Trends and determinants of high-risk fertility in Ethiopia from 2011 to 2019 using spatial and decomposition analysis

Global maternal and neonatal health face considerable challenges due to high-risk fertility behavior, which includes pregnancies that occur early, late, or closely spaced. This behavior significantly increases the chances of negative outcomes for mothers and newborns. It is essential to comprehend the patterns and geographical variances in high-risk fertility behavior to guide public health interventions and policy choices that seek to enhance reproductive health results. This study used three consecutive Ethiopian Demographic and Health Survey (EDHS) datasets from 2011 to 2019. The analysis involved a weighted sample of 28,421 women of reproductive age, drawn from these three surveys. Trend analysis, logit-based multivariate decomposition, and spatial analysis were employed to examine the trends and determinants of high-risk fertility. Data management and statistical analyses were conducted using STATA version 17/MP, while ArcGIS version 10.6 and SaTScan version 10.1 software were utilized for spatial analysis. Throughout the study period, the prevalence of high-risk fertility behavior declined from 62.4% (95% CI: 61.5, 63.2) in 2011 to 60.0% (95% CI: 58.7, 61.3) in 2019, corresponding to an annual reduction rate of approximately 0.48%. Decomposition analysis showed that compositional changes in women's characteristics explained the majority (116%) of the observed decline, indicating that changes in behavior (coefficients) partially offset the potential reduction. Factors such as maternal education, marital status, place of residency, region, and family size had a statistically significant impact on these changes. The spatial distribution of high-risk fertility behavior varied across different regions of the country. SaTScan analysis identified significant hotspot areas of high-risk fertility in Somali, South East Oromia, and Southern Nations, Nationalities, and Peoples Region consistently across all years covered by the Ethiopian Demographic and Health Surveys (EDHS). The study findings suggest a gradual decline in high-risk fertility behavior over the study period, although some regions and demographic groups continue to face challenges. Implementing targeted interventions that specifically address the identified hotspot areas and factors contributing to high-risk fertility behavior is recommended. These interventions should prioritize education, place of residency, and family planning services to effectively address the issue.