Health Systems Determinants of Delivery and Uptake of Maternal Vaccines in Low- and Middle-Income Countries: A Qualitative Systematic Review

Abstract

Maternal vaccination is considered a key component of the antenatal care package for improving maternal and child health. Low- and middle-income countries (LMICs) fall short of global targets to prevent maternal and neonatal deaths, with a disproportionate burden of vaccine-preventable diseases. Strategies towards ending preventable maternal mortality necessitate a health systems approach to adequately respond to this burden. This review explores the health systems determinants of delivery and uptake of essential maternal vaccines in LMICs. We conducted a qualitative systematic review of articles on maternal vaccination in LMICs, published between 2009 and 2023 in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Thematic analysis was conducted to identify key themes in the literature, interpreted within a conceptual framing that explores the systems determinants influencing maternal vaccines. Our search yielded 1309 records, of which 54 were included, covering 34 LMICs. Most of the included studies were from South America (28/54) and included pregnant women as the primary study population (34/54). The studies explored influenza (25/54) and tetanus toxoid (20/54) vaccines predominantly. The findings suggest that systems hardware (lack of clear policy guidelines, ineffective cold-chain management, limited reporting and monitoring systems) are barriers to vaccine delivery. Systems software (healthcare provider recommendations, increased trust, higher levels of maternal education) are enablers to maternal vaccine uptake. Findings show that formulation, dissemination and communication of context-specific policies and guidelines on maternal vaccines should be a priority for decision-makers in LMICs.

Vaccination Guidelines for Pregnant Women: Addressing COVID-19 and the Omicron Variant

“…The gestation period is associated with increased susceptibility to infections and often their severe course, as well as adverse effects on the fetus resulting from infection with specific pathogens [ 15 , 16 ]. Pregnancy causes a decrease in the number of B1 cells, which influences on deficiency of IgM antibodies and a decrease in the functionality of B cells [ 3 ].…”

“…These changes weaken the innate immunity of the pregnant woman and increase her susceptibility to infections [ 17 – 19 ]. During pregnancy, the activity of the complement system also increases, causing an increase in the immune response to some antibodies (eg, against influenza), leading to various obstetric complications (eg, preeclampsia) [ 15 ]. At the same time, adaptation in the mother’s immune system is the site of many physiological changes that protect her and the fetus from pathogens [ 5 , 16 , 17 ].…”

Lessons learned from COVID-19 vaccine acceptance among pregnant and lactating women from two districts in Kenya to inform demand generation efforts for future maternal RSV vaccines

“…Globally, tetanus toxoid-containing vaccines are the most widely vaccine recommended during pregnancy, with the majority of countries having a policy in place for maternal tetanus immunization [ 8 , 9 ]. Despite long-standing efforts to eliminate maternal and neonatal tetanus, 18 low- and middle-income countries have yet to achieve elimination, and several countries are still not meeting tetanus toxoid-containing vaccine coverage targets [ 9 , 10 ]. Barriers to optimal maternal vaccine uptake include health system issues, such as staff shortages and inadequate reporting systems [ 10 ].…”

“…Despite long-standing efforts to eliminate maternal and neonatal tetanus, 18 low- and middle-income countries have yet to achieve elimination, and several countries are still not meeting tetanus toxoid-containing vaccine coverage targets [ 9 , 10 ]. Barriers to optimal maternal vaccine uptake include health system issues, such as staff shortages and inadequate reporting systems [ 10 ]. However, healthcare provider (HCP) recommendation, effective communication between HCPs and beneficiaries, and HCP awareness of vaccination policies have also been shown to be important barriers to uptake [ 10 ].…”

“…Barriers to optimal maternal vaccine uptake include health system issues, such as staff shortages and inadequate reporting systems [ 10 ]. However, healthcare provider (HCP) recommendation, effective communication between HCPs and beneficiaries, and HCP awareness of vaccination policies have also been shown to be important barriers to uptake [ 10 ]. Proactively compiling experiences prior to introduction of RSV maternal vaccines in settings such as Kenya may help to increase maternal acceptance and uptake.…”