Vaccine hesitancy remains a challenge to achieving optimal childhood immunization coverage. This systematic review examined parental vaccine hesitancy in Saudi Arabia, with emphasis on paternal determinants and their association with vaccination uptake. Following PRISMA 2020 guidelines, databases were searched between January 2000 and January 2025. Hesitancy toward routine childhood vaccines was generally low (3%-20%), whereas hesitancy toward newer or non-mandatory vaccines, including COVID-19, influenza, and HPV, exceeded 50% in some settings. Studies reporting father-specific data indicated higher hesitancy among fathers, particularly regarding safety, novelty, and possible long-term effects. Common determinants included safety concerns, misinformation, social media influence, and low confidence in vaccine effectiveness. Hesitancy was associated with delayed schedules, incomplete immunization, and reduced uptake of optional vaccines. Vaccine hesitancy in Saudi Arabia appears vaccine-specific and influenced by sociocultural factors, with paternal attitudes playing a measurable role in immunization decision-making.