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

Maternal vaccination is a highly effective "three-for-one" intervention, protecting pregnant women, the fetus and the newborn infant from severe infectious disease. Yet implementation across Europe remains fragmented and inequitable, and no synthesis has jointly examined how health-system functions and behavioural drivers shape uptake and equity. We mapped policies across all 53 WHO European Region countries alongside a PRISMA-ScR-compliant scoping review (MEDLINE, Embase, CINAHL and Scopus; 2010-2025), applying the WHO health-system building blocks and Behavioural and Social Drivers frameworks to influenza, pertussis, COVID-19 and RSV vaccination. Across 163 included studies and policy sources, the evidence base was concentrated in Western Europe (128 studies, 78.5%). Antenatal uptake was highest where vaccines were free at the point of care, integrated into routine antenatal care, and delivered by empowered midwifery and primary care teams with clear responsibility for recommending and administering vaccination. Persistent inequalities by education, ethnicity, migration status, and late booking reflected structural access barriers and variable provider engagement as much as individual hesitancy. We propose a European roadmap linking harmonised policy standards, sustainable financing, antenatal integration, workforce training, modern information systems, and WHO Behavioural and Social Drivers communication and outreach strategies. This article contributes to the Lancet Regional Health Europe series "The future of maternal health in Europe".