Strategies to implement maternal vaccination: A comparison between standing orders for midwife delivery, a hospital based maternal immunisation service and primary care
Introduction
In recent years maternal immunisation has become an integral component of pregnancy care. Following the lead of the United Kingdom (UK) and the United States (US), many countries now recommend maternal influenza and pertussis vaccination during pregnancy. Both vaccines have been demonstrated to be highly efficacious in preventing maternal and neonatal morbidity and mortality [1], [2], [3].
However despite demonstrated efficacy and safety, uptake of these vaccines during pregnancy remains suboptimal. Barriers to uptake include failure to incorporate vaccination into routine pregnancy care, lack of healthcare provider (HCP) recommendation, concerns about safety, and access to vaccination services [4], [5], [6].
Numerous studies have highlighted the importance of HCP recommendation as an enabler of vaccination [7], [8], [9], [10]. As providers of population level vaccination programs, primary care physicians are well versed in discussing immunisation and often have an established capacity to store and administer vaccines in their clinics. However, in Australia and the US, midwives or obstetricians are often the only HCP many pregnant women consult during pregnancy so the logistics of incorporating maternal vaccination into pregnancy care need to be considered. Barriers to maternity services providing vaccination include lack of the necessary infrastructure to support vaccination, lack of training and knowledge of maternity care providers regarding current recommendations, and concerns about liability and reimbursement [4], [5].
Studies have also demonstrated that women’s intention to be vaccinated does not necessarily equate with receipt of vaccination. Competing time pressures, priorities, and difficulty accessing immunisation providers are barriers to vaccination despite an intention to do so [11]. In a study of influenza vaccination in pregnancy, women were 2.7 (CI 1.1–6.9, p = .035) times more likely to be vaccinated if the vaccine was offered at their pregnancy care facility compared to those who had to get the vaccine elsewhere [7].
At some locations, further barriers to vaccine administration include a requirement for a prescription from a doctor and obtaining the vaccine from a pharmacy. Such barriers can be readily overcome by instituting standing orders for midwife administration of vaccines without the need for physician review or prescription. The US Advisory Committee on Immunisation Practices has recommended the use of standing orders to improve immunisation rates for more than a decade [12]. One community hospital in the US increased their post-partum pertussis vaccine uptake from 18% to 69% (p < .001) with introduction of standing orders [13]. Similarly, two other US hospitals implemented standing order models and reported increased vaccination rates to approximately 80% compared to only 20% overall in the US [14], [15], [16].
In this study we implemented standing orders for midwife administration of acellular pertussis-containing vaccine (dTpa) during the third trimester and report on the impact of this change. In addition, with three different immunisation models utilised within the same healthcare network, this study provides a unique opportunity to directly compare different immunisation models in the Australian context.
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Materials and methods
Monash Health is the largest public healthcare network in Melbourne, Australia providing maternity care to over 10,000 women per year across three hospitals. Hospital A is a tertiary obstetric referral centre with an onsite immunisation service. Hospital B provides primary and secondary level maternity care to a large migrant and refugee population with approximately 3000 deliveries per annum. Hospital C provides primary and secondary level maternity care for approximately 3000 women each year.
Uptake
At hospital B uptake was recorded for 2848 deliveries over 56 weeks prior to implementation of standing orders and for 1766 deliveries over 34 weeks after the introduction of standing orders. The median number of deliveries (102, range 87–121) did not differ pre or post-implementation. Median uptake of antenatal dTpa increased significantly throughout the study period from a median of 39% (range 28–52%) prior to introducing standing orders, to 48% (range 42–63%) in the three months immediately
Discussion
Our study is unique in examining three models of implementation of maternal vaccination contemporaneously. Uptake of dTpa increased significantly across all three hospitals during the study period. This was most notable at hospital B where since the introduction of standing orders uptake increased more than twofold.
Conclusion
Maternal immunisation is the most effective strategy to reduce the burden of influenza and pertussis infection in infants. Given the diverse models of antenatal care, different methods of maternal immunisation delivery need to be considered. Hence, there is no “one size fits all” model for immunisation delivery in the pregnancy care setting. In some settings this may comprise a dedicated immunisation service, and in others the more traditional model of primary care. Both of these models in our
Acknowledgements
The authors wish to thank Michelle Knight for extraction of data from Birthing Outcome System, Karen Bellamy for assistance with validating BOS and Allison Deering and maternity care providers at hospital B who recognised the benefits for the pregnant women in their care and adopted standing orders enthusiastically.
Disclosure of Interests
SK has received funding from Glaxo Smith Kline for previous research on maternal vaccination.
Funding
This work was supported by an Australian Government Research Training Scholarship and the Victorian Department of Health. The funders were not involved in any aspect of the design or conduct of the study, nor in analysis or development of this manuscript.
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