How were pregnant women included in emergency COVID-19 vaccine delivery in The Gambia? A qualitative study of perspectives of healthcare workers and policy influencers.

Abstract

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. During the COVID-19 pandemic, evolving pregnancy-specific safety evidence contributed to delayed and inconsistent guidance, complicating integration of vaccination into routine maternal health services. 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. We conducted a qualitative exploratory study in The Gambia using semistructured key informant interviews with healthcare workers and policy influencers followed by facilitator-guided group discussions during a participatory workshop. Data were analysed using a hybrid deductive-inductive framework synthesis approach guided by the Consolidated Framework for Implementation Research (CFIR). The Gambia, within the Ministry of Health facilities and a national workshop venue. Data were collected between September 2023 and November 2024, following national expansion of COVID-19 vaccine eligibility to pregnant women in The Gambia. 15 key informants (healthcare workers and policy influencers involved in maternal health, immunisation and vaccine policy) and 29 participants in a subsequent participatory workshop. Across CFIR domains, implementation was shaped by evolving safety and eligibility guidance, which reduced confidence in counselling and contributed to hesitancy. Outer-setting influences included misinformation and social influence within households and communities, alongside trust in ministry of health actors and endorsement by religious and traditional leaders. Inner-setting constraints included fragmented delivery pathways not integrated into antenatal care, transport and cold-chain challenges, and weak documentation and adverse event reporting that limited visible safety reassurance. At the individual level, healthcare workers were trusted but constrained by staffing pressures, long waiting times and limited access to timely information, while visible role-modelling supported acceptance. Suggested strategies included early training, cross-cadre coordination, strengthened logistics and data systems, improved safety monitoring and communication, and investment in workforce retention and sustainable financing. Pregnancy-inclusive emergency vaccination requires coordinated action across 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 globally.