Tetanus neonatorum is a serious health problem in many developing countries where maternity care services are limited and immunization against tetanus is inadequate. In the past 10 years the incidence of tetanus neonatorum has declined considerably in many developing countries, thanks to improved training of birth attendants and immunization with tetanus toxoid for women of childbearing age. Despite this decline, WHO estimated in 2006 that tetanus neonatorum still caused about 257 000 deaths, mainly in the developing world. Most newborn infants with tetanus are born to non-immunized mothers delivered by an untrained birth attendant outside a hospital.

The disease usually occurs through introduction of tetanus spores via the umbilical cord, during delivery through the use of an unclean instrument to cut the cord, or after delivery by “dressing” the umbilical stump with substances heavily contaminated with tetanus spores, frequently as part of natal rituals.

In neonates, inability to nurse is the most common presenting sign. Tetanus neonatorum is typified by a newborn infant who sucks and cries well for the first few days after birth but subsequently develops progressive difficulty and then inability to feed because of trismus, generalized stiffness with spasms or convulsions and opisthotonos. The average incubation period is about 6 days, with a range from 3 to 28 days. Overall, case-fatality rates for neonatal tetanus are very high, exceeding 80% among cases with short incubation periods. Neurological sequelae including mild retardation occur in 5% to over 20% of those children who survive.

Prevention of tetanus neonatorum can be achieved through a combination of 2 approaches:

1. Improving maternity care, with emphasis on increasing the tetanus toxoid immunization coverage of women of childbearing age (especially pregnant women) and clean deliveries
   
   
2. Increasing the proportion of deliveries attended by trained attendants.
   
   Important control measures include licensing of midwives, providing professional supervision and education as to methods, equipment and techniques of asepsis in childbirth, and educating mothers, relatives and attendants in the practice of strict asepsis of the umbilical stump of newborn infants. The latter is especially important in many areas where strips of bamboo are used to sever the umbilical cord, or where ashes, cow dung poultices or other contaminated substances are traditionally applied to the umbilicus. In those areas, any woman of childbearing age visiting a health facility should be screened and offered immunization, no matter what the reason for the visit.
   
   Non-immunized pregnant women should receive at least 2 doses of tetanus toxoid, preferably as Td, according to the following schedule: the first dose at initial contact or as early as possible during pregnancy; the second dose 4 weeks after the first and preferably at least 2 weeks before delivery. A third dose could be given 6–12 months after the second, or during the next pregnancy. An additional 2 doses should be given at annual intervals, or during subsequent pregnancies. One of the five doses of tetanus toxoid should be given as Tdap where available, ideally while the mother is immediately postpartum or between pregnancies.
   
   A total of 5 doses of tetanus toxoid protects the previously unimmunized woman throughout the entire childbearing period. Women whose infants have a risk of neonatal tetanus, but who themselves have received 3 or 4 doses of DTP/DTaP as children, need only receive 2 doses of tetanus toxoid during each of their first 2 pregnancies.