Received: 15 May 2021 | Revised: 29 July 2021 | Accepted: 4 August 2021 DOI: 10.1111/jocn.16006 ORIGINAL ARTICLE Understanding factors that influence the decision to be vaccinated against influenza and pertussis in pregnancy: A qualitative study Antonia Arreciado Marañón PhD, MSN, BA, Professor1,2 | María Isabel Fernández-­Cano 1,2 PhD, MSc, Professor | Laura Montero-­Pons BA, CNM, Midwife3,4 | Maria Feijoo-­Cid 1,2 4,5 PhD, BA, Professor | Azahara Reyes-­Lacalle CNM, Midwife | Rosa Maria Cabedo-­ 4,6 Ferreiro CNM, Midwife | Josep Maria Manresa-­Domínguez MSc, BA, Professor1,2,7 | Gemma Falguera-­Puig PhD, MSc, CNM, Responsible for Sexual and Reproductive Health Care4,8 1 Department of Nursing, Faculty of Medicine, Universitat Autònoma de Abstract Barcelona, Barcelona, Spain Aims and Objectives: To identify how pregnant women perceive pertussis and influ- 2 Multidisciplinary Research Group in Health and Society (GREMSAS), enza and the factors that influence their decision to be vaccinated. Barcelona, Spain Background: Suffering from influenza during pregnancy increases complications in 3 Atenció a la Salut Sexual i Reproductiva the pregnant woman, foetus and newborn. Pertussis in children under six months of de Santa Coloma de Gramenet, Direcció d’Atenció Primària Metropolitana Nord, age causes severe complications. Maternal vaccination against influenza and pertussis Institut Català de la Salut, Barcelona, is effective and safe. However, vaccination rates are insufficient. Spain 4 Design: We conducted a qualitative descriptive study, using semi-­structured inter- Research Group Atenció a la Salut Sexual i Reproductiva (GRASSIR), Institut views. This research adheres to the COREQ guidelines and checklist. Universitari d'Investigació en Atenció Methods: We carried out 18 semi-­structured face-­to-­face interviews with pregnant Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain women, using intentional sampling and thematic analysis. 5 Atenció a la Salut Sexual i Reproductiva Results: We identified an overarching theme, ‘factors that influenced participants’ de Sabadell, Direcció d’Atenció Primària Metropolitana Nord, Institut Català de la decision to be vaccinated or not’, which was composed of four subthemes that were Salut, Barcelona, Spain in turn made up of 12 categories. The factors that influenced participants’ decision to 6 Atenció a la Salut Sexual i Reproductiva be vaccinated against influenza and pertussis were related to their knowledge of and de Granollers, Direcció d’Atenció Primària Metropolitana Nord, Institut Català de la their perception of risk for these diseases. Participants perceived the risk of pertussis Salut, Barcelona, Spain to be greater, and they focused their concern on the newborn. The recommendations 7 Unitat de Suport a la Recerca Metropolitana Nord, Institut Universitari and convictions of nurse-­midwives were the most important factors encouraging d'Investigació en Atenció Primària Jordi vaccination. Participants trusted their nurse-­midwives and most reported that they Gol (IDIAPJGol), Barcelona, Spain 8 would have been vaccinated if their midwife had recommended it. Other factors were Atenció a la Salut Sexual i Reproductiva Metropolitana Nord, Direcció d’Atenció linked to lack of information, fear and concerns about economic interests. Primària Metropolitana Nord, Institut Conclusions: The convictions and actions of the nurse-­midwife in recommending Català de la Salut, Barcelona, Spain vaccination to pregnant women are decisive. Strategies to improve vaccination rates This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made. © 2021 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd. J Clin Nurs. 2021;00:1–16.  wileyonlinelibrary.com/journal/jocn | 1 2 | ARRECIADO MARAÑÓN et al. Correspondence María Isabel Fernández-­C ano, Department should be directed to helping health professionals understand how their practice af- of Nursing, Faculty of Medicine, fects the final decision of pregnant women. Universitat Autònoma de Barcelona, Campus Bellaterra, Cerdanyola, Barcelona, Relevance to clinical practice: Understanding the factors that limit vaccination rates Spain. among pregnant women provides valuable information to nurse-­midwives that can Email: mariaisabel.fernandezc@uab.cat help to improve vaccination strategies and practices. Increased maternal vaccination rates would reduce morbidity and mortality among pregnant women and newborns. KEYWORDS immunisation, influenza vaccination, maternal health, midwifery, pertussis vaccination, pregnant vaccine, prenatal care, qualitative research 1 | I NTRO D U C TI O N What does this paper contribute to the wider Maternal vaccination is highly recommended to reduce the risk of global community? vaccine-­preventable diseases and their complications (Centers for • The study highlights the impact of nurse-­midwives on Disease Control & Prevention, n.d.-­b; National Immunisation Office, pregnant women's decision-­making about whether to be 2020; World Health Organisation, 2012, 2015). Vaccination rates for vaccinated against influenza and pertussis. influenza and for tetanus, diphtheria, and acellular pertussis (Tdap) • The attitude and conviction of the nurse-­midwife in rec- among pregnant women have risen. However, these vaccines con- ommending vaccination influenced the final decision of tinue to be underused. pregnant women. • Strategies to improve maternal vaccination rates should focus on nurse-­midwives who care for pregnant women 2 | BAC KG RO U N D throughout their pregnancy. Maternal vaccination is a strategy that protects the pregnant woman, the foetus and the newborn against preventable diseases such as influ- enza and pertussis (Vermillion & Klein, 2018). The immunity developed 75%, especially for influenza, with differences across western coun- by the pregnant woman is transferred via the placenta to the foetus, tries (Centers for Disease Control & Prevention, n.d.-­b; National protecting the neonate until he or she can be vaccinated at age two Immunisation Office, 2020; World Health Organisation, 2012, 2015). months (Vilajeliu et al., 2015). Pregnant women are no more likely to In the United States, the vaccination rate among pregnant women contract influenza than the general population, but if they do contract was 53.6% for influenza in the 2016–­2017 season (Ding et al., 2017) it, they are more likely to suffer from severe respiratory symptoms that and between 64% and 89% for pertussis in 2017, depending on the require hospitalisation or intensive care and/or result in death (Katz state (Centers for Diseases Control & Prevention, 2017). In the 28 et al., 2017). Suffering from influenza during the first trimester of European countries that recommend the influenza vaccine to preg- pregnancy is linked to complications, such as secondary pneumonia, nant women, the vaccination rate ranged from 0.5% to 58.6% in 2017 acute respiratory failure, and a higher risk of preterm birth or stillbirth (Mereckiene, 2018). Currently, eight European countries recommend (Psarris et al., 2019; World Health Organisation, 2012). Pertussis in- maternal vaccination for pertussis, with a vaccination rate of 64% of fection, caused by the bacillus Bordetella pertussis, produces severe pregnant women in Belgium (Maertens et al., 2016) and 80% in Spain pulmonary, neurological and nutritional complications (World Health (Ministerio de Sanidad, n.d.-­b). In 2018, in Spain's Catalonia region the Organisation, 2015) and potentially death in infants under age six vaccination rate among pregnant women was 29.2% for influenza and months (Centers for Disease Control & Prevention, n.d.-­a). 80.7% for pertussis (Ministerio de Sanidad, n.d.-­a). Maternal vaccination is safe and effective against influenza Pregnant women's final decision to receive the vaccines or not (Bratton et al., 2015; Psarris et al., 2019; Vygen-­Bonnet et al., 2020) is multifactorial and is linked mainly to factors related to pregnant and pertussis (Amirthalingam et al., 2014; McMillan et al., 2017). It women themselves and to health professionals (Lutz et al., 2018). protects the pregnant woman, foetus and newborn from possible Barriers that are known to prevent professionals from recommend- complications (Committee on Obstetric Practice, 2017; Phadke & ing the vaccine to pregnant women include inadequate training, Omer, 2016; World Health Organisation, 2012). inadequate reimbursement, concerns about safety, increased work- The Advisory Committee on Immunization Practices of the United load or unavailability of staff with the certification required to ad- States has recommended that pregnant women receive the influenza minister vaccines (Lutz et al., 2018; Vilca et al., 2018; Wilson et al., vaccine since 2004 (Harper et al., 2004) and the Tdap vaccine since 2015). Pregnant women report concerns about vaccine safety and 2012 (Centers for Disease Control & Prevention, n.d.-­b). However, the the lack of a recommendation from their health provider as the main vaccination rate for both diseases remains below the target rates of barriers to choosing to be vaccinated (Lutz et al., 2018; O’Shea et al., ARRECIADO MARAÑÓN et al. | 3 2018; Vilca et al., 2020). Similarly, receiving a recommendation from 27–­4 0 weeks of pregnancy (because the Tdap vaccine is adminis- a health professional is a decisive factor in pregnant women's deci- tered between weeks 27 and 36); (3) having received the Tdap vac- sion to be vaccinated (Lutz et al., 2018; O’Shea et al., 2018). Other cine; and (4) not having communication difficulties. An intentional determining factors are the influence of pregnant women's friends, sampling method was used, incorporating homogeneity criteria family and colleagues, access to information, and access to the vac- (being pregnant) and heterogeneity criteria in order to obtain the cine itself (Maisa et al., 2018; Wiley et al., 2015), although these vary maximum variability in responses. We sought maximum variation based on the context and the population (Wilson et al., 2015). across the following axes: the socioeconomic profile of the catch- Given the international consensus that pregnant women should ment area of the ASSIR, whether the person had received the influ- be vaccinated against influenza and pertussis (Centers for Disease enza vaccine or not, origin (locally born or foreign-­born), age (>30 or Control & Prevention, n.d.-­b; National Immunisation Office, 2020; <30) and education level (no education, basic education, university World Health Organisation, 2012, 2015) and the still low rates of education). Candidates were identified by the nurse-­midwives of vaccination, it is important to understand the factors that encourage the ASSIRs, whom we informed of the patient profiles needed for vaccine uptake among pregnant women. Acquiring extensive, in-­depth the study. The research team (AA, LM, RMC and AR) selected the information about the issue from the point of view of pregnant women candidates to be invited to participate in the study. A nurse-­midwife themselves is essential for understanding the phenomenon and for contacted the selected participants by phone or during a scheduled improving strategies to increase vaccination rates to be in line with visit, informed them about the study and sought their participation. international recommendations. Our objective was to identify how When the candidate agreed to participate, an interview was sched- pregnant women perceive influenza and pertussis and the factors that uled to coincide with one of her visits to the ASSIR. On the day of the influenced their decision to receive the corresponding vaccines or not. interview, the interviewer informed the participant about the study both orally and in writing, and the participant signed the informed consent document. There was no prior relationship between the 3 | M E TH O D S participants and the researchers. None of the selected participants declined to join the study. 3.1 | Design We chose a qualitative descriptive design (Colorafi & Evans, 2016), 3.4 | Data collection using semi-­structured face-­to-­face interviews to meet the study ob- jectives. This approach is ideal for understanding pregnant women's Individual face-­to-­face semi-­structured interviews were carried perceptions that condition their decision about whether to receive out between March 2018 and January 2019 to learn about the the influenza and pertussis vaccines. This research adheres to the participants’ views. Prior to the interviews, we developed a semi-­ Consolidated Criteria for Reporting Qualitative Research (COREQ; structured interview guide containing the topics to be explored and Tong et al., 2007; File S1). some questions that could be used if necessary. The topics were chosen according to the study objectives, the existing literature and the researchers’ reflections. The principal ones were knowledge 3.2 | Setting about influenza/pertussis disease and vaccination, perception of safety, effectiveness and benefits of vaccines, factors in deciding The study took place at the Sexual and Reproductive Health Care whether to get vaccinated, and professionals’ recommendation/non-­ (ASSIR) units of the province of Barcelona (Catalonia). The ASSIR units recommendation to be vaccinated (Table 1). We tested the guide in are part of a regional branch of the Spanish national health system the first interviews and made slight adjustments, which did not af- providing care to 1,400,000 citizens from 71 municipalities and of di- fect the topics, before arriving at the definitive guide. We added the verse socioeconomic statuses (Institut Català de la Salut. Generalitat de question, ‘Can you describe how they made the recommendation?’. Cataluya, n.d.). ASSIR units, which are linked to primary care, employ The data from the pilot interviews were retained and included in the nurse-­midwives, gynaecologist-­obstetricians, nurses, psychologists analysis. We prepared a data sheet to collect the participants’ soci- and administrative personnel. The monitoring of low-­risk pregnancies is odemographic data (age, country of origin, education level and num- conducted by nurse-­midwives, who are nurses who received two years ber of children), information about how each interview went, and the of specialised training. In Spain, the influenza and Tdap vaccines are interviewer's impressions of each interview. available at primary care centres and ASSIRs and are publicly financed. All of the interviews were conducted by the principal investiga- tor (AA), who took descriptive field notes both during and after each interview. The field notes provided contextual information about the 3.3 | Participants participant and the conditions in which each interview was conducted. The interviews were carried out in the ASSIR of each participant in a The population was pregnant women cared for at ASSIR units. private space. The interviews were audio-­recorded and lasted 35 min The inclusion criteria were (1) being at least age 18; (2) being at on average (between 22 and 50 min). At the end of each interview, 4 | ARRECIADO MARAÑÓN et al. TA B L E 1 Semi-­structured interview guide accurate and was given the opportunity to make changes. All of the Knowledge about influenza/pertussis vaccination among pregnant participants agreed that the summaries were accurate, and none of women them made changes. There was ongoing analysis after each interview Can you explain to me what you know about influenza/pertussis and the team decided jointly when saturation had been achieved. in pregnant women? Saturation was reached in interview 16, when new concepts and Do you think it's serious? For whom? topics ceased emerging. However, we opted to conduct two more in- And what do you know about influenza/pertussis vaccination in terviews to confirm saturation. Data collection was ceased after 18 pregnant women? interviews. Repeat interviews were not conducted. Factors in deciding to whether to get vaccinated Can you explain to me the main reasons that led you to get vaccinated against influenza/pertussis? 3.5 | Analysis Why did you get vaccinated against pertussis and not influenza? Professionals’ recommendation/non-­recommendation to be Analysis was conducted in the following steps. 1. A thematic analysis vaccinated was conducted (Berenguera et al., 2014) with the help of ATLAS-­ti Did a health professional recommend that you take the influenza/ pertussis vaccine? Who? (gynaecologist, nurse-­midwife…)? (version 8). Thematic analysis is a method for identifying, analysing and reporting patterns within data. 2. A word-­for-­word transcrip- Can you describe how they made the recommendation? What did they explain to you? tion of the interviews was conducted by an independent profes- Was it decisive? sional and checked later by two researchers (AA and MIF). 3. The Would you have been vaccinated against influenza if the nurse-­ transcripts and field notes were read and reread to achieve familiari- midwife had recommended it to you? sation with the data (AA). 4. The initial patterns detected in the pre-­ Would you have been vaccinated against pertussis if the nurse-­ analysis were noted, and a list of provisional topics was constructed midwife hadn't recommended it? (AA). 5. A line-­by-­line coding to identify meaning units (fragments Perception of the benefits of being vaccinated or not against of text that had meaning for our research) was conducted (AA). 6. influenza/pertussis These codes were then grouped into categories of a higher analytical Do you think there's any kind of benefit to getting vaccinated order. To undertake this process, we used categories gleaned from against influenza/pertussis when you're pregnant? What previous studies (deduction) and identified new categories in the benefit? For whom? interview responses (induction). We built an exhaustive system of Perception of risk from getting vaccinated or not against influenza/ categories that subsumed all of the codes described (AA and MIF). pertussis 7. An analysis was conducted category by category (AA and MIF). Do you think there is any risk involved in a pregnant woman Steps 6 through 7 were first carried out by AA. Subsequently, AA getting the influenza/pertussis vaccine? What are the risks? For whom? and MIF discussed the initial analysis until reaching consensus. 8. Do you think there is any risk involved in a pregnant woman not An explanatory framework drawing on the existing literature was getting the influenza/pertussis vaccine? What are the risks? generated (AA). 9. All team members participated in a process of dis- For whom? cussion and reflection until reaching consensus on the final analysis. Perception of the safety of the influenza/pertussis vaccine What is your opinion of the safety of the influenza/pertussis vaccine? 3.6 | Ethical considerations Perception of the effectiveness of the influenza/pertussis vaccine What is your opinion of the effectiveness of the influenza/ The study adheres to Declaration of Helsinki standards and was pertussis vaccine? approved by the Idiap Jordi Gol Ethics Committee. The principal Opinion of family and friends about the influenza/pertussis vaccine investigator (PI) obtained written informed consent from each par- What is your family and friends’ opinion of influenza/pertussis ticipant and ensured the participants’ confidentiality by assigning an vaccination (in general or for pregnant women)? Do they alphanumeric code to each one. Only the PI has access to the data, usually get vaccinated? which is stored in a password-­protected virtual space managed by Were you vaccinated as a child? Are your vaccines up to date? the university. Factors that can influence the vaccination of pregnant women Are there any factors that you think discourage pregnant women from getting vaccinated against influenza/pertussis? 3.7 | Enhancing trustworthiness We applied trustworthiness criteria (Lincoln & Guba, 1985). the interviewer conducted a member check, giving an oral report to Credibility was ensured by conducting a member check after each the interviewee that summarised the interview. At that moment, the interview so that the participants could confirm the accuracy of interviewee was asked whether the oral summary of her interview was the information collected (or rectify it if necessary). All participants ARRECIADO MARAÑÓN et al. | 5 TA B L E 2 Participants’ characteristics (n = 18) reported that our summary of their interview was accurate and none of them made changes. Credibility was also achieved by conducting Frequency (%) two additional interviews after reaching saturation and by involv- Age (in years) ing all of the researchers in the analysis phase. This approach also 20–­25 2 (11.1) helped us attain dependability, as did the detailed description of 26–­3 0 3 (16.7) each phase of the research and the decisions made. Transferability 31–­35 8 (44.4) to other similar contexts is facilitated by describing the context, the 36–­4 0 5 (27.8) selection of participants, the participants’ characteristics, the data Origin collection procedure and the analysis procedure. Finally, to reduce Spain 15 (83.3) bias, research decisions were undertaken by the team through an ar- duous process of reflection, thus ensuring confirmability. Moreover, Other countries 3 (16.7) we conducted member checks in which the participants confirmed Education level orally the accuracy of the information that we had recorded about University studies 9 (50.0) them. No university studies 9 (50.0) The team is composed of (1) nurses who hold a PhD and work Socioeconomic status a in university-­level teaching and research and (2) nurse-­midwives Above average 2 (11.1) who work in patient care and research. The PI (female) falls into the Average 9 (50.0) former category and additionally is an expert in qualitative meth- Below average 7 (38.9) ods. These aspects and the study objectives were communicated to Number of children participants. 0 10 (55.6) 1 6 (33.3) 2 2 (11.1) 4 | FI N D I N G S Vaccinated against pertussis Eighteen pregnant women participated in the study, although data Yes 18 (100) saturation was reached at interview 16. Participants’ mean age was No 0 33.2 years, and their median age was 34 years (ranging from 20 to 39; Vaccinated against influenza Table 2). Fifty percent had university studies. The moment of gestation Yes 5 (27.8) ranged from 29 to 39 weeks. Five participants had been vaccinated No 13 (72.2) against influenza. Table 3 shows a summary of the process of data Vaccinated against influenza prior to pregnancy coding and categorisation. The findings are organised around the main Yes 3 (16.7) theme (factors that influenced the participants’ decision to be vacci- No 15 (83.3) nated or not), which included four subthemes and 12 categories. a Calculated using the Indice Socioeconómico Territorial of the Factors that influenced participants’ decision to be vaccinated Instituto de Estadística de Cataluña.https://www.idesc​at.cat/ or not pub/?id=ist&lang=es 4.1 | Factors related to the participants themselves The flu is something that’s really, really ordinary. This year my husband and my son have had it. 4.1.1 | Knowledge about influenza and pertussis I03 Participants had different levels of knowledge about influenza and Pertussis is a disease that all participants had heard of, but most pertussis. They were aware of the symptoms and clinical course of knew little about. They had not contracted it, nor did they know any- influenza and what to do if they had it. Some described more specific one who had. Mostly what they knew was that pertussis affects the information, such as periodic mutations and their effect on vaccines. respiratory capacity of newborns. One participant (I06) had heard of This knowledge appeared to emerge from the mundanity of the flu, community outbreaks of pertussis. its seasonal recurrence and the fact that they or someone they knew had experienced it. I don't know very much. I know it's a disease that af- fects the lungs. The flu, I’m more aware of it, because yes at some point in my life I’ve had it…. Question: In whose lungs? The baby's, the mother's, I06 or whose? 6 | ARRECIADO MARAÑÓN et al. TA B L E 3 Overview of the coding process Theme Categories Subcategories Codes Factors that Factors related to Knowledge about influenza and About influenza: influenced the participants pertussis • The everyday nature of influenza participants’ themselves • Banalisation of the process decision to be • Knowing how to behave when faced with influenza vaccinated or not • Changing virus • Symptoms • Affects women About pertussis: • No knowledge • Little knowledge Perception of the severity of Influenza: influenza and pertussis • It’s not serious • It is transmitted to the baby • There can be complications if there are other conditions Pertussis: • Serious for the baby • Affects baby’s breathing Perception of the risk from not From not getting vaccinated against pertussis: getting vaccinated • The baby carries all of the risk • Breathing problems • I’m afraid of it • I don’t want to have regrets From not getting vaccinated against influenza: • I wouldn’t have gotten influenza • It only affects the mother • It’s easy to get over it • It doesn’t affect the baby • Greater risk than if you get vaccinated Factors related Actions of the health Pertussis: to health professional: information • Explicit recommendation professionals and/or recommendation • The professional takes vaccination for granted • ‘It’s time to get vaccinated’ • You should get vaccinated • Decisive explanations Influenza: • No recommendation • Recommendation not to get the vaccine • It’s not necessary • The nurse-­midwife doesn’t give her opinion Trust in the professional • Professional advice • Full confidence • Putting yourself in their hands • Trusting in spite of not being sure • It depends on the professional Participants who would have Would you have been vaccinated against influenza if the made a different decision if nurse-­midwife had recommended it to you? advised differently by the • Yes, if the nurse-­midwife recommends it nurse-­midwife • Yes, if the gynaecologist recommends it • Yes, with information about benefits • Yes, with information about risks • Yes, in spite of past experience • Yes, trust in professional • Maybe, if there is an explanation about risks • I wouldn’t have gotten vaccinated Would you have been vaccinated against pertussis if the nurse-­midwife hadn’t recommended it? • I wouldn’t have gotten vaccinated • Maybe not • It depends on my trust in the professional (Continues) ARRECIADO MARAÑÓN et al. | 7 TA B L E 3 (Continued) Theme Categories Subcategories Codes Factors related to the Benefits of the vaccine General benefits: vaccines • Individual and collective benefits • The more protection, the better • More benefits than risks • I don’t know, but I trust the health professional Pertussis vaccine: • For the baby • For the baby and the mother • For the baby and the community Influenza vaccine: • For the mother • For the mother and the baby • In the end, you catch it anyway Risks from getting vaccinated • There are no risks • There are no risks, but nothing is certain • I don’t know, but I trust the professional • I don’t know, but there are more benefits • There are risks, but there isn’t any information Vaccine safety Influenza and pertussis vaccines: • I think they are safe • I don’t know • I don’t know, but I think they are safe • I don’t know, but it’s worth it • You can catch influenza Factors that limit Information: too much or too • Lack of professional information vaccination little • Excess of non-­professional information • The weight of others’ opinions • Personal decision Fear • Inoculation of the virus • Contracting the disease Hidden interests and • Vaccine hesitancy alternative trends • Belief in alternative medicines I think the baby’s. Because she [nurse-­midwife] told Well, flu, it seems like we’ve all had it, right? You me precisely that they give it to you now because imagine those horrible seven days in bed, with a fever. until the baby’s two months old they can’t give it to Waiting for it to cycle through, and that’s it. (…) But them. So that way they’re protected…. But I don’t with the flu there’s not that risk at birth. know much more, really. Because it’s not a disease I10 I’ve heard about much. I16 In fact, there are a lot of people that die from the flu. In the case of the elderly, or people with, for example, some kind of heart condition or a health problem that 4.1.2 | Perception of the severity of they already had before. influenza and pertussis I04 Participants perceived influenza and pertussis to have different de- Although participants knew that a mother could infect her new- grees of severity. For the participants, influenza is not serious or at born with influenza, none of them reported that this could be serious least not as serious as other diseases. They believed that symptoms or involve complications for the baby (in contrast to their beliefs about could be more severe for pregnant women because they were un- pertussis). able to take medication, and for this reason, they talked about pos- sible complications. One participant (I04) talked about complications I don’t think it [the flu] is very serious, like hepatitis or in high-­risk groups such as older people or people with underlying something like that. But as soon as you get the flu, the health conditions. The participants did not identify pregnant women baby has it too. as a high-­risk group. I02 8 | ARRECIADO MARAÑÓN et al. In terms of pertussis, although participants had little knowledge Because I never have [caught the virus], so why would about it, they perceived it as dangerous, especially for the baby. I now? I04 Well, it’s a bacteria that lives in our body and that can affect babies more seriously… in the sense that they However, the perceived risk of not getting vaccinated against per- don’t have the same defences that adults have, and I tussis was greater. Even though participants lacked full information, think, if I’m not wrong, that with babies it can even be they reported that newborns lack of defences during the first months deadly. I’m not very sure, but I think more or less it’s of life (information that they received during the pregnancy check-­ that, that it would be more serious for them if they ups). They knew that not getting vaccinated against pertussis made caught it. (…) As far as I understood, it’s more for the the newborn more vulnerable to contracting the disease. Participants baby so that there wouldn’t be a problem. If I get it, I expressed fear and the desire to avoid feeling regret for not having can take an antibiotic, right? been vaccinated, if their baby was infected. I13 I don’t know about pertussis, but I’d rather prevent This perception of the risk of pertussis (in spite of participants’ it. I’d rather prevent it. Because at work we’ve seen limited knowledge) in many cases was constructed based on what the some children, although they were older, that caught nurse-­midwife told them. This health professional is the person that pertussis… that were hospitalised and had a hard expressed to them the seriousness of pertussis in newborns. time. So, I’d rather prevent it. I don’t want to have to regret it [not getting vaccinated] later. Well, the nurse-­midwife explained it to me. That for I04 babies it could be pretty serious. I16 Moreover, some participants reported that they chose to be vacci- nated because of the benefits to their child and would not have done The truth is that until the nurse-­midwife told me, I’d so if the benefits were only to themselves. never heard of pertussis. I17 I guess that if you get vaccinated against the flu, you’re less exposed. But that doesn’t mean that you won’t get it, because I’ve seen people that got vacci- 4.1.3 | Perception of the risk from not nated and they had it anyway. (…) If you don’t get vac- getting vaccinated cinated against pertussis and the risk is for the baby. And for the baby sometimes you do things that… you Participants perceived the risk of not getting vaccinated differently wouldn’t do for yourself. for influenza and pertussis. In the case of influenza, the perceived I07 risk was linked mainly to the mother and was understood as an ill- ness that they could overcome with typical treatments known to the general public. Moreover, participants referred to the possibility of 4.2 | Factors related to health professionals becoming infected despite having been vaccinated. They perceived the risk of influenza to the newborn as small or non-­existent. Even The role that the nurse-­midwife played in the vaccination of partici- participants who had been vaccinated against influenza (e.g. I04) pants was decisive in most cases, in particular her attitude toward perceived the risk as minimal. vaccines and the trust that she inspired in participants. Participants recognised that they would have made a different decision if it were But you think that maybe it’s, I don’t know. You have not for the nurse-­midwife. a bit of fever. (…) But you think, “Well, look, a cold or a flu that you can get over. As long as it doesn’t af- fect the foetus.” In contrast, the other one [pertussis]. 4.2.1 | Actions of the health professional: If the baby is born and doesn’t have these defences, information and/or recommendation since it’s him by himself, right? How he has to fight it, that’s scarier. Participants reported receiving different information from their I05 nurse-­midwife depending on the vaccine in question. In the case of pertussis, the nurse-­midwife gave them information, or an explicit I think if I hadn’t gotten the flu vaccine, nothing would recommendation to get vaccinated, or even scheduled the vaccina- have happened. I mean, nothing would have changed, tion appointment for them. The information that they recalled fo- because I doubt I would have caught the virus, really. cused on risks to the newborn if they did not receive the vaccine and ARRECIADO MARAÑÓN et al. | 9 benefits to the newborn if they did. However, several participants The actions of nurse-­midwives surrounding the influenza vaccine reported that they would have liked to receive more information. were not perceived in the same way by participants. Twelve partici- The nurse-­midwife's recommendation to be vaccinated was decisive. pants did not recall receiving information or the recommendation to Even in cases in which the participant's partner was reluctant. receive the vaccine. And the way she said it, she offered it to me, and she She told me about pertussis. She didn’t say anything talked to me. And I said, “Well ok” (…) I didn’t seek about the flu. documentation about what I need to do, whether I I16 need to get vaccinated or not while pregnant. I’ve al- ways let the nurse-­midwife guide me. When participants received advice from their nurse-­midwife to I11 be vaccinated against influenza, they often chose to do so. In fact, all of the participants who had been vaccinated against influenza Ten participants reported that their nurse-­midwife informed them had received this explicit recommendation (in one case by her family about the pertussis vaccine before advising that they get it. In other doctor). cases, the participants do not recall whether they received any infor- mation before receiving the recommendation. In seven cases, it was When I was pregnant it was flu season, and I was the proactive attitude of the nurse-­midwife that influenced the deci- working. Then X [nurse-­midwife] told me that she sion, rather than a recommendation per se. The nurse-­midwife sched- recommended that I get vaccinated and I didn’t mind. uled the first appointment for the pertussis vaccine in upcoming visits, I04 along with other routine care. In other cases, although the nurse-­midwife recommended the The first day I went… I mean, the first appointment influenza vaccine, the participant did not feel the same need as with after taking the pregnancy test…they give you a sheet pertussis. where they organise all the appointments that you’re going to have until the delivery. Maybe it says, “First She really said, “In week 28 it’s time for pertussis. This trimester blood work, second trimester blood work one you do have to get.” She offered me the flu vac- and third trimester blood work” and it already says, cine, but not so… But pertussis yeah. “week 30, pertussis vaccine”. I01 I13 When the participant asked her health professional about getting In such cases, the nurse-­midwife understood the pertussis vaccine the influenza vaccine (which happened infrequently), she was offered to be a standard procedure. the vaccine and information about it, but was not given a specific rec- ommendation about whether to take it. “Today it’s time to give you the vaccine,” and she got up and vaccinated me. She didn’t really advise that I take it. I asked her if she I12 could go out on a limb and tell me whether to take it or not. And she told me she couldn’t. That the infor- The way in which nurse-­midwives informed participants about the mation that she had wasn’t so clear as to be able to vaccine and recommended it to them also influenced their final deci- give me a resounding yes or a resounding no. Then sion. Mostly, the participants did not recall having been asked explicitly she explained what it’s about and that it’s offered to whether they wanted to be vaccinated. Instead, almost all participants pregnant women and older people because it’s a ben- (17) recalled receiving an explicit recommendation or being told how efit. But she didn’t advise me one way or another. beneficial it would be for the newborn. I18 When she was scheduling the next visit, she said, “At the next appointment it would be a good idea to get 4.2.2 | Trust in the professional the pertussis vaccine, because there are these risks. The baby can’t be vaccinated until he’s two months Trust in the nurse-­midwife was another aspect that was important to old and this way he would be covered.” And so it participants when they made a decision about vaccination. Trust is seemed ok to me. (…) But she didn’t ask, “Do you want basic in the face of little-­known health problems, especially consid- to or not?”. ering that they could affect participants’ babies and that they were I16 exposed to a wide array of information and opinions. 10 | ARRECIADO MARAÑÓN et al. I like her a lot. I trust her a lot, yes. She has given me The view and recommendation of the health professional were so a lot of confidence and I’ve seen that she’s, I don’t important that one participant said that she would have taken the vac- know… She cares a lot about her patients. So, I let her cine even though prior to her pregnancy she had caught influenza in guide me, and if she tells me to do something, I believe spite of being vaccinated. that it’s good for me and my baby. And because I don’t want to take any risks. Yes. If she had said to me, “Yes. You have to get it [the I16 influenza vaccine],” then I would have gotten it. Even though that happened the other time [contracting Participants did not trust just any health professional. They trusted influenza despite being vaccinated]. If she had said, professionals who had showed concern for them and their future “Yes, yes, get it,” I would have gone, obviously. newborn. I05 X [nurse-­midwife’s name], I do trust her. Because Some participants reported that they would have chosen to re- she's a pretty up-­to-­date professional… But there are ceive the vaccine if the nurse-­midwife had offered information about professionals and professionals… and in the day-­to-­ the benefits of doing so or the risks of not doing so. day you see it. There are people who are not… Well, that have fallen behind. (…) Yes, if the nurse-­midwife had told me to do it, surely I E03 would have. It’s just that the reason that I looked for information is also because of that, because she never Some participants trusted their nurse-­midwife fully and did what- gave me a resounding yes. So maybe that’s also a reason ever she recommended. This trust even overcame their reluctance why I took the initiative to seek out more information. about vaccination. I18 I trust all of the professionals that take care of me, Participants claimed that they would have chosen to receive the unless you’ve seen something that stands out… In my influenza shot if the recommendation from their health professional case, both the gynaecologist and the nurse-­midwife had been as convincing and directive as the recommendation for the are people that I trust completely. I mean, if there are pertussis vaccine. facts that I don’t know very well and they say to me, “Look, the most recommendable thing is…” then I go I think so, in the sense that if she had given me an ahead with what they tell me. explanation or had said to me, “Look [participant’s I17 name], in your case it would be a good idea because of this, because of that…” I would have let her guide me like I did for pertussis. 4.2.3 | Participants who would have made a I03 different decision if advised differently by the nurse-­ midwife Some participants did not have such a clear sense of what their re- sponse would have been, but they also believed that, had they received We asked participants if their decision to receive the vaccines or not information about the risk that influenza posed to their newborn, they would have been different if their health professional had made a differ- might have considered vaccination. None of the participants said they ent recommendation. Most participants who were not vaccinated against would not have chosen to receive the influenza vaccine even if it had influenza (10 out of 13) reported that they would have taken the influenza been recommended by their health professional. vaccine if their nurse-­midwife or gynaecologist had recommended it, but she had not. In contrast, they generally had received a recommendation If they’d explained that there were risks for the baby, to be vaccinated against pertussis. Among these participants, some al- I might have thought about it. luded to the trust they had placed in their health professional when mak- I01 ing decisions about topics they were not familiar with. As for pertussis, most participants (13) reported that if their nurse-­ I also would have read to see if there were pros and midwife had not recommended this vaccine—­or as in some cases, if cons, but if the professionals tell you, you have to let they had not taken for granted that the vaccine was required—­they them guide you, right? If you don’t know anything, it’s would not have chosen to be vaccinated. However, some added that not your field… Well, if they say it, then it must be even if their nurse-­midwife had not recommended this vaccine, they good for you, right? would have obtained information from other sources, because they I13 already knew about its importance. ARRECIADO MARAÑÓN et al. | 11 Mmm… no. If the nurse-­midwife hadn’t told me, no [I The flu vaccine, they didn’t tell me it was for the baby, wouldn’t have received the vaccine]. but for me, so that I wouldn’t get it during my pregnancy. I14 I05 I would have found out on my own, because of course This information about benefits comes from different places. things change, studies change. So, I guess I’m some- Information about pertussis mainly came from health professionals. one who trusts the most recent studies, really. (…) I But influenza was already known to them as a common infection, as mean, I guess I would have searched for information pointed out above. on my own and I would have asked other profession- als, to find out what I should do and decide. I03 4.3.2 | Risks from receiving the vaccine Most participants (15) talked about small risks linked to vaccination, 4.3 | Factors related to the vaccines which they contextualised within the view that there is no such thing as ‘zero risk’. Participants tended to be unconcerned about risks from 4.3.1 | Benefits of the vaccine vaccines and some reported that, in general, vaccines carried no risk for the pregnant woman, the foetus or the newborn. They believed For participants, receiving the vaccine meant protecting themselves either that the recommended vaccines posed no risk or posed only and their community against diseases. Protecting themselves ben- a minimal risk. This argument is also valid for the participants that efited both their future newborn and the general population. They questioned the safety of vaccines. perceived this collective benefit as important in the context of vac- cine hesitancy among some segments of the population. They re- I mean, for me the risk is minimal. For the baby, I un- ported that the more people who got vaccinated, the greater the derstand that if it’s the recommendation of a medical benefit for everyone. team and of a group of people that really care about health, then the risk must be very, very small. And in I know that now is a time when vaccines are pretty this case, I pretty much trusted this judgement. controversial, but I think they’re beneficial for the I06 person and society. Of course, I make sure that I don’t get infected and I also won’t infect anyone else. And Some participants believed that the influenza vaccine could make this way everything will go a bit better and with small a pregnant woman more likely to contract the virus. This idea came gestures we can get to where diseases that can’t be not from professionals but from the media. Despite its lack of scien- treated prophylactically don’t develop. tific validity, in some cases, this belief led participants to be vaccinated I06 against pertussis and not influenza. Some also reported the suppos- edly high risk of not being vaccinated. But now when I was pregnant, the more prevention the better. Because the flu vaccine, everyone says… Then yeah, I04 when they get it, they get sick. I haven’t heard that about the pertussis vaccine. But anyway, I don’t know. However, despite the benefits of vaccines that some partici- I01 pants described, the majority mentioned different beneficiaries, depending on the vaccine. They believed that getting the pertus- I think there’s a greater risk from not getting vacci- sis vaccine protected the foetus or newborn and only secondarily nated [against the flu], I believe. the mother. In contrast, they believed that the influenza vaccine I09 benefited primarily the mother and only secondarily the newborn. In some cases, the participant perceived no benefit, or she mini- mised it. 4.3.3 | Vaccine safety I didn’t get it [the pertussis vaccine] for myself, be- On the whole, participants were not worried about vaccine safety. cause that one’s for the baby. And thinking about the They believed that both vaccines were safe or said they were not sure if baby, I thought, “Yes [I’ll get it].” And they say that they were safe. Only the participants who spoke about vaccine-­related later they don’t have to vaccinate the baby, right? I did risks and about hidden interests doubted the vaccines’ safety. Health it more for him than for myself. professionals’ recommendations and convictions about vaccines were I07 sufficient to convince participants that vaccines have low risk. 12 | ARRECIADO MARAÑÓN et al. I mean, there’s a margin that I don’t think it’s 100% But I think that, being pregnant, I believe that there’s a safe. But I think that margin is smaller than that of lot behind vaccines, economic interests, pharmaceu- contracting the disease. tical companies, etc. I10 I12 4.4 | Factors that limit vaccination 5 | DISCUSSION When we asked explicitly about factors that kept pregnant women The findings were obtained through face-­to-­face interviews with from choosing to be vaccinated, the responses were in line with the participants, an aspect that favoured rapport and facilitated com- ones outlined above. munication (Berenguera et al., 2014). This facet distinguishes our study from other qualitative studies based on telephone interviews. In terms of factors related to pregnant women, participants had 4.4.1 | Information: too much or too little limited knowledge about influenza and pertussis and their severity, impressions that affected their decision to be vaccinated or not. Some participants talked about the overload of non-­professional in- They had general knowledge about influenza, but they did not know formation, which overwhelmed them and led to misinformation. The that pregnant women were considered a high-­risk group because of lack of professional information about risks and the consequences of the complications it can cause in them and their newborns. As a re- not receiving the vaccines led some to choose not to be vaccinated. sult, they assigned little importance to influenza. They perceived the risk to be low for themselves and non-­existent for their newborn. And out of ignorance, maybe, if a nurse-­midwife These findings differ in part from those published by Maher et al. doesn't recommend it, if she doesn't recommend that (2013). In this study carried out in Australia, most pregnant women they get vaccinated. (69%) believed that influenza had severe consequences for pregnant I11 women. This perception of severity is linked significantly to their willingness to be vaccinated, even though the risk, as in our findings, Even among some participants who believed that vaccination is focused on pregnant women (and not the newborn) and the belief a personal decision, the fact that they had professional information that the influenza vaccine provided greater protection to pregnant about pertussis but not influenza was crucial. women. Only 29% believed that maternal vaccination protected the newborn (Maher et al., 2013). The perception of severity, evidenced Of course, I guess that it will be at the personal level, a in Maher's study and not perceived by our participants, marked the personal decision… Because the information, at least difference between deciding to be vaccinated or not. in my case, about pertussis, they gave it to me. Our findings also showed that pregnant women had limited infor- I08. mation about pertussis, coinciding with other studies that signal that more than a third of pregnant women did not know about the risk that pertussis poses to babies under age one (Agricola et al., 2016). 4.4.2 | Fear Even so, they perceived a greater risk from pertussis than from influ- enza, and they understood this risk to be focused in the foetus and Fear of vaccines or of other dangerous substances or concern that the newborn, which led them to be vaccinated (Wiley et al., 2015). the vaccine could cause the disease (in the case of the influenza vac- The participants indicated that the decision to be vaccinated cine) was a factor keeping some women from getting vaccinated. would have been less clear if the benefit was only to themselves and not to their future newborn. Although women know that both vac- There are people that say that if you get vaccinated, some- cines are recommended during pregnancy (Healy et al., 2015), they times, it’s like they give you the virus. So, you can get the associate the pertussis vaccine with protecting the newborn and the disease, and it wouldn’t happen if they didn’t vaccinate you. influenza vaccine with protecting the mother or with protecting both I06 equally (Vilca et al., 2020; Wilcox et al., 2018). This association is also seen in online media articles on maternal vaccination and might explain lower rates of vaccination against influenza (Wilcox et al., 4.4.3 | Hidden interests, alternative medicine and 2018). It seems, therefore, that pregnant women value protecting vaccine hesitancy their newborn more than protecting themselves, and they feel an an- ticipated regret at the thought of something bad happening to their The existence of economic interests behind vaccination, trends in newborn because they did not get vaccinated (Maisa et al., 2018). alternative medicine and vaccine hesitancy were also mentioned by Pregnant women are more likely to agree to be vaccinated when participants as factors limiting vaccination. they understand that influenza and pertussis are risky for both the ARRECIADO MARAÑÓN et al. | 13 pregnant woman and the newborn and when they know that mater- risks, and helping the person to make decisions that are congruent nal vaccination protects the newborn (Yakut et al., 2020). For this with her personal values (Stacey et al., 2017). When nurse-­midwives reason, it is essential to increase pregnant women's perception of do not provide this information, as seen in our findings, pregnant risk and offer them more information that positions the newborn as women may assume that their nurse-­midwife has not recommended the main beneficiary of vaccination (Rodríguez-­Blanco et al., 2019; the vaccine because she has doubts about its efficacy and side ef- Wilcox et al., 2018; Wiley et al., 2015). fects, as seen in other studies (Maher et al., 2014). Encouraging a In terms of health professionals, as shown in numerous studies, change in attitude among health professionals is a priority, consid- our findings identify their recommendation as the most important ering that professionals’ attitude is key to achieving high vaccination aspect for pregnant women's decision to be vaccinated (Agricola rates (Maertens et al., 2016). et al., 2016; Lutz et al., 2018; O’Shea et al., 2018; Vilca et al., 2020) Trust in the health professional is critical (Wiley et al., 2015), and or at least among the main ones (Strassberg et al., 2018; Wales our participants reported that they would have taken the influenza et al., 2020; Yakut et al., 2020). The actions of the nurse-­midwife—­ vaccine if it had been recommended by their nurse-­midwife (see informing and/or recommending—­were crucial in our study for par- also Maertens et al., 2016, Maisa et al., 2018, and Agricola et al., ticipants’ decision-­making, although these actions were perceived 2016). According to Agricola, 34% of participants would have been differently depending on the vaccine. Nurse-­midwives recom- vaccinated if recommended by their care provider, even though 48% mended the pertussis vaccine, sometimes without even providing of them expressed concerns about vaccination. In work by Maher information to the participant. However, participants reported that et al. (2013) and Healy et al. (2015), these percentages were higher: nurse-­midwives did not recommend the influenza vaccine or inform 67% and 82%, respectively, said they would have been vaccinated. them about it. Not talking about vaccination with the health pro- The role of the health professional in decision-­making is clear and fessional is a noteworthy factor in a systematic review and other suggests yet again the need to encourage health professionals to studies conducted in the United States, which show that pregnant support vaccination in their patients. women want to receive more information from their care provid- Regarding vaccination, most participants perceived it to be ben- ers (Ellingson & Chamberlain, 2018; Lutz et al., 2018). The fact that eficial and to bear minimal risks that they had not thought much nurse-­midwives gave information and recommendations about the about, findings that coincide with a previous Australian study (Wiley influenza vaccine less often than about the pertussis vaccine is et al., 2015). Our participants also showed little concern about vac- congruent with the lower vaccination rate for influenza in pregnant cine safety, which coincides with a Belgian study (Maertens et al., women (29%) for Catalonia during the 2018–­2019 vaccination cam- 2016) and contrasts with other research (Wilson et al., 2015). In any paign (Ministerio de Sanidad, n.d.-­a). It seems that nurse-­midwives case, it leads us to conclude that there was not an a priori negative did not consider the influenza vaccine to be important and there- view of vaccines that had a major impact on participants’ decision. fore recommended it less frequently than they recommended the Along with the existence of a certain level of confidence in vaccines pertussis vaccine. Additionally, only 28% of health professionals in (Wales et al., 2020), we see the key role of nurse-­midwives in recom- Catalonia were vaccinated against influenza in the 2018–­2019 vac- mending vaccines, dispelling the erroneous idea that the influenza cination campaign. The main reason not to be vaccinated against vaccine benefits only—­or primarily—­the mother (Maher et al., 2013; influenza is fear of adverse effects, followed by the perceived lack Wilcox et al., 2018), and explaining that the influenza vaccine cannot of seriousness of the disease (Ferragut et al., 2020). Health profes- cause influenza infection (Maisa et al., 2018). Keeping in mind that sionals’ concern or scepticism about influenza vaccination could also pregnant women tend to place their newborns’ health ahead of their explain this fact (Sammon et al., 2013). There is a positive associa- own, emphasising the benefits to the newborn of maternal vaccina- tion between professionals’ perception of risk from influenza and tion against influenza could foster vaccination (Maher et al., 2013). their knowledge about the infection, as seen in studies conducted Finally, participants explicitly described as limiting factors fear, in Australia. These factors condition both their attitude about vacci- concerns about economic interests, and the lack of professional in- nation and their propensity to recommend it to others (Smith et al., formation (which leads pregnant women to seek information from 2016a, 2016b). non-­scientific sources). Again, we see the importance of having the The findings highlight factors that can be interpreted as even health professional inform pregnant women about vaccination. If more important than receiving the recommendation to be vacci- they do not do so, they run the risk that patients will resort to unreli- nated: the attitude, conviction and emphasis of the professional, able sources of information. Although some pregnant women consult which are different for the influenza vaccine than for other vaccines official sources, most use sources such as google to find information (Maher et al., 2014). Some nurse-­midwives conveyed conviction in related to influenza and pertussis (Wiley et al., 2015). Information their recommendation and even took vaccination for granted, treat- without a scientific basis can generate confusion and false beliefs ing it as a necessary procedure. Others opted to inform their patients about side effects that can discourage pregnant women from being and allowed them to decide for themselves whether to be vacci- vaccinated. Overexposure to this unreliable information, when not nated. However, relying on the person's informed decision-­making counterbalanced with reliable information from health profession- requires providing relevant information about options, benefits and als, can lead to confusion and the decision not to be vaccinated. 14 | ARRECIADO MARAÑÓN et al. 5.1 | Limitations and research design. AA, LM, RMC and AR involved in data collec- tion. AA and MIF involved in data analysis. AA and MIF involved in A possible limitation is that all participants were cared for in Spain's manuscript draft preparation and editing. All authors contributed to public health system. This system is used by most pregnant women critical review of the manuscript and final version approval. in Spain, but some pregnant women are cared for in private centres. However, women cared for in these centres still have the right to be DATA AVA I L A B I L I T Y S TAT E M E N T vaccinated in the public health system. Additionally, the ASSIRs we Data available on request from the authors. chose were located in areas with different income levels, allowing us to ensure maximum variability across participants. ORCID Antonia Arreciado Marañón https://orcid. org/0000-0002-3360-1430 6 | CO N C LU S I O N María Isabel Fernández-­Cano https://orcid. org/0000-0002-4267-2345 Our findings point to nurse-­midwives and their professional actions Laura Montero-­Pons https://orcid.org/0000-0002-9435-906X as the main factor in participants’ decision to be vaccinated or not. Maria Feijoo-­Cid https://orcid.org/0000-0002-7010-373X For this reason, efforts to improve maternal vaccination rates should Rosa Maria Cabedo-­Ferreiro https://orcid. be oriented toward these professionals. Nurse-­midwives could make org/0000-0001-5138-3927 a stronger and more convincing recommendation to their patients to Josep Maria Manresa-­Domínguez https://orcid. be vaccinated, especially against influenza. To do so, professionals org/0000-0001-8306-5798 need full conviction of the need for and suitability of these vaccines, based on scientific evidence. They also need to be aware that their REFERENCES professional practices can be decisive in their patients’ decision to Agricola, E., Gesualdo, F., Alimenti, L., Pandolfi, E., Carloni, E., be vaccinated or not. Professional advice should fill the empty space D’Ambrosio, A., Russo, L., Campagna, I., Ferretti, B., & Tozzi, A. E. (2016). Knowledge attitude and practice toward pertussis vacci- that pregnant women often fill with non-­scientific information that nation during pregnancy among pregnant and postpartum Italian can ultimately hurt their health and that of their future newborn. women. Human Vaccines & Immunotherapeutics, 12(8), 1982–­1988. 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