COVID-19 infections have been a major public health event since 2019 (1). The novel coronavirus has infected millions of people, disrupted health care systems, and caused global lockdowns (2). During the pandemic, the consistent use of face masks and maintenance of social distancing were identified as key preventive measures until mass vaccinations were initiated (3). Worldwide, once nations administered the vaccine, it substantially changed the course of the pandemic and saved millions of lives (4). Evidence has shown that pregnant women are likelier to become infected by SARS-CoV-2 (5). Pregnant women with COVID-19 infections are also at an elevated risk of severe illness and mortality (6, 7). Previous findings have shown that pregnant women hospitalized due to COVID-19 are likelier to be admitted to the intensive care unit (ICU), to require invasive ventilation, and to experience death compared with non-pregnant women with COVID-19 (8–11). Additionally, pregnant women with COVID-19 were found to have a higher risk of unfavorable birth outcomes, including stillbirth, preterm birth, cesarean delivery, and high rates of neonatal ICU admissions, compared with pregnant women without COVID-19 (12, 13). Limited evidence of vertical transmission of SARS-CoV-2 also exists (14). COVID-19 vaccination has been found to be the most efficient and effective way to prevent the transmission of SARS-CoV-2 to pregnant women and fetuses, as well as serious illness or other consequences, by producing immune responses during pregnancy (15, 16). The vaccine also protects the fetus or neonate against COVID-19 infection through the passive transplacental transfer of antibodies from the vaccinated mother during pregnancy (17). Thus, the Centers for Disease Control and Prevention, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists have strongly recommended that pregnant women be vaccinated to prevent maternal and fetal morbidity and mortality (18–20).

Low vaccine uptake has become a growing challenge worldwide (21–24). According to the World Health Organization (WHO), vaccine hesitancy was one of the top 10 health threats worldwide before the outbreak of the COVID-19 pandemic in 2019 (25). A previous literature review showed varying results for global vaccine acceptance during pregnancy (26).

Sudan was the first country in the Middle East and North Africa to obtain the COVID-19 vaccine through the Vaccines Global Access (COVAX) facility through the GAVI vaccine alliance, the Coalition for Epidemic Preparedness Innovations, the WHO, and UNICEF, a key delivery partner, in March 2021 (4, 27). By the end of 2021, it was anticipated that Sudan would obtain a 17 million doses from the COVAX facility, which would cover 20% of the populace (27). Furthermore, it was projected that in excess of 38 million doses would be secured to encompass at the minimum 45% of the Sudanese demographic prior to the realization of herd immunity (27, 28). Sudan administered the COVID-19 vaccine in three phases. Frontline health care workers were vaccinated in the first phase (28). In the second phase, people over 45 years of age with chronic medical conditions, school staff and teachers, and high-risk people who could not avoid exposure to COVID-19 due to the nature of their jobs were vaccinated (28, 29). In the third phase, pregnant women, lactating mothers, children, adolescents up to 16 years, and 80 people aged 16–45 years were vaccinated (29). In phase 3 of the vaccination campaign, there was a moderate level of vaccine availability to cater to this targeted population subset, ranging from 21 to 50% (28, 29). The financing of the third phase of COVID-19 vaccination necessitated the Sudanese government’s willingness to allocate funds toward the initiative amid the ongoing economic crisis (27). Internal funding and support for the health care system in Sudan have been lacking, which has been compounded by the long-standing economic sanctions in effect for two decades until 2017 (27, 28). To achieve the objective of vaccinating 50% of the population, the Sudanese government had to collaborate with external organizations to obtain funding and assistance in enhancing access to vaccines among citizens. Failure to do so would exacerbate the COVID-19 situation in the country (28).

The current fertility rate in Sudan is 4.4 births per woman (30). Previous studies have revealed varying rates of COVID-19 vaccine acceptance among pregnant women (31, 32). The acceptance rate for the COVID-19 vaccine among the Sudanese population has been low (33). However, no previous study has been conducted on acceptance of the COVID-19 vaccine by pregnant women in Sudan. Hence, this study aimed to determine COVID-19 vaccination acceptance and its predictors among pregnant women.

A total of 623 participants were included in this study. The median (IQR) age was 28 (24–32) years, the median (IQR) gestational age was 32 (27–38) weeks, and the median (IQR) parity was 3 (2–5). Two-thirds (66.4%) of the participants lived in rural areas. The numbers and proportions of the pregnant women and their husbands who had secondary school or higher-level education were 369 (59.2%) and 311 (49.9%), respectively. The majority (570, 91.5%) were housewife, participants with people over 60 years in their households numbered 434 (69.7%), and 27 (4.3%) of the pregnant women had comorbidities (Table 1). Only 17 (2.7%) of the pregnant women were willing to receive the COVID-19 vaccine, none of whom had a history of COVID-19 infection (Table 2). The results of the bivariate analysis showed that the pregnant women were likelier to receive the COVID-19 vaccine if their husbands had a secondary school education or higher (COR 4.86, 95% CI 1.38–17.07, p = 0.014), were employed (COR 3.49, 95% CI 1.09–11.14, p = 0.034), if their husbands had a history of COVID-19 infection (COR 9.97, 95% CI 1.94–50.97, p = 0.006), if they themselves believed that the COVID-19 vaccine was safe (COR 6.59, 95% CI 2.49–17.63, p < 0.001) and effective (COR 6.14, 95% CI 2.26–16.71, p < 0.001), and if hospital staff had discussed the COVID-19 vaccine with them (COR 5.46, 95% CI 1.94–15.35, p < 0.001; Table 3).

The results of the multivariable analysis showed that the variables that remained statistically significant predictors were as follows: husband’s education equal to secondary school or higher (adjusted odds ratio [AOR] 4.30, 95% CI 1.11–16.65 p = 0.035); and hospital staff discussed the COVID-19 vaccine with the pregnant women (COR 5.46, 95% CI 1.94–15.35, p < 0.001; Goodness of fit was evaluated by area under ROC curve which was 0.80 in the model; Table 3). Among the participants, the most frequent reason for not accepting the COVID-19 vaccination was concern about the side effects of the vaccine on the mother and her baby. The second most frequent reason was inadequate information about the safety of the vaccine, followed by the participants’ inability to find a suitable time to schedule an appointment for the vaccine, and the belief that the rate of COVID-19 infection was decreasing in the city of their residence (Table 4).

To the best of our knowledge, our study is the first to examine COVID-19 vaccine acceptance by pregnant women in Sudan. The findings showed a rate of COVID-19 vaccine acceptance in pregnant women of 2.7%, which is lower than the acceptance rate among African countries like Ethiopia (70.7%), South Africa (63.3%), and Cameroon (31%) (43–45). A systematic review and meta-analysis reported wide variations in countries around the globe for COVID-19 vaccine uptake among pregnant women, ranging from 7.0 to 68.7% (46). Contemporary research studies have reported an acceptance rate below 40% among pregnant women in India (18%), Singapore (30.3%), Ireland (38%), Turkey (37%), France (29.5%), and Japan (13.4%) (37, 47–51). On the other hand, China (77.4%), Thailand (60.8%), Saudi Arabia (68%), Qatar (75%), the United Kingdom (62.1%), Czechia (76.6%), Italy (84.5%), and the United States (76.2%) were reported to have more than a 60% acceptance rate among pregnant women (10, 32, 41, 42, 52–55).

The current study showed the lowest acceptance rate (2.7%) of COVID-19 vaccine uptake among pregnant women worldwide. The Africa CDC have reported a fully vaccinated rate for Sudan of 40.2% (56). However, our research indicates a notable lack of vaccination acceptance among pregnant women, which could result in a failure to reach the targeted phase 3 vaccination range of 21–50% in Sudan. This reluctance to receive a COVID-19 vaccination can be efficiently resolved by addressing the specific reasons that have been identified in our study. The primary concerns most commonly expressed by expectant mothers pertained to the safety of both their own health and that of their fetuses, thus corroborating the conclusions drawn from numerous antecedent studies (31, 37, 57–60). Additionally, a lack of sufficient information regarding the vaccine’s safety, as well as the inability to schedule a suitable time for the COVID-19 vaccination appointment during pregnancy, were cited as contributing factors in our research. The matter of vaccination trials or administration during pregnancy in Africa is shrouded in silence (61). The Pfizer-BioNTech vaccine, which has been approved, is not a live virus vaccination but rather an mRNA vaccine, and the Royal College of Obstetricians and Gynecologists has declared that there is insufficient evidence to support the routine use of COVID-19 vaccines for pregnant or breastfeeding women. Furthermore, women who plan to conceive within 3 months of receiving the first dose have been advised against getting vaccinated (62). The accelerated vaccine development process, which has employed modern technologies, has increasingly come under scrutiny (63). A survey conducted between August and December 2020, spanning 15 African countries, including Burkina Faso, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Gabon, Kenya, Malawi, Morocco, Niger, Nigeria, Senegal, South Africa, Sudan, Tunisia, and Uganda, polled over 15,000 adults aged 18 years and above. The Africa CDC collaborated with the London School of Hygiene & Tropical Medicine to conduct the survey, which revealed that a considerable majority (an average of 79%) of respondents in Africa would get vaccinated against COVID-19 if it was deemed safe and effective (64). Despite the absence of unequivocal proof regarding the timing and adverse effects of COVID-19 vaccination in pregnant women, no previous observational study or large case series has evinced any deleterious impact of the COVID-19 vaccine on the health of pregnant women or their neonates (65–71).

The findings of the present study showed an association between pregnant women whose husband’s education was equal to or higher than secondary level and a higher rate of COVID-19 vaccine acceptance. This can be rationalized by the indispensable role played by husbands in the process of making informed decisions pertaining to the administration of vaccines for women (72). This finding is similar to a study by Tefera et al. (73), who attributed the association to the ability of educated husbands to read and communicate to their wives news and social media messages related to the seriousness of COVID-19 infection and the positive effects of the vaccine. In Sudan, gender roles are characterized by a strong patriarchal influence, with rigid definitions in place. The male population is predominantly perceived as the primary breadwinners and decision-makers, while their female counterparts are predominantly viewed as homemakers. It is expected that husbands take on the economic responsibility of providing for their wives and children throughout their lifetimes (74).

Another important finding of our study was that the vaccination likelihood of pregnant women with whom any hospital staff discussed the potential benefits of the COVID-19 vaccine was higher compared with those who did not have that experience. This finding is consistent with the findings of recent studies by Riad et al. (10) in Czechia and Nganga et al. (75) in Kenya, which showed that the COVID-19 vaccine was likelier to be accepted by pregnant women if it was recommended by health care professionals (HCPs) and it was made accessible to them. The same findings were endorsed in a literature review by Wilson et al. (26). Therefore, it is highly recommended that HCPs be educated about evidence-based recommendations for maternal vaccinations during pregnancy to enable them to address vaccine-hesitant pregnant women (76, 77). The present study had the following limitations. Causal relationships could not be established because of the inherent limitations of the cross-sectional study design, the time factor in conducting the study during the COVID-19 pandemic produced limitations for properly validating the questionnaires, and the validation consisted only of expert judgment and a pilot study on 20 mothers, which is inadequate for proper psychometric validation of the tool.

Acceptance of the COVID-19 vaccination among the pregnant women in this study was extremely low. Discussions with pregnant women and their husbands by an HCP regarding the safety of the COVID-19 vaccine for both mother and baby are highly recommended. We also recommend that future vaccination campaigns focus on enhancing HCPs’ communication skills to ensure the engagement of pregnant women and promote vaccination uptake during pregnancy. The findings of our study could provide guidance for health care providers and policymakers in designing effective strategies to improve vaccine uptake during pregnancy in eastern Sudan.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The ethics committee of Gadarif University was approved the current study (reference number 15,06,2022). The patients/participants provided their written informed consent to participate in this study.

IA and OA-W conceived and designed the study. OO and SO prepared the manuscript. OO, IA, and SO supervised the study, and OA-W, RK, and IA contributed to the paper editing. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.