Antenatal influenza vaccination in urban Pune, India: clinician and community stakeholders’ awareness, priorities, and practices

Abstract

The World Health Organization (WHO) recommends antenatal influenza vaccination (AIV) for pregnant women at any stage of pregnancy. This study assessed fundamental aspects of AIV acceptance and demand among key stakeholders in urban Pune, India. Semi-structured interviews for rapid ethnographic assessment of AIV-related awareness, priorities, and practices were used to study clinicians and their communities of practice. A qualitative survey was conducted among 16 private clinicians providing antenatal care (ANC) in slum and middle-class areas of Pune. Following the survey, clinicians were informed about authoritative AIV recommendations. A qualitative community survey was also conducted with 60 women aged 20-35 years and 30 spouses from the same slum and middle-class practice areas of the ANC providers. Subsequently, a second clinician survey was conducted to assess changes in clinicians' awareness, priority, and vaccination practice. After this interview, clinicians were informed of community survey findings. Most community respondents were unaware of AIV, in contrast with well-known and widely used antenatal tetanus vaccination. They expressed confidence in vaccines and trust in the clinicians. Clinicians' advice was reportedly the most important determinant of community vaccine acceptance. Clinicians were confident of the safety of AIV and they anticipated patients' acceptance if recommended. The second clinician interview showed increased awareness of AIV policy, but clinicians were more skeptical about the severity of maternal influenza in their practice. Our findings indicate community acceptance though not demand for AIV. We recommend five essential elements for vaccination program strategies to improve coverage with AIV and other ANC vaccines.

The supply is there. So why can’t pregnant and breastfeeding women in rural India get the COVID-19 vaccine?

“…Trust in health care providers, including community health workers, was very high, as has been found in past studies in India [22]. A study from India among pregnant women and their health care providers regarding influenza vaccinations also found that health care providers were the most trusted sources for advice on the vaccination, and also that despite high interest among women, there was more uncertainty among their health care providers-although it did not seem as extreme as in this case [23]. Perhaps the novelty of the COVID-19 vaccine made providers additionally hesitant; the same could be true for hesitancy among community members as well, who are used to and accepting of other vaccines in pregnancy, such as tetanus.…”

Health Systems Determinants of Delivery and Uptake of Maternal Vaccines in Low- and Middle-Income Countries: A Qualitative Systematic Review

“…Eight studies conducted in Kenya [48], India [49,52,54], Thailand [42], Brazil [55], Ethiopia [56], and El Salvador [57] explored maternal vaccine delivery and uptake in the private health sector. Overall, these studies underscored the existence of weak co-ordination between public and private health sectors, as well as national immunization and ANC and/or MCH programs where maternal vaccine delivery is concerned.…”

“…Healthcare providers in Nicaragua and India described initiatives such as vaccine administration to women in waiting lines at antenatal clinics as an attempt to overcome such barriers and facilitate adequate coverage [52,65]. Adequate knowledge about VPDs and vaccine effectiveness demonstrated by healthcare providers was strongly associated with sound recommendations to pregnant women, across multiple contexts [42,54,66]. In countries where healthcare providers fueled vaccine hesitancy or rather promoted non-pharmaceutical interventions for VPDs, knowledge on the diseases and vaccine safety was generally reported to be low [42,67].…”

“…However, not all countries offer free antenatal services, and thus services provided during an antenatal visit might require out-of-pocket payment even if the vaccine administered during that same visit was free, as was observed in Thailand [39,42]. Also notable were the experiences in the private healthcare sector, where pregnant women tended to access ANC through the private sector but would then be referred to a public facility just to receive their vaccines because of the free access [54]. Notably, user fees for these services were shown to be associated with a lower vaccine coverage for tetanus and influenza vaccines [45,58,85,86].…”

Expert opinion on the way forward for improving maternal influenza vaccination in India

“…A major barrier is poor knowledge among obstetricians of the burden and severity of influenza infection in pregnant women and young infants and low levels of acceptance of the need for influenza vaccination, as evidenced by variable vaccine prescription practices among obstetricians that were reported by the expert panel and other published studies [12,13,15,48]. The panel also highlighted a lack of knowledge of optimal timing of vaccination among obstetricians or confusion about timing because of non-uniform recommendations from different medical professional bodies [16,17].…”