PREGNANT WOMEN’S COMPLIANCE WITH VACCINATION IN THE CONTEXT OF PANDEMICS: AN INTEGRATIVE REVIEW

Abstract

Objective
to analyze national and international publications regarding pregnant women’s compliance with vaccination in the context of pandemics.

Method
this is an integrative literature review, carried out in August 2021 in the LILACS, MEDLINE, Web of Science and Scopus databases, without language and publication time restriction. The descriptors indexed in DeCS and MeSH, Immunization, Vaccination, Pregnancy and Pandemics, combined using the Boolean operator, were used. The results obtained were exported to the EndNote reference manager software and, later, to the Rayyan - Intelligent Systematic Review application. The sample consisted of 27 studies. Analysis considered frequency and similarities between the studies.

Results
the factors that interfere with compliance with vaccination by pregnant women in pandemic times were highlighted: distrust of vaccines; concerns about vaccination safety in pregnancy or for the fetus’ health; lack of information and lack of knowledge about the benefits of vaccine. Moreover, the reasons for compliance were desire to protect the baby, knowledge about the pandemic, concern about the risk of infection, and recommendation and guidance on vaccination during prenatal care.

Conclusion
the factors that may interfere with compliance with vaccination were verified, mainly in relation to new vaccines in the context of pandemics. It is considered that investments in strategies related to immunization during pregnancy can provide health benefits, preventing preventable diseases in pregnant women and their babies.
DESCRIPTORS:
Pregnant Women; Pandemic; COVID-19; Vaccination; Nursing

Full text

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Literature
Review
Texto & Contexto Enfermagem 2023, v. 32:e20220117
ISSN 1980-265X DOI https://doi.org/10.1590/1980-265X-TCE-2022-0117en
HOW CITED: Vasconcelos PP, Lacerda ACT, Pontes CM, Guedes TG, Leal LP, Oliveira SC. Pregnant women’s compliance
with vaccination in the context of pandemics: an integrative review. Texto Contexto Enferm [Internet]. 2023 [cited YEAR
MONTH DAY]; 32: e20220117. Available from: https://doi.org/10.1590/1980-265X-TCE-2022-0117en
PREGNANT WOMEN’S COMPLIANCE
WITH VACCINATION IN THE CONTEXT OF
PANDEMICS: AN INTEGRATIVE REVIEW
Patrícia Pereira Vasconcelos1 
Ana Catarina Torres de Lacerda1 
Cleide Maria Pontes1 
Tatiane Gomes Guedes1 
Luciana Pedrosa Leal1 
Sheyla Costa de Oliveira1 
1Universidade Federal de Pernambuco, Programa de Pós-Graduação em Enfermagem. Recife, Pernambuco, Brasil.
ABSTRACT
Objective: to analyze national and international publications regarding pregnant women’s compliance with
vaccination in the context of pandemics.
Method: this is an integrative literature review, carried out in August 2021 in the LILACS, MEDLINE, Web of
Science and Scopus databases, without language and publication time restriction. The descriptors indexed
in DeCS and MeSH, Immunization, Vaccination, Pregnancy and Pandemics, combined using the Boolean
operator, were used. The results obtained were exported to the EndNote reference manager software and,
later, to the Rayyan – Intelligent Systematic Review application. The sample consisted of 27 studies. Analysis
considered frequency and similarities between the studies.
Results: the factors that interfere with compliance with vaccination by pregnant women in pandemic times
were highlighted: distrust of vaccines; concerns about vaccination safety in pregnancy or for the fetus’ health;
lack of information and lack of knowledge about the benets of vaccine. Moreover, the reasons for compliance
were desire to protect the baby, knowledge about the pandemic, concern about the risk of infection, and
recommendation and guidance on vaccination during prenatal care.
Conclusion: the factors that may interfere with compliance with vaccination were veried, mainly in relation to
new vaccines in the context of pandemics. It is considered that investments in strategies related to immunization
during pregnancy can provide health benets, preventing preventable diseases in pregnant women and their
babies.
DESCRIPTORS: Pregnant Women. Pandemic. COVID-19. Vaccination. Nursing.

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ADESÃO DE GESTANTES À VACINAÇÃO NO CONTEXTO DE PANDEMIAS:
REVISÃO INTEGRATIVA
RESUMO
Objetivo: analisar as publicações nacionais e internacionais com relação à adesão de gestantes à vacinação
no contexto de pandemias.
Método: revisão de literatura, tipo integrativa, realizada em agosto de 2021 nas bases de dados LILACS,
MEDLINE, Web of Science e SCOPUS, sem restrição de idioma e de tempo de publicação. Utilizaram-se os
descritores indexados no DeCS e MeSH: Immunization, Vaccination, Pregnancy e Pandemics, combinados
por meio do operador booleano. Os resultados obtidos foram exportados para o software gerenciador de
referências EndNote e, posteriormente, para o aplicativo Rayyan – Intelligent Systematic Review. A amostra
foi constituída por 27 estudos. A análise considerou a frequência e as similaridades entre os estudos.
Resultados: foram evidenciados os fatores que interferem na adesão à vacinação pelas gestantes em tempos
pandêmicos: desconança com as vacinas; preocupações sobre a segurança da vacinação na gravidez ou
para a saúde do feto; falta de informações e desconhecimento de benefícios sobre a vacina. Além disso, as
razões para a adesão foram o desejo de proteger o bebê, o conhecimento sobre a pandemia, a preocupação
com o risco de infecção e a recomendação e orientação sobre a vacinação durante o pré-natal.
Conclusão: foram vericados os fatores que podem interferir na adesão à vacinação, principalmente, com
relação às novas vacinas no contexto de pandemias. Considera-se que investimentos em estratégias com
relação à imunização na gravidez podem proporcionar benefícios para a saúde, prevenindo agravos evitáveis
em gestantes e em seus bebês.
DESCRITORES: Gestantes. Pandemia. COVID-19. Vacinação. Enfermagem.
ADHERENCIA A LA VACUNACIÓN DE MUJERES EMBARAZADAS EN
CONTEXTO DE PANDEMIA: REVISIÓN INTEGRATIVA
RESUMEN
Objetivo: analizar publicaciones nacionales e internacionales sobre la adherencia de las gestantes a la
vacunación en el contexto de pandemias.
Método: revisión de literatura, tipo integradora, realizada en agosto de 2021 en las bases de datos LILACS,
MEDLINE, Web of Science y SCOPUS, sin restricción de idioma y tiempo de publicación. Se utilizaron los
descriptores indexados en DeCS y MeSH, Immunization, Vaccination, Pregnancy y Pandemics, combinados
mediante el operador booleano. Los resultados obtenidos se exportaron al software gestor de referencias
EndNote y, posteriormente, a la aplicación Rayyan – Intelligent Systematic Review. La muestra estuvo
compuesta por 27 estudios. El análisis consideró la frecuencia y similitudes entre los estudios.
Resultados: se destacaron los factores que intereren en la adherencia a la vacunación de las gestantes en
tiempos de pandemia: desconanza en las vacunas; preocupaciones sobre la seguridad de la vacunación en
el embarazo o para la salud del feto; falta de información; y falta de conocimiento sobre los benecios de la
vacuna. Además, los motivos de adherencia fueron el deseo de proteger al bebé, el conocimiento sobre la
pandemia, la preocupación por el riesgo de infección y la recomendación y orientación sobre la vacunación
durante el prenatal.
Conclusión: se vericaron los factores que pueden interferir en la adherencia a la vacunación, principalmente
en relación a las nuevas vacunas en el contexto de pandemias. Se considera que las inversiones en estrategias
relacionadas con la inmunización durante el embarazo pueden brindar benecios para la salud, previniendo
enfermedades prevenibles en las gestantes y sus bebés.
DESCRIPTORES: Mujeres embarazadas. Pandemia. COVID-19. Vacunación. Enfermería.

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INTRODUCTION
A disease becomes a pandemic when it a󰀨ects large proportions, i.e., when a certain agent
spreads in several countries and in more than one continent, reaching a large number of people.1 In
recent years, the World Health Organization (WHO) has declared two pandemics: inuenza A H1N1
(H1N1), on June 11, 2009
2
; and Coronavirus Disease 2019 (COVID-19), declared on March 11, 2020.
3
Inuenza pandemic is a cyclical and unpredictable occurrence that is related to the emergence
of a new viral subtype, resulting from mutations capable of generating a new virus.4 The COVID-19
pandemic, caused by coronavirus (SARS-CoV-2), is responsible for presenting a broad clinical chart,
with complications in the respiratory tract and even death.5
Pregnant women represent a vulnerable group to outbreaks of infectious diseases due to the
physiological changes typical of pregnancy, which make them more susceptible to infection.6 For this
reason, they are included in priority groups for vaccination against inuenza and COVID-19.7
COVID-19’s clinical manifestations severely impact pregnant and postpartum women, leading
to unfavorable obstetric outcomes, such as preeclampsia, fetal distress, miscarriage, maternal
respiratory distress, prematurity, intrauterine growth restriction, increased need for surgical delivery,
coagulopathies followed by liver dysfunction and death.
6,8–9
With regard to H1N1, pregnant women can
present clinically severe forms, such as pneumonia, severe acute respiratory syndrome and deaths,
in addition to premature labor.10–11
Vaccines contribute to the eradication and e󰀨ective control of vaccine-preventable diseases,
reducing morbidity and mortality due to di󰀨erent diseases with a signicant impact on the population’s
health and quality of life.12–13 Therefore, vaccines are essential for disease prevention in large population
groups and their aggravations, including the impacts on health in relation to COVID-19 and Inuenza.
Vaccines are e󰀨ective and safe in pregnant and postpartum women and are well tolerated, with a low
percentage of side e󰀨ects.10–14
Despite the importance of vaccines, demonstrated by national and international institutions,
pregnant women have a low willingness to receive new vaccines, mainly developed in times of
epidemic and pandemic situations.15–17 Thus, guidance to pregnant women about vaccination is an
essential element in immunization programs as it allows them to acquire knowledge about the benets
of immunization.18
In the last decade, there have been great advances in the development of new vaccines with
the expansion of immunization programs.19 However, there is a need to know the factors that lead to
compliance with vaccination and to consolidate immunization strategies in the population of pregnant
and postpartum women, especially in pandemic contexts.20 Based on this assumption, this integrative
review aims to analyze national and international publications regarding pregnant women’s compliance
in the context of pandemics.
METHOD
This is an integrative review (IR), which consists of a method that provides synthesis of
knowledge, allowing the inclusion of experimental and non-experimental studies, for a complete
understanding of the phenomenon or problem analyzed with discussions of results for application in
evidence-based practice.21
The construction of this review covered six steps:22 research question elaboration; sampling
or literature search of primary studies; data extraction from selected studies; assessment of included
studies; interpretation of results; and IR presentation.
The guiding question was elaborated based on the PICo strategy:23 P (Population), I (Phenomenon
of Interest) and Co (Context). Population is represented by pregnant women; interest, by compliance

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with vaccination; and context, by pandemics. Based on the strategy, the following guiding question
was generated: what evidence is available in the literature on pregnant women’s compliance with
vaccination in the context of pandemics?
For the survey of primary studies, an advanced search was carried out in August 2021, via
electronic address, with access through the CAPES portal, in the following databases: Latin American
and Caribbean Literature in Health Sciences (LILACS) via Virtual Health Library (VHL); Medical
Literature Analysis and Retrieval System Online (MEDLINE/PubMed) via the National Library of
Medicine); Web of Science via Clarinet Analytics; and Scopus via Elsevier.
To search for articles, the exact descriptors, Immunization, Vaccination, Pregnancy and
Pandemics, were used, located in the Health Sciences Descriptors (DeCS)/Medical Subject Headings
(MeSH), combined using Boolean operators “OR” and “AND”, according to Chart 1.
Chart 1 – Search strategies used in databases. Recife, PE, Brazil, 2021.
Database Search strategies
LILACS Vaccination OR Immunization [Subject descriptor] AND Pregnancy
[Subject descriptor] AND Pandemics [Subject descriptor]
MEDLINE/PubMed
((((Vaccination [MeSH Terms]) OR (Immunization [MeSH Terms]))
AND (Pregnancy [MeSH Terms]))) AND (Pandemics [MeSH
Terms])
WEB OF SCIENCE Vaccination OR Immunization (Topic) AND Pregnancy (Topic) AND
Pandemics (Topic)
SCOPUS
(TITLE-ABS-KEY (vaccination) OR TITLE-ABS-KEY
(immunization) AND TITLE-ABS-KEY (pregnancy) AND TITLE-
ABS-KEY (pandemics))
We included primary articles that addressed vaccination in pregnant women in the context of
pandemics, published without language restriction and without time frame. We excluded literature review
articles, reections, guides, comments, abstracts of annals, theses, dissertations, course conclusion
works, letters to the editor, reports, o󰀩cial documents of national and international programs, book
chapters and e-books.
Database search identied 1,007 publications: 608 in Scopus; 329 in the Web of Science; 69 in
MEDLINE; and one in LILACS (Table 1). The results obtained were exported to the EndNote reference
manager software, in which 282 duplicate studies were excluded and, later, to the Rayyan application
– Intelligent Systematic Review – in which 31 more duplicated studies were excluded, leaving 694
articles that were selected for the review reading of titles and abstracts by two independent reviewers.
Table 1 – Publications found from the combination of descriptors according to database. Recife, PE, Brazil, 2021.
Descriptors LILACS MEDLINE Web Of Science Scopus Total publications
(Vaccination OR
Immunization) AND
Pregnancy AND
Pandemics
1 69 329 608 1007
The titles and abstracts of 694 articles were read with the help of Rayyan application to verify
their adequacy to the eligibility criteria, and 650 articles were excluded. From pre-selection, there were
a total of 44 articles and, after reading the full texts, 27 were selected, which answered the review’s

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guiding question. Figure 1 shows the steps for selecting articles that were part of IR, following the
Preferred Reporting Items for Systematic reviews and Meta Analyzes (PRISMA) recommendations.24
As for analysis, two independent reviewers blindly assessed the studies. In case of disagreement,
a third reviewer’s opinion was requested. The meetings for assessing the articles that would compose
the IR took place via Google Meet. The inclusion process of articles was in accordance with the
inclusion criteria and the research question; thus, an attempt was made to reduce the risk of selection
bias, giving it methodological rigor in the inclusion of studies until the nal sample.
Data from studies included in the IR were extracted using the instrument validated by URSI25,
considering the following variables: article identication (journal title, authors, country, year of
publication and language); study’s host institution; methodological characteristics (study design, sample
selection); performed interventions; results and implications; level of evidence; and methodological
rigor assessment. The selected articles’ methodological rigor was assessed according to the Critical
Appraisal Skills Program (CASP)26 criteria, and, to assess the strength of evidence of the research
included, the classication of the seven levels proposed by Fineout-Overholt was used.27
Figure 1 – Flowchart of sample selection steps from integrative review articles. Recife, PE, Brazil, 2021.

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In Figure 1, the screening and the process of selecting studies assessed to the nal sample
is presented following the PRISMA criteria.24 In Chart 2, there are the results presented descriptively
aiming at synthesizing and fostering the discussion. Regarding the interpretation of results, they were
analyzed qualitatively based on analysis of frequency and similarities between related studies, having
as its central point the analysis of factors regarding pregnant women’s compliance with vaccination.
RESULTS
Of the articles selected to compose the IR, 22 addressed vaccination in H1N1 pandemic, and
ve, the COVID-19 pandemic, and 26 studies were in English and published in 19 di󰀨erent journals. As
for study origin, the commonly found countries were the United States, Canada, Turkey, China, South
Korea, Australia and Switzerland. They were less often identied studies in Qatar, Iran, Morocco, Ivory
Coast, Brazil, the United Kingdom and India. The articles were, in their entirety, classied as level six
of evidence. As for methodological rigor, 24 articles were classied as level A, good methodological
quality and reduced bias (Chart 2).
With regard to study limitations and risks of bias presented by the authors, issues related
to selection bias,
28–34
memory bias
32,35–38
,
limitation in sample size
31,35,39–42
, results that cannot be
generalizable,36–37.42–43–45 and data limited to a single institution stood out.38,46
The studies of this IR have evidenced the factors that interfere with compliance with vaccination
by pregnant women, such as: distrust of future problems not yet discovered that vaccines can
cause in the long run28–29,46–47; concerns about vaccination safety in pregnancy or related to side
e󰀨ects29,31,35–36,40,45–46,48–49; concern about damage or any risks to the fetus’ health34,37,41–42,50,51; lack of
information about vaccine and ignorance of benet of vaccines32,42,52; listening or reading negative
news in the media45; concern with vaccine e󰀨ectiveness53; perception that they were not at risk of
severe illness36,49 (Chart 2).
With regard to the reasons for vaccination compliance, evidence points to the desire to protect
the baby,31,38,48 knowledge about the pandemic and concern about the risk of infection,36,43,52–53 the
recommendation and guidance on vaccination during prenatal care29,47 and reading about vaccine
e󰀩cacy or positive feedback from family or friends28 (Chart 2).
Chart 2 – Synthesis of primary studies related to pregnant women’s compliance regarding the vaccination
o󰀨ered in pandemic times. Recife, PE, Brazil, 2021.
Author/year/LoE*
RM† Objective and sample Result
Mohan S, et al28 2021
LoE:6
MR: Level A
- Explore attitudes towards
COVID-19 vaccination between
women in the perinatal period.
- Sample of 341 pregnant and
breastfeeding women.
The distrust of future vaccine problems
(70.6%) was a main reason for vaccination
hesitation. Factors that would increase
condence in accepting the vaccine were
reading about e󰀩cacy (33.8%) or positive
feedback from family or friends (8.1%).
Gencer H, et al45 2021
LoE:6
MR: Level A
- Determine the opinions of
pregnant women about vaccines
during pregnancy and childhood
and the e󰀨ect of COVID-19
pandemic on these opinions.
- Sample of 152 pregnant women.
The reasons for vaccination hesitation were
listening or reading negative media news
(21.7%) and believing that vaccines were not
safe or were concerned about side e󰀨ects
(21.7%).

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Author/year/LoE*
RM† Objective and sample Result
Goncu Ayhan S, et al51
2021
LoE:6
MR: Level A
- Dene COVID-19 vaccine
acceptance and hesitancy status
in a sample of pregnant women in
Ankara, Turkey.
- Sample of 300 pregnant women.
63% of pregnant women would refuse
the vaccine COVID-19 vaccine even if
recommended. Of these, 65.6% declared
concern about lack of data on vaccine safety
in the pregnant population, and 41.7%, the
possibility of harm to the fetus.
Stuckelberger S, et al30
2021
LoE:6
MR: Level A
- Investigate the COVID-19
vaccine availability among
pregnant and breastfeeding
Swiss women if the vaccine was
available as well as the factors
that contributed to its acceptance
or hesitation.
- Sample of 1551 Swiss women
(515 pregnant and 1,036
breastfeeding up to 90 days).
29.7% of pregnant women and 38.6%
breastfeeding women were willing to be
vaccinated against SARS-CoV-2.
Among participants, 10.5% mentioned fear
of potential consequences for the fetus/baby.
Women in the third trimester of pregnancy
who had received inuenza vaccination in the
previous year were more likely to receive the
vaccine.
Tao L, et al53 2021
LoE:6
MR: Level A
- Explore COVID-19 vaccine
acceptance and factors related to
vaccine acceptance based on the
health belief model.
- Sample of 1,392 pregnant
women.
Among the 315 pregnant women who
answered “no” or “not sure” of their intention
to be vaccinated with a COVID-19 vaccine,
54% refused any vaccination during
pregnancy due to concern about side e󰀨ects;
47.0% were concerned about safety; and
44.1% were concerned about vaccine
e󰀩cacy.
Im JH, et al48 2020
LoE:6
MR: Level A
- Assess changes in inuenza
vaccination coverage rates and
the related factors that inuence
them in pregnant women.
- Sample of 550 pregnant women.
The common reasons for receiving the
vaccine were preventing the u (49.7%)
and ensuring fetal health (46.3%). The most
common reason for non-vaccination was lack
of su󰀩cient information about vaccination
(36.9%).
Bettinger JA, et al39
2016
LoE:6
MR: Level A
- Investigate pregnant women’s
and new mothers’ attitudes
and behaviors in relation to
seasonal and pandemic inuenza
vaccination.
- Sample of 26 pregnant women
and eight postpartum women in
the focus group (FG); of these, 22
composed the online survey.
67.6% of FG participants agreed “somewhat”
about vaccine safety during pregnancy
and, for most of the, the vaccine’s unknown
risks do not outweigh the benets and
were concerned about adverse e󰀨ects of
vaccination.
In the online survey, 42% of unvaccinated
women did not feel informed enough to
make the decision to receive the vaccine;
42% were concerned about safety; and 50%
did not discuss vaccination with their health
professional.
Jung EJ, et al29 2016
LoE:6
MR: Level A
- Assess coverage rate and
perceptions of Korean women of
reproductive age about inuenza
vaccine during pregnancy and
conduct a virtual intervention to
increase their intention to receive
vaccination.
- Sample of 500 pregnant women
and 500 women of reproductive
age.
Among 764 participants, 62.7% did not
receive the vaccine during pregnancy and the
reasons for not vaccinating were concerns
about harmful e󰀨ects on the fetus (29.6%)
and lack of vaccine recommendation by
health professionals (12.9%). Of those
who received the vaccine, the reasons
for vaccination were perceived risk of
inuenza infection in babies (22.8%), health
professionals’ recommendation (26.7%) and
belief in vaccine e󰀩cacy (15.8%).
Chart 2 – Cont.

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Author/year/LoE*
RM† Objective and sample Result
Mccarthy EA, et al38
2015
LoE:6
MR: Level A
- Review facilitating and impeding
factors in promoting inuenza
vaccination during pregnancy to
inform future lay and professional
educational e󰀨orts.
- Final sample of 1,086
postpartum women.
65.0% of participants who remembered
vaccination being discussed or recommended
by a health professional were subsequently
vaccinated. The main reason for vaccinating
was the desire to protect the baby, which
increased from 66.7% in 2010 to 89.2% in
2014, while 47.1% chose not to vaccinate
during pregnancy because they do not
usually be vaccinated during pregnancy.
Halperin BA, et al49.
2014
LoE:6
MR: Level A
- Explore and compare pregnant
women’s pre- and post-
pandemic knowledge, attitudes,
beliefs and intended behaviors
regarding inuenza vaccination
(seasonal and/or pandemic)
during pregnancy in order to
determine the main factors
inuencing their decision to
comply with the inuenza vaccine
recommendations.
- Sample of 662 pregnant women
in the pre-pandemic period
(2005-2006) and 159 in the post-
pandemic period (2011).
The reasons for seasonal u vaccination
were protection against the disease for
themselves and their family (44% pre-
and 45% post-pandemic) and health
professionals’ recommendation (19% pre and
38% post), reasons for vaccination H1N1
(48% and 20%, respectively). Reasons for
not vaccinating against seasonal u were that
they did not need to receive immunization
(36% pre and 70% post) and concern about
side e󰀨ects (5% and 26%); reasons also cited
by women who did not receive the vaccine
against the H1N1 pandemic (26% and 14%,
respectively).
Lohiniva AL, et al34
2014
LoE:6
MR: Level A
- Describe pregnant women’s
perceptions related to H1N1
inuenza, to identify the factors
that encourage or discourage
them to take the A(H1N1)
monovalent vaccine pdm09 during
the response to the pandemic
(2009-2010), and the sources of
information that inuenced their
process of decision-making.
- Sample of 123 pregnant women.
Women feared that the vaccine could
negatively a󰀨ect their health and that of
their babies, and speech analysis identied
the interference of the social network in the
decision-making to receive the vaccine:
discussions with health professionals were
a positive factor for the decision-making for
vaccination, while rumor-based discussions
about complications and side e󰀨ects with
neighbors and friends often fuel the decision
not to vaccinate.
Ahluwalia IB, et al37
2014
LoE:6
MR: Level A
- Examine disparities in
vaccination coverage among
women who gave birth during
the 2009-2010 inuenza season,
when two separate inuenza
vaccinations were recommended.
- Sample of postpartum and
breastfeeding women, 27.153 for
seasonal inuenza and 27.372 for
H1N1.
Reasons cited for not receiving vaccination
include: lack of recommendation by health
care provider about a u shot during
pregnancy; concern about vaccine side
e󰀨ects; concern of harm to the fetus; habit of
not getting the u shot.
Kfouri RA, Richtmann
R46 2013
LoE:6
MR: Level B
- Describe the vaccination
coverage of pregnant women
for inuenza and factors
associated with vaccine refusal or
acceptance.
- Sample of 300 postpartum
women.
95.7% received the vaccine against inuenza
during pregnancy and, of these, 73.2% knew
that the vaccine would protect their child.
Among those who did not receive it, all were
unaware of the fact that the vaccine would
protect the baby, and 69.2% would have
been vaccinated if they had been informed of
neonatal protection.
Chart 2 – Cont.

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Author/year/LoE*
RM† Objective and sample Result
Tarrant M, et al41 2013
LoE:6
MR: Level A
- Examine factors associated with
the adoption of the 2009 inuenza
A/H1N1 vaccine among pregnant
women in Hong Kong.
- Sample of 549 postpartum
women.
91.1% did not receive any of the inuenza
A (H1N1) and/or seasonal vaccines during
pregnancy, and the reason cited was the fear
that the vaccine would cause side e󰀨ects
to them or their fetus (69.7% and 75.7%,
respectively), and reported that vaccination
should be avoided during pregnancy (78.8%).
Kouassi DP, et al52
2012
LoE:6
MR: Level A
- Assess awareness of the
pandemic and A(H1N1) pdm09
vaccine awareness and
acceptance in February 2010,
prior to the local availability of the
vaccine.
- Sample of 411 pregnant women.
Of the 80 women who said they would not
accept being vaccinated, 45% reported
lack of information about the vaccine as the
reason for not vaccinating. Women who are
aware of the pandemic and believe they are
susceptible to H1N1 u were more likely to
accept vaccination (75.4%).
Honarvar B, et al32
2012
LoE:6
MR: Level A
- Determine the acceptance rate
of inuenza vaccination, including
the 2009 pandemic inuenza
H1N1 and seasonal inuenza
vaccination, and the reasons for
acceptance or rejection among
pregnant women.
- Sample of 416 pregnant women.
Out of 92.06% of pregnant women who
refused the H1N1 inuenza vaccine, 30.28%
reported lack of information about vaccination
as the main reason for refusal. Of the 25
vaccinated pregnant women, 60% reported
having been vaccinated on the advice of
someone other than a health professional.
Schindler M, et al33
2012
LoE:6
MR: Level A
- Examine Swiss pregnant
women’s representations of the
risks associated with seasonal
u and its vaccination in the rst
wave.
- Sample of 29 postpartum
women.
The lack of recommendation, by health
professionals, about the dangerousness of
seasonal u and the protection a󰀨orded by
vaccines may have left pregnant women in a
state of indecision regarding vaccination.
Moukarram H, et al50
2012
LoE:6
MR: Level B
- Assess vaccine awareness and
uptake among pregnant women in
the local community.
- Sample of 200 pregnant women.
42.5% of pregnant women said they would
take the vaccine. Regarding the main
reasons for refusal, 43.5% reported concern
about possible risks to the fetus and 40.9%,
risk to themselves.
Bhaskar E, et al42 2012
LoE:6
MR: Level A
- Identify pandemic inuenza
vaccination rates among
pregnant women in Chennai
during the rst two months after
inuenza vaccine rollout and to
analyze factors associated with
vaccination.
- Sample of 140 pregnant women.
The inuenza vaccination rate was 12.8%.
The reasons for refusal were fear of
complications (28.5%), not knowing where
the vaccine was available (28.5%) and not
knowing the benets of vaccination (28.5%).
Kay WK, et al36 2012
LoE:6
MR: Level A
- Estimate pH1N1 vaccination
coverage among women in King
County during the third trimester
of pregnancy and identify
sociodemographic factors, beliefs
and practices associated with
vaccination.
- Sample of 4,205 postpartum
women.
The reasons cited by women not vaccinated
against H1N1 were not being able to nd
a vaccination provider (20.6%) and the
perception that they were not at risk of
serious illness (26.1%). The reasons reported
for not being vaccinated against the u were
safety issues (58%) related to the e󰀨ects of
the vaccine on the mother’s or fetus’ health.
Chart 2 – Cont.

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Author/year/LoE*
RM† Objective and sample Result
Steelsher GK, et al35
2011
LoE:6
MR: Level B
- Examine drivers and barriers to
pregnant women receiving the
H1N1 vaccine through a national
survey conducted during the
pandemic.
- Sample of 514 pregnant women.
The main reason for refusing to receive the
vaccine was concern about safety risks to the
fetus (62%) and to herself (59%).
Pregnant women who knew that the H1N1
vaccine provided protection against H1N1 u
for their babies were more likely to receive
the vaccine.
Dlugacz Y, et al54 2011
LoE:6
MR: Level A
- Identify factors associated with
acceptance or refusal of the
2009 H1N1 vaccination during
pregnancy.
- Sample of 1,325 postpartum
women.
34.2% received the 2009 H1N1 vaccine
during pregnancy; 54% unvaccinated women
indicated, as reason for refusal, concern
about the vaccine safety for the fetus.
Health professionals’ recommendation
was one of the reasons for accepting the
H1N1 vaccine. Of those who received the
recommendation, 56% were vaccinated.
Goldfarb I, et al31 2011
LOE:6
MR: Level A
- Dene the uptake of H1N1 and
seasonal inuenza vaccination
among women who delivered at
an urban teaching hospital during
the 2009-2010 H1N1 pandemic
and explore barriers to vaccinating
pregnant women.
- Sample of 366 postpartum
women.
81% received H1N1 and seasonal u
vaccines.
Factors for compliance were the desire
to protect themselves (>60%) and their
babies (>80%) and recommendation from
a health professional (>60%), while refusal
was motivated by media attention and
recommendation from government agencies
(<20%).
Fisher BM, et al402011
LOE:6
MR: Level A
- Determine inuenza vaccination
rates, both seasonal and H1N1
pandemic, in pregnancy during
the 2009-2010 inuenza season
and for those women not
vaccinated during pregnancy
to determine reasons for non-
compliance.
- Sample of 813 postpartum
women.
64% of participants received vaccination
against seasonal u, and 54%, against H1N1
u during pregnancy.
Of women who did not receive both vaccines,
25% reported not being well-informed about
the importance of the vaccine, 18% reported
concern about the vaccine’s e󰀨ects on fetal
health, and 9%, about maternal health.
Sakaguchi S, et al43
2010
LOE:6
MR: Level A
- Determine how many pregnant
women received the H1N1
vaccine after their call to
Motherisk and explore pregnant
women’s perceptions of the H1N1
vaccine and factors surrounding
the decision to receive
vaccination.
- Sample of 130 pregnant women.
Among pregnant women who received the
vaccine, 73.1% reported concern about the
risk of H1N1 infection in the fetus and/or
themselves as a reason for their decision;
34.6% cited recommendations to encourage
vaccination; and 3.8% mentioned a previous
history of complication or illness due to
inuenza. Of those who did not receive the
vaccine, 42.3% reported concerns about
safety for themselves and/or their fetus, and
23.1% did not nd the vaccine necessary.
Ozer A, et al46 2010
LOE:6
MR: Level A
- Determine factors that a󰀨ect
pregnant women’s decisions
in Turkey whether or not to be
vaccinated against 2009 H1N1
inuenza.
- Sample of 314 pregnant women.
The H1N1 vaccination rate was 8.9%. 75.5%
of the unvaccinated thought the vaccine was
harmful in the long term; 70.1% believed it
could cause miscarriage, 74.2% deformity in
their children and 72.3% infertility.
Chart 2 – Cont.

Texto & Contexto Enfermagem 2023, v. 32:e20220117
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Author/year/LoE*
RM† Objective and sample Result
White SW, et al44 2010
LOE:6
MR: Level A
- Audit the 2009 pandemic (H1N1)
inuenza vaccine acceptance
in pregnant women entering
the 2010 inuenza season in
Western Australia and identify why
some women did not receive the
vaccine.
- Sample of 479 pregnant women.
The H1N1 vaccination rate was 6.9%.
Reasons for not vaccinating were lack of
discussion or dialogue about the vaccine with
health professionals during prenatal care
(63.9%), concern about vaccination safety
by pregnant women (61.6%) and active
discouragement of prenatal vaccination
(19.6%).
*LoE: Level of Evidence proposed by Fineout-Overholt. †MR: methodological rigor through CAS instruments.
DISCUSSION
This IR presented articles on compliance with vaccination in pregnant women in two pandemics
that occurred in the last ten years: the Inuenza A/H1N1 pandemic, which occurred in 2009, and the
current COVID-19 pandemic, which started in 2019(2,3).
When analyzing the vaccination coverage rate evidence in the H1N1 pandemic, studies showed
that 95.7% of pregnant women were vaccinated in 2013 in Brazil,47 Canada (80%),43 USA (76.9% to
38.8%),37–41,52 Australia (6.9%) and44 Turkey (8.9%)46; however, in Iran, there was 92.06% refusal of
inuenza vaccination by pregnant women.32
Regarding the COVID-19 pandemic, in studies carried out before the vaccine was available, the
proportion of acceptance/willingness to receive the vaccine by pregnant women ranged from 29.7%
to 77.4%30,45,51,53. However, a study in Qatar showed a 75% rate of vaccine hesitancy, in which 25%
of women reported that they would probably or denitely not accept vaccination; 25.9% remained
insecure; and 28.3% would not have their children vaccinated.28
Vaccine hesitancy is dened as delay in accepting or refusing vaccines despite the availability
of vaccination services. It is a behavioral phenomenon that varies across time, place and types of
vaccines and includes factors such as complacency, convenience and trust. Complacency results
from low perceived risk of contracting vaccine-preventable disease. Convenience considers physical
and nancial availability, geographic accessibility, ability to understand and access health information.
Ultimately, trust is about vaccine e󰀩cacy and safety, health services’ and professionals’ competence
and managers’ motivations to recommend them.55
Concerns about vaccine safety and e󰀩cacy, distrust of vaccines, lack of knowledge about
vaccines during pregnancy as well as the lack of recommendations by health professionals were
some of the factors that inuenced vaccine acceptance and/or hesitation.30,36,42,45,48,51
Although vaccines are safe, e󰀨ective and recommended by health policies
7
, vaccine hesitancy
is often cited as a particularly present problem during pregnancy, as pregnant women are encouraged
to avoid medications with known or uncertain risks to the fetus.
56
In this IR, studies showed that women
choose not to vaccinate during pregnancy because they are not usually vaccinated during pregnancy
37,49
and that unvaccinated pregnant women were more likely to agree that vaccines should not be taken
during pregnancy because they believe that the risk would be greater in receiving vaccination during
pregnancy than in developing the disease.41
Authors stated that most pregnant women indicate their intention to receive COVID-19
vaccines, but they prefer to wait until the end of pregnancy so as not to expose their baby or after
weaning their children because the COVID-19 vaccine safety is relatively new and, probably, not
yet widespread.57,58 Distrust of vaccination ranks second in predicted reasons for not wanting to be
Chart 2 – Cont.

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vaccinated during pregnancy.59 Strengths cited in the study with regard to vaccine acceptance and
condence were perception of virus and disease risk, public trust, belief in the importance of having
a COVID-19 vaccine, and vaccine e󰀩cacy during pregnancy.58
Overall, pregnant and breastfeeding women reported vaccine safety for the child and the mother
as top priorities in relation to the COVID-19 vaccine and had a higher level of acceptance in the third
trimester of pregnancy, as a series of vaccines, including inuenza (H1N1) and Tdap vaccines, is
particularly recommended during the third trimester.57
From the studies that were part of the IR sample, it was observed that the lack of recommendation
by health professionals about vaccination and/or insu󰀩cient information were reasons for not vaccinating
pregnant women.
29,33,37,40,44,48,52
On the other hand, there was compliance with vaccination by pregnant
women who received recommendations or face-to-face discussions with health professionals during
the gestational period.31,34,36,38
Therefore, it is important that health professionals take advantage of vaccination experiences
on previous occasions and the perception that women have about vaccines, to provide e󰀨ective
advice to increase vaccination coverage during pregnancy.59 Health professionals have a relevant
role in prenatal care as providers of information and encouragers for vaccination, with an impact on
women’s compliance with vaccines in the pregnancy-postpartum period.7
Information support and provision about vaccination by health professionals is a great opportunity
to achieve a complete vaccination history of women. Thus, vaccination during pregnancy should be
analyzed as an opportunity to improve vaccination coverage of all vaccines, which are low in the
general population.60
The studies included in the IR stated that pregnant women who had knowledge about the
pandemic and the perception that they were susceptible to infection were more likely to accept
vaccination.35,52,53 Women who believed they were at high risk of serious illness or complications,
if infected with H1N1, had a higher prevalence of vaccination.36,49 However, the level of perceived
knowledge regarding the COVID-19 vaccine alone cannot predict vaccine acceptance.57
When analyzing the population prole of the IR studies, it was identied that H1N1 vaccination
coverage varied with age, as younger women had the lowest coverage31,37, while education did not
show a signicant association with vaccine acceptance.31,41–43,52 However, a study carried out in the
USA showed that women with complete higher education and aged over 35 years were more likely
to have been vaccinated against the H1N1 u.35
With regard to the COVID-19 pandemic, it was found that greater COVID-19 vaccine acceptance
was associated with young age, low level of education and high score of knowledge about COVID-19.53
However, another study pointed out that age over 40 years and educational level higher than high
school are associated with a higher rate of COVID-19 vaccine acceptance.30 However, women who
claimed to have a low economic situation and concern about the risks of vaccination had a high
vaccine hesitancy rate.45
Evidence indicates that women had opinions and attitudes favorable to the vaccine when a health
professional was the main source of information38,39,45,49, positive experience of personal vaccination
or those close to them34,50, previously vaccinated family members41 or when agreed with the benets
of vaccination in the gestational period34 and for advice and incentives for vaccination by others.32,43
In addition to this, women with a previous vaccination history are more likely to be vaccinated
in pandemic situations. Thus, having received inuenza vaccination in the previous year was a positive
predictor for accepting H1N1
,54
and SARS-CoV-2 vaccines
49
.
30
However, rumor-based discussions about
complications and side e󰀨ects with neighbors and friends discouraged the decision to be vaccinated.
34

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The information found in the media for compliance with vaccination was rarely cited by
studies43,45,49,50 as well as the recommendations from the o󰀩cial government campaign.31,47 However,
hearing or reading negative news in the media can be a factor in vaccine hesitancy.45
The internet is an increasingly used tool for obtaining information. Social media platforms
such as Facebook, Twitter and Instagram are complex and uid ecosystems in which vaccine-related
misinformation can spread widely.
61
Additionally, mobile applications, considering the epidemiological
scenario of COVID-19 in the world, are an innovative digital technology that o󰀨ers convenience and
benet to the population and managers in accessing knowledge and an attractive alternative for health
professionals’ continuing education.62
Regarding the vaccine against COVID-19, the dissemination of correct information in a
transparent manner must be reinforced, in order to avoid giving wrong or worrying information as a
resource to increase vaccine acceptance, especially for vulnerable populations53, since fake news
circulate more easily and because politicians with national visibility issue personal opinions against
vaccines.63
The main limitation of this IR is the possibility of losing relevant studies indexed in other
databases. Furthermore, the analysis performed on the publications is related to the search selection
criteria proposed in this study. However, it was possible to infer the factors related to pregnant women’s
compliance with vaccination in the context of pandemics. It should be noted that publication biases
may be related to the particularities of each host institution where the studies included in the review
were carried out.
CONCLUSION
The main factors in the vaccine decision of pregnant women in pandemic situations are related
to concerns about vaccine safety, fear of complications and its side e󰀨ects, lack of information about
the vaccine and lack of recommendation by health professionals. Moreover, the desire to protect the
baby, knowledge about the pandemic and the recommendation and guidance on vaccination are
factors for compliance with vaccination during the gestational period.
In view of this, it can be considered that investments in strategies related to immunization
during pregnancy provide health benets, preventing preventable diseases in pregnant women and
their babies. Strengthening immunization programs as an advanced practice and having prenatal
care as a window of opportunity for compliance with vaccines is considered relevant in vaccination
acceptance among pregnant and postpartum women, especially in the context of pandemics.
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NOTES
ORIGIN OF THE ARTICLE
This study is part of a dissertation – Fatores associados à adesão da vacinação contra covid-19
no período gestacional, presented to the Graduate Program in Nursing, Universidade Federal de
Pernambuco, in 2022.
CONTRIBUTION OF AUTHORITY
Study design: Vasconcelos PP, Oliveira SC.
Data collection: Vasconcelos PP.
Data analysis and interpretation: Vasconcelos PP.
Discussion of results: Vasconcelos PP.
Writing and/or critical review of content: Vasconcelos PP, Oliveira SC, Lacerda ACT, Pontes CM,
Guedes TG, Leal LP.
Review and nal approval of the nal version: Oliveira SC, Lacerda ACT, Pontes CM, Guedes TG.
ACKNOWLEDGMENT
To CAPES and UFPE, for nancial support to the researcher linked to the Graduate Programs at
UFPE, Notice 02/2021– PROPG.
CONFLICT OF INTEREST
There is no conict of interest.
EDITORS
Associated Editors: Gisele Cristina Manfrini, Maria Lígia dos Reis Bellaguarda.
Editor-in-chief: Elisiane Lorenzini.
HISTORICAL
Received: May 13, 2022.
Approved: December 06, 2022.
CORRESPONDING AUTHOR
Patrícia Pereira Vasconcelos
patricia.vasconcelos@ufpe.br