Mapping the delivery of interventions for vaccine-preventable infections in pregnancy in Victoria, Australia

Keywords: healthcare providers, healthcare services, hepatitis B, infections in pregnancy, influenza, maternity care, pertussis, vaccine-preventable infections.

In Australia, vaccination against influenza and pertussis is recommended for women during pregnancy. The vaccines were introduced to the National Immunisation Program in 2020 and 2018, respectively (Australian Technical Advisory Group on Immunisation (ATAGI) 2017). Additionally, universal hepatitis B birth dose is recommended for infants and has formed part of the National Immunisation Program since 2000 (Australian Technical Advisory Group on Immunisation (ATAGI) 2017).

Influenza and pertussis vaccination during pregnancy prevents disease in both women (Mertz et al. 2013) and their infants, particularly in the first few months of life (Amirthalingam et al. 2014; Dabrera et al. 2015; Australian Technical Advisory Group on Immunisation (ATAGI) 2017; Rowe et al. 2021). Maternal influenza and pertussis vaccination results in a risk reduction of disease in infants <2 months old by 56% and 80%, respectively (Nunes and Madhi 2017; Rowe et al. 2021).

Mother-to-child-transmission (MTCT) of chronic hepatitis B (CHB) is the predominant cause of CHB globally (Navabakhsh et al. 2011). Neonates with hepatitis B have a higher risk (95%) of developing chronic infection than adults (5%) (World Health Organization 2021). The prevention of MTCT of CHB will prevent future liver cancer deaths and eliminate CHB as a major public health threat (Lavanchy 2004; Navabakhsh et al. 2011; Giles et al. 2013; MacLachlan et al. 2020; World Health Organization 2020, 2021). Optimal prevention of mother-to-child transmission (PMTCT) of CHB involves testing all pregnant women for hepatitis B, viral load testing for those with CHB, and antiviral treatment in the third trimester for women with a high viral load (>200 000 IU/mL) (Australian Government Department of Health 2018; World Health Organization 2020). Infants born to mothers with CHB should receive hepatitis B immunoglobulin (HBIG) within 12 h and complete the series of infant vaccines for CHB, including hepatitis B birth dose (within 24 h) (Australian Technical Advisory Group on Immunisation (ATAGI) 2017). Infants born to women with CHB are recommended to undergo post-vaccination serological testing to confirm transmission has been successfully prevented (Australian Technical Advisory Group on Immunisation (ATAGI) 2017).

Pregnancy represents a key opportunity to engage women with CHB into ongoing care (Roder et al. 2021).

Coverage estimates of vaccines in pregnancy vary, with historically higher uptake of pertussis vaccine than influenza vaccine among pregnant women (Rowe et al. 2019). Estimates of hepatitis B birth dose vaccine uptake for infants have recently shown variation between Victorian hospitals, and infants born in private hospitals were less likely to receive a timely hepatitis B birth dose vaccine (Deng 2021), with 1 in 20 infants born to women with CHB not receiving a birth dose within 24 h. Despite effective PMTCT interventions, hepatitis B MTCT continues to occur (Shen et al. 2019; Deng 2021).

The aim of this study was to explore provider perspectives of service delivery from a system and healthcare personnel perspective. It provides insights and opportunities for improvements to service delivery for pregnant women, including women with CHB, to improve best practice and inform public policy in Victoria.

Two online surveys investigated service delivery for the prevention of influenza, pertussis and hepatitis B to identify barriers to optimal care during January–June 2021 in Victoria; (1) The Birthing Hospitals Survey captured information about service delivery for influenza and pertussis vaccination, and interventions to prevent MTCT of hepatitis B at the facility level; and (2) The Healthcare Providers Survey captured information from antenatal and postnatal care providers working in both community and hospital settings to identify individual perceptions and knowledge relating to the delivery of interventions for vaccine-preventable infections in pregnancy (Supplementary material).

Surveys were designed using Qualtrics (Qualtrics XM) and participation was voluntary with online consent. The Birthing Hospitals Survey was sent to all 56 Victorian birthing hospitals (aimed towards Maternity Unit Managers) and collected hospital name and role. The Birthing Hospitals Survey was emailed directly to hospitals via contact details provided by the Department of Health or found on their website; the survey was emailed twice within 3 months and if no response within 4 weeks, was followed up with a phone call. The Healthcare Providers Survey was distributed anonymously via professional peak networks including nursing, midwifery, and general practice associations. Participants who responded to The Healthcare Providers Survey were anonymous, with demographic information collecting age, gender, sector, role, rurality, and type of workplace (Supplementary material).

Surveys were analysed using Excel (Microsoft Corporation) and STATA 17 (StataCorp LLC). Pearson chi-squared analysis was performed on categorical data. P < 0.05 was accepted as the level of significance. Free-text responses were grouped and analysed through Excel into group themes such as concerns regarding communication between primary and tertiary providers, inadequate training and awareness of influenza, pertussis and CHB. Hospital size was determined by hospitals’ number of births per year (Hunt et al. 2019).

A Likert Scale of 1–5 (or Not Applicable) was utilised (1 = not confident at all, 5 = very confident). ‘Not applicable’ responses were included in the dominator. All multiple responses were included in the analysis, including all hospital duplicates. Definitive discrepancies such as yes or no were confirmed with duplicate hospitals via phone. A ‘yes or no’ plus ‘don’t know’ responses were counted as ‘yes or no’.

The study was exempted from ethical review as it was an evaluation funded project (Department of Health, Human Research Ethics Committee, verbal communication).

Out of the total 56 birthing hospitals in Victoria, 40 participants from 34 hospitals (61%) completed the survey. Most participants were from public hospitals (71%) and identified as maternity unit managers (85%). Overall, 34 (47%) hospitals were from metropolitan Melbourne. Table 1 describes characteristics of respondents.

Table 1.  Demographic characteristics of Victorian birthing hospitals survey participants.

Pertussis and influenza vaccines for pregnant women were routinely provided in 18 (53%) and 17 (50%) of hospital clinics, respectively. Of these, a majority were public hospitals (n = 15, 88% pertussis, n = 15, 83% influenza). Most services that provided influenza and pertussis vaccinations did so during antenatal clinic visits, and vaccination was mostly administered by midwives. Lack of vaccine supply was not identified as an issue.

Systems implemented by services to promote maternal vaccination included educational materials for women (51%) and checklists to prompt discussion of maternal vaccines (34%). Other tools included using hospital policy and procedures, clinical practice guidelines, mandatory questions in electronic medical records (EMR), standing orders and consent forms.

Most services relied on pregnant women to inform their GP that they had received vaccination in hospital (59% influenza; 77% pertussis) and noted vaccine administration on the shared care record (59%; 50% respectively). Few reported sharing information in the discharge summary, whereas three (two small and one large) public hospitals reported not having a standard method for communicating with a woman’s GP regarding vaccination.

When asked how the hospitals knew if influenza and pertussis vaccinations were administered to pregnant women in the community, most reported they rely on the woman to verbally inform the hospital (76% influenza; 85% pertussis) and/or routinely check the antenatal record booklet (Victorian Maternity Record) (32%; 41% respectively). Only one service reported routinely checking the Australian Immunisation Register (AIR) for the administration of influenza vaccination in the community.

Influenza and pertussis vaccinations were predominately recorded in the Birthing Outcomes System (BOS) (n = 19; n = 17 respectively) and in paper-based systems (n = 10 for both influenza and pertussis).

Hepatitis B birth dose and HBIG administration were recorded in various systems – predominately in the ‘My Health, Learning and Development’ book (Victorian Government 2019), (n = 30 birth dose; n = 27 HBIG), BOS (n = 26; n = 23 respectively) and paper-based systems (n = 21; n = 22 respectively). One public hospital reported that they do not have a standard procedure for recording HBIG administration.

Maternal influenza, pertussis and hepatitis B birth dose vaccinations were not consistently reported to the AIR, with 77% of hospitals not reporting to the AIR at all. Only two small–medium hospitals reported influenza vaccinations to the AIR and three reported pertussis and infant hepatitis B birth dose vaccinations.

For CHB service delivery, 53% (18/34) of hospitals provided an infectious diseases service at their hospital, with most of these (72%) being major public hospitals. Of the 18 hospitals, 55% of the survey respondents were unaware of the usual waiting time for a first appointment in their specialist service. Of the 16 hospitals that did not provide an infectious diseases specialist service at their facility, 69% were public hospitals and of these, 69% were located in regional Victoria.

Of the 18 hospitals providing CHB care, 55% (n = 10) reported having systems in place to ensure pregnant women with CHB were seen before 28 weeks’ gestation in their hospital’s viral hepatitis service. Only three services reported that pregnant women with CHB are internally managed within the maternity ward and did not require a referral. However, most services (91%) referred women to various internal and external departments, including referral to other outpatient specialist services (38%), external public medical specialist services (35%) and internal specialists within their antenatal service (32%).

When asked what standard procedures were used to confirm a woman’s CHB status during admission for delivery, 67% indicated that they would check the hospital’s EMR for laboratory results, 53% checked the BOS and 32% relied on verbal report from the woman. Most respondents indicated that they would actively seek consent from the woman prior to delivery for infant hepatitis B vaccinations: 88% for birth dose and 70% for HBIG. No hepatitis B birth dose vaccine supply issues were reported.

Common barriers identified by healthcare providers for influenza and pertussis vaccination included: women declining vaccination, women required to go to a different provider for vaccination; and lack of staff awareness. Table 2 further describes vaccination barriers.

Table 2.  Birthing Hospitals Survey: barriers to influenza, pertussis and hepatitis B vaccination and care delivery.

For hepatitis B guideline-based care delivery for mothers with CHB and their infants, common barriers included: no infectious diseases services available (n = 7); staff not adequately trained in CHB care and delivery (n = 3); and lack of communication among services (n = 3).

The most common barriers identified for hepatitis B birth dose and HBIG delivery were: women declining vaccination (n = 9 birth dose; n = 7 HBIG), lack of hepatitis B training and/or staff attitudes to hepatitis B birth dose vaccination (n = 4), and HBIG stock out (n = 3). One hospital reported HBIG was not routinely stocked on site, and some private hospitals (n = 2) reported inadequate access to vaccine storage facilities. One public hospital in regional Victoria reported not stocking hepatitis B birth doses as they do not provide care for women with CHB. Table 2 further describes CHB vaccination and care delivery barriers.

One-hundred and forty participants completed the survey; 59% (n = 83) were from community settings and 41% (n = 57) from hospital settings. Participants were predominately midwives and nurses. Table 3 describes demographic characteristics.

Table 3.  Demographic characteristics of healthcare provider survey participants.

Over half (59%) of the total respondents were confident that all pregnant women who do not speak English received appropriate interpreters; this was significantly higher in community settings than in hospitals (P < 0.05).

Most maternal services offered influenza (103; 74%) and pertussis (114; 81%) vaccinations. Community services offered routine influenza vaccination more commonly than hospitals (P < 0.01); however, there were no differences in routine pertussis vaccination between community and hospital services.

Procedures in hospitals to ensure discussions of maternal vaccines included checklists to prompt discussion (n = 53) and/or provision of educational materials about vaccinations to pregnant women (n = 71). Analysis showed that hospital services were more likely to follow a protocol of running checklists to encourage vaccination discussion, compared to community providers (P < 0.01).

Respondents determined previous influenza and pertussis vaccinations by mostly relying on pregnant women to inform the service (57%; 69% respectively), followed by checking Victorian maternity records (19%; 23% respectively). Hospital providers were more likely to rely on verbal confirmation compared to community providers, who checked multiple systems including the AIR to confirm vaccination (31% for both influenza and pertussis). No hospital provider in the healthcare providers survey reported using the AIR. Of the services providing antenatal vaccination in the community, vaccines were recorded in the EMR (84% influenza; 83% pertussis), paper-based records (8%; 11% respectively), uploaded to the AIR for both vaccines (7%) and in My Health Record (1%).

CHB status was confirmed through several methods: routinely ordered hepatitis B serology (n = 72), checking the EMR (n = 41), or via a paper-record provided by the woman (n = 38), verbal report from the pregnant woman (n = 29), direct contact with the woman’s other health service (n = 28), and/or checked BOS (n = 26). Three respondents reported no attempt to confirm CHB status. Next steps included referral to a specialist clinic in the public sector (n = 56), CHB consultation within the same service (n = 45): routine referral to the hospital antenatal clinic (n = 32); private specialist (n = 8); and/or referral to a GP with a special interest in CHB (n = 6). A minority of respondents did not provide clinical care to women with CHB (n = 4) or took no further action (n = 2).

Of those providing care for women with CHB (n = 98), 90% of respondents were confident that all pregnant women were offered a CHB test, but only 68% felt confident discussing the diagnosis. Only half of the respondents (53%) were confident that all pregnant women with CHB received hepatitis B viral load testing during their second trimester, and 48% were confident that pregnant women with CHB and a high viral load were prescribed antiviral therapy in the third trimester. Sixty percent were confident that all women with CHB were linked to ongoing care for their CHB during pregnancy and after delivery. Under half (48%) were confident that all pregnant women with CHB were advised to test their children for CHB post vaccination, as recommended in national guidelines. Of hospital respondents, over half were confident their hospital obtained consent from pregnant women prior to presenting for delivery for the administration of the birth dose (63%) and HBIG (60%). For infants born to mothers with CHB, 89% participants were confident in the timely administration of hepatitis B birth dose (within 24 h) and 84% for HBIG administration (within 12 h).

Hepatitis B resources and/or support offered to women with CHB during pregnancy was mainly written information either in English (n = 56) or another language (n = 51).

Key barriers to influenza and pertussis vaccination included pregnant women declining vaccination, women having to attend a different service for vaccination and lack of staff awareness and training. Hepatitis B birth dose and HBIG barriers included women declining vaccination, no standing orders, and lack of trained staff and/or variation in individual staff attitude to promoting vaccine, and no clear procedures and/or guidelines. Regarding guideline-based care for mothers with CHB and their infants, the main barriers were lack of adequately trained staff, lack of communication between services, and no standardised procedures. Further barriers are described in Table 4.

Table 4.  Healthcare Providers Survey: barriers to influenza, pertussis and hepatitis B vaccination and care delivery.

In both surveys, we were unable to determine significant differences between locality, as well as public versus private hospitals, due to the small sample size from private hospitals.

This study explored how perinatal services in relation to vaccine-preventable diseases are delivered to women and their infants in the Victorian health system. Our findings provide a unique Victorian-wide health systems perspective from hospitals and healthcare providers and add to the literature showing systemic gaps in coordinated and standardised clinical care for women and their infants.

Poor coverage has been observed in maternal influenza and pertussis vaccination in Australia and overseas (Mohammed et al. 2018; Rowe et al. 2019, 2021; Giles et al. 2021). When antenatal services do not provide maternal vaccines, it places the burden on pregnant women to seek vaccinations outside of the maternity care system. There is an opportunity to advocate for system changes in individual hospital services to embed vaccination administration in antenatal services and provide training and education for staff to promote uptake.

Previous studies in Australia have focused on some hospital-level CHB cascade of care showing, while screening has been reported to be high, subsequent steps including viral load testing, antiviral uptake, timely birth dose and HBIG do not reach all women (Giles et al. 2004; Markey et al. 2017; Shen et al. 2019; Deng 2021).

National and international research indicates that pregnant women did not have adequate hepatitis B knowledge and information to make informed decisions to prevent MTCT (World Hepatitis Alliance 2022; Yussf et al. 2022). It is critical that healthcare services engage with pregnant women and their families to ensure they are supported to prevent MTCT.

Healthcare providers reported system issues that point to areas that could be improved to increase access across the health system, including: access to CHB care, and developing standardised protocols to translate guidelines into practice for women with hepatitis B to ensure wherever women deliver, they receive best practice care for prevention of MTCT. A coordinated perinatal hepatitis B approach as seen in other jurisdiction and overseas could coordinate care delivery for women with CHB and their infants to reduce MTCT – similar hepatitis B perinatal state-run programs already exist in NSW, Australia, and the USA (New York State Department of Health 2011; NSW Health 2017; Arizona Department of Health Services 2018). Health services need additional support to provide coordinated vaccination and care to pregnant women in Victoria.

Recording of all vaccines in the AIR has become mandatory in Victoria from August 2021, including the three-doses of COVID-19 vaccination for all pregnancies. This is a crucial step to standardise recording of vaccination administration instead of relying on self-report from women. Our surveys conducted in 2021 show that implementation of AIR reporting and checking was an issue that perhaps the mandate will address. Improved vaccine recording and less reliance on women to report vaccination will not alone improve vaccination – same day access to services and staff education is likely to be required.

Potential limitations of our study include the small sample size and the nature of the cross-sectional study design, which does not determine the cause-and-effect of outcomes. Surveys were self-administered and may therefore be subject to responder recall and reporting bias. This study does not represent all healthcare services delivering care to pregnant women. Participation may have been limited by the impact of the coronavirus disease 2019 (COVID-19) pandemic on healthcare services. Despite these limitations, the findings provide important insights into system-level opportunities to improve care for pregnant women in Victoria.

The findings of this research can be used to inform healthcare system improvements for vaccine-preventable infections during pregnancy in Victoria. Opportunities to improve care for pregnant women and prevent MTCT of hepatitis B are summarised in Table 5.

Table 5.  Research findings-opportunities to improve care for pregnant women and prevent MTCT of hepatitis B.

This study identifies missed opportunities in influenza, pertussis and hepatitis B vaccination and care delivery. Coordinated and standardised system improvements including timely and appropriate equitable access to vaccination and clinical care across Victoria, is vital. Training and education for healthcare providers, improved recording and reporting and communications among health services are needed to appropriately respond to the needs of pregnant women and their infants to reduce the burden of vaccine-preventable infections during pregnancy and in early infancy.

Supplementary material is available online.

The authors confirm that the data supporting the findings of this study are available within the manuscript. Data cannot be shared due to privacy and confidentiality reasons.

The authors declare that they have no conflicts of interest.

This research was funded by the State Government, Victorian Department of Health.

BC identified the research question. BC and NR obtained funding. NY, NA, NR designed surveys and conducted consultations. NY, NR, NA, MP, JW, SR, RM developed survey questions. NY developed the first draft of the manuscript. NY analysed birthing hospitals survey data and AW analysed healthcare providers survey data. All authors contributed to the critical revision of the manuscript and have read and approved the manuscript.