Vaccination in pregnancy: Healthcare provider attitudes and practices

Abstract

Objective

To assess provider attitudes and practices regarding vaccination in pregnancy to discern strategies to increase vaccination rates in pregnancy, given that in the USA, various healthcare organizations recommend that pregnant individuals be vaccinated against influenza, pertussis, and SARS‐CoV‐2, but vaccination rates among gravidas remain suboptimal across these vaccines.

Methods

An Institutional Review Board‐approved survey was disseminated to obstetric healthcare providers by email from June through October 2021. Questions assessed provider demographics, attitudes, and practices surrounding vaccination in pregnancy. A total of 192 providers consented, 179 initiated the survey, and 153 completed it entirely. Statistical software (SAS) was used to perform descriptive statistics.

Results

All providers strongly agreed/agreed that all pregnant individuals should receive vaccines in pregnancy. Following patient vaccination consent, 13% reported needing to refer patients to alternative sites for vaccine administration. Following patient vaccination decline, 13% did not determine reasons for refusal, 30% did not re‐counsel at subsequent visits, and 92% did not ask another staff member to counsel the patient.

Conclusion

Despite provider support for maternal immunization, uptake of vaccines in gravidas remains suboptimal, demonstrating a gap between provider recommendations and patient uptake. These data highlight opportunities for intervention regarding counseling and vaccine availability to increase vaccine uptake in pregnancy.

Synopsis

US obstetrics providers strongly support vaccination in pregnancy, yet opportunities exist for improvement in counseling, documentation, and administration of vaccines to improve uptake among gravidas.

1. INTRODUCTION

The healthcare provider (HCP) plays a vital role in an individual's decision to vaccinate. HCPs have been reported in the literature as the “most trusted advisor” and greatest influence regarding decisions to vaccinate. ¹ Absence of a recommendation for vaccination by an HCP has been associated with vaccine hesitancy, whereas an offer or referral for a vaccine by an HCP has been associated with increased vaccine uptake. ² , ³ The obstetric HCP plays an especially crucial role in counseling for vaccination in pregnancy. Numerous studies have demonstrated that when an obstetric HCP recommends vaccination, the odds of vaccination in pregnancy increase between 5‐ and 50‐fold. ⁴ , ⁵ Furthermore, HCP recommendations for vaccination at every prenatal visit have been associated with increased patient vaccine confidence and uptake. ⁶

Vaccination is an essential component of prenatal care as pregnant individuals and their fetuses represent a unique population that is more susceptible to severe morbidity and mortality due to infection with vaccine‐preventable diseases. ⁴ , ⁷ In the USA, the American College of Obstetricians and Gynecologists (ACOG) and Centers for Disease Control and Prevention (CDC) recommend that persons who are or will become pregnant during influenza season receive an influenza vaccine; that all pregnant individuals receive a tetanus, diphtheria, and acellular pertussis (Tdap) vaccine with each pregnancy; and that all pregnant persons be fully immunized against severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). ⁴ , ⁸ , ⁹ Despite these recommendations, rates of vaccine acceptance among gravidas are well below 100% for all three vaccines: 54.5% for influenza, 53.5% for Tdap, and 13.5% for coronavirus disease 2019 (COVID‐19) according to data collected by the CDC in April 2021. ² , ¹⁰

Data emphasizing the role of the HCP in vaccination are readily available, but more information regarding HCPs' attitudes, perceived barriers, and practices regarding vaccination in pregnancy is needed. Furthermore, elucidating the extent and manner with which HCPs counsel pregnant patients on vaccination, as well as difficulties that providers experience in providing vaccines to consenting individuals, could offer insight into potential strategies to improve vaccine uptake in pregnancy.

2. MATERIALS AND METHODS

An anonymous, 39‐item survey was developed by the study team and approved by the Institutional Review Board at the University of Miami. Survey questions addressed HCPs' demographics, training level, specialty, state of practice, and practice setting. Providers were surveyed on their general attitudes regarding vaccination in pregnancy, practices regarding vaccine counseling and documentation, and perceived barriers to vaccination in pregnancy. Questions specific to attitudes and counseling for influenza, Tdap, and COVID‐19 vaccines were also included. Attitudinal questions were asked on a five‐point Likert‐type scale, from “strongly agree” to “strongly disagree.” The survey questions are included in Appendix A.

Healthcare providers of prenatal and obstetric care in the USA, including physicians, nurses, medical assistants, physician assistants, and advanced practice providers, were eligible for participation in the study. From June 2 to October 1, 2021, a description of the study along with an anonymous link to the informed consent and survey were emailed to eligible HCPs. Emails were sent via Qualtrics, directly by a study team member, or forwarded to participants by a list‐serv manager. HCP list‐servs used for survey dissemination included the University of Miami/Jackson Memorial Hospital health system obstetrics and gynecology (Ob/Gyn) and family medicine provider registry; the William A. Little Ob/Gyn Society registry, consisting of alumni of the University of Miami/Jackson Memorial Hospital Ob/Gyn residency; and a national registry of Ob/Gyn residency coordinators to allow for distribution to US Ob/Gyn residents. A total of 792 anonymous email surveys were distributed.

Informed consent was obtained via the Qualtrics email link and has been included in Appendix B. Consenting HCPs self‐administered the survey via Qualtrics. Survey completion took approximately 10 min. Descriptive (frequency) statistical analyses were performed using the statistical package SAS version 9.04 (SAS Institute Inc.).

3. RESULTS

A total of 192 HCPs consented to participate and 179 initiated the survey, yielding a survey uptake of 22.6%. Of those, 153 responded to all questions and 26 submitted incomplete surveys. Results of the 179 initiated surveys were included in the analysis. Table 1 highlights the demographic profile of participants. Most respondents identified as female (82%, n = 146), white (77%, n = 137), non‐Hispanic (79%, n = 141) physicians (95%, n = 169) who practice as Ob/Gyn generalists (71%, n = 123). Participating providers practice in over 26 states, with a majority practicing in the state of Florida (34%, n = 61), in an urban setting (80%, n = 143), and at an academic center (54%, n = 96).

TABLE 1.

Demographic profile of participating providers ^a

Characteristic
Gender identity (n = 178)
Female	146 (82.0%)
Male	31 (17.4%)
Prefer not to say	1 (0.6%)
Race (n = 178)
White	137 (77.0%)
Black or African American	17 (9.6%)
Asian	14 (7.9%)
Prefer not to say	10 (5.6%)
Ethnicity (n = 178)
Non‐Hispanic	141 (79.2%)
Hispanic	33 (18.5%)
Prefer not to say	4 (2.2%)
Provider status (n = 178)
Resident physician	85 (47.8%)
Fellow physician	13 (7.3%)
Attending physician	71 (39.9%)
Midwife	2 (1.1%)
APRN	2 (1.1%)
Other (PA, RN, MA, clinic staff)	5 (2.8%)
Specialty (n = 173)
Ob/Gyn generalist	123 (71.1%)
Ob/Gyn sub‐specialty	43 (24.9%)
Family medicine	7 (4.0%)
Ob/Gyn subspecialty (n = 43)
MFM	33 (76.7%)
REI	6 (14.0%)
GYO	3 (7.0%)
Family planning	1 (2.3%)
Region of practice (n = 179)
South b	98 (54.8%)
Northeast c	45 (25.1%)
Midwest d	21 (11.7%)
West e	15 (8.4%)
Practice setting (n = 179)
Urban	143 (79.9%)
Suburban	30 (16.8%)
Rural	6 (3.4%)
Practice description (n = 179)
Academic—public	83 (46.4%)
Hospital—university	31 (17.3%)
Hospital—community	20 (11.2%)
Private practice—group	14 (7.8%)
Academic—private	13 (7.3%)
Community Health Center	8 (4.5%)
Government Health Center/Hospital	4 (2.2%)
Private practice—individual	3 (1.7%)
Hospital—other	3 (1.7%)

Abbreviations: APRN, advanced practice registered nurse; GYO, gynecologic oncology; MA, medical assistant; MFM, maternal‐fetal medicine; PA, physician assistant; REI, reproductive endocrinology and infertility; RN, registered nurse.

^a Data are presented as number (percentage).

^b South: Arkansas, Florida, Georgia, Maryland, Oklahoma, Texas, South Carolina.

^c Northeast: Connecticut, Massachusetts, New Jersey, New York, Pennsylvania, Vermont.

^d Midwest: Illinois, Iowa, Wisconsin, Ohio, Michigan, Missouri, Nebraska.

^e West: Arizona, California, Colorado, New Mexico, Oregon.

Table 2 reports the attitudes of HCPs regarding vaccination in pregnancy. 87.5% (n = 147) of participants strongly agreed and 12.5% (n = 21) agreed that all pregnant individuals should receive vaccines that are safe during pregnancy. Attitudes regarding safety of vaccination in pregnancy were strongly positive, with most HCPs reporting that influenza (98%, n = 164), Tdap (99%, n =166), and COVID‐19 (98%, n = 164) vaccines are safe in pregnancy. Providers agreed that vaccination with influenza, Tdap, and COVID‐19 vaccines provides a direct benefit to the mother and fetus; however, 11% (n = 19) of HCPs did not agree that there is enough evidence to recommend COVID‐19 vaccination in pregnancy.

TABLE 2.

Provider attitudes regarding vaccination in pregnancy ^a

Attitude
All pregnant patients should receive vaccines that are safe in pregnancy (n = 168)
Strongly agree	147 (87.5%)
Agree	21 (12.5%)
Influenza vaccination during pregnancy has a direct benefit to the mother (n = 168)
Strongly agree	156 (92.9%)
Agree	12 (7.1%)
Influenza vaccination during pregnancy has a direct benefit to the fetus (n = 168)
Strongly agree	107 (63.7%)
Agree	41 (24.4%)
Neutral	15 (8.9%)
Disagree	5 (3.0%)
Tdap vaccination during pregnancy has a direct benefit to the mother (n = 168)
Strongly agree	65 (38.7%)
Agree	49 (29.2%)
Neutral	39 (23.2%)
Disagree	12 (7.1%)
Strongly disagree	3 (1.8%)
Tdap vaccination during pregnancy has a direct benefit to the fetus (n = 168)
Strongly agree	148 (88.1%)
Agree	14 (8.3%)
Neutral	4 (2.4%)
Disagree	1 (0.6%)
Strongly disagree	1 (0.6%)
COVID‐19 vaccination during pregnancy has a direct benefit to the mother (n = 168)
Strongly agree	154 (91.7%)
Agree	13 (7.7%)
Neutral	1 (0.6%)
COVID‐19 vaccination during pregnancy has a direct benefit to the fetus (n = 168)
Strongly agree	105 (62.5%)
Agree	42 (25.0%)
Neutral	18 (10.7%)
Disagree	2 (1.2%)
Strongly disagree	1 (0.6%)
At this present time, there is enough evidence to recommend the COVID‐19 vaccine to pregnant patients (n = 168)
Strongly agree	122 (72.6%)
Agree	27 (16.1%)
Neutral	9 (5.4%)
Disagree	5 (3.0%)
Strongly disagree	5 (3.0%)
Patients frequently ask me about the safety of the COVID‐19 vaccine in pregnancy (n = 168)
Strongly agree	89 (53.0%)
Agree	50 (29.8%)
Neutral	19 (11.3%)
Disagree	9 (5.4%)
Strongly disagree	1 (0.6%)

Abbreviations: COVID‐19, coronavirus disease 2019; Tdap, tetanus, diphtheria, and acellular pertussis.

^a Data are presented as number (percentage).

Table 3 reports providers' counseling practices. Approximately 22% (n = 34) of HCPs reported that they do not always counsel pregnant patients on the benefit of vaccination, and 66% (n = 104) of providers indicated not always involving other members of the healthcare team in counseling for vaccinations. Most providers reported that they provide counseling for influenza (82%, n = 129) and COVID‐19 (94%, n = 148) vaccines on a patient's first visit, regardless of trimester. For Tdap, 52% (n = 81) of providers indicated that they counsel in the second trimester, whereas 29% (n = 45) counsel in the third trimester. HCPs reported stronger efforts to always recommend that other members of the household get vaccinated against influenza (62%, n = 97) and COVID‐19 (86%, n = 135) compared with Tdap (52%, n = 82). Following patient vaccination decline, 13% (n = 20) of HCPs indicated not determining reasons for refusal, 30% (n = 47) reported not re‐counseling at subsequent visits, and 92% (n = 145) indicated not asking another member of the staff to re‐counsel the patient.

TABLE 3.

Provider practices on vaccine counseling in pregnancy ^a

Provider practice
Do you counsel pregnant patients on vaccines? (n = 157)
Always	123 (78.3%)
Sometimes	30 (19.1%)
Rarely	1 (0.6%)
Never	3 (1.9%)
Are other members of the healthcare team responsible for counseling vaccines? (n = 157)
Always	53 (33.8%)
Sometimes	85 (54.1%)
Rarely	14 (8.9%)
Never	5 (3.2%)
When do you counsel patients about influenza vaccination? (n = 157)
On their first visit, regardless of trimester	129 (82.2%)
First trimester	11 (7.0%)
Second trimester	15 (9.6%)
Third trimester	2 (1.3%)
Do you recommend that all household members of a gravida be vaccinated against influenza? (n = 157)
Always	97 (61.8%)
Sometimes	49 (31.2%)
Rarely	10 (6.4%)
Never	1 (0.6%)
When do you counsel patients about Tdap vaccination? (n = 157)
On their first visit, regardless of trimester	30 (19.1%)
First trimester	1 (0.6%)
Second trimester	81 (51.6%)
Third trimester	45 (28.7%)
Do you recommend that all household members of a gravida be vaccinated against Tdap? (n = 157)
Always	82 (52.3%)
Sometimes	47 (29.9%)
Rarely	22 (14.0%)
Never	6 (3.8%)
When do you counsel patients about COVID‐19 vaccination? (n = 157)
On their first visit, regardless of trimester	148 (94.3%)
First trimester	2 (1.3%)
Second trimester	7 (4.5%)
Do you recommend that all household members of a gravida be vaccinated against COVID‐19? (n = 157)
Always	135 (86.0%)
Sometimes	18 (11.5%)
Rarely	4 (2.6%)
Never	0 (0.0%)

Abbreviations: COVID‐19, coronavirus disease 2019; Tdap, tetanus, diphtheria, and acellular pertussis.

^a Data are presented as number (percentage).

Table 4 reports providers' documentation practices. Forty‐two percent (n = 65) of HCPs reported that documentation of vaccination counseling is not always performed. When documenting vaccine counseling, most providers indicated that they counsel the benefits of vaccination (71%, n = 112), the risks of vaccination (66%, n = 103), and the patient's decision (92%, n = 144). Approximately 22% (n = 34) of providers do not document receipt of vaccine administration.

TABLE 4.

Provider practices on documentation and administration of vaccines in pregnancy ^a

Provider practice
Do you document vaccine counseling in the medical record? (n = 157)
Always	92 (58.6%)
Sometimes	59 (37.6%)
Rarely	5 (3.2%)
Never	1 (0.6%)
When documenting, what information do you include? Select all that apply. (n = 157)
Recommended vaccine(s)	147 (94.9%)
Counseled benefits	112 (71.3%)
Counseled risks	103 (65.6%)
Patient's decision	144 (91.7%)
Vaccine administration	123 (78.3%)
If a patient consents to vaccination, what is your next step? (n = 157)
Administer immediately, per CDC recommendations	127 (80.9%)
Administer later, per CDC recommendations	10 (6.4%)
Refer patient to another site for vaccination	20 (12.7%)
If a patient accepts vaccination, do you encounter difficulties in administering them because of insurance‐related barriers? (n = 157)
Always	4 (2.5%)
Sometimes	33 (21.0%)
Rarely	67 (42.7%)
Never	53 (33.8%)
If a patient declines vaccination, do they express why? (n = 157)
Always	20 (12.7%)
Sometimes	128 (81.5%)
Rarely	9 (5.7%)
If a patient declines vaccination, do you document the patient's reason? (n = 157)
Always	51 (32.5%)
Sometimes	81 (51.6%)
Rarely	15 (9.6%)
Never	10 (6.4%)

Abbreviation: CDC, Centers for Disease Control and Prevention.

^a Data are presented as number (percentage).

When assessed on their perceptions regarding barriers to vaccination, 87% (n = 137) of providers reported that upon vaccination decline, patients sometimes or rarely provide rationale for refusal. Following patient vaccination consent, 13% (n =20) of providers indicated needing to refer patients to alternative sites for the administration of one or more vaccines in pregnancy. Additionally, 24% (n = 37) of providers reported that their patients always or sometimes experience insurance‐related barriers to immunization for any of the vaccines recommended during pregnancy.

Table 5 reports providers' perceptions on the demographic profile of patients perceived as most likely to accept or decline vaccination. Many participants reported that there were no noted differences across age (56%, n = 85), racial (57%, n = 87), and ethnic groups (59%, n = 90). Of the providers who perceived a difference in likelihood to uptake vaccination, the groups perceived as most likely to accept vaccination were ages 26–35 years (24%, n = 37), white (34%, n = 52), and non‐Hispanic (29%, n = 44). Those perceived by HCPs as most likely to decline vaccination were ages 16–25 years (23%, n = 35), black or African American (38%, n = 58), and Hispanic (28%, n = 42).

TABLE 5.

Provider perception of differences in vaccine uptake in pregnancy among various age, racial, and ethnic groups ^a

Provider perception
In which age group do you see the highest percentage of gravidas accepting vaccines? (n = 153)
Ages 16–25 years	5 (3.3%)
Ages 26–35 years	37 (24.2%)
Ages 36–45 years	26 (17.0%)
No noted difference across age groups	85 (55.6%)
In which age group do you see the highest percentage of gravidas declining vaccines? (n = 153)
Ages 16–25 years	35 (22.9%)
Ages 26–35 years	24 (15.7%)
Ages 36–45 years	13 (8.5%)
No noted difference across age groups	81 (52.9%)
In which racial group do you see the highest percentage of gravidas accepting vaccines? (n = 153)
White	52 (34.0%)
Black or African American	4 (2.6%)
Asian	10 (6.5%)
No noted difference across racial groups	87 (56.9%)
In which racial group do you see the highest percentage of gravidas declining vaccines? (n = 153)
White	16 (10.5%)
Black or African American	58 (37.9%)
No noted difference across racial groups	79 (51.6%)
In which ethnic group do you see the highest percentage of gravidas accepting vaccines? (n = 153)
Hispanic	19 (12.4%)
Non‐Hispanic	44 (28.8%)
No noted difference across ethnic groups	90 (58.8%)
In which ethnic group do you see the highest percentage of gravidas declining vaccines? (n = 153)
Hispanic	42 (27.5%)
Non‐Hispanic	23 (15.0%)
No noted difference across ethnic groups	88 (57.5%)

^a Data are presented as number (percentage).

4. DISCUSSION

This study provides insights into the attitudes, counseling, and documentation practices of a diverse group of US obstetric HCPs. The data provided by HCPs yield valuable perspectives regarding barriers to immunization within pregnancy, which can be useful for designing interventions to increase vaccine uptake in pregnancy.

In this population, 87.5% of HCPs strongly agreed and 12.5% agreed that pregnant individuals should be vaccinated with vaccines that are safe to receive in pregnancy and recommend vaccination to their patients in accordance with these views. Most HCPs agreed that influenza, Tdap, and COVID‐19 vaccines are safe in pregnancy and provide benefits to the mother and infant. Despite these provider sentiments and practices, uptake for these lifesaving vaccines remains suboptimal.

Ideally, 100% of providers would indicate that they always counsel pregnant individuals on vaccination in pregnancy. The data indicate, however, that approximately 22% of providers are not doing so. Additionally, when a patient declines vaccination, attempts to determine the patient's reasoning for decline may help to understand factors contributing to their refusal for vaccination; however, 13% of respondents reported not doing so. Similarly, it would be preferable for all providers to re‐counsel vaccine‐hesitant patients on subsequent visits, as this may afford patients the opportunity to later accept vaccination, potentially facilitating improved vaccine uptake. ⁶ Unfortunately, however, 30% of providers reported that they do not re‐counsel patients. One attributable factor for these findings may be time constraints placed on the obstetric HCP. ¹¹ In the US, most prenatal visits are scheduled for 15 min, during which the obstetric HCP must cover not only maternal and fetal assessments but also provide patient education on numerous important topics—only one of which is the benefits of maternal immunization. ¹² , ¹³ Vaccine counseling and administration in Ob/Gyn offices has been reported as requiring a median time of 29 min, more time compared with other fields, given the complexities of counseling for vaccination during pregnancy. ¹¹ There are several strategies that can be employed to alleviate the burden of these time constraints on the obstetric HCP. One important strategy is equipping patients with evidence‐based resources. ⁵ , ¹⁴ Providing patients with educational pamphlets or videos in prenatal clinic waiting rooms, or links to trusted online sources, allows for preliminary vaccination education, with no time detracted from the provider‐patient visit. ¹⁵ , ¹⁶ This in turn allows the HCP to provide a tailored counseling session during the prenatal visit. ¹⁵ , ¹⁶ Similarly, engaging in brief vaccine counseling on the first visit, and on each subsequent visit, can increase patient confidence for vaccine uptake when the time for immunization arrives. ⁵ , ¹⁴ , ¹⁷ In this study, only 19% of providers indicated that Tdap vaccine counseling is provided on the first visit. Providing earlier counseling for Tdap, before the recommended 27–36‐week window for vaccination, affords patients the opportunity to research the vaccine on their own and obtain answers to questions that may arise well in advance of vaccine uptake. Another strategy to alleviate the time constraints that may burden the obstetric HCP is involvement of other staff in vaccine counseling. In this population, 66% of providers reported not always using other members of the healthcare team to provide vaccine counseling. Similarly, upon patient vaccine decline, only 8% of providers use other staff members to re‐counsel a patient. Other members of the healthcare team are an invaluable resource that can be employed to provide vaccine counseling and re‐counseling in scenarios where a physician HCP may have limited time. ¹⁸

Documentation for vaccination counseling, vaccine uptake, and rationale for vaccine decline is not always performed by HCPs. Furthermore, when a patient is vaccinated at a third‐party site such as a pharmacy, there is no system for record of this vaccination to be shared with the provider. ¹⁹ Using a robust, national vaccination‐in‐pregnancy registry that can be accessed by all HCPs including physicians, nurses, advanced practice providers, and pharmacists, would allow for records of vaccination shortcomings. ²⁰ Easy identification of patients lacking vaccinations offers greater opportunity to intervene and offer patients the vaccines they require. Similarly, documentation of patient rationale for vaccine decline may afford the provider, or other members of the healthcare team that may be involved in counseling, an opportunity to provide tailored re‐counseling unique to each patient's concerns. ¹⁴

Increasing access to on‐site vaccination affords another valuable opportunity to increase vaccine uptake. ⁵ Approximately 13% of providers reported needing to refer patients to offsite locations for vaccine administration. One contributing factor may be higher costs associated with administering vaccines in Ob/Gyn offices, compared with other specialties. ¹¹ One study found that the average cost per vaccine administration is $43 in Ob/Gyn clinics, compared with $7 and $8 in family medicine and internal medicine clinics, respectively. ¹¹ Factors for this increased cost include greater time requirements for vaccine counseling in Ob/Gyn and higher rates of vaccine decline following counseling, for which time costs spent on counseling may not be reimbursable to some providers. ¹¹ Additionally, maintaining vaccine stocks and personnel for vaccine administration requires certain fixed overhead costs. ¹¹ For this reason, some Ob/Gyn offices may not have the ability to administer recommended vaccines within their prenatal clinic. However, for patients with limited means of transportation and time constraints due to work or familial obligations, the need for visits to additional sites for vaccine administration, such as pharmacies or other clinics beyond the prenatal care site, may pose a significant barrier to immunization. ²¹ Lowering the cost of providing vaccination services for the obstetric HCP may increase the number of providers capable of administering vaccines within their clinic. Strategies to reduce overhead costs include improving vaccine counseling efficiency and efficacy and increasing the ratio of vaccine uptake to vaccine counseling for Ob/Gyn providers. ¹¹ These strategies may help to ensure that more US prenatal clinics have the capacity to provide recommended vaccines, thereby reducing the burden on patients to accept vaccination. ¹⁸

Strategies to improve vaccine uptake among minority racial and ethnic groups are needed. Approximately 43% of HCPs reported a perceived difference in vaccination acceptance across racial and ethnic groups, with individuals who are black or African American (38%) and Hispanic (27%) perceived as most likely to decline vaccination. This report by participating HCPs is generally congruent with the literature, which demonstrates a vaccine‐specific difference in vaccine uptake in pregnancy by race and ethnicity. Data from 2019–2021 demonstrate that vaccination coverage for influenza was 61% for non‐Hispanic white, 67% for Hispanic, and 53% for black gravidas; for Tdap was 66% for non‐Hispanic white, 36% for Hispanic, and 39% for black gravidas; and for COVID‐19 was 20% for non‐Hispanic white, 12% for Hispanic, and 6% for black gravidas. ²² , ²³ The literature has demonstrated that vaccine uptake among these populations improves when a provider recommendation for vaccination is made. ²² Engaging in vaccine counseling that considers each patient's cultural and ethnic background may aide providers in improving vaccine uptake in minority populations.

This study has several limitations. First, these data are limited by sample size and geographic distribution of respondents, suggesting that these findings may not be representative of all US obstetric HCPs. This may be a result of the list‐servs used for dissemination, as some exclusively contained physicians practicing in Florida and in academic environments. Additionally, these data are limited by lack of survey completion by all consenting participants. This may be attributed to the time required to complete the survey in its entirety and the busy schedule of most obstetric HCPs. Lastly, the reliability of these data is limited by the survey methodology.

In summary, US providers strongly agree that pregnant individuals should be vaccinated against influenza, Tdap, and COVID‐19. The unique perspectives provided by obstetric HCPs regarding the perceived barriers to vaccination in pregnancy highlight opportunities for intervention to improve vaccine uptake in pregnancy. Increasing efforts to re‐counsel and determine patient rationale for vaccine refusal, using other members of the healthcare team, striving for better documentation strategies, and increasing availability and access to onsite vaccination during prenatal care may help to improve patient uptake of important, lifesaving vaccines in pregnancy.

AUTHOR CONTRIBUTIONS

JoNell Potter developed the idea for the study. Gabriella F. Rodriguez and Valerie Vilariño developed the study design and survey questions with input from Eva Agasse, Joan E. St. Onge, Shirin Shafazand, and JoNell Potter. Eva Agasse analyzed the data and Gabriella F. Rodriguez, Valerie Vilariño, and Eva Agasse created the tables. Gabriella F. Rodriguez drafted the manuscript with feedback from Eva Agasse and Valerie Vilariño. Joan E. St. Onge, Shirin Shafazand, and JoNell Potter critically appraised the manuscript. All authors (Gabriella F. Rodriguez, Valerie Vilariño, Eva Agasse, Joan E. St. Onge, Shirin Shafazand, and JoNell Potter) contributed to and approved the final manuscript.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to disclose.

APPENDIX A.

SURVEY QUESTIONS

Block 1: Provider demographics.

What is your gender?

• Male

• Female

• Transgender

• Non‐binary

• Prefer not to say

What is your race?

• White

• Black or African American

• Asian

• American Indian or Alaska Native

• Native Hawaiian or Pacific Islander

• Prefer not to say

What is your ethnicity?

• Hispanic

• Non‐Hispanic

• Prefer not to say

In what state do you practice?

• Alabama

• Alaska

• Arizona

• Arkansas

• California

• Colorado

• Connecticut

• Delaware

• Florida

• Georgia

• Hawaii

• Idaho

• Illinois

• Indiana

• Iowa

• Kansas

• Kentucky

• Louisiana

• Maine

• Maryland

• Massachusetts

• Michigan

• Minnesota

• Mississippi

• Missouri

• Montana

• Nebraska

• Nevada

• New Hampshire

• New Jersey

• New Mexico

• New York

• North Carolina

• North Dakota

• Ohio

• Oklahoma

• Oregon

• Pennsylvania

• Rhode Island

• South Carolina

• South Dakota

• Tennessee

• Texas

• Utah

• Vermont

• Virginia

• Washington

• West Virginia

• Wisconsin

• Wyoming

In which of the following settings do you practice?

• Urban

• Suburban

• Rural

Which of the following best describes your practice?

• Academic (private)

• Academic (public)

• Community health center

• Government health center/ hospital

• Health maintenance organization

• Hospital—community

• Hospital—university

• Hospital—other

• Private practice—group

• Private practice—individual

• Veterans Affairs

What is your provider status?

• Attending physician

• Fellow physician

• Resident physician

• Physician assistant

• Medical assistant

• Advanced practice registered nurse

• Registered nurse

• Licensed practical nurse

• Midwife

• Doula

• Medical student

• Other: _________

What is your specialty?

• Family medicine

• Ob/Gyn generalist

• Ob/Gyn sub‐specialty

  • Maternal‐fetal medicine

  • Gynecologic oncology

  • Family Planning

  • Gynecologic urology

  • Reproductive endocrinology and infertility

  • Minimally invasive surgery

• Other: __________

Block 2: General vaccination attitudes.

Which infections do you feel should be routinely discussed with pregnant patients? Select all that apply.

• Syphilis

• Gonorrhea

• Chlamydia

• Rubella

• Zika

• HIV

• Hepatitis B & C

• Influenza

• COVID‐19

• Pertussis

• Tetanus

• Diphtheria

• Polio

• Tuberculosis

• Meningococcus

• Varicella

Indicate which vaccines are safe in pregnancy. Select all that apply.

• Influenza

• Tdap (tetanus, diphtheria, and acellular pertussis)

• COVID‐19

• Hepatitis B

• Varicella

• Polio

• Meningococcus

• MMR (measles, mumps, rubella)

All pregnant patients should receive vaccines that are safe in pregnancy.

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

Influenza vaccination during pregnancy has a direct benefit to the mother.

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

Influenza vaccination during pregnancy has a direct benefit to the fetus.

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

Tdap vaccination during pregnancy has a direct benefit to the mother.

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

Tdap vaccination during pregnancy has a direct benefit to the fetus.

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

COVID‐19 vaccination during pregnancy has a direct benefit to the mother.

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

COVID‐19 vaccination during pregnancy has a direct benefit to the fetus.

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

At this present time, there is enough evidence to recommend the COVID‐19 vaccine to pregnant patients.

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

Patients frequently ask me about the safety of the COVID‐19 vaccine in pregnancy.

• Strongly agree

• Agree

• Neutral

• Disagree

• Strongly disagree

Block 3: Provider practices.

Do you counsel pregnant patients on vaccines?

• Always

• Sometimes

• Rarely

• Never

Are other members of the healthcare team responsible for counseling on vaccines?

• Always

• Sometimes

• Rarely

• Never

Do you follow CDC guidelines for vaccination in pregnancy?

• Always

• Sometimes

• Rarely

• Never

For which vaccines do you provide counseling? Select all that apply.

• Influenza

• Tdap

• COVID‐19

• Hepatitis B

• Varicella

• Polio

• Meningococcus

• MMR

When do you counsel patients about influenza?

• On their first visit, regardless of trimester

• First trimester

• Second trimester

• Third trimester

Do you recommend that all household members of a gravida be vaccinated against influenza?

• Always

• Sometimes

• Rarely

• Never

When do you counsel patients about Tdap?

• On their first visit, regardless of trimester

• First trimester

• Second trimester

• Third trimester

Do you recommend that all household members of a gravida be vaccinated against Tdap?

• Always

• Sometimes

• Rarely

• Never

When do you counsel patients about COVID‐19?

• On their first visit, regardless of trimester

• First trimester

• Second trimester

• Third trimester

Do you recommend that all household members of a gravida be vaccinated against COVID‐19?

• Always

• Sometimes

• Rarely

• Never

Do you document vaccine counseling in the medical record?

• Always

• Sometimes

• Rarely

• Never

When documenting, what information do you include? Select all that apply.

• Recommended vaccine(s)

• Counseled benefits

• Counseled risks

• Patient's decision

• Vaccine administration

• Other: ___________________

If a patient consents to vaccination, what is your next step?

• Administer immediately, per CDC recommendations

• Administer later, per CDC recommendations

• Refer patient to another site for vaccination

If a patient accepts vaccination, do you encounter difficulties in administering them because of insurance‐related barriers?

• Always

• Sometimes

• Rarely

• Never

If a patient declines vaccination, what do you do? Select all that apply.

• Determine patient's reasons for refusal

• Re‐counsel at another visit

• Ask another member of staff to counsel patient

• Nothing further

• Other: ___________________

If a patient declines vaccination, do they express why?

• Always

• Sometimes

• Rarely

• Never

If a patient declines vaccination, do you document the patient's reason?

• Always

• Sometimes

• Rarely

• Never

Block 4: Differences in vaccine uptake among racial, ethnic, and age groups.

In which age group do you see the highest percentage of gravidas accepting vaccines?

• Ages 16–25 years

• Ages 26–35 years

• Ages 36–45 years

• No noted difference across age groups

In which age group do you see the highest percentage of gravidas declining vaccines?

• Ages 16–25 years

• Ages 26–35 years

• Ages 36–45 years

• No noted difference across age groups

In which racial group do you see the highest percentage of gravidas accepting vaccines?

• White

• Black or African American

• Asian

• American Indian or Alaska Native

• Native Hawaiian or Pacific Islander

• No noted difference across racial groups

In which racial group do you see the highest percentage of gravidas declining vaccines?

• White

• Black or African American

• Asian

• American Indian or Alaska Native

• Native Hawaiian or Pacific Islander

• No noted difference across racial groups

In which ethnic group do you see the highest percentage of gravidas accepting vaccines?

• Hispanic

• Non‐Hispanic

• No noted difference across ethnic groups

In which ethnic group do you see the highest percentage of gravidas declining vaccines?

• Hispanic

• Non‐Hispanic

• No noted difference across ethnic groups

APPENDIX B.

PROVIDER SURVEY INFORMED CONSENT FORM

You are being asked to participate in the research project titled Provider Knowledge and Attitudes regarding Vaccination during Pregnancy. In this study, we are surveying medical professionals who provide care and treatment to pregnant women to assess their opinions and practices related to vaccination during pregnancy. You will be asked to complete an anonymous survey through the on‐line portal Qualtrics. Your time to complete the survey should be approximately 10 min.

During your participation in this study, it is not expected that you will experience any personal risk or discomfort. Your participation in this study is voluntary. If at any time you no longer not want to participate, you can withdraw from completing the survey and not submit your answers. There are no negative consequences if you decide to withdraw from the study. This is an anonymous survey so your decision to participate and not participate will not be linked to you in any way. Your decisions will not affect your educational or employment status at the University of Miami.

The survey is anonymous, and all responses will be kept completely confidential. If you have any questions, you can contact the Principal Investigator Dr. JoNell Potter in daytime hours at (305) 243–2173. If you have any questions about your rights as a research participant, you may contact the Human Subjects Research Office at the University of Miami at (305) 243–3195. By continuing from here, you are consenting to participate in this study.

Rodriguez GF, Vilariño V, Agasse E, St. Onge JE, Shafazand S, Potter J. Vaccination in pregnancy: Healthcare provider attitudes and practices. Int J Gynecol Obstet. 2022;00:1‐12. doi: 10.1002/ijgo.14572

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.