Maternal vaccination decision-making in urban and rural Bengaluru, India: A mixed methods study

Maternal immunization is key to reducing morbidity and mortality among both pregnant women and infants; however, improving maternal vaccination uptake remains a challenge globally. We conducted a mixed methods study using a social ecological model in urban and rural sites in Bengaluru, India, to examine vaccination decision-making and factors influencing vaccination during pregnancy at the individual, interpersonal, organizational, community and policy levels. We conducted semi-structured interviews with pregnant women and new mothers (<i>n</i> = 70) and family members (<i>n</i> = 11), four focus group discussions with 35 women, and in-depth interviews with healthcare providers (HCPs, <i>n</i> = 26) and policymakers (<i>n</i> = 16). A majority (67%) of women were not included in decisions regarding their own pregnancy-related healthcare, which were typically made by other family members, such as husbands and mothers-in-law. HCPs, including community workers, were most influential in maternal vaccination decision-making, followed by family members. Although national guidelines were the next most important influencer, policymakers tended to underestimate communities' trust in and reliance on these guidelines. Traditional media are considered more trustworthy and influential than social media. Trust in HCPs and long-standing community use and experience with tetanus vaccines promoted what may be characterized as passive acceptance as they were given as a matter of course at antenatal appointments. Use of a social ecological framework indicates that many influences beyond individual-level factors influence maternal vaccine acceptance in developing settings. Clear government priority and policy along with engagement with families, communities and various types of HCPs are likely to be critical in maximizing acceptance of newer maternal vaccines.