Interventions to improve vaccine coverage of pregnant women in Aotearoa New Zealand
Flynn Macredie 1 , Esther Willing
2 , Pauline Dawson 3 , Anna Howe 4 , Amber Young 1 *
1 School of Pharmacy, University of Otago, Dunedin, New Zealand.
2 Kōhatu – The Centre for Hauora Māori, University of Otago, Dunedin, New Zealand.
3 Department of Women’s and Children’s Health, University of Otago, Dunedin, New Zealand.
4 Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand.
Journal of Primary Health Care 15(3) 230-237 https://doi.org/10.1071/HC23041
Published: 13 July 2023
Abstract
Maternal vaccination against influenza and pertussis protects mothers and babies from severe disease and is recommended and funded in Aotearoa New Zealand. Despite this, maternal vaccination uptake is low, varies by region and is inequitable, with Māori and Pacific māmā (mothers) less likely to receive vaccination.
To determine what interventions currently exist to support and encourage maternal vaccination against influenza and pertussis and what changes and interventions could be implemented to improve coverage, with a focus on Māori and Pacific hapū māmā (pregnant mothers).
Interviews with six participants with diverse roles in the vaccination workforce were conducted. Participants were involved in education, certification and supporting vaccinators, high-level strategising, and vaccination. Interviews aimed to determine what interventions currently exist for hapū māmā, what changes need to be made to improve coverage and how Māori and Pacific people have been specifically engaged. Qualitative data analysis was used to determine themes.
Participants identified that interventions must focus on prioritising and emphasising the importance of maternal vaccination, promoting collaboration and innovation, making interventions accessible, and empowering Māori- and Pacific-driven avenues to vaccination. To create positive foundations, participants identified the importance of building and maintaining trust and affording mothers’ time and autonomy in vaccination.
Healthcare professionals need to proactively engage hapū māmā about vaccination and collaborate in service delivery. Interventions must be suitably accessible and allow for the autonomy of hapū māmā over vaccination decisions. Equity should be considered at the foundation of vaccine interventions to improve the accessibility of vaccines to all communities.
Keywords: communication, health services, immunisation, influenza, Maori health services, maternity care, pregnancy, primary health care, vaccinations.
| WHAT GAP THIS FILLS |
| What is already known: Maternal immunisation against influenza and pertussis is suboptimal. Current strategies are inequitable with mothers from Māori and Pacific backgrounds, and those from areas of high deprivation less likely to be vaccinated in pregnancy. |
| What this study adds: Many strategies should be enlisted to improve coverage, including supporting a wider vaccination workforce, building on strategies used for the COVID-19 roll out, and supporting prioritisation of maternal vaccination by healthcare providers and hapū māmā. Building trusting relationships remains the mainstay of effective service provision. |
Introduction
Influenza continues to cause severe disease, particularly in pregnant women.1,2 Research in Aotearoa New Zealand (NZ) shows pregnant women have 3.4-fold higher rates of hospitalisation due to influenza compared to non-pregnant women and the risk increases with each trimester (up to a 5-fold risk in the third trimester).3 Maternal infection can also result in preterm birth and fetal or neonatal death.4 Pertussis infection in children, especially those less than 1 year old, can result in hospitalisation in half of those infected, as well as brain damage, and death.1,5 Thus, it is important to promote effective prevention strategies against infection with pertussis or influenza for hapū māmā (pregnant mothers) and their pēpē (babies).
Maternal vaccination against influenza and pertussis can prevent severe influenza infection in hapū māmā and, through transfer of protective antibodies via placenta and breast milk, prevent pertussis and influenza infection in pēpē during their first few months of life.6,7 Both vaccines are safe and effective at preventing serious infection with these diseases in pregnancy and early infancy.8 Therefore, it is imperative that all māmā have access, knowledge, and resources necessary to enable vaccination.
It is widely reported that maternal immunisation in NZ is suboptimal.9,10 In 2020, only approximately half of hapū māmā received influenza and pertussis vaccination.10 Inequities also exist across ethnicities.10 Coverage of Māori and Pacific hapū māmā is as low as 13 and 18% respectively for influenza vaccination and 13 and 15% for pertussis vaccination.9 Likely contributing to this inequity is system barriers to accessing care, limited understanding of antenatal processes, and lack of support in accessing a Lead Maternity Carer.9,11–13 NZ studies identified that not receiving maternal vaccination may be due to lack of knowledge about recommended vaccines and lack of strong recommendations from a healthcare provider.13–17 Systemic vaccine coverage inequity likely contributes to inequitable disease burden in pēpē Māori. Pertussis hospitalisations have been consistently higher than hospitalisations among non-Māori and non-Pacific infants, particularly in those aged 1–2 months, who are still too young to be vaccinated for protection from infection.18 Given this, there is potential for the development of interventions to improve maternal vaccination coverage and equity; however, how these interventions would look, what challenges to vaccination they should tackle, and how they might work in practice is unknown.
This study aimed to determine interventions that would support and encourage maternal vaccination against influenza and pertussis, what changes could be implemented to improve coverage, and, from a system-level view, what Māori- and Pacific-centred interventions could potentially improve vaccine uptake in these groups.
Methods
Study design and setting
This was a kaupapa Māori-aligned qualitative study, utilising the principles of kaupapa Māori research, but it was not designed to specifically recruit Māori participants.19,20 Semi-structured interviews were conducted in December 2022 via Zoom. An interview guide was developed through a literature review looking at health service delivery, leadership and governance, health workforce,21 and health interventions for marginalised groups22–25 (see Appendix 1). The interview guide was reviewed by the research team and piloted with one regional immunisation advisor. Following the pilot, questions were slightly adapted to explore system weaknesses, although this did not change the scope or aims of the project.
The University of Otago Human Ethics Committee (Health) provided ethics approval (reference: D22/302).
Participants and recruitment
Purposive sampling of Immunisation Advisory Centre (IMAC) Regional Immunisation Advisors, educators, and employees providing vaccination support and outreach was undertaken. Participants were approached by email using contact details publicly available on the IMAC website. Snowballing recruitment occurred, where participants could recommend colleagues for participation. In order to provide sufficient information power for the generation of themes in the analysis, given the limited timeframe available for this study, four to eight participants were sought.26
Interviews were conducted at times convenient for the participants by FM with support either from AY or EW. Audio recordings were transcribed verbatim using Otter AI (Otter.ai Inc.) and transcriptions were checked for accuracy by FM. FM also took extensive notes for consideration in analysis. Informed consent, including consent for audio-recording was obtained prior to the interviews.
All researchers in the study are supportive of maternal vaccination. The Primary Investigator (FM) is a Māori health researcher with whakapapa (ancestry) to Tainui waka and Ngāti Korokī Kahukura. FM expressed his whakapapa Māori and interest in health equity research and medicine to participants when engaging in whakawhanaungatanga (introduction and relationship building). FM utilised reflexivity practices, such as identifying and acknowledging his own values and beliefs and how these could affect data collection and analysis and kept a researcher journal for note-taking throughout the project.
Analysis
The analysis of the paper was undertaken within a kaupapa Māori-based paradigm.19 A thematic framework based around the aims of the study was developed using an interpretive description methodology.27 The data were analysed using a directed qualitative content approach28 facilitated by NVivo (QSR international LLC) software. Interview transcripts were reread multiple times for accuracy by FM. FM allocated codes to the data and collected these into themes within the thematic framework. FM reviewed potential themes against the dataset and analysed further through reordering and merging data groups until the final themes were created. The final themes were reviewed by members of the research team.
Results
Six participants of diverse ethnicities including Māori were interviewed. Interview length varied from 40 to 70 min. Results were analysed around a framework based on the study aims, see Table 1.
| Weaving a comprehensive set of interventions to improve hapū māmā vaccine coverage | Creating a positive vaccination foundation | |
|---|---|---|
| Themes | Themes |
Weaving a comprehensive set of interventions to improve hapū māmā vaccine coverage
Four themes describe the importance of providing diverse access to vaccines.
Participants listed various challenges to maternal vaccination within health systems, healthcare providers (HCPs), and mothers’ personal circumstances.
Many participants suggested that vaccine coverage of hapū māmā should be prioritised at a general practice level. Two participants suggested that disseminating maternal vaccination coverage data to HCPs would improve prioritisation.
Maybe health professionals don’t know the stats, they don’t know how dire it is themselves to feel urgently about passing on the information. [P3]
Automatic recalls in patient management systems could help prioritisation. One participant felt that there is excellent uptake of vaccines by hapū māmā when recall is successful. However, there is hesitancy to use recalls if it is unknown if the pregnancy has progressed. Weaknesses in general practice recall systems were also identified, eg they may still struggle to prioritise maternal vaccination due to busy workloads, or they may not know their patients are pregnant.
Increased prioritisation at the individual level is also needed. All participants believed that the importance and recommendation of maternal vaccination is not well known among hapū māmā, resulting in lack of vaccination prioritisation. Two participants highlighted that improving knowledge requires support from all system levels, from the Ministry of Health to the vaccinating HCPs.
[Improving mothers’ knowledge of maternal vaccines] requires many layers … [a] multifaceted approach from the ministry level and onwards down. [P1]
To improve awareness, it is important that all HCPs involved in the care of hapū māmā have sufficient knowledge and recognise the importance of maternal vaccination. Six participants also acknowledged a lack of focus on getting hapū māmā vaccinated, commenting that the main prioritisation is often childhood and COVID-19 immunisation.
I think that the fact that that should be the priority got lost – it’s got lost with all the other health priorities that’ve come out. [P4]
Three participants placed particular emphasis on proactive engagement of hapū māmā in spaces that they occupy, such as Facebook groups, antenatal classes, or even waiting rooms.
Opportunistic vaccination was identified as a way to improve coverage, particularly in those who have difficulty prioritising maternal vaccination. Participants highlighted that childhood Outreach Immunisation Services can opportunistically vaccinate hapū māmā within the household against pertussis.
… we try and be as opportunistic as we can … we do actively ask if we come across any pregnant woman about if we would like a Boostrix [pertussis] vaccination. [P6].
COVID-19 vaccine hubs also present an opportunity to offer walk-in influenza vaccines.
Weaving comprehensive interventions requires innovation and collaboration between health services and providers. All participants stated that practice nurses deliver most maternal vaccinations. However, improved collaboration between general practice and midwives is needed to effectively deliver this service, eg practices may be unaware that their patients are pregnant.
… general practice often doesn’t know who of their patients are pregnant … [P5]
Combining forces to discuss vaccination with hapū māmā was also identified as important. For example, outreach services can provide information, although māmā may still prefer to discuss vaccination with their midwife before deciding.
When we [vaccination outreach services] might have come across pregnant women … they don’t necessarily decline it to us, they’ll say I want to talk to my LMC. [P6]
All participants considered widening the vaccinating health workforce important, with numerous benefits including improved staffing to facilitate innovation.
… with the vaccinating healthcare worker role, there’s been this encouragement for providers to think outside the square in terms of the people that they have in their clinics who are trusted and respected, but not trained, regulated healthcare professionals. [P4]
All participants thought midwives being able to vaccinate would be beneficial. However, it was acknowledged that our midwife workforce is overworked and understaffed. Furthermore, practical challenges exist around midwives administering vaccines.
So, I personally think it’s [the barrier is] time and the practicalities of providing vaccination … the need to have and maintain the cold chain, have a pharmaceutical fridge. [P4]
Two participants thought collaboration and integration of antenatal and vaccination services, such as vaccination hubs or vaccine fridges in hospital antenatal wards, could be potential solutions.
Could they [the midwives] work together with another organisation to come in and vaccinate on those days? I think that would be amazing. [P2]
All participants identified various barriers to accessing vaccination. This particularly affects rural whānau with limited transport, those with transient housing, and whānau with competing priorities, eg other children or employment. The importance of equity when planning interventions was raised, to help mitigate challenges and ensuring that whānau needs are being met.
the transient family … who are part of that coverage that we don’t see … These are the ones that should actually be the starting point in planning, I think, not ‘what works for the majority’ as the kind of planning lens. [P1]
One participant suggested that equity in designing interventions, ensuring they are accessible, requires a change in the framework by which success is measured.
A pop up after the rugby, you might get two people vaccinated … So people go, “that’s no good“. But it kind of is because they might be those two people that that would never get vaccinated otherwise. [P3]
All participants saw great potential benefit in drop-in, easily accessible vaccination venues. Vaccination in pharmacies was valued as they often offer better opening hours than general practice, mitigating some of the barriers to vaccination.
They [pharmacies] have proven themselves to be … an accessible vaccine centre … they are acknowledged and recognised as a competent and confident venue to go, they are open better hours than general practice. And they often can work on a walk-in basis. [P5]
All participants acknowledged Māori and Pacific health providers’ efforts in improving vaccine access for their communities during COVID-19 outreach. Some thought these services could be expanded to maternal vaccination.
Māori providers … they’ve stepped into a space they haven’t been in before, they have embraced it, they have taken on a culture reflective of their people which means that … their people have come on board with it and I just hope that we can take the learnings that we’ve got from that and utilise it because I really believe that vaccination in pregnancy, when it comes through those providers, will be really powerful. [P5]
Empowering Māori and Pacific health providers to deliver vaccinations has also led to innovations that were effective for vaccine delivery, eg drive-through vaccine clinics and those with connections to the community becoming vaccinators.
… the vaccinator health worker, so they could be your kaiāwhina, your healthcare assistants, anyone working within a health setting, really … And that’s actually helped a lot of our communities because they have really good connections within the communities. [P2]
All participants felt it was important to maintain and continue to support the wider vaccinating health worker role going forward. However, there was concern that the cessation of COVID-19 funding would lead to discontinuation of many innovative interventions.
… and a risk of that is that some of the really good initiatives that were developed through COVID may just fall off … there’s an awful lot of immunisation space funding that’s ceasing … without a very clear plan of what the scene looks like going forward. [P5]
Creating a positive vaccination foundation
Two themes were identified about the importance of having a positive experience in vaccination.
All participants commented on the influence of trusted individuals, whether that be a health professional, vaccinating health worker, or whānau member on vaccine decision-making.
[vaccine information comes from] that trusted person … gotta always hope it’s an auntie who’s confident to talk about a whole range of these issues or it’s a sister or it’s maybe that one worker that they’ve seen every time they’ve gone into the health practice. [P4]
Building trust however can take time, again highlighting the importance of midwives in the engagement of hapū māmā.
… the midwife’s in that great position that they’re gonna keep seeing them. And so hopefully, they will be a trusted person … [P3]
However, two participants expressed concern that the COVID-19 vaccine mandate may have negatively impacted this trust and thus the willingness to vaccinate.
… the impact of people being told what they ‘must do’ will have detrimental effects on people being recommended to have vaccines … [P5]
All participants highlighted that it is important to give hapū māmā sufficient time and space to feel like an informed decision around vaccination has been made. However, having time for a productive conversation around maternal vaccination can be challenging due to current health workforce staff shortages.
… talking about risks versus benefit … that takes longer than 15 minutes. [P2]
Two participants thought initial maternal vaccination discussions should be followed up later, particularly if māmā has declined vaccination or is hesitant. Another commented that early engagement about vaccination is important in building a commitment to vaccination.
The first immunisations start from pregnancy … the earlier a pregnant woman knows about vaccines and benefits and all that, it gives them time to feel like they’ve made an informed choice to continue vaccinating their child onwards … So, I think the earlier engagement really would be a great key. [P1]
Discussion
In NZ there have been recent successes with COVID-19 vaccine coverage, involving numerous examples of innovation in vaccine delivery to communities.29,30 This shows that under exceptional circumstances health services are able to adapt and innovate to improve uptake of vaccines. Our current low coverage rates for maternal immunisation need to be seen as a crisis that we can respond to as a health system.
Participants in our study thought a barrier to maternal vaccination was hapū māmā not receiving information about vaccination recommendations. Other studies that directly ask māmā about their experiences have also found that a lack of awareness prevents hapū māmā from being vaccinated.14,17 Participants in our study perceived that women tend to get vaccinated following a clear recommendation or being offered a vaccine. This finding is in line with previous maternal vaccination research which shows women are likely to receive maternal vaccines when they are recommended by a trusted healthcare provider.17 Improving HCPs' ability to discuss maternal immunisation, particularly for midwives, was highlighted as a potential intervention in another study.31 Which health provider should be primarily responsible for engaging women about vaccination is unclear. Our participants identified that while most maternal vaccinations currently occur at GP clinics, GPs do not consistently know if their patients are pregnant, there is variation in recall systems between practices, and, for many māmā, significant barriers exist in accessing GP services. Another NZ study found that GPs often have antenatal appointments but do not instigate recalls for vaccination.16 Participants in our study considered midwives to be the HCPs in the best position to discuss vaccination during pregnancy because of the ongoing relationship they have with māmā. Under the primary maternity services contract, midwives are expected to deliver Ministry of Health information on vaccination antenatally.32 However, some midwives might not be comfortable providing strong recommendations to vaccinate, believing this may adversely take away the ‘woman’s choice’ about whether to vaccinate in pregnancy.16 Furthermore, having in-depth conversations can be difficult because of workforce shortages33 and the large number of topics to be covered. The vaccination workforce must collaborate and support each other to engage māmā, rather than relying on a single entity to provide vaccination advice and delivery. Earlier engagement about maternal vaccination was highlighted as a potential remedy. The benefits of early engagement with caregivers in the context of HPV vaccine rollouts have been demonstrated, allowing trusted sources to be consulted to guide decision making.34 Participants would also like midwives to vaccinate; however, a number of known barriers exist to this service provision.16
While many women decide to vaccinate following a clear recommendation, participants emphasised that many systemic barriers to access exist. Māori and Pacific whānau have high intentions to vaccinate their tamariki (children), yet have lower timeliness to childhood vaccinations, highlighting the effect of disparities in access to healthcare.35 Increasing vaccine availability through community pharmacy does improve maternal vaccination coverage.36 Pharmacies can offer improved accessibility to communities as well as reducing burden on general practices.37 Participants in our study also emphasised the benefits of other vaccine interventions in the community. Iwi (tribe)-led interventions were rolled out in COVID-19 vaccine delivery.30 For example, Te Ranga Tupua (a collective of 12 iwi organisations) identified the needs of their communities and established vaccination clinics with information disseminated through iwi and hapū (subtribe) networks, improving Māori uptake of the COVID-19 vaccine despite the absence of Māori-focused engagement early in its rollout.29 These Māori-centred interventions that are in line with the developed theme of Empowering Māori and Pacific health providers to deliver vaccinations have the capability to overcome systemic inequities in health-service provision for Māori. Other interventions that could support maternal vaccination in Māori and Pacific peoples were identified by participants in this study. However, it is imperative that any intervention for these groups is co-designed to be culturally safe and effective. The themes Prioritising and emphasising importance of maternal vaccination, Promoting collaboration and innovation, Building and maintaining trust, and Making interventions accessible are good places to begin intervention design. Yet, developing the intricacies of what interventions look like and how they will be implemented requires careful co-design and kaupapa to ensure they are culturally safe and support equitable improvement in maternal vaccination coverage. Equity is an important consideration in planning vaccine interventions. Participants highlighted pop-up vaccine-clinics in strategic locations targeting populations with lower vaccination uptake as a good example of equitable interventions. For influenza vaccines, taking vaccines to target populations is successful in improving vaccine coverage of these groups.38 Outreach services can also help by opportunistically vaccinating hapū māmā. These services minimise access barriers and support equity in vaccination;39 however, they are expensive and resource intensive. Importantly, interventions delivering ‘few’ vaccinations can be considered a success depending on their context through an equity lens. This highlights the need to have an equity focus at higher levels of intervention planning such as in funding allocation and measurement of intervention success, ensuring that interventions that increase equity remain supported.
This study has a small sample size; however, small sample sizes are common with qualitative research.40 Furthermore, the interviews were reasonably long in duration to allow in-depth discussion, and a diverse range of opinions and experiences wereprovided. A strength of this study was the ability to gather information from key stakeholders at the system level in the health sector, identifying starting points to develop co-designed interventions in future research. Participant demographics were not collected to preserve participant anonymity. However, participants were purposively sampled based on their role as immunisation coordinators and support staff from IMAC to identify intervention improvements at a systems level. Moreover, themes identified in this study are in line with those from NZ and internationally.
Conclusion
In our study, participants highlighted the key role HCPs involved in hapū māmā care play in improving māmā’s knowledge and prioritisation of maternal vaccination. Equity should be considered at the foundation of vaccine interventions to improve the accessibility of vaccines to all communities. Expanding the vaccination workforce was perceived to improve coverage and it was noted that Māori and Pacific HCPs used this role to drive innovation, ensuring vaccine delivery was optimised for their communities. Given the importance of vaccination in pregnancy for māmā and tamariki, participants believed that building and maintaining trust through early engagement and follow up is key. Interventions to improve maternal vaccination must be adequately co-designed and, on implementation, undergo adequate review for key performance indicators for equitable vaccination coverage.
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Appendix 1. Interview guide
Thank you for participating in this study. The aim is to explore interventions, current and upcoming, that improve vaccine coverage of mothers in pregnancy against influenza, COVID-19 and pertussis, including any interventions specific for our Māori and Pacifica mothers and babies.
As outlined in the consent form, your privacy and confidentiality will be maintained. Do you consent to having the conversation recorded? Do you have any questions about the interview before we start?
Section 1: Whakawhānaungatanga
Where did you grow up? Where are you from?
What do you like to do in your spare time? Any passions or hobbies others might consider unusual?
What is your current role?
Section 2: Current interventions to boost maternal immunisation and perceptions about these interventions.
Where and when can vaccinations during pregnancy take place? (In hospitals, during GP visits, appointments with practice nurses, during midwife visits, in pharmacies).
What locations would be more frequently used for maternal immunisations and why?
What do you think are some barriers to vaccination in pregnancy?
How are these barriers to vaccination access in pregnancy minimised (eg outreach programmes)?
How are health staff supported to be able to have well informed conversations around vaccination in pregnancy?
How would you suggest appointments are managed to support conversations around vaccination (is vaccination a priority)?
How is information around vaccine availability, safety and efficacy conveyed (eg via pamphlet, advertisement, conversations with health care staff)?
Section 3: Māori and Pacific centred interventions
What considerations were given to Māori and Pacific world views in maternal vaccination programmes and recommendations?
Are any culturally appropriate resources or practices around maternal immunisation provided (eg Māori language, Pacific languages)?
How is knowledge of Māori and Pacific identities, world views and culture in the care of pregnant women being supported? (eg cultural competency programmes, clinical experience)?
Are Māori being engaged to support well informed conversations around vaccination in pregnancy? If so, how, who, what, where, when…? Why not?
Are Pacific communities being engaged in well informed support conversations around vaccination during pregnancy? If so, how, who, what, where, when…? Why not?
Section 4: To be implemented interventions to boost maternal immunisation
What are some of the challenges preventing increases in immunisation during pregnancy coverage?
(prompt) Coordination between health services for māmā hapū (midwife, GP and hospital)
What are current planned interventions to overcome these challenges for the future?
