MJA 198 (7) · 15 April 2013
The Medical Journal of Australia ISSN: 0025-
729X 15 April 2013 198 7 373-375
©The Medical Journal of Australia 2013
Belief Model and Precaution Adoption
Process Model of health behaviour.12
Questions covered self-reported
receipt of influenza vaccine during the
current pregnancy, demographic char-
acteristics, general attitudes toward
vaccination, perception of disease risk
and vaccine risk and benefit during
pregnancy, and information sources.
Face and content validity and internal
Research p 370
regnant women with influenza
have an increased risk of com-
plications, including hospital-
isation, intensive care unit admission,
preterm delivery and, in severe cases,
A growing body of evidence sup-
ports the safety and effectiveness of
inactivated influenza vaccine during
pregnancy. A recent review concluded
that influenza vaccine is safe to admin-
ister during any trimester.4 Two recent
randomised controlled trials found that
babies born to vaccinated mothers had
a reduced risk of contracting influenza
in the first 6 months of life.5,6 The 9th
edition of the Australian immunisation
handbook recommends influenza vac-
cine for all pregnant women who will
be in their second or third trimester
during influenza season, although it
can be given in any trimester.7 The
vaccine is free for all pregnant women.
Uptake of influenza vaccine by preg-
nant women in Australia is low, with
estimates ranging from about 7% to
40%.8-11 However, these estimates are
often from relatively small samples at
single sites dependent on local vac-
cination policies and procedures.
Our aims were to determine the
uptake of seasonal influenza vaccine
among a larger sample of pregnant
women residing in New South Wales,
and to identify barriers and facilitators
to vaccine uptake in pregnancy.
We used a self-administered question-
naire delivered to pregnant women
attending public hospitals in NSW.
The survey was based on the Health
consistency were examined through a
pilot study. The final questionnaire was
translated into Arabic and Chinese.
Sample size and recruitment
A non-random stratified sampling plan
was used to ensure a representative
sample of pregnant women in NSW.
Pilot data showed 15% vaccine uptake,
and a target sample of 783 was calcu-
lated to provide a 95% confidence
interval within 15% of the point esti-
mate. Data on women who had given
birth in NSW between 2004 and 2008
were obtained (J Bentley, Principal Epi-
demiologist, Health Services, Centre
for Epidemiology and Evidence, NSW
Ministry of Health, personal communi-
cation, 2010) and stratified by age, par-
ity and region of residence. Using these
population data, target sample propor-
tions were calculated for each stratum.
Women were recruited from ante-
natal clinic waiting rooms of three terti-
ary hospitals and one Aboriginal
community-controlled health service
(ACCHS). The sites were: a hospital in
metropolitan Sydney (Site A), with
about 5300 births per year; a hospital in
Sydney’s outer suburbs (Site B), with
4200 births per year; and a rural referral
hospital (Site C), with 800 births per
year. The ACCHS was associated with
Site C. During the study, Sites A and B
did not provide influenza vaccination
for pregnant women; however, it had
been offered at Site B in March–June
2011, before study commencement.
During recruitment, Site C ran an 8-
week influenza vaccination clinic onsite.
Recruitment took place between 27
July and 9 November 2011. Recruit-
ment days were rotated to ensure all
days of clinic operation were sampled.
All women attending on these days
Ethics approval was gained from the
human research ethics committee of
each participating institution, and the
NSW Aboriginal Health and Medical
We used 2 tests for differences in pro-
portions and backward logistic regres-
sion analysis. Data were analysed
using SPSS version 17.0 (IBM), and
QuickCalcs (GraphPad Software).
Uptake of influenza vaccine by pregnant
women: a cross-sectional survey
Design, setting and participants: Quantitative self-administered survey of
pregnant women, using a non-random, stratified sample from antenatal clinics at
three demographically diverse hospitals in NSW during the influenza season of 2011.
Main outcome measures: Self-reported influenza vaccine uptake while
pregnant; and attitudes, barriers and facilitators to vaccine acceptance during
Results: Of 939 women approached, 815 participated (87%). Influenza vaccine
uptake in pregnant women was 27%. Women who had received a
recommendation to have the vaccine were 20.0 times (95% CI, 10.9–36.9)
more likely to have been vaccinated. Forty-two per cent recalled receiving a
recommendation to be vaccinated. Other factors associated with vaccination
were study site, perceived infection severity, overall feelings toward vaccination
during pregnancy, vaccine accessibility, and willingness to take up the vaccine if
recommended. Concern about the baby’s safety was negatively associated with
vaccination (odds ratio, 0.5; 95% CI, 0.2–0.9), but 68% (95% CI, 63%–71%) of
women who expressed concern agreed they would have the vaccine if their
health care professional recommended it.
Conclusion: Recommendation from a health care provider is strongly
associated with influenza vaccine uptake among pregnant women and can
overcome their concerns about safety, but less than half the women surveyed
reported receiving such a recommendation. Educational material targeting
pregnant women and professional education and support for antenatal health
care providers are needed to increase awareness and recommendation.
Objectives: To determine influenza vaccination coverage among pregnant
women in New South Wales, and factors associated with vaccine uptake during
Kerrie E Wiley
Peter D Massey
DrPH, GCPH, RN,
Spring C Cooper
Nicholas J Wood
MB BS, FRACP, PhD,
BMed, FRACP, MPH,
Helen E Quinn
1 National Centre for
Immunisation Research and
Surveillance, The Children’s
Hospital at Westmead,
2 Discipline of Paediatrics
and Child Health,
University of Sydney,
3 Population Health,
Hunter New England
4 Western Sydney
Sexual Health Centre,
University of Sydney,
5 School of Public Health,
University of Sydney,
MJA 2013; 198: 373–375
Editorial p 349
MJA 198 (7) · 15 April 2013
The overall response rate was 87%
(815/939). Site-specific rates were: Site
A, 88% (349/398); Site B, 79% (234/
298); and Site C, 95% (232/243). The
overall sample proportions for age and
parity differed from the NSW popula-
tion data, so the data were weighted
for these variables. The weighted sam-
ple was comparable to women who
gave birth in NSW between 2004 and
2008 for age, parity and region of resi-
dence. At the time of the survey, the
participants had a mean gestation of 29
weeks (median, 30; range, 5–41), and
99% were >12 weeks’ gestation.
Most women received their ante-
natal care exclusively through public
hospital antenatal clinics (466/815,
57%). A quarter (201/815) received
shared antenatal care through their
general practitioner and the local pub-
lic hospital, and small numbers
received care through a birth centre,
private obstetrician or the ACCHS.
Five per cent of women (37/815)
identified as Aboriginal. Most (580/
815, 71%) spoke English at home, but
46 other languages were spoken, most
commonly Arabic, Cantonese or Man-
darin, and Hindi. Nearly half the
women (347/815, 43%) had completed
a university degree or higher.
Of the 815 women, 255 (31%)
reported an underlying condition that
put them at higher risk of complica-
tions from influenza.
Vaccine uptake and associated
Overall, 215 of 786 women (27%, 95%
CI, 24%–31%) had received influenza
vaccination during their current preg-
nancy (Site A, 75/340 [22%]; Site B, 39/
225 [17%]; Site C, 101/221 [46%]).
Of the 815 women, 324 (40%; 95%
CI, 36%–43%) correctly believed influ-
enza vaccination was recommended
during pregnancy, while 207 (25%;
95% CI, 23%–29%) incorrectly
thought it was not, and 276 (34%; 95%
CI, 31%–37%) were unsure.
Multivariate analysis showed that
women who had received a recom-
mendation to have influenza vaccina-
tion while pregnant were 20.0 times
(95% CI, 10.9–36.9; P<0.01) more
likely to have been vaccinated than
women who had not received a recom-
mendation. Other factors associated
with vaccine uptake are presented in
Factors found not to be significantly
associated with vaccine uptake
included previous influenza infection,
perceived likelihood of infection,
knowledge of recommendations, belief
that the vaccine would protect from
influenza, concern that the vaccine
would cause influenza, age, parity,
antenatal care type, level of education,
ethnicity, geographical area (rural v
urban), and the presence of maternal
comorbidities such as asthma, dia-
betes, obesity and hypertension.
Concern about the safety of the vac-
cine for the baby was negatively asso-
ciated with vaccination (Box).
However, of the 502 women who
Weighted percentage responses and adjusted odds ratios (AORs) for influenza vaccine uptake by pregnant women, by
associated study factors
Women who did
not have vaccine*AOR (95% CI)
Perceived severity of the consequences of influenza infection during pregnancy
Neither mild nor severe
Overall feelings toward influenza vaccination during pregnancy
Neither oppose nor support
Concerned about baby’s safety if having influenza vaccine during pregnancy
Neither disagree nor agree
Would have influenza vaccine while pregnant if GP recommended it
Neither disagree nor agree
It is difficult to get to the doctor to have influenza vaccine while pregnant
Neither disagree nor agree
Received recommendation to have influenza vaccine during this pregnancy
GP=general practitioner. *Weighted values. Percentages are of total respondents in each row. †Referent category.
MJA 198 (7) · 15 April 2013
expressed concern, 339 (68%; 95% CI,
63%–71%) agreed they would have the
vaccine if their doctor or midwife rec-
Of the 310 women who reported
from whom they had received a rec-
ommendation to have influenza vacci-
nation, 160 (52%; 95% CI, 46%–57%)
received it from their doctor and 35
(11%; 95% CI, 8%–15%) from a mid-
wife. Other sources of recommenda-
tion included antenatal clinic staff such
as receptionists (30; 10%; 95% CI, 7%–
14%) and family members (22; 7%;
95% CI, 5%–11%).
Women reporting an underlying
condition that put them at higher risk
of complications from influenza were
no more likely to have received the
vaccine than women not reporting this
(2=2.02; P=0.16) and were no more
likely to have received a recommenda-
tion to do so (2=0.02; P=0.88).
Our results show the importance of
health care provider recommendation
in pregnant women’s willingness to
receive influenza vaccination. Vaccine
uptake among women in this sample
was relatively low (27%), with signifi-
cant variation between study sites.
This study has some limitations.
First, few women in our sample
received antenatal care through private
obstetric providers. In NSW, about
26% of women seek antenatal care
from a private obstetrician or mid-
wife.13 Our sample can therefore be
considered representative of the public
obstetric care population only.
Second, our data on uptake relied
only on self-report. Self-report has
been identified as an acceptable proxy
to medical record audit for determin-
ing vaccine uptake in older adults.14,15
We anticipate pregnant women’s recall
to be equal or better, given that they
were unlikely to have received another
vaccine while pregnant in 2011.
Third, the data are cross-sectional
and although we were able to identify
associations between vaccine uptake
and certain study factors, we cannot
confirm these associations as causal.
However, the findings concur with
other studies that found health care
provider recommendation, safety per-
ceptions and access to vaccines are
major factors in vaccine uptake.16-18
Our findings suggest that women’s
concerns about the safety of the vac-
cine for their unborn child can be over-
come by health care provider
recommendation. Although women
who were concerned about their baby’s
safety were less likely to be vaccinated,
68% of them agreed that they would
have the vaccine if their doctor or mid-
wife recommended it.
Given that a minority of women
surveyed, including those at risk due to
underlying conditions, had received a
vaccination recommendation, it is
important to consider what would
increase recommendations from
health care providers. While some
studies have found that physicians are
aware of current recommendations,19
others report confusion among health
care providers about contraindications
and vaccine safety.20-22 These findings
highlight the need for professional
education and support for antenatal
Vaccine availability at the antenatal
clinic was an apparent contributor to
uptake. Site C, which had an onsite
vaccination nurse at the time of the
study and staff members who dis-
cussed the recommendations with
women in the waiting room, had a 46%
uptake. Sites A and B, which had sig-
nificantly lower uptake, had no such
programs during the study period. This
suggests that easily accessible vaccine is
likely to be important, but other con-
tributing factors cannot be ruled out.
Uptake by women who felt it was
easy to access the doctor for vaccina-
tion was not significantly different to
uptake by women who felt access was
difficult. One explanation may be that
women attending Site C (29% of the
study sample), who live in a rural set-
ting where access to a primary care
doctor is comparatively difficult, had
an alternative method of accessing
vaccination through the clinic.
Our results suggest that provision of
information about influenza vaccina-
tion for pregnant women will only par-
tially overcome the low uptake in this
group. Motivation and education of
antenatal care providers is also impor-
tant. Information for pregnant women
and providers, coupled with easily
accessible vaccine, have the potential
to substantially increase maternal
influenza vaccination coverage.
Acknowledgements: We acknowledge A Raeburn and P
Cashman of Hunter New England Area Population Health;
C King of the National Centre for Immunisation Research
and Surveillance; L Taylor and J Bentley of the Centre for
Epidemiology and Evidence, NSW Ministry of Health; and
the staff of Westmead Hospital Antenatal Clinic, Royal
Prince Alfred Women and Babies, and Tamworth Rural
Referral Hospital Antenatal Clinic. This study was funded
by the Financial Markets Foundation for Children (grant
Competing interests: Julie Leask participated in an
Australian Research Council Linkage grant on paediatric
influenza vaccination that received partial funding from
Received 19 Dec 2012, accepted 19 Mar 2013.
1 Neuzil KM, Reed GW, Mitchel EF, et al. Impact of influenza on acute
cardiopulmonary hospitalizations in pregnant women. Am J Epidemiol 1998;
2 ANZIC Influenza Investigators and Australasian Maternity Outcomes
Surveillance System. Critical illness due to 2009 A/H1N1 influenza in pregnant
and postpartum women: population based cohort study. BMJ 2010; 340: c1279.
3 Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus
infection during pregnancy in the USA. Lancet 2009; 374: 451-458.
4 Tamma PD, Steinhoff MC, Omer SB. Influenza infection and vaccination in
pregnant women. Expert Rev Respir Med 2010; 4: 321-328.
5 Eick AA, Uyeki TM, Klimov A, et al. Maternal influenza vaccination and effect on
influenza virus infection in young infants. Arch Pediatr Adolesc Med 2011; 165:
6 Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal influenza
immunization in mothers and infants. N Engl J Med 2008; 359: 1555-1564.
7 National Health and Medical Research Council. Australian immunisation
handbook. 9th ed. Canberra: NHMRC, 2008.
8 Lu AB, Halim AA, Dendle C, et al. Influenza vaccination uptake amongst
pregnant women and maternal care providers is suboptimal. Vaccine 2012; 30:
9 Mak DB, Daly AM, Armstrong PK, Effler PV. Pandemic (H1N1) 2009 influenza
vaccination coverage in Western Australia. Med J Aust 2010; 193: 401-404.
10 McCarthy EA, Pollock WE, Nolan T, et al. Improving influenza vaccination
coverage in pregnancy in Melbourne 2010-2011. Aust N Z J Obstet Gynaecol 2012;
11 White SW, Petersen RW, Quinlivan JA. Pandemic (H1N1) 2009 influenza vaccine
uptake in pregnant women entering the 2010 influenza season in Western
Australia. Med J Aust 2010; 193: 405-407.
12 Armitage CJ, Conner M. Social cognition models and health behaviour: a
structured review. Psychol Health 2000; 15: 173-189.
13 Li Z, McNally L, Hilder L, Sullivan EA. Australia’s mothers and babies 2009.
(AIHW Cat. No. PER 52; Perinatal Statistics Series No. 25.) Sydney: Australian
Institute of Health and Welfare, 2011.
14 MacDonald R, Baken L, Nelson A, Nichol KL. Validation of self-report of influenza
and pneumococcal vaccination status in elderly outpatients. Am J Prev Med
1999; 16: 173-177.
15 Mangtani P, Shah A, Roberts JA. Validation of influenza and pneumococcal
vaccine status in adults based on self-report. Epidemiol Infect 2007; 135: 139-143.
16 Centers for Disease Control and Prevention. Influenza vaccination coverage
among pregnant women: 2011-12 influenza season, United States. MMWR Morb
Mortal Wkly Rep 2012; 61: 758-763.
17 Naleway AL, Smith WJ, Mullooly JP. Delivering influenza vaccine to pregnant
women. Epidemiol Rev 2006; 28: 47-53.
18 Tong A, Biringer A, Ofner-Agostini M, et al. A cross-sectional study of maternity
care providers’ and women’s knowledge, attitudes, and behaviours towards
influenza vaccination during pregnancy. J Obstet Gynaecol Can 2008; 30:
19 Wu P, Griffin MR, Richardson A, et al. Influenza vaccination during pregnancy:
opinions and practices of obstetricians in an urban community. South Med J
2006; 99: 823-828.
20 Broughton DE, Beigi RH, Switzer GE, et al. Obstetric health care workers’
attitudes and beliefs regarding influenza vaccination in pregnancy. Obstet
Gynecol 2009; 114: 981-987.
21 Wallis DH, Chin JL, Sur DK. Influenza vaccination in pregnancy: current practices
in a suburban community. J Am Board Fam Pract 2004; 17: 287-291.
22 Lee T, Saskin R, McArthur M, McGeer A. Beliefs and practices of Ontario midwives
about influenza immunization. Vaccine 2005; 23: 1574-1578.