Determinants of COVID-19 Vaccination Decision-Making Behaviors among Pregnant Women in Sub-Saharan Africa: A Scoping Review

Despite the availability of the coronavirus disease 2019 (COVID-19) vaccination, uptake among pregnant women in Sub-Saharan Africa has been low. This scoping review aimed to identify and characterize determinants influencing COVID-19 vaccination decision-making behaviors among pregnant women in Sub-Saharan Africa. We searched five online databases for articles on COVID-19 vaccination among pregnant women in Sub-Saharan Africa. We identified studies published in English between March 2020 and April 2023 that assessed vaccine-specific issues, psychosocial constructs, and contextual factors associated with COVID-19 vaccination decision-making behaviors. Of the fourteen studies identified, over half (57.1%) were cross-sectional; three used qualitative research methods; and three involved multi-country participants. Most studies assessed COVID-19 vaccination acceptability and willingness. Overall, 85.7% of the publications examined knowledge, attitudes, or both as critical factors associated with COVID-19 vaccination. The prevalence of COVID-19 vaccine uptake during pregnancy was low in Sub-Saharan Africa (14.4–28%). While most current studies assess COVID-19 vaccination knowledge, research on maternal vaccination in Sub-Saharan Africa would benefit from the inclusion of theory-informed and driven studies that measure additional psychosocial factors and contextual constructs. Future studies should also employ study designs that can determine causal pathways of vaccination determinants and vaccination uptake.


Introduction
The World Health Organization (WHO) estimated that by October 2022, over 12 million cases and 255,912 deaths related to coronavirus disease 2019 (COVID- 19) would have been reported in Africa [1,2] Although COVID-19 cases in Sub-Saharan Africa account for approximately 2% of all those reported globally [1,3], most countries in Sub-Saharan Africa have inadequate epidemiological surveillance systems and have likely underestimated the impact of COVID-19 on maternal health outcomes [4,5]. Studies have consistently shown that pregnancy increases the risk of COVID-19-related complications [6,7]. In a cohort study of several sub-Saharan African countries, pregnant women infected with COVID-19 had a higher likelihood of intensive care unit (admissions (adjusted risk ratio: 2.0), respiratory support (adjusted risk ratio: 1.57), and in-hospital mortalities (adjusted sub-hazard ratio: 2.00) [8][9][10]. Data from South Africa indicated a 3.4% rise in perinatal mortality due to vaccination acceptance, intention, or uptake. The complete inclusion and exclusion criteria are included in the supplement information, Table S1.
We included studies published in English (observational studies, cross-sectional studies, clinical trials, case-control studies, cohort studies, and qualitative studies), government reports, studies from non-governmental organizations (NGOs), and dissertations conducted in Sub-Saharan Africa. We included studies published between March 2020 and April 2023 that addressed at least one of the exposures and at least one of the vaccination outcomes. We used the 3-year time frame because COVID-19 was declared a pandemic in March 2020 [28]. We excluded abstract-only publications, conference abstracts, reviews, commentaries, editorials, animal-model studies, studies that did not include pregnant women, studies examining only physiological aspects/clinical outcomes of COVID-19 vaccination outcomes during pregnancy, and studies conducted outside Sub-Saharan Africa.

Information Sources
The literature search of published studies was conducted from the following sources: Ovid Medline, Embase, Ovid Psych INFO, African Index Medicus (AIM), and ProQuest databases. The search for sources was conducted between 5 March 2023, and 5 April 2023. Search results from each database were exported and uploaded to Rayyan software [29].

Titles and Abstracts/Full-Text Screening
All citations were uploaded onto Ryann software, organized, and screened for duplicates [29]. Two reviewers (SAA) and (BL) independently conducted an initial screening of titles and abstracts for adherence to the inclusion and exclusion criteria. The two reviewers discussed disagreements and clarified the eligibility criteria. Both reviewers then evaluated the full-text screening of all identified publications for relevant publications. Discrepancies on the inclusion and exclusion criteria were resolved through consensus and discussion with other authors (CM, KB, and SM).

Data Charting Process
After completing the full-text screening for inclusion, a data charting tool was developed by SAA to determine variables to extract, which was verified by all authors. SAA independently charted the data from the included studies by identifying key study characteristics and noting other detailed information. The charting process was shared with BL, and data charts were updated based on findings that emerged from the data. The two reviewers discussed their findings or disagreements with the other reviewers (CM, KB, and SM) and established consensus.

Data Items
For each publication included in this scoping review, we abstracted data on study characteristics and organized the studies by author's last name, publication date, country or region, study title, participants, study design, and setting. We provided an overview of each study, including the determinants influencing COVID-19 vaccination, outcomes, and conclusions. We presented findings from the review by including specific constructs reported by studies, behavioral health frameworks used, and other contextual socio-cultural aspects (politics, policies, or health systems) mentioned in the study. We also included the outcomes regarding vaccine hesitancy/acceptance, intention, and uptake rates and reported the associations with determinants. The first reviewer (SAA) initially extracted and synthesized the data using forms obtained from JBI [30] and discussed the findings with the other authors (BL, SM, KB, and CM). The authors deliberated on the studies included for review and resolved disagreements through consensus.

Critical Appraisal of Individual Sources of Evidence
The first reviewer (SAA) conducted a critical appraisal for potential bias of the publications based on data collection methods and measures using the Joanna Briggs Institute critical appraisal tools [30] and the Mixed Methods Appraisal Tool (MMAT) [31]. We ranked the risk of bias as "low" if it was ≥70%, "moderate" if bias was 50-69%, and "high" if it was ≤49% [30]. The second reviewer (BL) assessed potential bias separately and compared the results. Discrepancies were resolved by discussion with their reviewer (CM). (See supplement information in Tables S3-S6).

Synthesis of Results
We used a second form to group publications based on reported psychosocial factors, contextual determinants, and behavioral health theories. Due to the heterogeneity of the studies (qualitative, mixed-methods, cross-sectional, and cohort studies), we used a narrative approach to analyze the included studies by utilizing text to summarize and explain findings [32]. A meta-analysis was not feasible, given the different variables assessed in the studies.

Selection of Sources of Evidence
A total of 748 studies were obtained from the Ovid Medline, Embase, Ovid Psych INFO, African Index Medicus (AIM), and ProQuest databases and exported to Rayyan software. After removing 116 duplicates, we screened 632 abstracts and titles. Following an initial screening, 569 studies were excluded, and two (2) could not be retrieved, leaving 61 publications for full-text screening. However, 49 publications did not meet the inclusion criteria, leaving 14 for the final review.
A PRISMA-SCR flow diagram describing the selection of sources of evidence is included in Figure 1 [33].

Characteristics of Sources of Evidence
The characteristics of the included studies are described in Table 1. All the included studies were observational studies [34][35][36][37][38][39][40][41][42][43][44][45][46][47], with most (n = 8) incorporating a cross-sectional study design [34,[36][37][38][39][40]42,45]. There was one prospective cohort study, two qualitative research studies, and three mixed-methods studies. No case-control, quasi-experimental, or randomized controlled trials were identified. The studies were conducted between 2021 and 2022. Two studies involved participants from multiple countries. The majority of the included studies were conducted in Ethiopia (n = 7; 50%), three in Kenya, while Cameroon and Nigeria each had one study. While ten studies were conducted in health facilities, two were conducted in the community, one was web-based, and one was conducted both online (Zoom) and in the community. Most studies included only pregnant women as study participants, although three studies compared pregnant women with other nonpregnant adults, and others included perspectives from lactating/postpartum women, healthcare workers, male family members, or policymakers. Approximately half (53%) of the quantitative studies had a sample size greater than five hundred. The study sample size in qualitative studies ranged from 18-84 participants.

Characteristics of Sources of Evidence
The characteristics of the included studies are described in Table 1. All the included studies were observational studies [34][35][36][37][38][39][40][41][42][43][44][45][46][47], with most (n = 8) incorporating a cross-sectional study design [34,[36][37][38][39][40]42,45]. There was one prospective cohort study, two qualitative research studies, and three mixed-methods studies. No case-control, quasi-experimental, or randomized controlled trials were identified. The studies were conducted between 2021 and 2022. Two studies involved participants from multiple countries. The majority of the included studies were conducted in Ethiopia (n = 7; 50%), three in Kenya, while Cameroon and Nigeria each had one study. While ten studies were conducted in health facilities, two were conducted in the community, one was web-based, and one was conducted both online (Zoom) and in the community. Most studies included only pregnant women as study participants, although three studies compared pregnant women with other non-pregnant adults, and others included perspectives from lactating/postpartum women, healthcare workers, male family members, or policymakers. Approximately half (53%) of the quantitative studies had a sample size greater than five hundred. The study sample size in qualitative studies ranged from 18-84 participants.

Critical Appraisal within Sources of Evidence
Following critical appraisals, 11 studies had a low risk of bias, while three (3) had a moderate risk. All the studies were descriptive. The qualitative studies did not provide information about the interviewers/data collectors, and there was no clarity on the research members who conducted inter-rater reliability. Two studies did not report the limitations associated with results from mixed-method designs. Many of the cross-sectional studies assessing vaccine hesitancy/acceptance reported using valid and reliable instruments. Most studies conducted appropriate statistical analysis by including multivariable regressions, but only one study identified confounding variables. The prospective study included in this review intended to measure vaccine uptake but could not adequately do so due to the unavailability of vaccines in some countries.

Results of Individual Sources of Evidence
The determinants of COVID-19 vaccination during pregnancy (vaccine-specific issues, psychosocial factors, and contextual factors) are described in Table 2. Results on vaccination acceptance/hesitancy, intention, and uptake are also presented in Table 2. Table 3 shows the associations between determinants and vaccination outcomes reported in the included studies.

Kenya
In-depth interviews (Qualitative) Communities Pregnant or lactating women (n = 29) healthcare workers (n = 20) policymakers (n = 10) Results of individual sources of evidence. * More than 10% of the participants.

Synthesis of Results
Vaccine Acceptance, Vaccine Intention, and Vaccine Uptake Studies included in the review reported information on the variables that influenced COVID-19 vaccine decision-making processes, including vaccine acceptability (hesitancy/willingness), vaccine intention, or vaccine uptake.
Vaccine Intention: Hailemariam et al. assessed COVID-19 vaccination intention as the only study outcome [39]. The study indicated that 31.3% of the study sample intended to receive the COVID-19 vaccination [39]. Vaccine intention was measured using a 6-point Likert scale in response to the question, "How likely do you think you are to get a COVID-19 vaccine when one is available?" Pregnant women with positive perceptions toward COVID-19 vaccines were three times (AOR: 3.04, p = 0.001) more likely to have COVID-19 vaccination intentions than those with negative perceptions [39].
Vaccine uptake: Out of the 14 studies, four studies assessed COVID-19 vaccination uptake among study participants [34,37,43,44]. The cross-sectional study conducted by Chekol Abebe et al. was the only study that examined vaccination uptake as the only outcome [37]. About 14.4% of the sample in an Ethiopian study had received the COVID-19 vaccination by March 2022, compared to 28% in Kenya [44]. Vaccination uptake was associated with higher knowledge (AOR: 3.52) and positive attitudes (AOR: 4.81) [37].

Vaccine-Specific Issues
Eight of the 14 studies (50%) discussed vaccine-specific issues associated with COVID-19 vaccination during pregnancy (Table 2). Vaccine effectiveness was considered among the factors influencing COVID-19 acceptance or uptake in Cameroon, Ethiopia, Kenya, and Nigeria. Study participants questioned vaccine effectiveness, with some participants stating, "I think it is not well studied" [35]. About 61.8% were uncertain about vaccine efficacy [38]. Naqvi et al. reported that fewer pregnant women in Kenya (17.4%) [43] believed that COVID-19 vaccines were very effective compared to pregnant women in the Democratic Republic of Congo (29.6%) and Zambia (48.1%) [43]. In some studies, participants questioned vaccine production reliability [38,41,47]. In Cameroon, 55.1% of pregnant participants reported that they would accept the vaccine if it were produced in Africa [38]. Since pregnant women were excluded from initial vaccine trials, some were unsure whether they were eligible for vaccines [41,47].

Psychosocial Constructs
The most common psychosocial factors assessed in the studies were knowledge/awareness (n = 7) and attitudes (n = 9). A few studies reported using validated scales to measure the various variables of knowledge and attitudes [36,42]. In most studies, participants had accurate knowledge of COVID-19 vaccines [35][36][37]42]. In a few studies, positive attitudes and knowledge were associated with vaccine acceptance [36]. However, in some studies, knowledge or attitudes were not significantly associated with COVID-19 vaccination acceptance [38,42,45].
A few studies also examined risk perceptions (n = 6), with mixed results on vaccine outcomes. Most studies reported a high perceived risk of COVID-19 infections, though these were not significantly associated with COVID-19 vaccination acceptance or uptake. Approximately 40% of the included studies reported fear/worry of side effects (n = 6), especially for the newborn, as reasons behind vaccine hesitancy or refusal during pregnancy. Tefara et al. report a participant's concern as "I am scared that the vaccine will pass to my baby and my baby will die. My baby could not resist the side effects" [46]. Study participants' decisions to accept vaccines were also associated with their trust in authorities (health care providers, politicians, and the government [34,38,43]. Trust was associated with vaccine hesitancy/refusal [34,43] and healthcare providers were reported as the most trusted sources of information [38]. In some cases, pregnant women did not trust the vaccine if they perceived that healthcare providers were also unvaccinated [35].

Contextual Influences
Studies using qualitative and mixed methods explored contextual factors influencing COVID-19 vaccination among pregnant women in Sub-Saharan Africa. Salient influences included social media, myths and misinformation, and a lack of clear communication with health care providers. Amiebenomo et al. [34] reported participants' references to historical events such as the Tuskegee syphilis study and claims of infertility in Kenya because of unverified speculations that tetanus vaccines from United Nations health agencies were adulterated [34]. However, in many studies, healthcare workers played a significant role in COVID-19 vaccination decision-making. Some myths and misinformation about COVID-19 vaccination were that the vaccine would cause infertility (contraceptive method), low libido in men, facial deformation, or would be used to "implant digital microchips" to control people's minds. Regarding politics/policies, some studies reported a lack of policy guidance on vaccination during pregnancy [41,47].
In studies conducted earlier in the pandemic, inadequate policy information influenced patient-provider recommendations [40,42]. A few studies assessing the role of influential leaders in religious and political settings did not report any significant association with COVID-19 vaccine acceptance or willingness. However, in a few studies, participants were hesitant to receive COVID-19 vaccines based on their religion, with some believing that COVID-19 was a punishment and should be addressed through prayers [46]. Before vaccines became available, pregnant women were willing to pay for the vaccines when they became available [43]. However, the cost of transportation to vaccination sites was reported as a potential barrier [41].

Inclusion of Behavioral Health Theories/Models
Although several studies measured psychosocial constructs, very few mentioned behavioral health theory constructs to frame and support their studies. The Knowledge Attitudes and Practice (KAP) Survey Model was used in two studies, though the authors did not always explicitly mention it as the guiding framework [37,44]. Limaye and colleagues mention the socio-ecological approach in the title and abstract but do not explicitly provide an application of the framework in their study [41].

Associations between COVID-19 Vaccination Determinants and Outcomes
Knowledge, attitudes, and risk perceptions were significantly associated with COVID-19 vaccination acceptance/willingness to take vaccines. Positive attitudes towards COVID-19 vaccination were associated with vaccination intention. Studies that examined vaccine uptake reported significant associations with perceived risk, knowledge, and attitudes (Table 3).

Summary of Evidence
This study reviewed fourteen studies on COVID-19 vaccination among pregnant women in Sub-Saharan Africa. The included studies, mainly cross-sectional observational studies, were conducted between March 2021 and April 2022, with the majority assessing COVID-19 vaccination acceptance as the primary outcome. Findings from the included studies conveyed vaccine hesitancy. WHO's Strategic Advisory Group of Experts on Immunization defines vaccine hesitancy as "a delay in acceptance or refusal of vaccination despite the availability of vaccination services [48,49]. Two studies assessed intention, while one reported vaccine uptake as the dependent variable.
Although emergency use of COVID-19 vaccines was made public in November 2020 [50,51], many countries in Sub-Saharan Africa did not receive vaccines until mid-2021 [3] through the COVAX initiative [14][15][16]52]. In addition, policies on COVID-19 vaccination during pregnancy varied across countries, as governments and health agencies relied on studies assessing vaccine safety and efficacy before making recommendations [53].
While it is unclear whether all countries in Sub-Saharan Africa have COVID-19 vaccines, recent data suggest vaccination efforts across countries [2,3,54]. Similar to prior systematic studies [25,55], pregnant participants in the included studies in this scoping review had low to moderate rates of COVID-19 vaccination acceptance. Many countries in Sub-Saharan Africa have scaled up vaccination efforts [3,53,54], with a few countries attaining their goals. Data on COVID-19 vaccination uptake during pregnancy in Sub-Saharan Africa is limited, as many countries report aggregate vaccination rates [54].
A systematic review of the COVID-19 vaccine among pregnant people in the United States reported COVID-19 vaccine intentions of 41-47.80% before vaccines became available [25]. Similar to our study findings, acceptability rates did not improve despite vaccine availability in the United States [25]. Rawal and colleagues reported the lack of provider counseling and fear of side effects as determinants of COVID-19 acceptance [25], results that closely matched our study outcomes. However, our study reported that family/friends, religious leaders, politicians, and the media influenced COVID-19 vaccination among pregnant women in Sub-Saharan Africa. These findings suggest the need to strengthen patient-provider communication and ensure the timely dissemination of accurate information in the region. Unlike the United States, the different country policies, health system infrastructure, and limited access to COVID-19 vaccines may have impacted vaccination acceptance and uptake.
Low vaccine coverage in Sub-Saharan Africa can partly be attributed to vaccine hesitancy due to a lack of confidence in vaccine safety, low perceived susceptibility to COVID-19, misinformation about the vaccine, and distrust of governments and public health authorities [56]. Positive attitudes toward the vaccine and a higher perceived risk of COVID-19 infection are associated with lower vaccine hesitancy [57]. However, in Sub-Saharan Africa, due to the variations in the impact of COVID-19 across countries, studies report mixed findings about the perceived risk of COVID-19 infection [4]. Researchers have examined determinants such as perceived risk and fear of side effects due to COVID-19 vaccination in the general population [55,58] and used findings from clinical studies to address COVID-19 vaccination concerns.
Several studies in this review reported low vaccine acceptability due to concerns about vaccine efficacy and effectiveness, despite prior research indicating that COVID-19 vaccines are safe and effective during pregnancy [8,19,20]. Contrary to a study conducted in 2020 by the African CDC across 15 African countries where about 78% of women were willing to take the COVID-19 vaccine [14], vaccine acceptance rates were much lower among pregnant women in this review. Uncertainty about vaccine production has also been reported in other studies in Africa [14,59]. The fast-track vaccine development raised questions about vaccine efficacy [60], given that some pharmaceutical drugs can take decades before being authorized for use [61].
Governments should engage community health workers and individuals working directly with women at the grassroots to enhance vaccine acceptability among pregnant populations in Sub-Saharan countries. For example, public health officials could leverage the role of community influencers and faith leaders in communicating about vaccine safety and effectiveness in pregnancy. COVID-19 vaccine coverage could also be increased by offering accurate information to media houses (Radio, TV, and newspapers), religious leaders, and government officials.
Over 90% of the included studies assessed knowledge or attitudes associated with COVID-19 vaccination, with a few authors using validated scales and providing a rationale for examining knowledge, attitudes, and practices associated with vaccination. Studies in this review reported high knowledge rates about COVID-19, although this was not always significantly associated with vaccine acceptance or uptake [38,45]. Positive attitudes towards COVID-19 vaccination did not always predict COVID-19 acceptance [42], which was comparable to other global studies [25]. The mixed findings from studies that examined only knowledge and attitudes as psychological factors suggest a need to address other factors that could influence vaccination.
Some studies included in this review also examined perceived risk, trust, and fear as psychosocial constructs influencing COVID-19 vaccination decision-making or uptake during pregnancy [34,38,39]. The fear of side effects from COVID-19 vaccines could be due to limited communication about vaccine safety during pregnancy. Studies in this review reported that healthcare providers' lack of effective communication with pregnant women has contributed to low vaccine acceptance [41,46]. Among pregnant populations in the United States, fear of adverse side effects influenced COVID-19 vaccination decisionmaking [25]. Some other research suggests that lack of trust in health authorities (health providers/health ministries) in Sub-Saharan Africa may be attributed to prior events, such as Polio vaccinations in Nigeria [62] and deworming efforts in Ghana [59,63], where there were concerns about the disease prevention efforts being conducted. Vaccine mistrust in Africa is linked to the history of colonial clinical and vaccine research abuse in Africa [59] and possibly the medical apartheid experienced by certain marginalized populations [64]. From the current study, it appears that unethical research, such as the Tuskegee experiment among African American populations [65], has led to mistrust in the new medical treatments [62,66] not just among African Americans but also across Black/African populations across the globe.
This review suggests a paucity of theory-informed studies assessing COVID-19 vaccination in Sub-Saharan Africa. The Knowledge, Attitudes, and Practices (KAP) model, frequently used in public health research to explore health behaviors and related changes, has been used by several researchers to understand how knowledge of COVID-19 vaccines, attitudes towards vaccination, and COVID-19 preventative behaviors such as vaccination [67] influence vaccination outcomes (hesitancy, intentions, or uptake). Besides using the KAP model [37,44] or mentioning the socio-ecological approach [41], studies did not report using other behavioral health theories or operationalizations of constructs to understand COVID-19 vaccination determinants in pregnancy. Other COVID-19 studies in Africa have used the health belief model, the theory of reasoned action, and other behavioral theories [68,69] to understand COVID-19 vaccination among the general population. Studies that are theory-based may be helpful to address specific behaviors and tailor interventions to increase vaccine uptake during pregnancy.
Many countries in Sub-Saharan Africa (SSA) are lower-middle-income countries (LMIC) or low-income countries (LIC) and could not afford to purchase COVID-19 vaccines for their populations until March 2021 (15). Most countries in Sub-Saharan Africa received COVID-19 vaccines under the COVAX partnership [70]. However, people became skeptical of COVID-19 vaccines after information was circulated that the "donated vaccines" were expired [71]. Lack of vaccines has also been reported in prior vaccine efforts. For example, findings from a study on influenza vaccine uptake among pregnant women in South Africa indicated that vaccine stock-outs, current illnesses, and vaccine hesitancy were associated with non-vaccination [72]. The lower rates of COVID-19 morbidities and mortalities reported in the SSA region compared to the higher magnitude of COVID-19-related deaths reported in Western countries (Europe and the Americas), China, and India [2,17] may have influenced the perceived risk of COVID-19, thus lowering the acceptability of COVID-19 vaccines.
Similar to the results from our study, scholars investigating the uptake of other maternal vaccines, such as influenza [73] and Tetanus vaccines [74], reported lower vaccine uptake rates than recommended among pregnant women across the globe. Results from one systematic review indicated that sub-optimal influenza vaccination during pregnancy was due to low perceived risk and concerns about vaccine safety and efficacy [73]. A global study on tetanus vaccination during pregnancy also reported lower vaccination rates in lower-tomiddle-income countries due to a lack of recommendations from providers [74]. Therefore, it is essential for healthcare providers to appropriately communicate with women about maternal vaccines, address concerns, and provide recommendations based on the risks.
In this review, studies also reported that the lack of guidance on COVID-19 vaccination policies during pregnancy influenced patient-provider communication and impacted perceptions about the vaccine [41,46]. The exclusion of pregnant women during the initial COVID-19 vaccination trials contributed to concerns about the safety and effectiveness of the vaccine for both the pregnant mother and the fetus [6,18]. While subsequent cohort studies have indicated vaccine efficacy and safety [8,20,75], many countries still have restrictive policies around COVID-19 vaccination in pregnancy [53,54]. In Sub-Saharan Africa, only 15 countries have explicit policies that recommend COVID-19 vaccination for some or all pregnant people [53]. This review included studies with participants from Ethiopia, Nigeria, and Zimbabwe, where national policies permit COVID-19 vaccination during pregnancy [53], as well as participants from the Central African Republic, Democratic Republic of Congo, Equatorial Guinea, and Lesotho, where national policies do not have positions regarding COVID-19 vaccinations for pregnant people [53]. As such, the different policies may have influenced COVID-19 vaccination acceptance or uptake rates.
Future studies on maternal vaccinations should consider using cohort study designs to examine if determinants associated with vaccination acceptance during the first few months of pregnancy influence vaccination uptake towards the end of the pregnancy period. Researchers in Sub-Saharan Africa could employ design studies informed by behavioral health theories, whose results could potentially be used to design evidencebased interventions.

Strengths and Limitations
A strength of the study is the focus on countries in Sub-Saharan Africa (SSA). This region has differences in country policies, capacity, and funding, which impact COVID-19 vaccination processes among pregnant women. In addition, previous COVID-19 vaccination reviews during pregnancy have often focused on clinical outcomes and demographic factors. Thus, this study provides unique perspectives on contextual and psychosocial issues not addressed by previous reviews. One limitation of this study is that countries in Sub-Saharan Africa are not only English-speaking countries. With many Francophone countries in Sub-Saharan Africa, excluding non-English publications may have restricted the sample of included studies and comprehensive perspectives on the determinants of COVID-19 vaccination in this region. In addition, factors associated with the COVID-19 pandemic have been constantly changing. Pregnant women's opinions on COVID-19 vaccination also likely shifted based on vaccine availability, government recommendations, and scientific evidence on vaccine safety and effectiveness. COVID-19 vaccination mandates in some countries could have contributed to higher uptake rates, even in vaccine-hesitant populations. The timing of the studies probably impacted the interpretation and generalizability of the findings because some studies were conducted before vaccination was available and proven safe during pregnancy.

Conclusions
This scoping review explored psychosocial, contextual, and vaccine-specific determinants for COVID-19 vaccination among pregnant women in Sub-Saharan Africa. Published studies suggest that pregnant women in Sub-Saharan Africa had high levels of COVID-19 knowledge but were concerned about vaccine safety and effectiveness, resulting in relatively low overall uptake, especially compared to other countries. Research on maternal COVID-19 vaccination in Sub-Saharan Africa would benefit from the inclusion of theory-informed studies that measure additional psychosocial factors and the influence of contextual issues on vaccine behaviors. With healthcare providers regarded as the most trusted source of information on COVID-19 vaccination, there is a need for timely implementation of health policies to improve vaccine acceptance. Future studies should also utilize prospective cohort or quasiexperimental design methods that connect vaccination determinants with vaccination uptake.

Data Availability Statement:
No new data were created or analyzed in this study. Data sharing is not applicable to this article.