Europe’s maternal vaccination gap: policies exist, but delivery falls short

Across the World Health Organization’s European Region, vaccines given during pregnancy are recommended almost everywhere, yet the women they are meant to protect frequently go unvaccinated. The answer, the authors argue, lies less in vaccine hesitancy among pregnant women than in the organisational machinery, or absence of it, that surrounds the offer of a vaccine during antenatal care.

The scale of the shortfall is striking. Maternal influenza and pertussis vaccination have been part of European health policies for a decade, but influenza coverage often falls below the WHO target of 75 percent. Pertussis coverage across the European Union ranges from 2 percent to 89 percent, with a median of just 50 percent, leaving many newborns unprotected during the vulnerable first months of life. The 2023–2024 resurgence of pertussis across Member States, the paper notes, illustrates the consequences of that incompleteness. Meanwhile, the newest addition to the maternal portfolio, respiratory syncytial virus vaccination, shows what is possible when delivery works: a 2026 study found that maternal RSV vaccination given more than two weeks before delivery reduced the risk of RSV-related hospitalisation in infants under three months by 82 percent. Yet even in England, which launched the first national maternal RSV programme in Europe on 1 September 2024, coverage reached only 64 percent among women giving birth in November 2025.

The policy mapping itself reveals a layered picture. Of 212 possible country–vaccine combinations across the four vaccines studied, influenza, pertussis/Tdap, COVID-19 and RSV, 157 had pregnancy-specific recommendations. Influenza led with recommendations in 48 of 53 countries, followed by pertussis/Tdap in 44, COVID-19 in 42, and RSV in just 23, reflecting the recency of regulatory approval and WHO’s September 2024 recommendation of the RSV preF vaccine for use at 24 to 36 weeks’ gestation. But the map thins out rapidly at the operational level: only 31 policies specified funding arrangements, and only 19 named a provider or delivery point. A recommendation, in other words, frequently exists without any stated answer to who will give the vaccine, where, and whether the woman must pay.

Where funding is described, the patterns matter for uptake. Influenza vaccines are free or reimbursed in 20 of the 21 countries that specify funding, and pertussis vaccines in 21 of 23. But the Czech Republic requires women to pay out of pocket for both, a direct financial disincentive the authors link to persistently low coverage, and in Austria pertussis vaccination is recommended but not publicly funded. For RSV the landscape is more fragmented still: of twelve countries reporting funding, only four, Bulgaria, Denmark, Slovenia and the United Kingdom, offer the vaccine free, while Austria, Croatia, Norway and Portugal do not fund it, Belgium and Luxembourg require co-payments, and the Netherlands and Slovakia leave it as an out-of-pocket cost. A Dutch qualitative study identified this arrangement, in which the infant monoclonal antibody nirsevimab is free but maternal vaccination is not, as a financial barrier to uptake.

The review’s most consistent finding concerns the provider recommendation. It was recorded in 94 of 105 studies in the social processes domain, more than any other construct, and where its effect was quantified the association was large. In a French cohort, 47 percent of women were vaccinated when a provider recommended the vaccine, compared with 3 percent when no recommendation was given. In Germany, 49 percent of women vaccinated following a doctor’s advice versus 3 percent without. In Greece, women who received a recommendation had uptake rates three times higher than those who did not. Yet the offer itself reaches strikingly few women: 19 percent in Greece reported receiving an obstetrician’s recommendation, 20 percent in Germany, and the offer rate in France was approximately 25 percent. Among Italian women who refused vaccination, 43 percent said their gynaecologist or obstetrician had simply not recommended it.

Behind the missing recommendations lies a workforce problem. Only 9 of the 163 included studies, about 6 percent, addressed vaccination training for the antenatal workforce, and most of those reported deficits. In the most detailed, 86 percent of midwives in Wales agreed that offering maternal vaccines was part of their role, yet 46 percent had received no vaccination training and 81 percent requested further education. French midwives have been authorised to prescribe maternal vaccines since 2016, but training was described as lagging behind that authority. Midwifery scope of practice varies widely: of 26 studies listing midwives as providers, only two documented prescribing authority and nine reported vaccine administration. In the Netherlands, midwives inform and refer women from 22 weeks, but general practitioners or youth healthcare services perform the vaccination, a split-role model that inserts an extra step, and an extra opportunity for attrition, between recommendation and injection.

Service delivery structure emerges as a decisive variable. The review identified six delivery models across Europe, from midwife-led integrated care in Wales to primary-care-based delivery in France, Germany, Switzerland and Ireland, obstetrician-led models in Italy, Greece and Türkiye, dedicated antenatal vaccination clinics, community outreach in Spain and Moldova, and multi-provider national programmes in Finland, the Netherlands and Denmark. Where the pathway was shortened and the vaccine was available on-site at the antenatal visit, coverage improved; where it was fragmented, requiring separate prescriptions, pharmacy collections and additional appointments, uptake fell. In France, women navigated a three-step pathway of prescription, pharmacy collection and a separate administration appointment, and French cohorts showed markedly higher uptake when vaccine stock was available on-site. In an Italian study, 69 percent of women said they would prefer to be vaccinated within their own antenatal care.

Equity gradients run through the evidence. Educational level was the most studied predictor, with higher education linked to greater influenza, pertussis and COVID-19 uptake across 20 European studies. Ethnicity and migration status were the most consistently reported dimensions: in the United Kingdom, White British women were significantly more likely to be vaccinated than Black or White Other/European women, and in Belgium women with an ethnic background outside the EU had significantly lower influenza coverage than Belgian-born women. Migrant women in the Netherlands and Italy faced language barriers and reduced healthcare contact. Crucially, provider recommendations were repeatedly shown to be less frequent among ethnic minority women, and targeted provisions for migrants, refugees or women with language barriers were explicitly described in fewer than five included studies. The authors conclude that interventions aimed at hesitancy alone are unlikely to close coverage gaps, because the barriers are structural as well as attitudinal.

The evidence base itself carries caveats the authors are careful to state. Most included studies, 117 of 163, were cross-sectional surveys, and only 11 were randomised or interventional, so associations such as that between provider recommendation and uptake should be read as consistent observational signals rather than causal effects. No formal risk-of-bias appraisal was performed, in keeping with scoping review methodology. The geographic concentration is severe: 128 of 163 studies, 78.5 percent, came from Western Europe, with Italy, the United Kingdom, France, the Netherlands and Spain alone accounting for 60 percent, leaving Eastern Europe, the Balkans, the South Caucasus and Central Asia sparsely represented. Roughly a third of studies concerned COVID-19 vaccination, whose pandemic-era polarisation and shifting guidance may limit generalisability, although health-worker recommendations appeared equally frequently in COVID-19 and other vaccine studies.

From this map the authors derive a roadmap rather than a template. They call on WHO Europe and the ECDC to convene Member States around harmonised voluntary minimum standards; on ministries to make recommended maternal vaccines free at the point of antenatal care and remove pay-and-claim steps; on programme leaders to adopt antenatal care as the default delivery platform with same-day, on-site administration; on professional bodies to embed mandatory vaccination training and expand midwives’ authorisation where frameworks permit; and on health authorities to build interoperable maternity and immunisation records with coverage routinely stratified by education, ethnicity, migration status and antenatal booking timing. Governance, they note, is a necessary but insufficient condition: formal alignment between advisory bodies, ministries and professional societies establishes that a vaccine should be offered, but does not determine whether, where, or by whom it is offered in practice. Closing that gap, they argue, is the tractable path from recommendation to protection for mothers and newborns across a region whose implementation remains fragmented and inequitable.

Subject of Research: Implementation of maternal vaccination policy, delivery and uptake across the WHO European Region

Article Title: Implementing antenatal vaccination in Europe: policy frameworks, barriers, and approaches for improving uptake

Article References: Deuster, E., Sheikh, J., Allotey, J., Bardaji, A., Bijlsma, M. W., Heath, P., Ladhani, S. N., Le Doare, K., Maertens, K., Thangaratinam, S., & Khalil, A. (2026). Implementing antenatal vaccination in Europe: policy frameworks, barriers, and approaches for improving uptake. The Lancet Regional Health – Europe, 71, Article 101898. https://doi.org/10.1016/j.lanepe.2026.101898

Image Credits: AI Generated

DOI: 10.1016/j.lanepe.2026.101898

Keywords: maternal vaccination, pregnancy, Europe, vaccine policy, RSV, pertussis, influenza, COVID-19, health equity, antenatal care, vaccine hesitancy, health systems