In today’s ever-changing global healthcare landscape, the quality of life of children has seen significant improvements. However, when we turn our attention to Africa, we uncover a grim reality of persistent high rate of infant and neonatal deaths that continue to cast a dark shadow in developing nations such as Nigeria. The current Sustainable Development Goals (SDGs) framework presents an ambitious goal which is to reduce the global neonatal mortality rate to seventy deaths or fewer per 100,000 live births by the year 2030. Achieving this goal is possible, but there are significant challenges, some of which may seem simple but have the potential to worsen an already challenging situation. More so there are easy and practical ways of preventing some of these diseases, some of which are readily available vaccines.

The use of unsterilized objects during childbirth leads to maternal tetanus, which can be just as fatal as other complications like pre-eclampsia – a condition that is often very fatal and occurs when there is uncontrolled high blood pressure in pregnancy. Maternal tetanus strikes during pregnancy, sometimes as early as six weeks of its conception, potentially causing neonatal infection through the umbilical cord. This occurs when the pregnant woman encounters contaminated instruments or becomes exposed to hazardous substances carrying the bacteria. Regrettably, these issues remain underreported, primarily due to systemic deficiencies in the Nigerian healthcare sector. Many women of childbearing age are unaware of the Tetanus Toxoid (TT) vaccine, a crucial tool in preventing these untimely deaths. The Tetanus Toxoid (TT) vaccine, a medical marvel was discovered in 1924, and has remained a formidable shield against this persistent adversary. TT vaccine is administered freely to women typically beginning at the age of fifteen, serving as a guardian of both mother and newborn. Tetanus, a disease caused by the malevolent Clostridium Tetani bacteria thrives in unsanitary conditions, hence its ability to hide in unsterilized instruments and hazardous substances.

Dr. Chris Inalegwu, a senior registrar in the Department of Pediatrics at Usman Danfodiyo University Teaching Hospital, explains, “Tetanus toxoid is the vaccine administered to prevent tetanus infection in children. Much like its vaccine counterparts, it contains inactivated tetanus toxins, which, when administered, stimulate the child’s immune system, promoting the development of antibodies against the harmful tetanus toxin, thus conferring protective immunity.” 

The challenges contributing to maternal and neonatal tetanus are complex, but one critical issue is the failure of healthcare officials to consistently administer the vaccine. It is imperative that pregnant women have access to information about maternal tetanus.

The Struggle of Pregnant Women for Information

Pregnant women, regardless of their location, often struggle to find the right information about maternal tetanus. Women in urban areas are not offered the information because it is perceived they do not need it, while women in rural areas are bombarded with so much information that essential information like TT vaccine falls through the cracks. However, an alarming majority of pregnant women who even receive the TT vaccine only do it out of necessity, with little understanding of its purpose. The gap between healthcare professionals and community health workers, who should be attending to these women is large and, in many cases, the community health workers lack the necessary patience and resources to explain vital information to pregnant women in a way that is easily understood. Most times women reject the vaccine because adequate information is not given. Amina Adamu, a mother and stay-at-home spouse in Bossa local government Niger state expressed confusion, saying, “I don’t know about the vaccine, but I know that whenever I become pregnant and go for antenatal sessions, they give me an injection into my left arm.” Her words, in Pidgin English, reflecting the reality faced by many women

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Kainji Medical Centre, New Bussa, Niger State

Though it is important for pregnant women as well as girls of childbearing age to take TT vaccine, they are also entitled to know what is being put into their bodies, because lack of consultation brings about distrust. Dr. Aishat Ahmad, an obstetrician and gynecologist in Minna General Hospital Niger State emphasized the importance of proper consultation, “In an ideal world, every woman visiting a hospital should have the right to be informed about her condition, educated about relevant aspects of her care, and provided with comprehensive information. Unfortunately, we find ourselves struggling with a lack of communication skills, which is symptomatic of our understaffed facilities. Antenatal coverage, especially in primary healthcare settings, is increasing, yet the number of women addressed by skilled healthcare workers remains dismally low. Regrettably, the luxury of time eludes us, preventing us from educating these women in a way that fosters genuine understanding.”

Neonatal Hospital, Minna Niger State

Challenges with Community Health Workers

Community health workers, often hailed as the bridge between communities and healthcare facilities, sometimes fail to stress the importance of the TT vaccine. This is especially challenging for women in rural communities with barrage of information shoved at them.

Loko Primary Health Care, Minna, Niger State. Also Known as Asibitin Mata

Abdulbasit Abdulsalam, a community health worker in Loko Primary Health Care Minna Niger State, said these women are the most vulnerable in terms of encountering instruments that may be carrying the tetanus bacteria and not much is available to them by way of meaningful information on how to adequately protect themselves, “On occasions, these women come from rural communities with limited access to healthcare professionals and when they converge on our hospital, we are invariably outnumbered, and the task of attending to them becomes a Herculean ordeal.”

The Entrance of Asibitin Mata

 Societal Beliefs and Ignorance

Cultural beliefs sometimes lead to ignorance and a misunderstanding of vaccines and injections. Some cultures encourage the use of unsterilized objects during childbirth, and there is inadequate information on proper sterilization methods. This is because in some families, there is a notion that women should avoid medical facilities during pregnancy, rejecting any form of care, including injections, as foreign influences from the West. Women who choose home births are seen as examples of strength and courage forgetting that these societal beliefs are ancient and only make it almost impossible to avoid maternal and neonatal tetanus. Shamsiya Maiyaki, a community health worker in Old Airport Clinic, Minna, notes, “One of the most formidable challenges we face is the stubbornness of certain village women. They often cite religious and cultural prohibitions against receiving injections. Sometimes, we even offer tokens of goodwill to tip the scales in favor of rationality.”

This deeply rooted cultural belief systems sometimes extends to the husbands, who may discourage their wives from seeking healthcare or subject them to maltreatment if they discover that their wives have visited healthcare facilities without their consent. Dr. Aishat Ahmad underscores the importance of involving husbands in the maternity process to ensure that newborns are safe. “It is essential that we actively engage husbands, empowering them to facilitate their wives’ timely access to healthcare facilities, guiding them away from the perils of home births.”

Delivery Suits at Neonatal Hospital, Minna Niger State

Cultural Customs and Health Risks

Dr. Chris explains that some cultural customs and traditions have caused more harm than good, especially for women who choose home births. “Tetanus in newborn children often results from a combination of factors like inadequate healthcare, poor hygiene, lack of knowledge about proper newborn care, and certain cultural practices.” Newborns in these settings are at risk of exposure to Tetanus-causing microorganisms, as the umbilical cord may be severed using unclean tools. Traditional practices like skin markings, tribal tattoos, and ear piercings, performed with old and infected instruments, further compound the risks. Traditional uvulectomy, conducted by traditional practitioners using unsterilized and unsanitary instruments, poses yet another danger.

The role of Government

One of the significant contributors to the prevalence of neonatal and maternal Tetanus is the apathy shown by government authorities responsible for maternal healthcare. The 2023 budget allocation to Nigeria’s healthcare sector reveals a meager sum of 1.17 trillion Naira, which is woefully insufficient. Women visit hospitals only to be told that vaccines are unavailable, forcing them into a cycle of repeated visits that result in despair. Government hospitals, often in a state of disrepair, force pregnant women to navigate staircases due to malfunctioning elevators or lack thereof, compounding their woes. The shortage of healthcare staff further worsens the problem, resulting in overcrowded antenatal clinics, where a solitary consultant must attend to an overwhelming throng of around two hundred women. Once the clock strikes noon, these consultants often end their shifts, casting a dark shadow over the prospects of women traveling from far-flung regions in pursuit of specialized care. Therefore, it is very pertinent for government to pay more attention to the healthcare sector, thereby providing good infrastructures and employing more skilled staff. “Delivering improved quality heath is an underpinned factor in my promise of renewed hope to Nigerians. That hope is ignited here today with the support of all mutilated partners and agencies. Health is back on the front burner” A statement by President Bola Ahmad Tinubu at a conference in Lagos. We hope he keeps his word.

Lack of Awareness  

The challenges arise from the dearth of knowledge among women of childbearing age regarding the Tetanus Toxoid vaccine. In rural communities, radio broadcasts and door-to-door campaigns constitute the primary sources of information. Privately owned radio stations and government-owned broadcasters often prioritize government-related programs and sponsored adverts, leaving little room for disseminating knowledge about the vaccine while the primary obligation of media houses is to inform and educate because they are the eyes and ears of the people. Media houses should do more in disseminating information about the vaccine first as a form of social responsibility.

Urban centres like Minna and some parts of the city of Kano lack sufficient information about the vaccine unless individuals seek counsel from medical professionals in hospitals or community health workers in primary health care. Single women often exhibit lower level of knowledge and awareness of the vaccine. In a cross-sectional study conducted by Victorine M, Mounting G, and Emmanuel N Tufon of Saint Louis University institute of health and Biomedical sciences, revealed that Married women are three times more likely to be engaged in Tetanus toxoid vaccine than single women. However, it is very important to have broad and inclusive sensitization programs because if girls from the age of 15 take their vaccine and are well sensitized, there will be less pressure on the health sector on the need to do it again especially during pregnancy as the women must have already taken all the required steps at that stage.

Primary healthcare facilities frequently lack a sufficient supply of Tetanus vaccines, leaving women frustrated after repeated visits. This continuous cycle of disappointment leads many women to give up their search for immunization and are resigned to their fate.

Dr. Chris clarifies further, “The Tetanus Toxoid vaccine is an integral component of the Expanded Program on Immunization. A child should receive a dose at birth, another at six weeks, followed by a third at ten weeks, as part of a pentavalent vaccine. Subsequently, two more doses are administered at 3-4 years and 14 years. However, these shots do not confer lifelong protection. Booster shots are requisite to maintain immunity effectively.”

Addressing the Dangers

Several actions need to be taken to ensure that the risks of contracting tetanus are reduced towards the overarching goal of achieving a lower rate of infant mortality. These include ensuring a mandatory and comprehensive immunization of women of childbearing age from age 15 and guaranteeing that they receive and complete their vaccine doses as expected. This will vastly reduce the risk of contracting the infection and as well foster a healthy society.

Tetanus Vaccine Booster Shot

Lack of awareness is one of the major concerns. When people are not aware of some of the dangers that they are vulnerable to, they tend to have a carefree attitude towards it. But if knowledge about the vaccine is widely disseminated, targeting women, men, and expectant couples, there would be a better take-up of the vaccine. House-to-house campaigns should be highly encouraged especially in rural communities so that people who do not have access to phones, Radios and TV will as well be aware of the vaccine. This can go together with educating Parents, especially mothers to promote hygienic practices, even if they already do so. By so doing, mothers will take care of themselves and their daughters, preparing them well even before they attain the age of marriage.

Bad sterilization practices are also one of the problems. Channeling enlightenment campaigns on the need to strictly adhere to equipment sterilization protocols both in rural and urban centers will go a long way. Traditional Birth attendants in remote regions should be carefully trained on how to locally sterilize equipment before and after use to reduce the risk of contracting Tetanus infection. City hospitals should also be supervised to ensure that they maintain sterilization protocols for the safely of mothers and their infants.

There should be more qualified healthcare staff with the existing staff given on the job and regular capacity training. This will ensure a seamless vaccine supply, reduce workload on the staff, and foster patient commitment where every patient will be attended to on time and appropriately.

The battle against maternal and neonatal Tetanus is a collective work that transcends borders and boundaries. Women and children are the bearers of our future, and it is our responsibility to safeguard their well-being. Government commitment, community awareness, and healthcare improvements are the headlight on the path to a brighter and healthier future for all. Maternal Tetanus should be taken seriously, as it is not just a health concern but a societal issue that impacts the well-being of our most vulnerable members – mothers and newborns. It is only through a concerted effort that we can protect our tomorrow.

This report was produced with support from the Women Radio Centre and MacArthur Foundation