key: cord-0777272-upbkk534 authors: Ward, Caoimhe; Megaw, Lauren; White, Scott; Bradfield, Zoe title: COVID‐19 vaccination rates in an antenatal population: A survey of women's perceptions, factors influencing vaccine uptake and potential contributors to vaccine hesitancy date: 2022-04-22 journal: Aust N Z J Obstet Gynaecol DOI: 10.1111/ajo.13532 sha: d4a60a111ae9528c6bcfc572a50b1d4dc6c58b86 doc_id: 777272 cord_uid: upbkk534 BACKGROUND: Pregnant women are at increased risk for severe COVID‐19 and are a priority group for vaccination. The discrepancy in vaccination rates between pregnant and non‐pregnant cohorts is concerning. AIMS: This study aimed to assess the perceptions and intentions of pregnant women toward COVID‐19 vaccination and explored vaccine uptake and reasons for vaccine hesitancy. MATERIALS AND METHOD: A cross‐sectional exploratory design was performed evaluating pregnant women receiving care in two metropolitan maternity units in Western Australia. The main measurable outcomes included vaccination status, intention to be vaccinated, and reasons for delaying or declining vaccination. RESULTS: In total, 218 women participated. Of these, 122 (56%) had not received either dose of the COVID‐19 vaccine. Sixty (28%) claimed that vaccination was not discussed with them and 33 (15%) reported being dissuaded from vaccination by a healthcare practitioner. Compared to vaccinated women, those who had not accepted vaccination were less likely to have had vaccination discussed by maternity staff, less aware that pregnant women are a priority group, and less aware that pregnancy increased the risk of severe illness. Unvaccinated women were concerned about the side effects of the vaccine for their newborn and their own health, felt there was inadequate information on safety during pregnancy, and felt that a lack of community transmission in Western Australia reduced the necessity to be vaccinated. CONCLUSION: Vaccine delay and hesitancy is common among pregnant women in Western Australia. Education of healthcare professionals and pregnant women on the recommendation for COVID‐19 vaccination in pregnancy is required. Pregnancy is an established risk factor for severe maternal COVID-19, with studies demonstrating an increased risk of intensive care unit admission, requirement for mechanical ventilation, and death among pregnant women compared to their nonpregnant counterparts. [1] [2] [3] Therefore, they are a priority group for COVID-19 vaccination. 1 Pregnancy complications in particular with the Delta variant are also increased, including preterm birth, stillbirth, preeclampsia, and emergency caesarean section. [4] [5] [6] The Royal Australian College of Obstetricians and Gynaecologists (RANZCOG) and the Australian Technical Advisory Group on Immunisation (ATAGI) acknowledge that pregnant studies citing vaccine effectiveness of 78-96% in pregnant women. [7] [8] [9] Common systemic side effects including headache, myalgia, chills, and fever are reported as less prevalent in the pregnant population. 10 Reassuringly, the COVID-19 vaccine has not been associated with adverse pregnancy or neonatal outcomes. 10 Despite the evidence supporting COVID-19 vaccination safety during pregnancy, the discrepancy in vaccination rates between pregnant and non-pregnant cohorts is widely reported. In October Gynaecologists encouraged all pregnant women to accept the vaccine, acknowledging only 15% of pregnant women in the UK were vaccinated. 11 Data on the rates of vaccination within the pregnant population in Australia are not uniformly collected which inhibits national reporting. As such, we must rely on anecdotal reports from jurisdictional data and leading experts' estimations in non-medical journals. Despite a lack of transparency in reporting, we are led to believe that vaccination rates of pregnant people in Australia range 30-70%. 12 Vaccine delay and hesitancy pose significant risks to public health where there is active community transmission. The population of Western Australia (WA) is a unique cohort, where no cases of COVID-19 were reported in the community for the duration of this eight-week study from September to October 2021. Anecdotally, this may be a precipitating factor in some women declining vaccination. This study aimed to assess the attitudes, perceptions, and intentions of pregnant women toward COVID-19 vaccination and explored vaccine uptake and potential reasons for vaccine hesitancy. Such information may be useful in refining public health strategies to improve vaccine uptake in this at-risk population. A cross-sectional exploratory design was used. Cross-sectional studies are known for their utility in providing insight into phenomena at discrete points in time. 13 Human research ethics approval was granted by the Women and Newborn Health Service Human Research Ethics Committee (number 42325). were offered an anonymous survey upon presentation regardless of gestation. Participants were presented with a participant information form alongside a QR code that, upon scanning, directed participants to an online survey. Completion of the survey constituted implied consent. Participants had access to the COVID-19 vaccine in the community for several weeks prior to commencement of the study. The study was ceased following a pre-agreed eight-week period. There was no existing validated tool available to evaluate the perceptions and intentions regarding COVID-19 vaccination uptake in pregnant women. The survey was developed by the investigators who have expertise in survey design and maternity care. Descriptive summaries were made using median, interquartile ranges, and ranges for continuous data or frequency distributions for categorical data. Four-point Likert scale responses (strongly agree, agree, disagree, and strongly disagree) were categorised into strongly agree/agree vs disagree/strongly disagree for univariate analysis. Gestations were divided into <28, 28-35, and >36 weeks for analysis. The unvaccinated cohort were divided into three subgroups: the vaccine accepting, who agreed to accept vaccination during pregnancy; the vaccine hesitant, who were unsure regarding vaccination; and the vaccine resistant, who would decline vaccination during pregnancy. Vaccination uptake groups were compared using χ 2 or Fisher exact tests. SPSS statistical software was used for analysis. P-values <0.05 were considered statistically significant. an eight-week period with a mean age of 31.9 years and a median gestation of 33 weeks (interquartile range (IQR): 27-36, range: 13-42). Participants were booked to birth in a variety of settings, including 20 women (9%) in the co-located midwifery-led birthing unit and 33 (15%) and 164 (75%) in medically led secondary and tertiary maternity hospitals, respectively (Table 1) (33.3%) at 36+ weeks, P = 0.004) ( Table 2) . Furthermore, those who were vaccinated or vaccine accepting were more likely to have discussed vaccination with a healthcare professional (n = 89 (85.6%) vs 60 (53.1%), P < 0.01), had greater awareness they were a priority for vaccination (n = 98 (93.3%) vs n = 75 (66.4%) P < 0.001) and were more aware they were at increased risk of severe illness (n = 101 (96.2%) vs n = 92 (81.4%) P < 0.01) ( Table 3) . Approximately 54.4% (n = 31) of women who did not speak English at home were unvaccinated. Of these women 25.8% (n = 8) (P < 0.001) were not aware that pregnant women were categorised as a priority group for vaccination. Although not statistically significant, the midwifery group practice had the highest percentage of fully vaccinated patients (36.7% (n = 18)) in comparison to patients who acquired tertiary maternity care (24.8% (n = 39)) or community midwifery program led care (20% (n = 10)) (P = 0.240). Among unvaccinated women, a more advanced gestation was associated with a lower intention to accept vaccination. Women at later gestations were less likely to accept the COVID-19 vaccine in pregnancy (n = 48 (66.7%) at 36+ weeks vs n = 49 (57%) at 28-35 weeks vs n = 23 (39.7%) at <28 weeks, P = 0.004) ( Table 2) . Among unvaccinated women, n = 16 (13.3%) were planning vaccination in the post-partum period (n = 4 (17.4%) at <28 weeks vs n = 7 (14.3%) at 28-35 weeks vs n = 5 (10.4%) at 36+ weeks, Women who had not discussed the vaccination with a healthcare practitioner were more likely to be of later gestation, 36+ weeks gestation, n = 31 (47%) vs n = 41 (27.5%) and less likely to be <28 weeks gestation, n = 10 (15.2%) vs n = 48(32.2%) compared to women who had discussed vaccination (P = 0.006). Of those who were vaccine hesitant or resistant, n = 39 (34.8%) indicated they would like more information and n = 73 (65.2%) responded that they had sufficient information. Compared to vaccinated and vaccine accepting women, this group more frequently relayed concerns regarding effect of the vaccine for their newborn vs n = 25 (25.3%), P < 0.001) and believed lack of community transmission of COVID-19 in WA reduced the necessity for vaccination (n = 34 (33.3%) vs n = 6 (6.1%), P < 0.001) ( Table 3 ). In total, almost one-third of patients claimed that the COVID-19 vaccine had not been discussed or were unsure if it had been discussed by a healthcare practitioner (n = 68, 31.2%) ( Table 3 ). Almost 1/5 women who had been advised against vaccination reported that they had been dissuaded from accepting vaccination by a healthcare provider, including their general practitioner (n = 20 (17%)), midwife (n = 8 (7%)), or obstetrician (n = 5 (4%)) ( Table 4 ). Although these numbers were small and not statistically significant, those advised against vaccination by a health professional were almost twice as likely to be vaccine hesitant or resistant compared to those who had not been so advised (n = 17 (25%) vs n = 7 (13%), P = 0.09) ( Table 4 ). Women who were vaccine hesitant or resistant were more likely to be advised against vaccination by a partner or family member (n = 32 (47.8%) vs n = 11 (20.4%), P = 0.002) ( Table 4 ). To our knowledge, this is the first study reporting vaccination per- vaccine. 17 Early data in this study indicate there may be a positive association between vaccination uptake and models that The fact data regarding pregnancy/breastfeeding status at time of vaccination are not collected by the national immunisation register must be urgently addressed. 19 The absence of long-term safety data in pregnancy is consistently cited by those who are vaccine hesitant or resistant. 14, 17, 20 This centralised col- Joint statement between RANZCOG and ATAGI about COVID-19 vaccination for pregnant women Characteristics of women of reproductive age with laboratory-confirmed SARS-CoV-2 infection by pregnancy status -United States Prevalence of maternal mortality and clinical course of maternal deaths in COVID-19 pneumonia-a cross-sectional study The association of COVID-19 infection in pregnancy with preterm birth: a retrospective cohort study in California Maternal and perinatal outcomes of pregnant women with SARS-CoV-2 infection at the time of birth in England: National cohort study Association of the delta (B.1.617.2) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with pregnancy outcomes SARS-CoV-2 vaccine effectiveness in preventing confirmed infection in pregnant women Effectiveness of the BNT162b2 mRNA COVID-19 vaccine in pregnancy Association between BNT162b2 vaccination and incidence of SARS-CoV-2 infection in pregnant women Preliminary findings of mRNA Covid-19 vaccine safety in pregnant persons Royal College of Obstetricians & Gynaecologists. RCOG supports calls from NHS to pregnant women to get vaccinated against COVID-19 Vaccination for pregnant women seriously lags national average Cross-sectional studies -what are they good for Factors that influence vaccination decision-making among pregnant women: a systematic review and meta-analysis Australian Government Department of Health. Coronavirus (COVID-19) case numbers and statistics Women's views on accepting COVID-19 vaccination during and after pregnancy, and for their babies: a multi-methods study in the UK COVID-19 vaccination perceptions and intentions of maternity care consumers and providers in Australia COVID-19 vaccine acceptance in pregnant women COVID-19 vaccine hesitancy among reproductive-aged female tier 1A healthcare workers in a United States medical center Covid-19 and pregnancy: vaccine hesitancy and how to overcome it Evidence and advocacy in Melbourne maternity care during the COVID-19 pandemic