Design, setting and participants: Quantitative self-administered survey of pregnant women, using a non-random, stratified sample from antenatal clinics at three demographically diverse hospitals in NSW during the influenza season of 2011.
Results: Of 939 women approached, 815 participated (87%). Influenza vaccine uptake in pregnant women was 27%. Women who had received a recommendation to have the vaccine were 20.0 times (95% CI, 10.9–36.9) more likely to have been vaccinated. Forty-two per cent recalled receiving a recommendation to be vaccinated. Other factors associated with vaccination were study site, perceived infection severity, overall feelings toward vaccination during pregnancy, vaccine accessibility, and willingness to take up the vaccine if recommended. Concern about the baby’s safety was negatively associated with vaccination (odds ratio, 0.5; 95% CI, 0.2–0.9), but 68% (95% CI, 63%–71%) of women who expressed concern agreed they would have the vaccine if their health care professional recommended it.
Conclusion: Recommendation from a health care provider is strongly associated with influenza vaccine uptake among pregnant women and can overcome their concerns about safety, but less than half the women surveyed reported receiving such a recommendation. Educational material targeting pregnant women and professional education and support for antenatal health care providers are needed to increase awareness and recommendation.
A growing body of evidence supports the safety and effectiveness of inactivated influenza vaccine during pregnancy. A recent review concluded that influenza vaccine is safe to administer during any trimester.4 Two recent randomised controlled trials found that babies born to vaccinated mothers had a reduced risk of contracting influenza in the first 6 months of life.5,6 The 9th edition of the Australian immunisation handbook recommends influenza vaccine for all pregnant women who will be in their second or third trimester during influenza season, although it can be given in any trimester.7 The vaccine is free for all pregnant women.
Uptake of influenza vaccine by pregnant women in Australia is low, with estimates ranging from about 7% to 40%.8-11 However, these estimates are often from relatively small samples at single sites dependent on local vaccination policies and procedures.
Our aims were to determine the uptake of seasonal influenza vaccine among a larger sample of pregnant women residing in New South Wales, and to identify barriers and facilitators to vaccine uptake in pregnancy.
We used a self-administered questionnaire delivered to pregnant women attending public hospitals in NSW. The survey was based on the Health Belief Model and Precaution Adoption Process Model of health behaviour.12 Questions covered self-reported receipt of influenza vaccine during the current pregnancy, demographic characteristics, general attitudes toward vaccination, perception of disease risk and vaccine risk and benefit during pregnancy, and information sources. Face and content validity and internal consistency were examined through a pilot study. The final questionnaire was translated into Arabic and Chinese.
A non-random stratified sampling plan was used to ensure a representative sample of pregnant women in NSW. Pilot data showed 15% vaccine uptake, and a target sample of 783 was calculated to provide a 95% confidence interval within 15% of the point estimate. Data on women who had given birth in NSW between 2004 and 2008 were obtained (J Bentley, Principal Epidemiologist, Health Services, Centre for Epidemiology and Evidence, NSW Ministry of Health, personal communication, 2010) and stratified by age, parity and region of residence. Using these population data, target sample proportions were calculated for each stratum.
Women were recruited from antenatal clinic waiting rooms of three tertiary hospitals and one Aboriginal community-controlled health service (ACCHS). The sites were: a hospital in metropolitan Sydney (Site A), with about 5300 births per year; a hospital in Sydney’s outer suburbs (Site B), with 4200 births per year; and a rural referral hospital (Site C), with 800 births per year. The ACCHS was associated with Site C. During the study, Sites A and B did not provide influenza vaccination for pregnant women; however, it had been offered at Site B in March–June 2011, before study commencement. During recruitment, Site C ran an 8-week influenza vaccination clinic onsite.
The overall response rate was 87% (815/939). Site-specific rates were: Site A, 88% (349/398); Site B, 79% (234/298); and Site C, 95% (232/243). The overall sample proportions for age and parity differed from the NSW population data, so the data were weighted for these variables. The weighted sample was comparable to women who gave birth in NSW between 2004 and 2008 for age, parity and region of residence. At the time of the survey, the participants had a mean gestation of 29 weeks (median, 30; range, 5–41), and 99% were > 12 weeks’ gestation.
Most women received their antenatal care exclusively through public hospital antenatal clinics (466/815, 57%). A quarter (201/815) received shared antenatal care through their general practitioner and the local public hospital, and small numbers received care through a birth centre, private obstetrician or the ACCHS.
Five per cent of women (37/815) identified as Aboriginal. Most (580/815, 71%) spoke English at home, but 46 other languages were spoken, most commonly Arabic, Cantonese or Mandarin, and Hindi. Nearly half the women (347/815, 43%) had completed a university degree or higher.
Of the 815 women, 324 (40%; 95% CI, 36%–43%) correctly believed influenza vaccination was recommended during pregnancy, while 207 (25%; 95% CI, 23%–29%) incorrectly thought it was not, and 276 (34%; 95% CI, 31%–37%) were unsure.
Multivariate analysis showed that women who had received a recommendation to have influenza vaccination while pregnant were 20.0 times (95% CI, 10.9–36.9; P < 0.01) more likely to have been vaccinated than women who had not received a recommendation. Other factors associated with vaccine uptake are presented in the Box.
Factors found not to be significantly associated with vaccine uptake included previous influenza infection, perceived likelihood of infection, knowledge of recommendations, belief that the vaccine would protect from influenza, concern that the vaccine would cause influenza, age, parity, antenatal care type, level of education, ethnicity, geographical area (rural v urban), and the presence of maternal comorbidities such as asthma, diabetes, obesity and hypertension.
Concern about the safety of the vaccine for the baby was negatively associated with vaccination (Box). However, of the 502 women who expressed concern, 339 (68%; 95% CI, 63%–71%) agreed they would have the vaccine if their doctor or midwife recommended it.
Of the 310 women who reported from whom they had received a recommendation to have influenza vaccination, 160 (52%; 95% CI, 46%–57%) received it from their doctor and 35 (11%; 95% CI, 8%–15%) from a midwife. Other sources of recommendation included antenatal clinic staff such as receptionists (30; 10%; 95% CI, 7%–14%) and family members (22; 7%; 95% CI, 5%–11%).
Women reporting an underlying condition that put them at higher risk of complications from influenza were no more likely to have received the vaccine than women not reporting this (χ2 = 2.02; P = 0.16) and were no more likely to have received a recommendation to do so (χ2 = 0.02; P = 0.88).
Our results show the importance of health care provider recommendation in pregnant women’s willingness to receive influenza vaccination. Vaccine uptake among women in this sample was relatively low (27%), with significant variation between study sites.
This study has some limitations. First, few women in our sample received antenatal care through private obstetric providers. In NSW, about 26% of women seek antenatal care from a private obstetrician or midwife.13 Our sample can therefore be considered representative of the public obstetric care population only.
Second, our data on uptake relied only on self-report. Self-report has been identified as an acceptable proxy to medical record audit for determining vaccine uptake in older adults.14,15 We anticipate pregnant women’s recall to be equal or better, given that they were unlikely to have received another vaccine while pregnant in 2011.
Third, the data are cross-sectional and although we were able to identify associations between vaccine uptake and certain study factors, we cannot confirm these associations as causal. However, the findings concur with other studies that found health care provider recommendation, safety perceptions and access to vaccines are major factors in vaccine uptake.16-18
Our findings suggest that women’s concerns about the safety of the vaccine for their unborn child can be overcome by health care provider recommendation. Although women who were concerned about their baby’s safety were less likely to be vaccinated, 68% of them agreed that they would have the vaccine if their doctor or midwife recommended it.
Given that a minority of women surveyed, including those at risk due to underlying conditions, had received a vaccination recommendation, it is important to consider what would increase recommendations from health care providers. While some studies have found that physicians are aware of current recommendations,19 others report confusion among health care providers about contraindications and vaccine safety.20-22 These findings highlight the need for professional education and support for antenatal care providers.
Vaccine availability at the antenatal clinic was an apparent contributor to uptake. Site C, which had an onsite vaccination nurse at the time of the study and staff members who discussed the recommendations with women in the waiting room, had a 46% uptake. Sites A and B, which had significantly lower uptake, had no such programs during the study period. This suggests that easily accessible vaccine is likely to be important, but other contributing factors cannot be ruled out.
Uptake by women who felt it was easy to access the doctor for vaccination was not significantly different to uptake by women who felt access was difficult. One explanation may be that women attending Site C (29% of the study sample), who live in a rural setting where access to a primary care doctor is comparatively difficult, had an alternative method of accessing vaccination through the clinic.
Our results suggest that provision of information about influenza vaccination for pregnant women will only partially overcome the low uptake in this group. Motivation and education of antenatal care providers is also important. Information for pregnant women and providers, coupled with easily accessible vaccine, have the potential to substantially increase maternal influenza vaccination coverage.
Weighted percentage responses and adjusted odds ratios (AORs) for influenza vaccine uptake by pregnant women, by associated study factors
Received 19 December 2012, accepted 19 March 2013
- 1. Neuzil KM, Reed GW, Mitchel EF, et al. Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women. Am J Epidemiol 1998; 148: 1094-1102.
- 2. ANZIC Influenza Investigators and Australasian Maternity Outcomes Surveillance System. Critical illness due to 2009 A/H1N1 influenza in pregnant and postpartum women: population based cohort study. BMJ 2010; 340: c1279.
- 3. Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet 2009; 374: 451-458.
- 4. Tamma PD, Steinhoff MC, Omer SB. Influenza infection and vaccination in pregnant women. Expert Rev Respir Med 2010; 4: 321-328.
- 5. Eick AA, Uyeki TM, Klimov A, et al. Maternal influenza vaccination and effect on influenza virus infection in young infants. Arch Pediatr Adolesc Med 2011; 165: 104-111.
- 6. Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal influenza immunization in mothers and infants. N Engl J Med 2008; 359: 1555-1564.
- 7. National Health and Medical Research Council. Australian immunisation handbook. 9th ed. Canberra: NHMRC, 2008.
- 8. Lu AB, Halim AA, Dendle C, et al. Influenza vaccination uptake amongst pregnant women and maternal care providers is suboptimal. Vaccine 2012; 30: 4055-4059.
- 9. Mak DB, Daly AM, Armstrong PK, Effler PV. Pandemic (H1N1) 2009 influenza vaccination coverage in Western Australia. Med J Aust 2010; 193: 401-404. <MJA full text>
- 10. McCarthy EA, Pollock WE, Nolan T, et al. Improving influenza vaccination coverage in pregnancy in Melbourne 2010-2011. Aust N Z J Obstet Gynaecol 2012; 52: 334-341.
- 11. White SW, Petersen RW, Quinlivan JA. Pandemic (H1N1) 2009 influenza vaccine uptake in pregnant women entering the 2010 influenza season in Western Australia. Med J Aust 2010; 193: 405-407. <MJA full text>
- 12. Armitage CJ, Conner M. Social cognition models and health behaviour: a structured review. Psychol Health 2000; 15: 173-189.
- 13. Li Z, McNally L, Hilder L, Sullivan EA. Australia’s mothers and babies 2009. (AIHW Cat. No. PER 52; Perinatal Statistics Series No. 25.) Sydney: Australian Institute of Health and Welfare, 2011.
- 14. MacDonald R, Baken L, Nelson A, Nichol KL. Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients. Am J Prev Med 1999; 16: 173-177.
- 15. Mangtani P, Shah A, Roberts JA. Validation of influenza and pneumococcal vaccine status in adults based on self-report. Epidemiol Infect 2007; 135: 139-143.
- 16. Centers for Disease Control and Prevention. Influenza vaccination coverage among pregnant women: 2011-12 influenza season, United States. MMWR Morb Mortal Wkly Rep 2012; 61: 758-763.
- 17. Naleway AL, Smith WJ, Mullooly JP. Delivering influenza vaccine to pregnant women. Epidemiol Rev 2006; 28: 47-53.
- 18. Tong A, Biringer A, Ofner-Agostini M, 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; 30: 404-410.
- 19. Wu P, Griffin MR, Richardson A, et al. Influenza vaccination during pregnancy: opinions and practices of obstetricians in an urban community. South Med J 2006; 99: 823-828.
- 20. Broughton DE, Beigi RH, Switzer GE, et al. Obstetric health care workers’ attitudes and beliefs regarding influenza vaccination in pregnancy. Obstet Gynecol 2009; 114: 981-987.
- 21. Wallis DH, Chin JL, Sur DK. Influenza vaccination in pregnancy: current practices in a suburban community. J Am Board Fam Pract 2004; 17: 287-291.
- 22. Lee T, Saskin R, McArthur M, McGeer A. Beliefs and practices of Ontario midwives about influenza immunization. Vaccine 2005; 23: 1574-1578.
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.