low- and middle-income countries in sub-Saharan Africa, Africa, and Asia. This is often due to unhygienic

birth practices. Vaccination with tetanus toxoid-containing vaccine during and around pregnancy provides

protection. A literature review from 1995 to 2024 was conducted in PubMed/MEDLINE, African Journals

Online, and Google Scholar following PRISMA guidelines to identify relevant publications. Thirteen studies

met the inclusion criteria and were assessed for evidence quality using an expanded PRISMA checklist. The

studies identified key factors influencing poor vaccination uptake among women of childbearing age,

including age(25-35years: AOR; 0.510-0.925), marital status (Married: AOR; 0.400-1.038), parity (3-4

Children: AOR; 0.200-5.050), antenatal care visits (Four or more: AOR; 0.048-1.710), place of delivery

(Health facility: AOR; 1.130-23.380), distance to health facilities (<30 minutes: AOR;1.050-4.600), media

exposure (Yes: AOR;1.968-2.820), wealth index (Rich: AOR; 0.630-7.230 or poor), educational level

Tetanus, is often a life-threatening infection, characteristically presenting with muscle spasms and nervous

dysfunction, due to the impregnation of wounds with the bacterium Clostridium Tetani [2], [4], [8], [9], [23].

Though it can affect all age groups, neonates and pregnant women, in countries typically located in the global

south, are at greater risk of infection especially due to unhygienic practices during delivery and/or confinement

at birth [1] - [3].

It is a commonly diagnosed affectation of these groups in countries designated as “high risk”, by the World

Health Organization. These countries, such as Nigeria, are mostly Low-and-Middle-Income countries in sub-

Saharan Africa, Africa, and Asia where tetanus remains mostly under-reported and a menace [23]. This

situation is reported to be mainly due to poor information on the disease, low level of education among women

childbearing age and pregnant women should take several doses of the tetanus toxoid vaccine based on an

internationally prescribed schedule [6], [22], [23]. To this end, it is recommended that a total of five tetanus

toxoid vaccine doses be administered to previously unimmunized persons or those with questionable

immunization status [5] – [7], [22], [23].

In consonance thereof, it is surmised that protection against tetanus in women of childbearing age and neonates

is guaranteed if women of childbearing age or pregnant women receive at least two doses of tetanus toxoid-

containing vaccine with the last dose being within the last three years; three doses of tetanus toxoid containing

vaccine with the last dose being within the last five years; four doses of tetanus toxoid containing vaccine with

the last dose being within the last ten years; or receive at least five doses or greater of tetanus toxoid containing

vaccine through the course of their lives [10], [22], [23].

Specifically, vaccination with tetanus toxoid-containing vaccine has been volunteered as being responsible for

Therefore, the foregoing considerations give impetus for this study which aims to interrogate the factors

affecting the uptake of tetanus toxoid-containing vaccines among women of child-bearing age in Low-and-

Middle Countries, using sub-Saharan Africa as a focal point, with a view to improving, significantly, the

coverage of target group vaccinations. This is more so as attempts at the elimination of maternal and neonatal

tetanus in low-and-middle-income-countries have focused mostly on targeted vaccination of women of

childbearing age and/or pregnant women.

A systematic approach was used to conduct the literature review in PubMed/MEDLINE and African Journals

Online databases, following PRISMA guidelines, to identify publications on factors affecting the uptake of

Childbearing age” OR “young adult women” AND “underdeveloped” OR “developing” OR “Low- and-

Middle- Income Countries”.

The search was conducted for the aforementioned time frame to elucidate the critical issues bedevilling the

effort of the World Health Organization (WHO), governments, and partners in the elimination of maternal and

neonatal tetanus in low-and-middle-income countries especially those classified as high risk. See the PRISMA

diagram (Figure 1) below.

Using the expanded PRISMA checklist (2020), an overall assessment of the quality of evidence, of selected

interrogations and /or requirements, in the designated areas of inquiry derived therefrom, for quality of

Table 1 below.

income countries.

4. Studies reporting on factors affecting the uptake of tetanus toxoid vaccine in the target group in low-

and-middle-income countries.

5. Studies which considered factors affecting immunization with tetanus toxoid vaccine in the following

categories:

i. Demand side factors (Target group related/Economic/Sociocultural/Education)

ii. Supply-side factors (Health system related/Logistics/Access/Utilization).

iii. Miscellaneous factors (Information/ Media/Peer groups).

6. Studies that satisfied the criteria for quality of evidence (as delineated in the assessment for quality of

evidence –Table 1).

independently by two authors (TE) and (SL). Selected papers were then retrieved and full-length versions were

read through and through. The following information was extracted from the selected papers:

a. Study population and area where the study was carried out.

b. Methodological approach and follow-up period.

c. Key findings of the study, as regards the following, by year and country.

i. Factors affecting uptake of tetanus toxoid vaccine in target group.

ii. Strategies for and progress towards elimination of maternal and neonatal tetanus through

iii. Outcomes and related factors for immunization of target group with tetanus toxoid vaccine.

d. Health system nuances that contribute to the outcomes of vaccination of the target group.

Articles that used multiple methodologies were included in more than one category. Any disagreements, in

extracted data, between the authors were resolved by consensus or by arbitration of a third review author

Following this, discussion of the findings is entertained, highlighting key findings and proffering possible

A total of thirteen primary studies were included in the systematic review. The studies were carried out in the

following Low-and-Middle-Income-Countries: Afghanistan, Angola, Central African Republic, Comoros,

Egypt, Ethiopia, Guinea, India, Kenya, Malawi, Mali, Nigeria, Pakistan, Papua New Guinea, Rwanda, Sierra-

Leone, Somalia, South Sudan, Sudan, Tanzania, Uganda, Yemen, Zambia and Zimbabwe. Also included was a

study conducted in one hundred and thirty-seven Low-and-Middle-Income-Countries (the aforementioned

countries inclusive). Five of the studies were conducted in urban areas, two of the studies in rural areas, and

seven studies in both urban and rural areas.

The period over which the studies were carried out ranged from a few weeks to five years. The types of studies

included in the review were all cross-sectional studies, though multiple methodologies were entertained at the

for the included studies are outlined herewith:

2) El-Adham et al, 2022: The key findings were, poor knowledge of TTCV/vaccination (50%), and lack of

3) Fenta et al, 2022: Quite significant in this study were, TT2+ uptake (41.6%), religion {orthodox -1; Muslim

Also, parity of the mother was noted to significantly affect the uptake of the tetanus toxoid vaccine. In this

and-effect relationship established by the included primary studies as well as the level of heterogeneity, where