Factors influencing initiation to complete use of tetanus-toxoid containing vaccine in Nigeria: a narrative review.

Abstract

Ensuring lifelong protection against tetanus infection is a global concern, and Nigeria is among the 10 countries that have not yet achieved full maternal and neonatal tetanus elimination (MNTE). With pregnant women in tetanus-prone regions commonly taking neonatal protective doses of 1-2 tetanus-toxoid-containing vaccine (TTCV) during each pregnancy or not using it at all, women of childbearing age are unlikely to gain lifetime immunity. Understanding why pregnant women disregard or rarely complete the recommended five doses of TTCV after delivery can help vaccine policymakers and all stakeholders who are working towards local and global elimination of tetanus-related cases tailor their strategies. The objective of this study is to review and synthesize findings from published literature on various factors that influence initiation to complete use of the recommended five doses of TTCV from the start of pregnancy to post-delivery in Nigeria. We carried out a structured narrative search of literature and synthesis to identify factors that inform Nigerian women's non- and repetitive use of the protective doses of TTCV during pregnancy and hinder the complete use of the recommended doses after delivery. An electronic database search was carried out in Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, Global Health, MEDLINE Plus, PubMed, Google Scholar, and the Edinburgh Research Archive to retrieve relevant articles published in English from 2000 to 2025. Seven articles and one published thesis met the criteria for inclusion in the narrative review. The factors that informed the trend of non- and repetitive 1-2 doses of TTCV were reported to be largely associated with misconceptions, geographical location, religious beliefs, parity, spousal approval, women's parents, missed appointments, competing priorities, lack of knowledge of vaccine, doses, and dose intervals. The factors that hinder pregnant women from completing the recommended five doses of TTCV after delivery included forgetfulness, loss of interest, and the assumption that TTCV is not necessary after the baby has been born. Most pregnant Nigerian women who claimed to have had up to five doses of TTCV did so either out of personal determination or by repeating 1-2 doses in subsequent pregnancies. Our findings strengthen the knowledge that the factors that influence pregnant Nigerian women's initiation or complete use of TTCV are complex and multifactorial. National vaccine policy and vaccine recommendations should be informed by studies that provide balanced perspectives and knowledge of the reasons pregnant Nigerian women disregard or rarely complete the recommended doses of TTCV. The findings also emphasize the need for a reorientation of vaccine recommenders and users to the use of TTCV beyond the period of pregnancy.