Factors that influence vaccination decision-making among pregnant women: A systematic review and meta-analysis

Exploring parental perspectives: Maternal RSV vaccination versus infant RSV monoclonal antibody

Respiratory Syncytial Virus poses a significant global public health threat, particularly affecting infants aged less than one year of age. Recently, two forms of passive immunization against infant RSV have been developed and brought to market; nirsevimab a long-acting monoclonal antibody (mAb) and RSV-PreF, a maternal RSV vaccine. The acceptability and uptake of these products will play a pivotal role in determining the success of any national immunization strategy aimed at safeguarding infants from RSV. It is crucial at this time to reflect on the factors that influence parental decisions surrounding immunization to facilitate more informed discussions, enhance healthcare communication, and contribute to the design of effective RSV prevention strategies that resonate with the concerns and aspirations of parents worldwide.

Effectiveness of cocoon strategy vaccination on prevention of influenza-like illness in young infants

During the initial half-year of their existence, infants cannot receive the influenza vaccine, yet they face the greatest susceptibility to severe influenza complications. In this study, we seek to determine whether influenza vaccination of maternal and household contacts is associated with a reduced risk of influenza-like illness (ILI) and severe acute respiratory infection (SARI) in infants. This work was prospectively conducted during the influenza season. A total of 206 infants were included in this study. The percentage of infants with only the mother vaccinated is 12.6% (n:26), and the percent of infants with all household contacts vaccinated is 16% (n:33). Among the infants with only the mother vaccinated, the effectiveness of influenza vaccine is estimated as 35.3% for ILI and 41.3% for SARI. Among infants with all household contacts vaccinated, the effectiveness is estimated as 48.9% for ILI and 76.9% for SARI. Based on the results of multivariate logistic regression analysis, all-household vaccination is a protective factor against SARI (OR: 0.07 95% CI [0.01-0.56]), household size (OR: 1.75, 95% CI [1.24-2.48]) and presence of secondhand smoke (OR: 2.2, 95% CI [1.12-4.45]) significant risk factors for SARI in infants. The mother alone being vaccinated is not a statistically significant protective factor against ILI (OR: 0.46, 95% CI [0.19-1.18]) or SARI (OR: 0.3, 95% CI [0.11-1.21]). Along with the obtained results and analysis, this study provides clear evidence that influenza vaccination of all household contacts of infants aged 0-6 months is significantly associated with protecting infants from both ILI and SARI.

Number of tetanus toxoid injections before birth and associated factors among pregnant women in low and middle income countries: Negative binomial poisson regression

BACKGROUND

In low- and middle-income countries where vaccination rates are low, tetanus is still an important threat to public health. Although maternal and neonatal tetanus remains a major global health concern, its magnitude and determinates are not well studied. Therefore, this study aimed to assess the number of tetanus toxoid injections and associated factors among pregnant women in low- and middle-income countries.

METHODS

Data from the most recent Demographic and Health Surveys, which covered 60 low- and middle-income countries from 2010 to 2022, was used for secondary data analysis. The study included a total of 118,704 pregnant women. A statistical software package, STATA 14, was used to analyze the data. A negative binomial regression of a cross-sectional study was carried out. Factors associated with the number of tetanus vaccinations were declared significant at a p-value of < 0.05. The incidence rate ratio and confidence interval were used to interpret the results. A model with the smallest Akaike Information Criterion and Bayesian Information Criterion values and the highest log likelihood was considered the best-fit model for this study.

RESULTS

In low- and middle-income countries, 26.0% of pregnant women took at least two doses of the tetanus toxoid vaccine. Factors such as maternal education, primary (IRR = 1.22, 95% CI: 1.17, 1.26), secondary (IRR = 1.19, 95% CI: 1.15, 1.23), higher (IRR = 1.16, 95% CI: 1.12, 1.20), employment (IRR = 1.11, 95% CI: 1.09, 1.13), 1-3 ANC visits (IRR = 2.49, 95% CI: 2.41, 2.57), ≥4 visits (IRR = 2.94, 95% CI: 2.84, 3.03), wealth index (IRR = 1.06; 95% CI: 11.04, 1.08), ≥birth order (IRR = 1.04, 95% CI: 1.02, 1.27), distance to health facility (IRR = 1.02, 95% CI: 1.00, 1.03), and health insurance coverage (IRR = 1.08; 95% CI: 1.06, 1.10) had a significant association with the number of tetanus vaccinations among pregnant women.

CONCLUSIONS AND RECOMMENDATIONS

This study concludes that the number of tetanus toxoid vaccinations among pregnant women in low- and middle-income countries is low. In the negative binomial model, the frequency of tetanus vaccinations has a significant association with maternal employment, educational status, wealth index, antenatal care visits, birth order, distance from a health facility, and health insurance. Therefore, the ministries of health in low and middle-income countries should give attention to those women who had no antenatal care visits and women from poor wealth quantiles while designing policies and strategies.

COVID-19 vaccine safety during pregnancy and breastfeeding in women with autoimmune diseases: results from the COVAD study

OBJECTIVES

We investigated coronavirus disease 2019 (COVID-19) vaccine safety in pregnant and breastfeeding women with autoimmune diseases (AID) in the COVID-19 Vaccination in Autoimmune Diseases (COVAD) study.

METHODS

Delayed-onset (>7 days) vaccine-related adverse events (AE), disease flares and AID-related treatment modifications were analysed upon diagnosis of AID vs healthy controls (HC) and the pregnancy/breastfeeding status at the time of at least one dose of vaccine.

RESULTS

Among the 9201 participants to the self-administered online survey, 6787 (73.8%) were women. Forty pregnant and 52 breastfeeding patients with AID were identified, of whom the majority had received at least one dose of COVID-19 vaccine (100% and 96.2%, respectively). AE were reported significantly more frequently in pregnant than in non-pregnant patients (overall AE 45% vs 26%, P = 0.01; minor AE 40% vs 25.9%, P = 0.03; major AE 17.5% vs 4.6%, P < 0.01), but no difference was found in comparison with pregnant HC. No difference was observed between breastfeeding patients and HC with respect to AE. Post-vaccination disease flares were reported by 17.5% of pregnant and 20% of breastfeeding patients, and by 18.3% of age- and disease-matched non-pregnant and non-breastfeeding patients (n = 262). All pregnant/breastfeeding patients who experienced a disease flare were managed with glucocorticoids; 28.6% and 20% of them required initiation or change in immunosuppressants, respectively.

CONCLUSION

This study provides reassuring insights into the safety of COVID-19 vaccines administered to women with AID during the gestational and post-partum periods, helping overcome hesitant attitudes, as the benefits for the mother and for the fetus by passive immunization appear to outweigh potential risks.

COVID-19 Vaccine Acceptance in Pregnancy

OBJECTIVE

 The purpose of the study is to evaluate the acceptance rate of the coronavirus disease 2019 (COVID-19) vaccine among pregnant women at our institution prior to recommendations by national organizations (American College of Obstetricians and Gynecologists/The Society for Maternal-Fetal Medicine) in July 2021 and to determine whether factors including health disparities are associated with acceptance.

STUDY DESIGN

 This is an Institutional Review Board exempt descriptive study. Anonymous surveys were administered from February 2021 to May 2021 to pregnant patients at Mount Sinai South Nassau's affiliated Maternal Fetal Medicine office. The survey was completed by 701 pregnant women. Descriptive statistics were calculated for the overall sample, as well as separately by group (acceptance versus declining/undecided about getting the COVID-19 vaccine). The two groups were compared using the chi-square test or Fisher's exact test and the two-sample t-test. Analysis was compared between two groups (patients who accepted the COVID-19 vaccine and people who declined/undecided about the vaccine). A result was considered statistically significant at the p < 0.05 level of significance.

RESULTS

 Of the 701 pregnant women who completed the survey, 96 patients accepted the vaccine. More pregnant women who were older accepted the COVID-19 vaccine compared with those who were younger (p = 0.0343). Pregnant women willing to get the flu vaccine and/or the Tdap vaccine in pregnancy were more likely to obtain the COVID-19 vaccine (p < 0.05). Pregnant patients who had household members willing to receive the COVID-19 vaccine sought to obtain the vaccine for themselves (p < 0.0001). Interestingly, pregnant women who had an underlying respiratory illness in the pregnancy were less likely to accept the COVID-19 vaccine than those who had either other or no medical problems (p < 0.05).

CONCLUSION

 There is a low rate of COVID-19 vaccine acceptance among pregnant women (13.69%). Efforts should be made to encourage the vaccine in this vulnerable population to protect them from the health risks of the COVID-19 virus.

KEY POINTS

· COVID-19 vaccine acceptance rates in our population were 13.6%.. · Accepting Tdap and influenza vaccines increased the likelihood of accepting the COVID vaccine.. · Pregnant patients with respiratory illnesses were more likely to decline the COVID vaccine..

Assessing the Impact of the COVID-19 Pandemic on Pregnant Women's Attitudes towards Childhood Vaccinations: A Cross-Sectional Study

The COVID-19 pandemic has globally disrupted immunisation practices, impacting vulnerable populations such as pregnant women (PW), who harbour concerns about future children's immunisations. This study aimed to assess the pandemic's impact on PW's attitudes towards childhood vaccinations. During three consecutive flu seasons from October 2019 to January 2022, a cross-sectional study was conducted in a large Italian teaching hospital using a questionnaire. The chi-square test was performed to compare each season. Across the 2019-2020 to 2021-2022 seasons, course attendance by PW surged from 105 to 340. Significant shifts in vaccination intentions were noted, including a 7.5% decrease in measles vaccination intent (p = 0.02) and a 10% decrease in that of pertussis (p = 0.004) from 2019-2020 to 2020-2021. While perceived contagion risk decreased, disease severity perceptions increased, with few significant differences. A statistically significant reduction was noted in the proportion of participants suspecting economic motives behind NHS workers' promotion of childhood vaccinations. Furthermore, the pandemic period saw an increase in the perceived utility of non-institutional websites and the advice of physicians outside the NHS. These findings will help develop evidence-based, tailored interventions and communication strategies to address vaccine hesitancy and ensure optimal vaccination coverage among children born during and after the pandemic.

Facilitators and barriers to vaccination uptake in pregnancy: A qualitative systematic review

INTRODUCTION

Vaccination during pregnancy protects both the mother and the foetus from vaccine-preventable diseases. However, uptake of the recommended vaccines (influenza, pertussis, COVID-19) by pregnant women remains low in Europe and the USA. Understanding the reasons for this is crucial to inform strategies to increase vaccination rates in pregnant women. This qualitative systematic review aimed to identify the barriers and facilitators to vaccination against influenza, pertussis/whooping cough and COVID-19 during pregnancy and identify possible strategies to increase vaccination rates.

METHODS

We conducted a comprehensive search of electronic databases, including Medline, PsycINFO, CINAHL, Web of Science, WHO database, Embase and grey literature to identify qualitative studies that explored barriers and facilitators to vaccine uptake among pregnant women (PROSPERO CRD42023399488). The search was limited to studies published between 2012 and 2022 conducted in high-income countries with established vaccination programmes during pregnancy. Studies were thematically analysed and underwent quality assessment using the Joanna Briggs Institute validated critical appraisal tool for qualitative research.

RESULTS

Out of 2681 articles screened, 28 studies (n = 1573 participants) were eligible for inclusion. Five overarching themes emerged relating to personal, provider and systemic factors. Barriers to vaccine uptake included concerns about vaccine safety and efficacy, lack of knowledge about vaccines' benefits and necessity, fear of adverse effects on the foetus or mother and low perception of disease severity. Facilitators included recommendations from trusted healthcare providers, easy access to vaccination, clear communication on the benefits and safety of vaccination, and positive social influences from family and friends. Strategies for increasing vaccination uptake included strong and proactive vaccine recommendations by trusted healthcare professionals, provision of vaccines during routine antenatal care, and clear and consistent communication about vaccines addressing pregnant women's concerns.

CONCLUSION

This review highlights the need for interventions that address the identified barriers to vaccine uptake among pregnant women. Recommendation from a healthcare provider can play a significant role in promoting vaccine uptake, as can clear risk/benefit communication and convenient access to vaccination. Addressing concerns about vaccine safety and providing accurate information about vaccines is also important.

Estimating COVID-19 vaccine acceptance in pregnant and lactating women: a cross-sectional study in Lebanon

BACKGROUND

The COVID-19 pandemic highlights vaccination's critical role in reducing morbidity and mortality, depending on public attitude. This study aims to identify the estimates of COVID-19 vaccine acceptance in pregnant and lactating women, as well as associated potential factors.

METHODS

A cross-sectional study was conducted between August and September 2021, through an online survey and with a paper survey distributed in gynecology and pediatric clinics. Pregnant and breastfeeding women aged 18 years and above were recruited. The attitude scale was created specifically for evaluating attitudes towards the COVID-19 vaccine.

RESULTS

In total, 207 women participated, with 132 breastfeeding, 74 pregnant and 1 experiencing both conditions. Of these, one hundred and twenty women (58%) considered themselves at risk for COVID-19 infection. In addition, 51.7% (n = 107) of women expressed the intent to receive the vaccine once available. A multivariable linear regression was conducted taking the COVID-19 vaccination attitude scale as a dependent variable. The results revealed an R-squared value of 0.558, indicating that approximately 55.8% of the variance in the attitude scale was accounted for by the included predictors. The results showed that preventive measures (ß=2.25, 95% Confidence Interval (CI) [1.02; 3.48], p < 0.001), preference for vaccines made in Europe and America (ß=1.23; 95% CI [0.69-1.77], p < 0.001), protect yourself for getting sick (ß=4.22, 95% Confidence Interval (CI) [2.83; 5.61], p < 0.001) and belief in the importance of vaccination for themselves and their baby (ß=3.49; 95% CI [2.01; 4.98], p < 0.001) were associated with a positive attitude towards vaccination. Conversely, experiencing a previous bad reaction to a vaccine (ß= -1.35; 95% CI [0.85-1.85], p < 0.001) and concerns regarding COVID-19 vaccine safety (ß= -4.09; 95% CI [-5.98; -2.21], p < 0.001) were associated with a negative attitude towards vaccination.

CONCLUSION

Our findings reveal that COVID-19 vaccine acceptability among pregnant and breastfeeding women, amidst the pandemic was insufficient to meet community immunity. The identified reasons for vaccine reluctance, notably concerns about safety for both personal health and the health of their pregnancy or newborns, along with insufficient information about the vaccine, underscore the pressing need to address these factors to improve immunization rates.

Attitudes and behaviors of maternal Tdap vaccination in Panama, Peru, and Colombia: An international cross-sectional study

INTRODUCTION

Despite a recommendation by PAHO for Tdap vaccination in pregnant women since 2019, uptake remains suboptimal across Latin America. This study evaluated the knowledge and attitudes of women towards maternal Tdap vaccination in Colombia, Peru, and Panama to identify the critical behavioral and social drivers of Tdap vaccine uptake during pregnancy.

METHODS

A cross-sectional online survey was undertaken between December 8, 2022, and January 11, 2023, targeting women in Colombia, Peru, or Panama with a child 12 months or under. We collected data on respondents' demographics, social and behavioral determinants of vaccine acceptance, determinants of vaccine uptake (using the validated 5As taxonomy), and previous vaccination experience.

RESULTS

In the 938 respondents who completed the survey (Panama, n = 325; Peru, n = 305; Colombia, n = 308), 73-80 % had received the influenza vaccine, whereas only 30-39 % had received a Tdap vaccine. Significant correlates of Tdap vaccine uptake common to all three countries included a health professional recommendation, knowledge of the vaccine and location of vaccination, perceived vulnerability to pertussis infection, perceived importance of immunization, and receipt of a reminder. In specific countries, nonvaccinated women were more likely to cite issues with ease of access (Panama, Colombia), affordability (opportunity costs; Peru, Colombia), and understanding the rationale for vaccination in pregnancy (Panama, Colombia).

CONCLUSION

To increase maternal Tdap vaccine uptake, health professionals should be encouraged to recommend vaccination consistently, and pregnant women should receive reminders explaining why and where to be vaccinated.

Promoting informed decision making about maternal pertussis vaccination: the systematic development of an online tailored decision aid and a centering-based group antenatal care intervention

Introduction

Maintaining and enhancing vaccine confidence continues to be a challenge. Making an informed decision not only helps to avoid potential future regret but also reduces susceptibility to misinformation. There is an urgent need for interventions that facilitate informed decision-making about vaccines. This paper describes the systematic development of two interventions designed to promote informed decision making and indirectly, acceptance of maternal pertussis vaccination (MPV) in the Netherlands.

Materials and methods

The 6-step Intervention Mapping (IM) protocol was used for the development of an online tailored decision aid and Centering Pregnancy-based Group Antenatal Care (CP) intervention. A needs assessment was done using empirical literature and conducting a survey and focus groups (1), intervention objectives were formulated at the behavior and determinants levels (2), theoretical methods of behavior change were selected and translated into practical applications (3), which were further developed into the two interventions using user-centered design (4). Finally, plans were developed for implementation (5), and evaluation (6) of the interventions.

Results

The needs assessment showed that pregnant women often based their decision about MPV on information sourced online and conversations with their partners, obstetric care providers, and peers. Responding to these findings, we systematically developed two interactive, theory-based interventions. We created an online tailored decision aid, subjecting it to four iterations of testing among pregnant women, including those with low literacy levels. Participants evaluated prototypes of the intervention positively on relevance and usability. In addition, a CP intervention was developed with midwives.

Conclusion

Using IM resulted in the creation of an online decision aid and CP intervention to promote informed decision making regarding MPV. This description of the systematic development of the interventions not only serves to illustrate design rationales, it will also aid the interpretation of the evaluation of the interventions, the development of future interventions promoting informed decision and acceptance of vaccines, and comparisons with other interventions.

Interventions to increase vaccination against COVID-19, influenza and pertussis during pregnancy: a systematic review and meta-analysis

BACKGROUND

Pregnant women and their babies face significant risks from three vaccine-preventable diseases: COVID-19, influenza and pertussis. However, despite these vaccines' proven safety and effectiveness, uptake during pregnancy remains low.

METHODS

We conducted a systematic review (PROSPERO CRD42023399488; January 2012-December 2022 following PRISMA guidelines) of interventions to increase COVID-19/influenza/pertussis vaccination in pregnancy. We searched nine databases, including grey literature. Two independent investigators extracted data; discrepancies were resolved by consensus. Meta-analyses were conducted using random-effects models to estimate pooled effect sizes. Heterogeneity was assessed using the I2 statistics.

RESULTS

From 2681 articles, we identified 39 relevant studies (n = 168 262 participants) across nine countries. Fifteen studies (39%) were randomized controlled trials (RCTs); the remainder were observational cohort, quality-improvement or cross-sectional studies. The quality of 18% (7/39) was strong. Pooled results of interventions to increase influenza vaccine uptake (18 effect estimates from 12 RCTs) showed the interventions were effective but had a small effect (risk ratio = 1.07, 95% CI 1.03, 1.13). However, pooled results of interventions to increase pertussis vaccine uptake (10 effect estimates from six RCTs) showed no clear benefit (risk ratio = 0.98, 95% CI 0.94, 1.03). There were no relevant RCTs for COVID-19. Interventions addressed the 'three Ps': patient-, provider- and policy-level strategies. At the patient level, clear recommendations from healthcare professionals backed by text reminders/written information were strongly associated with increased vaccine uptake, especially tailored face-to-face interventions, which addressed women's concerns, dispelled myths and highlighted benefits. Provider-level interventions included educating healthcare professionals about vaccines' safety and effectiveness and reminders to offer vaccinations routinely. Policy-level interventions included financial incentives, mandatory vaccination data fields in electronic health records and ensuring easy availability of vaccinations.

CONCLUSIONS

Interventions had a small effect on increasing influenza vaccination. Training healthcare providers to promote vaccinations during pregnancy is crucial and could be enhanced by utilizing mobile health technologies.

Impact of Actively Offering Influenza Vaccination to Frail People during Hospitalisation: A Pilot Study in Italy

Despite the worldwide recommendations for influenza immunisation, vaccination coverage for patients exposed to the highest risk of severe complications is still far from the optimal target. The need to take advantage of alternative methods to provide vaccination is essential. This study presents a hospital-based strategy which offers influenza vaccination to inpatients at discharge. This study was conducted during the 2022-2023 influenza season at the University Hospital of Palermo. A questionnaire was administered to identify the determinants for the acceptance of influenza vaccination in the frail population. Overall, 248 hospitalised patients were enrolled, of which 56.1% were female and 52.0% were over 65 years of age. The proportion of patients vaccinated against influenza during hospitalisation was 62.5%, an increase of 16% in influenza vaccination uptake among frail people in comparison with the previous influenza season (46.8% vaccinated during the 2021-22 influenza season). Factors significantly associated with vaccination acceptance were the following: to have received influenza vaccine advice from hospital healthcare workers (OR = 3.57, p = 0.001), to have been previously vaccinated for influenza (OR = 3.16 p = 0.005), and to have had a low level of education (OR = 3.56, p = 0.014). This study showed that offering influenza vaccination to hospitalised patients could be an effective strategy to increase vaccination coverage in the most vulnerable population, and these findings could be useful for planning and improving future influenza vaccination campaigns.

The protective role of maternal genetic immunization on maternal-fetal health and welfare

Pregnancy is a critical period associated with alterations in physiologic, biologic, and immunologic processes, which can affect maternal-fetal health through development of several infectious diseases. At birth, neonates have an immature immune system that makes them more susceptible to severe viral infections and diseases. For this reason, different maternal nutritional and immunization interventions have been used to improve the immune and health status of the mother and her neonate through passive immunity. Here, we reviewed the protective role of maternal immunization with different types of vaccines, especially genetic vaccines, during pregnancy in maternal-fetal health, immune response, colostrum quality, immune response, and anti-oxidative status. For this purpose, we have used different scientific databases (PubMed and Google Scholar) and other official web pages. We customized the search period range from the year 2000 to 2023 using the key words "maternal immunization" OR "gestation period/pregnancy" OR "genetic vaccination" OR "maternal-fetal health" OR "micronutrients" OR "neonatal immunity" "oxidative stress" OR "colostrum quality". The evidence demonstrated that inactivated or killed vaccines produced significant immune protection in the mother and fetus. Furthermore, most recent studies have suggested that the use of genetic vaccines (mRNA and DNA) during pregnancy is efficient at triggering the immune response in mother and neonate without the risk of undesired pregnancy outcomes. However, factors such as maternal redox balance, nutritional status, and the timing of immunization play essential roles in regulating immune response inflammatory status, antioxidant capacity, and the welfare of both the pregnant mother and her newborn.

Pertussis Non-Vaccination During Pregnancy Despite Advice From Prenatal Care Providers

OBJECTIVE

The purpose of this study was to measure the proportion of non-vaccination for pertussis in mothers in Canada who had been advised by their prenatal care provider to get vaccinated, and to identify sociodemographic factors and beliefs associated with non-vaccination.

METHODS

The Survey on Vaccination during Pregnancy (part of childhood National Immunization Coverage Survey) included biological mothers of children born from September 2018 to March 2019. This analysis was restricted to 2657 mothers who had been advised by their prenatal care provider to get vaccinated against pertussis during pregnancy and knew whether or not they had been vaccinated.

RESULTS

Of those who had been advised to get vaccinated against pertussis, 21% were not. This rate varied across provinces and territories, ranging from 9% in Prince Edward Island to 32% in Newfoundland and Labrador. Factors independently associated with pertussis non-vaccination included lower household income, having had past live births, and having received prenatal care from an obstetrician-gynecologist or a midwife compared to a family doctor. The risk of pertussis non-vaccination despite prenatal care advice was higher for those who disagreed that the baby would be at greater risk of pertussis if the mother did not get vaccinated. It was also higher for those who disagreed with statements regarding perceived benefits of vaccination. Conversely, disagreement with statements on perceived barriers was negatively associated with pertussis non-vaccination.

CONCLUSION

These findings highlight the underlying factors associated with non-vaccination against pertussis despite prenatal care provider recommendation. Some inaccurate beliefs about pertussis and vaccination during pregnancy persist, leading to non-vaccination.

Maternal pertussis vaccination behavior: Psychosocial, attitudinal and organizational factors

BACKGROUND

In December 2019, the maternal pertussis vaccination (MPV) became part of the Dutch National Immunization Program. This study aims to study MPV behavior and associated psychosocial, attitudinal and organizational factors of pertussis vaccination behavior during pregnancy in the Netherlands.

METHODS

We conducted a cross-sectional survey among pregnant women and recent mothers, up to six months post-partum. The primary outcome measure of this study was MPV behavior. Associations between psychosocial, attitudinal and organizational factors and MPV behavior were assessed using univariate and multivariate binary logistic regression analysis.

RESULTS

In total 1348 participants filled out the questionnaire, including 1282 (95.1%) MPV acceptors and 66 (4.9%) MPV refusers. The most important factors associated with MPV behavior were: attitude (aOR: 10.19; 95%CI: 4.30-24.16), outcome expectations (aOR: 8.94; 95%CI: 3.60-22.21), omission bias (aOR: 0.11; 95%CI: 0.02-0.59) and physical accessibility (aOR: 7.44; 95%CI: 3.37-16.46).

CONCLUSION

Pregnant women make their decision about the MPV primarily based on attitudinal and psychosocial factors, such as outcome expectations and attitude. A combination and variation of different messages, about the advantages (effectiveness) and disadvantages (side effects) of maternal vaccination, can be used in reaching pregnant women with a positive and negative attitude about the MPV. In addition, strategies to increase MPV uptake should not only focus on providing information, but also decrease experienced practical barriers, such as poor physical accessibility, in people that are intended to receive the MPV but are not getting vaccinated.

Effects of an online tailored decision aid to promote informed decision making about maternal pertussis vaccination in the Netherlands: A randomized controlled trial

INTRODUCTION

In 2019, maternal pertussis vaccination (MPV) during pregnancy was introduced in the Netherlands. New interventions to promote informed decision making (IDM) about vaccinations are highly needed, especially for new vaccinations. Decision aids (DAs) have the potential to support IDM. This study evaluates the effects of an online DA on IDM and MPV uptake.

METHODS

Pregnant individuals, recruited for the randomized controlled trial (RCT), who gave informed consent (N = 1,236) were randomly assigned to the control (N = 650; no information) or intervention condition (N = 586; DA at 18 weeks pregnancy). MPV uptake and IDM were primary outcomes, decisional certainty and psychological determinants of MPV uptake were secondary outcomes. Measures were taken at 18 weeks of pregnancy (baseline) and at 20 weeks of pregnancy (post-test); intervention use was logged. Data were analysed using intention-to-treat analyses, logistic regression, and linear mixed regression models.

RESULTS

Uptake of MPV was high in our sample (92.3 %). No significant effect of the DA condition on MPV uptake was found compared to the control condition. We found that the DA increased IDM (β = 0.24, p < .004) and one of its components level of knowledge about MPV (β = 0.31, p < .004). We also found an increase in decisional certainty (β = 0.24, p < .004), perceived susceptibility (β = 0.24, p < .004), severity of pertussis (β = 0.41, p < .004), and positive affect about MPV (β = 0.15, p < .004). There was a positive association between dose of the intervention and MPV uptake (β = 0.05, p < .004).

DISCUSSION

The DA seemed effective in promoting IDM about and determinants of MPV uptake. No main effect was found on MPV uptake, but MPV uptake was related to the level of exposure to the DA. People with high intentions towards MPV were overrepresented in the sample. However, effects on IDM were consistent among participants with different levels of MPV intention at baseline.

Reactogenicity, pregnancy outcomes, and SARS-CoV-2 infection following COVID-19 vaccination during pregnancy in Canada: A national prospective cohort study

OBJECTIVE

To describe self-reported reactogenicity, pregnancy outcomes, and SARS-CoV-2 infection following COVID-19 vaccination during pregnancy.

DESIGN

National, prospective cohort study.

SETTING

Participants across Canada were enrolled from July 2021 until June 2022.

POPULATION

Individuals pregnant during the COVID-19 pandemic, regardless of vaccination status, were included.

METHODS

The Canadian COVID-19 Vaccine Registry for Pregnant and Lactating Individuals (COVERED) was advertised through traditional and social media. Surveys were administered at baseline, following each vaccine dose if vaccinated, pregnancy conclusion, and every two months for 14 months. Changes to pregnancy or vaccination status, SARS-CoV-2 infections, or significant health events were recorded.

MAIN OUTCOME MEASURES

Reactogenicity (local and systemic adverse events, and serious adverse events) within 1 week post-vaccination, pregnancy and neonatal outcomes, and subsequent SARS-CoV-2 infection.

RESULTS

Among 2868 participants who received 1-2 doses of a COVID-19 vaccine during pregnancy, adverse events described included: headache (19.5-33.9%), nausea (4.8-13.8%), fever (2.7-10.2%), and myalgia (33.4-42.2%). Reactogenicity was highest after the 2nd dose of vaccine in pregnancy. Compared to 1660 unvaccinated participants, there were no statistically significant differences in adverse pregnancy or infant outcomes, aside from an increased risk of NICU admission ≥ 24 h among the unvaccinated group. During follow-up, there was a higher rate of participant-reported SARS-CoV-2 infection in the unvaccinated compared to the vaccinated group (18[47.4%] vs. 786[27.3%]).

CONCLUSIONS

Participant-reported reactogenicity was similar to reports from non-pregnant adults. There was no increase in adverse pregnancy and birth outcomes among vaccinated vs. unvaccinated participants and lower rates of SARS-CoV-2 infection were reported in vaccinated participants.

TWEETABLE ABSTRACT

No significant increase in adverse pregnancy or infant outcomes among vaccinated versus unvaccinated pregnant women in Canada.

Review of short-term and long-term adverse effects of covid-19 vaccination during pregnancy

BACKGROUND

The covid-19 pandemic sparked a debate about the safety of vaccines during pregnancy. However, pregnant women were excluded from the Pfizer-BioNTech vaccine phase 3 trials. As two years have passed since the first Covid-19 vaccine and more studies have been conducted, we want to evaluate the scientific literature to determine any actual risks in taking the vaccine during pregnancy.

METHODS

We conducted literature research using PubMed and Google Scholar databases from January to April 2023. As the review considers short- and long-term adverse effects it was divided into two parts. The first part was conducted as a systematic review. The second concerning long-term negative effects due to lack of research is a literature review. The inclusion criteria for the systematic review part were singleton pregnancies, women vaccinated during pregnancy, and studies from 2020 and later. The most common short-term pregnancy adverse effects were included in the search: preterm delivery, small gestation age, intrauterine death, congenital defects, stillborn, fetal growth retardation, spontaneous abortion. Maternal immune activation was the primary concern for the long-term adverse effects and whether vaccination could cause it. The search terms included maternal immune activation, fetal neurodevelopment, neuropsychiatric disorders and the studies used were from 2019.

RESULTS

Most studies showed no significant difference in short-term adverse effects between vaccinated and non-vaccinated women and their fetuses. However, the literature is insufficient to evaluate possible long-term adverse effects.

CONCLUSION

Available evidence supports the safety of administering SARS-CoV-2 vaccines to pregnant women, but further systematic reviews and meta-analyses are essential. Maternal immune activation caused by vaccination may impact a child's neurodevelopment and should be a concern for future studies.

COVID-19 disease and vaccination in pregnancy: understanding knowledge, perceptions and experiences among pregnant women and community leaders in Uganda

BACKGROUND

We investigated pregnant women and community leaders' knowledge, perceptions and experiences of the coronavirus disease 2019 (COVID-19) vaccination program during pregnancy in Uganda and how this changed over the course of the pandemic.

METHODS

We conducted 20 in-depth interviews (IDIs) and two group discussions (GDs) with pregnant women and four GDs with community leaders in Kawempe division of Kampala, Uganda. The first round of IDIs/GDs were carried out in March 2021. In July 2021, telephone IDIs were conducted with 7 pregnant women and 10 community leaders randomly selected from first-round interview participants. Themes were analysed deductively drawing codes from the topic guides.

RESULTS

In the first round, the majority of participants thought COVID-19 was not real because of misconceptions around government messaging/motivation and beliefs that Africans would not be affected. In the second round, participants recognised COVID-19 disease, because of rising case numbers and fatalities. There was increased awareness of the benefits of the vaccine. However, pregnant women remained unsure of vaccine safety and quality, citing side effects like fevers and general body weakness. Role models and coherent public health messaging and healthcare workers were key enablers of vaccine uptake.

CONCLUSIONS

Targeted and sustained COVID-19 communication and engagement strategies are needed, especially for pregnant women and others in their communities, to improve vaccine confidence during outbreaks.

Resources available for parent-provider vaccine communication in pregnancy in Canada: a scoping review

OBJECTIVE

Vaccination in pregnancy (VIP) is a protective measure for pregnant individuals and their babies. Healthcare provider's (HCP) recommendations are important in promoting VIP. However, a lack of strong recommendations and accessible resources to facilitate communication impact uptake. This study sought to determine the extent of and characterise the resources available for parent-provider vaccine communication in pregnancy in Canada using a behavioural theory-informed approach.

DESIGN

Scoping review.

METHODS

In accordance with the JBI methodology, nine disciplinary and interdisciplinary databases were searched, and a systematic grey literature search was conducted in March and January 2022, respectively. Eligible studies included resources available to HCPs practising in Canada when discussing VIP, and resources tailored to pregnant individuals. Two reviewers piloted a representative sample of published and grey literature using inclusion-exclusion criteria and the Authority, Accuracy, Coverage, Objectivity, Date, Significance guidelines (for grey literature only). Sixty-five published articles and 1079 grey reports were screened for eligibility, of which 19 articles and 166 reports were included, respectively.

RESULTS

From the 19 published literature articles and 166 grey literature reports, 95% were driven by the 'Knowledge' domain of the Theoretical Domains Framework, while n=34 (18%) addressed the 'Skills' domain. Other gaps included a lack of VIP-specific tools to address hesitancy and a lack of information on culturally safe counselling practices.

CONCLUSION

The study suggests a need for resources in Canada to improve VIP communication skills and improve access to vaccination information for HCPs and pregnant individuals. The absence of such resources may hinder VIP uptake.

Sources of COVID-19 Vaccine Promotion for Pregnant and Lactating Women in Bangladesh

COVID-19 vaccines are an effective public health intervention to reduce COVID-19-related morbidity and mortality. Given that pregnant and lactating women have a higher risk of severe COVID-19 complications, it is paramount to understand the factors that inform vaccine decision-making among this population. In this study, we sought to identify facilitators and barriers to COVID-19 vaccine acceptance and vaccine promotion in pregnant and lactating women in Bangladesh. We conducted 40 in-depth interviews with 12 pregnant women, 12 lactating women, and 16 health workers from one urban and four rural communities in Bangladesh. We used a grounded theory approach to identify emerging themes. Our results suggest that health workers and religious leaders played key roles in promoting COVID-19 vaccines in this population. Further, we found that the culture of trust in public health authorities and the existing vaccine infrastructure facilitated vaccine promotion. However, changes in vaccine eligibility and myths and rumors acted as both facilitators and barriers to vaccine promotion within our study. It is crucial that maternal immunization vaccine promotion efforts push pregnant and lactating women toward vaccine acceptance to protect the health of mothers and their babies. Additionally, as new maternal vaccines are developed and licensed, understanding how to best promote vaccines within this group is paramount.

Influenza vaccine uptake in Tunisia from two high-risk groups' perception and attitudes: a qualitative study

Background

Pregnant women (PW) and older adult with chronic diseases (ECD) are priority groups for the influenza vaccination. This study was designed to have a better insight into the influenza perceptions and barriers of the vaccine uptake from these groups' perspectives.

Methods

This qualitative study consisted of 20 focus group discussions (FGDs) enrolled from five governorates across the country (north, center, and south) between March 18 and July 10, 2019, in urban and rural areas. FGDs were conducted in Arabic (Tunisian dialect) and following the topic guide. Data were transcribed in the local language then translated into English and analyzed using Nvivo12 Software. This permitted the analysis thematic approach, using codes determined by the focus groups.

Results

A total of 170 individuals participated in the FGDs (84 ECD and 86 PW). Both groups recognized the weakness of the immune system as key determinant for severity. While PW raised the lack of information about the vaccine, the ECD emphasized accessibility problems. Five main barriers to influenza vaccination were identified: cultural barriers and use of traditional medicine, misleading or lack of information about influenza and the vaccine, advice against its uptake, problems of availability and accessibility of the vaccine as well as mistrust towards the vaccine including adverse effects, vaccine composition and effectiveness.

Conclusion

The study provided refined information from the perspectives of users to orient the policies regarding the promotion of influenza vaccine by decision makers among these two high risk groups.

Knowledge, attitudes, and practices toward seasonal influenza vaccination among healthcare workers and pregnant women in Pakistan: A mixed methods approach

Vaccine hesitancy is a significant public health issue globally. We aim to document the barriers toward seasonal influenza vaccine uptake among healthcare workers (HCWs) and pregnant women (PW) in Pakistan. We performed a concurrent mixed methods study in four cities (Karachi, Islamabad, Quetta, and Peshawar) across Pakistan from September to December 2021. The quantitative component consisted of independent cross-sectional surveys for PW and HCWs, and the qualitative component comprised of in-depth interviews (IDIs) and focus group discussions (FGDs) among HCWs. Simple linear regression was used to determine the association of sociodemographic variables with knowledge, attitudes, and practices. Overall, 750 PW and 420 HCWs were enrolled. Among the PW, 44% were willing to receive the vaccine if available free of cost. Only 44% of the HCWs were vaccinated; however, 86% intended to get vaccinated and were willing to recommend the vaccine to their patients. HCWs refused vaccine due to side-effects (65%), cost (57%), and allergies (36%). An education level of secondary school and above was predictive of higher attitude and knowledge scores while having received the COVID-19 vaccine was associated with higher practice scores for both PW and HCWs. Several themes emerged from the interviews: 1) HCWs' knowledge of influenza and its prevention, 2) HCWs' perception of motivators and barriers to influenza vaccine uptake and 3) HCWs' attitudes towrd vaccine promotion. We report low influenza vaccine coverage among HCWs and PW in Pakistan. Educational campaigns addressing misconceptions, and improving affordability and accessibility through government interventions, can improve vaccine uptake.

RSV awareness, risk perception, causes, and terms: Perspectives of pregnant and lactating women in Kenya to inform demand generation efforts for maternal RSV vaccines

Respiratory syncytial virus (RSV) causes a substantial proportion of acute lower respiratory tract infections (LRTI) among infants. In low- and middle-income countries, RSV may be responsible for approximately 40% of all hospital admissions of infants less than one year. A safe and immunogenic RSV vaccine, given to pregnant persons, is imminent. In this qualitative study, we sought to understand factors that could inform maternal vaccine decision-making to inform future demand generation strategies in Kenya. We conducted in-depth interviews with 24 pregnant and lactating persons from two counties, with two communities in each county. Four key themes emerged, including terms used for RSV, awareness of and risk perception related to RSV, causes of RSV, and questions about future maternal RSV vaccines. Regarding terms, no participant used the term RSV to describe the disease. Most participants associated RSV with cold things such as cold weather and cold food/drink. Most participants believed that RSV was caused by the cold or an unclean environment. Finally, key questions related to a maternal RSV vaccine were related to vaccine safety, and more specifically side effects. Questions arose related to vaccine effectiveness as well as timing of administration and dosing. A maternal RSV vaccine is on the horizon. However, vaccines do not save lives; vaccination does. As such, it is critical to develop and implement demand generation approaches to ensure that once a maternal RSV vaccine is available, communities are sensitized and willing to accept it.

"Figuring stuff out myself" - a qualitative study on maternal vaccination in socially and ethnically diverse areas in England

BACKGROUND

Maternal vaccinations against Influenza, Pertussis, and Covid-19 are recommended in the UK, and vaccines against further infections may become available soon. However, many pregnant women, especially in socially and ethnically diverse areas, have low vaccine uptake. Qualitative studies on the reasons and possible solutions are needed that are inclusive of disadvantaged and minority ethnic groups. We therefore aimed to understand the complex interplay between structural and behavioural factors contributing to the low maternal vaccine uptake in socially and ethnically diverse areas in London in the Covid-19 context.

METHODS

In 2022, we conducted semi-structured interviews and a focus group discussion among a purposive sample of 38 pregnant/recently pregnant women and 20 health service providers, including 12 midwives. Participants were recruited in ethnically diverse London boroughs. We followed a critical realist paradigm and used a thematic analysis approach.

RESULTS

The sample included participants who took all, some or none of the maternal vaccines, with some participants unsure whether they had taken or been offered the vaccines. Decision-making was passive or active, with the expectation for pregnant women to do their 'own research'. Participants described various individual, social and contextual influences on their decision-making as they navigated the antenatal care system. Missing or conflicting information from providers meant knowledge gaps were sometimes filled with misinformation from unreliable sources that increased uncertainties and mistrust. Both pregnant women and providers described structural and organisational factors that hindered access to information and vaccinations, including lack of training, time and resources, and shortcomings of health information systems and apps. Some participants described factors that facilitated vaccination uptake and many made recommendations for improvements.

CONCLUSIONS

Our study showed how structural and organisational factors can compound uncertainties around maternal vaccination among socially and ethnically diverse populations. Results highlight the need for more reliable resources, streamlined workflows, improved electronic information systems and training in their use. Roles and responsibilities should be clarified with potential greater involvement of nurses and pharmacists in vaccine provision. Education and communication should consider individual (language/digital) skills and needs for information and reassurance. Further research is needed to co-produce solutions with service users and providers.

Vaccine Hesitancy Phenomenon Evolution during Pregnancy over High-Risk Epidemiological Periods-"Repetitio Est Mater Studiorum"

(1) Background: The recent epidemiological events were high-stress level generators for humanity, particularly for pregnant women, influencing their attitude, behavior, and decisions regarding vaccination during pregnancy or regarding their future child. The aim of this study was to analyze the anti-pertussis vaccination decision-shaping factors in pregnant women during two epidemiological periods: the measles epidemic and the COVID-19 pandemic. (2) Methods: Two groups of pregnant women were invited to be part of a medical education program, having as the main theme the infectious disease risks and their prevention through vaccination. Before launching the program, participants received a 12-item questionnaire. From a total number of 362 pregnant women enrolled in the study, 182 participated in 2019, and 180 participated in 2022. (3) Results: The socio-demographic data revealed that the age of pregnant women participating in medical education programs increased in 2022 by 1.7 years (p < 0.01). In vitro fertilization was reported in a significantly higher proportion (20% in 2022 vs 9.8% in 2019, p < 0.01). Participation in community-initiated educational programs almost doubled during the pandemic time from 18.7% in 2019 to 33.9% in 2022 (p < 0.01). Pertussis vaccine acceptancy (VA) dropped from 85% in 2019 to 44.4% in 2022 (p < 0.01) (4) Conclusions: In this study, we reported fast-growing vaccine hesitancy and severe declared vaccine reluctance. The results of this complex long-term study, which evaluated pregnant women over several years, showed a five-fold increase in the percentage of pregnant women who disagreed with personal pertussis vaccination. This draws attention to the risks of pertussis epidemic outbreaks in pregnant women and their future infants in the first couple of months of life before the initiation of vaccination.

Vaccine hesitancy in pregnant Women: A narrative review

Pregnant women are often at higher risk for morbidity and mortality due to contracting vaccine-preventable diseases that result in adverse pregnancy outcomes such as spontaneous abortion, preterm births, and congenital fetal defects. For example, health care provider recommendation is correlated with maternal acceptance of influenza vaccination, however, up to 33 % of pregnant women remain unvaccinated irrespective of provider recommendation. Vaccine hesitancy is a multifactorial problem that both the medical and public health systems need to address synergistically. Vaccine education should incorporate balanced perspectives to deliver vaccine education. This narrative review addresses four questions: 1) what are the primary concerns of pregnant women that lead them to be hesitant about receiving vaccinations; 2) to what extent does the source (e.g. provider, friend, family) of vaccine advice and information influence a pregnant person's decision to accept a vaccine; 3) how does the delivery method of vaccine education influence their decision; 4) how can categorizing patients into four distinct groups based on their opinions and behavior regarding vaccines be used to improve provider-patient communication and increase vaccine acceptance. Results from the literature show that the three most common reasons for vaccine hesitancy include: i.) fear of side effects or adverse events; ii.) lack of confidence in vaccine safety; iii.) low perception of being at high risk of infection during pregnancy and/or not having previously received the vaccination when not pregnant. We conclude that vaccine hesitancy is dynamic therefore people do not always hold a static level of vaccine hesitancy. People may move between a continuum of vaccine hesitancy for a multifactorial reasons. A framework, characterized by levels of vaccine hesitancy before and during pregnancy, was constructed to help providers find balance between promoting individual health and public health while providing vaccine education.

Immunization during pregnancy: do healthcare workers recommend vaccination against influenza?

Background

A variety of circumstances can influence how widely vaccination during pregnancy is accepted. Healthcare workers (HCWs) are often seen as the main resource for recommending vaccination. The purpose of the current study was to determine whether Italian HCWs advise and recommend pregnant people to receive the influenza vaccinations, as well as what knowledge and attitudes affect their practices. A secondary aim of the study was to evaluate HCWs' knowledge and attitudes towards COVID-19 vaccination.

Methods

This cross-sectional study, took place between August 2021 and June 2022 in a randomly selected sample of HCWs in three Italian regions. The target population comprised obstetricians-gynecologists, midwives and primary care physicians, who provide medical care to pregnant people. The questionnaire consisted of 19 items divided into 5 parts gathered information about the participants' sociodemographic and professional characteristics, general knowledge about vaccinations during pregnancy, and vaccine-preventable diseases (VPDs), attitudes and practices towards immunization, and strategies to potentially increase vaccination uptake during pregnancy.

Results

Among the participants, 78.3% knew that pregnant people are at increased risk of severe complications from influenza, 57.8% that the influenza vaccine is not provided only in the 2nd/3rd trimester of pregnancy and 60% that pregnancy is a risk factor for severe COVID-19 infection. Of the enrolled HCWs, 10.8% believed that the potential risks of vaccines administered during pregnancy are greater than the benefits. An even higher proportion of the participants was unsure (24.3%) or did not deem (15.9%) that vaccinating against influenza during pregnancy reduces the risk of preterm birth and abortion. Moreover, 11.8% of the sample did not believe or was uncertain that COVID-19 vaccine must be offered to all pregnant people. Among HCWs, 71.8% advised women about influenza vaccination during pregnancy, and 68.8% recommended getting vaccinated against influenza during pregnancy. Results showed that good knowledge and positive attitudes were the strongest factors positively associated with advising women about influenza vaccination during pregnancy.

Conclusion

The gathered data showed that a sizable portion of the HCWs lacks up-to-date knowledge, underestimates the risks of contracting a VPD, and overestimates the risks of vaccine side effects during pregnancy. The findings shed light on such attributes useful to promote adherence to evidence-based recommendations among HCWs.

The Interplay of Perceived Risks and Benefits in Deciding to Become Vaccinated against COVID-19 While Pregnant or Breastfeeding: A Cross-Sectional Study in Italy

The present study examined the role of the perception of risks and benefits for the mother and her babies in deciding about the COVID-19 vaccination. In this cross-sectional study, five hypotheses were tested using data from a convenience sample of Italian pregnant and/or breastfeeding women (N = 1104, July-September 2021). A logistic regression model estimated the influence of the predictors on the reported behavior, and a beta regression model was used to evaluate which factors influenced the willingness to become vaccinated among unvaccinated women. The COVID-19 vaccination overall risks/benefits tradeoff was highly predictive of both behavior and intention. Ceteris paribus, an increase in the perception of risks for the baby weighed more against vaccination than a similar increase in the perception of risks for the mother. Additionally, pregnant women resulted in being less likely (or willing) to be vaccinated in their status than breastfeeding women, but they were equally accepting of vaccination if they were not pregnant. COVID-19 risk perception predicted intention to become vaccinated, but not behavior. In conclusion, the overall risks/benefits tradeoff is key in predicting vaccination behavior and intention, but the concerns for the baby weigh more than those for the mother in the decision, shedding light on this previously neglected aspect.

Acceptance of recommended vaccinations during pregnancy: a cross-sectional study in Southern Italy

Background

Vaccine administration is a recommended, safe, and effective measure to protect pregnant women against vaccine-preventable diseases (VPDs). Despite available guidance, maternal immunization rates for vaccination against influenza and with the reduced antigen content tetanus-diphtheria-acellular pertussis vaccine (Tdap) in Italy remain incredibly low. The primary goal of the study was to explore what Italian pregnant women knew about VPDs and immunization during pregnancy and what factors affected their decision to be vaccinated.

Methods

This cross-sectional study took place between October 2021 and April 2022 in the Southern part of Italy. All consecutive pregnant women, from those attending the selected facilities on randomly selected days, were approached to request participation. The inclusion criteria for participation were age ≥18 years, the ability to understand, speak, and read Italian, and being pregnant at any gestational age. The questionnaire, using a combination of checkboxes and free text answers, consisted of 32 items divided into five parts and lasted ~10 min.

Results

The results showed that 61% knew that the influenza vaccine is recommended and 48.7% knew that influenza could be risky during pregnancy; 74.1% wrongly reported that the Measles-Mumps-Rubella (MMR) vaccine is recommended during pregnancy. Seven out of 10 pregnant women believed that strong evidence supported the safety of vaccinations during pregnancy, and more than half (55.6%) thought they were at increased risk of severe illness with COVID-19. Women in the sample believed that vaccines received during pregnancy pose a risk of adverse events to the unborn child with a median value of 6 (IQR 3-9), on a scale ranging from 1 to 10. Similarly, the fear of contracting pertussis and influenza during pregnancy showed a median value of 6 (IQR 3-9) and 5 (IQR 3-8), respectively. Only 21.1% and 36.5% of women received influenza and Tdap vaccines during pregnancy.

Conclusion

Unrealistic risk perception with a negative attitude toward vaccines in pregnancy and a low percentage of vaccinated pregnant women confirm the urgency of training women to make informed choices to increase overall vaccine uptake.

Understanding the barriers and facilitators of vaccine hesitancy towards the COVID-19 vaccine in healthcare workers and healthcare students worldwide: An Umbrella Review

BACKGROUND

Healthcare workers (HCWs) and healthcare students display high levels of vaccine hesitancy with impact on healthcare provision, patient safety, and health promotion. The factors related to vaccine hesitancy have been reported in several systematic reviews. However, this evidence needs to be synthesised, as interventions to reduce vaccination hesitancy in this population are needed.

METHODS

This Umbrella Review aimed to explore the barriers and facilitators of vaccine hesitancy toward the COVID-19 vaccine for HCWs and healthcare students. The review was performed and reported in accordance with Joanna Briggs Institutes guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. A protocol was preregistered on PROSPERO (CRD42022327354). Eight databases were searched from November 2019 to 23rd May 2022 to identify any systematic reviews that explored factors associated with hesitancy towards the COVID-19 vaccine for HCWs or healthcare students.

RESULTS

A total of 31 studies were included in the review. The majority of studies (71%) were appraised as strong or moderate quality and there was a slight degree of overlap (<5%) of primary studies between the reviews. Vaccine hesitancy was more common among HCWs and healthcare students in specific occupational roles (e.g. nurses) than others (e.g. physicians). Frequent reasons for hesitancy were related to sociodemographic factors (gender, age, ethnicity), occupational factors (COVID-19 exposure, perceived risk, mandatory vaccination), health factors (vaccination history), vaccine-related factors (concerns about safety, efficacy, side-effects, rapid development, testing, approval and distribution of the vaccine), social factors (social pressure, altruism and collective responsibility), distrust factors (key social actors, pandemic management), information factors (inadequate information and sources, exposure to misinformation).

CONCLUSION

The results from this Umbrella Review have wide-reaching implications for the research area, healthcare systems and institutions and governments worldwide. Designing tailored strategies for specific occupational groups is pivotal to increasing vaccine uptake and securing a safe healthcare provision worldwide.

Maternal Vaccination and Vaccine Hesitancy

The American College of Obstetrics and Gynecology recommends influenza vaccine annually, Tdap with each pregnancy, and COVID-19 vaccine for those not previously vaccinated or who are due for boosters. The influenza and COVID-19 vaccines are safe during pregnancy and are effective in reducing morbidity in both the pregnant person and infant. The Tdap vaccine is given primarily to protect the newborn from pertussis through transplacental antibody transfer. Methods to enhance vaccination rates include stocking and giving vaccines in the obstetric office, recommending eligible vaccines at each visit, and focusing on the health of the infant in conversations with patients.

US Infant Pertussis Incidence Trends Before and After Implementation of the Maternal Tetanus, Diphtheria, and Pertussis Vaccine

Importance

Infants younger than 1 year have the highest burden of pertussis morbidity and mortality. In 2011, the US introduced tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination during pregnancy to protect infants before vaccinations begin.

Objective

To assess the association of maternal Tdap vaccination during pregnancy with the incidence of pertussis among infants in the US.

Design, Setting, and Participants

In this ecologic study, a time-trend analysis was performed of infant pertussis cases reported through the National Notifiable Diseases Surveillance System between January 1, 2000, and December 31, 2019, in the US. Statistical analysis was performed from April 1, 2020, to October 31, 2022.

Exposures

Maternal Tdap vaccination during pregnancy.

Main Outcomes and Measures

Pertussis incidence rates were calculated and compared between 2 periods-the pre-maternal Tdap vaccination period (2000-2010) and the post-maternal Tdap vaccination period (2012-2019)-for 2 age groups: infants younger than 2 months (target group of maternal vaccination) and infants aged 6 months to less than 12 months (comparison group). Incidence rate differences between the 2 age groups were modeled using weighted segmented linear regression. The slope difference between the 2 periods was estimated to assess the association of maternal Tdap vaccination with pertussis incidence among infants.

Results

A total of 57 460 pertussis cases were reported in infants younger than 1 year between 2000 and 2019; 19 322 cases (33.6%) were in infants younger than 2 months. During the pre-maternal Tdap vaccination period, annual pertussis incidence did not change among infants younger than 2 months (slope, 3.29 per 100 000 infants per year; P = .28) but increased slightly among infants aged 6 months to less than 12 months (slope, 2.10 per 100 000 infants per year; P = .01). There was no change in the difference in incidence between the 2 age groups (slope, 0.08 per 100 000 infants per year; P = .97) during the pre-maternal Tdap vaccination period overall. However, in the post-maternal Tdap vaccination period, incidence decreased among infants younger than 2 months (slope, -14.53 per 100 000 infants per year; P = .001) while remaining unchanged among infants aged 6 months to less than 12 months (slope, 1.42 per 100 000 infants per year; P = .29). The incidence rate difference between the 2 age groups significantly decreased during the post-maternal Tdap vaccination period (slope, -14.43 per 100 000 infants per year; P < .001). Pertussis incidence rate differences were significantly different between the pre-maternal and post-maternal Tdap vaccination periods (slope difference, -14.51 per 100 000 infants per year; P = .01).

Conclusions and Relevance

In this study, following maternal Tdap vaccine introduction, a sustained decrease in pertussis incidence was observed among infants younger than 2 months, narrowing the incidence gap with infants aged 6 months to less than 12 months. These findings suggest that maternal Tdap vaccination is associated with a reduction in pertussis burden in the target age group (<2 months) and that further increases in coverage may be associated with additional reductions in infant disease.

Acceptance of vaccination against pertussis, COVID-19 and influenza during pregnancy: a cross-sectional study

Background

This study aims to assess the uptake of maternal pertussis and COVID-19 vaccination and the intention towards accepting the maternal influenza vaccination. Insights into different socio-demographic factors related to maternal vaccination coverage might help to address vaccine acceptance and improve maternal vaccine uptake in the future.

Methods

We conducted a cross-sectional survey among pregnant women and recent mothers, up to 6 months post-partum. The primary outcome measures of this study were behaviour for maternal pertussis and COVID-19 vaccination, and maternal influenza vaccination intention. Associations between socio-demographic factors and maternal pertussis vaccination and maternal COVID-19 vaccination behaviour; and socio-demographic factors and maternal influenza vaccination intention were assessed using binary logistic regression analyses.

Results

In total 1361 respondents filled out the questionnaire. Almost all women (95%) were vaccinated against pertussis during pregnancy, while almost two-third were vaccinated against COVID-19 during pregnancy (58%) and almost one-third (28%) had a positive intention towards receiving the maternal influenza vaccination. Results show that young maternal age and low education level were associated with lower maternal vaccination acceptance.

Conclusion

Vaccination campaigns focusing on the severity of diseases that are prevented, are needed to increase maternal vaccine acceptance in younger and low-educated pregnant women. We expect that differences in vaccination coverage between the three maternal vaccinations might partly be explained by existing recommendations, campaigns and whether the vaccination is part of the national immunisation program.

Maternal third dose of BNT162b2 mRNA vaccine and risk of infant COVID-19 hospitalization

Infants are at a higher risk of Coronavirus Disease 2019 (COVID-19)-related hospitalizations compared to older children. In this study, we investigated the effect of the recommended third maternal dose of BNT162b2 COVID-19 vaccine during pregnancy on rates of infant COVID-19-related hospitalizations. We conducted a nationwide cohort study of all live-born infants delivered in Israel between 24 August 2021 and 15 March 2022 to estimate the effectiveness of the third booster dose versus the second dose against infant COVID-19-related hospitalizations. Data were analyzed for the overall study period, and the Delta and Omicron periods were analyzed separately. Cox proportional hazard regression models estimated hazard ratios and 95% confidence intervals (CIs) for infant hospitalizations according to maternal vaccination status at delivery. Among 48,868 live-born infants included in the analysis, rates of COVID-19 hospitalization were 0.4%, 0.6% and 0.7% in the third-dose, second-dose and unvaccinated groups, respectively. Compared to the second dose, the third dose was associated with reduced infant hospitalization with estimated effectiveness of 53% (95% CI: 36-65%). Greater protection was associated with a shorter interval between vaccination and delivery. A third maternal dose during pregnancy reduced the risk of infant hospitalization for COVID-19 during the first 4 months of life, supporting clinical and public health guidance for maternal booster vaccination to prevent infant COVID-19 hospitalization.

Maternity care provider acceptance of a future Group B Streptococcus vaccine - A qualitative study in three countries

INTRODUCTION

There are vaccines in clinical trials that target the bacterium Group B Streptococcus (GBS). When approved, GBS vaccines will be intended for administration to pregnant women to prevent infection in their infants. The success of any vaccine will depend on its' uptake in the population. Experience with prior maternal vaccines, e.g. influenza, Tdap and COVID-19 vaccines, teaches us that acceptance of vaccines, especially if novel, is challenging for pregnant women, and that provider recommendation is a key driver of vaccine uptake.

METHODS

This study investigated attitudes of maternity care providers towards the introduction of a GBS vaccine in three countries (the United States (US), Ireland, and the Dominican Republic (DR)) with different GBS prevalence and prevention practices. Semi-structured interviews with maternity care providers were transcribed and coded for themes. The constant comparative method, and inductive theory building were used to develop conclusions.

RESULTS

Thirty-eight obstetricians, 18 general practitioners and 14 midwives participated. There was variability in provider attitudes towards a hypothetical GBS vaccine. Responses ranged from enthusiasm to doubts over the need for a vaccine. Attitudes were influenced by perceived additional benefits of a vaccine over current strategy and confidence in the safety of vaccines during pregnancy. Knowledge, experience and approaches to GBS prevention differed geographically and according to provider type, and influenced how participants assessed the risks and benefits of a GBS vaccine.

CONCLUSION

Maternity care providers are engaged in the topic of GBS management and there is opportunity to leverage attitudes and beliefs that will support a strong recommendation for a GBS vaccine. However, knowledge of GBS, and of the limitations of current prevention strategies vary among providers in different regions, and between different provider types. Targeted educational efforts with antenatal providers should focus on highlighting safety data the potential benefits of vaccination over current strategies.

Barriers and facilitators of vaccine hesitancy for COVID-19, influenza, and pertussis during pregnancy and in mothers of infants under two years: An umbrella review

BACKGROUND

Vaccination during pregnancy has been repeatedly demonstrated to be safe and effective in protecting against infection and associated harms for the mother, developing baby, and subsequent infant. However, maternal vaccination uptake remains low compared to the general population.

OBJECTIVES

An umbrella review to explore the barriers and facilitators to Influenza, Pertussis and COVID-19 vaccination during pregnancy and within 2 years after childbirth, and to inform interventions to encourage uptake (PROSPERO registration number: CRD42022327624).

METHODS

Ten databases were searched for systematic reviews published between 2009 and April 2022 exploring the predictors of vaccination or effectiveness of interventions to improve vaccination for Pertussis, Influenza, or COVD-19. Both pregnant women and mothers of infants under two years were included. Barriers and facilitators were organised using the WHO model of determinants of vaccine hesitancy through narrative synthesis, the Joanna Briggs Institute checklist assessed review quality, and the degree of overlap of primary studies was calculated.

RESULTS

19 reviews were included. Considerable overlap was found especially for intervention reviews, and the quality of the included reviews and their primary studies varied. Sociodemographic factors were specifically researched in the context of COVID-19, exerting a small but consistent effect on vaccination. Concerns around the safety of vaccination particularly for the developing baby were a main barrier. While key facilitators included recommendation from a healthcare professional, previous vaccination, knowledge around vaccination, and communication with and support from social groups. Intervention reviews indicated multi-component interventions involving human interaction to be most effective.

CONCLUSION

The main barriers and facilitators for Influenza, Pertussis and COVID-19 vaccination have been identified and constitute the foundation for policy development at the international level. Ethnicity, socioeconomic status, concerns about vaccine safety and side effects, and lack of healthcare professionals' recommendations, are the most relevant factors of vaccine hesitancy. Adapting educational interventions to specific populations, person-to-person interaction, healthcare professionals' involvement, and interpersonal support are important strategies to improve uptake.

Influence of the COVID-19 pandemic and social media on the behaviour of pregnant and lactating women towards vaccination: a scoping review

BACKGROUND

Pregnant women, foetuses and infants are at risk of infectious disease-related complications. Maternal vaccination is a strategy developed to better protect pregnant women and their offspring against infectious disease-related morbidity and mortality. Vaccines against influenza, pertussis and recently also COVID-19 are widely recommended for pregnant women. Yet, there is still a significant amount of hesitation towards maternal vaccination policies. Furthermore, contradictory messages circulating social media impact vaccine confidence.

OBJECTIVES

This scoping review aims to reveal how COVID-19 and COVID-19 vaccination impacted vaccine confidence in pregnant and lactating women. Additionally, this review studied the role social media plays in creating opinions towards vaccination in these target groups.

ELIGIBILITY CRITERIA

Articles published between 23 November 2018 and 18 July 2022 that are linked to the objectives of this review were included. Reviews, articles not focusing on the target group, abstracts, articles describing outcomes of COVID-19 infection/COVID-19 vaccination were excluded.

SOURCES OF EVIDENCE

The PubMed database was searched to select articles. Search terms used were linked to pregnancy, lactation, vaccination, vaccine hesitancy, COVID-19 and social media.

CHARTING METHODS

Included articles were abstracted and synthesised by one reviewer. Verification was done by a second reviewer. Disagreements were addressed through discussion between reviewers and other researchers.

RESULTS

Pregnant and lactating women are generally less likely to accept a COVID-19 vaccine compared with non-pregnant and non-nursing women. The main reason to refuse maternal vaccination is safety concerns. A positive link was detected between COVID-19 vaccine willingness and acceptance of other vaccines during pregnancy. The internet and social media are identified as important information sources for maternal vaccination.

DISCUSSION AND CONCLUSION

Vaccine hesitancy in pregnant and lactating women remains an important issue, expressing the need for effective interventions to increase vaccine confidence and coverage. The role social media plays in vaccine uptake remains unclear.

The association of neonatal SARS-CoV-2 anti-spike protein receptor-binding domain antibodies at delivery with infant SARS-CoV-2 infection under the age of 6 months: a prospective cohort study

OBJECTIVES

The aim of this study was to assess the association between neonatal SARS-CoV-2 antibody level at delivery and infant SARS-CoV-2 infection under the age of 6 months and to identify predictive factors for neonatal antibody level at delivery.

METHODS

In a prospective observational study, conducted between September 2021 and mid-February 2022, cord blood sera were tested for SARS-CoV-2 anti-spike receptor-binding domain antibodies after maternal BNT162b2 vaccination or infection. Infants were followed up for 6 months for SARS-CoV-2 infection.

RESULTS

Sixty-seven mother-infant dyads were enrolled; nine of those did not meet the eligibility criteria. Of the 58 mother-infant dyads included, 6-month follow-up data were available for 57 mother-infant dyads. The mean ± standard deviation log SARS-CoV-2 anti-spike antibody level at delivery was lower among infants who were COVID-19 positive versus negative during follow-up (3.41 ± 0.74 AU/mL, n = 12; vs. 3.87 ± 0.84 AU/mL, n = 46; p 0.036); a log titre of ≥4.07 AU/mL (11 750) at delivery was associated with a significantly lower likelihood of infant infection (1/26 vs. 11/32 in infants with antibody level of <4.07 log AU/mL, OR = 0.076 [95% CI, 0.076, 0.64], p 0.018). A spline curve model showed a linear decrease in antibody levels when the last dose was administered at ≤30 weeks of gestation (50 days before delivery), after which the antibody levels increased (R² = 0.50). In multivariate analysis, more vaccine doses, prior maternal infection, and last administered dose at ≥31 weeks of gestation were associated with higher antibody levels at delivery.

DISCUSSION

Higher anti-spike antibodies at delivery were associated with decreased risk of COVID-19 at the age of <6 months; the antibody level decreased linearly when the last dose was administered at ≤30 weeks of gestation. Future research should assess the effectiveness of a second booster during pregnancy against infant infection.

Knowledge, Attitudes, Behavior, Acceptance, and Hesitancy in Relation to the COVID-19 Vaccine among Pregnant and Breastfeeding Women: A Systematic Review Protocol

A new coronavirus, SARS-CoV-2, was identified at the end of 2019. It swiftly spread all over the world, affecting more than 600 million people and causing over 6 million deaths worldwide. Different COVID-19 vaccines became available by the end of 2020. Healthcare workers and more vulnerable people (such as the elderly and those with comorbidities) were initially prioritized, followed by the entire population, including pregnant and breastfeeding women. Despite the safety and efficacy of COVID-19 vaccines, a certain level of skepticism was expressed, including among pregnant and breastfeeding women. There were several reasons for this reluctancy, among them, fear of side-effects for both women and fetuses. Nevertheless, acceptance, as well as hesitancy, were time, country and vaccine specific. This review will collect available evidence assessing knowledge, attitudes, behaviour, practice and acceptance/hesitancy of pregnant/breastfeeding women in relation to the COVID-19 vaccination. The PubMed/MEDLINE, Scopus and EMBASE databases will be consulted. A predefined search strategy that combines both free text and MESH terms will be used. The systematic review will adhere to the PRISMA guidelines and the results will be reported in both narrative and summary tables. A meta-analysis will be conducted if data are available.

"I was having an internal conflict with myself." COVID-19 vaccination decision-making processes among pregnant women

BACKGROUND

Vaccination serves as an efficient primary means of control for infectious diseases. However, in the case of the COVID-19 pandemic, pregnant women within the United States had the lowest rates of COVID-19 vaccination and reported the lowest intent to vaccinate.

OBJECTIVES

To explore the decision-making process for COVID-19 vaccination for people pregnant during the pandemic.

DESIGN

A secondary analysis of data from a mixed-methods study that examined the impact of COVID-19 on experiences of prenatal care, birth support, and delivery in the Southern United States.

METHODS

This study used a descriptive phenomenological approach to thematically analyze in-depth interviews (n = 20) with adult women who were pregnant by January 2020 and had their prenatal care and delivery during the pandemic beginning in March 2020. The transcripts were de-identified, coded, and thematically analyzed to saturation to identify drivers of COVID-19 vaccine decision-making based on COVID-19 vaccination status and timing. Comparative analyses were conducted to assess differences in decision-making processes based on race/ethnicity and parity. Participants also completed a sociodemographic survey that included their COVID-19 vaccination status.

RESULTS

Two themes emerged, the weighing of parallel risks and priorities from different sources resulting in vaccine decisional conflict and the need to reconcile that conflict via multiple strategies. All participants weighed priorities and risks from multiple areas of their lives and described internal conflict around vaccination. Participants described tailoring decisions to household dynamics, reconciling public and private values around vaccination, and the impact of their identities on the decision-making process. While many described concerns over vaccine safety and fetal health, uniquely, many highlighted weighing the impact of prior pregnancy loss history, with some choosing other preventive measures like social distancing or mask-wearing, which they deemed less risky.

CONCLUSION

Pregnant people make complex COVID-19 vaccination decisions, which must be considered in future vaccine messaging and advocacy for this group.

Factors influencing healthcare professionals' confidence in vaccination in Europe: a literature review

Health-care professionals (HCPs) have a fundamental role in vaccination, their own beliefs and attitudes affecting both their uptake and recommendation of vaccines. This literature review (n = 89) summarises evidence on HCPs’ perceptions of the risks and benefits of vaccination, trust, and perceptions of mandatory vaccination in Europe. HCPs across studies believed that vaccination is important to protect themselves and their patients. However, beliefs that some diseases such as influenza are less risky were reported by some HCPs as a reason for not getting vaccinated. Concerns about both short- and long-term side effects were identified among HCPs in most studies, such as those affecting the immune or neurological system. Mistrust toward health authorities and pharmaceutical industry was reported in some studies. The question of mandatory vaccination revealed mixed opinions, with some favoring self-determination and others viewing vaccination as a duty. This review highlights key factors influencing HCPs’ confidence in vaccination in Europe.

Protecting pregnant people & infants against influenza: A landscape review of influenza vaccine hesitancy during pregnancy and strategies for vaccine promotion

Before COVID-19, influenza vaccines were the most widely recommended vaccine during pregnancy worldwide. In response to immunization during pregnancy, maternal antibodies offer protection against potentially life-threatening disease in both pregnant people and their infants up to six months of age. Despite this, influenza vaccine hesitancy is common, with few countries reporting immunization rates in pregnant people above 50%. In this review, we highlight individual, institutional, and social factors associated with influenza vaccine hesitancy during pregnancy. In addition, we present an overview of the evidence evaluating interventions to address influenza vaccine hesitancy during pregnancy. While some studies have indicated promising results, no single intervention has consistently effectively increased influenza vaccine uptake during pregnancy. Using a social-ecological model of health framework, future strategies addressing multiple levels of vaccine hesitancy will be needed to realize the potential health benefits of prenatal immunization programs.

A mixed methods study of health care professionals’ attitudes towards vaccination in 15 countries

Background

Health care professionals are widely considered to be the most trusted source of information on vaccine-related topics. However, several are reporting their own hesitancy around certain vaccines, influencing their intention to vaccinate themselves as well as influencing their recommendations to their patients and target population.

Methods

A mixed-methods approach was used including an online survey (n = 1,504) in 15 countries which aimed to determine drivers of HCPs vaccine confidence and examine how these drivers vary across nations. Thirty in-depth semi-structured interviews were conducted with 10 HCPs in a subset of three countries (France, Greece and Hungry) to explore barriers to HCPs vaccine uptake and their role in addressing vaccine hesitancy among patients.

Findings.

The survey’s regression analysis identified that nurses/midwives and HCPs from Hungary, Italy, Romania and Switzerland were less confident in the safety, importance or effectiveness of vaccines in general. Morocco (35%), Turkey (53%) and Greece (69%) reported the lowest influenza vaccination coverage among HCPs. Morocco also reported the lowest rates of HCPs who were “highly likely” to recommend MMR vaccine (34%), HPV vaccine (31%) and Covid-19 vaccines (29%). More than third of HCPs reported a lack of trust in health authorities and in the information they provide. Thematic analysis revealed that concerns over the risk of side-effects associated with vaccines, preference for natural immunity, whether it was necessary to be vaccinated against influenza every year, not having any chronic disease risk factors, and vaccines mandates as the key barriers to HCPs vaccination against influenza and Covid-19.

Conclusion

HCPs have an important role in vaccination and their confidence in vaccination and health authorities must be improved as this may affect their uptake of vaccines and influence their recommendations to their patients. Investigating the impact of political, socio-economic and cultural contexts on concerns about vaccination among HCPs is also necessary.

Mapping the maternal vaccination journey and influencing factors for Māori women in Aotearoa New Zealand: a qualitative study

Introduction Uptake of maternal vaccinations (MVs) is suboptimal in Aotearoa New Zealand, particularly for Māori. Aim To describe Māori women's journeys regarding maternal pertussis and influenza vaccinations and explore influences on uptake. Methods Semi-structured interviews were conducted in Waikato, Aotearoa New Zealand, with pregnant or recently pregnant Māori women, and separately with Māori healthcare professionals (HCPs) to understand women's decisions regarding MVs and enablers and barriers to uptake. Results Nine women and nine HCPs were interviewed. Verbal communications from midwives, general practice and pharmacy strongly influenced women's journeys. Women's decisions appeared largely straight-forward, with influences including awareness, knowledge, underlying beliefs and previous MVs. Enablers for MV uptake included HCPs' discussions, pro-vaccination beliefs, and accessibility. Barriers for MV uptake included poverty (and transport), lack of awareness, insufficient knowledge of benefits, late presentation to the midwife and other commitments or challenges in the women's lives affecting prioritisation of the vaccine. Misconceptions, seasonality, and lower HCP emphasis impaired influenza vaccination uptake. Discussion With multiple barriers to accessing MVs, HCPs who see pregnant women are the primary resource to improve awareness, knowledge, and access through kōrero (discussions) with the woman and, where possible, being able to administer the vaccinations. These HCPs need to be well-informed, aware of likely concerns women may have and how to address them, encourage these discussions and preferably be trusted.

A socio-ecological exploration to identify factors influencing the COVID-19 vaccine decision-making process among pregnant and lactating women: Findings from Kenya

The vaccine decision-making process of pregnant and lactating women is complex. Regarding COVID-19, pregnant women are at increased risk for severe disease and poor health outcomes. While pregnant and lactating women were excluded from COVID-19 vaccine trials, available evidence suggests that COVID-19 vaccines are safe and protective during pregnancy. In this study, we used a socio-ecological approach to explore factors influencing the decision-making process for COVID-19 vaccines in pregnant and lactating women in Kenya, for the purpose of informing demand generation strategies. As pregnant and lactating women are influenced by many factors, we conducted 84 in-depth interviews with a variety of stakeholders, including 31 pregnant or lactating women, 20 healthcare workers such as nurses, midwives, doctors, and frontline workers, 25 male family members of pregnant or lactating women, and 8 gatekeepers such as community leaders and faith-based leaders. These individuals were recruited from six communities in Kenya: three urban, and three rural. We applied a grounded theory approach to identify emerging themes and organized emerging themes using the SAGE Vaccine Hesitancy model, which includes three categories of determinants of vaccine acceptance, including contextual influences, individual and group influences, and vaccine and vaccination specific issues. Myths, interpersonal norms, and religion emerged as themes related to contextual influences. Safety, risk perception, and the role of the healthcare worker emerged as themes related to individual and group influences. For vaccine and vaccination specific issues, emerging themes included availability, accessibility, and eligibility. While maternal immunization can substantially reduce the effect of infectious diseases in mothers and infants, vaccine acceptance is critical. However, vaccines do not save lives; vaccination does. We hope the results of this study can be used to tailor communication efforts to increase vaccine demand among pregnant and lactating women.

Women's attitude towards COVID-19 vaccination in pregnancy: A survey study in northern Italy

OBJECTIVE

To investigate attitudes and risk perceptions towards the coronavirus disease 2019 (COVID-19) vaccine and reasons for hesitancy among pregnant women.

METHODS

A prospective survey study was conducted at a University Maternity Department. Participants included any pregnant woman aged 18 years or older, able to understand the Italian language, who accessed the antenatal clinic for a prenatal appointment. The survey comprised questions about sociodemographic characteristics, pregnancy vaccination history, and perception of risk related to the immunization for the woman herself and her infant.

RESULTS

A total of 538 women completed the questionnaire, 445 (82.7%) accepted COVID-19 vaccination. Women vaccinated against pertussis were three times more likely to take up the COVID-19 vaccine (odds ratio [OR] 3.19; 95% confidence interval [CI] 1.78-5.72). Having had COVID-19 during pregnancy (OR 0.24; 95% CI 0.11-0.54), and having a high-risk perception towards the immunization for the fetus (OR 0.18; 95% CI 0.09-0.34) were factors associated with vaccine hesitancy. Lack of safety data in pregnancy and the possibility of harm to the fetus were the main concerns.

CONCLUSION

A trusting and supportive relationship with the healthcare professional to address fears, and the transmission of evidence-based information, are pivotal to guide women through an informed choice. Understanding the determinants implicated in women's decision making might guide towards effective public health strategies to boost vaccine acceptance.

Coronavirus disease 2019 (COVID-19) vaccine hesitancy among physicians, physician assistants, nurse practitioners, and nurses in two academic hospitals in Philadelphia

OBJECTIVE

To evaluate coronavirus disease 2019 (COVID-19) vaccine hesitancy among healthcare personnel (HCP) with significant clinical exposure to COVID-19 at 2 large, academic hospitals in Philadelphia, Pennsylvania.

DESIGN, SETTING, AND PARTICIPANTS

HCP were surveyed in November-December 2020 about their intention to receive the COVID-19 vaccine.

METHODS

The survey measured the intent among HCP to receive a COVID-19 vaccine, timing of vaccination, and reasons for or against vaccination. Among patient-facing HCP, multivariate regression evaluated the associations between healthcare positions (medical doctor, nurse practitioner or physician assistant, and registered nurse) and vaccine hesitancy (intending to decline, delay, or were unsure about vaccination), adjusting for demographic characteristics, reasons why or why not to receive the vaccine, and prior receipt of routine vaccines.

RESULTS

Among 5,929 HCP (2,253 medical doctors [MDs] and doctors of osteopathy [DOs], 582 nurse practitioners [NPs], 158 physician assistants [PAs], and 2,936 nurses), a higher proportion of nurses (47.3%) were COVID-vaccine hesitant compared with 30.0% of PAs and NPs and 13.1% of MDs and DOs. The most common reasons for vaccine hesitancy included concerns about side effects, the newness of the vaccines, and lack of vaccine knowledge. Regardless of position, Black HCP were more hesitant than White HCP (odds ratio [OR], ∼5) and females were more hesitant than males (OR, ∼2).

CONCLUSIONS

Although most clinical HCP intended to receive a COVID-19 vaccine, intention varied by healthcare position. Consistent with other studies, hesitancy was also significantly associated with race or ethnicity across all positions. These results highlight the importance of understanding and effectively addressing reasons for hesitancy, especially among frontline HCP who are at increased risk of COVID exposure and play a critical role in recommending vaccines to patients.

SARS-CoV-2 vaccine uptake and reasons for hesitancy among Canadian pregnant people: a prospective cohort study

BACKGROUND

Several vaccines against SARS-CoV-2 have been developed and approved at an unparalleled speed. Given that SARS-CoV-2 vaccines are recommended to pregnant people, our aim was to quantify vaccination uptake, and describe vaccination hesitancy and behavioural attitudes surrounding SARS-CoV-2 vaccination in pregnancy in Canada.

METHODS

The CONCEPTION study is an ongoing international study started in June 2020, evaluating the impact of the COVID-19 pandemic on the health of pregnant people and their children. For this study, pregnant people recruited from Apr. 20, 2021, to Feb. 8, 2022, and residing in Canada were invited to complete a Web-based survey. In addition to all CONCEPTION variables, data on vaccine uptake as well as personal knowledge of COVID-19 severity in pregnancy and of SARS-CoV-2 vaccine safety and efficacy were collected. Marginal risk differences and adjusted odds ratios (ORs) were calculated to assess determinants of SARS-CoV-2 vaccination during pregnancy.

RESULTS

From Apr. 20, 2021, to Feb. 8, 2022, 603 pregnant people were recruited and gave consent, of which 83.7% (n = 505) were vaccinated and 16.3% (n = 98) were not vaccinated against SARS-CoV-2. Uptake of the influenza vaccine in 2020/21 was a significant predictor of being vaccinated against SARS-CoV-2 or intention to be vaccinated (marginal risk difference 3.2%, 95% confidence interval [CI] 3.0% to 3.3%, adjusted OR 4.43, 95% CI 2.32 to 9.25), and being employed (marginal risk difference 11.2%, 95% CI 10.6% to 11.9%, adjusted OR 2.17, 95% CI 1.03 to 4.35) increased the likelihood of being vaccinated against SARS-CoV-2. Self-assessed knowledge of COVID-19 severity and vaccine efficacy was not associated with vaccine uptake.

INTERPRETATION

Among the Canadian pregnant people who responded to this study, vaccine uptake against SARS-CoV-2 was high. However, our results underscore the importance of improving knowledge transfer about the efficacy of SARS-CoV-2 vaccines in pregnancy to guide vaccination efforts.

Understanding Barriers and Facilitators to Maternal Immunization: A Systematic Narrative Synthesis of the Published Literature

Introduction

Vaccines are being developed against Group B Streptococcus and respiratory syncytial virus. These vaccines are designed to be given to pregnant women to protect infants; thus, their success depends on uptake in this population. Maternal immunization programs have struggled to achieve target coverage rates. This systematic narrative synthesis aims to define the most important barriers and facilitators for maternal immunization and to identify priority areas for future research.

Methods

A search strategy was developed in Medline and adapted according to the requirements of additional search engines. Two reviewers independently reviewed the studies, using pre-specified inclusion and exclusion criteria. Results sections of included studies were coded, and thematic analysis was used to identify prominent themes.

Results

321 studies were included in the final review. Most studies came from North America (37%), Europe (26%) or East Asia, Australia and New Zealand (22%). Low-and middle-income countries were under-represented. Five percent of studies came from Sub-Saharan Africa, and 2% came from South Asia. The prominent factors impacting maternal immunization were provider recommendation, perceived risks and benefits of maternal vaccines for the infant, race, birthplace, and access to healthcare. Few studies explored reasons behind racial and socioeconomic disparities in maternal immunization rates.

Discussion

A strong provider recommendation, equitable access to prenatal care and messaging that focuses on vaccine safety and infant benefits emerged as the key components for optimising vaccine uptake among pregnant women. Research among healthcare providers, minority groups and in low- and-middle-income countries was lacking. In anticipation of the expansion of maternal immunization programmes, focused research is needed to address these gaps and inform a successful public health strategy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-022-03508-0.