Predictors of maternal vaccination in the United States: An integrative review of the literature

doi:10.1016/j.vaccine.2016.06.042

Vaccine

Volume 34, Issue 34, 25 July 2016, Pages 3942-3949

https://doi.org/10.1016/j.vaccine.2016.06.042 Get rights and content

Highlights

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Constructs of the Health Belief Model were used the most to frame studies.
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Provider recommendation continues to be the most important predictor of vaccination.
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No provider-focused studies supported by a theoretical framework were found.
•
More research is needed on logistical barriers within obstetrical practice sites.
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Future research on maternal vaccination could use implementation science as a guide.

Abstract

Objectives

The purpose of this literature review was to identify, analyze, and synthesize existing research related to patient, provider, and health system predictors of maternal vaccination in the United States, strategies used to increase maternal vaccination rates, and major theoretical frameworks used to guide maternal vaccination research.

Methods

A search for evidence was conducted in CINAHL, PubMed, PsychINFO, Cochrane Systematic Reviews, and Google Scholar. Twenty-two articles were identified as best evidence for inclusion in this review: five randomized control trials, one cluster randomized trial, one mixed methods study, 12 observational studies, and three qualitative studies.

Results

Patient-focused predictors of maternal vaccination included provider recommendation; knowledge, attitudes, and beliefs; cues to action; and race and ethnicity. Provider-focused predictors included knowledge, attitudes, and beliefs; and multi-component intervention packages. Health system predictors included standing order protocols and practice site logistics. The major theoretical frameworks that emerged were the Health Belief Model, Theory of Reasoned Action/Theory of Planned Behavior, and Message Framing/Prospect Theory. Provider recommendation was the single most important predictor of vaccine acceptance among pregnant women.

Conclusions

An abundance of theoretically-supported, patient-focused research was found in the literature. A minimal number of U.S.-based, provider-focused research was found and none of these used a theoretical framework. Minimal research examining health system barriers to maternal vaccination was found. Additional research into the logistical barriers to maternal vaccination programs within obstetrical practice locations in other geographical locations within the U.S. is warranted. Future provider- and health system-focused research needs to be grounded in theory. The field of implementation science may offer the theoretical guidance necessary to better understand problems in obstetrical practice work flow and streamlining of vaccinations.

Introduction

Every year in the United States, over four million women give birth [1]. In 2012, the CDC reported 41,880 cases of pertussis with 18 deaths; 14 of those deaths were infants less than 12 months of age [2]. At the same time, during the 2012–2013 influenza season, 18 infants less than six months of age died from influenza [3]. Although the number of infant deaths due to pertussis and influenza is small compared to the total number of births each year, every single death is a tragedy because these are vaccine-preventable diseases. Infants cannot receive the first pertussis vaccine until two months of age [4] nor the influenza vaccine until six months of age [5]. For this reason, maternal vaccination is necessary to provide passive immunity to the infant for protection from these diseases during the first few months of life [6], [7], [8], [9], [10].

Despite the evidence, maternal vaccination rates remain suboptimal in the U.S., with only 50% of pregnant women receiving the influenza vaccine during the 2014–2015 influenza season [11] and only 14% receiving the Tdap vaccine from 2007 to 2013 [12], [13]. A recent study by Kharbanda et al. [14] acknowledged the low Tdap vaccination rates, but through analysis of Vaccine Safety Datalink (VSD) data from 2007 to 2013 they were able to demonstrate evidence of increasing rates; by 2013, 41.7% of pregnant women (n = 438,487) received the vaccine primarily during the third trimester. Although some progress has been made, optimal vaccination rates have yet to be achieved. Such a disparity in maternal vaccination presents a significant risk to the health and well-being of pregnant women and young infants.

This paper will present a synthesis of evidence related to patient, provider, and health system predictors of maternal vaccination in the U.S. This paper will also identify theoretical frameworks that have been used to describe, explain, and predict vaccine decision-making behaviors among pregnant women and providers. The research questions that guided this literature review were: in the U.S., (1) What are the predictors of maternal vaccination? (2) What strategies have been used to increase maternal vaccine acceptance? and (3) What theoretical frameworks have been used to guide maternal vaccine-related research? The outcomes of this literature review will support an argument for the need to use an alternative theoretical approach to address a major gap in provider- and health system-focused research.

Section snippets

Background

The CDC’s Advisory Committee on Immunization Practices (ACIP), supported by the National Vaccine Advisory Committee (NVAC) and the American College of Obstetricians and Gynecologists (ACOG) recommends all women who are or who will be pregnant during the influenza season, receive one dose of the influenza vaccine during every pregnancy, when available [3], [15], [16]. Likewise, it is recommended pregnant women receive one dose of Tdap between 27 and 36 weeks of every pregnancy [2], [3], [17].

Methods

A literature search for best evidence was conducted in CINAHL, PubMed, PsychINFO, Cochrane Systematic Reviews, and Google Scholar. Limiters set included English, humans, female, and research studies. Major keywords used to search the databases included pregnant women, vaccine uptake, pertussis, Tdap, influenza, maternal vaccination, predictors, and barriers. The search and selection process required consideration of two potential confounding factors: (1) the H1N1 influenza pandemic during the

Theoretical frameworks

Twelve studies, all of which were patient-focused, used a theoretical framework [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32]. Three prominent theories emerged from these studies (Table 2): Health Belief Model (HBM), Theory of Reasoned Action/Theory of Planned Behavior (TRA/TPB), and Message Framing/Prospect Theory (MFPT).

Conclusion

This review revealed several gaps in the existing literature on maternal vaccination. An abundance of patient-focused evidence was found to describe, explain, and predict the vaccine decision-making behaviors of pregnant women. The patient-focused research appears to be adequately supported by theory, although the selection of theories is somewhat limited. There is also a lack of current research examining the KAB of nurse midwives in the U.S. specifically. While the existing literature did

Conflict of interest

The authors declare they have no conflicts of interest.

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Vaccination during pregnancy by race/ethnicity: a focus on American Indians/Alaska Natives
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Vaccination during pregnancy reduces the incidence of infections and their associated adverse outcomes in both mothers and infants. The American College of Obstetricians and Gynecologists has recommended influenza and Tdap vaccination during pregnancy since 2004 and 2013, respectively. Several studies have examined disparities in vaccination rates during pregnancy by race/ethnicity. However, none have included American Indians/Alaska Natives as a specific racial/ethnic group on a national level. Current literature suggests that American Indian/Alaska Native infants experience increased morbidity and mortality from both influenza and pertussis infections compared with most other groups in the United States.
This study aimed to evaluate the uptake of influenza and Tdap vaccinations during pregnancy by race/ethnicity, with a specific focus on American Indian/Alaska Native people.
This cross-sectional study used data from the Pregnancy Risk Assessment Monitoring System. Comparisons of vaccine uptake across racial/ethnic groups (American Indian/Alaska Native, Asian, non-Hispanic Black, non-Hispanic White, Hispanic, and “None of the above”) were evaluated using weighted logistic regression analyses to estimate prevalence odds ratios with 95% confidence intervals. Models were adjusted for maternal age, parity, maternal education, marital status, payment method at delivery, prenatal care in first trimester, maternal smoking status, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation, and receipt of influenza vaccine reported by a health care provider.
For both vaccines, Asian respondents had the highest uptake (influenza, 70.1%; Tdap, 68.2%), whereas Black respondents reported the lowest uptake (influenza, 44.4%; Tdap, 57.9%). For the influenza vaccine, American Indian/Alaska Native respondents demonstrated a higher uptake compared with White respondents, and the magnitude of difference increased markedly after adjusting for respondent characteristics (adjusted odds ratio, 1.74; 95% confidence interval, 1.58–1.90). In the unadjusted analyses, Black individuals reported influenza vaccination at approximately half the rate of their White counterparts during pregnancy. This effect was attenuated but remained lower after adjustment for respondent characteristics (adjusted odds ratio, 0.73; 95% confidence interval, 0.70–0.76). For the Tdap vaccine, American Indian/Alaska Native respondents reported lower uptake than White respondents; however, this difference disappeared when adjusted for respondent characteristics (adjusted odds ratio, 0.99; 95% confidence interval, 0.83–1.19). Asian and Hispanic respondents displayed a similar uptake compared with their White counterparts for both vaccines.
Our findings indicate that there are racial/ethnic disparities in influenza and Tdap vaccination rates among pregnant individuals in the United States. Demonstration of increased uptake among American Indian/Alaska Native people in the crude analysis may reflect the success of various public health interventions through Tribal and Indian Health Service hospitals. Nonetheless, vaccination status during pregnancy remains seriously below national guideline recommendations. Greater measures must be taken to support preventative care in marginalized populations, with particular emphasis on community-driven solutions rooted in justice.
Covid-19 vaccination during pregnancy: A mixed-methods study of attitudes in a sample of Italian women and the role of health professionals’ communication
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We examined Italian pregnant women's attitudes about the diphtheria, tetanus, and pertussis (DTP) vaccine, seasonal influenza, and Covid-19 vaccines, healthcare professionals’ (HP) communication, reasons and potential predictors for non-adherence.
From August 2021 to January 2022, we carried out a cross-sectional study in Italy using an online self-administered questionnaire addressed to women of age and pregnant, designed using LimeSurvey and disseminated through social media. Questions explored vaccination attitude/perceptions, satisfaction, and trust in HPs’ information. Thematic analysis of free-text responses was performed using MaxQDA 2022. Statistical analyses were performed using STATA.
1594 responses were obtained. 52% of women hesitated to be vaccinated against Covid-19 while pregnant. Information received by HPs was deemed incomplete by 56% of participants, unclear by 52%, and untrustworthy by 46%; 49% felt unsupported in their decision-making process. This variable was one predictor of vaccine hesitancy together with concern about vaccine safety in the multivariate model. The analysis of open-ended questions revealed a pervasive feeling of dissatisfaction.
The perceived lack of adequate communication and support by HPs affected pregnant women’s decision-making process on Covid-19 vaccination.
HPs need to understand and communicate the importance of vaccination during pregnancy, learning to better tailor their messages.
COVID-19 vaccine acceptance and coverage among pregnant persons in the United States
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Pregnant persons are at higher risk of severe COVID-19. Although vaccination is recommended, COVID-19 vaccination rates are lower among pregnant persons compared to the non-pregnant population. We aimed to evaluate acceptance of any dose of COVID-19 vaccine during pregnancy. A national online cross-sectional survey of US adults who were pregnant between December 2020 and July 2021 was used to measure COVID-19 vaccine behaviors, attitudes, and beliefs. Post-stratification weighting was used to ensure representativeness to the US population. Marginal log-binomial models were used to estimate adjusted prevalence ratios (aPR) of COVID-19 vaccine acceptance, accounting for sociodemographic factors. Of 5,660 who responded to survey advertisements, 2,213 met eligibility criteria and completed the survey; 55.4% of respondents received or planned to receive COVID-19 vaccine prior to or during pregnancy, 27.0% planned to vaccinate after pregnancy, 8.8% were unsure and 8.7% had no plans to vaccinate. Individuals were more likely to receive or plan to receive COVID-19 vaccine if they had group prenatal care (aPR 1.57; 95% CI 1.40, 1.75), were employed in a workplace with a policy recommending vaccination (aPR 1.15; 95% CI 1.06, 1.26), and believed COVID-19 vaccines are safe (aPR 2.86; 95% CI 2.49, 3.29). Pregnant persons who were recommended COVID-19 vaccination by their healthcare provider less commonly reported concerns about vaccine safety (35.5% vs 55.9%) and were more likely to accept COVID-19 vaccines (aPR 1.52; 95% CI 1.31, 1.76). COVID-19 vaccine acceptance during pregnancy is not universal and public health intervention will be needed to continue to increase vaccine coverage.
COVID-19 vaccination among pregnant people in the United States: a systematic review
2022, American Journal of Obstetrics and Gynecology MFM
Pregnant people are at increased risk of COVID-19–related morbidity and mortality, and vaccination presents an important strategy for preventing negative outcomes. However, pregnant people were not included in vaccine trials, and there are limited data on COVID-19 vaccines during pregnancy. The objectives of this systematic review were to identify the safety, immunogenicity, effectiveness, and acceptance of COVID-19 vaccination among pregnant people in the United States.
Four databases (PubMed, Web of Science, CINAHL, and Google Scholar) were used to identify eligible studies published from January 1, 2020 through February 6, 2022.
Inclusion criteria were peer-reviewed empirical research conducted in the United States, publications in English, and research addressing 1 of the following topics: safety, immunogenicity, effectiveness, and acceptance of COVID-19 vaccination among pregnant people.
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View all citing articles on Scopus

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ReviewPredictors of maternal vaccination in the United States: An integrative review of the literature

Highlights

Abstract

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Background

Methods

Theoretical frameworks

Conclusion

Conflict of interest

Vaccine

Vaccine

Vaccine

Vaccine

Vaccine

Prev Med

Vaccine

Vaccine

Vaccine

Vaccine

Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women – advisory committee on immunization practices (ACIP), 2012

MMWR

The national vaccine advisory committee: reducing patient and provider barriers to maternal immunizations: approved by the national vaccine advisory committee on June 11, 2014

Public Health Rep

Use of diphtheria toxoid: tetanus toxoid-acellular pertussis vaccine as a five-dose series – supplemental recommendations of the advisory committee on immunization practices (ACIP)

Morb Mortal Wkly Rep

Prevention and control of influenza with vaccines: Recommendations of the ACIP – U.S., 2015–16 influenza season

Morb Mortal Wkly Rep

Immune responses in infants whose mothers received Tdap vaccine during pregnancy

Pedia Infect Dis J

Prevalence of pertussis antibodies in maternal delivery, cord, and infant serum

J Infect Dis

Importance of timing of maternal combined tetanus, diphtheria, and acellular pertussis (Tdap) immunization and protection of young infants

Clin Infect Dis

Influenza vaccination coverage among pregnant women – United States, 2014–15 influenza season

MMWR

Vaccination with tetanus, diphtheria, and acellular pertussis vaccine of pregnant women enrolled in Medicaid-Michigan, 2011–2013

MMWR

Pertussis and influenza vaccination among insured pregnant women – Wisconsin, 2013–2014

MMWR

Guiding principles for development of ACIP recommendations for vaccination during pregnancy and breastfeeding

Morb Mortal Wkly Rep

Committee opinion no. 608: influenza vaccination during pregnancy

Obstet Gynecol

Review
Predictors of maternal vaccination in the United States: An integrative review of the literature