The coronavirus disease 2019 (COVID-19) pandemic has brought numerous issues of disparity to the forefront. Among them are the inequalities that exist in healthcare access.
A new preprint discusses how women felt during the pandemic as they struggled to gain access to safe vaccination for themselves and for their babies. Up to 40% said they experienced difficulty, though they were able to reschedule their immunization appointments.
A preprint version of the study is available on the medRxiv* server while the article undergoes peer review.
Many routine immunizations for women and children have been affected by COVID-19. The UK's National Health Service (NHS) brought about changes in primary care and maternity services, putting pregnant women and children at the top of the list for routine immunization services. Nonetheless, the uptake of measles, mumps, and rubella (MMR) vaccine waned with the start of lockdowns.
Over the summer of 2020, childhood vaccine uptake continued to be low compared to prior years. Moreover, the pertussis vaccine that is advised for pregnant women between 16-32 weeks of pregnancy, registered a 4% drop in uptake after the first 2020 lockdown, plunging to the lowest level in five years.
The reason attributed to this drop is the advice to stay at home with healthcare utilization reduced to an as-necessary-only basis. Primary care services were less used, while the increased use of remote consultations over in-person visits may have made vaccinations less accessible to women.
The high-risk status of pregnancy may have contributed to the avoidance of vaccination as pregnant women became more hesitant to attend antenatal and vaccination appointments.
The current study aimed to evaluate the awareness of women after the pandemic, as well as their acceptance of and access to pertussis and childhood vaccines during this time.
What did the study show?
The majority of women (96%), including pregnant and postpartum women, knew of the recommendation for pertussis vaccination during pregnancy – often because they had already taken it during previous pregnancies. Of the small number who did not, they were more likely to have a household income below £25,000.
There was a distinct liking for information on vaccines from midwives and GPs, especially face to face. Women said they did not get opportunities to gain information about vaccines in pregnancy and other pregnancy-related issues compared to prior pregnancies.
About 72% of pregnant women, and 89% of new mothers, were vaccinated with the pertussis shot. Of the pregnant unvaccinated mothers, 84% were in the first or second trimester, and 87% were going to be vaccinated. Even among those who did not know about its necessity, three out of four said they favored it.
Almost every woman who had been vaccinated in an earlier pregnancy said she was vaccinated in the current pregnancy as well, with a vaccine refusal rate of 7%, but a change from unvaccinated to vaccinated status between the prior and current pregnancies in 30%.
Some reported feeling unsafe going to the hospital, while one referred to a racial disinformation theme around the vaccine.
Women who took the vaccine during pregnancy had certain common factors: they were more likely to be White, aged 30-34, and, among first-time mothers only, a household income below £25,000. Conversely, those in their third trimester without vaccination were likely to remain so, relative to the 30–34-year group.
Those who remained unvaccinated were still more likely to be from an ethnic minority and with a lower household income. Access Issues
62% said they had a GP appointment shifted or canceled due to the pandemic, with most of them getting online or phone appointments instead. The change was more often from the GP's side.
About 40% of women with a vaccine appointment with a GP, but only 8% with a hospital vaccine appointment, said it was shifted or canceled. About 43% had other appointments changed.
As a result, women understood that they had to take the effort to get their routine vaccines, which proved difficult for first-time women.
About a fifth of women said they had lost access to pregnancy vaccines, but 45% said they felt exposed to danger during vaccine appointments. Physical access was lower and the perception of risk higher, among non-White minorities relative to Whites, and among women with a lower household income relative to those in the highest income bracket.
This was also true of women under the age of 25 years with respect to less vaccine access, though not safe. Some also reported a confusing and difficult process for booking pregnancy appointments and vaccine shots.
About half the women who had been vaccinated at the hospital during prior pregnancies now received their shots in a GP surgery. Vaccination uptake was higher in Wales and Northern Ireland, all outside of the hospital, but almost half of Scottish and a third of English women were vaccinated in the hospital.
Travel to their GPs or to hospitals or clinics had been by public transport prior to COVID-19, for 40% of the women. This dropped steeply to 6% during the pandemic.
A quarter of unvaccinated pregnant women claimed that the pandemic was responsible, supported by the fact that only 2% of postpartum unvaccinated women said they did not want the vaccine, but 20% said the pandemic prevented them from being vaccinated.
In contrast, 43% of postpartum unvaccinated women did not know about it.
About 94% of women perceived infant vaccination as an important task even during COVID-19, and over three-quarters said it was a safe process. However, 45% reported physical difficulties in vaccinating their babies, especially those who reported the same with respect to their own pregnancy vaccines.
Those women most likely to report issues with access and safety, and lower importance for infant vaccination, were from non-White ethnicities. Conversely, younger women (<25 years) felt less safe, while low-income women put less importance on infant vaccination during this period.
What are the implications?
Women had an overall disruption of pertussis vaccination in pregnancy. Previous knowledge about the need for the vaccine, and prior pregnancy experiences, were key to shaping current pregnancy vaccine experiences.
Changes in appointments, the need to request and follow up on vaccine appointments, and confusion surrounding the process, were reported in this study of pregnant women. They were less satisfied with the quality of antenatal care compared to pre-pandemic levels, especially the lack of face-to-face appointments, which prevented them from getting the information and advice they needed.
Ethnic minorities, as expected, had lower vaccination rates, were more likely to feel unsafe during vaccine appointments, and experienced physical issues with vaccine accessibility. The basis for their feeling of unsafeness is rooted, perhaps, in the fact that their community has suffered disproportionately from the pandemic, and that they are more likely to be hospitalized with COVID-19.
Women from poorer households were more likely to not know about the vaccine at all or to think infant vaccination during the pandemic was unimportant. Such women represented a higher proportion of unvaccinated postpartum mothers and mothers of unvaccinated children.
To counter this, low-income and ethnic-minority women should be specifically targeted for vaccines, including the COVID-19 vaccine, as they are at increased risk for adverse outcomes, but are also less likely to be convinced about the need for the vaccine already.
medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.
- Skirrow, H. et al. (2021) "Women’s views and experiences of accessing vaccination in pregnancy during the COVID-19 pandemic: A multi-methods study in the United Kingdom". medRxiv. doi: 10.1101/2021.09.14.21263505.