ABSTRACT
Background
Coronavirus disease 2019 (COVID-19) has spread rapidly around the world, causing massive morbidity and mortality. Vaccination during puerperium protects both the mother and the newborn and is important to keep the pandemic under control.
Methods
Women who gave birth at Ankara City Hospital between February 11, 2021 and March 21, 2021 were included. Data were collected through a face-to-face questionnaire.
Results
We asked 412 postpartum women were surveyed about their acceptance of the COVID-19 vaccine; 137 (33.3%) of them wanted to be vaccinated, while 275 (66.7%) of them did not want to be vaccinated. Reasons for vaccination rejection; 209 (76%) of them stated that there was not enough information about the safety of the vaccine for the postpartum period, and 89 (32.4%) of them thought that the vaccine would not be effective for the disease. Three of the answers in the survey were found significantly different in high-risk pregnancy (HRP) group compared to low-risk pregnancy (LRP) group; 1) Having their babies to be vaccinated, 2) To be vaccinated if it will be recommended to the puerperal women, and 3) Feeling anxious about being infected by SARS-CoV-2 (p < .05).
Conclusions
Health authorities recommend the COVID-19 vaccine to breastfeeding mothers. However, a relatively low vaccination acceptance rate was observed in the present study. For newly developed vaccines, concern over vaccine safety is the biggest obstacle to vaccine administration. Therefore, the reasons that influence acceptance or refusal of vaccines are important for developing targeted communication strategies and healthcare policies.
KEYWORDS: COVID-19 vaccine, postpartum, acceptance, hesitancy
Introduction
The Coronavirus disease 2019 (COVID-19) has spread rapidly, causing massive global morbidity, mortality, and social disruption.1 There is currently no effective treatment for COVID-19. All countries are trying to control the spread of COVID-19 by implementing quarantines, social distancing, travel restrictions, and the wearing of face masks, but this has caused physical and psychosocial deterioration.
The use of vaccines to protect pregnant women and newborns from infectious diseases is very important in routine antenatal care. Despite this information, none of the COVID-19 vaccine trials included breastfeeding women.2 There are limited data on the effects of COVID-19 infection on newborn and breastfed babies born from infected mothers.3,4 However, major women’s health authorities recommend receiving the COVID-19 vaccine during breastfeeding and the continuation of breastfeeding in recently vaccinated persons.5 Vaccination in the postpartum period protects both the mother and the newborn.6
Vaccine hesitations and complex public health problems are the most important problems affecting the success of vaccination programs.7 The main reasons for hesitation are mistrust of the vaccine, worries about possible harmful effects of the vaccine, and mistrust of the public health system.7
For the time being, our knowledge is still limited about attitudes of puerperal women against COVID-19 vaccination. We aimed to determine the knowledge and concerns of puerperal women and draw attention to this important topic.
Material and methods
This cross-sectional study was conducted on those who gave birth at Ankara City Hospital between February 11, 2021 and March 21, 2021. Data were collected by three maternal-fetal medicine fellows using face-to-face questionnaires. Written informed consent was obtained from all participants. The protocol applied was approved by the Ministry of Health of the Republic of Turkey and the Medical Research Ethics Department of the hospital (E2-21-119). The first part of the questionnaire assessed socio-demographic characteristics, obstetric history, and vaccination history; in the second part, perception, precautions, attitude, and anxiety about the COVID-19 pandemic were assessed; the third part assessed attitude and level of knowledge about the COVID-19 vaccine. SPSS 22.0 statistical package program was used for data analysis. While evaluating the study data, statistical methods such as descriptive frequency, percentage, mean, standard deviation, and median were used to compare quantitative data. Chi-square (χ2) test was used for the comparison of categorical data. The compliance of the data to normal distribution was evaluated by Kolmogorov – Smirnow and Shapiro–Wilk tests. Spearman’s correlation test was used to examine the relationships between variables. Values with a probability (p) less than .05 will be considered significant and there will be a difference between groups, higher values will be considered insignificant and there will be no difference between groups.
Results
In total, 412 puerperal women who completed the questionnaire were included in our study. The high-risk pregnancy (HRP) group (203; 49.3%) included women with gestational hypertension (64), gestational diabetes mellitus (64), threatened preterm labor (35), fetal anomalies (18), multiple pregnancies (8), preterm premature rupture of the membranes (5), gestational cholestasis (5), and intrauterine growth restriction (3). Socio-demographic features are shown in Table 1. Of the 412 puerperal women, 363 (88.1%) were breastfeeding. Forty-five (10.9%) puerperal women have gotten a COVID-19 infection. When asked if they would receive the vaccine if it were offered to puerperal women, 137 (33.3%) of them stated their intent for vaccination, while 275 (66.7%) of them said they would not be vaccinated. Answers to the questionnaire and comparisons of the acceptance and refusal groups of the COVID-19 vaccine are shown in Tables 2 and 3. Correlations between COVID-19 vaccine acceptance and socio-demographic features are shown in Table 4.
Table 1.
Socio-demographic data
| Variables | (n = 412) N (%) mean ± SD median (min-max) | |
|---|---|---|
| Age | 28.69 ± 5.4 | |
| Gravidity | 2 (1–6) | |
| Parity | 2 (0–5) | |
| Gestational week at birth | 38 (24–42) | |
| Day after birth | 2 (0–24) | |
| Number of householder | 4 (2–9) | |
| Number of school kid | 0 (0–4) | |
| Number of person with co-morbidity | 0 (0–2) | |
| Number of >65 age householder | 0 (0–2) | |
| Income (month) (Turkish Lira) | 3721.80 ± 2200.57 | |
| High Risk Pregnancy | 203 (%49.3) | |
| Delivery by cesarean | 251 (%60.9) | |
| Education Status | None | 36 (%8.7) |
| Primary school | 51 (%12.4) | |
| Secondary school | 205 (%49.8) | |
| University | 120 (%29.1) | |
| Career | Housewife | 332 (%80.6) |
| Government official | 70 (%17) | |
| Private sector | 5 (%1.2) | |
| Worker | 5 (%1.2) | |
| Husband Career | Worker | 203 (%49.3) |
| Government Official | 128 (%31.1) | |
| Merchant | 58 (%14.1) | |
| Private sector | 23 (%5.6) | |
Table 2.
Answers of the women who want to vaccinate, or don’t want to vaccinate and who have high-risk pregnancy and low-risk pregnancy and comparing statistical significance of the answers
| Questions | Answers | Want to vaccinate n:137 (% 33.3) | Not want to vaccinate n:275 (% 66.7) | p-Value* | High risk pergnancy n:203(%49.3) | Low risk pregnancy n:209(%50.7) |
p-Value* |
|---|---|---|---|---|---|---|---|
| Did you ever get vaccinated? | Yes | 131 (%95.6) | 270 (%98.2) | .129 | 192 (%94.6) | 209 (%100) | .001 |
| No | 6 (%4.4) | 5 (%1.8) | 11 (%5.4) | ||||
| Did you get vaccinated in the last 5 years? | Yes | 123(%89.8) | 250(%90.9) | .713 | 180 (%88.7) | 193 (%92.3) | .203 |
| No | 14(%10.2) | 25(%9.1) | 23 (%11.3) | 16 (%7.7) | |||
| Is the influenza vaccine recommended in this pregnancy? | Yes | 2(%1.5) | 4 (%1.5) | .997 | 4 (%2) | 2 (%1) | .391 |
| No | 135 (%98.5) | 271 (%98.5) | 199 (%98) | 207 (%99) | |||
| If the influenza vaccine recommended would you get vaccinated in this pregnancy? | Yes | 65(%47.4) | 94(%34.2) | .009 | 65 (%32) | 94 (%45) | .007 |
| No | 72(%52.6) | 181(%65.8) | 138 (%68) | 115 (%55) | |||
| Did you get the influenza vaccine in this pregnancy? | Yes | ||||||
| No | 137(%100) | 275 (%100) | 203 (%100) | 209 (%100) | |||
| Is the tetanus vaccine recommended in this pregnancy? | Yes | 123 (%89.8) | 228(%82.9) | .064 | 172(%84.7) | 179 (%85.6) | .793 |
| No | 14(%10.2) | 47(%17.1) | 31 (%15.3) | 30 (%14.4) | |||
| Did you get the tetanus vaccine in this pregnancy? | Yes | 123 (%89.8) | 223(%81.1) | .023 | 172 (%84.7) | 174 (%83.3) | .683 |
| No | 14(%10.2) | 52(%18.9) | 31 (%15.3) | 35 (%16.7) | |||
| Do you prefer your baby to be vaccinated? | Yes | 137(%100) | 270 (%98.2) | .112 | 203 (%100) | 204 (%97.6) | .027 |
| No | 5(%1.8) | 5 (%2.4) | |||||
| Do you have a high risk of COVID-19 transmission at work? | Yes | 16(%11.7) | 17 (%6.2) | .053 | 13 (%6.4) | 20 (%9.6) | .237 |
| No | 121 (%88.3) | 258 (%93.8) | 190 (%93.6) | 189 (%90.4) | |||
| Did you have a close contact with COVID-19 positive person? | Yes | 18(%13.1) | 70(%25.5) | .004 | 39 (%16.3) | 65 (%26.3) | .013 |
| No | 119(%86.9) | 205(%74.5) | 170 (%83.7) | 154 (%73.7) | |||
| Do you give attention to hand hygiene while breastfeeding? | Yes | 113(%100) | 250(%100) | 175 (%100) | 188 (%100) | ||
| No | |||||||
| Do you give attention to mask usage while breastfeeding? | Yes | 104 (%92) | 230(%92) | .991 | 162(%92.6) | 172 (%91.5) | .704 |
| No | 9(%8) | 20(%8) | 13 (%7.4) | 16 (8.5) | |||
| Do you prefer an isolated place while breastfeeding? | Yes | 104 (%92) | 237(%94.8) | .307 | 153 (%87.4) | 188 (%100) | .001 |
| No | 9(%8) | 13(%5.2) | 22 (%12.6) | ||||
| Do you air the room before breastfeeding? | Yes | 102(%90.3) | 234(%93.6) | .262 | 152 (%86.9) | 184 (%97.9) | .001 |
| No | 11(%9.7) | 16(%6.4) | 23 (%13.1) | 4 (%2.1) | |||
| Are you afraid of infecting the baby with COVID-19 while breastfeeding? | Yes | 53(%42.7) | 105 (%39) | .486 | 73 (%38) | 85 (%42.3) | .388 |
| No | 71(%57.3) | 164(%61) | 119(%62) | 116(%57.7) | |||
| Do you have palpitation, sweating, or feeling of tightness in the chest, when you think that you were infected by COVID-19? | Yes | 13(%9.5) | 32(%11.6) | .510 | 30 (%14.8) | 15(%7.2) | .013 |
| No | 124(%90.5) | 243(%88.4) | 173 (%85.2) | 194(%92.8) | |||
| Do you have fear of death, when you think that you were infected by COVID-19? | Yes | 2(%1.5) | 18(6.5) | .024 | 15(%7.4) | 5(2.4) | .018 |
| No | 135(98.5) | 257(93.5) | 188(92.6) | 204(97.6) | |||
| Will you accept visitors to your home? | Yes | 14(%10.2) | 52(%18.9) | .023 | 13 (%6.4) | 53 (%25.4) | .001 |
| No | 123(%89.8) | 223(%81.1) | 190 (%93.6) | 156 (%74.6) | |||
| Did you get COVID-19? | Yes | 11(%8) | 34(%12.4) | .184 | 25 (%12.3) | 20 (%9.6) | .372 |
| No | 126(%92) | 241(%87.6) | 178 (%87.7) | 189 (%90.4) | |||
| Did COVID-19 treatment recommended to you? | Yes | 2(%18.2) | 11(%32.4) | .026 | 10 (%40) | 3(%15) | .016 |
| No | 9(%81.8) | 23(%67.6) | 15(%60) | 17 (%85) | |||
| Did you use recommended medicine for COVID-19? | Yes | 1(%50) | 8 (%72.8) | .035 | 8 (%80) | 1 (%33.3) | .013 |
| No | 1(%50) | 3(%27.2) | 2 (%20) | 2 (%66.7) | |||
| Did you hear the COVID-19 vaccine before? | Yes | 135(%98.5) | 263 (%95.6) | .125 | 199 (%98) | 199 (%95.2) | .115 |
| No | 2(%1.5) | 12(%4.4) | 4 (%2) | 10 (%4.8) | |||
| Do you think that you have enough information about the COVID-19 vaccine? | Yes | 56(%40.9) | 40(%14.5) | .001 | 53 (%26.1) | 43 (%20.6) | .184 |
| No | 81(%59.1) | 235(%85.5) | 150 (%73.9) | 166 (%79.4) | |||
| Do you think COVID-19 vaccine will harm your baby while breastfeeding? | Yes | 66(%48.2) | 230(%83.6) | .001 | 142 (%70) | 154 (%73.7) | .400 |
| No | 71(%51.8) | 45(%16.4) | 61 (%30) | 55 (%26.3) | |||
| Do you think that the vaccine will protect your baby from COVID-19? | Yes | 99(%72.3) | 62(%22.5) | .001 | 109 (%53.7) | 157 (%75.1) | .000 |
| No | 38 (%27.7) | 213(%77.5) | 94(%46.3) | 52 (%24.9) | |||
| If the COVID-19 vaccine will be recommended for puerperal women will you get vaccinated? | Yes | 137 (%100) | 82 (%40.4) | 55 (%26.3) | .002 | ||
| No | 275 (%100) | 121 (%59.6) | 154 (%73.7) |
Table 3.
Reasons for the COVID-19 vaccine refusal?
| Questions | Answers | Not want to vaccinate n = 275(%) |
High risk pregnancy n = 121(%) | Low risk pregnancy n = 154(%) | P-value* |
|---|---|---|---|---|---|
| Afraid of injection | Yes | 7(%2.5) | 7 (%5.8) | .002 | |
| No | 268(%97.5) | 114(%94.2) | 154(%100) | ||
| The vaccine is harmful to my body | Yes | 16(%5.8) | 11 (%9.1) | 5 (%3.2) | .040 |
| No | 259(%94.2) | 110(%90.9) | 149(%96.8) | ||
| The vaccine will cause COVID-19 infection | Yes | 30(%10.9) | 25 (%20.7) | 5 (%3.2) | .001 |
| No | 245 (%89.1) | 96 (%79.3) | 149(%96.8) | ||
| The vaccine is harmful for my baby | Yes | 65(%23.6) | 41 (%33.9) | 24(%15.6) | .001 |
| No | 210(%76.4) | 80 (%66.1) | 130(%84.4) | ||
| COVID-19 is not a serious disease | Yes | 21(%7.6) | 21(%17.4) | .001 | |
| No | 254(%92.4) | 100(%82.6) | 154(%100) | ||
| I have a low risk to get COVID-19 infection | Yes | 31(%11.3) | 26(%21.5) | 5 (%3.2) | .001 |
| No | 244(%88.7) | 95 (%78.5) | 149(%96.8) | ||
| I believe that even if I am sick, me and my baby will not encounter any negative events | Yes | 19(%6.9) | 9 (%7.4) | 10(%6.5) | .759 |
| No | 256(%93.1) | 112(%92.6) | 144(%93.5) | ||
| I don’t think that vaccine will work | Yes | 89(%32.4) | 36(%29.8) | 53 (%34.4) | .412 |
| No | 186(%67.6) | 85 (%70.2) | 101(%65.6) | ||
| Family members do not agree with the COVID-19 vaccine | Yes | 30(%10.9) | 10 (%8.3) | 20(%13) | .212 |
| No | 245(%89.1) | 111(%91.7) | 134(%87) | ||
| Lack of sufficient information about safety of COVID-19 vaccine in puerperium | Yes | 209(%76) | 76 (%62.8) | 133(%86.7) | .001 |
| No | 66 (%24) | 45 (%37.2) | 21(%13.6) | ||
| I think the virus get mutation | Yes | 41(%14.9) | 21 (%17.4) | 20(%13) | .313 |
| No | 234(%85.1) | 100(%82.6) | 134(%87) |
*Chi-squared test is applied.
Table 4.
Correlation between COVID-19 vaccine acceptance and socio-demographic features
| Age | Gravidity | Parity | Gestational week at birth | Day after birth | Number of householders | Number of school kid | Number of person with comorbidity | Number of >65 age householder | Income (month) (tl) | |
|---|---|---|---|---|---|---|---|---|---|---|
| r value** | .263 | .223 | .272 | .076 | -.056 | .274 | .179 | .072 | .000 | .011 |
| p value** | .001 | .001 | .001 | .122 | .256 | .001 | .001 | .143 | .999 | .828 |
** Spearman’s Correlation Analysis Test.
Discussion
In the present study, we found a low acceptance of the COVID-19 vaccine (33.3%) in the postpartum period. For those who accepted the vaccine, the idea that the vaccine would primarily protect the baby was an important factor and they also believed that they were adequately informed about the COVID-19 vaccine compared to those who refused vaccination. When we evaluated the reasons for vaccine refusal, the three most common answers were: 1) there was not enough reliable data about vaccine administration to puerperal women, 2) the vaccine could fail, and 3) the vaccine would harm the baby.
As the education level increases, access to up-to-date and scientific information about vaccination increases as well. The main sources of information were media resources. It is important to reach the whole society to explain the importance of vaccination. Therefore, informative resources should be used effectively. The perception that there was not enough information about the COVID-19 vaccine safety in the LRP group was significantly higher than in the HRP group. Mistrust of the COVID-19 vaccine was greater in women with LRP, indicating that informing them is a priority.
Several studies showed that the best approach to protect infants in the neonatal period is placental passive antibody transfer by vaccine efficacy. However, presently COVID-19 vaccine acceptance is still low in pregnancy.8 That’s why vaccination during the postpartum period becomes more important for newborn protection. Based on the mechanism of action of the vaccines, vaccine-induced immunoglobulin A protects the newborn against SARS-CoV-2 infection by passing into the breast milk.9 There is no data showing that the vaccine may harm the neonate during lactation. The vaccine appears to be safe for women who are breastfeeding.9 Breast milk contains nutrients, minerals, and vitamins that the baby needs, as well as many beneficial components, including immunoglobins, antiviral factors, cytokines, and leukocytes, thus reducing the risk of various diseases, including infection.9 Fenizia et al. found evidence of COVID-19 RNA in breast milk and detected anti-SARS-Cov-2 IgM when they tested for the presence of specific anti-SARS-CoV-2 IgM and IgG.10 In another study, it was found that 80% of milk samples taken from mothers who had COVID-19 contained IgA, which was predominantly secretory IgA.9 Those who refuse the vaccine should be informed about the potential benefits of breast milk to newborn babies.
The Advisory Committee on Immunization Practices (ACIP) recommends the COVID-19 vaccine to breastfeeding women when they meet the vaccination criteria based on priority groups, consistent with other major women’s health authorities.11–14 However, there are not enough safety data about vaccination during breastfeeding; this decision must be made after an individual risk-benefit assessment, which is also recommended by the Robert Koch Institute.15
Acceptance of influenza and COVID-19 vaccines were found to be similar in the present study. When the COVID-19 vaccine acceptance and refusal groups were compared, the acceptance group also expressed higher influenza vaccine acceptance. Ozceylan et al. reported a 2% decrease in vaccination rates in Turkey from 2016 to 2018, similar to that of developed countries.16 This situation is consistent with the increasing vaccine hesitation in public health in recent years.8,17 In the present study, mistrust of the COVID-19 vaccine was the most common reason for vaccine refusal. Therefore, healthcare providers should give detailed information about the effectiveness, safety, and benefits of vaccines.
In the present study, the acceptance rate of the tetanus vaccine during pregnancy was significantly higher than that of influenza and COVID-19 vaccines. Acceptance of the tetanus vaccine was significantly higher in the COVID-19 vaccine acceptance group than in the rejection group. A recent study showed that the vaccination rate was significantly higher in women who knew about the tetanus vaccine during pregnancy.18 Also, the tetanus vaccination program during pregnancy is an important health policy in our country. It is crucial to explain the vaccines’ positive effects on both maternal and newborn health to puerperal women for communal immunity achievement.
In the present study, we found that anxiety levels related to COVID-19 were higher in women with HRP compared to women with LRP. Acceptance of the COVID-19 vaccine was higher in women with HRP due to the increased level of anxiety. This group also did not want to receive visitors at home after delivery, which was consistent with high anxiety states. A recent study pointed out that the HRP population had high anxiety levels compared with the LRP population.19 Also, Singh et al. pointed the psychological impact of the COVID-19 pandemic on pregnant women and recommended psychological support for their well-being. Anxiety might be an explanation for our findings and psychological support might improve vaccine acceptance in the postpartum period.20
In the present study, there was a positive and low-level relationship between the acceptance of the COVID-19 vaccine and the number of people living at home, and the number of school-age children. Participants expressed concern over COVID-19 transmission due to the high number of people living at home and school-age children. A new meta-analysis found that the role of children in the household transmission of SARS-CoV-2 is very low.21 There is much disinformation and confusion about COVID-19 transmission that must be clarified to improve acceptance of the COVID-19 vaccine in priority groups.
The prospective design of our study, as well as its novelty, large spectrum, and understandable questionnaire, are its main strengths. The main limitations were the relatively low number of the study population, and the survey was performed in the early postpartum period, which was too early for enough attachment between the mothers and their babies.
In conclusion, the benefits of the vaccine are promising and health authorities recommend the COVID-19 vaccine to breastfeeding mothers. However, relatively low vaccination acceptance rate was observed in the present study. For newly developed vaccines, concern over vaccine safety is the biggest obstacle to vaccine administration. The most common reason for vaccine refusal was hesitancy about vaccine safety. Therefore, the reasons that influence acceptance or refusal of vaccines are important to develop targeted communication strategies and healthcare policies.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
References
- 1.Wang J, Jing R, Lai X, Zhang H, Lyu Y, Knoll MD, Fang H.. Acceptance of COVID-19 vaccination during the COVID-19 pandemic in China. Vaccines. 2020;8(3):482. doi: 10.3390/vaccines8030482. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Doshi P. Will covid-19 vaccines save lives? Current trials aren’t designed to tell us. BMJ. 2020;m4037:1–4. [DOI] [PubMed] [Google Scholar]
- 3.Ayhan SG, Oluklu D, Sinaci S, Atalay A, Erol SA, Tokalioglu EO, Yildirim M, Tekin OM and Sahin D. Fetal thymus size in pregnant women with COVID-19 infection. Gynecol Obstetrics Reprod Med. 2021;27(2):1–5. [Google Scholar]
- 4.Merewood A, Bode L, Davanzo R, Perez-Escamilla R. Breastfeed or be vaccinated—an unreasonable default recommendation. Lancet. 2021;397(10274):578. doi: 10.1016/S0140-6736(21)00197-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Rimmer A. Covid-19: breastfeeding women can have vaccine after guidance turnaround. Br Med J Publ Group. 2021;372:n64. [DOI] [PubMed] [Google Scholar]
- 6.Stafford IA, Parchem JG, Sibai BM. The coronavirus disease 2019 vaccine in pregnancy: risks, benefits, and recommendations. Am J Obstet Gynecol. 2021;224(5):484–95. doi: 10.1016/j.ajog.2021.01.022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Salmon DA, Dudley MZ, Glanz JM, Omer SB. Vaccine hesitancy: causes, consequences, and a call to action. Vaccine. 2015;33:D66–D71. doi: 10.1016/j.vaccine.2015.09.035. [DOI] [PubMed] [Google Scholar]
- 8.Goncu Ayhan S, Oluklu D, Atalay A, Menekse Beser D, Tanacan A, Moraloglu Tekin O, Sahin D. COVID-19 vaccine acceptance in pregnant women. Int J Gynaecol Obstet. 2021;154(2):291–96. doi: 10.1002/ijgo.13713. [published Online First: Epub Date]|. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Fox A, Marino J, Amanat F, Krammer F, Hahn-Holbrook J, Zolla-Pazner S, Powell RL. Evidence of a significant secretory-IgA-dominant SARS-CoV-2 immune response in human milk following recovery from COVID-19. MedRxiv. 2020;1–13. [Google Scholar]
- 10.Fenizia C, Biasin M, Cetin I, Vergani P, Mileto D, Spinillo A, Gismondo MR, Perotti F, Callegari C, Mancon A, et al. Analysis of SARS-CoV-2 vertical transmission during pregnancy. Nat Commun. 2020;11(1):1–10. doi: 10.1038/s41467-020-18933-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.ACo O. Vaccinating pregnant and lactating patients against COVID-19. Gynecologists. 2020;2021:1–31. [Google Scholar]
- 12.Hughes L. Coronavirus (COVID-19) and pregnancy: what maternal-fetal medicine subspecialists need to know 4.11. 20 (this is an update from draft posted on 3-17-2020). Washington (DC): The Society for Maternal-Fetal Medicine; 2020. [Google Scholar]
- 13.Elwood C, Boucoiran I, VanSchalkwyk J, Money D, Yudin M, Poliquin V. SOGC committee opinion–COVID-19 in pregnancy. J Obstetrics Gynaecol Can. 2020:1–8. [Google Scholar]
- 14.Chervenak FA, McCullough LB, Bornstein E, Johnson L, Katz A, McLeod-Sordjan R, Nimaroff M, Rochelson BL, Tekbali A, Warman A, et al. Professionally responsible coronavirus disease 2019 vaccination counseling of obstetrical and gynecologic patients. Am J Obstet Gynecol. 2021;224(5):470–78. doi: 10.1016/j.ajog.2021.01.027. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.McCullough LB, Bornstein E, Johnson L, Katz A, Nimaroff M. Professionally responsible COVID-19 vaccination counseling of obstetric/gynecologic patients Frank A. CHERVENAK, MD Department of Obstetrics and Gynecology Zucker School of Medicine at Hofstra/Northwell.
- 16.Özceylan G, Toprak D, Esen ES. Vaccine rejection and hesitation in Turkey. Hum Vaccin Immunother. 2020;16(5):1034–39. doi: 10.1080/21645515.2020.1717182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Palamenghi L, Barello S, Boccia S, Graffigna G. Mistrust in biomedical research and vaccine hesitancy: the forefront challenge in the battle against COVID-19 in Italy. Eur J Epidemiol. 2020;35(8):785–88. doi: 10.1007/s10654-020-00675-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Dağdeviren G, Örgül G, Yücel A, Şahin D. Tetanus vaccine during pregnancy: data of a tertiary hospital in Turkey. Turk J Med Sci. 2020;50(8):1903–08. doi: 10.3906/sag-2001-77. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Sinaci S, Tokalioglu EO, Ocal D, Atalay A, Yilmaz G, Keskin HL, Erdinc SO, Sahin D, Moraloglu Tekin O. Does having a high-risk pregnancy influence anxiety level during the COVID-19 pandemic? Eur J Obstetrics Gynecol Reprod Biol. 2020;255:190–96. doi: 10.1016/j.ejogrb.2020.10.055. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Singh S, Nair VG, Singh VV, Tiwari S, Arora D, Dey M, Tiwari R, Nair SV. Pregnancy-specific concerns and psychological impact of COVID-19 on antenatal women. Gynecol Obstetrics Reprod Med. 2021;1–6. doi: 10.21613/GORM.2021.1172. [DOI] [Google Scholar]
- 21.Zhu Y, Bloxham CJ, Hulme KD, Sinclair JE, Tong ZWM, Steele LE, Noye EC, Lu J, Xia Y, Chew KY, Pickering J. A meta-analysis on the role of children in SARS-CoV-2 in household transmission clusters. medRxiv. 2020;72(12):e1146–e1153. [DOI] [PMC free article] [PubMed] [Google Scholar]