Healthcare workers’ attitudes about vaccination of pregnant women and those wishing to become pregnant

The novel coronavirus disease (COVID‐19) outbreak has disrupted life globally reaching more than 200 million cases in August 2021 and nearly 4.5 million deaths [1, 2]. Epidemiologic studies suggest that the impact of the accompanying acute respiratory distress syndrome in pregnant women seems is accompanied by significant morbidity including risk of intubation, ICU admission, preterm birth and maternal mortality [3, 4]. Specifically, it seems that although pregnant women are less likely to present with symptoms such as fever, dyspnea, and myalgia, compared to the general population they have more than double the risk of being admitted to the NICU as well as 2.5 times the risk of requiring mechanical ventilation [5, 6]. Despite the fact that several organizations have issued specific guidelines that point towards vaccination of pregnant women [2, 7] there seem to be concerns among women and coverage seems to be quite low [8]. This attitude may be partially driven by the abundance of misinformation on the Internet that poses constraints to the uptake of the vaccine. To avoid the spread of misinformation the World Health Organization (WHO) has published an interim recommendation that specifically states that there is no need for pregnancy testing prior to vaccination, nor the need for delaying pregnancy because of vaccination [9].

On the other hand, maternal compliance with immunization protocols has been already documented [10]. However, it seems to be directly affected by physician compliance about their benefits in terms of reducing maternal and neonatal morbidity [10]. Previous studies addressing the issue of influenza vaccination in pregnant women have shown that the majority of patients perceives vaccination as riskier compared to the disease itself [11]. Positive physicians, attitude and appropriate guidance based on international recommendations can reverse this misperception. However, it seems that the various professions involved in healthcare seem to differ in terms of vaccine acceptability; therefore, implying a potential differential approach on the likelihood of vaccination of pregnant women as well as those that wish to conceive within the next few months [12].

To date, physicians’ and healthworkers’ perception about vaccination of pregnant women against COVID-19 is scarcely reported and it seems that a considerably minority of the sum of healthcare professionals seems to doubt about the benefits of vaccination during pregnancy [13]. This is driven by several reports that seem to argue the actual influence of the infection on maternal and neonatal pregnancy outcomes [14].

Taking this into consideration we conducted an anonymous electronic survey to evaluate this as well as to document their experience of womens’ attitudes to COVID-19 vaccination. The survey was distributed in May 2021 following notification about the benefits of vaccination in pregnant women. The study was approved by the institutional review board of Alexandra University Hospital of the National and Kapodistrian University of Athens. Healthcare workers agreed to participate in the present study.

Statistical analysis was performed in IBM SPSS (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp.). The normality of distribution was evaluated using the Kolmogorov Smirnov and graphical methods. Univariate and multivariate analyses were performed to evaluate the impact of health worker characteristics on the likelihood of suggesting the vaccination in pregnant women as well as women that wish to conceive naturally or with assisted reproduction.

Overall, 5.654 electronic mails were sent between May and July 2021 and 1,226 answers were retrieved (21.7% response rate). Of the sum of respondents, 504 were obstetricians, 214 midwifes and 176 pediatricians (Supplementary Material). Approximately 60% of them had either a Master of Science or a PhD, indicating a high level of education. The majority (58%) was involved in healthcare for more than 10 years. Approximately 80% of them prescribe the influenza and pertussis vaccine in pregnant women, indicating a high compliance with national standards on immunization of pregnant women. Ninety percent of respondents replied that they prescribe COVID-19 vaccination in women that wish to conceive, however, the rate falls to 80% for those that have schedules for imminent artificial reproductive techniques. Most respondents preferred to suggest vaccination with the mRNA vaccines (Supplementary Material).

Similar results were reported from obstetricians and pediatricians when analyzing the results that were retrieved from this subgroup of participants (90% responded that they would recommend COVID-19 immunization in women that wish to conceive).

At least 13% of women of reproductive age and 30% of women wishing to conceive with ART declined to do so according to respondents’ report. Approximately 38% of respondents suggested that the couple could try to conceive immediately, whereas the remaining answers referred to an interval that could preferably reach even six months from immunization. Approximately 1 in 2 physicians (obstetricians and pediatricians) suggests that a delay in ART is not recommended, whereas only 20% recommended an interval of 3–5 months.

Only 75% of respondents favored immunization during pregnancy and of those 48% responded that vaccination could be done in all trimesters of pregnancy. Approximately 40% of women decline; however, to receive vaccination. The mRNA vaccines were preferred from respondents. Of those that responded against vaccination of pregnant women the majority responded that they did so due to the increased risk of thrombosis and antenatal pathology. Five to 10% of them would suggest prenatal screening with one of the following methods: (i) non-invasive prenatal testing, (ii) chorionic villus sampling, (iii) amniocentesis or (iv) fetal cardiac ultrasound to ascertain normal pregnancy.

Following analysis (Tables 1 and 2) of the various factors that could potentially affect healthcare providers’ perception about vaccination of women that wish to conceive as well as of pregnant women, we observed that the most predominant factors of not suggesting vaccination were non-medical, non-midwife/nurse profession, non-involvement in higher education (MSc or PhD studies) as well as lack of adherence of guidelines for vaccination of pregnant women against seasonal flu and pertussis. Healthcare providers that were not vaccinated against COVID-19 were also less likely to suggest vaccination in both women that wish to conceive as well as pregnant women.

The findings of our study suggest that acceptance of vaccination of women that wish to conceive is high among healthworkers and even higher among obstetricians and pediatricians. However, there seems to be a moderate reluctance towards suggesting immunization of pregnant women and especially when it comes to vaccination during the first trimester of pregnancy. Several factors seem to influence the decision to recommend vaccination, including the level of education as well as the lack of adherence to current recommendations for vaccination of pregnant women against seasonal flu and pertussis. Taking this into consideration, we believe that further actions are needed to increase compliance of both groups, as evidence-informed recommendations will strengthen both the demand and delivery of vaccines.