Background / Introduction: Covid 19 Vaccines are effective public health interventions against viral outbreaks and pandemics through primary prevention. No study has been reported yet on the acceptability of the COVID-19 vaccine among pregnant women in Philippines. 

Aims and Objectives: To determine the acceptance of a COVID-19 vaccine among pregnant women. 

Materials and Methods: A cross-sectional, descriptive study using a questionnaire conducted at a tertiary Hospital in Olongapo City. Logistic regression analysis is performed to determine the factors for vaccine acceptability among pregnant women. 

Results: More than half of pregnant women (60.25%) accepted COVID-19 vaccination. Those above 30 years of age were almost twice likely (Odds Ratio=1.9, CI: 1.2 – 3.2) to accept the vaccine, compared to those who were 30 years old or younger. Women who were married or living with a partner were likewise 2.1 times more likely (OR=2.1, CI:  1.1 – 3.9) to accept the vaccine than single parent women. Furthermore, pregnant women who at least reached college-level education were 2.2 times more likely (OR = 2.2, CI: 1.3 – 3.6) to accept the vaccine. On the other hand, employed or self-employed pregnant women were 1.3 times more likely to have themselves vaccinated against COVID-19. Those in the first or third trimester of pregnancy were much more likely to accept the COVID-19 vaccine as compared to those on their second trimester of pregnancy (Odds Ratio = 12.7 and 17.7, respectively). Similarly, pregnant women with a comorbidity were found to be 3 times more likely to have themselves vaccinated. Although, their computed OR did not show statistical significance, the trend noted is applicable to the sample women in this study but not to the larger population of pregnant women.

Conclusion: Majority of the participants accept the COVID 19 vaccine regardless of the disparities in numbers vis a vis demographics and knowledge. Public health workers working hand-in-hand with Local Government Unit (LGU) efforts must be commended in their ongoing efforts towards COVID-19 vaccine acceptance. Mass campaign through education emphasizing benefits of the vaccine must continue to attain the biggest impact.

A global pandemic posing a major threat worldwide is the current 2019 coronavirus disease, known as COVID-19, and is caused by a severe acute respiratory syndrome called coronavirus-2 (SARS-CoV-2). Recent reports have raised concerns of negative outcomes in pregnancy such as preterm birth, neonatal pneumonia, vertical transmission of COVID-19 to the fetus and postpartum infections [1-8]. Several effective vaccines are now available for use worldwide. (14) However, the mere availability of a vaccine will not 

guarantee the uptake. For example, a vaccine against influenza A H1N1 was offered before, or at the onset of the second epidemic wave, but vaccination rates were found to be lower than expected, with a population coverage ranging from 0.4 to 59

1. questionnaire conducted at Tertiary Hospital from December 1, 2021 to April 30, 2022. 
2. Settings and Subjects

Tertiary hospital level III hospital with major departments accredited for residency training. Most of the high-risk charity patients were being referred to this institution by numerous lying-in centers. Hence called, the non-covid and covid 19 referral hospital of Olongapo city. Most of these patients were reliant on public health facilities such as the Tertiary hospital as it provides free of cost services.  There were over 20 headcounts at the out-patient department (OPD) per week and of these, about 150 were antenatal admissions per month.  The facility provides comprehensive free maternal  and   antenatal   care  package   based   on DOH and PHILHEALTH guidelines.

1. Sample Size

Total enumeration of pregnant women consults as well as admissions at Tertiary hospital for the period December 1, 2021 to April 30, 2022.

Participant selection and data collection

Participants were recruited from those who attended the antenatal clinic and obstetric admission during the study period.

All patients including pregnant women attending the Tertiary hospital during this pandemic, were screened for COVID-19 symptoms and if found positive were isolated for further care. 

All pregnant women attending the antenatal clinic during the study period were recruited. Those exhibiting symptoms of COVID-19 such as fever, cough, colds, sore throat, body pain etc. based on triage, were excluded   from  the   study. 

A   written invitation (Annex I) with the aim and objectives were explained to participants in English and or Filipino. The participants were assured that they were not discriminated against regarding their antenatal consultation should they refuse to participate. 

Data was collected using a structured questionnaire administered by the researcher.  Universal precaution measures were adopted during the data collection. 

A two-page questionnaire was adopted (Annex II) from European Journal of Medical and health sciences. (https://ejmed.org/index.php/ejmed/article/view/493?fbclid=IwAR3268L4a1O4jsMFFR13qEauRz2_0Y6WysAqgwlSarhr6AGo2ZjItEz2eTA): This research questionnaire underwent face and content validation based on a paper entitled women’s demographics, knowledge, attitudes and practice on COVID-19 infection that has been published abroad. The questionnaire is translated in English and with Filipino Translation (Annex I). Accomplished questionnaires were checked immediately for completeness. This was tested initially to 10 participants prior to large scale data collection.

In a study where 400 participants were recruited, 50 failed to complete the questionnaire, resulting to dropout rate of 12.5 %.

1. Questionnaire
2. Demographic questions include age, address, contact no., email address, marital status, educational attainment, occupation, parity, and age of gestation (AOG). It also includes the vaccination status and comorbidities
3. Knowledge 

Ila. The knowledge questions include from where or whom have the patient received information regarding the vaccine such as newspaper, social media/internet, barangay, friends and relatives.

IIb. The six specific symptoms of COVID-19 with yes or no answers include the following symptoms: cough, sore throat, body pain, fever, difficulty in breathing and tiredness. 

IIc. There were seven true or false questions The true or false questions were the following: the virus survives for days outside the body in the open air, the virus survives for days outside the body on a plastic surface, most people who get COVID-19 become very ill, smokers who get COVID-19 are more likely to get ill than non-smokers, you can have the virus without any symptoms, children get less ill from the virus than adults and only elderly people die from COVID-19. 

1. Attitude

The attitudes of the respondents were measured by five questions with yes or no answers: you may get infected by COVID-19, anyone in their family may get infected, the COVID-19 epidemic is a serious infection, the tertiary hospital will be able to handle the COVID-19 pandemic in the region and the government has provided sufficient information on the COVID-19 pandemic. 

1. Practices

The six practice questions consist of: do you cover your mouth when you sneeze or cough, do you use a face mask when you go to public places, do you keep a distance of 1-2 meters in public places, do you wash or sanitize your hands once you enter your house coming from outside, would you visit your family or friends during the COVID-19 epidemic and, would you visit a person who is diagnosed and isolated for a COVID-19 infection?

1. Measurements

The knowledge, attitudes and practices score of COVID-19 infection were measured using a score of one [1] for the correct and zero [0] for incorrect answers or positive [1] and negative [0] statements. Total   knowledge, attitudes and practices score were measured by adding the scores for the correct answers or on positive statements. 

1. Data analysis

Data was encoded using Microsoft Excel, and analyzed via SPSS version 22. Descriptive statistics such as mean with standard deviation (SD) for continuous variables and frequency distribution for categorical variables were undertaken.  Chi-square test and binary logistic regression were carried out to identify the factors for COVID-19 vaccine acceptability. P-values <0>

1. Ethical consideration

Ethical approval was granted by Research Ethics Committee. Participation was voluntary, and any respondent may discontinue participation at any time without prejudice. 

The study questionnaire contained a consent section that stated the purpose, nature, objectives of  the   study, declaration   of  confidentiality, and anonymity.

A total of 400 pregnant women participated in this study. More than half (67.3%) were between 14 to 30 years of age with mean of 22 years old. The level of maturity usually increases with age. In psychology, maturity can be operationally defined as the level of psychological functioning and decision making. Unlike younger counterparts whose decision making maybe largely influenced by their guardians or elders [63]. More than two-thirds (81.8%) had a partner, either married or unmarried. A strong relationship support increases the vaccination rate based on relationship surveys conducted abroad [64]. A vaccine meant to combat a pandemic does not work at an “individual level” but on a family level. There is a higher need to protect one another since the virus is highly transmissible at home [65]. Two-thirds (74%) were unemployed, with majority (61.8%) unable to reach college-level education. 

Similar to a study conducted in John Hopkins University noted the relationship between education level and vaccine acceptance varies across countries and geographic regions.[66] In most countries, individuals with college education or higher are more open to accepting a COVID-19 vaccine because higher education can lead to better understanding of the vaccine benefits and efficacy, effects on immunity, and benefits can outweigh the adverse effects of Cacho et al. Hence, increase the likelihood of vaccine willingness to more educated patients.[67] The Philippine government’s coronavirus task force has required the COVID-19 vaccination of employees doing on-site work, both public and private, in areas where there are enough supplies of COVID-19 vaccines. Presidential Spokesperson Harry Roque made the announcement last November 12, 2021. Hence, this advice came up to ramp up vaccination coverage as the government also eyes mandatory inoculation of the Philippine population.[68]

As regards age of gestation (AOG), majority (68.3%) were on their 2nd trimester of pregnancy and had 2 or more previous pregnancies. Only about 5% of the women in this study reported having a comorbidity (Table 1). Last Aug 12, 2021 Revised guidelines of DOH re-categorized pregnant patients as extended A3, along those with comorbidities and immunocompromised. Secretary Vergeire last March 2022 emphasized that “high-risk” pregnant women in their first trimester can be vaccinated as well, especially those with co morbidities [69]. It could be that majority of the patients either decide “earlier” due to benefits of vaccine, as compared to those with co-morbidities, or decide later such as those in their 3rd trimester of pregnancy, presumably understanding the stage of organogenesis has passed, lowering the risk of congenital malformation. Furthermore, vaccination prevents COVID 19 infection that may lead to possible preterm labor.Table 1 also shows that about three of every five pregnant women (60.25%) accepted the COVID-19 vaccine and had themselves vaccinated. Vaccine acceptance was found to be significantly associated with the following socio-demographic and clinical characteristics (p < 0> 0.05).   

p: p-value from chi-square test.

Table 1: Frequency of socio-demographic and clinical characteristics with covid-19 vaccination

Results showed a low mean knowledge score of 5.8 out of 12 (SD=3.4). Few of the participants knew about the symptoms   of a COVID-19 infection. This may be because of the idea that a person can have the virus without any symptoms, as indicated by almost 80% (77.3%). Moreover, almost a half of the participants (48.8%) knew that children get less ill from the virus than adults but not only elderly people die from COVID 19. 3 out of 4 (76.3%) knew of the virus survival outside the body in the open air, while more than half answered that the virus can also survive on a plastic surface (60.5%) (Table 2). Although knowledge on COVID-19 was not satisfactory, the attitude of the respondents was highly positive as the mean score was 4.4 out of 5 (SD=1.3). Approximately 9 per 10 pregnant women felt that they may get infected by COVID-19, that anyone in their family may get infected with the virus, and that the COVID-19 epidemic is a serious infection but around the same number believe that the local tertiary hospital will be able to handle COVID 19 pandemic in the community and that the government has provided enough information regarding COVID 19 (Table 2). The preventive practices of pregnant women were likewise found to be highly favorable as the mean practice score was 5.5 out of 6 (SD=1.0) although about 1 of 4 women (23.5%) stated that they would visit family or friends during lockdown while 1 of every 6 women (16.3%) stated that will visit a COVID 19 positive patient (Table 2).

Table 2: Knowledge, attitude and practices of pregnant women on covid

Chi-square tests of association showed that knowledge, attitude and practice toward COVID-19 were not significantly associated with vaccine acceptability (p>0.05). As seen in the table, regardless of the status of the pregnant women’s knowledge, attitude and practice toward COVID-19, majority chose to be vaccinated. (Table 3)

p: p-value from chi-square test

Table 3: Association of knowledge, attitude and practice with covid-19 vaccine acceptability

Multiple logistic regression analysis was conducted to determine the significant predictors for vaccine acceptability (Table 4). All the variables that were found to be significantly associated with vaccine acceptability from the bivariate analysis were entered in the analysis. The final model showed that women who were either in the first or third trimester of pregnancy were much more likely to accept the COVID-19 vaccine as compared to those on second trimester of pregnancy (OR = 12.7 and 17.7, respectively). Moreover, participants above 30 years of age were almost twice likely (OR=1.9, CI: 1.2 – 3.2) to accept the vaccine, compared to those who were 30 years old or younger. Women who were married or living with a partner were likewise twice likely (OR=2.1, CI:  1.1 – 3.9) to accept the vaccine compared to single-parent women. Furthermore, pregnant women who at least reached college-level education were twice likely (OR = 2.2, CI: 1.3 – 3.6) to accept the COVID-19 vaccine (Table 4). On the other hand, although employed or self-employed pregnant women were found to be 1.3 times more likely to have themselves vaccinated against COVID-19, the computed OR was not found to be statistically significant (p>0.05), implying that this association is true for the sample women in this study but not necessarily applicable to the general pregnant population. Similarly, a pregnant woman with a comorbidity was 3 times more likely to be vaccinated against COVID-19. This OR was not statistically significant however. 

Table 4: Factors associated with covid 19 vaccine acceptance based on logistic regression

The major source of patient’s information on Covid 19 disease and vaccination was obtained through social media accounting to almost half (44.7%) of the participants. Barangay Health Workers (BHW) and midwives ranked second as the source accounting to 25.2%. Followed by information obtained from relative, friend, newspapers, 17.0 %, 8.0 % and 4.7 % respectively. These findings point out that combined efforts of both the LGU social media campaign and healthcare providers efforts have been major source of the knowledge of on Covid-19 vaccine of the participants.

Table 6: Frequency of vaccine acceptors per barangay

Table 6 shows the distribution of the 241 vaccine acceptors per barangay. Majority reside in Sta Rita with 33 respondents, followed by New Banicain. Majority of the 159 non-acceptors came from New Cabalan and Gordon Heights.

Table 7: Frequency of pregnant women covid vaccine acceptors as of june 14, 2022, olongapo city.

From the study, about three of every five pregnant women (60.25%) accepted the COVID-19 Vaccine. The factors found to be significantly associated with vaccine acceptance include the following: trimester of pregnancy, age, marital status, level of education, employment status, and presence of comorbidities. Participants above 30 years of age were almost twice likely (OR=1.9, CI: 1.2 – 3.2) to accept the vaccine, compared to those who were 30 years old and younger. Women who were married or living with a partner were likewise 2.1 times more likely (OR=2.1, CI:  1.1 – 3.9) to accept the vaccine than single parent women. Pregnant women who at least reached college-level education were 2.2 times more likely (OR = 2.2, CI: 1.3 – 3.6) to the COVID-19 vaccine.  Employed or self-employed pregnant women were found to be 1.3 times more likely to have themselves vaccinated, similarly, pregnant women with a comorbidity were found to be 3 times more likely to have themselves vaccinated. Odds Ratios of these 2 variables were not statistically significant however. Women who were either in the first or third trimester of pregnancy were much more likely to accept the COVID-19 vaccine as compared to those in their second trimester of pregnancy, OR = 12.7 and 17.7 respectively.

Recommendations: 

The researcher may look into other variables such as knowledge and attitude of pregnant women on antenatal effects of the vaccine on the fetus and on themselves. Since the general knowledge and attitude about COVID-19 did not turn out to be significant determinants of vaccine acceptability for the study population. Additional studies comparing pregnant women with prenatal check-up (PNCU) versus without PNCU will prove to be valuable in assessing vaccine acceptability.

Study limitations:  

The findings may be influenced by possible selection   bias because there was no random selection of participants, and limited number of participants as well, limiting applicability of the associated factors to the general pregnant population. Another limitation is the bias of social desirability, as participants may have responded to questions, they deemed acceptable to the communities where they belong.