The CDC recommends Tdap (tetanus, diphtheria, acellular pertussis) vaccination during pregnancy as a strategy to protect infants against pertussis. Optimal time for the vaccination is between 27 and 36weeks gestation. This project looks at the providers’ as well as the patients’ perspectives as to why some women are not receiving the vaccine. An 8-question survey was sent out to obstetricians to assess physician’s perceptions on barriers to patients receiving the Tdap vaccination in pregnancy. A second survey was then administered to postpartum patients prior to discharge from the hospital. In the survey of obstetricians, 83% universally offered the Tdap vaccination to patients in the third trimester, and 71% of respondents stated that over half of all patients accepted the vaccine. Over half (56%) of physicians answered that they encounter barriers in trying to offer Tdap in their practice, and identified the lack of point of care availability (70%) as the most common barrier. Differences in vaccination rates of women based on different insurance types were noted, and 59% of providers answered that Medicaid patients were less likely to receive Tdap due to reimbursement issues. The patient survey revealed that 65% of patients were offered the vaccine in the third trimester, but only 37% received the vaccine. The reasons cited for not accepting the vaccine were lack of availability of vaccine in the physician’s office (44%), lack of patient understanding as to why the vaccine was important (36%), and concerns about vaccination safety (20%), This project illustrates the differences in obstetricians and patients perception on barriers for Tdap vaccination in pregnancy. This observed difference in the acceptance rates between statements by MD’s and those made by patients is statistically significant (Fisher’s Exact Test, p=0.0002). Strategies to improve vaccination rates must address barriers on both sides.

Keywords: tdap, obstetrician, vaccination in pregnancy, pertussis

Pertussis is a respiratory illness, also known as whooping cough, which is caused by the bacteria Bordetella Pertussis. It is highly contagious and can spread from person-to-person through airborne droplets. The group with the highest morbidity and mortality from pertussis is infants. In 2014, there were 3,330cases of pertussis in children younger than 6months, and 8deaths due to pertussis in infants younger than 3months of age in the United States.¹ In infants, the bacteria can travel from the upper to the lower respiratory tract. It has the potential to cause severe complications including necrotizing bronchitis, alveolar damage, intra-alveolar hemorrhage, fibrinous edema, macrophage rich alveolar infiltrates, lymphangiectasia, neutrophillic bronchopneumonia, and fibrin thrombi. In the most severe cases, it can lead to lead to pulmonary hypertension, respiratory failure, and death.²

The recommended immunization schedule released by the CDC recommends that infants do not receive the first Tdap vaccination until 2months of age.³ This leaves infants at a vulnerable state during the first two months of life, before they are able to get vaccinated. Previously, cocooning was recommended to help protect infants. Cocooning is an approach that involves administering the T dap vaccine to all women in the immediate postpartum period along with all other family members and caregivers who had not previously received the vaccine. The idea is to provide a protective cocoon of immunity around the newborn. This approach has proved to be difficult and insufficient when used alone.⁴ Currently, the CDC recommends vaccination during pregnancy in order to help increase infants’ protection against pertusssis. Health care providers should administer a dose of T dap during each pregnancy; regardless of the patient’s prior history of receiving T dap. The optimal time to vaccinate pregnant women is between 27 and 36weeks gestation in order to maximize the maternal antibody response and transfer to the infant, however it may be administered at any time in her pregnancy. If a woman has not been vaccinated, and T dap is not given during pregnancy, it should be given immediately post partum.⁵

The safety of the T dap vaccine has been a concern for patients and providers. The Advisory Committee Immunization Practices (ACIP) concluded that available data does not suggest any increased frequency or unusual patterns of adverse events in pregnant women who received T dap. The ACIP concluded that administration of T dap after 20weeks' gestation is preferred to minimize the risk for any low-frequency adverse event and the possibility that any spurious association might appear causative.⁶ Maternal T dap immunization in any trimester results in higher pertussis antibody concentrations during the period between birth and the first vaccine dose. The presence of these antibodies can potentially provide pertussis protection before T dap can be given to the infant.⁷

In order to ensure that all infants are receiving the best possible protection from pertussis, the most common reasons for patients not receiving the T dap vaccination during pregnancy need to be further investigated and addressed. Often times, patients and health care providers have different perceptions of health care. This project will investigate the compliance with the recommendation for all pregnant women to receive T dap vaccination in pregnancy from both the patient and the providers prospective and to identify reasons for noncompliance.

This multi-site study received IRB approval from both institutional IRBs. The first part of the project was a questionnaire for obstetricians regarding T dap vaccination in pregnancy. This survey was developed by members of the ACOG District XII Committee on Healthcare for Underserved Women, and distributed to all district members via email. ACOG District XII represents obstetricians in the entire state of Florida, as well as Columbia, South America. The survey was anonymous and consisted of 8 questions about T dap and point of care barriers. Consent was implied on member’s completion of the study. A copy of the survey is included as Figure 1. One hundred and thirty nine surveys were completed.

The second survey was given to obstetric patients in the post-partum period prior to discharge home. Patients were asked to complete the questionnaire but were not required to do so, as it was a voluntary study. Results were recorded in an anonymous survey database. No patient identifiers were obtained as part of the data collection, and all post-partum patients at each site were eligible for inclusion during the study period. The survey consisted of 8 questions, and is included as Figure 2. A total of two hundred and twenty surveys were completed by post-partum patients.

One hundred and thirty nine obstetricians and gynaecologists replied to the survey. Of respondents, 83%(116) answered that they offered the T dap vaccine to all pregnant patients in the third trimester. 71%(87) of the respondents stated that over half of all patients accepted the vaccine. Figure 3 outlines the reasons why physicians identified as reasons why patients where declining the vaccine. Safety concerns were the most common response, selected by 70%(89) of the respondents. This was following by followed by 43%(55) selecting lack of understanding of the importance, 35%(55) cited lack of vaccine availability 35% and 27%(30) identified concern for cost (27%).

Figure 3 Obstetrician-identified reasons why patients decline the Tdap vaccine (n=116).

Over half, 56%(71) of all physician respondents answered that they encounter barriers to offering Tdap in their office. When asked to identify the barrier, 19%(15) reported that it was a public health problem, 19%(15) responded it was too costly, and 56%(44) selected other. Thirty seven respondents completed the free text repose option regarding additional barriers to vaccination in their practice. Of those, seventeen identified insurance coverage as an issue and eight respondents of those specifically mentioned Medicaid as a barrier for vaccination administration. An additional seven respondents reported difficulty with stocking the vaccine and storage.

Out of all of the physician respondents, 16%(35) did not universally offer T dap to patients in the third trimester. Seventy percent (19) of those physicians reported the lack of point of care availability in their office was due to insurance reimbursement issues preventing office vaccination. Over half, 59%(71) of the providers answered that Medicaid patients are less likely to receive T dap during the third trimester due to lack of reimbursement and inability to pay out of pocket.

A total of two hundred and twenty two patient surveys were completed. Sixty five percent (143) of patients reported that they were offered the T dap vaccine during their third trimester, but only 37%(81) of patients actually received it. Thirty-six percent (79) patients had private or government-sponsored insurance (Tri Care, Medicare, VA), 60%(131) patients had Medicaid, and 3% (7) patients were uninsured. 3 patients did not have insurance status recorded. Figure 4 of private/government insured patients, 69.2%(54) received T dap in the 3rd trimester compared to 18.6%(23) of patients with Medicaid. Of the patients with private insurance who did not receive Tdap in the third trimester, 56%(5) cited education-related reasons, 30%(3) cited access reasons, and 22%(2) cited safety concerns. Of the patients with Medicaid insurance, 47%(25) cited lack of access, 40%(19) cited education reasons, and 19%(9) cited safety concerns (Figure 5).

Figure 4 Patient Report Insurance Status.

Figure 5 Patient Cited Reasons for not Receiving T Dap Vaccine.

Out of the 139 responses from MD’s regarding vaccination, in 79 cases (or 56%) it is claimed that the patients accepted the vaccinations, while out of 220 patients only 81(or 37%) stated that they accepted to receive the vaccinations. This observed difference in the acceptance rates between statements by MD’s and those made by patients is statistically significant (Fisher’s Exact Test, p=0.0002). This implies that there exists a large difference in the views of MD’s and patients regarding the vaccination. There is only a 2 in 10,000 chance that this difference is due to chance.

Our Survey showed that from the provider’s perspective, the biggest barriers to administering T dap vaccinations in the third trimester were insurance coverage, problems with storage and/or stocking vaccinations in their clinics, and patient concern for vaccination safety. The patients’ perspective was different from the providers’ perspective in that (lack of) access was the most common reason cited for not receiving the T dap vaccination, followed by not understanding why the vaccine is recommended and finally concern for health safety of the vaccine.

Insurance coverage is often a barrier to vaccination during pregnancy. Our data shows that only 18.6% of Medicaid patients received the T dap vaccination in the third trimester. When offered the vaccination in the postpartum period, 55% of Medicaid patients received the vaccine, illustrating that when the vaccine is immediately available Medicaid patients are more likely to receive the vaccine. When providers where asked if Medicaid patients were less likely to get the vaccine due to coverage, 59% answered yes. In the comments section of the survey, 17 providers mentioned insurance coverage as a barrier, and 8 of those specifically mentioned Medicaid. Several forms of Florida Medicaid do not cover the T dap vaccination in pregnancy or only covers it at certain locations such as the state health department. This lack of point of care availability places barriers to vaccination in front of patients, making it difficult o be compliant with the recommendation. The cost of the vaccine ranges from $40 to $100, which is unaffordable for some patients.

Although Medicaid recipients cited lack of access as the primary reason for not receiving T dap, those with private/government insurance cited lack of education as the primary reason for not receiving the vaccination. This is further evidenced by previous research with indicates that education can improve the update of this vaccination.⁸

Our data illustrates that T dap vaccination rates in pregnancy can be increased by improving both education and access to patients. Offering patients informational handouts or pamphlets explaining T dap and the reasons to vaccinate could be helpful in increasing a patient’s knowledge regarding the importance of vaccination. Likewise, re-offering the vaccination, even after a patient initially declines will open the door for more conversations between the physician and patient and possibly increase the likelihood of vaccination. The CDC has many resources for education about the Tdap vaccination during pregnancy including patient handouts, provider education articles, posters for clinics, and videos.⁹ In regards to access, advocating for insurance coverage for this vaccination is paramount. Medicaid reimbursement will allow patients to receive this vaccination in clinic as is the case for privately insured patients, thus increasing compliance with administration of the vaccine.

There are limitations in this study. The study was conducted in Florida, so some of the barriers such as stocking and insurance may not be generalizable to other states. It was estimated that in 2010, 48% of US births were covered by Medicaid. This patient population was 60% Medicaid, which may have bias due to socioeconomic status of patients. The biggest strength to this study is that it shows two perspectives on the issue, the providers’ and the patients’.

There are multiple reasons as to why there is poor adherence to the recommendations on Tdap vaccination in pregnancy. Based on our results, lack of access and lack of understanding of the importance of the vaccine are the two most common reasons patients offered for declining the vaccine. Further research is needed to determine if more education about the vaccination will improve patient acceptance rates of the vaccine. It is possible that using educational tactics could improve adherence to the recommendation that all pregnant women should receive the Tdap vaccination in the third trimester. Finally, advocating for universal coverage of Tdap by all insurance companies will greatly improve compliance with Tdap administration in the third trimester of pregnancy.

1. Obstetricians have different perceptions of their patients regarding the Tdap Vaccine.
2. The optimal time to vaccinate is during pregnancy.
3. Lack of patient understanding of vaccination importance leads to patients declining the vaccine.

We would like to acknowledge the assistance ACOG DXII Committee on HUW work.

Author declares that there is no conflict of interest.

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