Intimate partner violence and its associated factors among reproductive-age women in East Africa:-A generalized mixed effect robust poisson regression model.

BACKGROUND: The World Health Organization (WHO) has published estimates revealing that around one out of every three women across the globe has been a victim of either physical and/or sexual violence from an intimate partner or non-partner throughout their lifetime. The available evidence on intimate partner violence in East Africa is limited Consequently, the objective of this study was to evaluate the occurrence and factors linked to intimate partner violence in East Africa. METHODS: The study utilized the most recent data from the Demographic and Health Surveys (DHS) conducted between 2011 and 2018/19 in 11 countries in Eastern Africa. A total of 59,000 women were included in the study. Descriptive and inferential statistics were used to exmine factors associated with IPV. A mixed effect robust Poisson regression model was fitted to identify factors associated with intimate partner violence. The adjusted prevalence ratio (aPR) and its corresponding 95% confidence interval (CI) were employed to determine the presence of a significant association between intimate partner violence and the independent variables. RESULTS: In this study, the prevalence of intimate partner violence in East Africa was 43.72% with 95% CI 43.32% to 44.12%. In the mixed effect robust Poisson regression model:-Marital status, working status, parity, sex of household headed, wealth index, community poverty, and residence, were significantly associated with intimate partner violence. CONCLUSION: The prevalence of intimate partner violence in East Africa is high as compared to the global prevalence 30%, which hinders The Sustainable Development Goals (SDGs), specifically goal 5, aim to attain gender equality and empower women and girls worldwide by the year 2030 Women being previously married and cohabitated, working, having a high number of children, rural residents were positively associated with IPV and household and community wealth index and sex of household headed were negatively related with IPV in East Africa. Therefore, we recommend establishing effective health and legal response using an integrated policy approach and Special attention should be given to women who live rural and poorest to reduce IPV and to achieve Sustainable Development Goals (SDGs) goal 5.

Socioeconomic inequality in barriers for accessing health care among married reproductive aged women in sub-Saharan African countries: a decomposition analysis.

BACKGROUND: Accessibility of health care is an essential for promoting healthy life, preventing diseases and deaths, and enhancing health equity for all. Barriers in accessing health care among reproductive-age women creates the first and the third delay for maternal mortality and leads to the occurrence of preventable complications related to pregnancy and childbirth. Studies revealed that barriers for accessing health care are concentrated among individuals with poor socioeconomic status which creates health inequality despite many international organizations top priority is enhancing universal health coverage. Therefore, this study aimed to assess the presence of socioeconomic inequality in barriers for accessing health care and its contributors in Sub-Saharan African countries. METHODS: The most recent DHS data of 33 sub-Saharan African countries from 2010 to 2020 were used. A total sample of 278,501 married reproductive aged were included in the study. Erreygers normalized concentration index (ECI) and its concentration curve were used while assessing the socioeconomic-related inequality in barriers for accessing health care. A decomposition analysis was performed to identify factors contributing for the socioeconomic-related inequality. RESULTS: The weighted Erreygers normalized Concentration Index (ECI) for barriers in accessing health care was - 0.289 with Standard error = 0.005 (P value < 0.0001); indicating that barriers in accessing health care was disproportionately concentrated among the poor. The decomposition analysis revealed that wealth index (42.58%), place of residency (36.42%), husband educational level (5.98%), women educational level (6.34%), and mass media exposure (3.07%) were the major contributors for the pro-poor socioeconomic inequalities in barriers for accessing health care. CONCLUSION: In this study, there is a pro-poor inequality in barriers for accessing health care. There is a need to intensify programs that improve wealth status, education level of the population, and mass media coverage to tackle the barriers for accessing health care among the poor.

Individual and community-level determinants of knowledge of ovulatory cycle among women of childbearing age in Ethiopia: A multilevel analysis based on 2016 Ethiopian Demographic and Health Survey.

BACKGROUND: Knowledge of the ovulatory cycle (KOC) aids women to refrain and engage in sexual intercourse to avoid and to get pregnancy, respectively. The effect of community-level factors on KOC was not yet known in Ethiopia. Therefore, we aimed to investigate the community- and individual-level determinants of KOC among women of childbearing age. METHODS: We used the 2016 Ethiopian Demographic and Health Survey, and total weighted samples of 15,683 women were included. Intra-class correlation, median odds ratio, and deviance were executed for model comparison in which a model with the lowest deviance was the best model i.e. model III in this case. A multivariable multilevel logistic regression model was employed to identify community- and individual-level factors of correct KOC. In the ultimate model, an adjusted odds ratio (AOR) with a 95% confidence interval was reported and variables with a p<0.05 were considered as statistically significant. RESULTS: In this study, 3,698 [23.58% (95% CI; 22.92-24.25)] participants had correct KOC. Women's age in years, i.e. 20-24 (AOR = 1.46;1.28-1.68) 25-29 (AOR = 1.72; 1.49-1.99), 30-34 (AOR = 2.21; 1.89-2.58), 35-39 (AOR = 1.78; 1.51-2.09), 40-44 (AOR = 1.97; 1.65-2.37), and 45-49 (AOR = 1.78; 1.44-2.19), knowledge of contraceptive methods (AOR = 3.08; 2.07-4.58), increased women's educational level, i.e. higher (AOR = 4.24; 3.54-5.07), secondary (AOR = 2.89; 2.48-3.36), and primary (AOR = 1.57; 1.39-1.78), higher household's wealth index, i.e. richest (AOR = 1.71; 1.35-2.16), richer (AOR = 1.42; 1.16-1.72), middle (AOR = 1.29; 1.07-1.56), and poorer (AOR = 1.24; 1.03-1.48), current contraceptive use (AOR = 1.26; 1.13-1.39), menstruating in the last six weeks (AOR = 1.13; 1.03-1.24), women's media exposure (AOR = 1.20; 1.07-1.35), and being in the community with a high level of media exposure (AOR = 1.53; 1.24-1.88) were statistically significant with KOC. CONCLUSIONS: Knowledge of the ovulatory cycle was low in this study, which demands health education for women of childbearing age. Special attention should be given to teenagers, those with lower educational, and lower economic status. Besides, the strengthening of media campaigns could increase women's KOC, which is crucial for preventing unintended pregnancy.

Individual and community level factors associated with use of iodized salt in sub-Saharan Africa: A multilevel analysis of demographic health surveys.

INTRODUCTION: Iodine deficiency disorder a common problem in sub-Saharan Africa (SSA). It affects not only the health of the affected individual but also the economic development of the country. However, to the best of our knowledge, there is a scarcity in literature about the associated factors of iodized salt utilization in sub-Saharan Africa. Therefore, this study aimed to identify both individual and community level determinants of iodized salt utilization in sub-Saharan Africa. METHODS: This study used the appended datasets of the most recent demographic and health survey from 31 sub-Saharan countries. A total weighted sample of 391,463 households was included in the study. Both bivariable and multivariable multilevel logistic regression were done to determine the associated factors of iodized salt utilization in SSA. P value ≤ 0.05 was used to declare statistically significant variables. RESULTS: Those households with primary (AOR = 1.53, 95% CI = 1.50-1.57), secondary (AOR = 1.81, 95% CI = 1.76-1.86) and higher education level (AOR = 2.28, 95% CI = 2.17-2.40) had higher odds of iodized salt utilization. Households with middle (AOR = 1.05, 95% CI = 1.02-1.08), richer (AOR = 1.13, 95% CI = 1.09-1.17) and richest wealth index (AOR = 1.23, 95% CI = 1.18-1.28) also had an increased chance of using iodized salt. Households from high community media exposure (AOR = 2.07, 95% CI = 1.71-2.51), high community education level (AOR = 3.78, 95% CI = 3.14-4.56), and low community poverty level (AOR = 1.29, CI = 1.07-1.56) had higher odds of using salt containing iodine. CONCLUSION: Both individual and community level factors were found to be associated with use of salt containing iodine in sub-Saharan Africa. Education level, media exposure, community poverty level, wealth index, community education, and community media exposure were found to be associated with use of salt containing iodine in SSA. Therefore, to improve the use of iodized salt in the region, there is a need to increase access to media sources and develop the socioeconomic status of the community.

Trends of infant mortality and its determinants in Ethiopia: mixed-effect binary logistic regression and multivariate decomposition analysis.

BACKGROUND: Infant mortality remains a serious global public health problem. The global infant mortality rate has decreased significantly over time, but the rate of decline in most African countries, including Ethiopia, is far below the rate expected to meet the SDG targets. Therefore, this study aimed to investigate the trends of infant mortality and its determinants in Ethiopia based on the four consecutive Ethiopian Demographic and Health Surveys (EDHSs). METHODS: This analysis was based on the data from four EDHSs (EDHS 2000, 2005, 2011, and 2016). A total weighted sample of 46,317 live births was included for the final analysis. The logit-based multivariate decomposition analysis was used to identify significantly contributing factors for the decrease in infant mortality in Ethiopia over the last 16 years. To identify determinants, a mixed-effect logistic regression model was fitted. The Intra-class Correlation Coefficient (ICC) and Likelihood Ratio (LR) test were used to assess the presence of a significant clustering effect. Deviance, Akaike Information Criteria (AIC), and Bayesian Information Criteria (BIC) were used for model comparison. Variables with a p-value of less than 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to identify the statistically significant determinants of infant mortality. RESULTS: Infant mortality rate has decreased from 96.9 per 1000 births in 2000 to 48 per 1000 births in 2016, with an annual rate of reduction of 4.2%. According to the logit based multivariate decomposition analysis, about 18.1% of the overall decrease in infant mortality was due to the difference in composition of the respondents with respect to residence, maternal age, type of birth, and parity across the surveys, while the remaining 81.9% was due to the difference in the effect of residence, parity, type of birth and parity across the surveys. In the mixed-effect binary logistic regression analysis; preceding interval <  24 months (AOR = 1.79, 95% CI; 1.46, 2.19), small size at birth (AOR = 1.55, 95% CI; 1.25, 1.92), large size at birth (AOR = 1.26, 95% CI; 1.01, 1.57), BMI <  18.5 kg/m2 (AOR = 1.22, 95% CI; 1.05, 1.50), and twins (AOR = 4.25, 95% CI; 3.01, 6.01), parity> 6 (1.51, 95% CI; 1.01, 2.26), maternal age and male sex (AOR = 1.50, 95% CI: 1.25, 1.79) were significantly associated with increased odds of infant mortality. CONCLUSION: This study found that the infant mortality rate has declined over time in Ethiopia since 2000. Preceding birth interval, child-size at birth, BMI, type of birth, parity, maternal age, and sex of child were significant predictors of infant mortality. Public health programs aimed at rural communities, and multiparous mothers through enhancing health facility delivery would help maintain Ethiopia's declining infant mortality rate. Furthermore, improving the use of ANC services and maternal nutrition is crucial to reducing infant mortality and achieving the SDG targets in Ethiopia.

Prevalence and determinants of anemia among pregnant women in East Africa; A multi-level analysis of recent Demographic and Health Surveys.

INTRODUCTION: Anemia during pregnancy is a public health problem that leads to different life-threatening complications and poor pregnancy outcomes. So far, the evidence is scarce on pooled prevalence and determinants of anemia during pregnancy in East Africa for integrated intervention. Therefore, this study aimed to assess the prevalence and determinants of anemia among pregnant women in eastern Africa using recent Demographic and Health Surveys. METHOD: Secondary data analysis was conducted using data from recent Demographic and Health Survey datasets from 10 East African countries. A total of 8583 (weighted sample) pregnant women were included in the analysis. The multi-level mixed-effects generalized linear model (Poisson regression with robust error variance) was fitted to identify determinants of anemia. Finally, the adjusted prevalence ratio (aPR) with 95% CI and random effects for the multilevel generalized linear mixed-effects model was reported. RESULTS: In this study, the overall prevalence of anemia among pregnant women was 41.82% (95% CI: 40.78, 42.87) with a large difference between specific countries which ranged from 23.36% in Rwanda to 57.10% in Tanzania. In the multi-level analysis, teenage pregnant women (aPR = 1.22;95%CI:1.02, 1.40), unmarried women (aPR = 1.14; 95% CI;1.02,1.28), pregnant women who had unimproved toilet facility (aPR = 1.17;95%CI:1.06,1.27), and those women from countries with high illiteracy level (aPR = 1.12;95%CI; 1.07,1.18) had a higher prevalence of anemia during pregnancy. CONCLUSION: Anemia is still a public health problem in East Africa. Therefore, enabling the households to have improved toilet facilities by strengthening the existing health extension program, reducing teenage pregnancy, and improving the community literacy level is vital to reduce the prevalence of anemia during pregnancy in East Africa.

Pooled prevalence and associated factors of health facility delivery in East Africa: Mixed-effect logistic regression analysis.

BACKGROUND: Many mothers still give birth outside a health facility in Sub-Saharan Africa particularly in East African countries. Though there are studies on the prevalence and associated factors of health facility delivery, as to our search of literature there is limited evidence on the pooled prevalence and associated factors of health facility delivery in East Africa. This study aims to examine the pooled prevalence and associated factors of health facility delivery in East Africa based on evidence from Demographic and Health Surveys. METHODS: A secondary data analysis was conducted based on the most recent Demographic and Health Surveys (DHSs) conducted in the 12 East African countries. A total weighted sample of 141,483 reproductive-age women who gave birth within five years preceding the survey was included. All analyses presented in this paper were weighted for the sampling probabilities and non-response using sampling weight (V005), primary sampling unit (V023), and strata (V021). The analysis was done using STATA version 14 statistical software, and the pooled prevalence of health facility delivery with a 95% Confidence Interval (CI) was presented using a forest plot. For associated factors, the Generalized Linear Mixed Model (GLMM) was fitted to consider the hierarchical nature of the DHS data. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), and Likelihood Ratio (LR)-test were done to assess the presence of a significant clustering effect. Besides, deviance (-2LLR) was used for model comparison since the models were nested models. Variables with a p-value of less than 0.2 in the bivariable mixed-effect binary logistic regression analysis were considered for the multivariable analysis. In the multivariable mixed-effect analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the strength and significance of the association between the independent variable and health facility delivery. RESULTS: The proportion of health facility delivery in East Africa was 87.49% [95% CI: 87.34%, 87.64%], ranged from 29% in Ethiopia to 97% in Mozambique. In the Mixed-effect logistic regression model; country, urban residence [AOR = 2.08, 95% CI: 1.96, 2.17], primary women education [AOR = 1.61, 95% CI: 1.55, 1.67], secondary education and higher [AOR = 2.96, 95% CI: 2.79, 3.13], primary husband education [AOR = 1.19, 95% CI: 1.14, 1.24], secondary husband education [AOR = 1.38, 95% CI: 1.31, 1.45], being in union [AOR = 1.23, 95% CI: 1.18, 1.27], having occupation [AOR = 1.11, 95% CI: 1.07, 1.15], being rich [AOR = 1.36, 95% CI: 1.30, 1.41], and middle [AOR = 2.14, 95% CI: 2.04, 2.23], health care access problem [AOR = 0.76, 95% CI: 0.74, 0.79], having ANC visit [AOR = 1.54, 95% CI: 1.49, 1.59], parity [AOR = 0.56, 95% CI: 0.55, 0.61], multiple gestation [AOR = 1.83, 95% CI: 1.67, 2.01] and wanted pregnancy [AOR = 1.19, 95% CI: 1.13, 1.25] were significantly associated with health facility delivery. CONCLUSION: This study showed that the proportion of health facility delivery in East African countries is low. Thus, improved access and utilization of antenatal care can be an effective strategy to increase health facility deliveries. Moreover, encouraging women through education is recommended to increase health facility delivery service utilization.

Determinants of completing recommended antenatal care utilization in sub-Saharan from 2006 to 2018: evidence from 36 countries using Demographic and Health Surveys.

BACKGROUND: Every day in 2017, approximately 810 women died from preventable causes related to pregnancy and childbirth, with 99% of these maternal deaths occurring in low and lower-middle-income countries. Sub-Saharan Africa (SSA) alone accounts for roughly 66%. If pregnant women gained recommended ANC (Antenatal Care), these maternal deaths could be prevented. Still, many women lack recommended ANC in sub-Saharan Africa. This study aimed at determining the pooled prevalence and determinants of recommended ANC utilization in SSA. METHODS: We used the most recent standard demographic and health survey data from the period of 2006 to 2018 for 36 SSA countries. A total of 260,572 women who had at least one live birth 5 years preceding the survey were included in this study. A meta-analysis of DHS data of the Sub-Saharan countries was conducted to generate pooled prevalence, and a forest plot was used to present it. A multilevel multivariable logistic regression model was fitted to identify determinants of recommended ANC utilization. The AOR (Adjusted Odds Ratio) with their 95% CI and p-value ≤0.05 was used to declare the recommended ANC utilization determinates. RESULTS: The pooled prevalence of recommended antenatal care utilization in sub-Saharan Africa countries were 58.53% [95% CI: 58.35, 58.71], with the highest recommended ANC utilization in the Southern Region of Africa (78.86%) and the low recommended ANC utilization in Eastern Regions of Africa (53.39%). In the multilevel multivariable logistic regression model region, residence, literacy level, maternal education, husband education, maternal occupation, women health care decision autonomy, wealth index, media exposure, accessing health care, wanted pregnancy, contraceptive use, and birth order were determinants of recommended ANC utilization in Sub-Saharan Africa. CONCLUSION: The coverage of recommended ANC service utilization was with high disparities among the region. Being a rural residence, illiterate, low education level, had no occupation, low women autonomy, low socioeconomic status, not exposed to media, a big problem to access health care, unplanned pregnancy, not use of contraceptive were determinants of women that had no recommended ANC utilization in SSA. This study evidenced the existence of a wide gap between SSA regions and countries. Special attention is required to improve health accessibility, utilization, and quality of maternal health services.

Duration of birth interval and its predictors among reproductive-age women in Ethiopia: Gompertz gamma shared frailty modeling.

BACKGROUND: The World Health Organization recommended a minimum of 33 months between consecutive live births to reduce the incidence of adverse pregnancy outcomes. Poorly spaced pregnancies are associated with poor maternal and child health outcomes such as low birth weight, stillbirth, uterine rupture, neonatal mortality, maternal mortality, child malnutrition, and maternal hemorrhage. However, there was limited evidence on the duration of birth interval and its predictors among reproductive-age women in Ethiopia. Therefore, this study aimed to investigate the duration of birth interval and its predictors among reproductive-age women in Ethiopia. METHODS: A secondary data analysis was conducted based on the 2016 Ethiopian Demographic and Health Survey data. A total weighted sample of 11022 reproductive-age women who gave birth within five years preceding the survey was included for analysis. To identify the predictors, the Gompertz gamma shared frailty model was fitted. The theta value, Akakie Information Criteria (AIC), Bayesian Information Criteria (BIC), and deviance was used for model selection. Variables with a p-value of less than 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable Gompertz gamma shared frailty analysis, the Adjusted Hazard Ratio (AHR) with a 95% Confidence Interval (CI) was reported to show the strength and statistical significance of the association. RESULTS: The median inter-birth interval in Ethiopia was 38 months (95% CI: 37.58, 38.42). Being living in Addis Ababa (AHR = 0.15, 95% CI: 0.03, 0.70), being rural resident (AHR = 1.13, 95% CI: 1.01, 1.23), being Muslim religious follower (AHR = 6.53, 95% CI: 2.35, 18.18), having three birth (AHR = 0.51, 95% CI: 0.10, 0.83), having four birth (AHR = 0.30, 95% CI: 0.09, 0.74), five and above births (AHR = 0.10, 95% CI: 0.02, 0.41), and using contraceptive (AHR = 2.35, 95% CI: 1.16, 4.77) were found significant predictors of duration of birth interval. CONCLUSION: The length of the inter-birth interval was consistent with the World Health Organization recommendation. Therefore, health care interventions that enhance modern contraceptive utilization among women in rural areas and Muslim religious followers would be helpful to optimize birth interval.

Residential inequality and spatial patterns of infant mortality in Ethiopia: evidence from Ethiopian Demographic and Health Surveys.

BACKGROUND: Despite the remarkable decrease in infant mortality rate in most countries, the rate of decline is slow and it remains unacceptably high in Sub-Saharan Africa. The progress in infant mortality in Ethiopia is far below the rate needed to achieve the Sustainable Development Goal. Understanding the residential inequality and spatiotemporal clusters of infant mortality is essential to prioritize areas and guide public health interventions. Therefore, this study aimed to investigate the residential inequality and spatial patterns of infant mortality in Ethiopia. METHODS: A secondary data analysis was done based on the Ethiopian demographic and health surveys conducted in 2000, 2005, 2011, and 2016. A total weighted sample of 46,317 live births was included for the final analysis. The residential inequality was assessed by calculating the risk difference in infant mortality rates between urban and rural live births and presented using a forest plot. For the spatial patterns of infant mortality, the SaTScan version 9.6 and ArcGIS version 10.6 statistical software were used to identify the spatial patterns of infant mortality. RESULTS: The study revealed that the infant mortality rate significantly declined from 96.9 per 1000 live births [95% CI 93.6, 104.2] in 2000 to 48.0 per 1000 live births [95% CI 44.2, 52.2] in 2016 with an annual rate of reduction of 3.2%. The infant mortality rate has substantial residential inequality over time, which is concentrated in the rural area. The spatial distribution of infant mortality was significantly clustered at the national level in survey periods (global Moran's I, 0.04-0.081, p value < 0.05). In 2000, the most likely clusters were found in east Afar and at the border areas of south Amhara and north Oromia regions (LLR = 7.61, p value < 0.05); in 2005, at the border areas of Southern Nations Nationalities and People and in the entire Amhara region (LLR = 10.78, p value< 0.05); in 2011, at Southern Nations Nationalities and People and Gambella regions (LLR = 6.63, p value< 0.05); and in 2016, at east Oromia and northeast Somali regions (LLR = 8.38, p value < 0.05). CONCLUSION: In this study, though infant mortality has shown remarkable reduction, infant mortality remains a major health care concern and had significant spatial variation across regions. Besides, the study found that infant mortality was highly concentrated in rural areas. Identifying the hotspot areas of infant mortality would help in designing effective interventions to reduce the incidence of infant mortality in these areas. Therefore, the findings highlighted that public health interventions should target rural areas and identified hotspot areas to reduce the incidence of infant mortality.

Spatial distribution and determinants of the change in pre-lacteal feeding practice over time in Ethiopia: A spatial and multivariate decomposition analysis.

BACKGROUND: Pre-lacteal feeding persists in low and middle-income countries as deep-rooted nutritional malpractice. It imposes significant negative consequences on neonatal health, including increased risk of illness and mortality. Different studies revealed that pre-lacteal feeding practice is decreased over time. Even though different studies are done on the prevalence and determinants of pre-lacteal feeding practice, up to our knowledge, the spatial distribution and the determinants of the change in pre-lacteal feeding practice over time are not researched. OBJECTIVE: To assess the spatial distribution and determinants of the change in pre-lacteal feeding practice over time in Ethiopia. METHODS: We used the Ethiopian demographic and health surveys (EDHSs) data. For this study, a total weighted sample of 14672 (5789 from EDHS 2005, 4510 from EDHS 2011, and 4373 from EDHS 2016) reproductive-age women who gave birth within two years preceding the respective surveys and whoever breastfeed were used. The logit-based multivariate decomposition analysis was used to identify factors that contributed to the decrease in pre-lacteal feeding practice over the last 10 years (from 2005 to 2016). Using the 2016 EDHS data, we also conducted a spatial analysis by using ArcGIS version 10.3 and SaTScan version 9.6 software to explore the spatial distribution and hotspot clusters of pre-lacteal feeding practice. RESULT: Pre-lacteal feeding practice was decreased from 29% [95% Confidence interval (CI): 27.63-29.96%] in 2005 to 8% [95% CI: 7.72-8.83%] in 2016 with annual rate of reduction of 7.2%. The overall decomposition analysis showed that about 20.31% of the overall decrease in pre-lacteal feeding practice over the last 10 years was attributable to the difference in composition of women (endowment) across the surveys, while, the remaining 79.39% of the overall decrease was explained by the difference in the effect of characteristics (coefficient) across the surveys. In the endowment component, the difference in composition of residence, perception of distance from the health facility, maternal educational level, wealth status, occupation, ANC visit, place of delivery, the timing of breastfeeding initiation, and wanted last-child/pregnancy were found to be significant contributing factors for the decrease in pre-lacteal feeding practice. After controlling for the role of compositional changes, the difference in the effect of distance from the health facility, wealth status, occupation, antenatal care (ANC) visit, and wanted last-child/pregnancy across the surveys were significantly contributed to the observed decrease in pre-lacteal feeding practice. Regarding the spatial distribution, pre-lacteal feeding practice was non-random in Ethiopia in which the primary and secondary clusters' of pre-lacteal feeding identified in Somalia and the Afar region respectively. CONCLUSION: Pre-lacteal feeding practice has shown a significant decline over the 10-year period. Program interventions considering women with poor maternal health service utilization such as ANC visits, women with poor socioeconomic status, women with an unintended pregnancy, and women from remote areas especially at border areas such as Somali and Afar could decrease pre-lacteal feeding practice in Ethiopia.

Individual-and community-level determinants of neonatal mortality in the emerging regions of Ethiopia: a multilevel mixed-effect analysis.

BACKGROUND: Unlike infant and child mortality, neonatal mortality has declined steadily in Ethiopia. Despite the large-scale investment made by Ethiopia to improve the health of newborns and infants, it is among the regions with the highest burden of neonatal mortality. Although there are studies done on neonatal mortality in different areas of Ethiopia, as to our search of pieces of literature there is no study in Emerging regions of the country. Therefore, this study aimed to investigate the individual and community-level determinants of neonatal mortality in the Emerging regions of Ethiopia. METHODS: Using the 2016 Ethiopian Demographic and Health Survey (EDHS) data, secondary data analysis was done. A total weighted sample of 4238 live births in Emerging regions were included for the final analysis. A multilevel binary logistic regression was fitted to identify the significant determinants of neonatal mortality. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV) were used for assessing the clustering effect, and deviance for model comparison. Variables with a p-value < 0.2 in the bi-variable analysis were considered in the multivariable analysis. In the multivariable multilevel binary logistic regression analysis, Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare statistically significant determinants of neonatal mortality. RESULTS: The neonatal mortality rate in Emerging regions of Ethiopia was 34.9 per 1000 live births (95% CI: 29.8, 40.9). Being born to a mother who had no formal education (AOR = 1.79, 95% CI: 1.12, 2.88), being born to a mother who did not participate in making health care decisions (AOR = 1.25, 95% CI: 1.14, 1.79), and being twin birth (AOR = 6.85, 95% CI: 3.69, 12.70) were significantly associated with higher odds of neonatal mortality. On the other hand, being female (AOR = 0.67, 95% CI: 0.47, 0.95), having 1-3 Antenatal Care (ANC) visits (AOR = 0.34, 95% CI: 0.15, 0.74), high community media exposure (AOR = 0.64, 95% CI: 0.41, 0.98), and preceding birth interval of two to 4 years (AOR = 0.38, 95% CI: 0.24, 0.58) were significantly associated with lower odds of neonatal mortality. CONCLUSION: Neonatal mortality in Emerging regions of Ethiopia was unacceptably high. Maternal education, women's autonomy in making decisions for health care, sex of a child, type of birth, preceding birth interval, ANC visit, and community media exposure were found significant determinants of neonatal mortality. Therefore, empowering women in making health care decisions and increasing access to mass media play a major role in reducing the incidence of neonatal mortality in Emerging regions of Ethiopia.

Individual and community level factors associated with delayed first postnatal care attendance among reproductive age group women in Ethiopia.

BACKGROUND: Postnatal care (PNC) visits provide a huge benefit for ensuring appropriate breastfeeding practices, to monitor the overall health status of the newborn, to timely diagnose and intervene birth-related complications, and to plan future family planning options. Despite delayed PNC attendance have a great impact on the survival of the mother and the newborn it still receives less emphasis. As a result, most mothers do not receive PNC services early. We, therefore, aimed to determine individual and community level factors associated with delayed first Postnatal Care attendance among reproductive age group women in Ethiopia. METHODS: We used the most recent Ethiopian Demographic and Health Survey (EDHS 2016) data to determine associated factors of delayed first PNC in Ethiopia. A weighted sample of 4308 women with a live birth in the two years preceding the survey was included. A multilevel logistic regression analysis was used to analyze the data. Variables with p-value < 0.05 in the multivariable multilevel logistic regression analysis were declared significantly associated with delayed first PNC attendance. RESULTS: In this study, both individual level and community level factors were associated with delayed PNC attendance. Among the individual level factors: having four or more antenatal care visit [Adjusted Odd Ratio (AOR) = 0.73; 95% CI: 0.59, 0.92], delivery at a health facility [AOR = 0.04; 95% CI: 0.03, 0.05], and perceiving distance from the health facility as not a big problem [AOR = 0.73; 95% CI: 0.58, 0.91] were associated with lower odds of delayed first PNC attendance. Of community level factors: being in Oromia [AOR = 2.31; 95% CI: 1.38, 3.83] and Gambela [AOR = 2.01; 95% CI: 1.13, 3.56] regions were associated higher odds of delayed first PNC attendance. CONCLUSIONS: Both individual level and community level factors were found to be associated with delayed PNC attendance. Strengthening antenatal care utilization, institutional delivery, and appropriate distributions of maternal health services in each region and areas far apart from the health facility are recommended.

Complete basic childhood vaccination and associated factors among children aged 12-23 months in East Africa: a multilevel analysis of recent demographic and health surveys.

BACKGROUND: Complete childhood vaccination remains poor in Sub-Saharan Africa, despite major improvement in childhood vaccination coverage worldwide. Globally, an estimated 2.5 million children die annually from vaccine-preventable diseases. While studies are being conducted in different East African countries, there is limited evidence of complete basic childhood vaccinations and associated factors in East Africa among children aged 12-23 months. Therefore, this study aimed to investigate complete basic childhood vaccinations and associated factors among children aged 12-23 months in East Africa. METHODS: Based on the Demographic and Health Surveys (DHSs) of 12 East African countries (Burundi, Ethiopia, Comoros, Uganda, Rwanda, Tanzania, Mozambique, Madagascar, Zimbabwe, Kenya, Zambia, and Malawi), secondary data analysis was performed. The study included a total weighted sample of 18,811 children aged 12-23 months. The basic childhood vaccination coverage was presented using a bar graph. Multilevel binary logistic regression analysis was fitted for identifying significantly associated factors because the DHS has a hierarchical nature. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV), and deviance (-2LLR) were used for checking model fitness, and for model comparison. Variable with p-value ≤0.2 in the bi-variable multilevel analysis were considered for the multivariable analysis. In the multivariable multilevel analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported to declare the significance and strength of association with full vaccination. RESULTS: Complete basic childhood vaccination in East Africa was 69.21% (95% CI, 69.20, 69.21%). In the multivariable multilevel analysis; Mothers aged 25-34 years (AOR = 1.21, 95% CI: 1.10, 1.32), mothers aged 35 years and above (AOR = 1.50, 95% CI: 1.31, 1.71), maternal primary education (AOR = 1.26, 95% CI: 1.15, 1.38), maternal secondary education and above (AOR = 1.54, 95% CI: 1.36, 1.75), husband primary education (AOR = 1.25, 95% CI: 1.13, 1.39), husband secondary education and above (AOR = 1.24, 95% CI: 1.11, 1.40), media exposure (AOR = 1.23, 95% CI: 1.13, 1.33), birth interval of 24-48 months (AOR = 1.28, 95% CI: 1.15, 1.42), birth interval greater than 48 months (AOR = 1.35, 95% CI: 1.21, 1.50), having 1-3 ANC visit (AOR = 3.24, 95% CI: 2.78, 3.77), four and above ANC visit (AOR = 3.68, 95% CI: 3.17, 4.28), PNC visit (AOR = 1.34, 95% CI: 1.23, 1.47), health facility delivery (AOR = 1.48, 95% CI: 1.35, 1.62), large size at birth 1.09 (AOR = 1.09, 95% CI: 1.01, 1.19), being 4-6 births (AOR = 0.83, 95% CI: 0.75, 0.91), being above the sixth birth (AOR = 0.60, 95% CI: 0.52, 0.70), middle wealth index (AOR = 1.16, 95% CI: 1.06, 1.28), rich wealth index (AOR = 1.20, 95% CI: 1.09, 1.33), community poverty (AOR = 1.21, 95% CI: 1.11, 1.32) and country were significantly associated with complete childhood vaccination. CONCLUSIONS: In East Africa, full basic childhood vaccine coverage remains a major public health concern with substantial differences across countries. Complete basic childhood vaccination was significantly associated with maternal age, maternal education, husband education, media exposure, preceding birth interval, number of ANC visits, PNC visits, place of delivery, child-size at birth, parity, wealth index, country, and community poverty. Public health interventions should therefore target children born to uneducated mothers and fathers, poor families, and those who have not used maternal health services to enhance full childhood vaccination to reduce the incidence of child mortality from vaccine-preventable diseases.

Individual and community-level determinants, and spatial distribution of institutional delivery in Ethiopia, 2016: Spatial and multilevel analysis.

BACKGROUND: Institutional delivery is an important indicator in monitoring the progress towards Sustainable Development Goal 3.1 to reduce the global maternal mortality ratio to less than 70 per 100,000 live births. Despite the international focus on reducing maternal mortality, progress has been low, particularly in Sub-Saharan Africa (SSA), with more than 295,000 mothers still dying during pregnancy and childbirth every year. Institutional delivery has been varied across and within the country. Therefore, this study aimed to investigate the individual and community level determinants, and spatial distribution of institutional delivery in Ethiopia. METHODS: A secondary data analysis was done based on the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total weighted sample of 11,022 women was included in this study. For spatial analysis, ArcGIS version 10.6 statistical software was used to explore the spatial distribution of institutional delivery, and SaTScan version 9.6 software was used to identify significant hotspot areas of institutional delivery. For the determinants, a multilevel binary logistic regression analysis was fitted to take to account the hierarchical nature of EDHS data. The Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV), and deviance (-2LL) were used for model comparison and for checking model fitness. Variables with p-values<0.2 in the bi-variable analysis were fitted in the multivariable multilevel model. Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) were used to declare significant determinant of institutional delivery. RESULTS: The spatial analysis showed that the spatial distribution of institutional delivery was significantly varied across the country [global Moran's I = 0.04 (p<0.05)]. The SaTScan analysis identified significant hotspot areas of poor institutional delivery in Harari, south Oromia and most parts of Somali regions. In the multivariable multilevel analysis; having 2-4 births (AOR = 0.48; 95% CI: 0.34-0.68) and >4 births (AOR = 0.48; 95% CI: 0.32-0.74), preceding birth interval ≥ 48 months (AOR = 1.51; 95% CI: 1.03-2.20), being poorer (AOR = 1.59; 95% CI: 1.10-2.30) and richest wealth status (AOR = 2.44; 95% CI: 1.54-3.87), having primary education (AOR = 1.47; 95% CI: 1.16-1.87), secondary and higher education (AOR = 3.44; 95% CI: 2.19-5.42), having 1-3 ANC visits (AOR = 3.88; 95% CI: 2.77-5.43) and >4 ANC visits (AOR = 6.53; 95% CI: 4.69-9.10) were significant individual-level determinants of institutional delivery while being living in Addis Ababa city (AOR = 3.13; 95% CI: 1.77-5.55), higher community media exposure (AOR = 2.01; 95% CI: 1.44-2.79) and being living in urban area (AOR = 4.70; 95% CI: 2.70-8.01) were significant community-level determinants of institutional delivery. CONCLUSIONS: Institutional delivery was low in Ethiopia. The spatial distribution of institutional delivery was significantly varied across the country. Residence, region, maternal education, wealth status, ANC visit, preceding birth interval, and community media exposure were found to be significant determinants of institutional delivery. Therefore, public health interventions should be designed in the hotspot areas where institutional delivery was low to reduce maternal and newborn mortality by enhancing maternal education, ANC visit, and community media exposure.

Determinants of postnatal care utilization in sub-Saharan Africa: a meta and multilevel analysis of data from 36 sub-Saharan countries.

INTRODUCTION: Globally, over 65% of maternal deaths occur during the first 42 days of postpartum while the same proportion of neonatal deaths occur during the first 7 days of life. In sab- Saharan Africa, 4.7 million mothers, newborns, and children die on annual basis. As to our knowledge, there is no study on postnatal care utilization that incorporates all sub-Saharan Africa countries that had DHS data. Therefore, this study aimed at identifying pooled magnitude and determinants of postnatal care utilization in sub-Saharan Africa. METHOD: A population-based cross-sectional study from the most recent Demographic and Health Surveys data from the period of 2006 to 2018 of 36 SSA countries were used. A total weighted sample of 286,255 reproductive-age women who gave birth 5 years preceding the survey were included in the study. A meta-analysis of DHS data of each Sub-Saharan countries was conducted to generate pooled magnitude and a forest plot was used to present it. A multilevel logistic regression model was fitted to identify determinants of postnatal care utilization. The AOR (Adjusted Odds Ratio) with their 95% CI and p-value ≤0.05 was used to declare that determinates associated with postnatal care utilization. RESULT: The pooled magnitude of postnatal care utilization in sub-Saharan Africa countries was 52.48% [95% CI: 52.33, 52.63], with the highest postnatal care utilization in the Central Region of Africa (73.51%) and the low postnatal care utilization in Eastern Regions of Africa (31.71%). In the multilevel logistic regression model region, residence, age group, maternal education, maternal occupation, media exposure, ANC visit, place of delivery, and accessing health care were determinants of postnatal care utilization in Sub-Saharan Africa. CONCLUSION: The coverage of postnatal care service utilization was low with high disparities among the region. Being in rural residence, young age group, low education level, had no occupation, not exposed to media, a big problem to access health care, not had ANC visit, and home delivery was associated with low postnatal care service utilization. This study evidenced that there is a wide gap in postnatal care utilization between SSA countries. Special attention is required to improve health accessibility, utilization, and quality of maternal health services to increase postnatal care service utilization in the region.

Individual- and Community-Level Determinants for Complete Vaccination among Children Aged 12-23 Months in Ethiopia: A Multilevel Analysis.

BACKGROUND: Childhood vaccination continues to increase dramatically. In spite of the success of immunization programs to date, millions of children continued to die each year, and sub-Saharan Africa (SSA) accounted for the world's highest neonatal deaths. Childhood vaccination was designed as one of the most effective ways to reduce child mortalities from fatal vaccine-preventable diseases. Therefore, this study is aimed at investigating the individual- and community-level determinants of childhood complete vaccination in Ethiopia. METHODS: A secondary data analysis was done based on the 2016 Ethiopian Demographic and Health Survey (EDHS). A total weighted sample of 1,984 children aged 12-23 months was included for analysis. Considering the hierarchical nature of EDHS data, a two-level multilevel analysis for assessing individual- and community-level determinants of childhood complete vaccination was done. The intraclass correlation coefficient (ICC), Median Odds Ratio (MOR), Proportional Change in Variance (PCV), and deviance (-2LL) were used for model comparison and for checking model fitness. Variables with p value < 0.2 in the bivariable multilevel analysis were considered for the multivariable multilevel analysis. In the multivariable multilevel logistic regression analysis, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was reported to declare significant determinants of complete childhood vaccination. RESULTS: Overall complete vaccination status among children aged 12-23 months was 39% (95% CI: 36.8, 41.2). In the multilevel analysis, secondary or above educated mothers (AOR = 2.48; 95% CI: 1.41, 4.36), richest wealth status (AOR = 2.24; 95% CI: 1.16, 4.32), ≥four ANC visits (AOR = 2.77; 95% CI: 1.90-4.02), employed mothers (AOR = 1.66; 95% CI: 1.26, 2.18), urban residence (AOR = 1.84; 95% CI: 1.00, 3.51), and children in city administration (AOR = 2.66; 9% CI: 1.53, 4.62) were positively associated with vaccination status. On the other hand, children with a female household head (AOR = 0.68; 95% CI: 0.48, 0.96) were negatively associated. CONCLUSION: Overall, childhood full vaccination status was low compared with the WHO targets. Maternal education, wealth status, ANC visit, maternal occupation, residence, region, and sex of household head were significant predictors of childhood complete vaccination. As a result, it is better to design a compensation mechanism to the costs associated with childhood vaccination for the poor households and strengthen awareness creation for rural residents to improve the access, utilization, and continuum of vaccination service.

Prevalence and determinants of anemia among young (15-24 years) women in Ethiopia: A multilevel analysis of the 2016 Ethiopian demographic and health survey data.

BACKGROUND: Anemia is a major global public health problem that had tremendous impacts on human health, social and economic development. African countries contribute to the highest-burden of anemia among women, particularly in adolescent females and young women. Anemia among young women remains a public health problem in most parts of Africa, including Ethiopia. Therefore, this study aimed to investigate the prevalence and determinants of anemia among young women in Ethiopia. METHODS: A secondary data analysis was conducted based on the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total weighted sample of 5796 young women (15-24 years) was included in this study. We employed a multilevel analysis to assess factors associated with anemia since the EDHS has hierarchical nature. Deviance, Intraclass Correlation Coefficient (ICC) and Median Odds Ratio (MOR) were used for model comparison as well as for assessing model fitness. Variables with a p-value of less than 0.20 at bivariable multilevel analysis were considered for the multivariable multilevel analysis. In the multivariable multilevel analysis variables with p-value ≤ 0.05 were declared to be a significant factor associated with anemia, and the Adjusted Odds Ratio (AOR) with the 95% Confidence Interval (CI) were reported to assess the strength and direction of the association. RESULTS: The overall prevalence of anemia among young women was 21.7% (95%CI = 20.7%, 22.8%). In the multivariable multilevel binary logistic regression analysis; being Muslim religion follower [adjusted odds ratio (AOR) = 1.31, 95%CI = 1.07, 1.70] and being protestant religion follower [AOR = 1.31; 95%CI = 1.01, 1.71], being rural dweller [AOR = 1.34; 95%CI = 1.02, 1.78], and being married [AOR = 1.46; 95%CI = 1.22, 1.74] were significantly associated with higher odds of anemia among young women. While, modern contraceptive use (AOR = 0.66; 95%CI = 0.53, 0.83) were significantly associated with lower odds of anemia among young women. CONCLUSION: In this study, the prevalence of anemia among young women was high. Being a follower of Muslim and protestant religions, being married women, modern contraceptive use and being from the rural area were found to be significant determinants of anemia among young women. Therefore, giving special attention to these high-risk groups and distributing modern contraceptives for those in need of it could decrease this devastating public health problem in young women.

Spatial Distribution and Determinants of Early Marriage among Married Women in Ethiopia: A spatial and Multilevel Analysis.

BACKGROUND: Early marriage is a global public health problem that is mainly practiced in South Asia, Latin America, and sub-Saharan Africa including Ethiopia. It raises the risk of early childbearing of women, higher rates of divorce, and an increased risk of maternal and child death. However, little is known about the spatial distribution and determinants of early marriage in Ethiopia. Therefore, this study aimed to assess the spatial distribution and determinants of early marriage among ever-married women in Ethiopia. METHODS: A detailed analysis of the 2016 Ethiopian Demographic and Health Survey data was conducted. A total weighted sample of 11,646 reproductive-age married women were included in the analysis. To identify significant hotspot areas of early marriage the Bernoulli model was fitted using SaTScan version 9.6 software. Additionally, to explore the spatial distributions of early marriage across the country ArcGIS version 10.1 statistical software was used. For the determinant factors, the multilevel logistic regression model was fitted. Deviance was used for model comparison and checking of model fitness. In the multivariable multilevel analysis, Adjusted Odds Ratio (AOR) with 95% CI was used to declare significant determinants of early marriage. RESULTS: The finding of this study revealed that the spatial distribution of early marriage was significantly varied across the country with Global Moran's I = 0.719 and p value < 0.001. The primary clusters were detected in Tigray, Amhara, and Afar regions. Both individual and community-level factors were associated with early marriage. Having no formal education (AOR = 4.25, 95% CI 3.13-5.66), primary education (AOR = 3.37, 95% CI 2.80-4.92), secondary education (AOR = 1.75, 95% CI 1.32-2.33), and a decision made by parents (AOR = 1.88, 95% CI 1.68-2.09) were individual-level factors associated with higher odds of early marriage. Among the community-level factors, the region was significantly associated with early marriage. Thus, living in Afar (AOR = 1.82, 95%CI 1.37-2.42), Amhara (AOR = 1.77, 95% CI 1.38-2.77), and Gambela (AOR = 1.44, 95% CI 1.09-190) was associated with higher odds of early marriage. Whereas, living in Addis Ababa (AOR = 0.50, 95% CI 0.36-0.68) was associated with a lower chance of early marriage. CONCLUSION: The spatial distribution of early marriage was significantly varied in Ethiopia. Women's education, women's autonomy, and region were found to be the significant determinants of early marriage. Therefore, public health interventions targeting those identified significant hotspot areas of early marriage are crucial to reduce the incidence of early marriage and its consequence. In addition, enhancing women's education and empowering them to make their own choices are vital for changing the customs of the community and eliminating early marriage in Ethiopia.

Exploring spatial variations and factors associated with skilled birth attendant delivery in Ethiopia: geographically weighted regression and multilevel analysis.

BACKGROUND: Skilled birth attendant (SBA) delivery is vital for the health of mothers and newborns, as most maternal and newborn deaths occur at the time of childbirth or immediately after birth. This problem becomes worsen in Ethiopia in which only 28% of women give birth with the help of SBA. Therefore, this study aimed to explore the spatial variations of SBA delivery and its associated factors in Ethiopia. METHODS: A secondary analysis was carried out using the 2016 Ethiopian Demographic and Health Survey. A total weighted sample of 11,023 women who had a live birth in the 5 years preceding the survey was included in the analysis. Arc-GIS software was used to explore the spatial distribution of SBA and a Bernoulli model was fitted using SaTScan software to identify significant clusters of non-SBA delivery. The Geographic Weighted Regression (GWR) was employed in modeling spatial relationships. Moreover, a multilevel binary logistic regression model was fitted to identify factors associated with SBA delivery. RESULTS: In this study, SBA delivery had spatial variations across the country. The SaTScan spatial analysis identified the primary clusters' spatial window in southeastern Oromia and almost the entire Somalia. The GWR analysis identified different predictors of non- SBA delivery across regions of Ethiopia. In the multilevel analysis, mothers having primary and above educational status, health insurance coverage, and mothers from households with higher wealth status had higher odds of SBA delivery. Being multi and grand multiparous, perception of distance from the health facility as big problem, rural residence, women residing in communities with medium and higher poverty level, and women residing in communities with higher childcare burden had lower odds of SBA delivery. CONCLUSION: Skilled birth attendant delivery had spatial variations across the country. Areas with non-skilled birth attendant delivery and mothers who had no formal education, not health insured, mothers from poor households and communities, Primiparous women, mothers from remote areas, and mothers from communities with higher childcare burden could get special attention in terms of allocation of resources including skilled human power, and improved access to health facilities.