Review: Facilitators and barriers to vaccination uptake in pregnancy

St George's, University of LondonApr 23 2024

Researchers from St George’s, University of London have identified key barriers to vaccine uptake for whooping cough, flu and Covid-19 in pregnant women, and outline recommendations for addressing vaccine hesitancy. The results are from the first review of its kind and published today in the journal PLOS ONE.

Pregnant women are at increased risk of viral infections due to changes in their immune system during pregnancy. Vaccinations – particularly for influenza (flu), pertussis (whooping cough) and Covid-19 – are therefore highly recommended. If pregnant women choose not to have these vaccines, they not only put themselves at increased risk of disease, hospitalization and death, but also prevent their baby from having increased protection from birth.  

Despite the NHS and the WHO strongly recommending these vaccines in pregnancy, uptake remains low in the UK with only 51% of pregnant women having two doses of Covid-19 vaccine, 60% having the whooping cough vaccine and just 30% taking the flu jab.

To better identify the main barriers and facilitators for vaccine uptake in pregnant women, researchers carried out the first systematic review of qualitative interview-based studies published between 2012 and 2022 in high-income countries with established vaccination programmes throughout pregnancy. Countries included the UK, Australia, New Zealand and the USA.

Their search identified 2,681 relevant articles, of which 28 peer-reviewed articles covering 1,573 women were included in the review. The majority of studies (78%) focused on flu and whooping cough.

The review revealed that the main barriers to vaccine uptake in pregnant women included concerns about vaccine safety and efficacy, a lack of knowledge about the benefits and necessity of vaccines, fear of adverse effects to themselves and their baby, poor understanding in how severe these diseases can be without vaccination, lack of endorsement by healthcare professionals and barriers to physically accessing vaccines whilst juggling other health appointments and priorities.

Now, Dr Mohammad Razai and his team have laid out key recommendations they hope will be embedded into public health strategies. They centre on “five Cs” – confidence, complacency, convenience, communication and context. More specifically, their calls include [1]:

• make vaccinations more accessible, such as embedding them into antenatal routine visits, through workplace vaccination programmes, having just one appointment for all vaccinations, and providing appointment times outside of working hours
• stronger and more proactive recommendations from trusted healthcare professionals
• improved healthcare information resources and public health campaigns to better communicate the risks for mother and baby. Communications should be in multiple languages to support better health equality
• ensure obstetricians, GPs and midwives receive communication training to help them dispel myths and provide timely, accurate and evidence-based information on vaccination in pregnancy.
• support equity by targeting socio-economically vulnerable groups

Vaccine hesitancy remains very high among pregnant women, but vaccination against whooping cough, flu and Covid-19 in pregnancy is crucial. In this day and age, people should not be hospitalized or even die from diseases that are preventable by safe and effective vaccines.

Our work has collated the views of over 1,000 pregnant women, and we hope that the key recommendations we’ve set-out will be applied to public health strategies in the UK and further afield. We believe these are vital to tackle vaccine hesitancy and increase protection of mothers-to-be and their children.”

Dr Mohammad Razai, Lead researcher and Clinical Academic GP, Population Health Research Institute at St George’s, University of London

The team are now developing community interventions to boost vaccination rates among women with low uptake. This involves training midwives to counsel pregnant women on vaccinations and sharing real-life stories to empower informed decision-making.

Dr Razai’s In-practice Fellowship was funded by the National Institute for Health and Care Research (NIHR).