Tetanus toxoid immunization coverage and its determinants among pregnant women in Somalia: A cross-sectional analysis of the 2020 Demographic and Health Survey.

Maternal and neonatal tetanus (MNT) remains a significant, yet preventable, cause of death. Given that Somalia faces critically low immunization coverage, identifying the coverage and associated factors is essential for developing targeted public health strategies. This cross-sectional study analyzed data from 6411 pregnant women (aged 15-49 years) extracted from the 2020 Somalia Demographic and Health Survey (SDHS). Multivariable logistic regression was employed to determine the sociodemographic, geographic, and healthcare-related factors influencing satisfactory Tetanus Toxoid-Containing Vaccine (TTCV) immunization (≥2 doses). Satisfactory TTCV coverage was critically low at 20.20%. Significant socioeconomic disparities were observed; women in the highest wealth quintile had nearly three times higher odds of immunization (AOR: 2.76; 95% CI: 2.10-3.62) compared to those in the lowest quintile. Antenatal care (ANC) access was crucial, with 6-10 ANC visits increasing immunization odds by 2.68 times (AOR: 2.68; 95% CI: 1.81-3.96). Notably, nomadic women were 1.90 times more likely to be immunized than settled rural women (AOR: 1.90; 95% CI: 1.59-2.26). Facility-based delivery increased vaccination odds by 50% (AOR: 1.50; 95% CI: 1.28-1.76). Tetanus immunization coverage in Somalia is extremely insufficient and driven by deep-seated inequities. While nomadic populations show relative success due to outreach efforts, the health system fails socioeconomically disadvantaged and settled rural women. An urgent dual strategy is needed: strengthening routine ANC services and expanding tailored outreach to prevent tetanus deaths.