Strategies physicians reported as always or often used by more than half of health care providers when encountering a pregnant woman refusing a vaccine included stating confidence that it is safe to receive vaccines in pregnancy (96%), explaining that not getting the vaccine puts the fetus or newborn at risk (90%), explaining that not getting the vaccine puts the pregnant woman's health at risk (84%), discussing outbreaks of vaccine-preventable diseases (72%), informing the patient that not getting the vaccine is against the health care provider's recommendation (64%), and stating that they personally would get the vaccine or give it to a family member if pregnant (53%) (Table 3). In general, most of these strategies were perceived by a majority of physicians as “somewhat effective” at convincing a pregnant woman who has refused vaccination to choose to be vaccinated. The only strategy that stood out as being perceived as “very effective” by a substantial proportion of physicians (40%) was explaining that not getting the vaccine puts the fetus or newborn at risk.
Almost all ob-gyns strongly agreed that they were comfortable discussing influenza and Tdap vaccines with pregnant patients (98% and 96%, respectively). Fewer, however, agreed that they were comfortable addressing questions or concerns about the infant series of vaccines (18% strongly agree, 31% somewhat agree, 34% somewhat disagree, 16% strongly disagree). The most common barriers to discussing the risks and benefits of vaccines with pregnant women were other health issues taking precedence and the amount of time it takes (Fig. 4). The only other barrier endorsed as “major” or “somewhat” by more than 10% of respondents was “my belief that I am unlikely to change patients’” minds about their vaccination decision.
In this study, we provide information regarding ob-gyns' experiences with vaccine refusal among their pregnant patients and how they handle refusal. As in other recent work,22 we found few attitudinal barriers regarding vaccination among ob-gyns themselves. However, the majority of U.S. ob-gyns perceive that vaccine refusal among pregnant women is common, particularly for influenza vaccine. They report using a number of different strategies for addressing vaccine refusal, yet only one was perceived as very effective.
Although there is a large body of literature regarding parental vaccine refusal for childhood vaccines,23 few prior studies report the prevalence of vaccine refusal among pregnant women. It appears vaccine refusal among pregnant women may be more common than parental refusal of childhood vaccines. In a study of pediatricians and family physicians, 8% of physicians reported parental refusals of vaccination for 10% or greater of the children they care for.24 In this study, 62% of ob-gyns reported influenza vaccine refusals for 10% or greater of pregnant women and 32% reported Tdap refusals for 10% or greater. The Centers for Disease Control and Prevention indirectly reports influenza and Tdap vaccine refusal among pregnant women.25,26 Among pregnant women who received both a recommendation and an offer for influenza vaccine, in the 2016–2017 season, 70.5% reported being vaccinated, implying 29.5% refused, consistent with our data.25 For Tdap, among pregnant women who received both a recommendation and an offer, 69.9% reported vaccination, implying 30.1% refused,26 slightly higher than estimates based on our data. In either case, the conclusion is the same: vaccine refusal among pregnant women is common for both Tdap and influenza vaccines.
Perceived reasons for vaccine refusal among pregnant women include common misconceptions such as believing influenza vaccine makes them sick, but also included some findings not previously described such as the concern their child may develop autism. The possibility that childhood vaccines are associated with autism is perhaps the best studied safety question in the history of vaccination, and the findings are resoundingly clear that vaccines do not cause autism.27 Our finding that fears about autism are linked with vaccination refusal among pregnant women underscores the profound effect that safety information on vaccines, even if erroneous, influences the decisions of pregnant women.
The perceived effectiveness of strategies to address vaccine refusal was low with almost all strategies being endorsed as “very effective” by less than 20% of respondents, with one exception: 40% of ob-gyns reported that stressing a potential threat to the fetus or newborn by not vaccinating was “very effective” at convincing a woman who had refused vaccination to be vaccinated. In prior work with pediatricians and family physicians, no strategy examined was deemed “very effective” by more than 20% of respondents.28 Further work in this area should explore the vaccination decision-making process from the unique perspective of pregnant women.
Although the focus of this article is on vaccine refusal, we also report on use of standing orders, which are among the most effective evidence-based strategies for increasing vaccination uptake.29 In addition to increasing vaccination coverage and efficiency, standing orders may overcome attitudinal barriers. Although we know little about which communication techniques increase uptake of vaccines, science in other areas shows that “nudges” are often effective at overcoming attitudinal resistance to a desired behavior.29 Previous work has demonstrated the importance of social norms in the vaccination decision.30 Standing orders are a clear example of emphasis of a social norm by sending the message to both health care professionals and patients that vaccination is the default option. The barriers to use of standing orders are surmountable: for example, patients who prefer to speak with the health care provider before vaccination may still do so. Implementation of standing orders may reduce staff discomfort with answering questions and lead to better job satisfaction.29
There are strengths and limitations to this study. It was performed in a nationally representative sample of ob-gyns with a high response rate. Respondents' attitudes and practices, however, may have differed from nonrespondents, and the ob-gyns in our survey network may differ from ob-gyns overall, although prior work suggests not.19 Finally, this study examined reported practices and perceptions; actual practices were not observed.
Ob-gyns perceive vaccine refusal as common among pregnant women and report they spend significant time discussing vaccine concerns with pregnant patients. Ob-gyns perceive that emphasizing the importance of vaccination to protect the fetus or newborn as an effective strategy for addressing vaccine refusal. Future work should focus on testing evidence-based strategies for addressing vaccine refusal in the obstetric setting and understanding how the unique concerns of pregnant women influence the effectiveness of such strategies.
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