INTRODUCTION
It is estimated that each year about 2 million deaths of children aged <5 years out of 11 million deaths can be avoided by preventing birth intervals less than 24 months1. A short birth interval is a problem in second and third world countries, where 17% of women in marriage and of reproductive age have unmet family planning needs2. More than one-third (36%) of inter-pregnancy pregnancies happen earlier than 24 months in Ghana, and women’s unmet family planning need before 23 months post-birth is 77%3.
Trends in the Ghana demographic and health survey (GDHS, 1993), indicate that nearly 40% of married women reported unmet family planning needs, and by 2014, the GDHS reported an unmet need of 30%. Indicating the transformation within the two decades has been slower than expected4.
The World Health Organization reports that the most appropriate birth spacing between the last birth and the subsequent pregnancy is 24 months, and the interval between the previous birth and the next birth is 33 months5. Sufficient birth spacing between the last birth and next pregnancy helps the woman recover well from the last birth, either short or long birth interval can cause adverse maternal effects, neonatal, and poor child health outcomes6. A pooled study reportedthatbirth problems such as preterm, low birth weight, and small for gestational age are related to short (<18 months) and long (>59 months) birth intervals6. In another pooled study, there was a significant relation between birth spacing less than 24 months and infant mortality7. Also, other similar studies have indicated a relationship between short birth spacing and schizophrenia in offspring8. In pregnancy, a study has equally indicated a significant relationship between shorter inter-pregnancy spacing and pregnancy problems such as premature membrane rupture, placenta abruption, uterine rupture, and placenta previa9. Also, preeclampsia is associated with long birth spacing10.
A published pooled study in 2012 suggested possible mechanisms for the adverse concerns of short birth spacing, and some of them are inadequate maternal nutritional status with folate depletion, poor optimization of lactation for newborn babies, insufficient cervix, infections, poor uterine healing after birth, sibling rivalry, and poor remodeling of the endometrial blood vessel. Short birth spacing can also limit the chances for women’s economic growth and their relations11,12.
Many studies have examined birth spacing effects for the mother and baby10-12. However, little is known about the socioeconomic determinants of short birth interval, especially in Ghana. Knowledge of the factors associated with short birth spacing is important to help address the problem in Ghana and other developing countries, hence this study aimed to identify socioeconomic factors that predict small birth spacing among married women in Ghana.
METHODS
This study was a secondary data analysis of the crosssectional Ghana Multiple Indicator Cluster Survey (MICS) 2017–2018. The Ghana Statistical Service conducted this survey from October 2017 to January 2018 in collaboration with the Ministry of Health, Ministry of Education, Ministry of Sanitation and Water Resources, Ministry of Gender, Children and Social Protection, Ghana Health Service, and the Ghana Education Service, as part of the Global MICS Program. Technical support was provided by the United Nations Children’s Fund (UNICEF), with government funding and financial support of UNICEF, KOICA, UNDP, USAID, and the World Bank through the Statistics for Results Facility – Catalytic Fund (SRF-CF).
The sampling frame assumed was from the Ghana 2010 Population and Housing Census (PHC). This encompassed all women (34595) aged 15–49 years with a history of childbirth who were permanent occupants of selected households or visitors who stayed in households chosen the night before the survey. Only women (24838) with two or more birth histories were further used for birth interval analysis.
Ethical considerations
The MICS team of UNICEF approved the protocol for using the Ghana Multiple Indicator Cluster Survey 2017–2018 dataset for this study. Institutions in charge of ordering, funding, or supervising the surveys were held accountable for ethical procedures. Each participant provided verbal agreement, and adolescents aged 15–17 years were interviewed individually after adult approval was obtained in advance from their parents or caregivers. All participants were informed that their participation was entirely optional and that their data would be kept confidential and anonymous. Respondents were also told that they could refuse to answer any or all of the questions, and that they could end the interview at any time.
Study variables
Dependent variables
The primary outcome variables of this study were small or short birth intervals and child survival. A short birth interval was considered when the gap between current and previous birth was less than two years. With child survival, children of last birth at the time of the survey were considered alive or dead for child survival.
Statistical analysis
Statistical analysis was accomplished using SPSS version 20 (IBM Corp., 2011, and NY). Categorical variables results are presented using frequencies and percentages. The birth interval was classified as a small interval when the time duration of the current birth date from the previous birth date was less than two years. The association between dependent and independent variables was done using chisquared tests. A binary logistic regression model was used to identify predictor variables of short birth intervals. Statistical significance was set at p<0.05.
RESULTS
Respondents’ socioeconomic factors
Most (69.8%) of the mothers were aged 20–34 years, and pre-primary or none was dominant (40.3%) in terms of the mother’s educational level. About 60.3% were from rural areas. Even though most (53.4%) of the respondents had health insurance, the majority (30.5%) were the poorest in terms of the wealth index quintile (Table 1).
Table 1
Demographic characteristics of the study participants, Ghana 2017–2018(N=34595)
Factors associated with birth interval
The prevalence of short birth intervals in the study was 49.7%. Chi-squared analysis revealed a significant relationship between birth interval and mother’s age, mother’s educational level, area of residence, region, and household ethnicity(Table 2). Other associated socioeconomic factors were the health insurance status of the mother, wealth index quintile, and childbirth order (p<0.001). However, the functional difficulties level of the mother was not significantly associated with birth interval (p>0.541) (age 18–49 years) (Table 3).
Table 2
Chi-squared analysis of the relationship between participants’ demographic characteristics and birth interval, Ghana 2017–2018 (N=24838)
Table 3
Chi-squared analysis of the relationship between other studied factors and birth interval, Ghana 2017–2018(N=24838)
Predictors of short birth interval
Factors with significant relationships with the birth interval at the two variable analysis stage were further modelled in the binary logistic regression model to identify the predictors of short birth interval. Maternal age >20 years protected against short birth interval, 20–34 years (AOR=0.27; 95% CI:0.24– 0.31), ≥35years (AOR=0.10; 95% CI:0.85–0.133), another protective predictor variable was maternal educational level, JSS/JHS/Middle educational level was protective against short birth interval (AOR=0.88; 95% CI: 0.82–0.95), but higher maternal education associated with short birth interval (AOR=1.52; 95% CI: 1.24–1.86). Those in rural areas were more likely to report a short birth interval than those in urban areas (AOR=1.13; 95% CI: 1.05–1.21) (Table 4).
Table 4
Binary logistic regression for predictors’ short birth interval, Ghana 2017–2018 (N=24838)
When it comes to regional prediction, using the Western region as the reference, those from the Central region were 14% more likely to report a short birth interval (AOR=1.14; 95% CI: 1.01–1.29), but those in Upper East Region of the north less likely (AOR=0.64; 95% CI: 0.55–0.75). Also, comparing Akan to other ethnic groups, women of Mole Dagbani were 18% more likely to report small birth spacing (AOR=1.18; 95% CI: 1.02–1.38). Grusi women were 21% less likely to engage in short birth interval (AOR=0.79; 95% CI: 0.71–0.88). Women of the Mende tribe were also 15% less to engage in short birth interval (AOR=0.85; 95% CI: 0.73– 0.99). Mothers without health insurance were 10% more likely to engage in short birth interval compared to those with insurance (AOR=1.10; 95% CI: 1.05–1.16). Increased in wealth status predicted short birth interval among women using poorest wealth status as reference; second (AOR=0.87; 95% CI: 0.80–0.94), third (AOR=0.78; 95%, CI: 0.72–0.85), fourth (AOR=0.76; 95% CI: 0.69–0.84) and richest (AOR=0.67; 95% CI: 0.60–0.76). Finally, birth order of a child, using order of 2–3 as the reference: those with a childbirth order of 4 and above were more likely to report short birth interval, 4–6 (AOR=1.3; 95% CI: 1.22–1.37) and ≥7 (AOR=2.40; 95% CI: 2.14–2.68). The logistic regression model appropriately explained the outcome variable (short birth interval) since the Hosmer-Lemeshow goodness-of-fit test p-value was >0.05[χ2(8)=13.610, p=0.093], hence the model fits the study data (Table 4).
DISCUSSION
More than one-third (36%) of inter-pregnancy pregnancies happen earlier than 24 months in Ghana, and women’s unmet family planning need for 23 months post-birth was 77%3. The prevalence of short birth intervals is higher (49.7%) in this current study than the previously reported prevalence of 36%. Meanwhile, another study in Ghana reported a short birth interval prevalence to be 80.0%13.
In terms of child survival, the analysis further revealed that child survival is 44% less likely in children with a short birth interval. In addition, a similar study in Bangladesh, short birth interval predicted poor baby survival14. In another pooled research, there was a significant relation between birth spacing less than 24 months and infant mortality7. The clinical significance of this finding is that reducing short birth intervals can help reduce infant mortality in Ghana.
The main aim of this study was to identify maternal socioeconomic factors as predictors of short birth intervals in Ghana. Factors with significant relationships with a birth interval at the two variable analysis stage were further modelled with binary logistic regression model in multiple variables analysis to identify predictors of short birth interval.
Higher maternal age was identified as a lower risk for short birth intervals. Mothers of age 20–34 years were 73% less likely to have babies with the short birth interval than those aged <20 years, and those aged >34 years were 90% less likely to have babies with the short birth interval compared to those aged <20 years. This study finding is not consistent with the results of Ngianga-Bakwin and Stones15. However, this was consistent with other similar studies16,17.
In addition, the birth order of a child predicted short birth intervals. Children in birth order 4 were more likely to experience short birth interval compared to those in birth order 2–3, and this is not in line with an earlier study in which increased parity position of a child protected against short birth interval14,16. However, in another African study, the expanded parity position of a child predicted a short birth interval18. A study reported that women of a younger age at first marriage were less likely to engage in small birth spacing for their first birth interval19.
Another protector variable was mother educational level; a mother with JSS/JHS/Middle educational level was 22% less likely to engage in the short birth interval compared to those with pre-primary or no education, and this study finding is not different when compared with other similar studies in Africa12,15,16. However, those with higher educational level were 52% more likely to engage in the short birth interval when compared with those with preprimary education or none. This is in line with a previous study that reported increased education status as protection against short birth intervals12,15,16.
A study in Uganda reported a short birth interval prevalence of 52.4% among rural women20. In this current study, rural women were more likely to engage in a short birth interval when compared to urban women. Also, a study in Sub-Saharan Africa by Ngianga-Bakwin and Stones15 reported that urban women were less likely to engage in the short birth interval than those in rural areas. Also, in terms of regional prediction, those from the Central region in southern Ghana were more likely to engage in the short birth interval compared to those from the Western region in south Ghana. Those in the Upper East region of northern Ghana were less likely to engage in the short birth interval than those from the Western region in southern Ghana.
Furthermore, ethnicity had a significant relation with birth interval. Women of the Mole Dagbani ethnic group were 18% more likely to engage in the short birth interval than women of the Akan ethnic group. Women of the Grusi ethnic group were 20% less likely to engage in the short birth interval than those of the Akan ethnic group, and people of the Mande tribe were less likely to engage in small birth spacing. In Ghana, the ethnic variation of the birth interval is associated with sexual taboos. For instance, some ethnic groups have a shorter delay in returning to sex after birth, while some have a long wait in resuming sexual intercourse21.
Finally, concerning economic factors, increased wealth status was a protector of the short birth interval among women. Women of second, middle, fourth, and most affluent of the wealth index quintile were less likely to engage in the short birth interval than women of the poorest quintile. The trend of analysis indicates that improvement in women’s wealth index quintile leads to a decreased chance of short birth interval, and this is the same for other earlier studies in Africa12,15. Furthermore, the study revealed that women without health insurance coverage were more likely to engage in small birth spacing than women with health insurance coverage.
Limitations
This study was not without limitations; not all variables including religion, contraceptive use, duration of breastfeeding, were assessed, which, if explored, will help to shed more light on the research question. In addition, misclassification of inter-birth interval could have resulted from preterm births. Finally, recall of information can result in recall bias.
CONCLUSIONS
The prevalence of short birth intervals recorded by this study was high, and the sociodemographic factors that predicted short birth intervals included: increasing maternal age, high education level, rural residence, living in the Central region, not having health insurance, poorest wealth index, and high parity position. Finally, survival was lower for those with a small birth interval.
