In our study, we aimed to determine the prevalence and related factors of vaccine hesitancy and refusal in pregnant women. Pediatric vaccine acceptance in pregnant women was 72.2%, the prevalence of vaccine refusal was 3.4%, and the prevalence of vaccine hesitancy was 24.4%. The multivariate analysis findings of this study indicated that sociodemographic and obstetric characteristics were not effective in vaccine hesitancy/refusal. According to the multivariate logistic regression model, vaccine hesitancy/refusal was significantly higher in pregnant women who stated that they would not have their children have screening tests such as hearing and heel blood after birth, who had not used any folic acid during pregnancy, who had 2 doses of tetanus vaccine during pregnancy or in the last 10 years, who stated that they did not trust the content of vaccines, and who used social media as an information source about vaccines.
In this study, vaccine hesitancy in pregnant women was 24.4%. In studies conducted in Malaysia [23] and the USA [24], the prevalence of vaccine hesitancy (8%) was lower than our findings. In studies conducted in different countries and Turkey with families with children under the age of 5, the prevalence of vaccine hesitancy was between 6–14% [17, 25, 26].In general, the measurement tool used for vaccine hesitancy varies according to the socio-cultural characteristics of the research group, country, or research region. There may be differences in prevalence due to social and cultural reasons and self-reports of participants. Henrikson et al., in their randomized controlled trial, found the prevalence of maternal vaccine hesitancy as 12.6% and then 8% after 6 months. Vaccine hesitancy, which is high during pregnancy, may change over time [27].It has been stated that the vaccine decision-making process can develop over time and that it can continue in the first years of children after birth [4].The prevalence of vaccine refusal in pregnant women who stated that they would definitely not have their children receive childhood vaccines was 3.4% and it was 4.8% in families with children under the age of 5 in Turkey, which is lower than the finding of this study [17]
In our study, vaccine hesitancy was significantly higher in pregnant women who stated that they would not have their children have tests such as hearing and heel blood after birth. The common feature of the health beliefs of families who reject various preventive practices such as newborn and childhood screenings is that they are worried about the effectiveness of public health programs [7].In a qualitative study conducted in the United States on the examination of parents' refusal of vitamin K for their infants, it was found that parents also refused or postponed the hepatitis vaccine at birth [6].In another study on the rejection of vitamin K in the United States, it was reported that parents also refused protective services such as hepatitis B vaccine and erythromycin eye ointment [7].Similar to vaccines, trust in the content of the vitamin K injection and risk-benefit perception affect decision making in families. If families refuse vitamin K for their newborn, the risk of vaccine refusal and hesitancy increases. The multivariate analysis in our study showed that vaccine hesitancy and refusal were higher in pregnant women who had not used folic acid. If pregnant women do not know the importance of the use of folic acid and are concerned about its content, it is seen that pediatric vaccine hesitancy and refusal are higher. Pregnancy period is very suitable for determining the motivation and health beliefs of pregnant women in the acceptance of screening tests, vaccines, and multivitamin use. It is seen that concerns, fear, hesitancy, and refusal which are related to preventive health practices and experienced during pregnancy have a higher tendency to continue as a refusal of practices at childbirth and vaccine hesitancy and refusal after childbirth.
According to the Turkish Ministry of Health National Extended Immunization Program, the vaccination schedule for 2021 and 2022 for pregnant women, pediatric vaccine acceptance and attitudes were questioned. The pneumococcal vaccine came first among the antigen-specific vaccines that were rejected the most, with 4.7%, which was followed by MMR (4.3%) and varicella vaccine (4.2%). The vaccine that pregnant women stated they were most hesitant about was the pneumococcal vaccine (17.2%). In a study conducted in Turkey by İlter et al., families were found to mostly refuse hepatitis A, measles, mumps, and rubella (MMR) combination vaccines, and vaccines that were least refused included chickenpox vaccine, hepatitis B, Bacillus Calmette-Guérin, and Td vaccines [28].Tdab, KKK, and chickenpox were the most common vaccines that pregnant women intended to have their infants receive. In Italy, it was found that pregnant women mostly intended to have their infants receive Hexavalent (Diphtheria, Tetanus, whole cell pertussis, Hepatitis B, Haemophilus b, and the three IPV serotype antigens) after birth. In a study conducted with pregnant women in Italy, positive attitudes towards the efficacy, safety, and delivery of vaccines were associated with the intention to vaccinate with hexavalent [9].The national vaccination schedule of each country differs. In our country, unlike in developed countries, oral polio and BCG vaccines are administered, but meningococcal and rotavirus vaccines are not included in the national vaccination scheme. It is thought that awareness about vaccines and health literacy are effective in the intention to vaccinate.
The status of being informed by a midwife, physician, or health worker during pregnancy was not questioned in this study. It has been reported that providing information about the practices in antenatal care by health service providers during pregnancy increases this practice and acceptance of vaccines. In addition, previous studies have shown that informing pregnant women about vaccines increases maternal influenza and pertussis vaccine intake and acceptance.[29].However, the physician-targeted randomized controlled communication intervention study conducted by Henrikson et al. indicated that vaccine conversations did not reduce maternal vaccination [27].The univariate analysis and multivariate Model 1 showed that vaccine hesitancy was statistically higher in pregnant women who received a tetanus vaccine than those who did not receive two doses of tetanus vaccine during their pregnancy or in the last 10 years. Trust in the content of vaccines and getting information about vaccines is thought to increase vaccine acceptance. The most important reason why individuals and parents decide to vaccinate their children is "confidence" in the efficacy and safety of vaccines [2, 5].The perception that vaccines can cause short-term and long-term effects, such as autism and idiopathic diseases, is a cause for concern. In our study, vaccine hesitancy/refusal was significantly lower in pregnant women who had confidence in vaccines. Individuals use many different sources of information about vaccines (social media, health workers, websites of the ministry of health, friends, etc.). The more concerned they are about the safety of vaccines, the more information they seek about vaccines, and thus the more active their communication is. Mothers who perceive the safety of vaccines as a problem and fear its negative effects tend to favor alternative options [30].
The fact that social media has made it possible for individuals to take a role as a content producer causes personal content about anti-vaccination to circulate in digital environments [10].Similar to our study, individuals who follow anti-vaccine groups on social media have more vaccine hesitancy and refusal. It was determined that parents who postponed vaccination of their children made this decision under the influence of social media [4].Anti-vaccine groups on social media affect individuals emotionally and reduce confidence in vaccines by sharing their personal stories about the individual harm of vaccines [16]. Understanding how pregnant women's views on vaccines, as well as how information and misinformation about vaccines are shared online, are important to guide interventions to increase vaccine trust and coverage [31].The WHO has conceptualized three key dimensions with a model for identifying causes of vaccine hesitancy: lack of confidence (in effectiveness, safety, the system, or policymakers), complacency (perceived low risk of acquiring VPDs), and lack of convenience (in the availability, accessibility, and appeal of immunization services, including time, place, language, and cultural contexts) [32].It was observed in our study that the main reasons for vaccine hesitancy primarily included a lack of confidence and complacency. The most important reasons for vaccination hesitancy/refusal among pregnant women included thinking that "it may be harmful to the child"; distrust in vaccines, thinking that vaccines have serious side effects, and thinking that companies producing vaccines are malicious because they make huge incomes. In a study conducted in Malaysia, the most important reason was found as adverse side effects of vaccines (52.1%) [23].Vaccine hesitant parents are not "thoughtless parents;" they want the best to protect their children's health. Understanding the thoughts and feelings of these parents is important for solving the problem. According to the qualitative study by Dube et al., all mothers who accepted, refused, and were hesitant about vaccines wanted the best to protect their children's health. Mothers' vaccination decision includes different factors such as social norms, past experiences, emotions, values, and social network effects [33].
In conclusion, no correlation was found between sociodemographic and obstetric characteristics of pregnant women and pediatric vaccine hesitancy and refusal in our study. Vaccine hesitancy and refusal were found to be significantly higher in those who stated that they would not have their baby receive screening tests such as hearing and heel blood after birth, who had not used any folic acid during pregnancy, who stated that they did not trust the content of vaccines, and who used social media as a source of information about vaccines.
This study has some strengths. For example, it identified pediatric vaccine hesitancy and refusal and risk factors in pregnant women in a region of Turkey. The main limitation of this study is that as it was a cross-sectional study, it was not strong enough to accurately determine the temporal direction of the cause-effect relationship between factors associated with pediatric vaccine hesitancy and refusal. Data were collected based on a self-report questionnaire. Vaccine hesitancy and refusal may change over time, and expectant mothers may accept vaccines after the birth of the baby. Therefore, the results presented can only reflect the situation at the time when the data had been collected. Since the study was conducted in only one maternal university hospital, the results cannot be generalized to all pregnant women. Larger scale and stronger studies are needed to identify risk factors for vaccine hesitancy and refusal. The results of this study will shed light on future studies on monitoring vaccine hesitancy and refusal in pregnant women and determining strategies to be developed.