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Abstract
Background Maternal high-risk fertility behaviours (HRFBs) are common in African countries and can potentially affect child survival. Evidence of the burden of maternal HRFB on under-five children is scant in Ethiopia.
Objective To determine the burden of maternal HRFB on under-five children’s health status in Hadiya zone, Southern Ethiopia.
Design A facility-based cross-sectional study was conducted.
Setting All secondary and tertiary public healthcare centres; that are, one referral and three district hospitals providing comprehensive emergency obstetric care services in the Hadiya zone, Southern Ethiopia.
Participants Three hundred women of reproductive age (15–49 years) who had undergone childbirth in the 5 years preceding this study and living with at least one child younger than 5 years admitted to public hospitals in Hadiya zone were included.
Main outcome measure Under-five children’s health status.
Results The overall proportion of maternal HRFB among currently married women was 60.3%, with 35.0% falling into a single high-risk category and 25.3% falling into multiple high-risk categories. Children younger than 5 years born to mothers having HRFB had an increased chance of acute respiratory infections five times, diarrhoea six times, fever eight times, low birth weight six times and a chance of dying before the fifth birthday two times than children born to mothers with no risk. The risks of morbidity and mortality further increased when children were born to mothers falling into multiple high-risk categories.
Conclusions The overall proportion of maternal HRFB among currently married women was high in the study area. A statistically significant association was seen between maternal HRFB and health outcomes of children younger than 5 years old. Intervening to avert maternal HRFBs through family planning may help to reduce childhood morbidity and mortality.
- OBSTETRICS
- Community child health
- Maternal medicine
- Child protection
- Public health
Data availability statement
Data are available upon reasonable request. Data may be obtained from the correspondent author and are not publicly available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
This study was based on mothers’ interviews which is important to minimise information bias and increase its validity and completeness than using record review or secondary data.
Data were further analysed to explore the burden of specific types of maternal high-risk fertility behaviour (HRFB) as a single type or in combination other than the crude burden of maternal HRFB on under-five children’s health status.
The study has a limitation in that it was hospital-based and as a result of problematic births admission, the prevalence of maternal high-risk fertility and its burden on the health status of children younger than 5 years may be elevated.
Background
Maternal high-risk fertility behaviour (HRFB) is a bio-demographic factor that negatively affects child health. HRFBs generally include too-early or too-late childbearing, a higher number of live births and short birth intervals.1 Evidence from different works of the literature revealed that stillbirth, low birth weight (LBW) and prematurity were associated with HRFB.2–5
Infant and child mortality rates remain especially high in sub-Saharan Africa and South Asia; 80% of all under-five deaths occur in these regions readily due to preventable diseases.6 The Sustainable Development Goals require an under-five mortality rate of 25 per 1000 live births to be achieved by 2030.7 With the current trend of reduction, Ethiopia will be under challenge to achieving the target as of the deadline where the under-five mortality rate was 67 deaths per 1000 live births.8 Despite effective interventions aimed at reducing childhood mortality, infectious diseases such as pneumonia and diarrhoea remain major causes of death in children. Identifying the risk factors for these illnesses will be critically important for reducing childhood morbidity as well as mortality.1
Some studies documented the link between various components of maternal HRFBs and negative child health.1 For example, motherhood at either a very early (<18 years) or advanced age (>34 years) is associated with an increased likelihood of under-five morbidity and mortality.1 9 10 A study from Ethiopia indicated a higher risk of under-five mortality associated with maternal HRFBs, especially among women aged 15–18 years having a high ratio of continuous pregnancies, and shorter birth spacing.11 12 Another study that analysed 2016’s Ethiopian demographic and health survey data revealed that a single HRFB was not associated with under-five mortality, yet the presence of two or more maternal HRFBs was an important factor that increased the likelihood of under-five child death.13
To our knowledge, evidence of the burden of maternal HRFB on under-five children was scant in Ethiopia, and the available studies’ findings were based on the Ethiopian demographic and health survey data; thus this study was intended to evaluate the individual and combined influences of maternal HRFBs on the health status of children younger than 5 years old and specifically their association with an acute respiratory infection, diarrhoea, fever or LBW in children born within the past 5 years based on primary data.
Methods
Study design
A facility-based cross-sectional study was conducted.
Study setting and period
The study was conducted in the Hadiya zone, which is one of the administrative zones in Southern Nations, Nationalities and Peoples Regional State, Ethiopia. Hadiya zone with a 3542.66 km2 area has a population of 1 650 104 (820 102 males and 830 002 females and 384 474 childbearing age women) in 2018 (Hadiya zonal health department; 2018’s Zonal MCH and nutritional interventions performance report, Southern Ethiopia). The zone has 13 districts and four town administrations. Hossana is the capital town of the Hadiya zone which is located 230 km Southwest of Addis Ababa, the capital of Ethiopia. There are four hospitals in the zone (one referral and three district hospitals). All hospitals provide comprehensive emergency obstetric care services and a paediatric admission ward and the referral hospital had a neonatal intensive care unit (NICU). The study was conducted from 1 April to 30 June 2021.
Participants
Childbearing-age women who had gone through childbirth in the previous 5 years before the current study with their one child less than 5 years old admitted to public hospitals in Hadiya zone, Southern Ethiopia.
Inclusion criteria
Women of reproductive age (15–49 years) who had gone through childbirth in the previous 5 years with one child younger than 5 years were included.
Exclusion criteria
Participants with missing responses to the variables of interest, such as morbidity and mortality status of their children less than 5 years old and those with permanent difficulty communicating when communicating verbally either due to hearing problems or speech difficulties, were used as exclusion criteria but no mother–child pair fulfilled these criteria and excluded from the study.
Patient involvement
No patients were involved in the design of this study. We used the Strengthening the Reporting of Observational Studies in Epidemiology cross sectional checklist when writing our report.14
Data collection procedure and instrument
Data were collected using a structured interviewer-administered questionnaire (online supplemental file 1) which was developed after a thorough review of the literature.1–5 9–12 15 16 A face-to-face interview was held to gather data. The interview was held in a private area at admission or sometime later during their stay at a hospital near discharge depending on the child’s clinical condition. The overall data collection process was supervised by a trained general practitioner working in the study hospital. The paediatrics ward and NICU of the hospitals were visited for data collection. The information was collected during a retrospective birth history, in which women respondents list all of the children they have ever born, along with each child’s date of birth, survivorship status, and current age or age at death for deceased children. Child health status was declared from diagnosis identified using patient cards, admission log books, operation theatre log books, death summaries and mother interviews.
Supplemental material
Study variables and measurement
Outcome variables
Health status of children born in the last 5 years (acute respiratory infection, diarrhoea in the past 2 weeks, fever in the past 2 weeks, LBW and under-five child mortality). These categories were measured independently as ‘yes/no’ questions. Acute respiratory infection was measured as ‘yes’, if the child had cough, rapid breathing, blocked, or running nose; and otherwise ‘no’. These were measured against one index under-five child with admission.
Exposure variables
In this study, maternal HRFB (non-risk, high-risk category) and other exposure variables that were controlled as they are potential confounders included such as sociodemographic factors (age, residence, educational level, maternal occupation, husband occupation, monthly income, source of drinking water (protected/unprotected), media exposure); and reproductive health characteristics (contraceptive use, wanted pregnancy, antenatal care (ANC) follow-up, stillbirth, place of delivery and women autonomy).
The HRFBs that were examined in this study are related to maternal age at the time of delivery, birth order and birth interval.1 More specifically, all of the following circumstances were defined as high-risk: mother <18 years at the time of delivery, mother >34 years at the time of delivery, a most recent child born <24 months after a previous birth and most recent child of birth order >3. For analysis, any HRFB versus non-risk was coded as 1/0, respectively. The presence of any of the four conditions listed above was termed HRFB (coded as 1 and otherwise 0). These behaviours were further operationalised as (1) single high-risk behaviour versus none and (2) multiple high-risk behaviours versus none.
The women’s autonomy index was assessed by asking questions about who in the household makes decisions regarding maternal healthcare, large household purchases, visiting family and relatives, and child healthcare. For each of the four questions, a respondent received 1 point if she was involved in the decision and 0 points if she was not. These points were summed to yield total scores from 0 to 4.3 Individual respondents’ score was obtained by dividing the score by the maximum score that is 4. A score >0.5 was considered autonomous. The average value of the women’s autonomy index was calculated by adding up individual scores and dividing by the number of respondents.
Sample size and sampling procedure
The sample size for the study was determined using Epi-Info V.7.2.2.6 software using sample size estimation for a single population survey and using the assumptions: confidence level of 95%, power 80%, population size >10 000, expected frequency or proportion of reproductive-age women who had at least one HRFB of 76.9% from one study analysed 2016 Demographic and Health Surveys (DHS) data in Ethiopia,2 1:1 exposed to non-exposed ratio and 5% acceptable margin of error. Therefore, the final minimum sample size included in the study was 273+10% non-response rate=300.
All public hospitals in the Hadiya zone were included in the study. The last 6 months paediatric admission rate from each public hospital was used to proportionally allocate the sample size to each selected hospital. Women of childbearing age with their under-five children admissions to public hospitals were selected using systematic random sampling and the Kth interval was determined based on the paediatrics admission rate of the respective hospital. Accordingly, every two women were taken (570/300=1.9).
Data quality management
The questions prepared in English were translated into Amharic and back-translated to English by different expert translators to check for consistency (online supplemental file 1). A pretest was carried out at Worabe comprehensive hospital on 5% of the sample size for 1 week. Internal consistency reliability analysis was carried out for some questionnaire reliability. Data collectors were trained for 2 days on the objectives of the study, data collection techniques, and tools, and the data consistency and completeness were checked daily by a trained supervisor and the principal investigator, and spot corrections were taken. After data were collected, each questionnaire was coded and data cleaning was done before actual data analysis was conducted.
Data processing and analysis
Each questionnaire was checked for completeness, coded, and entered into Epi-data V.4.4 and exported to SPSS for Windows V.24 for analysis. The analysis was done after data cleaning was done. Frequencies, proportions, and measures of variation were used to describe the study population concerning sociodemographic and other relevant variables. Five different independent multivariable logistic regression models for each child’s health outcome were constructed containing maternal HRFB variable as predictor. Further analysis was also conducted, and accordingly, another five models were built for each child health outcome containing type of maternal HRFB categorised as no risk, single, or multiple and another five models were built for each child health outcome containing any specific types of maternal HRFB categories. Potential confounder variables were also included and controlled in each model to see the association between maternal HRFB with its types and categories and a child’s health status outcomes. Bivariate logistic regression was used to see the association between independent variables and between each independent variable and each outcome variable and a p value of <0.25 was used to recruit variables for the final multivariable logistic regression model. Model fitness for each final model was checked using the Hosmer and Lemeshow goodness of fit test and we declared that each model was fit. Statistical significance was assessed using ORs, a p value of <0.05 and 95% CIs.
Result
Sociodemographic characteristics
A total of 300 study participants (mother–child pairs) were included in the analysis. The mean age of participant mothers was 30.1 years±4.7. The majority of participant mothers were in the age group 25–30 years (45.7%) and two-thirds of them were rural residents (64.3%). Half of the mothers (50.3%) and more than half of the fathers (54.0%) attained primary education level. Three-fourths of the participant mothers (78.0%) were housewives in their occupation whereas almost half of their husbands (49.0%) were farmers. The median average estimated monthly income of the family was US$73.5 (IQR $56.7–$105.0). The majority of participants (90.0%) had media exposure and radio was the most common media (see table 1).
Sociodemographic characteristics of under-five children’s parents in Hadiya zone public hospitals, Southern Ethiopia (n=300)
Reproductive health characteristics
The family size of study participants ranges from 3 to 10 with a mean size of 5.7±1.9. The median number of under-five children participant mothers has 2 (IQR 1–2). The median age of mothers at marriage was 19 (IQR 18–20). The majority of participant mothers gave their last birth at a health facility (87.7%) and 90% of them had ANC follow-up for their last pregnancy. Two-thirds of mothers had 1–3 ANC contacts for their index delivery with a median of 3 (IQR 3–4). The proportion of mothers who ever gave stillbirth was 86.0% and 61% of mothers used contraceptives before their last pregnancy. One-third of the participant mothers (35.3%) had postnatal care follow-up for their index birth and 56.7% of mothers had planned and wanted index pregnancy. The average value of the women’s autonomy index was 0.71 and 54.1% of participant mothers were autonomous (see table 2).
Reproductive health characteristics of participant mothers in Hadiya zone public hospitals, Southern Ethiopia (n=300)
Under-five children’s health status
The mean age of the under-five years old children born to participant mothers in the past 5 years was 14.3 months±17.6. Among them, 52.3% were females. The proportion of children who experienced acute respiratory infections in the last 2 weeks was 67.3% with the most common symptom being cough (36.6%). One in five (23%) children had an episode of diarrhoea in the last 2 weeks and a half (52.3%) of the children encountered fever in the last 2 weeks. One-fifth (21.7%) of participant mothers lost their children before their fifth birthday (see figure 1).
Prevalence of low birth weight, morbidity and mortality among under-five children who were born within the past 5 years to currently married women in Hadiya zone, Southern Ethiopia (n=300 for each category). ARIs, acute respiratory infections; LBW, low birth weight; U5, under five.
Maternal HRFB
The age of mothers at the time of index delivery ranges from 18 to 40 with a mean age of 30.8 years±4.3 and 26.0% of them were older than 34 years. The median birth interval was 3 years (IQR 2–3) and 13.4% of mothers have <2 years inter-birth interval. More than half (52.0%), of children’s birth order was >3 with mean birth order of 4.1±1.7 and it ranges from 1 to 8. The overall proportion of maternal HRFB among currently married women was 60.3%, with 35.0% falling into a single high-risk category and 25.3% falling into multiple high-risk categories. The most common single maternal HRFB was birth order >3 (77.1%) and the most common multiple high-risk behaviours were age >34 and birth order >3 (81.6%) (see table 3).
Maternal high-risk fertility behaviour among currently married mothers who gave birth in the last 5 years in Hadiya zone public hospitals, Southern Ethiopia (n=300)
Burden of maternal HRFB on under-five children’s morbidity and mortality
Primarily, five different regression models were built for each morbidity status and mortality adjusted for several relevant variables to determine the burden of maternal HRFB on under-five children’s health status. Model 1 is for acute respiratory infections, model 2 for diarrhoea, model 3 for fever, model 4 for LBW and model 5 for under-five mortality outcomes. A statistically significant association was seen between maternal HRFB and health outcomes of under-five children. Children younger than 5 years born to mothers having HRFB had an increased chance of acute respiratory infections five times (adjusted OR (AOR): 5.52, 95% CI 2.22 to 13.73), diarrhoea seven times (AOR: 6.91, 95% CI 2.72 to 17.56), fever eight times (AOR: 8.23, 95% CI 4.10 to 16.53), LBW seven times (AOR: 6.72, 95% CI 3.36 to 13,43) and a chance of dying before the fifth birthday two times (AOR: 2.35, 95% CI 1.13 to 4.88) than children born to mothers with no risk (see table 4).
Association between maternal high-risk fertility behaviours among currently married women and health outcomes of under-five children in Hadiya zone public hospitals, Southern Ethiopia (n=300)
Second, the data were further analysed for the effects of any specific types of maternal HRFB and their combinations as single or multiple on the health status of under-five children. Accordingly, another five models were built for each child health outcome containing type of maternal HRFB categorised as no risk, single, or multiple and another five models were built for each child health outcome containing any specific types of maternal HRFB categories and all the models were adjusted for several relevant variables. The results showed, the risks of morbidity and mortality further increased when children were born to mothers falling into multiple high-risk categories. Mother aged >34 affects children by acquiring acute respiratory infections at four times higher odds (AOR: 4.44, 95% CI 1.41 to 13.96) compared with mothers aged between 18 and 34 years. Children born less than 24 months after the preceding birth were more likely to have acute respiratory infections (AOR: 5.16, 95% CI 1.49 to 17.91) and diarrhoea (AOR: 8.74, 95% CI 1.86 to 41.04). Compared with children born to birth order <3, children born to birth order >3 were five times more likely to experience acute respiratory infections (ARIs) in the past 2 weeks (AOR: 4.87, 95% CI 1.85 to 12.83), five times more likely to experience diarrhoea in the past 2 weeks (AOR: 4.85, 95% CI 1.26 to 18.68), six times more likely to experience fever in the past 2 weeks (AOR: 6.15, 95% CI 2.33 to 16.22) and two times more likely be LBW (AOR: 2.56, 95% CI 1.06 to 6.19). Combinations of maternal HRFB, that is, age >34 and birth interval <24 months, and birth order >3 significantly increased the chance of children experiencing ARIs (AOR: 4.21, 95% CI 1.27 to 13.97), diarrhoea (AOR: 5.11, 95% CI 1.10 to 23.77) and death before the fifth birthday (AOR: 5.05, 95% CI 1.34 to 18.99) (see table 4).
Discussion
As per the current study, the overall proportion of maternal HRFB among currently married women was 60.3%, with 35.0% falling into a single high-risk category and 25.3% falling into multiple high-risk categories. Overall, 76% of reproductive-age women were faced with high-risk fertility problems in Ethiopia according to 2016 DHS data.8 According to a study conducted in the Afar region of Ethiopia, the maternal HRFB prevalence was 86.3%.16 Another result indicates that 34% of women exhibited high-risk fertility patterns; 28.7% engaged in a single high-risk behaviour and 5.4% engaged in multiple high-risk behaviours in Bangladesh.1 Our finding was lower than the Ethiopian DHS data and study conducted in the Afar region, but higher than the prevalence in Bangladesh. The differences might be attributed to the socioeconomic status of the mother in study areas. This justification is evidenced by the finding from one study which revealed, maternal HRFB was highly clustered in the Somali and Afar regions of Ethiopia, as the current study is from southern region that’s non-spot area.2
A statistically significant association was seen between maternal HRFB and health outcomes of under-five children in the current study. Children younger than 5 years born to mothers having HRFB had an increased chance of acute respiratory infections five times, diarrhoea seven times, fever eight times, LBW seven times and a chance of dying before the fifth birthday two times than children born to mothers with no risk. HRFBs increased the risk of ARI, diarrhoea, fever and LBW by 22%, 18%, 29% and 27%, respectively in Bangladesh.1 From pooled data analysis of DHS and health surveys of Africa and Asia, HRFBs were associated with an increased risk of under-five child mortality in Asian and African countries.11 Our results also showed that the risks of morbidity and mortality further increased when children were born to mothers falling into multiple high-risk categories. Combinations of maternal HRFB, that is, age >34 and birth interval <24 months and birth order >3 in combination significantly increased the chance of children experiencing acute respiratory infections, diarrhoea, and death before the fifth birthday. One study that analysed the 2016’s Ethiopian demographic and health survey data also revealed under-five mortality was significantly associated with a combination of two or more maternal HRFBs.13 The results indicated a high burden of maternal HRFB on the health status of under-five years old children; thus required public health investment for tackling maternal HRFBs in order to safeguard children’s morbidity and mortality.
The study has a limitation in that it was hospital-based and as a result of problematic births admission, the prevalence of maternal high-risk fertility and its burden on the health status of children younger than 5 years may be elevated.
Conclusion
As per the current study, the overall proportion of maternal HRFB among currently married women was high in the study area. A statistically significant association was seen between maternal HRFB and health outcomes of children younger than 5 years old; so maternal HRFBs are important predictors of morbidity and mortality among children younger than 5 years. Intervening to avert maternal HRFBs through family planning may help to reduce childhood morbidity and mortality.
Data availability statement
Data are available upon reasonable request. Data may be obtained from the correspondent author and are not publicly available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Hossana College of Health Sciences, institution review board with the reference number ሆጤሳኮ-5030. Permission was granted from the concerned bodies of each public hospital in the Hadiya zone. Moreover, informed consent and assent were obtained from each mother–child pair after they were informed about the objective and purpose of the study, and their right not to participate in the study or withdraw in the middle. Confidentiality of the information was assured and data de-identified and de-linked were stored in a secure location.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors SK participated in the conception and design of the study, performed statistical analyses, and wrote the first to the final version of the manuscript. RD, EK, GK, WE and DD participated in the design of the study, and read and revised the draft versions of the manuscript. All authors contributed to all sections of the manuscript and approved the final version. SK is responsible for the overall content as the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.