PREGNANT WOMEN’S COMPLIANCE WITH VACCINATION IN THE CONTEXT OF PANDEMICS: AN INTEGRATIVE REVIEW

Vasconcelos, Patrícia Pereira; Lacerda, Ana Catarina Torres de; Pontes, Cleide Maria; Guedes, Tatiane Gomes; Leal, Luciana Pedrosa; Oliveira, Sheyla Costa de

doi:10.1590/1980-265X-TCE-2022-0117en

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Literature Review • Texto contexto - enferm. 32 • 2023 • https://doi.org/10.1590/1980-265X-TCE-2022-0117en copy

PREGNANT WOMEN’S COMPLIANCE WITH VACCINATION IN THE CONTEXT OF PANDEMICS: AN INTEGRATIVE REVIEW

ADHERENCIA A LA VACUNACIÓN DE MUJERES EMBARAZADAS EN CONTEXTO DE PANDEMIA: REVISIÓN INTEGRATIVA

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

to analyze national and international publications regarding pregnant women’s compliance with vaccination in the context of pandemics.

Method:

this is an integrative literature review, carried out in August 2021 in the LILACS, MEDLINE, Web of Science and Scopus databases, without language and publication time restriction. The descriptors indexed in DeCS and MeSH, Immunization, Vaccination, Pregnancy and Pandemics, combined using the Boolean operator, were used. The results obtained were exported to the EndNote reference manager software and, later, to the Rayyan - Intelligent Systematic Review application. The sample consisted of 27 studies. Analysis considered frequency and similarities between the studies.

Results:

the factors that interfere with compliance with vaccination by pregnant women in pandemic times were highlighted: distrust of vaccines; concerns about vaccination safety in pregnancy or for the fetus’ health; lack of information and lack of knowledge about the benefits of vaccine. Moreover, the reasons for compliance were desire to protect the baby, knowledge about the pandemic, concern about the risk of infection, and recommendation and guidance on vaccination during prenatal care.

Conclusion:

the factors that may interfere with compliance with vaccination were verified, mainly in relation to new vaccines in the context of pandemics. It is considered that investments in strategies related to immunization during pregnancy can provide health benefits, preventing preventable diseases in pregnant women and their babies.

DESCRIPTORS:
Pregnant Women; Pandemic; COVID-19; Vaccination; Nursing

Database	Search strategies
LILACS	Vaccination OR Immunization [Subject descriptor] AND Pregnancy [Subject descriptor] AND Pandemics [Subject descriptor]
MEDLINE/PubMed	((((Vaccination [MeSH Terms]) OR (Immunization [MeSH Terms])) AND (Pregnancy [MeSH Terms]))) AND (Pandemics [MeSH Terms])
WEB OF SCIENCE	Vaccination OR Immunization (Topic) AND Pregnancy (Topic) AND Pandemics (Topic)
SCOPUS	(TITLE-ABS-KEY (vaccination) OR TITLE-ABS-KEY (immunization) AND TITLE-ABS-KEY (pregnancy) AND TITLE-ABS-KEY (pandemics))

Descriptors	LILACS	MEDLINE	Web Of Science	Scopus	Total publications
(Vaccination OR Immunization) AND Pregnancy AND Pandemics	1	69	329	608	1007

Author/year/LoE* RM†	Objective and sample	Result
Mohan S, et al28 202128. Mohan S, Reagu S, Lindow S, Alabdulla M. COVID-19 vaccine hesitancy in perinatal women: a cross sectional survey. J Perinat Med [Internet]. 2021 [2021 Aug 28];49(6):678-85. Available from: http://doi.org/10.1515/jpm-2021-0069 http://doi.org/10.1515/jpm-2021-0069... LoE:6 MR: Level A	- Explore attitudes towards COVID-19 vaccination between women in the perinatal period. - Sample of 341 pregnant and breastfeeding women.	The distrust of future vaccine problems (70.6%) was a main reason for vaccination hesitation. Factors that would increase confidence in accepting the vaccine were reading about efficacy (33.8%) or positive feedback from family or friends (8.1%).
Gencer H, et al45 202145. Gencer H, Özkan S, Vardar O, Serçekuş P. The effects of the COVID 19 pandemic on vaccine decisions in pregnant women. Women Birth [Internet]. 2021 [cited 2021 Aug 28];35(3):317-23. Available from: http://doi.org/10.1016/j.wombi.2021.05.003 http://doi.org/10.1016/j.wombi.2021.05.0... LoE:6 MR: Level A	- Determine the opinions of pregnant women about vaccines during pregnancy and childhood and the effect of COVID-19 pandemic on these opinions. - Sample of 152 pregnant women.	The reasons for vaccination hesitation were listening or reading negative media news (21.7%) and believing that vaccines were not safe or were concerned about side effects (21.7%).
Goncu Ayhan S, et al51 202151. Goncu Ayhan S, Oluklu D, Atalay A, Menekse Beser D, Tanacan A, Moraloglu TO, et al. COVID-19 vaccine acceptance in pregnant women. Int J Gynaecol Obstet [Internet]. 2021 [cited 2021 Aug 28];154(2):291-296. Available from: http://doi.org/10.1002/ijgo.13713 http://doi.org/10.1002/ijgo.13713... LoE:6 MR: Level A	- Define COVID-19 vaccine acceptance and hesitancy status in a sample of pregnant women in Ankara, Turkey. - Sample of 300 pregnant women.	63% of pregnant women would refuse the vaccine COVID-19 vaccine even if recommended. Of these, 65.6% declared concern about lack of data on vaccine safety in the pregnant population, and 41.7%, the possibility of harm to the fetus.
Stuckelberger S, et al30 202130. Stuckelberger S, Favre G, Ceulemans M, Nordeng H, Gerbier E, Lambelet V, et al. SARS-CoV-2 Vaccine Willingness among Pregnant and Breastfeeding Women during the First Pandemic Wave: A Cross-Sectional Study in Switzerland. Viruses [Internet]. 2021 [cited 2021 Aug 30];13(7):1199. Available from: http://doi.org/10.3390/v13071199 http://doi.org/10.3390/v13071199... LoE:6 MR: Level A	- Investigate the COVID-19 vaccine availability among pregnant and breastfeeding Swiss women if the vaccine was available as well as the factors that contributed to its acceptance or hesitation. - Sample of 1551 Swiss women (515 pregnant and 1,036 breastfeeding up to 90 days).	29.7% of pregnant women and 38.6% breastfeeding women were willing to be vaccinated against SARS-CoV-2. Among participants, 10.5% mentioned fear of potential consequences for the fetus/baby. Women in the third trimester of pregnancy who had received influenza vaccination in the previous year were more likely to receive the vaccine.
Tao L, et al53 202153. Tao L, Wang R, Han N, Liu J, Yuan C, Deng L, et al. Acceptance of a COVID-19 vaccine and associated factors among pregnant women in China: a multi-center cross-sectional study based on health belief model. Hum Vaccin Immunother [Internet]. 2021 [cited 2021 Aug 30];17(8):2378-2388. Available from: http://doi.org/10.1080/21645515.2021.1892432 http://doi.org/10.1080/21645515.2021.189... LoE:6 MR: Level A	- Explore COVID-19 vaccine acceptance and factors related to vaccine acceptance based on the health belief model. - Sample of 1,392 pregnant women.	Among the 315 pregnant women who answered “no” or “not sure” of their intention to be vaccinated with a COVID-19 vaccine, 54% refused any vaccination during pregnancy due to concern about side effects; 47.0% were concerned about safety; and 44.1% were concerned about vaccine efficacy.
Im JH, et al⁴⁸ 2020 LoE:6 MR: Level A	- Assess changes in influenza vaccination coverage rates and the related factors that influence them in pregnant women. - Sample of 550 pregnant women.	The common reasons for receiving the vaccine were preventing the flu (49.7%) and ensuring fetal health (46.3%). The most common reason for non-vaccination was lack of sufficient information about vaccination (36.9%).
Bettinger JA, et al39 201639. Bettinger JA, Greyson D, Money D. Attitudes and Beliefs of Pregnant Women and New Mothers Regarding Influenza Vaccination in British Columbia. J Obstet Gynaecol Can [Internet]. 2016 [cited 2021 Sep 01];38(11):1045-52. 30. Available from: http://doi.org/10.1016/j.jogc.2016.08.004 http://doi.org/10.1016/j.jogc.2016.08.00... LoE:6 MR: Level A	- Investigate pregnant women’s and new mothers’ attitudes and behaviors in relation to seasonal and pandemic influenza vaccination. - Sample of 26 pregnant women and eight postpartum women in the focus group (FG); of these, 22 composed the online survey.	67.6% of FG participants agreed “somewhat” about vaccine safety during pregnancy and, for most of the, the vaccine’s unknown risks do not outweigh the benefits and were concerned about adverse effects of vaccination. In the online survey, 42% of unvaccinated women did not feel informed enough to make the decision to receive the vaccine; 42% were concerned about safety; and 50% did not discuss vaccination with their health professional.
Jung EJ, et al29 201629. Jung EJ, Noh JY, Choi WS, Seo YB, Lee J, Song JY, et al. Perceptions of influenza vaccination during pregnancy in Korean women of childbearing age. Hum Vaccin Immunother [Internet]. 2016 [cited 2021 Sep 02];12(8):1997-2002. Available from: http://doi.org/10.1080/21645515.2015.1119347 http://doi.org/10.1080/21645515.2015.111... LoE:6 MR: Level A	- Assess coverage rate and perceptions of Korean women of reproductive age about influenza vaccine during pregnancy and conduct a virtual intervention to increase their intention to receive vaccination. - Sample of 500 pregnant women and 500 women of reproductive age.	Among 764 participants, 62.7% did not receive the vaccine during pregnancy and the reasons for not vaccinating were concerns about harmful effects on the fetus (29.6%) and lack of vaccine recommendation by health professionals (12.9%). Of those who received the vaccine, the reasons for vaccination were perceived risk of influenza infection in babies (22.8%), health professionals’ recommendation (26.7%) and belief in vaccine efficacy (15.8%).
Mccarthy EA, et al38 201538. McCarthy EA, Pollock WE, Tapper L, Sommerville M, McDonald S. Increasing uptake of influenza vaccine by pregnant women post H1N1 pandemic: a longitudinal study in Melbourne, Australia, 2010 to 2014. BMC Preg Child [Internet]. 2015 [cited 2021 Sep 02];15:53. Available from: http://doi.org/10.1186/s12884-015-0486-3 http://doi.org/10.1186/s12884-015-0486-3... LoE:6 MR: Level A	- Review facilitating and impeding factors in promoting influenza vaccination during pregnancy to inform future lay and professional educational efforts. - Final sample of 1,086 postpartum women.	65.0% of participants who remembered vaccination being discussed or recommended by a health professional were subsequently vaccinated. The main reason for vaccinating was the desire to protect the baby, which increased from 66.7% in 2010 to 89.2% in 2014, while 47.1% chose not to vaccinate during pregnancy because they do not usually be vaccinated during pregnancy.
Halperin BA, et al49. 201449. Halperin BA, MacKinnon-Cameron D, McNeil S, Kalil J, Halperin SA. Maintaining the momentum: key factors influencing acceptance of influenza vaccination among pregnant women following the H1N1 pandemic. Hum Vaccin Immunother [Internet]. 2014 [cited 2021 Sep 03];10(12):3629-364. Available from: http://doi.org/10.4161/21645515.2014.980684 http://doi.org/10.4161/21645515.2014.980... LoE:6 MR: Level A	- Explore and compare pregnant women’s pre- and post-pandemic knowledge, attitudes, beliefs and intended behaviors regarding influenza vaccination (seasonal and/or pandemic) during pregnancy in order to determine the main factors influencing their decision to comply with the influenza vaccine recommendations. - Sample of 662 pregnant women in the pre-pandemic period (2005-2006) and 159 in the post-pandemic period (2011).	The reasons for seasonal flu vaccination were protection against the disease for themselves and their family (44% pre- and 45% post-pandemic) and health professionals’ recommendation (19% pre and 38% post), reasons for vaccination H1N1 (48% and 20%, respectively). Reasons for not vaccinating against seasonal flu were that they did not need to receive immunization (36% pre and 70% post) and concern about side effects (5% and 26%); reasons also cited by women who did not receive the vaccine against the H1N1 pandemic (26% and 14%, respectively).
Lohiniva AL, et al34 201434. Lohiniva AL, Barakat A, Dueger E, Restrepo S, El Aouad R. A qualitative study of vaccine acceptability and decision making among pregnant women in Morocco during the A (H1N1) pdm09 pandemic. PLoS One [Internet]. 2014 [cited 2021 Sep 02];9(10):e96244. Available from: https://doi.org/10.1371/journal.pone.0096244 https://doi.org/10.1371/journal.pone.009... LoE:6 MR: Level A	- Describe pregnant women’s perceptions related to H1N1 influenza, to identify the factors that encourage or discourage them to take the A(H1N1) monovalent vaccine pdm09 during the response to the pandemic (2009-2010), and the sources of information that influenced their process of decision-making. - Sample of 123 pregnant women.	Women feared that the vaccine could negatively affect their health and that of their babies, and speech analysis identified the interference of the social network in the decision-making to receive the vaccine: discussions with health professionals were a positive factor for the decision-making for vaccination, while rumor-based discussions about complications and side effects with neighbors and friends often fuel the decision not to vaccinate.
Ahluwalia IB, et al37 201437. Ahluwalia IB, Ding H, Harrison L, D'Angelo D, Singleton JA, Bridges C, et al. Disparities in influenza vaccination coverage among women with live-born infants: PRAMS surveillance during the 2009-2010 influenza season. Public Health Rep [Internet]. 2014 [cited 2021 Sep 03];129(5):408-16. Available from: http://doi.org/10.1177/003335491412900504 http://doi.org/10.1177/00333549141290050... LoE:6 MR: Level A	- Examine disparities in vaccination coverage among women who gave birth during the 2009-2010 influenza season, when two separate influenza vaccinations were recommended. - Sample of postpartum and breastfeeding women, 27.153 for seasonal influenza and 27.372 for H1N1.	Reasons cited for not receiving vaccination include: lack of recommendation by health care provider about a flu shot during pregnancy; concern about vaccine side effects; concern of harm to the fetus; habit of not getting the flu shot.
Kfouri RA, Richtmann R46 201347. Kfouri RA, Richtmann R. Influenza vaccine in pregnant women: immunization coverage and associated factors. Einstein [Internet]. 2013 [cited 2021 Sep 03];11(1):53-7. Available from: https://www.scielo.br/j/eins/a/3FXs74mjzbKvXLLbfGCQrNN/?format=pdf⟨=en https://www.scielo.br/j/eins/a/3FXs74mjz... LoE:6 MR: Level B	- Describe the vaccination coverage of pregnant women for influenza and factors associated with vaccine refusal or acceptance. - Sample of 300 postpartum women.	95.7% received the vaccine against influenza during pregnancy and, of these, 73.2% knew that the vaccine would protect their child. Among those who did not receive it, all were unaware of the fact that the vaccine would protect the baby, and 69.2% would have been vaccinated if they had been informed of neonatal protection.
Tarrant M, et al41 201341. Tarrant M, Wu KM, Yuen CY, Cheung KL, Chan VH. Determinants of 2009 A/H1N1 influenza vaccination among pregnant women in Hong Kong. Matern Child Health J [Internet]. 2013 [cited 2021 Aug 30];17(1):23-32. Available from: http://doi.org/10.1007/s10995-011-0943-1 http://doi.org/10.1007/s10995-011-0943-1... LoE:6 MR: Level A	- Examine factors associated with the adoption of the 2009 influenza A/H1N1 vaccine among pregnant women in Hong Kong. - Sample of 549 postpartum women.	91.1% did not receive any of the influenza A (H1N1) and/or seasonal vaccines during pregnancy, and the reason cited was the fear that the vaccine would cause side effects to them or their fetus (69.7% and 75.7%, respectively), and reported that vaccination should be avoided during pregnancy (78.8%).
Kouassi DP, et al52 201252. Kouassi DP, Coulibaly D, Foster L, Kadjo H, N'Zussuouo T, Traoré Y et al. Vulnerable groups within a vulnerable population: awareness of the A(H1N1) pdm09 pandemic and willingness to be vaccinated among pregnant women in Ivory Coast. J Infect Dis [Internet]. 2012 [cited 2021 Sep 03];206(Suppl 1):S114-20. Available from: http://doi.org/10.1093/infdis/jis532 http://doi.org/10.1093/infdis/jis532... LoE:6 MR: Level A	- Assess awareness of the pandemic and A(H1N1) pdm09 vaccine awareness and acceptance in February 2010, prior to the local availability of the vaccine. - Sample of 411 pregnant women.	Of the 80 women who said they would not accept being vaccinated, 45% reported lack of information about the vaccine as the reason for not vaccinating. Women who are aware of the pandemic and believe they are susceptible to H1N1 flu were more likely to accept vaccination (75.4%).
Honarvar B, et al32 201250. Moukarram H, Nargund A, Photiou A, Kiran TS. Awareness and acceptance of the pandemic influenza (H1N1v 2009) vaccination among antenatal patients in a district general hospital. J Obstet Gynaecol [Internet]. 2012 [cited 2021 Sep 03];32(6):537-9. Available from: https://doi.org/10.3109/01443615.2012.692738 https://doi.org/10.3109/01443615.2012.69... LoE:6 MR: Level A	- Determine the acceptance rate of influenza vaccination, including the 2009 pandemic influenza H1N1 and seasonal influenza vaccination, and the reasons for acceptance or rejection among pregnant women. - Sample of 416 pregnant women.	Out of 92.06% of pregnant women who refused the H1N1 influenza vaccine, 30.28% reported lack of information about vaccination as the main reason for refusal. Of the 25 vaccinated pregnant women, 60% reported having been vaccinated on the advice of someone other than a health professional.
Schindler M, et al33 201233. Schindler M, Blanchard-Rohner G, Meier S, Martinez de Tejada B, Siegrist CA, Burton-Jeangros C. Vaccination against seasonal flu in Switzerland: The indecision of pregnant women encouraged by healthcare professionals. Rev Epidemiol Sante Publique [Internet]. 2012 [cited 2021 Sep 03];60(6):447-53. Available from: http://doi.org/10.1016/j.respe.2012.03.008 http://doi.org/10.1016/j.respe.2012.03.0... LoE:6 MR: Level A	- Examine Swiss pregnant women’s representations of the risks associated with seasonal flu and its vaccination in the first wave. - Sample of 29 postpartum women.	The lack of recommendation, by health professionals, about the dangerousness of seasonal flu and the protection afforded by vaccines may have left pregnant women in a state of indecision regarding vaccination.
Moukarram H, et al50 201250. Moukarram H, Nargund A, Photiou A, Kiran TS. Awareness and acceptance of the pandemic influenza (H1N1v 2009) vaccination among antenatal patients in a district general hospital. J Obstet Gynaecol [Internet]. 2012 [cited 2021 Sep 03];32(6):537-9. Available from: https://doi.org/10.3109/01443615.2012.692738 https://doi.org/10.3109/01443615.2012.69... LoE:6 MR: Level B	- Assess vaccine awareness and uptake among pregnant women in the local community. - Sample of 200 pregnant women.	42.5% of pregnant women said they would take the vaccine. Regarding the main reasons for refusal, 43.5% reported concern about possible risks to the fetus and 40.9%, risk to themselves.
Bhaskar E, et al42 201242. Bhaskar E, Thobias S, Anthony S, Kumar V, Navaneethan -. Vaccination rates for pandemic influenza among pregnant women: An early observation from Chennai, South India. Lung India [Internet]. 2012 [cited 2021 Sep 03];29(3):232-5. Available from: http://doi.org/10.4103/0970-2113.99105 http://doi.org/10.4103/0970-2113.99105... LoE:6 MR: Level A	- Identify pandemic influenza vaccination rates among pregnant women in Chennai during the first two months after influenza vaccine rollout and to analyze factors associated with vaccination. - Sample of 140 pregnant women.	The influenza vaccination rate was 12.8%. The reasons for refusal were fear of complications (28.5%), not knowing where the vaccine was available (28.5%) and not knowing the benefits of vaccination (28.5%).
Kay WK, et al36 201236. Kay MK, Koelemay KG, Kwan-Gett TS, Cadwell BL, Duchin JS. 2009 pandemic influenza a vaccination of pregnant women: King County, Washington State, 2009-2010. Am J Public Health [Internet]. 2012 [cited 2021 Sep 10];42(Suppl 2):S172-9. Available from: http://doi.org/10.1016/j.amepre.2012.04.003 http://doi.org/10.1016/j.amepre.2012.04.... LoE:6 MR: Level A	- Estimate pH1N1 vaccination coverage among women in King County during the third trimester of pregnancy and identify sociodemographic factors, beliefs and practices associated with vaccination. - Sample of 4,205 postpartum women.	The reasons cited by women not vaccinated against H1N1 were not being able to find a vaccination provider (20.6%) and the perception that they were not at risk of serious illness (26.1%). The reasons reported for not being vaccinated against the flu were safety issues (58%) related to the effects of the vaccine on the mother’s or fetus’ health.
Steelfisher GK, et al35 201135. Steelfisher GK, Blendon RJ, Bekheit MM, Mitchell EW, Williams J, Lubell K, et al. Novel pandemic A (H1N1) influenza vaccination among pregnant women: motivators and barriers. Am J Obstet Gynecol [Internet]. 2011 [cited 2021 Aug 30];204(6 Suppl 1):S116-23. Available from: http://doi.org/10.1016/j.ajog.2011.02.036 http://doi.org/10.1016/j.ajog.2011.02.03... LoE:6 MR: Level B	- Examine drivers and barriers to pregnant women receiving the H1N1 vaccine through a national survey conducted during the pandemic. - Sample of 514 pregnant women.	The main reason for refusing to receive the vaccine was concern about safety risks to the fetus (62%) and to herself (59%). Pregnant women who knew that the H1N1 vaccine provided protection against H1N1 flu for their babies were more likely to receive the vaccine.
Dlugacz Y, et al 5454. Dlugacz Y, Fleischer A, Carney MT, Copperman N, Ahmed I, Ross Z, et al. 2009 H1N1 vaccination by pregnant women during the 2009-10 H1N1 influenza pandemic. Am J Obstet Gynecol [Internet]. 2012 [cited 2021 Sep 10];206(4):339.e1-8. Available from: http://doi.org/10.1016/j.ajog.2011.12.027 http://doi.org/10.1016/j.ajog.2011.12.02... 2011 LoE:6 MR: Level A	- Identify factors associated with acceptance or refusal of the 2009 H1N1 vaccination during pregnancy. - Sample of 1,325 postpartum women.	34.2% received the 2009 H1N1 vaccine during pregnancy; 54% unvaccinated women indicated, as reason for refusal, concern about the vaccine safety for the fetus. Health professionals’ recommendation was one of the reasons for accepting the H1N1 vaccine. Of those who received the recommendation, 56% were vaccinated.
Goldfarb I, et al31 201131. Goldfarb I, Panda B, Wylie B, Riley L. Uptake of influenza vaccine in pregnant women during the 2009 H1N1 influenza pandemic. Am J Obstet Gynecol [Internet]. 2011 [cited 2021 Sep 10];204(6 Suppl 1):S112-5. Available from: http://doi.org/10.1016/j.ajog.2011.01.007 http://doi.org/10.1016/j.ajog.2011.01.00... LOE:6 MR: Level A	- Define the uptake of H1N1 and seasonal influenza vaccination among women who delivered at an urban teaching hospital during the 2009-2010 H1N1 pandemic and explore barriers to vaccinating pregnant women. - Sample of 366 postpartum women.	81% received H1N1 and seasonal flu vaccines. Factors for compliance were the desire to protect themselves (>60%) and their babies (>80%) and recommendation from a health professional (>60%), while refusal was motivated by media attention and recommendation from government agencies (<20%).
Fisher BM, et al 4040. Fisher BM, Scott J, Hart J, Winn VD, Gibbs RS, Lynch AM. Behaviors and perceptions regarding seasonal and H1N1 influenza vaccination during pregnancy. Am J Obstet Gynecol [Internet]. 2011 [cited 2021 Sep 10];204(6 Suppl 1):S107-11. Available from: http://doi.org/10.1016/j.ajog.2011.02.041 http://doi.org/10.1016/j.ajog.2011.02.04... 2011 LOE:6 MR: Level A	- Determine influenza vaccination rates, both seasonal and H1N1 pandemic, in pregnancy during the 2009-2010 influenza season and for those women not vaccinated during pregnancy to determine reasons for non-compliance. - Sample of 813 postpartum women.	64% of participants received vaccination against seasonal flu, and 54%, against H1N1 flu during pregnancy. Of women who did not receive both vaccines, 25% reported not being well-informed about the importance of the vaccine, 18% reported concern about the vaccine’s effects on fetal health, and 9%, about maternal health.
Sakaguchi S, et al 4343. Sakaguchi S, Weitzner B, Carey N, Bozzo P, Mirdamadi K, Samuel N, et al. Pregnant women's perception of risk with use of the H1N1 vaccine. J Obstet Gynaecol Can [Internet]. 2011 [cited 2021 Sep 10];33(5):460-7. Available from: http://doi.org/10.1016/S1701-2163(16)34879-4 http://doi.org/10.1016/S1701-2163(16)348... 2010 LOE:6 MR: Level A	- Determine how many pregnant women received the H1N1 vaccine after their call to Motherisk and explore pregnant women’s perceptions of the H1N1 vaccine and factors surrounding the decision to receive vaccination. - Sample of 130 pregnant women.	Among pregnant women who received the vaccine, 73.1% reported concern about the risk of H1N1 infection in the fetus and/or themselves as a reason for their decision; 34.6% cited recommendations to encourage vaccination; and 3.8% mentioned a previous history of complication or illness due to influenza. Of those who did not receive the vaccine, 42.3% reported concerns about safety for themselves and/or their fetus, and 23.1% did not find the vaccine necessary.
Ozer A, et al46 201046. Ozer A, Arikan DC, Kirecci E, Ekerbicer HC. Status of pandemic influenza vaccination and factors affecting it in pregnant women in Kahramanmaras, an eastern Mediterranean city of Turkey. PLoS One [Internet]. 2010 [cited 2021 Sep 10];5(12):e14177. Available from: http://doi.org/10.1371/journal.pone.0014177 http://doi.org/10.1371/journal.pone.0014... LOE:6 MR: Level A	- Determine factors that affect pregnant women’s decisions in Turkey whether or not to be vaccinated against 2009 H1N1 influenza. - Sample of 314 pregnant women.	The H1N1 vaccination rate was 8.9%. 75.5% of the unvaccinated thought the vaccine was harmful in the long term; 70.1% believed it could cause miscarriage, 74.2% deformity in their children and 72.3% infertility.
White SW, et al44 201044. White SW, Petersen RW, Quinlivan JA. Pandemic (H1N1) 2009 influenza vaccine uptake in pregnant women entering the 2010 influenza season in Western Australia. Med J Aust [Internet]. 2010 [cited 2021 Sep 10];193(7):405-7. Available from: https://doi.org/10.5694/j.1326-5377.2010.tb03970.x https://doi.org/10.5694/j.1326-5377.2010... LOE:6 MR: Level A	- Audit the 2009 pandemic (H1N1) influenza vaccine acceptance in pregnant women entering the 2010 influenza season in Western Australia and identify why some women did not receive the vaccine. - Sample of 479 pregnant women.	The H1N1 vaccination rate was 6.9%. Reasons for not vaccinating were lack of discussion or dialogue about the vaccine with health professionals during prenatal care (63.9%), concern about vaccination safety by pregnant women (61.6%) and active discouragement of prenatal vaccination (19.6%).

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[1] CORRESPONDING AUTHOR
Patrícia Pereira Vasconcelo patricia.vasconcelos@ufpe.br