{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,14]],"date-time":"2026-09-14T18:12:25Z","timestamp":1789409545617,"version":"build-2803163510"},"reference-count":40,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2024,4,17]],"date-time":"2024-04-17T00:00:00Z","timestamp":1713312000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Gavi, the Vaccine Alliance"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vaccines"],"abstract":"<jats:p>Immunization of pregnant women against tetanus is a key strategy for reducing tetanus morbidity and mortality while also achieving the goal of maternal and neonatal tetanus elimination. Despite substantial progress in improving newborn protection from tetanus at birth through maternal immunization, umbilical cord practices and sterilized and safe deliveries, inequitable gaps in protection remain. Notably, an infant\u2019s tetanus protection at birth is comprised of immunization received by the mother during and before the pregnancy (e.g., through childhood vaccination, booster doses, mass vaccination campaigns, or during prior pregnancies). In this work, we examine wealth-related inequalities in maternal tetanus toxoid containing vaccination coverage before pregnancy, during pregnancy, and at birth for 72 low- and middle-income countries with a recent Demographic and Health Survey or Multiple Indicator Cluster Survey (between 2013 and 2022). We summarize coverage levels and absolute and relative inequalities at each time point; compare the relative contributions of inequalities before and during pregnancy to inequalities at birth; and examine associations between inequalities and coverage levels. We present the findings for countries individually and on aggregate, by World Bank country income grouping, as well as by maternal and neonatal tetanus elimination status, finding that most of the inequality in tetanus immunization coverage at birth is introduced during pregnancy. Inequalities in coverage during pregnancy are most pronounced in low- and lower-middle-income countries, and even more so in countries which have not achieved maternal and neonatal tetanus elimination. These findings suggest that pregnancy is a key time of opportunity for equity-oriented interventions to improve maternal tetanus immunization coverage.<\/jats:p>","DOI":"10.3390\/vaccines12040431","type":"journal-article","created":{"date-parts":[[2024,4,17]],"date-time":"2024-04-17T10:52:37Z","timestamp":1713351157000},"page":"431","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Comparison of Wealth-Related Inequality in Tetanus Vaccination Coverage before and during Pregnancy: A Cross-Sectional Analysis of 72 Low- and Middle-Income Countries"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4513-4582","authenticated-orcid":false,"given":"Nicole E.","family":"Johns","sequence":"first","affiliation":[{"name":"Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4580-3849","authenticated-orcid":false,"given":"Cauane","family":"Blumenberg","sequence":"additional","affiliation":[{"name":"International Center for Equity in Health, Federal University of Pelotas, Rua Mal Deodoro 1160, Pelotas 96020-220, Brazil"},{"name":"Causale Consulting, Avenida Adolfo Fetter 4331, Pelotas 96090-840, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6881-409X","authenticated-orcid":false,"given":"Katherine","family":"Kirkby","sequence":"additional","affiliation":[{"name":"Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adrien","family":"Allorant","sequence":"additional","affiliation":[{"name":"Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9558-937X","authenticated-orcid":false,"given":"Francine Dos Santos","family":"Costa","sequence":"additional","affiliation":[{"name":"International Center for Equity in Health, Federal University of Pelotas, Rua Mal Deodoro 1160, Pelotas 96020-220, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7324-9198","authenticated-orcid":false,"given":"M. Carolina","family":"Danovaro-Holliday","sequence":"additional","affiliation":[{"name":"Department of Immunization, Vaccines, and Biologicals, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carrie","family":"Lyons","sequence":"additional","affiliation":[{"name":"Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nasir","family":"Yusuf","sequence":"additional","affiliation":[{"name":"Department of Immunization, Vaccines, and Biologicals, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2022-8729","authenticated-orcid":false,"given":"Alu\u00edsio J. D.","family":"Barros","sequence":"additional","affiliation":[{"name":"International Center for Equity in Health, Federal University of Pelotas, Rua Mal Deodoro 1160, Pelotas 96020-220, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7322-672X","authenticated-orcid":false,"given":"Ahmad Reza","family":"Hosseinpoor","sequence":"additional","affiliation":[{"name":"Department of Data and Analytics, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,4,17]]},"reference":[{"key":"ref_1","unstructured":"World Health Organization (2019). Protecting All against Tetanus: Guide to Sustaining Maternal and Neonatal Tetanus Elimination (MNTE) and Broadening Tetanus Protection for All Populations, World Health Organization."},{"key":"ref_2","unstructured":"World Health Organization (2022, September 22). 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