COVID-19 vaccination in pregnancy: ambiguity in decision-making

Abstract

Throughout the COVID-19 pandemic, pregnant women/people were identified as an at-risk group of severe COVID-19 disease. Consequently, vaccine uptake among this group became a public health priority. However, the relationship between pregnancy and vaccination decision-making is complex, and the heightened uncertainty and anxiety produced through the pandemic further exacerbated this immunization decision. This study explores COVID-19 vaccination decision-making during pregnancy in Aotearoa New Zealand by using an online story completion survey tool. Ninety-five responses were received and analysed using thematic analysis where ambiguity was a core facet within and across stories. Three ambiguities were identified, including who makes the decision (agential), what the risks are (risk) and how immunity to this threat can be best achieved (immunity). We discuss the implications of this ambiguity and how the strong desire to protect the baby persisted across accounts. The recognition of the rather persistent ambiguity in vaccination decision-making helps conceptualize influencing factors taken into account in a more nuanced manner for further research, public health campaigns and health professionals. Future public health campaigns can consider redistributing responsibility for vaccination decision-making in pregnancy, traverse an either/or perspective of ‘natural’ and ‘artificial’ immunity-boosting and consider how risk is perceived through anecdotes and viral immediacy.

INTRODUCTION

On 11 March 2020, the World Health Organisation declared the COVID-19 outbreak a global pandemic (Cucinotta and Vanelli, 2020). Throughout the pandemic, pregnant women/people were identified as an at-risk group of severe COVID-19 disease (Zambrano et al., 2020; Geoghegan et al., 2021) and globally, pregnant women/people infected with COVID-19 have an increased risk of severe COVID-19 compared to non-pregnant women/people (Zambrano et al., 2020; Geoghegan et al., 2021; Wei et al., 2021).

Vaccination is one of the most cost-effective public health tools in the fight against COVID-19, reducing the transmission of the disease and also reducing the burden among vulnerable populations who are susceptible to contracting COVID-19 and developing severe symptoms (Doherty et al., 2016; Truong et al., 2022). The vaccine has been rolled out to pregnant women/people globally, where large-scale surveillance data indicate no safety concerns with administering the vaccine (Immunisation Advisory Centre, 2022), but there are yet to be clinical trials where pregnant women/people are included (Van Spall, 2021). Vaccinating during pregnancy may also offer temporary protection to the baby as there is evidence that infants receive antibodies to the virus through cord blood and breast milk when mothers are vaccinated (Gray et al., 2021). Despite these benefits, globally, COVID-19 vaccination rates during pregnancy remain low (27.5%) with a gap in understanding the factors influencing the decision to vaccinate during pregnancy persisting (Galanis, Vraka, Siskou et al., 2022).

Geoghegan et al. (2021) report that vaccine decision-making during pregnancy falls into three categories: acceptance, hesitancy or rejection. However, these categories function much more as a fluid continuum in which decisions sway back and forth, creating an elusive and divergent field for decisions to fester. COVID-19 vaccination decision-making factors have been linked, for instance, to political affiliation, ideological and partisan beliefs and misinformation (Ward et al., 2020; Fridman et al., 2021). Lupton (2022) also found that immunocompromised people were more likely to use vaccination to increase their chances of protection from COVID-19 compared to others, however, this did not include pregnant women/people. The existing literature shows that the COVID-19 vaccination decision is highly complex, exacerbated by the complexities of the pandemic and misinformation (Kennedy et al., 2021). Evidence suggests that concerns among individuals are due to people thinking that the creation of the COVID-19 vaccine was ‘rushed’, which has resulted in vaccine mistrust (Kennedy et al., 2021). The distrust in the vaccination led to a common ‘wait and see’ position, where individuals held off on vaccinating, to see how others reacted. Overall, the COVID-19 vaccination decision is complex for individuals dealing within complicated ecosystems (Kennedy et al., 2021).

Vaccination decision-making during pregnancy

Trends across vaccination decision-making studies suggest that pregnant women/people’s vaccination decisions are driven by the collective desire to protect their unborn child (Geoghegan et al., 2021; Karafillakis et al., 2021). Other factors, including social and cultural norms, family, communities, healthcare professional recommendations, lived experiences and beliefs around scientific data, all influence the vaccination decision (Geoghegan et al., 2021; Karafillakis et al., 2021).

At its core, however, the decision-making power tends to be attributed to the mother with an uneven burden of responsibility given for promoting the health of their baby (Lupton, 2012). These socio-cultural imperative constructs a ‘good mother’ as committing herself fully to her child’s needs. Within modern public health, motherhood has become the focus of injunctions, duties and obligations to ensure the production of healthy children (Thompson, 2021). In promoting the health of their babies, pregnant women/people are subjected to engage in regimes of self-regulation and discipline of their bodies (Lupton, 2012). Therefore, vaccination decision-making while pregnant can be based on the societal notion that a ‘good’ reproductive citizen must involve the mother in protecting their foetus by putting the needs of the foetus before their own (Wiley et al., 2015). The pressure to make the ‘right’ vaccination choice is immense, and guilt and blame for doing wrong feared.

The good mother discourse is paired with and exacerbated by the ‘pure’ and ‘delicate’ discourse that frames infants as precious and needing protection, due to their high value and small, helpless bodies (Lupton, 2011). ‘Pure infants’ are often viewed as highly permeable, easily contaminated by outside pollutants and requiring constant parental protection (Lupton, 2014). Within this context, mothers experience ambivalence in immunization discussions, particularly when subjecting their infants to potentially painful injections with ‘chemicals’ that could cause harm (Lupton, 2011). Equally, those who vaccinate tend to do so to promote good health for their infants (Lupton, 2011), suggesting that a felt obligation to protect their baby can go either way in vaccination decision-making. More recently in a study on pregnancy and COVID-19 vaccination, Geoghegan et al. (2021) found that women who were more likely to vaccinate trust scientific data compared to women who were less likely to vaccinate, who were conversely concerned about the lack of data and safety measures.

Emotions and vaccination decision-making

The decision to receive or refuse an immunization is often presented as rational reasoning resulting in informed choices (Lakomski and Evers, 2010). However, research has found that these rational decisions are interwoven with multiple emotional factors (Anraad et al., 2020). Informed decision-making has rationalist underpinnings, assumes basic weighing up and neglects the complex emotions at play when one makes a vaccine decision (Lakomski and Evers, 2010). Evidence suggests that most vaccine-hesitant people highly value being informed about immunisations before deciding to vaccinate or not (Attwell et al., 2017). During pregnancy, vaccination is a subject that involves multiple emotions, including regret, fear of vaccination and fear of disease (Anraad et al., 2020). Anraad et al. (2020) attributed vaccination intention to attitudes towards vaccines, beliefs about the safety and effectiveness of the vaccine, and an individual’s moral norms. Other factors such as anticipated regret of vaccination and uncertainty in the decision-making process were influenced by emotional decision-making (Anraad et al., 2020). Schuster et al. (2023) suggest that ‘emotions of burden’, including fear of being a bad mother and guilt if the wrong decision is made, are experienced through the COVID-19 vaccination decision. Understanding emotional decision-making provides a more nuanced approach to learning about mothers’ reasonings for receiving or refusing immunisations (Schuster et al., 2023). Schuster et al. (2023) suggest that public health campaigns must acknowledge the emotional burden that COVID-19 vaccine decision-making can place on pregnant women/people.

Vaccination ambiguity

Despite the effectiveness of the COVID-19 vaccine, vaccine hesitancy is one of the most significant barriers to achieving widespread coverage (Majid and Ahmad, 2020). Vaccine hesitancy refers to the delay in acceptance or refusal of vaccines despite availability of vaccination services (Majid and Ahmad, 2020). In a meta-synthesis, Díaz Crescitelli et al. (2020) examined 27 studies involving 1557 parents who were hesitant about vaccinating their child. The analysis identified five themes: risk conceptualization, mistrust towards vaccine-related institutions, healthcare professionals and the media, alternative health beliefs towards natural immunity, philosophical views on parental responsibility and information levels on immunization (Díaz Crescitelli et al., 2020). The authors conclude that healthcare providers need to approach the immunization decision by understanding what the parents feel is the right decision for their child and why (Díaz Crescitelli et al., 2020). By understanding why parents are hesitant in vaccinating their child, health professionals can then use effective communication and behavioural strategies to promote vaccine uptake (Díaz Crescitelli et al., 2020). Qiu et al. (2021) found that receiving a recommendation to vaccinate by a trusted healthcare professional significantly increased vaccine uptake among pregnant women/people. Karafillakis et al. (2021) found that receiving a maternal vaccination created anxiety and unease for women. Some women described the vaccination decision becoming more complicated during pregnancy as their relationship with their body changes when becoming responsible for their unborn child (Karafillakis et al., 2021). Reich (2016) discovered that, especially among higher-income families, parents were likely to be vaccine-hesitant because they saw immunization as an artificial ‘unnatural’ intervention. The study also found that parents perceived immunity from illness as natural and immunity from vaccination as dangerous (Reich, 2016). Lastly, Reich (2016) found that parents considered their ways of natural living as sufficient to enhance their children’s immunity, consequently deeming immunization unnecessary.

Ambiguity arises when disparate factors and interpretations cause tension and emerge as indecisiveness. The overwhelming information on vaccinations, risk perceptions and the desire to protect the unborn child, lead to ambiguity in decision-making (Bond and Nolan, 2011; Wang et al., 2015). Ambiguity in the decision-making process is caused by missing information to make an ‘informed’ vaccination decision (Bond and Nolan, 2011). Bond and Nolan (2011) found that concepts of dread, unfamiliarity and uncontrollability from the subjective perception of risk and ambiguity explained why many parents would receive or refuse vaccines for their children. This study found that lack of information created ambiguity, leading to vaccine-hesitant and -refusal parents (Bond and Nolan, 2011). Wang et al. (2015) found that when parents described their decision-making process around vaccinating, they expressed frustration over the overwhelming information from multiple sources, which led to ambiguity and uncertainty. Similarly, Bettinger et al. (2016) investigated the attitudes of pregnant women/people and new mothers regarding the seasonal influenza vaccination in Canada. The study found that ambiguity surfaced when mothers weighed up the risk between supposed immunity from vaccination compared to natural immunity, such as disease exposure and home remedies (Bettinger et al., 2016). The study also found an aversion to ambiguity in the decision-making process, where pregnant women/people would outright refuse the influenza vaccine to avoid ambiguous feelings (Bettinger et al., 2016). Overall, the literature reveals that the decision to receive or refuse vaccination during pregnancy is incredibly complex. This, oftentimes conflicting, complexity causes ambiguity and can lead to avoiding vaccination altogether as an avoidance strategy.

The COVID-19 pandemic posed a unique scenario in recent history where the emergence of a virus led to a rapid vaccine development with a global scope. This unique context heightened already ambiguous and complex decision-making landscapes pregnant women/people face when deciding on vaccinations during pregnancy. Recently published studies on Covid-19 vaccine decision-making have exposed some of the key determinants that affect this decision-making, yet none of these occurred in countries that adopted an elimination strategy for such an extended period. Further, it can be difficult to elicit sensitive and controversial information, with fear of judgement affecting what research participants share. In this study we adopt a story completion method using imaginative storytelling as means by which to elicit pregnant women/people’s socio-cultural discourses on receiving the COVID-19 vaccination.

Aotearoa New Zealand context

As an island nation, Aotearoa New Zealand was able to achieve an elimination strategy for COVID-19 and keep widespread community transmission under control until February 2022. This meant that the general population was use to life without COVID-19 in their community. To combat the disease, the New Zealand Government purchased the Pfizer BioNTech vaccine to administer to the public. The COVID-19 vaccination schedule in Aotearoa New Zealand included a first and second dose, and subsequently a booster six months thereafter. During the rollout of the COVID-19 vaccine in Aotearoa New Zealand, pregnant women/people were required to receive or refuse both influenza and Boostrix vaccines (immunization against whooping cough), as well as between one and three doses of the COVID-19 vaccine (Ministry of Health, 2022). This was a unique, time-bound situation that demanded more ambiguous decision-making.

METHODOLOGY

We used a post-structuralist approach to understand how pregnant women/people navigated COVID-19 vaccination decisions during pregnancy, drawing on story completion methods to explore factors that influence the vaccination decision-making process during pregnancy. With a post-structuralist lens, story completion then becomes a method for examining the knowledge systems and discourse which inform participants’ thinking (Gravett, 2019). A qualitative story completion method offers a unique approach to data collection, asking participants to write hypothetical stories that are answered in third person, responding to a stimulus which presents the beginning of a plot to a story (Clarke et al., 2019). Story completion deliberately aims to not uncover personal views or experiences of the study’s participants, rather, the participant is analysed as a complex and variable function of discourse (Gravett, 2019). By adopting a post-structuralist approach, we were able to examine the stories through discourse, tropes, constructions or discursive repertories that inform participants’ understanding and decision-making (Gravett, 2019). Story completion methods allowed participants’ to write freely when completing their stories about a sensitive topic with no stigma.

The story stem was piloted to a sample (4) of participants before the online platform went live. As no problems with the story stem were identified, the four pilot responses were incorporated in the final sample (Clarke et al., 2019). We recruited participants through social media platforms including Facebook and Instagram, newsletters and websites of parenting-related organisations in Aotearoa New Zealand (e.g. Parents Centre Aotearoa, Pregnancy Infancy Parents Support, Pregnancy Anxiety and Depression Aotearoa, Breastfeeding New Zealand).

Data were collected through an online platform (Qualtrics online survey software). Participants responded to a PDF advertisement targeting pregnant people including neutral language on the COVID-19 vaccination to ensure we advertised to people with diverse views.

‘You are invited to participate in a study about pregnancy and Covid-19 vaccination decision-making. We would like to hear from those that did or did not vaccinate’.

Participants were then invited to join the study via a URL link which sent them to an information page, including obtaining consent. They were then required to complete the story, providing as much detail as they wanted about the protagonist’s decision-making process in receiving or refusing the COVID-19 vaccine. Participants were encouraged to be imaginative when completing the story, and write for as little or as long as needed, but were given a ten-minute writing guide to complete the story. Once the story was completed, participants were asked to provide demographic data, including age, gender, ethnicity, stage of pregnancy, geographical location, level of study, job status and if they received or refused a dose of the COVID-19 vaccination. Victoria University of Wellington Human Ethics Committee granted ethical approval for this study (0000029992).

A total of 95 responses were recorded. The average word count of participants’ stories was 121 words. Within the participants narratives, 53 stories led to Ari vaccinating, 15 stories led to the protagonist not vaccinating, 20 stories were unexplicit in their vaccination decision and six stories resulted in Ari vaccinating post-partum. The following demographic data was also collected (Table 1):

Story stem

‘Ari is in the second trimester of pregnancy and is now eligible to receive the COVID-19 vaccination. Ari is not sure about the vaccine and has seen the effects COVID-19 has had on others. But Ari is also getting pressure from whānau (family) and peers to not get the vaccination. Ari feels conflicted… What happens next?’

Analysis

We drew on reflexive thematic analysis (Braun and Clarke, 2013), to explore horizontal (across) and vertical (within) patterning in the data (Clarke et al., 2019). The data was loaded into NVivo for analysis. The first author began by analysing the data horizontally, exploring patterns broadly using complete coding methods to gain a first sense of the data (Braun and Clarke, 2013). Noticing three distinct trajectories of stories (yes, no, uncertain about vaccination decision), she then moved on to analysing data vertically, categorizing each story. For each category, she then analysed every story horizontally, looking at the ‘bits’ of the story that participants told, that were part of the decision-making process and supported Ari in deciding to vaccinate or not. While the frequency of accounts can be an important factor, through pattern-based analysis, it is essential to capture elements in the data that are most meaningful to achieve the research aim (Braun and Clarke, 2013). Interested in the inbetween, the stories in which the fictional character was torn in her decision were of particular interest to us. We followed the ‘ambiguous decision-making’ lead and coded for, and read through these stories, exploring the sources of ambiguity. We then progressed to developing themes, beginning this process by looking at codes and collating data, looking for similarities and overlaps between codes. We used visual mapping for this process to assist in exploring the relationships between codes and themes, subthemes and overarching themes (Braun and Clarke, 2013). The next step involved firming up the themes: (i) revising and going back to the coded and collated data to ensure the themes cover most of the coded and collated data, and (ii) re-reading the entire data set to ensure the themes achieve the research aim (Braun and Clarke, 2013). The final process included selecting excerpts and checking in on our process and theoretical orientation.

FINDINGS

The most intriguing and complex stories conveyed ambiguity and contained no clear cut decision-making pathway. The prevalence of ambiguity across the stories led us to develop three themes that describe distinct but related realms of ambiguity in COVID-19 vaccine decision-making: Agential, risk and immunity ambiguity.

Agential ambiguity

A core theme in the data was the ambiguity on who held agency over the vaccine decision. This was exhibited through a sense of ‘being torn’ between ‘my’ decision as a mother and other agents (e.g. health professionals, friends, family, mandate) implicated in the decision. There was a sense of clashing between ‘rational’ and ‘emotive’ agencies in navigating the complexity of receiving the vaccine. Across some stories Ari was described as rationally knowing vaccination was the right decision, but emotional pulls drove her to feel ambiguous about the vaccine. For instance, even though the midwife ‘tells her that the vaccine is completely safe for her and her baby’ and friends are ‘all confident in the vaccine’ it can be difficult to surpass emotions that make her feel ‘uncertain, what if something goes wrong and it hurts her baby? If she makes that choice and something bad happens, her family will be devastated and might blame her’ (P74). In this story, Ari is worried about her family blaming her for making the wrong decision. This blame is internalized and the responsibility is attributed to herself. The thought of making the wrong decision causes anxiety for Ari as she is under pressure from her family to make the right decision. Stories like these displayed much discomfort in feeling the sole responsibility for independently making the ‘right’ choice. In some instances Ari is placed into a context that relieves her of holding responsibility over this decision.

Various strategies were used for resolving ambiguity, such as legislated vaccination or religious beliefs. In some participants’ narratives, external agencies such as work, communities and families caused uncertainty during the decision-making process (although noticeable was no explicit mentioning of the co-parent). Some stories see the protagonist (Ari) deflecting the decision, in order to protect herself. For instance, in one story, Ari was torn between the expectations of vaccination between her church and work. For Ari, the ambiguity was created when her work, which plays a big role in Ari’s life, required her to be vaccinated, but her church leader and elders disapproved of the vaccine.

Ari’s family doesn’t want her to get the vaccine. The church leader and her elders have disapproved of the vaccine; therefore, her family are anti-vaccination. Unfortunately, Ari’s work requires her to get the vaccine, and she has done a lot of independent research with her GP wants want is best for her baby. Therefore, Ari had to go behind her family’s back and get the vaccine. They do not know she has done this. (P25)

Ari is stuck in the middle, trying to please her church and family, while also conflicted that she needs her vaccination to be able to work. This story shows that Ari is torn, but by using the words ‘what is best for my baby’ and ‘independent advice’, she absolves herself from any guilt around going against her family’s wishes. The story indicates that Ari is still an agent in the decision but that work acted as a shield to explain why she had to get the vaccine. In this instance, work is used as a rationalisation for vaccination, that seeks to resolve the moral ambiguity around whose decision it is, or around who is the right authority to listen to.

A common subtheme was the contrast between collective and individual agencies in decision-making and was resolved for Ari by some through asserting autonomy, framed with a strong notion of individualism. Ari was often positioned as the key person responsible for the decision-making, with her ‘need[ing] all the information offered from all sides’ because ‘at the end of the day, it should be her choice in what she does’ and people should ‘should also let Ari decide for herself’ (P3). Though diverging opinions contributed to Ari’s uncertainty, some participants reported Ari managed to ‘reassert’ their agency by reminding themselves that it was their own call after all. In contrast, for some a more collective agential distribution made it harder to come to a decision when these opinions diverged. Here ambiguity was ‘resolved’ by seeking moral ‘guides’ who could be held onto for this decision, therewith rationalising the ‘need’ to vaccinate no matter what and collectivising the decision.

Ari talked to her whānau [family], as she values their opinions of them. Ari talked to the kaumātua [elder] in her whānau, and they recommended that she get the vaccine because the nurses at the kaupapa health clinic [Māori health service] said it was safe. Ari and the kaumātua also wanted to keep the pēpi [baby] safe because that was what was most important to them at the end of the day. Although Ari’s immediate whānau recommended not getting the vaccine, speaking to the elders within her community was vital to help Ari to make the decision to get the vaccine. (P21)

Within this story, Ari values the opinions of the kaumātua (Indigenous Māori elder) and health care professional recommendation. The ambiguity was created when her whānau (family) and kaumātua had contradicting views on vaccination. Ari is torn between two external agencies within her community, but ultimately, wants to do what is best for her baby. Within this story, the participant writes, ‘at the end of the day, that was most important to them’. Compared to other stories, here, the decision was framed as collective, it is not just Ari that needs to feel at ease with the decision; it is also her family and the broader community, the collective.

In many of the stories, the pull between collectivism and individualism was ambiguous and Ari was often caught in the middle. Although vaccination is a ‘collective tool’, the ideologies of ‘choice’ and ‘autonomy’ were woven through the data with very little discourse arising from the collective benefit, or herd immunity that is a core goal of immunization. Overall, it seems that who has the agency over the decision to receive or refuse the COVID-19 vaccine is messy.

Risk ambiguity

Ambiguity was often conveyed in participants’ narratives through engaging in constant risk assessments with clear pointers that there was little to no guidance on this decision-making and weighing of risks. Particularly for participants stories who conveyed Ari as a first-time mother and undertaking the vaccination decision, there was a confluence of ‘newness’ with pregnancy (deciding for two) and a pandemic. Risk perceptions were woven throughout nearly all stories with a strong notion that this risk assessment was necessary for protecting the vulnerable baby; however how to protect them was riddled with ambiguity.

A key risk weighed up heavily was the potential harm from vaccination versus harm from the virus. Potential harm from vaccination became a risk for Ari due to the perceived threat of injecting a foreign substance into their body that could harm their unborn child.

Ari talks with midwives and friends in the medical field. She considers and weighs up the risk of catching COVID-19 versus the risk of having a bad reaction to the vaccine. As time progresses and COVID-19 becomes more and more active in the community, Ari decides that the likelihood of catching COVID-19 and something bad happening is much more likely than having a bad reaction to the vaccine, so she gets the vaccine. (P45)

With the delayed presence of COVID-19 in the community (compared to many other countries) it appeared that some participants described Ari as perceiving the risk from vaccine harm greater than the virus because of its absence, and unlikelihood of contraction. One way of mitigating this vaccination risk was to vaccinate post-partum. The perceived risk of harm was, for them, reduced, but benefits retained as they were able to transfer immunity to their infant via breast milk: ‘if immunity for the baby can be achieved by receiving the vaccination after birth, she is considering waiting’ (P18). The volatility of the time, but also the power of anecdotes, is reflected in some fast shifting of perspectives:

During Ari’s final trimester, there was a news article about a newborn baby who contracted COVID-19 and has been hospitalised in the neonatal unit. Due to the thought of missing out on any time with her baby or the risk of her baby becoming seriously ill (or worse), Ari decided to get her vaccine before her baby was born. (P18)

This story captures the changing volatility of risk perception, and the ways in which embodied stories impact in contrast to abstract facts. Due to the periodic community outbreaks of COVID-19 in Aotearoa New Zealand (particularly in Auckland, due to the international arrivals who went through quarantine) there were temporal fluctuations of COVID-19 presence and absence. This impacted the perceived risk and affected the vaccine decision-making process. At times Ari felt a sense of security when the virus was not ‘here’ despite the risk of immediate occurrence at any time (and the delayed time for full vaccination coverage to come into effect). However, as community cases increased, it tore the protagonist (Ari) back and forth. Some stories showed Ari only getting vaccinated once COVID-19 was in her community. As the risk of COVID-19 in Aotearoa New Zealand’s communities changed rapidly, the narrative collected within this dataset intensified the risk of ambiguity. Due to the ‘newness’ of the vaccine, and the change of advice for pregnant women at the Government level in the early stages of vaccine rollout in Aotearoa New Zealand, Ari was often narrated to be unsure about the diverging risks.

The conflict stems from the fact that previously, pregnant women were advised not to vaccinate. The turnaround from unsafe to safe seems to have occurred very quickly. This hasn’t left much time to study any health implications for mum or baby, both short or long term. Ari agrees with her family because of this reasoning, not because of misinformation about how a vaccine works or anti mandate mentality (which is fine because everyone has a right to their opinion). Ari discusses her options with her midwife and asks her to send links to the most recent scientific studies to help her decide. Given this is September 2021 and the government is still using level 4 lockdowns, the transmission of the virus is slow. The Omicron variant does not exist yet, and the risk of exposure can be easily managed by limiting interactions with non-vaccinated people and contact tracing. Ari decides not to get vaccinated at this time. However, as the Omicron variant arrives in December 2021 and Ari’s due date is rapidly approaching, she changes her mind about being vaccinated, understanding that over the next few weeks, she will pass on antibodies to her unborn child. (P15)

This story illustrates the fluctuating and thought-out decision-making processes some participants’ described Ari as going through to weigh up the risks of vaccination/viral infection. The protagonist situates herself as someone who draws on scientific evidence to support her decision whilst distinguishing herself from her family who does not vaccinate because of ‘misinformation’ or an ‘(anti)mandate mentality’. Her calculated shift from evaluating her risk of transmission across different virus variants shows that her perceived risk of infection at that stage overrules her uncertainty about the scientific evidence that has been produced. The results show a huge variance in risk assessment, often not tied to one particular worldview, but to a shifting sense of risk to the baby depending on the context at hand. This story illustrates how ambiguity can be created over time, in which different assessments of risk can create varied understandings of vaccine safety and necessity.

Immunity ambiguity

The third theme immunity ambiguity intersects with risk and agential ambiguity, but distinctively captures varying feelings and practices of how ‘good immunity’ might be achieved. A key narrative found across the dataset was an ambiguity between ‘artificial’ (vaccine-induced) immunity and ‘natural’ (through infection and/or healthy lifestyle practices) immunity. In many narratives there was some assertion that wellbeing practices, such as eating healthy foods and avoiding harmful substances, would boost ‘natural’ immunity and be a superior way to combat the risk of COVID-19 as well as the vaccine.

Ari thinks about it, but ultimately doesn’t get the vaccine. She feels there’s insufficient studies and evidence of the vaccine on pregnant women. She just made sure she ate the right food and exercised properly and did other things to make sure she was as healthy as possible for the baby. No one can give her back her baby if anything bad happens. The Government or Ministries will only apologise as there’s nothing else they can do. (P13)

This story captures the ambiguity between ‘artificial’ and ‘natural’ immunity. Ari made her vaccination decision by ensuring that she protects herself by living a healthy lifestyle—a discourse regularly seen throughout vaccination history. Conversely, other participants noted that immunity through vaccination is the best way to protect oneself: ‘She finds out that Pfizer is known to be safe for pregnant women and decides that this would be a good time to be vaccinated since it can pass on protective antibodies to her wee baby and help protect baby after birth’ (P89). This account places trust in immunity through vaccination to protect their baby.

In contrast, there were notions of what is not allowed during pregnancy and questioning of ‘why on earth’ a new substance is allowed, when even ibuprofen is not:

Ari’s whānau [family] are strong in their beliefs in saying that if you can’t eat this and that while pregnant or take ibuprofen or other drugs that’s going to harm pēpi [baby], why the hell would it be safe to take the vaccine! Ari wants to protect her baby and she will do whatever it takes to do so! While pregnant you can’t go to the dentist to pull out a tooth that’s infected because of the injection. So Ari decides that she is not going to risk it for the sake of her pēpi, and instead she carries on with life focusing on her own wellbeing and making sure she is safe along with the support of her living whānau. (P14)

The arguments presented here draw conclusions that the inability to even eat certain foods and take over-the-counter medications indicates that the vaccine is not safe. Such inductive reasoning unsettled Ari’s vaccination decision, and then diverted the need for the vaccine by then focusing on looking after their wellbeing to strengthen immunity instead.

Participants’ narratives showed immunity ambiguity towards the vaccination, which they equated with past vaccine practices. Past experiences of non-vaccine-induced immunity were drawn upon to question why then would they require a COVID-19 vaccine.

Ari does want to get the vaccine, but she isn’t sure about what is in the vaccine, and the long-term side effects haven’t been tested. Ari is also scared that the vaccine will hurt the baby, and she has never had a vaccine while pregnant with her other children, so why should she now? The decision would be easier if it were just Ari. However, she trusts her family and values their opinion, so she doesn’t get the vaccine and delivers a healthy, happy baby. (P2)

Here, Ari relates her own experience of refusing other vaccines while being pregnant, but indicates she would be happy to vaccinate it if was just her. She is protecting her ‘pure’ and ‘delicate’ baby from substance harm. The participant also writes that Ari delivers a healthy, happy baby, which is a way of convincing the reader and maybe herself, that she has made the right decision to refuse the COVID-19 vaccine. To some extent there is some equating of ‘healthy’ with the non-vaccination of the baby.

Within many narratives vaccines were pulled back and forth in their capacity to be lifesaving technologies (solution) or harmful substances (enemy). The lack of long-term data due to the ‘newness’ of the disease and subsequent vaccine, was prevalent among participants’ stories. This caused immunity ambiguity for Ari by wanting to protect the unborn child, but being hesitant about how ‘new’ the vaccine is. The lack of long-term data went against Ari’s desire to protect her unborn child, and situated the vaccine immunity as intermittingly the enemy and the solution. For instance, vaccine-induced immunity was desired: ‘Ari feels confident in having herself vaccinated’, at the same time as situating the vaccine as a potential enemy to the health of the baby: ‘but is unsure of whether there are negative long-term consequences on the foetus’ (P6). Whilst there was a sense of desperation for vaccine-induced immunity, often ‘natural’ immunity was seen as more desirable and safe for the baby.

In contrast, the following narrative leans toward viewing the vaccine as being a technology that contributed to their unborn child growing healthy and strong. The act of vaccinating while pregnant, whilst still inducing anxiety, was seen to pass antibodies to the unborn child, protecting them in and outside of the womb.

Ari feels nervous about whether the vaccine will impact her baby negatively, as it does not seem that there has been much time to test any long-term impacts. When COVID-19 was absent in the New Zealand community, it was easy to ignore the decision to get vaccinated. Now that the virus has become widespread, there is pressure to make an active decision to either get vaccinated or not. On the one hand, it is unclear whether getting vaccinated will impact Ari’s, unborn baby. On the other hand, getting vaccinated could provide protection, especially if antibodies are provided to the baby. This may protect the baby once it is born, given it won’t be able to get vaccinated itself. In the end, Ari decides to follow the professional advice and get vaccinated in the hope of protecting her baby. (P55)

Despite ambiguity, Ari was here leaning more towards vaccination as the solution. The participant also uses the word ‘hope’ concerning the protection of her baby, signalling that although Ari has sought medical advice, there is still ambiguity. Ari hopes there are no effects on her baby, but all she can do is trust an expert’s advice.

DISCUSSION

This study explores the arising ambiguities in the decision-making processes of receiving the COVID-19 vaccination during pregnancy. These ambiguities presented as being torn between who makes the decision (agential), what the risks are (risk) and how immunity to this threat can be best achieved (immunity). A unified theme that was woven throughout was that decisions and contemplations were driven by a desire to do ‘what is best for my baby’, strongly correlating with the good mother discourse prevalent in New Zealand society.

The findings show that many participants’ described Ari as being indecisive about vaccinating. In a similar vein to other research, the need to decide about vaccination during pregnancy is associated with guilt, stress and anxiety (Gunderson and Barrett, 2015). Our findings illustrate the complexity of the decision-making process to vaccinate, contrasting the perceived divide between pro- and anti-vaccination. People who are vaccine-hesitant are often portrayed as conspiracy theorists Schuster et al. (2023). Schuster et al. (2023) dispute this rhetoric and suggest that vaccine hesitancy is a psychological state rather than indecision for individuals that fall in the ‘middle-ground’ between vaccine acceptance and refusal. Similarly to the current study, Schuster et al. (2023) found that mothers experienced this decision as a burden, including fear of being a ‘bad mother’ and anticipated feelings of guilt if the wrong COVID-19 vaccination decision were to be made. A key feature throughout the data was the ambiguity that persisted in many of the decision-making stories. In the context of the COVID-19 global pandemic, individuals made decisions to receive or refuse the COVID-19 vaccine under uncertainty and reducing ambiguity in the decision-making process can encourage individuals to vaccinate (Courbage and Peter, 2021). Participants’ narratives represented the complex nature of COVID-19 vaccination decision-making, and pregnant women/people were under much pressure during this time. Additionally, the ever-present media environment of the 21st century led people to multiple, sometimes contradictory, sources of information regarding COVID-19 and vaccination (Courbage and Peter, 2021). Participants’ narratives noted the uncertainty on the likelihood of being infected, the severity of their infection, new strains and the efficacy of the vaccine and its side effects. These factors can affect decision-making and influence people’s behaviour (Courbage and Peter, 2021). Pregnant women/people faced a double burden of uncertainty with the pandemic and the new responsibility for their baby creating exacerbated uncertainties.

Across the findings notions of individualism and choice featured heavily, reflecting the neoliberal discourse relayed upon mothers. In a neoliberal society, mothers are expected to support themselves and their families through autonomy and personal responsibility (Lavee, 2015). This was reflected in our findings, as participants stated that the decision held much pressure, and they feared the guilt and blame Ari would encounter if she made the ‘wrong’ decision. As Salecl (2010) observes, whilst choice is often figured as freedom under neoliberalism, it can also function as a kind of ‘tyranny’, placing an anxiety-provoking burden on the chooser. The freedom to choose was often conflicted within the participants’ narratives, as external agents, such as family, friends, work, health care professionals and communities, influenced the decision-making process. The ‘newness’ of the COVID-19 pandemic and the lack of guidance meant that individuals used information gathering to decide whether to vaccinate or not and, in some cases, relied heavily on external agencies for support. Notions of ambiguity and a ‘tug of war’ between internal and external agencies showed the protagonist in the participants’ stories as yearning for external opinions and support within the decision-making process. There is an apparent lack of collective decision-making frameworks for vaccination, which considering the importance of family, as part of the decision-making unit, could de-individualize the vaccination decision and allow pregnant women/people to feel safe and supported.

A key finding from this study was that the prevalence of COVID-19 in the community affected how participants described Ari’s decision-making, which was a fluctuating occurrence across the data collection period. Similarly, Karafillakis et al. (2021) assert that vaccination decision-making shows that the greater the prevalence and severity of a disease, the more likely mothers vaccinate. Similarly to this study, Lupton (2022) found that individuals weighed up risks such as COVID-19 cases in the community and vaccination rates when considering vaccinating. Within the current study, some stories noted that anecdotal information, such as a story of a pregnant woman contracting COVID-19 and becoming severely ill, resulting in Intensive Care Unit (ICU) admission for the infant, impacted vaccine decision-making. This story, in turn, led the protagonist to vaccinate. Storytelling (particularly via social media) has been used substantively in the anti-vaccine movement to spread fear of vaccine injury. Combining science and stories to combat the spread of misinformation has been suggested as an effective tool for promoting vaccination uptake (Shelby and Ernst, 2013), and is indicated within our findings as a potentially fruitful strategy to pursue.

The study found that some participants described Ari as being affected by misinformation in the COVID-19 vaccine decision-making process. This often resulted in avoiding vaccination and instead focusing on wellbeing, strengthening natural immunity through supplements, reducing stress, and eating nutritional foods. It was noticeable that this idea of natural immunity presupposed privilege, where the protagonist believed that healthy eating and alternative practices would boost immunity and, therefore, vaccination was unnecessary. Reich (2014) found that mothers had unacknowledged privilege when considering if vaccines were appropriate for children. Mothers within Reich’s study viewed vaccines as a necessary evil for children whose parents failed to care for them through elite feeding and care practices. Although both immunity-boosting health practices and vaccination complement each other, the findings in this study indicate that misinformation could lead pregnant women/people to believe that good health practices alone will suffice. Similarly, Smith et al. (2022) found that participants refusing vaccination used alternative practices to boost immunity against diseases, such as alternative therapies, altering lifestyle factors, dietary practices, supplements, breastfeeding and homoeopathic immunization. However, focusing on health and wellbeing and accessing healthy, nutritious food requires time, resources and skills (Smith, 2022), which is inequitably distributed. The pervasiveness of the ‘natural immunity boosting’ discourse has inequitable consequences for women, babies and families. The privilege of being able to rely on immune-boosting foods and practices is built on the back of access to warm homes, healthcare access and lower chronic stress, ultimately linking to the privileged access to the social determinants of health. When the virus arrives the unequal distribution of wealth disproportionately disadvantages more marginalized families. Emphasizing the complementary roles of vaccines and other immune-boosting health practices, rather than as either/or approaches to immunity, may help traverse antagonism for vaccines over ‘natural’ immune-boosting.

Strengths and limitations

Using story completion methods in this study is a unique way to understand socio-cultural discourses around COVID-19 vaccination decision-making. Story completion methods create a non-intrusive research technique (Clarke et al., 2019) which complemented researching a sensitive and complex topic of immunization. Along with this, story completion methods allowed us to use online tools to collect data, which was necessary during the global pandemic and also allowed for geographical access across Aotearoa New Zealand.

A limitation of using story completion methods is the wide variation in the richness of the participants’ stories. Some stories were long, complicated and highly creative and others were short and simple, which limited the analysis of these stories. Another limitation of the methodology is that data generated from story completion methods is sometimes believed to be less transparent and harder to analyse, such as identifying patterns or themes compared to traditional self-report data (Clarke et al., 2019). Story completion techniques are often criticized for not being ‘reality’, and participants’ stories are, therefore, artificial (Clarke et al., 2019). However, Clarke et al. (2019) argue that what is ‘real’ and ‘artificial’ is an ontological question, and where one sits determines how valid the artificial critique is.

CONCLUSION

Pregnant women/people with COVID-19 disease have an increased risk of developing severe symptoms and are four times more likely to be admitted to hospital ICUs (Wei et al., 2021). Vaccination is one of the most cost-effective public health tools to combat disease, including COVID-19, preventing the spread of the disease while reducing the burden among vulnerable populations and healthcare systems (Doherty et al., 2016; Truong et al., 2022). In this study, we used storytelling to get participants engaged in narrative constructions using a third person, allowing us to analyse constructions of COVID-19 vaccination decision-making. Overall, we found that the decision is incredibly complex and beyond categories of pro- or anti-vaccination. Pregnant women constructed Ari’s immunisation decisions as ambiguous and challenged conventional binary vaccination discourse. More collective and distributed agency for vaccination decision-making could help reduce the pressure and guilt placed upon those who are pregnant and needing to make vaccination decisions. Further research should also explore how opposing discourses (natural immunity vs. vaccine immunity) could be melded for the combined marketing of vaccine uptake.

AUTHOR CONTRIBUTIONS

The study was the first author’s Masters thesis. She designed the study, collected the data and drove analysis and write-up. The second author supervised the project and intellectually contributed to the project and article across all stages.

REFERENCES