Acceptability of Clinical Trials on COVID-19 during Pregnancy among Pregnant Women and Healthcare Providers: A Qualitative Study

Factors influencing the participation of pregnant and lactating women in clinical trials: A mixed-methods systematic review

BACKGROUND

Poor representation of pregnant and lactating women and people in clinical trials has marginalised their health concerns and denied the maternal-fetal/infant dyad benefits of innovation in therapeutic research and development. This mixed-methods systematic review synthesised factors affecting the participation of pregnant and lactating women in clinical trials, across all levels of the research ecosystem.

METHODS AND FINDINGS

We searched 8 databases from inception to 14 February 2024 to identify qualitative, quantitative, and mixed-methods studies that described factors affecting participation of pregnant and lactating women in vaccine and therapeutic clinical trials in any setting. We used thematic synthesis to analyse the qualitative literature and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. We compared quantitative data against the thematic synthesis findings to assess areas of convergence or divergence. We mapped review findings to the Theoretical Domains Framework (TDF) and Capability, Opportunity, and Motivation Model of Behaviour (COM-B) to inform future development of behaviour change strategies. We included 60 papers from 27 countries. We grouped 24 review findings under 5 overarching themes: (a) interplay between perceived risks and benefits of participation in women's decision-making; (b) engagement between women and the medical and research ecosystems; (c) gender norms and decision-making autonomy; (d) factors affecting clinical trial recruitment; and (e) upstream factors in the research ecosystem. Women's willingness to participate in trials was affected by: perceived risk of the health condition weighed against an intervention's risks and benefits, therapeutic optimism, intervention acceptability, expectations of receiving higher quality care in a trial, altruistic motivations, intimate relationship dynamics, and power and trust in medicine and research. Health workers supported women's participation in trials when they perceived clinical equipoise, had hope for novel therapeutic applications, and were convinced an intervention was safe. For research staff, developing reciprocal relationships with health workers, having access to resources for trial implementation, ensuring the trial was visible to potential participants and health workers, implementing a woman-centred approach when communicating with potential participants, and emotional orientations towards the trial were factors perceived to affect recruitment. For study investigators and ethics committees, the complexities and subjectivities in risk assessments and trial design, and limited funding of such trials contributed to their reluctance in leading and approving such trials. All included studies focused on factors affecting participation of cisgender pregnant women in clinical trials; future research should consider other pregnancy-capable populations, including transgender and nonbinary people.

CONCLUSIONS

This systematic review highlights diverse factors across multiple levels and stakeholders affecting the participation of pregnant and lactating women in clinical trials. By linking identified factors to frameworks of behaviour change, we have developed theoretically informed strategies that can help optimise pregnant and lactating women's engagement, participation, and trust in such trials.

Efficacy and safety of hydroxychloroquine for treatment of mild SARS-CoV-2 infection and prevention of COVID-19 severity in pregnant and postpartum women: A randomized, double-blind, placebo-controlled trial

INTRODUCTION

Pregnant women have an increased risk of severe COVID-19. Evaluation of drugs with a safety reproductive toxicity profile is a priority. At the beginning of the pandemic, hydroxychloroquine (HCQ) was recommended for COVID-19 treatment.

MATERIAL AND METHODS

A randomized, double-blind, placebo-controlled clinical trial was conducted in eight teaching hospitals in Spain to evaluate the safety and efficacy of HCQ in reducing viral shedding and preventing COVID-19 progression. Pregnant and postpartum women with a positive SARS-CoV-2 PCR (with or without mild COVID-19 signs/symptoms) and a normal electrocardiogram were randomized to receive either HCQ orally (400 mg/day for 3 days and 200 mg/day for 11 days) or placebo. PCR and electrocardiogram were repeated at day 21 after treatment start. Enrollment was stopped before reaching the target sample due to low recruitment rate. Trial registration EudraCT #: 2020-001587-29, on April 2, 2020.

CLINICAL TRIALS

gov # NCT04410562, registered on June 1, 2020.

RESULTS

A total of 116 women (75 pregnant and 41 post-partum) were enrolled from May 2020 to June 2021. The proportion of women with a positive SARS-CoV-2 PCR at day 21 was lower in the HCQ group (21.8%, 12/55) than in the placebo group (31.6%, 18/57), although the difference was not statistically significant (P = 0.499). No differences were observed in COVID-19 progression, adverse events, median change in QTc, hospital admissions, preeclampsia or poor pregnancy and perinatal outcomes between groups.

CONCLUSIONS

HCQ was found to be safe in pregnant and postpartum women with asymptomatic or mild SARS-CoV-2 infection. Although the prevalence of infection was decreased in the HCQ group, the statistical power was insufficient to confirm the potential beneficial effect of HCQ for COVID-19 treatment.

Qualitative interview study exploring the perspectives of pregnant women on participating in controlled human infection research in the UK

INTRODUCTION

Pregnant women have been historically excluded from interventional research. While recent efforts have been made to improve their involvement, there remains a disparity in the evidence base for treatments available to pregnant women compared with the non-pregnant population. A significant barrier to the enrolment of pregnant women within research is risk perception and a poor understanding of decision-making in this population.

OBJECTIVE

Assess the risk perception and influences on decision-making in pregnant women, when considering whether to enrol in a hypothetical interventional research study.

DESIGN

Semistructured interviews were undertaken, and thematic analysis was undertaken of participant responses.

PARTICIPANTS

Twelve pregnant women were enrolled from an antenatal outpatient clinic.

RESULTS

Participants were unanimously positive about enrolling in the proposed hypothetical interventional study. Risk perception was influenced by potential risks to their fetus and their previous experiences of healthcare and research. Participants found the uncertainty in quantifying risk for new research interventions challenging. They were motivated to enrol in research by altruism and found less invasive research interventions more tolerable.

CONCLUSION

It is vital to understand how pregnant women balance the perceived risks and benefits of interventional research. This may help clinicians and scientists better communicate risk to pregnant women and address the ongoing under-representation of pregnant women in interventional research.

Pregnant women with diabetes and their clinician's experience of participating in a pilot randomised controlled trial of corticosteroid administration in late pregnancy: A qualitative study

BACKGROUND

Little research exists to support the administration of corticosteroids to pregnant women with diabetes. Pregnant women are often excluded from clinical trials due to concerns of harm to the foetus.

AIM

This study aimed to understand the experiences of women and clinicians of participating in the Prevention of neonatal Respiratory distress with antenatal corticosteroids before Elective Caesarean section in women with Diabetes pilot randomised controlled trial to determine the acceptability of the study protocol.

METHODS

Women and clinicians participating in the pilot trial were invited to complete a telephone interview regarding their experiences of participating. Qualitative data were collected and subsequently analysed using thematic analysis.

RESULTS

A total of 13 women and nine clinicians were recruited between June 2020 and May 2022 for a telephone interview. Participating in the study was deemed acceptable by women and clinicians. Women chose to participate in the study due to the perceived low risk of harm associated with the intervention and for altruistic reasons. The high level of clinical support and information provided for the duration of the pilot trial was valued by women and clinicians. All clinicians highlighted the importance of conducting the trial to inform evidence-based practice.

CONCLUSIONS

Pregnant women are more likely to participate in clinical trials when perceived risks are low and they are well-informed during decision-making. Clinicians will support clinical trials when they perceive a benefit to practice and feel assured that women receive extensive monitoring and support. Incorporating these factors into study protocols is more likely to be successful in recruiting pregnant women and maintaining the engagement of clinical staff for the duration of clinical trials.

PATIENT OR PUBLIC CONTRIBUTIONS

Patients were invited to be participants in this study. A consumer has been included in the planning and oversite of the large multicentre trial.

COVID-19 Vaccination Booster Dose: Knowledge, Practices, and Intention among Pregnant/Planning to Get Pregnant and Lactating Women

Pregnant women are at higher risk of developing severe COVID-19 symptoms. Therefore, booster dose against COVID-19 was recommended for this special population in Jordan. However, vaccine hesitancy/refusal remains the main obstacle to providing immunity against the spread of COVID-19. Thus, the aim of this study is to examine the intention of pregnant/planning to get pregnant and lactating women towards receiving a booster dose against COVID-19 and its associated factors. A questionnaire was given to Jordanian pregnant/planning to get pregnant and lactating females. A total of 695 females were enrolled in the study. Older age, having a chronic disease, high education, high income, and high perceived risk of COVID-19 were significantly associated with higher knowledge about COVID-19. High perceived risk of COVID-19 was significantly associated with better practice. Participants who anticipated they might contract COVID-19 in the next six months, had high perceived risk of COVID-19, had high knowledge, had received the COVID-19 vaccine based on conviction, and smokers had higher intention to receive a booster dose of the COVID-19 vaccination. In order to increase pregnant and lactating women's intention to receive a booster dose of the COVID-19 vaccine, public health organizations should consider developing comprehensive health education campaigns.

Experiences of women in prenatal, childbirth, and postpartum care during the COVID-19 pandemic in selected cities in Brazil: The resignification of the experience of pregnancy and giving birth

The COVID-19 pandemic has impacted public and private health systems around the world, impairing good practices in women's health care. However, little is known about the experiences, knowledge, and feelings of Brazilian women in this period. The objective was to analyze the experiences of women, seen at maternity hospitals accredited by the Brazilian Unified Health System (SUS, acronym in Portuguese), regarding health care during pregnancy, childbirth, and postpartum periods, their interpersonal relationships, and perceptions and feelings about the pandemic. This was a qualitative, exploratory research, carried out in three Brazilian municipalities with women hospitalized in 2020, during pregnancy, childbirth, or postpartum period, with COVID-19 or not. For data collection, semi-structured individual interviews (in person, by telephone, or by digital platform) were conducted, recorded and transcribed. The content analysis of thematic modalities was displayed as per the following axes: i) Knowledge about the disease; ii) Search for health care in prenatal, childbirth, and postpartum periods; iii) Experience of suffering from COVID-19; iv) Income and work; and v) Family dynamics and social support network. A total of 46 women were interviewed in São Luís-MA, Pelotas-RS, and Niterói-RJ. Use of media was important to convey information and fight fake news. The pandemic negatively impacted access to health care in the prenatal, childbirth, and postpartum periods, contributing to worsening of the population's social and economic vulnerabilities. Women experienced diverse manifestations of the disease, and psychic disorders were very frequent. Social isolation during the pandemic disrupted the support network of these women, who found social support strategies in communication technologies. Women-centered care-including qualified listening and mental health support-can reduce the severity of COVID-19 cases in pregnant, parturient, and postpartum women. Sustainable employment and income maintenance policies are essential to mitigate social vulnerabilities and reduce risks for these women.

COVID-19 vaccine reluctance and possible driving factors: A comparative assessment among pregnant and non-pregnant women

The coronavirus disease of 2019 (COVID-19) constitutes a serious threat to pregnant women. One of the key strategies for preventing and managing the COVID-19 epidemic is vaccination. Herd immunity is significantly hampered by COVID-19 vaccine reluctance, which poses a potential threat to population health. Therefore, the present work intends to ascertain the incidence and severity of COVID-19 vaccine hesitancy among Pakistani pregnant women, the determinants driving their decision, and a comparative assessment with non-pregnant participants. This cross-sectional survey was carried out from November 2021 to February 2022. The validated vaccination attitude examination (VAX) scale about vaccination reluctance was undertaken by participants, who were also required to indicate whether they would be inclined to acquire the COVID-19 vaccine along with the reasons for reluctance. In comparison to the non-pregnant category with 353 participants, the group of 372 pregnant participants who responded to the questionnaire had a much greater proportion of hesitant respondents. Likewise, contrasted to 31% of non-pregnant participants, about 40% of them attributed their willingness to get vaccinated against coronavirus to social media. They also demonstrated a considerably stronger mean score on all subcategories of the VAX measure. The adjusted odd ratio findings showed that the independent factors for vaccine reluctance appeared to be trusting rumors on social media (adj OR: 2.58), not being afraid of covid-19 (adj OR: 2.01), not believing in COVID-19 existence (adj OR: 2.53), and not believing in vaccines (adj OR: 4.25). Uncertainty about the COVID-19 vaccine is very prevalent among expectant mothers. The investigation accentuates the pressing need to administer COVID-19 vaccination to the general public, including expectant mothers who might be anxious about the vaccine.

Strategies to Increase Willingness to Receive a COVID-19 Vaccine among Nursing Home Staff

BACKGROUND

Nursing home (NH) staff and residents have been prioritized to receive COVID-19 vaccinations. However, NH staff have been hesitant. This study explored what strategies were used to overcome this hesitancy and which of these were found to be important by NH staff to increase their willingness to take a COVID-19 vaccine.

METHODS

This study employed a sequential exploratory qualitative design. The COVID-19 MINUTES study aimed to describe the challenges presented by, responses to, and impact of the COVID-19 pandemic in NHs. The minutes of COVID-19 outbreak teams (COTs) in Dutch long-term care organizations (n = 41) were collected and coded using content analysis. Textual units from December 2020 to April 2021 that regarded strategies to increase staff's vaccination willingness (n = 67) were selected. Subsequently, to validate these data, two panels of NH healthcare workers (HCWs) and policy workers (PWs) (n = 8) selected, discussed, and ranked the strategies that they found to be important using a modified nominal group technique.

RESULTS

The strategies described in the minutes included financial reimbursements, personal contact, story sharing, logistics support, role models, visual information, and written information. Except for financial reimbursement, all these strategies were considered important or very important by the panel participants. Some organizations combined multiple strategies.

CONCLUSION

The strategies that were found important in combination may be used more broadly and should be developed further with the involvement of HCWs.

"Maternal Vaccination Greatly Depends on Your Trust in the Healthcare System": A Qualitative Study on the Acceptability of Maternal Vaccines among Pregnant Women and Healthcare Workers in Barcelona, Spain

The World Health Organization (WHO) identified vaccine hesitancy as one of the top 10 threats to global health in 2019. Health promotion and education have been seen to improve knowledge and uptake of vaccinations in pregnancy. This qualitative study was conducted based on phenomenology, a methodological approach to understand first-hand experiences, and grounded theory, an inductive approach to analyse data, where theoretical generalisations emerge. Data were collected through semi-structured interviews with pregnant women attending antenatal care services and healthcare workers (HCWs) in Barcelona, Spain. Interviews were audio-recorded, transcribed, and coded, and notes were taken. Inductive thematic analysis was performed, and data were manually coded. Pertussis was reported as the most trusted vaccine among pregnant women due to its long-standing background as a recommended vaccine in pregnancy. The influenza vaccine was regarded as less important since it was perceived to cause mild disease. The COVID-19 vaccine was the least trustworthy for pregnant women due to uncertainties about effectiveness, health effects in the mid- and long-term, the fast development of the vaccine mRNA technology, and the perceptions of limited data on vaccine safety. However, the necessity to be vaccinated was justified by pregnant women due to the exceptional circumstances of the COVID-19 pandemic. The recommendations provided by HCW and the established relationship between the HCW, particularly midwives, and pregnant women were the main factors affecting decision-making. The role of mass media was perceived as key to helping provide reliable messages about the need for vaccines during pregnancy. Overall, vaccines administered during pregnancy were perceived as great tools associated with better health and improved quality of life. Pregnancy was envisioned as a vulnerable period in women's lives that required risk-benefits assessments for decision-making about maternal vaccinations. A holistic approach involving the community and society was considered crucial for health education regarding maternal vaccines in support of the work conducted by HCWs.

Knowledge, attitudes, and practices related to the COVID-19 pandemic among pregnant women in Bangkok, Thailand

BACKGROUND

Pregnancy is associated with increased risk for severe COVID-19. Few studies have examined knowledge, attitudes, and practices (KAP) related to pregnancy during the pandemic. This study investigated the association between socio-demographic characteristics and KAP related to COVID-19 among pregnant women in an urban community in Thailand.

METHODS

A cross-sectional online survey was distributed among pregnant women in Bangkok, Thailand from July-August 2021. Binary logistic regression was conducted to test the association between socio-demographic characteristics and KAP related to COVID-19, and a Spearman's analysis tested correlations between KAP scores.

RESULTS

A total of 150 pregnancy survey responses were received. Most participants were third trimester (27-40 weeks gestation; 68.0%). Pregnancy had never been risked contracting COVID-19 (84.7%). Most expressed concerns about being infected with COVID-19 during pregnancy and following birth (94.0 and 70.0%, respectively). The results of binary logistic regression analysis found associations between knowledge and marital status (OR = 4.983, 95%CI 1.894-13.107). In addition, having a bachelor's degree or higher was associated with higher attitude scores (OR = 2.733, 95%CI 1.045-7.149), as was being aged 26-30 (OR = 2.413 95%CI 0.882-6.602) and 31-35 years of age (OR = 2.518-2.664, 95%CI 0.841-8.442). Higher practice scores were associated with having a bachelor's degree or higher (OR = 2.285 95%CI 1.110-6.146), and income ≥15,001 bath (OR = 4.747 95%CI 1.588-14.192). Correlation analysis found a weak positive correlation between knowledge and practice scores (r = 0.210, p-value = 0.01).

CONCLUSION

Participants overall had high KAP scores. This study can guide public health strategies regarding pregnant women and COVID-19. We recommend that interventions to improve and attitude and practice scores. Knowledge on pregnancy and COVID-19 should focus on reducing fear and improving attitudes toward the care of patients as well as the promotion of preventive practices.

Determinants of COVID-19 Vaccination Hesitancy among Romanian Pregnant Women

Universal COVID-19 immunization is seen as a critical approach for limiting the spread of SARS-CoV-2 and reducing the danger of new variations emerging in the general population, especially in pregnant women. The literature and accessible research data indicate that vaccination intentions vary greatly by country, with Romania ranking among the European nations with the lowest vaccination rates. Thus, we aimed to investigate the prevalence and extent of COVID-19 vaccine hesitancy among pregnant women in Romania and the factors influencing their decision. A cross-sectional study was conducted on pregnant women referred to the Obstetrics and Gynecology Clinic of the Timisoara Municipal Emergency Hospital in Romania. Participants were asked to complete the validated VAX scale about vaccine hesitancy and to report their willingness to receive a COVID-19 vaccine and their reasons for hesitancy. The group of 184 pregnant women who completed the survey recorded significantly more hesitant respondents than the non-pregnant group with 161 respondents (52.2% vs. 40.3%). They had significantly higher average scores in all VAX scale subsections, while 78.1% of them gave credits to social media for their COVID-19 vaccination decision, compared with 63.0% of non-pregnant women. The independent risk factors for hesitancy were determined as not being afraid of COVID-19 OR = 1.89, below-average income OR = 2.06, trusting social media rumors OR = 2.38, not believing in SARS-CoV-2 existence OR = 2.67, and being a vaccination non-believer OR = 3.15. We advocate for pregnant women to get vaccinated against COVID-19 and for the development of targeted campaigns to address the factors of hesitation. This research emphasizes the critical need for delivering the COVID-19 immunization to the whole community, including pregnant women who may have vaccine-related concerns.

Effect of Home-Based Tele-Pilates Intervention on Pregnant Women: A Pilot Study

Pilates is effective for training the core muscles and stabilizing the hip joints, which provides relief from pelvic pain and low back pain during pregnancy. However, there are no specific guidelines on appropriate physical exercises for pregnant women due to the current pandemic. We aimed to apply the exercise standard proposed by the American College of Obstetricians and Gynecologists to home-based tele-Pilates exercise (HTPE), to determine its effect on the physical and mental health of pregnant women. We randomly divided the subjects into the following two groups who completed 8 weeks of HTPE (50 min/day, 2 days/week): (a) Pilates exercise (PE, n = 7) and (B) non-Pilates exercise (CON, n = 7). HTPE was performed by adjusting the program every 3 weeks, based on pain and physical fitness levels. We measured body composition, muscles of the hip joint, pelvic tilt, Oswestry Disability Index (ODI), and Pittsburgh Sleep Quality Index (PSQI), before and after HTPE. Following HTPE, while the percentage of body fat and body mass index had significantly decreased, the body fat mass did not change in the PE group (p < 0.05). The PE group showed an increase in strength of the left and right hip flexion and hip abduction, compared to the CON group (p < 0.01). The ODI and PSQI were significantly decreased in the PE group (p < 0.05). Therefore, the 8-week HTPE program is an effective exercise for pregnant woman that reduces body fat metabolism and strengthens muscles of the hip joint, thus alleviating pregnancy-induced low back pain and insomnia.

COVID-19 Vaccine Acceptability Among Women Who are Pregnant or Planning for Pregnancy in Saudi Arabia: A Cross-Sectional Study

PURPOSE

Few studies in the literature deal with the acceptance of being vaccinated while pregnant. This study aimed to investigate the acceptance rate of the COVID-19 vaccine among pregnant women and those who are planning for pregnancy in Saudi Arabia.

METHODS

This cross-sectional study used an online self-administered questionnaire in Saudi Arabia between 12 June and 1 August 2021. The first section described the demographic characteristics of the study participants (five items), participants' perceptions about COVID-19 (three items), participants' hesitancy about receiving the COVID-19 vaccine (nine items), perceived benefits of receiving the COVID-19 vaccine (four items), and motivations and causes of action for receiving the COVID-19 vaccine (three items).

RESULTS

A total of 431 women who met the inclusion criteria were involved in this study. The study participants showed moderate scores in terms of their COVID-19 vaccination perception, hesitancy, perceived benefits and causes of action that ranged between 53.3% and 65.0%. The mean perception score for all participants was 8.0 (standard deviation (SD): 2.8) out of 15. The mean hesitancy score for was 27.6 (SD: 7.3) out of 45. The mean perceived benefits score was 13.0 (SD: 4.5) out of 20. The mean causes of action score was 9.0 (SD: 3.7) out of 15. Pregnant women or those who are planning to be pregnant are more hesitant to receive the COVID-19 vaccination (p=0.001). Those aged below 29 years who reported receiving the COVID-19 vaccine showed higher levels of perceived benefits (p<0.05).

CONCLUSION

Pregnant women and those who are planning to be pregnant have a moderate score in terms of their COVID-19 vaccination perception, hesitancy, perceived benefits and causes of action regarding the COVID-19 vaccine. More public health awareness regarding the safety of the COVID-19 vaccine are needed to gain public trust in the vaccination and the healthcare system.