A narrative review of vaccine hesitancy in pregnant women published in Vaccine in June 2023 concludes that “vaccine hesitancy is dynamic”, suggesting that people “do not always hold a static level of vaccine hesitancy”. The authors state that people “move between a continuum of vaccine hesitancy” for “multifactorial reasons”. Literature indicates that the most common reasons for vaccine hesitancy include the following: 

  1. Fear of side effects or adverse events 
  2. Lack of confidence in vaccine safety 
  3. Low perception of being at high risk of infection during pregnancy and/or not having previously received the vaccination when not pregnant 

A framework, characterised by varying levels of hesitancy before and during pregnancy, can be used to support health providers in “promoting individual health and public health while providing vaccine education”.  

Why pregnancy? 

The authors note that in many countries, vaccination against vaccine-preventable diseases has “significantly increased the general population’s life expectancy”. However, pregnancy “increases the risk for morbidity and mortality” due to these vaccine-preventable diseases. Acknowledging the precautionary-principle approach, which reverses the burden of proof, the authors suggest that research on vaccine safety and efficacy generally excludes pregnant patients.  

“This gap in vaccine research in pregnant populations contributes to vaccine hesitancy for both patient and provider.” 

Infections during pregnancy can increase adverse pregnancy outcomes alongside disease-related morbidity and mortality. Thus, vaccination during pregnancy provides protection to both the mother and the developing foetus. The American College of Obstetrics and Gynaecologists (ACOG) recommends vaccination against several diseases during pregnancy, including seasonal influenza, Tdap, and the COVID-19 vaccine.  

Vaccine hesitancy 

We know that vaccine hesitancy and/or refusal are complex issues and the paper calls for collaboration between medical and public health systems to address them “synergistically”.  

“Vaccine hesitancy in pregnant people is a unique issue as a pregnant mother may view concern for vaccination through either a parental lens – having concern for the vaccine’s impact on the health of the unborn baby, and/or through a personal lens – having concern for the vaccine’s impact on her own health.” 

Although increasingly prevalent and pernicious, vaccine hesitancy is not a new phenomenon. For example, mandatory smallpox vaccination enforced in The Vaccination Acts of 1853 and 1867 encountered “fierce resistance”. Furthermore, vaccine hesitancy in the African American community has “deep historical roots” like the Tuskegee syphilis study. Retracted links between the MMR vaccine and autism continue to influence vaccine hesitancy.  

“The political polarisation of the COVID-19 pandemic increased vaccine hesitancy and vaccine refusal among groups of people who were not historically vaccine resistant.”  

The authors draw a link between the US presidential election of 2020 and an affiliation between vaccine hesitancy and “political ideology”, calling it a “proxy for exercise of personal freedom and autonomy over physical body”.  

Vaccine education 

The paper states that vaccine education must “incorporate balanced neutral perspectives”. It must be delivered to hesitant populations, including the vulnerable and immunocompromised. Although maternal vaccination is correlated with health care provider recommendation, up to 33% of pregnant people remain unvaccinated against vaccine-preventable diseases “irrespective of provider recommendation”.  

The review 

The paper aims to answer several questions: 

  1. What are the primary concerns of pregnant people that lead them to be hesitant about receiving vaccinations? 
  2. To what extent does the source of vaccine advice and information influence a pregnant person’s decision to accept a vaccine? 
  3. How does the delivery method of vaccine education influence their decision? 
  4. How can categorising patient into four distinct groups based on their opinions and behaviour regarding vaccines be used to improve provider-patient communication and increase vaccine acceptance? 

The researchers conducted a “structured search of the literature” across three databases: PubMed, Web of Science, and CinHAL. The terms “vaccine acceptance”, “vaccine hesitancy”, “pregnancy” were used and articles written in English were included. An initial search yielded 133 results with 49 unique titles, with a total of 30 articles being screened. 10 articles met the inclusion criteria, which are as follows: 

  • 50% of the subjects included in the study must be pregnant at the time of the study. 
  • Studies surveyed pregnant women about maternal vaccination during the course of their pregnancy.  

The search concludes that sources of vaccine information, ranging from the internet or health care providers to family and friends, had the “greatest influence on a hesitant person’s willingness to accept a vaccine”. The delivery method was important but less influential.  

“The sources of education with the greatest influence on vaccine acceptance during pregnancy were institutional backed sources, followed by verbal education from family members.”  
Hesitancy is dynamic 
“Vaccine hesitancy is dynamic in that patients do not always hold a static level vaccine hesitancy or resistance.”  

Therefore, the authors suggest that providers must have effective strategies to address concerns as patients fluctuate between different levels of hesitancy or resistance. They propose that health care providers consider a suggested framework to deliver vaccine information to pregnant persons based on their current feelings towards vaccination. The framework offers a “neutral approach” to vaccine education that is not based on race, education status, or political persuasion. By contrast, it categorises patients into four groups based on what stage of vaccine acceptance they place themselves in.  



People who place themselves in group 1 of the framework may be the most resistant of the groups to vaccine information and education, and the authors identify an “ethical obligation for providers to not give up” in the face of difficulty to counsel. Do you think the framework is a comprehensive tool for health care providers, and where would you place yourself within it? If you would like to read the study in full, please access it here! Don’t forget to subscribe to our weekly newsletter here.