Influenza and Tetanus, Diphtheria, and Acellular Pertussis Vaccination Coverage During Pregnancy: Pregnancy Risk Assessment Monitoring System, 2020

Abstract

Objectives:

Estimates of vaccination coverage during pregnancy and identification of disparities in vaccination coverage can inform vaccination campaigns and programs. We reported the prevalence of being offered or told to get the influenza vaccine by a health care provider (hereinafter, provider); influenza vaccination coverage during the 12 months before delivery; and tetanus, diphtheria, and acellular pertussis (Tdap) vaccination coverage during pregnancy among women with a recent live birth in the United States.

Methods:

We analyzed 2020 data from the Pregnancy Risk Assessment Monitoring System from 42 US jurisdictions (n = 41 673). We estimated the overall prevalence of being offered or told to get the influenza vaccine by a provider and influenza vaccination coverage during the 12 months before delivery. We estimated Tdap vaccination coverage during pregnancy from 21 jurisdictions with available data (n = 22 020) by jurisdiction and select characteristics.

Results:

In 2020, 84.9% of women reported being offered or told to get the influenza vaccine, and 60.9% received it, ranging from 35.0% in Puerto Rico to 79.7% in Massachusetts. Influenza vaccination coverage was lower among women who were not offered or told to get the influenza vaccine (21.4%) than among women who were offered or told to get the vaccine (68.1%). Overall, 72.7% of women received the Tdap vaccine, ranging from 52.8% in Mississippi to 86.7% in New Hampshire. Influenza and Tdap vaccination coverage varied by all characteristics examined.

Conclusions:

These results can inform vaccination programs and strategies to address disparities in vaccination coverage during pregnancy and may inform vaccination efforts for other infectious diseases among pregnant women.

Influenza during pregnancy is associated with severe maternal illness^1,2 and increased risk of poor infant outcomes, including preterm birth. ² The Advisory Committee on Immunization Practices (ACIP) ³ and the American College of Obstetricians and Gynecologists ⁴ recommend that pregnant women receive the influenza vaccine to protect themselves and their infants. ACIP specifically recommends that all women who are pregnant or who might be pregnant or postpartum during the influenza season receive the influenza vaccine. The influenza vaccine can be safely administered before and at any time during pregnancy and has been shown to reduce the risk of infection by 50% ⁵ and the risk of hospitalization by an average of 40% ⁶ ; it also has been shown to protect infants from influenza during the first 6 months of life, when they are ineligible for vaccination. ⁷ Similarly, both ACIP^8,9 and the American College of Obstetricians and Gynecologists ⁴ recommend the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine during every pregnancy, preferably during 27-36 weeks’ gestation. The Tdap vaccine during pregnancy protects infants during the first 2 months after birth, when they are at the greatest risk of contracting pertussis and having severe infection-related complications, including pneumonia and death.^10-12

Despite recommendations, vaccination coverage during pregnancy is suboptimal and varies by certain characteristics (eg, education, race and ethnicity, health insurance status) and receipt of offer or referral for vaccination by a health care provider (hereinafter, provider). ¹³ The Centers for Disease Control and Prevention (CDC) conducted an internet panel survey and found that only 30.7% of women who were pregnant during the 2020-2021 influenza season received both the influenza and Tdap vaccines. ¹³ Seasonal influenza vaccination coverage among pregnant women was 54.5%, while 53.5% reported receipt of the Tdap vaccine during pregnancy. ¹³ However, these estimates of influenza and Tdap vaccination coverage are based on a nonprobability sample and assess coverage only at the national level. Population-based jurisdiction-level estimates of vaccination during pregnancy and assessment of vaccination coverage by demographic characteristics can inform vaccination campaigns and programs to maximize impact. We analyzed data from the Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based and jurisdiction-specific surveillance system conducted among women with a recent live birth in the United States. Our objectives were to report the prevalence of being offered or told to get the influenza vaccine by a provider, influenza vaccination coverage during the 12 months before delivery, and Tdap vaccination coverage during pregnancy—overall, by jurisdiction, and by selected demographic, access-to-care, and other characteristics.

Materials

Data Source and Population

PRAMS is conducted by CDC in collaboration with participating jurisdictions’ health departments. Details about the PRAMS methodology are published elsewhere. ¹⁴ PRAMS uses a standardized protocol, with options to complete the survey via mail or telephone. Surveys capture self-reported information about behaviors and experiences before, during, and after pregnancy. Responses are linked to birth certificate data. All surveys contain “core” questions. Jurisdictions can also include optional “standard” questions, which address additional topics. Data are weighted for sample design, nonresponse, and noncoverage to produce estimates representative of jurisdictions’ live birth populations. While not all people who are sampled identify as women, PRAMS does not collect data on gender identity. The term “women” is used to align with the birth certificate.

This analysis included 39 states, the District of Columbia, New York City, and Puerto Rico that achieved a weighted response rate ≥50%. The overall mean weighted response rate for these jurisdictions was 59% (50%-81%). ¹⁵ The PRAMS protocol was reviewed and approved by CDC’s Institutional Review Board and each participating jurisdiction’s institutional review board.

Exposures

Characteristics examined were respondent age, race and ethnicity, education, prenatal participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), type of prenatal health care insurance, number of prenatal care visits, number of previous live births, and jurisdiction. Characteristics were selected a priori and based on previous literature. ¹³ Most characteristics were from birth certificate data available in the PRAMS dataset; however, data on prenatal health insurance were from the PRAMS survey.

Outcomes

In this analysis, we examined 3 outcomes: (1) being offered or told to get the influenza vaccine by a provider, (2) influenza vaccination coverage during the 12 months before delivery, and (3) Tdap vaccination coverage during pregnancy. To measure if women were offered or told to get the influenza vaccine, all respondents were asked the core question “During the 12 months before the delivery of your new baby, did a doctor, nurse, or other health care worker offer you a flu shot or tell you to get one?” The response options were no and yes. To measure influenza vaccination coverage before or during pregnancy, all respondents were asked the core question “During the 12 months before the delivery of your new baby, did you get a flu shot?” The response options were no; yes, before my pregnancy; and yes, during my pregnancy. In Montana, Washington State, and New York City, respondents who reported not getting the influenza vaccine were asked the standard question “What were your reasons for not getting a flu shot during the 12 months before the birth of your new baby?” Respondents could indicate no or yes to these statements: “My doctor didn’t mention anything about a flu shot,” “I was worried about side effects of the flu shot for me,” “I was worried that the flu shot might harm my baby,” “I was not worried about getting sick with the flu,” “I do not think the flu shot works,” “I don’t normally get a flu shot,” and “Other.”

To measure Tdap vaccination coverage during pregnancy, respondents from 20 states and New York City were asked the standard question “During your most recent pregnancy, did you get a Tdap shot or vaccination? A Tdap vaccination is a tetanus booster shot that also protects against pertussis (whooping cough).” The response options were no, yes, and I don’t know. Women in Colorado were asked, “Did you receive a Tdap vaccination before, during, or after your most recent pregnancy? A Tdap vaccination is a shot that protects against tetanus, diphtheria, and pertussis (whooping cough). Tdap was new in 2005.” The response options were no; yes, I received Tdap before my pregnancy; yes, I received Tdap during my pregnancy; yes, I received Tdap after my pregnancy; and I don’t know. Respondents who did not receive Tdap vaccination or who received it before or after pregnancy were categorized as not receiving it during pregnancy. PRAMS did not collect information on being offered or told to get the Tdap vaccine.

Statistical Analysis

We calculated the weighted prevalence, with 95% CIs, for being offered or told to get the influenza vaccine, influenza vaccination coverage, and Tdap vaccination coverage—overall, by jurisdiction, and by selected characteristics. In addition, we evaluated differences in influenza vaccination coverage by being offered or told to get the influenza vaccine overall and by selected characteristics in a stratified analysis.

We used the Wald χ² test, with significance set at P < .05, and 95% CIs (ie, nonoverlapping) to identify significant differences across groups within each characteristic. Among 41 673 PRAMS respondents from 42 jurisdictions, 40 997 completed the question on being offered or told to get the influenza vaccine by a provider and 40 795 completed the question on influenza vaccination; 40 446 (97.2% weighted) respondents completed both questions. Among the subset of respondents who were asked the question on Tdap vaccination from 21 jurisdictions (n = 22 258), 22 020 (98.9% weighted) completed the question. We performed all analyses using SAS-callable SUDAAN version 11.0.04 (RTI International) to account for the complex survey design of PRAMS.

Results

Among 41 673 women from 42 jurisdictions, 55.2% were non-Hispanic White (hereinafter, White), 57.4% had ≥11 prenatal care visits, 58.6% were aged 25-34 years, 59.6% had private health insurance for prenatal care, 60.4% were multiparous, 62.9% had completed some college or more, and 67.8% did not participate in WIC prenatally. Being offered or told to get the influenza vaccine by a provider and both influenza and Tdap vaccination coverage differed by jurisdiction and all characteristics examined (Tables 1-3; Figures 1 and 2). We observed similar patterns in differences across all 3 outcomes. Rates of being offered or told to get the influenza vaccine and both influenza and Tdap vaccination coverage were lower among women aged ≤24 years versus ≥25 years; among women who were non-Hispanic Black (hereinafter, Black) versus White, non-Hispanic American Indian or Alaska Native (hereinafter, American Indian or Alaska Native), or non-Hispanic Asian or Pacific Islander (hereinafter, Asian or Pacific Islander); among women with a high school diploma or less versus an associate’s degree or higher; among women who were uninsured or had Medicaid versus private health insurance; among women with ≤10 prenatal care visits versus ≥11 prenatal care visits; among women who participated in WIC prenatally versus did not; and among women who had ≥3 previous live births versus ≤2 previous live births. We observed disparities by race and ethnicity, prenatal WIC participation, and prenatal health insurance across all outcomes.

Table 1.

Overall sample distribution and prevalence of being offered or told to get the influenza vaccine by a health care provider during the 12 months before infant delivery, by selected characteristics, among women with a recent live birth—PRAMS, 39 states, the District of Columbia, New York City, and Puerto Rico, 2020 ^a

Characteristic	Overall, no. b (weighted %) c	Health care provider offered or told women to get the influenza vaccine (n = 40 997) b
		No. b	Weighted % (95% CI) d
Total	41 673 (—)	35 377	84.9 (84.3-85.5)
Age group, y e
≤17	470 (1.0)	326	69.2 (61.7-75.8)
18-24	8677 (20.7)	6904	79.1 (77.6-80.5)
25-34	24 233 (58.6)	20 944	86.4 (85.6-87.1)
≥35	8291 (19.6)	7201	87.6 (86.4-88.8)
Race and ethnicity e
Non-Hispanic Black	7439 (15.5)	6052	80.5 (79.0-82.0)
Non-Hispanic White	18 580 (55.2)	16 290	87.7 (87.0-88.4)
Non-Hispanic American Indian or Alaska Native	1933 (0.8)	1674	88.1 (83.6-91.5)
Non-Hispanic Asian or Pacific Islander	3196 (5.4)	2788	87.9 (85.6-89.8)
Non-Hispanic Other f	2522 (3.3)	2169	84.6 (81.2-87.4)
Hispanic	7898 (19.8)	6320	79.6 (77.9-81.2)
Education e
≤High school diploma or GED	15 114 (37.0)	12 001	78.8 (77.6-79.9)
Completed some college	7882 (17.4)	6601	83.4 (81.9-84.8)
Associate’s degree	3694 (8.5)	3210	88.2 (86.6-89.7)
≥Bachelor’s degree	14 663 (37.0)	13 321	91.0 (90.2-91.7)
Prenatal WIC participation e
Yes	14 220 (32.2)	11 507	80.5 (79.3-81.6)
No	26 835 (67.8)	23 362	87.1 (86.4-87.8)
Prenatal health insurance statusg,h
Private	22 353 (59.6)	19 998	89.9 (89.2-90.5)
Medicaid	15 213 (36.6)	12 337	80.7 (79.6-81.8)
Uninsured	1009 (2.8)	716	60.8 (55.2-66.2)
Publicly or state funded	307 (1.1)	240	82.1 (75.7-87.2)
No. of prenatal care visits e
0	676 (1.6)	423	62.7 (56.0-69.0)
1-5	3033 (5.8)	2371	77.7 (74.8-80.4)
6-10	14 952 (35.2)	12 545	83.4 (82.4-84.4)
≥11	22 023 (57.4)	19 226	87.2 (86.4-87.9)
No. of previous live births e
0	16 624 (39.7)	13 925	83.5 (82.6-84.5)
1	12 788 (32.6)	11 065	87.3 (86.3-88.3)
2	6736 (16.2)	5807	85.8 (84.4-87.2)
≥3	5455 (11.6)	4527	81.8 (79.8-83.6)

Abbreviations: GED, General Educational Development; PRAMS, Pregnancy Risk Assessment Monitoring System; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

^aData source: Shulman et al. ¹⁴

^bUnweighted sample size; sample size for selected characteristics may vary because of missing responses on the PRAMS survey or missing data on the birth certificate.

^cPercentages for individual categories might not total to 100 because of rounding.

^dThe Wald χ² test and 95% CIs (ie, nonoverlapping CIs) were used to determine differences in the prevalence of being offered or told to get the influenza vaccine across groups within each characteristic. All differences were significant at P < .001.

^eBirth certificate variable.

^fNon-Hispanic Other includes women who self-reported multiple races or other non-White on the birth certificate.

^gPRAMS survey variable.

^hHealth insurance is coded as Medicaid (Medicaid or state-named Medicaid program); private (private only, any other health insurance in combination with private, TRICARE, or other military insurance); no health insurance (no health insurance or Indian Health Service only; in Alaska, this includes Alaska Tribal Health System, which is part of the Indian Health Service response option); publicly or state-funded insurance includes state-specific government plans or programs such as State Children’s Health Insurance Program/Children’s Health Insurance Program.

Table 2.

Influenza vaccination coverage during the 12 months before infant delivery, overall and by being offered or told to get the influenza vaccine by a health care provider, by selected characteristics, among women with a recent live birth—PRAMS, 39 states, the District of Columbia, New York City, and Puerto Rico, 2020 ^a

Characteristic	Overall vaccination coverage (n = 40 795) b		Health care provider offered or told women to get the influenza vaccine (n = 40 446) b
			Yes		No
	No. b	Weighted % (95% CI)c,d	No. b	Weighted % (95% CI)c.d	No. b	% (95% CI) c	P value
Total	26 207	60.9 (60.1-61.7)	24 670	68.1 (67.3-68.9)	1382	21.4 (19.8-23.2)	—
Age group, y e							.004
≤17	238	45.3 (37.8-53.2)	203	55.5 (45.7-64.9)	31	22.1 (13.0-35.1)
18-24	4743	50.2 (48.5-51.9)	4364	58.8 (56.9-60.7)	343	18.0 (15.4-20.9)
25-34	15 638	62.9 (61.9-63.9)	14 797	69.5 (68.5-70.5)	763	22.4 (20.0-24.8)
≥35	5586	67.0 (65.3-68.7)	5304	73.0 (71.3-74.7)	245	24.5 (20.4-29.1)
Race and ethnicity e							<.001
Non-Hispanic Black	3510	41.4 (39.6-43.2)	3251	48.2 (46.1-50.2)	218	13.5 (11.2-16.3)
Non-Hispanic White	12 530	65.3 (64.3-66.3)	11 971	71.6 (70.5-72.6)	527	22.7 (20.1-25.4)
Non-Hispanic American Indian or Alaska Native	1266	68.4 (63.0-73.4)	1194	73.0 (67.4-77.9)	63	36.7 (21.2-55.5)
Non-Hispanic Asian or Pacific Islander	2479	77.2 (74.3-79.8)	2324	83.6 (80.8-86.0)	143	31.6 (24.3-40.1)
Non-Hispanic Other f	1529	58.5 (54.5-62.5)	1447	64.6 (60.3-68.7)	71	24.5 (16.5-34.7)
Hispanic	4837	59.2 (57.3-61.1)	4429	68.5 (66.4-70.5)	358	23.1 (19.7-26.8)
Education e							<.001
≤High school diploma or GED	8032	49.5 (48.2-50.8)	7353	58.2 (56.7-59.7)	595	17.6 (15.5-19.8)
Completed some college	4443	52.2 (50.4-54.0)	4177	59.5 (57.5-61.4)	239	17.9 (14.7-21.7)
Associate’s degree	2363	62.8 (60.2-65.3)	2235	68.0 (65.3-70.6)	122	24.4 (18.8-30.9)
≥Bachelor’s degree	11 192	75.8 (74.6-76.9)	10 744	80.0 (78.9-81.1)	413	33.0 (28.9-37.3)
Prenatal WIC participation e							.01
Yes	7741	50.7 (49.3-52.1)	7134	58.6 (57.0-60.1)	540	18.9 (16.6-21.5)
No	18 113	65.7 (64.8-66.6)	17 199	72.2 (71.2-73.1)	826	23.4 (21.2-25.8)
Prenatal health insurance statusg,h							<.001
Private	16 205	71.0 (70.0-72.0)	15 467	76.0 (75.0-76.9)	674	28.1 (25.2-31.2)
Medicaid	7798	47.2 (45.9-48.6)	7205	54.4 (52.9-55.9)	525	17.5 (15.4-19.9)
Uninsured	524	41.9 (36.8-47.2)	476	61.5 (54.7-67.9)	42	12.6 (7.5-20.4)
Publicly or state funded	176	65.0 (57.1-72.3)	163	74.2 (65.3-81.4)	12	25.6 (12.4-45.6)
No. of prenatal care visits e							<.001
0	277	35.1 (29.2-41.5)	246	49.2 (40.9-57.5)	30	12.1 (7.0-20.0)
1-5	1572	49.3 (46.1-52.5)	1427	59.0 (55.4-62.5)	121	14.9 (10.5-20.7)
6-10	9189	58.8 (57.5-60.1)	8620	66.5 (65.1-67.9)	497	20.6 (18.0-23.4)
≥11	14 613	64.1 (63.1-65.1)	13 852	70.2 (69.2-71.3)	707	24.2 (21.7-26.8)
No. of previous live births e							.04
0	10 879	63.6 (62.4-64.8)	10 168	71.6 (70.3-72.8)	657	23.4 (20.9-26.2)
1	8349	63.3 (61.9-64.7)	7935	69.7 (68.3-71.1)	367	20.3 (17.4-23.6)
2	4067	57.8 (55.9-59.7)	3837	63.9 (61.8-65.9)	199	22.6 (18.5-27.3)
≥3	2874	49.2 (46.9-51.4)	2693	56.7 (54.3-59.2)	158	16.4 (12.6-21.1)

Abbreviations: GED, General Educational Development; PRAMS, Pregnancy Risk Assessment Monitoring System; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

^aData source: Shulman et al. ¹⁴

^bUnweighted sample size; sample size for selected characteristics may vary because of missing responses on the PRAMS survey or missing data on the birth certificate.

^cThe Wald χ² test and 95% CIs (ie, nonoverlapping CIs) were used to determine differences in influenza vaccination coverage during the 12 months before delivery across groups within each characteristic.

^dAll differences were significant at P < .001.

^eBirth certificate variable.

^fNon-Hispanic Other includes women who self-reported multiple races or other non-White on the birth certificate.

^gPRAMS survey variable.

^hHealth insurance is coded as Medicaid (Medicaid or state-named Medicaid program); private (private only, any other health insurance in combination with private, TRICARE, or other military insurance); no health insurance (no health insurance or Indian Health Service only; in Alaska, this includes Alaska Tribal Health System, which is part of the Indian Health Service response option); publicly or state-funded insurance includes state-specific government plans or programs such as State Children’s Health Insurance Program/Children’s Health Insurance Program.

Table 3.

Tdap vaccination coverage during pregnancy, overall and by selected characteristics, among women with a recent live birth—PRAMS, 20 states and New York City, 2020 ^a

Characteristic	Received Tdap vaccine (n = 22 020) b
	No. b	Weighted % (95% CI)c,d
Total	15 829	72.7 (71.8-73.5)
Age group, y e
≤17	123	52.6 (42.1-62.9)
18-24	2827	64.1 (61.9-66.3)
25-34	9642	75.5 (74.4-76.5)
≥35	3235	73.6 (71.6-75.5)
Race and ethnicity e
Non-Hispanic Black	2526	59.4 (57.1-61.7)
Non-Hispanic White	7870	76.4 (75.3-77.5)
Non-Hispanic American Indian or Alaska Native	537	74.1 (67.5-79.8)
Non-Hispanic Asian or Pacific Islander	1463	76.3 (73.0-79.3)
Non-Hispanic Other f	1055	67.1 (62.3-71.6)
Hispanic	2333	69.5 (67.2-71.8)
Education e
≤High school diploma or GED	4854	61.9 (60.2-63.6)
Completed some college	2865	70.1 (68.0-72.2)
Associate’s degree	1431	76.4 (73.7-78.9)
≥Bachelor’s degree	6549	82.8 (81.6-83.9)
Prenatal WIC participation e
Yes	4704	64.9 (63.3-66.5)
No	10 830	76.2 (75.1-77.2)
Prenatal health insurance statusg,h
Private	9773	80.7 (79.7-81.7)
Medicaid	4953	63.9 (62.2-65.5)
Uninsured	211	41.2 (34.0-48.7)
Publicly or state funded	69	49.9 (36.7-63.1)
No. of prenatal care visits e
0	137	44.1 (35.2-53.4)
1-5	788	54.9 (50.8-59.0)
6-10	5485	71.3 (69.8-72.8)
≥11	9001	75.8 (74.7-76.9)
No. of previous live births e
0	6694	77.5 (76.2-78.7)
1	4885	74.1 (72.5-75.6)
2	2440	68.6 (66.4-70.8)
≥3	1777	58.4 (55.6-61.1)

Abbreviations: GED, General Educational Development; PRAMS, Pregnancy Risk Assessment Monitoring System; Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

^aData source: Shulman et al. ¹⁴

^bUnweighted sample size; sample size for selected characteristics may vary because of missing responses on the PRAMS survey or missing data on the birth certificate.

^cDenominator includes those who responded yes, no, and I don’t know.

^dThe Wald χ² test and 95% CIs (ie, nonoverlapping CIs) were used to determine differences in Tdap vaccination coverage during pregnancy across groups within each characteristic. All differences were significant at P < .001.

^eBirth certificate variable.

^fNon-Hispanic Other includes women who self-reported multiple races or other non-White on the birth certificate.

^gPRAMS survey variable.

^hHealth insurance is coded as Medicaid (Medicaid or state-named Medicaid program); private (private only, any other health insurance in combination with private, TRICARE, or other military insurance); no health insurance (no health insurance or Indian Health Service only; in Alaska, this includes Alaska Tribal Health System, which is part of the Indian Health Service response option); publicly or state-funded insurance includes state-specific government plans or programs such as State Children’s Health Insurance Program/Children’s Health Insurance Program.

Figure 1.

Being offered or told to get the influenza vaccine by a health care provider and influenza vaccination coverage during the 12 months before infant delivery, by jurisdiction, among women with a recent live birth—Pregnancy Risk Assessment Monitoring System, 39 states, the District of Columbia, New York City, and Puerto Rico, 2020. Data source: Shulman et al. ¹⁴

Figure 2.

Tetanus, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination coverage during pregnancy, by jurisdiction, among women with a recent live birth—Pregnancy Risk Assessment Monitoring System, 20 states and New York City, 2020. Data source: Shulman et al. ¹⁴

Among 40 997 women who answered the question on being offered or told to get the influenza vaccine by a provider, 84.9% were offered or told to get it, ranging from 63.4% in Puerto Rico to 93.9% in Massachusetts (Figure 1). The percentage of respondents who reported being offered or told to get the influenza vaccine was lower among women who were Black (80.5%) and Hispanic (79.6%) than among women who were American Indian or Alaska Native (88.1%), Asian or Pacific Islander (87.9%), or White (87.7%); among women who were uninsured (60.8%), had Medicaid (80.7%), or had other publicly or state-funded prenatal health insurance (82.1%) than among women with private prenatal health insurance (89.9%); and among women who participated in WIC prenatally (80.5%) than among women who did not (87.1%) (Table 1).

Among 40 795 women who answered the question on influenza vaccination, 60.9% were vaccinated during the 12 months before delivery of their most recent live birth (Table 2) (12.4% before pregnancy and 48.5% during pregnancy), ranging from 35.0% in Puerto Rico to 79.7% in Massachusetts (Figure 1). Influenza vaccination coverage was lower among women who were Black (41.4%) than among women who were Asian or Pacific Islander (77.2%), American Indian or Alaska Native (68.4%), White (65.3%), or Hispanic (59.2%); among women who were uninsured (41.9%) or had Medicaid (47.2%) than among women who had private prenatal health insurance (71.0%); and among women who participated in WIC prenatally (50.7%) than among those who did not (65.7%).

Influenza vaccination coverage was lower among women who were not offered or told to get the influenza vaccine (21.4%) than among those who were offered or told to get the vaccine (68.1%) (Table 2). When examining influenza vaccination coverage by being offered or told to get the influenza vaccine, vaccination coverage was consistently lower among women who were not offered or told to get it than among those who were, regardless of respondent characteristics. The variation of influenza vaccination coverage by characteristics examined was similar to that observed for the entire sample when analyses were restricted to women who reported that they were offered or told to get the influenza vaccine and to women who did not report being offered or told to get it.

Among women in Montana, Washington State, and New York City who reported reasons for not getting the influenza vaccine—data availability varied by reason (n = 528 [“other”] to n = 834 [“don’t normally get the flu shot”])—the most commonly cited reason was that they did not normally get a flu shot (71.5%). Women also indicated that they were worried about the side effects of the vaccine for themselves (49.0%), worried that the vaccine might harm their baby (37.8%), did not think that the flu shot works (36.3%), were not worried about getting sick with the flu (35.1%), other reason (24.4%), and their doctor did not mention anything about a flu shot (16.0%).

Among 22 020 women from 21 jurisdictions, 72.7% reported receiving the Tdap vaccine during pregnancy (Table 3), ranging from 52.8% in Mississippi to 86.7% in New Hampshire (Figure 2). Tdap vaccination coverage during pregnancy was lower among women who were Black (59.4%) than among women who were White (76.4%), Asian or Pacific Islander (76.3%), American Indian or Alaska Native (74.1%), or Hispanic (69.5%); among women who were uninsured (41.2%), had other publicly or state-funded prenatal health insurance (49.9%), or had Medicaid (63.9%) than among women with private prenatal health insurance (80.7%); and among women who participated in WIC prenatally (64.9%) than among women who did not (76.2%).

Discussion

More than three-fifths of women with a live birth in 2020 from 42 US jurisdictions reported receiving the influenza vaccine during the 12 months before delivery, with most vaccinations occurring during pregnancy. In addition, among the 21 jurisdictions with data on the Tdap vaccine, nearly three-quarters of women reported receiving it during pregnancy. Both influenza and Tdap vaccination coverage differed by jurisdiction and by all characteristics examined. Influenza vaccination coverage also differed by being offered or told to get influenza vaccination by a provider.

Estimates of influenza and Tdap vaccination coverage from PRAMS (60.9% and 72.7%, respectively) were higher than estimates from an internet panel survey on pregnant women conducted by CDC during the 2020-2021 influenza season (54.5% and 53.5%). ¹³ However, these estimates are not directly comparable because of different methodologies. The difference with our findings might also be explained by the period assessed, because women who completed the PRAMS survey might have become pregnant before the 2020-2021 influenza season, and the number of jurisdictions that included the PRAMS question on the Tdap vaccine were limited.

Unique to PRAMS, we assessed vaccination coverage by jurisdiction. Influenza and Tdap vaccination coverage differed across jurisdictions, which might be explained by differences in provider and health care delivery practices, preferences, and attitudes toward vaccination among pregnant people and strategies implemented by jurisdictions to address barriers to vaccination during pregnancy. Examples of strategies that several jurisdictions have implemented to address barriers to vaccination include providing incentives to health plans, increasing access to vaccinations through alternative sites (eg, pharmacies), and using data to identify populations and regions with low vaccination coverage. ¹⁶ For example, Massachusetts was among the jurisdictions with the highest reported prevalence of women being offered or told to get the influenza vaccine by a provider and influenza vaccination coverage. The Massachusetts Department of Health has a history of supporting vaccine education and access to vaccinations statewide through collaboration with community-based organizations to share tailored, accurate, and culturally appropriate messages about the importance of influenza vaccination, as well as establishing additional venues, including obstetrics sites, to administer the vaccine. ¹⁷ Massachusetts also has programs to reimburse public providers for administration of the vaccine to incentivize providers to incorporate vaccine programs into their practices. ¹⁸

Similar to other studies,^13,19 our findings indicate that influenza and Tdap vaccination coverage was lower among women who were aged ≤24 years (vs ≥25 y), were Black (vs White, American Indian or Alaska Native, Asian or Pacific Islander, or Hispanic), had a high school diploma or less (vs associate’s degree or higher), were uninsured or had Medicaid (vs private health insurance), had ≤10 prenatal care visits (vs ≥11 prenatal care visits), participated in WIC prenatally (vs did not), and had ≥3 previous live births (vs ≤2 previous live births). Data from a population-based survey assessing COVID-19 vaccination coverage found similar disparities in vaccination coverage among pregnant women. ²⁰ Also consistent with prior literature,^21,22 reasons cited for not getting the influenza vaccine among pregnant women included that they do not normally get vaccinated, concerns about vaccine safety and effectiveness, not being worried about getting sick with influenza, and lack of provider offer or recommendation. Additionally, in a survey of obstetrician–gynecologists, a frequently reported strategy to address vaccine refusal among pregnant patients was education on the safety of vaccines in pregnancy and the risks to the fetus/newborn and to the patient if not vaccinated. ²³ Lower vaccination coverage in populations that have been disproportionately affected may stem from mistrust due to a history of racial discrimination and having been victims of unethical health research.^24,25 Measures of structural racism are associated with inequitable access to vaccines in the United States.^13,24,26 Social determinants of health, such as inadequate transportation and health insurance coverage, also contribute to lower influenza vaccination coverage. ²⁷ Community-driven approaches can improve confidence in the uptake of any vaccine, including influenza and Tdap vaccines, and can improve equitable access to them.^28,29

Influenza vaccination coverage was lower among women who were not offered or told to get the influenza vaccine by a provider than among women who were offered or told to get the vaccine by a provider. As observed in data from an internet panel survey, ¹³ provider offer and referral for vaccination are strongly associated with higher vaccination prevalence among pregnant people, for both influenza and Tdap vaccines. In addition, provider recommendation for vaccination has been shown to be the strongest factor associated with COVID-19 vaccination among pregnant people. ²⁰ We observed differences in whether women were offered or told to get the influenza vaccine by all characteristics examined. We found that 81% of women who were Black and 80% of women who were Hispanic were offered or told to get the influenza vaccine as compared with 85% to 88% of women from other racial and ethnic groups. This finding underscores the importance of equitable provision of care by providers discussing, offering, or recommending the influenza vaccine to all people who are pregnant or will be pregnant during influenza season. Addressing implicit and structural bias is important for delivery of quality patient-centered care. Pregnant people from racial and ethnic minority groups are more likely than pregnant people who are White to not receive evidence-based care for conditions such as opioid use disorder ³⁰ and more likely to not report mistreatment during maternity care. ³¹ Actions that providers can take to improve vaccination coverage include engaging with all patients in patient-centered care, having respectful conversations on the importance of vaccination, and offering and providing referrals for vaccinations, including following up with patients when referrals are made. ³² However, among women who reported that a provider offered or told them to get the influenza vaccine, vaccination coverage still differed by characteristics examined. For example, among women who were offered or told to get the vaccine, 48% who were Black reported being vaccinated, as compared with 65% to 84% from other racial and ethnic groups. These differences highlight the importance of addressing factors that influence vaccination, such as racism, ³³ lack of culturally competent care, ³⁴ and structural barriers (eg, health insurance coverage, cost, and access to regular primary care) related to vaccine access and coverage.^21,22,27

Strengths and Limitations

This study had several strengths, including the use of a population-based sample of women with a recent live birth and the ability to estimate jurisdiction-level influenza and Tdap vaccination coverage. However, our findings also had several limitations. First, PRAMS is a cross-sectional survey with self-reported data and is subject to social desirability and recall bias. Women who receive a vaccine might be more likely than women who do not receive a vaccine to recall a conversation in which their provider offered or told them to get the vaccine. Second, our results may be generalizable only to women who resided in the participating jurisdictions in the analysis and had pregnancies that ended in live births. Third, we were unable to assess when respondents were offered or told to get the influenza vaccine and whether it happened prior to vaccination. Fourth, the survey did not distinguish whether women were “offered” or “told to get” the influenza vaccine, and similar information about Tdap vaccine was unavailable. Fifth, we were unable to assess influenza vaccination coverage by influenza season because PRAMS does not capture the date when the vaccine was received. However, all women delivering in 2020 would have been pregnant during the 2019-2020 or 2020-2021 influenza seasons.

Conclusions

Jurisdictions can implement innovative approaches to improve vaccination coverage among pregnant people, such as providing accurate and clear messages to address vaccine hesitancy,^35,36 especially for infectious diseases that disproportionately affect pregnant people and their infants, such as influenza^5-7 and pertussis.^10-12 Population-based jurisdiction-level prevalence estimates of vaccination coverage during pregnancy and by select characteristics can inform vaccination programs and strategies to address disparities in vaccination coverage during pregnancy. These results may inform efforts for vaccination against other infectious diseases among pregnant people.