Understanding Barriers and Facilitators to Maternal Immunization: A Systematic Narrative Synthesis of the Published Literature

Abstract

Introduction: Vaccines are being developed against Group B Streptococcus and respiratory syncytial virus. These vaccines are designed to be given to pregnant women to protect infants; thus, their success depends on uptake in this population. Maternal immunization programs have struggled to achieve target coverage rates. This systematic narrative synthesis aims to define the most important barriers and facilitators for maternal immunization and to identify priority areas for future research.

Methods: A search strategy was developed in Medline and adapted according to the requirements of additional search engines. Two reviewers independently reviewed the studies, using pre-specified inclusion and exclusion criteria. Results sections of included studies were coded, and thematic analysis was used to identify prominent themes.

Results: 321 studies were included in the final review. Most studies came from North America (37%), Europe (26%) or East Asia, Australia and New Zealand (22%). Low-and middle-income countries were under-represented. Five percent of studies came from Sub-Saharan Africa, and 2% came from South Asia. The prominent factors impacting maternal immunization were provider recommendation, perceived risks and benefits of maternal vaccines for the infant, race, birthplace, and access to healthcare. Few studies explored reasons behind racial and socioeconomic disparities in maternal immunization rates.

Discussion: A strong provider recommendation, equitable access to prenatal care and messaging that focuses on vaccine safety and infant benefits emerged as the key components for optimising vaccine uptake among pregnant women. Research among healthcare providers, minority groups and in low- and-middle-income countries was lacking. In anticipation of the expansion of maternal immunization programmes, focused research is needed to address these gaps and inform a successful public health strategy.

Keywords: Global; Hesitancy; Maternal immunization; Pregnancy; Vaccine.

Fig. 1

PRISMA flow diagram for study selection showing both searches. The initial searchwhich took place on 02/13/2019 and a repeat Medline search on 1/19/2021

Fig. 2

Geographic distribution of included studies

Fig. 3

Vaccines mentioned in included studies

Fig. 4

Interplay of factors influencing uptake of vaccines in pregnancy, grouped according to the SAGE working group’s determinants of vaccine hesitancy. Contextual (sociodemographic/geo-political), Individual and social group influences, Vaccine specific uses