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Vaccinations during pregnancy are an unborn child’s first immunisation event. They are a safe, effective way of protecting hapū māmā (pregnant people) and pēpi (babies) against whooping cough (pertussis), influenza, and Covid-19 which are more likely to be severe during pregnancy and in early life. Despite being recommended for many years, fewer mothers receive pertussis (48% in 2020) and influenza (44% in 2020) immunisation in Aotearoa New Zealand (NZ) than in Australia and the United States. Importantly, although the risk of these diseases is highest among Māori, Pacific Peoples, and people living in areas of high deprivation, these groups are less likely to be immunised during pregnancy. Thus, to protect pēpi and hapū māmā from severe disease, urgent steps are needed to boost maternal immunisation particularly for Māori, Pacific Peoples, and those living in marginalised communities. Such steps will complement the recently announced health target of 95% of children receiving all recommended immunisations by 24 months of age.

Maternal vaccination protects māmā during pregnancy and are the first immunisation event for pēpi, protecting them during the first months of life when they are vulnerable to infection but not yet old enough to be immunised themselves.1  This briefing outlines how we are performing in equitable maternal immunisation coverage in Aotearoa New Zealand (NZ) within the context of childhood immunisation targets, and reviews opportunities for raising immunisation coverage in this key group. 

Why is maternal immunisation important?

In NZ, deaths from pertussis occur almost exclusively in unimmunised infants.2 Among infants who require intensive care, permanent brain or lung damage is common.2 In 2023, 20 infants under 5 months old were hospitalised with pertussis, most of which were Māori or Pacific pēpi3. Four of these infants died4

The risk of complications from influenza infection in pregnancy is substantial for hapū māmā2; 5. Influenza in pregnancy increases the likelihood of preterm birth and low birth weight6 and may also be associated with an increased risk of maternal6, fetal, and neonatal death.5

Covid-19 vaccination is also recommended and funded for all hapū māmā in New Zealand, but is not included in this study.1

Maternal immunisation coverage: current evidence

Maternal immunisation coverage in NZ is below 50% and Māori and Pacific people are significantly less likely to be immunised than other groups.7 Those from areas of high deprivation are also less likely to be immunised, with Māori and Pacific māmā living in these areas at greatest disadvantage. These findings reflect stark inequities in access to maternal health care and signal the need for system change. 

Geospatial analyses from 2013 to 2020 found the low overall maternal immunisation coverage meant that more than 90,000 women and their babies were not protected.8 Significant regional variation in maternal immunisation coverage for influenza and pertussis was also concerning.8 Areas such as Canterbury, Auckland and Capital & Coast have relatively high levels of immunisation coverage compared to Tairāwhiti, Waikato, Northland, Bay of Plenty, West Coast and Taranaki (Figure 1). These findings are available in our interactive app (Figure 2) at: and a summary of immunisation coverage from 2013–2020 can be found in the Appendix below. Many areas with low maternal immunisation rates also have persistently low childhood immunisation coverage.9 However, there are further intra-regional variations as declining and stagnating coverage can be found even in more affluent areas.10 

Figure 1. Overall level of maternal immunisation coverage for Influenza and Pertussis from 2013 to 2020 by District Health Board.

Colour coded maps of NZ and charts showing local immunisation rates in NZ
Colour coded maps of NZ and charts showing local immunisation rates in NZ
Figure 2.  A screenshot of the interactive app Shiny app example (condition, by year).
Screenshot of app showing colour-coded map of NZ
Screenshot of app showing colour-coded map of NZ

Unlocking opportunities for equitable improvements

Many factors contribute to poor and inequitable immunisation uptake including accessibility of maternal healthcare11, transport and childcare costs, and time constraints.12 Outstanding bills at general practices can prevent some māmā from seeking free immunisations13 or they may assume there will be an associated charge.14 Lack of awareness about disease severity and the availability and importance of maternal immunisation15, particularly among Māori and Pacific whānau (extended families)16, and a mistrust of the health system also contribute.17 

Recent challenges with the Covid-19 immunisation rollout resulted in the spread of misinformation, mistrust and vaccine hesitancy which has extended to childhood and maternal immunisations.18 Innovations in service delivery to improve coverage of the Covid-19 immunisation drive proved effective in the pandemic response, but these have largely not been carried over into the other funded immunisations in NZ.19 

The government proposes immunisation targets and incentives for general practice to improve immunisation coverage so that 95% of tamariki are fully immunised at 24 months of age. It is not clear whether these targets will improve maternal immunisation as having targets only for childhood immunisation could divert attention away from immunising hapū māmā. Hapū māmā who are immunised may be more likely to vaccinate their pēpi20, so including hapū māmā in targets could be beneficial. 

Health targets have previously improved childhood immunisation coverage and significantly reduced inequities for Māori and Pacific.21 These targets were effective because the previous District Health Boards (DHBs) were accountable for meeting them and for coordinating the health services within their region.22 However, if accountability for the new proposed targets is with general practice, this will put pressure on primary care and risk inadequate resources for an already stretched sector.  Accountability at general practice level may also worsen outcomes for whānau who need additional support with immunisation, as they may have difficulty enrolling with a practice which is focused on reaching targets.23

A multifaceted approach is needed to improve immunisation uptake nationally. Our research team is collaborating with the healthcare sector in an HRC-funded project to co-design interventions with iwi healthcare providers to improve maternal immunisation coverage. We are taking a multisystem approach, developing tools and resources to support health systems to work effectively, healthcare providers provide services, and individuals to be vaccinated. If we can demonstrate success, our ambition is for the resources and tools developed during this project to be implemented across NZ to improve immunisation coverage and health outcomes for whānau. 

What's new in this briefing?

  • Maternal immunisation coverage needs to improve. With the ongoing threat of pertussis outbreaks and seasonal influenza, hapū māmā and pēpi continue to be at risk of severe infection.
  • There is particularly low coverage for Māori and Pacific people and those in deprived communities that are likely to be more vulnerable to rapid spread of infectious diseases.
  • Whilst immunisation targets can work to reduce inequities, providing monetary incentives for boosting coverage at the health provider level could drive further inequitable service delivery. 

Implications for public health policy and practice

  • Systems changes are needed to immunise the communities who need it most. Healthcare providers need to get the information and services to them so whānau are able to make informed decisions and then access the services they need.
  • Immunisation targets and incentives, if used, need to also include maternal vaccination 
  • Interventions to improve immunisation coverage need to be multifactorial, tailored to communities and contribute to equitable outcomes.

Author details 

Dr Amber Young, He Rau Kawakawa | School of Pharmacy, Te Whare Wānanga o Ōtākou | University of Otago, Ōtepoti | Dunedin

Dr Matthew Hobbs, Faculty of Health | Te Kaupeka Oranga, and GeoHealth Laboratory | Te Taiwhenua o te Hauora, University of Canterbury | Te Whare Wānanga o Waitaha, Christchurch | Otautahi, New Zealand | Aotearoa.

Associate Professor Esther Willing, Kōhatu - Centre for Hauora Māori | Division of Health Sciences | Te Whare Wānanga o Ōtākou, University of Otago| Ōtepoti | Dunedin, New Zealand | Aotearoa

Dr Gabrielle McDonald, Kōhatu - Centre for Hauora Māori | Division of Health Sciences | Te Whare Wānanga o Ōtākou, University of Otago| Ōtepoti | Dunedin, New Zealand | Aotearoa

Dr Pauline Dawson, Women’s And Children’s Health | Te Tari Hauora Wāhine me te Tamariki, Dunedin School of Medicine | Te Kura Whaiora o Ōtepoti, University of Otago | Te Whare Wānanga o Ōtākou, Ōtepoti | Dunedin

Dr Lukas Marek, GeoHealth Laboratory | Te Taiwhenua o te Hauora, University of Canterbury | Te Whare Wānanga o Waitaha, Christchurch | Otautahi, New Zealand | Aotearoa

Dr Louise Fangupo, He Rau Kawakawa | School of Pharmacy, Te Whare Wānanga o Ōtākou | University of Otago, Ōtepoti | Dunedin

Professor Peter McIntyre, Women’s And Children’s Health | Te Tari Hauora Wāhine me te Tamariki, Dunedin School of Medicine | Te Kura Whaiora o Ōtepoti, University of Otago | Te Whare Wānanga o Ōtākou, Ōtepoti | Dunedin

Appendix 1 – A summary of influenza and pertussis coverage in pregnancy 2013-2020

Infographic showing charts and statistics relating NZ influenza immunisation in pregnancy
Infographic showing charts and statistics relating to NZ pertussis immunisation in pregnancy

Creative commons

Public Health Expert Briefing (ISSN 2816-1203)


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Public health expert commentary and analysis on the challenges facing Aotearoa New Zealand and evidence-based solutions.


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