Background: Maternal vaccination has proven to be a successful intervention to protect pregnant woman and neonates from infectious diseases. Limited research has been published on the determinants of maternal vaccination acceptance and uptake in The Gambia. Given that additional maternal vaccines may be available soon, these factors are important to ascertain. Aim: To gain a contextualized understanding of the supply and demand factors influencing antenatal care service utilization and maternal vaccination acceptance in The Gambia. Methods: Qualitative focus group discussions and in-depth interviews as well as quantitative questionnaires were conducted across four regions of The Gambia (West Coast, North Bank, Central River and Upper River) identifying participants from both urban and rural settlements. Data analysis used inductive coding, wherein the unprocessed textual data was read and interpreted to create concepts and themes. The Strategic Advisory Group of Experts (SAGE) on Immunization Working Group framework was used to better understand and assess the findings within an analytical framework. Results: The qualitative study population included 96 pregnant women and women with infants and 20 health care workers. The quantitative study population included nine health facilities data. Previous vaccination experiences, individual weighing of risks and benefits, vaccine literacy, accessibility, affordability, quality of care, immunisation schedule and recommendations from health care providers act as barriers and enablers to maternal vaccination acceptance. Health care workers and male partners were trusted local actors who shape perceptions of maternal vaccines and influence utilisation of antenatal care services. Maternal vaccination decision-making was not an autonomous choice but one dependent on social relations, more so male partner endorsement. These study findings are presented in a contextualized conceptual framework. Conclusion: Antenatal care service utilization and maternal vaccination acceptance are overall influenced by individual, group, contextual, vaccine and vaccination-specific factors. Women’s utilisation of antenatal care services depends on access dimensions of health services, health facilities and health care workers. Women’s acceptance of vaccination during pregnancy is influenced by complex and intersecting individual, sociocultural, organizational, and structural factors.