ABSTRACT
Presumptive and Motivational Interviewing communication styles have successfully promoted childhood and adolescent vaccination to parents, but less is known about effective communication approaches during pregnancy to promote maternal vaccination and childhood vaccines. In Australian public antenatal settings, midwives provide a substantial proportion of care and are highly accessed and trusted sources of vaccine information for expectant parents. However, there are no evidence-based interventions incorporating communication strategies and resources for midwives to optimize discussions and promote acceptance of maternal and childhood vaccines. This study aimed to gather qualitative data from midwives to inform the design of a feasible and acceptable vaccine communication intervention package building on an evidence-based model utilized with US obstetricians. We explored midwives’ attitudes and values regarding maternal and childhood vaccination, their perceived role in vaccine advocacy and delivery, and barriers and enablers to implementation of a potential communication intervention. We recruited 12 midwives for semi-structured interviews at two Australian tertiary public hospitals (one with antenatal vaccines onsite, one without). Interviews were analyzed using thematic template analysis. Midwives supported vaccination but expressed varied views regarding its centrality to their role. Most reported receiving minimal or no training on vaccine communication. Their communication practices focused primarily on vaccine information provision rather than persuasion, although some midwives shared personal views and actively encouraged vaccination. More vaccine and communication training and resources were requested. Findings highlight the need for communication tools that align with midwifery standards for practice to support midwives to address parents’ questions and concerns about maternal and childhood vaccines.
Introduction
Pregnancy is a key time in which expectant parents begin making decisions about vaccines.Citation1 Not only does the mother need to decide whether to accept recommended vaccinations for influenza and pertussis during pregnancy, but both parents usually begin thinking about infant and early childhood vaccines.Citation1,Citation2 In Australia, current coverage for maternal vaccination is reported to be between 65% and 80% for pertussis and 45–60% for flu, with lower levels in certain at-risk groups.Citation1,Citation3,Citation4 Increasing and sustaining high coverage rates are critical – especially as new maternal vaccines for respiratory syncytial virus (RSV) and Group B Streptococcus are introduced and antenatal vaccine decisions and discussions become even more complex.Citation5
Three quarters of Australian mothers give birth in public hospitals,Citation1,Citation6 where midwives provide a substantial proportion of antenatal care. Not all public antenatal hospitals deliver vaccines, due to limitations in resources, facilities or funding, but midwives in all settings are expected to provide vaccine information and to recommend maternal pertussis, influenza, and infant hepatitis B vaccinations.Citation1,Citation7,Citation8 Midwives are not professionally required to discuss later childhood vaccines, but parents indicate that they would like more information about these vaccines during the antenatal period.Citation1 While expectant parents in the public antenatal system report that midwives are their most highly accessed and trusted source of vaccine information,Citation1 there are gaps in our understanding of how midwives think about, discuss, or advocate for both maternal and childhood vaccination. In particular, several recent studies have highlighted deficiencies in midwifery education and training related to vaccination and vaccine communication,Citation9-Citation11 but there have been no studies exploring the types or features of vaccine communication training that would be most acceptable to them.
Communication approaches
The clinical encounter between health professionals and parents is crucial to shaping attitudes towards vaccination, and provider recommendation is the primary driver of vaccine uptake among pregnant women.Citation12,Citation13 Effective interactions with providers can address questions and concerns and encourage hesitant individuals towards vaccination, while poor interactions contribute to vaccine rejection.Citation14 However, there is no firm consensus on the ‘best’ communication approach for professionals to take. Two different approaches that have proven effective in increasing parents’ acceptance of adolescent or childhood vaccines are presumptive communication (e.g. “It’s time for your shots”)Citation15 and the more participatory Motivational Interviewing (MI)-based communication.Citation16-Citation18 MI is a structured counseling approach designed to guide people towards change through active listening, eliciting specific concerns, and asking permission to share information or views.
While these approaches have shown success with parents of childrenCitation15,Citation17 or adolescents,Citation18 there is limited evidence regarding their suitability for midwife-led interventions to enhance maternal and childhood vaccine uptake. Rather than the prescriptive approach that physicians may adopt, the Nursing and Midwifery Board of Australia Midwife Standards for PracticeCitation19 promotes use of evidence to facilitate informed decision-making, participation in care and self-determination whilst supporting the woman’s choice.Citation20,Citation21 It is therefore unclear if the presumptive style or even the guiding approach of MI can align with midwives’ values, or whether a hybrid approach may be more acceptable. While recent research suggests that the majority of public antenatal midwives are supportive of vaccination,Citation1,Citation11 any vaccine promotion intervention must acknowledge and navigate the tensions between advocating for vaccination and respecting a woman’s agency.Citation10
There are a number of factors that drive uptake of maternal and childhood vaccines, and multicomponent interventions are well suited to addressing multiple barriers simultaneously. An evidence-based framework for such interventions features components targeting the Practice, Provider, and Parent levels (P3).Citation22 These components include nudges like parent and provider reminders, training to improve provider communication and encourage vaccine recommendation, and parent information resources addressing vaccine benefits and disease severity.Citation23 To date, no intervention applying this framework has been adapted or developed for use by midwives in the Australian antenatal setting.
Therefore, to inform the design, content and format of a practical and ideologically suitable intervention to optimise midwives’ vaccine discussions with expectant parents, we explored how midwives think and feel about vaccination; its place in their professional practice; their receptivity to delivering behaviour-change oriented interventions; and the feasibility of intervention delivery in different antenatal settings.
Results
Participants
We interviewed seven midwives from the Royal Women’s Hospital (RWH) in Melbourne, Victoria, and five from King Edward Memorial Hospital (KEMH) in Perth, Australia. Most RWH midwives were recruited through the clinic manager, while most from KEMH responded to the recruitment flyer. While participants varied in age and years of practice, midwives from the same hospital had mostly homogenous professional experiences leading to saturation in themes relatively rapidly. Demographic data from participating midwives are shown in .
Table 1. Demographic attributes.
Themes
Our coding template included seven overarching themes: (1) WHO are midwives; (2) HOW do midwives communicate about and/or deliver vaccines; (3) WHEN and HOW MUCH vaccine information do midwives provide; (4) WHERE do midwives practice and communicate; (5) WHAT vaccination resources are available or needed; (6) PERCEPTIONS ABOUT PARENTS’ knowledge and attitudes; (7) BARRIERS AND ENABLERS to vaccination delivery and/or implementation of a vaccine promotion intervention. Each main theme included a number of subthemes inductively derived from the transcripts. Key findings are summarised in the text and supporting quotes for each theme are presented in . Participants are identified with their number and either “RWH” or “KEMH”.
Table 2. Themes and supporting quotes from midwife interviews.
Table 3. Recommendation language and practices.
Table 4. Suggested topics and formats for professional training.
Table 5. Expressed barriers and implied enablers to discussion and delivery of maternal vaccines.
1. WHO are midwives
Perceived roles and professional values
We asked midwives to describe their practice structure and reflect on how vaccination fitted into their professional role. Responses were mixed – some saw vaccination as a minor or routine element, while others viewed it as a key feature of their role. There was widespread agreement that delivering and discussing vaccination was a task shared by a number of other health professionals, including specialist immunization midwives, GPs and obstetricians. In particular, discussion of childhood vaccines beyond the birth dose of hepatitis B was seen as the purview of nurses in the community who care for women and children after birth.
Some midwives preferred to defer to other providers to discuss vaccines because they sought to maintain the trust and rapport they see as unique between midwives and pregnant women. Several expressed reservations about pushing vaccination too strongly or sharing their personal views, even though all the interviewed midwives recommended and supported vaccination. As one midwife said, the power of personal stories could be a double-edged sword:
I don’t know whether I should use my personal feelings about it. Because also it works the other way. You might get some midwives that are not pro-vaccination. And I wouldn’t like to think that any of them are saying: ‘Well, I wouldn’t give my baby that.’ KEMH3
Previous training
Most midwives received little or no training about vaccination or techniques to effectively communicate about vaccines during their degree programs, especially with regard to childhood vaccines. A handful had pursued and self-funded additional training, such as completing a module developed by the South Australian Department of Health.Citation24 Those who had completed additional training reported feeling confident in their knowledge and ability to discuss vaccines, but about half of the interviewed midwives (predominantly those from the RWH) expressed uncertainty and a lack of confidence. Childhood vaccines presented the greatest challenge.
2. HOW do midwives communicate about and/or deliver vaccines
Making recommendations
All the midwives said they recommended maternal influenza and pertussis vaccines and infant hepatitis B, but there was considerable variation in the perceived origin of the recommendation. Sources of the recommendation included the hospital, the State Health Department, doctors in the hospital, or a vague “we”. Few midwives, if any, made a personal recommendation. See for specific recommendation practices.
After making a recommendation, the degree to which the midwives pressed or followed up the issue upon encountering hesitance varied. Informed choice was clearly of paramount importance, but individual midwives had different interpretations on how best to achieve this. Some accepted parents’ initial decisions (“Obviously you can’t push anything on them; people have their views.” RWH2), while others explored the reasons for hesitancy, offered additional information, or returned to the conversation several times.
Message content and framing
When discussing vaccines, the midwives all shared the basic information about disease risks, side effects, vaccine benefits, and schedule. Some also said they provided details about vaccine ingredients, government policies (e.g., the Victorian “No Jab, No Play” mandatory vaccination policy), or more physiological details about vaccines in pregnancy.
However, the way they presented information could vary depending on the vaccine they were discussing. Generally, pertussis vaccination was presented in terms of protecting the baby, while influenza was primarily to protect the mother. The midwives all said that mothers prioritize their baby’s health above their own, and agreed that messages about the protective effects of maternal vaccines on newborns seem to resonate most strongly (“All these women are doing it for the baby, everything they do…they’re not thinking about themselves at all.” KEMH3). Childhood vaccines were discussed much less frequently and with less urgency. Two midwives also said they didn’t push the birth hepatitis B vaccine because they knew the infants would have another opportunity to receive that vaccine (“Because we know that the baby does have it in the community as well, I think that’s another reason why we don’t probably push it any further.” RWH1).
Description and perceptions of vaccine delivery and related practices
At the RWH, maternal vaccines are not routinely delivered on site. There is no vaccine refrigerator or dedicated space for immunization delivery in the clinic; women are referred back to their GPs to access vaccinations. Some midwives perceived this as a potential barrier, though it wasn’t obvious how it could be addressed. At KEMH, there is often an immunization midwife on staff who can deliver the vaccines in the on-site vaccination clinic, and midwives who have completed immunizer training can deliver vaccines in their antenatal consultations. Regardless of vaccine availability, midwives at both hospitals thought that the uptake of maternal vaccines among women in their care was relatively high.
3. WHEN and HOW MUCH vaccine information do midwives provide
Timing and frequency
Hospital- or state-level protocols determine key moments of intervention during pregnancy care, and our research demonstrated differences between settings where midwives deliver vaccines (KEMH) and settings where they do not (RWH). The RWH midwives told us that there is no standardized point in pregnancy to discuss maternal vaccines – it is up to the individual midwives to remember to raise the topic and make time to share information and answer questions (“We don’t really have a very good framework in terms of what education we should be providing at every antenatal appointment.” RWH4). The majority said they would introduce maternal vaccines at the initial booking visit (generally between 16–22 weeks), and then would follow up around 28–30 weeks. Many midwives discussed vaccines multiples times, throughout pregnancy. Both influenza and pertussis are recommended all year round, although influenza can be harder to promote in the summer months. Most RWH midwives indicated that they would mention hepatitis B vaccine along with the maternal vaccines at the initial booking visit and again late in pregnancy, when women presented during labour, or on the postnatal ward in the days following birth. There did not appear to be a structured time to obtain parental consent for this vaccine at the RWH, and midwives described a reluctance to seek it during labour.
At KEMH, midwives described offering pertussis and influenza vaccines at a set time (early in the third trimester). This was structured by an antenatal vaccination protocol and clinical practice guidelines of the hospital and the Western Australian government.Citation25 KEMH midwives described the ‘schedule of care’ for consent discussions regarding birth hepatitis B to occur at 28 weeks of pregnancy, and one midwife described using the discussion about maternal pertussis vaccine as an additional cue to segue into childhood vaccines.
Midwives in both settings said that they discussed other childhood vaccines less frequently, for less time and at less consistent time points. Some said they never really discussed them at all. When midwives were asked when they thought would be most appropriate to bring up childhood vaccines, they generally agreed that they would do so along with the hepatitis B discussion, late in pregnancy or following birth.
Information quantity
Most midwives agreed that vaccine discussions were relatively brief – generally 1–5 min long. Some said most women did not need or want more detailed information, others said they lacked information to provide or did not feel confident discussing vaccines in more depth, and some described time constraints. Even less time was spent on childhood vaccines, which in many cases, were only discussed if the parents brought them up. Some midwives from KEMH said that occasionally, vaccine conversations could last 20–30 min if the parents had particular concerns.
4. WHERE do midwives practice and communicate
Midwives at both hospitals work across different rooms throughout the day. At the RWH, midwives have access to computers and printers to print materials as needed, but there is no repository of pre-printed materials in the antenatal clinic. On the ground floor of the hospital, there is a community information center with a library of resources. Midwives at KEMH described having intermittent access to computers, but said that pre-printed resources are widely available.
5. WHAT vaccination resources are available or needed
Currently available resources
Midwives described utilizing a range of resources to support their vaccination discussions with expectant parents, but there was no single, comprehensive resource available to them. Most described using print resources to supplement their discussions of vaccines (e.g., “Having your baby at the Women’s” booklet, Western Australian Department of Health leaflets, child health and development record). Some midwives – particularly those at KEMH – felt that these resources provided adequate information (“Anything they ask about, we’ve got a leaflet for.” KEMH3). However, an RWH midwife said there was very little detail on influenza in the standard pregnancy booklet: “There’s not a lot of information there” (RWH1).
In addition to the standard print resources, midwives reported accessing information from the Infection Control department at the hospital (by phone), hospital policy sheets on their intranet, vaccine manufacturer leaflets, an orientation book for new staff or recent graduates, a hospital app (currently not functional), Better Health Channel or other online sources, or the mother’s standardised health record. One midwife described telling mothers to do their own research, saying, “I’d probably tell them to Google it to be honest” (KEMH5). However, she subsequently reflected that this might bring up misinformation.
Suggested resources and training
When we asked midwives about potential resources that could help them in their work, the value of a single source of information was highlighted: “I think if there was, like, an education hub type thing for vaccinations in pregnancy.” KEMH5. Several midwives from Victoria also agreed that printed fact sheets would be helpful, and the majority from both hospitals were strongly in favor of online resources, like an educational website or app for parents.
In addition to resources to share with parents, some midwives in Victoria suggested adding a sticker for women’s charts to prompt vaccine discussions and/or record whether the mother had received the vaccines during pregnancy. Midwives at KEMH already use stickers to denote both vaccines and vaccination education provided.
When asked what they thought would help midwives in general to become better advocates for vaccination, midwives in both hospitals suggested more professional education and training. outlines suggested topics and formats for professional training.
6. PERCEPTIONS ABOUT PARENTS’ knowledge and attitudes
While interviews with midwives cannot conclusively determine the knowledge gaps or needs of expectant parents, the midwives’ perceptions of what parents know and feel can inform our understanding of what should be included in potential resources.
Knowledge
The most common questions women asked tended to be practical, such as which vaccines are due, who will deliver them and when they should have them. Some midwives felt women were generally well informed about both maternal influenza and pertussis vaccines, but many thought there were gaps in women’s knowledge. Interestingly, there was disagreement about the nature of these gaps – some thought influenza was more commonly understood than pertussis, while others thought the reverse. Despite acknowledging these gaps, several midwives felt that women are overloaded with information during pregnancy.
Attitudes
The midwives agreed that most women seemed relatively accepting of vaccinations, with few questions or concerns. Pregnant women who asked more detailed questions or expressed uncertainty were generally more hesitant about the influenza vaccine – hesitancy around pertussis was less common. Some women perceived the flu itself as less serious than pertussis, while others were particularly concerned about the vaccine’s side effects (“Women are maybe more hesitant to get the flu compared to pertussis…They think they’re going to have more reactions to it.” KEMH4). Participants also described some mothers not seeing particular childhood vaccines as necessary.
Several midwives mentioned the influence of social media – both positive and negative – on women’s attitudes towards maternal and childhood vaccines. In WA, where a newborn died of pertussis and the Light for Riley media campaign for maternal pertussis vaccination originated in 2015,Citation26 midwives said this was a driving factor in increasing awareness and acceptance. Media warnings about the upcoming flu season were also seen as encouraging vaccine uptake. However, midwives agreed that social media could also spread misinformation and increase uncertainty (“It’s hard because there is so much anti-vaccine stuff saturating social media” KEMH2).
7. BARRIERS and ENABLERS to vaccination delivery and/or implementation of a vaccine promotion intervention
The midwives raised a number of potential barriers to discussing and delivering vaccines in the public antenatal setting. We categorized these barriers according to the COM-B model, which was developed by implementation science researchers to help conceptualize the different drivers and inhibitors of behavior change: capability, motivation, and opportunity.Citation27 In , we present the barriers expressed by the midwives, along with implied enablers related to these barriers.
Discussion and conclusion
All the midwives in our study had similar impressions of what expectant parents know, feel and want to know about maternal and childhood vaccinations. Midwives in both hospitals perceived mothers to be more hesitant about influenza vaccine than pertussis. This perception is supported by data from the state of New South WalesCitation13,Citation28 and a recent Federal Government report,Citation29 which indicate that despite generally rising coverage rates, women still have safety concerns about the influenza vaccine during pregnancy.
Similar to other Australian research,Citation29 the midwives told us that women value vaccinations they perceive as benefitting their babies more than vaccines benefitting themselves. This finding adds weight to recent public health ethics arguments regarding whether women should be recommended vaccines that predominantly benefit their unborn babies. It demonstrates that ethicists should take pregnant women’s subjectivity and embodied reasoning seriously – women do not make decisions about maternal vaccination in a vacuum, but as mothers who have a legitimate interest in protecting their fetuses and infants.Citation30 However, despite knowing that women most value vaccines that they perceive as benefitting their babies, we found that many midwives are still presenting the influenza vaccine as primarily benefitting the mother. Our findings regarding some midwives’ lack of emphasis on the birth dose of hepatitis B vaccine support earlier studies showing that this is the most commonly refused vaccine,Citation1 and reporting midwives’ ambivalence in promoting it.Citation31
While structural levers, such as having vaccines on site, are key determinants of maternal vaccination uptake,Citation32 provision of maternal vaccines alone does not ensure that midwives are knowledgeable and confident in encouraging mothers to vaccinate. The on-site delivery of maternal influenza and pertussis vaccines may have contributed to KEMH midwives seeing it as important to their role and feeling more confident in their vaccine knowledge, but even among these midwives there were a range of views, communication approaches and expressed knowledge and communication skills gaps. It is possible that having a dedicated immunization midwife on staff may actually create an environment where other midwives have fewer detailed vaccine discussions themselves. While the provision of vaccines on site in all Australian antenatal hospitals is an important goal, this will not replace the need for informed, confident communication between midwives and expectant parents. As additional vaccines are added to the antenatal schedule, discussions, and decision-making about vaccines will become even more complex for both providers and expectant parents. Furthermore, increasing midwives’ confidence discussing or directing parents to reliable information about childhood vaccines is an important goal: providing this information before the first vaccination appointment is not only what parents want,Citation1,Citation2 it has also been shown to increase intention to vaccinate and vaccine uptake.Citation33 The midwives we interviewed expressed a desire and preference for additional training and supportive materials that addressed vaccine facts and/or communication strategies that suited their schedules and office infrastructure.Citation11 There was clearly a need and appetite for more detailed and tailored resources and information, particularly at RWH.
We were particularly interested in the suitability and applicability of either presumptive communication or Motivational Interviewing – or a combination of the two – for Australian midwives discussing vaccination. Professional standards require midwives to discuss the risks and benefits of vaccines, but not specifically to recommend vaccination.Citation25 Nevertheless, all midwives expressed that they were required to follow clinical guidelines and all recommended vaccination. Most midwives used passive language in their framing to mothers (“It is recommended”) even if they added urging qualifiers to this (“highly recommended”). When midwives sought to add more heft to their recommendations, their language of “we” drew on the institutional setting (including as a premise for funding), or they referred to doctors or research. Given that several midwives actively stated that they did not give personal recommendations and generally refrained from sharing their personal beliefs or practices, we concluded that the midwives in our study may reject both the presumptive approach (in general) and the personal recommendation aspect of existing MI-inspired approaches. This is supported by Frawley et al.’s qualitative study of Australian midwives working in a variety of contexts, which found that many of them did not see it as their role to persuade women to accept vaccines.Citation10 However, we considered that the public hospital midwives we interviewed may embrace the recommendation aspect of MI without making it personal. Some did indicate that they would prefer not to adopt any kind of guiding approach that would influence parents’ decision, but the eagerness of other midwives to better understand the reasons for parents’ hesitancy suggested that these midwives might embrace an MI-based communication intervention that could help them elicit parents’ concerns and share knowledge.
Study limitations
This qualitative study filled an important research gap in Australia and internationally in considering the applicability of existing vaccine communication interventions to midwives’ discussions with expectant parents. Although the sample size was small, saturation was reached quickly at each site, possibly reflecting homogeneity of professional experiences at a particular location. A broader sample of study sites may have generated additional themes, though Frawley et al. identified similar themes despite interviewing participants in more varied locations.Citation10 There were demographic differences across both sites, with KEMH midwives being older and more experienced than the RWH cohort. This may also be due to slight differences in recruitment, with participants self-selecting at KEMH, and identified by a key informant (clinic manager) at RWH. These features may have led to differences in views that may not necessarily reflect the organization more broadly. Differences between the hospitals, particularly with regard to the presence or absence of vaccines on site, should not be taken as indicative of differences between broader state health policies; we know, for example, that other hospitals delivering maternity care in Victoria do have vaccines on site.Citation32
Next steps and conclusions
From the themes and views expressed by midwives in this study, we aim to develop a multi-component intervention to optimize midwives’ vaccine discussions with expectant parents in the Australian context. In addition to our qualitative data, we will build on the theory and adapt resources developed for the US-based P3+ study, which utilizes the P3 multi-component intervention framework with elements at the Practice-, Provider- and Parent-levels to improve vaccine uptake and acceptance targeted at obstetricians in private practice.Citation12,Citation22 In our next phase, we are developing practical prototype P3 intervention for the Australian public antenatal setting, which we will present to midwives in focus groups to iteratively adapt and apply changes to the intervention based on their feedback. The P3-MumBubvax intervention package will be piloted in a large, tertiary public maternity hospital to determine the feasibility and acceptability. It will then be tested in a national randomized controlled trial to primarily improve maternal influenza vaccine uptake.
Materials and methods
Study design, setting, and recruitment
We used a descriptive qualitative study design, conducting semi-structured interviews with midwives. This study design is widely used in health care and nursing research to help explain or understand “the who, what and where of events or experiences.”Citation34
We recruited midwives working in public antenatal settings within two large tertiary hospitals: King Edward Memorial Hospital (KEMH) in Western Australia and the Royal Women’s Hospital (RWH) in Victoria. Studying midwives in two different institutions in two Australian states enabled us to consider the impact of differences in health-care delivery as dictated by State governments, and hospitals within states, who make independent decisions about funding, policy, and practice. At the RWH, vaccines are not available on site and pregnant women need to make a separate visit to their GP. At KEMH, midwives are trained and authorized to deliver vaccines to pregnant women onsite, either in the clinic rooms or at the hospital immunization clinic. For many shifts, there is also a dedicated immunization midwife who discusses vaccines with pregnant women in the waiting area.
In each site, we engaged with clinic managers to develop an understanding of the various clinics, birthing models and care practices. We asked clinic managers to identify potential key informant midwives to interview, representing a range of roles and levels of experience, and distributed the study recruitment flyer. Interested midwives contacted the research team to organize an interview. To recruit additional midwives, clinic managers also disseminated the recruitment flyer through internal staff emails, and participating midwives were asked to share the study details with their peers (i.e., snowballing).Citation35
Midwives were eligible to participate if they were involved in some aspect of antenatal care provision and were able to speak and understand English. All participating midwives were consented, completed a brief anonymous demographic survey, and received a $25 card for their time.
Ethics approval was obtained in WA (RGS00000000736) and VIC (HREC 37338A).
Data collection
We conducted semi-structured individual interviews, both telephone and face-to-face, based on scheduling availability and preference of the participant. Interviews generally lasted between 20 and 40 min. All interviews were audio-recorded and professionally transcribed. The two interviewers (JK and KA) used a single, open-ended question guide (Additional File 1). The questions focused primarily on the participants‘ perceived professional role, with regard to vaccination, and the nature of their current practice and communication about vaccines. We also asked them to describe how they record vaccine data. Research team meetings were conducted regularly via telephone so that both interviewers could compare their experiences and incorporate reflections for improving subsequent interviews.
Data analysis
Thematic analysis was performed on all interview transcripts, coding them in NVivo10.Citation36 Given that our aim was to understand midwives’ views and roles to inform intervention design, we used template analysis to keep our analysis focused on the applied purpose of the study. Template analysis is a structured yet flexible form of thematic analysis that generally begins with some a priori themes, which are then adapted through initial analysis to form a coding template.Citation37
We derived a priori themes from the TIDieR (Template for Intervention Description and Replication) checklist, which outlines the key features to be reported when describing complex interventions.Citation38 While these themes provide overarching categories for interview data related to intervention features, they were not specific or detailed enough to capture the full range of the interview data. Therefore, two authors (JK and KA) separately analyzed the first interview transcript, using open coding to inductively identify themes emerging from the text. Each author grouped these emerging themes into the template categories where possible, and added or modified categories as necessary. Along with a third author (MD), we discussed and compared our initial analyses and agreed on a single customized coding template fit for our study purpose. One author (JK) then coded all transcripts with this template. Further minor additions and modifications to the template were discussed periodically with the full study team.
Disclosure of potential conflicts of interest
Katie Attwell has previously been employed by the Immunisation Alliance of Western Australia to conduct social research using an unrestricted grant from Sanofi Pasteur. She has also received travel, accommodation and conference registration support from GSK, and travel, accommodation and speakers fees from Merck. The other authors have no conflicts to declare.
Ethics, consent, and permissions
Ethics approval was obtained in WA (RGS00000000736) and VIC (HREC 37338A). Consent for Publication is not applicable to the current research study.
Availability of data and materials
Supporting data are available from the lead authors upon written request.
Supplemental Material
Download MS Word (30 KB)Acknowledgments
The authors are grateful to the midwives interviewed at both hospitals, and to clinic managers Barb Lourey and Trish Ryan who facilitated our access. We acknowledge and thank our wider team who consulted on study design: Helen Marshall, Julie Leask, Kerrie Wiley, Tom Snelling, and Penny Haora. Penny provided valuable context and understanding on the regulation and recommendation protocol for Australian midwives. We thank our research assistants Annette Alafaci and Shevaun Drislane, who provided valuable support at different stages of the project. We also thank Anne O’Leary at Women and Newborn Ethics Committee for helping us to navigate the ethics for KEMH.
Supplemental data
Supplemental data for this article can be accessed here.
Additional information
Funding
References
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