Influenza immunization in pregnancy: overcoming patient and health care provider barriers

doi:10.1016/j.ajog.2012.06.077

American Journal of Obstetrics and Gynecology

Volume 207, Issue 3, Supplement, September 2012, Pages S67-S74

https://doi.org/10.1016/j.ajog.2012.06.077 Get rights and content

Seasonal influenza imparts disproportionate morbidity and death to pregnant women. Immunization against influenza is the most effective intervention to mitigate the burden of influenza disease during pregnancy; nevertheless, immunization rates remain suboptimal in this patient population. Therefore, there is a clear need for strategies to optimize influenza vaccination among pregnant women. We reviewed potential patient and health care provider barriers to influenza immunization and propose effective strategies for overcoming them.

Section snippets

Patient barriers to vaccination

Patient uptake of preventive care measures like immunization likely is affected by demographics, beliefs, attitudes, perceptions, motivations, and expectations.24, 32 Reported patient barriers to maternal influenza vaccination are summarized in Table 1 and include safety concerns, lack of knowledge about influenza and its serious nature during pregnancy, fear of needles, vaccination history, general mistrust of the medical establishment, view of obstetrician-gynecologists as vaccinators, and

Health care provider barriers to vaccination

Perhaps the most important factor in a pregnant woman's decision to receive the influenza vaccine has been shown to be a compelling recommendation from her health care provider.35, 43 Based on 2006 Pregnancy Risk Assessment and Monitoring System data, “my physician did not mention anything about a flu vaccine during my pregnancy” was the second most cited reason for not receiving the influenza vaccine.⁴⁴ Based on results from a CDC internet survey, 71% of women who were offered vaccination by

Final thoughts

Pregnant women are at increased risk for influenza-related morbidity and death. Immunization against influenza is the most effective intervention to mitigate the burden of influenza disease during pregnancy; nevertheless, immunization rates remain suboptimal in this patient population. To optimize influenza vaccination among pregnant women, it is critical that patient and health care provider barriers are recognized and addressed.

It is imperative that the health care provider learn the art of

References (66)

M. Greenberg et al.
Maternal mortality in the epidemic of Asian influenza, New York City, 1957
Am J Obstet Gynecol
(1958)
D.W. Freeman et al.
Deaths from Asian influenza associated with pregnancy
Am J Obstet Gynecol
(1959)
T.V. Hartert et al.
Maternal morbidity and perinatal outcomes among pregnant women with respiratory hospitalizations during influenza season
Am J Obstet Gynecol
(2003)
D.J. Jamieson et al.
H1N1 2009 influenza virus infection during pregnancy in the USA
Lancet
(2009)
T.K. Mak et al.
Influenza vaccination in pregnancy: current evidence and selected national policies
Lancet Infect Dis
(2008)
F.M. Munoz et al.
Safety of influenza vaccination during pregnancy
Am J Obstet Gynecol
(2005)
P.D. Tamma et al.
Safety of influenza vaccination during pregnancy
Am J Obstet Gynecol
(2009)
P. Lu et al.
Influenza vaccination of recommended adult populations, US, 1989-2005
Vaccine
(2008)
F.M. Munoz et al.
Vaccines in pregnancy
Infect Dis Clin North Am
(2001)
B.M. Fisher et al.
Behaviors and perceptions regarding seasonal and H1N1 influenza vaccination during pregnancy
Am J Obstet Gynecol
(2011)

M.H. Yudin et al.

Pregnant women's knowledge of influenza and the use and safety of the influenza vaccine during pregnancy

J Obstet Gynaecol Can

(2009)

I. Goldfarb et al.

Uptake of influenza vaccine in pregnant women during the 2009 H1N1 influenza pandemic

Am J Obstet Gynecol

(2011)

W.S. Vitek et al.

Vaccine eligibility and acceptance among ambulatory obstetric and gynecology patients

Vaccine

(2011)

A. Tong et al.

A cross-sectional study of maternity care providers' and women's knowledge, attitudes, and behaviours towards influenza vaccination during pregnancy

J Obstet Gynaecol Can

(2008)

D.R. Johnson et al.

Barriers to adult immunization

Am J Med

(2008)

M.L. Power et al.

Obstetrician-gynecologists' practices and perceived knowledge regarding immunization

Am J Prev Med

(2009)

S.J. Schrag et al.

Vaccination and perinatal infection prevention practices among obstetrician-gynecologists

Obstet Gynecol

(2003)

B. Gonik et al.

The obstetrician-gynecologist's role in vaccine-preventable diseases and immunization

Obstet Gynecol

(2000)

A.E. Fiore et al.

Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009

MMWR Recomm Rep

(2009)

W.L. Irving et al.

Influenza virus infection in the second and third trimesters of pregnancy: a clinical and seroepidemiological study

BJOG

(2000)

A. Reid

The effects of the 1918-1919 influenza pandemic on infant and child health in Derbyshire

Med Hist

(2005)

W.J. Woolston et al.

Epidemic pneumonia (Spanish Influenza) in pregnancy: effect in one hundred and one cases

JAMA

(1918)

J.W. Harris

Influenza occurring in pregnant women: a statistical study of thirteen hundred and fifty cases

JAMA

(1919)

K.M. Neuzil et al.

Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women

Am J Epidemiol

(1998)

S. Cox et al.

Hospitalizations with respiratory illness among pregnant women during influenza season

Am J Obstet Gynecol

(2006)

S. Cox

Influenza and pregnant women: hospitalization burden, United States, 1998-2002

J Womens Health

(2006)

D.J. Wilkinson et al.

Influenza in the neonatal intensive care unit

J Perinatol

(2006)

A.C. Miller et al.

Novel influenza A (H1N1) virus among gravid admissions

Arch Int Med

(2010)

Critical illness due to 2009 A/H1N1 influenza in pregnant and postpartum women: population based cohort study

BMJ

(2010)

J.K. Louie et al.

Severe 2009 H1N1 influenza in pregnant and postpartum women in California

N Engl J Med

(2010)

A.M. Siston et al.

Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States

JAMA

(2010)

J.A. Englund et al.

Maternal immunization with influenza or tetanus toxoid vaccine for passive antibody protection in young infants

J Infect Dis

(1993)

C.V. Sumaya et al.

Immunization of pregnant women with influenza A/New Jersey/76 virus vaccine: reactogenicity and immunogenicity in mother and infant

J Infect Dis

(1979)

Cited by (80)

Comparison of attitudes toward routine maternal vaccines and COVID-19 vaccines among pregnant patients in an urban safety-net setting
2023, Journal of the National Medical Association
To explore attitudes toward tetanus-diphtheria-acellular pertussis (Tdap), influenza, and COVID vaccines among English- and Spanish- speaking pregnant individuals in a safety net setting.
Pregnant people aged 18 years or older were recruited from outpatient clinics between August 2020 and June 2021. Interviews were conducted via phone in English or Spanish, recorded, transcribed, and translated verbatim. Data were qualitatively analyzed using modified grounded theory and content analysis.
42 patients participated (22 English-speaking, 20 Spanish-speaking). Most participants expressed positive attitudes towards both routine prenatal vaccinations and COVID-19 vaccines, endorsing the belief that vaccines promote health and considering vaccines a social norm. Positive attitudes were similar for the three vaccines, and among Spanish- and English-speaking individuals. Participants trusted their healthcare provider's recommendations and felt comfortable receiving booster doses of vaccines they had received successfully in the past. Vaccine concerns differed by each vaccine. Despite limited knowledge, few participants expressed concerns about Tdap vaccines. Concerns around influenza vaccines often stemmed from personal experience and centered around ineffectiveness and increased risk of flu-like illnesses. Participants expressed the most concerns related to COVID vaccinations, including misinformation about serious side effects and distrust around accelerated approval of the vaccines. Many participants wished to know more about the side effects and safety of vaccinating during pregnancy, especially regarding the fetus's health.
Most participants supported routine prenatal vaccinations, including COVID vaccines. Clinicians are trusted information sources and can help reinforce positive attitudes and social norms of receiving vaccinations in pregnancy while addressing vaccine-specific concerns.
This work was supported by Suzanne Cutler Vaccination Education & Research Fund at the Boston University Chobanian and Avedisian School of Medicine for funding and support.
Vaccine Hesitancy in Women's Health
2023, Obstetrics and Gynecology Clinics of North America
Vaccination options for pregnant women during the Omicron period
2023, Journal of Reproductive Immunology
Omicron exhibits reduced pathogenicity in general population than the previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants. However, the severity of disease and pregnancy outcomes of Omicron infection among pregnant women have not yet been definitively established. Meanwhile, substantial proportions of this population have doubts about the necessity of vaccination given the reports of declining efficacy of coronavirus disease 2019 (COVID-19) vaccines. Herein, we comprehensively discuss the clinical outcomes of infected pregnant women during the Omicron period and summarize the available data on the safety and efficacy profile of COVID-19 vaccination. The results found that the incidence of moderate and severe disease, maternal mortality, pregnancy loss, preterm delivery, stillbirth, preeclampsia/eclampsia, and gestational hypertension during the Omicron period are similar to those during the Pre-Delta period. In view of the effects of mass vaccination and previous natural infection on disease severity, the virulence of Omicron in pregnant women may be comparable to or even higher than that of the Pre-Delta variant. Moreover, the currently approved COVID-19 vaccines are safe and effective for pregnant women. Particularly, those who received a second or third dose had significantly less severe disease with little progression to critical illness or death compared with those who were unvaccinated or received only one dose. Therefore, in the case of the rapid spread of Omicron, pregnant women should still strictly follow preventive measures to avoid infection and receive the COVID-19 vaccine in a timely manner.
Overcoming barriers to COVID-19 vaccination of pregnant women
2022, Gynecology and Obstetrics Clinical Medicine
Citation Excerpt :
Healthcare providers are long-standing essential partners in the recommendation and safe administration of vaccines.48,69 Positive attitudes toward immunization in pregnant women are reported with provider's recommendation for vaccination.49,50 They build confidence in patients who believe vaccinations are unsafe.51
COVID-19 in pregnancy is associated with an increased risk of severe maternal illness, ICU admissions, mechanical ventilation and deaths. Vaccination is the best way to protect pregnant women against these known risks of infection in pregnancy. There is an urgent need to prioritize strategic responses to optimize vaccination among expectant mothers. In this paper, we reviewed potential patient and healthcare provider barriers to COVID-19 immunization and propose effective strategies for overcoming them.
Perceptions and attitudes towards vaccination during pregnancy in a peri urban area of Lima, Peru
2021, Vaccine
Maternal immunization has the potential to reduce both maternal and infant morbidity and mortality by protecting women from complications during pregnancy as well as conferring protection for babies who are too young to be vaccinated. Limited evidence is available about the drivers of maternal immunization in middle-income countries such as Peru. Vaccines against tetanus, diphtheria and influenza are recommended beginning in the second trimester in Peru; however, vaccination coverage has remained low in Peru compared to other countries in the region. As additional vaccines are recommended for administration in pregnancy, a better understanding of the perceptions and attitudes of pregnant women that influence vaccination are needed to design communication materials.
We conducted an exploratory qualitative study to understand the individual level factors influencing pregnant women’s vaccine uptake. We interviewed pregnant women about their knowledge, perceptions and experiences with vaccination during pregnancy. Community health workers recruited women in a peri urban area of Peru in April 2018.
Twelve women were interviewed, the majority of which had received vaccination during the current pregnancy. The most common reasons for vaccination were to protect the baby and because vaccines are effective. Concerns included vaccine safety during pregnancy and adverse effects on the unborn baby. Some women mentioned that because vaccines are given later in pregnancy, the unborn baby is stronger, so vaccines will not harm them. Women highlighted that the main reason for not being vaccinated was lack of information. They also noted that they were the decision-maker in whether or not they were vaccinated. Most women said that they trusted healthcare providers and that trust was linked to providing information through open communication.
Overall, participants were supportive of maternal vaccination. They believed that vaccines were effective in protecting both their unborn baby and themselves. The main reason given for non-vaccination was lack of knowledge about vaccination in pregnancy. The strong desire expressed by study participants to get more information presents an opportunity for immunization programs to develop interventions that facilitate better information dissemination to pregnant women to increase vaccination uptake.
Pregnant women & vaccines against emerging epidemic threats: Ethics guidance for preparedness, research, and response
2021, Vaccine
Citation Excerpt :
In explaining why the vaccine is recommended for use in pregnancy, the communication plan should be sensitive to issues of low vaccine confidence among pregnant women and the communities in which they live, as well as public anxieties surrounding outbreaks and epidemics. The communication plan should also be sensitive to the critical role that health care providers can play in increasing the likelihood of vaccine acceptance [71,72]. Health care providers vary in knowledge and attitudes about vaccination in pregnancy.
Zika virus, influenza, and Ebola have called attention to the ways in which infectious disease outbreaks can severely – and at times uniquely – affect the health interests of pregnant women and their offspring. These examples also highlight the critical need to proactively consider pregnant women and their offspring in vaccine research and response efforts to combat emerging and re-emerging infectious diseases. Historically, pregnant women and their offspring have been largely excluded from research agendas and investment strategies for vaccines against epidemic threats, which in turn can lead to exclusion from future vaccine campaigns amidst outbreaks. This state of affairs is profoundly unjust to pregnant women and their offspring, and deeply problematic from the standpoint of public health. To ensure that the needs of pregnant women and their offspring are fairly addressed, new approaches to public health preparedness, vaccine research and development, and vaccine delivery are required. This Guidance offers 22 concrete recommendations that provide a roadmap for the ethically responsible, socially just, and respectful inclusion of the interests of pregnant women in the development and deployment of vaccines against emerging pathogens. The Guidance was developed by the Pregnancy Research Ethics for Vaccines, Epidemics, and New Technologies (PREVENT) Working Group – a multidisciplinary, international team of 17 experts specializing in bioethics, maternal immunization, maternal-fetal medicine, obstetrics, pediatrics, philosophy, public health, and vaccine research and policy – in consultation with a variety of external experts and stakeholders.

View all citing articles on Scopus

: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Vaccine Program Office, the Centers for Disease Control and Prevention, or the Food and Drug Administration.

: B.G. is a member of advisory committees for Merck Vaccines, Sanofi-Pasteur Vaccines, Novartis Vaccines, and GlaxoSmithKline Biologicals Vaccines, a speaker for Merck Vaccines, Sanofi-Pasteur Vaccines, and GlaxoSmithKline Biologicals Vaccines, and a member of the Michigan Advisory Committee on Immunization Practices and the ACOG Vaccine Expert Working Group. The remaining authors report no conflict of interest.

: Reprints not available from the authors.

View full text

SupplementInfluenza immunization in pregnancy: overcoming patient and health care provider barriers

Section snippets

Patient barriers to vaccination

Health care provider barriers to vaccination

Final thoughts

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Lancet

Lancet Infect Dis

Am J Obstet Gynecol

Am J Obstet Gynecol

Vaccine

Infect Dis Clin North Am

Am J Obstet Gynecol

J Obstet Gynaecol Can

Am J Obstet Gynecol

Vaccine

J Obstet Gynaecol Can

Am J Med

Am J Prev Med

Obstet Gynecol

Obstet Gynecol

Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009

MMWR Recomm Rep

Influenza virus infection in the second and third trimesters of pregnancy: a clinical and seroepidemiological study

BJOG

The effects of the 1918-1919 influenza pandemic on infant and child health in Derbyshire

Med Hist

Epidemic pneumonia (Spanish Influenza) in pregnancy: effect in one hundred and one cases

JAMA

Influenza occurring in pregnant women: a statistical study of thirteen hundred and fifty cases

JAMA

Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women

Am J Epidemiol

Hospitalizations with respiratory illness among pregnant women during influenza season

Am J Obstet Gynecol

Influenza and pregnant women: hospitalization burden, United States, 1998-2002

J Womens Health

Influenza in the neonatal intensive care unit

J Perinatol

Novel influenza A (H1N1) virus among gravid admissions

Arch Int Med

Critical illness due to 2009 A/H1N1 influenza in pregnant and postpartum women: population based cohort study

BMJ

Severe 2009 H1N1 influenza in pregnant and postpartum women in California

N Engl J Med

Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States

JAMA

Maternal immunization with influenza or tetanus toxoid vaccine for passive antibody protection in young infants

J Infect Dis

Immunization of pregnant women with influenza A/New Jersey/76 virus vaccine: reactogenicity and immunogenicity in mother and infant

J Infect Dis

Supplement
Influenza immunization in pregnancy: overcoming patient and health care provider barriers