Although rates of population increase are now much slower in the developed world than in the developing countries, the world’s population has been growing rapidly in recent decades. Much of this increase comes from high-fertility Africa countries. Sub-Saharan Africa and Asia particularly have population growth rates that are outpacing their economic growth [
Like many other Sub-Saharan African countries, fertility rate is profoundly higher in Ethiopia (4.8) as compared to the global figure (2.69) [
Birth interval, defined as the number of months between the birth of the child under study and the immediately preceding birth to the mother, has a critical effect on the population size and the health status of the mother and her child [
Beyond the health and survival implications of high levels of closely spaced and unintended births, high fertility rates accelerate population growth and undermining development efforts across all sectors. Closely spaced births have a potentially devastating impact on both the individual and the society. This pattern, combined with high levels of unplanned fertility, makes it difficult for women to become productive members of society, thereby limiting their contribution to economic development [
While it is difficult to pinpoint the exact reasons, it has been established that the undesirable consequences of shorter interbirth intervals on perinatal, infant, and child survival and maternal mortality have been mainly attributed to maternal nutritional depletion syndrome [
Sibling competition increases in the situation of shorter interbirth intervals. It is argued that when a newborn comes, it is likely that the family will invest more of its limited resources in the form of care to the newborn and the other children are more likely to suffer or merely receive inadequate share of the resources distributed among siblings [
On the other hand, optimal birth spacing yields the greatest health, social, and economic benefits for the family [
The Federal Ministry of Health (FMOH), reproductive health department, and health bureaus of respective regions have made concerted effort to reduce fertility. They have been applying multipronged approaches at local and national levels, fostering an enabling environment for family planning being at the heart of a variety of important strategies to address optimal birth spacing, and decreasing fertility [
Women in developing countries, however, still have shorter birth intervals than they would prefer [
In Ethiopia like many other Sub-Saharan African countries, fertility and maternal and child mortality are still high. Thus, acquiring research based knowledge of these problems is key step in undertaking appropriate intervention.
Therefore, the finding of this study would be helpful in reminding local and possibly nationwide policy makers of how fertility and birth spacing situation looks like in the study area and to design appropriate strategies for encouraging greater use of optimal birth spacing and thereby ensuring further declines in fertility and maternal and child mortality. It is also hoped that the result of this research will be an input for regional and district health care planners and program managers in designing site specific and scientifically sound interventions to address the gap in the utilization of family planning and optimal birth spacing.
In addition, the result will provide important information to local health care providers, community based health extension workers, civil organizations, and facility managers to design appropriate interventions suitable to their clients at facility and community level which can play an indispensable role in convincing mothers to optimize their birth interval in the district.
Finally, it is also expected to provide baseline information for further robust follow-up studies.
Birth spacing is an important maternal and child health intervention. Studies have confirmed that healthy pregnancy timing and spacing are important interventions to improve infant, child, and maternal health. Although every pregnancy carries a risk of maternal death or morbidity, some pregnancies are at higher risk than others [
Recommendations for birth spacing made by international organizations were based on information that was available several years ago. Previous evidences by the World Health Organization (WHO) and other international organizations recommended that waiting for at least 2-3 years between pregnancies can reduce infant and child mortality and promote maternal health [
According to the study done in Saudi Arabia, the mean duration of interbirth interval was reported to be 2.38 years [
Similar Study from Rufiji, Tanzania, showed that the median interbirth interval was found to be 33.4 months. The same study revealed that 48.4% of the respondents had a birth interval below the WHO recommended minimum duration of 36 months [
Community based cross-sectional study conducted in Urban Saudi Arabia showed that the median duration of birth interval was 33.5 months. In this study, about a quarter of women had mean birth interval of <2 years while 35.1% had waited between 2 and 3 years [
Similarly, study from Ethiopia indicated that the majority (57%) of women were practicing short birth interval length (<3 years) with the median birth interval of 33 months [
Evidences from different studies have stressed that the role of sociodemographic, economic, and birth history was significant in influencing interbirth intervals among child-bearing age mothers [
According to health facility based cross-sectional study done among multiparous women in Babol, Northern Iran, age of the mother was a major determinant of birth interval. It indicated that as age increases birth interval decreases. Among the study participants, half (50%) of the women aged <20 years old and 0.9% of women ≥35 years old had a birth interval of <2 years, while 42.9% of the mothers aged ≥35 years old had a birth interval of ≥6 years, which increased with increasing maternal age, while the birth interval of <2 years decreased with increasing maternal age (
Findings from African countries showed similar evidence. According to study done in Tanzania, maternal age was inversely related with nonadherence to the recommended minimum length between two live births. The proportion of interbirth intervals that were poorly spaced was highest (76%) among youngest (15–19) women and declined rapidly with increasing age to as low as 30% among the oldest (45–49) women (
In line with the above findings, report from Ethiopian DHS 2011 showed that young maternal age had significant association with birth interval. The median birth interval increases with age, ranging from 28.5 months for births to women aged 15–19 to 38.7 months for births to women aged 40–49 months [
Female education also is found to be a strong predictor of Birth intervals. Study done in Nepal indicated that level of education has shown strong statistical association with birth interval. Women with educational level of secondary stage and above were more likely to have longer birth intervals than those with elementary or no formal education [
Study done in southern Ethiopia showed that maternal education has protective effect for short birth interval in which women who had no formal education were 1.9 times more likely to have short birth interval practice as compared to those who had formal education (AOR 1.89, 95% CI (1.15, 3.37)) [
Regarding the occupation of respondents, study from Nepal, indicated that occupation of mothers found to be significant predictor of birth interval. Working mothers were more likely to have longer birth intervals than house wife mothers (
According to the study done in Nepal, occupations of husbands were significantly associated with birth intervals. Women whose husbands were engaged in agriculture had longer birth intervals as compared to those working in business and cottage industry [
It has also been found that the place where a woman resides influences the length of intervals between their births. Study in Nepal and Tanzania indicated that women residing in urban areas had longer birth intervals than their rural counterparts (
Economic status of respondents was also found to be a strong predictor of birth interval. Study done in Saudi Arabia indicated that shorter birth intervals were independently predicted by lower family income [
In contrast, study conducted in Lemo District, Ethiopia, showed that the median length of birth interval grew as one shift from lowest quartile to highest quartile of the wealth index (AOR = 0.49, 95% CI (0.25, 0.96)) [
With respect to place of delivery, study in Rufiji, Tanzania, showed that the interbirth intervals for which the index child was born elsewhere other than in a health facility were more likely to be less than the recommended minimum length compared with those for which the index child was born in a health facility (OR = 1.81, 95% CI (1.68–1.94)) [
The same study from Tanzania indicated that interbirth intervals corresponding to twins or multiple births of the index child were less likely to be shortly spaced compared with those corresponding to singleton birth of the index child (OR = 0.76, 95% CI (0.59–0.97)) [
According to study done in Manipur, the median birth interval of respondents was indicated to decrease with the increasing in the age at first marriage of women (
Study in Nepal also indicated that age when they have started sexual relationship with their spouses has statistically significant positive association with birth interval [
Study in Pakistan indicated that preceding birth interval has statistical association with current birth interval [
Study in Babol, Northern Iran, indicated that respondents with history of still births and child mortality showed statistically strong association with birth spacing [
Survival status of the preceding child was also found to be a major predictor of birth intervals. According to the study done in Pakistan, mothers whose previous child was dead were more likely to have short birth interval compared to those with surviving child [
Regarding pregnancy plan, study done in Denmark indicated respondents with planned pregnancy were more likely to have longer birth intervals than those who reported that their pregnancy occurred unintentionally [
Parity has also significant positive impact on the risk of having subsequent birth. Study in Manipur and Babol, Northern Iran, indicated that birth interval increases with increasing parity (
According to the study conducted in Iran among multiparous women, duration of breast-feeding was found to be an independent predictor of birth intervals. It showed that women who breast feed their child for longer than 24 months were more likely to have longer birth intervals than those who feed for less than 6 months (AOR = 0.01, 95% CI (0.004–0.046)) [
As opposed to the above, finding from Lemo District, Ethiopia, showed that duration of breast-feeding has inverse relationship with birth intervals. Women who breast feed for 7 to 12, 13 to 23, and 24 and above months were found to be significant predictors of short birth interval [
Contraceptive method utilization was also cited as one of the major determinants of length of birth intervals. Study done in Manipur indicated that women who used modern contraception were more likely to have longer birth intervals than those who never used any contraceptive method (
Regarding Knowledge of respondents, optimal birth spacing until the next pregnancy for Egyptian women is generally understood to refer to a 2-3 year period [
According to study done on Saudi Arabian women, 90.8% of the respondents had used one method for birth spacing, the most popular being oral contraceptive pills (65.1%) followed by the intrauterine device (24.5%) and breastfeeding (20.6%) [
About half of the women in this study lacked awareness about the known benefits of longer birth intervals and adequate child spacing. A significant proportion of the respondents were not aware that longer birth interval could lead to improvement in the child’s height (60.1%), weight (45.8%), intelligence (50.7%), and school performance (41.5%) as well as lowering the risk of infant and perinatal mortality and morbidity (47.3%). The majority (88.5%), however, perceived that long birth intervals would decrease the risk of maternal mortality and morbidity [
According to the study in Saudi Arabia in which women were asked about their ideal birth interval, 12 (2.8%) women stated that they had no preference, 22 (5.2%) preferred <2 years, 123 (28.2%) preferred 2 years, 159 (36.5%) preferred 3 years, and 120 (27.5%) preferred >3 years. Test for preferred and actual birth interval showed statistically significant relationship (
Different studies indicated that the majority of mothers had positive attitude towards birth spacing [
In summary, evidence from different literatures revealed that age of the mother, occupational status of the mother, educational status of the mother, place of residence, monthly income, husband’s educational status, husband’s occupational status, sex of the index child, survival status of the index child, parity, duration of breast-feeding, and modern contraception use were factors found to be independent predictors of interbirth intervals.
The general objective was to assess determinants of interbirth interval among child-bearing age women who have at least two consecutive live births in Arba Minch Zuria Woreda, SNNP, Ethiopia, 2014.
The specific objective was to identify determinants of interbirth intervals among child-bearing age women having at least two consecutive live births.
This study was conducted from January to July 2014 in Arba Minch Zuria District, demographic and health survey joint venture project (research) site. In this district, demographic and health survey project was launched by Ethiopian public health association and center for disease control of USA (EPHA and CDC) in collaboration with Arba Minch University in eight rural and one suburban villages having three climatic zones (highland, semihighland, and lowland). It has been an input for local, regional, and national health care planning, policy making, and research projects by generating dependable data related to birth, death, and migration events.
Arba Minch Zuria is one of the districts found in south nations, nationalities, and people’s regional state. It is located in the Great Rift Valley. The administrative town of this district, Arba Minch, is located about 502 Kms to south west of Addis Ababa, the capital city of Ethiopia. The district is situated 1285 meters above sea level. Gamo as ethnicity (69.53%) and Protestants (53.91%) as religion are the dominant ones. According to the report from central statistical agency, 2007, this district has a total population of 164,529, of which about 82,199 were men and 82,330 were women [
Community based unmatched case control study design supplemented by qualitative method was employed to assess determinants of interbirth interval among women of child-bearing age who had at least two consecutive live births in Arba Minch Zuria Woreda research site from February to April 2014.
Source population was all child-bearing age women found in Woreda who experienced at least two successive deliveries and the last delivery occurred within the past five years prior to the data collection.
Study population was randomly selected women of child-bearing age living in Woreda who have at least two consecutive births, the last delivery being within the past five years prior to the survey on which the actual study was to be conducted.
Inclusion criteria are as follows: For controls: women who gave live birth within the last 5 years and have at least two consecutive live births with birth interval of 3–5 years between the latest two successive live births inclusive. For cases: women who gave live birth within the last 5 years and have at least two consecutive live births with birth interval of less than 3 years between the latest two successive live births.
Exclusion criteria are as follows: Clients who were mentally ill and could not make logical judgment.
The sample size was determined by the formula used for unmatched case control study using Open EPI INFO version 3.5.1 software by taking account of the major determinant factors.
Accordingly, a minimum detectable OR (Odds Ratio) of 2, a 5% level of precision, a power of 90%, and a 2-to-one allocation ratio of optimum birth interval (controls) to short birth interval (cases) were assumed.
An additional nonresponse rate of 10% was also considered. The proportion of mothers who utilized modern contraception among controls was also considered to be 68.4% [
For the qualitative method, focus group discussions on purposely selected cases and controls as well as their husbands were conducted using open ended questions until information is saturated. In the study, sixteen FGDs were conducted involving a total of 128 participants (64 males and 64 females). Eight groups were from parents who had interbirth interval less than 3 years (four groups of husbands and four groups of mothers) and eight groups were from parents who had after birth an interval of three to five years (four groups from each of husbands and mothers).
Regarding the sampling procedure, first, all the nine rural kebeles found in Arba Minch Zuria District DHS research site were selected (Figure
Schematic presentation of sampling procedure for Quantitative study among child-bearing age group mothers in Arba Minch Zuria Woreda, SNNPs, Ethiopia, 2014.
Once the study kebeles were identified, parents (mothers and their husbands) living in the four kebeles and having different birth histories were selected purposely from the list of households found in each kebele. Individuals who were believed to be the most informative about the subject under study were selected. Being married, having not been involved in any previous survey, and being not related with each other were additional criteria used to select the study participants. To assist in finding and recruiting the discussants, community based health extension workers, development army leaders, and kebele administrators were consulted. Once the women were chosen, their husbands were also recruited to the study in order to gain a full understanding of the knowledge and perceptions of birth interval. Mothers and their husbands who were sick and incapable of making discussions at the time of the study were not included. Discussants were classified by sex, area of residence, and level of birth interval to capture heterogeneity among different subgroups and homogeneity within a group.
To determine children’s birth dates and their respective birth intervals, immunization cards were referred. For participants whose children were not immunized, community based health extension workers were consulted since they have full and up-to-date document of all vital statistics. Finally, child-bearing age women who gave birth with in the last five years and had at least two consecutive live births were invited to participate in the FGDs.
This study obtained data from the interviews of mothers residing in sampled households. Structured and pretested questionnaire was employed to obtain information on obstetric history, socioeconomic status, contraception use, breast-feeding practice, and attitude towards birth spacing and family planning. The questionnaire was adopted from different previously done studies and adapted to the local context of the study area [
Eight high school graduates who were familiar with the local language and customs were recruited as interviewers. Four B.S. degree holding health care workers supervised the data collection process. Data collectors and supervisors were trained for three days on census procedures, questions included in the questionnaire, interview techniques, and importance of privacy and confidentiality of the information obtained from the respondents. Before conducting the main study, pretest was carried out on 5% of the sample size (20 cases and 20 controls) from one kebele, which was not included in the main study. Based on the result, data collectors were reoriented and the questionnaire was modified as appropriate. Data collected from each respondent were checked for completeness, clarity, and consistency by the principal investigator and the supervisors at the end of each data collection day.
For the qualitative study, data were collected through focus group discussions (FGDs) with mothers and their husbands to explore their perceptions about interbirth intervals. Open ended semistructured and flexible questionnaire was used as a guide for the discussion process. Separate FGDs for men and women were held. The discussions were conducted in a quiet room according to the preference of discussants to enable them to speak more freely about their perceptions. Two moderators and one field assistant were recruited to collect the desired information. At the begging of the discussion, the moderator introduced all participants, explained the topic and purpose of the discussion, and made them aware that each and every opinion was important and wanted and that they should feel free to express it.
Husbands’ FGDs were moderated by the principal investigator. Since mothers could relatively openly express their ideas with females without being afraid and shy, FGDs for mothers were moderated by registered female B.S. degree holding nurse. Data were tape-recorded by a research assistant after thorough communication had been made with discussants. Each FGD lasted within 90–120 minutes. The number of FGDs was determined by the saturation of ideas. Discussion questions included perceived knowledge about short and optimal birth intervals, perceived disadvantages of short birth intervals, perceived advantages of optimal birth intervals, reasons for having short birth intervals, and decision-making about interbirth intervals.
Independent variables are as follows: Sociodemographic factors: occupational status of the mother, marital status of the mother, ethnicity, educational status of the mother, religion of the mother, husband’s educational status, and husband’s occupational status. Economic status: wealth index. Birth history: age at first marriage, age at last delivery, number of living children, sex of the preceding child, delivery place of the preceding child, survival status of the preceding child, pregnancy plan, multiple pregnancy, ANC visit during previous pregnancy, women’s decision-making power, and husbands belief regarding birth spacing. Breast-feeding practice, knowledge on birth interval, attitude towards birth spacing and family planning, and knowledge and practice of modern contraceptive methods.
Dependent variables are as follows: Short interbirth interval.
Some operational definitions are given as follows: Maternal death: deaths of women while pregnant or within 42 days after termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental cause [ Positive attitude: mothers were considered as having positive attitude towards optimal birth spacing and contraception if they scored above mean correct answers from attitude measuring questions. Negative attitude: mothers were considered as having negative attitude towards optimal birth spacing and contraception if they scored mean and below correct answers from attitude measuring questions. Short interbirth interval: it refers to less than 3 years’ birth interval between the birth of the child under study and the immediately preceding live and surviving birth to the mother [ Optimal birth interval: it denotes to 3–5 years’ birth interval (including 3 and 5 years) between the birth of the child under study and the immediately preceding live and surviving birth to the mother [ Permanent resident: mothers who have been living in Arba Minch Zuria Woreda for more than six months.
Data quality was ensured during collection, coding, entry, and analysis. During data collection, adequate training and follow-up were provided to all data collectors and supervisors. The principal investigator and supervisor conducted a day-to-day on-site supervision during the whole period of data collection.
At the end of each day, the questionnaires were reviewed and checked for completeness, accuracy, and consistency by the supervisor and investigator and corrective discussion was undertaken with all the research team members. Remarks were given during morning times on how to eliminate or minimize errors and take corrective actions timely. Codes were given to the questionnaires during the data collection so that any identified errors are traced back using the codes.
Data were first checked manually for completeness and then it was coded and entered into Epi-Info version 3.5.1 statistical software and cleaned thoroughly before being transferred to SPSS version 16 for further analysis. The data were further cleaned by visualizing and calculating frequencies and sorting in SPSS. Corrections were made according to the original data.
After appropriate coding, the data were entered using Epi Info version 3.5.3 and exported to SPSS version 20 software for analysis. Univariate analysis was computed for each independent variable to assess their individual proportion. Then, bivariate analysis was executed to examine crude association of predictors with short interbirth intervals. Finally, variables which had
For the qualitative data, all the audiotaped FGDs were transcribed verbatim after listening again and again. All observations made by the field assistant were recorded as field notes. Then, translation was made from Amharic (official and working language) to English. To assure the validity of the translation, another person, proficient in both languages, checked and commented on it. Both transcription and translation of FGDs were made by the investigators. When there was no consensus during translation, both the principal and the coinvestigators replayed the original recordings and compared them with the transcripts until agreement was reached. Finally, the principal investigator double-checked against the original recordings and the research team analyzed using content analysis.
Prior to coding, reading and rereading were done by the principal investigator. Summarizing of the word-for-word transcripts was carried out. The transcripts (questions and their respective responses) were prepared in Microsoft Word, saved in plain text, and entered to open code software (qualitative data analysis software). Once the transcript is entered, the investigators read the transcript again in order to become familiar with the responses. Then, the transcripts were coded according to the emergent categories. The principal investigator conducted the coding process. After completion of the coding process, themes were developed and classified. Contents were also supplemented with illustrations of direct quotes from the discussion. Then, final themes were compared among various groups’ discussants to know the differences and similarities according to their perspectives about factors influencing short birth intervals. The findings were finally presented in the form of narratives.
After approval, ethical clearance was obtained from Institutional Review Board (IRB) of College of Medicine and Health sciences, Arba Minch University. Then, official letter was written from College of Medicine and Health Sciences to Arba Minch Zuria District health office. Permission letters from district health office were processed before starting data collection. At the beginning of the data collection, informed consent was obtained from each respondent after thorough explanation of the purpose and the procedures of the study. For respondents whose age is less than 18 years old, informed consent was planned to be obtained from their parents/guardians. However, since minimum age of the respondents was 19 years, written informed consent was secured only from the respondents themselves. Mothers were also informed that all the data obtained from them would be kept confidential and anonymous. To ensure confidentiality, names of respondents were replaced by code numbers.
The findings of this study will be communicated to College of Medicine and Health Sciences, Arba Minch University, SNNP Health Bureau and Arba Minch Zuria Woreda Health Office. The findings will also be presented in various seminars/workshops and publication will be considered in scientifically reputable journals.
Six hundred thirty-six child-bearing age women who had at least two live births were interviewed making a response rate of 100%. The mean age of the respondents was 31 years (SD ±5.16). Eighty-one (38.1%) of the cases and 181 (42.7%) of the controls were within the age range of 25–29 years. The majority (107) (50.5%) of the cases and 226 (53.3) of the controls were married at the age of 18 years or less. Regarding educational status, one hundred sixty-nine (79.7%) of the cases and 203 (48.0%) controls had not attended formal education. The poorest wealth index was computed at 63 (29.7%) and 64 (15.1%) in the cases and controls, respectively (Table
Univariate and bivariate analysis of socioeconomic characteristics of child-bearing age mothers in Arba Minch Zuria District, Gamo Gofa Zone, Ethiopia, 2014.
Variables | Cases |
Controls |
Crude Odds Ratio (95% CI) |
|
---|---|---|---|---|
Age at last delivery | ||||
17–24 | 29 (13.7) | 76 (17.9) | 0.61 (0.38–1.09) | 0.095 |
25–29 | 81 (38.2) | 181 (42.7) | 0.71 (0.44–1.15) | 0.163 |
30–34 | 63 (29.7) | 105 (24.8) | 0.95 (0.57–1.60) | 0.855 |
≥35 | 39 (18.4) | 62 (14.6) | 1 | |
Age at first marriage | ||||
12–18 | 107 (50.5) | 226 (53.3) | 0.56 (0.24–1.10) | 0.173 |
19–24 | 94 (44.3) | 185 (43.6) | 0.60 (0.26–1.39) | 0.234 |
25–29 | 11 (5.2) | 13 (3.1) | 1 | |
Religion | ||||
Protestant | 150 (70.8) | 284 (67.0) | 0.88 (0.157–4.949) | 0.887 |
Orthodox | 60 (28.3) | 136 (32.1) | 1.06 (0.197–5.83) | 0.950 |
Others |
2 (0.9) | 4 (0.9) | 1 | |
Ethnicity | ||||
Gamo | 158 (74.5) | 363 (85.6) | 2.07 (0.69–6.18) | 0.193 |
Zeysie | 50 (23.6) | 42 (9.9) | 5.65 (1.78–17.92) | 0.003 |
Others |
4 (1.9) | 19 (4.5) | 1 | |
Marital status | ||||
Married | 204 (96.32) | 414 (97.6) | 0.61 (0.24–1.58) | 0.315 |
Single/widowed/divorced | 8 (3.8) | 10 (2.4) | 1 | |
Educational level of mothers | ||||
No formal education | 169 (79.7) | 203 (48) | 4.28 (2.91–6.29) | 0.000 |
Has formal education | 43 (20.3) | 221 (52) | 1 | |
Mothers’ occupation | ||||
Housewife | 195 (92.0) | 369 (87.0) | 1.81 (0.81–9.79) | 0.101 |
Merchant | 9 (4.2) | 22 (5.20) | 2.18 (0.51–9.36) | 0.294 |
Farmer | 5 (2.4) | 17 (4.00) | 1.57 (0.32–7.66) | 0.578 |
Others |
3 (1.4) | 16 (3.8) | 1 | |
Husbands’ educational level | ||||
No formal education | 132 (64.7) | 200 (48.3) | 2.01 (1.42–2.83) | 0.000 |
Has formal education | 72 (35.3) | 214 (51.7) | 1 | |
Husband’s occupation | ||||
Farmer | 171 (83.8) | 342 (82.6) | 0.77 (0.421–1.42) | 0.403 |
Daily laborer | 15 (7.4) | 43 (10.4) | 0.53 (0.233–1.22) | 0.134 |
Others |
18 (8.8) | 29 (7.0) | 1 | |
Wealth index | ||||
Poorest | 63 (29.70) | 64 (15.10) | 5.27 (2.92–9.51) | 0.000 |
Second | 48 (22.60) | 79 (18.60) | 3.25 (1.79–5.91) | 0.000 |
Middle | 41 (19.30) | 87 (20.50) | 2.52 (1.38–4.62) | 0.003 |
Fourth | 40 (18.90) | 87 (20.50) | 2.46 (1.34–4.51) | 0.004 |
Richest | 20 (9.40) | 107 (25.20) | 1 |
Among the above socioeconomic factors, ethnicity, educational status of both parents, and wealth index of the respondents showed crude statistical association with short interbirth interval. The odds of experiencing short interbirth interval were higher for mothers who were illiterate or unable to read and write as compared to those who attended formal education. Similarly, as wealth index of respondents decreased, the likelihood of having short interbirth interval was high (Table
Ninety-nine (46.7%) of the cases and 216 (50.9%) controls were reported to have three up to four live children. Five (2.3%) of the cases and 11 (2.6%) of the controls had still birth between the last two live births. Ninety-nine (46.7%) and 299 (70.5%) of cases and controls, respectively, had planned pregnancy. Twenty-two (10.4%) of the cases and 57 (13.4%) of the controls gave birth in health institution for their preceding child. The majority (178) (84.0%) of the cases breast fed for less than 24 months, while 383 (90.3%) of the controls breast-fed for 24 months or above. Sixty-six (31.1%) of the cases and 283 (66.7%) of the controls utilized modern contraceptive method after the delivery of the preceding child but before they got pregnant with the last child (Table
Univariate and bivariate analysis of obstetric, breast-feeding, and contraception history of child-bearing age mothers in Arba Minch Zuria District, Gamo Gofa Zone, Ethiopia, 2014.
Variables | Cases |
Controls |
Crude Odds Ratio (95% CI) |
|
---|---|---|---|---|
Number of living children | ||||
0–2 | 23 (10.8) | 48 (11.3) | 1 | |
3-4 | 99 (46.7) | 216 (50.9) | 0.957 (0.551–1.66) | 0.874 |
≥5 | 90 (42.5) | 160 (37.7) | 1.17 (0.670–2.055) | 0.575 |
Sex of the preceding child | ||||
Female | 149 (70.3) | 151 (35.6) | 4.27 (2.99–6.10) | 0.000 |
Male | 63 (29.7) | 273 (64.4) | 1 | |
Still birth before last child | ||||
No | 207 (97.6) | 413 (97.4) | 1.10 (0.378–3.215) | 0.858 |
Yes | 5 (2.4) | 11 (2.6) | 1 | |
Abortion before the last child | ||||
No | 206 (97.2) | 411 (96.9) | 1.09 (0.41–2.90) | 0.869 |
Yes | 6 (2.8) | 13 (3.1) | 1 | |
Status of the preceding child | ||||
Alive | 212 (100) | 420 (99) | 90.96 (0.000–5.1) | 0.504 |
Dead | 0 (0) | 4 (0.9) | 1 | |
Previous pregnancy plan | ||||
No | 113 (53.3) | 125 (29.5) | 2.73 (1.94–3.84) | 0.000 |
Yes | 99 (46.7) | 299 (70.5) | 1 | |
ANC in preceding pregnancy | ||||
No | 107 (50.5) | 103 (24.3) | 3.18 (2.24–4.50) | 0.000 |
Yes | 105 (49.5) | 331 (75.7) | 1 | |
Place of previous delivery | ||||
Health institution | 22 (10.4) | 57 (13.4) | 0.75 (0.442–1.26) | 0.270 |
Home | 190 (89.6) | 367 (86.6) | 1 | |
Contraceptive use before last pregnancy | ||||
No | 146 (68.9) | 141 (33.3) | 4.44 (3.12–6.33) | 0.000 |
Yes | 66 (31.1) | 283 (66.7) | 1 | |
Decision maker about F/P | ||||
Self (mother) | 49 (23.10) | 86 (20.30) | 1 | |
Both husband and wife | 143 (67.5) | 294 (69.30) | 0.798 (0.423–1.50) | 0.485 |
Husband only | 20 (9.40) | 44 (10.40) | 0.854 (0.57–1.28) | 0.442 |
Husband’s attitude towards optimal birth spacing | ||||
Negative | 17 (8.30) | 24 (5.80) | 1 | 0.178 |
Positive | 187 (91.7) | 390 (94.2) | 0.648 (0.342–1.22) | |
Mothers’ attitude towards optimal birth spacing and FP | ||||
Negative | 78 (36.80) | 158 (37.3) | 0.98 (0.696–1.379) | 0.908 |
Positive | 134 (63.2) | 266 (62.7) | 1 | |
Mother correctly defines optimal birth spacing | ||||
No | 55 (25.90) | 122 (28.8) | 0.87 (0.60–1.258) | 0.453 |
Yes | 157 (74.10) | 302 (71.2) | 1 | |
Duration of breast-feeding | ||||
0–11 months | 22 (10.40) | 4 (0.90) | 61.95 (20.18–190.18) | 0.000 |
12–23 months | 156 (73.6) | 37 (8.70) | 47.49 (28.76–78.42) | 0.000 |
≥24 months | 34 (16.00) | 383 (90.30) | 1 |
On bivariate analysis, sex of the preceding child, pregnancy plan for the last child, antenatal care follow-up during the preceding pregnancy, contraceptive utilization before getting pregnant for the last child, and duration of breast-feeding for the preceding child had showed significant statistical association with short birth interval. Female sex of the preceding child was positively associated with experiencing short birth interval. Similarly, the odds of experiencing short birth interval were about 3 times higher for mothers who did not have pregnancy plan for their last child than those who had a plan to get pregnant. The likelihood of having short birth interval was 3 times higher for mothers who did not attend ANC follow-up during the preceding pregnancy as compared to those who attended it. Mothers who did not use modern contraceptive method before getting pregnant with the last child were 4 times more likely to experience short birth interval as compared to those who used it. Duration of breast-feeding of the preceding child had also showed significant statistical association. The odds of having short birth interval were about 49 times higher for mothers who breast-fed their preceding child for less than 24 months as compared to their counterparts who breast-fed for 24 months or more (Table
To determine the factors independently affecting interbirth interval of the last two children born to the study participants, bivariate and multivariate analysis was carried out. In multivariable logistic regression analysis, educational status of the mother, contraceptive utilization, duration of breast-feeding, sex of the preceding child, age during delivery of the last child, and wealth index were found to be independent predictors of short birth interval (Table
Multivariate analysis of determinant factors among child-bearing age mothers in Arba Minch Zuria District, Gamo Gofa Zone, Ethiopia, 2014.
Variables | Crude Odds Ratio (95% CI) | Adjusted Odds Ratio (95% CI) |
|
---|---|---|---|
Educational status of respondents | |||
No formal education | 4.28 (2.91–6.29) |
|
|
Has formal education | 1 | 1 | |
Occupational status of respondents | |||
Housewife | 1.81 (0.81–9.79) | 1.00 (0.17–5.86) | 1.00 |
Merchant | 2.18 (0.51–9.36) | 1.46 (0.16–13.24) | 0.737 |
Farmer | 1.57 (0.32–7.66) | 2.68 (0.31–23.23) | 0.372 |
Others |
1 | 1 | |
Age at delivery of the last child | |||
17–24 | 0.61 (0.38–1.09) | 0.98 (0.36–2.66) | 0.965 |
25–29 | 0.71 (0.44–1.15) | 0.90 (0.40–2.00) | 0.789 |
30–34 | 0.95 (0.57–1.60) | 2.58 (1.08–6.15) | 0.032 |
≥35 | 1 | 1 | |
Contraceptive use before the last pregnancy | |||
No | 4.44 (3.12–6.33) |
|
|
Yes | 1 |
|
|
Sex of the preceding child | |||
Female | 4.27 (2.99–6.10) |
|
|
Male | 1 |
|
|
Breast-feeding duration of the preceding child | |||
<24 months | 48.9 (30.02–79.68) |
|
|
≥24 months | 1 |
|
|
Place of previous delivery | |||
Health institution | 0.75 (0.442–1.26) | 1.53 (0.61–3.80) | 0.364 |
Home | 1 | 1 | |
Wealth index | |||
Poorest | 5.27 (2.92–9.51) |
|
|
Second | 3.25 (1.79–5.91) | 6.46 (2.26–8.48) | 0.001 |
Middle | 2.52 (1.38–4.62) | 3.98 (1.39–11.38) | 0.010 |
Fourth | 2.46 (1.34–4.51) | 3.96 (1.41–11.13) | 0.009 |
Richest | 1 | 1 | |
Previous pregnancy plan | |||
No | 2.73 (1.94–3.84) | 1.44 (0.90–2.61) | 0.225 |
Yes | 1 | 1 |
Level of education showed strong statistical association with short interbirth interval. Mothers with no formal educational were about 3 times (AOR = 3.40, 95% CI: (
Similarly, mothers who breast-fed the preceding child for less than 24 months were more likely to have short interbirth interval than their counterparts of mothers who breast-fed for 24 months or more (AOR: 60.19, 95% CI (
In this study, sixteen focus group discussions involving a total of 128 participants (64 males and 64 females) were conducted. Eight groups were from parents who had interbirth interval less than 3 years (four groups of husbands and four groups of mothers) and eight groups were from parents who had interbirth interval of three to five years (four groups of husbands and four groups of mothers).
All discussants were health development army members. Short and optimal birth spacing participants ranged in age from 22 to 35 years and from 23 to 44 years, respectively. Educationally, the majority of the mothers and husbands did not attend formal education. Almost all of the women and men discussants were housewives and farmers, respectively. Their parity and interbirth intervals ranged from three to nine and one to five years, respectively. The contents of the discussion included perceived knowledge of women and men about short and optimal birth intervals, perceived disadvantages of short birth intervals, perceived advantages of optimal birth intervals, reasons for having short birth intervals, decision-making about interbirth intervals, and the effect of religion on decision-making about interbirth intervals.
Almost all mother and husband discussants defined birth spacing correctly. For all of them, birth spacing until the next delivery was understood as extending the period of time between the two consecutive births in the manner that could allow the mother to recover from pregnancy, labor, childbirth, and lactation, replace her nutritional stores, and provide time for the last child to self-feed and take independent care. The duration of time for short interbirth interval as defined by majority of the women and men discussants conformed to the world health organization recommendation. According to them, short birth interval refers to birth interval of less than three years. However, discussants were unable to differentiate between optimal and long birth intervals. The majority of the discussants who were experiencing short and optimal birth intervals realized that birth interval is said to be optimal when it is greater than three years.
Very few advantages were noted by some of the discussants. Some women and husbands who were experiencing short birth intervals reported that having closely spaced births was advantageous to early complete child birth before the woman gets weak: “
Understanding the determinants of short interbirth interval is critical for many Sub-Saharan African countries like Ethiopia, where perinatal mortality and fertility remain alarmingly high. Thus, this community based case control study identified factors influencing short interbirth interval among mothers who had at least two live births with their last child born within the last five years in Arba Minch Zuria District, Ethiopia.
Even though no statistical association was revealed, the majority of the respondents defined optimal birth spacing correctly. Similarly, almost all FGD male and female discussants, irrespective of their level of birth interval know the year limits for optimal birth spacing. However, discussants were unable to differentiate between optimal and long birth intervals.
In this study, the odds of having short interbirth interval were higher among mothers who had no formal education as compared to their women counterparts who attended formal education. This finding is consistent with evidences from study conducted in Saudi Arabia, Nepal, Jordan, and Pakistan [
Similarly, mothers who breast-fed the preceding child for less than 24 months were more likely to have short interbirth interval than their counter parts of mothers who breast-fed for 24 months and above. This study finding was congruent with evidences from Manipur, Iran, Jordan, Pakistan, Ahvaz (Iran), Egypt, and Nigeria [
Wealth index of the mother was also a strong predictor of short interbirth interval. Consistent with evidence from study done in Saudi Arabia [
Statistically significant association was also seen between short birth interval and age of the mother. In line with study from northern Iran, Tanzania, Saudi Arabia, Nepal, Denmark, Jordan, and Pakistan [
Although no statistical association was demonstrated, the majority of the study participants reported that short birth interval jeopardizes the health of the mother and the new born child. Similarly, irrespective of their level of birth spacing, the majority of the discussants from all categories underlined that short interbirth intervals are by no means important for the health of the mother, the new born baby, the father, the rest of the children at home, and the overall quality of life of the family:
When interpreting the finding of the present study, the following limitations should be considered. The source of data for this study was based on the self-report of mothers, and no validation of information was made with any objective sources such as health facility cards except for immunization cards of their children. But respondents were critically informed about the importance of giving accurate information by assuring the confidentiality of their responses and it is logical to assume that biases are less likely in birth interval related events as compared to other sensitive issues. Finally, there could be a recall bias since women were asked for information about events that occurred in the distant past though different life events were used to memorize them.
Optimal interbirth interval has significant role in reducing fertility and maternal and child mortality. However, birth interval of children varied with different biological and socioeconomic factors of their families. Educational status of the mother, contraceptive utilization, duration of breast-feeding, sex of the preceding child, age during delivery of the last child, and wealth index of respondents were independent predictors of short interbirth interval between the last two live births. Thus, the Ethiopian Ministry of Health together with its stakeholders should strengthen the existing strategies of providing information, education, and communication giving critical attention to women and their husbands to advance their awareness about the importance of modern contraceptive utilization, breast-feeding, and optimal birth spacing. Policy makers should also design new strategies to encourage women to pursue their education to at least primary school level. Moreover, this study considered only a single birth interval and therefore further researches, involving more than two interbirth intervals, should be done to make these findings more informative.
Antenatal care
Adjusted Odds Ratio
Central Statistics Agency
Ethiopian Demographic and Health Survey
Epidemiological information (statistical software)
Federal Ministry of Health
Millennium Development Goals
Maternal mortality ratio
Odds Ratio
Statistical Package for Social Sciences
Sub-Saharan African countries
Total fertility rate
United Nations Fund for Population Affairs
United Nations International Children’s Fund
World Health Organization.
The authors declare that they have no competing interests.
Desta Hailu and Teklemariam Gulte contributed equally to this work.
First and foremost, the authors would like to extend their deepest gratitude and appreciation to Arba Minch University, College of Medicine and Health Sciences, for financial assistance and for providing the authors with the opportunity to conduct this research project. The authors’ sincere thanks also go to all librarians of Arba Minch University for their valuable input in making all reference materials accessible, which have paramount importance for the development of this project proposal. The authors would also like to extend their gratitude to all study participants for their cooperation and commitment in responding to the authors’ interviews and to their data collectors and supervisors for their extensive devotion at fieldwork. Last but not least, the authors are grateful to Arba Minch University Demographic and Health Survey coordination office staff members, particularly Mr. Tayu Tatek, for their invaluable support in providing the necessary baseline information which was an input to our census work.