Novel pandemic A (H1N1) influenza vaccination among pregnant women: motivators and barriers

cr

www.AJOG.org

Novel pandemic A (H1N1) influenza vaccinationamong pregnant women: motivators and barriersGillian K. SteelFisher, PhD, MSc; Robert J. Blendon, ScD; Mark M. Bekheit, JD; Elizabeth W. Mitchell, PhD, MA;
Jennifer Williams, MSN, MPH, FNP-BC; Keri Lubell, PhD; Jordon Peugh, MA; Charles A. DiSogra, DrPH, MPH
dwcmstw2m

notH2mwt2fwvdfv

cetabflwtpinbaCtbu

Even in the first months following theApril emergence of 2009 novel pan-

demic influenza A (H1N1), data sug-gested that pregnant women were atincreased risk for hospitalization anddeath.1 Parallel trends have been seen inpast pandemic influenzas,2-4 likely be-ause the cardiovascular, immune, andespiratory changes that occur normally

We sought to examine motivators and bar(H1N1) vaccination among pregnant womewomen using a random online sample (237pregnant women reported getting the vacciattitudinal factors including believing the vacprovider recommendations. Women in raceducation, and women �35 years were leviews and experiences. Despite H1N1 vacciinfluenza rates, barriers like safety concernproviders that encourages women to beliebaby may be compelling. Messaging and ocustomization to increase vaccination amo

Key words: H1N1, pregnant women, vacc

From the Harvard School of Public Health, BoBekheit) and John F. Kennedy School of GoveCenters for Disease Control and Prevention, AWilliams); and Knowledge Networks, Menlo

Presented, in part, at a scientific and technical mPrevention in Atlanta, GA, by Dr SteelFisher on MWomen, Mothers of Infants, and the H1N1 Outbpresented at a meeting entitled “Pandemic InfluePregnant Women and Newborn” put forth by ththe Association of Maternal and Child Health Proin Atlanta, GA, on Aug. 12, 2010, and entitled “MH1N1 Response.”

Received Dec. 16, 2010; revised Feb. 7, 2011; a

Reprints not available from the authors.

Conflict of Interest: none.

The findings and conclusions in this report are threpresent the official position of the Centers for D

The poll was funded under a cooperative agreemPrevention and the National Public Health Inform

Publication of this article was supported by the Cthe Association of Maternal and Child Health Pro

0002-9378/$36.00 • © 2011 Mosby, Inc. All rights

S116 American Journal of Obstetrics & Gynecology

uring pregnancy also make pregnantomen more susceptible to influenza

omplications.5,6 Based on such infor-ation, pregnant women were among

everal groups prioritized for receivinghe monovalent 2009 H1N1 vaccinehen it became available in October009,7,8 and there were significant com-unication efforts to encourage preg-

s related to monovalent 2009 influenza AWe conducted a national poll of pregnantnd opt-in supplement (277). In all, 42% ofVaccination was positively associated withe is very safe or benefits the baby, and withethnic minority groups, women with lesslikely to get the vaccine and had differingion rates that are higher than past seasonalay persist in a pandemic. Messaging fromhe vaccine is very safe and benefits theirach during future pandemics may requireigh-risk groups.

ion

n (Drs SteelFisher and Blendon, and Mrent, Cambridge, MA (Dr Blendon);

nta, GA (Drs Mitchell and Lubell, and Msk, CA (Ms Peugh and Dr DiSogra).

ing at the Centers for Disease Control and19, 2010, in a presentation entitled “Pregnantk.” A similar set of selected findings werea Revisited: Special Considerations fornters for Disease Control and Prevention andms. The slides were presented by Dr Mitchellrnal Health Communication During the 2009

pted Feb. 14, 2011.

of the authors and do not necessarilyase Control and Prevention.

t with the Centers for Disease Control andn Coalition.

ters for Disease Control and Prevention andms.

reserved. • doi: 10.1016/j.ajog.2011.02.036

Supplement to JUNE 2011

ant women to get the vaccine through-ut the pandemic.9 (This article uses theerm “H1N1 vaccine” rather than “20091N1 vaccine” when referring to the

009 H1N1 influenza A vaccine to avoidisperception about when the vaccineas taken. Some participants may have

aken it in 2009 while others took it in010.) To help prepare for any possibleuture pandemic influenza outbreak inhich pregnant women will likely beulnerable again, it may be useful to un-erstand the motivators and barriers

or pregnant women getting the H1N1accine.There has been very little research con-

erning pregnant women’s views of, andxperiences with, the H1N1 vaccine. Al-hough the circumstances of a pandemicre different than seasonal influenza out-reaks, research concerning seasonal in-uenza vaccination among pregnantomen may nonetheless provide a guide

o possible motivators and barriers forregnant women. The annual seasonal

nfluenza vaccination rate among preg-ant women is relatively low, hoveringetween 10-15%,10 which suggests therere significant barriers to vaccination.oncern about the vaccine’s safety for

he fetus is believed to be a key attitudinalarrier to seasonal influenza vaccineptake among pregnant women.5,11-13

Conversely, vaccination may be posi-tively associated with: having had theseasonal influenza vaccine in the past;discussing the vaccine with a physician;knowing that seasonal influenza is a par-ticular risk to pregnant women; and be-lieving that the baby would benefit if amother got the vaccine while she waspregnant.14 It is not clear whether thesefactors manifest the same way in a pan-demic influenza. For example, barriersto influenza vaccination may be reducedin the face of an apparently more deadly

riern.) a

ne.cinial/ssnats mve tutreng h

inat

stornmtla

Par

eetay

reanz

e Cegraate

cce

oseise

enatio

engra

strain.

mcegfa

tbdnBwSb1sgiSdKepmyitioiRsn

www.AJOG.org Supplement

There are plausible differences in mo-tivators and barriers to pandemic influ-enza vaccination among different sub-groups of pregnant women, although noresearch in this area yet exists. For exam-ple, although studies of pregnant womenhave had sample sizes too small to ev-aluate differences in vaccination ratesacross racial/ethnic groups, data fromthe general public suggest that racial/eth-nic minorities are less likely to get theseasonal influenza vaccine.15-19 Barriersfor racial/ethnic minorities appear to re-late both to differences in access to careand attitudes about vaccination.20-22

Pregnant women in lower socioeco-nomic groups, who are less likely to getprenatal care overall,23 may also face dif-ferent barriers and motivators for vacci-nation. Further, older and younger pre-gnant women may have a differentevaluation of risk in pregnancy24; these

ay translate to different vaccine-spe-ific attitudes and experiences. This is anspecially important area of inquiryiven that these groups are at higher riskor pregnancy-related complicationsside from those related to influenza.23

The current study seeks to examine themotivators for and barriers against preg-nant women receiving the H1N1 vaccinethrough the use of a national poll con-ducted during the pandemic. After re-porting the vaccination rate overall, thisanalysis examines 6 factors related to thedecision by pregnant women to get theH1N1 vaccine. We examine: (1) aware-ness of the vaccine recommendation forpregnant women; (2) concern about theillness for themselves and their babies;(3) views of the vaccine’s safety for preg-nant women; (4) views of its benefits forthe fetus; (5) interactions with a healthcare provider; and (6) experience withseasonal influenza vaccination. Finally,we examine differences in vaccinationrates and how factors that are associatedwith vaccination differ across demo-graphic subgroups, including racial/eth-nic minorities, age, and education.

Materials and methodsPregnant women comprise a very smallpercentage of the population, esti-mated in some studies as approximately
1%.1,25-27 (The Centers for Disease Con-
rol and Prevention reports statistics onirths rather than pregnancies due to theifficulties in capturing data on all preg-ancies that may not result in births.ased on estimates from 2007, thereere 4,316,233 live births in the Unitedtates, with a fertility rate of 69.5 liveirths per 1000 women and girls aged5-44 years.) To get a nationally repre-entative sample of this low-incidenceroup, researchers in the Harvard Opin-on Research Program at the Harvardchool of Public Health recruited a ran-om sample of pregnant women fromnowledge Network’s online Knowl-

dgePanel to participate in a poll. Thisrobability-based panel of approxi-ately 50,000 US residents aged �13

ears is built through random-digit dial-ng and address-based sampling ratherhan voluntary, opt-in approaches, andncludes participants who do not havenline access except that provided by be-

ng in the Knowledge Networks panel.esults from this approach have been

hown to be comparable to results fromational telephone polls.28 From this

panel, 13,851 women aged 18-50 yearswere sampled and invited by e-mail tocomplete the survey. From among thoseinvited, 9285 women responded to thesurvey (67% cooperation rate) and 237were identified as currently pregnant. Toaccount for nonresponse biases in the re-cruiting process, respondents wereweighted to match the US census esti-mates of key demographic and house-hold variables, including age, race/eth-nicity, geographic region, metropolitanstatus, income, education, and, amongHispanics, primary language profi-ciency. To increase the power of the anal-yses, researchers supplemented this sam-ple with 277 pregnant women from anopt-in sample of women aged 18-50years who preidentified as pregnant. Thesupplementary sample is maintained byResearchNow (Chicago, IL) as part of a6-million person database designed forresearch in low-incidence populations.All participants double opted in andwere screened using multiple qualitychecks, including third-party reviews ofprofiles and matching to US postal re-cords. Pregnancy status was reconfirmed
during in-field screening. This supple-
Supplement to JUNE 2011 Amer

mentary sample was weighted to matchthe randomly selected sample using: ageof mother, trimester, race/ethnicity, geo-graphic region, metropolitan status, in-come, and education. After weightingthe opt-in sample, there were few statis-tically significant differences between the2 samples with respect to key demo-graphics; however, the opt-in samplewas more likely to have more educationwhen compared with the KnowledgePanelsample even after weighting. All datawere collected from Jan. 29 through Feb.26, 2010, and the total sample size was514 pregnant women. Researchers at theHarvard School of Public Health had noaccess to any identifying informationfrom respondents and the study wastherefore deemed not human subjectsresearch by the Harvard School of PublicHealth’s Office of Human ResearchAdministration.

The poll was designed by researchersusing input from formative research uti-lizing focus groups of pregnant and re-cently pregnant women conducted in fall2009, as well as a careful literature reviewand comparison to existing polling dataconcerning 2009 H1N1 influenza andvaccines more generally. It included ap-proximately 70 closed-ended substan-tive questions, and 14 closed-ended de-mographic questions. Where relevant,comparisons between subgroups aremade using 2-tailed z-tests that accountfor the use of weighted data. Only differ-ences that are statistically significant us-ing a conventional alpha level of 0.05 arereported.

ResultsVaccinationApproximately 4 in 10 pregnant women(42%) reported that they had receivedthe H1N1 vaccine, and another 8% saidthey expected to get it by the end ofMarch 2010 (Table 1). Half of pregnantwomen said they either did not intend toget the H1N1 vaccine for themselves(37%) or were not sure about getting theH1N1 vaccine by the end of March 2010(13%) (Table 1).

Awareness of vaccine recommendationMost pregnant women heard either “a
lot” (41%) or “some” (45%) about the
ican Journal of Obstetrics & Gynecology S117

SteelFisher. H1N1 vaccine motivators and barriers among pregnant women. Am J Obstet Gynecol 2011.

Supplement www.AJOG.org

S118 American Journal of Obstetrics & Gynecology Supplement to JUNE 2011

H1N1 vaccine (Table 1), and most(82%) knew that the public health rec-ommendation was for pregnant womento get the H1N1 vaccine (not shown).There was not a statistically significantdifference in vaccination rates betweenpregnant women who had heard “a lot”about the vaccine and those who had not(Table 2).

Concern about 2009 H1N1 influenzaA third (34%) of pregnant women re-ported that they were concerned thatthey might get sick from 2009 H1N1 in-fluenza during the next 12 months, andalmost half (49%) of pregnant womensaid they were concerned that their babymight get sick from 2009 H1N1 influ-enza after being born (Table 1). H1N1influenza vaccination among pregnantwomen who were concerned that theypersonally would get sick from 2009H1N1 influenza and those who were notconcerned about this risk to themselveswere statistically equivalent (38% vs44%) (Table 2). Pregnant women whowere concerned about their baby get-ting sick from 2009 H1N1 influenzawere more likely than those who werenot concerned about this to have re-ceived the H1N1 vaccine (50% vs 33%)(Table 2).

About half (52%) of pregnant womenbelieved that, in general, pregnantwomen were more likely than other peo-ple to become seriously ill from 2009H1N1 influenza (Table 1). Almost thesame percentage of pregnant women ei-ther believed that pregnant women werenot more likely than other people to getseriously ill from 2009 H1N1 influenza(13%) or said they did not knowwhether pregnant women were morelikely than others to get seriously illfrom 2009 H1N1 influenza (35%) (Ta-ble 1). Pregnant women who believedthat this group is at greater risk of be-coming seriously ill from 2009 H1N1influenza were more likely to have re-ceived the H1N1 vaccine than thosewho did not know or did not believethis (54% vs 28%) (Table 2).

When women who had not receivedthe H1N1 vaccine were asked about themajor reasons for their decision (Table

TABLE 1Vaccination rates, attitudes, and experiences of pregnant women

Vaccination rates, attitudes, and experiences

Among pregnantwomen (n � 514)

n %

H1N1 vaccination.....................................................................................................................................................................................................................................

Yes, got vaccine for themselves 213 42.....................................................................................................................................................................................................................................

Intended to get vaccine by end of March 2010 41 8.....................................................................................................................................................................................................................................

Did not intend to get vaccine by end of March 2010 191 37.....................................................................................................................................................................................................................................

Not sure if they would get vaccine by end of March 2010 69 13..............................................................................................................................................................................................................................................

Amount heard about H1N1 vaccine.....................................................................................................................................................................................................................................

A lot 211 41.....................................................................................................................................................................................................................................

Some 232 45.....................................................................................................................................................................................................................................

A little 62 12.....................................................................................................................................................................................................................................

Nothing at all 8 2..............................................................................................................................................................................................................................................

Concern about self getting 2009 H1N1 during next 12 mo.....................................................................................................................................................................................................................................

Concerned 173 34.....................................................................................................................................................................................................................................

Not concerned 337 66..............................................................................................................................................................................................................................................

Concern about baby getting 2009 H1N1 during next 12 mo after she or he is born.....................................................................................................................................................................................................................................

Concerned 249 49.....................................................................................................................................................................................................................................

Not concerned 263 51..............................................................................................................................................................................................................................................

Belief in greater risk of becoming seriously ill from 2009 H1N1 for pregnant womencompared to other people

.....................................................................................................................................................................................................................................

Believe 269 52.....................................................................................................................................................................................................................................

Do not believe 68 13.....................................................................................................................................................................................................................................

Do not know 178 35..............................................................................................................................................................................................................................................

Safety of vaccine for pregnant women.....................................................................................................................................................................................................................................

Very safe 131 26.....................................................................................................................................................................................................................................

Somewhat safe 212 41.....................................................................................................................................................................................................................................

Not very safe 107 21.....................................................................................................................................................................................................................................

Not at all safe 53 10..............................................................................................................................................................................................................................................

Believe that 2009 H1N1 vaccine provides protection to baby after born.....................................................................................................................................................................................................................................

Believe 162 32.....................................................................................................................................................................................................................................

Do not believe 59 12.....................................................................................................................................................................................................................................

Are not sure 285 55..............................................................................................................................................................................................................................................

Discussed 2009 H1N1 vaccine with health care provider.....................................................................................................................................................................................................................................

Yes, discussed vaccine 319 62.....................................................................................................................................................................................................................................

No, did not discuss vaccine 195 38..............................................................................................................................................................................................................................................

Recommendation from health care provider to get 2009 H1N1 vaccine while pregnant.....................................................................................................................................................................................................................................

Received recommendation to get vaccine 254 49.....................................................................................................................................................................................................................................

Received recommendation to NOT get vaccine 21 4.....................................................................................................................................................................................................................................

Received no recommendation from provider 44 9.....................................................................................................................................................................................................................................

Did not discuss H1N1 vaccine with provider 195 38..............................................................................................................................................................................................................................................

Seasonal flu vaccination status (since Sept. 2009).....................................................................................................................................................................................................................................

Received seasonal flu vaccine 202 39.....................................................................................................................................................................................................................................

Have not received seasonal flu vaccine 311 61..............................................................................................................................................................................................................................................

All data are weighted.

3), few cited reasons indicating a lack of


concern about 2009 H1N1 influenza,such as not believing they were at risk ofgetting 2009 H1N1 influenza (15%) orthat they would get seriously ill from2009 H1N1 influenza (15%). Similarly,few noted that a major reason was theability to get medication to treat 2009H1N1 influenza if they did become sick

TABLE 2Factors related to 2009 H1N1 vacci

Factors related to vaccination decision

Amount heard about 2009 H1N1 vaccine..........................................................................................................

Heard a lot about 2009 H1N1 vaccine (n �..........................................................................................................

Heard some, little, or nothing at all about...................................................................................................................

Concern about self getting 2009 H1N1..........................................................................................................

Concerned about getting sick from 2009 H..........................................................................................................

Not concerned about getting sick from 20...................................................................................................................

Concern about baby getting 2009 H1N1..........................................................................................................

Concerned that their baby may get sick frborn (n � 249)..........................................................................................................

Not concerned that their baby may get sicis born (n � 263)

...................................................................................................................

Risk of 2009 H1N1 for pregnant women..........................................................................................................

Believe pregnant women are at greater ris..........................................................................................................

Do not know or do not believe that pregnafrom 2009 H1N1 (n � 245)

...................................................................................................................

Safety of 2009 H1N1 vaccine..........................................................................................................

2009 H1N1 vaccine is very safe for pregn..........................................................................................................

2009 H1N1 vaccine is somewhat/not very...................................................................................................................

Benefit of vaccine for fetus..........................................................................................................

Believe that 2009 H1N1 vaccine provides..........................................................................................................

Do not know or do not believe that 2009 Hflu for their baby (n � 352)

...................................................................................................................

Vaccine recommendation from health care pr..........................................................................................................

Received recommendation from their healpregnant (n � 254)..........................................................................................................

Did not receive recommendation from thepregnant (n � 260)

...................................................................................................................

Seasonal influenza vaccine status..........................................................................................................

Received seasonal influenza vaccine since..........................................................................................................

Have not received seasonal influenza vacc...................................................................................................................

All data are weighted.a Statistical differences at 95% significance level. Comparison

Comparisons are made using t tests that account for weight

SteelFisher. H1N1 vaccine motivators and barriers among

with it (11%).

Views of vaccine safetyTwo-thirds (67%) of pregnant women be-lieved the H1N1 vaccine is safe (26% very,41% somewhat) for pregnant women totake (Table 1). However, this percentagewas statistically significantly less than thepercentage of women who said that theseasonal influenza vaccine is safe for preg-

tion decision among pregnant wome

.........................................................................................................................

11).........................................................................................................................

9 H1N1 vaccine (n � 303).........................................................................................................................

.........................................................................................................................

1 flu during next 12 mo (n � 173).........................................................................................................................

1N1 flu during next 12 mo (n � 337).........................................................................................................................

.........................................................................................................................

2009 H1N1 during next 12 mo after she or he is

.........................................................................................................................

om 2009 H1N1 during next 12 mo after she or h

.........................................................................................................................

.........................................................................................................................

f becoming seriously ill from 2009 H1N1 (n � 2.........................................................................................................................

omen are at greater risk of becoming seriously

.........................................................................................................................

.........................................................................................................................

women (n � 128).........................................................................................................................

at all safe for pregnant women (n � 370).........................................................................................................................

.........................................................................................................................

tection against 2009 H1N1 for their baby (n � 1.........................................................................................................................

1 vaccine provides protection against 2009 H1N

.........................................................................................................................

er.........................................................................................................................

are provider to get 2009 H1N1 vaccine while

.........................................................................................................................

alth care provider to get 2009 H1N1 vaccine w

.........................................................................................................................

.........................................................................................................................

pt. 2009 (n � 202).........................................................................................................................

since Sept. 2009 (n � 311).........................................................................................................................

e made between response categories–eg, those who heard a lot

gnant women. Am J Obstet Gynecol 2011.

nant women (81%) (not shown). Further,


when asked about the safety of these vac-cines for additional populations, the samepattern existed. Fewer pregnant womensaid the H1N1 vaccine is safe than said theseasonal influenza vaccine is safe for: (1)women who are breast-feeding (65% vs77%); (2) children aged 6 months-1 year(61% vs 75%); and (3) “generally, for most

Received H1N1 vaccine

n %

..................................................................................................................

93 44..................................................................................................................

120 40..................................................................................................................

..................................................................................................................

65 38..................................................................................................................

148 44..................................................................................................................

..................................................................................................................

125 50a

..................................................................................................................

86 33

..................................................................................................................

..................................................................................................................

144 54a

..................................................................................................................

69 28

..................................................................................................................

..................................................................................................................

110 86a

..................................................................................................................

99 27..................................................................................................................

..................................................................................................................

87 54a

..................................................................................................................

126 36

..................................................................................................................

..................................................................................................................

166 65a

..................................................................................................................

47 18

..................................................................................................................

..................................................................................................................

149 74a

..................................................................................................................

64 21..................................................................................................................

t vaccine and those who heard some, little, or nothing at all.

na n

......... .........

2......... .........

200......... .........

......... .........

1N......... .........

09 H......... .........

......... .........

om

......... .........

k fr e

......... .........

......... .........

k o 69)......... .........

nt w ill

......... .........

......... .........

ant......... .........

/not......... .........

......... .........

pro 62)......... .........

1N 1

......... .........

ovid......... .........

th c

......... .........

ir he hile

......... .........

......... .........

Se......... .........

ine......... .........

s ar abouing.

pre

people to take”(79%vs86%)(notshown).


pre


Pregnant women who believe the vac-cine is very safe for pregnant women totake are more likely to get the vaccinethan women who think the vaccine issomewhat, not very, or not at all safe(86% vs 27%) (Table 2).

Pregnant women who had not re-ceived the H1N1 vaccine most oftencited concerns about safety risks to thebaby they are expecting (62%) and tothemselves (59%) as a major reason fortheir position (Table 3).

Views of vaccine benefits for fetusA third (32%) of pregnant women knewthat getting the H1N1 vaccine whilepregnant provides protection to theirbaby against 2009 H1N1 influenza (Ta-ble 1). A majority (55%) said that theydid not know if it provides any protec-tion to their baby against 2009 H1N1 in-fluenza, and 12% did not believe that thiswas true (Table 1). Pregnant womenwho knew that the H1N1 vaccine pro-vides protection against 2009 H1N1 in-fluenza for their baby were more likelythan those who did not know or believethis to have received the H1N1 vaccine(54% vs 36%) (Table 2).

Interactions with a health care providerA majority (62%) of pregnant womendiscussed getting the H1N1 vaccine

TABLE 3Major reasons pregnant women did

Major reasons

Saying a major reason is . . ...........................................................................................................

Concern about safety risks to baby..........................................................................................................

Concern about safety risks to self..........................................................................................................

Do not think at risk of getting 2009 H1N1..........................................................................................................

Do not think would get very sick if got 200..........................................................................................................

Health care provider recommended wait o..........................................................................................................

If get H1N1, can get medication to treat it..........................................................................................................

Cannot afford to pay for 2009 H1N1 vacci...................................................................................................................

All data are weighted.

SteelFisher. H1N1 vaccine motivators and barriers among

while pregnant with their health care


provider, although a sizeable minority(38%) said they did not (Table 1). Most(80%) pregnant women who had such adiscussion received a recommendationto get the H1N1 vaccine while they arepregnant (not shown), meaning thatabout half (49%) of pregnant womenoverall received a recommendation toget the H1N1 vaccine (Table 1). About afifth of pregnant women who discussedgetting the H1N1 vaccine with theirhealth care provider said that either thepractitioner made no recommendationas to whether they should get the H1N1vaccine (14%) or recommended againstthe H1N1 vaccine during pregnancy(7%) (not shown). Pregnant womenwho received a recommendation fromtheir health care provider to get theH1N1 vaccine while they were pregnantwere more likely than those who did notreceive such a recommendation to havereceived the H1N1 vaccine (65% vs18%) (Table 2).

Few pregnant women who had not re-ceived the H1N1 vaccine said that a ma-jor reason for their decision was a re-commendation from their health careprovider to wait or not get the H1N1 vac-cine at all (11%) (Table 3).

Seasonal influenza vaccinationApproximately the same number of

ot get/were not sure about getting 2

.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

1N1.........................................................................................................................

t get it at all.........................................................................................................................

.........................................................................................................................

.........................................................................................................................

gnant women. Am J Obstet Gynecol 2011.

pregnant women reported that they had


received the seasonal influenza vaccinesince September 2009 as had received theH1N1 vaccine (39% vs 42%) (Table 1).Pregnant women who had received theseasonal influenza vaccine in this timeperiod were more likely than those whohad not done so to have received theH1N1 vaccine (74% vs 21%) (Table 2).

Differences in vaccination rates andpredictive variables across subgroupsH1N1 influenza vaccination amongpregnant women varied across demo-graphic groups (Table 4). Those whowere white and non-Hispanic, had com-pleted college or more, or were aged �35years were each more likely to have beenvaccinated against 2009 H1N1 influenzathan their relevant counterpart (50% vs28%, 54% vs 33%, and 58% vs 38%,respectively).

Pregnant women in racial/ethnic mi-nority groups were more likely thanwhite pregnant women to be concernedabout getting 2009 H1N1 influenza(42% vs 29%) (Table 4). However, theywere less likely to receive a recommenda-tion to get the vaccine from their healthcare provider (37% vs 57%).

Compared to women with more edu-cation, women with less education wereless likely to believe that: (1) pregnantwomen (generally) are at greater risk of

H1N1 vaccine for themselves

mong pregnant women who said they willot or were not sure about trying to get1N1 vaccine for themselves by end ofarch 2010 (n � 260)

%

..................................................................................................................

61 62..................................................................................................................

52 59..................................................................................................................

40 15..................................................................................................................

39 15..................................................................................................................

28 11..................................................................................................................

27 11..................................................................................................................

11 4..................................................................................................................

n 009

AnHM

n

......... .........

1......... .........

1......... .........

......... .........

9 H......... .........

r no......... .........

......... .........

ne......... .........

becoming seriously ill from 2009 H1N1


TABLE 4Vaccination rates, attitudes, and experiences of pregnant women by race/ethnicity, education, and age

Vaccination rates, attitudes,and experiences

Total

Race/ethnicity EducationAge, y

MinorityWhite,non-Hispanic <Some college

>Graduatedcollege <35 >35

(n � 514) % (n � 195) % (n � 320) % (n � 308) % (n � 206) % (n � 426) % (n � 88) %

Vaccination.......................................................................................................................................................................................................................................................................................................................................................................

Yes, got vaccine (213) 42 (55) 28 (159) 50a (101) 33 (112) 54a (162) 38 (51) 58a

.......................................................................................................................................................................................................................................................................................................................................................................

No, did not get (296) 58 (136) 70a (159) 50 (203) 66a (93) 45 (260) 61a (36) 40................................................................................................................................................................................................................................................................................................................................................................................

Amount heard about 2009 H1N1vaccine

.......................................................................................................................................................................................................................................................................................................................................................................

A lot (211) 41 (98) 51a (113) 35 (132) 43 (79) 38 (166) 39 (45) 51.......................................................................................................................................................................................................................................................................................................................................................................

Heard some, little, or nothingat all

(302) 59 (87) 49 (207) 65a (175) 57 (127) 62 (259) 61 (44) 49

................................................................................................................................................................................................................................................................................................................................................................................

Concern about self getting 2009H1N1 in next 12 mo

.......................................................................................................................................................................................................................................................................................................................................................................

Concerned (173) 34 (81) 42a (92) 29 (105) 34 (68) 33 (148) 35 (25) 29.......................................................................................................................................................................................................................................................................................................................................................................

Not concerned (337) 66 (114) 58 (224) 70 (199) 65 (138) 67 (279) 65 (59) 67................................................................................................................................................................................................................................................................................................................................................................................

Concern about baby getting 2009H1N1 in next 12 mo after baby isborn

.......................................................................................................................................................................................................................................................................................................................................................................

Concerned (249) 49 (101) 52 (148) 47 (146) 47 (103) 50 (204) 48 (45) 51.......................................................................................................................................................................................................................................................................................................................................................................

Not concerned (263) 51 (94) 48 (169) 53 (161) 52 (102) 50 (220) 52 (43) 49................................................................................................................................................................................................................................................................................................................................................................................

Belief in greater risk of becomingseriously ill from 2009 H1N1 forpregnant women

.......................................................................................................................................................................................................................................................................................................................................................................

Believe (269) 52 (97) 50 (171) 54 (136) 44 (132) 64a (220) 52 (49) 56.......................................................................................................................................................................................................................................................................................................................................................................

Do not know or do notbelieve

(246) 48 (97) 50 (148) 46 (172) 56 (74) 36 (207) 49 (39) 44

................................................................................................................................................................................................................................................................................................................................................................................

Safety of vaccine for pregnantwomen

.......................................................................................................................................................................................................................................................................................................................................................................

Very safe (131) 26 (40) 20 (91) 29 (62) 20 (69) 33a (93) 22 (38) 44a

.......................................................................................................................................................................................................................................................................................................................................................................

Somewhat/not very/not at allsafe

(372) 73 (153) 79 (219) 71 (238) 79a (139) 66 (323) 78a (49) 56

................................................................................................................................................................................................................................................................................................................................................................................

Benefit of vaccine to fetus.......................................................................................................................................................................................................................................................................................................................................................................

Believe (162) 32 (67) 34 (95) 30 (75) 24 (87) 42a (132) 31 (30) 34.......................................................................................................................................................................................................................................................................................................................................................................

Do not believe or are notsure

(344) 67 (126) 65 (217) 68 (226) 73 (119) 57 (286) 67 (57) 65

................................................................................................................................................................................................................................................................................................................................................................................

Recommendation from healthcare provider to get 2009 H1N1vaccine while pregnant

.......................................................................................................................................................................................................................................................................................................................................................................

Received recommendation (254) 49 (71) 37 (183) 57a (127) 41 (127) 62a (204) 48 (50) 57.......................................................................................................................................................................................................................................................................................................................................................................

Did not receiverecommendation

(260) 51 (114) 63 (137) 43 (181) 59 (79) 38 (222) 52 (39) 43

................................................................................................................................................................................................................................................................................................................................................................................

Seasonal influenza vaccination(since Sept. 2009)

.......................................................................................................................................................................................................................................................................................................................................................................

Received seasonal influenzavaccine

(202) 39 (72) 37 (130) 41 (104) 34 (98) 48a (160) 38 (42) 48

.......................................................................................................................................................................................................................................................................................................................................................................

Have not received seasonalinfluenza vaccine

(311) 61 (122) 63 (189) 59 (204) 66a (107) 52 (266) 63 (45) 51

................................................................................................................................................................................................................................................................................................................................................................................

All data are weighted.a Statistical differences at 95% significance level. All comparisons in right columns are made between paired counterparts: women in racial/ethnic minorities compared to white, non-Hispanic women

(white); women with less compared to more education; and women who are aged �35 years compared to those aged �35 years. Comparisons are made using t tests that account for weighting.

SteelFisher. H1N1 vaccine motivators and barriers among pregnant women. Am J Obstet Gynecol 2011.

Supplement to JUNE 2011 American Journal of Obstetrics & Gynecology S121

tedafsttatcbctmosmh

cntvPaadtgpd

pspiesidtemtsspttbcmeh

iftwqtpnmitp


influenza (44% vs 64%); (2) the H1N1vaccine provides protection against 2009H1N1 influenza for their baby (24% vs42%); or (3) the vaccine is very safe forpregnant women (20% vs 33%). Womenwith less education were also less likely tohave received a recommendation for theH1N1 vaccine from a provider (41% vs62%) and less likely to have receivedthe seasonal influenza vaccine (34% vs48%).

Older pregnant women were signifi-cantly more likely than younger preg-nant women to believe the vaccine is verysafe for pregnant women (44% vs 22%).

CommentMore pregnant women received theH1N1 vaccine this year than have re-ceived seasonal influenza vaccine in pastyears. The overall estimate of 42% in thispoll is consistent with H1N1 vaccinationrates seen in other studies of pregnantwomen (38%,29 44%,30 and 46.6%31).This suggests pregnant women’s reac-tions to the pandemic influenza were dif-ferent than their reactions to seasonal in-fluenza, and they were more motivatedto get the vaccine. Nonetheless, a major-ity of pregnant women did not get vacci-nated, and thus barriers remain thatmust be addressed in the case of a futurepandemic.

Data from this study confirm that justknowing the H1N1 vaccine is recom-mended or hearing more about the vac-cine itself is not enough to motivatemany pregnant women to get the H1N1vaccine, even in the case of a pandemic.The data also suggest, however, that spe-cific messages, including those focusedon the risks of the illness and the benefitsof the vaccine to the baby, as opposed tothe mother, may be compelling. Con-versely, concern about vaccine safety isa persistent barrier to vaccination in apandemic. There is little research to ex-plain the ways in which such attitudes areformed, and so additional study in thisarea may be needed to address concernsappropriately.

Analyses here also support the ideathat receiving a recommendation from ahealth care provider is a motivator forpregnant women to get vaccinated
against a pandemic strain.32-35 It may a

herefore be important to continue toncourage obstetricians and midwives toiscuss vaccination with their patients,s well as to provide clinicians with in-ormation about the effectiveness andafety of vaccines for their pregnant pa-ients. Messages to clinicians may be par-icularly effective if they also have a par-llel focus on the benefits of the vaccineo the baby since other research suggestslinicians may also be unaware of theseenefits.15 For women who are not in theare of a health care provider, such ashose in very early stages of pregnancy, it

ay be helpful to reach out throughther channels, like World Wide Webites, with more broadly scripted recom-

endations from spokespeople who areealth care providers.Finally, the data here reinforce a con-

ern that women in racial/ethnic mi-ority groups and those with less educa-

ion may be at greater risk for not beingaccinated against a pandemic strain.regnant women who are younger maylso be at greater risk for this. Motivatorsnd barriers for these groups appear toiffer, so messages and outreach stra-egies need to complement differentroups’ needs through targeted ap-roaches in future vaccination effortsuring a pandemic.There are limitations to this study that

revent us from exploring additional is-ues of interest. First, although the sam-le size is larger than in many other stud-

es of pregnant women, it is too small toxplore the experiences and beliefs of keyubgroups of pregnant women, includ-ng racial and ethnic groups, in moreepth using multivariate analyses, andhere is limited power to detect differ-nces that may exist between some esti-ates that were found to not differ in

hese data. Further, the data are cross-ectional, and thus, the cross-tabulationshow associations between attitudes, ex-eriences, and vaccination rates ratherhan causal relationships. In addition,he data concerning vaccination areased on participant interviews withoutonfirmation by medical record, whichay have resulted in recall bias; how-

ver, it is not clear that such bias wouldave been systematically associated with
ny attitudinal, demographic, or behav-

oral variables and resulted in con-ounded relationships. Finally, there ishe potential for nonresponse bias, asell as biases due to specific wording ofuestions and the order in which ques-ions were asked. These data, however,rovide important insights into preg-ant women’s views and suggest key ele-ents for consideration when attempt-

ng to increase vaccination rates amonghis target group with respect to futureandemic strains. f

ACKNOWLEDGMENTSWe are grateful for the assistance of severalpeople who facilitated the development of thismanuscript, including: Juliette Kendrick, MD,FACFP; William Pollard, PhD; Capt Kitty McFar-lane, CMN, MPH; and Patricia Mersereau, RN,MN, CPNP, at the Centers for Disease Controland Prevention; as well as Johanna Mailhot,MSc, at the Harvard Opinion Research Programat the Harvard School of Public Health.

REFERENCES1. Siston AM, Rasmussen SA, Honein MA, et al.Pandemic 2009 influenza A(H1N1) virus illnessamong pregnant women in the United States.JAMA 2010;303:1517-25.2. Harris JW. Influenza occurring in pregnantwomen: a statistical study of thirteen hundredand fifty cases. JAMA 1919;72:978-80.3. Freeman DW, Barno A. Deaths from Asianinfluenza associated with pregnancy. Am J Ob-stet Gynecol 1959;78:1172-5.4. Greenberg M, Jacobziner H, Pakter J, WeislBA. Maternal mortality in the epidemic of Asianinfluenza, New York City, 1957. Am J ObstetGynecol 1958;76:897-902.5. Naleway AL, Smith WJ, Mullooly JP. Deliver-ing influenza vaccine to pregnant women. Epi-demiol Rev 2006;28:47-53.6. Bridges CB, Fukuda K, Cox NJ, SingletonJA. Prevention and control of influenza: recom-mendations of the Advisory Committee on Im-munization Practices (ACIP). MMWR MorbMortal Wkly Rep 2001;50:1-44.7. National Center for Immunization and Respi-ratory Diseases, Centers for Disease Controland Prevention. Use of influenza A (H1N1) 2009monovalent vaccine: recommendations of theAdvisory Committee on Immunization Practices(ACIP), 2009. MMWR Morb Mortal Wkly Rep2009;58:1-8.8. Fiore AE, Uyeki TM, Broder K, et al. Preven-tion and control of influenza with vaccines: rec-ommendations of the Advisory Committee onImmunization Practices (ACIP), 2010. MMWRRecomm Rep 2010;59:1-62.9. Mitchell EW. Maternal communication duringthe 2009 H1N1 response. Presented at: Pan-demic influenza revisited: special consider-
ations for pregnant women and newborn. Cen-

c2Cvb

23Iip3smeeG3Ids


ters for Disease Control and Prevention and theAssociation of Maternal and Child Health Pro-grams; Atlanta, GA: Aug. 12, 2010.10. Centers for Disease Control and Preven-tion. Self-reported influenza vaccination cover-age trends 1989-2003 among adults by agegroup, risk group, race/ethnicity, health-careworker status, and pregnancy status, UnitedStates, National Health Interview Survey (NHIS)[Table]. Available at: http://www.cdc.gov/flu/professionals/vaccination/pdf/vaccinetrend.pdf.Accessed Nov. 8, 2010.11. Yeager DP, Toy EC, Baker B. Influenza vac-cination in pregnancy. Am J Perinatol 1999;16:283-6.12. Munoz FM, Englund JA. Vaccines in preg-nancy. Infect Dis Clin North Am 2001;15:253-71.13. Yudin MH, Salaripour M, Sgro MD. Preg-nant women’s knowledge of influenza and theuse and safety of the influenza vaccine duringpregnancy. J Obstet Gynaecol Can 2009;31:120-5.14. Silverman NS, Greif A. Influenza vaccinationduring pregnancy: patients’ and physicians’ at-titudes. J Reprod Med 2001;46:989-94.15. Singleton JA, Santibanez TA, Wortley PM.Influenza and pneumococcal vaccination ofadults aged �65: racial/ethnic differences.Am J Prev Med 2005;29:412-20.16. Lu P, Bridges CB, Euler GL, Singleton JA.Influenza vaccination of recommended adultpopulations, US, 1989-2005. Vaccine 2008;26:1786-93.17. Link MW, Ahluwalia IB, Euler GL, BridgesCB, Chu SY, Wortley PM. Racial and ethnicdisparities in influenza vaccination coverageamong adults during the 2004-2005 season.Am J Epidemiol 2006;163:571-8.18. Linn ST, Guralnik JM, Patel KV. Disparitiesin influenza vaccine coverage in the UnitedStates, 2008. J Am Geriatr Soc 2010;58:1333-40.19. Byrant AS, Worjoloh A, Caughey AB, Wash-
ington AE. Racial/ethnic disparities in obstetric A
outcomes and care: prevalence and determi-nants. Am J Obstet Gynecol 2010;202:335-43.20. Lindley MC, Wortley PM, Winston CA,Bardenheier BH. The role of attitudes in under-standing disparities in adult influenza vacci-nation. Am J Prev Med 2006;31:281-5.21. Centers for Disease Control and Preven-tion. Reasons reported by Medicare beneficia-ries for not receiving influenza and pneumococ-cal vaccinations–United States, 1996. MMWRMorb Mortal Wkly Rep 1999;48:886-90.22. Hebert PL, Frick KD, Kane RL, McBean AM.The causes of racial and ethnic differences ininfluenza vaccination rates among elderly Medi-care beneficiaries. Health Serv Res 2005;40:517-37.23. Department of Health and Human Services.Healthy people 2010, conference edition.Available at: http://www.healthypeople.gov/document/HTML/Volume2/16MICH.htm#_Toc494699663. Accessed Nov. 8, 2010.24. Luke B, Brown MB. Elevated risks of preg-nancy complications and adverse outcomeswith increasing maternal age. Hum Reprod2007;22:1264-72.25. Jamieson DJ, Honein MA, Rasmussen SA,et al. Novel influenza A (H1N1) pregnancy work-ing group. H1N1 2009 influenza virus infectionduring pregnancy in the USA. Lancet 2009;374:451-8.26. Callaghan WM, Rasmussen SA, JamiesonDJ, et al. Health concerns of women and infantsin times of natural disasters: lessons learnedfrom hurricane Katrina. Matern Child Health J2007;11:307-11.27. Martin JA, Hamilton BE, Sutton PD, et al.Births: final data for 2007, national vital statisticsreports. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_24.pdf. Ac-essed Nov. 5, 2010.8. Yeager DS, Krosnick JA, Chang LC, et al.omparing the accuracy of RDD telephone sur-eys and Internet surveys conducted with proba-ility and non-probability samples. August 2009.
vailable at: http://www.knowledgenetworks. 3

com/insights/docs/Mode-04_2.pdf. AccessedNov. 8, 2010.29. Singleton JA, Santibanez TA, Lu PJ, et al.Interim results: influenza A (H1N1) 2009 mon-ovalent vaccination coverage–United States,October-December 2009. MMWR Morb MortalWkly Rep 2010;59:44-8.30. Singleton JA. Who got the H1N1 vaccine?Findings from the US 2009-2010 influenza vac-cination surveillance systems. Available at: http://cdc.confex.com/cdc/nic2010/webprogram/Session10675.html. Accessed Nov. 12, 2010.31. Ahluwalia IB, Jamieson DJ, D’Angelo DV, etal. Seasonal influenza and 2009 H1N1 influenzavaccination coverage among pregnant wo-men–10 states, 2009-10 influenza season.MMWR Morb Mortal Wkly Rep 2010;59:1541-5.32. National Women’s Health Resource Cen-ter. New survey shows pregnant women un-aware, misinformed about flu shot benefitsduring pregnancy. Available at: http://www.healthywomen.org/content/press-release/new-survey-shows-pregnant-women-unaware-misinformed-about-flu-shot-benefits-du?context�press-release/2008&context_title�Views&context_description�. Accessed Sept. 16,010.3. Ogbum T, Espey EL, Contreras V, Arroyo P.

mpact of clinical interventions on the rate ofnfluenza vaccination in pregnant women. J Re-rod Med 2007;52:753-6.4. Tong A, Biringer A, Ofner-Agostini M, Up-hur R, McGeer A. A cross-sectional study ofaternity care providers’ and women’s knowl-

dge, attitudes, and behaviors towards influ-nza vaccination during pregnancy. J Obstetynaecol Can 2008;30:404-10.5. Wallis DH, Chin JL, Sur DK, Lee MY.ncreasing rates of influenza vaccinationuring pregnancy: a multisite interventionaltudy. J Am Board Fam Med 2006;19:
45-9.

http://www.cdc.gov/flu/professionals/vaccination/pdf/vaccinetrend.pdf

http://www.cdc.gov/flu/professionals/vaccination/pdf/vaccinetrend.pdf

http://www.healthypeople.gov/document/HTML/Volume2/16MICH.htm%23_Toc494699663



http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_24.pdf

http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_24.pdf

http://www.knowledgenetworks.com/insights/docs/Mode-04_2.pdf

http://www.knowledgenetworks.com/insights/docs/Mode-04_2.pdf

http://cdc.confex.com/cdc/nic2010/webprogram/Session10675.html



http://www.healthywomen.org/content/press-release/new-survey-shows-pregnant-women-unaware-misinformed-about-flu-shot-benefits-du?context=press-release/2008%26context_title=Views%26context_description=






Documents

Novel pandemic A (H1N1) influenza vaccination among pregnant women: motivators and barriers