Caesarean delivery on maternal request: the perspective of the postpartum women.

BACKGROUND: Caesarean delivery on maternal request (CDMR) is an increasing delivery option among women. As such, we aimed to understand the reasons that led pregnant women to request a caesarean delivery. METHODS: A phenomenological study was conducted with semi-structured interviews, in a convenience sample, for women who had undergone a CDMR between March and June 2023, in a public reference university hospital in Campinas, Brazil. The interviews were recorded, transcribed and subjected to thematic analysis, supported by Nvivo®, and Reshape®. RESULTS: We interviewed eighteen women between 21 and 43 years of age. The reasons for C-section as their choice were: 1) fear of labour pain, 2) fear for safety due to maternal or fetal risks, 3) traumatic previous birth experiences of the patient, family or friends 4) sense of control, and 5) lack of knowledge about the risks and benefits of C-section. CONCLUSIONS: The perception of C-section as the painless and safest way to give birth, the movement of giving voice and respecting the autonomy of pregnant women, as well as the national regulation, contribute to the increased rates of surgical abdominal delivery under request. Cultural change concerning childbirth and better counseling could support a more adequate informed decision-making about delivery mode.

Mortality in children under 5 years of age with congenital syphilis in Brazil: A nationwide cohort study.

BACKGROUND: Congenital syphilis (CS) is a major and avoidable cause of neonatal death worldwide. In this study, we aimed to estimate excess all-cause mortality in children under 5 years with CS compared to those without CS. METHODS AND FINDINGS: In this population-based cohort study, we used linked, routinely collected data from Brazil from January 2011 to December 2017. Cox survival models were adjusted for maternal region of residence, maternal age, education, material status, self-declared race and newborn sex, and year of birth and stratified according to maternal treatment status, non-treponemal titers and presence of signs and symptoms at birth. Over 7 years, a total of 20 057 013 live-born children followed up (through linkage) to 5 years of age, 93 525 were registered with CS, and 2 476 died. The all-cause mortality rate in the CS group was 7·84/1 000 person-years compared with 2·92/1 000 person-years in children without CS, crude hazard ratio (HR) = 2·41 (95% CI 2·31 to 2·50). In the fully adjusted model, the highest under-five mortality risk was observed among children with CS from untreated mothers HR = 2·82 (95% CI 2·63 to 3·02), infants with non-treponemal titer higher than 1:64 HR = 8·87 (95% CI 7·70 to 10·22), and children with signs and symptoms at birth HR = 7·10 (95% CI 6·60 to 7·63). Among children registered with CS, CS was recorded as the underlying cause of death in 33% (495/1 496) of neonatal, 11% (85/770) of postneonatal, and 2·9% (6/210) of children 1 year of age. The main limitations of this study were the use of a secondary database without additional clinical information and the potential misclassification of exposure status. CONCLUSIONS: This study showed an increased mortality risk among children with CS that goes beyond the first year of life. It also reinforces the importance of maternal treatment that infant non-treponemal titers and the presence of signs and symptoms of CS at birth are strongly associated with subsequent mortality. TRIAL REGISTRATION: Observational study.

Quality assurance in health professions education: Role of accreditation and licensure.

OBJECTIVE: The aim of this paper is to provide an overview of the major quality assurance strategies, accreditation and licensure, in health professions education. It explores the nature of these regulatory processes using Brazil and the United States as examples because these large systems are at different ends of the developmental continuum. For each, it describes the tensions that arise, offers a critical synthesis of the evidence and maps out future directions. RESULTS: Given wide variability among operating medical schools in curricular design, length of study, resources and facilities for clinical training and supervision, the nature of regulatory bodies varies considerably. Nonetheless, they share tensions related purpose and process including quality assurance versus quality improvement, outcomes versus process and continuous versus episodic evaluations and assessments. Clear evidence of effectiveness, especially for accreditation, is scarce and difficult to obtain, particularly as it relates to health outcomes. CONCLUSIONS: Regulatory processes need to be built around clear definitions of the goals for each stage of professional development, the current movement towards competency-based education and the variable durations of medical education. These changes must motivate revisions in the content and process of programmes for accreditation and licensure, complimentary efforts towards quality of care, and stimulate a significant research effort.

Identifying the response process validity of clinical vignette-type multiple choice questions: An eye-tracking study.

INTRODUCTION: Clinical vignette-type multiple choice questions (CV-MCQs) are widely used in assessment and identifying the response process validity (RPV) of questions with low and high integration of knowledge is essential. Answering CV-MCQs of different levels of knowledge application and integration can be understood from a cognitive workload perspective and this can be identified by using eye-tracking. The aim of the pilot study was to identify the cognitive workload and RPV of CV-MCQs of different levels of knowledge application and integration by the use eye-tracking. METHODS: Fourteen fourth-year medical students answered a test with 40 CV-MCQs, which were equally divided into low-level and high-level complexity (knowledge application and integration). Cognitive workload was measured using screen-based eye tracking, with the number of fixations and revisitations for each area of interest. RESULTS: We found a higher cognitive workload for high-level complexity (M = 121.74) compared with lower-level complexity questions (M = 51.94) and also for participants who answered questions incorrectly (M = 94.31) compared with correctly (M = 79.36). CONCLUSION: Eye-tracking has the potential to become a useful and practical approach for helping to identify the RPV of CV-MCQs. This approach can be used for improving the design and development of CV-MCQs, and to provide feedback to inform teaching and learning.[Box: see text].

Gas6 drives Zika virus-induced neurological complications in humans and congenital syndrome in immunocompetent mice.

Zika virus (ZIKV) has the ability to cross placental and brain barriers, causing congenital malformations in neonates and neurological disorders in adults. However, the pathogenic mechanisms of ZIKV-induced neurological complications in adults and congenital malformations are still not fully understood. Gas6 is a soluble TAM receptor ligand able to promote flavivirus internalization and downregulation of immune responses. Here we demonstrate that there is a correlation between ZIKV neurological complications with higher Gas6 levels and the downregulation of genes associated with anti-viral response, as type I IFN due to Socs1 upregulation. Also, Gas6 gamma-carboxylation is essential for ZIKV invasion and replication in monocytes, the main source of this protein, which was inhibited by warfarin. Conversely, Gas6 facilitates ZIKV replication in adult immunocompetent mice and enabled susceptibility to transplacental infection. Our data indicate that ZIKV promotes the upregulation of its ligand Gas6, which contributes to viral infectivity and drives the development of severe adverse outcomes during ZIKV infection.

Cross-Cultural Adaptation of the Communication Assessment Tool for Use in a Simulated Clinical Setting.

Construct: The Communication Assessment Tool (CAT) is a 14-item instrument developed in English to assess medical trainees' interpersonal communication skills from the patient's perspective in clinical settings. Background: Using validated instruments and simulated patients constitutes good practice in assessing doctor-patient communication. The CAT was designed for use in real practice, but has not yet been applied to assessing OB-GYN residents' delivery of bad news in Objective Structured Clinical Examination (OSCE) stations. This study aims to provide validity evidence for using the CAT to assess residents' interpersonal communication skills under difficult circumstances in a simulated clinical setting in Brazil. Approach: Cross-cultural adaptation comprised translation into Portuguese, synthesis of translations, and back-translation. Next, a committee of 10 external and independent experts rated the items for linguistic equivalence and relevance to the overall scale. Researchers used the expert ratings to produce a preliminary Brazilian-Portuguese version. This version was applied by four simulated patients to assess 28 OB-GYN residents completing two, 10-minute OSCE stations focused on delivering bad news. Item and scale content validity indices and internal-consistency reliability were calculated. Simulated patients were interviewed to clarify any doubt regarding the content and usability of the tool and their response process. Findings: Thirteen of the 14 items in the Brazilian-Portuguese version were considered "equivalent" by at least 70% of the experts. All items were considered relevant by 100% of the experts. The Item Content Validity Index ranged from .9 to 1, and the Scale Content Validity Index was .99. The instrument showed good reliability for both scenarios (Cronbach's alpha > .90). Simulated patients considered the CAT easy to understand and complete. Conclusions: This study provides validity evidence for using the Brazilian-Portuguese CAT in a simulated clinical environment to assess OB-GYN residents' delivery of bad news. Based on this study's findings, the OB-GYN Department organized an annual formative assessment for residents to improve their interpersonal communication skills. This version of the CAT may also be applicable to other specialties.

Ultrasound diagnosis of microcephaly: a comparison of three reference curves and postnatal diagnosis.

PURPOSE: To evaluate which reference curve (RC)-Snijders, Intergrowth 21st (IG21) and World Health Organization (WHO)-is more accurate for microcephaly diagnosis. METHODS: Retrospective cohort study with more than 30,000 exams in more than 11,000 women. Microcephaly was confirmed by a neonatologist at birth and positive predictive values (PPVs) and misdiagnosis were assessed. RESULTS: A total of 71 cases were confirmed as microcephaly at birth. IG21 and Snijders PPVs showed to be more significant over WHO's (p < 0.001), without difference between them (p = 0.39). All RC were superimposed and did not show significant difference. When evaluated in different fragments, three trends were observed (until 30 weeks, between 30 and 36 and after 36 weeks of gestational age), with the latter interval showing a significant difference between IG21 and WHO (p = 0.0079). Conversely, WHO exhibited only one misdiagnosis, a much lower rate than Snijders, who missed eight cases and IG21, nine. CONCLUSION: WHO's RC appears to misdiagnose fewer cases, which could be useful for a population screening, while IG21's RC presented a more significant PPV, being more useful for a more precise final diagnosis in reference centers.

Adverse effects of antiretroviral therapy in pregnant women infected with HIV in Brazil from 2000 to 2015: a cohort study.

BACKGROUND: Antiretroviral therapy (ART) use in pregnancy presents unquestionable benefits in preventing mother-to-child transmission (MTCT) of HIV although it is associated with maternal adverse effects. The aim of this study was to evaluate the adverse effects of antiretroviral therapy in pregnant women infected with HIV. METHODS: Cohort study of pregnant women infected with HIV followed at the CAISM/UNICAMP Obstetric Clinic from 2000 to 2015. The following maternal adverse effects were observed: anemia, thrombocytopenia, allergy, liver function test abnormalities, dyslipidemia and diabetes. Data collected from patients' files was added to a specific database. Descriptive analysis was shown in terms of absolute (n) and relative (%) frequencies and mean, median and standard deviation calculations. Chi-square or Fisher exact test (n < 5) and relative risk (RR) with its respective p values were used for categorical variables and Student t-test (parametric data) or Mann-Whitney (non-parametric data) for the quantitative ones. A 95% confidence interval (CI) and a significant level of 0.05 were used. A multivariate Cox Logistic Regression was also done. Data analysis was conducted using SAS version 9.4. RESULTS: Data from 793 pregnancies were included. MTCT rate was 2.3%, with 0.8% in the last 5 years. Maternal adverse effects were: dyslipidemia (82%), anemia (56%), liver function test abnormalities (54.5%), including hyperbilirubinemia (11.6%), fasting glycemia alteration (19.2%), thrombocytopenia (14.1%), and allergic reaction (2.7%). The majority of adverse effects deemed related to ART in this study were mild according to DAIDS scale. In the multivariate analysis, co-infections and starting ART during pregnancy were risk factors for maternal anemia, while CD4 count higher than 200 cells/mm3 was protective. Nevirapine, nelfinavir and atazanavir regimens increased the risk for liver function tests abnormalities. Lopinavir use during pregnancy increased the risk for fasting glycemia alteration. CONCLUSION: The evolution of the national guidelines of antiretroviral therapy for pregnant women improved adherence to the treatment and resulted in a significant reduction of MTCT. Despite the high frequency of maternal adverse effects, they are mostly of low severity. Newer ART medications with improved efficacy and significantly more favorable tolerability profiles should reduce the incidence of ART-related adverse effects.

Adverse effects in children exposed to maternal HIV and antiretroviral therapy during pregnancy in Brazil: a cohort study.

BACKGROUND: Antiretroviral therapy (ART) in pregnancy was associated with a drastic reduction in HIV mother-to-child transmission (MTCT), although it was associated with neonatal adverse effects. The aim of this study was to evaluate the neonatal effects to maternal ART. METHODS: This study was a cohort of newborns from HIV pregnant women followed at the CAISM/UNICAMP Obstetric Clinic from 2000 to 2015. The following adverse effects were evaluated: anemia, thrombocytopenia, liver function tests abnormalities, preterm birth, low birth weight and congenital malformation. Data collected from patients' files was added to a specific database. Descriptive analysis was shown in terms of absolute (n) and relative (%) frequencies and mean, median and standard deviation calculations. The association between variables was tested through Chi-square or Fisher exact test (n < 5) and relative risk (RR) with its respective p values for the categorical ones and t-Student (parametric data) or Mann-Whitney (non-parametric data) for the quantitative ones. The significant level used was 0.05. A multivariate Cox Logistic Regression was done. Statistical analysis was performed using SAS version 9.4. RESULTS: Data from 787 newborns was analyzed. MTCT rate was 2.3%, with 0.8% in the last 5 years. Observed neonatal adverse effects were: liver function tests abnormalities (36%), anemia (25.7%), low birth weight (22.5%), preterm birth (21.7%), children small for gestational age (SGA) (18%), birth defects (10%) and thrombocytopenia (3.6%). In the multivariate analysis, peripartum CD4 higher than 200 cells/mm3 was protective for low birth weight and preterm birth, and C-section was associated with low birth weight, but not with preterm birth. Neonatal anemia was associated with preterm birth and exposure to maternal AZT. Liver function tests abnormalities were associated with detectable peripartum maternal viral load and exposure to nevirapine. No association was found between different ART regimens or timing of exposure with preterm birth, low birth weight or congenital malformation. CONCLUSION: Highly active antiretroviral treatment in pregnant women and viral load control were the main factors associated with MTCT reduction. Antiretroviral use is associated with a high frequency but mainly low severity adverse effects in newborns.

Specific Biomarkers Associated With Neurological Complications and Congenital Central Nervous System Abnormalities From Zika Virus-Infected Patients in Brazil.

Background: Zika virus (ZIKV) infections have been linked to different levels of clinical outcomes, ranging from mild rash and fever to severe neurological complications and congenital malformations. Methods: We investigated the clinical and immunological response, focusing on the immune mediators profile in 95 acute ZIKV-infected adult patients from Campinas, Brazil. These patients included 6 pregnant women who later delivered during the course of this study. Clinical observations were recorded during hospitalization. Levels of 45 immune mediators were quantified using multiplex microbead-based immunoassays. Results: Whereas 11.6% of patients had neurological complications, 88.4% displayed mild disease of rash and fever. Several immune mediators were specifically higher in ZIKV-infected patients, and levels of interleukin 10, interferon gamma-induced protein 10 (IP-10), and hepatocyte growth factor differentiated between patients with or without neurological complications. Interestingly, higher levels of interleukin 22, monocyte chemoattractant protein 1, TNF-α, and IP-10 were observed in ZIKV-infected pregnant women carrying fetuses with fetal growth-associated malformations. Notably, infants with congenital central nervous system deformities had significantly higher levels of interleukin 18 and IP-10 but lower levels of hepatocyte growth factor than those without such abnormalities born to ZIKV-infected mothers. Conclusions: This study identified several key markers for the control of ZIKV pathogenesis. This will allow a better understanding of the molecular mechanisms of ZIKV infection in patients.

Factors Associated with Preference for Vaginal Birth among Undergraduate Students from Southern Brazil.

BACKROUND: Cesarean rates in Brazil have reached over 50 percent of all births. Multiple factors have been studied aiming to explain these rates. Mode of delivery preferences among university students may provide insights into strategies to reduce those numbers. METHODS: A cross-sectional study was conducted enrolling students who attended Health Sciences and Human Sciences undergraduate programs in 2013. Participants answered a semi-structured questionnaire about which mode of delivery they considered the "best" (less risky and more beneficial) and the "preferred" mode (the one they would choose for themselves or their partners). Pearson chi-square was used to assess association among variables. Multiple regression analysis identified independent factors associated with the outcome measures. RESULTS: Among the 797 students who provided complete responses (76% response rate), the mean age was 22.6 years, 61.6 percent were female, 2.6 percent had previous pregnancies, and 56.7 percent were born by cesarean. Vaginal birth was chosen as the "best" mode of delivery by 91.2 percent, and the "preferred" mode by 75.5 percent of students. Being male, born vaginally, and a Health Sciences student was associated with a preference for vaginal birth. Being a Health Sciences student and born vaginally was associated with considering vaginal birth the "best" mode of delivery. CONCLUSIONS: Our findings indicate that the recognition of the benefits of vaginal birth do not always translate into a personal preference for vaginal birth. The student's own mode of birth was a strong predictor of their preferences for mode of delivery.

Bleeding patterns of HIV-infected women using an etonogestrel-releasing contraceptive implant and efavirenz-based or lopinavir/ritonavir-based antiretroviral therapy.

OBJECTIVES: The use of progestogen-only contraceptives may cause a change in bleeding pattern, which is a common cause of discontinuation of these methods. Co-administration with some antiretroviral therapies (ART) changes the bioavailability of the etonogestrel (ENG)-releasing contraceptive implant, possibly affecting the bleeding pattern. Bleeding patterns were evaluated in HIV-positive users of the ENG implant co-administered with two common ART regimens. METHODS: Forty-five HIV-positive women who wished to use an ENG implant were included in this study: 15 had received zidovudine/lamivudine (AZT/3TC) + lopinavir/ritonavir (LPV/r) for ≥3 months (LPV/r-based ART group), 15 had received AZT/3TC + efavirenz (EFV) for ≥3 months (EFV-based ART group), and 15 had not received ART (non-ART group). Bleeding patterns were evaluated at 3 and 6 months after implant placement using a standard bleeding calendar. RESULTS: Amenorrhoea and infrequent bleeding rates were higher in the LPV/r-based ART group (50% and 36%, respectively) than in the other groups (non-ART group, 36% and 29%, respectively; EFV-based ART group, 7% and 14.5%, respectively; p = 0.01). The EFV-based ART group more frequently had regular bleeding (71.5%) compared with the other groups (LPV/r-based ART group, 7%; non-ART group, 21%; p = 0.01). The proportions of women with frequent and prolonged bleeding were similar (p > 0.05) in the three groups. CONCLUSIONS: The co-administration of EFV-based or LPV/r-based ART with the ENG implant affected the expected bleeding patterns during use of the implant, although unfavourable bleeding (frequent and prolonged) was not associated with the medications under evaluation.

Impact of a nationwide study for surveillance of maternal near-miss on the quality of care provided by participating centers: a quantitative and qualitative approach.

BACKGROUND: The Brazilian Network for Surveillance of Severe Maternal Morbidity was established in 27 centers in different regions of Brazil to investigate the frequency of severe maternal morbidity (near-miss and potentially life-threatening conditions) and associated factors, and to create a collaborative network for studies on perinatal health. It also allowed interventions aimed at improving the quality of care in the participating institutions. The objective of this study was to evaluate the perception of the professionals involved regarding the effect of participating in such network on the quality of care provided to women. METHODS: A mixed quantitative and qualitative study interviewed coordinators, investigators and managers from all the 27 obstetric units that had participated in the network. Following verbal informed consent, data were collected six and twelve months after the surveillance period using structured and semi-structured interviews that were conducted by telephone and recorded. A descriptive analysis for the quantitative and categorical data, and a thematic content analysis for the answers to the open questions were performed. RESULTS: The vast majority (93%) of interviewees considered it was important to have participated in the network and 95% that their ability to identify cases of severe maternal morbidity had improved. They also considered that the study had a positive effect, leading to changes in how cases were identified, better organization/standardization of team activities, changes in routines/protocols, implementation of auditing for severe cases, dissemination of knowledge at local/regional level and a contribution to local and/or national identification of maternal morbidity. After 12 months, interviewees mentioned the need to improve prenatal care and the scientific importance of the results. Some believed that there had been little or no impact due to the poor dissemination of information and the resistance of professionals to change practice. In this second interview, a lack of systematic surveillance after the end of the study, difficulty in referring cases and changes in the leadership of the unit were mentioned. CONCLUSION: In the opinion of these professionals, participating in a network for the surveillance of severe maternal morbidity represented a good strategy for improving services, even in reference centers.

Perspectives of professionals participating in the Brazilian Network for the Surveillance of Severe Maternal Morbidity regarding the implementation of routine surveillance: a qualitative study.

BACKGROUND: The Brazilian Network for the Surveillance of Severe Maternal Morbidity was developed in Brazil with the participation of 27 centers in different regions of the country. The objective of the network project was to evaluate the frequency of severe maternal morbidity (near-miss and potentially life-threatening conditions) and the factors involved with these clinical conditions. Over the data collection period, this project implemented a surveillance system to identify these cases in the participating institutions. The objective of the present study was to evaluate the perspective of the professionals who participated in this network regarding the surveillance of cases of severe maternal morbidity, the facilities and difficulties encountered in involving colleagues in the process, and participants' proposals to give continuity to this practice of qualifying maternal healthcare. METHODS: A descriptive study with a qualitative approach was conducted in which coordinators, investigators and managers at all the 27 obstetric units participating in the network were interviewed. Data were collected at 6 and 12 months after implementation of the network during semi-structured telephone interviews that were recorded following verbal informed consent. Thematic content analysis was performed of the responses to the open questions in the interviews. RESULTS: In the opinion of 60% of the participants, involving their colleagues in the surveillance process proved difficult, principally because these professionals were not very interested in the research project, but also because they found it difficult to review concepts and professional practices, because they had an excessive workload or due to operational and technical difficulties. The great majority considered that support from government agencies providing financial resources would be crucial to enable surveillance to be maintained or expanded and also to train a larger number of professionals and improve work conditions. The majority of participants found it difficult to define the ideal time interval at which surveillance should be conducted. CONCLUSION: The investigators, coordinators and managers involved in the Brazilian network project mentioned several problems that had to be confronted during this process; however, in their opinion the project should be maintained and even expanded in view of its potential to contribute towards improving obstetric care.

Use of electrocautery for coagulation and wound complications in Caesarean sections.

OBJECTIVE: To evaluate the safety of electrocautery for coagulation during Caesarean sections. STUDY DESIGN: A randomized, controlled, clinical pilot study was performed at a university maternity hospital. After admission for delivery and decision to perform a C-section, volunteers were randomized to either the intervention group (use of electrocautery for coagulation) or nonintervention group. The women were examined at the time of postpartum discharge (day 3), at days 7 to 10, and again at days 30 to 40 for signs of infection, hematoma, seroma, or dehiscence. Data were analyzed using an intention-to-treat analysis, and risk ratios were calculated. RESULTS: No significant differences were found between the two groups. Only 2.8% of patients in the intervention group developed surgical wound complications during hospitalization. However, 7 to 10 days following discharge, these rates reached 23.0% and 15.4% in the intervention and nonintervention groups, respectively (RR = 1.50, 95% CI = 0.84-2.60). CONCLUSION: Further studies should confirm whether the use of electrocautery for coagulation does not increase the risk of surgical wound complications in patients undergoing Caesarean sections.

Urinary symptoms and pelvic floor muscle function during the third trimester of pregnancy in nulliparous women.

AIM: To evaluate pelvic floor muscle (PFM) function and its association with urinary symptoms in the third trimester of pregnancy. MATERIAL AND METHODS: A cross-sectional study was conducted among 91 nulliparous women at 30-34 weeks of pregnancy. PFM was evaluated by surface electromyography (sEMG) and manual muscle testing, while urinary symptoms were identified by interview. Chi-square and Fisher's exact tests were used to analyze proportions and Mann-Whitney test was used to analyze differences in means. RESULTS: Average sEMG values were 4.8 µV for basic tonus (BT), 19.2 µV for maximum voluntary contraction (MVC), and 12.9 µV for average sustained contraction (ASC), and 48.4% presented muscle strength grade 3. Nocturia was reported by 80.2%, followed by increased daytime frequency (59.3%), stress urinary incontinence (50.5%), and urge urinary incontinence (25.3%). No association was found between urinary symptoms and MVC or ASC or PFM manual tested strength. CONCLUSION: No association was observed between PFM function and urinary incontinence, except decreased BT among late third trimester pregnant women with irritative bladder symptoms.

Vaccination during pregnancy: A golden opportunity to embrace.

Immunization strategies are part of routine pregnancy care to prevent infectious diseases in the mother, the fetus, and the newborn. Maternal immunization recommendations followed the recognition of the consequences of infectious diseases in pregnancy, including vertical transmission and perinatal consequences. The recent COVID-19 pandemic highlighted the issue of vaccination among pregnant individuals. Recommendations vary globally; however, Tdap, influenza, and, recently, COVID-19 vaccines are routinely recommended during pregnancy. There are several new maternal immunization products in the pipeline, including those directed against malaria, cytomegalovirus, Group B Streptococcus, herpes simplex virus, and respiratory syncytial virus. Important challenges must be addressed in all countries to guarantee that pregnant individuals and their babies receive the best care possible, including uptake of recommended immunizations by their entire target population groups. These challenges include disseminating appropriate data for vaccine recommendations and many others, such as ensuring stakeholder endorsement, achieving in-country distribution and administration, adequate vaccine supply, and a well-organized healthcare system, ideally offering the immunization free of charge. More recently, the hesitancy of pregnant women to receive immunizations highlights the relevance of cultural aspects and other contextual factors affecting vaccine uptake among pregnant individuals.