Human Vaccines & Immunotherapeutics

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Acceptance of a COVID-19 vaccine and associated

factors among pregnant women in China: a multi-
center cross-sectional study based on health belief
model

Liyuan Tao, Ruitong Wang, Na Han, Jihong Liu, Chuanxiang Yuan, Lixia Deng,
Chunhua Han, Fenglan Sun, Min Liu & Jue Liu

To cite this article: Liyuan Tao, Ruitong Wang, Na Han, Jihong Liu, Chuanxiang Yuan, Lixia
Deng, Chunhua Han, Fenglan Sun, Min Liu & Jue Liu (2021) Acceptance of a COVID-19 vaccine
and associated factors among pregnant women in China: a multi-center cross-sectional study
based on health belief model, Human Vaccines & Immunotherapeutics, 17:8, 2378-2388, DOI:
10.1080/21645515.2021.1892432

To link to this article: https://doi.org/10.1080/21645515.2021.1892432

Published online: 14 May 2021. Submit your article to this journal

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HUMAN VACCINES & IMMUNOTHERAPEUTICS
2021, VOL. 17, NO. 8, 2378–2388
https://doi.org/10.1080/21645515.2021.1892432

RESEARCH PAPER

Acceptance of a COVID-19 vaccine and associated factors among pregnant women in

China: a multi-center cross-sectional study based on health belief model
Liyuan Tao a, Ruitong Wangb, Na Hanc, Jihong Liud, Chuanxiang Yuane, Lixia Dengf, Chunhua Hang, Fenglan Sunh,
Min Liub, and Jue Liu b,i
a
Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China; bDepartment of Epidemiology and Biostatistics, School of
Public Health, Peking University, Beijing, China; cDepartment of Obstetrics, Tongzhou Maternal and Child Health Hospital, Beijing, China; dDepartment
of Obstetrics, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan Province, China; eDepartment of Obstetrics, Qianjiang
Maternal and Child Health Hospital, Qianjiang City, Hubei Province, China; fDepartment of Obstetrics, Qianjiang Central Hospital, Qianjiang City, Hubei
Province, China; gDepartment of Obstetrics, Qujing Maternal and Child Health Hospital, Qujing City, Yunnan Province, China; hDepartment of
Obstetrics, Shexian Maternal and Child Health Hospital, Shexian City, Hebei Province, China; iNational Health Commission Key Laboratory of
Reproductive Health, Peking University Health Science Center, Beijing, China

ABSTRACT ARTICLE HISTORY

Background: Vaccine hesitancy has been recognized as an urgent public health issue. We aimed to Received 21 January 2021
explore the acceptance of a COVID-19 vaccine and related factors among pregnant women, a vulnerable Revised 6 February 2021
population for vaccine-preventable diseases. Accepted 14 February 2021
Methods: A multi-center cross-sectional study among pregnant women was conducted in five provinces KEYWORDS
of mainland China from November 13 to 27, 2020. We collected sociodemographic characteristics, COVID-19; pregnant women;
attitude, knowledge, and health beliefs on COVID-19 vaccination. Locally weighted scatterplot smoothing vaccine; acceptance; vaccine
regression analysis was used to assess the trends of vaccination acceptance. Multivariable logistic regres­ hesitancy
sion was performed to identify factors related to vaccination acceptance.
Results: Among the 1392 pregnant women, the acceptance rate of a COVID-19 vaccine were 77.4% (95%
CI 75.1–79.5%). In the multivariable regression model, the acceptance rate was associated with young age
(aOR = 1.87, 95% CI: 1.20–2.93), western region (aOR = 2.73, 95% CI: 1.72–4.32), low level of education
(aOR = 2.49, 95% CI: 1.13–5.51), late pregnancy (aOR = 1.49, 95% CI: 1.03–2.16), high knowledge score on
COVID-19 (aOR = 1.05, 95% CI: 1.01–1.10), high level of perceived susceptibility (aOR = 2.18, 95% CI:
1.36–3.49), low level of perceived barriers (aOR = 4.76, 95% CI: 2.23–10.18), high level of perceived benefit
(aOR = 2.18, 95% CI: 1.36–3.49), and high level of perceived cues to action (aOR = 15.70, 95% CI:
8.28–29.80).
Conclusions: About one quarters of pregnant women have vaccine hesitancy. Our findings highlight that
targeted and multipronged efforts are needed to build vaccine literacy and confidence to increase the
acceptance of a COVID-19 vaccine during the COVID-19 pandemic, especially for vulnerable populations.

Introduction by WHO show that a total of 48 vaccine candidates are cur­

Coronavirus disease 2019 (COVID-19) is a new acute respira­
tory infectious disease that has become a major global public
health event. As of November 22, 2020, there have been over
100 million confirmed cases and over 2 million deaths reported
globally since the start of the COVID-19 pandemic1. Scientists
are nervously looking for effective treatments and preventions
against the COVID-19. In the protection of susceptible people,
vaccination is the most effective way to prevent infectious
diseases, and enough vaccination can produce effective herd
immunity.2–4 At present, there is an urgent need to develop,
produce and vaccinate safe and effective vaccines on a global
scale, and various scientific institutions are also making full
efforts in this regard. Advances in virology, molecular biology,
and immunology have also brought new breakthroughs in
vaccine development, resulting in nucleic acid-based (mRNA,
DNA) vaccines, viral vectored vaccines, and subunit vaccines.
COVID-19 has brought all vaccine types to the forefront of the
fight against the pandemic. The landscape documents provided
rently in the clinical evaluation stage, and 164 candidate vac­
cines are in the preclinical evaluation stage.5
Despite remarkable advances in vaccine research and devel­
opment, vaccine hesitancy has been recognized as a public
health threat.6 Vaccine hesitancy, reflecting concerns about
the decision to vaccinate oneself or one’s children, is believed
to be responsible for decreasing vaccine coverage and an
increasing risk of outbreaks for vaccine-preventable disease.7
Some studies reported that the acceptance of COVID-19 vac­
cine in the general population varied in different countries,
90% in China,8 70% in the United States,9,10 75% in France.11,12
A global survey reported that 28.5% of the participants would
be unlikely or not sure to take a COVID-19 vaccine, ranged
from 10% to 45%.13 Previous studies had shown that a broad
range of factors contributed to vaccine hesitancy, including the
compulsory nature of vaccines, their coincidental temporal
relationships to adverse health outcomes, unfamiliarity with
vaccine-preventable diseases, and lack of trust.7 Lazarus and

CONTACT Jue Liu jueliu@bjmu.edu.cn Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing 100191, China.
© 2021 Taylor & Francis Group, LLC

colleagues found that lower levels of trust in information for
government sources were associated with less likely to accept a
COVID-19 vaccine in a cross-sectional study conducted in 19
countries.13
Studies have shown a decline in the willingness to vaccinate
over the past decade, along with the increasingly vocal anti-
vaccination lobby around the world.14,15 It is important to
understand the population’s vaccination barriers, which will
help us to carry out the popularization of COVID-19 vaccines
more effectively, especially among vulnerable population (e.g.,
pregnant women). Pregnant women usually have lower will­
ingness and more concerns about vaccination for vaccine-pre­
ventable disease (i.e., influenza) than the general
population.16,17 Maternal immunizations contribute to the
protection of infants from serious diseases during the early
period of life.18 In China, pregnant women have been listed
as the priority population to receive influenza vaccines at any
gestational age to prevent them from adverse pregnancy out­
comes and protect their infants from influenza since 2014.19
Although as the population recommended for vaccination in
priority, pregnant women are often unwilling to receive influ­
enza vaccination because of their lack of relevant knowledge,
negative attitudes toward vaccines, no experience in influenza
vaccination, and worry about the occurrence of adverse events
and uncertain vaccine safety.20,21 Individually tailored mes­
sages for pregnant women who have vaccine concerns are
helpful to avoid vaccine refusal.22 However, literature on the
acceptance of a COVID-19 vaccine and related factors among
pregnant women was scarce. According to the report on prior­
itizing uses of COVID-19 vaccines in the context of limited
supply by the WHO, pregnant women warrant particular con­
sideration, as this group has been disadvantaged with respect to
the development and deployment of vaccines in previous
pandemics.23 Understanding the willingness of COVID-19
and causes of vaccine hesitancy pregnant women is crucial to
make tailored preparation to address hesitancy and built vac­
cine literacy. In the present study, we conducted a hospital-
based multi-center cross-sectional study among pregnant
women in mainland China to explore the acceptance of a
COVID-19 vaccine and factors related to vaccine acceptance
based on the health belief model, a commonly used theory
model on vaccine hesitancy.24
Methods
Study design and participants
This was a multi-center hospital-based cross-sectional study
among pregnant women in mainland China. We adopted a
multistage sampling approach to select participants. In the first
stage, we divided mainland China into three (eastern, central
and western) regions, according to the National Bureau of
Statistics of China. Five provinces were randomly selected,
namely Beijing (eastern), Hebei (eastern), Hubei (central),
Anhui (central), and Yunnan (western), which, respectively,
represent eastern, central, and western region in China. In the
second stage, we selected a convenience sample of six hospitals
from different regions of China, namely Tongzhou Maternal
HUMAN VACCINES & IMMUNOTHERAPEUTICS 2379
and Child Health Hospital (Beijing), Qianjiang Maternal and
Child Health Hospital (Hubei), Shexian Maternal and Child
Health Hospital (Hebei), Mingguang Maternal and Child
Health Hospital (Anhui), the Second Affiliated Hospital of
Kunming Medical University (Yunnan), Qujing Maternal
and Child Health Hospital (Yunnan). In the third stage, all
pregnant women who received antenatal care in obstetric
clinics of 6 hospitals from November 13 to 27, 2020 were
recruited. Inclusion criteria were 1) women aged 18 years
or above; 2) pregnant women who attended antenatal
clinics in the participating obstetric hospitals during 13
November 2020 to 27 November 2020; 3) voluntary agree­
ment to participant in the present study. The study was
approved by the Ethical Committee of Peking University
Third Hospital and conducted according to the Helsinki
Declaration. Informed consent was obtained from all
participants.
Data collection
Based on a review of the literature on the acceptance of vacci­
nation on respiratory infectious disease (e.g., influenza) in
pregnant women,20,24,25 we developed a structured question­
naire to collect data on sociodemographic characteristics,
health status, knowledge on COVID-19 infection, attitude
toward COVID-19 vaccination, and health beliefs related
with COVID-19 infection and vaccination.
Sociodemographic characteristics included age group,
region, education, occupation, monthly household income
per capita. Health status included gravidity, parity, gestational
trimester, history of adverse pregnancy outcomes, history of
chronic disease, history of influenza vaccination, and gesta­
tional complications.
History of adverse pregnancy outcomes of pregnant women
was collected by asking the question ‘Do you have the history
of any adverse pregnancy outcomes, such as miscarriage, low
birth weight, stillbirth, preterm birth, or macrosomia? (yes or
no)’. We used the question ‘have you been diagnosed as having
any chronic disease, such as cardiovascular disease, diabetes,
hypertension, respiratory diseases, or cancer? (yes or no)’ to
collect the history of chronic disease. Gestational complica­
tions refer to currently having been diagnosed as gestational
diabetes mellitus, gestational hypertension, gestational thyroid
disorder, gestational anemia in this study.
In the present study, knowledge toward COVID-19 infec­
tion consisted of 17 items, including source of infection,
route of transmission, susceptible population, common
symptoms, high-risk population for severe illness and
death, individual preventive measures for COVID-19 infec­
tion. There were three possible responses (yes, no, or not
sure). For each item, if correct answer was chosen, the
respondent received 1 score. Wrong answer or responses
“unknow” received zero score. The sum of the score for all
the 17 items was calculated as the total knowledge score on
COVID-19, which ranged from 0 to 17. The higher the
score, the more knowledge participants got. The total knowl­
edge score was divided into three groups (low, moderate,
high) by tertiles.
2380 L. TAO ET AL.
Attitude toward COVID-19 vaccination
The primary outcome is the acceptance of a potential COVID-19
vaccine. The acceptance of a potential COVID-19 vaccine was
collected by the question “If a vaccine for the COVID-19 infec­
tion becomes available, will you get vaccinated during preg­
nancy? (yes, no or not sure)”. Pregnant women who responded
“no or not sure” were then asked the reasons for vaccine hesita­
tion by the question “What makes you unwilling (or unsure) to
get the vaccine?”. Acceptable price for the COVID-19 vaccine
was also collected among all participants by the question “How
much do you think the price of the COVID-19 vaccine is
acceptable? (cost of whole stage of vaccination)” followed by
the response options “only acceptable for free”, “<200 RMB”,
“201–400 RMB”, ”401–600 RMB”, and “>600 RMB”.
Health beliefs related with COVID-19 infection and
vaccination
To further assess the factors related to the attitude toward
COVID-19 vaccine, we developed several questions based on
the health belief model.24,26 We adapted and modified questions
from the previous published literature on other vaccine-preven­
table disease.24,26 All participants responded to the questions.
The health belief model included five dimensions that might
influence individuals’ health behaviors, namely perceptions of
susceptibility, severity, barriers, benefits and cues to action. It is
assumed in the health belief model that individuals are more
likely to take behaviors to prevent disease (such as vaccination) if
they perceive that they are susceptible to the disease, the disease
is severe, the behavior is beneficial, or the barriers are
minimal.26,27 The recommendation from doctors on vaccination
or health education messages can also influence the vaccination
behaviors, which is cues to action.28 In the present study, there
were totally 12 items focused on factors related to the attitude
toward COVID-19 vaccine, including perceived susceptibility to
COVID-19 infection for mother and infant (2 items), perceived
severity of COVID-19 infection for mother and infant (2 items),
perceived barriers of COVID-19 vaccination (3 items), benefits
of COVID-19 vaccination (3 items) and cues to action (2 items).
The response answers of “very concerned or agree”, “moderate
concerned or not sure”, “not concerned or disagree” was
recorded as 3, 2, and 1 score, respectively. The summed scores
for each dimension of the health belief model framework were
calculated accordingly. The participants were divided into three
groups (low, moderate, high) by tertiles according to the
summed score for each HBM dimension. A pilot testing was
conducted among a convenience sample of 20 pregnant women
and the Cronbach’s α coefficient of the health belief model
constructs was 0.81 for perceived susceptibility, 0.88 for per­
ceived severity, 0.76 for perceived barriers, 0.87 for perceived
benefits, and 0.95 for cues to action, respectively, showing a good
internal consistency reliability.
Data analysis
Characteristics of all the recruited pregnant women were
summarized by using frequencies and percentages. The
total proportion of the acceptance of a COVID-19 vaccine
and its 95% CI was calculated, as well as the proportions
of the acceptance of a COVID-19 vaccine by different
characteristics. We used Pearson’s χ2 test to compared
the acceptance of a COVID-19 vaccine by sociodemo­
graphic characteristics, health status, knowledge factors,
and health beliefs. Cochran-Armitage test for trend was
used for examining the trend of proportion of the accep­
tance of a COVID-19 vaccine by characteristics.
To assess the adjusted associations of factors related to
the acceptance of a COVID-19 vaccine, we used multivari­
able logistic regression model. We adjusted for sociodemo­
graphic characteristics (age group, region, education,
occupation, monthly household income per capita), health
status (gravidity, parity, gestational trimester, history of
adverse pregnancy outcomes, history of chronic disease,
history of influenza vaccination, and gestational complica­
tions), total knowledge score on COVID-19 (as continuous
variable), health belief (susceptibility, severity, barriers, ben­
efits, and cues to action). Adjusted odds ratios with 95%CIs
for each variable were calculated. We used locally weighted
scatterplot smoothing regression analysis to assess the
trends in the acceptance of a COVID-19 vaccine and the
total knowledge score on COVID-19. All the data analyses
were conducted by using R (version 3.6.3) and SAS (ver­
sion 9.4).
Results
Characteristics of the study population
A total of 1392 pregnant women were included in this
study (Table 1). 55.4% of them were 30 years old or
below, and 35.9% had a bachelor’s degree or above. 38.6%
were first pregnant women, 32.0% women had a history of
adverse pregnancy outcomes, and 2.3% women had a his­
tory of chronic disease. Only 8.8% of all participants had
history of influenza vaccination. There were 23.5% women
diagnosed with gestational complications in the current
pregnancy.
Acceptance of a COVID-19 vaccine of pregnant
women by sociodemographic characteristics, health
status, and knowledge factors
The proportion of acceptance of a COVID-19 vaccine were
77.4% (95%CI 75.1–79.5%) among all participants. The
acceptance rates decreased significantly along with the
increasing age (p trend<0.05), from 81.7% in women aged
25 years or below to 66.7% in women aged above 40 years.
Pregnant women with younger age, lower education, living
in western region, second and third gestational trimester,
with gestational complications, and higher knowledge score
on COVID-19 infection were more likely to accept COVID-
19 vaccination (all p < .05, Table 1). The acceptance rates of
a COVID-19 vaccine were significantly increased with the
increasing total knowledge score on COVID-19 infection by
locally weighted scatterplot smoothing regression analysis
(p < .01, Figure 1). Nearly one quarter (24.4%) of all
participants only accept the COVID-19 vaccination for
 HUMAN VACCINES & IMMUNOTHERAPEUTICS 2381

Table 1. Acceptance of a COVID-19 vaccine of pregnant women in China by sociodemographic characteristics, health status and
knowledge factors.
Acceptance of a COVID-19 vaccine
Characteristics Total (%) n (%) 95% CI p value
Total 1392 (100.0) 1077 (77.4) 75.1–79.5
Sociodemographic characteristics
Age group (year) 0.04*
≤25 197 (14.2) 161 (81.7) 75.9–86.6
26–30 574 (41.2) 449 (78.2) 74.7–81.5
31–35 460 (33.0) 357 (77.6) 73.6–81.2
36–40 137 (9.8) 94 (68.6) 60.5–75.9
>40 24 (1.7) 16 (66.7) 46.8–82.8
Region <0.01*
Eastern 704 (50.6) 499 (70.9) 67.4–74.1
Central 404 (29.0) 328 (81.2) 77.2–84.8
Western 284 (20.4) 250 (88.0) 83.9–91.4
Education <0.01*
Less than high school 238 (17.1) 186 (78.2) 72.6–83.0
High school or some college 654 (47.0) 532 (81.3) 78.2–84.2
Bachelor ‘s degree 434 (31.2) 316 (72.8) 68.5–76.8
Postgraduate degree 66 (4.7) 43 (65.2) 53.2–75.8
Occupation 0.06
Housewife 505 (36.3) 405 (80.2) 76.6–83.5
Employed 887 (63.7) 672 (75.8) 72.9–78.5
Monthly household income per capita (RMB) 0.11
≤3000 208 (14.9) 168 (80.8) 75.0–85.7
3001–5000 468 (33.6) 374 (79.9) 76.1–83.4
5001–10000 505 (36.3) 376 (74.5) 70.5–78.1
>10000 211 (15.2) 159 (75.4) 69.2–80.8
Health status
Gravidity 0.84
1 537 (38.6) 417 (77.7) 74.0–81.0
≥2 855 (61.4) 660 (77.2) 74.3–79.9
Parity 0.93
0 726 (52.2) 561 (77.3) 74.1–80.2
≥1 666 (47.8) 516 (77.5) 74.2–80.5
Gestational trimester <0.01*
First trimester (1–13 week) 396 (28.4) 263 (66.4) 61.7–70.9
Second trimester (14–28 week) 383 (27.5) 307 (80.2) 75.9–83.9
Third trimester (≥28 week) 613 (44.0) 507 (82.7) 79.6–85.5
History of adverse pregnancy outcomes 0.92
Yes 445 (32.0) 345 (77.5) 73.5–81.2
No 947 (68.0) 732 (77.3) 74.5–79.9
History of chronic disease 0.92
Yes 32 (2.3) 25 (78.1) 61.8–89.6
No 1360 (97.7) 1052 (77.4) 75.1–79.5
History of influenza vaccination 0.09
Yes 122 (8.8) 102 (83.6) 76.3–89.4
No 1270 (91.2) 975 (76.8) 74.4–79.0
Gestational complications <0.01*
Yes 327 (23.5) 272 (83.2) 78.8–86.9
No 1065 (76.5) 805 (75.6) 72.9–78.1
Knowledge factors
Total knowledge score on COVID-19 <0.01*
Low 434 (31.2) 309 (71.2) 66.8–75.3
Moderate 471 (33.8) 371 (78.8) 74.9–82.3
High 487 (35.0) 397 (81.5) 77.9–84.8

free. There were totally 80.4% of pregnant women who
responded that the acceptable price of the COVID-19 vac­
cine (cost for the whole stage of vaccination) was
<200 RMB.
Comparison of the acceptance of a COVID-19 vaccine
by health beliefs
Pregnant women who were concerned about getting
COVID-19 were more likely to accept COVID-19 vaccina­
tion (79.0%) than those not concerned (63.5%, p < .01,
Table 2). Pregnant women who agreed with the benefit of
vaccination to her fetus and baby had higher level of
acceptance (78.7%) than those not agreed (57.0%, p
< .01). Pregnant women perceived cues to action (receiving
vaccine recommendation from doctors) were more likely to
accept COVID-19 vaccine (80.6%) than those not perceived
(33.3%, p < .01). The acceptance rates of a COVID-19
vaccine were significantly higher in pregnant women with
high level of perceived susceptibility to COVID-19 infec­
tion, severity of COVID-19 infection, benefits of COVID-19
vaccination, and cues to action than those with low level
2382 L. TAO ET AL.
(all p trend<0.05), while it was significantly lower in preg­
nant women with higher level of perceived barriers of
vaccination (50.8% vs 91.3%, Figure 2).
Factors associated with the acceptance of a COVID-19
vaccine
In the multivariable regression model (Table 3), the acceptance
of a COVID-19 vaccine was associated with young age
(aOR = 1.87, 95% CI: 1.20–2.93), western region (aOR = 2.73,
95% CI: 1.72–4.32), low level of education (aOR = 2.49, 95% CI:
1.13–5.51), late pregnancy (aOR = 1.49, 95% CI: 1.03–2.16),
high knowledge score on COVID-19 (aOR = 1.05, 95% CI:
1.01–1.10), high level of perceived susceptibility (aOR = 2.18,
95% CI: 1.36–3.49), low level of perceived barriers (aOR = 4.76,
95% CI: 2.23–10.18), high level of perceived benefit
(aOR = 2.18, 95% CI: 1.36–3.49), and high level of perceived
cues to action (aOR = 15.70, 95% CI: 8.28–29.80).
Reasons for responding not intend to be vaccinated
with a COVID-19 vaccine
Among the 315 (22.6%, 95% CI: 20.5%-24.9%) pregnant
women with vaccine hesitancy, 54% of them refuse any vacci­
nation during pregnancy due to their worry on any side effect.
47.0% of them concerned about the safety and 44.1% con­
cerned about the efficacy of the COVID-19 vaccine on preg­
nant women and unborn baby (Figure 3).
Discussion
To our knowledge, this is the first study to investigate the
acceptance of a COVID-19 vaccine and associated factors
among pregnant women. In this multi-center hospital-based
cross-sectional study, we found that acceptance rate of a
COVID-19 vaccine was 77.4% (95%CI 75.1–79.5%) among
Figure 1. The trends in the acceptance of a COVID-19 vaccine and the total
knowledge score on COVID-19 by locally weighted scatterplot smoothing regres­
sion analysis.
pregnant women in mainland China. Our findings were
much lower than the results in the general population in
China (almost 90%) in previous study.8,13 However, the will­
ingness of vaccination was higher than that of the general
population in other countries, such as the United States
(75.42%), Italy (70.79%), Canada (68.74%), Germany (68.42),
Russia (54.85%).13 Another cross-sectional study found that
only 57.6% of adults living in the United States were willing to
be vaccinated for COVID-19 when the vaccine was available.9
At the same time, our results were more consistent with the
results of the survey in France in March this year in the general
population. The study showed that 74% of participates would
be willing to receive the COVID-19 vaccine among the general
population in France.12
A lower acceptance was also observed in other vaccine-
preventable diseases among pregnant women than the gen­
eral population, such as seasonal influenza. Pregnant women
are among the recommended vaccinated population of the
seasonal influenza vaccine with priority by the WHO as they
are the important risk group for infection,29 and studies has
been shown that both pregnant women and infants would
benefit from the vaccination.30,31 However, previous surveys
showed that the acceptance of the seasonal influenza vaccine
was low among pregnant women, which was 70.5% in the
United States,32 27.9% in Italy,33 47.5% in the United
Kingdom,34 and 76.28% in China.24 Meanwhile, the uptake
of seasonal influenza vaccines among adults around the world
was relatively low, which was 41% in the United States in
2016,35 43.6% in Korea during 2011/12 season,36 42.1%
among adults with chronic conditions in Italy during 2017/
18 season37 and 15.2% among adults aged above 50 in
Singapore in 2016.38 The acceptance rate of COVID-19 vac­
cination in this study was close to the influenza vaccination
rate among Chinese pregnant women in previous studies
(both are close to 75%), which meant that about a quarter
of pregnant women have vaccine hesitation. Our findings
highlighted that vaccine hesitation is still worthy to be
noticed, when the COVID-19 vaccine was available for the
public.
Our study showed that younger pregnant women were
more likely to accept COVID-19 vaccination. The willingness
of vaccination among pregnant women ≤25 years old was
81.7%, and women over 40 years old was 66.7%. This suggested
that the younger pregnant woman, the more focused on the
covid-19 vaccine’s protective effect. When it comes to influenza
vaccination, previous studies had also shown that younger
people were more likely to be vaccinated in the pregnant
women.17,25 But in the general population, this result was the
opposite. Older people seemed to be more willing to receive the
COVID-19 vaccine than younger people.9,11,13 This finding
might reflect the fact that the pregnant women with advanced
maternal age are more worried about the side effects of the
vaccine on pregnancy, while the older people in the general
population are more worried about the risk of disease. Our
results also suggested that pregnant women in western China
and low education level have higher COVID-19 vaccination
intentions. The pregnant women with higher education level
Table 2. Comparison of the acceptance of a COVID-19 vaccine by health beliefs (n = 1392).
Acceptance of
a COVID-19 vaccine
Dimensions of Health Belief Model Item Response Total (%) n (%) 95% CI p value
Susceptibility Are you concerned about getting COVID-19 Not concerned 148 (10.6) 94 (63.5) 55.6-70.9 <0.01*
Concerned 1244 (89.4) 983 (79.0) 76.7-81.2
Are you concerned about unborn baby getting COVID-19 Not concerned 121 (8.7) 74 (61.2) 52.3-69.5 <0.01*
Concerned 1271 (91.3) 1003 (78.9) 76.6-81.1
Severity If a pregnant woman gets COVID-19, she is more likely to have severe illness Disagree 50 (3.6) 33 (66.0) 52.3-77.9 0.05
Agree 1342 (96.4) 1044 (77.8) 75.5-80.0
If a pregnant woman gets COVID-19, the illness could harm her unborn baby Disagree 17 (1.2) 9 (52.9) 30.3-74.6 0.02*
Agree 1375 (98.8) 1068 (77.7) 75.4-79.8
Barriers Vaccine can cause a person to get sick with COVID-19 Disagree 456 (32.8) 372 (81.6) 77.8-84.9 <0.01*
Agree 936 (67.2) 705 (75.3) 72.5-78.0
Vaccine is not safe during pregnancy Disagree 142 (10.2) 130 (91.5) 86.1-95.3 <0.01*
Agree 1250 (89.8) 947 (75.8) 73.3-78.1
Vaccine is not an effective way to prevent a pregnant woman from getting COVID-19 Disagree 230 (16.5) 203 (88.3) 83.6-91.9 <0.01*
Agree 1162 (83.5) 874 (75.2) 72.7-77.6
Benefits Giving vaccine to a pregnant woman will benefit her fetus and baby Disagree 86 (6.2) 49 (57.0) 46.4-67.1 <0.01*
Agree 1306 (93.8) 1028 (78.7) 76.4-80.9
Getting vaccine during pregnancy is a benefit for the pregnant woman Disagree 67 (4.8) 36 (53.7) 41.8-65.3 <0.01*
Agree 1325 (95.2) 1041 (78.6) 76.3-80.7
Vaccine could protect the baby during the first months of life Disagree 77 (5.5) 41 (53.2) 42.2-64.1 <0.01*
Agree 1315 (94.5) 1036 (78.8) 76.5-80.9
Cues to action If doctors recommended vaccine, I would get vaccinated Disagree 96 (6.9) 32 (33.3) 24.5-43.1 <0.01*
Agree 1296 (93.1) 1045 (80.6) 78.4-82.7
If family members recommended vaccine, I would get vaccinated Disagree 132 (9.5) 58 (43.9) 35.7-52.5 <0.01*
Agree 1260 (90.5) 1019 (80.9) 78.6-83.0
Response of “not sure” was combined into “disagree” and “very concerned “or “moderate concerned” was combined into “concerned” in this table.
HUMAN VACCINES & IMMUNOTHERAPEUTICS
2383
2384 L. TAO ET AL.
Figure 2. The acceptance of a COVID-19 vaccine by five dimensions of health beliefs model (n = 1392).
had higher vaccine hesitation in China, which was related to
their knowledge of COVID-19 vaccine, and they might get
more negative information about the COVID-19 vaccine.
Therefore, this suggested that we should strengthen the timely
disclosure and transparency of vaccine research8 and develop­
ment and monitoring information, and conduct health educa­
tion by professional health care personnel, to reduce public
concerned about vaccine safety.39,40 In terms of the choice of
vaccination period, pregnant women in the second and third
trimesters had higher willingness to receive the COVID-19
vaccination than those in the first trimester (82.7% vs 66.4%,
80.2% vs 66.4%). The situation was similar to the study of
influenza vaccination willingness among pregnant women in
Southeast Asia.16,20,25
In this study, we set some questions to test the knowledge
level of pregnant respondents, such as source of infection,
route of transmission, susceptible population, and common
symptoms et al. It was gratifying to note that our study found
a positive correlation between total knowledge score in
COVID-19 and willingness to receive COVID-19 vaccines. In
the general population, many studies had also shown that
higher levels of education lead to greater acceptance of
COVID-19 vaccines.10,13 Higher levels of education tend to
be associated with higher scores in knowledge. However, our
previous results have shown that high levels of education
among pregnant women are contrary to COVID-19 vaccina­
tion intentions. This also suggests that in the vaccination pub­
licity of COVID-19 vaccine, we should strengthen the
dissemination of correct information, so as to avoid giving
wrong or worrying information to people with high education
level in the early stage of vaccine development.
Pregnant women are one of the vulnerable populations.
Evidence is emerging that pregnant women are at elevated risk
of serious disease, further increased if they have preexisting
comorbidities, and may be at elevated risk of adverse pregnancy
outcomes as well.23,41,42 Previous studies showed that COVID-
19 infection was associated with higher rate of preterm birth,
preeclampsia, cesarean, and perinatal death among pregnant
women.43 In the present study, health belief model theory pro­
vided a good framework for assessing the attitude toward
COVID-19 vaccination among pregnant women. We found
that perceived susceptibility, benefit, and cues to action was
positively associated with willingness of vaccination, while per­
ceived barriers were negatively associated with willingness of
vaccination. Our findings were consistent with the results in
other vaccine-preventable diseases in previous studies.24,44
There are relatively little data about the safety and efficacy of
COVID-19 vaccines in pregnant women. Studies specific to
pregnancy needs to be done, for example, pregnancy-specific
safety and bridging studies and from participants who inadver­
tently become pregnant during phase III trials in the future.23
More evidence on pregnant women ‘s willingness of vaccination
and related factors of vaccine hesitation is also needed in other
countries.
Currently, there are two licensed COVID-19 inactivated
vaccines with market approval in China. According to
Chinese Center for Disease Control and Prevention, the
number of COVID-19 vaccination has exceeded 24 million
doses in China up to January 31, 2021.45 Adults aging from
18 to 59, especially those who have higher risks of corona­
virus exposure due to their occupations, are recommended
to be vaccinated with COVID-19 vaccines.46 Due to possi­
ble perceived risks of vaccination in pregnant women and
potential exposure of their fetus to medication, a large
proportion of COVID-19 vaccine clinical trials specifically
excluded pregnant women.47 However, the exclusion of
 HUMAN VACCINES & IMMUNOTHERAPEUTICS 2385

Table 3. Factors associated with the acceptance of a COVID-19 vaccine (n = 1392).

Multivariable regression model
Characteristics n Adjusted OR (95% CI) p value
Sociodemographic characteristics
Age group (year)
≤35 1231 1.87 (1.20–2.93) 0.01*
>35 161 1 (Reference)
Region
Eastern 704 1 (Reference)
Central 404 1.29 (0.89–1.86) 0.18
Western 284 2.73 (1.72–4.32) <0.01*
Education
Less than high school 238 2.49 (1.13–5.51) 0.02*
High school or some college 654 2.85 (1.45–5.59) <0.01*
Bachelor ‘s degree 434 1.58 (0.83–3.03) 0.17
Postgraduate degree 66 1 (Reference)
Occupation
Housewife 505 1.06 (0.73–1.54) 0.75
Employed 887 1 (Reference)
Monthly household income per capita (RMB)
≤3000 208 1 (Reference)
3001–5000 468 0.99 (0.61–1.61) 0.96
5001–10000 505 0.94 (0.57–1.55) 0.81
>10000 211 1.29 (0.71–2.34) 0.41
Health status
Gravidity
1 537 1 (Reference)
≥2 855 0.87 (0.53–1.43) 0.58
Parity
0 726 1 (Reference)
≥1 666 0.98 (0.63–1.52) 0.93
Gestational trimester
First trimester (1–13 week) 396 1 (Reference)
Second trimester (14–28 week) 383 1.39 (0.94–2.04) 0.09
Third trimester (≥28 week) 613 1.49 (1.03–2.16) 0.04*
History of adverse pregnancy outcomes
Yes 445 1.11 (0.76–1.62) 0.58
No 947 1 (Reference)
History of chronic disease
Yes 32 0.66 (0.26–1.69) 0.39
No 1360 1 (Reference)
History of influenza vaccination
Yes 122 1.30 (0.74–2.28) 0.36
No 1270 1 (Reference)
Gestational complications
Yes 36 1.18 (0.80–1.74) 0.40
No 1356 1 (Reference)
Knowledge and health belief factors
Total knowledge score on COVID-19 1392 1.05 (1.01–1.10) 0.01*
Susceptibility
Low 148 1 (Reference)
Moderate 609 1.47 (0.94–2.30) 0.09
High 635 2.18 (1.36–3.49) <0.01*
Severity
Low 22 1 (Reference)
Moderate 514 0.97 (0.33–2.84) 0.95
High 856 1.17 (0.39–3.45) 0.78
Barriers
Low 181 4.76 (2.23–10.18) <0.01*
Moderate 1052 2.20 (1.28–3.77) <0.01*
High 159 1 (Reference)
Benefit
Low 61 1 (Reference)
Moderate 976 1.14 (0.57–2.27) 0.72
High 355 2.20 (0.95–5.07) 0.07*
Action
Low 113 1 (Reference)
Moderate 822 4.92 (3.00–8.05) <0.01*
High 457 15.70 (8.28–29.80) <0.01*
*p < 0.05.

pregnant women from COVID-19 vaccine clinical trials and adverse pregnancy outcomes.47 Currently, pregnant
may result in missed opportunities to identify effective women are not in the priority population to be vaccinated.
and safe prevention and treatments to prevent infection Post marketing research of COVID-19 vaccines on risk-
2386 L. TAO ET AL.
Figure 3. Reasons for responding “No” or “Not sure” regarding intend to be vaccinated with a COVID-19 vaccine (n = 315).
benefit assessment among vulnerable populations (e.g.,
pregnant women and old population) based on real-world
study is warranted in the future.48
There were several limitations in this study. First, hospitals
were not randomly selected at the second stage. Nevertheless, it
was a multicenter study conducted in six hospitals from eastern,
central, and western regions to better reflect the vaccination
intention of pregnant women in China. Second, pregnant
women who never took antenatal examination were not
included in this study. Third, this study was conducted only in
China. The findings should be explained with caution when
extrapolating to other countries. Studies are needed to con­
ducted among pregnant women in other countries in the future.
In conclusion, 77.4% of pregnant women are willing to be
vaccinated during when a COVID-19 vaccine is available in main­
land China. The acceptance rate was associated with young age,
western region, low level of education, late pregnancy, high knowl­
edge score on COVID-19, high level of perceived susceptibility,
low level of perceived barriers, high level of perceived benefit, and
high level of perceived cues to action. These findings suggest that
targeted and multipronged efforts are needed to build vaccine
literacy and confidence to increase the acceptance of a COVID-
19 vaccine, especially for vulnerable populations.
Acknowledgments
This study was funded by the National Key Research and Development
Project of China (2020YFC0846300; 2019YFC1710301), the National
Science and Technology Key Projects on Prevention and Treatment of
Major infectious disease of China (2020ZX10001002) and the National
Natural Science Foundation of China (71874003 and 81703240). We
thank all the health workers in the department of obstetrics clinic unit
of the six hospitals for their great efforts made on data collection.
Disclosure of potential conflicts of interest
The authors declare no potential conflicts of interest.
Funding
This work was supported by the National Natural Science Foundation of
China [71874003 and 81703240]; National Key Research and
Development Project of China [2020YFC0846300; 2019YFC1710301];
National Science and Technology Key Projects on Prevention and
Treatment of Major infectious disease of China [2020ZX10001002].
ORCID
Liyuan Tao http://orcid.org/0000-0003-3497-1326
Jue Liu http://orcid.org/0000-0002-1938-9365
Author contributions
Jue Liu contributed to conception, design, data acquisition and interpretation,
and revised the manuscript. Liyuan Tao contributed to design, data acquisition
and interpretation, performed all statistical analyses, drafted and revised the
manuscript. Ruitong Wang contributed to conception, design, data acquisi­
tion, and revised the manuscript. Na Han, Jihong Liu, Chuanxiang Yuan, Lixia
Deng, Chunhua Han, Fenglan Sun contributed to data collection and revised
the manuscript. Min Liu contributed to revised the manuscript. All authors
gave final approval and agree to be accountable for all aspects of the work.
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