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Women's Health Education Program (WHEP) Blog Disparities in Maternal Vaccination Rates of Tdap and Influenza Vaccine and COVID-19 Takeaways

Doctor/nurse giving vaccine injection to pregnant woman.

January 19, 2022
Samantha Kruger, Drexel University College of Medicine

Maternal vaccination with influenza and Tdap (tetanus toxoid, reduced diphtheria toxoid and acellular pertussis) are recommended and administered to pregnant people to reduce the risk of severe illness for themselves and their babies. However, despite these recommendations, vaccination rates are low and racial disparities exist.

To assess Tdap and influenza coverage, the CDC developed an internet panel survey for pregnant women during the 2019-2020 influenza season. Of the 1,841 responders, 61.2% reported receiving the influenza vaccine and 56.6% reported receiving the Tdap vaccine. Hispanic (35.8%) and non-Hispanic Black (38.8%) women had the lowest Tdap vaccination coverage, compared with white women (65.5%). Ethnic/racial disparities decreased overall compared to the prior flue season, but Tdap vaccination rates among Hispanic women decreased in comparison to prior years.

Despite ethnic/racial disparities decreasing overall comparted to the prior flu season, Tdap vaccination rates among Hispanic women decreased in comparison to prior years.

Data from this survey indicates that a significant number of people remain unvaccinated despite recommendations, putting both themselves and their babies at risk.

Of note, only 66.6% of surveyed pregnant women reported receiving a provider offer of influenza vaccine, 14.5% received recommendation but no offer, and 19% reported receiving no recommendation. In regard to Tdap, 67.4% reported receiving provider offers, 11.9% received recommendations but no offer, and 20.7% received no recommendation.

Importantly, vaccination rates were significantly increased in all ethnic/racial groups when providers encouraged and strongly recommended vaccines to their patients and either directly provided or referred patients to a vaccination provider.

Additional survey data revealed the main reason for not receiving an influenza vaccination was the belief that the vaccine was not effective (20.2%) and the most common reason for not receiving Tdap vaccine was the lack of understanding that the vaccine needs to occur with each pregnancy (45.1%).

The CDC offers resources to address these apparent miscommunications or missing conversations so providers can effectively communicate with patients. Some examples include providing patients with specific reasons for recommending the vaccine and demonstrating positive experiences with the vaccine. There are even “Vaccine Toolkits” available for providers on ACOG’s website.

In order to best address the vaccine disparities and improve vaccination rates in pregnant people, providers should be aware of common misconceptions about vaccinations and underlying reasons for hesitancy. They should be well prepared to have conversations that address the reasons that women remain unvaccinated. Some strategies may include screening pregnant women at each visit for vaccination status, patient education and repeated discussions about the safety and benefits of vaccines.

Although COVID-19 vaccination rates in pregnant people have been improving, there are important takeaways from this data on influenza and Tdap vaccines that can be applied to discussions on COVID-19 vaccination.

I believe that similar persistent and frequent conversations about safety and benefit of the COVID-19 vaccine will prove effective in increasing vaccination rates in this population. I feel the role of the provider becomes particularly important in addressing vaccine hesitancy. There is so much misinformation circulating, and pregnant people were not included in initial clinical trials for the vaccines. The most commonly cited reasons for declining the COVID-19 vaccine is limited data in pregnant women from clinical trials and concern for harm to the fetus.

Providers caring for pregnant patients should seek to address the COVID-19 vaccination misinformation head on and provide concrete examples of the safety of the vaccines in pregnant patients. These examples may include the reassuring animal studies, pregnant people inadvertently included in clinical trials with no adverse effects reported, and the CDC’s close monitoring of pregnant women since vaccinations were approved for this population.


  • Kahn KE, Black CL, Ding H, et al. Influenza and Tdap Vaccination Coverage Among Pregnant Women — United States, April 2018. MMWR Morb Mortal Wkly Rep 2018;67:1055–1059. DOI:

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