Int J Gynecol Obstet, 1992, 39: 123-130 International Federation of Gynecology and Obstetrics
Maternal Nigeria
123
tetanus toxoid coverage during pregnancy
J.A. Owa and 0.0.
in Ile-Ife,
Makinde
Department of Paediatrics and Child Health and Department of Obstetrics and Gynecology, Faculty of Health Sciences, Obafemi Awolowo University, Ile-rfe (Nigeria)
(Received January 13th, 1992) (Revised and accepted April 15th, 1992)
Abstract A cluster survey on maternal tetanus toxoid (TT) coverage was carried out in the Ile-Ife Central Local Government Area. Out of the 896 mothers of babies O-12 months old who were interviewed, 668 (74.6%) claimed they received TT during pregnancy, this was confirmed in 37 (4.10/o) and in only 25 (2.8%) of these cases could the babies be said to have been protected from neonatal tetanus (NNT) at birth. About 35% of the babies were delivered at home/churches where most babies with NNT are usually born.
Keywords: Cluster survey; Tetanus Toxoid; Coverage; Pregnancy; Nigeria. Introduction
Neonatal tetanus (NNT) is a major public health problem in Nigeria. It is among the leading causes of neonatal death in Nigeria [l-6] and many developing countries [7]. The high incidence of NNT in the community is caused by unhygienic care during delivery and of the umbilical cord [7-91. Effective methods for prevention of NNT through hygienic care during delivery and of the umbilicus, and maternal immunisation with tetanus toxoid (TT) have been available 0020-7292/92/$05.00 0 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
for many years [ l-101. These preventive measures have not been afforded the deserved attention because of the lack of appreciation of the magnitude of the problem [lo]. In Nigeria for example, there is paucity of data on community-based survey on NNT. Most available reports on NNT in Nigeria are based on hospital records. Reference to maternal coverage with TT during pregnancy are usually on mothers of babies with NNT [11,12]. These are usually disadvantaged people and data based on them are likely to grossly underestimate the true figure of TT coverage during pregnancy. As part of the preventive measures against NNT at the community level, a communitybased survey on maternal TT coverage during pregnancy was carried out in November, 1990. This was a part of the baseline data of community-based study on prevention of NNT. It is believed that information obtained in this study will be applicable to many parts of the country and other parts of Africa. Population and methods
The study area was the Ile-Ife Central Local Government Area covering an area of about 629.41 sq. km. with a projected population of about 1 million. The design of the study was based on World Health Organisation (WHO) guidelines on a community-based survey on NNT Social Issues
124
Owa and Makinde
[13,14]. It was a cluster survey with Primary Health Care (PHC) Wards as the cluster units. At the time of the survey there were 12 Health Districts divided into 45 PHC wards. Thirty PHC wards were selected from the PHC wards. The first ward was selected by lot. The next ward to the first ward selected and then next one omitted and then the 4th and 5th wards to the selected 6th ward omitted and 7th and 8th selected until the all 30 wards were selected. In all, 30 of 45 PHC wards were surveyed. This was because the distribution of the population according to the wards or villages was not available. The houses in the wards were already numbered. The Primary Health Care numbers were used to locate the center of each ward and a coin was tossed to decide the direction of the interview. Thereafter consecutive houses were entered until the required number of subjects were interviewed. The study was directed by a consultant Epidemiologist sponsored for the study by the Nigeria CCCD project. The WHO designed prototype cluster form for tetanus toxoid immunization of women [14] was used as shown in Appendices 1 and 2 and analysis of data was also done according to guidelines laid down by the WHO [14]. A total of 26 interviewers, including two supervisors, in addition to the authors, carried out the survey between November 15 and 22, 1990. It took such a long period because a survey on incidence of NNT at the community level was also carried out at the same time. The mothers interviewed were mothers of children under 1 year old (O-12 months). Tetanus toxoid shots were easy to differentiate from other injections because this was usually given over the left deltoid muscle and mothers were well-informed in the clinic about the injection which was being given. The card that was commonly available at home is the EPI card given to the mother after delivery. There is a provision for the maternal TT record on the first page. Unfortunately this was not always recorded because the card was usually issued after delivery. InrJ
Gynecol Obsret 39
EPI card IMMUNISATIONS
DATE
REM-
GIVEN
ARKS
POLIO & DPT 6 WEEKS POLIO & DPT 10 WEEKS POLIO & DPT 14 WEEKS
MEASLES 9 MONTH
MOTHER’S
TETANUS
TOXOID
Results
A total of 4251 households were studied giving 141.7 households per cluster. The study was planned to cover at least 630 mothers. The number of mothers actually interviewed was 896. The results are presented in Table 1. The number of doses of tetanus toxoid covered was limited to the last two doses. These were the two doses received in the last pregnancy. This was to minimise problems associated with recalls since immunisation cards were not always available. Of the 896 mothers interviewed, 742 (82.8%) had antenatal care (ANC) visits to the health institutions and 458 (5 1.1%) visited for reasons other than ANC visits. Nineteen (4.1%) of the women only visited health institutions for reasons other than an ANC visit and 303 (40.8%) of those who had an ANC visit did not have other visits to health institutions. Of the 742 who had an ANC visit 668 (90%) claimed to have had at least one dose of
Maternal tetanus toxoid coverage during pregnancy in Nigeria
Table 1. Evaluation form-tetanus Area: Date of first interview: Date of last interview:
toxoid immunization of women.
Ife Central L.G.A. 15/l l/90 22/I l/90
Age group of children whose mothers are to be evaluated: Number of mothers in survey:
Number
TT2 TT3 TT4 TT5 Source: HOS HC OUT PRIV Antenatal care Other visits to health facilities Delivery of baby at: Home HC/HOS Other (Total) Priv Church Roadside Not stated Children protected against neonatal tetanus Total number of households Average number of households per cluster:
37 25
0- 12 months 896 TOTAL CARD PLUS HISTORY
TOTAL CARD
TTI
125
Percentage 4.1 2.8
Number
Percentage
668 585
74.6 65.3
204 785 112 152 742 458
16.3 62.6 8.9 12.1 82.8 51.1
195 459 242 110 116 3 13
21.8 51.2 27.0 12.3 12.9 0.3 1.5
25
2.8
4251 141.7
TT and 585 (78.8%), two doses of TT. In a very small proportion of the mothers, 37 (5.5%) out of 668 (or 4.1% of total) this was confirmed by the date on the card and more than half of these were from Outreach campaigns. By the WHO criteria [14] only 25 (2.8%) of the 896 babies can be said to be protected against NNT at birth, through confkmation on the cards. About half of the babies were delivered in the hospitals, primary health centers or government maternity centers and one fifth at home as against 742 (82.8%) who had an ANC visit (P < 0.001). Of the 242 delivered
in other places almost half of these were in mission houses. Comments Neonatal tetanus is one of the vaccinepreventable diseases and this can be done effectively at the Primary Health Care Centers. Over 60% of the doses of TT received by the women interviewed were in the PHC centers suggesting that this is a major health care delivery section of the health sector and therefore an area to concentrate on for the immunisation activities. Social Issues
126
Owa and Makin&
Most of the women who visited health institutions for reasons other than ANC also had ANC visits. These other visits to health institutions could have provided opportunity for immunisation for only 19 (2.1%) of the $96 mothers. The 116 (12.9%) women who delivered in the church (mission houses) constituted a special risk group because most of these belong to the Christ Apostolic Church discourages its members from taking injections or drugs. Most of the 228 women who did not receive TT during pregnancy belong to this group. The reason usually given by mothers who have ANC for delivery at home or mission houses is that labor pains start at night and it is more convenient to deliver at home or in nearby mission houses rather than wait for transport that may not be available. The women are well-informed about tetanus toxoid and are told when the injection is given. It is the only injection that is given to the mothers over the left detoid. The PHC is readily accessible to mothers and TT is given at every opportunity. In the hospitals TT is given only during ANC visiting periods. The mothers usually had the EPI cards issued to them only after delivery. Although this card had provision for maternal TT, this was seldom recorded. The result is that most mothers who had received TT during pregnancy did not have it documented. Although 585 (65.32%) of the mothers claimed to have had two doses of TT during pregnancy, only in 25 (4.3%) (i.e. 2.8% of 896) of these could the babies be said to have been protected at birth going strictly by WHO guidelines and documentation available in the cards. A previous report from Ilesa [ 121showed that about 30% of mothers of babies with NNT gave the history that they had received TT in pregnancy and this was confirmed in most cases from the maternity records. It is very likely that most of the 585 mothers had l’T as claimed by them. Home-based maternal TT records were not being used in our health institutions. The only available source of this Int J Gynecol Obster 39
information was the infant EPI card which was often issued to the mothers after the baby had been delivered. This information was therefore not recorded in most of the cards available at home. To overcome this, a separate card has been introduced for the maternal TT immunisation record. In fact the only space available in the infant EPI card is for only TTi and TT,. A home-based maternal TT record based on WHO prototype [15] is currently being tried in the Ile-Ife Central Local Government Area of Osun State. This has provision for the TTi-TTs as currently recommended [ 151. Apart from information on maternal TT immunisation, the present study, Appendix 3 [15] and Table 1 also provide data on the proportion of babies delivered in various places - home, hospital, health centers, private health institution and mission houses. It was noted that the group who delivered in the mission houses constituted a special risk group because of their attitude towards health care delivery sectors - orthodox or traditional. There is an urgent need to co-opt this group into the PHC sector. This is currently being vigorously pursued in Ile-Ife Central L.G.A. and other parts of Nigeria. The data from this study and Ilorin [17] show that Nigeria’should be regarded as one of the countries in which NNT is a serious health problem [ 161. This is because mortality from NNT is high (12/1000 live births) [ 171 and TT immunisation coverage during pregnancy is low [ 161, below the 76- 100% recommended coverage. The poor coverage is not all due to ignorance. It is partly due to late booking for ANC and poor attendance at ANC clinics by mothers who delivered at home and mission houses. About 35% of the babies were delivered at home and mission houses where they could easily be infected. These findings could be true of many parts of Nigeria and many African countries. Recommended actions are therefore: [ 161 to increase TT coverage identify districts with low coverage - carry out miss-
h4aiernal tetanus toxoid coverage during pregnancy in Nigeria
ed opportunity surveys - investigate new NNT cases - report NNT cases by district. Health education must be intensified to reach the group who deliver at home and mission houses and to train all the birth attendants in the mission houses all over the country as is currently being done in Ile-Ife Central Local Government Area and other parts of Oyo and Osun States. In addition, there is an urgent .need to introduce a separate home-based maternal TT record into the health institutions all over the country. This will help to improve the maternal TT coverage documentation.
9
10
11
12
Acknowledgment 13
This work was supported financially by the Nigerian CCCD project. References Efftong CE: Neonatal morbidity and mortality in Ibadan: A review of cases seen in the outpatient clinic. J Trop Pediatr 22: 265, 1976. Ransome-Kuti 0: The problems of paediatric emergencies in Nigeria. Nig Med J 2: 62, 1972. Adeyokunnu AA, Taiwo 0, Antia AU: Childhood mortality among 22 255 consecutive admissions in the University College Hospital, Ibadan. Nig J Pediatr 7: 7, 1980. Oyedeji GA, Olamijulo SK, Joiner KT: Neonatal tetanus in Ilesa Nigeria: A review of the present status. Nig Med J 12: 349, 1982. Idoko A: Neonatal tetanus in Benue-Plateau State. Nig J Pediatr 2: 45, 1975. Oruamabo RS, Nbuagbaw LT: Neonatal tetanus in PortHarcourt. Nig J Pediatr 13: 115, 1986. Stanfield JP, Galaxak A: Neonatal tetanus in the world today. Bull WHO 62: 647, 1984. Galaxka A, Gasse F, Henderson RH: Neonatal tetanus in the world and the Global Expanded Programme on Immunisation. Proceedings of the Eighth International Conference on Tetanus (eds G Nistico, B Bytchenko, B
14
127
Bixxini, RP Triau), 471 Pythagora Press, Rome-MilanLeningrad, 1989. Galway K, Walf B, Sturgis R: Vaccine-Preventable Diseases. In: Child Survival: Risks and the Road to Health. Institute for Resources Development. Westinghouse 16, 1987. Hinman AR, Foster SO, Wassilsk SGR: Neonatal tetanus: potential for elimination in the world. Pediatr Infect Dis 6: 813, 1987. EBiong CE, Antia-Obong OE, Young MU: The Prevalence of Neonatal Tetanus in Nigeria: The experience from the University of Calabar Teaching Hospital During the Period of the Expanded Programme on Immunisation. A paper presented at the 15th Annual Scientific Conference of West African College. of Physicians Benin City, Nigeria, 1991. Owa JA, Makinde 00: Neonatal tetanus in babies of mothers immunised with tetanus toxoid during pregnancy. Trop Doctor 20: 156, 1990. The EPI Coverage Survey: World Health Organisation. WHO/EPI/MLM/COV/88, October, 1988. Gala&a A, Stroh G: Neonatal Tetanus: Guideliens on the Community-Based Survey on Neonatal Tetanus Mortali-
ty. World Health Organisation Expanded Programme on Immunisation. WHO/EPI/GEN/86/8, 1986. 15 World Health Organisation: Expanded Programme on Immunisation: Prevention of neonatal tetanus through immunisation. WHOlEPF86.9 Revl. 1986. 16 World Health Organisation: Expanded Programme on Immunisation: Global Advisory Group on Neonatal Tetanus Elimination. EPbGAG189lWP.9 Tokyo, Japan. 1989. 17 Babaniyi OA, Parakoyi BD: Mortality from neonatal tetanus in Ilorin: Results of community-based survey. J Trop Pediatr 35: 137, 1989.
Address for reprints:
J.A. Owa Deputmemt of Paediatrics and Child Health Obafemi Anolowo University P.O. Box 617 ile-Ife, Nigeria
Social Issues
128
Owa and Makinde
Appendix 1
Cluster Form Tetanus Toxoid Immunization of Women (I) Cluster number: (2) Date: (3) Area: (4) Range of birth From: Until: Woman
number
(5) E”
dates:
. I
I
I
I
I
I
(2
(
I
I
I
I
I
I
I
I
I
I
I
I
I
I
1
in cluster
4
3
5
I
I
I
I
I
I
I
I 1
6
8
(6) Birth date of child Yes/N0
(7) Immunization card
1
(8) J-I.
Date/+/O SOUPX Date/+/O
l-r2
S0ttICe
ii % z
l-l-3
Date/+/O SOlXCe
l-T4
Date/+/O
health
facility
during
last
P=gnancY (I I) Delivery baby
HOme
of
HCIHOS Other Y&N0
(12) Child protected against tetanus
neoatal
I (13) Tally (14) Name
of households
visited,
of interviewer:
Signature:
KEYDate/+/O: Date = copy date of immunization + = mother reports immunizatmn 0 = immunization not given
from card. was given
if available
Source: HC = Health Centre HOS = Hospital OUT = Outreach PRIV
In1
J Gynecol Obstet 39
= Private
Maternal tetanus toxoid coverage during pregnancy in Nigeria
129
Appendix 2
Cluster Form Tetanus Toxoid Immunization of Women TOTAL
(5) 1
Utaral (3) Area: (4) Range of birth,g;t;;: From: Until: 713188
Card
P 8
Card PIUS
.g trs
History
E Woman
number
I
2
3
4
5
6
7
l/6/87
lO/ll/8i
l/4/87
2/2/88
13/l/88
9/7/87
IZ/ll/Ei
in cluster
(6) Birth date of child
HC
Source rr4
Date/+/O
3112&l
0
SOUrCe l-r5
(IO) Other
Date/+/O
HC 0
0
pWXted
(141 Name
0
1411018t
12/E/85
0
0
0
0
0
visits to
(12) Chtld
(13) Tally
0
HC
Other
against tetanus
HC
HC 0
8
Y
YesMo
neoatal
of households
vislted:
1111
1111Ill1 /Ill Ill1 Ill1 II/l
of interviewer:
Signature,
KEYDate/+/@ Date = copy date of mumtnization + = mother reports immunization 0 = immunization not given
from card. was given
if available
Source: HC = Health
Centre
HOS = Hospital OUT = Outreach PRIV
= Private
Social Issues
130
Owa and M&in&
Appendix 3
Summary Form Tetanus Toxoid Immunization of Women (2) Date of first interview: Dale ol last interview: (3) Area: (4) A@ group of children whose mothers arc evaluated
Int J Gynecol Obstet 39
Maternal Nigeria
123
tetanus toxoid coverage during pregnancy
J.A. Owa and 0.0.
in Ile-Ife,
Makinde
Department of Paediatrics and Child Health and Department of Obstetrics and Gynecology, Faculty of Health Sciences, Obafemi Awolowo University, Ile-rfe (Nigeria)
(Received January 13th, 1992) (Revised and accepted April 15th, 1992)
Abstract A cluster survey on maternal tetanus toxoid (TT) coverage was carried out in the Ile-Ife Central Local Government Area. Out of the 896 mothers of babies O-12 months old who were interviewed, 668 (74.6%) claimed they received TT during pregnancy, this was confirmed in 37 (4.10/o) and in only 25 (2.8%) of these cases could the babies be said to have been protected from neonatal tetanus (NNT) at birth. About 35% of the babies were delivered at home/churches where most babies with NNT are usually born.
Keywords: Cluster survey; Tetanus Toxoid; Coverage; Pregnancy; Nigeria. Introduction
Neonatal tetanus (NNT) is a major public health problem in Nigeria. It is among the leading causes of neonatal death in Nigeria [l-6] and many developing countries [7]. The high incidence of NNT in the community is caused by unhygienic care during delivery and of the umbilical cord [7-91. Effective methods for prevention of NNT through hygienic care during delivery and of the umbilicus, and maternal immunisation with tetanus toxoid (TT) have been available 0020-7292/92/$05.00 0 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
for many years [ l-101. These preventive measures have not been afforded the deserved attention because of the lack of appreciation of the magnitude of the problem [lo]. In Nigeria for example, there is paucity of data on community-based survey on NNT. Most available reports on NNT in Nigeria are based on hospital records. Reference to maternal coverage with TT during pregnancy are usually on mothers of babies with NNT [11,12]. These are usually disadvantaged people and data based on them are likely to grossly underestimate the true figure of TT coverage during pregnancy. As part of the preventive measures against NNT at the community level, a communitybased survey on maternal TT coverage during pregnancy was carried out in November, 1990. This was a part of the baseline data of community-based study on prevention of NNT. It is believed that information obtained in this study will be applicable to many parts of the country and other parts of Africa. Population and methods
The study area was the Ile-Ife Central Local Government Area covering an area of about 629.41 sq. km. with a projected population of about 1 million. The design of the study was based on World Health Organisation (WHO) guidelines on a community-based survey on NNT Social Issues
124
Owa and Makinde
[13,14]. It was a cluster survey with Primary Health Care (PHC) Wards as the cluster units. At the time of the survey there were 12 Health Districts divided into 45 PHC wards. Thirty PHC wards were selected from the PHC wards. The first ward was selected by lot. The next ward to the first ward selected and then next one omitted and then the 4th and 5th wards to the selected 6th ward omitted and 7th and 8th selected until the all 30 wards were selected. In all, 30 of 45 PHC wards were surveyed. This was because the distribution of the population according to the wards or villages was not available. The houses in the wards were already numbered. The Primary Health Care numbers were used to locate the center of each ward and a coin was tossed to decide the direction of the interview. Thereafter consecutive houses were entered until the required number of subjects were interviewed. The study was directed by a consultant Epidemiologist sponsored for the study by the Nigeria CCCD project. The WHO designed prototype cluster form for tetanus toxoid immunization of women [14] was used as shown in Appendices 1 and 2 and analysis of data was also done according to guidelines laid down by the WHO [14]. A total of 26 interviewers, including two supervisors, in addition to the authors, carried out the survey between November 15 and 22, 1990. It took such a long period because a survey on incidence of NNT at the community level was also carried out at the same time. The mothers interviewed were mothers of children under 1 year old (O-12 months). Tetanus toxoid shots were easy to differentiate from other injections because this was usually given over the left deltoid muscle and mothers were well-informed in the clinic about the injection which was being given. The card that was commonly available at home is the EPI card given to the mother after delivery. There is a provision for the maternal TT record on the first page. Unfortunately this was not always recorded because the card was usually issued after delivery. InrJ
Gynecol Obsret 39
EPI card IMMUNISATIONS
DATE
REM-
GIVEN
ARKS
POLIO & DPT 6 WEEKS POLIO & DPT 10 WEEKS POLIO & DPT 14 WEEKS
MEASLES 9 MONTH
MOTHER’S
TETANUS
TOXOID
Results
A total of 4251 households were studied giving 141.7 households per cluster. The study was planned to cover at least 630 mothers. The number of mothers actually interviewed was 896. The results are presented in Table 1. The number of doses of tetanus toxoid covered was limited to the last two doses. These were the two doses received in the last pregnancy. This was to minimise problems associated with recalls since immunisation cards were not always available. Of the 896 mothers interviewed, 742 (82.8%) had antenatal care (ANC) visits to the health institutions and 458 (5 1.1%) visited for reasons other than ANC visits. Nineteen (4.1%) of the women only visited health institutions for reasons other than an ANC visit and 303 (40.8%) of those who had an ANC visit did not have other visits to health institutions. Of the 742 who had an ANC visit 668 (90%) claimed to have had at least one dose of
Maternal tetanus toxoid coverage during pregnancy in Nigeria
Table 1. Evaluation form-tetanus Area: Date of first interview: Date of last interview:
toxoid immunization of women.
Ife Central L.G.A. 15/l l/90 22/I l/90
Age group of children whose mothers are to be evaluated: Number of mothers in survey:
Number
TT2 TT3 TT4 TT5 Source: HOS HC OUT PRIV Antenatal care Other visits to health facilities Delivery of baby at: Home HC/HOS Other (Total) Priv Church Roadside Not stated Children protected against neonatal tetanus Total number of households Average number of households per cluster:
37 25
0- 12 months 896 TOTAL CARD PLUS HISTORY
TOTAL CARD
TTI
125
Percentage 4.1 2.8
Number
Percentage
668 585
74.6 65.3
204 785 112 152 742 458
16.3 62.6 8.9 12.1 82.8 51.1
195 459 242 110 116 3 13
21.8 51.2 27.0 12.3 12.9 0.3 1.5
25
2.8
4251 141.7
TT and 585 (78.8%), two doses of TT. In a very small proportion of the mothers, 37 (5.5%) out of 668 (or 4.1% of total) this was confirmed by the date on the card and more than half of these were from Outreach campaigns. By the WHO criteria [14] only 25 (2.8%) of the 896 babies can be said to be protected against NNT at birth, through confkmation on the cards. About half of the babies were delivered in the hospitals, primary health centers or government maternity centers and one fifth at home as against 742 (82.8%) who had an ANC visit (P < 0.001). Of the 242 delivered
in other places almost half of these were in mission houses. Comments Neonatal tetanus is one of the vaccinepreventable diseases and this can be done effectively at the Primary Health Care Centers. Over 60% of the doses of TT received by the women interviewed were in the PHC centers suggesting that this is a major health care delivery section of the health sector and therefore an area to concentrate on for the immunisation activities. Social Issues
126
Owa and Makin&
Most of the women who visited health institutions for reasons other than ANC also had ANC visits. These other visits to health institutions could have provided opportunity for immunisation for only 19 (2.1%) of the $96 mothers. The 116 (12.9%) women who delivered in the church (mission houses) constituted a special risk group because most of these belong to the Christ Apostolic Church discourages its members from taking injections or drugs. Most of the 228 women who did not receive TT during pregnancy belong to this group. The reason usually given by mothers who have ANC for delivery at home or mission houses is that labor pains start at night and it is more convenient to deliver at home or in nearby mission houses rather than wait for transport that may not be available. The women are well-informed about tetanus toxoid and are told when the injection is given. It is the only injection that is given to the mothers over the left detoid. The PHC is readily accessible to mothers and TT is given at every opportunity. In the hospitals TT is given only during ANC visiting periods. The mothers usually had the EPI cards issued to them only after delivery. Although this card had provision for maternal TT, this was seldom recorded. The result is that most mothers who had received TT during pregnancy did not have it documented. Although 585 (65.32%) of the mothers claimed to have had two doses of TT during pregnancy, only in 25 (4.3%) (i.e. 2.8% of 896) of these could the babies be said to have been protected at birth going strictly by WHO guidelines and documentation available in the cards. A previous report from Ilesa [ 121showed that about 30% of mothers of babies with NNT gave the history that they had received TT in pregnancy and this was confirmed in most cases from the maternity records. It is very likely that most of the 585 mothers had l’T as claimed by them. Home-based maternal TT records were not being used in our health institutions. The only available source of this Int J Gynecol Obster 39
information was the infant EPI card which was often issued to the mothers after the baby had been delivered. This information was therefore not recorded in most of the cards available at home. To overcome this, a separate card has been introduced for the maternal TT immunisation record. In fact the only space available in the infant EPI card is for only TTi and TT,. A home-based maternal TT record based on WHO prototype [15] is currently being tried in the Ile-Ife Central Local Government Area of Osun State. This has provision for the TTi-TTs as currently recommended [ 151. Apart from information on maternal TT immunisation, the present study, Appendix 3 [15] and Table 1 also provide data on the proportion of babies delivered in various places - home, hospital, health centers, private health institution and mission houses. It was noted that the group who delivered in the mission houses constituted a special risk group because of their attitude towards health care delivery sectors - orthodox or traditional. There is an urgent need to co-opt this group into the PHC sector. This is currently being vigorously pursued in Ile-Ife Central L.G.A. and other parts of Nigeria. The data from this study and Ilorin [17] show that Nigeria’should be regarded as one of the countries in which NNT is a serious health problem [ 161. This is because mortality from NNT is high (12/1000 live births) [ 171 and TT immunisation coverage during pregnancy is low [ 161, below the 76- 100% recommended coverage. The poor coverage is not all due to ignorance. It is partly due to late booking for ANC and poor attendance at ANC clinics by mothers who delivered at home and mission houses. About 35% of the babies were delivered at home and mission houses where they could easily be infected. These findings could be true of many parts of Nigeria and many African countries. Recommended actions are therefore: [ 161 to increase TT coverage identify districts with low coverage - carry out miss-
h4aiernal tetanus toxoid coverage during pregnancy in Nigeria
ed opportunity surveys - investigate new NNT cases - report NNT cases by district. Health education must be intensified to reach the group who deliver at home and mission houses and to train all the birth attendants in the mission houses all over the country as is currently being done in Ile-Ife Central Local Government Area and other parts of Oyo and Osun States. In addition, there is an urgent .need to introduce a separate home-based maternal TT record into the health institutions all over the country. This will help to improve the maternal TT coverage documentation.
9
10
11
12
Acknowledgment 13
This work was supported financially by the Nigerian CCCD project. References Efftong CE: Neonatal morbidity and mortality in Ibadan: A review of cases seen in the outpatient clinic. J Trop Pediatr 22: 265, 1976. Ransome-Kuti 0: The problems of paediatric emergencies in Nigeria. Nig Med J 2: 62, 1972. Adeyokunnu AA, Taiwo 0, Antia AU: Childhood mortality among 22 255 consecutive admissions in the University College Hospital, Ibadan. Nig J Pediatr 7: 7, 1980. Oyedeji GA, Olamijulo SK, Joiner KT: Neonatal tetanus in Ilesa Nigeria: A review of the present status. Nig Med J 12: 349, 1982. Idoko A: Neonatal tetanus in Benue-Plateau State. Nig J Pediatr 2: 45, 1975. Oruamabo RS, Nbuagbaw LT: Neonatal tetanus in PortHarcourt. Nig J Pediatr 13: 115, 1986. Stanfield JP, Galaxak A: Neonatal tetanus in the world today. Bull WHO 62: 647, 1984. Galaxka A, Gasse F, Henderson RH: Neonatal tetanus in the world and the Global Expanded Programme on Immunisation. Proceedings of the Eighth International Conference on Tetanus (eds G Nistico, B Bytchenko, B
14
127
Bixxini, RP Triau), 471 Pythagora Press, Rome-MilanLeningrad, 1989. Galway K, Walf B, Sturgis R: Vaccine-Preventable Diseases. In: Child Survival: Risks and the Road to Health. Institute for Resources Development. Westinghouse 16, 1987. Hinman AR, Foster SO, Wassilsk SGR: Neonatal tetanus: potential for elimination in the world. Pediatr Infect Dis 6: 813, 1987. EBiong CE, Antia-Obong OE, Young MU: The Prevalence of Neonatal Tetanus in Nigeria: The experience from the University of Calabar Teaching Hospital During the Period of the Expanded Programme on Immunisation. A paper presented at the 15th Annual Scientific Conference of West African College. of Physicians Benin City, Nigeria, 1991. Owa JA, Makinde 00: Neonatal tetanus in babies of mothers immunised with tetanus toxoid during pregnancy. Trop Doctor 20: 156, 1990. The EPI Coverage Survey: World Health Organisation. WHO/EPI/MLM/COV/88, October, 1988. Gala&a A, Stroh G: Neonatal Tetanus: Guideliens on the Community-Based Survey on Neonatal Tetanus Mortali-
ty. World Health Organisation Expanded Programme on Immunisation. WHO/EPI/GEN/86/8, 1986. 15 World Health Organisation: Expanded Programme on Immunisation: Prevention of neonatal tetanus through immunisation. WHOlEPF86.9 Revl. 1986. 16 World Health Organisation: Expanded Programme on Immunisation: Global Advisory Group on Neonatal Tetanus Elimination. EPbGAG189lWP.9 Tokyo, Japan. 1989. 17 Babaniyi OA, Parakoyi BD: Mortality from neonatal tetanus in Ilorin: Results of community-based survey. J Trop Pediatr 35: 137, 1989.
Address for reprints:
J.A. Owa Deputmemt of Paediatrics and Child Health Obafemi Anolowo University P.O. Box 617 ile-Ife, Nigeria
Social Issues
128
Owa and Makinde
Appendix 1
Cluster Form Tetanus Toxoid Immunization of Women (I) Cluster number: (2) Date: (3) Area: (4) Range of birth From: Until: Woman
number
(5) E”
dates:
. I
I
I
I
I
I
(2
(
I
I
I
I
I
I
I
I
I
I
I
I
I
I
1
in cluster
4
3
5
I
I
I
I
I
I
I
I 1
6
8
(6) Birth date of child Yes/N0
(7) Immunization card
1
(8) J-I.
Date/+/O SOUPX Date/+/O
l-r2
S0ttICe
ii % z
l-l-3
Date/+/O SOlXCe
l-T4
Date/+/O
health
facility
during
last
P=gnancY (I I) Delivery baby
HOme
of
HCIHOS Other Y&N0
(12) Child protected against tetanus
neoatal
I (13) Tally (14) Name
of households
visited,
of interviewer:
Signature:
KEYDate/+/O: Date = copy date of immunization + = mother reports immunizatmn 0 = immunization not given
from card. was given
if available
Source: HC = Health Centre HOS = Hospital OUT = Outreach PRIV
In1
J Gynecol Obstet 39
= Private
Maternal tetanus toxoid coverage during pregnancy in Nigeria
129
Appendix 2
Cluster Form Tetanus Toxoid Immunization of Women TOTAL
(5) 1
Utaral (3) Area: (4) Range of birth,g;t;;: From: Until: 713188
Card
P 8
Card PIUS
.g trs
History
E Woman
number
I
2
3
4
5
6
7
l/6/87
lO/ll/8i
l/4/87
2/2/88
13/l/88
9/7/87
IZ/ll/Ei
in cluster
(6) Birth date of child
HC
Source rr4
Date/+/O
3112&l
0
SOUrCe l-r5
(IO) Other
Date/+/O
HC 0
0
pWXted
(141 Name
0
1411018t
12/E/85
0
0
0
0
0
visits to
(12) Chtld
(13) Tally
0
HC
Other
against tetanus
HC
HC 0
8
Y
YesMo
neoatal
of households
vislted:
1111
1111Ill1 /Ill Ill1 Ill1 II/l
of interviewer:
Signature,
KEYDate/+/@ Date = copy date of mumtnization + = mother reports immunization 0 = immunization not given
from card. was given
if available
Source: HC = Health
Centre
HOS = Hospital OUT = Outreach PRIV
= Private
Social Issues
130
Owa and M&in&
Appendix 3
Summary Form Tetanus Toxoid Immunization of Women (2) Date of first interview: Dale ol last interview: (3) Area: (4) A@ group of children whose mothers arc evaluated
Int J Gynecol Obstet 39
