Vaccine Hesitancy in Pregnant Women: A Narrative Review

"It is important for providers to have effective vaccine strategies to address patients' concerns about vaccination as they fluctuate between different levels of vaccine hesitancy or resistance."

Vaccine hesitancy in pregnancy is a unique issue, as a pregnant mother may view concern for vaccination through either a parental lens (having concern for a vaccine's impact on the health of the unborn baby) or through a personal lens (having concern for the vaccine's impact on her own health). This narrative review describes vaccine hesitancy as a multifactorial problem that both the medical and public health systems need to address synergistically. It addresses 4 questions: (i) What are the primary concerns of pregnant women that lead them to be hesitant about receiving vaccinations? (ii) To what extent does the source (e.g., provider, friend, family) of vaccine advice and information influence a pregnant person's decision to accept a vaccine? (iii) How does the delivery method of vaccine education influence their decision? (iv) How can categorising patients into 4 distinct groups based on their opinions and behaviour regarding vaccines be used to improve provider-patient communication and increase vaccine acceptance?

A structured search of the literature was conducted across 3 databases (PubMed, Web of Science, and CinHAL), using the search terms "vaccine acceptance" AND "vaccine hesitancy" AND "pregnancy". Of the 30 full-text articles that were reviewed, only 10 met inclusion criteria. Results from the literature show that the 3 most common reasons for vaccine hesitancy include: (i) fear of side effects or adverse events; (ii) lack of confidence in vaccine safety; and (iii) low perception of being at high risk of infection during pregnancy and/or not having previously received the vaccination when not pregnant. Notably, pregnant people may move between higher or lower states of vaccine hesitancy based on their personal experiences, previous pregnancy experiences, vaccine education, and their current pregnancy.

The literature suggests that sources of vaccine information for a pregnant women (healthcare providers, family, spouse, friends, internet, healthcare pamphlet) had the greatest influence on a hesitant person's willingness to accept a vaccine. The method (verbal counseling, a written handout, a video) in which the vaccine education was delivered, while important, was less influential in swaying a hesitant pregnant woman to receive a vaccine.

In light of the dynamic nature of vaccine hesitancy in pregnancy, the researchers propose a 4-group framework to guide clinicians in vaccination counseling efforts:

1. People who would identify with group 1 would classify themselves as "never willingly accept the provider recommended vaccination while not pregnant and therefore they won't accept the provider recommended vaccination while pregnant." The researchers recommend these patients be offered vaccines, be given access to information, and, if they express willingness to engage, be counseled on the pros and cons of being vaccinated while pregnant. However, providers should not alienate these patients and possibly harm the patient-provider trust necessary to deliver counseling on the many other recommendations to improve pregnancy outcomes (e.g., diet, exercise, substance use, weight gain).
2. People who identify with group 2 would "always accept provider recommended vaccinations while not pregnant but would be hesitant to accept the provider recommended vaccine during pregnancy". The researchers suggest that counseling for these patients focus on safety for and benefit to the baby.
3. People who identify with group 3 would "not accept the provider recommended vaccine while not pregnant but would be willing to accept provider recommended vaccine during pregnancy" because there is understanding that accepting the vaccine while pregnant provides protection to the fetus. Patients in this category need access to vaccines and reminders but do not require substantial counseling.
4. People who identify with group 4 would "always accept provider recommended vaccinations while not pregnant and therefore will always accept provider recommended vaccination while pregnant." The recommendation for this group is similar to group 3.

"Using this framework for patient-provider education facilitates tailoring vaccine education specific to a person's current state of hesitancy or acceptance and adapt the education as the levels of hesitancy vary over time. This not only avoids any racial or political biases held by the provider, but also allows providers to understand reasons for vaccine hesitancy or refusal....This framework to deliver vaccine information can be a tool to help providers find balance between promoting individual health and public health while providing vaccine education."