Immunization

Midwife and client with baby discuss vaccination

Vaccination recommendations and guidelines are constantly changing. Pregnant people are at greater risk than non-pregnant people for more severe illness from exposure to some vaccine-preventable diseases. Accordingly, midwives need to be aware of current guidelines for vaccinations that can be offered to pregnant people.

Five things midwives need to know about vaccination in pregnancy and infants

How midwives can support informed choice

Midwives are well-positioned to support clients in making informed choices about immunization for themselves and their families. Midwives can increase their confidence and competency in navigating these discussions by engaging in continuing education opportunities. Further, midwives can direct clients towards reliable, accessible and evidence-based resources to help families pursue their own research and education.

  • The Canadian Association of Midwives has developed resources for midwives and clients to learn more about immunization and to support health decisions.
  • The University of British Columbia offers a free, online 1-hour course "Midwifery Immunization Communication" that provides midwives with tools to educate clients about the science and role of vaccines and immunizations in the perinatal period and beyond.  
  • The Vaccines in Pregnancy Canada website provides clients and families with evidence-based information with the goal of providing the knowledge and tools to make informed, confident decisions about vaccination in pregnancy. The website is maintained by a partnership of universities and children's hospitals.

How a vaccine becomes approved for use in care

The journey of a vaccine from bench to bedside involves a series of rigorous steps.

  1. Vaccine development (the "bench" stage) involves exploratory trials (scientists develop a vaccine), preclinical trials (lab and animal studies) and clinical trials (multi-phase trials with human volunteers). 
  2. During the scientific review stage, Health Canada assesses vaccine safety before approving use in clinical care. They will approve a vaccine if it is safe, it works, it meets manufacturing standards, and the benefits outweigh the risks.
  3. The government coordinates the purchase, logistics and distribution of vaccines across Canada.
  4. The National Advisory Committee on Immunization (NACI) will make recommendations for the use of vaccines in Canada, including targeting vaccines to at-risk groups, but each province/territory leads their own implementation of these recommendations.
  5. The Public Health Agency of Canada (PHAC) and Health Canada are responsible for monitoring vaccines use and reporting on side effects related to immunization.

Since many clinical trials exclude pregnant persons as study participants, the Society of Obstetricians and Gynecologists of Canada (SOGC) and the AOM, as well as similar bodies around the world, summarize and share knowledge with care providers related to infectious diseases during childbearing.

What vaccines are included in the Ontario midwifery drug regulation

The Ontario Designated Drugs and Substances Act was updated in 2024 and now includes that midwives may prescribe and/or administer an increased number of routine vaccinations and immune globulins for both clients and infants. The regulation includes that midwives may administer any medication on the order of a physician (member of the CPSO) or a nurse practitioner (member of the CNO who holds an extended certificate of registration as a registered nurse). Midwives should review the regulation and familiarize themselves with the vaccines listed.

Some additional resources:

  • The Ontario Public Health webpage contains client-friendly information about vaccines for babies.
  • Toronto Public Health has published this handy printable chart of the Ontario publicly funded immunization schedule (applicable to health regions across Ontario).
  • The Canadian Immunization Guide outlines recommendations for immunizations for clients that have missed, unknown or interrupted vaccination series.
  • The AOM RM Rx mobile app provides easy to access information for quick refreshers while on-the-go, including dosing, warnings and precautions.

What to document when administering a vaccine

Documentation for vaccine administration is of key importance, both for pregnant individuals and infants. While a national vaccination registry is not yet in place, there are multiple levels of surveillance in place to protect Canadians.

The following should be recorded:

  • Date and site of administration
  • Medication name, drug identification number (DIN), dosage, lot number, expiry date

If a client has a yellow immunization record card, a midwife can update it with any vaccines they administer. Midwifery practice settings where publicly funded vaccines are administered may order new yellow immunization cards from their public health unit. These cards can be issued by midwives to newborns.

How to report adverse events following immunization

In Ontario, adverse events following immunization (AEFI) are reported to Public Health Ontario (PHO). To report an AEFI, the provider can complete an AEFI Reporting Sheet (available on the PHO website) and submit it directly to their local public health unit. AEFIs can include an untoward sign or symptom, or even a disease that occurs after a person receives a vaccine. More severe AEFIs can include anaphylaxis or hospitalization. Mild AEFIs must be reported within 7 days of becoming aware of it, while severe AEFIs must be reported within 1 business day.

  • See this fact sheet from Public Health Ontario for more information about AEFIs, including a list of the types of adverse events to report.
  • You can use this directory to find your local public health unit website and contact information.

The Special Immunization Clinic (SIC) Network has experts to manage care for individuals that have had an AEFI or who are at high risk of an AEFI. Reports of AEFIs are investigated and then gathered from all jurisdictions and reviewed by Public Health Association of Canada (PHAC) and Health Canada in the Canadian Adverse Events Following Immunization Surveillance System (CAEFISS) surveillance system. A national screening program is also in place to review hospital admissions of pediatric patients to investigate if it may be related to vaccination complications.

Common Exposed Illnesses and their Recommendations

Influenza

The influenza vaccine should be offered to all pregnant people at any stage of pregnancy to protect against influenza-related morbidity and mortality. (1, 2) Guidelines from the NACI are published annually ahead of the flu season.

For more detail, visit the AOM Influenza webpage.

Tdap (Tetanus, Diphtheria, Pertussis)

Tdap vaccination should be offered to all pregnant people in every pregnancy, regardless of previous Tdap vaccination history, as a means of protecting the infant from pertussis. (2, 3)

The National Advisory Council on Immunizations (NACI) recommends vaccination between 27 and 32 weeks (3); the SOGC recommends Tdap between 21 and 32 weeks. (2)

Ontario's integrated Public Health Information System (iPHIS) reported a significant surge in cases of pertussis in 2024.

COVID-19

The NACI and the SOGC recommends all pregnant people get vaccinated, regardless of trimester or chest/breastfeeding status. 

PHAC states that for those who were previously vaccinated, pregnancy is an indication for an annual dose of COVID-19 vaccine, although there is no specific recommendation for a dose of COVID-19 vaccine in every pregnancy. Pregnant individuals are not included in the list of higher risk individuals for whom two doses of COVID-19 vaccine per year are recommended.

See also the AOM COVID-19 webpage.

Respiratory syncytial virus (RSV)

The RSV vaccine is available to pregnant residents of Ontario from 32 to 36 weeks gestational age who will give birth near the start of or during the respiratory illness season.  When administered during pregnancy at least 2 weeks prior to birth, infants are protected from birth up to six months of age.

Nirsevimab is a long-acting monoclonal antibody, not a vaccine, for RSV prophylaxis in infants. It can be administered to infants born during RSV season shortly after birth.

For most dyads, one of these options is sufficient. NACI recommends nirsevimab as the preferred product to protect infants due to current evidence of superior efficacy, duration of protection, and available safety data.

Read more about immunization options and find additional resources on the AOM RSV page.

Rubella

Immunity to rubella can be assumed if there is documentation of an individual having received one dose of a rubella vaccine (e.g. MMR) after 12 months of age, laboratory-confirmed disease, or laboratory evidence of immunity. (2) No additional rubella vaccine is required postpartum for clients who meet the above criteria, even when there is no rubella IgG detectable by conventional assays.

If vaccination after 12 months cannot be confirmed by documentation and there is no serologic evidence of immunity or laboratory-confirmed disease, a booster of the rubella vaccine in the postpartum period is considered best practice. The SOGC advises delaying rubella vaccination if the client received Rh-immune globulin or other blood products. (2)

Hepatitis B

The SOGC (2018) recommends that seronegative pregnant people at high risk for acquiring hepatitis B infection during pregnancy be offered recombinant hepatitis B vaccine series, which is not contraindicated in pregnancy. Pregnant people at high risk include:

  • those with more than one sex partner within the last six months
  • those being evaluated or treated for an STI
  • those with recent or current injection drug use
  • those with exposure to a partner with a known hepatitis B infection
  • health care workers
  • household contact with an individual with known hepatitis B
  • those who are susceptible to hepatitis B infection (hepatitis B surface antigen and antibody negative)

Hepatitis A

Vaccinating pregnant people for hepatitis A is indicated when the person is travelling to an endemic area or when there has been close contact to a person with a known hepatitis A diagnosis. Infection with hepatitis A may lead to liver failure.

Special circumstances or populations and considerations

 
Circumstance/population Consideration
Travel Common immunizations for international travel include:
  • Cholera and travellers’ diarrhea
  • Hepatitis A
  • Meningococcal disease
  • Yellow fever 

Recommendations around vaccinating pregnant travelers are dependent on multiple factors, including the destination, duration of travel, risk of contracting the disease, and the severity of the effect of the disease and/or the vaccine on the pregnant person and/or fetus. For information on travel vaccinations, refer to Public Health Agency of Canada's Statement on Pregnancy and Travel. 

Midwives should be aware that travel within North America may also expose clients to preventable and unpreventable infectious diseases. For example, the US has had reported cases of West Nile virus transmitted by mosquitos, but no vaccination is available. On the other hand, dengue fever has also been reported and a vaccine to prevent infection is available.   
Newcomers and/or migrants

Newcomers, refugees and internationally adopted infants in midwifery care may require additional considerations including:

  • Arriving without records or documentation
  • Differences in immunization schedules
  • Differences in vaccine availability or formulations 
  • Differences in immunization recommendations
Midwives

As a largely gendered health care workforce, midwives are at greater risk for exposure to infectious diseases, including during pre-conception and pregnancy periods. Practicing midwives and practice groups should consider the risk of exposure to themselves and exposure to clients, particularly with higher case counts for preventable infections like pertussis or measles in recent years.  

Additional resources

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Safe medication practice 
AOM webpage on safe prescribing and administration of medication.

Prescribing medication new to midwives 
AOM webpage with an FAQ about prescribing medications that are new to a midwife.

Vaccine storage & handling 
AOM webpage with information, resources and an FAQ about safe vaccination storage, handling and transportation.

Guideline: No. 357 - Immunization in Pregnancy (2018)
The Society of Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guideline about immunizations in pregnancy.