Vaccine 23 (2005) 1574–1578

Beliefs and practices of Ontario midwives about influenza immunization

Todd Leea, Refik Saskinb, Margaret McArthurb, Allison McGeera,b,∗a Faculty of Medicine, 600 University Avenue, Room 1460, University of Toronto, Toronto, Ont., Canada M5G 1X5

b Shared Department of Microbiology, Toronto Medical Laboratories and Mount Sinai Hospital, Toronto, Ont., Canada M5G 1X5

Received 30 May 2004; received in revised form 18 September 2004; accepted 22 September 2004Available online 30 October 2004

Abstract

With an increasing number of births in Ontario being conducted by midwives, we undertook a survey of the beliefs and practices of 256licensed Ontario midwives and student midwives about immunization, particularly against influenza. Overall, 42.9% (48/112) of midwivesconsidered that they knew a lot about immunization; however, 36.2% (38/105) reported no education about immunization during their training.A small majority (55.9%) were in favour of vaccination in general and only 2 of 113 reported spending more than 1 h discussing vaccinationw re workersi influenza.G ing vaccinet vaccine,a y ofi©

K

1

crmdchincpanP

m-ding

hisbeenoutince

ectlynsid-ainstthe

ro-se areesfs ofhows tar-

0d

ith their clients. Only 26.9% reported having received influenza vaccine in the previous season (compared to 60% of all health can Ontario). Overall, only 37% believed that influenza vaccine is effective, and 22% believed that the vaccine was a greater risk than

raduation in 1998 or prior was associated with belief in the effectiveness in vaccine, having been vaccinated, and recommendo clients. Midwives who reported being immunized themselves were more likely to believe in the safety and efficacy of influenzand to recommend vaccination to their clients (26% versus 3%,p= 0.001). If greater attention is not focused on promoting the utilit

mmunization to midwives, the success of population immunization programs may be compromised.2004 Elsevier Ltd. All rights reserved.

eywords: Influenza; Immunization; Midwifery

. Introduction

Immunization is one the most important advances in theontrol of communicable diseases. Yet, even with a trackecord of proven success, there are still many barriers to opti-al vaccine uptake. While no licensed vaccines have beenemonstrated to be harmful during pregnancy, some vac-ines are associated with theoretical risks; consequently, itas often been regarded as best to avoid immunization dur-

ng pregnancy. This attitude among public health experts isow changing. For instance, it is clear that the influenza vac-ine is safe during pregnancy, and expert bodies agree thatregnant women with underlying conditions putting themt risk for complications from influenza should be vacci-ated[1,2]. The US Advisory Committee in Immunizationractice now recommends influenza vaccine for all preg-

∗ Corresponding author. Tel.: +1 416 586 3118; fax: +1 416 586 3140.E-mail address:amcgeer@mtsinai.on.ca (A. McGeer).

nant women[1], and the Canadian National Advisory Comittee on Immunization encourages all persons (inclupregnant women) to be vaccinated against influenza[2]. Inthe province of Ontario (population 12 million) where tstudy was conducted, the provincial government hasoffering the influenza vaccine on a yearly basis, withcharge, to all Ontarians who wish to be vaccinated s2000–2001.

Other vaccines and vaccine programs which may dirbenefit pregnant women and/or their fetuses are being coered. Immunization of pregnant, susceptible women agpertussis may protect their infants from serious illness infirst 3 months of life[3]. Vaccines for pregnant women to ptect their neonates against group B streptococcal diseaalso under development[4]. If these immunization strategiare to be effective, it is important to understand the belieobstetrical care providers regarding immunization andthis may affect the successes of immunization programgeting pregnant women.

264-410X/$ – see front matter © 2004 Elsevier Ltd. All rights reserved.

oi:10.1016/j.vaccine.2004.09.024

T. Lee et al. / Vaccine 23 (2005) 1574–1578 1575

Midwifery has been a regulated health care profession inOntario since 1994. The midwife’s scope of practice is de-fined in the Ontario Midwifery Act of 1991 as “the assessmentand monitoring of women during pregnancy, labour and thepost-partum period and of their newborn babies, the provi-sion of care during normal pregnancy, labour and post-partumperiod and the conducting of spontaneous normal vaginal de-liveries”[5]. Acts midwives can perform include the prescrip-tion and administration of medications, including parenteralmedications, if they are designated in the regulation. Hepati-tis B immunoglobulin and vaccine are two such medications;influenza vaccine is not currently included. Midwifery train-ing in Ontario occurs at three universities and consists of a 4year bachelor of sciences degree.

The number of pregnancies attended by midwives in On-tario increased from 1.2% in 1994 to 4.2% in 2000, to anestimated 6% in 2004. The number of practitioners contin-ues to increase by more than 15% per year. According to theAssociation of Ontario Midwives: “[a client] can have eithera midwife or a doctor for [their] pregnancy, birth and new-born care. Midwives, obstetricians and family physicians areall considered primary caregivers. A primary caregiver takessole responsibility for [a client’s] care. Having two caregiversis viewed as a duplication of health care services”[6]. Ac-cording to this view, for expectant mothers under a midwife’sc ntactw y bet

be-l im-m On-t

2

t/m andb nzav anda d us-i pre-vh

id-w n-t eturnw s af-t d 4w tors,t ail ore s atM werer rees e origi and

the hard copy was stored without identifying data pendinganalysis.

Survey results were analyzed using SPSS 11.5 (SPSSInc. Chicago, IL). For analysis, the variables were re-codedto combine the strongly agree and agree responses as wellas the strongly disagree and disagree responses. Compar-isons between groups were performed using Chi-square orFisher’s exact test.p-Values of less than 0.05 were consid-ered significant. The survey did not include a section for open-ended comments; however, numerous copies were returnedwith open-ended comments attached. These comments wererecorded and coded by theme for analysis.

3. Results

Overall, 93 of 220 (42%) practicing midwives and 20 of56 (36%) midwifery students responded. Of the 113 respon-dents, 94 specifically reported their graduation dates: 5 hadgraduated before 1988, 3 between 1988 and 1993, 27 between1994 and 1998, 41 between 1999 and 2003, and 18 reportedthat they were still in school. Most respondents (72/102, 72%)were trained in Ontario. The majority, (78/113, 69%) hadcompleted other post-secondary education before becominga midwife, with 58% (66/113) having completed a bachelor’so

ationr wasc .4%( 97%( heirc /77)e

edu-c ddi-t .9%( im-m

re inf f ad-v ationa greeo hasbo tiont

re-s fe buto 22%fO rtantt por-t

en ofi vedt and

are, the only health care provider that they come in coith during their pregnancy and post partum period ma

heir midwife.In order to better understand midwives’ knowledge,

iefs and practices concerning immunization, particularlyunization against influenza, we undertook a survey of

ario midwives and midwifery students.

. Methods

A two page survey (http://individual.utoronto.ca/leews.pdf) was created to discern midwives’ knowledgeeliefs about immunization in general, about the influeaccine and its safety, about the risks from influenza,bout vaccination in pregnancy. This survey was create

ng a combination of new questions and some that hadiously been used in studies of chiropractic students[7] andomeopathic physicians[8].

In February, 2002, our survey was mailed to all 220 mives registered with the Association of Midwives of O

ario. Stamped, self-addressed envelopes for survey rere included. Reminder cards were mailed 3 week

er the first mailing and the complete survey re-maileeeks later. With the assistance of the program direc

he survey was administered on a single occasion via mmail to the 56 students in midwifery training programcMaster and Laurentian Universities. These surveys

eturned anonymously by mail with the exception of thtudents who emailed their responses. In these cases thnal email was deleted after the survey was printed out

-

r graduate degree.Among respondents, the reported influenza vaccin

ate for the 2002/3 season was 26.5% (30/113). Allergyited as the reason for not being immunized in only 22/83) of unvaccinated respondents. For their clients,75/77) of midwives estimated that fewer than 10% of tlients were vaccinated against influenza; with 76% (59stimating an immunization rate of less than 5%.

Despite 36.2% (38/105) of respondents reporting noation about immunization during their training, and an aional 46.7% (49/105) reporting not enough education, 4248/112) of midwives agreed that they knew a lot aboutunization.Overall, 55.9% of respondents agreed that they a

avour of vaccination in general and 53.2% that the risk oerse reactions is outweighed by the protection vaccinffords the general public. However, 26.8% did not ar were undecided that there is proof that immunizationeen effective in decreasing infectious disease (Table 1) andnly 24.1% agreed that they would recommend vaccina

o their clients.With respect to influenza vaccine, 60.9% of midwives

ponded that they believed the influenza vaccine to be sanly 37.3% agreed that the vaccine was effective, and

elt that people get sick from the influenza vaccine (Table 2).nly 22.5% agreed that influenza vaccination was impo

o protect themselves and 32.4% that vaccination was imant to protect their clients.

In response to questions about the perceived burdnfluenza on Ontario, 52.3% (56/107) of midwives beliehat the annual incidence of influenza was between 10

1576 T. Lee et al. / Vaccine 23 (2005) 1574–1578

Table 1Beliefs of Ontario midwifes and midwifery students regarding immunization

Question Disagree Neutral Agree

In general, I am in favour of vaccination (N= 111) 11 (10%) 38 (34%) 62 (56%)The risk of a few adverse reactions is outweighed by preventing the disease in the general public (N= 111) 21 (19%) 31 (28%) 59 (53%)There is little proof that immunization is effective in preventing infectious diseases (N= 112) 82 (73%) 19 (17%) 11 (10%)I recommend vaccination to my clients (N= 108) 13 (12%) 69 (64%) 26 (24%)

Table 2Midwife beliefs about the influenza vaccination

Question Disagree Neutral Agree

The influenza vaccine is safe for the general public (N= 110) 16 (15%) 27 (25%) 67 (67%)The influenza vaccine is effective (N= 110) 26 (24%) 43 (39%) 41 (37%)People get sick from the influenza vaccine (N= 111) 54 (49%) 32 (29%) 25 (23%)People get influenza from the influenza vaccine (N= 110) 81 (74%) 25 (23%) 4 (4%)My getting vaccinated against influenza is important to protect myself (N= 111) 66 (60%) 20 (18%) 25 (23%)My getting vaccinated against influenza is important to protect my clients (N= 111) 55 (50%) 20 (18%) 36 (32%)If infected, I am likely to transmit influenza to my clients (N= 110) 21 (19%) 25 (23%) 64 (58%)

Table 3Midwife beliefs about influenza vaccination in pregnancy

Questions Disagree Neutral Agree

In pregnancy, an influenza infection has few serious consequences (N= 106) 39 (37%) 30 (28%) 37 (35%)For my clients, the risk of the flu shot is greater than the risk of getting the flu (N= 106) 46 (43%) 37 (35%) 23 (22%)In pregnancy, the flu shot is safe in the 1st trimester (N= 105) 35 (33%) 39 (37%) 31 (30%)In pregnancy, the flu shot is safe in the 2nd trimester (N= 105) 12 (11%) 36 (34%) 57 (54%)In pregnancy, the flu shot is safe in the 3rd trimester (N= 104) 9 (9%) 36 (35%) 59 (57%)I recommend flu vaccination to pregnant clients (N= 106) 44 (42%) 53 (50%) 9 (9%)

25% in the general population (89.7% believed incidence tobe above 10%) and 44.9% felt that more than 10% of thoseinfected would require hospitalization. When specificallyasked about influenza and vaccination during pregnancy,37% disagreed that influenza infection during pregnancy hadfew serious consequences; however 22% agreed that the riskof the vaccination was greater than the risk of influenza and35% were neutral (Table 3). Just over 50% of midwives feltthat vaccine was safe during the second and third trimesters,and only 8.5% recommended influenza immunization totheir pregnant clients.

Overall, 47 midwives reported spending between 0 and20 h with each client, 45 between 20 and 40 h, 19 between40 and 60 h, and two reported greater than 80 h with each

client. However, only two reported spending more that 1 hdiscussing immunization.

There were no significant associations between the uni-versity where the midwife trained or the amount of educa-tion received prior to midwifery training and their beliefs andpractices regarding vaccination. However, there were signifi-cant differences between midwives who graduated in 1998 orprior versus those who graduated later or were still in school(Table 4).

Midwives who reported that they were immunized againstinfluenza themselves were more likely to agree that: the riskof adverse reactions is outweighed by preventing disease(23/29 versus 36/82p= 0.004), that the vaccine is safe for thegeneral public (25/29 versus 42/81p= 0.003), that influenza

Table 4Comparison of beliefs of Ontario midwives and midwifery students towards vaccination and influenza vaccine by year of graduation

Statement Number* (%) agree OR (95% CL)

Graduated≤ 1998 Graduated > 1999

I recommend vaccination to my clients 11/38 (29%) 9/52 (17%) 1.9 (0.7–5.3)Influenza vaccine is effective 22/37 (59%) 14/55 (25%) 4.3 (1.8–10.5)Being vaccinated protects myself 15/39 (38%) 8/54 (15%) 3.6 (1.3–9.7)Being vaccinated protects clients 20/39 (51%) 12/54 (22%) 3.7 (1.5–9.0)This year I was vaccinated 18/39 (51%) 10/55 (18%) 3.9 (1.5–9.8)Risk of flu shot greater than risk of flu 7/39 (18%) 12/53 (23%) 0.7 (0.2–2.1)V 1%) 8.4)I %) 24)

answe

accine is safe in 2nd trimester 27/38 (7recommend flu vaccination to my clients 6/39 (15

∗ Denominators in each cell may vary because not all respondents

22/53 (42%) 3.5 (1.4–2/53 (4%) 4.6 (0.9–

red each question.

T. Lee et al. / Vaccine 23 (2005) 1574–1578 1577

vaccine is effective (21/29 versus 20/81p= 0.009), that vac-cination is important to protect both themselves and theirclients (20/29 versus 5/82 and 25/29 versus 11/82p= 0.009),that if they are infected they are more likely to transmit theinfection to their clients (26/30 versus 38/80p= 0.01), thatfor their clients the risk of influenza is greater than the risk ofthe flu shot (20/28 versus 26/78p= 0.02), and that they wouldrecommend vaccination to their pregnant clients (6/28 versus3/78p= 0.015). They also recommended influenza vaccineto a greater number of their clients (6/23 versus 2/64 recom-mended vaccine to more than 5% of their clientelep= 0.009).

4. Discussion

The 2002 influenza vaccination rate amongst midwiveswho responded to the survey was 26.5%, compared to im-munization rates of 61% for hospital and nursing homehealth care workers and volunteers, 42% for community-based health care workers, 41% for emergency service work-ers, and 28% and 47% for the overall population aged 25–44and 45–64 years, respectively (unpublished information, On-tario Ministry of Health and Long Term Care). Our data foundthat immunization status is strongly correlated with immu-nization beliefs and practices, so this low vaccination ratei fectc l.

theU g in-fl only2 cinew antw -t ever,t self-r iansi n ift

ouro ouro ore,f vac-c ccinew ina-t n toc bouti t, ifa eryp is Bi uneg ut-l cre-t

eredm morel ,

midwives who self-reported that they “knew a lot” about im-munization were more likely to recommend vaccines (OR3.395%CI 1.3–8.3). However, there was no statistically sig-nificant correlation between self-reported knowledge and im-munization status.

In their written comments, many midwives wrote that be-cause they practice informed choice they don’t advise clientsor make any recommendations with regards to any interven-tion; rather, they only provide clients with information andallow them to make the choice themselves. However, as abare minimum standard of care, a discussion of immunizationwould seem essential to permit clients to make an informedchoice. Unfortunately, most midwives reported that they of-ten did not discuss influenza immunization, implying thatit is outside of their scope of practice and that the respon-sibilities for vaccination belonged to the family physician.However, because the midwife is the primary care provider,they must be the one to address important public health is-sues such as discussing maternal and post-natal immuniza-tion.

Of additional concern, our data suggests that recent gradu-ates and those who are currently in training are far less likelyto view immunization as an important public health measurethan are older graduates. Whether our findings are specific tocurrent trends in the education or culture of midwifery, or iti nnotb hichm es forc ationo ng onp ndb im-p iveso oicest

arel ratew ad-e lievet ikelyt d be-h oser siblet boute am-p cantd ally,t e ort lica-b onep ion-a lessl ild-h ld ber haveu

s clearly of concern. It is also clear that, in order to efhange, one would have to start at a very personal leve

In a study of obstetricians and pregnant women innited States, 74% of physicians reported discussinuenza vaccine with their pregnant patients (although2% of women surveyed report discussing influenza vacith their physician). Approximately, 8% of the pregnomen in that 2001 study were immunized[9]. Our study es

imates that less than 5% of clients are immunized; howhis is based on midwives’ recollections and was not aeported estimate. Like the midwives in our study, physicn that study were more likely to recommend vaccinatiohey had been vaccinated.

Only 56% of midwives agreed that they were in favf immunization in general, and only 24% were in favf recommending vaccination to their clients. Furtherm

ewer than 60% of midwives agreed that the influenzaine is safe and only 37% agreed that the influenza vaas effective. This suggests that a lack of faith in vacc

ion may be a major hurdle in recommending vaccinatiolients. Even midwives who stated that they knew a lot ammunization reported that that they received insufficienny, education about immunization during their midwifrogram. This is particularly concerning as both hepatit

mmunization and the administration of hepatitis B immlobulin are explicitly within the scope of practice as o

ined by law and are administered at the midwife’s dision.

Another study found that nurses who correctly answore knowledge-based questions about influenza were

ikely to be immunized against influenza[10]. In our study

s a part of the larger societal anti-vaccination trend cae distinguished from our data. However, it is a trend wust be recognized when planning preventative strategi

ommunicable diseases in pregnancy. The recommendf a trusted health care provider can have a strong beariatient immunization[11]; consequently, the behaviours aeliefs of midwives with regards to immunization mayact not only upon the immunization status of the midwr their clients themselves, but also on the parental ch

o immunize their children.The conclusions that can be drawn from this study

imited by the fact that is a survey, and that the responseas relatively low. The responding population may notquately reflect the population studied; however, we be

hat that those interested in vaccines would be more lo respond to such a survey, so that overall beliefs anaviours are likely to be of even more concern than theported here. Since all data was self-reported, it is poshat responses about immunization rates in clients or aducation received are incorrect. The relatively small sle size may also not have permitted us to detect signifiifferences between different demographic groups. Fin

he study was limited to midwives registered to practicraining in Ontario, so that the results may not be apple to other jurisdictions. It is of note, however, thatrevious survey comparing attitudes of health professls towards immunization, identified that midwives were

ikely than physicians or nurses to believe that routine chood vaccinations had good scientific support and shouecommended, and more likely to believe that vaccinesnacceptable dangers[12].

1578 T. Lee et al. / Vaccine 23 (2005) 1574–1578

This study only addressed influenza immunization, and toa lesser extent, beliefs about immunization in general. Fur-ther, characterization of midwives’ attitudes towards otherinfectious diseases in pregnancy, including hepatitis B orthe human immunodeficiency virus, would significantly con-tribute towards understanding this growing field of healthcare.

As more pregnancy care shifts to midwives, their beliefsin vaccination become increasingly more important. Increas-ing education concerning immunization and developing awillingness to communicate this information to their clientsshould be a priority so as not to miss opportunities both for theprevention of influenza, but also for other potentially vaccinepreventable illnesses in this vulnerable population.

References

[1] Advisory Committee on Immunization Practices. Prevention andControl of Influenza: recommendations of the Advisory Committeeon Immunization Practices (ACIP). MMWR 2004;53:1–40; availableat http://www.cdc.gov/mmwr/preview/mmwrhtml/rr53e430a1.htm.

[2] National Advisory Committee on Vaccination, Statement for the2003–4 season. CCDR 2004;30:ACS-3 available at:http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/04vol30/acs-dcc-3/index.html.

[3] National Consensus Conference on Pertussis. Can Commu-nic Dis Report; 2003;21S3:1–39; available at: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/03vol29/29s3/index.html.

[4] Baker CJ, Rench MA, McInnes P. Immunization of pregnant womenwith group B streptococcal type III capsular polysaccharide-tetanustoxoid conjugate vaccine. Vaccine 2003;21:3468–72.

[5] Consolidated Statutes of Ontario, Midwifery Act, 1991 S.O.1991. c.31,http://www.canlii.org/on/sta/cson/20030327/s.o.1991c.31,accessed, October 5, 2003.

[6] Association of Ontario Midwives, What is a midwife?http://www.aom.on.ca/midwifery, accessed, May 1, 2003.

[7] Busse JW, Kulkarni AV, Campbell JB, Injeyan HS. Attitudes to-ward vaccination: a survey of Canadian chiropractic students. CMAJ2002;166:1531–45.

[8] Lehrke P, Nuebling M, Hofmann F, Stoessel U. Attitudes ofhomeopathic physicians towards vaccination. Vaccine 2001;19:4559–64.

[9] Silverman N, Greif A. Influenza vaccination during pregnancy. Pa-tients’ and physicians’ attitudes. J Reprod Med 46(11):989–94.

[10] Martinello RA, Jones L, Topal JE. Correlation between healthcareworkers’ knowledge of influenza vaccine and vaccine receipt. InfectControl Hosp Epidemiol 24(11):845–47.

[11] Kyaw MH, Nguyen-Van-Tam JS, Pearson JC. Family doctor advice isthe main determinant of pneumococcal vaccine uptake. J EpidemiolCommunity Health 1999;53:589–90.

[12] Jelleyman T, Ure P. Attitudes to immunization: a survey of healthprofessionals in the Rotarua district. N Z Med J 2004;117:1–12(www.nzma.org.nz/journal/117-1189/769).