Tetanus Toxoid Immunization Status and Associated Factors among Mothers in Hawzen, Eastern Zone of Tigray, Ethiopia, 2019

1. INTRODUCTION

Tetanus is a non-communicable disease transmitted via exposure to the spores of the bacteria Clostridium tetani [1]. Around 3.3 million neonatal deaths occur globally annually, with approximately 34,000 due to neonatal tetanus [2, 3]. Neonatal tetanus is related to improperly or insufficiently immunized mothers (and through passive immunity process the infant) usually due to poor sanitation (e.g., unclean delivery environment, poor cord care) in the intra-partal and post-partal periods. The disease, sometimes called the ‘disease of the 7^th day’, presents in the neonate usually within 14 days post-delivery with a nearly 100% case-fatality rate without intensive care access [4].

According to the United Nations Children’s Fund (UNICEF), in 2018, approximately 72% of reproductive age women globally were adequately immunized. Such immunity included vaccination of tetanus toxoid (TT) of at least two doses for pregnant or reproductive age women can decrease neonatal mortality by 94% (95% CI: 80-98%) [5]. Previous studies have discussed factors like age of mothers, misconceptions about immunization, educational status, residence, fear of side effects, use of modern contraceptives, as well as knowledge and awareness of vaccinations as significantly associated with the status of TT coverage [5-10].

Between 2000 and 2019, Ethiopia shifted from not meeting to meeting the WHO goals of Maternal Newborn Tetanus Elimination (MNTE) [5, 11]. Despite these efforts of extended immunizations and campaigning Tetanus Toxoid vaccinations, Ethiopia continues to have the highest neonatal tetanus morbidity and mortality rates due to low TT immunization coverage combined with a higher number of mothers who gave birth at home in the area of the unsafe and unsterile environment [11, 12]. There is a paucity of studies regarding TT status and factors associated with its low coverage in Ethiopia and specifically in the Tigray study area. Thus, this study is aimed to determine the status of TT immunization coverage and predictors of the likelihood of TT immunization in the study area.

2. METHODS

3. RESULTS

3.1. Socio-demographic and Health Services Related Characteristics

Five hundred and fifteen women who had given birth in the last 12 months before the survey participated yielding a 100% response rate. Regarding residence, [460(89.3%)] were urban

Table 1.

Variables	Category	Frequency[N=515]	Percentage (%)
Age of mother	<20	322	62.5
	20-30	52	10.1
	>30	141	27.4
Residence	Rural	55	10.7
	Urban	460	89.3
Religion	Orthodox	418	81.2
	Protestant	58	11.3
	Muslim	39	7.6
Ethnicity	Tigray	500	97.1
	Afar	15	2.9
Marital status	Married	373	72.8
	Single	138	26.8
	Divorced	4	0.8
Maternal educational status	No formal education	246	47.8
	Elementary school	120	23.3
	Secondary and above	149	28.9
Husband educational status	No formal education	277	53.8
	Elementary school	136	26.4
	Secondary and above	102	19.8
Mother occupational status	Housewife	312	60.6
	Government employee	94	18.2
	Self-employed	109	21.2

and (97.1%) were Tigrian by ethnicity. Concerning educational status, [246 (47.8%)] mothers and [277 (53.8%)] husbands have no formal education, and [312 (60.6%)] mothers were housewives by occupation (Table 1).

3.4. Reasons for not Starting and Non-compliance of TT Vaccination

Mothers were asked for reasons why they did not start TT vaccination and not compliant, to which [21(4.1%)] of them respond as fear of side effects due to misconceptions, lack of information about the vaccine [15(2.9%)], and service are too far away to participate[11(2.1%)]. Other women spoke of service unavailability, religious reasons, and lack of interest (Fig. 2).

Table 2.

Items	Category	Frequency	Percentage
Have you ever heard of TT vaccine?	Yes	439	85.2
	No	76	14.8
Do you know the importance of TT vaccine?	Yes	453	88
	No	62	12
Which type of disease is prevented by TT vaccine?	TB	118	22.9
	Tetanus	339	65.8
	Measles	31	6
	Others*	27	5.3
Who is given priority for the vaccination?	Female of any age	152	29.5
	Male of any age	29	5.6
	Women of reproductive age	276	53.6
	I do not know	58	11.3
How many times should this vaccine be taken?	One dose	31	6
	Two dose	2	0.4
	Three dose	29	5.6
	Four dose	54	10.5
	Five dose	372	72.2
	I do not know	27	5.2

^*e.g. family planning, pneumonia, meningitis

Table 3.

Variable	Category	Frequency	Percentage
Distance travelling to health facility	<1km	270	52.4
	>1km	245	47.6
Travelling time from home to health facility	<1 hour	410	79.6
	>1 hour	105	20.4
Availability of TT vaccine service at every health facility	yes	371	72
	no	144	28
Where did you get information about the vaccine?	Health institution	224	43.5
	School	232	45
	Media	59	11.5

Table 4.

Variables	Category	Frequency	Percentage
ANC follow up	Yes	409	79.4
	No	106	20.6
Number of antenatal visits	1	174	33.78
	2-3	181	35.14
	≥4	54	10.48
Number of children	1	21	4.1
	2-4	281	54.6
	>4	213	41.4
Using of modern contraceptive	Yes	269	52.2
	No	246	47.8
Future fertility plan	Yes	331	64.3
	No	184	35.7

Table 5.

Variables	Category	<TT2 No (%)	≥TT2 No (%)	COR(95% CI)	AOR(95% CI)
Age of mother	<20	224(72.7)	98(47.3)	0.25(0.16, 0.38)	0.19(0.10, 0.32)*
	20-30	33(10.7)	19(9.2)	0.33(0.17, 0.63)	0.29(0.12, 0.69)
	>30	51(16.6)	90(43.5)	1	1
Distance travelling to health facility	<1Km	145(47.1)	125(60.4)	1	1
	>1Km	163(52.9)	82(39.6)	0.58(0.408, 0.83)	0.8(0.49, 1.32)
Future fertility plan	No	147(47.7)	37(17.9)	0.24(0.16, 0.36)	0.30(0.17, 0.53)*
	yes	161(52.3)	170(82.1)	1	1
Using of modern contraceptive	No	158(51.3)	88(42.5)	0.7(0.49, 1.00)	0.66(0.40, 1.08)
	Yes	150(48.7)	119(57.5)	1	1
Antenatal care	No	78(25.3)	28(13.5)	0.46(0.28, 0.74)	1.65(0.18, 15.49)
	Yes	230(74.7)	179(86.5)	1	1
Number of ANC visit	1	126(54.3)	50(27.6)	0.25(0.13, 0.48)	0.38(0.18, 0.82)*
	2-3	85(36.6)	98(54.1)	0.73(0.39, 1.36)	0.75(0.37, 1.51)
	≥4	21(9.1)	33(18.2)	1	1
Place to get information	Health institution	136(44.2)	88(42.5)	1	1
	School	132(42.9)	100(48.3)	1.36(0.74, 2.50)	1.32(0.59, 2.95)
	Media	40(13)	19(9.2)	1.56(0.87, 2.92)	4.49(1.82, 11.07)*
Mothers educational status	No formal education	167(54.2)	79(38.2)	0.4(0.27, 0.62)	0.79(0.45, 1.39)
	Elementary school	72(23.4)	48(23.2)	0.58(0.35, 0.94)	0.64(0.32, 1.29)
	Secondary and above	69(22.4)	80(38.6)	1	1
Husband educational status	No formal education	161(52.3)	116(56)	0.64(0.40, 1.01)	1.33(0.64, 2.75)
	Elementary school	99(32.1)	37(17.9)	0.33(0.19, 0.57)	1.02(0.45, 2.32)
	Secondary and above	48(15.6)	54(26.1)	1	1

*= significant variables, AOR= Adjusted odds ratio, COR=Crude odds ratio.

4. DISCUSSION

This community-based cross-sectional study aimed to determine the status of TT immunization and associated factors. The study identified low utilization of TT immunization among reproductive aged women, while the age of mothers, future fertility plan, number of antenatal care visits and places where information to get were found to be significantly associated with the status of TT immunization.

This study revealed that more than half of mothers were not protected against tetanus at their last birth, which is comparable to findings from the Ethiopian Demographic Health Survey 2016 [11]. This is lower than the WHO target of over 90% and the Ethiopian Ministry of Health recommendations of greater than 90% compliance at the national and greater than 80% compliance at the district level [4, 11, 13]. The finding of this study is also lower than the previous studies, which ranged from 55% to 75.5% compliance conducted in Ghana [10], Kenya [14], Tselemit (Tigray) [12], Pakistan [15], and KembataTembaro [8]. This might be due to a difference in sample size, socio-demographic and topographic accessibility of health services. This low coverage of TT vaccination might be contributed by poor knowledge of women about the disease and the vaccine as evidenced from the finding of this study, though a significant number of mothers know the importance of the vaccine, still many women remain unaware for the prevention of neonatal tetanus. Due to this, a significant number of women are not protected at their last birth for neonatal tetanus, particularly it is worst in rural, low socio economic and who did not receive a formal education. All efforts of extended immunizations and campaigning Tetanus Toxoid vaccinations took place in the country, however, did not bring improvements from the morbidity of neonatal tetanus, perhaps more than 50% of women still gave birth at home in an unsafe, unsterile environment easily prone to the bacteria. Hence forward, empowering and educating women on the importance of the vaccine, severity and fatality of the disease is paramount.

The current study also found mothers whose age was less than 20 years were less likely to receive two doses of TT injection compared to mothers whose age was greater than 30 years. The result was in line with the finding of research conducted in Kembata Tembaro (Ethiopia), Kenya, Vientiane, and India [6, 8, 9]. Possible reasons for this age-related variance may be due to this age group not actively participating in different health-related issues, immaturity concerning taking responsibility for child health care, and lacking past exposure such that they will not develop practical knowledge towards their health care, hard to find them in the involvement of TT immunization.

Those mothers who had no future plan for fertility were less likely to receive two doses of TT injection compared to mothers who had a future plan for fertility. This is consistent with a study conducted in Bangladesh [16]. Mothers who had future fertility plans were aware of taking responsibility for child health care, their health seeking behavior is raised to have a healthy child and those with future fertility plans may use family planning, as health information is given during family planning services due to service integration.

Mothers who attend only one antenatal care visit were less likely to receive two doses of TT injection compared to mothers who attended four or more antenatal care visits. This finding is further supported by research done in Kembata Tembaro (South Ethiopia), Kenya, and Pakistan [8, 14, 15]. Repeated health facility visits for ANC follow-up give an opportunity for TT vaccine injections and avoidance of missed vaccinations.

Furthermore, those mothers who got information from the media were more likely to receive two doses of TT injection compared to those who got information about TT vaccine from health institutions. This might be explained as those who had access to media outlets can receive information without restriction and without limitation and they can be more active and decision-maker about their health care, rather information gained from health institutions may be limited due to poor counseling technique and incompetence of health care providers.

CONCLUSION AND RECOMMENDATION

This study concluded that more than half of the mothers were not protected against tetanus at their last birth. This study also revealed that the age of mothers, future fertility plans, number of antenatal care visits and places where to get information were significant factors associated with TT immunization uptake of mothers. To increase the proportion of mothers protected at birth, awareness creation and immunization campaigns should be directed to school-aged groups, during preconception care, and antenatal care should also be strengthened. Furthermore, more studies are needed to determine the absolute proportion of mothers protected from tetanus at birth by antibody testing.

REFERENCES