"Those Who Do Not Vaccinate Don't Love Themselves, Or Anyone Else": A Qualitative Study of Views and Attitudes of Urban Pregnant Women Towards Maternal Immunisation in Panama

"Continued success of a maternal immunisation programme depends on high coverage, which is linked to attitudes and acceptance among target populations."

Panama is ethnically and culturally diverse, with marked health inequities, particularly between urban and rural populations. In fact, while the maternal mortality ratio for Panama is moderate with 41.6 deaths per 100,000 live births, in some indigenous areas, the death rate can be as high as 658 per 100,000. This study investigates views and attitudes towards maternal immunisation among 56 pregnant women through in-depth interviews and focus groups in two main urban centres in Panama (San Miguelito and Panama City).

Key results:

• Maternal immunisation as a social norm: Most participants perceive vaccination as a key component of maternal healthcare, not an elective part of it. As one woman said, "Vaccinating is part of our culture, you just do it". Another mother echoed her peers, "(I got vaccinated because) everyone did it." Both general immunisation and maternal immunisation were perceived by most women as expected.
• Influencers in health decision-making: Many of the women said their husbands and partners played a key role in their health decision-making. Several described their own husband's trust in medical advice, though one participant said, "A friend of mine [did not get vaccinated because her] husband wouldn't let another man touch her - culture, and education levels [influence vaccination]."
• Perceptions of disease risk versus perceptions of vaccine safety and effectiveness: Participants had heightened perceptions of disease risk and felt vulnerable - and recognised that vaccines can mitigate such risk. Some women talked about the power of maternal vaccines not only for themselves, but also for their unborn babies. Reports from peers, or positive experiences of other pregnant women who were vaccinated, were important influences on their perception of the effectiveness and safety of maternal immunisation.
• Refusal of maternal vaccines as negligence: Most of the women did not report refusing maternal immunisation. To vaccinate during pregnancy was perceived by participants as a mother's act of love towards her baby and the community. Vaccine refusal as negligence was not only associated with maternal vaccination, but also with childhood vaccination.
• Sources of information and influences on decision-making: Most participants reported intense information seeking behaviour regarding their overall health, particularly using the internet. A few women mentioned concerns and misconceptions that arose from information they came across online, particularly from YouTube. Even with high internet usage, most of the pregnant women reported consulting with healthcare providers (HCPs) before making health-related decisions. Participants reported that husbands, when asked about these issues, usually advised them to revert to their HCP for guidance.
• Importance of HCP recommendations of maternal immunisation: Some women reported they received limited information from their HCPS about specific vaccines, but that the HCP recommendation was still enough to convince them to vaccinate. Sometimes the high reliance on the HCP recommendation, or lack thereof, was reported by several women as occasionally driving them away from maternal vaccination.
• Religious compatibility with vaccination and implication for indigenous communities: Most participants did not see their religious beliefs as an impediment to maternal vaccination or immunisation in general and some even framed their own religious beliefs in a way that encourages vaccination. However, several mentioned other traditional cultural and religious practices that view vaccination differently. Such practices would be predominant mostly in rural settings, particularly within indigenous territories, or comarcas.
• Fragmentation in access to maternal vaccination: Women's reports of their experiences pursuing vaccination pointed to access barriers (e.g., cost and availability) to maternal immunisation in Panama City and San Miguelito. There was mixed use of private and public health services.
• Concerns, misconceptions, and rumours about maternal vaccination: While acceptability of maternal vaccines was high in this sample, some pregnant women expressed concerns and doubts (e.g., that maternal vaccines could cause miscarriages). One mother discussed her suspicions around maternal immunisation, "We are the guinea pigs, they test vaccines on us before sending to South America," and another participant reported mistrust due to information gathered online: "I've seen on YouTube that many vaccines are made of animal organs and there are vaccines, such as the polio vaccine, that's responsible for HIV in humans..."

Communication-related implications:

• In light of the pregnant women's reports of high involvement of their husbands and partners in their overall health decision-making, future health communication for maternal immunisation should consider addressing both pregnant women and their partners.
• The high number of participants who said they would consider maternal vaccination only if directly prescribed by their HCPs, alongside a patchy health system and inconsistent recommendations, implies that other policy strategies (e.g., targeted communication campaigns) may be needed to ensure that the majority of pregnant women are reached.
• HCPs should provide more information and encourage women to openly discuss with them any concerns they might have regarding immunisation during pregnancy.
• Future studies should elicit the perspectives of rural and indigenous groups, as the picture of maternal immunisation confidence in this study is likely to be different in other regions in Panama, particularly in the comarcas.

In conclusion: "The government of Panama has promoted maternal immunisation as an important strategy to increase maternal health in the country....Pregnant women's willingness to receive maternal immunisations even when information provided was scarce was suggestive of high levels of trust in HCPs. Even so, HCPs and health officials should remain alert to any rumours, misinformation and concerns expressed by pregnant women. Many participants reported difficulties in accessing maternal vaccination, pointing to financial and physical issues which merit further investigation."