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Background. Maternal and neonatal tetanus remains a public health problem in low-and-middle-income countries despite the increasing investment in tetanus toxoid containing vaccines (TTCV). Nigeria still records fatalities from tetanus, predominantly in women of reproductive age and in newborns. This is largely due to poor access to vaccinations and high rates of unsupervised labour and childbirth. We aim to investigate the antenatal uptake of TTCV and associated factors among first-time pregnant women in Nigeria. Methods. Data obtained from the 2018 Nigeria Demographic Health Survey (NDHS) was used to generate a list of eligible patients who in the last five years had undergone their first childbirth experience. Data was analysed using univariable and multivariable analyses and reported using a 95% confidence interval. Results. A total of 3640 participants were included in the analysis. 59.6% (95% CI, 57.6-61.8) of participants had received at least two doses of TTCV. Uptake of TTCV irrespective of current marital status was independently associated with number of and place of antenatal care. Other factors associated with receiving two doses of TTCV in all participants were ownership of mobile phones and region of residence. Among the currently married participants, wealth quintiles, region of residence, and having a polygamous family were additional associated factors. Conclusion. There was low uptake of the minimal required dosage of TTCV among first-time pregnant women with the lowest uptake in Northern regions relative to Southern regions. We recommend mixed methods studies to further explore the motivation behind TTCV uptake in pregnant women which can help guide future policies and interventions to improve uptake of tetanus immunization in Nigeria.
The 2018 NDHS dataset is a nationally representative sample of 42,000 households that adopted a stratified two-stage sampling design for recruitment and enrollment. The NDHS classified each locality in Nigerian states and the Federal Capital Territory into urban and rural areas based on population size cut-off points. A locality was classified as urban if there was a population size of 20,000 or more. The first stage sampling—the primary sampling units (PSUs)—included selection of 1400 enumeration areas (EAs) with probability proportional to EA size. The second stage of sampling involved selection of 30 households from every selected cluster using equal probability systematic sampling. The detail of sampling design, implementation, and data collection has been published in the NDHS report [13]. The primary outcome of this analysis was the proportion of women that received at least two doses of TTCV. “TTCV uptake” in this analysis refers to the receipt of at least two doses of TTCV. Analysis was restricted to women in the five years preceding the survey with a childbirth experience, with a surviving child. These women were described as “first-time mothers.” Women whose pregnancy resulted in a termination, miscarriage, and stillbirth or whose child died before the survey were excluded as there was no information on the age of these children. Since maternal and neonatal tetanus elimination has been associated with administration of at least 2 doses of TTCV in pregnancy, eligible women were categorised into two groups as follows: (i) women who received a minimum of 2 doses of TTCV and (ii) women who received no or less than 2 doses of TTCV. Subgroup analysis was conducted based on marital status to further explore the impact of this on TTCV uptake. Explanatory variables were selected based on review of the literature on maternal and neonatal tetanus elimination policy, program, and interventions. These variables were marital status (never/formerly in union—“not currently in a union” vs. currently married), age of woman at childbirth (<20 years or ≥20 years), number of antenatal visits (no visit, 1 to 3 visits, 4 to 7 visits, and 8 or more visits), place antenatal care was sought (homes/others, government hospitals, government health centres/post or other public facilities, private hospitals, or clinics), wanted pregnancy (No—later or no more, Yes), sex of household head (male or female), household size (3 or less, 4 to 6, and 7 or more), current employment (no, yes), ownership of a mobile phone (no, yes), wealth quintile (poorest, poorer, middle, richer, and richest), highest level of education (no formal education, primary, secondary, and tertiary), exposure to mass media (none at all, at least one of radio, TV, and newspaper), health insurance coverage (no, yes), religion (Christianity, Islam, and others), and geopolitical region (North Central, North East, North West, South East, South South, and South West). Further explanatory variables were included as part of the subgroup analysis conducted based on marital status. These included type of union (monogamous or polygamous), husband highest level of education (no formal education, primary, secondary, and tertiary), and husband occupation (professional/managerial/technical/skilled, sales or services, agricultural, clerical/skilled or others, and unemployed). Other variables included were perceived difficulty in accessing healthcare and decision-making power of woman. We used four questions in NDHS on getting medical help to describe perceived difficulty in accessing health care: (1) getting permission to get medical help, (2) getting money needed for treatment, (3) distance to health facility, and (4) not wanting to go to health facilities alone (code = 0, if response is “not a big problem” and code = 1, if “big problem”). Women were categorised into tertiles of low, medium, and high perceived difficulty in accessing health care using principal component analysis (PCA). Decision-making power of women was measured with four questions: (1) who usually decides on respondent's health care? (2) Who usually decides on large household purchases? (3) Who usually decides on visits to family or relatives? (4) Who usually decides what to do with money husband earns? Each of the four questions was coded as follows: “0” if the response was “others or only partner,” “1” if the decision was made “jointly with partner,” and “2” if the decision was made “alone.” A PCA was performed, and collated scores were categorised to the decision-making power of women into tertiles (low, medium, and high). We performed a separate analysis on all first-time mothers (irrespective of marital status) and on currently married women. This was to explore the roles of variables that were collected among currently married women and are likely to be associated with maternal health care seeking behaviour. Such variables included decision-making power, polygyny, husband level of education, husband occupation, and age difference between wife and husband. Descriptive statistics of background characteristics and all analysed variables was performed, in all women who had received at least two doses of TTCV. These were presented as a proportion (percentage) with a 95% confidence interval (CI). Multicollinearity testing was performed by using a variance inflation factor cut-off of five to examine collinearity among variables. There was no evidence of collinearity from variables [14]. Using crude and adjusted ordinal logistic regression, association between background characteristics and adequate TTCV immunization was tested for all first-time mothers and separately for currently married first-time mothers. For currently married first-time mothers only, the following variables were also included in the model: decision-making power, husband level of education, polygyny, husband occupation, and age difference between spouses. In this analysis, we adjusted for the complex survey design (weighting, stratifications, and clustering). All statistical analyses were performed using the STATA program version 16.0 (StataCorp, College Station, Texas, USA) at a 0.05 level of significance.
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