Perceptions of COVID-19 vaccination during pregnancy in CHASING COVID Cohort of US adults in 2023

This study of the Chasing Covid Cohort reveals that fewer than half of U.S. adults perceived COVID-19 vaccines as safe or effective during pregnancy, with positive perceptions significantly linked to having a regular healthcare provider and trusting public health institutions.

The Gist

Imagine the COVID-19 vaccine as a shield that pregnant people can wear to protect themselves and their babies from a very dangerous storm. While doctors and health experts have been shouting from the rooftops that this shield is safe and works well, a new study suggests that many people are still standing on the sidelines, unsure if they should put it on.

This paper, titled "Perceptions of COVID-19 Vaccination During Pregnancy," is like a giant mood ring for the United States. Researchers took a snapshot of nearly 4,500 adults (including women who could become pregnant) in late 2023 to see what they were thinking about this specific shield.

Here is what they found, broken down into simple concepts:

1. The "Half-and-Half" Confusion

The study found that the public's mind is split down the middle.

• The Safety Question: Only about 40% of people agreed that the vaccine is safe for pregnancy. It's like asking a crowd if a parachute is safe to jump with; less than half said "Yes, definitely," while the rest were either "I'm not sure" or "No, I think it might be dangerous."
• The Effectiveness Question: Slightly more people (just over 50%) believed the vaccine actually works to stop severe sickness.
• The "Uncertainty" Zone: A huge chunk of people (about 30-40%) didn't pick a side. They were stuck in the middle, saying, "I don't know enough to decide."

2. The "Trust Compass"

The most powerful force in this study wasn't age, money, or education—it was trust. Think of trust as a compass that points people toward the vaccine.

• The Doctor's Word: If a person trusted their personal doctor or healthcare provider, they were much more likely to believe the vaccine was safe. It's like having a trusted mechanic tell you a car is safe to drive; you're far more likely to get behind the wheel.
• The Government's Word: Similarly, trusting big health organizations (like the CDC or WHO) acted like a giant magnet, pulling people toward believing the vaccine was safe and effective.
• The Result: People who trusted these sources were two to three times more likely to agree that the vaccine is safe compared to those who didn't trust them.

3. The "Social Network" Effect

The study also looked at who people hang out with.

• If a person's household was already vaccinated, that person was much more likely to think the vaccine was safe. It's like being in a room full of people wearing raincoats; you're more likely to believe it's raining and put one on too.
• Conversely, people who were worried about anxiety or depression didn't necessarily have different views on the safety of the vaccine, but those with higher education and income levels were generally more likely to trust the science.

4. The "Black and White" Gap

The researchers noticed a distinct gap based on race.

• Non-Hispanic White participants were more likely to trust the vaccine's safety and effectiveness.
• Non-Hispanic Black participants were significantly less likely to agree that the vaccine was safe or effective, even when looking at other factors. This suggests that historical and systemic issues have created a "trust barrier" that is harder to climb for some communities.

5. The "Pregnant vs. Potential" Group

The study looked at two groups:

1. All adults (everyone over 18).
2. Women of reproductive age (women aged 18–49 who could get pregnant).

The results were surprisingly similar for both groups. Even though not everyone in the second group was currently pregnant, their worries and thoughts about the vaccine were just as intense. This tells us that the "fear of the unknown" regarding pregnancy vaccines isn't just a problem for those currently expecting; it's a worry for many women planning for the future.

The Bottom Line

The paper concludes that the biggest hurdle to getting pregnant people vaccinated isn't a lack of medical data; it's a lack of trust.

Imagine the vaccine is a lifeboat. The researchers found that even though the lifeboat is sturdy and safe, many people are afraid to jump in because they don't trust the people handing out the life jackets (the doctors) or the people who built the boat (the health agencies).

The study suggests that to get more people on board, we can't just hand out more facts. We need to fix the trust compass. We need doctors and health officials to build stronger, more personal relationships with their communities so that when they say, "This is safe," people actually believe them.

Important Note: This study only asked people what they thought and felt. It did not track who actually got the shot. It's a map of the mindset, not a record of the action.

Technical Summary

Technical Summary: Perceptions of COVID-19 Vaccination During Pregnancy in a Cohort of US Adults (CHASING COVID)

Problem Statement
Pregnant individuals face a significantly elevated risk of severe COVID-19 outcomes, including ICU admission, invasive ventilation, and mortality, compared to non-pregnant peers of reproductive age. While vaccination is proven to reduce severe infection risks and adverse birth outcomes, uptake remains critically low. As of December 2024, only 13% of pregnant women in the U.S. had received the updated 2024–25 vaccine, with significant disparities observed across race, age, and socioeconomic status. Despite recommendations from the CDC and ACOG, significant gaps persist in understanding the specific drivers of vaccine hesitancy during pregnancy. This study addresses the need to deconstruct diverse perspectives on vaccine safety and efficacy to inform nuanced health communication strategies.

Methodology
The study utilized data from the CHASING COVID Cohort, a national prospective study of U.S. adults initiated in March 2020. The analysis focused on 4,488 participants who completed enrollment surveys between March and July 2020 and the December 2023 follow-up survey. The cohort included all adults and a specific sub-analysis of women of reproductive age (18–49 years).

• Data Collection: Perceptions were measured in December 2023 using five Likert-scale statements regarding long-term side effects, research sufficiency, safety, efficacy in reducing severe disease, and infant protection. Responses were categorized into "Agreement," "Uncertainty," and "Disagreement."
• Statistical Analysis: Exploratory Factor Analysis (EFA) identified two distinct constructs: Safety Perceptions and Efficacy Perceptions. Bivariate analyses (chi-square tests) examined associations between these constructs and participant characteristics. Multivariable robust Poisson regression models were employed to calculate adjusted prevalence ratios (aPR) for "any agreement" versus "some disagreement" and "any agreement" versus "uncertainty," controlling for age, gender, race/ethnicity, education, income, anxiety/depression symptoms, susceptibility to severe disease, vaccination status, and trust in information sources.

Key Contributions and Results
The study provides a granular analysis of vaccine perceptions across a large, diverse cohort, distinguishing between safety and efficacy beliefs.

• Perception Levels: Among all respondents, less than half (40.4%) agreed that the vaccine is safe during pregnancy, while just over half (58.2%) agreed on its efficacy. Among women of reproductive age, safety agreement was 40.7% and efficacy agreement was 59.7%.
• Factor Structure: The EFA confirmed two robust factors. Safety perceptions were driven by beliefs regarding long-term side effects and research sufficiency (Cronbach's alpha 0.84). Efficacy perceptions were driven by beliefs regarding the reduction of severe disease and infant protection (Cronbach's alpha 0.85).
• Demographic Correlates:
  • Race/Ethnicity: Non-Hispanic Black participants were significantly less likely to agree with safety (aPR=0.81) and efficacy (aPR=0.91) statements compared to Non-Hispanic White participants.
  • Education and Income: Higher education and income levels were positively associated with agreement on both safety and efficacy.
  • Children in Household: The presence of children under 18 in the household was associated with lower agreement on safety and efficacy.
• The Role of Trust: Trust emerged as the most significant predictor of positive perceptions.
  • Public Health Institutions: Trust in agencies (CDC, WHO, FDA) was strongly associated with agreement on safety (aPR=2.48) and efficacy (aPR=1.73) among all adults.
  • Healthcare Providers: Trust in personal physicians and healthcare professionals was significantly associated with agreement on safety (aPR=1.23) and efficacy (aPR=1.13).
  • Personal Doctor: Having a personal doctor was significantly associated with agreement on efficacy (aPR=1.05) but not safety in the fully adjusted model for all adults.
• Mental Health: Moderate-to-severe anxiety and depression symptoms were not significantly associated with perceptions of vaccine efficacy, though they showed some association with safety perceptions in bivariate analyses that diminished in multivariable models.
• Subgroup Nuance: Among women of reproductive age, trust in healthcare providers remained a strong predictor for safety (aPR=1.34), while trust in public health institutions was the strongest predictor for both safety (aPR=2.15) and efficacy. Interestingly, women of reproductive age who were more susceptible to severe COVID-19 were less likely to agree with safety statements (aPR=0.75).

Significance and Claims
The paper concludes that perceptions of COVID-19 vaccination during pregnancy are shaped by a complex interplay of demographic factors, healthcare experiences, and, most critically, trust. The authors claim that the strong association between trust in public health institutions and healthcare providers and positive vaccine perceptions underscores the vital role these entities play in risk communication.

The study posits that current strategies for improving vaccine uptake may be insufficient given the suboptimal rates. The authors suggest that future efforts must prioritize fostering trust at two levels:

1. Individual Level: Strengthening provider-patient relationships.
2. Institutional Level: Implementing transparent, community-centered communication strategies.

The paper explicitly notes limitations, including the inability to infer causality between beliefs and actual uptake due to the small number of currently pregnant participants in the cohort. Consequently, the authors frame their findings as insights into perceptions rather than direct predictors of behavior, calling for future research to explore the relationship between these beliefs and actual vaccination behavior during pregnancy. The study emphasizes that addressing the specific concerns of key subpopulations through trusted messengers is essential for developing effective health communication.