Pregnant Women and Tdap Vaccination, Internet Panel Surveys, United States, April 2014 and April 2015

At a glance

The best way to help protect young infants from whooping cough is for their mothers to get a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination during pregnancy. To estimate Tdap vaccination coverage among pregnant women, CDC analyzed data on Tdap vaccination from two Internet panel surveys.

Authors: Katherine E. Kahn, MPH; Carla L. Black, PhD; Helen Ding, MD, MSPH; Amy Parker Fiebelkorn, MSN, MPH; Jennifer L. Liang; DVM; Indu B. Ahluwalia, PhD; Sarah W. Ball, ScD; Sara M.A. Donahue, DrPH, MPH; Rebecca Fink, MPH; Rebecca Devlin, MA

Leidos, Atlanta, GA; Immunization Services Division, National Center for Immunization and Respiratory Disease, CDC; Eagle Medical Services, LLC, San Antonio, TX; Division of Bacterial Diseases, National Center for Immunization and Respiratory Disease, CDC; Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC; Abt Associates Inc., Cambridge, MA; Abt SRBI, New York, NY.

Summary

Pertussis (whooping cough) is a contagious respiratory illness that can lead to hospitalization and death, especially among infants <12 months12.

Infants are not recommended to be vaccinated against whooping cough until they are 2 months old12. The best way to help protect young infants from whooping cough is for their mothers to get a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination during pregnancy3. Infants whose mothers get a Tdap vaccination while pregnant have a lower risk of getting whooping cough and related complications early in life3456. Two studies from the United Kingdom suggest that up to 90% of infants are protected against whooping cough by vaccination of their mother during pregnancy78. Since late 2012, CDC, the American College of Obstetricians and Gynecologists, the American College of Nurse-Midwives, and the American Academy of Family Physicians recommend that women receive a Tdap vaccination during every pregnancy, optimally at 27 through 36 weeks of gestation3456.

Few recent national estimates of Tdap vaccination coverage among pregnant women are available. Based on the Pregnancy Risk Assessment Monitoring System (PRAMS) in 2011, before Tdap vaccination was recommended during every pregnancy, 9.7% of women who had a live birth were vaccinated during their pregnancy9.

To estimate Tdap vaccination coverage among pregnant women, CDC analyzed data on Tdap vaccination from two Internet panel surveys. The first survey was conducted March 31 through April 11, 2014, among women who were pregnant any time since August 2013, and the second survey was conducted March 31 through April 6, 2015, among women who were pregnant any time since August 2014. Women who had completed their pregnancy and delivered a live infant at the time of the surveys were included in the analysis. Differences of at least five percentage points between estimates are noted.

Figure 1. Receipt of most recent Tdap vaccination among recently pregnant women who had a live birth, Internet panel surveys, United States, April 2014 and April 2015

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Receipt of most recent Tdap vaccination among recently pregnant women who had a live birth, Internet panel surveys, United States, April 2014 and April 2015
Pertussis (whooping cough) is a contagious respiratory illness that can lead to hospitalization and death, especially among infants <12 months.

Key Findings

  • In 2015, Tdap vaccination coverage during pregnancy among women who had a live birth was 42.1%, an increase compared with 2014 vaccination coverage (27.0%).
    • The proportion of recently pregnant women who received their most recent Tdap vaccination before or after pregnancy decreased in 2015 (39.9%) compared with 2014 (53.9%), as vaccination coverage during pregnancy increased in agreement with the recommendation.
    • The proportion of recently pregnant women who reported never receiving a Tdap vaccination was similar in 2015 (18.0%) compared with 2014 (19.1%).
  • Among respondents to the 2015 Internet panel survey who had visited a doctor or other medical professional since July 1, 2014, 63.2% received an offer of Tdap vaccination, 15.0% received a recommendation for but no offer of vaccination, and 21.7% did not receive a recommendation for Tdap vaccination.
  • Women who received a recommendation for and an offer of Tdap vaccination from a doctor or other medical professional were more likely to be vaccinated during pregnancy.
    • These women were over three times more likely to be vaccinated during pregnancy compared with women who received only a recommendation for vaccination but no offer of vaccination (61.0% versus 19.7%).
    • They were more than twenty-six times more likely to be vaccinated compared with women who did not receive a recommendation for vaccination (61.0% versus 2.3%).

Conclusion/Recommendation

Health care personnel are encouraged to strongly recommend and offer Tdap vaccination to pregnant women during every pregnancy, optimally at 27 through 36 weeks gestation, to help prevent whooping cough in their infants.

Who Was Vaccinated?

In 2014, younger (18-24 years) and older (35-49 years) pregnant women were less likely to be vaccinated (23.8% and 21.0%, respectively) than pregnant women 25-34 years (30.5%). In 2015, coverage among all age groups was similar. Coverage was higher in 2015 compared with 2014 among pregnant women in all age groups.

Figure 2. Tdap vaccination coverage during pregnancy among recently pregnant women who had a live birth, by age, Internet panel surveys, United States, April 2014 (n=484) and April 2015 (n=580)A

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Tdap vaccination coverage during pregnancy among recently pregnant women who had a live birth*, by age, Internet panel surveys, United States, April 2014 (n=484) and April 2015 (n=580)
Coverage was higher in 2015 compared with 2014 among pregnant women in all age groups.

  • In 2014, Tdap vaccination coverage was highest among non-Hispanic white women (33.5%) compared with non-Hispanic black (10.3%), Hispanic (24.3%), and non-Hispanic other women (25.6%).
  • In 2015, coverage among non-Hispanic other women (47.4%) was higher compared with non-Hispanic white women (42.2%) and non-Hispanic black women (38.3%).
  • Coverage was higher in 2015 compared with 2014 among women in all race/ethnicity groups.

Figure 3. Tdap vaccination coverage during pregnancy among recently pregnant women who had a live , by race/, Internet panel surveys, United States, April 2014 (n=484) and April 2015 (n=580)

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Tdap vaccination coverage during pregnancy among recently pregnant women who had a live birth*, by race/ethnicity†, Internet panel surveys, United States, April 2014 (n=484) and April 2015 (n=580)
Coverage during pregnancy by race/ethnicity.

  • In 2014, Tdap vaccination coverage was higher among pregnant women with more than a college degree (33.5%) compared with women with a high school diploma or less (26.7%) and women with some college education (22.0%).
  • Women with a college degree had higher coverage (28.9%) than women with some college education (22.0%).
  • In 2015, coverage was higher among women with a high school diploma or less (47.4%) compared with women who had some college education (41.2%) and women with a college degree (38.6%).
  • Women with more than a college degree (44.6%) had higher coverage than women with a college degree (38.6%).
  • Coverage was higher in 2015 compared with 2014 among women at all education levels.

Figure 4. Tdap vaccination coverage during pregnancy among recently pregnant women who had a live birth, by education, Internet panel surveys, United States, April 2014 (n=484) and April 2015 (n=580)A

Tdap vaccination coverage during pregnancy among recently pregnant women who had a live birth*, by education, Internet panel surveys, United States, April 2014 (n=484) and April 2015 (n=580)
Coverage was higher in 2015 compared with 2014 among women at all education levels.

  • In both 2014 and 2015, pregnant women who reported having private/military medical insurance as their only insurance during pregnancy had higher vaccination coverage (30.0% and 45.5%, respectively) than women who reported having any type of public medical insurance (24.8% and 37.9%, respectively).
  • Tdap vaccination coverage was higher in 2015 compared with 2014 among all women regardless of insurance type.

Figure 5. Tdap vaccination coverage during pregnancy among recently pregnant women who had a live , by type of medical , Internet panel surveys, United States, April 2014 (n=474) and April 2015 (n=567)

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Vaccination percentages shown for Private/military only in 2014 was 30.0; in 2015, 45.5. For any public insurance, 2014 was 24.8; in 2015, 37.9.
Vaccination percentages shown for Private/military only and Any public in 2014 and 2015.

  • In both 2014 and 2015, pregnant women who were living below poverty had similar vaccination coverage compared with women who were living at or above poverty.
  • Tdap vaccination coverage increased in 2015 compared with 2014 among all women regardless of poverty status.

Figure 6. Tdap vaccination coverage during pregnancy among recently pregnant women who had a live birth, by poverty status, Internet panel surveys, United States, April 2014 (n=482) and April 2015 (n=578)CA

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Vaccination percentages shown by poverty status. At or above poverty: in 2014, 27.6; in 2015, 42.4. Below poverty: in 2014 24.9; in 2015, 40.2.
Vaccination percentages shown for poverty status in 2014 and 2015.

  • In 2015, among women who reported visiting a doctor or other medical professional at least once since July 1, 2014, 63.2% reported receiving an offer of Tdap vaccination from a doctor or other medical professional, 15.0% received a recommendation but were not offered the vaccine, and 21.7% did not receive a recommendation for Tdap vaccination.
  • Tdap vaccination coverage among pregnant women was highest (61.0%) among women who reported that their doctor or other medical professional offered the vaccination.
    • Among pregnant women who reported receiving a recommendation for but no offer of vaccination from their doctor or other medical professional, 19.7% were vaccinated.
    • Only 2.3% of pregnant women who reported that they did not receive a recommendation for vaccination from their doctor or other medical professional were vaccinated.

Figure 7. Tdap vaccination coverage during pregnancy among recently pregnant women who had a live , by medical professional recommendation and offer of Tdap , Internet panel survey, United States, April 2015 (n=578)

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Percentage vaccinated who were offered 61%, recommended but did not offer 19.7%, and no recommendation or offer 2.3%.
Percentage vaccinated who were offered, recommended but did not offer, and no recommendation or offer.

In 2015, respondents who had never received a Tdap vaccination or who had been vaccinated but not during their most recent pregnancy were asked to report their reasons for not receiving Tdap vaccination.

  • The most commonly reported reasons for not receiving Tdap vaccination indicated a lack of awareness regarding Tdap vaccination and the recommendation to receive Tdap vaccination during pregnancy (43.7%).
  • Other commonly reported reasons were related to safety risks or side effects of vaccination, and included concern about side effects, vaccination-related safety risks to the mother, and vaccination-related safety risks to her baby (23.9%).
  • Potential barriers to vaccination access, such as lack of medical insurance or cost (3.0%) and lack of time (3.4%) were reported much less frequently as reasons for not receiving Tdap vaccination.

Figure 8. Most commonly reported for not receiving Tdap vaccination among recently pregnant women who had a live birth and did not receive Tdap during their most recent pregnancy, Internet panel survey, United States, April 2015 (n=355)

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Most commonly reported reasons for not receiving Tdap vaccination among recently pregnant women who had a live birth and did not receive Tdap during their most recent pregnancy, Internet panel survey, United States, April 2015 (n=355)
Distribution of reasons for not receiving Tdap vaccinations.

What Can Be Done?

Overall, estimates of Tdap vaccination coverage during pregnancy from the 2015 survey were higher compared with estimates from the 2014 survey. In 2015, Tdap vaccination coverage was highest among pregnant women who reported that their doctor or other medical professional offered Tdap vaccination (61.0%) compared to pregnant women who reported receiving a recommendation without an offer of vaccine (19.7%) and did not receive a recommendation at all (2.3%). The most common reasons for not receiving a Tdap vaccination were related to a lack of awareness about the need for Tdap vaccination (43.7%) and concern about safety risks or side effects related to Tdap vaccination (23.9%). Continued efforts are needed to improve Tdap vaccination coverage among pregnant women, including:

  • All HCP should assess the vaccination status of pregnant women at every health care visit.
  • A recommendation with an offer of vaccination from a doctor or other medical professional has been strongly associated with vaccination during pregnancy.
  • If all pregnant women are assessed for vaccination status at every health care visit and receive both a recommendation for and offer of Tdap vaccination from their HCP, vaccination coverage should increase.

  • More than half of the recently pregnant women who had a live birth in the 2015 survey had not been vaccinated during their most recent pregnancy.
  • HCP should encourage their pregnant patients to receive Tdap vaccination at 27 through 36 weeks of pregnancy to give their infants the most protection at birth, since protective antibodies will be at their highest about two weeks after getting the vaccine [3].
  • HCP who are not able to stock and offer the Tdap vaccine themselves should offer their pregnant patients a strong referral, providing specific information on where patients can go to get the vaccine, and a patient-specific prescription if needed. HCP should also follow up with patients to ensure that the vaccination was obtained.

Data Source and Methods

CDC conducted Internet panel surveys from March 31–April 11, 2014 and March 31–April 6, 2015 to assess end-of-season influenza (flu) vaccination coverage estimates among pregnant women1011. Questions about Tdap vaccination were included in both surveys. Questions about recommendation for and offer of Tdap vaccination from a medical professional and reasons for not receiving Tdap vaccination were added in 2015. Women 18–49 years who were pregnant at any time since August 1, 2013 for the 2014 survey, or since August 1, 2014 for the 2015 survey, were eligible for the survey. Participants were recruited from pre-existing, national, opt-in, general population Internet panels operated by Survey Sampling International, which provides panel members with online survey opportunities in exchange for nominal incentives. In 2014, of 2,127 panel members who were eligible and started the survey, 2,042 (96.0%) completed the online survey; and in 2015, 2,053 (94.6%) of 2,171 eligible panel members completed the survey. Data were weighted to reflect the age, race/ethnicity, and geographic distribution of the total U.S. population of pregnant women12131415.

Survey respondents were asked if they ever had a Tdap vaccination and, if so, whether they received their most recent vaccination before, during, or after their most recent pregnancy. Pregnancy status questions included whether respondents were currently pregnant at the time of the survey or had been pregnant any time since August 1, 2013 in the 2014 survey, and since August 1, 2014 in the 2015 survey. Recently pregnant women were asked if they had a live birth. The current analysis included only recently pregnant women who had a live birth. Women who reported receiving vaccination during their most recent pregnancy were counted as vaccinated during pregnancy, while women who reported never being vaccinated or being vaccinated before or after their most recent pregnancy were counted as not vaccinated during pregnancy. In the 2014 survey, 91 out of 575 women with a live birth (15.8%) were not included in the analysis because they did not know if they had ever received a Tdap vaccination or did not know if the Tdap vaccination was received during their pregnancy, leaving a final analytic sample of 484. In the 2015 survey, 106 out of 686 women with a live birth were not included (15.5%), leaving a final analytic sample of 580. In 2015, respondents who had at least one medical visit since the preceding July were asked if any doctor or other medical professional had recommended or offered Tdap vaccination during their most recent pregnancy. Also in 2015, respondents who had not received Tdap vaccination during their most recent pregnancy were asked about reasons why they were not vaccinated.

Weighted analyses were conducted using SAS v9.2 survey procedures. Because the opt-in Internet panel samples were based on those who initially self-selected for participation in each panel rather than random probability samples, statistical measures, such as calculation of confidence intervals and tests of differences, were not performed16 A change between years, or a difference between groups, was noted when there was a difference in estimates of at least five percentage points.

Sample Demographics

A total of 484 and 580 women who were pregnant any time from August 1, 2013 or August 1, 2014, until completion of the survey in 2014 or 2015, respectively, were included in the analysis. Table 1 shows the frequency of women in each demographic subgroup in the 2014 and 2015 surveys.

Table 1. Demographic characteristics of recently pregnant women who had a live birth, United States, Internet panel surveys, April 2014 and April 2015A

Characteristics 2014
unweighted
n		 2014
weighted
%		 2015
unweighted
n		 2015
weighted
%
Overall 484 100.0 580 100.0
Age group
18-24 years 99 30.0 130 25.9
25-34 years 299 54.4 350 59.1
35-49 years 86 15.6 100 15.1
Race/ethnicity†
Non-Hispanic white 334 56.4 345 57.5
Non-Hispanic black 47 18.5 77 17.3
Hispanic 62 18.4 112 17.4
Non-Hispanic other 41 6.6 46 7.8
Education
High school degree or less 89 21.3 130 23.3
Some college 127 28.9 168 29.2
College degree 196 37.6 215 36.3
More than a college degree 72 12.2 67 11.2
Insurance status‡
Private/military insurance only 301 57.4 320 55.0
Any public insurance 172 42.6 247 45.0
Living in poverty§
At or above poverty 386 74.8 446 75.5
Below poverty 96 25.2 132 24.5

Limitations

The findings in the report are subject to several limitations.

  • The sample was not necessarily representative of all pregnant women in the United States because the survey was conducted among a smaller group of volunteers who were already enrolled in a preexisting, national, opt-in, general-population Internet panel rather than a randomly selected sample.
  • Some bias might remain after weighting adjustments, given the exclusion of women with no Internet access and the self-selection processes for entry into the panel and participation in the survey. Estimates might be biased if the selection processes for entry into the Internet panel and a woman's decision to participate in this particular survey were related to receipt of vaccination.
  • All results are based on self-report and not validated by medical record review. However, our vaccination coverage estimates are similar to a recently published estimate based on provider-reported data from the Vaccine Safety Datalink (VSD) sites (42.1%)17
  • Baker R, Brick JM, Bates NA, et al. Summary report of the AAPOR Task Force on non-probability sampling. J Surv Stat Methodol 2013;1:90–143.
  • Formal statistics were not used to determine differences in vaccination coverage estimates between groups and seasons.
  • Some subgroups had small sample sizes.
  • Estimates could be biased due to the exclusion of ~13% of respondents who did not know their vaccination status. Sensitivity analysis showed that actual vaccination could have ranged from 43.0% to 55.0% in 2016.

Despite these limitations, Internet panel surveys are considered a useful assessment tool for timely evaluation of Tdap vaccination coverage during pregnancy.

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National Center for Immunization and Respiratory Diseases
  1. * Respondents were asked if they were currently pregnant or had been pregnant any time since August 1, 2013 or 2014 in the 2014 and 2015 surveys, respectively. Women were included in the analysis if they were recently pregnant (since August 1st), had delivered a live birth, and knew their Tdap vaccination status and timing of their most recent vaccination.
  2. † Race/ethnicity was self-reported. Women categorized as white, black, or other race were identified as non-Hispanic. The other race category included Asians, American Indians and Alaska Natives, Native Hawaiian or other Pacific Islander, multiracial, and other races. Women identified as Hispanic might be of any race.
  3. § Poverty status was defined based on the reported number of people and children living in the household and annual household income, and the U.S. Census poverty thresholds
  4. || Respondents who reported seeing a doctor or other medical professional since July 2014 in the 2015 survey were asked if a doctor or other medical professional had recommended or offered Tdap vaccination during their pregnancy. Nearly all (99.8%) participants included in the study had seen a doctor or medical professional since July 2014. Questions regarding provider recommendation and offer of Tdap vaccination were not included in the 2014 survey.
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  • ‡ Women considered to have any public insurance selected at least one of the following when asked what kind of medical insurance they had: Medicaid, Medicare, Indian Health Service, state sponsored medical plan, or other government plan. Women considered to have private/military insurance selected only one or both of the following: private medical insurance or military medical insurance. Tdap vaccination coverage was not calculated for respondents who reported that they had no insurance of any type due to small numbers (n<30).
  • ¶ Respondents who reported never receiving a Tdap vaccination were asked about their reasons for never receiving Tdap vaccination. Respondents who reported receiving Tdap vaccination but not during their most recent pregnancy were asked about their reasons for not receiving Tdap vaccination during pregnancy. Responses from the two groups of unvaccinated women were combined and similar responses grouped together. More than one reason could be selected. Questions regarding reasons for non-vaccination were not included in the 2014 survey.
  • ** ‘Lack of knowledge/awareness’ included selection of one or more of the following responses: do/did not need the vaccination, didn’t know I was supposed to get the Tdap vaccine, didn’t know that I needed the Tdap vaccination during my pregnancy, never heard of the Tdap vaccine, or selected “other” and specified already received Tdap or was thought up to date on vaccination.
  • †† ‘Concern about safety risks or side effects’ included selection of one or more of the following responses: concern about possible safety risks to my baby if I got vaccinated, concern about side effects, or concern about possible safety risks to myself if I got vaccinated.
  • ‡‡ ‘Lack of concern about whooping cough’ included selection of one or more of the following responses: it’s unlikely my baby would get whooping cough, it’s unlikely I would get whooping cough, if I get whooping cough I will just get medication to treat it, or if my baby gets whooping cough I will just get medication to treat it.
  • §§ ‘Lack of insurance coverage/cost’ included selection of one or more of the following responses: not covered by my insurance, don’t have insurance, co-pay costs too much, or Tdap vaccination costs too much.