Effect of a multi-modal intervention on immunization rates in obstetrics and gynecology clinics

Am J Obstet Gynecol. 2016 May;214(5):617.e1-7. doi: 10.1016/j.ajog.2015.11.018. Epub 2015 Nov 25.


Background: There is increasing attention on immunizations by obstetrician-gynecologists and a need to improve vaccination rates for all women.

Objective: To evaluate the effect of a multimodal intervention on rates of immunization with tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); and influenza in outpatient obstetrics and gynecology clinics.

Study design: Immunization rates at 2 clinics were compared pre- and post-implementation of multiple interventions at a public integrated health-care system. Study interventions began on June 6, 2012 and concluded on May 31, 2014; the preimplementation time period used was June 6, 2010 to June 5, 2012. Interventions included stocking of immunizations in clinics, revision and expansion of standing orders, creation of a reminder/recall program, identification of an immunization champion to give direct provider feedback, expansion of a payment assistance program, and staff education. All women aged 15 and older who made a clinic visit during influenza season were included in the influenza cohort; women who delivered an infant during the study time period and had at least 1 prenatal visit within 9 months preceding delivery were included in the Tdap cohort; each clinic visit by a nonpregnant woman aged 15-26 years was assessed and included in the HPV analysis as an eligible visit if the patient was lacking any of the 3 HPV vaccines in the series. The primary outcome was receipt of influenza and Tdap vaccine per current American College of Obstetricians and Gynecologists guidelines and receipt of HPV vaccine during eligible visits. Influenza and Tdap were assessed with overall coverage rates at the institutional level, and HPV was assessed at the visit level by captured opportunities. All analyses included generalized estimating equations and the primary outcome was assessed with time as a covariate in all models.

Results: A total of 19,409 observations were included in the influenza cohort (10,231 pre- and 9178 post-intervention), 2741 in the Tdap cohort (1248 pre- and 1493 post-intervention), and 12,443 in the HPV cohort (7966 pre- and 4477 post-intervention). Our population was largely Hispanic, English-speaking, and publicly insured. The rate of influenza vaccination increased from 35.4% pre-intervention to 46.0% post-intervention (P < .001). The overall rate for Tdap vaccination increased from 87.6% pre-intervention to 94.5% post-intervention until the recommendation to vaccinate during each pregnancy was implemented (z = 4.58, P < .0001). The average Tdap up-to-date rate after that recommendation was 75.0% (z = -5.77, P < .0001). The overall rate of HPV vaccination with an eligible visit increased from 7.1% before to 23.7% after the intervention.

Conclusion: Using evidence-based practices largely established in other settings, our intervention was associated with increased rates of influenza, Tdap, and HPV vaccination in outpatient underserved obstetrics and gynecology clinics. Integrating such evidence-based practices into routine obstetrics and gynecology care could positively impact preventive health for many women.

Keywords: human papillomavirus (HPV); immunizations; influenza; tetanus, diphtheria, and acellular pertussis (Tdap); vaccines in pregnancy.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Ambulatory Care Facilities
  • Colorado
  • Diphtheria Toxoid
  • Evidence-Based Practice
  • Female
  • Gynecology
  • Health Promotion / organization & administration*
  • Humans
  • Influenza Vaccines
  • Obstetrics
  • Papillomavirus Vaccines
  • Pertussis Vaccine
  • Tetanus Toxoid
  • Vaccination / statistics & numerical data*
  • Young Adult


  • Diphtheria Toxoid
  • Influenza Vaccines
  • Papillomavirus Vaccines
  • Pertussis Vaccine
  • Tetanus Toxoid