Interventions to reduce neonatal mortality from neonatal tetanus in low and middle income countries - a systematic review

Abstract

BackgroundIn 1988, WHO estimated around 787,000 newborns deaths due to neonatal tetanus. Despite few success stories majority of the Low and Middle Income Countries (LMICs) are still struggling to reduce neonatal mortality due to neonatal tetanus. We conducted a systematic review to understand the interventions that have had a substantial effect on reducing neonatal mortality rate due to neonatal tetanus in LMICs and come up with feasible recommendations for decreasing neonatal tetanus in the Pakistani setting.MethodsWe systemically reviewed the published literature (Pubmed and Pubget databases) to identify appropriate interventions for reducing tetanus related neonatal mortality. A total of 26 out of 30 studies were shortlisted for preliminary screening after removing overlapping information. Key words used were “neonatal tetanus, neonatal mortality, tetanus toxoid women”. Of these twenty-six studies, 20 were excluded. The pre-defined exclusion criteria was (i) strategies and interventions to reduce mortality among neonates not described (ii) no abstract/author (4 studies) (iii) not freely accessible online (1 study) (iv) conducted in high income countries (2 studies) and (v) not directly related to neonatal tetanus mortality and tetanus toxoid immunization (5). Finally six studies which met the eligibility criteria were entered in the pre-designed data extraction form and five were selected for commentary as they were directly linked with neonatal tetanus reduction.ResultsInterventions that were identified to reduce neonatal mortality in LMICs were: a) vaccination of women of child bearing age (married and unmarried both) with tetanus toxoid b) community based interventions i.e. tetanus toxoid immunization for all mothers; clean and skilled care at delivery; newborn resuscitation; exclusive breastfeeding; umbilical cord care and management of infections in newborns c) supplementary immunization (in addition to regular EPI program) d) safer delivery practices.ConclusionThe key intervention to reduce neonatal mortality from neonatal tetanus was found to be vaccination of pregnant women with tetanus toxoid. In the resource poor countries like Pakistan, this single intervention coupled with regular effective antenatal checkups, clean delivery practices and compliance with the “high- risk” approach can be effective in reducing neonatal tetanus.

Perception and utilization of tetanus toxoid immunization among pregnant women attending a tertiary centre in North-West Nigeria

“…4 The enormity of the danger posed by the poor obstetric care services across the continent is demonstrated by the finding in a study conducted at the Kilifi County Hospital, Kenya, that reported that 98% of the neonatal tetanus admissions at the hospital from 1999 to 2013 were home deliveries. 5 While evidence from studies has shown that immunization of pregnant women or women of child bearing age with two or more doses of tetanus vaccine (TT2+) protects the mother and the newborn baby from tetanus (with 94% reduction in mortality from neonatal tetanus), and at least 80% TT2+ coverage is needed to achieve MNT elimination, 6,7 data from the Nigeria Demographic and Health Survey (NDHS) 2013 showed wide variation and predominantly low TT2+ coverage rates across the country, ranging from 27.1% in the North-West geopolitical zone of the country (the study area) to 82.0% in the South-East zone; and with a national TT2+ coverage rate of 48%. 4 Similar to the situation in Nigeria, studies conducted in other sub-Saharan African countries including Ethiopia, 8 Kenya, 9 and Benin Republic, 10 also established a direct association between health facility utilization by pregnant women (particularly antenatal clinic attendance) and acceptance of TTCV by them, as the ANC visits avail the healthcare providers the opportunity to educate them on the benefits of TT immunization and its schedule.…”

Risk factors of neonatal tetanus in Wenzhou, China: a case control study

“…5,7 In some resourcepoor settings of the world, unsterile deliveries and poor post-natal hygiene compound the risk of neonatal tetanus. [12][13][14][15] The cultural diversity of childbirth practices and cord management, untrained birth attendants, uneducated parents, poor antenatal care and lack of immunization against tetanus have also been associated with the disease. 4,5,16,17 Furthermore, seasonality, geographical location, climate, prevalence of C. tetani and a rural agricultural population are also related to the incidence of neonatal tetanus.…”

Unequal Access to Maternal and Neonatal Health in Indonesia with Gender Perspective

“…Financial difficulty in another emerged as the major issue among women who did not fulfil the minimum requirements of four antenatal care services or two postnatal care services within the first month after delivery [10], [11]. This was related to the cost of health services, transportation costs, or both.…”