The Adult Vaccine Access Coalition (AVAC) appreciated the opportunity to respond to the Senate Finance Committee’s request for evidence-based proposals to improve maternal health. Low maternal immunization rates are one of the many factors contributing to poor maternal health outcomes in the United States. AVAC made several recommendations including reducing financial barriers for pregnant women; addressing provider issues around billing, coding, and low rates of reimbursement; strengthening education and encouragement so that women are aware of and receive recommended immunizations during each pregnancy; and improving data collection and reporting through a widespread implementation of interoperable health information technology (HIT), Immunization Information Systems (IIS), and electronic health record (EHR) systems.

Read the full letter below and here


Date: April 3, 2020
To: Senate Finance Committee Chairman Grassley & Ranking Member Wyden
From: Adult Vaccine Access Coalition (AVAC)

Re: Maternal Health Bill and Immunizations

The Adult Vaccine Access Coalition (AVAC) appreciates the opportunity to respond to the Committee’s request for evidence-based proposals to improve maternal health.

AVAC consists of over 55 organizational leaders in health and public health that are committed to addressing the range of barriers to adult immunization and to raising awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system. Our priorities and objectives are driven by a consensus process with the goal of enabling the range of stakeholders to have a voice in the effort to improve access to and utilization of adult immunizations.

We appreciate your interest in modernizing and improving the capabilities of the maternal health care. Low maternal immunization rates are one of the many factors contributing to poor maternal health outcomes in the United States. A recent report by the Centers for Disease Control and Prevention’s (CDC) National Vital Statistics Reports found that the number of women dying each year during pregnancy or childbirth has remained steady. Significant disparities emerged however when these figures were reviewed by age and race, with the rate of maternal death being three times higher among black women as compared to white and Hispanic women. Similar patterns can be seen with respect to maternal immunization rates.

The Advisory Committee on Immunization Practices (ACIP) has issued recommendations on the importance of maternal immunization. Since 2004, ACIP has recommended that all pregnant women receive the influenza vaccine and has made a similar recommendation for the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine since 2012. A study of insurance claims from public and commercial payers in the American Journal of Preventive Medicine1 found maternal immunization rates increased across regions of the country and payers over the period from 2010 to 2017. However, the report noted significant variability depending on age, race, region and number of obstetric visits during a pregnancy, among other factors. A 2018 survey by the Centers for Disease Control and Prevention (CDC) found that, “many pregnant women are unvaccinated, and they and their babies continue to be vulnerable to influenza and pertussis infection and potentially serious complications including hospitalization and death.”2 Over the survey period (October 2017-March 2018), and 49.1 percent of women reported receiving the influenza vaccine, while 54.4 percent reported receiving Tdap. These rates, however, are notably lower for minority women.3

The work around maternal health comes a critical time for vaccines. Vaccine confidence and hesitancy issues remain a challenge, including among pregnant women. Despite the well-known benefits of immunizations, more than 50,000 adults die in the United States from vaccine-preventable diseases each year. Adult coverage lags behind current federal targets for recommended vaccines during pregnancy. Additionally, pregnant women seeking access to and coverage for vaccines encounter multiple barriers, including lack of information about recommended vaccines, financial hurdles, and technological and logistical obstacles. In addition, there are several new vaccines in the research pipeline for life threatening conditions that could provide important health benefits to pregnant women and their children.

Seeking to better understand some of the ongoing challenges and barriers to successful maternal immunization, the National Vaccine Advisory Committee (NVAC) convened a working group to review the current state of maternal immunizations, identify existing best practices as well as programmatic gaps in this field of preventive medicine. In 2015, NVAC issued a report highlighting the range of patient and provider challenges as well as offering recommendations.4

As immunizations are a highly cost-effective form of preventive medicine that help save lives by protecting the health and wellbeing of individuals and families in communities nationwide, it is in our nation’s interest to improve immunization coverage rates as a means to improve maternal health outcomes. We greatly appreciate the Committee’s consideration of the following recommendations as you work to develop maternal health legislation.

I. Coverage and standards of care to improve maternal health.

Vaccines should be equally accessible for pregnant women among all insured populations. Financial barriers can prevent pregnant women, particularly those with public insurance coverage5, from receiving recommended immunizations during the time of pregnancy. Concurrently, provider issues around billing, coding, and low rates of reimbursement can discourage providers from stocking vaccines and recommending them to obstetric patients. We urge the Committee to consider the following provisions around coverage and access:

  • Improve Provider Billing for Maternal Immunization Services. Direct HHS ASH, in coordination with CMS, HRSA and payers to develop a workplan and proposed budget to improve upon current process issues related to billing, coding and payment for maternal immunizations, including a review of challenges around vaccine purchase, storage and handling.
  • Vaccine Counseling and Administration Reimbursement. Develop payment mechanisms for CMS/HRSA to reimburse for the costs associated with counseling a patient and vaccine administration.
  • Eliminate Cost Sharing Barriers for Maternal Immunization. Require state Medicaid plans that offer immunization coverage to do so with no cost sharing for pregnant/postpartum women.

II. Addressing disparities and disparate outcomes.

There is a need to strengthen the appreciation and recognition of the value of immunization during pregnancy and beyond. Greater attention and effort are needed to drive meaningful improvements in immunization rates among the maternal population. Consistent education and encouragement can be strengthened so that women are aware of and receive recommended immunizations during each pregnancy. This communication should be strategic, evidence-based, and culturally appropriate and should reflect the health literacy, language. At the same time, providers play an essential role in providing education and counseling to patients and must have the tools and resources to do this job effectively in the course of providing care to patients.

Lack of a strong provider recommendation of immunization during pregnancy results in missed opportunities to protect pregnant women and from conferring immunity protection to their newborns as well. We recommend the following provisions around education and outreach:

  • Maternal Immunization Education Materials. HHS ASH, CMS and CDC to work with federal and state partners, public health, medical professional and minority health organizations to develop and distribute communication strategies and educational materials to aid health care providers in effectively communicating the risks and benefits of maternal immunization and childhood immunization.
  • Communication Campaign. Coordinate the dissemination of a comprehensive toolkit and other resources aimed at improving obstetrical provider immunization office workflow and administration (ie. business practice and billing support, adoption of NVAC adult standards of care, utilization of AFIX).
  • Data collection and effective evaluation to improve outcomes and quality. Improvements in maternal immunization are needed and can help to improve outcomes and quality of care for pregnant and post-partum women. We strongly recommend:
    • Incentivize Widespread Adoption of Maternal Composite Measure. Encourage the widespread adoption of the
      National Committee for Quality Assurance (NCQA) prenatal immunization composite measure (influenza and
      Tdap)6 across federally-funded health care providers and programs (ie. CHC, FQHCs, RHCs and Medicaid
    • Establish initial incentives for federally-funded providers who implement the maternal composite measure
      and additional rewards for demonstrating ongoing improvements in maternal immunization rates among their

III. Improve data collection and reporting on maternal immunization.

Widespread implementation of interoperable health information technology (HIT), Immunization Information Systems (IIS), and electronic health record (EHR) systems have the potential to improve monitoring of vaccine preventable disease and vaccine coverage rates in real time at a population level and better address gaps in vaccination coverage among pregnant women, as well as to facilitate the exchange of data that can improve coordination and the quality and patient outcomes of preventive care. AcademyHealth, the National Academy for State Health Policy (NASHP) and the Colorado Children’s Immunization Coalition (CCIC) through formation of a Community of Practice (CoP) sought to study and improve immunization rates for pregnant women and children on Medicaid. This collaboration comprised of five states’ Medicaid, and public health agency immunization programs in a shared commitment to leveraging data through IIS to identify gap areas of coverage and monitor improvements in immunization rates.7 At the same time, economic data gathering and analysis, including an assessment of the burden of vaccine preventable disease during pregnancy and the direct and indirect costs that can be averted through increased use of vaccines for the maternal population would go a long way in making the case for increased immunization. We recommend the following provisions to strengthen data and reporting:

  • Strengthen IIS Interoperability and Reporting. Authorize HHS grants in coordination with CMS, CDC, and ONC, to enhance uptake, use, and interoperability of state and local IIS with provider health record systems to improve the bidirectional exchange of maternal immunization data among providers, IIS, and public health authorities.
  • Medicaid Data Report. Study looking at coverage and access to immunization services for pregnant and postpartum women who do not have another source of coverage.

Again, thank you for the opportunity to share these recommendations and look forward to working with the Committee to improve maternal health outcomes in this country. If you have any questions or would like to discuss these recommendations further, please contact AVAC Managers Abby Bownas ( or Lisa Foster ( for additional information.

  3. (slides 14 and 15)
  6. (slides 18-26)