IMPRINT fellow Neisha Sundaram from the London School of Hygiene and Tropical Medicine completed her project 'Understanding theinfluence of public, provider, policy and contextual factors on maternal vaccine acceptance.'

Vaccination during pregnancy, also known as maternal vaccination, has the potential to prevent disease and death among mothers and their infants. Available maternal vaccines are safe and effective in preventing disease, and maternal vaccination can have a tremendous impact in low- and middle-income countries where burden of disease is very high and access to adequate healthcare can be challenging. However, vaccines can only be effective if people have access to them and take them. A majority of research undertaken on maternal vaccination has been in higher-income settings and little is known about decision-making and factors supporting or hindering acceptance of vaccines during pregnancy inlower-income settings.

Neisha Sundaram and her team explored factors that influence decision-making and acceptance of vaccines during pregnancy in low-income urban, higher-income urban and rural areas in Bangalore, India, through interviews and discussions with various stakeholders. They spoke with pregnant women, new mothers, other family and community members, public and private healthcare providers and local-, national- and global-level policymakers, to understand vaccine acceptance comprehensively.

The researchers found that awareness of maternal tetanus vaccines among community members was high, and they were widely accepted. They were also prioritised and recommended by healthcare providers and policymakers. Awareness of influenza and other maternal vaccines were limited among community members; however, a majority were willing to take them if they were recommended by their healthcare provider. Neisha Sundaram and her team also found that community knowledge and experience with a vaccine were important for uptake. In contrast to what has been reported in the literature from Western Europe and North America, over two-thirds of pregnant women and new mothers reported not being personally involved in healthcare decision-making during their pregnancies. This was especially so in the rural and urban low-income sites. Pregnancy-related healthcare decisions were reported to have largely been made by husbands and mothers-in-law.

Most healthcare providers, and local- and national-level policymakers did not consider introducing any maternal vaccines, other than tetanus, a priority. It was found that government guidelines on recommended vaccines greatly influenced both healthcare providers' recommendation of these vaccines and community members' willingness to take these vaccines, but policymakers were often unaware of this influence.

In summary, Neisha Sundaram and her team found that while individual-level factors such as awareness are important, other provider-level, policy- and programme-level and contextual social and cultural factors play a key role in influencing maternal vaccination in some settings and need to be considered to improve uptake of maternal vaccines.