Determinants of anemia level among reproductive-age women in 29 Sub-Saharan African countries: A multilevel mixed-effects modelling with ordered logistic regression analysis.

BACKGROUND: Despite the implementation of different nutritional and non-nutritional interventions, 43% of reproductive-age women in Africa suffer from anemia. Recent evidence also shows that none of the Sub-Saharan African (SSA) countries are on the track to achieve the nutrition target of 50% anemia reduction by 2030. To date, information on the level of anemia and its determinants among reproductive-age women at the SSA level is limited. Thus, this study aimed to estimate the pooled prevalence of anemia level and its determinants in SSA countries. METHODS: We used a pooled data of 205,627 reproductive-age women from the recent demographic and health surveys of 29 SSA countries that were conducted between 2010-2021. A multilevel mixed-effects analysis with an ordered logistic regression model was fitted to identify determinants of anemia level and the deviance value was used to select the best-fitted model. First, bivariable ordinal logistic regression analysis was done and the proportional odds assumption was checked for each explanatory variable using a Brant test. Finally, in a multivariable multilevel ordinal logistic regression model, a p-value<0.05 and AOR with the corresponding 95% CI were used to identify determinants of anemia level. All analyses were done using Stata version 17 software. RESULTS: The pooled prevalence of anemia among women of reproductive age in SSA was 40.5% [95% CI = 40.2%-40.7%], where 24.8% [95% CI: 24.6%-25.0%], 11.1% [95% CI = 10.9%-11.2%], and 0.8% [95% CI = 0.7%-0.8%] had mild, moderate, and severe anemia, respectively. The prevalence significantly varied from the lowest of 13% in Rwanda to the highest of 62% in Mali, and anemia was found as a severe public health problem (prevalence of ≥ 40%) in 18 countries. The regression result revealed that polygamous marriage, women and husband illiteracy, poor household wealth, shorter birth interval, non-attendance of antenatal care, underweight, unimproved toilet and water facilities, and low community-level women literacy were positively linked with high anemia level. Additionally, the likelihood of anemia was lower in women who were overweight and used modern contraception. CONCLUSIONS: Overall results showed that anemia among women of reproductive age is a severe public health problem in SSA countries, affecting more than four in ten women. Thus, enhancing access to maternal health services (antenatal care and contraception) and improved sanitation facilities would supplement the existing interventions targeted to reduce anemia. Moreover, strengthening women's education and policies regulating the prohibition of polygamous marriage are important to address the operational constraints.