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The risk factors and pregnant women's willingness toward the SARS-CoV-2 vaccination in various countries: A systematic review and meta-analysis

Open AccessPublished:February 10, 2022DOI:https://doi.org/10.1016/j.cegh.2022.100982

      Abstract

      Introduction

      Pregnant women will benefit from research on immunization during pregnancy because they will have more accurate information on the SARS-CoV-2 vaccine. The purpose of this study was to determine the risk factors and pregnant women's desire to get the SARS-CoV-2 vaccine in various countries.

      Methods

      A search of PubMed, ProQuest, and EBSCO for related publications published (January and December 2021) on risk factors and pregnant women's desire to get the SARS-CoV-2 vaccine in various countries. The Pooled Odds Ratio (POR) were calculated using fixed and random-effect analysis. The I-squared formula was used to calculate the heterogeneity. Egger's and Begg's tests were used to identify study bias. STATA 16.0 was used for data analysis.

      Results

      This study revealed good practice has the highest POR (8.99), followed by received influenza vaccine last year (2.72), high perception of SARS-CoV-2 vaccine (2.70), >35 years (2.01), sufficient information about the SARS-COV-2 vaccine (1.94), higher school education (1.84), and third trimester (1.35) with pregnant women's desire toward the SARS-CoV-2 vaccination. The heterogeneity analysis revealed homogenous among risk factors in >35 years, high perception of SARS-CoV-2 vaccine, good practice, and third trimester (I2 ≤ 50%). In the articles combined in this study, there was no indication of study bias.

      Conclusion

      The insights of this study might help the authorities in determining the most effective strategy to deploy SARS-CoV-2 mass immunization campaigns for pregnant women.

      Keywords

      1. Introduction

      Many people have died as a condition of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak.
      • Nindrea R.D.
      • Usman E.
      • Katar Y.
      • Sari N.P.
      Acceptance of COVID-19 vaccination and correlated variables among global populations: a systematic review and meta-analysis.
      Massive human death has resulted in public health issues, overwhelmed health systems, interrupted distribution chains and the economy.
      • Nindrea R.D.
      • Sari N.P.
      How does family planning services respond to the SARS-CoV-2 pandemic in Indonesia?.
      ,
      • Nindrea R.D.
      • Usman E.
      • Firdawati Sari NP.
      The challenges: management of infectious medical waste during the pandemic COVID-19 in health care facilities in Indonesia.
      Pregnant women may be more vulnerable to SARS-CoV-2 infection than non-pregnant women.
      • Kotlar B.
      • Gerson E.
      • Petrillo S.
      • Langer A.
      • Tiemeier H.
      The impact of the COVID-19 pandemic on maternal and perinatal health: a scoping review.
      • Ellington S.
      • Strid P.
      • Tong V.T.
      • et al.
      Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, january 22-june 7, 2020.
      • Collin J.
      • Byström E.
      • Carnahan A.
      • Ahrne M.
      Public Health Agency of Sweden's Brief Report: pregnant and postpartum women with severe acute respiratory syndrome coronavirus 2 infection in intensive care in Sweden.
      Severe illness is defined as a condition that necessitates hospitalization, intensive care, the use of a ventilator, special breathing equipment, and/or death. According to certain studies, infection with the SARS-CoV-2 in pregnant mothers is related to a higher chance of a severe illness course, requiring invasive ventilation or ecmo, and/or death.
      • Ellington S.
      • Strid P.
      • Tong V.T.
      • et al.
      Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status - United States, january 22-june 7, 2020.
      ,
      • Collin J.
      • Byström E.
      • Carnahan A.
      • Ahrne M.
      Public Health Agency of Sweden's Brief Report: pregnant and postpartum women with severe acute respiratory syndrome coronavirus 2 infection in intensive care in Sweden.
      In another research, a link between SARS-CoV-2 and the likelihood of preterm and cesarean births was discovered.
      • Khoury R.
      • Bernstein P.S.
      • Debolt C.
      • et al.
      Characteristics and outcomes of 241 births to women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection at five New York city medical centers.
      Vertical transmission of the virus, which can induce hydrops fetalis and fetal death.
      • Ferraiolo A.
      • Barra F.
      • Kratochwila C.
      • et al.
      Report of positive placental swabs for SARS-CoV-2 in an asymptomatic pregnant woman with COVID-19.
      ,
      • Popescu D.E.
      • Cioca A.
      • Muresan C.
      • et al.
      A case of COVID-19 pregnancy complicated with hydrops fetalis and intrauterine death.
      Children are more vulnerable to asymptomatic illnesses, but they also carry the SARS-COV-2 virus, which they may pass on to others, especially pregnant women.
      • Mehta N.S.
      • Mytton O.T.
      • Mullins E.W.S.
      • et al.
      SARS-CoV-2 (COVID-19): what do we know about children? A systematic review.
      ,
      • Ludvigsson J.F.
      Children are unlikely to be the main drivers of the COVID-19 pandemic - a systematic review.
      Pregnant women who are infected with SARS-CoV-2 have a higher risk of preterm delivery and other poor pregnancy outcomes than pregnant women who are not infected with SARS-CoV-2.
      • Nindrea R.D.
      • Usman E.
      • Katar Y.
      • Sari N.P.
      Acceptance of COVID-19 vaccination and correlated variables among global populations: a systematic review and meta-analysis.
      It's also important to note that the SARS-CoV-2 pandemic leads pregnant women to be concerned about their fetus's and personal health, which has a substantial impact on their well-being.
      • Mortazavi F.
      • Mehrabadi M.
      • KiaeeTabar R.
      Pregnant women's well-being and worry during the COVID-19 pandemic: a cross-sectional study.
      Immunization during pregnancy research will give information on vaccine safety and efficacy concerns. It has been produced information for healthcare practitioners and patients on how to utilize it in counseling.
      • Chervenak F.A.
      • McCullough L.B.
      • Bornstein E.
      • et al.
      Professionally responsible coronavirus disease 2019 vaccination counseling of obstetrical and gynecologic patients.
      Unfortunately, insufficient study has been conducted to establish the global population's sentiments regarding vaccination among pregnant women. To our knowledge, no previously published study has been subjected to meta-analysis.

      2. Materials and methods

      2.1 Study design and research sample

      A meta-analysis studies were undertaken to review current studies related to risk factors and pregnant women's desire to get the SARS-CoV-2 vaccine in various countries. This study follows the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines.
      • Liberati A.
      • Altman D.G.
      • Tetzlaff J.
      • et al.
      The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions:explanation and elaboration.

      2.2 Eligibility criteria

      Original articles having a cross-sectional study design, English language, and human participants as study subjects were only considered for inclusion. Exclusion criteria for the study included the unavailability of a full text version, irrelevant topics, and data from articles that could not be used for further evaluation.

      2.3 Search approach and study collection

      A search of PubMed, ProQuest, and EBSCO for related publications published (January and December 2021) with keywords (“pregnant women” AND “COVID-19” OR “coronavirus” OR “SARS-CoV-2” AND “vaccine” AND “acceptance”). In this study, pregnant women's desire toward the SARS-CoV-2 vaccination was the dependent variable. The independent variables were the risk factors of SARS-CoV-2 vaccine willingness. The literature quest was carried out by two independent investigators. After the initial search, the duplicates were manually deleted, and the title/abstracts were screened for possible relevance. Following that, the full-texts of possible papers were evaluated using the criterion.

      2.4 Data extraction

      Data was retrieved by two separate authors using structured extraction forms. The quality of the publications was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). Articles were categorized into low, medium, and high quality groups using the numbers 0–3, 4–6, and 7–9.
      • Wells G.A.
      • Shea B.
      • O'Connell D.
      • et al.
      The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses.
      PRISMA flowcharts were used to show the stages required in looking for study publications (Fig. 1).

      2.5 Data analysis

      The Pooled Odds Ratio (POR) from the obtained data was calculated with a 95% confidence interval for further data analysis. I2 indicates that there was heterogeneity between publications if it was greater than 50%. The random effect analysis was used if the outcome was heterogeneous, and the fixed effect analysis was used if it was homogenous. Furthermore, the results were summarized as forest plots, and Egger's and Begg's tests were used to examine study bias. There was no publication bias among the studies, according to the p > 0.05 findings of the two tests. The role of covariate in lower middle income countries (LMICs) was investigated using restricted-maximum likelihood random effects meta-regression. Processing and analysis of all data, STATA 16.0 was used.

      3. Results

      A total of 12 recent studies were considered in this systematic review (Table 1). There were 15,444 participants in all that participated in the study.
      • Goncu Ayhan S.
      • Oluklu D.
      • Atalay A.
      • et al.
      COVID-19 vaccine acceptance in pregnant women.
      • Battarbee A.N.
      • Stockwell M.S.
      • Varner M.
      • et al.
      Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during august-december 2020.
      • Levy A.T.
      • Singh S.
      • Riley L.E.
      • Prabhu M.
      Acceptance of COVID-19 vaccination in pregnancy: a survey study.
      • Geoghegan S.
      • Stephens L.C.
      • Feemster K.A.
      • Drew R.J.
      • Eogan M.
      • Butler K.M.
      "This choice does not just affect me." Attitudes of pregnant women toward COVID-19 vaccines: a mixed-methods study.
      • Hailemariam S.
      • Mekonnen B.
      • Shifera N.
      • et al.
      Predictors of pregnant women's intention to vaccinate against coronavirus disease 2019: a facility-based cross-sectional study in southwest Ethiopia.
      • Mose A.
      • Yeshaneh A.
      COVID-19 vaccine acceptance and its associated factors among pregnant women attending antenatal care clinic in Southwest Ethiopia: institutional-based cross-sectional study.
      • Nguyen L.H.
      • Hoang M.T.
      • Nguyen L.D.
      • et al.
      Acceptance and willingness to pay for COVID-19 vaccines among pregnant women in Vietnam.
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • et al.
      COVID-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries.
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave: a cross-sectional study in Switzerland.
      • Sutton D.
      • D'Alton M.
      • Zhang Y.
      • et al.
      COVID-19 vaccine acceptance among pregnant, breastfeeding, and nonpregnant reproductive-aged women.
      • Tao L.
      • Wang R.
      • Han N.
      • et al.
      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.
      • Wang R.
      • Tao L.
      • Han N.
      • et al.
      Acceptance of seasonal influenza vaccination and associated factors among pregnant women in the context of COVID-19 pandemic in China: a multi-center cross-sectional study based on health belief model.
      Table 1Systematic review of pregnant women's willingness toward the SARS-CoV-2 vaccination and associated factors.
      1st authorYearStudy locationStudy designSample sizeRisk factors (OR, 95% CI)NOS
      Goncu Ayhan et al.
      • Goncu Ayhan S.
      • Oluklu D.
      • Atalay A.
      • et al.
      COVID-19 vaccine acceptance in pregnant women.
      2021Ankara, TurkeyCross-sectional300Sufficient information about the SARS-CoV-2 vaccine (2.07, 1.22–3.51)7
      Battarbee et al.
      • Battarbee A.N.
      • Stockwell M.S.
      • Varner M.
      • et al.
      Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during august-december 2020.
      2021U.S.Cross-sectional multicenter915Higher school education (2.40, 1.30–4.70)

      Received influenza vaccine last year (2.60, 1.90–3.60)
      8
      Levy et al.
      • Levy A.T.
      • Singh S.
      • Riley L.E.
      • Prabhu M.
      Acceptance of COVID-19 vaccination in pregnancy: a survey study.
      2021New YorkSurvey study653Sufficient information about the SARS-CoV-2 vaccine (30.95, 9.55–100.33)7
      Geoghegan et al.
      • Geoghegan S.
      • Stephens L.C.
      • Feemster K.A.
      • Drew R.J.
      • Eogan M.
      • Butler K.M.
      "This choice does not just affect me." Attitudes of pregnant women toward COVID-19 vaccines: a mixed-methods study.
      2021Dublin, IrelandOnline survey300>35 years old (1.36, 0.80–2.32)

      Higher school education (1.78, 1.09–2.92)
      6
      Hailemariam et al.
      • Hailemariam S.
      • Mekonnen B.
      • Shifera N.
      • et al.
      Predictors of pregnant women's intention to vaccinate against coronavirus disease 2019: a facility-based cross-sectional study in southwest Ethiopia.
      2021Southwest EthiopiaCross-sectional412>35 years old (6.73, 3.84–11.79)

      Higher school education (5.87, 3.14–10.97)

      High perception of SARS-CoV-2 vaccine (4.35, 2.73–6.95)
      7
      Mose et al.
      • Mose A.
      • Yeshaneh A.
      COVID-19 vaccine acceptance and its associated factors among pregnant women attending antenatal care clinic in Southwest Ethiopia: institutional-based cross-sectional study.
      2021Southwest EthiopiaCross-sectional396>35 years old (2.55, 1.06–6.08)

      Higher school education (3.28, 1.92–5.59)

      Sufficient information about the SARS-CoV-2 vaccine (3.24, 1.78–5.89)

      Good practice (9.15, 8.73–12.19)
      7
      Nguyen et al.
      • Nguyen L.H.
      • Hoang M.T.
      • Nguyen L.D.
      • et al.
      Acceptance and willingness to pay for COVID-19 vaccines among pregnant women in Vietnam.
      2021VietnamCross-sectional651Higher school education (1.98, 1.24–3.14)

      High perception of SARS-COV-2 vaccine (2.71, 1.93–3.82)
      7
      Skjefte et al.
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • et al.
      COVID-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries.
      2021U.S., U.K., India, Brazil, Russia, Spain, Argentina, Colombia, Mexico, Peru, South Africa, Italy, Chile, Philippines, Australia and New ZealandCross-sectional5,294Higher school education (1.31, 1.12–1.54)

      Received influenza vaccine last year (3.29, 2.91–3.72)
      8
      Stuckelberger et al.
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave: a cross-sectional study in Switzerland.
      2021SwitzerlandCross-sectional1,551>35 years old (2.00, 1.30–3.00)

      Higher school education (1.70, 1.30–2.20)

      Received influenza vaccine last year (3.60, 2.80–4.70)

      Third trimester (1.40,1.00–2.00)
      7
      Sutton et al.
      • Sutton D.
      • D'Alton M.
      • Zhang Y.
      • et al.
      COVID-19 vaccine acceptance among pregnant, breastfeeding, and nonpregnant reproductive-aged women.
      2021U.S.Online survey1,012Received influenza vaccine last year (2.25, 1.66–3.05)7
      Tao et al.
      • Tao L.
      • Wang R.
      • Han N.
      • et al.
      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.
      2021ChinaCross-sectional1,392Higher school education (2.85, 1.45–5.59)

      Sufficient information about the SARS-CoV-2 vaccine (1.05, 1.01–1.10)

      Third trimester (1.49,1.03–2.16)
      7
      Wang et al.
      • Wang R.
      • Tao L.
      • Han N.
      • et al.
      Acceptance of seasonal influenza vaccination and associated factors among pregnant women in the context of COVID-19 pandemic in China: a multi-center cross-sectional study based on health belief model.
      2021ChinaCross-sectional2,568Sufficient information about the SARS-CoV-2 vaccine (2.63, 1.38–5.00)

      Received influenza vaccine last year (1.81, 1.18–2.80)

      High perception of SARS-CoV-2 vaccine (2.48, 1.83–3.35)

      Good practice (8.27, 5.35–12.77)

      Third trimester (1.27, 0.98–1.65)
      8
      Total samples15,444
      NOS score7.17 ± 0.58
      Abbreviation: CI = confidence interval; OR = odds ratio; NOS, Newcastle–Ottawa Quality Assessment Scale.
      Table 1 is based on a review of 12 cross-sectional studies that looked at risk factors and pregnant women's desire to have the SARS-CoV-2 vaccine in various countries. This research revealed variables related to willingness of SARS-CoV-2 vaccination among pregnant women >35 years, higher school education, sufficient information about the SARS-COV-2 vaccine, high perception, good practice, received influenza vaccine last year and third trimester.
      Meta-estimate of willingness of pregnant women toward the SARS-CoV-2 vaccination and associated factors (Table 2 and Fig. 2).
      Table 2Meta-estimate of pregnant women's willingness toward the SARS-CoV-2 vaccination and associated factors.
      Risk factors1st authorOR (95% CI)POR (95% CI)Heterogeneity
      I
      • Nindrea R.D.
      • Sari N.P.
      How does family planning services respond to the SARS-CoV-2 pandemic in Indonesia?.
      (%)
      p-value
      >35 years2.01 (1.10–2.93)45.290.35
      Geoghegan et al.
      • Geoghegan S.
      • Stephens L.C.
      • Feemster K.A.
      • Drew R.J.
      • Eogan M.
      • Butler K.M.
      "This choice does not just affect me." Attitudes of pregnant women toward COVID-19 vaccines: a mixed-methods study.
      1.36 (0.80–2.32)
      Hailemariam et al.
      • Hailemariam S.
      • Mekonnen B.
      • Shifera N.
      • et al.
      Predictors of pregnant women's intention to vaccinate against coronavirus disease 2019: a facility-based cross-sectional study in southwest Ethiopia.
      6.73 (3.84–11.79)
      Mose et al.
      • Mose A.
      • Yeshaneh A.
      COVID-19 vaccine acceptance and its associated factors among pregnant women attending antenatal care clinic in Southwest Ethiopia: institutional-based cross-sectional study.
      2.55 (1.06–6.08)
      Stuckelberger et al.
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave: a cross-sectional study in Switzerland.
      2.00 (1.30–3.00)
      Higher school education1.84 (1.40–2.28)51.980.02
      Battarbee et al.
      • Battarbee A.N.
      • Stockwell M.S.
      • Varner M.
      • et al.
      Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during august-december 2020.
      2.40 (1.30–4.70)
      Geoghegan et al.
      • Geoghegan S.
      • Stephens L.C.
      • Feemster K.A.
      • Drew R.J.
      • Eogan M.
      • Butler K.M.
      "This choice does not just affect me." Attitudes of pregnant women toward COVID-19 vaccines: a mixed-methods study.
      1.78 (1.09–2.92)
      Hailemariam et al.
      • Hailemariam S.
      • Mekonnen B.
      • Shifera N.
      • et al.
      Predictors of pregnant women's intention to vaccinate against coronavirus disease 2019: a facility-based cross-sectional study in southwest Ethiopia.
      5.87 (3.14–10.97)
      Mose et al.
      • Mose A.
      • Yeshaneh A.
      COVID-19 vaccine acceptance and its associated factors among pregnant women attending antenatal care clinic in Southwest Ethiopia: institutional-based cross-sectional study.
      3.28 (1.92–5.59)
      Nguyen et al.
      • Nguyen L.H.
      • Hoang M.T.
      • Nguyen L.D.
      • et al.
      Acceptance and willingness to pay for COVID-19 vaccines among pregnant women in Vietnam.
      1.98 (1.24–3.14)
      Skjefte et al.
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • et al.
      COVID-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries.
      1.31 (1.12–1.54)
      Stuckelberger et al.
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave: a cross-sectional study in Switzerland.
      1.70 (1.30–2.20)
      Tao et al.
      • Tao L.
      • Wang R.
      • Han N.
      • et al.
      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.
      2.85 (1.45–5.59)
      Sufficient information about the SARS-COV-2 vaccine1.94 (0.94–2.95)61.700.02
      Goncu Ayhan et al.
      • Goncu Ayhan S.
      • Oluklu D.
      • Atalay A.
      • et al.
      COVID-19 vaccine acceptance in pregnant women.
      2.07 (1.22–3.51)
      Levy et al.
      • Levy A.T.
      • Singh S.
      • Riley L.E.
      • Prabhu M.
      Acceptance of COVID-19 vaccination in pregnancy: a survey study.
      30.95 (9.55–100.33)
      Mose et al.
      • Mose A.
      • Yeshaneh A.
      COVID-19 vaccine acceptance and its associated factors among pregnant women attending antenatal care clinic in Southwest Ethiopia: institutional-based cross-sectional study.
      3.24 (1.78–5.89)
      Tao et al.
      • Tao L.
      • Wang R.
      • Han N.
      • et al.
      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.
      1.05 (1.01–1.10)
      Wang et al.
      • Wang R.
      • Tao L.
      • Han N.
      • et al.
      Acceptance of seasonal influenza vaccination and associated factors among pregnant women in the context of COVID-19 pandemic in China: a multi-center cross-sectional study based on health belief model.
      2.63 (1.38–5.00)
      High perception of SARS-CoV-2 vaccine2.70 (2.13–3.27)00.26
      Hailemariam et al.
      • Hailemariam S.
      • Mekonnen B.
      • Shifera N.
      • et al.
      Predictors of pregnant women's intention to vaccinate against coronavirus disease 2019: a facility-based cross-sectional study in southwest Ethiopia.
      4.35 (2.73–6.95)
      Nguyen et al.
      • Nguyen L.H.
      • Hoang M.T.
      • Nguyen L.D.
      • et al.
      Acceptance and willingness to pay for COVID-19 vaccines among pregnant women in Vietnam.
      2.71 (1.93–3.82)
      Wang et al.
      • Wang R.
      • Tao L.
      • Han N.
      • et al.
      Acceptance of seasonal influenza vaccination and associated factors among pregnant women in the context of COVID-19 pandemic in China: a multi-center cross-sectional study based on health belief model.
      2.48 (1.83–3.35)
      Good practice8.99 (7.42–10.56)00.67
      Mose et al.
      • Mose A.
      • Yeshaneh A.
      COVID-19 vaccine acceptance and its associated factors among pregnant women attending antenatal care clinic in Southwest Ethiopia: institutional-based cross-sectional study.
      9.15 (8.73–12.19)
      Wang et al.
      • Wang R.
      • Tao L.
      • Han N.
      • et al.
      Acceptance of seasonal influenza vaccination and associated factors among pregnant women in the context of COVID-19 pandemic in China: a multi-center cross-sectional study based on health belief model.
      8.27 (5.35–12.77)
      Received influenza vaccine last year2.72 (2.09–3.35)74.92<0.001
      Battarbee et al.
      • Battarbee A.N.
      • Stockwell M.S.
      • Varner M.
      • et al.
      Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during august-december 2020.
      2.60 (1.90–3.60)
      Skjefte et al.
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • et al.
      COVID-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries.
      3.29 (2.91–3.72)
      Stuckelberger et al.
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave: a cross-sectional study in Switzerland.
      3.60 (2.80–4.70)
      Sutton et al.
      • Sutton D.
      • D'Alton M.
      • Zhang Y.
      • et al.
      COVID-19 vaccine acceptance among pregnant, breastfeeding, and nonpregnant reproductive-aged women.
      2.25 (1.66–3.05)
      Wang et al.
      • Wang R.
      • Tao L.
      • Han N.
      • et al.
      Acceptance of seasonal influenza vaccination and associated factors among pregnant women in the context of COVID-19 pandemic in China: a multi-center cross-sectional study based on health belief model.
      1.81 (1.18–2.80)
      Third trimester1.35 (1.10–1.60)00.78
      Stuckelberger et al.
      • Stuckelberger S.
      • Favre G.
      • Ceulemans M.
      • et al.
      SARS-CoV-2 vaccine willingness among pregnant and breastfeeding women during the first pandemic wave: a cross-sectional study in Switzerland.
      1.40 (1.00–2.00)
      Tao et al.
      • Tao L.
      • Wang R.
      • Han N.
      • et al.
      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.
      1.49 (1.03–2.16)
      Wang et al.
      • Wang R.
      • Tao L.
      • Han N.
      • et al.
      Acceptance of seasonal influenza vaccination and associated factors among pregnant women in the context of COVID-19 pandemic in China: a multi-center cross-sectional study based on health belief model.
      1.27 (0.98–1.65)
      Abbreviation: CI = confidence interval; OR = odds ratio; POR= Pooled odds ratio; I2 > 50%, heterogeneity.
      Fig. 2
      Fig. 2Forest plots of the risk factors and pregnant women's willingness toward the SARS-CoV-2 vaccination in various countries.
      Table 2 and Fig. 2 revealed good practice has the highest POR (95% CI) (8.99, 7.42–10.56), followed by received influenza vaccine last year (2.72, 2.09–3.35), high perception of SARS-CoV-2 vaccine (2.70, 2.13–3.27), >35 years (2.01, 1.10–2.93), sufficient information about the SARS-COV-2 vaccine (1.94, 0.94–2.95), higher school education (1.84, 1.40–2.28), and third trimester (1.35, 1.10–1.60) with desire of pregnant women toward the SARS-CoV-2 vaccination. The heterogeneity analysis revealed homogenous among risk factors in >35 years, high perception, good practice, and third trimester (I2 ≤ 50%).
      The findings of Egger's and Begg's tests to identify study bias (Table 3).
      Table 3The findings of Egger's and Begg's tests to identify study bias.
      Risk factorsStudy bias
      Egger's testBegg's test
      >35 years0.7660.857
      Higher school education0.9340.054
      Sufficient information about the SARS-CoV-2 vaccine0.3490.120
      High perception of SARS-CoV-20.4450.065
      Good practice0.8900.700
      Received influenza vaccine last year0.5300.132
      Third trimester0.3570.106
      p > 0.05, no publication bias.
      Table 3 revealed that based on the results of Egger's and Begg's tests (p > 0.05), an associated factors of >35 years, higher school education, sufficient information, high perception, good practice, received influenza vaccine last year, and third trimester had no study bias among publications included.
      The relationship between LMICs and pregnant women's desire toward the SARS-CoV-2 vaccination based on meta-regression (Fig. 3).
      Fig. 3
      Fig. 3The relationship between LMICs and pregnant women's desire to get vaccinated against SARS-CoV-2 based on meta-regression.
      Fig. 3 revealed that the relationship between LMICs and decreased pregnant women's desire toward the SARS-CoV-2 vaccination (p=<0.001). This study found that pregnant women's desire toward the SARS-CoV-2 vaccination varies depending on the country type.

      4. Discussion

      Our findings revealed that pregnant women who received the SARS-CoV-2 immunization had a high level of practice about the vaccine. Vaccine practice rates can support in the planning of activities and initiatives that will assist increase knowledge and reassure people about the safety and advantages of vaccines, which will help prevent the spread of the virus and minimize the negative impacts of this historic pandemic.
      • Brewer N.T.
      • Chapman G.B.
      • Gibbons F.X.
      • Gerrard M.
      • McCaul K.D.
      • Weinstein N.D.
      Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination.
      ,
      • Prematunge C.
      • Corace K.
      • McCarthy A.
      • Nair R.C.
      • Pugsley R.
      • Garber G.
      Factors influencing pandemic influenza vaccination of healthcare workers--a systematic review.
      Identification of practice and vaccination rates for SARS-CoV-2 vaccines can assist in the selection of the most effective communication method for boosting vaccination confidence.
      • Lin C.
      • Tu P.
      • Beitsch L.M.
      Confidence and receptivity for COVID-19 vaccines: a rapid systematic review.
      Because mothers have the biggest effect on whether or not to vaccinate their children and other family members, it is equally critical to assess trust and the most important determinants of pregnant women's vaccination acceptance.
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • et al.
      COVID-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries.
      ,
      • Nindrea R.D.
      • Usman E.
      • Katar Y.
      • Darma I.Y.
      • Warsiti Hendriyani H.
      • Sari N.P.
      Dataset of Indonesian women's reproductive, high-fat diet and body mass index risk factors for breast cancer.
      According to the results of this investigation, there is a link between receiving influenza vaccine last year and pregnant women's acceptance of SARS-CoV-2 immunization. Women who had previously received an influenza vaccination reacted better to the SARS-CoV-2 vaccination. Women who were hesitant to obtain a SARS-CoV-2 vaccine expressed worries about vaccine safety and efficacy. Almost all pregnant women chose their obstetrician/gynecologist as their most trusted source of SARS-CoV-2 facts, with >40% choosing their gynecologist.
      • Skjefte M.
      • Ngirbabul M.
      • Akeju O.
      • et al.
      COVID-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries.
      The desire to get the SARS-CoV-2 vaccine was linked to high perception. This finding is consistent with prior studies in which high perception or sensitivity was linked to acceptance and willingness COVID-19 vaccination.
      • Harapan H.
      • Wagner A.L.
      • Yufika A.
      • et al.
      Willingness-to-pay for a COVID-19 vaccine and its associated determinants in Indonesia.
      ,
      • Harapan H.
      • Wagner A.L.
      • Yufika A.
      • et al.
      Acceptance of a COVID-19 vaccine in Southeast Asia: a crosssectional study in Indonesia.
      Furthermore, women who saw COVID-19 as a danger among their acquaintances were more likely to get the immunization than others.
      Our research also found that as people become older, they are more likely to develop chronic conditions including hypertension, renal disease, and heart disease, which can lower a pregnant woman's immunity and raise the risk of SARS-CoV-2 related morbidity and death. As a result, it may instill fear in the elderly population, leading to a greater willingness to receive the SARS-CoV-2 vaccination.
      • Mose A.
      • Yeshaneh A.
      COVID-19 vaccine acceptance and its associated factors among pregnant women attending antenatal care clinic in Southwest Ethiopia: institutional-based cross-sectional study.
      When compared to pregnant women who had limited understanding about SARS-CoV-2, those who had high information were more likely to receive SARS-CoV-2 vaccine. This might be explained by the fact that pregnant women with good understanding of SARS-CoV-2 would be aware of the virus's severity to themselves and their fetus, allowing them to readily receive SARS-CoV-2 vaccination to mitigate the pandemic's effects.
      • Di Crosta A.
      • Ceccato I.
      • Marchetti D.
      • et al.
      Psychological factors and consumer behavior during the COVID-19 pandemic.
      Higher-educated pregnant women were more likely to wish to acquire the SARS-CoV-2 vaccine. Previous research have found a significant level of concern against the SARS-CoV-2 immunization among the less educated. This might be because more educated people have easier access to vaccination facts and are better able to interpret facts about the SARS-CoV-2 vaccine's advantages and risks. On the contrary, vaccination misinformation is more likely to affect persons who are less informed.
      • Malik A.A.
      • McFadden S.M.
      • Elharake J.
      • Omer S.B.
      Determinants of COVID-19 vaccine acceptance in the US.
      We revealed that being pregnant in the second trimester was a negative predictor of SARS-CoV-2 vaccination uptake when compared to the third trimester, indicating a potential concern of caused fetal abnormalities. Fear of any potential detrimental negative consequences of the vaccination on their pregnancy or newborn, as well as worries about safety and advantages, have been identified as important factors for vaccine aversion in various studies.
      • Battarbee A.N.
      • Stockwell M.S.
      • Varner M.
      • et al.
      Attitudes toward COVID-19 illness and COVID-19 vaccination among pregnant women: a cross-sectional multicenter study during august-december 2020.
      ,
      • Lutz C.S.
      • Carr W.
      • Cohn A.
      • Rodriguez L.
      Understanding barriers and predictors of maternal immunization: identifying gaps through an exploratory literature review.
      The essential battle against the pandemic is to figure out what factors influence pregnant women's willingness to get COVID-19 vaccines.
      • Hailemariam S.
      • Mekonnen B.
      • Shifera N.
      • et al.
      Predictors of pregnant women's intention to vaccinate against coronavirus disease 2019: a facility-based cross-sectional study in southwest Ethiopia.
      As more information on the safety and effectiveness of the COVID-19 immunization becomes known, immunization acceptance, perceived motivators, and barriers to acceptance may change among pregnant women.
      • Geoghegan S.
      • O'Callaghan K.P.
      • Offit P.A.
      Vaccine safety: myths and misinformation.
      Acceptance of the COVID-19 vaccination and its determinants among pregnant women differs throughout the world. As a result, vaccination efforts targeting this community should be tailored to the needs of each country in order to have the most effect.
      • De Figueiredo A.
      • Simas C.
      • Karafllakis E.
      • Paterson P.
      • Larson H.J.
      Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study.
      ,
      • Nindrea R.D.
      • Sari N.P.
      • Lazuardi L.
      • Aryandono T.
      Validation: the use of google trends as an alternative data source for COVID-19 surveillance in Indonesia.
      Our study's strength was performed in various countries. As a result, this is a good setting for investigating potential relationships between pregnant women's willingness toward the SARS-CoV-2 vaccination among LMICs and non-LMICs. There are a few limitations in this meta-analysis study. Three publications appeared to be acceptable in this study, but they lacked sufficient evidence and yielded negligible data estimation findings. The possibility of selection bias will be exacerbated as a result of this issue. Furthermore, we excluded articles written in other languages. This may limit epidemiological data from nations that do not speak English.
      The findings suggest that health authorities should establish immediate promotion of health programs and distribute more accurate information. Authorities should take steps to ensure that individuals have access to sufficient facts, adopt positive vibes, and hold high perception about SARS-CoV-2 vaccinations. Another recommendation is for obstetric care specialists to make a clear advice to pregnant women to get the vaccination. This will likely enhance COVID-19 vaccine uptake. Apart from that, community-based engagement activities may be necessary to adapt pregnant women education materials and increase communication and shared decision-making in order to accomplish universal health coverage in pregnant immunization.

      5. Conclusion

      This finding results revealed the risk factors for pregnant women's willingness toward the SARS-CoV-2 vaccination, good practice has the highest risk, followed by received influenza vaccine last year, high perception, >35 years, sufficient information, higher school education and third trimester. The heterogeneity analysis revealed homogenous among risk factors in >35 years, high perception, good practice, and third trimester. The insights of this research might help the authorities in determining the most effective strategy to deploy SARS-CoV-2 mass immunization campaigns for pregnant women.

      Funding/financial support

      This research received no funding from public, private, or non-profit sources.

      Declaration of competing interest

      The authors declare that they have no competing interests.

      Acknowledgments

      The authors would like to thank Riyani Betri Novialita, MA, for her help with data collecting.

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