Synergies Between Health System Programs

Key Evidence: Kenyan children born outside of a health facility with the aid of a traditional birth attendant were around 80% more likely to be non-vaccinated or under-vaccinated than children born in a government health facility.

Key Evidence: In India, children whose mothers received tetanus vaccination during their pregnancy were 22-31% less likely to have delayed vaccination (depending on the vaccine) than children of unvaccinated mothers. Those born at home were nearly 3 times more likely to receive BCG vaccination late and 41% more likely to receive their first dose of DTP late than those born in a public health facility.

Key Evidence: Children in Pakistan born to women who had 3 or 4 antenatal care (ANC) visits were 40-60% more likely to receive all required vaccines on time than children whose mothers made only 1 or 2 ANC visits.

Key Evidence: The likelihood of a child 12-23 months of age in Myanmar having completed their vaccinations was more than 3 times greater if his or her mother had received tetanus vaccination during pregnancy, and almost 2 times greater if she made at least 4 antenatal care visits than mothers who hadn’t, after other factors, such as parents’ educational level, household income, residence (rural vs. urban) and mother’s age, were controlled for.

Key Evidence: Use of recommended maternal health care services — defined as at least 4 antenatal care visits, having a skilled attendant at birth, and delivery in a health facility — was a predictor of timely vaccination of mothers’ infants in a study conducted in Ghana. Compared to children whose mothers received one or two of these services, infants born to mothers who received all three interventions were roughly 30% more likely to be fully vaccinated by 12-23 months of age, while children whose mothers received none of these services were only about half as likely to be fully vaccinated. Investing in maternal health, which creates familiarity with the health system and increases mothers’ knowledge about disease prevention, can improve the health of both the mother and her children beyond infancy.

Key Evidence: Ethiopian mothers use of any of three maternal health services — antenatal care, delivery services, or tetanus vaccination — significantly increased the likelihood of their children being fully immunized by 12-23 months of age. Therefore, national immunization initiatives should concentrate on improving access of pregnant women to these key maternal health services.

Key Evidence: A study in Ghana using nationally representative survey data found that children born in an institutional setting had a substantially higher proportion of full vaccination (73.9%) compared to those born at home (60.8%). Children born in a health facility—either public or private—had 1.71 times the odds of receiving a full vaccination schedule compared to children born at home.

Key Evidence: In an effort to reach children with vitamin A deficiency in the African countries of Angola, Chad, Cote d’Ivoire, and Togo, vitamin A supplementation was administered during Polio vaccine campaigns. This led to a minimum coverage of 80% for vitamin A and 84% for polio vaccine in all of the immunization campaigns. During the second year of vitamin A integration into the polio vaccination campaign, coverage exceeded 90% for both vitamin A and polio vaccination in all four countries.

Key Evidence: Communities with higher rates of health services utilization, particularly institutional childbirth, were more likely to have higher immunization coverage rates.

From the VoICE editors: This data, from a study in the Democratic Republic of Congo, had an adjusted odds ratio of 2.36.

Key Evidence: Missed opportunities for vaccination i.e. percentage of children who failed to attain full immunization coverage (FIC) among those receiving one or more other health interventions were assessed through a study of 14 geographically diverse countries. In children with a vaccination rate below 70%, FIC was observed to be lowest in children born to mothers who failed to attend antenatal care across countries. The largest difference in FIC (54%) was observed in Côte d’Ivoire comparing children born to mothers who attended four or more ANC visits compared to no ANC visits. The presence of skilled birth attendant (SBA) was linked to higher rates of FIC with a 36% lower FIC in children born without a SBA in Nigeria. Post-natal care (PNC) acted as a factor contributing to 31% increase in FIC in the children who received PNC in Ethiopia. Vitamin A supplementation and sleeping under an insecticide treated bed net (ITN) were also positively linked to increase in FIC in the Democratic Republic of Congo and Haiti respectively.

Key Evidence: Mothers in Nigeria were between 2-4 times more likely to have fully immunized children if they attended 1-3 antenatal care (ANC) visits, between 2.5-8 times more likely if they attended 4-7 ANC visits, and between nearly 3-14 times more likely if they attended at least 8 ANC visits compared to those who had no ANC.

From the VoICE Editors: Similar findings have been seen in many LMICs, including Senegal, Bangladesh, Indonesia, India, Zimbabwe, and Southwest Ethiopia. 

Key Evidence: In this mixed-methods implementation study, routine immunization and family planning services were integrated across health facilities and community sites across two rural districts in Malawi, Dowa and Ntchisi. The total number of women accessing family planning services during the study period increased by 14% while DPT immunization rates for children remained consistent. In interviews, parents and providers found the integration of family planning and immunization services to be feasible and beneficial, indicating a win-win for both services.

Key Evidence: An analysis of rotavirus vaccine introduction in two Latin American countries (Honduras and Peru) suggests that the introduction of the vaccine might have had a favorable impact on coverage and timing of other similarly scheduled vaccinations.

Key Evidence: Increased uptake of immunization for vaccine-preventable diseases, particularly in low- and middle-income countries, could save the lives of thousands of mothers and children each year. The disease burden of tetanus, influenza, and pertussis has been minimized in many countries through maternal immunization, but wider applications of this strategy are now needed.

Key Evidence: In Rwanda, HPV vaccine introduction through a new school-based delivery program provided the opportunity to offer additional health services to all school-children (girls and boys), including health promotion sessions, de-worming and opportunities for voluntary, free circumcision.