Prevalence and factors associated with rural mothers’ protection against tetanus: a cross-national analysis in 33 sub-Saharan African countries

Abstract Background Sub-Saharan Africa (SSA) and South Asia account for most new cases of tetanus. Despite efforts by the World Health Organization to eradicate tetanus, it still causes many maternal mortalities. We examined the prevalence and risk factors associated with tetanus protection among rural mothers in 33 SSA countries. Methods Data were extracted from the most recent Demographic and Health Surveys of 33 SSA countries. A sample of 162 601 women from rural areas was drawn. Both descriptive and binary logistic regression analyses were conducted. Results Overall, approximately half (49.3%) of rural mothers were protected against tetanus. The association between maternal age, education, marital status, working status, distance to the health facility and number of antenatal visits were statistically significant with rural mothers’ protection from tetanus. Also, relationship to the household head, household size and frequency of listening to radio, reading a newspaper and watching television were statistically significant in predicting rural mothers’ protection from tetanus. Conclusions Policies and interventions by stakeholders must target high-risk populations, including adult women, those of poorer wealth status, those without media exposure and mothers with low educational attainment.


Background
Tetanus is a bacterial infection caused by the Clostridium tetani bacterium. 1It is a toxin-mediated disease that is highly lethal, non-communicable and characterized by muscle spasms and autonomic nervous system dysfunction. 1Because of poor maternal tetanus toxoid immunization rates, maternal tetanus remains a public health issue worldwide. 2orldwide, 75 million women and their newborns remain unprotected against tetanus, 3 putting them at risk of contracting the disease, dying from it or suffering life-threatening health effects. 4Tetanus can develop in pregnant women and newborns due to poor hygiene following birthing. 2Maternal tetanus can develop during pregnancy or within 6 weeks of delivery. 4Tetanus in pregnancy is a problem for health equity since it disproportionately affects individuals who are poor, disadvantaged and without access to quality healthcare. 2 Sub-Saharan Africa (SSA) and South Asia account for most new cases of tetanus. 3The two regions account for 82% of all tetanus cases globally. 5For instance, 77% of all deaths from tetanus occur in South Asia and SSA. 5 Evidence from the World Health Organization (WHO) suggests the majority of SSA nations struggled to meet the tetanus immunization objective meant to be achieved in the region, which is responsible for about half of the world's maternal and neonatal tetanus fatalities. 1 For instance, a study from Ethiopia reported that vaccine coverage may vary depending on the education and affluence of women. 6dditionally, it has been determined from the results of various studies that antenatal care (ANC) visits, women's education, income, distance to the health facility, place of residence, maternal age at first birth, women's employment status and media exposure are significantly linked to mothers who received tetanus vaccination. 6espite efforts by the WHO to eradicate tetanus, it still causes a sizable number of maternal mortalities. 7Maternal tetanus causes at least 5% of maternal mortality in the world's poorest regions. 8Most of the obstacles to the eradication of maternal and neonatal tetanus are linked to socio-economic issues and healthcare systems. 8According to Gashaw, 6 accelerating the elimination of maternal and neonatal tetanus in these nations, such as Mali, Nigeria, Sudan and Somalia, among others, will necessitate modifications to current maternal and neonatal tetanus elimination techniques, including innovations. 6ince many of the poorest and most neglected population groups are underserved regarding healthcare access, the tetanus problem is particularly severe in developing nations such as African countries. 9For instance, a previous study reported that mothers living in urban areas were more likely to receive the double tetanus vaccine than those in rural areas in Somalia and Sierra Leone. 10 To the best of our knowledge, this is the first subregional analysis in SSA examining the associated factors of rural mothers' protection from vaccination against maternal tetanus, despite the pervasiveness of tetanus in SSA. 1 , 3 , 5 Although previous studies exist, these were done at the country level, and another in 10 East African countries.This situation presents a substantial knowledge gap, as the magnitude and dynamics of tetanus from the regional perspective are unclear.This study seeks to narrow the existing knowledge gap.The aim of our study was to examine the prevalence and risk factors associated with tetanus protection among rural mothers in 33 SSA countries.The findings of our study will expand the current literature on tetanus and demonstrate the general picture of what exists in the subregion (e.g. which country is doing better) and how public health measures can be put in place to solve the tetanus problem in specific countries and in the subregion as a whole.

Data source
The analysis in this study is based on data extracted from the most recent Demographic and Health Surveys (DHS) (2010-2020) of 33 SSA countries that had the variables of interest included in the analysis (see Figure 1 ).The DHS is a nationally representative cross-sectional survey conducted every 5 y. 11The survey used a two-stage stratified cluster sampling approach to select samples of women in the reproductive age group (15-49 y) and men ages 15-64 y.The DHS is ideal for our study because it collects comprehensive information on various topics, including fertility, immunization coverage, tetanus toxoid injection and infant and maternal mortality.A sample of 162 601 women from rural areas was drawn from 33 SSA countries.MEASURE DHS approved the use of the dataset after reviewing our concept note.The dataset can be accessed at https://dhsprogram.com/methodology/survey/surveydisplay-491.cfm.We relied on the Strengthening the Reporting of Observational Studies in Epi-demiology statement in conducting this study and writing the manuscript. 12

Outcome variable
The outcome variable employed for this study was 'protection against tetanus'.This was derived from the question on the number of tetanus toxoid injections received during the pregnancy of the most recent birth.The response was captured dichotomously, with '0' for women who received less than two tetanus toxoid injections during the pregnancy of their most recent birth and '1' for women who received two or more injections.This categorization is based on the WHO's recommendation of at least two doses of tetanus toxoid injection during pregnancy, which is considered adequate.

Statistical analysis
Two types of statistical analysis were performed: descriptive and binary logistic regression analyses.The descriptive analysis involved the bivariate analysis between the country variable and the outcome variable.It also showed the background characteristics numbers and percentages by the outcome variables.The associated χ 2 test scores are also presented.Bivariate logistic regression was carried out to ascertain the statistically significant association between each selected explanatory variable and the outcome.Subsequently, multivariate logistic regression was employed to examine the significant association between the explanatory variables and the rural mothers' protection against tetanus by adjusting for the net effects of all statistically significant variables.Using a 95% confidence interval (CI), the adjusted odds ratios (ORs) for each variable were determined.The data were handled and examined using Stata version 17 (StataCorp, College Station, TX, USA).The outcomes were sample weighted to address any under-or oversampling of participants from the total population.The survey's complex design was accounted for in the analysis by using the svy command in Stata in all the estimations.A multicollinearity test was conducted to rule out the presence of multicollinearity in the fitted multivariate logistic regression model.

Results
Table 1 shows the prevalence distribution of rural mothers protected against tetanus by their country of residence in SSA.Overall, 49.3% of rural mothers are protected from tetanus in 33 SSA countries.Liberia has the highest proportion of rural mothers protected from tetanus (79.5%).This is followed by Sierra Leone (76.5%),Malawi (72.1%) and Burkina Faso (71.0%).Burundi recorded the least proportion (27.4%) of rural mothers who are protected from tetanus (see Figure 1 ).From the bivariate anal-ysis, it can be observed that the prevalence of tetanus protection among rural mothers was statistically significantly different regarding the country of residence of mothers (see Table 1 ).
Table 2 shows the distribution of rural mothers' protection against tetanus by their background characteristics in 33 SSA countries.The association between maternal age and mothers' protection from tetanus was statistically significant (p < 0.001).The prevalence of protection against tetanus among rural mothers is relatively high for the younger age categories compared with the older age categories.For instance, the highest uptake was among women 20-24 y of age (54.3%) and the lowest uptake of 43.4% was in rural mothers ages 40-44 y.When it comes to maternal education, the lowest uptake (44.7%) was recorded for mothers who had no education compared with those with primary education (51.2%) and secondary and above (58.1%).This association was statistically significant (p < 0.001).Rural mothers with the poorest wealth status recorded a lower percentage (44.9%) of protection against tetanus compared with a higher percentage (57.9%) in the richest mothers.There was a statistically significant (p < 0.001) difference in mothers' protection against tetanus for those who were never married (53.1%), married (48.8%) and formerly married (52.7%).Mothers who indicated they were working had a higher percentage (50.8%) of tetanus protection compared with mothers who were not working (46.5%).This relationship was statistically significant (p < 0.001).
Mothers who regard the distance to the facility as not being a problem had a higher percentage (50.5%) of protection against tetanus compared with those who considered the distance to be a big problem (48.0%).It was more common (61.5%) for mothers who had more than four ANC visits to be protected against tetanus than mothers who had less than four ANC visits (37.9%).
A total of 58.3% of rural mothers who had a parity of one were protected from tetanus while 44.8% of those with a parity of four or more were protected from tetanus.This association was statistically significant (p < 0.001).A total of 61.2% of rural mothers who read a newspaper/magazine were protected from tetanus compared with 48.6% of rural mothers who did not read a newspaper/magazine.Similarly, 54.8% of rural mothers who listened to radio almost every day were protected from tetanus compared with 46.2% of those who did not listen at all.Regarding the frequency of watching television, a higher proportion (59.1%) of mothers who watched television almost every day were protected from tetanus compared with those who did not watch television (48.5%).

Factors associated with protection against tetanus
A binary logistic regression model was fitted to examine the factors statistically significantly associated with rural mothers' protection against tetanus.Table 3 shows the unadjusted and adjusted ORs from the binary logistic regression and their respective CIs.Rural mothers who reported working had increased odds of 1.12 (95% CI 1.08 to 1.13) of being protected against tetanus compared with mothers who were not working.Rural mothers who said distance to the health facility was not a big problem had increased odds of 1.15 (95% CI 1.12 to 1.17) of protection against tetanus than their counterparts who said distance to the health facility was a big problem.The number of ANC visits was statistically significant with rural mothers' protection from tetanus.From Table 3 , mothers who had four or more ANC visits were 2.82 (95% CI 2.75 to 2.88) times more likely to be protected from tetanus compared with mothers who had less than four ANC visits.
When it comes to the frequency of radio listening, rural mothers who listened to radio less than once (aOR 1.14 [95% CI 1.10 to 1.17]), at least once (aOR 1.09 [95% CI 1.06 to 1.12]) and almost every day (aOR 1.12 [95% CI 1.03 to 1.21]) had higher odds of protection from tetanus than mothers who did not listen to radio.Similarly, rural mothers who watched television less than once (aOR 1.06 [95% CI 1.03 to 1.10]) and at least once (aOR 1.04 [95% CI 1.00 to 1.09]) were more likely to be protected from tetanus than mothers who did not watch television.Regarding country of residence, rural mothers in Zambia had the lowest likelihood of 0.08 (95% CI 0.07 to 0.09) of being protected from tetanus compared with their counterparts residing in Burkina Faso.

Discussion
This study examined the factors associated with tetanus protection among rural-dwelling mothers in SSA.Overall, less than half of mothers residing in rural areas in SSA were protected against tetanus.The scope of this study was wider than that of Belay et al., 2 as we looked at 33 countries as opposed to the 10 East African countries.Risk factors (age, wealth status, media exposure, a problem with distance to the health facility, marital status, frequency of ANC visits and maternal level of education) associated with tetanus protection among rural mothers are discussed in detail.
The study revealed that the odds of being protected against tetanus were significantly lower among adult women than adolescent girls.Similar findings were reported in a related study. 2 However, the result contradicts the findings of a multicountry  study 16 that found that adults were more likely to be protected against tetanus than adolescent girls.Also, the finding contrasts with a related study from Nigeria 17 that found no significant association between age and the likelihood of being protected against tetanus.A plausible explanation for this association could be that health education on vaccination against tetanus often targets adolescent girls and young women due to their likelihood of engaging in risky behaviours such as unprotected sex and having multiple sexual partners.Also, it is possible that adolescent girls might have received more recent and comprehensive tetanus vaccinations during their childhood or adolescence, ensuring higher levels of protection.In contrast, adult women might have received fewer booster doses of the vaccine, leading to reduced immunity against tetanus.Consistent with previous studies, 2 , 16 , 18 this study showed that higher maternal education was significantly associated with a higher likelihood of being protected against tetanus.This result can be explained from the perspective that higher maternal education predisposes or exposes women to health information and services that tend to increase their knowledge about International Health the nature and importance of protecting themselves against tetanus, hence encouraging the uptake of preventive interventions such as the tetanus toxoid vaccine.Another possible explanation could be that mothers with a higher level of education are likely to be empowered to make autonomous decisions about their healthcare, 19 , 20 including taking actions to protect themselves from tetanus.
Our findings show that being employed and having a higher wealth status corroborated related studies. 16 , 21 , 22One study by Yaya et al. 18 found no significant association, but their sample size was smaller, which could explain the difference.Also, being employed empowers women to be autonomous in their healthcare decision making, which is likely to reflect in their uptake of preventive interventions.High wealth status increases the income and financial resources of women in rural areas to afford the cost of transportation, health screening and maternity costs that ordinarily would be a barrier to their likelihood of being protected against tetanus. 16n line with prior studies, 23 , 24 this study showed that media (radio and television) exposure significantly increased the likelihood of women in rural areas being protected against tetanus.This observation is not surprising, as exposure to media increases women's access to information on tetanus and the need to take up preventive measures.Relatedly and surprisingly, the study revealed that a higher frequency of ANC visits increased the odds of women in rural areas being protected against tetanus.The result aligns with evidence from previous studies. 2 , 16During ANC sessions, healthcare providers offer education on a variety of potential health risks, including tetanus.Hence the more women attend ANC sessions, the more likely they are to be educated about the dangers of not taking preventive actions to protect themselves against tetanus.
Similar to the findings of Belay et al., 2 our study also found that women who did not have a problem with the distance to health facilities were 1.15 times more likely to be protected against tetanus compared with those who had a problem with distance, although this finding differs from Yeshaw et al. 16 and Liyew and Ayalew. 25We think that a possible explanation for this could be related to transportation costs.Relatedly, the findings from this study are supported by prior literature 2 , 25 that identified marital status as a significant factor associated with tetanus protection among rural-dwelling mothers in SSA.

Policy implications
Our study highlights the need for advocacy and leveraging the available media platforms to advance awareness about tetanus prevention.Also, there is a need to expand pro-poor interventions such as health insurance schemes to ensure that women of low wealth status can access tetanus toxoid injections.

Strengths and limitations of the study
The strength of this study lies in the use of a large sample size that is representative of 33 SSA countries.The implication is that the findings can be extrapolated to rural-dwelling women of reproductive age in SSA.Nevertheless, we cannot infer any causal pathways in the identified factors associated with rural mothers' protection against tetanus in SSA due to the nature of the study design (cross-sectional).The questions on the number of tetanus toxoid injections received during the pregnancy were self-reported, hence there is a likelihood of recall bias.Also, important factors such as community norms and beliefs could not be assessed in this study due to the use of a secondary dataset.Future studies can explore the causal pathways in the factors associated with rural mothers' protection against tetanus in SSA.

Conclusions
In conclusion, the factors associated with rural mothers' protection against tetanus in SSA include age, wealth status, media exposure, problem with distance to the health facility, marital status, frequency of ANC visits and maternal level of education.To further improve rural-dwelling women's protection against tetanus, policies and interventions must target high-risk populations, including adult women, those with a poorer wealth status, those without media exposure and those with low educational attainment.Given that the distance to the health facility was a significant factor, it is imperative to improve community-based health services to be able to reach women in rural areas who have a challenge with the distance to health facilities.
Authors' contributions: WA and CA contributed to the conceptualization and study design.CA performed the data analysis.WA, CA, JO, EA and VBB provided technical support and critically reviewed the manuscript for intellectual content.All authors read and amended drafts of the article and approved the final version.WA had final responsibility to submit for publication.

Figure 1 .
Figure 1.Map showing the proportion of mothers from rural areas protected against tetanus in 33 SSA countries.Dark shaded areas were not included in the study.

Table 1 .
Countries, survey years and percentage of rural mothers protected against tetanus in 33 SSA countries

Table 2 .
Background characteristics of rural mothers protected against tetanus in SSA (N = 162 601)

Table 3 .
Binary logistic regression results of factors associated with protection against tetanus