Antenatal care service delivery and factors affecting effective tetanus vaccine coverage in low- and middle-income countries: results of the Maternal Immunisation and Antenatal Care Situational Analysis (MIACSA) project

Objectives:To map the integration of existing maternal tetanus immunization programmes within ante-natal care (ANC) services for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with high performance maternal vaccine service delivery.Design:A mixed methods, cross sectional study with four data collection phases including a desk review,online survey, telephone and face-to-face interviews and in country visits was undertaken between 2016 and 2018. Associations of different service delivery process components with protection at birth (PAB) andwithcountrygroupswereestablished.PABwasdefinedastheproportionofneonatesprotectedatbirthagainstneonataltetanus. Regression analysis and structural equation modelling was used to assess associations of different variables with maternal tetanus immunization coverage. Latent class analysis (LCA), was used to group country performance for maternal immunization, and to address the problem of multicollinearity.Setting:LMICs.Results: The majority of LMICs had a policy on recommended number of ANC visits, however most were yet toimplementtheWHOguidelinesrecommendingeightANCcontacts.Countriesthatrecommended>4ANC contacts were more likely to have high PAB > 90%. Passive disease surveillance was the most common form of dis-ease surveillance performed but the maternal and neonatal morbidity and mortality indicators recorded differed between countries. The presence of user fees for antenatal care and maternal immunization was significantly associated with lower PAB (<90%).Conclusions:Recommendations include implementing the current WHO ANC guideline to facilitate increased opportunities for vaccination during each pregnancy. Improved utilisation of ANC services by increasing the demand side by increasing the quality of services, reducing any associated costs and supporting user fee exemptions, or the supply side can also enhance utilisation of ANC services which are positioned as an ideal platform for delivery of maternal vaccines