COVID-19 Vaccine Acceptance Among Pregnant, Lactating, and Nonpregnant Women of Reproductive Age in Turkey: A Cross-Sectional Analytical Study

Abstract Objective: This study aims to identify the rates of coronavirus disease 2019 (COVID-19) vaccine acceptance, the reasons for receiving and not receiving the vaccine, and the associated factors among pregnant, lactating, and nonpregnant women of reproductive age. Methods: This cross-sectional and analytical study was conducted online in Turkey, at the end of the fourth wave of the COVID-19 pandemic, between February and May 2022. A total of 658 women (230; 35% pregnant) (187; 28.4% lactating) (241; 36.6% nonpregnant) women of reproductive age participated in the study. Results: Vaccine acceptance rates were found to be 91.7% in nonpregnant women of reproductive age, 77% in lactating women, and 59% in pregnant women (P < 0.05). The highest rate of vaccine hesitancy was observed in pregnant women (31.3%), and vaccine rejection rate was the highest in lactating women (10.2%). Pregnancy (odds ratio [OR] = 3.98; confidence interval [CI] = 1.13-14.10), and the breastfeeding period (OR = 3.84; CI = 1.15-12.78), increased vaccine hesitancy approximately four times. Conclusions: Lack of knowledge about and confidence in the COVID-19 vaccine is still one of the barriers to vaccine acceptance today. Health-care providers (HCPs) should provide effective counseling to pregnant, lactating, and nonpregnant reproductive-aged women based on current information and guidelines.


Coronavirus disease 2019 (COVID-19
) is a contagious acute respiratory infection and a global public health problem.3][4] Compared with healthy pregnant women, pregnant women infected with COVID-19 have abortus, gestational hypertension, thromboembolism, and premature birth.5][6] In addition, there are studies in the literature stating that the clinical symptoms of COVID-19 in pregnant women are similar to those in nonpregnant women. 7,8There is no direct evidence of intrauterine vertical transmission of SARS-CoV-2 during pregnancy, and the risk of transmission through breast milk is very low. 4,6In addition, it was found that the mode of delivery did not cause a difference in COVID-19 transmission to newborns; however, it was revealed that COVID-19 infection increased the cesarean section rates considerably (77-91%) and negatively affected the mode of delivery. 6,9here has been no specific treatment for the disease since the onset of the COVID-19 pandemic. 10Vaccination is a proven method to cope the COVID-19 pandemic and is being implemented globally. 2,3Vaccination is essential to prevent negative consequences in pregnant, lactating, and reproductive age populations as well as in the whole society.Many vaccines are recommended during pregnancy, as maternal antibodies pass into the fetal circulation by means of the transplacental route and protect the newborn.Thus, the vaccine administered can protect the mother, fetus, and baby. 11Pregnant and lactating women were not included in the development trials of the COVID-19 vaccine due to concerns about possible adverse consequences of the vaccine to the fetus/newborn or to the breastfeeding process.Therefore, there are limited data on vaccine safety and pregnancy and breastfeeding outcomes compared with the general population. 4,12r organizations such as the Center for Disease Control and Prevention (CDC), American College of Obstetricians and Gynecologists (ACOG), Society for Maternal-Fetal Medicine (SMFM), and the World Health Organization (WHO) have recommended that pregnant and lactating women be vaccinated against COVID-19, 13,14 and many countries have provided vaccine guidance for pregnant and lactating women. 12It has also been reported that COVID-19 vaccines provide protection for the baby through breastfeeding. 13,14Controversies regarding the use of vaccines in high-risk pregnant and lactating women still continue. 12omen of reproductive age planning pregnancy may have significant concerns about the effects of the COVID-19 vaccine on reproductive health and the infertility process. 2 There is no evidence that COVID-19 vaccines can affect the fertility of women or men.In addition, it is reported that people who have infertility treatment, frozen embryo transfer, egg freezing, ovulation induction, intrauterine insemination, and oocyte or who donate sperm can safely vaccinate against COVID-19. 15accine hesitancy in the fight against COVID-19 is considered a public health threat. 16The success of the vaccines depends not only on their efficacy but also on their acceptance. 12,17COVID-19 vaccine acceptance should be between approximately 67% and 80% in the general population to reduce the spread of the disease. 180][21] The rate of vaccine hesitancy is 28.5% globally, 22 while it is 31% in Turkey. 23regnant and lactating women are more likely to refuse vaccination than nonpregnant women due to the unknown longterm health effects of the vaccine on the fetus/newborn, concerns about losing the fetus, and lack of research on vaccines. 5,12,17In addition, many factors such as gender, region of residence, race, ethnicity, education level, employment status, past vaccination experiences of individuals, perceived health risk, recommendation of the vaccine by health professionals, and the efficacy and safety of the vaccine affect vaccine acceptance. 12,16,17The number of studies investigating COVID-19 vaccine acceptance and the motivating factors, and the causes of vaccine hesitancy among pregnant, lactating and reproductive age women is limited.In addition, it is thought that this study will be an important scientific resource against future pandemics, as it provides evidence about vaccine acceptance and motivations for pregnant, lactating, and reproductive age women.The present study aims to reveal the rates of COVID-19 vaccine acceptance among pregnant, lactating, and nonpregnant women of reproductive age, and to identify the factors motivating this population to receive the vaccine, the barriers to receiving the vaccine, and the associated factors.

Design
This cross-sectional and analytical study was conducted online in Turkey at the end of the fourth wave of the COVID-19 pandemic, between February and May 2022.The National COVID-19 vaccination program in Turkey started with the Sinovac vaccine on January 13, 2021, and the Pfizer-BioNTech vaccine was included in the program on April 12, 2021.The first stage of the vaccination program included health workers and disadvantaged individuals (disabled, those living in nursing homes, elderly people over 65).In the second stage of the vaccination program, individuals working in the service sector and those between the ages of 50 and 64 were vaccinated.The third stage of the vaccination program included individuals between the ages of 17 and 49.At least 2 doses of vaccination have been completed at the country level in the age group studied. 24

Sample
The target population of the study consisted of pregnant women, lactating women, and nonpregnant women of reproductive age.The number of women in the 18-49 age group in Turkey is approximately 22 million. 25No sample selection was performed in the study.A total of 658 pregnant, lactating, and nonpregnant women who were literate in Turkish, who had Internet access, and who agreed to participate in the study on the specified dates were included in the study.The study aimed to reach women admitted to the clinics and polyclinics of 2 public hospitals in İzmir in the west of Turkey and 2 public hospitals in Bartın and Ordu in the north of Turkey.It was aimed to reach the following groups of women: (a) those between the ages of 18 and 49 admitted to Obstetrics and Gynecology clinics or polyclinics; (b) women in the Pediatrics Unit, Newborn Services, and Healthy Child Follow-up Polyclinics for examination or visit; (c) women in the breastfeeding counseling groups; and (d) women who take part in groups on social media (Instagram, Facebook), where information and counseling on mother-baby care issues of the same hospitals are provided.
The data were collected by distributing the leaflet containing the research information and quick response (QR) code and sharing the research link online on social media.Leaflets containing QR codes were hung in the waiting rooms and breastfeeding rooms of the hospital.Women were informed about access by means of QR code on the leaflet.In addition, the QR-coded brochure was shared with the women in the waiting rooms by the researchers.Informed consent was obtained from the participants before moving on to the survey items on the survey platform.An average of 6-8 min is needed to fill out the survey.Data were based on self-report of the participants.

Question form
The form developed by the researchers in line with the literature consisted of 3 parts and same questions were posed to all 3 groups (pregnant women, lactating women, and nonpregnant women of reproductive age).The first part included 8 questions regarding the demographic characteristics of the participants (age, marital status, education level, region of residence, employment status, and perception of monthly income, etc.) and 11 questions on obstetric characteristics (number of pregnancies and births, reproductive age period, gestational age, and postpartum period [in months], pregnancy and postpartum problems, and breastfeeding).The second part included 4 questions on the history of COVID-19 infection, the history of influenza vaccination in the past 2 y, and the history of previous vaccination rejection.The third part included 7 questions regarding the COVID-19 vaccine acceptance status (1 = yes; 2 = no), and those who selected "yes" were asked how many doses of the vaccine they received in total; which type of vaccine (Pfizer/BioNTech vaccine, SinoVac) and how many doses they received; vaccine information sources; and reasons for vaccine acceptance, vaccine rejection, and vaccine hesitancy. 2,4,10,12,17,18,26,27he questionnaire form used in the study was sent to 3 experts in the field to evaluate its validity and reliability.Necessary adjustments were made to the questionnaire form after expert opinions.Before starting the research, a pilot study was conducted with 15 women.

The fear of COVID-19 scale
The scale was developed by Ahorsu et al. in 2020 to reveal the level of fear related to COVID-19.The scale was adapted to Turkish culture. 28The scale consists of "7" items under "1" factor, and the items are rated on a 5-point Likert type scale from "1" (strongly disagree) to "5" (strongly agree).The minimum and maximum scores that can be obtained from the scale are 7 and 35 points, respectively, and no items in the scale are reverse-coded.Higher scores indicate greater levels of fear of COVID-19.The Cronbach's alpha internal consistency coefficient for the Turkish version of the scale is .84.In this study, the Cronbach's alpha was calculated as .85.

Statistical Analysis
The Statistical Package for the Social Sciences version 23.0 package program (IBM Corp.; Armonk, NY) was used to analyze the data.Frequency (percentage) was calculated for categorical variables.Mean (standard deviation), median (interquartile range (IQR), and minimum-maximum values were calculated for continuous variables.The Kolmogorov-Smirnov and Shapiro-Wilk tests were performed to test whether the research data showed normal distribution.In the evaluation of COVID-19 vaccine acceptance, vaccine rejection was coded as "0" dose, vaccine hesitancy was coded as "1" dose, and vaccine acceptance was coded as ≥ "2" doses.The Kruskal-Wallis test, the Mann-Whitney U-test, and the chi-squared test or Fisher's exact test were used in group comparisons and vaccine acceptance analysis.The level of significance was set at P < 0.05 in the analysis of the data.The regression model could not be performed as there were no strong predictors affecting vaccine acceptance on a group basis.The multinomial logistic regression analysis was performed to identify the potential predictors of COVID-19 vaccine acceptance or rejection and hesitancy rates for all participants, including the associated variables and baseline demographic data.All inferential tests were performed with an assumed confidence level (CI) of 95% and significance level (Sig.)P < 0.05.

Basic Characteristics of the Participants
A total of 658 women (230; 35% pregnant, 187; 28.4% lactating, and 241; 36.6% nonpregnant) of reproductive age participated in the study.The main characteristics of the participants are presented in Table 1 according to the groups.A total of 22.2% of the pregnant women and 24.6% of the lactating women were found to have encountered a problem during pregnancy and lactation, and 89.8% of the lactating women were found to breastfeed.The level of fear of COVID-19 was found to be moderate.It was revealed that 9.1% of the participants had influenza vaccination in the past 2 y, and 5.9% had a history of vaccination rejection.The history of influenza vaccination and vaccination rejection was higher in nonpregnant women of reproductive age compared with pregnant and lactating women (P < 0.05).The comparison of the main characteristics of the pregnant women, the lactating women, and the nonpregnant women of reproductive age showed that there was no significant difference only between perceived income level and the COVID-19 fear level scores (P > 0.05), and there was a significant difference between other variables (P < 0.05) (Table 1).

Vaccine Acceptance, Reasons for Vaccine Acceptance or Rejection, and Hesitancy, Sources of Information
The COVID-19 vaccine acceptance rate in women of reproductive age (18-48 y) was found to be 76.3%.Vaccine acceptance rates among the groups were as follows: nonpregnant women of reproductive age (91.7%), lactating women (77%), and pregnant women (59%; P < 0.05).Vaccine hesitancy was the highest in pregnant women (31.3%), and vaccine rejection was the highest in lactating patients (10.2%).The median COVID-19 vaccine acceptance dose was calculated as three in pregnant and lactating women and as four in nonpregnant women of reproductive age, and a highly significant difference was observed between the groups (p < 0.05  2).The first reason why pregnant (55.5%) and nonpregnant women of reproductive age (56.4%) were vaccinated was a lack of no other choice for protection, while the main reason for vaccination for the lactating women (50.6%) was to protect the baby (Figure 1).Among the reasons behind COVID-19 vaccine rejection or hesitancy in pregnant women, the most common cause was having had COVID-19 infection (9.7%) and the thought that the vaccine will harm the pregnancy or the baby (8.6%).In lactating women, the main reason for vaccine rejection was not trusting the vaccine (25.6%), and for the nonpregnant women of reproductive age, the main reason was lack of enough information about the vaccine (65%) (Figure 2).

Factors Affecting Vaccine Acceptance
The relationships among the potential predictors of COVID-19 vaccine acceptance by groups are shown in Table 3. COVID-19 vaccine acceptance rates were found to be significantly higher in pregnant women with low (primary education) or high (≥ university) education level, who were ≥30 y old, who were working, who had multigravida, who were multiparous, who perceived their income as medium or good, who were living in the western or central regions of Turkey, and who had a history of flu vaccine in the past 2 y (P < 0.05).In lactating women, COVID-19 vaccine acceptance rates were found to be high in mothers with high levels of COVID-19 fear, who had multigravida, who were multiparous and ≥30 y old, and who were not breastfeeding their babies (P < 0.05).However, the vaccination acceptance rate (27.3%) was found to be quite low in lactating women with a history of vaccination rejection (P < 0.05).Vaccine acceptance rates were higher in nonpregnant and nonlactating women of reproductive age who had a high level of COVID-19 fear and who finished university or a higher level (P < 0.05).Considering all the participants, it was found that women with a high level of Disaster Medicine and Public Health Preparedness    Disaster Medicine and Public Health Preparedness COVID-19 fear, those ≥30 y of age, those who were single, those with a high level of education (≥ university) or a low level of education (primary education), those who were working and living in the western and central region of the country, and those who were smoking, who were primiparous, and who had a history of influenza vaccination in the past 2 y had significantly higher rates of vaccination acceptance (P < 0.05) (Table 3).
The multivariate regression analysis model performed to identify the strong predictors of COVID-19 vaccine acceptance explained 41% of the variables (p < 0.05) (Table 4).In the regression analysis model, COVID-19 vaccine acceptance and vaccine rejection were found to be related with low fear of COVID-19 (OR = .4).

Discussion
This multicenter online study provides significant data on vaccine acceptance and its associated factors in groups of pregnant and lactating women, and nonpregnant women of reproductive age.The vaccine acceptance rate of nonpregnant women of reproductive age was found to be quite high (91.7%);however, the vaccine acceptance rate was low in lactating (77%) and especially in pregnant (59%) women.Pregnancy and the breastfeeding period increased vaccine hesitancy approximately 4 times.In studies conducted before the vaccination program in our country, the willingness to be vaccinated in pregnant women was 37% and 52.6%, 10,26 whereas this rate was found to be 33% in postpartum women. 29In a study of 17,871 participants including pregnant women and mothers with children under 18 y of age in 16 countries, 52% of the pregnant women and 73.4% of the nonpregnant women stated their intention to be vaccinated. 18eta-analysis studies reported that the global prevalence of COVID-19 vaccine acceptance during pregnancy is approximately 49-54%. 30,31In China, where the pandemic started, the acceptance rate of the COVID-19 vaccine was found to be higher (77.4%) among pregnant women. 17The study conducted with 1012 participants in Columbia showed that nonpregnant women (76.2%) had the highest vaccine acceptance rate, followed by lactating (55.2%) and pregnant women (44.3%). 5One study conducted with pregnant and lactating women in Czechia demonstrated that the vaccine acceptance rate was 76.6% in pregnant women, while it was 48.8% in lactating women, indicating a significant difference between the 2 groups.In parallel with the literature, it has been observed that vaccine acceptance is lower during pregnancy and lactation due to the concern of harming the pregnancy, fetus, or newborn.
The main reasons for the nonpregnant women of reproductive age to be vaccinated were to protect themselves against COVID-19 infection and to protect family members.The main reasons for receiving the COVID-19 vaccine for pregnant women were to protect against the COVID-19 infection and to follow the recommendations of the health personnel.The main reason for receiving the COVID-19 vaccine for lactating women was to protect their babies.In the literature, the fear of contracting  Disaster Medicine and Public Health Preparedness  COVID-19 infection and transmitting the infection to others, safety of the vaccine, acceptance of the vaccine by health-care professionals, and chronic diseases are among the reasons for getting vaccinated. 5,32The major factors supporting vaccine acceptance are trust in health-care professionals, government and the pharmaceutical industry, and media/social media. 33There are various thoughts about the efficacy and safety of the vaccine and its side effects.The reasons behind vaccine hesitancy are insufficient information about the vaccine; fear of getting the virus with the vaccine, change the genetic structure, and cause infertility; the thought that people are being used as a guinea pig in the vaccine application, the vaccine will be ineffective as a result of the mutation of the COVID-19 virus and will harm the pregnancy and the baby, and it will have long-term side effects and harm the breastfeeding process. 12,18,34,35Vaccine hesitancy is recognized as 1 of the top 10 threats to global health by the WHO. 36In this study, the most common reasons for vaccine hesitancy or rejection were the lack of knowledge about the vaccine in women of reproductive age, the presence of COVID-19 infection in pregnant women, and the concern that it may harm the baby and not trusting the vaccine in lactating women.The pregnant women were concerned about getting vaccinated because they feared that the vaccine might harm the unborn baby, cause pregnancy complications, and unknown long-term health consequences. 35One study revealed that Singaporean pregnant women were concerned about the safety of the vaccine (92.9%), while lactating mothers were concerned about possible adverse effects on the baby (75.6%). 34Current results suggest that concerns and barriers to vaccine acceptance are similar.
In our study, health-care providers (HCPs) were ranked first among vaccine information sources for all participants.In pregnant and lactating women, preference for HCPs and familyfriends was significant.Nonpregnant women of reproductive age, on the other hand, preferred scientific publications such as books, journals, and articles with the statements of official institutions (Turkey Ministry of Health or the WHO) and showed a significant difference compared with pregnant and puerperal women.This difference may be due to the fact that pregnant and lactating women have more contact with health professionals to receive care specific to the period they are in.Disinformation through social media and conspiracy theories increase anxiety and hesitation about the vaccine. 36Confidence in HCPs, scientific authorities, and strong scientific evidence are strongly associated with vaccine acceptance. 37Individuals are more likely to accept the COVID-19 vaccine when they receive advice from health-care professionals.It is hoped that vaccine acceptance by HCPs will increase the vaccine acceptance rates among the general public. 12,18,36,38HCPs have an important consultancy role in immunization programs and should address COVID-19 vaccine concerns with up-to-date information.HCPs should inform pregnant women of the maternal and fetal risks associated with the transmission of COVID-19 infection and build confidence by providing available information about the benefits and potential side effects of vaccines, based on the current evidence.Therefore, HCPs are of great importance in COVID-19 vaccine acceptance. 12,27here are many factors affecting COVID-19 vaccine acceptance.Factors such as individuals' psychosocial, cultural, and demographic characteristics; explanations of HCPs, COVID-19 infection experiences, the presence of a chronic illness, and previous history of vaccine rejection affect vaccine acceptance. 12,17t has been observed that COVID-19 vaccine acceptance is low in females and younger age groups, and the acceptance rate increases with increasing age. 20,235][6] Elderly pregnant women are more likely to be afraid of being infected with COVID-19 and to accept COVID-19 vaccine. 17,18In this study, the vaccine acceptance rate was found to be high in pregnant women over 30 years of age and lactating mothers.The study revealed that vaccine hesitancy increased 2.5 times in women aged 18-29 in the general population.As age increases, vaccine acceptance increases.
Studies have shown that higher education levels have increased confidence in and acceptance of the COVID-19 vaccine. 22,33,37In this study, those with primary school education level had 9 times more vaccine hesitancy and those with high school education level had approximately 4.5 times more vaccine hesitancy compared with those with a higher level of education.However, contrary to our study, there are studies showing that individuals with a postgraduate education level have higher hesitancy and negative beliefs about the COVID-19 vaccine compared with those with a low level of education. 17,39,40The study revealed that fear of COVID-19 affected vaccine acceptance during periods other than pregnancy, but low-level fear of COVID-19 in the general population increased vaccine rejection.It was observed that participants' fear of the COVID-19 pandemic affected their vaccine acceptance and has become a motivating factor.Similarly, 1 study revealed that extreme fear of COVID-19 infection increased vaccine acceptance. 5t was further revealed that vaccine rejection rates increased approximately 3.5 times in women who perceived their family income as low or middle.This finding may be attributed to low education level and cultural characteristics.Some studies found that those with middle or high income showed a positive attitude toward the vaccine. 21,26,41Low-income groups have been shown to be at higher risk of contracting COVID-19 due to their overcrowded living conditions, use of public transport, and greater likelihood of working outside the home. 40It is, therefore, important to bridge the gap between COVID-19 vaccine acceptance among individuals in lower and upper socio-economic groups.
In this study, vaccine hesitancy increased 2.5 times in unemployed women.Contrary to working women in some studies, vaccine acceptance rate increased in nonworking women, 42,43 and no relationship was found in others. 33,43These differences in vaccine acceptance may be due to differences in the population, such as different demographics, economics, and education levels.Fertility was a strong determinant influencing vaccine acceptance in the study, with nulliparous women experiencing approximately 8-fold, and primiparous women 3.5 times vaccine hesitancy.In studies, it has been determined that young, single, nulliparous or women who are planning a future pregnancy experience vaccine hesitancy due to the side effects of vaccines and safety concerns. 18,43Acceptance of the vaccine, knowledge, beliefs, and attitudes toward the vaccine affect childless women more.
Factors such as trust in the safety and efficacy of COVID-19 vaccines, not being afraid of possible side effects, trust in childhood vaccines, and history of past influenza vaccination may cause pregnant women to accept COVID-19 vaccines. 18,26,39,44In the present study, vaccine acceptance rates were found to be higher in pregnant women who have had the flu vaccine in the last two years.The vaccination acceptance rate was found to be lower in lactating women with a history of vaccination rejection.In the whole research population, the rate of COVID-19 vaccine rejection increased 8.5-fold in women with a history of vaccine rejection.Previous negative attitudes toward the vaccine seem to affect the rates of being vaccinated against COVID-19.HCPs have an important role in immunization programs.Trust in HCPs and scientific authorities and strong scientific evidence increases vaccine acceptance. 37All vaccinations during pregnancy are optional; however, HCPs need to inform women about the risks of contracting COVID-19 infection during pregnancy, as well as the benefits and potential side effects of current vaccines, based on available evidence, and thus build confidence.

Limitations
The study was conducted online, which brought about some negative aspects related to conducting a study in the electronic environment such as security concerns, uncertainty regarding the respondents, problems in accessing the data collection forms, and misunderstanding of the research questions.

Conclusions
As a result, the vaccine acceptance rate was found to be low in pregnant and lactating women, and in this group of women, vaccine hesitancy increased approximately 4 times compared with nonpregnant reproductive-aged women.The scarcity of data describing the safety and efficacy of the COVID-19 vaccine in pregnant and lactating women and concerns about the fetus and infant adversely affected the vaccine acceptance rates.Vaccine acceptance levels in pregnant and lactating Turkish women are insufficient to provide herd immunity.Many professional committees have provided HCPs with recommendations to assist pregnant and lactating women in making vaccine decisions.HCPs should provide individuals with evidence-based information in support of their vaccine acceptance decision and explain the risks and benefits of vaccination.Therefore, it can be stated that HCPs in primary care play a key role in informing society and individuals.Vaccination campaigns should be made especially for pregnant and lactating women and guidelines should be published.
Data Availability.Due to the sensitive nature of the questions asked in this study, survey respondents were assured raw data would remain confidential and would not be shared.

Figure 1 .
Figure 1.Reasons of pregnant, lactating, and reproductive aged women for receiving the COVID-19 vaccine.
).The median dose of the Sinovac vaccine was "2" in all reproductive age groups, and the median dose of Pfizer/ BioNTech vaccine was 1 in pregnant and lactating women, and 2 doses in nonpregnant women of reproductive age (P < 0.05).
(P < 0.05).The nonpregnant women of reproductive age preferred statements/websites of the Turkey Ministry of Health and World Health Organization (63.9%) and scientific publications such as books/magazines/articles (24.9%) to receive information about COVID-19, while the pregnant (45.2%) and lactating (40.6%) women were found to obtain information more from family and friends than women of reproductive age (29.0%;P < 0.05) (Table

Table 1 .
Main characteristics of pregnant, lactating, and nonpregnant women of reproductive age Note: X, mean; SD, standard deviation; *Kruskal-Wallis test; x 2 = chi-squared test; p < 0.05, column percentage was taken.

Table 3 .
Relationship between the main characteristics of pregnant, lactating, and nonpregnant women of reproductive age and COVID-19 vaccine acceptance

Table 4 .
Multinomial regression analysis of factors associated with COVID-19 vaccine acceptance