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Helping the hardest to reach

23 September, 2011

Helping the hardest to reach

How do you eliminate a disease globally? Wendy Golledge explores the challenges faced by the Pampers and UNICEF tetanus campaign as it works to protect mothers and babies in the poorest countries.

Midwives magazine: Issue 6 :: 2011

How do you eliminate a disease globally? Wendy Golledge explores the challenges faced by the Pampers and UNICEF tetanus campaign as it works to protect mothers and babies in the poorest countries.

As midwives working in the UK, it’s easy to take for granted the level of health care available to British women. According to The state of the world’s children report, less than 12 in every 100,000 will lose their life during pregnancy and childbirth, 99% give birth with a midwife at their side and, as a result, infant mortality is at an all-time low of five per 1000 (UNICEF, 2011). What’s more, immunisation programmes are so well established that diseases that remain fatal worldwide, like maternal and newborn tetanus (MNT), rarely cross British women’s minds.

Thanks to funding provided by the likes of the Pampers and UNICEF ‘1 pack = 1 vaccine’ campaign, the number of women and babies who lose their lives to this disease in the developing world is steadily falling.

Since the launch of the tetanus programme in 2006, Pampers and UNICEF have helped protect around 100 million women and babies from MNT, and the campaign is supporting activities in 25 countries where the disease is still a threat. Of those 25, a further seven are expected to complete their MNT vaccination programmes by the end of 2011.

However, an estimated 130 million women are still at risk and a baby dies every nine minutes (Black et al, 2010). The majority of these babies are born in the poorest, most isolated places in the world, such as Papua in eastern Indonesia where Maria Engel is due to have her eighth baby. Here, elimination – defined as less than one case of newborn tetanus per 1000 live births per district (International Journal of Epidemiology, 2010) – still seems a world away.

Maria is one of the lucky ones. Sawa Erma, the tiny remote village where she lives, may be a two and a half hour boat ride from the nearest town of Agats, but money from the MNT programme has helped to ensure that she received three vital tetanus toxoid (TT) vaccines. These injections will keep her safe for the next five years, and her unborn baby will be protected for the first two months of its life.

 A global journey

Getting vaccines to mothers like Maria is fraught with difficulty. The TT vaccine needs to be kept between 2˚C and 8˚C; not easy in a country where temperatures regularly soar to 42˚C. This poses a huge logistical challenge to UNICEF and government health workers. In this case, the vaccine is made in West Java and flown to Jayapura, the capital of the province of Papua. They are then flown to Timika, before being put on a 19-seat plane to the tiny landing strip near Agats.

A short speedboat ride takes them to the central vaccine store in Agats, where they stay until they are distributed to health centres in more rural areas. For its journey to villages like Sawa Erma, the vaccine is packed in cool boxes, which will keep it at the correct temperature for a mere six hours. Due to poor infrastructure, difficult road conditions and large areas of swampland isolating the country’s 12,000 islands, it’s often difficult to predict how long it will take to reach far-flung destinations. This means that journeys have to be carefully planned if the vaccines are to stand a chance of remaining viable on arrival. The only way to tell if the TT vaccine is still effective is via a little red dot on the vial. This ‘vaccine vial monitor’ turns dark red if the contents has got too warm and is no longer usable.

When a vaccine does arrive safely, it’s the job of health workers like Yularata Maura to administer it. Yularata works in a tiny health centre based in a small rural village. Health sessions only run from 8am to lunch-time once a month and cater for nine different isolated communities. Yularata and her colleagues can see more than 200 women in one four-hour session.

But for Yularata, the more she sees, the better. ‘This time a year ago, there was no-one here, now lots of women come wanting to be immunised because we also go house to house to tell them about the campaign and why it’s important.’

Yularata’s house calls are carried out in a ‘health boat’ and are a lifeline for many, as the centre’s catchment area spans a giant swamp. 

Mobilising the community
Education is another major part of Yularata’s job. In the remote communities she works in, many mothers still adhere to traditional birthing practices. For some, this means building themselves a hut on stilts over the water in late pregnancy. They must go there to give birth alone, and tradition states they remain in the hut for three days, until they are no longer considered ‘unclean’ by the community. One in five mothers in Papua don’t have a skilled health worker there when they go into labour (UNICEF, 2011) and for others, their birth is attended only by a ‘birth witch’, the Indonesian term for a traditional birth attendant. However, generally birth witches have received no ‘official’ training. They usually pick up the practice from their mother and, unless they are educated by local health workers, know nothing of the importance of hygiene in preventing the spread of MNT.

Equally challenging is the task of educating mothers-to-be so they understand the importance of getting their TT vaccines at the right time and they keep their vaccination card, which details what vaccines they have had and when.

As Papua is in the most inaccessible part of the country, it’s the last area of Indonesia to eliminate MNT. The government often struggles to find health workers willing to work in such remote areas, which is so desperately needed.

Incentives for doctors to work in these areas include giving them a house, a speed boat and an extra $US1000 per month. To address the issue of a lack of trained workers, the government is also looking to introduce a compulsory internship scheme where all newly qualified doctors need to spend a certain amount of time in a remote area. 

A different approach
Hope lies in continued funding and the innovative ways some health workers are getting vaccines out to those most in need. The TT vaccine is now being taken into schools, to ensure all girls aged between 12 and 19 are protected before they have their first child. The girls can also be educated about the dangers of tetanus and taught the importance of hygienic birth practices.

It’s a small step, but solutions like these will make the difference in the fight to eliminate MNT globally. 


Black R, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. (2010) Global, regional, and national causes of child mortality in 2008: a systematic analysis. The Lancet 375: 1969-87.

Blencowe H, Lawn J, Vandelaer J, Roper M, Cousens S. (2010) Tetanus toxoid immunization to reduce mortality from neonatal tetanus. International Journal of Epidemiology 39(suppl 1): i102–i109.

UNICEF. (2011) The state of the world’s children 2011: Adolescence – an age of opportunity. See: http://www.unicef.org/sowc2011/fullreport.php (accessed 21September 2011).

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