By Dr. Folake Olayinka
Years ago as a young doctor in Nigeria, I was drawn to a baby's weak cry while I did my ward rounds that evening. After delivery at home, the mother had been rushed with her baby to the hospital.
The baby was not nursing and the cord was quite foul smelling with some sort of local mixture applied to it. The baby had contracted a deadly tetanus infection and was having muscle spasms and could not suck. The mother had not received the tetanus vaccine while pregnant and the delivery was not hygienic. Vaccinating pregnant women with tetanus toxoid allows her to pass on the protective antibodies to the child, which protects the child within the first few months of life.
Progress in public health sometimes feels slow, but the recent announcement by the World Health Organization (WHO) that India had eliminated maternal and neonatal tetanus is cause for celebration.
This major public health achievement can be attributed to India's focused approach on making maternal and newborn care accessible to all, according to Dr. Poonam Khetrapal Singh, WHO Regional Director for South-East Asia Region. The occurrence of neonatal tetanus is a triple failure: of vaccination services, antenatal care, and obstetric care. Yet India has shown by its elimination of maternal and neonatal tetanus that prevention, even in poorly served areas, is possible.
Until just a few decades ago India accounted for 150,000 to 200,000 tetanus cases in newborns annually, more than anywhere else in the world. Such tetanus cases are now reduced to less than one case per 1,000 live births in all its 675 districts. The entire South-East Asia Region has now achieved elimination of maternal and neonatal tetanus, becoming the second region, after Europe, to achieve the feat.
Attending quality prenatal care services at least four times during pregnancy has been found to be a critical part of ensuring both mother and baby are healthy. Part of this care should include immunization and discussion of hygienic birth practices for prevention of tetanus in mothers and their newborns. During these visits, antenatal care providers also deliver a range of services to the pregnant woman and her family, such as counselling, health education, micronutrient supplementation, screening and treatment of hypertension to prevent eclampsia, HIV testing and medications to prevent mother-to-child transmission of HIV in cases of maternal HIV-positivity, and prevention of malaria.
Tetanus is caused by a bacterium which grows in the absence of oxygen, for example in dirty wounds or in the umbilical cord if it is not cut and kept clean. Neonatal tetanus is a deadly disease, often causing muscular spasms and death within days due to respiratory failure.
In the 1980s more than one million people died each year from tetanus, with about three-quarters of them infants in the first month of life, when as many as 80% of infections result in death. That number of deaths globally has been reduced by over 90% and maternal and neonatal tetanus has been eliminated from all but 19 countries. The vaccine to prevent maternal and neonatal tetanus was introduced in 103 countries by the end of 2015 and an estimated 83% of newborns were protected against tetanus through timely maternal immunization. Obviously access to safe and clean delivery with appropriate cord care are also important in preventing infections including tetanus in newborns. Neonatal tetanus can also be prevented by immunizing women of child bearing age with tetanus toxoid containing vaccines outside of pregnancy and is key for elimination.
Despite this huge success, the percentage of women with at least four prenatal care visits was only 64% in 2014 and 58% in 2015, according to UNICEF. Fewer than half of women in the poorest households are likely to receive antenatal care in Africa and Asia. With such low ANC attendance and poor access to care in many places, the goal of maternal vaccinations and positive pregnancy outcomes remains elusive for many.
In a rural community in Liberia earlier this year, I met a pregnant woman who had walked for two hours for prenatal care. She had come with a lively group of women all chattering and all pregnant. They knew the importance of prenatal care and came together from their distant community for the service. Since the health facility had only one trained midwife, they patiently waited and ended up spending almost the whole day there. What an irony -a very different experience in most developed countries where women do not have to walk two hours to attend antenatal care, neither is tetanus a disease that is seen anymore, yet the joy of motherhood experienced when the baby is healthy is the same. Large expansions in antenatal care coverage are still needed to provide the strong platforms to achieve and sustain maternal vaccinations and antenatal care to all pregnant women.
With the help of many interventions, that tiny baby with tetanus I treated so long ago survived. But many are not so lucky. Providing care for the mother during pregnancy has huge implications not just for her health but also for the child she carries and her community. Many health problems in pregnant women can be prevented, detected and treated during antenatal care by trained health workers. India is a good example of how to do just that.
Dr. Folake Olayinka works with JSI in Arlington, Virginia and is public health specialist with particular interest in immunization, maternal and child health and infectious diseases. She is an Aspen New Voices Fellow. Follow her on Twitter @joflakes