At the outset of the 2009–2010 H1N1 vaccination campaign, obstetricians represented a potentially important point of access to H1N1 vaccine for pregnant women. However, the extent to which obstetricians would be involved in the campaign was unclear, as seasonal influenza vaccination rates among pregnant women had languished at <15 % since first recommended in 1997 [1
]. This national survey of obstetricians demonstrates that access to H1N1 vaccine among obstetricians was widespread. These findings, confirmed by other research [7
], also show that the rate of H1N1 vaccine availability in the practice setting was higher than that seen previously for seasonal influenza vaccine [8
], and was slightly higher than the reported availability of seasonal influenza in their practices for the 2009–2010 and 2010–2011 seasons. Obstetrician involvement may have been influenced by early reports of influenza-related mortality in pregnant women [11
], as well as coordinated efforts by public health officials and professional societies, such as the American College of Obstetricians and Gynecologists (the College), to communicate to providers the importance of participating as H1N1 vaccinators [12
]. In a pandemic situation, having vaccine in the obstetric setting is an efficient way to target pregnant women, and the majority of pregnant women who received H1N1 vaccine were vaccinated in the obstetric setting [13
Consistent with our finding that the majority of obstetricians strongly recommended H1N1 vaccine to their patients, vaccine coverage data indicate that almost half of pregnant women were vaccinated with the H1N1 vaccine [13
]. Provider recommendation was a key factor associated with receipt of H1N1 vaccine by pregnant women [13
]. However, the lower proportion of obstetricians who strongly recommended first-trimester vaccination, as well as the perceived patient reluctance toward first-trimester vaccination, observed in this survey is consistent with lower first-trimester recommendations [7
] and vaccination rates shown previously [9
]. This may reflect the fact that first-trimester vaccination was not recommended until the 2004–2005 influenza season [20
]. It also may reflect the general lack of data about the safety of vaccination at this stage of pregnancy. As a broader base of both scientific and empirical data is established, obstetricians and patients may become more comfortable with first-trimester vaccination. Helping obstetricians translate relevant information for patients, such as recent data demonstrating the benefits of maternal influenza vaccination for infants’ health [21
], is an important point of emphasis for future pandemic situations.
Vaccine supply was the main barrier for obstetricians, even though pregnant women were one of the five sub-populations specifically targeted for vaccination [5
]. When vaccine supply was limited in the early stages of the vaccination campaign, state and local health departments—who had responsibility for allocation of vaccine—varied widely in the populations and provider types prioritized in their allocation. Moreover, the first doses to become available were live attenuated intranasal vaccine (LAIV) [24
], which cannot be given to pregnant women; it is plausible that obstetricians and pregnant women were frustrated that H1N1 vaccine doses were available, but not available to pregnant women. In subsequent weeks, as a limited supply of inactivated doses became available, obstetricians who were given vaccine faced decisions on how to allocate the limited amount within their patient population. Results from this survey indicate that when obstetricians prioritized which pregnant patients would receive H1N1 vaccine, they generally focused on those who were in more than one of the five vaccine target groups in the national recommendations (e.g. pregnant patients who were also healthcare workers) [5
]. For future pandemic situations, clear guidance (for example, indicating that providers with insufficient supply should prioritize based on number of risk factors or severity of high-risk condition) would be helpful. The finding that relatively few obstetricians reported having a major problem with lack of thimerosal-free vaccine indicates that concerns about thimerosal may be outweighed by the desire for timely vaccination during a public health emergency.
Practical aspects of vaccination in the practice setting, including reimbursement and billing, were rated as non-problems by the majority of obstetricians. The relative ease of these logistical issues is important to future pandemic situations: while the vast majority of obstetricians responding to this survey indicated that they would be willing to provide vaccine in a future influenza pandemic, those who reported major problems with H1N1 vaccination (beyond vaccine supply issues) were substantially less willing to vaccinate in a future pandemic. Thus, there appears to be both a present and future benefit to facilitating obstetricians’ involvement in influenza vaccination. More broadly, it seems likely that any type of public health emergency in which pregnant women would be considered a priority patient population would benefit from the participation of obstetricians, both in preparedness efforts (e.g. planning, training) and implementation of the actual emergency response.
Some limitations are noted for this study. These results represent self-reported attitudes, behaviors and practices, and the study was not designed to independently verify the accuracy of self-report. Also, as is inherent with mail surveys, there is the potential for response bias. Though our analyses demonstrated minimal differences in demographic characteristics between respondents and non-respondents, obstetricians who did not provide H1N1 vaccine may have been less likely to respond. While we cannot ascertain the magnitude of this bias, the response rate for this study compares favorably with other recent, national surveys of obstetricians (42–66 %) [7
]. In addition, the implications of our findings for improving the experiences of obstetricians participating in future pandemic vaccination efforts are unlikely to be affected by lower response from those who did not provide H1N1 vaccine.
In conclusion, given the generally positive experiences of obstetricians in the 2009–2010 H1N1 vaccination campaign, and the H1N1 vaccination rates for pregnant women, public health officials should continue to include obstetricians in their planning efforts around pandemic influenza. Addressing concerns about first-trimester vaccination, developing guidelines for sub prioritization of vaccine in the event of severe supply constraints, and continued facilitation of the logistical aspects of vaccination should be emphasized in future influenza pandemics.