Rev. Enferm. UFSM, v.14, e5, p.1-19, 2024
Submission: 5/15/2023 • Acceptance: 1/24/2024 • Publication: 2/19/2024
Original article
Immunization of pregnant women in times of the COVID-19 pandemic*
Imunização da gestante em tempos de pandemia da COVID-19
Inmunización de mujeres embarazadas en tiempos de pandemia de COVID-19
Katherine
Slowinski Knapp I
Maria
Aparecida Baggio II
Helder
Ferreira I
Adriana
Zilly I
Rosane
Meire Munhak da Silva I
I Universidade Estadual do Oeste do Paraná. Foz do Iguaçu, Paraná, Brazil
II Universidade Estadual do Oeste do Paraná. Cascavel, Paraná, Brazil
* Product of Scientific Initiation Project "Coping with COVID-19 and Maternal and Child Care (Enfrentamento da COVID-19 e a Assistência Materno-Infantil)", State University of Western Paraná, 2023.
Abstract
Objective: analyze and compare the immunization of pregnant women during the COVID-19 pandemic in western Paraná. Method: this is an analytical, cross-sectional study carried out in the ninth and tenth regional health departments of Paraná. A total of 823 puerperal women took part, and data was collected using a survey and information from medical records between September and December 2021. Descriptive analysis and the chi-square test were used, with a significance level of 5%. Results: the ninth region performed better in immunization against Hepatitis-B, Influenza, Diphtheria, Tetanus and Pertussis compared to the tenth region. Vaccination against COVID-19 had low uptake in both regions, the reasons for which were: fear, own choice, medical advice and the wish to wait for the child to be born. Conclusion: new strategies and awareness campaigns are needed to increase the vaccination rate among pregnant women, especially for the COVID-19 vaccine, considering the complications for maternal and child health.
Descriptors: Pregnancy; Women's Health; Immunization; Vaccination Coverage; COVID-19
Resumo
Objetivo: analisar e comparar a imunização de gestantes no período da pandemia da COVID-19 no Oeste do Paraná. Método: pesquisa analítica e transversal, realizada na nona e décima regionais de saúde do Paraná. Participaram 823 puérperas. A coleta de dados foi conduzida por inquérito e informações do prontuário entre setembro a dezembro de 2021. Utilizaram-se análise descritiva e teste de qui-quadrado com nível significância de 5%. Resultados: a nona regional apresentou melhor desempenho na imunização contra Hepatite-B, Influenza, Difteria, Tétano e Coqueluche em comparação à décima regional. A vacinação contra COVID-19 teve baixa adesão em ambas as regionais, cujos motivos foram: medo, opção própria, orientação médica e desejo de esperar o filho nascer. Conclusão: são necessárias novas estratégias e campanhas de sensibilização para aumentar o índice vacinal entre gestantes, sobretudo para a vacina contra COVID-19, considerando as complicações para a saúde materno-infantil.
Descritores: Gestação; Saúde da Mulher; Imunização; Cobertura Vacinal; COVID-19
Resumen
Objetivo: analizar y comparar la inmunización de mujeres embarazadas durante la pandemia de COVID-19 en el Oeste de Paraná. Método: investigación analítica y transversal, realizada en la novena y décima región sanitaria de Paraná. Participaron 823 puérperas. La recolección de datos se realizó mediante encuesta e información de historias clínicas entre septiembre y diciembre de 2021. Se utilizó análisis descriptivo y prueba de chi cuadrado con un nivel de significancia del 5%. Resultados: la novena región presentó mejor desempeño en inmunización contra Hepatitis B, Influenza, Difteria, Tétanos y Tos Ferina en comparación con la décima región. La vacunación contra la COVID-19 tuvo baja adherencia en ambas regiones y los motivos fueron: miedo, elección personal, consejo médico y deseo de esperar a que nazca el niño. Conclusión: son necesarias nuevas estrategias y campañas de sensibilización para aumentar la tasa de vacunación entre las mujeres embarazadas, especialmente de la vacuna contra la COVID-19, considerando las complicaciones para la salud materna e infantil.
Descriptores: Embarazo; Salud de la mujer; Inmunización; Cobertura de vacunación; COVID-19
Prenatal care, given its importance in protecting women through screening for risk indicators, immunization, prophylaxis, obstetric therapeutic interventions, counseling, and health education, is essential for minimizing risks, especially during critical periods such as the COVID-19 pandemic,1 since it directly influences the reduction of maternal and infant morbidity and mortality.2-3
Immunization of pregnant women, an important tool for promoting the health and well-being of the mother and fetus, has been hampered by COVID-19, as have other essential primary care actions.4 COVID-19 is a disease caused by the SARS-CoV-2 virus and was declared a pandemic by the World Health Organization in 2020.5-6
It is known that due to the pandemic and to control the transmission of the virus, attendance at health services have been drastically reduced in many countries, especially for health promotion and disease prevention services, which include immunization.7 During pregnancy, the recommended immunizations are against Influenza, Hepatitis B, Tetanus and Diphtheria (dT) or Tetanus, Diphtheria and Pertussis (dTpa), which confer a protective factor against severe forms of these infections. In addition to these immunizers, pregnant women have been included as a priority group for vaccination against COVID-19 due to the increased risk of aggravation by this disease.4
The presence of infections during pregnancy is associated with complications such as fetal death, malformations, premature birth and neonatal infections. However, many of these infections are immune-preventable and the maternal vaccination strategy preserves the health of the newborn, as the antibodies cross the placental barrier and provide passive protection for approximately 12 months of life, since their own humoral response is still relatively inefficient.4,8
Pregnant women and their offspring are considered to be a group at greater risk of morbidity and mortality from vaccine-preventable diseases due to the physiological and immunological changes that occur in the pregnancy cycle.9-10 Data corroborated by a study that analyzed 17 pregnant women diagnosed with severe influenza showed that 88% needed to be hospitalized, 53% used mechanical ventilation, 29% underwent emergency caesarean section and 24% died. Only 14% of these women had received the influenza vaccine during pregnancy.11
In this context, since vaccination status is influenced by intrinsic and extrinsic factors, the role of health professionals becomes essential in times of health crisis and can influence women in their decisions about immunization during pregnancy.12
The aim of this study is to analyze and compare the immunization of pregnant women during the COVID-19 pandemic in western Paraná.
This is an analytical, cross-sectional study carried out in four maternity hospitals in the Western region of the state of Paraná, Brazil, located in the municipalities of Cascavel, Foz do Iguaçu, Medianeira and Matelândia. These were intentionally chosen because they provide care through the Unified Health System (Sistema Único de Saúde, SUS).
The maternity hospital in Cascavel, the headquarters of the tenth regional health department, is a reference point for high-risk and normal-risk pregnancies, as well as neonatology for all the municipalities belonging to this regional department, providing exclusive SUS services.
The maternity hospital in Foz do Iguaçu, headquarters of the ninth region, is a reference point for high-risk pregnancies and neonatology for all nine municipalities that make up this regional health department, and provides care through the public and private systems. In addition to high-risk care, it is also responsible for regular and intermediate risk care in the municipality itself and Santa Terezinha de Itaipu. The maternity wards in Medianeira and Matelândia provide services through the public and private systems, and care for normal and intermediate risk pregnant women from Medianeira, Matelândia, Ramilândia and Serranópolis do Iguaçu, all of which belong to the ninth regional health department
For the sample calculation, the number of births that occurred in 2020 in the municipalities of interest to the study was taken into account, considering N size (number of elements) of the population; n size (number of elements) of the sample; nº a first approximation for the sample size; E0 tolerable sampling error. The following formulas were used: n0 = 1 / (E0)2. 0,05 = 400 / n = N . n0 / N + n0
A margin of error of 5% and a 95% confidence level were considered. A safety margin of 10% was set, in view of losses during data collection.
A total of 823 puerperal women hospitalized in rooming-in were included, regardless of maternal age or gestational age. The exclusion criteria were puerperae with clinical and/or mental health problems, recorded in their medical records, which could prevent them from taking part in the study. However, none of the participants approached had any description in their medical records of decompensated clinical problems (such as hypertensive syndromes, hemorrhages, among others) or mental health problems (such as postpartum depression).
A structured instrument was used, designed by nurse-teachers with expertise in maternal and child health research. The instrument contained the following variables: Sociodemographic data: age, schooling, family income and government subsidy; Gestational data: number of pregnancies, prenatal consultations and comorbidities; Immunization data: complete or incomplete vaccination (anti-Hepatitis B; dTtpa; Influenza; COVID-19) and reasons for incomplete or no immunization.
The data collection period was from September to December 2021, carried out using a survey, in the rooming-in, approximately 24 hours after the birth of the child, in the room itself, but without the presence of companions and health professionals. The participants were invited to take part in the study by first explaining the objectives of the study and, when they accepted, their signatures were collected on the Free and Informed Consent Form, in two copies: one was kept by the participant and the other by the researcher. The answers were marked on a printed questionnaire by the researchers themselves, and after each survey was finished, they were asked to agree to their answers, but none of them reported needing to be checked.
The surveys were carried out by female nursing students from a public institution, who had been previously trained by the researchers in charge, who have professional and academic experience in the field of maternal and child health. Pilot tests (not included in the data collection) were used to train the students and to adapt the research instrument, which was drawn up and validated by the researchers responsible. Data was also searched for in electronic medical records and the pregnant woman's health card.
The data was organized in Excel® spreadsheets by independent double entry. For data analysis, the variables studied were organized in double entry tables and absolute and relative frequencies were calculated. The analysis sought to establish a comparison between the two regional health departments studied, distributing the types of vaccines and relating them to sociodemographic factors and obstetric profile. The chi-square test with a significance level of 5% was used to verify this association and the XLStat2014® program was used.
The study was reported according to the criteria of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative. It was approved by the Human Research Ethics Committee of the State University of Western Paraná under Opinion No. 4.837.617 and complied with all the ethical precepts involving research with human beings. This research is part of a larger project entitled Coping with COVID-19 and Maternal and Child Care (“Enfrentamento da COVID-19 e a Assistência Materno-Infantil”).
Table 1 illustrates the comparison of vaccination coverage between the two regions in relation to Anti-Hepatitis B, Influenza, dTpa and COVID-19 immunization, which showed statistical relevance (p<0.05). It was observed that the ninth region showed better performance in immunization rates compared to the tenth region, maintaining rates above 90% in immunobiologicals related to Influenza, Anti-Hepatitis B and dTpa. However, regarding vaccination against COVID-19, the tenth regional health department had better results, with 79% of pregnant women immunized, while the ninth region had just over 50%.
Table 1 - Vaccination coverage of pregnant women against Hepatitis B, Influenza, dTtpa and COVID-19. Western Paraná state, Brazil, 2023
|
|
9th Regional Health Department |
10th Regional Health Department |
|
||
|
Variables |
n |
% |
n |
% |
p-value* |
|
Anti-Hepatitis B |
380 |
93.9 |
364 |
87.0 |
0.006 |
|
Influenza |
386 |
95.3 |
370 |
88.5 |
0.005 |
|
dTpa |
397 |
98.0 |
392 |
96.8 |
0.028 |
|
COVID-19 |
227 |
56.0 |
330 |
79.0 |
0.001 |
* Chi-square test for proportions
Regarding immunization against Hepatitis B (Table 2) and socio-economic aspects, when comparing the two regional health departments, there was statistical significance (p<0.05) for pregnant women in the tenth health regional department who were under 19 years old, had more schooling (12 years or more) and a higher income (one to three minimum wages), while in the ninth region, there was a lower income (one minimum wage or less) and less schooling (five to 11 years).
Regarding the obstetric profile and immunization against Hepatitis B, no statistical significance was observed when comparing the regional health departments (Table 2).
Table 2 - Socioeconomic characterization and obstetric profile related to Hepatitis B immunization of pregnant women. Western Paraná state, Brazil, 2023
|
9th Regional health department |
10th Regional health department |
p-value# |
||||
|
n |
% |
n |
% |
|||
|
Socioeconomic characterization |
|
|
|
|
# |
|
|
Age |
|
n=376 |
|
n=357 |
|
0.035 |
|
|
<19 years old |
15 |
4.0 |
37 |
10.4 |
|
|
|
19 - 34 years old |
315 |
83.8 |
278 |
77.9 |
|
|
|
≥35 years old |
46 |
12.2 |
42 |
11.8 |
|
|
Schooling |
|
n=370 |
|
n=362 |
|
0.001 |
|
|
0 - 4 years |
8 |
2.2 |
2 |
0.6 |
|
|
|
5 - 8 years |
66 |
17.8 |
30 |
8.3 |
|
|
|
9 - 11 years |
95 |
25.7 |
39 |
10.8 |
|
|
|
≥ 12 years |
201 |
54.3 |
291 |
80.4 |
|
|
Family income |
|
n=346 |
|
n=352 |
|
0.001 |
|
|
<1 |
70 |
20.2 |
25 |
7.1 |
|
|
|
1 - 3 wages |
251 |
72.5 |
300 |
85.2 |
|
|
|
≥4 wages |
25 |
7.2 |
27 |
7.7 |
|
|
Government |
|
n=376 |
|
n=363 |
|
0.119 |
|
Subsidy |
Received |
108 |
28.7 |
85 |
23.4 |
|
|
|
Did not receive |
268 |
71.3 |
278 |
76.6 |
|
|
Obstetric profile |
|
|
|
|
|
|
|
Number of pregnancies |
|
n=374 |
|
n=361 |
|
0.081 |
|
|
Primigravida |
113 |
30.2 |
132 |
36.6 |
|
|
|
Multiparous |
261 |
69.8 |
229 |
63.4 |
|
|
Nº of appointments |
|
n=356 |
|
n=352 |
|
0.3278 |
|
|
<6 |
38 |
10.7 |
29 |
8.2 |
|
|
|
≥6 |
318 |
89.3 |
323 |
91.8 |
|
|
Comorbidities |
|
n=376 |
|
n=363 |
|
0.054 |
|
|
Yes |
96 |
25.5 |
117 |
32.2 |
|
|
|
No |
280 |
74.5 |
246 |
67.8 |
|
*Minimum wage (2022): R$1.212,00.
# Chi-square test
Table 3 - Socioeconomic characterization and obstetric profile related to influenza immunization of pregnant women. Western Paraná state, Brazil, 2023
|
Variables |
9th Regional Health Department |
10th Regional Health Department |
p-value# |
|||
|
n |
% |
n |
% |
|||
|
Socioeconomic characterization |
|
|
|
|
# |
|
|
Age |
|
n=381 |
|
n=360 |
|
0.015 |
|
|
<19 years old |
18 |
4.7 |
37 |
10.3 |
|
|
|
19 - 34 years old |
317 |
83.2 |
284 |
78.9 |
|
|
|
≥35 years old |
46 |
12.1 |
39 |
10.8 |
|
|
Schooling |
|
n=375 |
|
n=368 |
|
0.001 |
|
|
0 - 4 years |
8 |
2.1 |
3 |
0.8 |
|
|
|
5 - 8 years |
65 |
17.3 |
32 |
8.7 |
|
|
|
9 - 11 years |
100 |
26.7 |
40 |
10.9 |
|
|
|
≥12 years |
202 |
53.9 |
293 |
79.6 |
|
|
Family income |
|
n=349 |
|
n=357 |
|
0.001 |
|
|
<1 |
70 |
20.1 |
28 |
7.8 |
|
|
|
1 - 3 wages |
254 |
72.8 |
300 |
84.0 |
|
|
|
≥4 wages |
25 |
7.2 |
29 |
8.1 |
|
|
Government |
|
n=381 |
|
n=369 |
|
0.069 |
|
Subsidy |
Received |
111 |
29.1 |
85 |
23.0 |
|
|
|
Did not receive |
270 |
70.9 |
284 |
77.0 |
|
|
Obstetric profile |
|
|
|
|
|
|
|
Number of pregnancies |
|
n=379 |
|
n=367 |
% |
0.121 |
|
|
Primigravida |
117 |
28.9 |
134 |
36.5 |
|
|
|
Multiparous |
262 |
64.7 |
233 |
63.5 |
|
|
Nº of appointments |
|
n=359 |
|
n=357 |
|
0.442 |
|
|
<6 appointments |
35 |
8.6 |
28 |
7.8 |
|
|
|
≥6 appointments |
324 |
80 |
329 |
92.2 |
|
|
Comorbidities |
|
n=381 |
|
n=369 |
|
0.114 |
|
|
Yes |
95 |
24.9 |
112 |
30.4 |
0.015 |
|
|
No |
286 |
75.1 |
257 |
69.6 |
|
*Minimum wage (2022): R$1.212,00.
# Chi-square test
Regarding immunization against influenza (Table 3), the greatest differences found between the regional health departments were in the under-19 age group, education level equal to or greater than 12 years, and higher income, that is, between one and three minimum wages in the tenth regional health department.
In the ninth region, there was statistical significance (p<0.05) for lower schooling (five to 11 years) and lower income (equal to or less than one minimum wage). When comparing the regions in terms of influenza immunization and obstetric profile, there were no statistical differences (Table 3).
Regional health departments were also compared in terms of dTpa immunization (Table 4) and socioeconomic status. The data was similar to the other immunizations, except the receipt of government subsidies. In the tenth regional health department, immunized pregnant women received the subsidy less frequently than pregnant women in the ninth (p<0.031). For the information related to the obstetric profile, there was no statistical significance.
For immunization against COVID-19 (Table 5), in the tenth region, the greatest differences were found for immunized pregnant women aged under 19, with 12 years or more of schooling and an income of between one and three minimum wages, while in the ninth, the statistical relevance was for pregnant women with between five and 11 years of schooling (p=0.001) and an income of one minimum wage or less (p=0.005). Once again, there was no statistical evidence for the obstetric profile (p>0.05).
Table 4 - Socioeconomic characterization and obstetric profile and the relationship with dTpa immunization of pregnant women in the ninth and tenth regional health departments. Western Paraná state, Brazil, 2023
|
Variables |
9th Regional Health Department |
10th Regional Health Department |
p-value# |
|||
|
n |
% |
n |
% |
|||
|
Socioeconomic characterization |
|
|
|
|
# |
|
|
Age |
|
n=393 |
|
n=383 |
|
0.016 |
|
|
<19 years old |
18 |
4.6 |
38 |
9.9 |
|
|
|
19 - 34 years old |
326 |
83.0 |
301 |
78.6 |
|
|
|
≥35 years old |
49 |
12.5 |
44 |
11.5 |
|
|
Schooling |
|
n=387 |
|
n=390 |
|
0.001 |
|
|
0 - 4 years |
8 |
2.1 |
2 |
0.5 |
|
|
|
5 - 8 years |
68 |
17.6 |
32 |
8.2 |
|
|
|
9 - 11 years |
101 |
26.1 |
44 |
11.3 |
|
|
|
≥12 years |
210 |
54.3 |
312 |
80.0 |
|
|
Family income |
|
n=360 |
|
n=377 |
|
0.001 |
|
|
<1 |
71 |
19.7 |
25 |
6.6 |
|
|
|
1 - 3 wages |
262 |
72.8 |
317 |
84.1 |
|
|
|
≥4 wages |
27 |
7.5 |
35 |
9.3 |
|
|
Government |
|
n=393 |
|
n=391 |
|
0.031 |
|
Subsidy |
Received |
115 |
29.3 |
87 |
22.3 |
|
|
|
Did not receive |
278 |
70.7 |
304 |
77.7 |
|
|
Obstetric profile |
|
|
|
|
|
|
|
Number of pregnancies |
|
n=391 |
|
n=389 |
|
0.135 |
|
|
Primigravida |
120 |
30.7 |
140 |
36.0 |
|
|
|
Multiparous |
271 |
69.3 |
249 |
64.0 |
|
|
Nº appointments |
|
n=370 |
|
n=379 |
|
0.265 |
|
|
<6 appointments |
39 |
10.5 |
30 |
7.9 |
|
|
|
≥6 appointments |
331 |
89.5 |
349 |
92.1 |
|
|
Comorbidities |
|
n=393 |
|
n=391 |
|
0.061 |
|
|
Yes |
98 |
24.9 |
122 |
31.2 |
|
|
|
No |
295 |
75.1 |
269 |
68.8 |
|
*Minimum wage (2022): R$1.212,00.
# Chi-square test
Table 5 - Socioeconomic characterization and obstetric profile and the relationship with immunization against COVID-19 of pregnant women. Western Paraná state, Brazil, 2023
|
Variables |
9th Regional Health Department |
10th Regional Health Department |
p-value# |
|||
|
n |
% |
n |
% |
|||
|
Socioeconomic characterization |
|
|
|
|
# |
|
|
Age |
|
n=225 |
|
n=322 |
|
0.283 |
|
|
<19 years old |
7 |
3.1 |
19 |
5.9 |
|
|
|
19 - 34 years old |
189 |
84.0 |
258 |
80.1 |
|
|
|
≥35 years old |
29 |
12.9 |
45 |
14.0 |
|
|
Schooling |
|
n=221 |
|
n=328 |
|
0.001 |
|
|
0 - 4 years |
4 |
1.8 |
2 |
0.6 |
|
|
|
5 - 8 years |
33 |
14.9 |
25 |
7.6 |
|
|
|
9 - 11 years |
48 |
21.7 |
29 |
8.8 |
|
|
|
≥12 years |
136 |
61.5 |
272 |
82.9 |
|
|
Family income |
|
n=209 |
|
n=317 |
|
0.005 |
|
|
<1 |
32 |
15.3 |
21 |
6.6 |
|
|
|
1 - 3 wages |
163 |
78.0 |
271 |
85.5 |
|
|
|
≥4 wages |
14 |
6.7 |
25 |
7.9 |
|
|
Government |
|
n=225 |
|
n=329 |
|
0.977 |
|
Subsidy |
Received |
50 |
22.2 |
74 |
22.5 |
|
|
|
Did not receive |
175 |
77.8 |
255 |
77.5 |
|
|
Obstetric profile |
|
|
|
|
|
|
|
Number of pregnancies |
|
n=223 |
|
n=327 |
|
0.293 |
|
|
Primigravida |
68 |
30.5 |
115 |
35.2 |
|
|
|
Multiparous |
155 |
69.5 |
212 |
64.8 |
|
|
Nº of appointments |
|
n=213 |
|
n=321 |
|
0.961 |
|
|
<6 appointments |
14 |
6.6 |
22 |
6.9 |
|
|
|
≥6 appointments |
199 |
93.4 |
299 |
93.1 |
|
|
Comorbidities |
|
n=225 |
|
n=329 |
|
0.095 |
|
|
Yes |
53 |
23.6 |
100 |
30.4 |
|
|
|
No |
172 |
76.4 |
229 |
69.6 |
|
*Minimum wage (2022): R$1,212.00.
# Chi-square Test
Among the participants who did not receive the COVID-19 vaccine, the most cited reasons in the tenth region were: fear (27.5%), own choice (23.5%), and medical advice (17.7%). In the ninth region, the reasons were: their own choice (16.8%), medical advice (14.2%), and the desire to wait for their child to be born (15.9%).
Discussion
The vaccination schedule for pregnant women consists of three immunizations: against Hepatitis B, Diphtheria, Tetanus and Pertussis (dTpa) and against Influenza. The results of this study, of more than 80% of pregnant women, corroborate data from a study that assessed prenatal care in the ninth, tenth and seventeenth regional health departments in Paraná prior to the COVID-19 pandemic.13
As far as vaccination coverage is concerned, the National Immunization Program (NIP) recommends vaccination rates of 95% for most immunizers, with the aim of protecting the population individually and collectively against vaccine-preventable diseases. In recent years, there has been a significant drop in vaccination for various immunobiologicals in Brazil and around the world, including among pregnant women, intensified by the COVID-19 pandemic.14-15 In Brazil, vaccination coverage is not homogeneous, implying a risk for the population.14
Regarding the COVID-19 vaccine, it was given to a smaller extent than the other immunobiologicals. This data suggests that pregnant women are hesitant to vaccinate themselves with this vaccine in particular, since the reasons for not doing so involved: fear, their own choice, and medical advice, and at no time was the unavailability of doses mentioned. This reinforces the results found in another study carried out in Turkey, whose sample of pregnant women also had low acceptance of the COVID-19 vaccine. The authors found that pregnant women in the first trimester were more interested in receiving the vaccine than pregnant women in the second or third trimesters, and the possibility of damage to the fetus was also included among the reasons for hesitation.16
A North American survey showed that before the COVID-19 vaccine became available, between 41% and 47% of pregnant women would like to receive it,17 a result much higher than that found in Croatia, which identified only 16% of pregnant women.18 It was found that having previously refused the influenza vaccine, lack of guidance from a health professional, lower education level, younger age, African-American race and Hispanic ethnicity were factors associated with pregnant women refusing the COVID-19 vaccine.17
Even so, the tenth region had better vaccination rates against COVID-19, around 20% more than the ninth region. This may be related to sociodemographic aspects, given that in the tenth region there was a significant difference in higher levels of schooling. It is understood that pregnant women's decisions about immunization, especially against COVID-19, may be influenced by social and family factors or by misconceptions about the vaccine, a practice intensified during the pandemic.14
A comparative analysis between the regional health departments shows that the socio-economic data differ. In the tenth region, the greatest significance, for all the immunizations observed, was related to higher schooling, higher income and lower receipt of government subsidies. In the ninth region, there was a lower level of education, lower income and greater receipt of subsidies.
It is known that in Brazil, socioeconomic status and access to health services is a determining factor in achieving a higher vaccination coverage rate among pregnant women. Therefore, it is understood that socioeconomic inequalities can compromise immunization actions.19 Even so, the ninth region performed better for Hepatitis B, Influenza and dTpa vaccines when compared to the tenth region, even with significance for lower schooling and family income.
One study found that, when compared to pregnant women with no schooling or only elementary schooling, those with higher education were the ones who received the most Anti-Hepatitis B immunizations. It was also observed that having a paid job and a greater number of prenatal consultations were associated with less vaccine absence.19
The Hepatitis B vaccine is the most effective preventive method for Hepatitis B virus (HBV) infection. Its vertical transmission is associated with a high risk of the child developing chronic infection. Therefore, the aim of administering this immunizer during pregnancy is not only to protect the pregnant woman from acquiring the virus but also to protect the newborn.4,12
Influenza immunization should be administered to all pregnant women, regardless of gestational week, during vaccination campaigns. This study found that the ninth regional health department achieved the best results.
For the 2022 National Influenza Vaccination Campaign, the target was for 90% of priority groups to be vaccinated, which included pregnant women due to their higher risk of complications caused by the influenza virus. The use of this vaccine can reduce the burden on health systems and help prevent new outbreaks of respiratory diseases caused by the influenza virus,20 information also confirmed by the California Department of Public Health.10
The incorporation of the dTpa vaccine into the vaccination schedule for pregnant women in 2014 was due to the significant increase in cases of Pertussis in children under one year old, to offer indirect immunity to the newborn. As a result, there was a decrease in Pertussis cases in children. A study showed that, since the vaccine was introduced, there has been a 63.6% reduction in children aged 0 to 2 months and a 26.6% reduction in children aged 3 months to one year.21-22 In both regional health departments evaluated, the dTpa vaccine reached more than 90% of pregnant women.
The NIP includes strategies to ensure that vaccination coverage is maintained, such as setting targets, vaccination campaigns, expanding the target population and partnership policies.23 With the current scenario regarding the drop in vaccinations, it is necessary for these measures to be intensified and associated with the role of the nursing professional, who has the opportunity to intervene in the health-disease process by carrying out activities aimed at updating the vaccination card, using effective communication and carrying out health education with the population and team, providing accessible educational material.24 A study carried out in prenatal clinics in Winchester, Virginia and Jacksonville, Florida, showed that black pregnant women with lower educational levels received less information about vaccines and, consequently, were less likely to receive immunizations.25
In view of the above, vaccination is an important practice for public health, as it helps to reduce morbidity and mortality rates.23 Therefore, treating the vaccination schedule without seriousness can lead to a number of problems, as well as serious public health problems, because it increases the risk of the population acquiring vaccine-preventable diseases and new epidemics emerging.26
Brazil is among the countries most affected by the COVID-19 pandemic.27 In epidemiological week 46, the period of data collection for this study, the countries with the highest number of cumulative deaths were the United States, with 771,013 recorded deaths, followed by Brazil, with 612,587.28 Although the most critical scenario of the pandemic has passed, new cases and deaths from the disease are still being recorded. In the Coronavirus Epidemiological Report for the state of Paraná, between April 17 and 24, 2023 there were 2,097 new reported cases of the disease and 53 deaths.29
Another aspect observed is the integration between regional health departments and the importance of keeping targets and actions aligned to achieve higher immunization rates throughout the population, specifically among pregnant women, in order to reduce maternal and infant morbidity and mortality rates.
The limitations of this study are the unprecedented nature of the topic due to the recent pandemic, and the need to investigate the reasons why pregnant women do not get vaccinated in order to propose effective strategies to improve vaccination coverage among pregnant women. This research contributes to the knowledge of the vaccination reality of pregnant women in the ninth and tenth regional health departments of the state of Paraná during the pandemic period, to provide support for the elaboration of actions and public policies that promote the improvement of prenatal care, especially in the guidelines regarding the immunization of pregnant women.
Although the results obtained are not unsatisfactory for most immunobiologicals, new strategies, and awareness-raising campaigns are needed to increase the vaccination rate of pregnant women, especially about the COVID-19 vaccine. It is important for health professionals, particularly nurses, to address the issue of immunization during prenatal consultations, as well as to check the Pregnant Women's Handbook for records of vaccinations in order to advise patients on the importance and benefits they bring to both themselves and their children.
References
1. Reis JN, Campos GKP, Rodrigues LA, Rodrigues AFM. Classificação dos fatores que interferem na cobertura vacinal das gestantes de alto risco no Município de Colatina-ES. Braz J Health Rev. 2021;4(1):1440-53. doi: 10.34119/bjhrv4n1-121
2. Vaichulonis CG, Silva RR, Pinto AIA, Cruz IR, Mazzetti AC, Haritsch L, et al. Evaluation of prenatal care according to indicators for the Prenatal and Birth Humanization Program. Rev Bras Saúde Mater Infant. 2021;21(2):441-50. doi: 10.1590/1806-93042021000200006
3. Mascalhusk SC, Teixeira EMB, Ferrari RAP, Santos IDL, Medeiros FF, Cardelli AAM. Qualidade da assistência no pré-natal em um município do norte do Paraná. Enferm Rev [Internet]. 2022;25(2):34-43. [acesso em 2023 abr 16]. Disponível em: http://periodicos.pucminas.br/index.php/enfermagemrevista/article/view/25463/20200
4. Kfouri RA, Martins CMR, Lajos GJ, Giamberardino HIG, Cunha J, Pereira LDC, et al. Imunização na gestação, pré-concepção e puerpério [Internet]. Rio de Janeiro (RS): Sociedade Brasileira de Pediatria; 2020 [acesso em 2023 abr 29]. Disponível em: https://sbim.org.br/images/files/notas-tecnicas/22771e-dt-imunizao-gestaao-pre-concepao-e-puerperio.pdf
5. Godoi APN, Bernardes GCS, Almeida NA, Melo SN, Belo VS, Nogueira LS, et al. Severe Acute Respiratory Syndrome by COVID-19 in pregnant and postpartum women. Rev Bras Saúde Mater Infant. 2021;21(2):461-69. doi: 10.1590/1806-9304202100S200008
6. Ren LL, Wang YM, Wu ZQ, Xiang ZC, Guo L, Xu T, et al. Identification of a novel corona virus causing severe pneumonia in human: a descriptive study. Chin Med J (Engl). 2020;199;1015-24. doi: 10.1097/CM9.0000000000000722
7. Lopes Júnior LC, Souza TM, Sobreira LB, Daleprane CLV, Denadai IR, Martins NB, et al. Análise da cobertura vacinal durante a pandemia de COVID-19 em Vitória, Brasil. J Hum Growth Dev. 2021;31(3):387-397. doi: 10.36311/jhgd.v31.12122
8. Wang X, Yang P, Zheng J, Liu P, Wei C, Guo J, et al. Dynamic changes of acquired maternal SARS-CoV-2 IgG in infants. Sci Rep. 2021;11(1):8021. doi: 10.1038/s41598-021-87535-x
9. Munoz FM, Sheffield JS, Beigi RH, Read JS, Swamy GK, Jevaji I, et al. Research on vaccines during pregnancy: protocol design and assessment of safety. Vaccine. 2013;31(40):4274-79. doi: 10.1016/j.vaccine.2013.07.042
10. Gabutti G, Conforti G, Tomasi A, Kuhdari P, Castiglia P, Prato R, et al. Why, when and for what diseases pregnant and new mothers "should" be vaccinated. Hum Vaccin Immunother. 2017;13(2):283-90. doi: 10.1080/21645515.2017.1264773
11. Louie JK, Salibay CJ, Kang M, Glenn-finer RE, Murray EL, Jamieson DJ. Pregnancy and severe influenza infection in the 2013-2014 influenza season. Obstet Gynecol. 2015;125(1):184-92. doi: 10.1097/AOG.0000000000000593
12. Silva TPR, Gomes CS, Carmo AS, Mendes LL, Rezende EM, Velasquez-Melendez G, et al. Análise espacial da vacinação contra hepatite B em gestantes em área urbana no Brasil. Ciênc Saúde Colet. 2021;26(3):1173-82. doi: 10.1590/1413-81232021263.28262018
13. Ruiz LKFT, Franchi JVO, Colombo NCR, Medeiros FF, Ferrari RAP, Pelloso SM, et al. Assistência pré-natal em serviços públicos de saúde do Estado do Paraná. Res Soc Dev. 2021;10(2):e37010212543. doi: 10.33448/rsd-v10i2.12543
14. Raposo MCM, Moura LS, Lima MS, Freitas MG, Lima JA, Santos TMS, et al. Análise da cobertura vacinal da COVID-19 em gestantes em uma unidade básica de saúde no município de Maceió-AL. Res Soc Dev. 2022;11(15):e369111537481. doi: 10.33448/rsd-v11i15.37481
15. Silva TPR, Vimieiro AM, Gusmão JS, Souza JFA, Lachtim SAF, Vieira EWR, et al. Transmission risk classification for vaccine-preventable diseases in Minas Gerais, Brazil: two years since the onset of the COVID-19 pandemic. Ciênc Saúde Colet. 2023;28(3):699-710. doi: 10.1590/1413-81232023283.11192022
16. Goncu Ayhan S, Oluklu D, Atalay A, Menekse Beser D, Tanacan A, Moraloglu Tekin O, et al. COVID-19 vaccine acceptance in pregnant women. Int J Gynaecol Obstet. 2021;154(2):291-6. doi: 10.1002/ijgo.13713
17. Rawal S, Tackett RL, Stone RH, Young HN. COVID-19 vaccination among pregnant people in the United States: a systematic review. Am J Obstet Gynecol MFM. 2022;4(4):100616. doi: 10.1016/j.ajogmf.2022.100616
18. Tatarević T, Tkalčec I, Stranić D, Tešović G, Matijević R. Knowledge and attitudes of pregnant women on maternal immunization against COVID-19 in Croatia. J Perinat Med. 2022;51(3):317-23. doi: 10.1515/jpm-2022-0171
19. Oliveira SC, Silva TPP, Silva TPR, Velasquez-Melendez G, Mendes LL, Martins EF, et al. Social and obstetric inequalities and vaccination in pregnant women. Rev Bras Enferm. 2020;73(4):e20190099. doi: 10.1590/0034-7167-2019-0099
20. Ministério da Saúde (BR). Informe Técnico. 24ª Campanha Nacional de Vacinação contra a Influenza (Versão Atualizada) [Internet]. Brasília (DF): Ministério da Saúde; 2022 [acesso em 2023 abr 10]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z/c/calendario-nacional-de-vacinacao/arquivos/informe-da-24a-campanha-nacional-de-vacinacao-contra-a-influenza.pdf
21. Santos PAN, Porto BM, Almeida CTC, Cavalcante MIA, Montenegro MA, Alves JAG. A DTPA vaccination in pregnant women and pertussis cases in Brazil: a 6-year analysis. Braz J Develop. 2022;8(7):53089-98. doi: 10.34117/bjdv8n7-295
22. Machado LZ, Marcon CEM. Incidência de coqueluche em crianças menores de 1 ano e relação com a vacinação materna no Brasil, 2008 a 2018. Epidemiol Serv Saúde. 2022;31(1):e2021625. doi: 10.1590/S1679-49742022000100029
23. Corrêa SMC, Vasconcelos PF, Passos JS, Marques VG, Tanajura NPM, Nascimento DR, et al. As possíveis causas da não adesão à imunização no Brasil: uma revisão de literatura. Rev Eletrônica Acervo Saúde. 2021;13(4):2178-091. doi: 10.25248/reas.e7030.2021
24. Teixeira VB, Abreu HSC, Silva HCDA, Messias CM, Barboza BFS, Silva MRB. Os desafios do profissional de enfermagem para uma cobertura vacinal eficaz [Internet]. Nursing. 2019 [cited 2023 May 01];22(251):2862-7. Available from: https://revistanursing.com.br/index.php/revistanursing/article/view/283/267
25. Callahan AG, Strassberg ER, Rhoades CP, Varghese L, Schulkin J, Power ML. Pregnant women's opinions and acceptance of influenza and Tdap vaccines. J Womens Health (Larchmt). 2022;31(5):656-64. doi: 10.1089/jwh.2021.0365
26. Martins KM, Santos WLS, Álvares ACM. The importance of immunization: integrative review. Rev Iniciaç Cient Ex [Internet]. 2018 [acesso em 2023 abr 30];2(2):96-101. Disponível em: https://revistasfacesa.senaaires.com.br/index.php/iniciacao-cientifica/article/view/153/108
27. Muraro AP, Rocha R, Boing AC, Oliveira LR, Melanda FN, Andrade ACS. Óbitos por condições de saúde posteriores à COVID-19 no Brasil. Ciênc Saúde Colet. 2023;28(2):331-6. doi: 10.1590/1413-81232023282.16752022
28. Ministério da Saúde (BR). Boletim Epidemiológico especial: COVID-19 [Internet]. Brasília (DF): Ministério da Saúde; 2017 [acesso em 2023 dez 06]. Disponível em: https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/boletins/epidemiologicos/covid-19/2021/boletim_epidemiologico_covid_90_30nov21_eapv5.pdf
29. Secretaria de Saúde do Estado do Paraná. Boletim - Informe Epidemiológico Coronavírus [Internet]. Brasília (DF): Secretaria de Saúde do Estado do Paraná; 2023 [acesso em 2023 abr 30]. Disponível em: https://www.saude.pr.gov.br/Pagina/Coronavirus-COVID-19
Funding: to the Research for the SUS Program: Shared Health Management - PPSUS Edition 2020/2021, for funding the research.
Authorship contributions
1 – Gabriela Gomes Espindola
Corresponding author
Nurse – gabrielagespindola@gmail.com
Conception, development of the research and writing of the manuscript
2 – Katherine Slowinski Knapp
Nurse – katherinesknapp11@gmail.com
Conception, development of the research and writing of the manuscript
3 – Maria Aparecida Baggio
Nurse, PhD – mariabaggio@yahoo.com.br
Review and approval of the final version
4 – Helder Ferreira
Nurse, PhD - heelfer@gmail.com
Review and approval of the final version
5 – Adriana Zilly
Nurse, PhD – aazilly@hotmail.com
Review and approval of the final version
6 – Rosane Meire Munhak da Silva
Nurse, PhD – zanem2010@hotmail.com
Conception, development of the research and writing of the manuscript
Scientific Editor in Chief: Cristiane Cardoso de Paula
Associate Editor: Graciela Dutra Sehnem
How to cite this article
Espindola GG, Knapp KS, Baggio MA, Ferreira H, Zilly A, Silva RMM. Immunization of pregnant women in times of the COVID-19 pandemic. Rev. Enferm. UFSM. 2024 [Access on: Year Month Day]; vol.14, e5:1-19. DOI: https://doi.org/10.5902/2179769283758