Bridging the birth dose gap: A scoping review of implementation challenges for birth dose and rotavirus vaccines in low- and middle-income countries

Rotavirus vaccination (RVV) has substantially reduced childhood diarrhoeal morbidity and mortality globally. However, interest in neonatal or birth-dose schedules is increasing to provide earlier protection and potentially reduce intussusception risk. Understanding barriers and implementation challenges of current RVV and other birth-dose vaccines (BDVs), including hepatitis B birth dose, Bacillus Calmette-Guérin, and oral polio vaccine, is essential to inform this transition in low- and middle-income countries. This review therefore aims to examine the supply- and demand-side factors influencing the uptake, timeliness, and implementation of RVV and BDV in low- and middle-income countries. A scoping review was conducted across PubMed, Scopus, Cochrane, and grey literature from Portal Garuda from database inception to 5 March 2025. Original studies assessing determinants, enablers, and barriers of any BDV or RVV implementation, uptake, or timeliness were included. An analytical framework was developed inductively to classify factors as supply- or demand-side and was refined through discussions among reviewers. From 8,502 identified records, a total of 93 articles were included in the review. Identified supply-side enablers and barriers encompassed domains related to policy and governance, health system capacity, healthcare accessibility, and programmatic interventions. On the demand side, key enablers included higher caregiver education, higher socioeconomic status, health facility birth, and older maternal age, whereas major barriers included home birth, lower socioeconomic status, rural residence for BDV, and incomplete or delayed uptake of other routine vaccinations for RVV. Implementation and uptake of BDV and RVV were influenced by both supply- and demand-side factors, including policy support, health system capacity and access, targeted interventions, and socioeconomic disparities in vaccine uptake. Transitioning from infant-dose to birth-dose RVV will require addressing existing implementation challenges and ensuring timely vaccination at birth to achieve equitable coverage.