Patterns and determinants of short and long birth intervals among women in selected sub-Saharan African countries

Medicine, Volume 99, No. 19, Year 2020

Interpretation

Optimal birth spacing (defined as a birth spacing of 24-59 months) is incontrovertibly linked to better health outcomes for both mothers and babies. Using the most recent available Demographic and Health Survey data, we examined the patterns and determinants of short and long birth intervals among women in selected sub-Saharan African (SSA) countries.Reproductive health and sociodemographic data of 98,934 women from 8 SSA countries were analyzed. Unadjusted and adjusted multinomial logistic regression models were used to examine the net relationship between all the independent variables and short and long birth intervals.Overall, the majority of women in all the countries optimally spaced births. However, a significant proportion of women had short birth intervals in Chad (30.2%) and the Democratic Republic of Congo (Congo DRC) (27.1%). Long birth spacing was more common in Eastern and Southern African countries, with Zimbabwe having the highest rate of long term birth interval (27.0%). Women who were aged 35 years and above in Uganda (RRR = 0.72, CI = 0.60-0.87), Tanzania (RRR = 0.62, CI = 0.49-0.77), Zimbabwe (RRR = 0.52, CI = 0.31-0.85), Nigeria (RRR = 0.82, CI = 0.72-0.94) and Togo (RRR = 0.67, CI = 0.46-0.96) had significantly lower odds of having short birth intervals compared to women aged 15-24 years. Older women (above 34 years) had increased odds for long birth intervals in all countries studied (Chad (RRR = 1.44, CI = 1.18-1.76), Congo DRC (RRR = 1.73, CI = 1.33-2.15), Malawi (RRR = 1.54, CI = 1.23-1.94) Zimbabwe (RRR = 1.95, CI = 1.26-3.02), Nigeria (RRR = 1.85 CI = 1.56-2.20), Togo (RRR = 2.12, CI = 1.46-3.07), Uganda (RRR = 1.48, CI = 1.15-1.91), Tanzania RRR = 2.12, CI = 1.53-2.93).The analysis suggested that the determinants of long and birth intervals differ and varies from country to country. The pattern of birth spacing found in this study appears to mirror the contraceptive use and fertility rate in the selected SSA countries. Birth intervals intervention addressing short birth intervals should target younger women in SSA, especially in Chad and Congo DRC, while intervention for long birth spacing should prioritize older, educated and wealthy women. The data for this present study was drawn from the Demographic and Health Survey (DHS) of eight purposively selected countries from the key regions of SSA. The choice was also informed by the availability of data in the past 5 years (from 2013–2018), geographical representation and variations in fertility and contraceptive prevalence rates. The child recode dataset of the following countries was used; Chad (2014–2015) and Congo DRC (2013–14) from the Central Africa region; Uganda (2016) and Tanzania (2015–16) from the East Africa region; Nigeria (2013) and Togo (2013–2014) from the West Africa region; and Malawi (2015–2016) and Zimbabwe (2015) from the Southern Africa region. To determine the proportion of women who had long, short and optimal birth spacing, only women who have had more than one birth are eligible. Women who had only one birth were dropped from the sample. The full analytic sample size has been presented in Supplementary Digital Content (Supplementary Digital Content, Table 1). The DHS program is a nationally representative, cross-sectional survey that is collected every 5 years in participating countries. The child recode, which was used for this study, has one record for every child born in the 5 years preceding the survey of interviewed women. It contains the information relating to the mother’s pregnancy, the child’s delivery, postnatal care and immunization, among others. The data for the mothers of each of these children are included. The dependent variable for this study is birth spacing. This has been described as the duration between a preceding birth and index birth measured as the number of months between the birth of the child being studied and the immediately preceding child birth of the mother.[1,3,5] The objective of this study is to estimate the proportion of women who had short, optimal, and long birth spacing in the selected countries. This could only be achieved by focusing only on closed birth intervals. Although the limitations of using closed birth intervals have been well documented in demographic research,[15,27,28] there is public health and clinical relevance of studying the prevalence of short and long birth spacing. Although the World Health Organization (WHO) and other international organizations have suggested a waiting period of at least 2 to 3 years between pregnancies to reduce infant and child mortality, and also to benefit maternal health, recent studies supported by the United States Agency for International Development[29] have encouraged longer birth spacing, of 3 to 5 years, as possibly being more advantageous.[30] The variable measuring the self-reported length of time in months between the most recent birth (index birth) and the previous birth is continuous. This variable was based on the WHO and USAID definition of optimal birth spacing into: < 24 months “short birth spacing”, 24 to 60 months “optimal birth spacing” and >60 months “long birth spacing”. Optimal birth spacing was used as the reference interval for all analyses, based on previous literature reporting this interval as the best. Based on the literature, we have included several covariates in our models that are likely to be associated with both short and long term birth intervals. The independent variables include age, sex of preceding child, survival of preceding birth, place of residence, marital status, educational level, employment status and wealth status, which is a proxy for household socioeconomic status captured through a wealth index based on household possessions and amenities. Detailed methodology on how the DHS constructs the wealth index has been discussed in the literature.[31] Age was defined as the age of the mother at the time of the index birth and was categorized as; “15 to 24”, “25 to 34” and “35+”. Due to the uncertainty associated with child survival in several countries in SSA, we controlled for sex and the survival of the preceding child. Educational attainment was classified as either no education, primary only, secondary and higher education. Employment status was categorized into women who were working and not working. The wealth quintile given in the DHS was regrouped into low (lowest and second quintiles), middle and high (fourth and highest quintiles) to examine the effect of socioeconomic status on the different birth intervals. Three levels of analysis were employed in this paper, that is, univariate analysis, bivariate descriptive, unadjusted and adjusted multinomial logistic modeling. The univariate analysis presented the median birth-spacing according to socio-demographic characteristics. In the bivariate analysis, the percentage distributions of birth spacing were presented according to the selected demographic characteristics. Unadjusted and adjusted multinomial logistic regressions were then employed to examine the independent and net relationship between all the independent variables and the outcome variable due to the nature of the outcome.[32] The multinomial logistic regression was used because the outcome variable had three categories: < 24 months “short birth spacing”, 24 to 60 months “optimal birth spacing” and >60 months “long birth spacing”. Optimal birth spacing was used as the reference interval for all analyses. A P value < .05 was considered statistically significant. We used asterisk to indicate certain level of P value in tables as follows: ∗P < .05; ∗∗P < .01; ∗∗∗P < .001. Sampling weights were applied to adjust for differences in the probability of selection and to adjust for non-response in order to produce the proper representation. Individual weights were used for descriptive statistics in this study, using Stata 14 for Windows. This study was exempted from ethical review by the committee because the study used deidentified publicly available datasets which are completely anonymous and do not contain any personal, confidential and identifying information or characteristics of the respondents. The study adhered to the ethical standards of the Helsinki Declaration by the World Medical Association. The DHS datasets can be downloaded online and are freely available for use by researchers upon request. In order to access the data from the website, a written request needed to be submitted to the measure DHS and permission was granted to use the data for this survey. Datasets are available from; https://dhsprogram.com/data/available-datasets.cfm.

AI Digest

Study Justification:

– Optimal birth spacing (24-59 months) is linked to better health outcomes for mothers and babies.
– This study examines the patterns and determinants of short and long birth intervals among women in selected sub-Saharan African countries.
– The findings can inform interventions to improve birth spacing and reproductive health in these countries.

Highlights:

– Majority of women in the selected countries have optimally spaced births.
– Chad and Congo DRC have a significant proportion of women with short birth intervals.
– Eastern and Southern African countries have higher rates of long birth spacing, with Zimbabwe having the highest rate.
– Older women have lower odds of short birth intervals and higher odds of long birth intervals in all countries studied.
– Determinants of birth intervals differ between countries.

Recommendations for Lay Reader:

– Interventions to address short birth intervals should target younger women, especially in Chad and Congo DRC.
– Interventions for long birth spacing should prioritize older, educated, and wealthy women.
– Improving access to contraception and reproductive health services can help improve birth spacing.

Recommendations for Policy Maker:

– Develop targeted interventions to address short birth intervals in Chad and Congo DRC, focusing on younger women.
– Implement programs to promote long birth spacing among older, educated, and wealthy women.
– Strengthen access to contraception and reproductive health services to support optimal birth spacing.
– Invest in education and awareness campaigns to promote the benefits of birth spacing.

Key Role Players:

– Ministry of Health
– National Family Planning Programs
– Non-governmental Organizations (NGOs)
– Community Health Workers
– Health Facilities and Clinics
– Educators and Schools

Cost Items for Planning Recommendations:

– Contraceptives and Family Planning Supplies
– Training and Capacity Building for Health Workers
– Awareness Campaigns and Education Materials
– Infrastructure and Equipment for Health Facilities
– Monitoring and Evaluation Systems
– Research and Data Collection
– Program Management and Coordination

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a large sample size of 98,934 women from 8 sub-Saharan African countries. The study uses recent data from the Demographic and Health Survey, which is a nationally representative survey. The study also employs multinomial logistic regression models to examine the relationship between independent variables and birth intervals. However, to improve the evidence, the abstract could provide more information on the specific methodology used, such as the variables included in the models and the statistical significance of the findings. Additionally, it would be helpful to include information on the limitations of the study and any potential biases in the data.

Abstract

The data for this present study was drawn from the Demographic and Health Survey (DHS) of eight purposively selected countries from the key regions of SSA. The choice was also informed by the availability of data in the past 5 years (from 2013–2018), geographical representation and variations in fertility and contraceptive prevalence rates. The child recode dataset of the following countries was used; Chad (2014–2015) and Congo DRC (2013–14) from the Central Africa region; Uganda (2016) and Tanzania (2015–16) from the East Africa region; Nigeria (2013) and Togo (2013–2014) from the West Africa region; and Malawi (2015–2016) and Zimbabwe (2015) from the Southern Africa region. To determine the proportion of women who had long, short and optimal birth spacing, only women who have had more than one birth are eligible. Women who had only one birth were dropped from the sample. The full analytic sample size has been presented in Supplementary Digital Content (Supplementary Digital Content, Table 1). The DHS program is a nationally representative, cross-sectional survey that is collected every 5 years in participating countries. The child recode, which was used for this study, has one record for every child born in the 5 years preceding the survey of interviewed women. It contains the information relating to the mother’s pregnancy, the child’s delivery, postnatal care and immunization, among others. The data for the mothers of each of these children are included. The dependent variable for this study is birth spacing. This has been described as the duration between a preceding birth and index birth measured as the number of months between the birth of the child being studied and the immediately preceding child birth of the mother.[1,3,5] The objective of this study is to estimate the proportion of women who had short, optimal, and long birth spacing in the selected countries. This could only be achieved by focusing only on closed birth intervals. Although the limitations of using closed birth intervals have been well documented in demographic research,[15,27,28] there is public health and clinical relevance of studying the prevalence of short and long birth spacing. Although the World Health Organization (WHO) and other international organizations have suggested a waiting period of at least 2 to 3 years between pregnancies to reduce infant and child mortality, and also to benefit maternal health, recent studies supported by the United States Agency for International Development[29] have encouraged longer birth spacing, of 3 to 5 years, as possibly being more advantageous.[30] The variable measuring the self-reported length of time in months between the most recent birth (index birth) and the previous birth is continuous. This variable was based on the WHO and USAID definition of optimal birth spacing into: 60 months “long birth spacing”. Optimal birth spacing was used as the reference interval for all analyses, based on previous literature reporting this interval as the best. Based on the literature, we have included several covariates in our models that are likely to be associated with both short and long term birth intervals. The independent variables include age, sex of preceding child, survival of preceding birth, place of residence, marital status, educational level, employment status and wealth status, which is a proxy for household socioeconomic status captured through a wealth index based on household possessions and amenities. Detailed methodology on how the DHS constructs the wealth index has been discussed in the literature.[31] Age was defined as the age of the mother at the time of the index birth and was categorized as; “15 to 24”, “25 to 34” and “35+”. Due to the uncertainty associated with child survival in several countries in SSA, we controlled for sex and the survival of the preceding child. Educational attainment was classified as either no education, primary only, secondary and higher education. Employment status was categorized into women who were working and not working. The wealth quintile given in the DHS was regrouped into low (lowest and second quintiles), middle and high (fourth and highest quintiles) to examine the effect of socioeconomic status on the different birth intervals. Three levels of analysis were employed in this paper, that is, univariate analysis, bivariate descriptive, unadjusted and adjusted multinomial logistic modeling. The univariate analysis presented the median birth-spacing according to socio-demographic characteristics. In the bivariate analysis, the percentage distributions of birth spacing were presented according to the selected demographic characteristics. Unadjusted and adjusted multinomial logistic regressions were then employed to examine the independent and net relationship between all the independent variables and the outcome variable due to the nature of the outcome.[32] The multinomial logistic regression was used because the outcome variable had three categories: 60 months “long birth spacing”. Optimal birth spacing was used as the reference interval for all analyses. A P value < .05 was considered statistically significant. We used asterisk to indicate certain level of P value in tables as follows: ∗P < .05; ∗∗P < .01; ∗∗∗P < .001. Sampling weights were applied to adjust for differences in the probability of selection and to adjust for non-response in order to produce the proper representation. Individual weights were used for descriptive statistics in this study, using Stata 14 for Windows. This study was exempted from ethical review by the committee because the study used deidentified publicly available datasets which are completely anonymous and do not contain any personal, confidential and identifying information or characteristics of the respondents. The study adhered to the ethical standards of the Helsinki Declaration by the World Medical Association. The DHS datasets can be downloaded online and are freely available for use by researchers upon request. In order to access the data from the website, a written request needed to be submitted to the measure DHS and permission was granted to use the data for this survey. Datasets are available from; https://dhsprogram.com/data/available-datasets.cfm.

Materials

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide information and reminders about optimal birth spacing, prenatal care, and postnatal care. These apps can also include features such as appointment scheduling, medication reminders, and access to telemedicine services.

2. Community Health Workers: Train and deploy community health workers to educate women and families about the importance of birth spacing and provide counseling on family planning methods. These workers can also conduct home visits to monitor the health of pregnant women and provide referrals to healthcare facilities.

3. Telemedicine Services: Establish telemedicine services to provide remote consultations and follow-up care for pregnant women in remote or underserved areas. This can help overcome geographical barriers and improve access to specialized maternal healthcare services.

4. Maternal Health Vouchers: Implement voucher programs that provide financial assistance to women for accessing maternal healthcare services, including prenatal care, delivery, and postnatal care. These vouchers can be distributed to women in need, particularly those with limited financial resources.

5. Public Awareness Campaigns: Launch public awareness campaigns to educate communities about the benefits of optimal birth spacing and the importance of maternal healthcare. These campaigns can use various media channels, such as radio, television, and social media, to reach a wide audience.

6. Strengthening Healthcare Infrastructure: Invest in improving healthcare infrastructure, particularly in rural and underserved areas, by establishing or upgrading maternal healthcare facilities. This includes ensuring the availability of skilled healthcare providers, essential medical equipment, and necessary medications.

7. Integration of Maternal Health Services: Integrate maternal health services with other healthcare programs, such as family planning, immunization, and nutrition services. This can improve the efficiency and effectiveness of service delivery and ensure comprehensive care for women throughout the reproductive cycle.

8. Empowering Women: Promote women’s empowerment and gender equality through initiatives that provide education and economic opportunities. Empowered women are more likely to make informed decisions about their reproductive health and have better access to maternal healthcare services.

It is important to note that the implementation of these innovations should be context-specific and tailored to the needs and resources of each country or region.

AI Innovations Description

Based on the description provided, the recommendation to improve access to maternal health based on the study’s findings is as follows:

1. Targeted interventions for short birth intervals: In countries like Chad and the Democratic Republic of Congo (Congo DRC), where a significant proportion of women have short birth intervals, it is important to prioritize interventions that address this issue. These interventions should specifically target younger women, aged 15-24 years, who are at higher risk of having short birth intervals. By providing education and access to family planning services, these interventions can help women space their pregnancies adequately, leading to better maternal and child health outcomes.

2. Interventions for long birth spacing: In Eastern and Southern African countries, such as Zimbabwe, where long birth spacing is more common, interventions should prioritize older, educated, and wealthy women. These interventions can focus on providing comprehensive reproductive health services, including family planning, to this specific group of women. By addressing barriers to accessing contraception and promoting the benefits of longer birth spacing, these interventions can help improve maternal health outcomes.

3. Tailored interventions based on country-specific determinants: The study highlights that the determinants of short and long birth intervals vary from country to country. Therefore, it is crucial to design interventions that take into account the specific context and determinants of each country. This can be achieved through further research and analysis to identify the key factors influencing birth spacing in each country. By understanding these determinants, interventions can be tailored to address the unique challenges and barriers faced by women in different countries.

4. Strengthening health systems: To effectively implement the recommended interventions, it is important to strengthen health systems in the selected sub-Saharan African countries. This includes improving access to quality reproductive health services, ensuring the availability of a range of contraceptive methods, training healthcare providers, and addressing infrastructure and resource gaps. By strengthening health systems, women will have better access to the services and support they need to make informed decisions about birth spacing and improve their maternal health.

Overall, the findings of this study provide valuable insights into the patterns and determinants of birth intervals in sub-Saharan African countries. By implementing the recommended interventions, policymakers and healthcare providers can work towards improving access to maternal health and ultimately reducing maternal and child mortality rates in these countries.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations for improving access to maternal health:

1. Increase awareness and education: Implement comprehensive education programs that focus on the importance of birth spacing and its impact on maternal and child health. This can include community outreach programs, workshops, and educational materials targeting women and their families.

2. Strengthen family planning services: Improve access to and availability of family planning services, including contraceptives, in the selected sub-Saharan African countries. This can involve training healthcare providers, expanding the range of contraceptive methods available, and ensuring consistent supply chains for contraceptives.

3. Address socio-economic barriers: Develop interventions that target socio-economic factors that may influence birth spacing, such as poverty, education, and employment. This can include initiatives to improve economic opportunities for women, provide financial support for family planning services, and promote girls’ education.

4. Enhance healthcare infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas, to ensure that women have access to quality maternal healthcare services. This can involve building or upgrading healthcare facilities, training healthcare workers, and providing necessary medical equipment and supplies.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators that can measure the impact of the recommendations, such as the proportion of women using contraceptives, the average birth spacing interval, and maternal and child health outcomes.

2. Collect baseline data: Gather data on the current status of maternal health, birth spacing, and access to healthcare services in the selected sub-Saharan African countries. This can be done through surveys, interviews, and analysis of existing data sources.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the defined indicators. This model should consider factors such as population demographics, healthcare infrastructure, and socio-economic conditions.

4. Input data and run simulations: Input the collected baseline data into the simulation model and run multiple simulations to estimate the potential impact of the recommendations. This can involve adjusting different variables and parameters to assess various scenarios.

5. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. This can include comparing different scenarios, identifying key drivers of change, and assessing the feasibility and effectiveness of the recommendations.

6. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from experts and stakeholders. This can help improve the accuracy and reliability of the simulations and ensure that the recommendations are evidence-based.

By following this methodology, policymakers and healthcare professionals can gain insights into the potential impact of different interventions and make informed decisions to improve access to maternal health in sub-Saharan African countries.

Authors & Co-Authors

Statistics:

Citations: 11

Authors: 2

Identifiers:

DOI: 10.1097/MD.0000000000020118

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Chad, Congo, Malawi, Multi-Countries, Nigeria, Tanzania, Togo, Uganda, Zimbabwe

Study Design:

Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Female