Determinants of Tetanus Toxoid Immunization Among Pregnant Women in Somaliland: Evidence from the 2020 Nationwide Survey Using a Zero-Inflated Negative Binomial Model

Abstract Background Tetanus Toxoid immunization is a critical public health intervention for reducing maternal and neonatal mortality. Despite global recommendations, Tetanus Toxoid coverage remains low in several low- and middle-income countries, including Somaliland. Objectives This study aims to assess the prevalence and determinants of Tetanus Toxoid immunization among pregnant women in Somaliland using the 2020 Somaliland Demographic Health Survey. Methods A cross-sectional analytic study was conducted using the 2020 Somaliland Demographic Health Survey. Data from 2,584 women aged 15–49 years. STATA 17 was used for analysis. Descriptive statistics were used to examine immunization coverage. The chi-square test was used to identify bivariate associations between TT uptake and explanatory variables. Given the nature of the count outcome and high proportion of zeros, a zero-inflated negative binomial regression model was applied. The result was interpreted using incidence rate ratios with 95% confidence intervals. The model with the lowest AIC and BIC values and the highest log likelihood was selected as the best fit. Results Only 14.24% of pregnant women received at least two Tetanus Toxoid doses, while 73.03% received none. ANC attendance (IRR = 3.93; 95% CI: 3.32–4.66), wealth index, maternal employment (IRR = 0.41; 95% CI: 0.23–0.75 for unemployed), institutional delivery, and distance to health facility (IRR = 1.17; 95% CI: 1.02–1.34) were significantly associated with Tetanus Toxoid uptake. Regional disparities and media exposure were also observed. Conclusion Tetanus Toxoid immunization among pregnant women in Somaliland is alarmingly low and shaped by both socio-demographic and reproductive health factors. Targeted interventions should focus on expanding ANC coverage, reducing geographic and economic barriers, empowering women, enhancing awareness through media, and improving physical access to healthcare facilities. These findings are aligned with SDG 3 in Somaliland.