The association between area of residence and sufficient antenatal tetanus vaccination in women ages 15–49 in Afghanistan: an analysis of the 2015 DHS dataset

Background Neonatal tetanus (NT) is a deadly nervous system disorder that is endemic to Afghanistan. Administering sufficient doses of tetanus toxoid containing vaccine (TTCV) during pregnancy can pass antibodies to the fetus and therefore prevent NT. Using survey data, we investigated the association between area of residence (urban or rural) and sufficient antenatal TTCV coverage among women aged 15–49 years in Afghanistan during their most recent pregnancy in the past 5 years that resulted in a live birth. Mother’s education level was also assessed as a potential effect modifier. Methods Secondary analysis was performed on data from the 2015 Afghanistan Demographic and Health Survey (AfDHS). The 2015 AfDHS was a nationally representative survey with participants selected in a stratified two-stage sample design from urban and rural areas across Afghanistan’s 34 provinces. Data were analyzed on 19,737 women ages 15–49 that had a live birth in the 5 years preceding the survey. The relationship between area of residence and sufficient antenatal TTCV was assessed in a multivariable logistic regression model, adjusting for several confounding variables. Results 55.1% (95% CI = 51.6–58.5%) of urban women and 53.9% (95% CI = 49.7–57.9%) of rural women had sufficient tetanus vaccination coverage in their most recent pregnancy. In multivariate analysis, there was strong evidence for greater odds of sufficient antenatal tetanus vaccination in rural areas (OR = 1.62; 95% CI = 1.18–2.24, p = 0.003). There was no effect modification on this association by mother’s education level. Conclusions Women in rural areas of Afghanistan have greater odds of receiving sufficient antenatal tetanus vaccination than women in urban areas. Further study into factors contributing to this urban-rural disparity is needed. Targeted antenatal tetanus vaccination strategies for urban and rural women will be necessary as Afghanistan continues to work towards NT eradication. Supplementary Information The online version contains supplementary material available at 10.1186/s41256-020-00180-1.


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Since Hammal 1389, have you had any other pregnancies that did not result in a live birth?
Did you have any miscarriages, abortions or stillbirths that ended before 1389?
When did the last such pregnancy that terminated before 1389 end? C C C Are you pregnant now?
How many months pregnant are you?
When you got pregnant, did you want to get pregnant at that time?
Did you want to have a baby later on or did you not want any (more) children?
Have you ever had a pregnancy that miscarried, was aborted, or ended in a stillbirth?
When did the last such pregnancy end?
How many months pregnant were you when the last such pregnancy ended? When was the last time you used a method? Which method was that? When did you start using that method? How long after the birth of (NAME)?

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How long did you use the method then?
Why did you stop using the (METHOD)? Did you become pregnant while using (METHOD), or did you stop to get pregnant, or did you stop for some other reason?

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In what month and year was the sterilization performed? As part of your antenatal care during this pregnancy, were any of the following done at least once: Did you give a urine sample? Did you give a blood sample?
Was your blood pressure measured?
Where did you receive antenatal care for this pregnancy?
Anywhere else?
How many months pregnant were you when you first received antenatal care for this pregnancy?
How many times did you receive antenatal care during this pregnancy?
LAST BIRTH During this pregnancy, how many times did you get a tetanus injection?
At any time before this pregnancy, did you receive any tetanus injections?
Before this pregnancy, how many times did you receive a tetanus injection?
During this pregnancy, were you given an injection in the arm to prevent the baby from getting tetanus, that is, convulsions after birth?
During (any of) your antenatal care visit(s), were you told about things to look out for that might suggest problems with the pregnancy? How many years ago did you receive the last tetanus injection before this pregnancy?
During this pregnancy, were you given or did you buy any iron tablets or iron syrup?
Anyone else?
During the whole pregnancy, for how many days did you take the tablets or syrup?
During this pregnancy, did you take any drug for intestinal worms?
Who assisted with the delivery of (NAME)? 2 1 1 2 1 2 When (NAME) was born, was he/she very large, larger than average, average, smaller than average, or very small? Was (NAME) weighed at birth?
How much did (NAME) weigh? In the first two months after delivery, did you receive a vitamin A dose like (this/any of these)?
Has your menstrual period returned since the birth of (NAME)?
Did your period return between the birth of (NAME) and your next pregnancy?
For how many months after the birth of (NAME) did you not have a period?
Have you had sexual intercourse since the birth of (NAME)?
For how many months after the birth of (NAME) did you not have sexual intercourse?
Did you ever breastfeed (NAME)?
LAST BIRTH Anything else?
Are you still breastfeeding (NAME)?
Did (NAME) drink anything from a bottle with a nipple yesterday or last night?
How long after birth did you first put (NAME) to the breast?
In the first three days after delivery, was (NAME) given anything to drink other than breast milk?
What was (NAME) given to drink? Hepatitis B-0 dose, that is given at birth, along with BCG?
A DPT/PENTAVALENT vaccination, that is, an injection given in the thigh, sometimes at the same time as polio drops?
A measles injection or an MMR/MR injection-that is, a shot in the arm at the age of 9 months or older -to prevent him/her from getting measles?
How many times was the DPT/PENTAVALENT vaccination given? A PCV vaccination, that is, an injection given in the thigh, to prevent him/her from getting pneumonia?
How many times was the PCV vaccination given?
How many times was measles or MMR/MR injection given?
Has (NAME) had any vaccinations that are not recorded on this card, including vaccinations given in a national immunization day campaign?
Please tell me if (NAME) had any of the following vaccinations: Polio vaccine, that is, drops in the mouth?
How many times was the polio vaccine given?
A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?
Was the first polio vaccine given in the first two weeks after birth or later?
LAST BIRTH Within the last six months, was (NAME) given a vitamin A dose like (this/any of these)?
In the last seven days, was (NAME) given sprinkles with iron or any micronutrient powder like (this/any of these)?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less?
Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
Now I would like to know how much (NAME) was given to drink during the diarrhea (including breastmilk).
Did you seek advice or treatment for the diarrhea from any source? When (NAME) had diarrhea, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?
Was (NAME) given any drug for intestinal worms in the last six months?
Has (NAME) had diarrhea in the last 2 weeks?
Was there any blood in the stools?
LAST When (NAME) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?
Was the fast or difficult breathing due to a problem in the chest or to a blocked or runny nose? Did you seek advice or treatment for the illness from any source?
Now I would like to know how much (NAME) was given to drink (including breastmilk) during the illness with a (fever/cough).
Was he/she given less than usual to drink, about the same amount, or more than usual to drink?
IF LESS, PROBE: Was he/she given much less than usual to drink or somewhat less? When (NAME) had a (fever/cough), was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
IF LESS, PROBE: Was he/she given much less than usual to eat or somewhat less?  ( DRANK FORMULA 559 CHECK 558 (CATEGORIES "g" THROUGH "u"): NOT A SINGLE AT LEAST ONE "YES" "YES" 561 Now I would like to ask you about liquids or foods that (NAME FROM 557) had yesterday during the day or at night. I am interested in whether your child had the item I mention even if it was combined with other foods.

Clear broth?
Juice or juice drinks?
Milk such as tinned, powdered, or fresh animal milk?
Any foods made from beans, peas, lentils, or nuts?
Cheese or other food made from milk?
Fresh or dried fish? Eggs?
IF YES: How many times did (NAME) drink infant formula?
IF YES: How many times did (NAME) eat yogurt?
Bread, rice, noodles, porridge, or other foods made from grains?
Any other liquids?
IF YES: How many times did (NAME) drink milk?
Any meat, such as beef, lamb, goat, chicken, or duck?
Pumpkin, carrots, squash that are yellow or orange inside? Now I would like to ask you some questions about your recent sexual activity. Let me assure you again that your answers are completely confidential and will not be told to anyone. If we should come to any question that you don't want to answer, just let me know and we will go to the next question.
When was the last time you had sexual intercourse? How long would you like to wait from now before the birth of (a/another) child?
After the birth of the child you are expecting now, how long would you like to wait before the birth of another child? How many of these children would you like to be boys, how many would you like to be girls and for how many would it not matter if it's a boy or a girl?
In the last few months have you: Heard about family planning on the radio? Seen anything about family planning on the television?
Would you say that using contraception is mainly your decision, mainly your husband's decision, or did you both decide together?
Read about family planning in billboard?
Heard from local community leaders?
Heard from health professionals?
Seen or read about family planning in internet?
Read about family planning in a newspaper or magazine? What was the highest level of school he attended: primary, secondary, or higher?
As you know, some women take up jobs for which they are paid in cash or kind. Others sell things, have a small business or work on the family farm or in the family business.
In the last seven days, have you done any of these things or any other work?
Although you did not work in the last seven days, do you have any job or business from which you were absent for leave, illness, vacation, maternity leave, or any other such reason?
Have you done any work in the last 12 months?
What is your occupation, that is, what kind of work do you mainly do?
Do you do this work for a member of your family, for someone else, or are you self-employed?
How old was your husband on his last birthday?
Did your (last) husband ever attend school?
What was the highest grade he completed at that level?
That is, what kind of work does he mainly do?
What is your husband's occupation?
What was your (last) husband's occupation?
That is, what kind of work did he mainly do?
Aside from your own housework, have you done any work in the last seven days? Where did you go?
Is a wife justified in refusing to have sex with her husband when she knows he has sex with other women?
If a wife knows her husband has a disease that she can get during sexual intercourse, is she justified in asking that they use a condom when they have sex? Now I need to ask some more questions about your relationship with your (last) husband.

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First, I am going to ask you about some situations which happen to some women. Please tell me if these apply to your relationship with your (last) husband? a) He (is/was) jealous or angry if you (talk/talked) to other men? b) He frequently (accuses/accused) you of being unfaithful? c) He (does/did) not permit you to meet your female friends? d) He (tries/tried) to limit your contact with your family?
Now I would like to ask you questions about some other important aspects of a woman's life. You may find some of these questions very personal. However, your answers are crucial for helping to understand the condition of women in Afghanistan. Let me assure you that your answers are completely confidential and will not be told to anyone and no one else in your household will know that you were asked these questions.
Did your (last) husband ever: How often did this happen during the last 12 months: often, only sometimes, or not at all? say or do something to humiliate you in front of others?
threaten to hurt or harm you or someone you care about?
insult you or make you feel bad about yourself?