Determinants of births protected against neonatal tetanus in Ethiopia: A multilevel analysis using EDHS 2016 data.

BACKGROUND: Even though there is low coverage of maternal health services such as antenatal care and skilled birth attendant delivery as well as poor sanitary practice during delivery in Ethiopia, the proportion of births protected by the tetanus vaccine is low. Thus, this study aimed to investigate the determinants of births protected against neonatal tetanus in Ethiopia.
OBJECTIVE: To assess the determinants of births protected against neonatal tetanus in Ethiopia.
METHOD: The study was based on secondary data analysis of the Ethiopian Demographic and Health Survey 2016 data. A weighted sample of 7590 women who gave birth within five years preceding the survey was used for analysis. We conducted a multilevel analysis, due to the hierarchical nature of the data. Variables with p-value <0.05 in the multivariable analysis were declared to be significantly associated with having births protected against neonatal tetanus. RESULT: In this study, mothers with primary education [adjusted odds ratio (AOR) = 1.23; 95%CI: 1.04, 1.44] and secondary and above education [AOR = 1.36; 95%CI: 1.06, 1.73], media exposure [AOR = 1.35; 95%CI: 1.15, 1.58], not perceiving distance from the health facility as a big problem [AOR = 1.24; 95%CI: 1.08,1.42], one antenatal care (ANC) visit [AOR = 1.56; 95%CI: 2.71, 4.68], two to three ANC visit [AOR = 11.82; 95%CI: 9.94,14.06], and four and more ANC visit [AOR = 15.25; 95%CI: 12.74, 18.26], being in Amhara [AOR = 0.59; 95%CI: 0.38,0.92], Afar [AO = 0.41; 95%CI: 0.25,0.66], and Harari [AOR = 1.88; 95%CI: 1.15,3.07] regions, being in communities with higher level of women education [AOR = 1.25; 95%CI: 1.03,1.52], and higher level of media exposure [AOR = 1.22; 95%CI: 1.01,1.48] were significant predictors of having a protected birth against neonatal tetanus.
CONCLUSION: In this study, both individual level and community level factors were associated with having protected birth against neonatal tetanus. Therefore, strengthening maternal health services such as ANC visits and interventions related to increasing media campaigns regarding tetanus could increase the immunization against tetanus among reproductive-age women. In addition, it is also better to give attention to those reproductive age group women from remote areas and also better to distribute maternal services fairly and equally between regions.

Background

In Ethiopian, the Expanded Program on Immunization (EPI) was launched in 1980 [1]. Its target groups are children under one year of age and women of reproductive age group (15–49 years of age). The currently available EPI vaccines in Ethiopia are Bacille Calmette-Guerin (BCG), Measles, DPT-HepB-Hib or pentavalent, Rotavirus, Pneumococcus Vaccine (PCV), Oral Polio Vaccine (OPV), and Tetanus Toxoid (TT) Vaccines [1].

Tetanus is one of the vaccine-preventable bacterial disease caused by a toxin produced by Clostridium tetani [2]. Maternal and neonatal tetanus (MNT) is a triple failure of the public health system (immunization Programme, antenatal care, and clean and safe birth practices) which mostly affect disadvantaged and underserved population groups, who did not have access to adequate health services [3]. Because most neonatal tetanus (NT) infections occur during childbirth, due to inadequate/poor sanitary conditions, newborns need to have maternal antibodies against tetanus that are obtained through the placenta [3,4].

Even though the elimination of MNT was achieved in most of the countries, by the end of 2015, there were still 21 countries that had not yet attained the elimination of MNT [3]. Globally by 2017, there were 30,848 newborn deaths due to neonatal tetanus [5]. In many lower and middle-income countries, in which many mothers and neonates died at home during delivery, births and deaths are not officially reported and the burden of mortality due to tetanus cannot be estimated [3]. Despite Ethiopia validated the elimination of MNT, it is not an end in itself and its maintenance needs an ongoing vaccination Programme and improved public health infrastructure [6].

Giving tetanus immunization for women of childbearing age and pregnant women is an intervention that is taken to protect both the mother and the newborns from tetanus [7]. If mothers took the appropriate number of doses of the TT vaccine during or before pregnancy, both the mother and her child will be safe from tetanus during delivery [8].

In many countries including Ethiopia, TT vaccination is part of routine maternal health care services in which a minimum of two doses of the vaccine is given to pregnant women during pregnancy if the mother did not taka the vaccine before. However, the overall childbearing mothers should take five doses of TT vaccine. These five doses protect tetanus throughout women's reproductive years [3,9,10].

Globally 82% of newborns were protected at birth through maternal TT vaccination, with at least two doses of tetanus toxoid vaccine [11]. In Africa, the proportions of childbearing women with at least two doses of tetanus-containing vaccine and the proportions of newborns protected at birth were 69% and 77% respectively in 2015 [12]. In Ethiopia, according to the Ethiopian Demographic and Health Survey (EDHS) 2016 report, only 49% of women had their last birth protected against neonatal tetanus/had received sufficient doses of TT vaccine [13].

Evidences revealed different determinants of births protected against NT such as maternal age [14], maternal education [15-18], maternal occupation [17,19], marital status [17,20], wealth status [19-21], birth order [19], antenatal care (ANC) [19,22,23], distance from the health facility [16,21,23], media exposure [22,24-26], residence [14], and region [24,27,28].

Even though there is low coverage of maternal health services such as ANC (only 32% of mothers had at least 4 ANC visits) and skilled birth attendant delivery (only 26% of mothers delivered in the presence of skilled birth attendant) as well as poor sanitary practice during delivery in Ethiopia [13], the proportion of births protected against NT is low. Besides, to the best of our knowledge evidence showing the factors influencing births protected against NT is limited in Ethiopia and no study was done based on nationally representative data. In addition, previous studies consider only individual level factors while our study considers both individual and community level determinants of births protected against NT. Thus, this study aimed to investigate the determinants of births protected against neonatal tetanus in Ethiopia. The finding of this study would probably help health professionals and policymakers to generate evidence that strengthens and maintain current efforts of eliminating MNT.

Method

Data source and study population

This study was based on secondary data analysis of the 2016 EDHS, which was conducted from January 18, 2016, to June 27, 2016. The sampling frame used for the 2016 EDHS was a complete list of 84,915 enumeration areas (EAs) created for the 2007 Population and Housing Census (PHC). The survey used a stratified cluster sampling selected in two-stages. In the first stage, a total of 645 clusters or EAs were selected and in the second stage, 28 households per cluster were selected. For our study, a total weighted sample of 7590 women who gave birth within five years preceding the survey was used. Detailed information on sampling technique and questioner, in general about the survey, is obtained from the EDHS 2016 report [13].

Variables of the study

The outcome variable was a birth protected against neonatal tetanus, which was a binary outcome variable coded as “0” if it was not protected and “1” if it was protected. The independent variables in this study were further classified into individual and community level factors. The individual-level factors used in this study were; maternal age, maternal education, maternal occupation, marital status, household wealth status, media exposure, perception of distance from the health facility, birth order, household size, wanted last-child, ANC visit for their last pregnancy, and ever had of a terminated pregnancy. Four community-level variables; residence, region, community-level media exposure, and community level of women's education were also used as an independent variable in this study. The community-level factors, community-level media exposure, and community level of women's education were created by aggregating individual-level factors since these variables are not directly found from the survey.

Operational definitions

Household wealth status

Derived using principal components analysis and it was directly available in the EDHS dataset with the five categories (lowest, second, middle, fourth, and highest) [13]. It was re-coded as poor (includes the lowest and second category), middle, and rich (includes the fourth and richest categories) for our analysis

Media exposure

Created by combining whether a respondent reads the newspaper, listens to the radio, and watch television and coded as “yes” if the mother was exposed to at least one of the three media and “no” otherwise.

Community level of media exposure

A community level variable measured by the proportion of women who had exposed to at least one media; television, radio, or newspaper and categorized based on national median value as low (communities with <50% of women exposed) and high (communities with ≥50% of women exposed) community level media exposure.

Community level of women education

Aggregate values measured by the proportion of women with a minimum of primary level of education derived from data on respondents' level of education. Then, it was categorized using national median value to values: low (communities with <50% of women have at least primary education) and high (communities with ≥ 50% of women have at least primary education) community level of women education.

Data management and statistical analysis

Further coding of the data and analysis was done using Stata version 14. Throughout the study, weighting was done to adjust for non-proportional sample selection and for non-responses as well to restore the representativeness of the data. We used the multilevel logistic model, because of the EDHS data by itself is hierarchical. We first conducted bivariable multilevel logistic regression analysis and then we fitted multivariable multilevel logistic regression analysis, for variables with p<0.20 in the bivariable analysis. In the multivariable multilevel logistic regression analysis, variables with p<0.05 were declared to be significantly associated with having births protected against NT. We fitted four models containing variables of interest. The null model (fitted without explanatory variables), Model I (examined the effects of individual-level factors only), model II (containing only community-level factors), and Model III containing both individual and community-level factors. Intraclass correlation coefficient (ICC), a proportional change in variance (PCV), and median odds ratio (MOR) were used to examine clustering and the extent to which community-level factors explain the unexplained variance of the null model. Model comparison/fitness was checked by deviance and the model with the lowest deviance was used as the best-fitted model.

Ethical consideration

The EDHS was conducted based on the permission of the government, and informed consent was taken and participants' confidentiality was assured during that time. For this study, we accessed the data set based upon request (www.dhsprogram.com online) and there was no ethical approval required. Moreover, there are no names of individuals or household addresses in the data files.

Results

Sociodemographic characteristics

A total weighted sample of 7590 women who gave birth within five years preceding the survey was used in our analysis. The median age of the study participants was 28(IQR = 24–34) years. The majority (63.12%) of the study participants had no formal education and 43.55% were from poor wealth status. More than two thirds (66.21%) of women had no media exposure and 58.06% of women perceive distance from the health facility as a big problem. The majority (73.43%) of women’s last child was wanted. Regarding birth order and ANC visit, 51.04% and 37.13% of study participants had a birth order of four and above and no ANC visit respectively. Most (87.23%) of the respondents were from a rural part of Ethiopia. Regarding region, 41.23%, 21.50%, and 21.09% of study participants were from Oromia, Amhara, and Southern Nation Nationalities and Peoples Region (SNNPR) respectively. While small proportions of study participants were from Harari, Gambela, and Dire Dawa. More than half of the study participants were from communities with a higher level of women education and media exposure (Table 1).

Table 1

Respondents sociodemographic characteristics.

Variables	Frequency	Percentage
Maternal age
15–19	339	4.47
20–24	1,465	19.30
25–29	2,165	28.53
30–34	1,661	21.89
35–39	1,206	15.89
40–44	547	7.20
45–49	207	2.73
Maternal education
No formal education	4,791	63.12
Primary education	2,150	28.32
Secondary and above	649	8.55
Maternal occupation
Working	3,512	46.27
Not working	4,078	53.73
Marital status
Married	7,020	92.49
Unmarried	570	7.51
Household size
Less than five	3,636	47.92
Five or above	3,954	52.09
Household wealth status
Poor	3,306	43.55
Middle	1,588	20.93
Rich	2,696	35.52
Media exposure
Yes	2,565	33.79
No	5,025	66.21
Perception of distance from the health facility
A big problem	4,407	58.06
Not a big problem	3,183	41.94
Birth order
1st	1,434	18.90
2nd to 3rd	2,282	30.06
4th and above	3,874	51.04
Wanted the last child
Wanted	5,574	73.43
Not wanted	2,016	26.57
ANC visit
No ANC visits	2,818	37.13
One	335	4.41
Two to three	2,007	26.45
Four and above	2,430	32.01
Ever had of a terminated pregnancy
Yes	680	8.96
No	6,910	91.04
Residence
Urban	969	12.77
Rural	6,621	87.23
Region
Tigray	537	7.08
Afar	71	0.94
Amhara	1,632	21.50
Oromia	3,130	41.23
Somalia	269	3.54
Benishangul	81	1.06
SNNPR	1,601	21.09
Gambela	21	0.27
Harari	17	0.23
Addis Ababa	198	2.61
Dire Dawa	33	0.44
Community-level of women education
Low	3,744	49.33
High	3,846	50.67
Community-level of media exposure
Low	3,475	45.79
High	4,115	54.21

Random effect model and model fitness

As shown in Table 2, the ICC in the null model was 0.307, which indicates about 30.7% of the variations in having births protected against NT were attributable to differences between clusters/communities. Similarly, the higher MOR value (3.17) in the null model indicates there was significant variation between clusters. This is interpreted as; if we randomly choose an individual from two different clusters, those from a higher risk cluster had 3.16 times higher odds of being having births protected against NT as compared to those individuals who come from the lower risk cluster. Furthermore, the higher PCV (77%) in the final model revealed that 77% of the variations of protected birth against neonatal tetanus were attributable to both individual and community-level factors. Table 2 also revealed the best-fitted model was the final model (model III) since it had the lowest deviance (7257.66).

Table 2

Random effect model and model fitness for determinants of births protected against neonatal tetanus.

Parameter	Null model	Model I	Model II	Model III
ICC	0.307	0.129	0.149	0.094
MOR	3.16(2.86–3.53)	1.93(1.79–2.12)	2.05(1.90–2.25)	1.75(1.60–1.92)
PCV	Reference	0.67	0.61	0.77
Model fitness
Deviance	9106.8054	7346.89	8711.55	7257.66

Determinants of births protected against neonatal tetanus

For multivariable multilevel analysis, we consider only variables with p<0.2 in the bivariable analysis. In the multivariable multilevel analysis maternal education, media exposure, perception of distance from the health facility, ANC visit, region, community-level women education, and community-level media exposure were significantly associated with having births protected against NT. The odds of having a protected birth against NT was 1.23 [adjusted odds ratio (AOR) = 1.23; 95%CI: 1.04, 1.44] and 1.36 [AOR = 1.36; 95%CI: 1.06, 1.73] times higher among mothers with primary education and secondary and above educational level respectively as compared to mothers who had no formal education. Mothers who were exposed to media had 1.35 [AOR = 1.35; 95%CI: 1.15, 1.58] times higher odds of having a protected birth against NT as compared to their counterparts. Looking at the perception of distance from the health facility, mothers who did not perceive distance from the health facility as a big problem had 1.24 [AOR = 1.24; 95%CI: 1.08,1.42] times higher odds of having a protected birth against NT as compared to their counterpart. The odds of having a protected birth against NT was 1.56 [AOR = 1.56; 95%CI: 2.71, 4.68], 11.82 [AOR = 11.82; 95%CI: 9.94,14.06], and 15.25 [AOR = 15.25; 95%CI: 12.74, 18.26] times among mothers who attend one, two to three and four and above ANC visits respectively as compared to mothers who had no ANC follow up. Regarding region, mothers from Amhara and Afar had 41% [AOR = 0.59; 95%CI: 0.38, 0.92] and 59% [AOR = 0.41; 95%CI: 0.25, 0.66] lower odds of having births protected against NT as compared to mothers from Addis Ababa. Besides, mothers from Harari had 1.88 [AOR = 1.88; 95%CI: 1.15, 3.07] times higher odds of having a protected birth against NT. The odds of having a protected birth against NT was 1.25 [AOR = 1.25; 95%CI: 1.03, 1.52] and 1.22 [AOR = 1.22; 95%CI: 1.01, 1.48] times among mothers from communities with higher-level women education and a higher level of media exposure respectively as compared to their counterpart (Table 3).

Table 3

Multivariable multilevel logistic regression analysis of determinants of births protected against neonatal tetanus in Ethiopia, 2016.

Variables	Null model	Model I (AOR 95%CI)	Model II (AOR 95%CI)	Model III (AOR 95%CI)
Maternal age
15–19		1.00		1.00
20–24		1.25(0.92–1.69)		1.26(0.93–1.71)
25–29		1.14(0.83–1.58)		1.14(0.83–1.57)
30–34		1.22(0.86–1.72)		1.20(0.84–1.70)
35–39		1.06(0.74–1.53)		1.05(0.73–1.52)
40–44		0.96(0.63–1.45)		0.97(0.64–1.47)
45–49		1.26(0.75–2.13)		1.29(0.77–2.18)
Maternal education
No formal education		1.00		1.00
Primary education		1.32(1.13–1.54)		1.23(1.04–1.44) *
Secondary and above		1.50(1.18–1.89)		1.36(1.06–1.73) *
Maternal occupation
Working		1.06(0.93–1.20)		1.06(0.93–1.20)
Not working		1.00		1.00
Household size
Less than five		1.00		1.00
Five or above		1.07(0.92–1.25)		1.07(0.92–1.25)
Household wealth status
Poor		1.00		1.00
Middle		1.09(0.91–1.31)		1.02(0.84–1.22)
Rich		1.35(1.13–1.61)		1.16(0.96–1.40)
Media exposure
Yes		1.44(1.24–1.68)		1.35(1.15–1.58) ***
No		1.00		1.00
Perception of distance from the health facility
A big problem		1.00		1.00
Not a big problem		1.25(1.09–1.43)		1.24(1.08–1.42) **
Birth order
1st		1.00		1.00
2nd to 3rd		1.11(0.92–1.35)		1.10(0.91–1.33)
4th and above		1.28(0.99–1.65)		1.26(0.98–1.62)
Wanted the last child
Wanted		1.00		1.00
Not wanted		1.09(0.93–1.27)		1.08(0.92–1.26)
ANC visit
No ANC visits		1.00		1.00
One		3.57(2.72–4.69)		3.56(2.71–4.68) ***
Two to three		11.70(9.85–13.91)		11.82(9.94–14.06) ***
Four and above		15.30(12.83–18.24)		15.25(12.74–18.26) ***
Ever had of a terminated pregnancy
Yes		1.00		1.00
No		1.11(0.90–1.37)		1.13(0.91–1.39)
Residence
Urban			1.00	1.00
Rural			0.58(0.45–0.75)	1.15(0.89–1.51)
Region
Addis Ababa			1.00	1.00
Tigray			0.77(0.48–1.22)	0.64(0.42–1.01)
Afar			0.22(0.13–0.36)	0.41(0.25–0.66) ***
Amhara			0.54(0.34–0.86)	0.59(0.38–0.92) *
Oromia			0.52(0.33–0.83)	1.08(0.70–1.68)
Somalia			0.48(0.30–0.78)	1.10(0.70–1.73)
Benishangul			0.79(0.48–1.30)	0.93(0.58–1.49)
SNNPR			0.62(0.39–0 .98)	071(0.46–1.10)
Gambela			0.46(0.28–0.74)	0.76(0.48–1.20)
Harari			1.19(0.72–1.98)	1.88(1.15–3.07) *
Dire Dawa			0.99(0.60–1.62)	1.143(0.71–1.83)
Community level of women education
Low			1.00	1.00
High			1.95(1.59–2.39)	1.25(1.03–1.52) *
Community-level of media exposure
Low			1.00	1.00
High			1.88(1.55–2.29)	1.22(1.01–1.48) *

Note; AOR = Adjusted Odds Ratio, CI = Confidence Interval

* = P<0.05

** = P<0.01

*** = P<0.001

Discussion

Even though in Ethiopia giving birth in unsanitary conditions is common, less than half of births are protected against NT [13]. Therefore, we investigated the determinants of births protected against neonatal tetanus in Ethiopia using EDHS 2016 data. Both individual level and community level factors were associated with having births protected against NT. Among the individual-level factors maternal education, media exposure, perception of distance from the health facility, and ANC visit were associated with having births protected against NT. Of community-level factors region, community level of women education, and community level of media exposure were significantly associated with having births protected against NT.

In this study mothers having primary, and secondary and above education were more likely to have births protected against NT as compared to those mothers with no formal education. This finding is in line with studies done in Egypt [15], Nigeria [17], and Ethiopia [18]. The possible explanation might be that educated mothers might generally have greater knowledge and awareness regarding the benefits of immunization. Besides, educated mothers might have a greater decision-making power regarding their health and they mostly have the freedom to travel outside the home to seek care which can improve uptake of immunizations such as immunization against tetanus.

Mothers with media exposure had higher odds of having births protected against NT as compared to their counterparts. This is congruent with studies done in sub-Saharan Africa [26], Nigeria [25], and Ethiopia [18]. This is because, in recent years information regarding maternal and child health are distributed through different medias such as television, radio, and newspapers and this might increase the mother's knowledge on safe motherhood and utilization of maternal health services. In addition, media exposure is helpful for the adoption of different behaviors that bring positive behavioral changes towards immunization for vaccine-preventable diseases.

Consistent with studies done in Ethiopia [18,23], mothers who perceive distance from the health facility as a big problem had lower odds of having births protected against NT. This might be due to the costs such as time and transportation due to distant/remote health centers or vaccination centers. In addition, since full tetanus immunization in reproductive age women needs repeated visits to health facilities, such extra visits might be boring and tiring for women especially if they are far from the institution, which gives the immunization service.

Antenatal care visit was another factor that was associated with having births protected against NT in which mothers who had ANC visits were more likely to have births protected against NT. This is congruent with studies in Kenya [19] and Ethiopia [18,23]. This might be because in Ethiopia tetanus immunization is one of the ANC service package and women who had ANC visits had an opportunity to take the immunization. The other possible explanation is contact with healthcare providers might allow getting information about the benefits of taking full or recommended doses of tetanus for both the mother and the newborn.

There were also regional variations of births protected against NT in this study. This regional variation of tetanus immunization is consistent with different studies conducted elsewhere [24,27,28]. This might be because of the sociocultural difference as well as due to inequality in the distribution of health facilities and health personnel in different regions of Ethiopia. Moreover, mothers from border regions such as Afar might have limited access to information regarding maternal health services and other services like access to school/education.

Moreover, mothers from communities with a higher level of women education have higher odds of having births protected against NT. This might be due to communities with a high concentration of educated women indicates greater awareness, autonomy, and decision-making power for utilization of maternal health services during pregnancy and childbirth and this might intern can have its influence on taking vaccinations for vaccine-preventable diseases such as tetanus. In this study, we also found that mothers from communities with a higher level of media exposure have higher odds of having births protected against neonatal tetanus. This might be women from communities with a higher level of media exposure might get important and timely information about devastating but vaccine-preventable diseases such as tetanus.

This study had both strengths and limitations. Regarding the strength of the study, since it was based on the representative EDHS data, we can generalize our findings to the reproductive age group women in Ethiopia. Besides, we used an appropriate model (multilevel analysis) considering the hierarchical nature of the data and we can have a better estimation of parameters. However, in our study, important variables such as women's knowledge regarding tetanus was not assessed since this variable was not found in the survey. Since it was based on a maternal report for the question “how many tetanus doses (number of vaccinations) did you took during your lifetime and your last pregnancy" there may be recall bias. Moreover, we cannot establish the temporal relationship of the independent variables and dependent variable due to the cross-sectional nature of the data.

Conclusion

In this study, both individual level and community level factors were associated with having protected birth against NT. Mothers with primary and above education, having media exposure, not perceiving distance from the health facility as a big problem, having ANC visit, being women from communities with a higher level of women education, and a higher level of media exposure were significantly associated with higher odds of protected birth against NT. There were also geographical variations in the likelihood of protected births against NT. Therefore, strengthening maternal health services such as ANC visits and interventions related to increasing media campaigns regarding tetanus could increase the immunization against tetanus among reproductive-age women. In addition, it is also better to give attention to those reproductive age group women from remote areas and also better to distribute maternal services fairly and equally between regions.

14 Aug 2020

PONE-D-20-07884

Determinants of Births Protected Against Neonatal Tetanus in Ethiopia: A multilevel analysis using EDHS 2016 data.

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper addresses prevention of maternal and neonatal tetanus in Ethiopia. This paper does not add any novel knowledge to what is already known. The paper has a lot of grammatical and language errors and will need a lot of work before being considered for publication.

Introduction:

1. Please correct "Since most of the neonatal tetanus infections OCCUR due to poor sanitary conditions during delivery.."

2. Add some discussion around the routine TT vaccinations and special vaccine programs in the country.

3. It would be helpful if the authors could specify the latest coverage figures for ANC, skilled birth attendant and sanitary practices where they have specified "Even though there is low coverage of maternal health services such as antenatal care and skilled birth attendant delivery as well as poor sanitary practice during delivery in Ethiopia".

Methods:

1. Please correct "The individual-level factors used in this study WERE;..."

2. Please correct "..., and ever had of terminated pregnancy"

3. The authors state that "The community-level factors, community-level media exposure and community level of women's education, were created by aggregating individual-level factors since these variables are not directly found from the survey." It is not clear from the text that how these variables were aggregated and created. Moreover, if these variables are already considered at the individual level; I see no added benefit of constructing a new aggregate variable from individual data.

4. I would suggest if authors could provide some operational definitions for some variables in Table 1 including wealth status and media exposure.

Results:

1. The methods section specify that "... a total weighted sample of 7590 women who gave birth within two years preceding the survey was used" while in the results section it states that "A total weighted sample of 7590 women who gave birth within five years preceding the survey was used in our analysis." Please make this information consistent throughout the text.

2. Table 1 specifies that most of the women in the sample belonged to Oromia (41%); Amhara (21%) and SNNPR (21%) regions. It would be helpful if the authors could provide some details on these regions in the text.

3. As stated earlier, it has not been specified how were the community level aggregates for 'Community-level of women education' and 'Community-level of media exposure' were obtained. Please add these details and also specify the why these variables were generated.

4. It would be inappropriate to make conclusions about associations between religion and regions ("Regarding religion, mothers from Amhara and Afar had 41% [AOR = 0.59; 95%CI: 0.38,0.92] and 59% [AOR = 0.41; 95%CI: 0.25,0.66] lower odds of having births protected against NT as compared to mothers from Addis Ababa. Besides, mothers from Harari had 1.88 [AOR = 1.88; 95%CI: 1.15,3.07] times higher odds of having a protected birth against NT.") since 80% of the sample were from three regions only.

5. Table 3: Please present the findings from one final model only.

Discussion:

1. Considering that the data pertains to three regions namely: Oromia (41%); Amhara (21%) and SNNPR (21%) regions; there should be some discussion around the generalisability of these findings in the context of these regions.

2. It might not be appropriate to make conclusions about the regional associations ("There were also regional variations of births protected against NT in this study. Being mothers in the afar and Amhara region are less likely to have births protected against NT and being in the Harari region has higher odds of having births protected against NT.)

Reviewer #2: Major comments

1. In the background, where authors have made a case on TT vaccination coverage, it is important to mention the coverage of TT vaccination in women of reproductive ages in Ethiopia. At the same time, it is important to highlight the neonatal tetanus related deaths in the country?

2. Line 84-88: Authors have quoted predictors from Asian studies, it would be important to underscore the literature on TT from African context. Many of the studies are cited which are from Pakistan, Bangladesh and even from Cairo.

3. The current DHS from Ethiopia was published in 2019. However, authors have used 2016 DHS findings. Can you please explain the reason for not utilising the current survey?

4. Mother’s media exposure has been explained with studies from Africa and also with studies from Israel, and Indonesia which doesn’t look appropriate here. Authors should explain the predictors in light of studies from African region only. Again in line 225, distance as a predictor has been explained with study from Peshawar, Pakistan.

5. I believe the region specific variation needs further explanation.

Minor comments

6. It is better to use low and middle income countries, in place of developing countries.

7. Line 86, Antenatal care should be antenatal care

8. Line 89, antenatal care can be used as ANC as it has been abbreviated before.

9. Line 165: please write in full what is PCV?

10. Line 189: it should be region and not religion.

11. Line 197 and 198: this heading looks odd here?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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15 Sep 2020

Date: August 2020

Point by point response to editor’s and reviewers comment

Title: Determinants of Births Protected Against Neonatal Tetanus in Ethiopia: A multilevel analysis using EDHS 2016 data.

Manuscript number: PONE-D-20-07884

Dear editor and reviewers: We really appreciate your useful/valuable comments and suggestions for improving this manuscript. Below is a point-by - point response to the questions / comments you raised. Thank you again for considering this manuscript.

Author’s response to editor’s comment

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Author’s response: Thank you. We amended the manuscript according to the journal style.

2. We note that you have indicated that data from this study are available upon request. In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Author’s response: Thank you. In the revised cover letter, we stated that all result-based data is available in the manuscript. However, the data set was accessed through legal requesting and we cannot attach here with the manuscript as supporting information since it is not ethically acceptable. However, anyone who want the data set can access from the Measure DHS program at http://www.dhsprogram.com, through legal requesting. In addition, in the revised manuscript, we put the authorization letter, which stated, “The data must not be passed on to other researchers/bodies without the written consent of DHS. However, if you have co-researcher registered in your account for this research paper, you are authorized to share the data with them”, as supporting information.

3. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 3 in your text; if accepted, production will need this reference to link the reader to the Table.

Author’s response: Thank you. We refer/cite table 3 in the text.

AUTHORS RESPONSE TO REVIEWERS COMMENT

Reviewer #1

The paper addresses prevention of maternal and neonatal tetanus in Ethiopia. This paper does not add any novel knowledge to what is already known. The paper has a lot of grammatical and language errors and will need a lot of work before being considered for publication.

Author’s response: Dear reviewer, thank you for an important issue you raised. This study is based on a nationally representative data, studies conducted before were either institution based or conducted in specific areas of the country, which might be very crucial for policymakers or other responsible bodies. In addition, all of the studies conducted before concerns about individual level factors but this study incorporates community level factors. Therefore, this study helps policymakers to set appropriate interventions at both individual and community level.

Moreover, we extensively edited and corrected language and grammatical errors in our manuscript.

Introduction:

1. Please correct "Since most of the neonatal tetanus infections OCCUR due to poor sanitary conditions during delivery.."

Author’s response: Thank you for the comment. We amended it in the revised manuscript.

2. Add some discussion around the routine TT vaccinations and special vaccine programs in the country.

Author’s response: Dear reviewer thank you for this important concern you raised. We incorporated the routine immunization/vaccine programs in Ethiopia (See the first paragraph of the background section). Regarding the routine TT immunizations in Ethiopia, we indicated that TT vaccine is part of maternal health services and every reproductive age women should receive five doses of TT (as early as possible, after 4 weeks of the 1st dose, after 6weaks of the 2nd dose, after 1years of the 3rd dose, and after one years of the 4th dose) (see background section paragraph five).

3. It would be helpful if the authors could specify the latest coverage figures for ANC, skilled birth attendant and sanitary practices where they have specified, "Even though there is low coverage of maternal health services such as antenatal care and skilled birth attendant delivery as well as poor sanitary practice during delivery in Ethiopia".

Author’s response: Thank you for your comment. We consider it/we added the figures (about ANC skilled birth attendant coverage) in the revised manuscript. However, it was difficult to have an actual figure regarding poor sanitary practices during delivery but in reality, there is inadequate sanitary practices during delivery in poor clinical setups like Ethiopia

Methods:

1. Please correct "The individual-level factors used in this study WERE;..."

Author’s response: Amended in the revised manuscript.

2. Please correct "..., and ever had of terminated pregnancy"

Author’s response: Amended accordingly

3. The authors state that "The community-level factors, community-level media exposure and community level of women's education, were created by aggregating individual-level factors since these variables are not directly found from the survey." It is not clear from the text that how these variables were aggregated and created. Moreover, if these variables are already considered at the individual level; I see no added benefit of constructing a new aggregate variable from individual data.

Author’s response: Thank you for raising this important issue. We indicated how these community level variables were created in the revised manuscript (see operational definitions). As you know community level factors are very important factors for utilization of maternal health services, we considered the community level factors by aggregating them from the respective individual level factors to indicate the neighboring effect. This helps policymakers to take intervention at both individual and community levels. For example, women from communities with lower level of media exposure might be clustered in specific areas and taking appropriate intervention in this group of women could have a great advantage to increase maternal health services including immunization services.

4. I would suggest if authors could provide some operational definitions for some variables in Table 1 including wealth status and media exposure.

Author’s response: Thank you for the comment. We accepted the comment and put the operational definition of some important variables in the revised manuscript.

Results:

1. The methods section specify that "... a total weighted sample of 7590 women who gave birth within two years preceding the survey was used" while in the results section it states that "A total weighted sample of 7590 women who gave birth within five years preceding the survey was used in our analysis." Please make this information consistent throughout the text.

Author’s response: Thank you. It was to mean “within five years” and amended it in the revised manuscript.

2. Table 1 specifies that most of the women in the sample belonged to Oromia (41%); Amhara (21%) and SNNPR (21%) regions. It would be helpful if the authors could provide some details on these regions in the text.

Author’s response: We considered your comment in the revised manuscript (details about region is indicated).

3. As stated earlier, it has not been specified how were the community level aggregates for 'Community-level of women education' and 'Community-level of media exposure' were obtained. Please add these details and also specify the why these variables were generated.

Author’s response: Thank you. These variables were created since they were not directly available in the DHS but known to have associated with maternal health service utilization by different studies (such as a study by Yebyo HG, Gebreselassie MA, Kahsay AB; 2014). As we stated before these community level variables were created to show the effect of these variables at the cluster or the community level (see operational definition). Identifying factors at the community and individual levels could help policymakers to intervene both at individual and community levels.

4. It would be inappropriate to make conclusions about associations between religion and regions ("Regarding religion, mothers from Amhara and Afar had 41% [AOR = 0.59; 95%CI: 0.38,0.92] and 59% [AOR = 0.41; 95%CI: 0.25,0.66] lower odds of having births protected against NT as compared to mothers from Addis Ababa. Besides, mothers from Harari had 1.88 [AOR = 1.88; 95%CI: 1.15,3.07] times higher odds of having a protected birth against NT.") since 80% of the sample were from three regions only.

Author’s response: Really thank you for the comment. As you know, in the EDHS, to generate statistics that are representative of the Ethiopia as a whole (in the 11 regions), the number of women surveyed in each region should contribute to the size of the total sample in proportion to size of the region. However, if some regions have small populations, then a sample allocated in proportion to each region’s population may not include sufficient women from each region for analysis. To solve this, regions with small populations were oversampled. In addition, a sampling statistician determines how many women should be interviewed in each region in order to get reliable statistics. Furthermore, in order to get statistics that are representative of Ethiopia, the distribution of the women in the sample needs to be weighted (or mathematically adjusted) such that it resembles the true distribution in Ethiopia. Women from a small region, like Harari, Dire Dawa… should only contribute a small amount to the national total. Women from a large region, like Oromia, Amhara, and SNNPR should contribute much more. Therefore, DHS statisticians mathematically calculate a “weight” which is used to adjust the number of women from each region so that each region’s contribution to the total is proportional to the actual population of the region.

Therefore, since our analysis was based on weighting we expect the appropriate statistical estimate and representativeness of the sample in each region and the country in general. Due to this, we authors putt region as independent variable and make a conclusion for its association with our outcome variable. Dear reviewer we are open to remove it if it does not make sense for you still.

5. Table 3: Please present the findings from one final model only.

Author’s response: Dear reviewer thank you for the comment. As you indicated, we can put the final model only. However, since it was a multilevel analysis it is better to indicate all the models we fitted in the final table. This makes the paper consistent and easy to understand for readers since we indicated as we fitted four models in the method section as well as in the result section (random effect analysis). Moreover, papers on multilevel analysis report all the models fitted, not only the final model, in one table to make clear for both statisticians and other readers such as clinicians. If it does not make sense for you still, we are open to put the final model only (which includes both individual and community level variables simultaneously).

Discussion:

1. Considering that the data pertains to three regions namely: Oromia (41%); Amhara (21%) and SNNPR (21%) regions; there should be some discussion around the generalizability of these findings in the context of these regions.

Author’s response: Thank you for raising very important issue again. As we stated above, the EDHS data was collected based on two-stage cluster sampling proportional to the total populations of the regions, in which the three regions had the highest total population, so had large samples. However, with sampling and weighting, it is possible to have/interview enough women to provide reliable statistics at national and regional levels. So, our analysis was based on weighting which restore representativeness of the samples. In addition, we employed a multilevel analysis in order to have better statistical estimate. Therefore, we can generalize our findings in the context of the regions of Ethiopia.

2. It might not be appropriate to make conclusions about the regional associations ("There were also regional variations of births protected against NT in this study. Being mothers in the afar and Amhara region are less likely to have births protected against NT and being in the Harari region has higher odds of having births protected against NT.)

Author’s response: Thank you. We amend it accordingly in the revised manuscript. We avoided “Being mothers in the afar and Amhara region are less likely to have births protected against NT and being in the Harari region has higher odds of having births protected against NT” and we put simply as there was regional variations of protected births against NT in general. Dear reviewer, as we sated before we can make conclusions about regional associations since we conducted our analysis based on weighting to make the sample representative to each regions and the country in general.

Reviewer #2

1. In the background, where authors have made a case on TT vaccination coverage, it is important to mention the coverage of TT vaccination in women of reproductive ages in Ethiopia. At the same time, it is important to highlight the neonatal tetanus related deaths in the country?

Author’s response: Dear reviewer thank you for raising an important issue. We accept your comment on highlighting the neonatal tetanus related deaths in the country. However, most NT deaths occur in the community and are not reported due to the population size (make it difficult for surveillance) and traditional value towards neonatal death, we are unable to find the current exact figure and highlight the neonatal tetanus related deaths in the country. Even though the country validated (partially) to have achieved NT elimination (reports less than 1 case per 1000 livebirths) this might be due to under reporting and we the authors expect more cases since most (greater than two-thirds) of mothers in Ethiopia gave birth at home. However, according to EDHS 2016 report, only half of reproductive women took sufficient doses of TT (two and above TT doses) during their pregnancy. Information about these are shown in the background section paragraph six.

2. Line 84-88: Authors have quoted predictors from Asian studies, it would be important to underscore the literature on TT from African context. Many of the studies are cited which are from Pakistan, Bangladesh and even from Cairo.

Author’s response: Thank you. In the revised version of our manuscript we consider studies done in African countries.

3. The current DHS from Ethiopia was published in 2019. However, authors have used 2016 DHS findings. Can you please explain the reason for not utilising the current survey?

Author’s response: Thank you for the comment. It is not fully available (only the mini EDHS released) so we used the DHS 2016 data.

4. Mother’s media exposure has been explained with studies from Africa and also with studies from Israel, and Indonesia which doesn’t look appropriate here. Authors should explain the predictors in light of studies from African region only. Again in line 225, distance as a predictor has been explained with study from Peshawar, Pakistan.

Author’s response: Thank you. We consider only studies done in African context in the revised manuscript.

5. I believe the region specific variation needs further explanation.

Author’s response: Thank you. We consider your comment and add further explanations.

6. It is better to use low and middle income countries, in place of developing countries.

Author’s response: Thank you for the comment. We used low and middle-income countries instead of developing countries in the revised manuscript.

7. Line 86; Antenatal care should be antenatal care

Author’s response: Amended in the revised manuscript

8. Line 89, antenatal care can be used as ANC as it has been abbreviated before.

Author’s response: Thank you. We consider it throughout the revised manuscript.

9. Line 165: please write in full what is PCV?

Author’s response: Thank you for the comment. We indicated its full meaning which means Proportional change in Variance in the method section like MOR and ICC.

10. Line 189: it should be region and not religion.

Author’s response: Thank you. We amend it in the revised manuscript.

11. Line 197 and 198: this heading looks odd here?

Author’s response: Thank you. In plos one’s journal style, the title of the table should be putted immediately below the text expressing it. Therefore, it was the title of the table showing the text written above it and we added the table number in the text, which was missed.

Submitted filename: AUTHORS RESPONSE (TT).docx

Click here for additional data file.

16 Nov 2020

Determinants of Births Protected Against Neonatal Tetanus in Ethiopia: A multilevel analysis using EDHS 2016 data.

PONE-D-20-07884R1

Dear Dr. Teshale,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: No

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

Reviewer #3: Thanks for responding and revising your manuscript. Please a few notes:

1. I would suggest if you could specify that both individual and community level variables were assessed in the abstract methodology.

2. There are still a grammatical corrections needed. Please read through and make changes accordingly.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: Yes: Rehana A Salam

18 Nov 2020

PONE-D-20-07884R1

Determinants of Births Protected against Neonatal Tetanus in Ethiopia: a multilevel analysis using EDHS 2016 data.

Dear Dr. Teshale:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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