{"@context":{"@language":"en","Affiliation":"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool","AggregatedSourceRepository":"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider","Citation":"https:\/\/open.library.ubc.ca\/terms#identifierCitation","Contributor":"http:\/\/purl.org\/dc\/terms\/contributor","CopyrightHolder":"https:\/\/open.library.ubc.ca\/terms#rightsCopyright","Creator":"http:\/\/purl.org\/dc\/terms\/creator","DateAvailable":"http:\/\/purl.org\/dc\/terms\/issued","DateIssued":"http:\/\/purl.org\/dc\/terms\/issued","Description":"http:\/\/purl.org\/dc\/terms\/description","DigitalResourceOriginalRecord":"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO","FullText":"http:\/\/www.w3.org\/2009\/08\/skos-reference\/skos.html#note","Genre":"http:\/\/www.europeana.eu\/schemas\/edm\/hasType","IsShownAt":"http:\/\/www.europeana.eu\/schemas\/edm\/isShownAt","Language":"http:\/\/purl.org\/dc\/terms\/language","PeerReviewStatus":"https:\/\/open.library.ubc.ca\/terms#peerReviewStatus","Provider":"http:\/\/www.europeana.eu\/schemas\/edm\/provider","Publisher":"http:\/\/purl.org\/dc\/terms\/publisher","PublisherDOI":"https:\/\/open.library.ubc.ca\/terms#publisherDOI","Rights":"http:\/\/purl.org\/dc\/terms\/rights","RightsURI":"https:\/\/open.library.ubc.ca\/terms#rightsURI","ScholarlyLevel":"https:\/\/open.library.ubc.ca\/terms#scholarLevel","Subject":"http:\/\/purl.org\/dc\/terms\/subject","Title":"http:\/\/purl.org\/dc\/terms\/title","Type":"http:\/\/purl.org\/dc\/terms\/type","URI":"https:\/\/open.library.ubc.ca\/terms#identifierURI","SortDate":"http:\/\/purl.org\/dc\/terms\/date"},"Affiliation":[{"@value":"Other UBC","@language":"en"},{"@value":"Non UBC","@language":"en"}],"AggregatedSourceRepository":[{"@value":"DSpace","@language":"en"}],"Citation":[{"@value":"BMC Public Health. 2022 Feb 05;22(1):237","@language":"en"}],"Contributor":[{"@value":"Children's Hospital (Vancouver, B.C.). Vaccine Evaluation Center","@language":"en"},{"@value":"Children's Hospital (Vancouver, B.C.). Research Institute","@language":"en"}],"CopyrightHolder":[{"@value":"The Author(s)","@language":"en"}],"Creator":[{"@value":"Rubincam, Clara","@language":"en"},{"@value":"Greyson, Devon","@language":"en"},{"@value":"Haselden, Constance","@language":"en"},{"@value":"Saunders, Robin","@language":"en"},{"@value":"Bettinger, Julie A.","@language":"en"}],"DateAvailable":[{"@value":"2022-02-23T15:46:18Z","@language":"en"}],"DateIssued":[{"@value":"2022-02-05","@language":"en"}],"Description":[{"@value":"Background\r\n                Growing evidence shows that many parents begin the decision-making process about infant vaccination during pregnancy and these decisions \u2013 once established \u2013 may be resistant to change. Despite this, many interventions targeting vaccination are focused on communicating with parents after their baby is born. This suggests that the prenatal period may constitute a missed opportunity for communicating with expectant parents about infant vaccination.\r\n              \r\n              \r\n                Methods\r\n                Using a longitudinal qualitative design, we conducted two interviews (prepartum and postpartum) with women (n\u2009=\u200919) to explore the optimal timing of vaccination information. The data were analyzed thematically, and examined across all sets of pre- and post-partum interviews as well as within each individual participant to draw out salient themes.\r\n              \r\n              \r\n                Results\r\n                Most participants formed their intentions to vaccinate before the baby was born and indicated that they would welcome information about vaccination from their maternity care providers. However, few individuals recalled their maternity care providers initiating vaccination-related conversations with them.\r\n              \r\n              \r\n                Conclusion\r\n                The prenatal period is an important time to begin conversations with expectant parents about vaccinating their infants, particularly if these conversations are initiated by trusted maternity care providers. More information is needed on how maternity care providers can be better supported to have these conversations with their patients.","@language":"en"}],"DigitalResourceOriginalRecord":[{"@value":"https:\/\/circle.library.ubc.ca\/rest\/handle\/2429\/80864?expand=metadata","@language":"en"}],"FullText":[{"@value":"Rubincam\u00a0et\u00a0al. BMC Public Health          (2022) 22:237  https:\/\/doi.org\/10.1186\/s12889-022-12658-3RESEARCHIs the\u00a0pre-natal period a\u00a0missed opportunity for\u00a0communicating with\u00a0parents about\u00a0immunizations? Evidence from\u00a0a\u00a0longitudinal qualitative study in\u00a0Victoria, British ColumbiaClara Rubincam1,2, Devon Greyson3,4, Constance Haselden1, Robin Saunders5 and Julie A. Bettinger2* Abstract Background: Growing evidence shows that many parents begin the decision-making process about infant vac-cination during pregnancy and these decisions \u2013 once established \u2013 may be resistant to change. Despite this, many interventions targeting vaccination are focused on communicating with parents after their baby is born. This suggests that the prenatal period may constitute a missed opportunity for communicating with expectant parents about infant vaccination.Methods: Using a longitudinal qualitative design, we conducted two interviews (prepartum and postpartum) with women (n = 19) to explore the optimal timing of vaccination information. The data were analyzed thematically, and examined across all sets of pre- and post-partum interviews as well as within each individual participant to draw out salient themes.Results: Most participants formed their intentions to vaccinate before the baby was born and indicated that they would welcome information about vaccination from their maternity care providers. However, few individuals recalled their maternity care providers initiating vaccination-related conversations with them.Conclusion: The prenatal period is an important time to begin conversations with expectant parents about vaccinat-ing their infants, particularly if these conversations are initiated by trusted maternity care providers. More information is needed on how maternity care providers can be better supported to have these conversations with their patients.Keywords: Vaccine, Vaccination, Parent, Decision-making, Interviews, Health care provider, Midwives, Doctors\u00a9 The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article\u2019s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article\u2019s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:\/\/ creat iveco mmons. org\/ licen ses\/ by\/4. 0\/. The Creative Commons Public Domain Dedication waiver (http:\/\/ creat iveco mmons. org\/ publi cdoma in\/ zero\/1. 0\/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.BackgroundVaccines are an effective public health intervention to combat a variety of communicable diseases [1], yet pedi-atric immunization rates remain suboptimal in Canada [2], especially in the province of British Columbia (BC) [3\u20136]. These low immunization rates are often attrib-uted to parental distrust or suspicion about the safety of vaccines [7]. Beyond the estimated 12% of parents who refuse all or some of the recommended vaccines, a recent Canada-wide survey indicated that even among parents who accepted all recommended vaccines, 40% reported \u201cdoubts and concerns with vaccinating my child\u201d [6]. Moreover, respondents from British Columbia Open Access*Correspondence:  jbettinger@bcchr.ubc.ca2 Vaccine Evaluation Center, BC Children\u2019s Hospital Research Institute, University of British Columbia, A5-950 West 28th Street, Vancouver, BC V5Z 4H4, CanadaFull list of author information is available at the end of the articlePage 2 of 10Rubincam\u00a0et\u00a0al. BMC Public Health          (2022) 22:237 were more likely to refuse all vaccines compared to the national average [6].Growing evidence shows that many women begin the decision-making process about infant vaccination during pregnancy [6, 8\u201313] and these decisions \u2013 once estab-lished \u2013 may be resistant to change [14]. Existing stud-ies have documented key concerns about vaccination among pregnant women [15, 16] and new parents [17\u201319] that required skilled communication and thought-fully disseminated information from trusted health care sources. Despite the evidence on the importance of the pre-natal period as a decision-making time, interven-tions to address vaccination concerns largely center on doctor-parent communication post-childbirth [20\u201322]. As a result, the pre-natal period may be an underutilized opportunity for initiating communication about vaccina-tions [23]. Few studies, to date, have examined the evo-lution of beliefs and practices about vaccination during pregnancy and through the child\u2019s first months of life [14, 24, 25]. To our knowledge, none have been conducted in British Columbia.To explore the potential for vaccination communica-tion prenatally, this study examined women\u2019s decision-making processes about pediatric vaccinations during two distinct time periods: the third trimester of preg-nancy and 4-6 months after birth, in order to explore the optimal time to provide parents with information about infant vaccines, and identify mothers\u2019 perceptions of the ideal source of information about immunizations.MethodsThis longitudinal qualitative study [26, 27] recruited English-speaking participants through maternity care providers (physicians and midwives), complementary and alternative health care providers (acupuncturists and naturopaths), and pre-natal classes offered through a regional health authority, a local college, and a parenting resource center in Victoria, British Columbia, Canada. Women choosing midwifery care as well as those under physician care were deliberately sought, as some studies have found that mothers with midwifery-assisted birth are more likely to delay vaccinations, vaccinate selec-tively, or not vaccinate at all [19, 24, 28].\u00a0 The model of maternity care differs for each patient in British Colum-bia, but in general, a woman receives maternity care from either a midwife, a specialist obstetrician\/gynecolo-gist, or a family physician with a maternity practice. This may be in addition to a relationship with a regular fam-ily physician, though an increasing number of patients are \u201cunattached\u201d, meaning they do not have a regular family physician to provide longitudinal care outside of maternity care. In British Columbia, longitudinal health care providers (family doctors) typically provide care to infants and young children, and therefore could be the providers of vaccinations.An exploratory and descriptive model was used for this study as the main purpose was to better understand the decision-making processes of expectant and new moth-ers [29, 30]. Purposive sampling was used to ensure diverse views on child vaccination intentions and beliefs by recruiting pregnant women and using a preliminary screening question,\u201cWhat would you say is your overall perspective on children\u2019s vaccinations?\u201d [31]. Participants were not screened for ethnocultural or income diversity. A related arm of this research project involved speak-ing with some of the co-parents of participants; these data indicated the vast majority of vaccination decisions were made by the mothers (as all partnerships were male-female). As a result, the data from fathers were not considered to be salient to the current analysis and were excluded from this in-depth exploration of mothers\u2019 deci-sion-making processes.Data collectionThe first round of individual interviews began in Octo-ber 2015 and the final interviews of the second round were completed in November 2016. Both the first and second interviews were semi-structured and iterative in nature, which enabled the interview guide to be adjusted in response to emerging lines of inquiry throughout data collection. Interviews ranged in length from 30 to 90 min and were audio-recorded. The first interviews, completed during the third trimester of pregnancy, sought to estab-lish mothers\u2019 beliefs and intentions regarding vaccination. All first interviews were conducted in person, either at the interviewee\u2019s home or in the offices of the local pub-lic health unit or the prenatal and postpartum resource center from where they were recruited. The second inter-views occurred 4-6 months after birth and followed up on mothers\u2019 beliefs and practices regarding vaccination, with particular attention to how these may have evolved or solidified since the first interview [10], whether moth-ers had initiated 2- and 4-month vaccinations, and their intentions towards subsequent vaccinations.1 The second interview was either in person at the interviewee\u2019s home or over the phone, depending on interviewee preference. The interviewer was one of the co-authors of the study, a university-affiliated researcher. For a portion of the interviews, the interviewer was pregnant, a fact known to participants. The study was approved by the Univer-sity of British Columbia Children\u2019s and Women\u2019s Health 1 Each province in Canada determines their own vaccination schedule. The schedule in British Columbia involves vaccines at 2- (DtaP-HB-IPV-Hib, Men-C, PCV13, and RotaTeq), 4- (DtaP-HB-IPV-Hib, PCV13, and RotaTeq), 6 months (DtaP-HB-IPV-Hib, and RotaTeq).Page 3 of 10Rubincam\u00a0et\u00a0al. BMC Public Health          (2022) 22:237  Centre of British Columbia Research Ethics Board (H15-01709). Participants provided written informed consent, and received a $25 gift card for a local grocery store as compensation for their time after each interview.Recruitment, data collection, and data analysis for the first round of interviews were conducted until data sat-uration was achieved, defined as when no new themes emerged after 3 successive interviews [32\u201334]. We miti-gated attrition between study waves by conducting most interviews on site (e.g. at expectant and new mothers\u2019 homes) or at the local pregnancy and birth resource center, and no participants were lost to follow up.AnalysisDuring analysis and write-up, participants were assigned letter codes to further protect their identities and privacy, and all identifying information was redacted from tran-scripts. Transcripts were inductively coded using NVivo 11 (released in 2015) by one author into main themes and sub-themes. This thematic analysis assigned preliminary codes to the data to describe the content (for example: \u2018trust in maternity care provider\u2019) [30, 35]. This was fol-lowed by identifying and discussing patterns of themes with the larger study team [36]. Initial analysis proceeded cross-sectionally, enabling exploration of emerging themes as the prenatal interviews were being completed. Once both interviews were complete, analysis was con-ducted longitudinally, by reading the first and second interview transcripts for each participant together as a single case. This enabled exploration of how each mother described the evolution of her vaccination decision making over time, and ultimately yielded the dominant themes of the optimal timing of and source of informa-tion about infant vaccinations, which are described in this paper.ResultsA total of 19 English-speaking mothers participated in the first and second round of interviews, with no attrition between interview waves. Participants reported a variety of socio-economic backgrounds and ages (see Table\u00a0 1), although those with higher educational outcomes and higher household incomes were disproportionately rep-resented. The majority (84%) were first-time mothers, in part due to the fact that multiparous women may have less time for research. Eleven participants (58%) were in the care of midwives. This represents an oversampling of this population as approximately 20% of pregnant women in BC are in the care of midwives, and 15% of women have a midwifery-attended birth. Overall, the sample dis-proportionately represents English-speaking first-time mothers with higher household incomes, higher educa-tional attainment, and under midwifery care.Through these interviews, certain common themes emerged about when participants formed their inten-tions to vaccinate, who they trusted to inform this deci-sion, and when they would have preferred to receive information about vaccination. The majority of partici-pants formed their intentions to vaccinate during the prenatal phase, although few recalled receiving formal guidance from their health care provider (HCP) about this decision. They described the quality of their rela-tionships with their prenatal and postnatal care pro-viders in terms of the level of trust they placed in the health information they provided. Participants\u2019 narra-tives indicated the prenatal period was the optimal time for vaccination information delivery, and that prenatal care providers were the optimal sources of information about vaccination.Table 1 Characteristics of Study Participants (N = 19)n (%)Household Income Less than $50,000 4 (21.05%) Between $50,000-$100,000 7 (36.84%) More than $100,000 7 (36.84%) Opted to skip the question 1 (5.26%)Education Certificate\/Diploma 4 (21.05%) Bachelors Degree 11 (57.5%) Masters Degree 3 (15.79%) PhD or above 1 (5.26%)Marital Status Married 14 (73.68%) Common law 5 (26.32%)Employment Status Employed full time 15 (78.95%) Unemployed 3 (15.79%) Homemaker 1 (5.26%)Maternity care provider Midwife 11 (57.5%) Family Doctor (providing both primary and mater-nity care)1 (5.26%) Family Doctor (providing maternity care only) 5 (26.32%) Obstetrician\/Gynecologist 2 (10.53%)Number of children First time mother 16 (84.21%) Has previous children 3 (15.79%)Longitudinal care Yes \u2013 has regular family doctor 16 (84.21%) No \u2013 does not have regular family doctor 3 (15.79%)Age Mean 33 (range 24-38)Page 4 of 10Rubincam\u00a0et\u00a0al. BMC Public Health          (2022) 22:237 Prenatal intentions to\u00a0vaccinateAt the time of the first interview (third trimester of pregnancy), most participants (n = 15) had formed their vaccination intentions. No noticeable differences were observed in this regard between primiparous and mul-tiparous participants. Asked about her intentions, one second time mother stated, \u201cOh we\u2019re definitely going to vaccinate. I vaccinated my daughter\u201d (Participant L, Pre-natal interview2). Another participant explained, \u201cWe will be vaccinating?... Probably the full schedule\u201d. (PQ, Pre). A first-time mother stated her comfort with follow-ing the official guidelines, saying, \u201cI\u2019m happy to go with just what is the standard practice\u201d (PF, Pre).Four participants \u2013 all first-time mothers who had reported higher levels of doubt or concern around vac-cines\u2014had not formed a clear intention regarding vac-cination at the time of the prenatal interview. These women spoke about the need for more information, to do their own research, to speak with a trusted health care professional, and to give the decision about vaccination more thought. One first time mother explained:I think, I mean I think it\u2019s something that we\u2019ll look into, but again, I don\u2019t know much about it for babies, and I don\u2019t know the timing and when any-thing actually happens, so it\u2019s probably just some-thing that we\u2019ll have to talk about more. Learn more about with the doctor and stuff when we get there [PB, Pre).Referring to a family member who had previously had an unexpected reaction following vaccination, one par-ticipant responded to the question about intentions regarding vaccination:P: Um, if I had to say right now I\u2019d say probably selectively.I: Mhmm.P: Um, maybe delayed if our son had a poor reaction like my brother did(PO, Pre).Another refused to answer definitively, saying \u201cI\u2019m not claiming that we\u2019re not going to vaccinate and I\u2019m not claiming that we are\u201d (PI, Pre).One participant was reserving her final decision about whether to administer the full infant vaccination sched-ule or a selective approach until she had confirmation from her family doctor:P: I don\u2019t know enough.I: Yeah. So you\u2019re sort of waiting for the recommen-dation from your doctor to make that decision?P: Yeah (PB, Pre).In review, the dominant theme in this population was to have already decided to follow the vaccine schedule while participants were still pregnant. Notably those who were undecided on whether or not to follow the sched-ule indicated they were awaiting a further conversation with their health care providers, in the hopes to clarifying some areas of concern including side-effects and adverse reactions.Conversations with\u00a0maternity care providers about\u00a0vaccinationAlthough most participants had established intentions regarding vaccination by the final trimester of the pre-natal period, few recalled their maternity care providers initiating any substantial communication about infant vaccination, although they did recall conversations about other newborn interventions such as vitamin K injec-tion and vitamin D supplementation. This indicates that many participants felt they had formed their intentions independently of the advice or consultation of their maternity health care professional. We did not observe any differences in this regard between first time mothers and mothers with other children, or among participants whose maternity care providers were midwives, family physicians, or obstetricians.Participants under the care of midwives were almost unanimous when asked whether they had spoken with them about vaccination during the prenatal phase:P: Ummmmm, not really. I don\u2019t [pause] think that\u2019s in their scope of practice (PF, Pre, with a midwife providing maternity care).P: She (midwife) said that she\u2019s not really qualified to offer any \u2013 like, they\u2019re not really taught a lot about vaccinations \u2013 they\u2019re taught to \u2013 you know \u2013 the specific ones that might be of interest at certain points in the pregnancy or in the six weeks postna-tal or whatever, but yeah, she said I\u2019ll try to find you some stuff online and then the next time I saw her she said \u2018Well, there\u2019s this one website but it seemed kind of angry\u2019. And I said, \u2018Yeah, I\u2019ve probably found that one\u2019. (PI, Pre, in midwifery care).Asked at the follow-up interview to recall whether her health care provider discussed vaccinations during the pregnancy, this same participant confirmed:P: She did not, not at all. I asked her about them and she was like \u201cI\u2019m sorry I can\u2019t advise you, I don\u2019t know anything\u201d (PI, Post, in midwifery care).2 For the duration of the article, the participant code will be shortened to \u2018PL\u2019, \u2018PQ\u2019, etc. to refer to the participant letter, and \u2018Pre\u2019 or \u2018Post\u2019 to refer to the tim-ing of the interview.Page 5 of 10Rubincam\u00a0et\u00a0al. BMC Public Health          (2022) 22:237  One participant thought these discussions were com-ing in the postnatal phase, stating, \u201cNo they haven\u2019t [ini-tiated this conversation yet]. I suspect she probably will maybe after the birth.\u201d However, after this participant\u2019s delivery, she described being referred to the public health unit rather than having a conversation with her mid-wife, \u201cI think she just said, you know, your vaccinations are being done at the public health unit. I think is pretty much what she said.\u201d (PQ, Post).Although the infant vaccination schedule was not a topic of discussion, participants reported that their maternity care providers spoke with them about other types of early health interventions for their infants:I: Your midwives haven\u2019t talked to you about vacci-nation after the baby\u2019s born?P: No.I: Did they talk to you about Vitamin K?P: Yes, um hum (PB, Pre).When asked if her midwives had raised the topic of infant vaccination yet, one woman responded,Not actually for the baby yet except they said--it is Vitamin K shot right at the beginning--so that\u2019s not really vaccinations. Um, so we haven\u2019t really dis-cussed those immediate things, which maybe we should have (PJ, Pre).Participants reported the absence of discussions about vaccination across multiple sources of prenatal education:I: Has your maternity doctor talked about vaccines at all with you?P: Uh no.I: And then, the prenatal class here, did they talk about vaccines at all?P: No, it was like labour and delivery class and stuff like that, and like breastfeeding stuff (PC, Pre).Those participants with a primary care family doctor also reported a lack of conversations about vaccination in the prenatal phase. One woman had seen her family doc-tor for her own health issues during the pregnancy and they had discussed seeing each other after the delivery: \u201cUm, but he didn\u2019t mention, you know, \u2018and then we\u2019ll talk about the vaccination schedule\u2019. He didn\u2019t really say any of that\u201d (PF, Pre). This same participant\u2019s midwives did not engage in-depth with the topic of vaccinations either:I: Did your midwives talk to you about vaccination? Either in the \u2013 after I saw you in the prenatal phase, or in the post partum visits?P: Um, I don\u2019t think so. I believe they may have said, like, you should phone them [the public health units] soon to schedule, or something like that\u2026Because they\u2019re kind of behind [overbooked], but I don\u2019t think we really had a conversation about vaccinations (PF, Post).Another participant with a primary care family doctor echoed this sentiment, saying \u201cI don\u2019t think it\u2019s some-thing that\u2019s really come up\u201d. (PG, Post). Some maternity care providers may have avoided the topic with mothers they felt were already decided about vaccination. When asked whether her maternity doctor had spoken with her about infant vaccines, one first time mother reported \u201cNo, \u2018cause he knew that I wanted to give my daughter shots and make sure that she gets them\u201d (PC, Post).A few participants took a more proactive approach to initiating these conversations with their maternity care providers about immunizations. One participant shared that \u201cwe wanted to know what he [maternity doc-tor] would do with his own kids\u201d (PD, Post), and having received a satisfactory answer, proceeded with vaccina-tion herself. However, not all participants reported get-ting satisfactory answers to their questions:I think I asked a little bit \u2013 I actually asked her why Hepatitis B was included [in the infant schedule] and she said she didn\u2019t know. She said her kids were not vaccinated for it, but they were born in Ontario when they were younger and they didn\u2019t do it out there\u2026But yeah, I don\u2019t think we really had a -- my midwife and I did not have a formal discussion about it (PB, Post).In short, though few women reported any discussions about infant vaccines during the prenatal period with their maternity care providers, many wanted such discus-sions to occur.Women\u2019s trust in\u00a0their maternity care providersFor participants who had a regular family doctor before they became pregnant (n = 16), the majority of them were receiving maternity care from a different HCP than the one who provided their longitudinal primary care. As well, a subset of participants (n = 3) did not have a regular family physician before or after their pregnancy. As a result, most participants in this study received their maternity care from someone other than their regular family physician, either because they chose a different model of care (i.e. midwife), or because they did not have a regular family doctor. Participants in this study described the quality of their relationships with their maternity and primary care providers in contrast-ing ways. Most participants reported a relatively strong, trusting relationship with their maternity care providers, Page 6 of 10Rubincam\u00a0et\u00a0al. BMC Public Health          (2022) 22:237 regardless of provider type. One woman, who had chosen a midwifery practice for her care, described the quality of care:I never felt rushed. They were always happy to answer my questions especially in the first trimester when I was vomiting constantly. I was really wor-ried and they were really responsive to emails and\u2014things like that and not that the doctor route neces-sarily would have been that different, I don\u2019t know, but I like the extent of the care I was getting (PM, Pre).Another participant described the aspects of maternity care that were important to her:P: She\u2019s [midwife] very relaxed. She\u2019s very gentle. She\u2019s excellent at explaining her motivations behind decisions.I: Mmm.P: She\u2019s really excellent at making sure that I have all the information I need, and she\u2019s certainly not afraid to bring in other experts when she feels that there\u2019s a need. So yeah, she\u2019s very informed and just I think a really excellent practitioner.(PQ, Pre).A participant with an OBGYN expressed confidence in their care of her uncomplicated pregnancy:I: You feel good about the care, and you feel confi-dent going forward \u2013P: I feel like if something was wrong, he would prob-ably would spend more time with me but there\u2019s no reason to, which is fine (PC, Pre).A patient with a maternity doctor felt confidence in the quality of her care:I feel like she\u2019s really supportive of me and she only does maternity patients so I feel like it\u2019s really focused care (PG, Pre).As a way of illustrating her trust in her provider\u2019s rec-ommendation, one woman explained her plans for the influenza vaccine for herself:P: Well, I\u2019m going to go see my midwife today so I was going to actually ask her today about it [influ-enza vaccine] [laughter].I: Okay, so you\u2019ll sort of see whether she recommends it?P: Yeah.I: Do you feel like that would change your decision around it if she--?P: Yeah, yeah, it probably would \u2018cause I trust what she has to say.I: Mmm, okay, so if she came down strongly in favour that you would do it?P: Yeah (PL, Pre).In contrast to the close, trusting relationships described by participants between themselves and their mater-nity providers, the majority of women did not report a longstanding or overly trusting relationship with their longitudinal HCP. Some women in the sample had only recently secured a spot in a family practice, others had a regular HCP that they were ambivalent about, while oth-ers did not have a regular family doctor and remained largely dependent on the walk-in clinic system for their longitudinal health care needs.Participants described their relationship with their lon-gitudinal HCP in the following terms:P: I have a family doctor. Um\u2026its not anyone that I feel close to at all. I don\u2019t even think she knows I\u2019m pregnant. Yeah. So. [Laughs] (PE, Pre).P: Uh, my previous family doctor just retired so I don\u2019t really know much about him, but I do have a family doctor (PJ, Pre).A common theme was of participants feeling fortunate to have secured a primary care family physician, regard-less of the quality of the relationship. One woman stated, \u201cYes, I\u2019m extremely excited that I actually even have a family doctor to see. \u2018Cause I realize that they can\u2019t turn down pregnant women but when you\u2019re not pregnant anymore, they, like, if you\u2019re just going to see a family doctor, I don\u2019t think they have to keep you around\u201d (PC, Pre).Another participant echoed this sentiment of feeling privileged to have access to longitudinal primary care, saying:P: My family doctor is \u2013 she\u2019s in town though, kind of in this area. So it\u2019s a bit of a drive. I\u2019m debating whether or not to stay with her or to switch \u2013 to try to switch to somebody closer but it\u2019s so hard to get into [a practice]. So I haven\u2019t gone about putting my name on wait lists yet\u201d (PM, Pre).Some participants were unattached \u2013 without a longi-tudinal HCP - in the first interview, and a few remained so in the second. When asked who was looking after her and her baby in the postpartum phase, one woman responded simply, \u201cNo family doctor. They are hard to come by\u201d (PO, Pre).This lack of longitudinal primary care caused some par-ticipants to wonder about where to go for more informa-tion about their baby\u2019s health. One participant without a primary care provider commented:The more I think about it, the more I realize how Page 7 of 10Rubincam\u00a0et\u00a0al. BMC Public Health          (2022) 22:237  much I don\u2019t know. And I don\u2019t actually know where to find that information. And I mean, when you have a child, I\u2019m sure people care a lot more. But even as an adult, I don\u2019t know - there\u2019s a lot I don\u2019t know about vaccinations, so, it will be interesting to, I guess, I don\u2019t know, find some resources for that (PH, Pre).Particularly in contrast to their relationships with their primary care providers, participants\u2019 close and trusting relationships with their maternity care providers under-scores the importance of using this time to initiate and follow-up on conversations about vaccinations with expectant mothers.DiscussionThe majority of participants in this study reported hav-ing formed an intention about infant vaccinations by the time their baby was born. Most planned on vaccinating their infant according to the provincial schedule and without delays. Regardless of whether they were plan-ning to vaccinate or not, some participants described persistent uncertainty or concerns about vaccines in the prenatal phase. They were readily able to articulate their questions or concerns during this phase, and appeared eager to receive advice and additional information from trusted health care providers.Most participants described their maternity care pro-viders as competent, trustworthy, and generally capable of explaining health issues to them in ways that brought deeper confidence and understanding. However, despite suggesting that they would be receptive to their mater-nity care providers\u2019 recommendations about infant vac-cinations, few women reported that these providers had initiated conversations about infant vaccinations, either in the prenatal phase or the postpartum period. These findings reinforce and add context to other studies indi-cating that the overwhelming majority of women wish to receive vaccination information well in advance of the vaccination appointment. Wu et\u00a0 al. found that 70% of participants wanted information about vaccines dur-ing pregnancy, although only 18% reported receiving this information during the prenatal period [37]. Simi-larly, Vannice et\u00a0al. reported that more than 95% of par-ticipants expressed a preference for receiving vaccination information during pregnancy or prior to the vaccination appointment [11]. In our study, when participants asked their provider specifically about infant vaccines, their maternity care providers deferred to other HCPs or sug-gested the participant seek answers elsewhere.The lack of prenatal communication about the infant immunization schedule may not be of significant con-cern for those women who remain confident about their infant immunization decision throughout the pregnancy and postpartum period. However, for those women who experience doubts about infant vaccination in the prena-tal phase, the absence of discussions with their maternity care provider constitutes a missed opportunity to elicit information and recommendations from a trusted pro-fessional. These parents may be \u2018hesitant compliers\u2019, as Enkel and colleagues describe, those who fully vaccinate but still report concerns [38], or they may be those who selectively vaccinate, delay vaccination or refuse vac-cinations altogether. Glanz et\u00a0 al. (2013) found that par-ents with doubts or concerns were more likely to begin the deliberation process about infant vaccinations ear-lier than parents who unquestioningly accepted vaccines and recommended engaging obstetricians to address these concerns [10]. In a recent national survey of Cana-dian parents, those reporting low trust in vaccines were more likely to say the vaccination decision was difficult [6]. Harmsen et\u00a0al\u2019s (2013) study suggested parents who refused all or some vaccines did not feel they were receiv-ing sufficient information from official sources [39].These findings build on data from earlier studies sug-gesting that parents who are hesitant towards vaccination are particularly receptive to counsel about vaccination from sources they perceive to be \u2018alternative\u2019 to tradi-tional or allopathic medicine, including midwives [18, 24, 39]. It further supports existing findings that the prenatal period is an invaluable window of opportunity to disseminate vaccination information to hesitant par-ents at a time when they are information seeking and open to trusted sources of information [10\u201314, 40\u201346]. Other studies suggest that the postpartum period is not an optimal time to receive information about vaccines because parents do not feel they have adequate time to assess new information due to the exhaustion of dealing with a new baby [14, 40\u201342, 47, 48]. A recent systematic review of parents\u2019 views on vaccination communication found that parents preferred information to be commu-nicated well in advance of their date of vaccine adminis-tration [49] to provide adequate time for reflection and decision-making.While these findings highlight the importance of early communication from a health care provider, it is impor-tant to note that not all clinician-patient relationships are predicated on high levels of trust. While many inter-ventions to promote vaccination are based on a \u201cstrong physician-parent relationship\u201d [22, 50\u201352], the findings from this study serve as a reminder that some patients view their relationships with their longitudinal HCP as functional or adequate at best, and few reported a long-standing, trusting relationship with this provider. Par-ticipants\u2019 trust in their maternity care providers takes on increased significance in the context of changes in Page 8 of 10Rubincam\u00a0et\u00a0al. BMC Public Health          (2022) 22:237 the provision of primary care and public health services across Canada. Statistics Canada suggests that the rate of unattached patients (i.e. no family physician) is on the rise [53], meaning that increasing numbers of Canadians will be without a regular family physician. These changes intensify the importance of the trusting relationship women describe with their prenatal care providers, par-ticularly for those parents with doubts or concerns about vaccines. While those who are hesitant are still deliberat-ing about the vaccination decision, these maternity care providers may constitute the best opportunity for them to elicit the advice of a trusted health care professional [24].Further research is needed to explore the extent to which Canadian maternity care providers feel that dis-cussions about infant immunizations are within their scope of practice, in line with studies from other coun-tries [54\u201357]. Recent research by some study authors with BC midwives indicate that while the majority of BC midwives do discuss vaccines with their clients at some point in their care, those who do not often cite a desire to avoid pressuring patients or make them uncomfortable [58].Few studies to date have tested the effect of informa-tional interventions delivered during the prenatal phase on postnatal vaccination uptake rates. One study in Japan found that intentions to vaccinate and vaccination uptake were higher among parents who received prenatal educa-tion about vaccinations [59]. A US study found vaccina-tion knowledge was higher among those who received a prenatal education intervention, although no differences were noted with regards to infant vaccine initiation [60]. Another study found no difference in positive views towards vaccination among mothers who received vac-cine information materials before the 2-month postpar-tum visit and those who received it during the 2-month visit. However, 95% of these study participants still stated they wished for vaccine education materials to be pro-vided to them during pregnancy or prior to the 2-month vaccination visit [11]. More research is needed to explore the impact of earlier initiation of vaccination informa-tion delivery on vaccination uptake. It may be the ear-lier timing of vaccination information is a necessary but not sufficient element in the vaccination decision, with the source of vaccination information being of equal or greater importance. Given the close and trusting rela-tionships with maternity care providers reported by women in our study, a vaccine recommendation followed by additional vaccination information from the mater-nity care provider may be important. What emerges from our study, and reinforces earlier work, is a clear consen-sus that women wish for opportunities to review infant\/child vaccination information during pregnancy. Taken together, these findings and data from our study suggest vaccination information should be provided in an ongo-ing and sustained manner, beginning in pregnancy and ideally continuing on throughout the infant\u2019s first months of life.LimitationsThis study was a longitudinal qualitative study and thus results cannot be generalized beyond the study popula-tion or translated into quantifiable results. Though every effort was made to recruit participants from a wide vari-ety of health care provider types, locations in Victoria, and socio-economic circumstances, participants with lower household incomes, those with less educational attainment, and those experiencing employment or hous-ing instability were underrepresented or not represented as participants in the study. First time mothers were also more likely to participate, and it may be that the addi-tional time commitment for interviews made it challeng-ing for multiparous women to participate in this study. It is also possible the identity of the researcher influenced the nature of the findings, as participants shared insights from their pregnancies and post-partum life with another woman who was visibly pregnant. Findings from the co-parents (all fathers in this sample) were not reported alongside these data, as the majority of mothers indi-cated they were the sole or primary decision-maker with regards to their child\u2019s vaccination. However, this could be explored in future studies with a more socio-economi-cally, linguistically, and ethnoculturally diverse sample, as these may reveal important variations in decision-making around health care. We would caution against any effort to generalize these findings beyond the study population. However, the general themes identified by participants resonated closely with findings from other studies and highlight the importance of pregnancy as a crucial time of information gathering and decision making regarding infant vaccination.ConclusionThis study provides detailed evidence of the importance of the pre-natal period in the decision-making process about infant vaccination, and highlights the significant role maternity care providers can play in discussions with pregnant clients about infant vaccines. Further research on current maternity care providers\u2019 practices around recommending infant vaccination may help inform efforts to enlist this trusted body of professionals in the crucial task of advocating for, and educating about infant vaccines.AbbreviationHCP: Health care provider.Page 9 of 10Rubincam\u00a0et\u00a0al. BMC Public Health          (2022) 22:237  AcknowledgementsThe authors wish to thank all participants in this study who provided their time and insights into their decision-making processes. They also acknowl-edge the cooperation with Island Health public health nurses and staff, family physicians, midwives, and Mothering Touch parenting resource center for assistance in recruiting participants.Authors\u2019 contributionsJAB, CR and DG conceptualized the study. RS and CH helped to refine the research questions, and assisted with recruitment of participants. CR con-ducted the interviews. JAB, CR and DG analyzed the data and synthesized the results. CR drafted the manuscript. JAB, DG, RS, and CH provided comments and edits to manuscript. All authors read and approved the final manuscript.FundingFunding for this study was received from the Island Health Research Support Competition fund and the BC Immunization Committee. CR was supported by the Michael Smith Foundation for Health Research\u2019s Postdoctoral Trainee Award.Availability of data and materialsThe datasets generated during the current study are not publicly available due to the fact that permission was not sought at the time of participant interviews to share recordings or transcripts outside of the research team.DeclarationsEthics approval and consent to participateAll methods used in this study were carried out in accordance with the rel-evant guidelines and regulations, and consent to participate was sought from all participants prior to each interview. Participants provided written informed consent. The study was approved by the University of British Columbia Chil-dren\u2019s and Women\u2019s Health Centre of British Columbia Research Ethics Board (H15-01709).Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Author details1 Island Health, Victoria, BC, Canada. 2 Vaccine Evaluation Center, BC Children\u2019s Hospital Research Institute, University of British Columbia, A5-950 West 28th Street, Vancouver, BC V5Z 4H4, Canada. 3 Department of Communication, University of Massachusetts, Amherst, USA. 4 University of British Columbia, Vancouver, BC, Canada. 5 South Island Division of Family Practice, Victoria, BC, Canada. Received: 5 March 2021   Accepted: 27 January 2022References 1. Andre F, Booy R, Clemens J, John T, Lee B, Lolekha S, et al. Vaccination greatly reduces disease, disability, death, and inequity worldwide. Bull World Health Organ. 2008;86:140\u20136. 2. UNICEF Canada. Stuck in the Middle. 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A prenatal intervention study to improve timeliness of immunization initiation in Latino infants. J Community Health. 2003;28(2):151\u201365.Publisher\u2019s NoteSpringer Nature remains neutral with regard to jurisdictional claims in pub-lished maps and institutional affiliations.","@language":"en"}],"Genre":[{"@value":"Article","@language":"en"}],"IsShownAt":[{"@value":"10.14288\/1.0406637","@language":"en"}],"Language":[{"@value":"eng","@language":"en"}],"PeerReviewStatus":[{"@value":"Reviewed","@language":"en"}],"Provider":[{"@value":"Vancouver : University of British Columbia Library","@language":"en"}],"Publisher":[{"@value":"BioMed Central","@language":"en"}],"PublisherDOI":[{"@value":"10.1186\/s12889-022-12658-3","@language":"en"}],"Rights":[{"@value":"Attribution 4.0 International (CC BY 4.0)","@language":"en"}],"RightsURI":[{"@value":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/","@language":"en"}],"ScholarlyLevel":[{"@value":"Faculty","@language":"en"},{"@value":"Researcher","@language":"en"},{"@value":"Other","@language":"en"}],"Subject":[{"@value":"Vaccine","@language":"en"},{"@value":"Vaccination","@language":"en"},{"@value":"Parent","@language":"en"},{"@value":"Decision-making","@language":"en"},{"@value":"Interviews","@language":"en"},{"@value":"Health care provider","@language":"en"},{"@value":"Midwives","@language":"en"},{"@value":"Doctors","@language":"en"}],"Title":[{"@value":"Is the pre-natal period a missed opportunity for communicating with parents about immunizations? Evidence from a longitudinal qualitative study in Victoria, British Columbia","@language":"en"}],"Type":[{"@value":"Text","@language":"en"}],"URI":[{"@value":"http:\/\/hdl.handle.net\/2429\/80864","@language":"en"}],"SortDate":[{"@value":"2022-02-05 AD","@language":"en"}],"@id":"doi:10.14288\/1.0406637"}