Midwives' Attitudes, Beliefs and Concerns about Childhood Vaccination: A Review of the Global Literature

"Vaccine hesitancy among midwives has been recorded anecdotally in a number of settings...and in the media..."

Studies indicate that many parents make childhood vaccination decisions during pregnancy, highlighting the importance of midwives in this process. This international literature review describes the attitudes and communication practices of midwives in developed countries towards childhood vaccines. The intent is to inform the development of resources tailored to the midwifery model of care, supporting midwives in advocating for childhood vaccination.

Across the 9 studies - both quantitative and qualitative - included in the review, 5 themes were identified:

1. Overall support for vaccination - Midwives' support for vaccination varied in different settings, but, across the studies, the majority of midwives supported vaccination. Apparent variations might be partly explained by the different jurisdictions included in the review. In some settings, like Australia and New Zealand, midwifery-centred care is mainstream, with midwives leading the majority of antenatal care. This potentially explains the predominantly vaccine supportive views in those settings.
2. Perception of scientific support for vaccination - Midwives' reservations about the level of scientific justification for vaccination were often centred on what is not yet known, rather than mistrust of the current evidence.
3. Vaccines and the perception of safety/danger - Most midwives felt that vaccines were safe; a minority were unsure, or believed they were unsafe. There were 3 aspects to vaccination that emerged in the theme of danger: the number of vaccines, administration of vaccines early in life, and vaccine ingredients. These translated into certain beliefs about how danger might manifest, with prevalence explored in the quantitative studies.
4. Necessity of vaccination - The majority of midwives agreed that childhood vaccines are necessary. Among those who expressed doubt, a commonly held opinion was that vaccine-preventable diseases such as measles are relatively benign and do not warrant vaccination against them.
5. The midwifery model of care - The philosophy of midwifery professional practice is based on the principles of informed choice, empowerment, and engagement - with birth as a natural process. This approach prioritises individual decision-making over broadly applicable rules and recommendations. Viewing vaccination in this way may lead to an individualised approach to risk, which can have ramifications for the broader public health aspects of vaccination. For example, midwives in a Quebec, Canada, study emphasised conscious and informed choice, as well as their willingness to accept vaccine refusal if it appeared reasoned. An Australian qualitative study pointed to a dearth of discussion between midwives and their patients on the possible public health implications of the individual choice not to vaccinate. The Quebec midwives also emphasised the need to maintain the relationship with the birthing mother if she chose not to vaccinate.

The findings suggest the possibility for further research. For example, midwifery's emphasis on freedom of choice aligns with what is known about vaccine-hesitant parents, which raises the question of whether these parents are more likely to seek antenatal care from midwives with similar philosophies. According to the researchers, there is a need to further study midwives as an information source, and identify the types of parents who choose midwife-led births and link this to vaccine uptake.

Furthermore, the fact that the researchers were unable to identify research on existing communication interventions designed for midwives signals a potential gap in the available resources. Two studies proposed interventions from their findings. One found that midwives rated professional training, reading, and personal experience most influential on their attitudes, and so this study suggested collegial and work-based settings for midwives' continuing education. The researchers of the present study add that such training would be most effective if it explicitly engaged with midwifery professional practice and identity and emphasised the individual benefits of vaccination to the newborn.