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East Afr Med J. 1993 Jul;70(7):434-7.

Epidemiological factors associated with neonatal tetanus mortality: observations from a cluster survey in Nigeria.

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Department of Paediatrics, Specialist Hospital, Yola, Adamawa State, Nigeria.


A cluster survey on neonatal tetanus (NNT) mortality was conducted in Kano Metropolis, Northern Nigeria, to investigate epidemiological factors associated with NNT mortality. The survey was a two-stage cluster sampling technique and lasted for two weeks. A total of 2,623 live-births were recorded over a 12-month period. Less than 40% of the births followed two or more antenatal visits and tetanus toxoid coverage was 32.0%. Over 60% of births were outside hospitals and related facilities. Of the epidemiological factors investigated, only antenatal care, tetanus toxoid coverage, hospital delivery, poor cord management and traditional surgery showed significant association with NNT death. It is suggested that an appropriate community-specific prevention strategy for the region should include health education to improve utilisation of antenatal and hospital-delivery facilities, discourage traditional surgery and improve tetanus toxoid coverage. A case is also made for training and involvement of traditional birth attendants (TBAs) since most deliveries occurred outside hospitals and related facilities.


Data obtained from a survey conducted in Kano Metropolis in northern Nigeria in July 1990 on a cluster sample of 2623 live births within the year were used to investigate epidemiological factors associated with neonatal tetanus (NNT) mortality. The sample included 1283 males and 1340 females, of which 79 died (54 from NNT). The NNT mortality rate is a high 20.6/1000. 51% of births in the sample were to mothers who received at least one prenatal visit. 37.9% of births involved mothers who received two or more prenatal visits, which is the typical pattern in developing countries. 32% were immunized with a tetanus toxoid vaccine, which is much higher than the typical 14% in developing countries. 40% were hospital or related health facility births. Low socioeconomic status was attributed to 60% of the infants. Over 80% of mothers practiced purdah, and 83% had a health facility within their cluster. Prenatal care, tetanus toxoid vaccine coverage, hospital delivery, poor cord management, and traditional surgery were related to NNT. Poor cord management and traditional surgery increased the risk of mortality, and the other factors reduced the risk. There were relative, but insignificant, risks associated with a male birth, low socioeconomic status, and the purdah system. One recommendation is for improvements in traditional birth attendant training. Affordability and use of health facilities are affected by the purdah system and the low socioeconomic status of most mothers. Prevention should stress good cord management, which Chinese studies show to be effective in reducing NNT mortality. Tetanus toxoid vaccine is recommended for all mothers who are attending any health facility for any reason. Mass immunization campaigns are an additional means of supplementing coverage. Traditional surgery such as circumcision, vulvectomy, ear piercing, and facial marking should be discouraged. Health education is recommended as a means of increasing use of health care facilities, discouraging unhealthful practices, and increasing immunization.

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