Background: Lower rates of COVID-19 vaccination among pregnant women prompt an investigation into the underlying reasons. This study aims to explore the attitudes of pregnant women in Pakistan regarding COVID-19 vaccination decision-making and to identify the factors influencing their vaccine uptake.

Methods: A cross-sectional survey of pregnant women was conducted at two hospitals in Karachi in February-May 2024. The survey included a four-point Likert scale to evaluate 19 attitudes toward COVID-19 vaccination during pregnancy. These attitudes were later grouped into nine categories: disease risk perception, vaccine effectiveness, vaccine safety, general hesitancy (including concerns about vaccine ingredients), self-efficacy, social norms and family norms. Multivariable logistic regression was performed to identify attitudes associated with vaccine uptake.

Results: Among the 400 women surveyed, 46 % (95 %CI: 41-51) reported being vaccinated against. COVID-19. Participants with higher COVID-19 risk perception were 5.71 times more likely to be vaccinated than their counterparts (95 %CI: 2.65-12.29). Those with higher self-efficacy and those who believed their friends or family had received or would receive the vaccine, had 2.28 (95 %CI: 1.08-4.65) times and 2.19 (95 %CI: 1.03-4.65) times higher odds of being vaccinated, respectively. The adjusted odds ratio for general vaccine hesitancy was 0.37 (95 %CI: 0.18-0.78), indicating that women with higher hesitancy were 63 % less likely to be vaccinated compared to those with lower hesitancy. Furthermore, women with less support from family regarding vaccine decision-making were 69 % less likely to be vaccinated than those who received more support.

Conclusion: Attitudes associated with increased vaccination among pregnant women were higher COVID-19 risk perception, higher self-efficacy, and supportive social norms. In contrast, general vaccine hesitancy, and unsupportive family norms were significant barriers to vaccination during pregnancy. Targeted strategies are needed to address women's concerns about vaccine ingredients and promote supportive family influences, enhancing vaccine uptake in this important group.