Journal of Midwifery &Women’s Health www.jmwh.orgCommentary

Creating a Conversation About ImmunizationsCarol Hayes, CNM, MN, MPH

A related patient education handoutcan be found at the end of this issueand at www.sharewithwomen.org

The Centers for Disease Control and Prevention (CDC)recommend that all pregnant women be vaccinated dur-ing pregnancy with the influenza and the tetanus, diph-theria, and pertussis (Tdap) vaccines.1 A new AmericanCollege of Nurse-Midwives (ACNM) position statement onimmunizations for women who are pregnant or postpartum2

recommends that midwives follow the CDC vaccine rec-ommendations in pregnancy. Recently, ACNM also updatedthe position statement on vaccines for women and theirfamilies.3 These statements affirm that midwives should as-sess all women for their immunization status; provide womenwith current information regarding the control of commu-nicable diseases by vaccination, the risks and benefits of im-munizations, current immunization guidelines, and locationswhere immunizations are available in the community; pro-vide immunizations in the clinical setting when feasible; andmaintain currency in evidence-based information regardingthe risks and benefits of available vaccines. ACNM joins nu-merous other organizations in recognizing the safety of vac-cines and recommending that women be vaccinated. Thoseorganizations include the American Academy of Pediatrics,4American Congress of Obstetricians and Gynecologists,5 Na-tional Association of Pediatric Nurse Practitioners,6 Instituteof Medicine,7 March of Dimes,8 Agency for Healthcare Re-search and Quality,9 Food and Drug Administration,10 andWorld Health Organization.11 All of these organizations con-firm the safety of vaccines.

Despite rigorous research and data on the safety of vac-cines, myths andmisconceptions abound. To counteract thesemyths and misconceptions, ACNM has created a suite of im-munization resources formidwives.12 Thesematerials includea Talking Points document that was created with the mid-wife in mind. This document addresses many of the miscon-ceptions and concerns that women have about vaccines andgives midwives a framework for beginning a dialogue withwomen about immunizations. The new ACNM resource pagealso contains links to theACNMimmunization position state-ments; resources for ordering and administering vaccines; andlinks to several resources from the CDC and other organi-zations, including Spanish-language resources. In addition,the resource page includes ACNM’s new collection of Be aSuper Mom materials, which include patient handouts (fre-quently asked questions [FAQs] about vaccines, FAQs aboutthe whooping cough [pertussis] vaccine, FAQs about the

Address correspondence to Carol Hayes, CNM, MN, MPH, 2665 SpicerLane, Decatur, GA 30033. E-mail: carolhayescnm@gmail.com

Table 1. Tips for ImprovingVaccination Rates inWomenReview each woman’s vaccine history at each visit.

Recommend that women be vaccinated at each visit if they are

not up-to-date on their vaccines. Every woman needs to hear

their clinician’s commitment to the evidence on the benefits of

vaccines. More patients agree to be vaccinated when their

clinicians assume that they will be vaccinated.

Create a hard stop in electronic health records to confirm annual

influenza each year, pertussis in each pregnancy, and other

vaccines for completion of series.

Create a reminder in paper health records for vaccinations by

using a screening form.

Clinicians may bill simply for screening women for vaccinations.

The current protocol terminology code for screening should be

on every super bill. One option for screening is to have women

indicate whether they have had their annual influenza vaccine

when they update their contact information.

flu vaccine, and understanding vaccines during pregnancy),posters to hang in midwives’ offices, and coloring pages thatcan be given to children who accompany their mothers to vis-its. The patient education brochures and coloring book arealso available on ACNM’s Our Moment of Truth Web site.13In this issue of the Journal of Midwifery and & Women’sHealth, you will find a Share with Women patient educationhandout on immunizations for women and families, as well asa handout on immunizations during pregnancy.

Midwives have a responsibility to be informed about thefacts and science of vaccines and to give sound advice towomen. Most women underestimate the severity of vaccine-preventable diseases and the safety of the vaccines. These arethe first areas to focus onwhen beginning a discussion on vac-cines. Research shows that a recommendation from a healthcare professional is the top predictor of patients getting vac-cinated. Vaccination rates are low when the clinician hesitatesto recommend vaccinations.14

The CDC recommends that clinicians share a strong rec-ommendation for vaccines using 5 steps (share, highlight, ad-dress, remind, and explain).15 First, share the reasons whythe recommended vaccine is right for each patient based onher health status and risk factors. Second, highlight posi-tive personal experiences with vaccination. Third, addresspatient questions and any concerns about adult vaccines, in-cluding safety and effectiveness, in plain and understandablelanguage. Fourth, remind patients that vaccine-preventablediseases still exist in the United States and can be serious

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for them as well as for friends and family members. Finally,explain the potential costs of getting the disease, includingserious health effects, time lost (missing work, activities, andfamily events), and financial costs. The acronym SHARE canbe used to remember these steps. Tips for improving vaccina-tion rates in women can be found in Table 1.

In this age of the 9-minute prenatal visit and mind-numbing electronic health record clicks, clinicians can easilyforget about or choose to not address some preventive healthmessages. The safety and efficacy of immunizations is a con-versation that cannot be overlooked.

REFERENCES

1.Centers for Disease Control and Prevention. Guidelines for vacci-nating pregnant women. Updated April 2013. http://www.cdc.gov/vaccines/pubs/preg-guide.htm. Accessed June 11, 2014.

2.American College of Nurse Midwives. Position statement: Im-munization in pregnancy and postpartum. Approved May 2014.http://midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000289/Immunization-in-Pregnancy-and-Postpartum-May-2014.pdf. Accessed June 2014.

3.American College of Nurse Midwives. Position statement: Immuniza-tion status of women and their families. Updated December 2013.http://midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000072/Immunization-Status-Women-and-Families-Dec-2013.pdf. Accessed June 2014.

4.American Academy of Pediatrics. Vaccine Safety. Updated October30,2013.http://www2.aap.org/immunization/families/safety.html. Ac-cessed June 14, 2014.

5.American College of Obstetricians and Gynecologists. Update on im-munization and pregnancy: Tetanus, diphtheria, and pertussis vacci-nation. Committee Opinion Number 566, June 2013 Obstet Gynecol.2013;121:1411-1414.

6.National Association of Pediatric Nurse Practitioners. NAPNAPposition statement on immunizations. J Pediatr Health Care.2011;25(2):e6-e8. doi:10.1016/j.pedhc.2010.11.007

7.Institute of Medicine. The childhood immunization schedule andsafety: Stakeholder concerns, scientific evidence, and future studies.Updated 2013. www.iom.edu/childimmunizationschedule, AssessedJune 18, 2014.

8.March of Dimes. Vaccinations during pregnancy. Updated February2013.http://www.marchofdimes.com/pregnancy/vaccinations-during-pregnancy.aspx Accessed June 11, 2014.

9.Agency for Healthcare Research and Quality. Safety of vaccinesused for routine immunization in the United States. July 1, 2014.http://www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=1930&PCem=EN. Accessed July 2, 2014.

10.Food andDrug Administration. Vaccine safety questions and answers.Updated June 6,2011.http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/ucm133806.htm Accessed June 11,2014.

11.World Health Organization http://www.who.int/topics/vaccines/en/.Accessed June 18, 2014

12.American College of Nurse Midwives. Immunization Resourcesfor Midwives. http://www.midwife.org/Immunization-Resources-for-Midwives. Accessed June 2014.

13.American College of Nurse Midwives. Understanding the Im-portance of Vaccines—Become a Supermom and Protect Your-self & Your Family. http://www.midwife.org/omot-vaccines-during-pregnancy Accessed June 18, 2014.

14.Opel DJ, Heritage J, Taylor JA, et al. The architecture of provider-parent vaccine discussions at health supervision visits. Pediatrics.2013;132(6):1037-1046. doi:10.1542/peds.2013-2037

15.Centers for Diseases Control and Prevention. SHARE astrong vaccine recommendation. A series on standards foradult immunization practice. Updated March 11, 2014.http://www.cdc.gov/vaccines/hcp/patient-ed/adults/downloads/standards-immz-practice-recommendation.pdf. Accessed June 18,2014.

482 Volume 59, No. 5, September/October 2014