Tetanus vaccination during pregnancy reduces risk of neonatal mortality in India, study finds

BMJ 2013; 347 doi: (Published 25 September 2013) Cite this as: BMJ 2013;347:f5808
  1. Sanjeet Bagcchi
  1. 1Kolkota

British and Indian researchers have called for mandatory immunisation against tetanus for pregnant women in India, after finding that vaccination reduces neonatal mortality.

Tetanus vaccination, folic acid tablets, and antenatal visits are the major components of antenatal care in India. However, there is very little evidence that these interventions help reduce neonatal mortality.

For the study the researchers used discrete time logistic regression models to investigate the association between the neonatal mortality and the three interventions using data from India’s District Level Household Survey-3, conducted during 2007-08. The results, reported in the journal Health Policy and Planning, are based on 58 609 singleton first births to women during the three years preceding the survey.1

The study found that neonatal mortality was significantly lower for infants whose mothers attended four or more antenatal visits (odds ratio 0.69 (95% confidence interval 0.60 to 0.81)), consumed 90 or more folic acid tablets (odds ratio 0.85 (0.73 to 0.99)), or received two or more tetanus injections (odds ratio 0.73 (0.63 to 0.83)).

When the researchers analysed different combinations of the three interventions, they found that tetanus injections provided the main protective effect. Tetanus injections reduced the risk of neonatal mortality even among women who did not take folic acid (odds ratio 0.69 (0.60 to 0.78)) or did not attend four antenatal appointments (odds ratio 0.75 (0.66 to 0.86)).

The researchers calculated that 6% (95% confidence interval 4% to 8%) of neonatal deaths in India could be attributed to a lack of at least two tetanus injections during pregnancy.

Saseendran Pallikadavath, senior lecturer and coordinator at the Global Health and Social Care Unit at the University of Portsmouth, England, told the BMJ: “Based on these [findings], we concluded that at least two tetanus toxoid injections provided the most protective effect for neonatal mortality and ANC [antenatal care] visits or IFA [iron-folic acid] tablets were not important to reduce neonatal mortality.”

Pallikadavath recommended that at least two tetanus toxoid injections should be made mandatory for pregnant women through the Indian government’s primary healthcare system.


Cite this as: BMJ 2013;347:f5808


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