COVID-19 vaccine acceptance and associated factors among pregnant women attending antenatal care in public health facilities of Addis Ababa, Ethiopia, 2022

Asfaw Mengesha Marcho^1,&, Zemichael Gizaw², Belay Golie Yimer¹

 

¹Ethiopian Public Health Institution, Addis Ababa, Ethiopia, ²Gondar University, Ethiopia

 

 

^&Corresponding author
Asfaw Mengesha Marcho, Ethiopian Public Health Institution, Addis Ababa, Ethiopia.

 

 

 

 

Coronavirus disease 2019 (COVID-19) is a highly communicable respiratory infection caused by the severe acute respiratory syndrome coronavirus 2 and the COVID-19 pandemic has imposed a huge morbidity and mortality burden at the same time severely interrupting society´s health and economic system of the world [1, 2]. Ethiopian Public Health Institution (EPHI) as of March 17, 2022, had a total of 469,329 confirmed cases with over 7488 total deaths [3-5]. Pregnant women may be more prone to severe COVID-19 infection due to decreased immunity and overstress because factors such as chronic stress, obesity, asthma, underlying inflammatory conditions, and socioeconomic factors are also known to increase the risk of viral infection and exacerbate complications during pregnancy [6]. Many respiratory diseases such as SARS, MERS, and influenza have been associated with increasing the rate of intensive care unit (ICU) admission, mechanical ventilation, and death in pregnant women [7].

 

Literature also indicated that COVID-19 infection during pregnancy will increase the risk of other adverse women´s and neonatal health complications [8]. However, research on COVID-19 in pregnant women is limited [9]. Pregnant women are prone to a higher risk of severe COVID-19-related complications compared with non-pregnant women [8]. In addition to these COVID-19 infections overlap with other influenza and resulting co-morbidity will likely exacerbate diseases and death during pregnancy [10]. Even though the exact number of pregnant women getting COVID-19 infection is unknown, it estimated that millions of pregnant women may have COVID-19 infection, based on the estimated prevalence of 1-10% [11]. In South Africa 53% COVID-positive pregnant women had symptoms, but occurrence of adverse fatal event was low [12].

 

Pregnant women in Ethiopia had a lower acceptance rate of the COVID-19 vaccine than the general population, which is expected to be 65-78 percent [13]. COVID-19 vaccination before and during pregnancy is safe and effective. The benefits of receiving a COVID-19 vaccine outweigh any known or potential risks of vaccination during pregnancy [14].

 

In the studies done at Debre Tabor, Debre Markos and central Gondar zone public health facilities vaccine acceptance were 14% ,18% and 62 % respectively [2,15, 16].another study done at country level in Ethiopia vaccine acceptability was 61% [3].

 

However, in Addis Ababa which is the largest and capital city in Ethiopia no previous studies determine acceptance rate, nor investigate the reasons why pregnant mothers hesitant to use the COVID-19 vaccination.

 

 

Study area and period

 

The population of women in the reproductive age group in Ethiopia is 24,069,145.932 (23.4%) while in Addis Ababa it is 1,275,380 (34.6%) [17]. Addis Ababa city has a population of 5,228,000 according to 2022 United Nations population projection [18]. Administratively, the city is divided into 10 sub-cities with 116 districts. Addis Ababa city has a total of 101 public health centers. This study was conducted among pregnant women attending ANC at those public health facilities from September -November 2022.

 

Study design

 

An institution-based cross-sectional study was conducted to assess COVID-19 vaccine acceptance and associated factors among pregnant women attending antenatal care in public health centers of Addis Ababa city administrations of Ethiopia 2022.

 

Study population

 

The study population were pregnant women attending antenatal care in public health centers of Addis Ababa city administrations of Ethiopia 2022. Pregnant women attending antenatal care in public health facilities of Addis Ababa city administrations of Ethiopia who accepted to participate were included in the study. Pregnant women who were seriously ill were excluded from the study.

 

Sample size determination

 

The sample size was determined using a single population proportion formula with the following assumptions: vaccine acceptance among pregnant women in southwestern Ethiopia = 71%([13]. 95% confidence interval (level of significance), level of significance (alpha) = 0.05, and margin of error (d) = 5%.

 

 

By adding a 10% non-response rate, the final sample size was 348.

 

Sampling technique and sampling procedures

 

First, all public health facilities of Addis Ababa were identified. Simple random sampling using computer generated lottery method was applied to select nine public health facilities.

 

Proportional allocation was applied to determine adequate sample from each selected health centers (Figure 1).

 

Operational Definition

 

Vaccine acceptance: willingness to take the vaccine without any refuse. COVID-19 vaccine acceptance: was measured using self-response (yes and no) questions. Respondents who responded “yes” to each willingness question received a score of 1 (willing to vaccination) and “a score of 0 (refusing to vaccination) was given for “no” responses [13].

 

Allergic to medication: participants response on whether they experienced allergic reactions after taking any medication (score 1 for yes, and 0 for no).

 

Being young: yes (1) for age category between 18-24 years as World Health Organization otherwise no (2)

 

Data collection procedure

 

Data were collected after getting informed consent from each respondent by using a structured pretested interviewer-administered questionnaire. The questionnaire design was based on previous studies [19-21]. The questionnaire was translated from English into Amharic language and then pretested to check for any meaning variation or ambiguity.

 

Data quality assurance

 

Data collection facilitators were trained for two days. Pre-test was conducted in health centers other than those selected for the study. Close supervision was carried out by the principal investigators during data collection procedures. The data were checked for completeness, clarity, consistency and accuracy.

 

Data analysis

 

Data were checked, coded and entered into Epi-info version 7.2 and exported to SPSS version 23 for analysis. Descriptive data analysis results were presented in text, tables, chart and figures. Variables included into multivariable logistic regression analysis had a p <0.25 at bivariable analysis. In the adjusted model, factors significantly associated with vaccine acceptability were identified based on aOR with 95% CI that did not include 1 and p-value less than 0.05 and fits Hosmer and Lem show model test.

 

Ethical consideration

 

Ethical clearance for this study was given by the ethical review board of Addis Ababa Medical and business College with reference number AAMBC/STU/11.379 and date 15/11/2019. Addis Ababa city Administration provided a letter of support. Informed consent was obtained from each participant that was included in the study. Findings were disseminated to public health facilities and partners in Addis Ababa city.

 

 

COVID-19 vaccine acceptance, socio-demographic characteristics and practices Measures (N =348)

 

There was a total of 348 respondents. Majority 143 (41.1%) were aged 26-35 years old, 97 (27.87%) were aged 15-25 years old, 92 (26.72%) aged 36-45 years old and the rest greater than 45 years above. Most of them 281 (80.7%) were married, 152 (43.7%) had a diploma and above, and 132 (37.9%) were civil servants (Table 1). Vaccine acceptance among pregnant women attending antenatal care was 58% (95%CI:52.7-63.3) i.e. 202/348 (Figure 2).

 

Among the 202 participants that were willing to accept the vaccine, 82.7% (167/202) believed that COVID-19 vaccination decreases the risk of symptomatic infection compared to 57.5% (84/146) among those not willing to accept the vaccine; and 74.8% (151/202) responded that vaccination decreases the risk of COVID-19 transmission compared to 56.2% (82/146) who were not willing to get vaccinated. Moreover, 65.8% (133/202) of the respondents who were willing to be vaccinated believed/assumed that the vaccine is an effective treatment of the infection compared to 38.4% (56/146) who were not willing to get vaccinated (Table 2).

 

Fifty-two percent (112/202) of the respondents who would accept the COVID-19 vaccine reported that they usually wear masks.

 

Factors associated with vaccine acceptance

 

We run a bivariable binary logistic regression to assess the association between different variables and acceptance of COVID-19 vaccination (Table 2). Variables with p-value less than 0.25 in bivariable binary logistic regression were entered into multivariable logistic regression. Those factors were: being allergic to medication, previous COVID-19 infection; assumptions/beliefs that COVID-19 vaccine decreases risk of transmission, vaccine decreases symptomatic infection, vaccine provides immediate protection after first dose and vaccine is an effective treatment for active COVID-19 infection, being young (18-24 years old), assumption/belief that the vaccine affects fetus, and having a family member who had been hospitalized or died.

 

The final multivariate logistic regression model showed that vaccine acceptability among pregnant women attending antenatal care was statistically significantly associated with: fear of allergic reactions to the medication (aAOR:0.2, 95% CI:0.13-0.58), assuming/belief that the vaccine decreases severe symptoms (aAOR:2.4, 95% CI:1.1-5.1), and assuming/belief that the vaccine was effective treatment for active infection (aAOR:2.4, 95% CI:1.14-5.0). On the other hand, young women and those who perceived that the vaccine might affect the fetus had statistically significantly reduced odds of accepting COVID-19 vaccination (aAOR:0.1, 95% CI: 0.05-0.2 and aAOR:0.2, 95% CI: 0.05-0.82) respectively (Table 3).

 

 

This is an institution-based cross-sectional study conducted to assess COVID-19 vaccine acceptability among pregnant women attending ANC services in different public health facilities in Addis Ababa, Ethiopia. In this study Covid-19 vaccine acceptance was 58% (95% CI:52.7%-63.3%). This finding is consistent with the study done at central Gondar zone public hospitals and public health institutions in Ethiopia which reported vaccine acceptance at 62% (95% C.I: 57.6-66.3) and 61% (95% C.I: 56.9-60.1) respectively [ 2,3]. On the contrary, this vaccine acceptance level is higher than what was reported in the studies done at Debre Tabor and Debre Markos public health facilities where vaccine acceptance was 14% and 18 respectively [22, 23]. This difference may be due to the availability of alternative media sources and greater access to information on COVID-19 vaccination in Addis Ababa city compared to the other study areas. On the other hand, this finding is lower than the 70.7% vaccine acceptance reported in the study done in southwest Ethiopia [13]. The difference may be due to differences in the study times, because the southwest Ethiopia study was done during the peak of COVID-19, when pregnant women were likely to be more worried about catching the disease which possibly increased their willingness to accept the vaccine.

 

The current finding is also lower than what was reported in other sub-Saharan African countries: Ethiopia (97.9%), Nigeria (86.2%), Uganda (84.5%), Malawi (82.7%) and Burkina Faso (82.5%) [24]. The latter study was a phone survey (phone calling) which is prone to selection and response biases that may have contributed to the high acceptance levels. However, our finding of 58% is consistent with global COVID-19 vaccine acceptance in pregnant women which was 54% (95% CI: 45-62) [18].

 

The current study identified several factors that were significantly associated with COVID-19 vaccine acceptance. The assumptions that vaccination decreases the risk of symptomatic infection and that the vaccine was an effective treatment for COVID-19 infection were associated with increased likelihood to accept vaccination. While being younger in age assumption that the vaccine affects the fetus and being allergic to medication were negative factors associated with less likelihood to accept vaccination making them potential barriers.

 

In this study younger pregnant mothers (18-24 years old) were 90% less likely to accept to receive the COVID-19 vaccine. Most young mothers are likely to be primi-para and more sensitive and concerned about their fetus, causing them to over think of the fetal condition if they take the vaccine. Worse still as first time mothers its their first exposure to vaccination during pregnancy. This finding is consistent with studies done at Debre Markos, Debre tabor and southwest Ethiopia [22, 23].

 

The current finding that assuming vaccine affects fetus was negatively significantly associated with vaccine acceptance, agrees with findings from the Debre tabor public health institutions study [22]. Notably the current study quantified the relationship between assuming vaccine has effect on fetus and vaccine acceptability by odds ratio than only describing the reason for hesitancy as was the case in the Debre tabor study. Also, the Debre tabor study identified being married as a significant factor associated with vaccine acceptance but the current study excluded being married from the regression analysis, because it is already known that most of pregnant attending antenatal care are married no need to do further analysis. This finding is supported by the study done at Debre Markos public health institution [23].

 

Studies done in China and Ankara [15, 16] also support the finding that assuming that the vaccine can harm the fetus is associated with vaccine acceptability. However, these aforementioned studies identified lower education, gestational complication and higher knowledge on Covid-19 as factors that were significantly associated COVID-19 vaccine acceptance contrary to what we found in the current study.

 

Compared to studies done at Debre tabor, Debre Markos, southwest Ethiopia and central Gondar zone [2, 22-24], the current study identifies significant associations between the assumptions that vaccination decreases symptomatic infection and COVID-19 vaccine is effective treatment for active COVID-19 infection with vaccine acceptance. This study recognized gaps that are likely to prevent attainment of the WHO COVID-19 immunization target of 70% [25].

 

 

In conclusion more than half of the pregnant women expressed willingness to accept the vaccine for COVID-19 in the studied health centers. The main factors associated with COVID-19 vaccination acceptability was being allergic to medication, assuming vaccine was an effective treatment for active infection, assuming vaccine decreases symptomatic COVID-19 infection, perceived effect of the vaccine on the fetus, and age. Health care professionals should routinely educate pregnant women on COVID-19 vaccine role in treatment of COVID-19, adverse events and effects on fetus during their ANC visits. COVID-19 vaccine awareness creation at public meetings, television and radio programs should be prioritized, highlighting the benefits of the vaccine to pregnant women and their babies and dispelling taboos about the vaccine. Awareness creation on vaccination safety and timely management of adverse drug reaction can increase vaccination acceptance in pregnant women. We recommend conducting a study on COVID-19 vaccination safety in pregnant women in Ethiopia to help address the perceived barriers and assist more pregnant women to accept COVID-19 vaccine.

 

 

The authors declare no competing interests.

 

 

AMM was the principal investigator. ZG and BGY were his academic advisors. All authors played a crucial role in overall activities from title selection to final research activities including manuscript write up activities. All agreed to be accountable in all aspects of the manuscript and consented to its being submitted for publication.

 

 

We acknowledge Addis Ababa Medical and Business College for the opportunity to conduct this study, the academic advisors Dr. Ze Michael Gizaw (Assoc. Prof) A and Mr. Belay Golie and also Atikilt Jomole who funded the research work.

 

 

Table 1: Socio-demographic characteristics of respondents(N=348)

Table 2: Binary logistic regression analysis of factors associated with Covid-19 vaccine acceptance among pregnant women attending ANC at Addis Ababa public health centers, 2022

Table 3: Factors associated with COVID-19 vaccine acceptance among pregnant women attending ANC at Addis Ababa public health centers,2022(N=348)

Figure 1: Schematic Presentation of Sampling Procedures

Figure 2:Vaccine acceptance among pregnant women attending ANC Visit, Addis Ababa city public health centers,2022

 

 

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