Identifying Barriers to Vaccination

ACOG has piloted a maternal influenza review program (MIRP) in four states, using a retrospective review of pregnant women hospitalized with influenza during the 2012-2013 influenza season.

This review utilizes the Fetal and Infant Mortality Review (FIMR) methodology developed by the National Fetal and Infant Mortality Review (NFIMR) program, a partnership between ACOG and the Maternal and Child Health Bureau (MCHB). ACOG worked on this project in collaboration with the Association of State and Territorial Health Officers (ASTHO), the Centers for Disease Control and Prevention (CDC), and NFIMR.

Qualified state health department staff carried out the protocol of the project in each state. The pilot project was conducted in Colorado, Minnesota, New York, and Rhode Island. 

The pilot program identified potentially preventable issues and barriers (e.g. system failures, vaccine hesitancy, patient concerns around vaccine safety) that contribute to morbidity and mortality in pregnant women caused by seasonal influenza. The goal of the project was for these reviews to lead to improved general health for childbearing women and their infants and development of local and national policies and program service systems to increase influenza vaccination coverage among pregnant women.

The protocol for the project is based on five pillars:

  • Case Identification
  • Data Abstraction
  • Maternal Interview
  • Case Review and Community Action Teams

Findings and Recommendations for Systems Improvement


Through its Maternal Influenza Review Program, ACOG has summarized key findings and recommendations from the four states’ reviews that resonated among the state reports. ACOG also collected from the states the number of cases of pregnant women hospitalized with influenza illness who were vaccinated and who were not. Most hospitalized pregnant women were vaccinated against influenza prior to hospitalization as identified by self-report, maternal interviews and record abstraction.

States Participating CRT Cases Reviewed Vaccinated* Unvaccinated Unknown 
4 58 41 16  1


Common Findings

Systems Level

  • Inconsistent documentation of immunization recommendations
  • Lack of consistency among providers with regard to infection control regulations in labor and delivery units
  • Many ob-gyns do not offer influenza vaccine in their offices, instead referring patients elsewhere which increases the risk of women going unvaccinated. Patients trust their ob-gyn, and ob-gyns need to start recommending and offering influenza vaccine
  • Inability of family members to get vaccinated due to insurance coverage issues or provider’s inability to vaccinate family (i.e., ob-gyn not being able to vaccinate a father, or a pediatrician not being able to vaccinate a parent)
  • Immunizations need to be further integrated into electronic medical records and tailored for ob-gyn providers
  • Adult immunization registries are underused but may be a good way to document and track immunization records


  • Reasons why patients are not vaccinated need to be explored
  • Concerns over vaccine safety among patients need to be addressed
  • Misconceptions about influenza vaccine need to be debunked. i.e., “the flu vaccine isn’t effective” or “the flu vaccine will make me sick”

*Note: Some of the cases are self-reported, are based on chart review and not laboratory confirmation, and lack information on timing of vaccination during pregnancy and circumstances leading to hospitalization and illness outcomes. The cases need to be considered with how many pregnant women were hospitalized with influenza during the 2012-2013 influenza season in the state. Information in this report suggests that a portion of women who were hospitalized were in fact immunized with influenza vaccine earlier in the season. This finding is not totally unexpected given current influenza vaccine effectiveness, and deserves further investigation.  Importantly, the key clinical message is that women who present with signs and symptoms suggestive of influenza and who report a history of earlier receipt of influenza vaccine should still be managed as if they have influenza until confirmatory testing is completed.  This includes, but is not limited to, use of antivirals and compliance with local Infection Control practices. Population-based literature exists for this purpose, and information collected about individual cases may not fill requirements necessary to contribute to this scientific knowledge base. Influenza after vaccination is not unexpected. But vaccination is thought to decrease the risk of Intensive Care Unit admission and death as compared to those who are unvaccinated on a population level. It is possible that some of these unvaccinated pregnant women were sicker than those who were vaccinated.

Messaging should focus on the increased risk of severe illness and complications during pregnancy:

  • Providers need to take time to discuss influenza vaccine with their patients and if patients decline, need to have the conversation at each subsequent visit.
  • Lack of education of urgent care center and emergency room staff on the assessment and treatment of pregnant women presenting with influenza-like illness.This includes differentiating between normal side effects of pregnancy and symptoms of influenza.

Recommendations to address common findings include:

  • Further training of providers to better identify influenza among pregnant women and how the cases were confirmed
  • Educate patients on the risks of influenza during pregnancy, risk reduction, and provide a strong recommendation for vaccination
  • Examine the differences between patients who have been vaccinated and those who have not to better understand the success of many vaccination programs
  • Educate urgent care clinics on how to manage pregnant patients with flu-like symptoms and to understand the guidelines for administering antiviral medication to pregnant women
  • Need for better integration of care between primary care, ob-gyn, and hospital
  • Additional patient education needed for those refusing to be vaccinated. There is a need for providers to also educate patients about risks of not getting immunized
  • Educate patient about limiting her contact with those sick or not vaccinated
  • Provide more options for free flu vaccines for pregnant women and their partners who may not have insurance

Additional Information

Tool Kit for State and Local Health Departments

The Maternal Influenza Review Program, A Tool Kit for State and Local Health Departments (2016) provides more information about the project, results, and details the pilot project so that it can be replicated. The tool kit provides a strategy that NFIMR can offer to any state that wishes to review maternal hospitalizations for influenza and potential strategies to increase influenza vaccination coverage for pregnant women.

Please visit the FIMR/HIV website for more information.


1. Centers for Disease Control and Prevention (CDC). Influenza vaccination coverage among pregnant women: 2011-12 influenza season, United States. MMWR Morb Mortal Wkly Rep 2012; 61:758.
2. Håberg SE, Trogstad L, Gunnes N, et al. Risk of fetal death after pandemic influenza virus infection or vaccination. N Engl J Med 2013; 368:333.
3. Omer SB, Goodman D, Steinhoff MC, et al. Maternal influenza immunization and reduced likelihood of prematurity and small for gestational age births: a retrospective cohort study. PLoS Med 2011; 8:e1000441.
This project is made possible by cooperative agreement number 1U38OT000161 from the Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Health Officials (ASTHO).  Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC or ASTHO.