Attitudes towards antenatal vaccination, Group B streptococcus and participation in clinical trials: Insights from focus groups and interviews of parents and healthcare professionals

Maternal Immunization Decision-Making Among Pregnant and Lactating People in Kenya: A Qualitative Exploration of Peer Influences on Vaccine Decision-Making for a Future RSV Vaccine

INTRODUCTION

Respiratory syncytial virus (RSV) is a leading cause of respiratory illness in infants globally, with new maternal RSV vaccines on the horizon. Vaccine decision-making during pregnancy is shaped by individual, interpersonal, community, and societal factors. This study explored key interpersonal influences on maternal vaccine decision-making among pregnant and lactating people (PLP) and community members in Kenya.

METHODS

This qualitative study conducted in-depth interviews with six pregnant people, 18 lactating people, and 10 community members in one rural and one urban county in Kenya. Data were analyzed using a grounded theory approach.

RESULTS

Participants identified the pregnant person themself, male partners, other family members, peers, and healthcare providers (HCPs) as key influences on the maternal immunization decision-making process. The majority of interviewed PLP believed that decision-making during pregnancy should be left to themselves due to autonomy and their role as the primary caregiver. Community members, including male partners, also identified pregnant people as the key decision-maker. While some PLP said they deferred to male partners to make vaccine decisions, more felt that men were not as informed on maternal and child issues as themselves or other female peers and relatives. HCPs emerged as important influences and information sources for PLP during decision-making.

DISCUSSION

Understanding who influences vaccine-decision making during pregnancy will help inform demand generation strategies, and in turn, uptake of future maternal vaccines, including RSV vaccines. Given the strong role HCPs and peers have in the decision-making process, targeting key potential influences is essential to improve vaccine acceptance.

Women's knowledge of and attitudes towards group B streptococcus (GBS) testing in pregnancy: a qualitative study

BACKGROUND

20-25% pregnant women in the UK carry group B streptococcus (GBS) which, if left undetected, is transmitted from pregnant mothers to their babies during birth in 36% of cases. This transmission leads to early onset GBS infection (EOGBS) in 1% of babies which is a significant cause of mortality and morbidity in newborns. The literature available suggests women's knowledge of GBS is low, with many women unaware of the GBS bacterium. In addition, attitudes towards GBS testing have not been widely examined, with research mostly focusing on attitudes towards potential GBS vaccination.

AIM

To examine women's knowledge of GBS in pregnancy and their attitudes towards GBS testing.

METHODS

Semi-structured interviews with 19 women (5 pregnant and 14 postpartum). Interviews were transcribed and analysed using systematic thematic analysis.

RESULTS

Four main theme categories were identified. Participants had varying levels of awareness of GBS, with the information provided by health professionals not being clearly explained or the importance of GBS being downplayed. Participants wanted more information and to feel informed. Overall, the majority had positive attitudes towards being offered and taking up GBS testing, and this study identified some of the key factors influencing their decision. These included: seeing GBS testing as just another routine procedure during pregnancy; that it would lower the risk of their baby becoming unwell; provide reassurance; and allow them to prepare; and provide informed choices. Participants also expressed a few common concerns about GBS testing: questioning the invasiveness of the procedure; risks to themselves and the baby; and the risk of receiving antibiotics.

CONCLUSIONS

Women need clear, detailed information about GBS and GBS testing, and women's concerns are important to address if routine GBS testing is implemented. The efficacy of implementing routine universal testing in the UK is currently being investigated in a large multi-centre clinical trial; the GBS3trial, further qualitative research is needed to look at the acceptability of different methods of GBS testing, as well as the acceptability of GBS testing to women in specific groups, such as those planning a home birth or those from different ethnic backgrounds.

Maternity care provider acceptance of a future Group B Streptococcus vaccine - A qualitative study in three countries

INTRODUCTION

There are vaccines in clinical trials that target the bacterium Group B Streptococcus (GBS). When approved, GBS vaccines will be intended for administration to pregnant women to prevent infection in their infants. The success of any vaccine will depend on its' uptake in the population. Experience with prior maternal vaccines, e.g. influenza, Tdap and COVID-19 vaccines, teaches us that acceptance of vaccines, especially if novel, is challenging for pregnant women, and that provider recommendation is a key driver of vaccine uptake.

METHODS

This study investigated attitudes of maternity care providers towards the introduction of a GBS vaccine in three countries (the United States (US), Ireland, and the Dominican Republic (DR)) with different GBS prevalence and prevention practices. Semi-structured interviews with maternity care providers were transcribed and coded for themes. The constant comparative method, and inductive theory building were used to develop conclusions.

RESULTS

Thirty-eight obstetricians, 18 general practitioners and 14 midwives participated. There was variability in provider attitudes towards a hypothetical GBS vaccine. Responses ranged from enthusiasm to doubts over the need for a vaccine. Attitudes were influenced by perceived additional benefits of a vaccine over current strategy and confidence in the safety of vaccines during pregnancy. Knowledge, experience and approaches to GBS prevention differed geographically and according to provider type, and influenced how participants assessed the risks and benefits of a GBS vaccine.

CONCLUSION

Maternity care providers are engaged in the topic of GBS management and there is opportunity to leverage attitudes and beliefs that will support a strong recommendation for a GBS vaccine. However, knowledge of GBS, and of the limitations of current prevention strategies vary among providers in different regions, and between different provider types. Targeted educational efforts with antenatal providers should focus on highlighting safety data the potential benefits of vaccination over current strategies.

A socio-ecological exploration to identify factors influencing the COVID-19 vaccine decision-making process among pregnant and lactating women: Findings from Kenya

The vaccine decision-making process of pregnant and lactating women is complex. Regarding COVID-19, pregnant women are at increased risk for severe disease and poor health outcomes. While pregnant and lactating women were excluded from COVID-19 vaccine trials, available evidence suggests that COVID-19 vaccines are safe and protective during pregnancy. In this study, we used a socio-ecological approach to explore factors influencing the decision-making process for COVID-19 vaccines in pregnant and lactating women in Kenya, for the purpose of informing demand generation strategies. As pregnant and lactating women are influenced by many factors, we conducted 84 in-depth interviews with a variety of stakeholders, including 31 pregnant or lactating women, 20 healthcare workers such as nurses, midwives, doctors, and frontline workers, 25 male family members of pregnant or lactating women, and 8 gatekeepers such as community leaders and faith-based leaders. These individuals were recruited from six communities in Kenya: three urban, and three rural. We applied a grounded theory approach to identify emerging themes and organized emerging themes using the SAGE Vaccine Hesitancy model, which includes three categories of determinants of vaccine acceptance, including contextual influences, individual and group influences, and vaccine and vaccination specific issues. Myths, interpersonal norms, and religion emerged as themes related to contextual influences. Safety, risk perception, and the role of the healthcare worker emerged as themes related to individual and group influences. For vaccine and vaccination specific issues, emerging themes included availability, accessibility, and eligibility. While maternal immunization can substantially reduce the effect of infectious diseases in mothers and infants, vaccine acceptance is critical. However, vaccines do not save lives; vaccination does. We hope the results of this study can be used to tailor communication efforts to increase vaccine demand among pregnant and lactating women.

Adherence to screening and management guidelines of maternal Group B Streptococcus colonization in pregnancy

Aims

To investigate Group B Streptococcus (GBS) colonization in pregnancy; adherence to antenatal GBS screening and adherence to the intrapartum antibiotics protocol within two models of care (midwifery and non‐midwifery led).

Design

This retrospective quantitative study has employed a descriptive design using administrative health data.

Methods

Data from five maternity hospitals in metropolitan and regional Western Australia that included 22,417 pregnant women who gave birth between 2015 and 2019 were examined, applying descriptive statistics using secondary data analysis.

Results

The study revealed an overall GBS colonization rate of 21.7% with similar rates in the different cohorts. A lower adherence to screening was found in the midwifery led model of care (MMC, 68.76%, n = 7232) when compared with the non‐midwifery led model of care (NMMC, 90.49%, n = 10,767). Over the 5 years, screening rates trended down in the MMC with stable numbers in the counterpart. Adherence in relation to intrapartum antibiotic prophylaxis revealed discrepant findings between the study groups.

Conclusion

Adherence to screening and management guidelines of maternal GBS colonization in pregnancy is lower within the MMC when compared with the NMMC.

Impact

This is the first cohort study to describe the adherence to the recommended Western Australian GBS screening guidelines in the two different models of care. Findings may assist in the guidance and improvement of clinical protocols as well as the planning of clinical care in relation to GBS screening to reduce the risk of neonatal GBS infection.

'My primary purpose is to protect the unborn child': Understanding pregnant women's perceptions of maternal vaccination and vaccine trials in Europe

Despite the important benefits of maternal vaccination for pregnant women and newborns, vaccination uptake is low in many European countries. Differences in vaccination policies and recommendations, as well as concerns about vaccine safety can partly explain inadequate coverage rates and women's hesitancy to get vaccinated during pregnancy. This study aims to explore pregnant women's experiences, decision-making processes and perceptions towards maternal vaccination and maternal vaccine trials in France, Germany, Italy, Spain and the United Kingdom. Qualitative interviews and focus groups were conducted with 258 pregnant women identified through local research panels and snowballing. Topic guides translated in local languages were designed to explore women's awareness and perceptions of maternal vaccination, and willingness to participate in vaccine trials during pregnancy. A thematic analysis was conducted. Pregnant women were found to have low awareness about maternal vaccination, with many reporting not having received a recommendation to vaccinate from their doctors. Strong trust in health professionals indicate that strengthened recommendations could improve vaccination uptake. Vaccination decision-making in pregnancy was described in the context of a highly emotional period, generating anxiety and fears around the safety of vaccines. Pregnancy was also discussed as a period during which women develop nurturing and protective identities. However, depending on the information they received as well as influences from experts, families and peers, women either perceived vaccination as a threat to their babies' safety or as a means to protect them. Attitudes towards maternal vaccine trials were less ambiguous, with most pregnant women strongly rejecting the notion of taking part in trials. While strategies to improve pregnant women's awareness and perceptions of maternal vaccination are needed, it is equally important to understand why healthcare professionals may not be recommending vaccination. More coordinated strategies across Europe could help strengthen communication and trust in maternal vaccination.

A qualitative study of the views of healthcare professionals on providing vaccines information to patients

Background Healthcare professionals (HCPs) such as pharmacists, general practitioners and practice nurses are a trusted source of vaccines information for patients in primary care. Global regulators have highlighted the key role of HCPs in fostering confidence in COVID-19 vaccines. Objective This study aims to gain insight into the views and experiences of HCPs on providing vaccines information to patients. Setting Primary care general practice surgeries and community pharmacies in Ireland. Methods Qualitative, semi-structured interviews were conducted with 14 HCPs (five General practitioners [GPs], four practice nurses and five community pharmacists) identified through purposive and convenience sampling. The interviews were analysed by inductive thematic analysis. Main outcome measure Participants’ views and experiences of providing vaccines information to patients. Results Five key themes were identified: roles and responsibilities, perception of risk, perception of the public, building a relationship, and emotion. HCPs were motivated by duty and care for their patients. They respected patient autonomy and were driven by their concern for public health. HCPs were influenced by their perception of risk and their perceptions of the public. HCPs practiced patient-centred care by providing tailored vaccines information. They favoured an approach of providing patients with information and support to make their own decision. The topic was emotive; HCPs empathised with patients but were also frustrated by their perceived inability to change some patients’ views. Conclusion The provision of vaccines information by HCPs to patients is multifactorial with participants mindful of patient autonomy and the HCP role to support vaccinations as a public health priority. Participants suggested that education and support on vaccines communication would enable them to support the vaccines uptake in their practice.

Cost-effectiveness of maternal immunization against neonatal invasive Group B Streptococcus in the Netherlands

BACKGROUND

Neonatal invasive Group B Streptococcus (GBS) infection causes considerable disease burden in the Netherlands. Intrapartum antibiotic prophylaxis (IAP) prevents early-onset disease (EOD), but has no effect on late-onset disease (LOD). A potential maternal GBS vaccine could prevent both EOD and LOD by conferring immunity in neonates.

OBJECTIVE

Explore under which circumstances maternal vaccination against GBS would be cost-effective as an addition to, or replacement for the current risk factor-based IAP prevention strategy in the Netherlands.

METHODS

We assessed the maximum cost-effective price per dose of a trivalent (serotypes Ia, Ib, and III) and hexavalent (additional serotypes II, IV, and V) GBS vaccine in addition to, or as a replacement for IAP. To project the prevented costs and disease burden, a decision tree model was developed to reflect neonatal GBS disease and long-term health outcomes among a cohort based on 169,836 live births in the Netherlands in 2017.

RESULTS

Under base-case conditions, maternal immunization with a trivalent vaccine would gain 186 QALYs and prevent more than €3.1 million in health care costs when implemented in addition to IAP. Immunization implemented as a replacement for IAP would gain 88 QALYs compared to the current prevention strategy, prevent €1.5 million in health care costs, and avoid potentially ~ 30,000 IAP administrations. The base-case results correspond to a maximum price of €58 per dose (vaccine + administration costs; using a threshold of €20,000/QALY). Expanding the serotype coverage to a hexavalent vaccine would only have a limited additional impact on the cost-effectiveness in the Netherlands.

CONCLUSIONS

A maternal GBS vaccine could be cost-effective when implemented in addition to the current risk factor-based IAP prevention strategy in the Netherlands. Discontinuation of IAP would save costs and prevent antibiotic use, however, is projected to lead to a lower health gain compared to vaccination in addition to IAP.

Clinical Drug Trial Participation: Perspectives of Pregnant Women and Their Spouses

OBJECTIVE

This study aimed at investigating the factors influencing clinical drug trial participation by pregnant women and their spouses.

METHODS

This hospital-based cross-sectional study was conducted at Women's Hospital, School of Medicine, Zhejiang University, from July to September 2020. A self-administered questionnaire was distributed to pregnant women and their spouses in the maternity ward. The questionnaire consisted of two sections: The first part was aimed at collecting demographic information data while the second part consisted of 10 open-ended questions regarding clinical drug trial knowledges, financial compensation, risk awareness, psychological impact, and pregnancy outcomes.

RESULTS

A total of 206 questionnaires (115 from pregnant women and 91 from their spouses) were included in the statistical analysis. About 50% of pregnant women and their spouses had heard of clinical trials (50.43% vs 49.45%, p=0.888). Compared to their spouses, the proportion of pregnant women who thought that there is a need for the development of drugs during pregnancy was significantly higher (94.78% vs 16.48%, p=0.008). Moreover, a significant number of full-time employed pregnant women believed that clinical drug trials will increase the possibility of disease cure, relative to part-time/not employed pregnant women (98.21% vs 88.13%, p=0.030). Spouses whose education levels were below high school and those whose education level was high school or above exhibited significant differences regarding whether financial compensation will motivate their participation in clinical trials (77.78% vs 58.90%, p=0.044). Pregnant women and their spouses had no significant differences regarding various aspects: drug treatment during pregnancy, clinical trial drugs should be free, the need to increase the protection of pregnant women in clinical trials.

CONCLUSION

Due to fetus-associated concerns, most pregnant women are reluctant to be included in clinical trials. However, pregnant women and their spouses agree that medical treatment should be accessible for illnesses during pregnancy, and clinical drug trials during pregnancy should be performed. The usage of untested or sub-therapeutic drug regimens in clinical practice paradoxically increases the risk for fetuses. When recruiting pregnant volunteers for clinical drug trials, researchers should conduct in-depth consultations and comprehensively inform the pregnant women and their families on the pros and cons of their involvement.

Impact of late-onset group B streptococcus infection on families: An observational study

OBJECTIVES

Understand the parental impact of having a baby affected by late-onset group B Strep (LOGBS) infection. Understand the social, mental and financial impact on parents/carers or family members of those affected by LOGBS infection. Investigate family information needs and experiences of information provided.

STUDY DESIGN

We devised a 57-item online survey, composing of binary and matrix questions and free text answers. The survey was distributed internationally to families with a baby(ies) affected by LOGBS infection. The questionnaire was designed as a collaborative effort by Group B Strep Support, its medical advisory panel members, midwives, neonatologists, parents and volunteer analysts. Data were collected from June to September in 2018.

RESULTS

531 participants responded. 252 babies (55 %) made a full recovery from their LOGBS infection, 145 (32 %) recovered with long term sequelae and 61 (13 %) died. 126 respondents (32 %) felt there was a minor to substantial impact on their child's day to day life as a consequence of LOGBS infection. 343 respondents (69 %) had not heard about GBS before their child developed LOGBS infection. 338 respondents (77 %) did not receive an information leaflet on GBS. As a result of their child's LOGBS infection, 177 respondents (39 %) experienced either minor or substantial financial difficulty and 314 respondents (70 %) felt that their own or a family member's mental health was affected. 300 respondents (66 %) experienced problems with planning or reduced enjoyment of subsequent pregnancies. 102 respondents (29 %) reported their other children experienced difficulty due to their sibling's LOGBS infection.

CONCLUSIONS

The results of our study provide a novel insight into families' experiences following a baby affected by LOGBS infection. Study findings suggests that families suffer significant financial and psychological difficulties as a result of LOGBS infection. Furthermore, information needs are frequently being left unmet.

Factors that influence vaccination decision-making among pregnant women: A systematic review and meta-analysis

BACKGROUND

The most important factor influencing maternal vaccination uptake is healthcare professional (HCP) recommendation. However, where data are available, one-third of pregnant women remain unvaccinated despite receiving a recommendation. Therefore, it is essential to understand the significance of other factors and distinguish between vaccines administered routinely and during outbreaks. This is the first systematic review and meta-analysis (PROSPERO: CRD 42019118299) to examine the strength of the relationships between identified factors and maternal vaccination uptake.

METHODS

We searched MEDLINE, Embase Classic & Embase, PsycINFO, CINAHL Plus, Web of Science, IBSS, LILACS, AfricaWideInfo, IMEMR, and Global Health databases for studies reporting factors that influence maternal vaccination. We used random-effects models to calculate pooled odds ratios (OR) of being vaccinated by vaccine type.

FINDINGS

We screened 17,236 articles and identified 120 studies from 30 countries for inclusion. Of these, 49 studies were eligible for meta-analysis. The odds of receiving a pertussis or influenza vaccination were ten to twelve-times higher among pregnant women who received a recommendation from HCPs. During the 2009 influenza pandemic an HCP recommendation increased the odds of antenatal H1N1 vaccine uptake six times (OR 6.76, 95% CI 3.12-14.64, I2 = 92.00%). Believing there was potential for vaccine-induced harm had a negative influence on seasonal (OR 0.22, 95% CI 0.11-0.44 I2 = 84.00%) and pandemic influenza vaccine uptake (OR 0.16, 95% CI 0.09-0.29, I2 = 89.48%), reducing the odds of being vaccinated five-fold. Combined with our qualitative analysis the relationship between the belief in substantial disease risk and maternal seasonal and pandemic influenza vaccination uptake was limited.

CONCLUSIONS

The effect of an HCP recommendation during an outbreak, whilst still powerful, may be muted by other factors. This requires further research, particularly when vaccines are novel. Public health campaigns which centre on the protectiveness and safety of a maternal vaccine rather than disease threat alone may prove beneficial.

Evaluation of women's worries in different strategies for the prevention of early onset group B streptococcal disease in neonates

OBJECTIVE

Early onset group B streptococcal (EOGBS) disease is an important cause of neonatal morbidity and mortality. EOGBS preventive strategies aim to reduce the risk of neonatal complications. Two new strategies to prevent EOGBS were implemented in two regions in the Netherlands: a risk-based and a combination strategy and were compared to the Dutch strategy in a third region. Little is known how women feel about preventive EOGBS strategies, the consequences for management during labour, side effects such as harm caused by over prescribing of antibiotics or anxiety caused by screening. Women's worries in pregnancy overall and on women's worries related to GBS regarding the different strategies were explored.

METHODS

Design - Setting - Participants - Interventions (if appropriate) - Before implementation of the two new strategies, all three regions worked according to the Dutch strategy. Women completed the Cambridge worry scale and a newly developed worry scale aimed to detect GBS related worries at 35 weeks of pregnancy before (T0) and after (T1) implementation of new strategies. Analyses were performed to test whether women's overall worries in pregnancy and their GBS related worries differed between the three strategies.

MEASUREMENTS AND FINDINGS

In total 1369 women participated, 519 before implementation (T0) and 850 during implementation (T1) of EOGBS preventive strategies. Mean overall worries in pregnancy and GBS related worries were low during the whole study period in all three regions. No differences were found in total mean GBS related worries between the three strategies during implementation (T1). When looking at the combined 10% highest CWS and/or GBS related worries during implementation the adjOR were 1.94 (95% CI 1.21-3.12) for the combination strategy, 2.09 (95% CI 1.42-3.08 for primiparity and 6.37 (95% CI 2.98-13.60) for having a different country of origin.

KEY CONCLUSIONS

Overall women had minor GBS related worries in all EOGBS preventive strategies. Implementation of the combination strategy, primiparity and having a different country of origin are associated with the highest levels of overall worries in pregnancy and GBS related worries.

IMPLICATIONS FOR PRACTICE

The low level of women's worries combined with limited effects and cost effectiveness of the three strategies suggests that the strategy with the least costs and lowest antibiotic use should be implemented. A more tailored approach seems needed to address the specific needs of primiparous women and of women from different countries of origin when implementing the combination strategy.

Antenatal vaccination against Group B streptococcus: attitudes of pregnant women and healthcare professionals in the UK towards participation in clinical trials and routine implementation

INTRODUCTION

Maternal vaccination is increasingly part of antenatal care in the UK and worldwide. Trials of Group B streptococcus vaccines are ongoing. This study investigated the attitudes of pregnant women and healthcare professionals towards antenatal vaccination, both in routine care and a clinical trial setting.

MATERIAL AND METHODS

Survey of 269 pregnant women, 273 midwives/obstetricians and 97 neonatal doctors across seven sites in the UK assessing attitudes towards antenatal vaccinations, knowledge of Group B streptococcus, a hypothetical Group B streptococcus vaccine, and participation in clinical vaccine trials.

RESULTS

68% of pregnant women intended to receive a vaccine during their current pregnancy (183/269) and 43% (of all respondents, 115/269) reported they would be very/fairly likely to accept a vaccine against Group B streptococcus despite only 29% (55/269) knowing what Group B streptococcus was. This increased to 69% after additional information about Group B streptococcus was provided. Twenty-four percent of pregnant women reported they would be likely to take part in a clinical trial of an unlicensed Group B streptococcus vaccine. Fifty-nine percent of maternity professionals and 74% of neonatologists would be likely to recommend participation in a Group B streptococcus vaccine trial to women, with the vast majority (>99%) willing to be involved in such a study. Incentives to take part cited by pregnant women included extra antenatal scans and the opportunity to be tested for Group B streptococcus.

CONCLUSION

Pregnant women and healthcare professionals were open to the idea of an antenatal Group B streptococcus vaccine and involvement in clinical trials of such a vaccine. Education and support from midwives would be key to successful implementation.