Vaccine decision-making begins in pregnancy: Correlation between vaccine concerns, intentions and maternal vaccination with subsequent childhood vaccine uptake
Introduction
Nearly half of Australian parents have some concerns about childhood vaccines [1], [2], with approximately 3.3% of children affected by registered or presumptive vaccine objection. Whilst approximately 93% of Australian children are fully immunised [3], [4], there is considerable regional variation and many parents report complying with the National Immunisation program schedule despite significant concerns [5]. Maintaining and increasing childhood vaccination rates requires that we understand parents’ concerns and the optimal decision-making time points to address them.
Healthcare providers (HCPs) are the most frequently accessed source of vaccine information [6], are highly trusted [7], [8], and play a key role in shaping parental attitudes towards maternal [9], [10] and childhood vaccination [11]. The nature and content of HCPs’ vaccine discussions has been studied [12], but less is known about the optimal timing for delivery of this information. Parents want balanced information about vaccination benefits and harms, the chance to be able to ask questions and to feel a sense of control over the process [13], [14].
Childhood vaccine decision-making begins prenatally [15], [8]. Compared to parents who accept all vaccines, those who refuse or delay are twice as likely to report thinking about vaccines prenatally, and eight times more likely to report ongoing re-evaluation of their vaccination decisions [8]. The provision of vaccine information before the first vaccine visit has been shown to improve knowledge about vaccination, intention to vaccinate, and uptake [14] and is what parents want [16], [17]. However, evidence suggests that information alone is not enough and that provision of vaccine information using effective communication skills as part of the healthcare encounter is what is needed to address vaccine concerns [18] and that such discussions should occur during pregnancy [8].
Currently there is no mandated time point in Australia to discuss childhood vaccination with expectant parents, although many antenatal providers discuss Hepatitis B vaccine at birth. Midwives in public hospitals, private and public obstetricians and GPs are encouraged to recommend and facilitate pertussis and flu vaccination in pregnancy [9]. However, ensuring uptake of these vaccines is challenging [19]. In Australia, a funded, state-based maternal pertussis vaccination program was introduced in Australia in 2015, alongside the already funded maternal influenza vaccination program [9].
There are no data available in Australia to determine whether vaccine concerns of expectant mothers, particularly first time mothers, correlate with childhood and maternal vaccine uptake. In this study, we aimed to ascertain whether vaccine information is received in pregnancy and post-delivery, mothers’ attitudes and concerns regarding childhood vaccination and maternal immunisation uptake. We also aimed to determine any correlation between a) intentions and concerns regarding childhood vaccination, (b) concerns about pregnancy vaccination, (c) socioeconomic status (SES) and (d) uptake of influenza and pertussis vaccines during pregnancy and routine vaccines during childhood.
Section snippets
Design, setting, participants
We sought to recruit 300 women to complete surveys at four sites (1200 women total); two public hospitals in Melbourne, Victoria (Vic); one public hospital in Adelaide, South Australia (SA) and one in Perth, Western Australia (WA). Between October 2015 and April 2016, researchers asked pregnant women attending antenatal appointments to complete the survey using iPads. After ascertaining interest and eligibility (including English proficiency), an information sheet was provided and consent
Participants/demographics for initial survey in pregnancy
Between October 2015 and March 2016, 975 (82%) of 1184 of parents approached, consented to participate. By State, 464 (95%) of 490 parents consented to participate in Victoria, 231 (78%) of 295 in South Australia and 280 (70%) of 399 in Western Australia. The survey took between 10 and 15 min to complete, with the majority of women completing the survey in the antenatal clinic. Between 16–20% of mothers were sent the survey via email link but only 27–30% completed the survey at home when
Discussion
This study confirms that vaccine decision-making begins prenatally with many expectant mothers undecided about vaccinating their child after delivery. This was most significant for first time mothers who reported higher levels of vaccine hesitancy, expressed greater vaccine concerns and were more undecided about vaccinating their unborn child than mothers with children. Furthermore, only half of all expectant mothers strongly agreed that they had enough knowledge to make a decision about
Conclusion
Australian pregnant women birthing in the public system are strongly supportive of childhood vaccination. First time mothers are more vaccine hesitant and undecided about childhood vaccination and only two thirds of all mothers believed they received enough information during pregnancy. New interventions to improve both education and communication on childhood and maternal vaccines, delivered predominantly by midwives in the Australian public hospital system, may reduce vaccine hesitancy for
Acknowledgements
We would like to acknowledge all the mothers who participated in the study and the research assistants at Telethon Kids Institute in Perth and Women’s and Children’s Hospital in Adelaide. This study was supported by grants from the Murdoch Childrens Research Institute and the Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute. KP is supported by an NHMRC Early Career Fellowship (APP1054394) and HM by an NHMRC Career Development Fellowship (APP1084951).
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