Abstract
ObjectivesTo map the integration of existing maternal tetanus immunization programmes within antenatal care (ANC) services for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with high performance maternal vaccine service delivery. DesignA mixed methods, cross sectional study with four data collection phases including a desk review, online survey, telephone and face-to-face interviews and in country visits was undertaken between 2016 and 2018. Associations of different service delivery process components with protection at birth (PAB) and with country groups were established. PAB was defined as the proportion of neonates protected at birth against neonatal tetanus. Regression analysis and structural equation modelling was used to assess associations of different variables with maternal tetanus immunization coverage. Latent class analysis (LCA), was used to group country performance for maternal immunization, and to address the problem of multicollinearity. SettingLMICs. ResultsThe majority of LMICs had a policy on recommended number of ANC visits, however most were yet to implement the WHO guidelines recommending eight ANC contacts. Countries that recommended > 4 ANC contacts were more likely to have high PAB > 90%. Passive disease surveillance was the most common form of disease surveillance performed but the maternal and neonatal morbidity and mortality indicators recorded differed between countries. The presence of user fees for antenatal care and maternal immunization was significantly associated with lower PAB (<90%). ConclusionsRecommendations include implementing the current WHO ANC guideline to facilitate increased opportunities for vaccination during each pregnancy. Improved utilisation of ANC services by increasing the demand side by increasing the quality of services, reducing any associated costs and supporting user fee exemptions, or the supply side can also enhance utilisation of ANC services which are positioned as an ideal platform for delivery of maternal vaccines.
Highlights
In 2015, an estimated 303,000 women died from pregnancyrelated causes [1], and 2.6 million babies were stillborn [2]
The Maternal Immunization and Antenatal Care Situational Analysis (MIACSA) project has identified aspects of maternal tetanus immunization that need to be strengthened and gaps that need to be addressed to inform the introduction of additional maternal vaccines into antenatal care services
Increasing the number of countries adopting the current World Health Organization (WHO) recommendation for eight antenatal contacts thereby increasing opportunities for vaccination during pregnancy
Summary
In 2015, an estimated 303,000 women died from pregnancyrelated causes [1], and 2.6 million babies were stillborn [2]. In 2017 an estimated 2.5 million babies died in the first month of life [3] Many of these deaths would be preventable through increased access to and use of quality health care during pregnancy and childbirth. The third SDG on good health and wellbeing, aims to end preventable deaths of newborns and children under five years of age by 2030, with a target to further reduce neonatal mortality to at least as low as 12 per 1,000 live births and under five mortality to at least as low as 25 per 1,000 live births [5]. Infectious diseases, pneumonia and sepsis are leading causes of death in children under five years of age [6], some of which may be preventable by maternal immunization
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