"I'd Do It for My Baby": Lessons Learned from Qualitative Research on COVID-19 Vaccination among Pregnant Women in Côte d'Ivoire

"Understanding the perceptions of COVID-19 vaccines and barriers to vaccination is critical to increasing uptake among pregnant women."

In January 2023, almost two years after COVID-19 vaccines were authorised for the general Ivorian population, the Government of Côte d'Ivoire authorised the vaccine for pregnant women. In Côte d'Ivoire, Breakthrough ACTION works with the Ministry of Health, the Risk Communication Technical Working Group, the COVID-19 task force, the Ministry of Education, local non-governmental organisations, leaders of grassroots associations and interest groups, and other partners to promote COVID-19 vaccination through mass and social media, community engagement, and infodemic management. To support efforts to achieve the government's goal of 70% COVID-19 vaccination coverage, Breakthrough ACTION conducted a qualitative study in three sites in Côte d'Ivoire to explore perceptions of COVID-19 vaccination to complement a multi-wave knowledge, attitudes, and practices (KAP) survey. This analysis focuses on a subset of the data related to attitudes about and barriers to vaccination during pregnancy.

The findings presented here primarily reflect data collected through 76 in-depth interviews and 18 focus group discussions (featuring journey mapping with recently vaccinated adults) conducted in Abidjan, Bouaké, and San Pedro in November 2022. These major urban centres were selected due to their low vaccination coverage at the time of the study. Relevant insights from a cross-sectional KAP survey with 3,000 participants conducted by Breakthrough ACTION in Abidjan, Bouaké, Yakro, and San Pedro in August-September 2022 are also referenced here to frame and enrich the qualitative findings.

The qualitative research with 214 adults (including pregnant women) revealed key themes that align with the World Health Organization (WHO) behavioural and social drivers (BeSD) of vaccination framework, including cognitive and emotional factors like perceived disease risk and vaccine confidence (constructs also present in the Extended Parallel Process Model (EPPM) under the labels of perceived severity, perceived susceptibility, perceived response efficacy, and perceived self-efficacy), and social processes such as family support or health worker recommendations. Pregnant women, and those who influence pregnant women, expressed serious concerns about vaccine safety during pregnancy, while questioning the seriousness of COVID-19.

More specifically:

• Data from the August 2022 KAP survey of 3,000 participants indicate that, while 71% of respondents agreed that the COVID-19 vaccines available in Côte d'Ivoire were safe, only 9% agreed that the COVID-19 vaccines were safe for pregnant women. Of those who had heard rumours, 28% spontaneously mentioned the rumour that vaccines can cause infertility or reproductive health problems. The rumour was likewise mentioned by participants in the November 2022 qualitative study.
• The decision to recommend the vaccine for pregnant women came after more than a year of deliberation by the independent committee established when COVID-19 vaccines became available in 2021. Most participants knew that the COVID-19 vaccine had not initially been recommended for pregnant women. Some participants felt that the policy change alone would be enough to motivate pregnant women to get vaccinated, but others felt that it would be difficult to convince pregnant women that the vaccine is safe for them and their babies in the wake of the original restriction; pregnant women expressed a need for more information, including an understanding of what motivated the policy change.
• Pregnant women who participated in the study expressed a preference for waiting until after giving birth to get vaccinated against COVID-19, to be safe. They viewed the COVID-19 vaccine as risky during pregnancy but seemed unaware of the heightened risks that COVID-19 illness poses to pregnant women and babies.
• Pregnant participants stated that if they believed that the COVID-19 vaccine was good for the baby, they would put aside their fears and get vaccinated. Reframing the conversation around the dangers of COVID-19 for pregnant women and their babies and positioning the COVID-19 vaccine as safe during pregnancy and protective, both during pregnancy and afterwards, could encourage uptake among this segment of the population.
• Practical issues did not seem to play a major role here: Though the journey mapping exercises were not conducted with pregnant women, participants in those exercises described the vaccination sites as well advertised and marked and said the providers were welcoming.

The EPPM posits that perceived risk paired with an easily actionable solution can motivate behaviour change. It also warns that fear in the absence of concrete solutions can be paralysing. To increase uptake of COVID-19 vaccination during pregnancy, Breakthrough ACTION recommends that risk communicators reframe COVID-19 as risky to pregnant women and their babies and the vaccine as safe and protective. Also, the messaging needs to clarify that approval was delayed for pregnant women to allow for further testing among pregnant women. The policy change was made considering evidence that supports that the vaccine as safe and protective for pregnant women and their babies.

Potential strategies to reinforce perceptions of COVID-19 vaccine safety for pregnant women outlined in the paper include:

• Providing frequent and consistent messaging through both interpersonal (door-to-door) and mass media channels to reassure women that the vaccines are safe during pregnancy;
• Leveraging prenatal consultations and the trusted relationship between health workers and pregnant women for both counseling and vaccination;
• Engaging influential others (e.g., family members, friends, and community leaders) to support pregnant women in the decision to accept vaccination against COVID-19; and
• Offering positive testimonials from women who became pregnant after being vaccinated or who had an uncomplicated pregnancy and healthy child after vaccination to help combat rumours that the vaccine negatively affects fertility and reproductive health. Such testimonials could foster positive attitudes towards the vaccine before a woman even becomes pregnant and encourage broad vaccination among women of reproductive age.

Breakthrough ACTION Côte d'Ivoire presented these findings and recommendations to the national vaccination task force, health district management teams, and the head of the midwives' association and has used them in a co-creation workshop with pregnant women to design concrete interventions to promote COVID-19 vaccination among pregnant women. The paper's authors encourage others to validate the findings in their own context.