The success of routine childhood vaccination programs hinges in part on the intention of parents to seek childhood vaccinations. Most parents in the United States (US) favor vaccination; however, patterns of childhood vaccinations vary considerably with some parents choosing to delay or refuse some or all vaccinations for their child.[1–3] Studies suggest that parental decisions about childhood vaccinations may be solidified during pregnancy[4] or, in some cases, earlier.[5] Pregnancy represents an opportunity to proactively promote health interventions as patients are highly engaged in prenatal care, view prenatal care providers as trusted sources of information, and are highly motivated to achieve best outcomes for themselves and their infants. This may also be an opportunity to proactively engage in vaccine counseling to reach parents before vaccination decisions become entrenched. There is currently limited research on childhood vaccination promotion interventions delivered proactively during pregnancy.[6]

There are two key research gaps prior to implementing childhood vaccination promotion interventions during pregnancy. First, little is known about the willingness of prenatal providers to advocate for childhood vaccinations during pregnancy. Prenatal providers are not formally trained to discuss childhood vaccinations, as their primary focus is on maternal health and pregnancy outcomes.[7] Current evidence suggests that training prenatal care providers on vaccines recommended during pregnancy can increase provider confidence and comfort with vaccination discussions.[8] However, studies on effectiveness of training prenatal providers on childhood vaccinations are lacking, and current childhood vaccination training programs cater to pediatric, not prenatal providers.[7, 9, 10] Further research is necessary to describe prenatal providers’ perceived role as vaccination advocates and any training needs specific to childhood vaccinations.

Second, multicomponent strategies that incorporate tailored and dialogue-based information may be more effective at increasing vaccine uptake.[30] However, the evidence is mixed for the use of such strategies to promote the importance of childhood vaccinations during pregnancy. Some studies describing efforts to promote childhood vaccinations during prenatal care show promise with respect to intervention acceptability and impact on timeliness or coverage of childhood vaccinations.[11–15] However, in a study from New Zealand, Veerasingham et al.[16] found that encouraging vaccination information received during pregnancy had no impact on the timeliness of infant immunizations. While the authors used participants’ self-reported classification of information as encouraging or discouraging, they did not analyze the content or quality of the information. These data suggest the need for further research to establish the most effective strategies to mitigate vaccine hesitancy in the prenatal care period and in prenatal care settings.

As part of a cooperative agreement with the US Centers for Disease Control and Prevention (CDC), we sought to implement and evaluate a multicomponent intervention to promote the importance of childhood vaccinations as part of routine prenatal care. To inform intervention implementation, we collected information from a diverse group of prenatal care providers practicing in routine prenatal care settings in the US on their perceived role as a vaccine advocate, training needs around childhood vaccination, as well as feasibility of and implementation factors for the proposed multicomponent intervention. Study findings may help inform quality improvement goals and efforts related to vaccinations in prenatal practices.

The methods of this study are described in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist for cross-sectional studies (Supplementary File 1, Supplementary Table 1).[17]

In total, 1677 survey responses were received, and the total response rate was 2.5% based on estimated combined membership of ACOG and ACNM (n=66,500). Data from 495 respondents were included in the final analytic dataset after evaluation of eligibility and data validity (see: Figure 1). Data from 1,182 records were assessed as invalid. A sensitivity analysis was conducted comparing provider and practice characteristics between included and excluded records. A higher proportion of excluded records corresponded to the first or second response options presented for each question as compared to included records, indicating higher likelihood that excluded responses from this step were from entities skimming the survey (Supplementary Table 3 of Supplementary File 1).

Table 1 summarizes practice characteristics, provider characteristics, and provider behaviors among those who were included in the analysis. Of the providers electing to provide demographic information, just over half were between the ages of 31-40 years (n=253, 51.1%), and a little over half were female (n=282, 57.0%). Three-fourths were non-Hispanic or Latino or Spanish origin (n=379, 76.6%). The two most frequently reported racial groups among providers were White (n=313, 63.2%) and Black or African American (n=62, 12.5%). Certified nurse-midwives, certified midwives, and certified professional midwives comprised the largest provider group (n=186, 37.6%) followed by nurse practitioners and physician assistants (PA) (n=89, 18.0%). Including years spent in residency, most providers had worked in prenatal care for 2-10 years (n=298, 60.2%). Slightly more providers worked in a practice in an urban (n=253, 51.1%) rather than rural setting. There were similar numbers of providers from the different US Department of Health and Human Service (HHS) regions; the largest region represented in this sample was HHS region 4, which includes Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee (n=78, 15.8%).

Most providers reported that their practice focused on obstetrics only or obstetrics and gynecology (n=265, 53.5%), and a majority served high risk patients (n=386, 78.0%). There were similar numbers of providers practicing in federally qualified health centers, community health clinics, academic medical centers, and private practice. A little over one third of the providers reported working in a practice of 3-10 providers (n=166, 33.5%) and saw an average of more than 20 patients who were pregnant per week (n=179, 36.2%). When asked about their perceptions of vaccine hesitancy of patients compared to the rest of their state, about half of providers reported hesitancy at their clinic to be ‘about average’ (n=200, 40.4%).

Figure 2 shows practice policies regarding vaccination, a provider’s own vaccination status, practice policies for vaccination during pregnancy, and patterns of recommending vaccinations in general and specifically to pregnant people. A majority of providers reported vaccine mandates for employees at their practice (n=381, 90.9%). Among providers reporting their own vaccination status, a vast majority had completed the initial series of COVID-19 vaccines, and influenza vaccine for the 2021-22 season (n=406, 97.8%; n=401, 97.1%, respectively), while slightly fewer had received the COVID-19 booster dose (n=381, 92.1%). Overall, n=311 (62.8%) reported recommending vaccines to patients most of the time (51-90% of the time, n=121, 24.4%) or routinely (91-100% of the time, n=190, 38.4%). When probed about recommendations for specific vaccines, only about half of the providers reported recommending influenza vaccine or the Tdap vaccine during pregnancy (n=244, 49.3%; n=227, 45.9%, respectively), and fewer recommended COVID-19 vaccine during pregnancy (n=210, 42.4%). Seventy percent of the providers reported practice policies that excluded unvaccinated patients (n=292, 69.7%). (Data not shown)

Findings on providers’ perceived role as a vaccine advocate measured using the MovAd scale are displayed in Figure 3. Notably, over half of participants reported agreement with all but one statements (percent agreement ranging from 46.7% - 65.1%). When assessing sub-scale scores, Autonomy and Value scored highest, followed closely by Knowledge and Impact. Sub-scale item on Value “Vaccination is an important topic I want to discuss with others” had the highest percent agreement among providers. The lowest percent agreement among providers was for the statement from the sub-scale item on Impact “If I discuss vaccination, it will very much change views on this topic”.

Providers were asked to assess their confidence in topics about childhood vaccines and to indicate preferences around mode, duration, and frequency of training sessions (data not shown). Providers were least confident, defined as a rating of 1 or 2 on a 5-point Likert scale of confidence, on details of the development processes for childhood vaccines (n=190, 38.4%), information about childhood vaccine ingredients (n=180, 36.4%), and how childhood vaccine recommendations are developed (n=173, 34.9%). When asked about preferred training mode, in-person presentation was the most preferred mode for a majority of providers (n=328, 66.2%), followed by recorded webinar or video (n=67, 13.5%). Roughly half of providers indicated 60 minutes as the most acceptable duration for each training session, with slightly higher numbers if continuing medical education (CME) credits were not provided (CME provided: n=218, 44.0%; CME not provided: n=268, 54.1%). Half of providers indicated they would attend the trainings even if they had to pay for them (n=231, 46.7%). For a four-session training program, the most preferred frequencies were four sessions offered once a week (n=131, 26.5%), and four sessions offered once every month (n=117, 23.6%).

Participants’ responses regarding intervention feasibility are presented in Figure 4. These results show a high proportion of agreement, which includes ‘Agree’ and ‘Completely Agree’ on feasibility of all three proposed intervention components. Of the three proposed intervention components, providers reported highest percent agreement on the feasibility of the educational website, followed by the provider recommendation and vaccine navigator components. Across these questions, we observed neutral responses (neither agree nor disagree) from 16-28% of respondents.

Figures 5 & 6 display key perceived facilitators and challenges to implementation. The most important perceived facilitator among prenatal providers were educational materials or resources on childhood vaccinations for patients (n=250, 57.7% important). There was very little variability between the other 6 presented facilitating factors, and half of providers indicated all were of similar importance (% importance variation: 48.3% - 51.4%). Among the subset of providers who also saw children (n=36, 7.2%), quality improvement goals to increase childhood vaccinations were identified as an important facilitating factor (n=20, 55.6%). The top perceived challenges identified by providers include availability of staff resources, availability of time during appointment, and adequate training on childhood vaccines (% challenging: n=208 (48.0%), n= 207(47.8%), n= 197 (45.4%), respectively).

The findings of this study inform the implementation of a multicomponent prenatal intervention to promote the importance of vaccinations recommended for children after birth. In addition, findings provide information for relevant professional organizations and policy makers on knowledge, attitudes, beliefs and behaviors of prenatal providers regarding vaccination recommendations for children and during pregnancy. Study findings may be used to inform quality improvement goals and programs related to vaccination promotion.

The first major finding of this study was the large disparity between provider vaccine behavior and provider vaccination recommendations during pregnancy. The large gap between providers’ behavior could be related to their perceived impact as a vaccine advocate, and in part to variations in practice policies mandating vaccines for employees versus patients. While the proposed multicomponent intervention promotes importance of early childhood vaccinations, there may be an opportunity to couple childhood vaccination recommendations with maternal vaccination recommendations during pregnancy. In a prior study, we reported that only 67% of participants who were pregnant from one of the implementation settings planned to vaccinate their child with all recommended vaccines, and fewer (35%) planned to get the COVID-19 vaccine for their child after birth.[32] These data reiterate the significance of intervening during pregnancy to promote the importance of maternal and childhood vaccinations. Strengthening provider capacity to make a strong recommendation in favor of vaccination remains a critical need in this population. Our survey only asked about childhood vaccination training needs. The most highlighted topics pertained to vaccine development, testing, and recommendations, and less about the diseases being prevented by vaccines, suggesting the need to bolster provider capacity to answer questions about the how vaccines are developed, tested, and recommended.

The second major finding was the high feasibility of the proposed intervention components. When asked about intervention feasibility, providers reported the most feasible component to be the educational website, followed closely by provider recommendation and vaccine navigator. The degree of feasibility of intervention components may be associated with resource and time availability, as the website potentially requires the least resources and the navigator the most. Healthcare providers consistently rank as the most trusted resource on vaccine information in studies with parents.[24] Nevertheless, there are data to suggest that, compared to non-vaccine hesitant parents, those who are vaccine-hesitant may have lower trust in health providers.[25, 26] Not surprisingly, pediatric providers report spending 5-30 more minutes per appointment,[27, 28] sometimes over a period of several months,[28] when counseling vaccine-hesitant parents. This additional time spent on vaccine counseling often conflicts with providers’ schedule and may come at the cost of other preventive health services that need to be completed at each visit, leading to provider frustration.[28, 29] Yet, interventions that use provider-independent strategies to mitigate vaccine hesitancy have limited effectiveness.[30, 31] Further research is needed to understand how to effectively leverage the provider-patient relationship in primary care settings to mitigate vaccine hesitancy, while minimizing the burden on provider time. This is particularly important in the context of prenatal care where the providers face the dual burden of caring for the patient who is pregnant and the unborn baby. One strategy to facilitate prioritization of vaccine discussions may be to compensate providers for vaccine counseling, even if they do not administer the vaccine at the visit.

The third major finding was the identification of specific perceived barriers and facilitators of intervention implementation in routine prenatal settings. The facilitators identified in our study included providing educational materials and resources on early childhood vaccinations for patients. Coupled with the reported feasibility of the educational website, these results strengthen evidence toward the utility of the proposed intervention. With these facilitating factors, three main challenges emerged: availability of staff resources, adequate training on childhood vaccines, and availability of time during the appointment. Notably, over half of providers did not identify these or other factors as challenges to implementation, suggesting opportunity rather than barriers toward implementing the intervention.