What predicts health facility delivery among women? analysis from the 2021 Madagascar Demographic and Health Survey.

BACKGROUND: One of the pivotal determinants of maternal and neonatal health outcomes hinges on the choice of place of delivery. However, the decision to give birth within the confines of a health facility is shaped by a complex interplay of sociodemographic, economic, cultural, and healthcare system-related factors. This study examined the predictors of health facility delivery among women in Madagascar. METHODS: We used data from the 2021 Madagascar Demographic and Health Survey. A total of 9,315 women who had a health facility delivery or delivered elsewhere for the most recent live birth preceding the survey were considered in this analysis. Descriptive analysis, and multilevel regression were carried out to determine the prevalence and factors associated with health facility delivery. The results were presented as frequencies, percentages, crude odds ratios and adjusted odds ratios (aORs) with corresponding 95% confidence intervals (CIs), and a p-value < 0.05 was used to declare statistical significance. RESULTS: The prevalence of health facility delivery was 41.2% [95% CI: 38.9-43.5%]. In the multilevel analysis, women aged 45-49 [aOR = 2.14, 95% CI = 1.34-3.43], those with secondary/higher education [aOR = 1.62, 95% CI = 1.30-2.01], widowed [aOR = 2.25, 95% CI = 1.43-3.58], and those exposed to mass media [aOR = 1.18, 95% CI = 1.00-1.39] had higher odds of delivering in health facilities compared to those aged 15-49, those with no formal education, women who had never been in union and not exposed to mass media respectively. Women with at least an antenatal care visit [aOR = 6.95, 95% CI = 4.95-9.77], those in the richest wealth index [aOR = 2.74, 95% CI = 1.99-3.77], and women who considered distance to health facility as not a big problem [aOR = 1.28, 95% CI = 1.09-1.50] were more likely to deliver in health facilities compared to those who had no antenatal care visit. Women who lived in communities with high literacy levels [aOR = 1.54, 95% CI = 1.15-2.08], and women who lived in communities with high socioeconomic status [aOR = 1.72, 95% CI = 1.28-2.31] had increased odds of health facility delivery compared to those with low literacy levels and in communities with low socioeconomic status respectively. CONCLUSION: The prevalence of health facility delivery among women in Madagascar is low in this study. The findings of this study call on stakeholders and the government to strengthen the healthcare system of Madagascar using the framework for universal health coverage. There is also the need to implement programmes and interventions geared towards increasing health facility delivery among adolescent girls and young women, women with no formal education, and those not exposed to media. Also, consideration should be made to provide free maternal health care and a health insurance scheme that can be accessed by women in the poorest wealth index. Health facilities should be provided at places where women have challenges with distance to other health facilities. Education on the importance of antenatal care visits should also be encouraged, especially among women with low literacy levels and in communities with low socioeconomic status.

Geostatistical linkage of national demographic and health survey data: a case study of Tanzania.

BACKGROUND: When Service Provision Assessment (SPA) surveys on primary health service delivery are combined with the nationally representative household survey-Demographic and Health Survey (DHS), they can provide key information on the access, utilization, and equity of health service availability in low- and middle-income countries. However, existing linkage methods have been established only at aggregate levels due to known limitations of the survey datasets. METHODS: For the linkage of two data sets at a disaggregated level, we developed a geostatistical approach where SPA limitations are explicitly accounted for by identifying the sites where health facilities might be present but not included in SPA surveys. Using the knowledge gained from SPA surveys related to the contextual information around facilities and their spatial structure, we made an inference on the service environment of unsampled health facilities. The geostatistical linkage results on the availability of health service were validated using two criteria-prediction accuracy and classification error. We also assessed the effect of displacement of DHS clusters on the linkage results using simulation. RESULTS: The performance evaluation of the geostatistical linkage method, demonstrated using information on the general service readiness of sampled health facilities in Tanzania, showed that the proposed methods exceeded the performance of the existing methods in terms of both prediction accuracy and classification error. We also found that the geostatistical linkage methods are more robust than existing methods with respect to the displacement of DHS clusters. CONCLUSIONS: The proposed geospatial approach minimizes the methodological issues and has potential to be used in various public health research applications where facility and population-based data need to be combined at fine spatial scale.

Facility readiness and counseling during antenatal care and the relationship with early breastfeeding in Haiti and Malawi.

BACKGROUND: Early initiation of breastfeeding (within an hour of birth) has benefits for newborn health and survival. Optimal breastfeeding supports growth, health, and development. Health facilities provide essential pregnancy, maternal, and newborn care and offer support for early breastfeeding. We examined the relationship between the breastfeeding-related health service environment during antenatal care (ANC) and early initiation of breastfeeding. METHODS: Using data from recent Service Provision Assessment (SPA) surveys in Haiti and Malawi, we defined three indicators of the health service environment: availability of facilities with ANC services reporting routine breastfeeding counseling; provider training on breastfeeding; and breastfeeding counseling during ANC. We linked SPA data geographically to Demographic and Health Surveys (DHS) data from Haiti and Malawi. Multilevel, multivariable logistic regressions examined associations between the health service environment and early initiation of breastfeeding, controlling for women's background characteristics, with separate analyses for urban and rural residence. RESULTS: Over 95% of facilities in Haiti and Malawi reported routinely providing breastfeeding counseling during ANC. Only 40% of both urban and rural providers in Malawi and 29 and 26% of providers at urban and rural facilities in Haiti (respectively) received recent training in counseling on breastfeeding. Further, only 4-10% of clients received counseling. Breastfeeding counseling was generally more common among clients who attended ANC with a provider who had received recent training. After linking SPA and DHS data, our analysis showed that having more providers recently trained on breastfeeding was significantly associated with increased odds of early breastfeeding among women in urban areas of Haiti and Malawi. Additionally, women in urban areas of Malawi lived near facilities with more counseling during ANC were more likely to begin breastfeeding within an hour of birth compared with women in areas with less counseling. CONCLUSIONS: Our study identified gaps in the health system's capacity to implement the recommended global guidelines in support of optimal breastfeeding practices. While breastfeeding counseling during ANC can promote early breastfeeding, counseling was not common. The study provides evidence that provider training could help improve counseling and support for early initiation of breastfeeding.

Factors Associated with Anemia Status Among Children Aged 6-59 months in Ghana, 2003-2014.

BACKGROUND: In 2008, 78% of Ghanaian children under 5 years old were anemic versus 48% of children globally. In this study, we identified proximal and distal determinants of severe-moderate anemia and mild anemia related to socioeconomic status, nutrition, and health access. METHODS: Using data from the 2003, 2008, and 2014 Ghana Demographic and Health Surveys (GDHS), the odds of severe-moderate anemia and mild anemia compared to no anemia, in relation to various hypothesized risk factors, were assessed using a multivariable, multinomial logistic regression, which accounted for survey design. RESULTS: From among 7739 households sampled, severe-moderate anemia was found in approximately 52%, 56%, and 40% of children during 2003, 2008, and 2014, respectively. The proportion of children diagnosed as not anemic was 26% in 2003, 22% in 2008, and 33% in 2014. There are large disparities in anemia prevalence among regions and between urban and rural areas. In 2014, children who were younger (aged 6-24 months), had a recent fever, were from poorer families, and whose mothers were less educated had greater odds of being severely-moderately anemic. These results remained significant when controlling for other risk factors. Predictors of anemia in Ghana remained relatively consistent among the three time periods when the GDHS was administered. CONCLUSIONS: The prevalence of anemia in Ghana among children aged 6-59 months has remained unacceptably high. To reduce anemia in these children, the Ghanaian government should concentrate on educating women through both the traditional school system and antenatal care visits.

Childhood stunting and wasting in Myanmar: Key drivers and implications for policies and programmes.

Child undernutrition is a public health and development problem in Myanmar that is jeopardizing children's physical and cognitive development and the country's social and economic progress. We identified key drivers of child stunting (low height-for-age) and wasting (low weight-for-height) in a nationally representative sample (n = 3,981) of children 0-59 months of age. The national prevalence of child stunting and wasting was 28% and 7%, respectively. Boys were more likely to be stunted or wasted than girls. Older children 24-35 months were at the highest risk of stunting compared with children under 6 months (risk ratios [RR] 10.34; 95% CI [6.42, 16.65]) whereas the youngest, under 6 months, were at the highest risk of wasting compared with children 36-59 months (RR 2.04; 95% CI [1.16, 3.57]). Maternal height <145 cm (RR 5.10; 95% CI [3.15, 8.23]), perceived small child size at birth (RR 2.08; 95% CI [1.62, 2.69]), and not benefiting from institutional delivery (RR 1.52; 95% CI [1.24, 1.87]) were associated with an increased risk of child stunting, as were maternal occupation, unimproved household drinking water, living in delta, coastal or upland areas, and poorer household wealth index quintile. Increased risk of child wasting was associated with maternal underweight (RR 1.64; 95% CI [1.11, 2.42]) and open defecation (RR 1.91; 95% CI [1.25, 2.92]) as well as maternal occupation and residence in a coastal area. Our findings indicate that the key drivers of child undernutrition in Myanmar are multifaceted and start in utero. Investing in scaling-up multisectoral approaches that include nutrition-specific and nutrition-sensitive interventions with a focus on improving maternal nutrition is essential for reducing child undernutrition and contributing to further gains in the country's human and economic development.

Access to sanitation and violence against women: evidence from Demographic Health Survey (DHS) data in Kenya.

Violence against women (VAW) is a serious public health and human rights concern. Literature suggests sanitation conditions in developing countries may be potential neighborhood-level risk factors contributing to VAW, and that this association may be more important in highly socially disorganized neighborhoods. This study analyzed 2008 Kenya Demographic Health Survey's data and found women who primarily practice open defecation (OD), particularly in disorganized communities, had higher odds of experiencing recent non-partner violence. This study provides quantitative evidence of an association between sanitation and VAW that is attracting increasing attention in media and scholarly literature throughout Kenya and other developing countries.

Climate, migration, and the local food security context: Introducing Terra Populus.

Studies investigating the connection between environmental factors and migration are difficult to execute because they require the integration of microdata and spatial information. In this article, we introduce the novel, publically available data extraction system Terra Populus (TerraPop), which was designed to facilitate population-environment studies. We showcase the use of TerraPop by exploring variations in the climate-migration association in Burkina Faso and Senegal based on differences in the local food security context. Food security was approximated using anthropometric indicators of child stunting and wasting derived from Demographic and Health Surveys (DHS) and linked to the TerraPop extract of climate and migration information. We find that an increase in heat waves was associated with a decrease in international migration from Burkina Faso, while excessive precipitation increased international moves from Senegal. Significant interactions reveal that the adverse effects of heat waves and droughts are strongly amplified in highly food insecure Senegalese departments.

Early-life air pollution and green space exposures as determinants of stunting among children under age five in Sub-Saharan Africa.

BACKGROUND: Childhood malnutrition is a major public health issue in Sub-Saharan Africa (SSA) and 61.4 million children under the age of five years in the region are stunted. Although insight from existing studies suggests plausible pathways between ambient air pollution exposure and stunting, there are limited studies on the effect of different ambient air pollutants on stunting among children. OBJECTIVE: Explore the effect of early-life environmental exposures on stunting among children under the age of five years. METHODS: In this study, we used pooled health and population data from 33 countries in SSA between 2006 and 2019 and environmental data from the Atmospheric Composition Analysis Group and NASA's GIOVANNI platform. We estimated the association between early-life environmental exposures and stunting in three exposure periods - in-utero (during pregnancy), post-utero (after pregnancy to current age) and cumulative (from pregnancy to current age), using Bayesian hierarchical modelling. We also visualise the likelihood of stunting among children based on their region of residence using Bayesian hierarchical modelling. RESULTS: The findings show that 33.6% of sampled children were stunted. In-utero PM2.5 was associated with a higher likelihood of stunting (OR = 1.038, CrI = 1.002-1.075). Early-life exposures to nitrogen dioxide and sulphate were robustly associated with stunting among children. The findings also show spatial variation in a high and low likelihood of stunting based on a region of residence. IMPACT STATEMENT: This study explores the effect of early-life environmental exposures on child growth or stunting among sub-Saharan African children. The study focuses on three exposure windows - pregnancy, after birth and cumulative exposure during pregnancy and after birth. The study also employs spatial analysis to assess the spatial burden of stunted growth in relation to environmental exposures and socioeconomic factors. The findings suggest major air pollutants are associated with stunted growth among children in sub-Saharan Africa.

Intimate Partner Violence and Pregnancy Termination Among Women in Sub-Saharan Africa.

Intimate partner violence (IPV) is predominant in sub-Saharan Africa (SSA) and has serious adverse effects on the physical, psychological, and reproductive health of those who experience it. For reproductive health outcomes, experiencing IPV has been linked to higher odds of unintended pregnancies that can result in abortion. Hence, we examined the association between IPV and pregnancy termination among women in SSA. This study used data from the Demographic and Health Surveys (DHSs) of 25 countries in SSA, which adopted a cross-sectional study design. Bivariable and multivariable binary logistic regression models were used to examine the association between IPV and pregnancy termination. The results were presented as crude odds ratios (cORs) and adjusted odds ratios (aORs), with 95% confidence intervals (CIs). The prevalence of IPV and pregnancy termination were 40.8% and 16.5%, respectively. The odds of pregnancy termination was higher among women who had experienced IPV [cOR = 1.57, 95% CI = 1.52-1.61] compared to those who had never experienced IPV. This persisted after controlling for potential confounders [aOR = 1.56, 95% CI = 1.51-1.61]. At the country level, IPV had a significant association with pregnancy termination in all the countries considered, except Sierra Leone and Namibia. These findings highlight the need for laws and policies to protect women from IPV in SSA, especially in the countries that recorded higher odds of IPV and pregnancy termination.

Use of catch-up vaccinations in the second year of life (2YL) platform to close immunity gaps: A secondary DHS analysis in Pakistan, Philippines, and South Africa.

BACKGROUND: Immunity gaps caused by COVID-19-related disruptions highlight the importance of catch-up vaccination. Number of countries offering vaccines in second year of life (2YL) has increased, but use of 2YL for catch-up vaccination has been variable. We assessed pre-pandemic use of 2YL for catch-up vaccination in three countries (Pakistan, the Philippines, and South Africa), based on existence of a 2YL platform (demonstrated by offering second dose of measles-containing vaccine (MCV2) in 2YL), proportion of card availability, and geographical variety. METHODS: We conducted a secondary data analysis of immunization data from Demographic and Health Surveys (DHS) in Pakistan (2017-2018), the Philippines (2017), and South Africa (2016). We conducted time-to-event analyses for pentavalent vaccine (diphtheria-tetanus-pertussis-Hepatitis B-Haemophilus influenzae type b [Hib]) and MCV and calculated use of 2YL and MCV visits for catch-up vaccination. RESULTS: Among 24-35-month-olds with documented dates, coverage of third dose of pentavalent vaccine increased in 2YL by 2%, 3%, and 1% in Pakistan, Philippines, and South Africa, respectively. MCV1 coverage increased in 2YL by 5% in Pakistan, 10% in the Philippines, and 3% in South Africa. In Pakistan, among 124 children eligible for catch-up vaccination of pentavalent vaccine at time of a documented MCV visit, 45% received a catch-up dose. In the Philippines, among 381 eligible children, 38% received a pentavalent dose during an MCV visit. In South Africa, 50 children were eligible for a pentavalent vaccine dose before their MCV1 visit, but only 20% received it; none with MCV2. CONCLUSION: Small to modest vaccine coverage improvements occurred in all three countries through catch-up vaccination in 2YL but many missed opportunities for vaccination continue to occur. Using the 2YL platform can increase coverage and close immunity gaps, but immunization programmes need to change policies, practices, and monitor catch-up vaccination to maximize the potential.

Robust relationship between ambient air pollution and infant mortality in India.

BACKGROUND: Ambient exposure to fine particulate matter (PM2.5) is one of the top global health concerns. We estimate the associations between in-utero and perinatal exposure to PM2.5 and infant, neonatal and postneonatal mortality in India. We evaluate the sensitivity of this association to two widely-used exposure assessments. METHOD: We linked nationally representative anthropometric data from India's 2015-2016 Demographic and Health Survey (n = 259,627 children under five across 640 districts of India) with satellite-based PM2.5 concentrations during the month of birth of each child. We then estimated the associations between PM2.5 from each dataset and child mortality, after controlling for child, mother and household factors including trends in time and seasonality. We examined if factors: urban/rural, sex, wealth quintile and state modified the associations derived from the two datasets using Wald tests. RESULTS: We found evidence that PM2.5 impacts infant mortality primarily through neonatal mortality. The estimated association between neonatal mortality and PM2.5 in trimester 3 was OR: 1.016 (95% CI: 1.003, 1.030) for every 10 µg/m3 increase in exposure. This association was robust to the exposure assessment used. Child sex was a significant effect modifier, with PM2.5 impacting mortality in infant girls more than boys. CONCLUSIONS: Our results revealed a robust association between ambient exposure to PM2.5 in the latter period of pregnancy and early life with infant and neonatal mortality in India. Urgent air pollution management plans are needed to improve infant mortality in India.

A mediation analysis of the role of girl child marriage in the relationship between proximity to conflict and past-year intimate partner violence in post-conflict Sri Lanka.

BACKGROUND: Studies from many contexts indicate that proximity to conflict is associated with increased likelihood of intimate partner violence (IPV), and girl child marriage is associated with both proximity to conflict and increased IPV. In this study, we consider whether girl child marriage acts as a mediator of the association between proximity to conflict and IPV in the context of Sri Lanka, which sustained long-term conflict until 2009. METHODS: We analyzed responses of currently partnered women between ages 18 and 49 in the 2016 Sri Lankan Demographic and Health Survey (N = 13,691). Using logistic regression analyses, we measured associations between proximity to conflict (residence in districts which were central, proximal, or distal to the regions where the war occurred) and the outcomes of IPV and girl child marriage, and secondarily assessed girl child marriage as a possible mediator of the association between proximity to conflict and past year IPV. RESULTS: Women residing in districts central to conflict, as compared to districts distal to conflict, had increased odds of past year sexual, physical, and emotional IPV, with the odds of sexual IPV increasing the most (adjusted odds ratio/aOR 4.19, 95% confidence interval/CI 2.08-8.41). Residing in districts proximal to conflict compared to those distal to conflict was associated with lower odds of past year physical and emotional IPV, with the greatest decrease in emotional IPV (aOR 0.31, CI 0.18-0.54). Girl child marriage was more likely in districts central to conflict as opposed to those distal to conflict (aOR 1.89, CI 1.22-2.93), and partially mediated the relationship between centrality to conflict and IPV. CONCLUSIONS: Our findings demonstrate that residing in districts central to conflict compared to those distal to conflict is associated with greater odds of IPV and girl child marriage in post-conflict Sri Lanka, with girl child marriage partially mediating the association between centrality to conflict and IPV. Residence in districts proximal to conflict appears protective against IPV. Future research should investigate what factors are responsible for decreased IPV in districts proximal to violence, and whether these factors can be reproduced to mitigate the increased prevalence of IPV in districts central to conflict.

Determinants of contraceptive use among married women in Indonesia.

Background: Contraceptives in family planning are used to control the timings between pregnancies. Although the number of those using family planning has increased, determinants of contraceptive use among married women in Indonesia remain insufficient. This research aimed to identify the factors associated with contraceptive use among married women in Indonesia. Methods: This study employed data from the Indonesian Demographic and Health Survey 2017. We selected 35,621 married women aged 15-49 years. Then, the determinants of contraceptive use among married women in Indonesia were examined by binary logistic regression. Results: Women's age (Adjusted Odds Ratio (AOR)=0.529; 95% CI=0.470-0.597), the number of living children (AOR=44.024; 95% CI=33.193-58.390), education level (adjusted odds ratio=2.800; 95% CI=2.181-3.594), wealth index (AOR=1.104; 95% CI=0.978-1.246), frequency of watching television (AOR=1.555; 95% CI=1.321-1.829), and frequency of using the Internet (AOR=0.856; 95% CI=0.794-0.924) were significantly associated with contraceptive use among married women. Conclusions: This study highlights the determinants of contraceptive use among married women in Indonesia. Women's age, the number of living children, education level, wealth index, and access to information may influence contraceptive use among these women. This study emphasizes that health education and promotion on the importance of using contraception should be initiated in innovative ways.

Drivers of Under-Five Stunting Trend in 14 Low- and Middle-Income Countries since the Turn of the Millennium: A Multilevel Pooled Analysis of 50 Demographic and Health Surveys.

BACKGROUND: Understanding the drivers contributing to the decreasing trend in stunting is paramount to meeting the World Health Assembly's global target of 40% stunting reduction by 2025. METHODS: We pooled data from 50 Demographic and Health Surveys since 2000 in 14 countries to examine the relationships between the stunting trend and potential factors at distal, intermediate, and proximal levels. A multilevel pooled trend analysis was used to estimate the association between the change in potential drivers at a country level and stunting probability for an individual child while adjusting for time trends and child-level covariates. A four-level mixed-effects linear probability regression model was fitted, accounting for the clustering of data by sampling clusters, survey-rounds, and countries. RESULTS: Stunting followed a decreasing trend in all countries at an average annual rate of 1.04 percentage points. Among the distal factors assessed, a decrease in the Gini coefficient, an improvement in women's decision-making, and an increase in urbanization were significantly associated with a lower probability of stunting within a country. Improvements in households' access to improved sanitation facilities and drinking water sources, and children's access to basic vaccinations were the important intermediate service-related drivers, whereas improvements in early initiation of breastfeeding and a decrease in the prevalence of low birthweight were the important proximal drivers. CONCLUSIONS: The results reinforce the need for a combination of nutrition-sensitive and -specific interventions to tackle the problem of stunting. The identified drivers help to guide global efforts to further accelerate stunting reduction and monitor progress against chronic childhood undernutrition.

Early-life exposure to ambient fine particulate air pollution and infant mortality: pooled evidence from 43 low- and middle-income countries.

BACKGROUND: Many low- and middle-income countries are experiencing high and increasing exposure to ambient fine particulate air pollution (PM2.5). The effect of PM2.5 on infant and child mortality is usually modelled using concentration response curves extrapolated from studies conducted in settings with low ambient air pollution, which may not capture its full effect. METHODS: We pool data on more than half a million births from 69 nationally representative Demographic and Health Surveys that were conducted in 43 low- and middle-income countries between 1998 and 2014, and we calculate early-life exposure (exposure in utero and post partum) to ambient PM2.5 using high-resolution calibrated satellite data matched to the child's place of residence. We estimate the association between the log of early-life PM2.5 exposure, both overall and separated by type, and the odds of neonatal and infant mortality, adjusting for child-level, parent-level and household-level characteristics. RESULTS: We find little evidence that early-life exposure to overall PM2.5 is associated with higher odds of mortality relative to low exposure to PM2.5. However, about half of PM2.5 is naturally occurring dust and sea-salt whereas half is from other sources, comprising mainly carbon-based compounds, which are mostly due to human activity. We find a very strong association between exposure to carbonaceous PM2.5 and infant mortality, particularly neonatal mortality, i.e. mortality in the first 28 days after birth. We estimate that, at the mean level of exposure in the sample to carbonaceous PM2.5-10.9 µg/m3-the odds of neonatal mortality are over 50% higher than in the absence of pollution. CONCLUSION: Our results suggest that the current World Health Organization guideline of limiting the overall ambient PM2.5 level to less than 10 µg/m³ should be augmented with a lower limit for harmful carbonaceous PM2.5.

Maternal factors contributing to under-five mortality at birth order 1 to 5 in India: a comprehensive multivariate study.

The objective of the study is to assess maternal factors contributing to under-five mortality at birth order 1 to 5 in India. Data for this study was derived from the children's record of the 2007 India National Family Health Survey, which is a nationally representative cross-sectional household survey. Data is segregated according to birth order 1 to 5 to assess mother's occupation, Mother's education, child's gender, Mother's age, place of residence, wealth index, mother's anaemia level, prenatal care, assistance at delivery , antenatal care, place of delivery and other maternal factors contributing to under-five mortality. Out of total 51555 births, analysis is restricted to 16567 children of first birth order, 14409 of second birth order, 8318 of third birth order, 5021 of fourth birth order and 3034 of fifth birth order covering 92% of the total births taken place 0-59 months prior to survey. Mother's average age in years for birth orders 1 to 5 are 23.7, 25.8, 27.4, 29 and 31 years, respectively. Most mothers whose children died are Hindu, with no formal education, severely anaemic and working in the agricultural sector. In multivariate logistic models, maternal education, wealth index and breastfeeding are protective factors across all birth orders. In birth order model 1 and 2, mother's occupation is a significant risk factor. In birth order models 2 to 5, previous birth interval of lesser than 24 months is a risk factor. Child's gender is a risk factor in birth order 1 and 5. Information regarding complications in pregnancy and prenatal care act as protective factors in birth order 1, place of delivery and immunization in birth order 2, and child size at birth in birth order 4. Prediction models demonstrate high discrimination that indicates that our models fit the data. The study has policy implications such as enhancing the Information, Education and Communication network for mothers, especially at higher birth orders, in order to reduce under-five mortality. The study emphasises the need of developing interventions to address the issues of anaemia, mothers working in the agricultural sector and improving relevant literacy among mothers.