Pregnant women are at increased risk of severe illness and adverse pregnancy outcomes during infectious disease outbreaks, yet they are frequently excluded from early emergency vaccine responses. This study examined how pregnant women were included in The Gambia’s COVID-19 vaccine rollout and identified priorities to strengthen pregnancy-inclusive preparedness for future emergencies.
The study used a qualitative exploratory design combining semistructured key informant interviews with a subsequent participatory workshop featuring facilitator-guided group discussions. Analysis followed a hybrid deductive–inductive framework synthesis approach guided by the Consolidated Framework for Implementation Research (CFIR). This approach allowed mapping of observed implementation factors across established domains to inform actionable strategies.
Data were collected in The Gambia within Ministry of Health facilities and at a national workshop venue. Collection took place between September 2023 and November 2024, after the national expansion of COVID-19 vaccine eligibility to pregnant women in The Gambia. The study engaged 15 key informants—healthcare workers and policy influencers involved in maternal health, immunisation and vaccine policy—and 29 participants in the participatory workshop.
Across CFIR domains, multiple determinants influenced how pregnancy-inclusive vaccination was implemented. Evolving safety and eligibility guidance emerged as a cross-cutting influence that affected provider confidence, counselling practices and community acceptance. The analysis grouped facilitators and barriers into outer-setting, inner-setting and individual-level factors to clarify where interventions are needed.
Community-level and external factors shaped uptake and acceptance. Misinformation circulating in households and communities reduced confidence and increased hesitancy. Social influence within families played a key role in pregnant women’s decisions. At the same time, trust in Ministry of Health actors and public endorsement by religious and traditional leaders supported acceptance, indicating that community engagement and credible messengers are important outer-setting levers.
Service organisation and system-level constraints limited integration of vaccination for pregnant women. Delivery pathways were fragmented and not integrated into routine antenatal care, creating missed opportunities for vaccination. Logistical challenges included transport and cold-chain issues that impeded reliable vaccine delivery. Weak documentation and limited adverse event reporting reduced visible safety reassurance for both providers and communities.
Healthcare workers were described as trusted advisers for pregnant women, but they faced constraints that limited effective vaccine delivery. Staffing pressures and long waiting times undermined service accessibility. Providers had limited access to timely, pregnancy-specific information when guidance evolved, which reduced confidence in counselling. Conversely, visible role-modelling by health personnel and leaders supported vaccine acceptance among pregnant women.
Participants recommended multifaceted strategies addressing guidance, workforce, logistics, data and community engagement. Key priorities identified were:
The study concluded that pregnancy-inclusive emergency vaccination requires coordinated action across evolving guidance, community engagement, service organisation, workforce readiness and safety monitoring. Embedding these determinants within routine preparedness—rather than relying on ad hoc emergency responses—can improve equity and effectiveness of vaccine delivery for pregnant women. The findings highlight actionable areas for policy makers and health system planners to prioritize if they aim to include pregnant populations early and effectively in future emergency vaccination efforts.
The source provided participant numbers, data collection timeframe and the analytical framework used. Specific methodological details beyond those reported in the source excerpt (for example, interview guides, full sampling approach, or explicit limitations) were not provided in the excerpt and therefore are not summarized here.