COVID-19 vaccine uptake and associated risk factors among first antenatal care attendees in Zambia, 2021-2022: a repeated cross-sectional study

ABSTRACT Introduction Pregnant women are considered a high-risk group for COVID-19, and a priority for vaccination. Routine antenatal (ANC) care provides an opportunity to track trends and factors associated with vaccine uptake. We sought to evaluate COVID-19 vaccine uptake among pregnant women attending ANC in Zambia. Methods We conducted a repeated cross-sectional study in 39 public health facilities in four districts in Zambia from September 2021 to September 2022. Pregnant women who were aged 15-49 years were enrolled during their first ANC visit. Every month, ∼20 women per facility were interviewed during individual HIV testing and counseling. We estimated vaccine uptake as the proportion of eligible participants who self-reported having received the COVID-19 vaccine. Results A total of 9,203 pregnant women were screened, of which 9,111 (99%) were eligible and had vaccination status. Of the 9,111 included in the analysis, 1,818 (20%) had received the COVID-19 vaccine during the study period, with a trend of increasing coverage with time (0.5% in September 2020, 27% in September 2022). Conversely, 3,789 (42%) reported not being offered a COVID-19 vaccine. We found that older age, education, employment status, and prior COVID-19 infection were significantly associated with vaccine uptake. Conclusion COVID-19 vaccine uptake among pregnant women was lower than estimates from the general population (27% across the four districts in September 2022), pointing to missed opportunities to protect this high-risk group. ANC visits were a viable point for conducting COVID-19 surveillance. Incorporating the vaccine as part of the routine ANC package might increase coverage in this group. Teaser key message Antenatal care clinics could be an easy and sustainable platform for increasing COVID-19 vaccine uptake among pregnant women. Key Findings Despite evidence that COVID-19 vaccines are safe in pregnancy, vaccine uptake was low among pregnant women in Zambia through the end of 2022. Various demographic characteristics were associated with the uptake of COVID-19 vaccines. Key Implications It is acceptable and feasible to assess COVID-19 vaccination uptake and hesitancy among pregnant women attending ANC. ANC may provide an easy, sustainable platform for routinely monitoring COVID-19 and other disease outbreaks. Key vaccination messages and mass vaccination strategies can be designed and adopted for pregnant women to reduce vaccine hesitancy and consequently, increase vaccine uptake. COVID-19 vaccination could be incorporated into routine antenatal care to help increase vaccination coverage among pregnant women seeking antenatal care services.