Mapping the maternal vaccination journey and influencing factors for Māori women in Aotearoa New Zealand: a qualitative study

Keywords: access to medicines, health equity, healthcare professionals, Indigenous population, influenza vaccination, Māori, maternal vaccination, midwifery, pertussis vaccination, vaccine hesitancy.

Pertussis (whooping cough) and influenza vaccinations during pregnancy are recommended and funded in Aotearoa New Zealand (NZ).¹ Pertussis causes hospitalisations and deaths of young infants,^2,3 disproportionately affecting Māori infants.² A tetanus–diphtheria–acellular pertussis (Tdap) vaccination during pregnancy protects young infants.⁴

Increased influenza-associated mortality and hospitalisations,⁵ and adverse foetal outcomes are associated with influenza during pregnancy,⁶ disproportionately affecting Māori.⁵ Maternal influenza vaccination is associated with reduced risk of influenza infection⁷ and influenza-associated hospitalisation of pregnant women⁸ and infants.⁹

Uptake of maternal pertussis and influenza vaccinations is low in NZ (48 and 31%, respectively in 2018), particularly in Māori.¹⁰

In NZ, most women enrol with a general practice for primary health care, which provides a free antenatal consultation. A lead maternity carer (LMC; usually a self-employed midwife) typically provides care during pregnancy and childbirth and to young infants. Primary maternity care is fully funded; private specialists have a patient charge.¹¹ Maternal vaccinations are typically not provided by midwives for logistical reasons,¹² but are fully funded in general practice, hospitals and, more recently, in pharmacy (influenza nationally and pertussis only in Waikato, Aotearoa New Zealand).

Non-uptake of maternal pertussis vaccination in NZ arises from lack of awareness, safety or effectiveness concerns, or discouragement from healthcare professionals (HCPs).^13,14 Significant health inequities exist for Māori, with health services less accessible for Māori, and many Māori finding public health services ‘hostile and alienating’.¹⁵ Factors underpinning inequitable maternal health in Aotearoa New Zealand are cultural factors, geographical access, political context, inequitable maternal health, colonialism, acceptability and the maternity care system.¹⁶

Despite Māori women preferring Māori midwives,¹⁶ and comprising about 20% of those giving birth,¹⁷ Māori midwives comprise only 10% of the midwifery workforce, with concerns about being under-resourced and at risk of burn-out, and insufficient use of Māori research to inform midwifery activities.¹⁸ Government support in 2021 aimed to increase Māori and Pacific midwifery numbers.¹⁷ Increasingly, Hapū Wānanga, a free kaupapa Māori antenatal educational service for Māori hapū māmā (pregnant women), is being offered around Aotearoa New Zealand.

With a lower uptake of MVs in Māori¹⁹ and disproportionally greater hospitalisation for Māori infants with pertussis,² research is needed to help address deficiencies in the system and maximise the use of enablers, increasing uptake for Māori and subsequently reducing incidence and harms of a vaccine-preventable disease in Māori infants. Therefore, we aimed to describe the Māori woman’s journey regarding MVs and ascertain facilitators and barriers to uptake.

The NZ Ministry of Health Northern B Health and Disability Ethics Committee granted ethical approval (18/NTB/43).

The Waikato District Health Board (DHB) includes over 426 000 people,²⁰ 58% living in urban areas.

As part of a larger study exploring the effects of funding and promoting MVs through pharmacies,²¹ and barriers and enablers to MVs, this manuscript analyses interviews from nine Māori women and nine Māori HCPs for Māori women’s journey to having MVs. Eligible participants were women aged ≥16 years who were pregnant or had a young infant; and midwives, community pharmacists and general practice staff. Whānau were welcome to join for the interview.

Using maximal variation,²² we selected women with variation in age, geographical location, MV status, place of vaccination and number of previous pregnancies. Four women were recruited and interviewed at a small-town pharmacy where the interviewer worked, and five at an extended hours city pharmacy with a large catchment. The NZ College of Midwives and snowballing aided midwife recruitment. The Māori HCPs comprised five midwives, a practice nurse, a general practitioner, a pharmacist, and a practice manager. Three participants worked in practices with a Māori focus and predominantly Māori clientele.

Following informed consent, semi-structured interviews were conducted face-to-face (kanohi ki te kanohi) in a private room (all women’s interviews) or face-to-face or by telephone (HCPs) between November 2018 and May 2019. Key topic discussions were awareness of and knowledge about MV during pregnancy, pertussis and influenza diseases, the woman’s journey to having MVs, barriers and enablers to MVs, and demographics (Supplementary File S1). A koha (a New Zealand Māori custom that can be translated as a gift, present, offering, donation or contribution) of a NZ$30 voucher was provided to participants after all interviews.

Interviews were audio-recorded, transcribed verbatim, checked, then coded by NG using NVIVO Pro (QSR International). Audio files were deleted after transcripts were checked, and the transcriptionist deleted all files. NG had access to all audio files and transcripts, and SM had access to the Māori wāhine interview audio files and transcripts. Files were stored on a password-controlled computer. Coding nodes included specific topics asked about in the interview (eg enablers and barriers (deduction) and emerging themes (induction, not reported here)). Analysis was qualitative descriptive, and involved mapping the journey and systematically working through all barriers and enablers in the coding nodes, looking for differences and similarities between interviews (between women, and between the women and the HCPs), using a deductive approach and qualitative description. The journey is described below, with barriers and enablers discussed as they affected the journey. Reporting specifies the vaccination (ie pertussis or influenza) when specifically mentioned.

Following training (face-to-face with the first author, and going through an interview together), the second author, a male Māori pharmacist, interviewed the women using an interview guide, receiving feedback following initial interviews. An experienced interviewer, a female NZ European pharmacist (the first author), conducted HCP interviews, coded all transcripts, conducted analysis, and reported findings. These findings were reviewed by SM and OS before being finalised.

Interviews took 10–23 min (average 16 min) with each of the nine Māori women and 19–52 min (average 34 min) with each of the nine Māori HCPs. The characteristics of the Māori women participants (Table 1) and Māori HCP participants (Table 2) are presented below.

Table 1.  Characteristics of Māori women participants.

Table 2.  Characteristics of Māori healthcare provider participants.

Fig. 1 shows the participants’ vaccination/non-vaccination journeys for pertussis and influenza MVs. Most women indicated MV awareness came verbally from a HCP (some had multiple HCPs mention it, one recalled no mentions), but not from family or friends.

Fig. 1.  The woman’s journey to receiving a maternal vaccination based on Māori women participants’ interviews. The weighting of lines reflects the number of participants mentioning these. The bracketed numbers indicate how many women had them. 3 + 1 indicates three women who received maternal vaccination/s in general practice and one expecting to.

Women decided their MV actions, apparently influenced primarily by their beliefs, knowledge, perception of personal risk and HCP information or emphasis. MV posters, pamphlets or information online appeared unimportant for awareness or decisions.

Women frequently mentioned HCPs’ influence, particularly midwives, primarily raising awareness, and therefore enabling uptake (Table 3).

… [my midwife] gave a lot of information. (W14)

Sometimes influenza vaccination uptake was affected by the HCP’s lack of emphasis. W15 heard about both MVs from the pharmacist, but only had the pertussis vaccination because ‘the hospital never said to get [influenza vaccination]’ and the pharmacist had no stock, and indicated little need in summer. Another had the pertussis vaccination on the midwife’s advice, but not influenza, indicating the midwife’s support was less for influenza: ‘…it was sort of if you want to you can, but…’.

Awareness was an important facilitator. Most women participants knew of one or both MVs (Fig. 1); however, some HCPs reported many clients had little or no awareness. A newly qualified midwife managing mainly young Māori first-time mothers, reported no awareness. The pharmacist reported many women late in pregnancy were unaware of MVs. Supporting this, W2 only became aware of MVs and had them in late pregnancy because of the pharmacist’s recommendation, despite previous pregnancies and early midwife engagement. A rural GP who discussed MV in antenatal appointments also commented on low awareness. Conversely, a midwife reported high awareness, but had mainly repeat clients and reported mentioning MVs multiple times.

A couple of midwives reported that women engaging the midwife late or missing scheduled appointments might not receive MV information (eg W3 engaging the midwife at 27 weeks’ gestation; Table 4).

Knowledge of benefits, risks, and the infection the vaccination prevented strongly influenced decisions, which linked with beliefs. Most women knew pertussis vaccination protected the baby. Others were less informed, despite HCPs mentioning MVs (Table 4). One woman knowing ‘nothing’ of MVs (first presenting to her midwife at 27 weeks), had neither MV, but wanted more information on the benefits and risks.

Yeah I would like to know a bit more about them. Like when yous do give out information out about them do yous give the good side and the bad side? (W3)

Several HCPs suggested insufficient or incorrect knowledge about safety discouraged women from having MVs (eg from rumours from whānau or online anti-vaxxers (although neither arose in women’s interviews)).

A GP and some midwives worried that overwhelming information in consultations could hinder MV information uptake. Several HCPs observed that women who were more educated or who worked in health care were often more informed and on-board with MVs, but many clients reportedly had low health literacy.

Most women reported that they sought no information about MVs, although one woman researched online, another questioned the pharmacist, and one questioned her midwife. Two women reported brief discussion with family, but none appeared to seek advice or be directly influenced by family or friends. However, some HCPs interviewed noted family sometimes influenced the decision to have vaccinations.

Trust could aid the HCPs influence. Some women spoke of trust regarding where they were vaccinated. The pharmacist reported recommending a MV had greater success with known than casual clients. A nurse and a practice manager reported Māori and their whānau (family) need to feel safe and that mistrust could be a barrier to uptake. The practice manager stressed some Māori preferred a Māori provider and suggested a need to understand the people, take time with them, and understand the person’s situation. Most participants supported pharmacy MV provision for awareness and access.

Seven women received at least one MV. Enablers and barriers affected uptake, many of which were linked (Tables 3, 4). For example, influence of HCPs was affected by trust and relationships.

Table 3.  Enablers to maternal vaccinations for Māori women.

Table 4.  Barriers to maternal vaccinations for Māori women.

Most women suggested decisions about having MVs involved minimal consultation with or influence from partners, family, or friends, as they or their partner considered it was the woman’s decision alone (‘my body, my decision’). Some women did not discuss MVs with family, friends, or their partner. Even an 18-year-old woman living with her parents and partner, did not discuss MVs with them except to mention her concern about possible pain.

Families’ or friends’ views sometimes opposed the participants’ actions. A first-time mother receiving the pertussis vaccination indicated she was uninfluenced by friends suggesting MVs were unnecessary. One participant receiving both vaccinations noted their family ‘don’t believe in getting them’. W1 had no vaccinations despite having a ‘pro-vaccination’ mother who ‘pushed it’, whereas the partner was ‘… quite open to me kind of making the decision, being my body … and… pregnancy being a new thing to him …’, recognising W1’s greater knowledge from having had a previous pregnancy.

However, one participant, her sister and mother all went together to receive the influenza vaccination. Another woman told her family and pregnant cousin about MVs to raise awareness.

Midwife M11 noted ‘Māori women are a little bit more independent’, not needing whānau input. Another midwife noted considerable variability in whānau involvement in the pregnancy, from being ‘super involved’ to having no involvement. However, a couple of HCP participants considered the whānau important given the importance of women in the Māori world and the sacred time of being hapū (pregnant), a concept that was not discussed by the women. N5 suggested Māori women would check with their whānau about MVs, because ‘…they’re making a decision for their whole whānau.’

Decisions about MVs usually appeared easy and straight-forward without women seeking information, confirmed also by several midwives.

I chose not to look up the good and bad because I feel like there’s pros and cons in both and I just made up my mind that I think they’re good. (W6)

Having MVs in previous pregnancies normalised it, making the decision easy. Participant W1 appeared influenced by previously having had no MVs.

However, one participant researched whooping cough online, and another, after hearing about MVs from the pharmacist, ‘asked all the questions right then and there’, and then had it:

… I didn’t know anything before I got the whooping cough one and the flu jab in pregnancy and … thought you couldn’t get anything while you were pregnant … and I was actually quite happy that I got it done. (W2)

An important enabler was the motivation to be vaccinated to protect the baby, particularly with pertussis.

… I was keen for it because … anything to help my baby. (W4)

Two women articulated that maternal protection from influenza would keep them well for the baby, one noting her increased risk as an asthmatic, and another reporting low immunity (Table 3). However, most focused on the baby.

… in pregnancy I was more worried about my unborn baby than myself… (W2)

Underlying beliefs regarding vaccination generally or influenza vaccination commonly influenced participants’ decisions.

I quite like being vaccinated, especially during pregnancy and for baby after baby’s born… I find it most important that my babies are vaccinated [on-time]. (W12)

Awareness of a young child affected badly by an illness motivated two participants to have a pertussis MV. Some women believed that influenza vaccination could cause influenza or make a person sick, that influenza was not serious, or they were healthy as reasons for not having influenza vaccination.

… I have some women who just say ‘I never get the flu, I’m not going to have that’ and I say ‘you really need to read the information.’ (M7)

W1 considered the vaccinations unnecessary, raising various reasons, including ‘… females were made to do it [carry a baby] I suppose.’ Similarly, the GP noted women’s concerns about over-medicalisation during pregnancy. A midwife reported most clients received no MVs (despite awareness) because their personality was to ‘actively be healthy’, and other midwives reported some women were against vaccination. W3 received no MVs believing ‘…there’s always a bad side to medicines…’. Needle phobia contributed to one participant’s decision against MVs and another to only have the pertussis vaccination.

Some women’s non-prioritisation of MVs strongly emerged from HCPs, particularly midwives. Challenges to prioritising vaccinations arose from: the busyness of pregnancy, other children, or work; chaotic lives; and/or poverty (eg transportation and housing insecurity). HCPs observed some women would struggle booking a vaccination appointment or finding which pharmacies provided vaccinations, making access difficult where there were challenges to prioritising maternal vaccination.

… it’s hard enough to make an appointment with the GP… let alone make time to get there… and if they’re not employed they often don’t have the resources to get… to the GP. (M9)

They ring me ‘Oh I’m pregnant again, having a baby in a couple of months…’… they just have a different attitude towards their self-care, and sometimes they don’t have good influences…. … their financial situation … doing vaccinations and looking after themselves is their lowest priority. (M11)

…it’s not so much that they don’t want to do it, it’s just… not a priority. (M11)

One midwife noted that a client whose child was hospitalised with pertussis was unvaccinated in her next pregnancy, being young with post-natal depression ‘…trying to get through just the basics was complicated for her’. (M9)

Some women prioritised a vaccine to protect her baby over protecting herself, or put other children’s needs over getting a MV.

Asked for their recommendations, women suggested MV awareness be raised further through midwives, pharmacy and general practice, and pamphlets and online information be available on MVs.

MV rates are lower for Māori, those with greater deprivation and greater parity (number of births), and in women with no LMC or who have few antenatal visits.¹⁰ Our findings revealed multiple barriers, including insufficient awareness and knowledge about MVs and access challenges. Prioritisation by women was important, and often related to poverty and/or busyness with work or children. However, enablers included knowledge, pro-vaccination beliefs, easy access to MVs, and informative, trusted HCPs.

Decisions regarding MVs appeared straightforward, based particularly on beliefs, knowledge, and influenced by previous MVs and emphasis from HCPs. Knowledge gaps and misinformation existed, but women participants usually sought no further information.

Other studies have also found HCPs strongly influenced MV uptake in Indigenous women,^23–25 although our finding that pharmacists helped with this was new. Protection of the baby has arisen as an enabler of MV in similar research,²³ and could be better used to aid MV prioritisation. Like our research, other studies have found that Māori rated trust and relationships as important for maternal care.²⁶ Mistrust has emerged elsewhere in marginalised groups regarding MVs, but did not emerge from the women participants in this research, possibly because the group was small and recruited through a pharmacy.

Although whānau are often important in Māori pregnancies,²⁷ as some HCPs observed, this did not come through from women when they discussed MVs, possibly reflecting the small participant numbers, or the ease of MV decisions and the concept of ‘my body–my decision’.

Vaccinating outside of general practice (eg in schools, or community outreach) aids with access for Māori.^28,29 MV administration by antenatal care providers aided uptake in rural Aboriginal women,²³ but has logistical barriers in NZ.¹² Funded pharmacy availability aids uptake by Māori,³⁰ but few rural pharmacies provide vaccinations, and barriers need addressing.³¹ Co-locating midwives with providers who vaccinate, vaccination outreach, and providing petrol vouchers through midwives might help with uptake.

Recommending MVs without discussion of benefits may be insufficient for women to prioritise vaccination. For example, misconceptions about influenza vaccine and illness were common, as found by another study.³² Other studies have found differences between perceptions of maternal influenza and pertussis vaccinations.³³ HCP maternal influenza vaccination discussions could focus on keeping the hapū woman well for her pēpe [baby].

Māori women in our study appeared more influenced by oral communication than leaflets, which is similar to other research regarding MVs.³³ Multiple discussions aiming to address knowledge gaps by different well-informed, trusted HCPs is recommended. Early presentation to the midwife enables MV discussion opportunities. Barriers to accessing a midwife such as midwifery shortages,^34,35 poverty,²⁶ and navigating the system,^26,35 need addressing. A culturally safe environment,²⁶ sufficient numbers of midwives and proactive support on the maternity pathway from the first health provider antenatal contact may encourage early access. Relationships and trust would be aided by early midwife presentation, more Māori HCPs and culturally competent HCPs. NZ’s model of a single LMC is likely to help with both relationship and trust.^34,35

Women participants varied in age, parity, first midwife engagement, and MV status. Interviewing Māori HCPs working predominantly with Māori provided breadth in understanding MV uptake, including indirect insights for the highest-needs women.

A Māori pharmacist interviewed the Māori women. Existing relationships with some could aid trust, but they may have provided answers to please the interviewer. Two Māori co-authors reviewed the findings.

Pharmacy-based recruitment missed those unengaged with the health system, and only two women received no MVs (although a further four did not receive an influenza vaccination). However, almost all women have a midwife, and we spoke to Māori midwives who provided useful insights on women who were not vaccinated. Snowballing, recruiting women through midwives or Māori health providers, and more interviews, particularly of women who did not receive the pertussis MV, could have broadened the participant range and found further barriers and enablers and we recommend this for future research. Two interviews with women were short at 10 min each, limiting the richness of data, and potentially reflecting the challenges for women of making time for an interview when they have young children and other demands. For some women, the interviews found a fast decision without a lot of additional consideration, no discussion with the family, no looking for information, typically little discussion with anyone, limiting the potential length of the interview. For example, in one 10-min interview, the woman was unaware of MVs, and no MVs were given and the interview was short because of the lack of experience and knowledge about MVs to explore. This still provided useful insights because the person indicated underlying relevant beliefs and had presented very late (27 weeks) to the midwife following challenges accessing midwifery care, potentially limiting time to be told about MVs. We were not aiming for data saturation, but rather a breadth of perspectives including both the women and Māori HCPs who see them. We relied on MV self-report.

Further research could usefully include more Māori women who have not had MVs, rangatahi wāhine (young women), and women who have low engagement with health services. There is also a need to explore how to optimise HCP messaging about MVs to Māori, and the effect on MV uptake by enabling early access to midwives.

We found decisions around MVs were often fairly straight-forward for Māori women, but multiple barriers to uptake include lack of awareness, misinformation, prioritisation and access issues, but HCPs and pro-vaccination beliefs strongly influenced uptake. Maximising opportunities for well-informed (and preferably trusted) HCPs to raise awareness and build knowledge about MVs could help Māori women access and prioritise MVs. Vaccinations without an appointment at convenient locations, enabling early presentation to midwives, and overcoming transport barriers could also help.

Supplementary material is available online.

Data from this study are not available as per the information sheet and consent form for the participants, and also because of potential to identify participants.

N.G. was a member of the National Executive of the Pharmaceutical Society of New Zealand during the research and has received funding from Green Cross Health (a provider of primary healthcare services including pharmacy and general practice), the Pharmacy Guild of New Zealand and the Pharmaceutical Society of New Zealand for reclassifying vaccinations to allow pharmacist administration. S.M. is a partner in a community pharmacy and received funding for conducting interviews in this study. H. P.-H. has participated in expert advisory boards to the GSK group of companies, Merck, and Pfizer, but has not personally received honorarium. She has also led investigator-led studies funded by the GSK group of companies. C.C.G. was a member of the Immunisation Subcommittee of the Pharmacology and Therapeutics Advisory Committee 2012–19. He is a named investigator on this project and has been an investigator on other immunisation-related projects funded by the GSK group of companies. O.S. has no conflicts of interest to report other than funding from the GSK group of companies for this project. F.D. has no conflicts of interest to report.

This work was supported by GlaxoSmithKline Biologicals SA (study ID: 208667) and the Health Research Council of New Zealand (16/815). GlaxoSmithKline Biologicals SA was provided the opportunity to review a preliminary version of this manuscript for factual accuracy, but the authors are solely responsible for the final content and interpretation. The funders had no role in the collection, analyses or interpretation of data, in the writing of this manuscript (except for the review for factual accuracy), or in the decision to publish the results. The authors received no financial support or other form of compensation related to the development of the manuscript.