Association of Discrimination and Health Care Experiences With Incomplete Infant Vaccination During COVID-19

The COVID-19 pandemic has profoundly affected the lives of pregnant individuals and their infants, resulting in prenatal health care disruptions,¹ reduced duration of postpartum hospitalization, a sharp decrease in infant vaccination rates,² and other stressful situations. Understanding predictors of vaccination, particularly when vaccine hesitancy is increasing,³ is important to developing public health policies and preventive interventions to increase vaccine uptake.⁴ We prospectively investigated how maternal experiences predicted vaccination status among infants born during the COVID-19 pandemic. Specifically, we examined the contribution of COVID-19–related health care limitations (eg, prenatal telehealth care, <2 days postpartum hospitalization), perinatal experiences (eg, discrimination, birth satisfaction), COVID-19–related stress,¹ and known social determinants of health to vaccination status of infants at 3 to 5 months of age.⁴

We analyzed data from the first and third time points of the Stony Brook COVID-19 Pregnancy Experiences (SB-COPE) Study for this report. A prospective logistic regression prediction model was used while analyzing data. Between April 25 and May 14, 2020, 4388 pregnant women across the US who were 18 years or older were recruited through social media to participate in the SB-COPE Study and completed the baseline study survey (point 1), with follow-up surveys in July 2020 (point 2) and October 2020 (point 3). A total of 1107 infants were 3 to 5 months old (12 weeks to 23 weeks) at time point 3. Study measures included validated instruments assessing sociodemographic, maternal and infant characteristics, maternal psychological stress, and health care experiences. The primary outcome measure was vaccination uptake, assessed by asking mothers whether the infant had received all, some, or none of the recommended vaccines. We categorized vaccine uptake dichotomously with 0 indicating fully vaccinated vs 1 indicating incomplete vaccination (received some/none of the recommended vaccines). We performed bivariate analyses to examine associations between predictors and vaccine uptake, followed by stepwise binary logistic regression to identify unique predictors of vaccine uptake. Waiver of documentation of consent was approved by the institutional review board of Stony Brook University. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines were used. P values were 2-sided with a .05 significance threshold.

The 1107 infants in this study were born between April 27, 2020, and July 30, 2020. A total of 89 infants (8.0%) had incomplete vaccine uptake at age 3 to 5 months (51 [4.6%] received some vaccines and 38 [3.4%] did not receive any vaccines). Additional study sample characteristics can be found in Table 1. In bivariate analyses, incomplete vaccine uptake was associated with previously established predictors (eg, parity, education, health insurance) and with COVID-19– and non–COVID-19–related stress factors (eg, income loss, discrimination, receiving telehealth prenatal care, and briefer postpartum hospitalization) (Table 1). Several key predictors persisted in the multivariate analysis (Table 2). These included perinatal care limitations (telehealth prenatal care and brief postpartum hospitalization), COVID-19–related income loss, and experiencing discrimination owing to one’s race, gender, sexuality, or body size. Mothers with greater concern about perinatal infection and greater birth satisfaction had decreased risk of incomplete vaccine uptake.

Perinatal care limitations, experiencing discrimination during pregnancy, and preterm birth were the strongest predictors of incomplete vaccination status at age 3 to 5 months. COVID-19–related income loss was also associated with increased risk of incomplete vaccination, possibly due to limited access to health care or affordability of health care. Reliance on telehealth prenatal care and on brief postpartum hospitalization may diminish opportunities for vaccine education. While this study is limited by its self-selected sample and self-report data, it is strengthened by the prospective design and inclusion of an array of previously established and newly identified predictors.

Since vaccination status in early infancy is overwhelmingly predictive of future up-to-date vaccination status,⁵ strategies to address perinatal care limitations and discrimination merit serious consideration by policy makers, health care organizations, and obstetric and pediatric clinicians.^4,6 To promote infant vaccination, special attention should be given to vulnerable women who experienced financial loss or discrimination or had negative health care experiences. Policies and protocols are needed to guarantee sufficient patient education about infant vaccination regimens, especially when health care is disrupted.

Accepted for Publication: September 17, 2021.

Published Online: November 22, 2021. doi:10.1001/jamapediatrics.2021.4710

Corresponding Author: Heidi Preis, PhD, Department of Psychology, Stony Brook University, Stony Brook, NY 11794 (heidi.preis@stonybrook.edu).

Author Contributions: Dr Preis had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Preis, Lobel, Mahaffey.

Drafting of the manuscript: Preis.

Critical revision of the manuscript for important intellectual content: Lobel, Mahaffey, Pati.

Statistical analysis: Preis.

Obtained funding: Preis, Lobel, Mahaffey.

Administrative, technical, or material support: Preis, Lobel.

Supervision: Lobel, Mahaffey.

Conflict of Interest Disclosures: Drs Preis, Lobel, and Mahaffey reported a grant from Stony Brook University Office of the Vice President for Research and Institute for Engineering-Driven Medicine. Drs Preis and Lobel reported a grant from the National Institutes of Health/National Institute on Drug Abuse. Drs Lobel and Mahaffey reported a grant from the State University of New York. Dr Mahaffey reported a grant from the National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr Pati reported a patent for the Keeping Families Healthy Orientation Guide (TXu 2-021-713) issued by Stony Brook University, Department of Pediatrics; is a co-investigator for a grant funded by the Klingenstein Third Generation Foundation; and is an external advisor to McKinsey and Company.

Funding/Support: Funding for this study was provided by a Stony Brook University Office of the Vice President for Research and Institute for Engineering-Driven Medicine COVID-19 seed grant. Dr Preis received support from the National Institutes of Health (grant R21DA049827) during the preparation of this article. Dr Mahaffey received support from the National Institutes of Health (grant K23HD092888) during preparation of this article.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.