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Background  Tetanus is a vaccine-preventable disease that can occur in all populations, with neonates and pregnant women being at the most risk. Ethiopia has the highest maternal and neonatal tetanus morbidity and mortality rates. Besides, only 49% of mothers get vaccinated with adequate tetanus toxoid in Ethiopia which is below the world health organization recommendation. To date, there is limited evidence on the individual and community level determinants of poor tetanus toxoid (TT) immunization. Therefore, this study aimed to assess individual and community-level factors associated with poor TT immunization coverage in Ethiopia.    Method  Secondary data analysis was conducted using the 2016 Ethiopian demographic and health survey. A total of 7043 pregnant women were included in the current study. A multilevel logistic regression model was used to identify individual and community level determinants of poor tetanus toxoid immunization. Finally, the adjusted odds ratio with a 95% confidence interval was reported.    Results  In the multilevel logistic regression model adjustment ,  having no Antenatal care visit (AOR = 5.64; 95% CI:2.48,7.30) and having one to three antenatal care visit (AOR = 1.50; 95% CI: 1.19–1.82); poor wealth index (AOR = 1.26; 95% CI: 1.03, 1.54); not being exposed to media (AOR = 1.29; 95% CI: 1.10, 1.51); maternal unemployment (AOR = 1.15; 95% CI: 1.10, 1.31); rural residence (AOR = 1.13; 95% CI: 1.08, 1.72); and high community illiteracy (AOR = 1.28; 95% CI: 1.03, 1.58) were associated with higher odds of poor tetanus toxoid immunization. Whereas, iron uptake during pregnancy (AOR = 0.59; 95% CI: 0.51, 0.68), was associated with lower odds of poor tetanus toxoid immunization.    Conclusion  In this study tetanus toxoid (TT) vaccine utilization was affected by both community and individual-level factors. Therefore, focusing on antenatal care services especially encouraging pregnant women to have at least four visits, consulting women to be exposed to media, improving community literacy and maternal employment will help to minimize TT underutilization.

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Individual and community-level determinants of poor tetanus toxoid immunization among pregnant women in Ethiopia using data from 2016 Ethiopian demographic and health survey; multilevel analysis