ann marie navar, mhs institute for vaccine safety johns hopkins school of public health

Missed Opportunities for Prenatal Immunization Education:

The pediatric prenatal visit, routine obstetric care, and hospital education classes

Ann Marie Navar, MHSInstitute for Vaccine Safety

Johns Hopkins School of Public Health

Significance

• 13% of parents report not having enough information to make “good decisions” about immunizations Gust AJPM 2005;29(2):105-12

• New Hepatitis B birth dose recommendations ACIP December 2005

• All healthy infants born to HBsAg - mothers

• Parental concerns• 25% worry about immune system weakening Gellin

Pediatrics 2000;106(5):1097-103

Background• ACOG / AAP guidelines for prenatal are: no

discussion of immunizations

• AAP recommendations for prenatal visit: 1996 & 2001

• No national data on prenatal visit• 96.5% women have prenatal care by the 2nd

trimester Hamilton. National Vital Statistics Reports 20004 53(9)

• Hospital class lifetime non-attendance for mothers: 34% Lu. MCH Journal 2003;7(2) 87-93.

Objectives

• Determine the frequency of the pediatric prenatal visit

• Determine the percent of obstetricians that provide or are willing to provide information about immunizations to

pregnant women

• Determine the frequency immunization education in hospital based education

practices

Methods• Telephone Survey: 100 pediatric practices,

100 obstetric practices + hospitals• Pediatric: 10 questions

– Office prenatal visit policy, frequency

• OB: 9 questions– Information given during prenatal care

• Hospital: 11 questions– Information given as part of classes, proportion taking

class

Obstetric Study Population• Office-based, with phone # in AMA

Masterfile

• Nationwide, random sample• 132 numbers called in order of random #

− 17 bad numbers

− 2 no longer practicing

− 1 ID/neurology/travel medicine clinic

− 12 GYN only, specialists don’t deliver

Obstetric Study Population

• Final sample=100 obstetric practices• 308 MD, DO, NP, Midwives

• 30 States Represented

• Response rate: 71% (n=71)

Obstetric Respondents

• Nurse-23

• Office manager-16

• Other Administration-15

• Medical Assistant-12

• Doctor/Nurse Practitioner-5

Hospital Study Population

• 78 Hospitals Identified• Some OB’s Identified more than 1

• 28 States represented

• Response rate=65% (n=55)

Pediatric Study Population• Office-based, with phone # in AMA

Masterfile

• Nationwide, random sample• 126 numbers called in order of random #

− 14 bad #s

− 3 non-pediatricians − Emergency med, Internal Med, Family Med

Pediatric Study Population

• Final sample=100 pediatric practices• 33 States Represented

• 380 MD, DO, NP

• Response rate: 85% (n=85)

Pediatric Respondents

• Secretary/Receptionist-59

• Office manager-11

• Nurse-10

• Nurse Supervisor-3

• Doctor-2

Obstetric Practices

QuestionYes

n (%)No

n (%)

Maybe/Don’t know n (%)

Refer to Hospital-based Classes

n=7160 (85) 10 (14) 1 (1)

Provide Information on Hepatitis B

n=7123 (32) 42 (59) 6 (8)

Provide Information on other Vaccines

n=7116 (23) 52 (73) 3 (4)

Obstetric Practices Not Providing Vaccine Information

* Circumcision, Car Safety, Pets, Screening Tests, Cord Blood Banking, Literature from Pharmaceutical Companies, Formula Samples

QuestionYes

n (%)No

n (%)

Maybe/Don’t know

n (%)Willing to Provide Immunizatio Info n=52(no info on routine inz)

34 (65) 9 (17) 9 (18)

Provide info on other topics related to child health* n=38 (no info on routine inz or hep b)

21 (54) 17 (44) 1 (3%)

Pediatric Practices

Question Yesn (%)

Non (%)

Offer a Prenatal Visit n=85 66 (78%) 19 (22)

Visit free n=63 50 (79%) 5 (8)

Discuss Vaccines n=38

21 (55) 14 (37)

* Office policy, hours, practice characteristics, questions from the parent “selling the practice”

Don’t Know/Mayben (%)

8 (13)

3 (8)

Pediatric Practices• 27.5 minutes: Average duration of prenatal

visit• Range: 15-60 minutes

• 39%: Average proportion of 1st time mothers that get a visit in practices that offer a visit• Range: 0-99%

• Larger practices more likely to offer a prenatal visit• 1-2, 3-4, 5+ physicians (OR=6.1, p<0.001)

Number of practices reporting vs. percent of 1st time mothers receiving a pediatric

prenatal visit

0

2

4

6

8

10

12

14

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Num

ber o

f pra

ctic

es

Percent of 1st time mothers receive a prenatal visit

Hospital Classes

36% Number of class attendees/number of births at the hospital

86% Women are first-time mothers

35% Classes charge a fee

80% Hospitals provide information regarding routine immunizations in any class

74% Women take a class that includes information on immunizations

Limitations

• Respondents unsure of physician practices• OB: Clinical staff (physicians, nurses) less

likely than non-clinical staff (office managers, receptionists) to report providing information about vaccines (OR=0.4, p=0.09)

• OB: No difference in willingness (OR=1.3, p=0.73)

Limitations• Respondents unsure of physician practices

• Many “maybe/don’t know” responses

• OB: Clinical staff (physicians, nurses) less likely than non-clinical staff (office managers, receptionists) to report providing information about vaccines (OR=0.4, p=0.09)

• OB: No difference in willingness (OR=1.3, p=0.73)

• Pediatricians: Clinical staff more likely to report vaccines discussed (OR=2.6, p=0.4)

• Small sample size – large CI’s

Recommendations• Multiple opportunities to provide information about

immunizations during routine prenatal care

• Assess the utility of incorporate immunization information during routine obstetric prenatal care

• Encourage a pediatric prenatal visit for mothers desiring more information about vaccines

• Incorporate immunization education during prenatal visit hospital based education classes

• New Hepatitis B recommendations as impetus for hospital classes/Obstetric practices

Johns Hopkins Bloomberg School of Public Health

Ann Marie Navar, MHS

Neal A. Halsey, MD

Martha M. Montgomery

University of Florida College of Medicine

Daniel A. Salmon, PhD

Terrell C. Carter, MHS

Thank you!