Determinants of tetanus-unprotected births in Tanzania: a multilevel analysis using the 2022 Tanzania Demographic and Health Survey data

Tetanus is a preventable bacterial disease that poses a significant public health challenge, particularly in low-income regions where immunization rates are low and hygienic birth practices are often inadequate. Neonates are especially vulnerable when their mothers lack sufficient antitoxins due to incomplete vaccination. Although Tanzania has achieved the elimination of maternal and neonatal tetanus, challenges in attaining high vaccination coverage persist. Therefore, this study aimed to investigate the determinants of tetanus-unprotected births in Tanzania. The study was based on a secondary analysis of data from the 2022 Tanzanian Demographic and Health Survey (DHS). A weighted sample of 5,745 women was used for analysis. Multilevel mixed-effects models with robust Poisson regression were applied to identify the determinants of tetanus-unprotected births. In the multivariable regression model, adjusted prevalence ratios (APR) with 95% confidence intervals (CI) were used to estimate the strength of associations, with a p-value of < 0.05 considered statistically significant. The prevalence of tetanus-unprotected births was 20.52% (95% CI: 19.49–21.55). Maternal age (35–49 years: APR = 1.62, 95% CI: 1.31–1.99), being employed (APR = 0.84, 95% CI: 0.75–0.93), currently being in a union or living with a man (APR = 1.47, 95% CI: 1.09-2.00), living in households with five or more members (APR = 1.22, 95% CI: 1.06–1.41), not wanting the last child (APR = 1.26, 95% CI: 1.13–1.40), having a birth order of four or more for the index child (APR = 2.18, 95% CI: 1.68–2.82), attending only one antenatal care visit (APR = 1.89, 95% CI: 1.45–2.48), and a history of pregnancy termination (APR = 1.17, 95% CI: 1.03–1.32) were identified as significant determinants of tetanus-unprotected births. Efforts to reduce tetanus-unprotected births should target older mothers, unemployed women, those in unions, and women with high birth orders or a history of pregnancy termination. Key strategies include promoting comprehensive antenatal care visits, expanding vaccination education to target older women, empowering women through employment, involving male partners in maternal health decisions, and supporting women with unintended pregnancies.