Vaccination against pertussis and influenza in pregnancy: a qualitative study of barriers and facilitators

doi:10.1016/j.puhe.2018.05.025

Public Health

Volume 162, September 2018, Pages 111-117

https://doi.org/10.1016/j.puhe.2018.05.025 Get rights and content

Highlights

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Many unvaccinated pregnant women are willing to be vaccinated.
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Pregnant women trust and value advice from healthcare workers, especially midwives.
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Weak endorsement by healthcare workers led some women to undervalue vaccination.
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The burden of making extra appointments for vaccination hinders some women.
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Pregnant women want to protect their baby; not all women know vaccination does this.

Abstract

Objectives

Influenza and pertussis vaccination programmes have been in place for pregnant women in the UK since 2009 and 2012, respectively. In 2015, vaccine uptake rates were 55% for influenza and 63% for pertussis in Northern Ireland. We conducted a qualitative study with the aim of learning about the views of pregnant women and identifying potential barriers to vaccination in pregnancy.

Study design

Qualitative study using focus groups and in-depth interviews.

Methods

We conducted focus group discussions and interviews on vaccination in pregnancy using a discussion guide developed in consultation with stakeholders and service users. Pregnant women were recruited on-street. We performed inductive coding of transcripts and thematic analysis, using a phenomenological approach.

Results

Sixteen pregnant women participated. We identified six key themes. Information and knowledge: Vaccinated and unvaccinated women demonstrated similar levels of knowledge and desire for information, preferring direct communication with healthcare professionals. The influence of others: Some vaccinated participants reported firm endorsements of vaccination by healthcare professionals including midwives, while some unvaccinated women recalled neutral or reticent staff. Acceptance and trust: Most women expressed trust of health professionals. Fear and distrust: Vaccinated individuals expressed concerns about side-effects more than unvaccinated women. A few unvaccinated women expressed distrust of vaccines and healthcare systems. Responsibility for the baby: Both groups prioritised protecting the baby but unvaccinated participants were concerned about vaccine-related harm. Accessing vaccination: Multiple appointments, lack of childcare, time off work and having responsibility to organise vaccination hindered some participants from getting immunised. Some women were willing to be vaccinated but did not recall being offered vaccination or were not sufficiently motivated to make arrangements themselves.

Conclusion

Healthcare professionals appear to have a vital influential role in pregnant women's decisions about vaccination. Involving midwives and improving convenience of vaccination access may increase uptake. Strategies to develop interventions should address the aforementioned barriers to meet the pregnant women's needs.

Introduction

Seasonal influenza and pertussis are common, but potentially serious, communicable diseases that can be prevented by vaccination. Seasonal influenza infection during pregnancy may result in serious complications for the woman, and the newborn, who can catch the infection from the mother.¹ Since the 2009 influenza A/H1N1 pandemic, pregnant women have been eligible for influenza vaccination at any stage of pregnancy during the influenza season.² Uptake for the 2015/16 seasonal influenza vaccine by pregnant women in Northern Ireland (NI) was 55%³ and 42% in England.⁴ The childhood pertussis vaccine greatly reduces the incidence of pertussis, but infants are at risk of pertussis-related hospitalisation and death before they are vaccinated or develop an adequate immune response.⁵ Babies of women who receive pertussis vaccination during their pregnancy have a 90% reduced risk of pertussis during the first two months of life.6, 7 In 2012, the United Kingdom experienced a national outbreak of pertussis in infants too young to be vaccinated,8, 9 leading to the recommendation that pregnant women be vaccinated for pertussis between 28 and 32 weeks of pregnancy to protect the infant via maternal antibodies.⁹ This recommendation was extended, and since 2016, pertussis vaccination can be given from week 16 of pregnancy.¹⁰ In 2015, uptake of pertussis vaccination among pregnant women was estimated to be 63% in NI¹¹ and 58% in England.¹²

There is limited information available about whether low uptake of seasonal influenza and pertussis vaccinations by pregnant women is due to factors relating to the healthcare system, women's knowledge, attitudes and beliefs, social norms, or a combination of these factors. We designed and conducted a qualitative study to investigate the reasons why pregnant women receive, or do not receive, vaccination during pregnancy. The aim of the study was to provide information that would help us plan improvements to services that offer vaccinations to pregnant women.

Section snippets

Study design

We chose a qualitative study design to elicit information about pregnant women's knowledge, attitudes, beliefs, and experiences relating to vaccination in pregnancy. We developed a discussion guide as part of a multidisciplinary group, including a midwife consultant, general practitioner, public health doctors and nurses, an epidemiological scientist, and an academic with experience of qualitative study design and conduct. The discussion guide was refined in consultation with members of a

Study population

Three focus group discussions and one interview took place in March and April 2017. Focus groups included 15 participants of different ages, social grades, and included first-time and mothers who had previous pregnancies (Table 2). All women were at least 16 weeks pregnant at the time of recruitment (February–March 2017) and hence, eligible for both vaccinations during their current pregnancy.

Themes

We identified six themes that described reasons why pregnant women choose to get or to not get

Discussion

Vaccination against pertussis and influenza during pregnancy is a safe, simple and potentially life-saving intervention. A sizeable minority of the eligible population does not get vaccinated. We identified possible reasons for women not being vaccinated and suggest strategies that might improve uptake.

There has been little previous research about the factors affecting vaccination of women in pregnancy against influenza and pertussis, particularly in the context of the UK.¹⁵ Winslade et al.,¹²

Acknowledgements

The authors wish to thank the study participants. We gratefully acknowledge Kostas Danis for his critical review of this manuscript.

Author roles

AM, DB, AQ, JJ and DTB were involved in the conception and design of the study. AM and SM analysed and interpreted the data. CT, DTB contributed to the analysis and interpretation of the data. AM, SM and DTB drafted the manuscript. All authors were involved in revision and approval of the final content before submission.

Ethical approval

Research ethics approval was obtained from

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Original ResearchVaccination against pertussis and influenza in pregnancy: a qualitative study of barriers and facilitators

Highlights

Abstract

Objectives

Study design

Methods

Results

Conclusion

Introduction

Section snippets

Study design

Study population

Themes

Discussion

Acknowledgements

Author roles

Ethical approval

Publ Health

Vaccine

Vaccine

Vaccine

Vaccine

Women Birth

Risk management of seasonal influenza during pregnancy: current perspectives

Int J Wom Health

Saving lives, improving mothers' care – lessons learned to inform future maternity care from the UK and Ireland confidential enquiries into maternal deaths and morbidity 2009–12

Influenza immunisation programme for England GP patient groups data collection survey season 2015 to 2016

Pertussis: still a cause of death, seven decades into vaccination

Curr Opin Pediatr

Effectiveness of maternal pertussis vaccination in England: an observational study

Lancet

Effectiveness of vaccination during pregnancy to prevent infant pertussis

Pediatrics

Original Research
Vaccination against pertussis and influenza in pregnancy: a qualitative study of barriers and facilitators