Assessment of immunization among newborns: comparison between children delivered vaginally and by cesarean section

Arvinder Pal Singh Narula, Prakash Prabhakarrao Doke, Varsha Mahesh Vaidya, Archana Vasantrao Patil, Tushar Madhavrao Panchanadikar, Girija Narendrakumar Wagh


Background: Timely administration of vaccines, particularly for hepatitis B birth dose within 24 hours of birth is of immense importance. It is considered as an indicator of quality of immunization programme. This study aimed to assess effect of mode of delivery and type of hospital on immunization among newborns.

Methods: This large multi-site study was conducted in Pune district having population of 9.43 million. A total of 13 hospitals were selected which included all government hospitals performing more than five cesarean sections per month, and one government and one private medical college hospital. Cesarean section and vaginally deliveries were enrolled in 1:1 ratio. Their children were followed till discharge. Data were collected by obstetrician or qualified nurse.

Results: During study period 3,112 women were enrolled.  The relative risk of not getting vaccine Hepatitis B birth dose before 24 hours among cesarean delivered newoborns was 1.08. The relative risk of not getting zero polio and BCG among cesarean delivered newborns was 0.71 and 0.76 respectively. All these differences were significant. The coverage for all vaccines was better in sub district hospitals than others. Coverage of all vaccines in government teaching hospital was better than private.

Conclusions: Cesarean section enabled better coverage among newborns probably due to length of stay. Whereas the physical and mental stress after cesarean section resulted lesser coverage of hepatitis B birth dose within 24 hours. Opportunities of timely Hepatitis B birth dose administration were missed probably due to lack of knowledge among health workers about ideal timing.


BCG, Cesarean, Timely hepatitis birth dose, Vaginal delivery, Zero polio

Full Text:



International Institute for Population Sciences. National Family Health Survey-4, 2015-16: India Fact Sheet. Vol. I. 2017:1-637.

Ministry of Women and Child Development G of I. Rapid Survey on Children 2013-14. April;2015;1-14.

Ministry of Health & Family Welfare G of I. National Health Policy, 2017.

Goverment of India. National Health Portal, Mission Indradhanush.

International Institute for Population Sciences. National Family Health Survey - 4 District Fact Sheet Pune Maharashtra. 2015.

International Institute for Population sciences. National Family Health Survey - 4 2015-16. State Fact Sheet, Maharashtra. 2015.

World Health Organization. Hepatitis B : Imunization, Vaccices and Biologicals. Who 2016. Available at:

Accessed 3 May 2016.

Puliyel J, Naik P, Puliyel A, Agarwal K, Lal V, Kansal N, et al. Evaluation of the Protection Provided by Hepatitis B Vaccination in India. Indian J Pediatr. 2018;85(7):510-6.

Feldstein LR, Mariat S, Gacic-Dobo M, Diallo MS, Conklin LM, Wallace AS. Global Routine Vaccination Coverage-2017. MMWR Morb Mortal Wkly Rep. 2018;67(45):1261-4.

Moturi E, Tevi-Benissan C, Hagan JE, Shendale S, Mayenga D, Murokora D, et al. Implementing a Birth Dose of Hepatitis B Vaccine in Africa: Findings from Assessments in 5 Countries. J Immunol Sci. 2018;Suppl(5):31-40.

Pham TT, Le HM, Nguyen DT, Maertens K, Leuridan E, Theeten H, Hendrickx G, Van Damme P. Assessment of the timely administration of the hepatitis B and BCG birth dose and the primary infant vaccination schedule in 2015–2016 in the Mekong Delta, Viet Nam. Vaccine. 2018;36(38):5760-5.

Wiesen E, Lagani W, Sui G, Arava J, Reza S, Diorditsa S, et al. Assessment of the hepatitis B birth dose vaccination program, Papua New Guinea, 2014. Vaccine. 2017;(2015):1-6.

World Health Organization. Hepatitis B birth dose vaccination in India. 2016. Available at: Accessed on 3 January 2010.

Narayana HV, Kaniambady BL. Study on hepatitis B birth dose vaccination coverage, promoting the same in a private Rural Medical College, Karnataka, South India. Natl J Community Med. 2017;8(6):295-8.

Allison RD, Patel MK, Tohme RA. Hepatitis B vaccine birth dose coverage correlates worldwide with rates of institutional deliveries and skilled attendance at birth. Vaccine. 2017;35(33):4094-8.

Kuruvilla TA, Bridgitte A. Timing of zero dose of OPV, first dose of hepatitis B and BCG vaccines. Ind Pediatr. 2009;46(11):1013.

Chang MS, Gavini S, Andrade P, McNabb-Baltar J. Caesarean section to prevent transmission of hepatitis B: A meta-analysis. Can J Gastroenterol Hepatol. 2014;28(8):439-44.

Yang M, Qin Q, Fang Q, Jiang L, Nie S. Cesarean section to prevent mother-to-child transmission of hepatitis B virus in China: A meta-analysis. BMC Pregnancy Childbirth. 2017;17(1):1-10.

Pan CQ, Zou H Bin, Chen Y, Zhang X, Zhang H, Li J, et al. Cesarean section reduces perinatal transmission of hepatitis B virus infection from hepatitis b surface antigen-positive women to their infants. Clin Gastroenterol Hepatol. 2013;11(10):1349-55.

Debaje SP. Assessment of Zero’ dose of Polio Vaccine and Factors Influencing Coverage of Zero Polio Dose in India. 2014;1(4):99-102.

WHO and UNICEF. India: WHO and UNICEF estimates of immunisation coverage: 2017 revision. 2019.1-18.

World Health Organization. WHO vaccine-preventable diseases: monitoring system. 2019 global summary. 2019. Available at: Accessed on 3 January 2010.

Bhatnagar P, Gupta S, Kumar R, Haldar P, Sethi R, Bahl S. Estimation of child vaccination coverage at state and national levels in India. Bull World Health Organ. 2016;94(10):728-34.

World Health Organization. Global Health Sector Strategy on Viral hepatitis 2016-2021 towards ending viral hepatitis. 2016: 1-56.