Shifts in age pattern, timing of childbearing and trend in fertility level across six regions of Nigeria: Nigeria Demographic and Health Surveys from 2003-2018

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Study Justification:
This study examines the shifts in the age pattern of fertility, timing of childbearing, and trend in fertility levels across six regions of Nigeria from 2003 to 2018. The justification for this study is based on the projected increase in Nigeria’s population from 200 million in 2019 to 450 million in 2050 if the fertility level remains at the current level. Understanding the changes in fertility patterns and trends is crucial for policymakers to develop effective strategies to manage population growth and plan for the future.
Highlights:
– Minimal decline in mean children ever born (CEB) between 2003 and 2018, except for the age group 20-24 years.
– Similar age patterns of fertility across the regions from 2003 to 2018.
– Marginal increase in the mean age at first birth from 21.3 in 2003 to 22.5 in 2018.
– Variation in mean age at first birth and mean CEB across the regions.
– Nigeria’s estimated total fertility level declined from 6.1 in 2003 to 5.7 in 2018.
Recommendations:
– Implement policies to constrict the spread of fertility distribution across the regions in Nigeria.
– Develop strategies to further reduce fertility levels, especially among younger age groups.
– Focus on increasing awareness and access to family planning services to enable individuals to make informed decisions about childbearing.
Key Role Players:
– Ministry of Health: Responsible for implementing policies and programs related to reproductive health and family planning.
– National Population Commission: Provides data and statistics on population trends and demographics.
– Non-Governmental Organizations (NGOs): Engage in advocacy, awareness campaigns, and service delivery related to reproductive health and family planning.
– Community Leaders: Play a crucial role in disseminating information and promoting family planning practices at the community level.
Cost Items for Planning Recommendations:
– Awareness Campaigns: Budget for media campaigns, community outreach programs, and educational materials.
– Family Planning Services: Allocate funds for the provision of contraceptives, training of healthcare providers, and establishment of family planning clinics.
– Research and Monitoring: Set aside resources for data collection, analysis, and monitoring of the impact of implemented policies and programs.
– Capacity Building: Invest in training programs for healthcare providers, policymakers, and community leaders to enhance their knowledge and skills in reproductive health and family planning.
Please note that the provided recommendations and key role players are based on the information provided in the study and may need to be further tailored and expanded upon by policymakers and stakeholders in Nigeria.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it is based on data from the Nigeria Demographic and Health Surveys conducted in 2003, 2008, 2013, and 2018. The study utilized a cross-sectional population-based design and a two-stage cluster sampling technique to select women aged 15-49 years. The changes in the timing of childbearing were examined, and the age pattern of fertility was analyzed using the Gompertz Relational Model. The findings provide insights into the shifts in age pattern, timing of childbearing, and trend in fertility levels across six regions of Nigeria. To improve the evidence, it would be helpful to provide more details on the sample sizes and response rates for each survey round, as well as any limitations or potential biases in the data collection process.

Background Nigeria’s population is projected to increase from 200 million in 2019 to 450 million in 2050 if the fertility level remains at the current level. Thus, we examined the shifts in the age pattern of fertility, timing of childbearing and trend in fertility levels from 2003 and 2018 across six regions of Nigeria. Method This study utilised the 2003, 2008, 2013, and 2018 Nigeria Demographic and Health Survey datasets. Each survey was a cross-sectional population-based design, and a two-stage cluster sampling technique was used to select women aged 15-49 years. The changes in the timing of childbearing were examined by calculating the corresponding mean ages at the birth of different birth orders for each birth order separately to adjust the Quantum effect for births. The Gompertz Relational Model was used to examine the age pattern of fertility and refined fertility level. Result In Nigeria, it was observed that there was a minimal decline in mean children ever born (CEB) between 2003 and 2018 across all maternal age groups except aged 20-24 years. The pattern of mean CEB by the age of mothers was the same across the Nigeria regions except in North West. Nigeria’s mean number of CEB to women aged 40-49 in 2003, 2008, 2013 and 2018 surveys was 6.7, 6.6, 6.3 and 6.1, respectively. The mean age (years) at first birth marginally increased from 21.3 in 2003 to 22.5 in 2018. In 2003, the mean age at first birth was highest in South East (24.3) and lowest in North East (19.4); while South West had the highest (24.4) and both North East and North West had the lowest (20.2) in 2018. Similar age patterns of fertility existed between 2003 and 2018 across the regions. Nigeria’s estimated total fertility level for 2003, 2008, 2013 and 2018 was 6.1, 6.1, 5.9 and 5.7, respectively. Conclusion The findings showed a reducing but slow fertility declines in Nigeria. The decline varied substantially across the regions. For a downward change in the level of fertility, policies that will constrict the spread of fertility distribution across the region in Nigeria must urgently be put in place.

Nigeria has the largest population in Africa and the 14th largest in landmass. According to the 2006 Population and Housing Census conducted in Nigeria, the country’s population was 140,431,790 [17, 18], but the 2019 projection is based on the 2006 census figure, as the base year was above 200 million [19]. The country comprises 36 states with a Federal Capital Territory and is structured into six geopolitical zones, which are North Central (NC), North East (NE), North West (NW), South East (SE), South-South (SS) and South West (SW). The study utilized data from the 2003, 2008, 2013 and 2018 Demographic and Health Surveys (NDHS). Each survey was a cross-sectional population-based design, and a two-stage cluster sampling technique was used to select women aged 15–49 years. The 2003 NDHS programme made use of the sampling frame designed for the 1991 population census, while the sampling frame designed for the 2006 population and housing census was used for 2008, 2013 and 2018 NDHS but with modification due to expansion in the number of households between the census period and the survey years defined in all the survey rounds, the primary sampling unit (PSU) was a cluster tagged as the Enumeration Areas (EAs) from the 1991 and 2006 EA census sampling frames. Samples for the 2003 and 2008 surveys were selected using a stratified two-stage cluster design consisting of 365 clusters in 2003 NDHS and 888 clusters in 2008 NDHS. While 2013 and 2018 NDHS were conducted at three and two stages, respectively. For 2013, 893 localities were selected at the first stage with probability proportional to the size and with an independent selection from each sampling stratum. In the second stage, one EA was randomly selected from most of the selected localities. In a few larger localities, more than one EA was selected. In total, 904 EAs were selected. After selecting the EAs and before the main survey, a household listing operation was carried out in all the selected EAs. For 2018 NDHS, at the first stage, 1400 EAs were selected; and a household listing which served as a sampling frame was conducted on the selected EAs. In the second stage, 30 households were selected from each cluster by an equal probability of systematic sampling. The number of households interviewed in 2003, 2008, 2013, and 2018 was 7864, 34070, 40680 and 42000, respectively. The number of women aged 15–49 years interviewed for these year periods used in the study is given as 7620, 33385, 38948, and 41821, respectively. A detailed description of the methodology of the data set used for this study may be found in NDHS main report [15]. The changes in the timing of childbearing were examined by calculating the corresponding mean ages at the birth of different birth orders of the study periods. The mean was calculated for each birth order separately to adjust the Quantum effect for births. The level of fertility is influenced by changes in the timing of childbearing (Tempo) and children ever born (Quantum) [12]. Where μ is the mean age of childbearing that measures the timing of childbearing; x(i) is the central age-point in the age interval, and I is the age group containing the upper age limit of the childbearing span; and f(i) denotes the fertility rate experienced by women in each age group. The shifts in the age pattern of fertility can be examined by looking at observed or model age-specific fertility rates. However, due to reporting errors and the truncation effect; observed age-specific fertility may be inappropriate to describe the age pattern of fertility [20]. Thus, in an attempt to describe the fertility age pattern, several mathematical models have been proposed. These models have been used successfully to fit the age-specific fertility rates in different populations. One of such model was a relational method between a standard fertility schedule and any other schedule proposed by Brass [20]. The model is based on the assumption that the cumulative age pattern of fertility follows a Gompertz distribution function. However, it was found later that this model has two major shortcomings: first, it involves using total fertility (TF), which may be biased. The second shortcoming is the assumption that fertility has been constant. Nevertheless, Zaba’s Ratio method of 1981, which this study used, was an improved variant of the model proposed by Brass [21]. Two sets of data were used in the study. These are the women’s data set (individual recode) and children’s data set (child recode). All the variables needed in both the women’s data set and children’s data set for the study were extracted using SPSS. The variables used to estimate the numerator of TFR, the month and year of the child’s birth, were extracted from the children’s data set with the ID variable and matched with the women’s data. The observed ASFRs as presented in Fig 2 was obtained through direct estimation as described by Moultrie et al. [21]. While the estimated ASFRs were attained indirectly by following the procedures known as the “Ratio method” developed by Moultrie et al. [21]. The Gompertz parameters derived through these procedures were used to describe the age pattern of fertility and refine observed ASFRs. In the method, the average parities, 5Px, of women in each age group (x, x+5) for x = 15, 20, ——- 45, were calculated. Then the fertility standard developed by Booth [20] was chosen to fit the model as follows: Where: The plots of z(x)–e(x) against g(x) and z(i)–e(i) against g(i) (on the same set of axes) that were almost on the same line was used to fit the model. The values of α (intercept) and β (slope) are the parameters. The level of fertility (TFR) was estimated indirectly by applying the above-derived parameters (α & β) to the current fertility gompits. The parameters α & β for the periods were compared; α indicates the location of fertility, and β shows the spread in relation to the standard. Sample weights were applied to each case to adjust for differences in the probability of selection. Weighting is important to increase the sample’s extent of representativeness and reduce the errors associated with sample selection bias. Since the authors of this manuscript did not collect the data, we sought permission from the MEASURE DHS website and access to the data was provided after our intent for the request was assessed and approved on the 10th of March 2021. The DHS surveys are ethically accepted by the ORC Macro Inc. Ethics Committee and the Ethics Boards of partner organizations in different countries, such as the Ministries of Health. The women who were interviewed gave either written or verbal consent during each of the surveys.

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

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based platforms that provide pregnant women and new mothers with important health information, reminders for prenatal and postnatal care appointments, and access to teleconsultations with healthcare providers.

2. Community Health Workers: Train and deploy community health workers to provide maternal health education, conduct regular check-ups, and facilitate referrals for pregnant women and new mothers in rural and underserved areas.

3. Telemedicine: Establish telemedicine services that allow pregnant women and new mothers to consult with healthcare professionals remotely, reducing the need for travel and improving access to specialized care.

4. Maternal Health Vouchers: Implement a voucher system that provides pregnant women with subsidized or free access to essential maternal health services, including antenatal care, skilled birth attendance, and postnatal care.

5. Maternal Waiting Homes: Establish maternal waiting homes near healthcare facilities to provide temporary accommodation for pregnant women who live far away, ensuring they have a safe and supportive environment to stay in before giving birth.

6. Transportation Support: Develop transportation initiatives, such as community-based transportation networks or partnerships with ride-sharing services, to help pregnant women and new mothers overcome transportation barriers and reach healthcare facilities for prenatal and postnatal care.

7. Maternal Health Education Campaigns: Launch targeted campaigns to raise awareness about the importance of maternal health, including family planning, antenatal care, and safe delivery practices, using various media channels and community engagement strategies.

8. Strengthening Health Infrastructure: Invest in improving healthcare infrastructure, including the construction and renovation of healthcare facilities, equipping them with necessary medical supplies and equipment, and ensuring the availability of skilled healthcare professionals.

9. Maternity Waiting Clinics: Establish maternity waiting clinics within healthcare facilities to provide pregnant women with a safe and comfortable place to stay during the final weeks of pregnancy, ensuring they have immediate access to skilled birth attendants.

10. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-profit organizations to leverage resources, expertise, and technology in order to improve access to maternal health services and address the unique challenges faced by pregnant women in Nigeria.

It is important to note that the implementation of these innovations should be context-specific and consider the local cultural, social, and economic factors in Nigeria.
AI Innovations Description
Based on the provided description, the recommendation to improve access to maternal health in Nigeria is to implement policies and interventions that address the slow decline in fertility rates and reduce the spread of fertility distribution across the regions. This can be achieved through the following strategies:

1. Family planning services: Increase access to and availability of family planning services, including contraceptives, to enable women to make informed decisions about the timing and spacing of their pregnancies.

2. Health education and awareness: Implement comprehensive health education programs that promote awareness about the benefits of maternal health services, including antenatal care, skilled birth attendance, and postnatal care.

3. Strengthen healthcare infrastructure: Improve the quality and accessibility of healthcare facilities, particularly in rural areas, by investing in infrastructure, equipment, and trained healthcare professionals.

4. Community engagement: Engage local communities, traditional leaders, and religious institutions to promote positive attitudes towards maternal health and encourage community support for pregnant women.

5. Maternal health subsidies: Provide financial incentives or subsidies for maternal health services, particularly for vulnerable populations, to reduce financial barriers and increase utilization of services.

6. Mobile health interventions: Utilize mobile health technologies to deliver maternal health information, reminders, and support to pregnant women, especially in remote areas where access to healthcare facilities is limited.

7. Strengthen data collection and monitoring: Improve the collection and analysis of maternal health data to identify gaps and monitor progress towards improving access to maternal health services.

By implementing these recommendations, Nigeria can work towards improving access to maternal health services, reducing maternal mortality rates, and ensuring the well-being of mothers and their children.
AI Innovations Methodology
Based on the provided description, here are some potential recommendations for improving access to maternal health in Nigeria:

1. Strengthening healthcare infrastructure: Investing in healthcare facilities, equipment, and personnel in both urban and rural areas can improve access to maternal health services. This includes ensuring the availability of skilled healthcare providers, well-equipped clinics and hospitals, and reliable transportation for pregnant women.

2. Increasing awareness and education: Implementing comprehensive maternal health education programs can help raise awareness about the importance of prenatal care, safe delivery practices, and postnatal care. This can be done through community outreach programs, media campaigns, and partnerships with local organizations.

3. Improving antenatal care services: Enhancing the quality and accessibility of antenatal care services can contribute to better maternal health outcomes. This includes providing regular check-ups, screenings, and counseling services to pregnant women, as well as promoting early detection and management of complications.

4. Strengthening emergency obstetric care: Ensuring that emergency obstetric care is readily available and accessible can significantly reduce maternal mortality rates. This involves equipping healthcare facilities with the necessary resources, such as skilled healthcare providers, emergency equipment, and blood transfusion services.

5. Promoting family planning services: Expanding access to family planning services can help women make informed decisions about their reproductive health and spacing of pregnancies. This can contribute to reducing unintended pregnancies, high-risk pregnancies, and maternal mortality.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators that measure access to maternal health, such as the number of antenatal care visits, percentage of skilled birth attendance, maternal mortality rate, and contraceptive prevalence rate.

2. Data collection: Collect relevant data on the selected indicators from various sources, including surveys, health records, and population data.

3. Baseline assessment: Analyze the collected data to establish a baseline for the current status of access to maternal health in different regions of Nigeria.

4. Model development: Develop a simulation model that incorporates the identified recommendations and their potential impact on the selected indicators. This could involve using statistical modeling techniques, such as regression analysis or mathematical modeling, to estimate the expected changes in the indicators based on the implementation of the recommendations.

5. Sensitivity analysis: Conduct sensitivity analysis to assess the robustness of the model and explore different scenarios and assumptions. This can help understand the potential variations in the impact of the recommendations under different conditions.

6. Projection and evaluation: Use the simulation model to project the potential impact of the recommendations over a specific time period. Evaluate the projected outcomes against the baseline to determine the effectiveness of the recommendations in improving access to maternal health.

7. Policy recommendations: Based on the simulation results, provide evidence-based policy recommendations to stakeholders, policymakers, and healthcare providers to guide decision-making and resource allocation for improving access to maternal health.

It is important to note that the methodology described above is a general framework and may require customization based on the specific context and available data in Nigeria.

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