Protective doses of tetanus toxoid immunization and its associated factors among mothers in southern Ethiopia

ABSTRACT

The World Health Organization recommends tetanus toxoid immunization before or during pregnancy for all women of childbearing age. The goal is to reduce maternal and neonatal mortality due to tetanus. According to the 2016 Ethiopia Demographic and Health Survey (EDHS) report, more than half (51%) of women did not receive protective doses of tetanus immunization. To the best of our knowledge, this study uniquely tried to assess the level of protective doses of tetanus toxoid immunization in southern Ethiopia. A community-based cross-sectional study was conducted among 580 randomly selected participants. Variable with p-value of less than .25 in the bivariate analysis were included in the multivariable logistic regression analysis. Finally, statistical significance was declared at a p-value of less than .05. The proportion of protective doses of tetanus toxoid immunization uptake in the area was found to be 41.9% (95% CI: 38–46%). Being enrolled in formal education [AOR = 6.55, 95% CI: 3.23–9.01], having at least two postnatal care visits [AOR = 3.82; 95% CI: 1.78–6.40], having at least four antenatal care visits [AOR = 2.56; 95% CI: 1.41–4.34], and being visited by Health Extension Workers [AOR = 2.66; 95% CI: 1.42–4.01] were found to be factors enhancing the uptake of protective doses of tetanus toxoid immunization. Generally, the uptake or prevalence of the protective doses of tetanus toxoid immunization in the area was lower than the World Health Organization’s target. Therefore, all responsible bodies, including healthcare providers, need to strengthen counseling mothers to enhance the uptake of tetanus toxoid immunization.

KEYWORDS:

• Protective doses
• tetanus toxoid
• immunization
• mothers
• southern Ethiopia

Introduction

Tetanus is a disease caused by Clostridium tetani, a deadly bacterium that produces neurotoxin. Soil, dust, manure, and the environment are the habitats for the bacterium and its resistant spores.¹ Both humans and animals carry Clostridium tetani. During defecation, human or animal reservoirs release the bacterium along with the spores it produces. The bacteria enter the body through an open wound and release a toxin that affects the central nervous system and causes the symptoms of the disease.²

According to the European Centre for Disease Prevention and Control (ECDC) report, tetanus cases occur more often among women than in men, with a woman-to-male ratio of 1:0.4.³ It can occur in both pregnant women and neonates. Maternal tetanus can occur during pregnancy or within 6 weeks after giving birth, whereas neonatal tetanus occurs within the first 28 d of life. It develops as a result of poor (unclean) cord care and deficient maternal tetanus antitoxins due to no or missed immunization.⁴

Among adults and pregnant women, the burden of the disease ranges from localized muscle spasms to generalized tetanus. In localized tetanus, initial wound inoculation is small, and there is less favorable condition for C.tetani to replicate, the symptoms may resolve within 1 to 2 months. But, in most cases, the disease may progress to generalized tetanus. Generalized tetanus is characterized by an initial sore throat and difficulty swallowing, generalized weakness, and respiratory and autonomic dysfunction. The majority of deaths are caused by autonomic dysfunction. In neonates, the disease is characterized by high fever, rigidity, spasms, and opisthotonos. Mortality from neonatal tetanus is as high as 80%.⁵

Women of childbearing age should receive tetanus toxoid (TT) immunization as a preventative measure. The TT vaccine is safe for all women, and no evidence has also been shown of any negative effect on pregnant women. For protection at birth, “women should receive two or more doses during the last pregnancy, or at least two doses before the last pregnancy, with the last dose 3 y before the birth; or three doses within the previous 5 y; or four doses with the last dose 10 y before the previous pregnancy; or receiving five doses or more before the previous pregnancy,” according to the World Health Organization (WHO).^4,6

For lifetime protection, a woman needs to receive five doses of the TT vaccine, spaced by at least one month between the first and second doses and at least six months between the second and third doses, followed by two more doses spaced by at least one year between each. The WHO developed strategies like the provision of TT immunization and supplementary immunization activities (SIAs) to protect mothers and neonates from tetanus. In addition to tetanus prevention, these strategies help sustain maternal and neonatal tetanus immunization programs.⁴

According to the WHO’s goal, at least 80% of pregnant women should receive TT immunization.⁴ However, sluggish tetanus elimination progress has been observed in the WHO African Region, particularly in the ten countries of the region, including Ethiopia. Although 75% (35 out of 47) of the member countries achieved the goal, only 79 million women were vaccinated with protective doses in the region.⁷ Evidence showed that Ethiopia had a lower uptake of protective doses of TT immunization. For instance, according to the 2016 Ethiopia Demographic and Health Survey (EDHS) report, more than half (51%) of women did not receive protective doses of tetanus immunization. The highest (82%) and lowest (30%) utilization were observed in Addis Ababa and Afar Regional State, respectively. Moreover, in the South Nation Nationalities and Peoples Regional (SNNPR) State, more than half of the women received protective doses.⁸

According to scientific evidence, the majority of maternal and neonatal tetanus cases are linked to inequality of access to health care services.^9–11 Various socio-demographic and obstetric factors determine mothers’ utilization of TT immunization. Of the socio-demographic factors, maternal literacy,^12–14 young age,^12–15 higher family income,¹⁴ and dwelling in an urban area^16,17 were factors that positively influenced the uptake of TT immunization. Higher numbers of antenatal care (ANC) visits,^12–15,18 multiparty,^12,16 giving birth in a health facility,¹² having a postnatal care (PNC) visit,¹⁸ and having a plan for childbirth were obstetric factors that positively influenced the uptake of TT immunization.¹⁵ In addition, maternal knowledge about TT immunization,^17,19,20 being exposed to information about TT immunization,^13,15 and long distances to a health facility^13,16 were also found to be factors predicting the utilization of TT immunization. Aside from maternal education status, the husband’s education status increases the mother’s TT immunization uptake.^12,17

According to the Ethiopia National Expanded Program on Immunization, which is controlled by the Federal Ministry of Health (FMoH), Gamo Zone is one of the zones labeled as high risk for maternal and neonatal tetanus. The National EPI office also recommended that periodic data collection and monitoring should be done^21,22; as part of this ongoing process, this study will try to assess the level of protective doses of TT immunization among mothers. Again, this study will be one of its kind since it will provide information regarding TT immunization in the study area where there is not enough evidence on the level of protective doses of TT immunization.

Methods and materials

Study design, period, and setting

A community-based cross-sectional study was conducted from March 20–August 3, 2020, at the Arba Minch Health and Demographic surveillance site (AM-HDSS). AM-HDSS is located in the Gamo Zone of southern Ethiopia. The surveillance site is managed by both EDHS and Arba Minch University, and it is centered in two rural and semi-urban (Arba Minch Zuria and Gacho Baba) districts in the Gamo zone. These two districts have eleven (11) kebeles (the lower administrative units). The districts had a total population of 164,529. Of these, more than half (82,330) were female. Women of reproductive age accounted for more than half (42,121) of the female population. Regarding healthcare facility coverage, there were four health centers, forty health posts, and thirty-two private clinics in the area.

Study participants and eligibility criteria

All mothers who gave birth in the AM-HDSS were considered the source population of this study, whereas all randomly selected mothers (who gave birth in the last six months) in the AM-HDSS were considered the study population. All eligible mothers who gave birth in the last six months and lived at least six months in the area were included in the study. However, mothers who were severely sick and unavailable during data collection were excluded from this study.

Sample size determination and sampling procedure

The sample size of this study was calculated for both the first and second objectives using Epi Info version-7 statistical software. For the first objective, the maximum sample was calculated by assuming a 95% confidence level, a 4% margin of error, a population proportion of 72.5% that was taken from the study done in Damboya District, and a 5% non-response rate. Accordingly, the maximum sample size for the first objective was 503.

For the second objective, we assumed a 95% confidence level, 80% power, and a ratio of unexposed (64.9%) to exposed (76.1%) equivalent to 1.¹⁹ The total calculated sample was 552. By considering a 5% non-response rate, we have used the maximum sample size of n = 580. Since the sample size for the second objective was greater than the first, we used the maximum sample size of n = 580 in this study.

The study participants were selected using a sampling frame that was prepared by the AM-HDSS. AM-HDSS office routinely registers health and demographic information, including recent pregnancies and delivery, in the catchment area. First, the office provided us with information on maternal identification, kebele, and household identification of women who gave birth at the site. According to the data from AM-HDSS, a total of 8751 mothers who gave birth in the last 6 months before the survey resided in the 11 kebeles within the 2 districts. Next, we proportionally allocated our sample size to each kebele, within which these 8751 mothers were found. Then, study participants were randomly selected using a computer-generated table method (Figure 1). Finally, each selected participant’s house was visited using the maternal identification and house identification numbers. Participant recruitment was started on March 23, 2020, and ended on April 30, 2020.

Figure 1. A schematic presentation of the sampling procedures.

Data collection tools and procedures

Nine experienced data collectors interviewed the participants using a structured and pretested questionnaire; we recruited healthcare professionals, specifically midwives and nurses, with experience in collecting data for community-based surveys on at least two separate occasions. The questionnaire was adapted from previous literature after different reviews and appropriate amendments had been made.^20,23–25 The data collection questionnaire contains questions on socio-demographic characteristics, obstetric characteristics, health service-related characteristics, TT immunization status, and knowledge- and attitude-related factors. First, the study participants were asked whether they had ever gotten vaccinated against TT or not. Then the documented evidence (maternal health cards or home-based records and ANC registration logbooks) of the ever-vaccinated participants was reviewed. Similarly, in case of unknown vaccination status (when the mother was unsure of vaccination history or did not have a home-based record), the ANC registration logbooks were reviewed. Finally, based on the documented evidence of the participants, the prevalence of protective dose uptake was calculated.

Data quality control

To secure the quality of the data, the English version of the questionnaire was translated into Amharic (a local language) for common understanding. To check the consistency of the meaning, the Amharic version was translated back to English. The three-day training, regarding the objectives of the study, data collection, and the way participants’ privacy was maintained, was given to the data collectors and supervisors. A pretest was conducted on 5% of the total sampled population in the Mirab Abaya district before the actual data collection. The data were collected using Open Data Kit (ODK) software. In addition, the supervisor checked the collected data on a daily basis for completeness and consistency.

Operational definitions

Knowledge towards TT immunization

Nine questions were asked for the knowledge part, each correct answer was given “1” and the wrong answer was given “0”; the total response contains a maximum of 9 points and a minimum of 0. The overall knowledge of the study participants was assessed using the mean score of each participant’s answer to all knowledge-related questions.

Attitude towards TT immunization

Attitude toward tetanus toxoid immunization was assessed using 6 items. A correct statement with options strongly agree, agree, Neutral, disagree, and strongly disagree are scored 5, 4, 3, 2, and 1, respectively. The scores were classified into two levels: favorable attitude (80%-100%) and unfavorable attitude (≤79%).

Protective doses

If the participant received two or more TT doses during the previous pregnancy, or at least two doses before the previous pregnancy, with the last dose 3 y before the birth, or three doses within the previous 5 y, or four doses with the last dose 10 y before the last pregnancy, or received five doses or more before the last pregnancy.⁴

Data processing and analysis

The data collected by using the centralized data server of the Open Data Kit (ODK) software were transferred into the Statistical Package for Social Sciences (SPSS) version 20.0 for analysis. The data were checked for completeness and consistency and then cleaned before analysis. The descriptive statistics were presented using proportions, frequencies, tables, and figures. A binary logistic regression analysis was conducted to identify the association between the uptake of protective doses of TT immunization and independent variables. The independent variables shown to be associated with the outcome variable at a p-value of less than .25 in the bivariate analysis were further analyzed in the multivariate logistic regression analysis. During the analysis, a goodness-of-fit test was measured using the Hosmer and Lemeshow test; a test p-value of .351 was found. Finally, the adjusted odds ratio (AOR) with a p-value of less than .05 at a 95% CI was considered an independent association.

Results

Socio-demographic characteristics of participants

A total of 577 mothers participated in this study, with a response rate of 99.4%. The mean age of participants was 28.8 (standard deviation (SD) ± 6.38) y. About three-fourths of the respondents were within the age group of 20–34 y. The majority, 568 (98.4%) of the study participants, were married. In terms of education, roughly half of the participants were unable to read or write. More than three-fourths, or 451 (78.2%) of the participants, were housewives by occupation. Moreover, the majority, 494 (85.4%) of the participants, were rural residents (Table 1).

Table 1. Socio-demographic characteristics of mothers in southern Ethiopia.

Variables	Category	Frequency (N)	Percent (%)
Maternal age	15–19 y	31	5.4
	20–34 y	434	75.2
	35–49 y	112	19.4
Place of residence	Rural	493	85.4
	Semi-urban	84	14.6
Maternal educational status	Unable to read and write	288	49.9
	Read and write with no formal education	12	2.1
	Primary school	203	35.2
	Secondary	55	9.5
	Grade 12 or above	19	3.3
Maternal occupational status	Housewife	451	78.2
	Merchant	107	18.5
	Other*	19	3.3
Marital status	Married	568	98.4
	Other**	9	1.6
Husband educational status	Unable to read and write	284	50
	Read and write with no formal education	12	2.1
	Primary school	199	35
	Secondary	55	9.7
	Grade 12 or above	18	3.2
Husband occupational status	Governmental employee or employer	31	5.5
	Farmer	407	71.7
	Merchant	81	14.3
	Daily laborer	30	5.2
	Other***	19	3.3

*Daily laborer, farmer, Governmental employee or employer, House worker (maid) and Student **Divorced, Widowed and Never married. ***Driver and Student.

Obstetric characteristics of the participants

The majority, 542 (93.9%), of the participants reported that their last pregnancy was planned. Regarding ANC utilization, more than three-fourths (76.4%) of the participants had ever had ANC visits. Of those who ever visited the ANC during their last pregnancy, 225 (51%) had three visits. About half (50.1%) of the participants started their ANC visit within the first trimester of their previous pregnancy. The majority (86.7%) of participants have a plan for childbirth. Regarding the PNC visits, 142 participants had two or more PNC visits.

Prevalence of protective doses tetanus toxoid immunization among the participants

Of the total of 345 (59.8%) participants who received TT immunization, about 242 (41.9%) received protective doses of TT immunization (Figure 2). Of those who received TT immunization, 189 (54.8%) and 4 (1.2%) received the second dose and the fifth dose, respectively (Figure 3).

Figure 2. Tetanus toxoid immunization status of mothers in southern Ethiopia.

Figure 3. Tetanus toxoid immunization dose distribution among mothers in southern Ethiopia.

More than half (52.2%) of the participants’ source of information about TT immunization was the immunization card, which accounts for 200 (52.2%) mothers. Of the total number of participants who received the TT vaccine, 325 (94.2%) were immunized during their last pregnancy.

The participants reported a lack of awareness (37.7%), a lack of counseling (35.3%), having not faced a problem (5.6%), distance from a health facility (5.60%), a lack of a service provider (9.4%), and the absence of a provider during the immunization schedule (6.4%) as their main reasons for having not received any doses of TT immunization.

Health service-related characteristics of the study participants

Three hundred sixty-four (63.1%) mothers had obtained tetanus toxoid vaccine service from the nearest health institution. Four hundred twenty-six (73.8%) of them used to walk less than 1 hour on foot to reach the nearest health facility and 435 (75.4%) mothers had waited for less than thirty minutes to obtain TT Vaccine from health institutions. One hundred twenty-five (21.7%) mothers were visited by health extension package workers in their homes during the last pregnancy time (Table 2).

Table 2. Health service-related factors among mothers who gave birth in the last months in southern Ethiopia.

Variables	Category	Frequency(N)	Percent (%)
Vaccine service in the nearest health institution	Yes	364	63.1
	No	60	10.4
	Don’t know	153	26.5
Time to reach the nearest health facility	Less than one hour	426	73.8
	More than one hour	151	26.2
Waiting time for TT Vaccine service	Less than thirty minute	435	75.4
	Thirty to sixty-minute	113	19.6
	More than one hour	29	5
Health workers respect	No	108	18.7
	Yes	405	70.2
	Don’t know	64	11.1
Trust on the service	No	45	7.8
	Yes	461	79.9
	Don’t know	71	12.3
Health extension package worker home visit	No	452	78.3
	Yes	125	21.7

Participants’ knowledge and attitudes toward tetanus toxoid immunization

Concerning the tetanus toxoid vaccine, 308 (93.6%) of women had mentioned as a vaccine given for tetanus and 321 (97.6%) of the respondents mentioned the purpose of the TT vaccine that helps to protect mother and child (Table 3). Nearly two-thirds, or 213 (64.7%), of the participants had poor knowledge about TT immunization (Figure 4).

Figure 4. Participants’ knowledge of tetanus toxoid immunization among mothers in southern Ethiopia.

Table 3. Women’s responses to knowledge-related questions about tetanus toxoid immunization in southern Ethiopia.

Variables	Response	Frequency(N)	Percent (%)
Tetanus toxoid vaccine	Vaccine given for Yellow fever	2	0.7
	Vaccine given for tetanus	308	93.6
	Vaccine given for polio	8	2.4
	Vaccine given for measles	11	3.3
The purpose of TT vaccine	To protect the mother & child	321	97.6
	To protect the child only	7	2.1
	To protect the mother only	1	0.3
The necessity of the vaccine for pregnant mother	Yes	325	98.8
	NO	4	1.2
Number of TT vaccine should be given	One	11	3.3
	Two	31	9.4
	Three	90	27.4
	Four	82	25
	Five	113	34.3
	Six	2	0.6
The minimum interval to take the second dose	Four weeks	296	90
	Six months	23	7
	One year	10	3
The minimum interval to take the fifth dose of TT	Four weeks	111	33.7
	Six months	116	35.3
	One year	102	31
Protection of single valid doses TT	For One year	237	72
	For three year	55	16.7
	For ten year	23	7
	Have no protection at all	14	4.3
The minim vaccine need to prevent tetanus	One dose	25	7.6
	Two doses	56	17
	Three doses	130	39.5
	Four doses	42	12.8
	Five doses	35	10.6
	Don’t know	41	12.5
To get lifelong protection	One dose	6	1.8
	Two doses	16	4.9
	Three doses	34	10.3
	Four doses	66	20.1
	Five doses	141	42.9
	Don’t know	66	20.1

Out of the total participants, 257 (44.5%) of the participants were agreed that the tetanus toxoid vaccine increases the likelihood of getting miscarriage whereas more than forty percent (44.4%) of the participants agreed that the tetanus toxoid vaccine causes child malformation (Table 4). Overall, 191 (33.1%) of the participants had a favorable or positive attitude toward TT immunization (Figure 5).

Figure 5. Participants’ attitudes toward tetanus toxoid immunization among mothers in southern Ethiopia.

Table 4. Responses to the item of participant attitude toward tetanus toxoid immunization in southern Ethiopia.

Items	Strongly disagree	Disagree	Neutral	Agree	strongly agree
	N (%)	N (%)	N (%)	N (%)	N (%)
TT vaccine increase likelihood of getting miscarriage	4(0.7)	16(2.8)	191(33.1)	257(44.5)	109(18.9)
Five doses of TT enough to obtain lifelong protection	66(11.4)	100(17.3)	211(36.6)	177(30.7)	23(4)
A single dose of TT is enough to prevent tetanus	1(0.2)	11(1.9)	220(38.1)	250(43.3)	95(16.5)
TT vaccine make my child unintelligent	4(0.7)	32(5.5)	216(37.4)	230(39.9)	95(16.5)
TT vaccine cause malformation to my child		21(3.6)	223(38.6)	240(41.6)	93(16.2)
Two doses of TT vaccine provide lifelong protection	2(0.3)	22(3.8)	226(39.2)	256(44.4)	71(12.3)

Factors associated with uptake of protective doses of tetanus toxoid immunization

Variables like maternal age, family income, maternal educational status, having television, frequency of ANC visits, frequency of PNC visits, Health Extension Workers’ home visits, awareness toward TT immunization, and distance to the nearest health facility showed an association (in the bivariate logistic regression analysis) with the uptake of the protective doses of TT immunization at a p-value of less than .25. However, in multivariate analysis (after controlling for potential confounders), the participants’ educational status (AOR = 6.55, 95% CI: 3.23–9.01), the number of ANC visits (AOR = 2.56; 95% CI: 1.41–4.34), HEWs home visit (AOR = 2.66; 95% CI: 1.42–4.01), and the number of PNC visits (AOR = 3.82; 95% CI: 1.78–6.40) were variables that showed a significant association (at a p-value of less than .05) (Table 5).

Table 5. Bivariate and multivariate logistic regression analysis results for factors associated with uptake of protective doses of tetanus toxoid immunization among mothers in southern Ethiopia.

Variables	Uptake of protective doses of TT vaccine		COR(95% C1)	AOR(95% CI)	p-value
	Yes	No
Maternal age (in year)
15–19	11(35.5%)	20(64.5%)	1	1
20–34	202(46.5%)	232(53.5%)	1.58(0.74–3.38)	1.86(0.92–4.33)	.16
35–49	29(25.9%)	83(74.1%)	0.63(0.27–1.48)	1.27 (0.65–3.01)	.42
Mothers’ educational status
Not attended formal education	51(17%)	249(83%)	1	1
Attended formal education	191(69%)	86(31%)	10.84(7.31–16.08)	6.55(3.23–9.01)	.000**
Having television
No	155(34.7%)	292(65.3%)	1	1
Yes	87(66.9%)	43(33.1%)	3.81(2.51–5.76)	1.02(0.73–2.33)	.07
Frequency of ANC visit
≤3	152(34.7%)	286(65.3%)	1	1
≥4	90(64.7%)	49(35.3%)	3.45(2.31–5.15)	2.56(1.41–4.34)	.000**
Frequency of PNC visit
<2	132(30.3%)	303(69.7%)	1	1
≥2	110(77.5%)	32(22.5%)	7.89 (5.06–12.29)	3.82(1.78–6.40)	.001**
HEWs home visit
Not visited	179(39.6%)	273(60.4%)	1	1
Visited	63(50.4%)	62(49.6%)	1.55(1.04–2.30)	2.66(1.42–4.01)	.001*
Mothers’ awareness toward TT immunization
No	114(46%)	134(54%)	1	1
Yes	128(38.9%)	201(61.1%)	0.74(0.53–1.04)	1.96 (0.92–4.43)	.32
Time to reach the nearest health facility
Less than one hour	256(60.1%)	170(39.9%)	1.37(0.94–1.99)	0.46 (0.22–0.79)	.15
More than one hour	79(52.3%)	72(47.7%)	1

COR: crude odds ratio; AOR: adjusted odds ratio; CI: confidence interval; *significant association at p-value < .05; **strongly significant association at p-value > .001.

Discussion

Prenatal immunization of women of childbearing age against TT is the most effective and economic intervention strategy for the prevention of maternal and neonatal tetanus.⁷ This study aimed to evaluate the uptake of protective doses of TT immunization and identify its associated factors among mothers.

Accordingly, the findings of this study revealed that the uptake of the protective doses of TT immunization in the area was 41.9% (95% CI: 38%–46%). This finding is consistent with the previous study conducted in Hawzen, Tigray Region (40.2%)¹⁶ and Dukem Town, Ethiopia, where 39.2% of participants received protective doses of TT immunization.²⁵ However, the current finding is higher than the findings from Gambia (34.8%) and Kakamega County Referral Hospital, Kenya (29%).^26,27 However, it is lower compared to the EDHS 2016 report(49%).⁹ On the other hand, the finding is lower than the previous global and local findings, like the studies conducted in the Minas Gerais State of Brazil (59.2%), Bangladesh (49.9%), Baghdad (59.3%), Ghana (82.1%), Sudan (60.0%), the University of Gondar Comprehensive Specialized Hospital (69.8%), Debretabor (56.2%), the Errer District of Eastern Ethiopia (51.8%), and the Damboya district of SNNPR State (72.5%).^{15,17,19,23–25,28–30} This variation could be related to the socio-demographic differences, study design, and level of exposure to TT immunization information. In addition, the difference could be related to the variation in the quality of the immunization program in the study area.

In this study, maternal education was found to be significantly associated with TT vaccine uptake. When compared to their counterparts, participants who received formal education were more than six times more likely to receive protective doses of the TT vaccine. This finding is consistent with the EDHS 2016 report⁹ and studies conducted in Baghdad, Errer District, Eastern Ethiopia, Sudan, and Debre Brahan Town.^13,15,23,31 This association could be related to the educated participants’ easy access to information and the mothers’ increased power and confidence in their decision to be vaccinated.

In this study, participants who had at least four ANC visits during their last pregnancy were 2.5 times more likely to be vaccinated with the protective doses of TT immunization than those who had a maximum of three ANC visits. This finding is consistent with the studies conducted in Brazil, East Africa, Sudan, and Hawzen (Tigray Region).^7–11 This association is connected to the fact that an increased frequency of ANC visits exposes mothers to information about TT immunization. Furthermore, the TT immunization schedule is frequently adjusted to coincide with the schedule of ANC visits for pregnant mothers.

In this study, the frequency of PNC visits showed a significant association with TT immunization. Participants who had at least two PNC visits during their last delivery were nearly four times more likely to have been vaccinated with the protective doses of TT immunization than those who had a single PNC visit. This finding is consistent with a study conducted in Brazil.¹¹ This association might be due to the fact that the mothers who had higher PNC visits got informed about the importance of the TT immunization and its schedule and, correspondingly, were vaccinated against tetanus.

Moreover, participants who had received home visits from HEWs were 2.6 times more likely to receive protective doses of TT immunization than their counterparts. This finding is consistent with a study done in the Damboya District of SNNPR State.¹⁰ This association could be due to the HEW’s adequate counseling about TT immunization.

However, the study participant’s age, maternal awareness, and distance from the nearest health facility were not statistically significantly associated with the uptake of protective doses of TT. The above-mentioned factors are important predisposing and enabling factors for utilization of any health service, including TT immunization.^{14,16,17,20,23,28} In line with our findings, these aforementioned studies did not come up with statistically significant results regarding study participant knowledge and attitude toward TT immunization. But, it’s known that being knowledgeable about and having a positive attitude will have an impact for health service utilization. So, improving the knowledge of mother will change their attitude on TT immunization, which ultimately improves TT utilization among mothers. Again, it should not be undermined that the benefit of vaccinating women of reproductive age will save the life of her and her child in later life.

Strength and limitation of this study

Unlike most of the previous institution-based studies, this study was conducted in rural communities, where various socio-demographic and service-related factors are ingrained. However, this quantitative investigation would miss some possible socio-cultural barriers that could decrease the uptake of TT immunization. Thus, future investigations need to consider an explanatory design to dig out likely barriers.

Conclusion

In general, the uptake of protective doses of TT immunization among participants in the area was low as compared to the WHO’s target and the national figure. Maternal educational status, the frequency of ANC and PNC visits, and HEWs’ home visits were variables that independently predicted the uptake of protective doses of TT immunization. Hence, the concerned bodies need to strengthen the TT immunization program in the area. Moreover, healthcare workers need to reinforce prenatal counseling about the TT immunization.

Authors’ contribution

MG and TW conceived, designed, and wrote this research article. MG also participated in analysis and final write up of this article. WG participated in analysis and original manuscript draft. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The Institutional Review Board (IRB) of Arba Minch University College of Medicine and Health Sciences approved the study’s ethical clearance, with the reference number IRB/182/12. This research follows the declaration of Helsinki for human participants study. A written informed consent was obtained from each study participant after a detailed explanation of the components of ethical issue. Participants aged less than 18 y were interviewed after obtaining informed consent from their parents or guardians.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data used to support the findings of this study are available from the corresponding author upon request.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.