To Vaccinate or not to Vaccinate? Women's Perception of Vaccination in Pregnancy: A Qualitative Study

"The qualitative approach gives voice to the thoughts and concerns of women as they make the complex decision to vaccinate in pregnancy."

Vaccination against influenza and pertussis is recommended in pregnancy, but Public Health England estimated that only 40.3% of pregnant women had the seasonal flu vaccine in 2012/2013, with pertussis vaccine uptake at 54% in 2014. Conducted in Dublin, Ireland, this qualitative study gives insight into pregnant women's concerns and influencing factors as they make the choice to vaccinate (or not). This information could be used by healthcare providers involved in maternity care to improve vaccination rates in pregnancy.

Seventeen women aged 23-44 years participated in a semi-structured interview. The majority of women were Irish (n = 12), although there was one Polish, one Nigerian, one Spanish, one Maltese, and one Pakistani participant, reflecting the varying ethnicities admitted to the large maternity hospital. Thirteen of the 17 women had received the influenza vaccine in pregnancy, while only 9 had received the pertussis vaccine.

Three themes emerged:

1. Healthcare providers influence pregnant women's choice to vaccinate: 12 of the 13 women vaccinated were positively influenced by their general practitioner (GP), midwife, or hospital consultant to have the influenza vaccine. Some women took a passive role in seeking any further information regarding the influenza vaccine once it was recommended to them. Two of the unvaccinated group said they were not offered the vaccine by their healthcare provider. Others among the vaccinated group commented that the vaccine was not stressed enough and that healthcare providers did not engage them in meaningful discussions about vaccination. The women commended the availability of the vaccine at their community GP visits, but they repeatedly commented that it was not discussed enough in the hospital environment - either by the midwives or by their consultant obstetrician. Four women described stories that negatively influenced their decision to vaccinate or caused them to proceed with more caution. Some referred to the bad press surrounding certain vaccines, such as the link between the H1N1 vaccine and narcolepsy, and the (completely discredited) link between autism and the measles, mumps, and rubella (MMR) vaccine. The story that the vaccine can give you the flu negatively influenced 2 of the unvaccinated group. Family and friends were not seen as a major influence to decision-making about vaccination but were seen to be largely positive.
2. There is a deficiency in women's knowledge regarding vaccine safety: Women believed there were risks associated with the influenza vaccine but had a poor understanding of what these risks were.
3. There is a lack of awareness and promotion of pertussis vaccination: Seven women interviewed had never heard of the pertussis vaccine. For many who did receive the vaccine, they explained their healthcare provider was much less involved in giving information on this vaccine compared to the influenza vaccine, and these women sought other sources of information to inform their choice. Several had to engage their healthcare provider in discussion about the vaccine; the women alluded to some ambiguity among healthcare providers over who is responsible for discussing and offering the pertussis vaccine.

In reflecting on the findings, the researchers note that both positions of vaccinating and not vaccinating despite uncertainty were found in this study. Similarly, not all vaccinated and unvaccinated women had engaged in deliberation. This suggests that these findings are not fully explained by health behaviour theories that presume deliberation on pros and cons of vaccination using all sources of information available.

In conclusion, the researchers urge clinicians to be cognizant of the important role they play in advising women to vaccinate in pregnancy. Uptake could be increased by having vaccines available at hospital antenatal clinics in addition to primary care, with staff promoting both the influenza and pertussis vaccines, addressing any concerns women may have, and reassuring them about safety. Given the lack of safety information, the researchers recommend that this be a focus of future media campaigns promoting vaccination in pregnancy.