Factors affecting the vaccination choices of pregnant women for their children: a systematic review of the literature

Figures & data

Table 1. Papers assessing the knowledge of and attitudes toward pediatric vaccinations and vaccination choices of pregnant women.

					Findings
First author, year	Country	Type of survey; tool	Sample size	Vaccinations	Knowledge	Sources of information	Attitudes	Intention to vaccinate/ vaccination uptake
Wroe, 2004^Citation29	New Zealand	Quantitative; ad hoc tool	195	Childhood vaccination	-	-	Reasons for vaccinating: child protection; community benefits. Reasons against: side effects; preference for natural immunity; child being too young, diseases resistance to immunizations; distrust of the received information; emotional reasons	Intention to vaccinate: 67%
Heyman, 2010^Citation30	USA	Quantitative; ad hoc tool	300	HPV	Most of the sample had previous knowledge about HPV infection and vaccination	Television (77%); OBGYN (25.3%); News Media (29.5%); Another MD (11.5%); Internet (11.1%); Friend (8.8%); Other (6.0%).	Reasons against vaccinating: side effects and interactions; need for more information	Intention to vaccinate: male infant 27.7%, female infant 40.0%
Morin, 2012^Citation31	Canada (Quebec)	Quantitative; ad hoc validated tool	343 (278 pregnant)	Rotavirus	High level of knowledge on gastroenteritis and rotavirus infection and vaccination	Media (44%); health professionals (32%); family or friends (16%).	-	Intention to vaccinate: 74.0% (among the 29% of the sample who had already heard about rotavirus vaccine)
Saitoh, 2013^Citation32	Japan	Quantitative (RCT); ad hoc validated tool	116 (37 pregnant in intervention group, 42 controls),	Childhood vaccination	Limited knowledge about vaccinations and self-reported knowledge related to the individual understanding of childhood vaccinations	-	Choices influenced by perceived severity and social norms. Average scores for the perceived benefits of vaccinations were slightly higher than those for the perceived barriers of vaccinations.	Control group: 50.0% for all vaccines; 33% only some vaccines Pre-intervention group: 52.99% for all vaccines, 26.5% only some vaccines
Weiner, 2015^Citation33	USA	Quantitative; ad hoc tool	200	Childhood vaccination	High knowledge level of vaccine efficacy and safety, except for two statements. 42% of women reported being dissatisfied with their current knowledge level	Internet (36%); family (27%); healthcare professionals (22.5%)	Relatively positive beliefs and perceptions regarding childhood vaccines: recognized importance, uncertainty about safety (eg. autism)	Intention to vaccinate: Acceptors 75%; Delayers /Decliners 14.5%; Uncertain 10.5%;
Dubé, 2016^Citation34	Canada (Quebec)	Qualitative; ad hoc tool	55	Childhood vaccination	Self-perceived lack of knowledge	-	Reasons for vaccinating: protection, safety and efficacy of vaccines. Reasons against: side effects; preference for natural immunity, distrust in the received information and in public authority.	Favorable to all vaccines; n = 24, full uptake n = 21; unfavorable: n = 6, uptake = 0; hesitant: n = 25, full uptake n = 15
Grant, 2016^Citation35	New Zealand	Quantitative; ad hoc tool	11,226 (6,822 pregnant women; 4,404 partners)	Childhood vaccination	-	-	-	Intention to vaccinate 81%, vaccine uptake 70% of surveyed infants
Mohd Azizi, 2017^Citation36	Malaysia	Quantitative; validated tool (PACV)^Citation41,Citation42	545 (102 pregnant)	Childhood vaccination	-	Internet (65.6%); brochures (56.9%); healthcare professionals (49.4%); TV (44.1%).	Main concerns on vaccination: side effects; efficiency and safety Vaccine-hesitant: 11.6%	-
Cunningham, 2018^Citation37	USA	Quantitative; validated tool (PACV)^Citation41,Citation42	648 (610 pregnant women; 38 partners)	Childhood vaccination	-	-	Vaccine-hesitant: 8%
Gualano, 2018^Citation38	Italy	Quantitative; ad hoc tool	1,820	Childhood vaccination	-	Internet (65.7%); word of mouth (47.7%); health professionals (37.3%)	Most of the sample was in favor of compulsory vaccination	-
Dailey, 2018^Citation39	USA	Quantitative; validated tool (PACV)^Citation41,Citation42	945	Childhood vaccination	-	-	Vaccine-hesitant: 14.1%	-
Corben, 2018^Citation40	Australia	Quantitative; ad hoc tool	231	Childhood vaccination	-	-	High level of support for childhood vaccination. Almost all respondents agreed that the benefits of vaccines outweighed the risks	Intention to vaccinate: 92.2% Vaccination uptake: 83.2% within 30 days of the recommended date for each vaccine, 12.1% after minor delay (< 10% of follow-up days)
Betsch, 2018^Citation41	Germany	Quantitative (longitudinal); ad hoc tool	943	Childhood vaccination	-	-	Relatively positive attitude toward vaccination across all times	-
Danchin, 2018^Citation42	Australia	Quantitative (RCT); ad hoc tool	975	Childhood vaccination	Most of the sample agreed that they had enough knowledge to make a decision about vaccinating their child	Midwives (66%); general practitioners (58%); obstetrician (38%)	High support for childhood vaccination, considered safe, effective and necessary. Main concerns: too many vaccines and for uncommon disease; allergies.	Vaccination uptake: 89%
Rosso, 2019^Citation43	Italy	Quantitative ad hoc validated tool	458	Childhood vaccination	Limited knowledge of vaccine efficacy and safety, with high rates of uncertainty regarding some statements. 30% rated their level of knowledge of vaccinations at least adequate	Word of mouth (62.6%); media 33.6%); health professionals (38%)	Most respondents agreed with the importance of vaccines. Main concerns: side effects; distrust in pharmaceutical companies	Highest intention rates: hexavalent vaccine 76.8%; anti-MMR 64.3%.
Bechini, 2019^Citation44	Italy	Quantitative; ad hoc tool	214	Childhood vaccination	High rates of uncertainty regarding agreement with statements on vaccines safety and efficacy. 41% percent rated their knowledge of vaccines as low.	Word of mouth (50%), family doctor (45.7%), mass media (35.7%), pediatricians (21.4%), gynecologists (16.2%), institutional web-sites (19.5%)	Recognized importance of vaccines for protecting individual and the community, fear of side effects. Agreement with compulsory vaccinations.	Highest intention rates for tetanus (78%), meningitis B and C (74 and 77%), pertussis and measles (70%)

Figure 1. PRISMA Flow diagram. Legend: Number of studies identified by search strategy, number of studies excluded and included during primary and secondary (full -text) screening, and final number of studies included”.

Table 2. Critical appraisal of the quality of evidence based on the Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies*.

	Selection					Comparability			Outcome			Overall total	Quality Category**
Study	Sample represents target population	Sample size	Non-respondents	Measurement tool	Subtotal/5	Control for the most important factor	Control for other factors	Subtotal/2	Outcome assessment	Statistical test	Subtotal/3	Total/10	High (>7) Moderate (5–7) Low (<5)
Bechini 2019	0	0	0	1	1	0	0	0	1	1	2	3	Low
Betsch 2018	1	1	0	1	3	1	1	2	1	1	2	7	Moderate
Corben 2018	0	0	0	1	1	1	1	2	2	1	3	6	Moderate
Cunningham 2018	0	1	0	2	3	1	1	2	1	1	2	7	Moderate
Daley 2018	1	1	0	2	4	1	0	1	1	1	2	7	Moderate
Danchin 2018	1	0	0	1	2	1	0	1	2	1	3	6	Moderate
Grant 2016	1	1	0	1	3	1	1	2	1	1	2	7	Moderate
Gualano 2018	1	1	0	0	2	1	1	2	1	1	2	6	Moderate
Heyman 2010	0	0	0	1	1	1	1	2	1	1	2	5	Moderate
Mohd Azizi 2017	0	0	0	2	2	1	1	2	1	1	2	6	Moderate
Morin 2012	0	1	0	2	3	1	1	2	1	1	2	7	Moderate
Rosso 2019	0	0	0	2	2	1	1	2	1	1	2	6	Moderate
Satoih 2013	1	1	0	2	4	1	0	1	1	1	2	7	Moderate
Weiner 2015	1	1	0	1	3	0	0	0	1	0	1	4	Low
Wroe 2004	0	0	0	1	1	1	1	2	1	1	2	5	Moderate
Total number of studies	6/14	7/14	0/14	13/14		12/14	10/14		14/14	13/14
Mean												5.86

*Herzog et al. Are healthcare workers’ intentions to vaccinate related to their knowledge, beliefs and attitudes? a systematic review. BMC Public Health 2013, 13:154

** The sum of scores for all subscale items were used to categorize overall study quality as either high (>7), moderate (5–7), or low (<5); from: Roberts SSH, Teo W-P, Warmington SA. Effects of training and competition on the sleep of elite athletes: a systematic review and meta-analysis Br J Sports Med 2019;53:513–522.

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Heyman KP, Worley MJ Jr, Frey MK, Kessler RT, Bodurka DC, Slomovitz BM. Willingness of pregnant women to vaccinate themselves and their newborns with the HPV vaccine. Vaccine. 2011;29(28):4618–22. doi:10.1016/j.vaccine.2011.04.062.

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Morin A, Lemaître T, Farrands A, Carrier N, Gagneur A. Maternal knowledge, attitudes and beliefs regarding gastroenteritis and rotavirus vaccine before implementing vaccination program: which key messages in light of a new immunization program? Vaccine. 2012;30(41):5921–27. doi:10.1016/j.vaccine.2012.07.050.

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