Determinants of the Number of Tetanus-Toxoid Injections Before Birth Among Pregnant Women in Somalia: A Multilevel Analysis.

Abstract

Background: Maternal and neonatal tetanus remains a major public health concern in Somalia, where low immunization coverage contributes to preventable mortality. Despite global progress, Somalia continues to report suboptimal tetanus-toxoid (TT) vaccine uptake due to conflict, weak health systems, and socioeconomic barriers. This study examined multilevel factors associated with the number of TT injections before birth among Somali women.

Methods: We analyzed data from the Somali Health and Demographic Survey (2020), including 4841 pregnant women aged 15-49. A mixed-effects negative binomial regression model addressed overdispersion, excess zeros, and hierarchical structure (region and residence). Model fit was assessed using Akaike (AIC) and Bayesian (BIC) information criteria.

Results: Only 32.6% of women received at least one TT injection, whereas 67.4% received none. Higher TT uptake was associated with older age (IRR = 1.62; 95% CI = 1.09-2.42), higher wealth (IRR = 1.49; 95% CI = 1.01-2.18), prior vaccination (IRR = 1.76; 95% CI = 1.44-2.16), antenatal care visits (IRR = 1.02; 95% CI = 1.01-1.04), employment (IRR = 1.41; 95% CI = 1.00-1.97), clinic deliveries (IRR = 1.23; 95% CI = 1.01-1.50), and health insurance (IRR = 5.24; 95% CI = 1.04-26.47). Conversely, zero uptake was more likely among nomadic women (AOR = 1.40; 95% CI = 1.06-1.85), those with no prior vaccination (AOR = 3.64; 95% CI = 2.76-4.80), home deliveries (AOR = 1.42; 95% CI = 1.18-1.71), no phone ownership (AOR = 1.31; 95% CI = 1.02-1.68), and women whose husbands lacked education (AOR = 1.27; 95% CI = 1.02-1.58).

Conclusion: TT vaccine coverage among pregnant women in Somalia remains critically low and is shaped by socioeconomic inequities, healthcare access, and household decision-making. Strengthening antenatal care integration, targeted outreach for nomadic populations, economic empowerment, health education, and expanding insurance coverage are essential to improve maternal immunization and eliminate neonatal tetanus.