Maternal Immunization in Malawi: A Mixed Methods Study of Community Perceptions, Programmatic Considerations, and Recommendations for Future Planning

In general, maternal immunisation in low- and middle-income countries (LMICs) remains low. One exception is the uptake of tetanus toxoid-containing vaccine (TTV) in Malawi, where the 2015-16 demographic health survey reports 73% of women received 2 or more doses of TTV in their last pregnancy. PATH and the University of Malawi's Centre for Social Research conducted a mixed-methods study in 2015 to document community perceptions of maternal immunisation, using tetanus vaccine as an example, and to identify factors perceived to be important to successfully introducing other maternal vaccines, such as influenza vaccine, in Malawi.

The researchers carried out this study among 274 participants in Rumphi (Northern Region), Dowa (Central Region), and Zomba (Southern Region), selecting 2 health facilities and their surrounding catchment areas in each district to represent a mix of rural, peri-urban, and urban populations. They conducted 18 focus group discussions (FDGs) with pregnant and recently pregnant women and their family members and 76 semi-structured interviews with pregnant and recently pregnant women, community leaders, health workers, public health programme managers, non-governmental partners, and policymakers.

Key findings:

• Community knowledge of disease transmission and prevention: In all focus groups, there was a general understanding that tetanus vaccines can protect both a mother and her infant from disease. There is no direct translation of the word "influenza" in either of the study areas' primary local languages; however, recognition of "flu" was widely expressed by focus group participants after the term was introduced by facilitators.
• Community acceptance of maternal immunisation: Citing their experience and knowledge of tetanus and TTV, pregnant women expressed an overall positive view of maternal immunisation. Despite general acceptance, some pregnant women described experiencing an adverse event following prior immunisations (a sore arm, swollen hands) and questioned whether symptoms would be more severe if 2 vaccines were given at the same time. When asked to identify concerns around vaccines administered to pregnant women, male and female family members, health workers, and managers suggested that new vaccines could be misperceived as contraceptives or may cause an abortion.
• Health care decision-making and support for pregnant women: In individual interviews, 46% of pregnant women identified community health workers as their main source of information on whether to receive vaccines, followed by friends or neighbours (34%) and doctors or nurses (29%). During FGDs with pregnant women, community leaders were also identified as important advisors for health care, and radio and newspapers were cited as sources of healthcare information. It was commonly expected that a pregnant woman would have a discussion with her husband or male partner, or inform him of her intent to seek care, rather than formally request permission to get vaccinated.
• Facilitators and challenges to receiving antenatal care (ANC), including maternal vaccines: In response to the question of how health services, including immunisation services for pregnant women, could be improved, family members across sites cited more respectful health providers and provision of clear information on the relevant diseases and the purpose of the vaccines, including their positive and negative attributes. Three non-users of immunisation services attributed their non-use to membership in a religious group that they reported does not allow members to receive medical care from health facilities.
• Perceptions of programmatic and operational factors important to maternal immunisation: Healthcare workers explained that they require women to receive TTV before they are offered any other ANC services, describing this as a key factor in promoting high immunisation coverage. Pregnant women and male and female family members described community efforts to increase coverage of health services for pregnant women, including local laws requiring tetanus vaccination, ANC attendance, and delivery in a health facility. In discussions about the feasibility of adding a new vaccine to current vaccination coverage tracking systems, health workers and managers explained that while vaccination coverage is currently documented at the level of the community and health facility, information is not shared between healthcare sites, making it difficult to track vaccination status if a woman visits multiple health facilities during her pregnancy.
• Selected recommendations for country-level maternal immunisation planning mentioned by study participants:
  • Intensify education and social mobilisation for community members, which is linked to increased vaccine acceptance and minimised misperceptions of vaccines; education about seasonal influenza disease and the specific vaccine introduced was characterises as particularly important. However, a recurrent theme expressed by health workers was concern that sensitising and educating the community about a new vaccine could lead to an increased workload for them.
  • Advocate the benefit of the influenza vaccine to both the pregnant woman and her infant, instead of prioritising one beneficiary over the other.
  • Use simple, direct communication messages, though it could be difficult to translate more complex, nuanced messages into local languages.
  • Provide clear information on the side effects of any new maternal vaccine, including about the safety of concomitant administration of any new vaccine with TTV.

In short, this study unearthed several factors that could support the successful expansion of maternal immunisation in Malawi, including high health worker acceptance and community trust in vaccines in the study districts, including vaccines administered in pregnancy. With regard to influenza disease specifically, however, the researchers found limited awareness and low priority of its prevention by pregnant women and health workers, indicating a strong need for communication sensitisation. This could help dispel misconceptions, reduce vaccine resistance based on misinformation, and be an avenue to support women who fear pain from injections. Further engagement of social networks and family members, including men, may be a useful strategy for gaining support for ANC attendance and vaccination during pregnancy. In the Malawi context specifically, it could be advantageous to engage certain faith communities. Hesitancy to receive vaccinations and other health services may be higher among certain social or ethnic groups and may need to be addressed with targeted advocacy efforts.

In addition to community education, the researchers indicate that generating buy-in of key decision makers in Malawi will be valuable to the introduction of new maternal vaccines, but may be challenging for influenza given its currently low perceived priority compared to other diseases such as malaria and HIV.

Furthermore, they suggest, as new vaccines are developed specifically for use in pregnant women, safety monitoring will be important for vaccine decision-making, introduction, and confidence. Since adverse events occur in pregnancy that are unrelated to vaccination, systematic monitoring of pregnancy outcomes will be needed before new maternal vaccines are introduced in LMICs to provide baseline data on adverse events and to allow for accurate causality assessments.

"Results of this study have been shared with Malawi's Ministry of Health and can help inform both future vaccine introduction in Malawi and efforts to introduce new maternal vaccines or increase vaccination coverage in other LMICs."