19 and the vaccines with their health care providers at prenatal visits. They mentioned both initiating those conversations themselves as well as their health care providers initiating conversations. In situations where they were hesitant about getting the vaccine, they said that they decided to trust their health care provider’s suggestion to get vaccinated because they wanted to protect their baby’s development. They also talked about the importance of thinking about other family members and friends who had passed due to COVID-19 when deciding and stated that they did not want to regret not choosing to get vaccinated.
The unvaccinated participants did not mention having conversations with health care providers about the COVID-19 vaccines as frequently as the vaccinated participants. Several mentioned that their health care providers did not initiate conversations about vaccination, and others stated that their providers did not formally recommend the vaccines or they recommended waiting until they were in the third trimester, when the baby was better developed, to get vaccinated. The primary reasons for considering vaccination among the unvaccinated groups included ability to travel and having a safer pregnancy and baby. They stated that they would feel safer getting the vaccines if the CDC recommended the vaccines and if the vaccines had received lengthier longitudinal reviews for safety.
Table 3: Reasons for vaccination among both vaccinated and unvaccinated focus group participants
Health Provider Counsel
“When I went to my eight-week appointment, the doctor mentioned you need to get your vaccine…it’s not about me anymore, it’s about the baby, it’s what the doctor’s recommending”
“I just went on advice from my doctor. …I trust her….”
Protecting against COVID-19 infection for self and baby
“After having so many complications, the risk of the vaccine outweighed getting the virus.”
“What motivated me to get it was that one of the employees at work sent out a text saying that someone tested positive for COVID.”
“I wanted to get it from the beginning. It wasn’t until I saw on YouTube that another pregnant lady got it. I really wanted to get it because protecting myself and the baby outweighed the negatives for me.”
Remembering those who lost their lives to COVID-19
“I had a family member…who passed away suddenly from COVID. I was like, “Well, maybe fertility could be affected” …but the more I sat with it, I was like, “I have access to this, and if she had had access to it, maybe she’d still be here.”
“I was reading the research, but I still wasn’t convinced until I thought about the people that we’ve lost, who, if they had had access to it, maybe they’d still be here.”
Health care provider counsel and social media
“I’m just not going to get it until once I’m done breastfeeding. My OB and my doula, there’s not enough research to say what’s going to happen.”
“I was told by the OB GYN…that they haven’t seen any bad things happen for people that were pregnant getting the vaccine. They recommended me to get it. I’m also in a Facebook Pregnancy During COVID group …[they] were posting research that made me feel more comfortable getting it when it’s available for me.”
Protecting against COVID-19 infection for self and baby
“If I can get the vaccine during my pregnancy, and the baby [can] be born with the vaccine to make him less at risk for having major complications “
“I have changed. I wasn’t going to even think about it. But then seeing the effects that people have had. And the thought of being able to protect the baby.”
Government recommendations to get vaccinated
“It would have to be the CDC that puts those regulations or the government.”
“I would get it so that I can travel. It’s just that they make it like you’re restricted. If they just say, “You have to be vaccinated to come here.””
Unvaccinated participants raised several concerns about the vaccines that were related to why they had, thus far, chosen not to receive the vaccine. Statements about concerns about the safety of the vaccines; concerns about the speed at which the vaccines were produced, implying that they were not fully tested; and concerns about the history of using marginalized communities for intentional neglect and for testing of products, “using as guinea pigs,” highlight the long-standing issues that the COVID-19 pandemic has forced the health care industry to recognize.
Table 4: Reasons for not seeking vaccination among the unvaccinated participants
Vaccine safety concerns
“I am already high risk… I just rather just wait, maybe after I give birth, then maybe I’ll get it”
“After pregnancy, I might take it but right now, I don’t know how my body’s going to react or the baby.”
“It was made so quickly and so many different brands made it…With all the other vaccines we have… there was just years and years and years of research.”
“There’s definitely not a lot of research on the long-term effect on a child when you receive it when you’re pregnant…And hearing people having miscarriages after the vaccine also freaked me out.”
Mistrust of the government and institutions
“I don’t care if I was pregnant, not pregnant…. The fact that they even offering, what? Chicken sandwiches or cookies or free tuition. Why are you shoving this vaccine down my throat like this?”
“An aunt of mine got the Johnson and Johnson vaccine…and I told her they can’t even get baby powder right. If they can’t get baby powder right, do you really think I’m going to let them inject me and possibly this child here?”
“So many other things that people of color have been screaming out for the government to pay attention to. And they’ve always fallen on deaf ears. …we’ve been suffering for, since we got here. But now all of a sudden you want to use every person of color and push this vaccine onto black folk. Call it the Syphilis. Call it Tuskegee, whatever. I’m not a follower. I’ll blaze my own path.”
I don’t understand what’s the big push all of a sudden? Maybe in a year or two, maybe. But it came out so fast. And again, we’ve had so many other things in our black community…I don’t want to be a Guinea pig. The testing on pregnant women of color…if you look back on our history. The things that they have done, the government to us as test dummies.”
“I’m not going to say it’s a conspiracy theory. I just think it just came out too fast. At first, they were searching for a cure. Then all of a sudden they have a cure, and it’s like three separate vaccines. But they all do the same thing. But they all have different effective rates and stuff. It doesn’t make sense…”
This paper presents timely information that is useful for public health messaging to pregnant people who are reluctant to receive the COVID-19 vaccines and for improving practices and equity in health care. Both vaccinated and unvaccinated groups had heard about the negative effects of COVID-19 in pregnancy. Vaccinated participants stated that they had conversations with health care providers about the COVID-19 vaccines and that their primary reason for vaccination was related to protecting themselves and their babies. In comparison, few unvaccinated participants reported having conversations with health care providers. Reasons for not receiving vaccine included the history of unethically testing medical treatments on people of color, the speed at which the vaccine was developed, and lack of research on impact on fetal development.
At the time of the focus groups, just 19.7% of pregnant people overall had received at least one dose of the COVID-19 vaccines. Among non-Hispanic pregnant women, vaccination was highest among Asian women (29.2%) followed by White women (23.8%) others (18.7%), and Black women (7.8%); 14% of Hispanic women had been vaccinated.20 Rates have increased and as of August 15, 2021, 23.8% of pregnant women had been vaccinated, but disparities still exist.20 Since participants stated that engagement with health care providers was important for deciding to vaccinate, public health agencies and organizations should develop communication strategies and talking points to distribute to providers to facilitate provider-patient engagement on the COVID-19 vaccines in pregnancy. These strategies must be culturally-appropriate and sensitive to the diverse perspectives on pregnancy and lifestyles. 27 Findings also suggest that there are opportunities for improved health communication messages about the testing and safety of the vaccines by health care providers considering that participants stated that they valued providers’ opinions and perspectives.
Relatedly, because participants said they were reluctant to consider vaccination because of historical and current racist practices in health care, health care organizations and individuals should invest in addressing structural and systemic racism in health care to improve quality of care and to improve patient trust in the vaccines. Efforts to improve research on racism and bias in health care and the social environment, finance community-based solutions and workforce development, and advance policy to reduce disparities are critical to sustainably improve equity.28
Further, these findings present a time-bound response by participants during the COVID-19 pandemic. At the time of data collection, while pregnant people were eligible for the COVID-19 vaccines, no agency or organization formally recommended the vaccines for pregnant people. At the end of July, ACOG, and SMFM recommended the COVID-19 vaccines for pregnant people and CDC made a similar recommendation in August (American College of Obstetricians and Gynecologists, 2021; Centers for Disease Control and Prevention, 2021b). The project should be repeated in order to collect more timely data for decision-making.
These findings are important for effective public health messaging to pregnant women who might be willing, yet hesitant, about receiving the COVID-19 vaccine. While this project’s findings are useful for identifying perceptions of the COVID-19 vaccine among pregnant women of color, there are limitations. As noted earlier, because of the evolving nature of the COVID-19 pandemic, these results represent a time-bound perspective of pregnant persons of color. Since the discussions, new published research studies have presented information about the effects of COVID-19 on pregnant women and their infants. Additionally, as the pandemic shifts, new, more transmissible and deadly, virus variants have resulted in more severe impacts of COVID-19 on pregnant women. Revised guidance has also been published by national maternal and child health organizations. New data should be collected to capture more current perspectives of the COVID-19 vaccines to understand how recent events and information may have affected perceptions of the COVID-19 vaccine. Further, this paper’s study was small and findings may not be generalizable to all women. Additional study should be undertaken to capture diverse perspectives.
The author thanks Christina Brigance and Roland Estrella from the March of Dimes Science and Strategy Office and Kara Polen, Neha Shinde, Betsy Mitchell, and William Paradies from the Centers for Disease Control and Prevention. This project was supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Service (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. Government.
The author has no relevant financial disclosures or conflicts of interest.
Dr. Kathryn Mishkin has over a decade of public health and international development policy, project management, and evaluation work in 14 countries. She currently serves as acting Sr. Director of Science, Data, Evaluation, and Innovation at March of Dimes where she leads program and initiative evaluation and quality improvement efforts to describe impact and optimize success. She holds multiple leadership positions within the American Public Health Association and serves on national and local Boards of Directors. Dr. Mishkin holds a Doctorate in Health Policy, Management, and Behavior, a Masters in Public Health (Global Health), and a Masters in Sustainable International Development. She completed her undergraduate degree at Smith College.