High-risk fertility behavior among women in Somalia: prevalence and associated factors from the 2020 demographic and health survey

Abstract Background High-risk fertility behavior (HRFB) relates to maternal age at birth, birth spacing, and parity, all of which correlate with health outcomes for mothers and children. In Somalia, where maternal and child mortality rates are among the highest globally, understanding these patterns is necessary for public health planning. This study assessed the prevalence of HRFB and identified associated socio-demographic factors among Somali women. Methods A secondary analysis was performed using data from the 2020 Somalia Demographic and Health Survey (SDHS). The final sample consisted of 19,012 women of reproductive age (15–49 years) who had at least one live birth in the five years preceding the survey. HRFB was defined by at least one of the following: maternal age at birth < 18 or > 34 years, a preceding birth interval < 24 months, or a birth order of four or higher. Analyses were conducted using Stata/SE version 19.5. Survey weights were applied to account for the SDHS complex sampling design, including clustering and stratification, and to generate nationally representative estimates. Multivariable Poisson regression with robust standard errors was used to estimate Adjusted Prevalence Ratios (APRs) and 95% Confidence Intervals (CIs). Results The overall weighted prevalence of HRFB was 73.3% (95% CI: 72.2%–74.4%). The most frequent risk components were short birth intervals (50.3%) and high birth order (38.9%). In the multivariable analysis, a higher prevalence of HRFB was associated with maternal age of 35 years or older (aPR = 1.23; 95% CI: 1.17–1.29), television use (aPR = 1.06; 95% CI: 1.02–1.10), and current contraceptive use (aPR = 1.05; 95% CI: 1.01–1.09). Women in nomadic residences (aPR = 0.94; 95% CI: 0.90–0.99) showed a lower prevalence of HRFB compared to those in urban areas. Significant regional differences were observed, with the highest prevalence of risk found in the Galgaduud, Togdheer, Hiraan, and Lower Juba regions. Conclusions HRFB is highly prevalent among women in Somalia, driven mainly by short birth intervals and high birth order. Maternal health programs should prioritize postpartum birth spacing and target older, high-parity women, particularly in high-burden regions, while leveraging the protective traditional practices found in nomadic communities.