Young infants remain highly vulnerable to infectious diseases ¹ , partially because vaccination is not feasible or effective for most diseases during the first months of life ¹ . Maternal immunization has the potential to yield protection for both the mother and their infant ² . Clinical studies have demonstrated protection of infants against various infectious diseases such as pertussis and influenza through the placental transfer of antibodies from vaccinated mothers ^{3, 4} . Hence, the importance of promoting maternal immunization, especially in settings where the risk of infection during pregnancy and early infancy is high.

Despite proven advantages and significant progress in maternal immunization worldwide, many countries in Africa, including Kenya, recommend only tetanus- diphtheria (Td) vaccination for pregnant women, and coverage remains suboptimal in some regions ⁵ . Some of the determinants of low vaccine uptake in the African region include living in urban or peri-urban areas; few dedicated economic and human resources; lack of sufficient vaccines due to demand and supply inconsistencies and barriers to vaccine acceptance by pregnant women and their communities ^{5– 7} . Healthcare providers can play a key role in overcoming these barriers. Studies in the United States have shown that women who had discussions about vaccine benefits with their antenatal care providers were more likely to accept vaccine during pregnancy ⁸ .

Pregnant women have shown that they rely and trust healthcare providers for immunization related information ² . A couple of studies in Asia and Africa have shown that healthcare provider recommendation not only improve vaccine acceptance in pregnant women but can also motivate their male-partners to accept maternal vaccination. This patient-provider relationship has been seen particularly important in low-to-middle income countries (LMIC) ^{9, 10} . Providers’ attitudes and beliefs towards vaccination have also been shown to influence vaccine recommendations for pregnant women ¹¹ . Despite high morbidity and mortality of vaccine preventable disease in LMIC such as Kenya ¹² , most of the research assessing the knowledge, attitudes, and beliefs of health providers towards maternal immunization has been conducted in high- income settings ¹³ . The objective of this study was to assess attitudes and beliefs of antenatal care providers towards maternal vaccination in Kenya.

A total of 150 participants were included in this study (see underlying data ¹⁶ ). Most of the participants were female (77.3%), nurses (89.3%) and over 30 years of age (67.3%) ( Table 1).

Nearly all of the ANC providers had positive attitudes towards maternal vaccination in general (when no vaccine was specified), agreeing that vaccines are one of the safest strategies to protect both mother and newborns from diseases, and can be administered even when they are suffering from chronic conditions such as HIV. Nearly 80% of the providers agreed that influenza is a matter of concern in pregnant women. Approximately 97% of the providers agreed that Td vaccine is effective and should be administered in pregnancy ( Table 2).

Providers responded that myths and misconceptions about vaccines in the society did not affect their decisions related to maternal vaccination. A majority also expressed that political leaders do not influence provider’s decision to accept vaccines. Similarly, most participants disagreed that ethnic/cultural background or religious beliefs influenced their attitudes or beliefs towards vaccination. ( Table 3).

Educational resources to guide women about vaccines (92.7%) and supply of vaccines by government sector (87.3%) were reported to be accessible in enough quantity ( Table 4). However, logistical (66%) and human resources (52.7%) were reported to be less available for vaccine delivery. Furthermore, 78% believed that pregnant women take all the scheduled vaccines even when they migrate to new places. In addition, they feel that their patients trusted their suggestions and information about vaccine recommendation.

Results from this study of ANC providers in Kenya highlight the important role that these professionals play supporting maternal vaccinations that are currently recommended in the country (currently, only TT), as well as potential opportunities for the introduction of additional vaccines for pregnant women. First, the providers had favorable attitudes towards vaccine administration and believed that a greater number of vaccines should be recommended to protect both mother and the child from preventable diseases and associated debilitating outcomes. Second, providers reported that religion, myths or political opinions do not influence their attitudes and recommendations around maternal vaccination. Third, almost all providers perceived that women consider them as a trustworthy source of information about vaccinations. Finally, it was reported that healthcare centers were well equipped with educational materials. There was also an uninterrupted supply of vaccines from the government sector.

Providers perception of having adequate vaccine supplies was contradictory to a report of 2011 –2015 from the Kenya Division of Vaccines and Immunization, that cited both demand and supply challenges in vaccine availability ¹² . There have been incidents of depleted vaccine supply some African countries, including Kenya and Tanzania ¹⁸ . One of the reasons behind the divergent results might be that our study included mostly accessible clinics and hospitals located within or near urban areas with good infrastructure. It is also possible that efforts to improve vaccine supplies based on previous assessments have been noticed by the providers.

It is important to note that the perceptions of HCPs around maternal immunization are mostly based on the experience with tetanus vaccines (either TT or Td). Maternal immunization against tetanus has been implemented for decades in Kenya. Similarly, partly due to programs to improve coverage, the TT vaccine is regarded as a safe and effective to prevent childhood tetanus ¹⁹ . While the introduction of other maternal vaccines (e.g. influenza) can benefit from the experience with TT, each new vaccine that is introduced will need to be assessed individually and efforts to promote coverage need to be catered to their specific characteristics.

Efforts to introduce maternal immunization with influenza in Kenya are ongoing. Influenza virus infection was reported as one of the concerns during pregnancy in Kenya ²⁰ . Since ANC providers are regarded as a main source of information, this is another opportunity where policymakers and immunization managers can partner with HCP to inform and motivate pregnant women to receive an influenza vaccine once the recommendation is enacted.

Globally, studies have shown the influence of ethnicity and cultural background on acceptance of different vaccines ^{21– 23} . An encouraging finding from this study was that providers reported that religion, politics and ethnic background did not negatively impact their attitudes and beliefs towards maternal vaccination.

A limitation of this study is that we only included 4 out of 47 counties in Kenya, however the areas selected in our study represented a diversity of geographic areas (low and high population density, urban and rural). Similarly, most of those surveyed were female nurses and approximately half were of Luo ethnicity. Thus, these results may not be representative of the overall knowledge, attitudes and beliefs among all healthcare workers in Kenya. Also, only a small proportion of the participants were physicians, which reflects the small number of physicians available to provide ANC in this country ²⁴ . These limited diversity of the study participants might have contributed to the lack of variation in responses which precluded the analysis of predictors. Even though the questionnaire was especially developed based on qualitative work with our target population and it was piloted with practitioners and health workers from the sites of interest, we did not collect data on validity or reliability. Similarly, we did not collect information on the number of providers that were approached and declined to participate. Other limitations are the potential for socially desirable responses. Finally, as previously discussed, only one vaccine (TT) is currently recommended for pregnant women in Kenya.

Taking into account the positive attitudes of healthcare providers, and their recommendations of introduction of new vaccines, this study supports relying on ANC providers as partners to improve maternal vaccine acceptance in Kenya. Campaigns to improve vaccine acceptance in this setting should be implemented in coordination with providers and leverage their willingness to recommend maternal vaccines. It would also be important to identify the sources of training and information that have facilitated this widespread acceptance of maternal immunization among providers in Kenya, and potentially try to replicate these approaches in similar settings.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.