COVID-19 vaccine hesitancy among pregnant women attending public antenatal clinics in Dar es Salaam, Tanzania

ABSTRACT

The COVID-19 pandemic has claimed over six million lives and caused significant morbidities globally. The development and use of COVID-19 vaccines is a key strategy in ending this. There is a general public hesitancy on vaccine uptake, including pregnant women who are at high risk of severe forms of the disease and death when infected with the virus. To determine the magnitude of hesitancy toward COVID-19 vaccines and the associated factors among pregnant women attending public antenatal clinics in Dar es Salaam‬. This was a cross-sectional analytical study conducted among 896 pregnant women attending antenatal clinics at public health facilities in Dar es Salaam. A structured interviewer-based questionnaire, in an electronic form, was used. The analysis was done by a multivariable linear regression model using STATA 16 to obtain factors associated with vaccine hesitancy, and P < .05 was considered significant. The proportion of pregnant women with vaccine hesitancy was 45%. Hesitancy was higher among unemployed pregnant women (AOR 2.16 (95% CI 1.36–3.42) and the self-employed group (AOR 1.62 (95% CI 1.07–2.44). It was also higher among pregnant women with poor attitudes to COVID-19 vaccines (AOR 2.44 (95% CI 1.75–3.39) and women who had low perceived benefits of the vaccines (AOR 2.57 (95% CI 1.83–3.60). COVID-19 vaccine-targeted interventions should aim at the provision of knowledge on COVID-19 and the COVID-19 vaccine and address poor attitudes and perceptions that pregnant women have on these vaccines.

KEYWORDS:

• COVID-19
• vaccine hesitancy
• pregnant

Introduction

The coronavirus 2019 (COVID-19) pandemic has caused enormous loss of life and morbidities, with over six million deaths globally.¹ Pregnant women are at increased risk of developing severe disease and admissions to the intensive care unit (ICU) and mechanical ventilation compared to non-pregnant women.^2–5 Pregnant women in their third trimester who are obese, are >35 years or have comorbidity conditions are at higher risk of severe and critical disease with increased risk of pre-eclampsia, gestational diabetes, cesarean section delivery, and maternal deaths.^2,6–9

Several literature have documented higher rates of iatrogenic preterm birth, smaller gestation babies, stillbirths, and increased admission to neonatal intensive care units among neonates of pregnant women infected with COVID-19.^2,4,10 Despite the increased mortality and morbidity, there are no increased cases of congenital anomalies or vertical transmission reported from the infection to date.^2,5,6 Evidence suggests that recovery from COVID-19 has been associated with cardiac function impairment¹¹ and survivors still suffer from either neurological, physical, and/or psychological sequela 2 years post-infection.¹² Moreover, there is a higher risk of developing new onset type 1 diabetes mellitus in children who are infected with COVID-19¹³

There is no cure for COVID-19 infection and vaccines are considered the most promising approach for curbing the pandemic and are being vigorously pursued.¹⁴ Several vaccines are available since 2021, and all do not contain an active virus and cannot cause an infection.¹⁵ Available data from systemic reviews and meta-analysis show that vaccination during pregnancy reduced the risk of infection by 60% and ICU admissions by 82%, and it also reduced the risks of stillbirth and preterm birth no harmful effects on pregnant women or the fetus and new-born have been shown from the systemic reviews^15,16 and there is evidence of passive immunity against SARS-CoV-2 in new-borns after maternal vaccination with mRNA vaccines.¹⁷

It is now recommended by most health public authorities to vaccinate pregnant women to prevent the severity and consequences of COVID-19.^18–22 These recommendations are based on increasingly reassuring data regarding the safety and efficacy of COVID-19 vaccines during pregnancy, as well as data that pregnancy itself is associated with an increased risk of severe infection.^19,20,23,24 The benefits of the COVID-19 vaccine in pregnant and non-pregnant women extend beyond reduced morbidity and mortality, to improved mental health status, reduced health system costs, and a return to individual and family economic activities that were paralyzed during the COVID-19 pandemic.^19,25

The WHO Strategic Advisory Group of Experts on the vaccine (SAGE) defines Vaccine hesitancy as “a delay in acceptance or refusal of vaccination despite the availability of vaccination services.”²⁶ Unfortunately, several systemic reviews have reported global COVID-19 vaccine hesitancy among pregnant women^27–32 and this has been influenced mainly by the socio-demographic characteristics of respondents,^33–36 their obstetrics history,³⁷ and their poor knowledge and attitude toward COVID and COVID-19 vaccine.^30,34,37,38

In Tanzania, the first COVID-19 case was reported in March 2020,³⁹ and the COVID-19 vaccine was authorized to be used from July 2021.⁴⁰ The initial vaccination mandate gave priority to frontline healthcare workers, and groups that were at high risk of severe morbidities and deaths that included those ≥50 years, chronic/underlying medical conditions such as hypertension, diabetes, and respiratory conditions. In August 2021, the Ministry of Health recommended vaccination for pregnant women to be offered when the benefits outweigh the potential risks. The decision to vaccinate is based on individual choice, personal values, and understanding of the benefits of protecting against the risk of infection and/or morbidity and mortality of COVID-19⁴⁰

Vaccine hesitancy hinders efforts to control the spread of COVID-19 infection and this prolongs the public health crisis, leading to a higher number of severe cases and higher mortality rates.^41,42 Increased cases and hospitalizations overwhelm the fragile healthcare system of low-income countries and reduce the capacity to handle other health issues. Tanzania as a lower-middle-income country can further be affected economically with the lockdowns, restrictions, and reduced economic activities that are associated with COVID-19 waves. Overall, COVID-19 vaccine uptake in Tanzania is low (<10% of population) as of April 2022⁴³ and the magnitude of hesitancy to vaccinate especially among pregnant women in Tanzania is not known yet. Hence, the study was aimed at determining the vaccine hesitancy magnitude toward COVID-19 vaccines and its associated factors among pregnant women.

The health behavior model has several components: perceived susceptibility to infection and severe infection, perceived benefits and risks, social norms, cues to action, self-efficacy, and health behaviors have been used in several studies to find the reason for the COVID-19 vaccine hesitancy.^35–44–46 Similarly, it has been used in this study as it provides a structured framework for understanding why people make the decisions they do regarding their health and it offers a way to systematically analyze and predict behavior based on psychosocial, social, and environmental factors.

Materials and methods

Study design, setting, and population

This cross-sectional analytic study was done at four public health facilities of Dar es Salaam at four different levels: primary health center, district hospital, regional and tertiary-level hospital; Buguruni health center, Mnazi Mmoja district hospital, Amana Regional hospital, and Muhimbili National Hospital, respectively. Dar es Salaam is an important economic city with a population of over six million⁴⁷ people, which made it to be the most affected region during the COVID-19 pandemic in Tanzania.⁴⁸ All studied facilities provide antenatal care services from Monday to Friday and COVID-19 vaccines are also provided at the same health facility but not at the antenatal clinic.

Sample size

Sample size was calculated using the Kelsey formula for a cross-sectional analytical study;

$n=\frac{p\left(1-p\right){\left(\frac{z\alpha }{2}+z\beta \right)}^2\left(r+1\right)}{r{\left(p1-p2\right)}^2}$

n = is the sample size in each study group of pregnant women,

p1 – proportion of exposed, p2 – proportion of unexposed

r- ratio of exposed to non-exposed where r is 1:1.

p1 – p2 – clinically meaningful difference in the vaccine hesitancy proportion between the two groups, p- is the average of p1 and p2

p (1-p) is the variance of the anticipated proportion difference

$\frac{z\alpha }{2}$ - corresponds to two-tailed significance level (1.96 for α = 5%) and zβ - corresponds to a power of 80%

The sample size calculation was based on the following assumption;

The exposure is good attitude toward COVID-19 vaccine. The proportion of unexposed with outcome was taken to be 5%, and the proportion of exposed with outcome was 10% (odds ratio-2.1).⁴⁹ The estimated sample size was computed using OpenEpi online calculator and was found to be n = 443; therefore, 2n = 886. Loss to follow up is assumed to be 10%, which was added to the total sample size. Therefore, a minimum of 984 pregnant women were required for this study. The Kelsey formula was used to provide adequate sample size in order to obtain factors associated.

Sampling technique

The sample size was divided among the four hospitals by stratified sampling using probability proportion to size (PPS). Based on ANC attendees booked for the past 6 months at each facility, the minimum number expected per facility was extrapolated.

Sampling fraction = n/Nx100, where by n = sample size (984) and N = total number of minimum participants expected to be recruited during the study period (1924)

Therefore, sampling fraction = 51.1%

Table

HEALTH FACILITY	Muhimbili	Amana	Mnazi Mmoja	Buguruni	TOTAL
Minimum number expected	329	477	580	538	1924
Minimum sample size	168	244	297	275	984

Systematic random sampling technique was used at each facility. Sampling interval was determined by dividing the expected number of ANC attendees into the sample size (1924/984) which gave a sampling interval of 2. The first case was selected using lottery method, then every second pregnant woman coming to ANC service was interviewed until the total sample size was reached.

Inclusion criteria

We included all pregnant women at the age of ≥18 who were attending antenatal clinics at the selected health facilities

Exclusion criteria

Pregnant women who were sick or unable to communicate

Data collection procedure

Data was collected from 17^th October to 25^th November 2022 by the main author and eight research assistants who were recent graduates from the Muhimbili University of Health and Allied Sciences. The research assistants were trained in sampling, data collection tools, and procedures. Using the antenatal registry book, the first participant was identified by lottery method, then every second attendee was recruited after being asked for a written consent. Recruitment and questionnaire filling was done after they had received services or in case of long queues as they waited for the services. No incentives were provided to the participants for their participation in this study.

Data collection tool

An interviewer-administered structured questionnaire in the local language – Kiswahili (Appendix 1B) was used to collect the data. The questionnaire was in an electronic Red Cap and was pretested and piloted in 20 pregnant women attending antenatal care in a nonparticipating health facility. The questionnaire was adapted from various studies^{34,37,38,45,46} and was divided into the following parts:

1. Socio-demographic and obstetric factors part with age (years), marital status, education level, occupation/employment, income, having household members who are at risk due to age of comorbid conditions, gravidity, parity, gestation age, and perceived pregnancy risk.

2. Knowledge of COVID-19 infection and COVID-19 vaccine.

3. Questions on perceptions, attitudes, and trust using the Health Belief Model constructs

4. COVID-19 and vaccine hesitancy status

Data management and analysis

Responses to all questions in the Red Cap were made mandatory before submitting the questionnaire to avoid incomplete filling and missing data. The electronically filled questionnaires in the Red Cap were automatically transferred to a local server that was password protected. The data was downloaded by the data manager as an excel file that was used in STATA 16 for analysis.

Covid-19 vaccine hesitancy was assessed with a Likert scale question. A response of very unlikely/somewhat unlikely/not sure to get the vaccine when it is available was used to define women with vaccine hesitancy and was subsequently used to find the proportion of pregnant women with COVID-19 vaccine hesitancy.

The level of knowledge on the COVID-19 vaccine was determined using a set of seven questions, and a score of ≥70% or above was considered good knowledge. Similarly, a score of ≥70% of the items under the attitude and perception sections was used to define the good attitude and high perception, respectively. High-risk pregnancies were defined as pregnancies with an existing medical and/or obstetric condition as reported by the participants or documented on their antenatal card.

The dependent variable which was vaccine hesitancy and the independent variables which were socio-demographic and obstetrics characteristics, knowledge, and attitude toward COVID-19 vaccine and behavioural/perception toward vaccination were summarized using frequencies and percentages. Measures of association were calculated using cross-tabulation and binary logistic regression, and multivariable logistic regression was used to find factors associated at p-value <.05. The independent variables used in multiple linear regression were the one in linear relationship with dependent variable, with p value <.2 in bivariate analysis and with no multicollinearity

Ethical issues

The study was reviewed and received an ethical permit from MUHAS Institutional Review Board with Ref No: MUHAS-REC-09-2022–1364. Permission to conduct research was sought from the Ministry of Health, the President’s Office Regional Administration, and Local Government (PO-RALG), and individual health facilities’ administration. Written informed consent was sought from the pregnant women after the purpose of the study and their right to withdraw from the interview was explained. Privacy and confidentiality were respected throughout the research. Those who wished to vaccinate the same day were directed to the vaccination area.

Results

A total of 3876 (new and repeated) pregnant women attended ANC in the four public health facilities during the study duration. The sample included 968 women who met inclusion criteria, however, 72 refused to participate, and we remained with 896 who were analyzed. The response rate was 93%

As shown in Table 1, Majority of the pregnant women (81.4%) in the study were between 20 and 34 years of age, nearly half had a secondary level of education, and were self-employed and 86.7% were married. A high proportion of women (89.2%) had low-risk pregnancies (no existing medical and/or obstetric condition as reported by the participants or documented on their antenatal card) and 53.8% were in their third trimester of pregnancy.

Table 1. Socio-demographic and obstetrics characteristics of pregnant women attending antenatal clinics at public health facilities of Dar-es-Salaam.

Variable	Frequency (n)	Percent (%)
Age group	Mean = 28.34 ± 5.57
<20	30	3.3
20–34	729	81.4
≥35	137	15.3
Education level
No formal	25	2.8
Primary	316	35.3
Secondary	408	45.5
Higher	147	16.4
Occupation status
Employed	187	2.9
Self-employed	435	48.5
Unemployed	274	3.6
Marital status
Married/cohabiting	776	86.7
Single/widow/separated	120	13.3
Parity
Nulliparous	277	3.9
One	272	3.4
Two	223	24.9
Three and above	124	13.8
Pregnancy risk
High	97	1.8
Low	799	89.2
Gestation age (weeks)
Up to 13 weeks	104	11.6
14–27 weeks	310	34.6
28 weeks and above	482	53.8

The proportion of pregnant women who had vaccine hesitancy was found to be 44.9% (402/896) as shown in Figure 1. This was computed from number of women who were somewhat unlikely to vaccinate, very unlikely to vaccinate and those who did not reveal their response. As shown in Figure 1, almost a quarter (200/896) reported that it was very unlikely for them to vaccinate which represents a stronger level of hesitance and 12.8% (115/896) were not ready to reveal their response but these are considered to have hesitancy as they do delay vaccination coverage as per WHO-SAGE definition³⁶

Figure 1. COVID-19 vaccine hesitancy and acceptance as indicated by the likelihood of the pregnant women to take the vaccine when available.

As shown in Table 2, 36.8% of the pregnant women interviewed believed that very few people in the community would take the COVID-19 vaccine though over half believed that their close family, friends, community, and religious leaders would want them to get the vaccine. Only 35.8% of the pregnant women were very likely to get the vaccine if it was recommended by a doctor or nurse and only 10.3% reported to have been vaccinated during pregnancy, though most of them (63.6%) reported that it was not difficult at all to access it. About a third of pregnant women were not sure if they could trust the vaccine or if the vaccine was safe. More than 94.0% reported never to have been diagnosed with COVID-19, caring for a close family member/having a family member who died of a suspected COVID-19 infection.

Table 2. Perceived social norms, action efficacy, divine will, and COVID-19 status.

1. If a vaccine for COVID −19 were available COVID-19 in your community, what portion of the people you know do you think would get the vaccine?	a. Most people would get the vaccine 18.3%
	b. About half of people would get the vaccine 16.3%
	c. Very few people would get the vaccine 36.8%
	d. Don’t know/won’t say 28.6%
2. Do you think that most of your close family and friends would want you to get a COVID-19 vaccine?	a. Yes 52.3%
	b. No 24.6%
	c. Don’t know/won’t say 23.1%
3. Do you think that most of your community leaders and religious leaders would want you to get a COVID-19 vaccine?	a. Yes 69.2%
	b. No 15.3%
	c. Don’t know/won’t say 15.5%
4. If a doctor or nurse recommended that you get the COVID-19 vaccine, how likely would you be to get it?	a. Very likely 35.8%
	b. Somewhat likely 24.9%
	c. Not likely 22.6%
	d. Don’t Know/Won’t say 16.7%
Access
5. How difficult is it for you to get to the clinic where vaccines are normally offered?	a. Very difficult 5.9%
	b. Somewhat difficult 30.5%
	c. Not difficult at all 63.6%
Perceived action efficacy
6. If you were to get the vaccine for COVID-19, how likely would it be that you would get COVID-19 disease after that?	a. Very likely 11.8%
	b. Somewhat likely 19.3%
	c. Not likely at all 43.6%
	d. Don’t Know/Won’t say 25.3%
7. How much would you trust a new COVID-19 vaccine?	a. Not trust it at all 12.2%
	b. Trust it a little 23.2%
	c. Trust it a moderate amount 16.3%
	d. Trust it a lot 21.2%
	e. Don’t Know/Won’t say 27.1%
8. How safe do you think it would be for you to get a COVID-19 vaccine?	a. Not safe at all 18%
	b. Mostly safe 34.8%
	c. Very safe 13.5%
	d. Don’t Know/Won’t say 33.6%
9. If one has been infected with COVID-19, vaccination with the COVID-19 vaccine is unnecessary.	a. Agree a little 8.8%
	b. Agree a lot 17.4%
	c. Disagree a little 22.1%
	d.Disagree a lot 27.3%
	e. Don’t Know/Won’t say 24.3%
10. Most people will eventually get infected with COVID-19, so getting the COVID-19 vaccine is unnecessary.”	a. Agree a little 9.5%
	b. Agree a lot 13.8%
	c. Disagree a little 23.1%
	d. Disagree a lot 30.8%
	e. Don’t Know/Won’t say 22.8%
Perceived divine will
11. Do you think that God (or Allah or the gods) approve(s) or disapprove(s) of people getting a COVID-19 vaccine?	a. I believe that God approves 12.6%
	b. I believe that God does not approve 10.4%
	c. Don’t Know/Won’t say 77%
12. Whether I get COVID-19 or not is purely a matter of God’s will or chance. The actions I take will have little bearing on whether or not I get COVID-19.”	a. Agree with a little 17.4%
	b. Agree with a lot 19.5%
	c. Disagree a little 33.5%
	d. Disagree a lot 29.6%
COVID-19 status and Vaccination.
1. Have you ever been diagnosed or treated for COVID-19 symptoms/disease?	Yes 2.7%
	No 94.9%
	Not sure 2.4%
2. Have you cared for close family member who had COVID-19 symptoms/disease?	Yes 5.4%
	No 94.6%
3. Has someone in your family died of COVID-19 or of suspected COVID-19 disease?	Yes 3.6%
	No 94%
	Don’t know 2.3%
4. Are you vaccinated with COVID-19 vaccine?	Yes 10.3%
	No 89.7%

Among women who had poor attitudes toward COVID-19 vaccines, 24.2% revealed that they did not trust the vaccines, 18.7% believed that they did not need vaccines because they are healthy and at low risk, and 16.3% believed that even if they get COVID-19 infection they will not became seriously ill as shown in Table 3.

Table 3. Attitudes of pregnant women toward COVID-19 vaccines.

Attitudes	AGREE	NOT SURE	DISAGREE
	n (%)	n (%)	n (%)
1. I think the COVID-19 vaccine probably will not work	90(10.0)	331(37.0)	475(53.0)
2. I don’t trust the COVID-19 vaccine	217(24.2)	202(22.5)	477(53.3)
3. I think the COVID-19 vaccine is unnecessary	126(14.1)	213(23.8)	557(62.1)
4. I think it is not important to get a vaccine to protect people from COVID-19	118(13.1)	219(24.4)	559(62.4)
5. I don’t need vaccine because I am healthy and at low risk for infection	168(18.7)	237(26.5)	491(54.8)
6. I do not need a COVID-19 vaccine because even if I get infected, I will not become seriously ill	146(16.3)	277(30.9)	473(52.8)

More than 40% of women as shown in Table 4 had low perceptions on susceptibility and severity of COVID-19 infection. They were not worried about their likelihood of getting infection or dying from the infection. With regards to perceived benefits of COVID-19 vaccines, majority of women (>50%) perceived that the vaccine will decrease their risk of getting the infection and its complications. On perceived barriers, 71.1% of women were concerned with the efficacy of the vaccines and about 30% were worried of side effects of the vaccines and had concerns that they may receive fake or faulty vaccines.

Table 4. Perceptions of pregnant women toward COVID-19 vaccines.

		AGREE	NOT SURE	DISAGREE
		n (%)	n (%)	n (%)
Perceived susceptibility and severity of COVID-19
1	I am worried about the likelihood of getting infected by COVID-19	310(34.6)	205(22.9)	381(42.5)
2	I am at high risk of COVID-19 because of my health conditions	211(23.5)	244(27.2)	441(49.2)
3	I will be very sick if I get infected by COVID-19	185(20.6)	355(39.6)	356(39.7)
4	I am very concerned that I could die from COVID-19	209(23.3)	319(35.6)	368(41.1)
Perceived benefits of vaccine
1	I think vaccination is good because it will make me less worried about COVID-19	562(62.7)	196(21.8)	138(15.4)
2	I believe vaccination will decrease my risk of getting infected by COVID-19	564(62.9)	208(23.2)	124(13.8)
3	I think the complications of COVID-19 will decrease if I get vaccinated and then get infected with the coronavirus	531(59.3)	245(27.3)	120(13.4)
Perceived barriers to vaccine
1	I am worried about the possible side effects of the COVID-19 vaccination	351(39.2)	279(31.1)	266(29.7)
2	I am concerned about the efficacy of COVID-19 vaccine	637(71.1)	137(15.3)	122(13.6)
3	I have a concern that I may receive a faulty/fake vaccine	344(38.4)	287(32.0)	265(29.6)
4	It concerns me that the development of the vaccine is too rushed to test its safety properly	300(33.5)	390(43.5)	206(23.0)
5	I am concerned about the long-term side effects of the COVID-19 vaccination.	233(26.0)	380(42.4)	283(31.6)

As shown in Table 5, the variables that were controlled for in the logistic model were education level, age, marital status, occupation, knowledge, attitude, perceived susceptibility, and perceived benefits of vaccine as these were the variables that showed association in the bivariate analysis and had no multicollinearity. Unemployed pregnant women were twice as likely to have vaccine hesitancy compared to employed women (AOR 2.16 (95% CI 1.36–3.42) P-value < .001), and similarly pregnant women with poor attitudes to COVID-19 vaccines had two times the odds of vaccine hesitancy than women with a good attitude (AOR 2.44 (95% CI 1.75–3.39) P-value < .001). Pregnant women who had low perceived benefits of vaccines were twice as likely to have vaccine hesitancy as those who perceived the vaccines to be beneficial (AOR 2.57 (95% CI 1.83–3.60) P-value < .001).

Table 5. Factors associated with COVID-19 vaccine hesitancy among pregnant women using a binary logistic regression model.

	Vaccine hesitancy	Bivariate analysis		Multivariable analysis
Variable	n (%)	COR (95% CI)	P value	AOR (95% CI)	P value
Age group
≥35	70(50.2)	1	1	1	1
<20	113(44.8)	1.25(0.56–2.77)	.58	0.67(0.27–1.64)	.38
20–34	219(43.2)	0.72(0.50–1.05)	.09	0.63(0.43–0.95)	.03
Education level
Higher	56(38.1)	1	1	1	1
No formal	13(52.0)	1.76(0.75–4.13)	.19	0.65(0.25–1.70)	.38
primary	154(48.7)	1.54(1.04–2.30)	.03	0.87(0.54–1.40)	.57
Secondary	179(43.9)	1.27(0.86–1.87)	.22	0.98 (0.63–1.53)	.94
Occupation
Employed	63(33.7)	1	1	1	1
Self-employed	197(45.3)	1.63(1.14–2.33)	.007	1.62(1.07–2.44)	.02
Unemployed	142(51.8)	2.12(1.44–3.11)	<.001	2.16(1.36–3.42)	.001
Marital status
Married/cohabiting	342(44.1)	1	1	1	1
Single/widow/divorced	60(50.0)	1.27(0.86–1.86)	.22
Parity
Three and above	54(43.5)	1	1	1	1
Nulliparous	125(45.1)	1.07(0.70–1.63)	.769
One	120(44.1)	1.02(0.67–1.57)	.916
Two	103(46.2)	1.11(0.72–1.73)	.636
Gestation age (weeks)
up to 13 weeks	47(45.2)	1	1	1	1
14 to 27 weeks	143(46.1)	1.04(0.66–1.62)	.868
28 weeks and above	212(44.0)	0.95(0.62–1.46)	.822
Pregnancy risk
High	45(46.4)	1	1	1	1
Low	357(44.7)	0.93(0.61–1.42)	.749
Knowledge level
Good (≥70%)	146(41.2)	1	1	1	1
Poor (<70%)	256(47.2)	1.28(0.97–1.67)	.078	0.92(0.69–1.24)	.60
Attitude status
Good (≥70%)	212(35.0)	1	1	1	1
Poor (<70%)	190(65.3)	3.49(2.60–4.68)	<.001	2.44(1.75–3.39)	<.001
Perceived susceptibility and severity
High (≥70%)	71(36.8)	1	1	1	1
Low (<70%)	331(47.1)	1.53(1.10–2.12)	.011	1.28(0.90–1.81)	.17
Perceived benefits of the vaccine
High (≥70%)	222(35.5)	1	1	1	1
Low (<70%)	180(66.4)	3.59(2.66–4.85)	<.001	2.57(1.83–3.60)	<.001
Perceived barriers
High (≥70%)	8(44.4)	1	1	1	1
Low (<70%)	394(44.9)	1.02(0.40–2.60)	.971

Discussion

The study showed that nearly half of the pregnant women attending ANC in public facilities of Dar es Salaam showed COVID-19 vaccine hesitancy during pregnancy. The hesitancy was mainly influenced by individual attitudes and perceptions toward vaccination and perceived susceptibility and severity of COVID-19 infection.

In this study, almost half of the pregnant women attending public health facilities had COVID-19 vaccine hesitancy. This is a concerning finding especially when there is evidence of severe morbidity, death, and hospitalization for this group and increased adverse events for their fetuses. This result coincides with several systemic reviews that have been conducted worldwide.^{32,34,37,44,50,51} It is also worth noting that certain vaccines like Tetanus Toxoid (TT) have been recommended for pregnant women for many years in Tanzania and have a strong safety record; however, 50.3% of women were reported to have either one or no TT vaccination in the analysis of data from the 2015/2016 Tanzania demographic and health survey.⁵² Pregnant women with lower education levels were noted to have less vaccine hesitancy compared to higher education levels. Similar findings were reported in Kenya⁵³ and Singapore.³³ This is inconsistent with studies that reported that higher than primary education improves acceptance of being vaccinated⁴⁵ as well as increases in intention to be vaccinated against COVID-19 than their counterparts.⁵⁴ A possible explanation for this is that women who are highly educated are better informed about the lack of safety data on the vaccine.

The study revealed that pregnant women who were unemployed and self-employed were more likely to have vaccine hesitancy than employed women. Comparable findings were reported in other studies from various regions.^55–57 Strong recommendations on vaccinations in Tanzania have been given to people who were employed to prevent further workplace outbreaks and to prevent infection among workers and their customers. The high hesitancy could also be due to the fact that individuals who work primarily outside or in uncrowded conditions may feel less at risk of contracting COVID-19; however, these women are still at risk from exposure through their working husbands.

There is a concern on whether parity, pregnancy trimester, and pregnancy risk affect the intention to be vaccinated. Pregnant women in their first trimester with low parity and low-risk pregnancy are expected to have a higher hesitancy to vaccinate due to fear of teratogenicity, concerns about fetal safety, and perception of low risk of COVID-19 infection acquisition, respectively. There is limited literature that has reported associations of these obstetric factors to vaccine hesitancy. Our study found no significant association between these obstetric factors and vaccination hesitancy, though it was noted that women in their first pregnancy, third trimester and with a low-risk pregnancy had higher hesitancy.

Our findings are in line with previous literature that revealed a lack of or poor knowledge of the COVID-19 vaccine in the pregnant population influences the decision of not vaccinating during pregnancy.^34,37,38 The majority of pregnant women in the study were not aware of any guidelines on vaccination during pregnancy and were not sure of vaccine effects on their health, and pregnancy and this could explain why they were hesitant to vaccinate.

Pregnant women who had a poor attitude to the COVID-19 vaccine were found to have more hesitancy toward vaccination similar to other studies that found a positive attitude toward COVID-19 vaccination increased the chance of accepting the vaccine.^30,58 The majority disclosed primary reasons for hesitancy to receive the COVID-19 vaccine were; not trusting the vaccine, believing they do not need the vaccine because they are healthy and at low risk for infection, and they do not need a COVID-19 vaccine because even if they get infected, they will not become seriously ill.

Pregnant women who had heightened perceptions of increased susceptibility to COVID-19 and high perceived severity of the disease during pregnancy showed less hesitancy toward being vaccinated than those without added risk perception. The findings were similar to other studies in the general population as well as in the pregnant population.^28,33,34 The majority were worried about their likelihood of getting the infection, being at higher risk, and they were concerned that they could die of COVID-19 infection.

Participants with low perceived benefits to vaccination were found to have high hesitancy toward vaccination. Many women did not believe vaccination would reduce their chances of having the disease or decrease complications in case they acquired an infection after vaccination. Though the perceived barrier did not have a statistically significant influence on hesitancy, it is worth noting that the majority of pregnant women (71.1%) were concerned with the efficacy of the vaccine and more than a quarter were worried about side effects, of receiving a faulty/fake vaccine and that the vaccine was too rushed to be manufactured. There are well-publicized events that showed long-term mistreatment and experiments that have been done to Africans that have created fear toward western medicine.⁵⁹ These are important concerns to be addressed while counseling pregnant women about vaccination.

Understanding the reasons for COVID-19 vaccine hesitancy among pregnant women in Tanzania provides valuable insights and informs strategies to address the issue. Identifying the knowledge, attitude, and perceptions of pregnant women on COVID-19 vaccine and specific types of misinformation they have can help develop targeted communication campaigns. This could involve addressing the rumors about vaccine safety, efficacy, or potential side effects through clear, accurate, and accessible information. Understanding factors such as perceived accountability can guide efforts to rebuild trust and strengthen confidence in the vaccination process.

Strength and limitation

To our knowledge, this is the first multicentre study done to assess COVID-19 vaccine hesitancy in pregnant women and factors associated with Tanzania from different levels of public health facilities. As the study was done among the urban population in Dar es salaam city, there may be differences between women living in the rural or semi-urban area. However, the city was the most affected, and we believe has received more attention such that residents are more likely to embrace vaccine than in the rural set-up.

The study might have been affected by a social desirability bias, as participants may have responded to questions in a manner that is viewed favorably by others, though they ensured confidentiality and received non-judgmental responses from the data collectors.

Conclusion

Nearly half of the pregnant women in public health facilities had COVID-19 vaccine hesitancy, and it was highly influenced by individual poor attitudes and perceptions toward both, the disease and the vaccine. Hesitancy was also higher among the unemployed and self-employed women.

Authors’ contributions

Z. H. Y.: Principal investigator, study design, data collection, data analysis, and manuscript preparation (Lead). F. A. A.: Participated in study design, data analysis, and critical review of the manuscript. F. A. and A. A.: Participated in study design and critical review of the manuscript. All authors read and approved the final manuscript

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author at the reasonable request

Ethical approval and consent to participate

The ethical clearance for the study was obtained from the Muhimbili University of Health and Allied Science (MUHAS) research and publication committee with Ref No MUHAS-REC-09-2022–1364. All participants signed a written consent form.

Implication policy

Successful vaccination coverage can be achieved by sharing information on COVID-19 and its vaccine and addressing myths and misinformation about the vaccine. Moreover, there is a need to maintain transparency regarding the efficacy and shortcomings of vaccines to get public trust and confidence in the vaccine.

Abbreviations

ACOG	=	American College of Obstetricians and Gynaecologists
ANC	=	Ante-Natal Care
CDC	=	Centers for Disease Control and prevention
MNH	=	Muhimbili National Hospital
MUHAS	=	The Muhimbili University of Health and Allied Sciences
RCOG	=	Royal College of Obstetricians and Gynaecologists
SAGE	=	Strategic Advisory Group of Expert
WHO	=	World Health Organization

Acknowledgments

The authors would like to acknowledge the AMNE SALIM COVID-19 Research fund for funding the study, MUHAS Research and publication team for their continuous support, the Ministry of Health, President’s Office Regional Administration and Local Government, health facilities administrators for providing permission to conduct research, Regional Health Management Team (RHMT) members for their guidance and support during data collection and lastly we appreciate the support provided by pregnant women who were willing to participate in the study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplemental data

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2023.2269777.

Additional information

Funding

This study was funded by Amne Salim COVID-19 Research Fund. The funding body did not participate in designing the study, data collection, analysis, and manuscript preparation.