The Interrelationship Between Population Dynamics And Childhood Mortality In Butajira District South Central Ethiopia

The population of Ethiopia is still growing by 2.6% per annum mainly due to high fertility of 4.8rnchildren per woman. Though increasing in the current decade, only about a quarter of marriedrnwomen used family planning methods in 2011. Though early childhood mortality diminished inrnrecent years, this decline was not statistically significant in infant mortality. Levels and extent ofrnreductions in the three components of population change and their relationships varied acrossrndifferent regions and by urban-rural setting in the country.rnPrevious studies elsewhere showed relationship between population dynamics and health.rnStudies also revealed that intervention in one component of population change affects anotherrncomponent. A body of literature on insurance and replacement fertility response of childhoodrnmortality were documented in least developing countries. Moreover, selection, disruption,rnadaptation, environmental theories had also documented the relationship between migration withrnfertility and under-five mortality. Migration might select people with different fertility behaviorrnand childhood mortality experience compared to those without such behavior. If those with lessrnnumber of children migrate, the fertility and child mortality of non-migrants in the place ofrnorigin would be inflated compared to those of the migrants. Among the latter group, therndisruption due to migration might contribute to reduction in fertility or increase in earlyrnchildhood mortality. Besides, the group might adapt the fertility behavior of the population in thernarea of destination.rnIn this regard, this thesis aimed at measuring levels of and assessing relationships betweenrnfertility, contraception, under-five mortality and migration in the designated area of the study. Itrn rn rnalso tried to identify main proximate and distal factors of each of these components of populationrnchange in the context of the recently introduced village-based health extension program,rnreproductive health strategy and population policy in the densely populated Butajira District ofrnSouth Central Ethiopia.rnMethodsrnThe study was hosted by the Butajira Demographic Surveillance System which is located aboutrn135 kms from Addis Ababa in the southern direction. Qualitative and quantitative methods werernemployed in this study. The quantitative research used two data sources. The longitudinalrnsurveillance database up to the end of 2008 was extracted to recruit study women of reproductivernage for the cross-sectional study which aimed at measuring levels and identifying determinantsrnof fertility, contraception and the unmet need of family planning. The database was also used tornhave a detailed insight into early childhood mortality and out-migration in the district. Standardrndata collection instruments of the INDEPTH-Network and Measure DHS were contextuallyrnadapted for the longitudinal database and the cross-sectional survey respectively. A priori focusrngroup discussions were held to incorporate the community’s terminologies and opinions. A totalrnof 11,133 women of reproductive age were recruited from the surveillance database and 9,996 ofrnthem responded positively.rnEspecially trained and experienced field staff collected the data. There was rigorous supervision.rnData sources were managed by softwares having internal consistency checking mechanisms.rnCleaning was done at desk. Serious anomalies were taken back to the field for reconciliation,rnwhile others were rectified by imputing values from logical flows in the questionnaire.rnFrequency distributions, cross-tabulations and graphical presentations were done. Event historyrnanalysis was used to calculate person time of exposure, incidence and prevalence rates usingrn rn rnlongitudinal data. Odds ratio along with the 95% confidence interval in binary logistic regressionrnwas used to determine association between covariates and the binary outcome of interest. In therncase of fertility, Bongaart’s model to measure the inhibition effects of proximate determinantsrnand the incidence rate ratio in Poisson regression along with the 95% confidence interval wasrnused to measure the association between fertility and covariates. Poisson regression was alsornused to measure associations of background characteristics with out-migration and under-fivernmortality. Assumptions of all the statistical models used in this study were checked.rnResultsrnThe total fertility rate of 5.3 children per woman was high and comparable to the rest of Ethiopiarnwith rural-urban disparity (Highland, TFR=5.7, Lowland, TFR=6.6 and Urban, TFR=3.3).rnPostpartum infecundability due to breastfeeding (Ci=0.68) significantly deducted fertility fromrnits biological maximum. The contribution of contraception (Cc-u=0.57, Cc-e=0.43) and nonmarriagern(Cm-u=0.53, Cm-e=0.41) was important among urbanites and educated women. Abortionrncontributed a significant role to reduce fertility among school youth (Ca=0.76). The fertilityrnincidence rate ratio was 1.38: 95% CI (1.27, 1.49) times higher among those married before theirrn15 birthday, 1.24: 95% CI (1.10, 1.39) times higher among uneducated, 1.95: 95% CI (1.84,rn2.06) times higher among those families with large size, 1.67: 95% CI (1.59, 1.76) times higherrnwith child death experience and 1.06: 95% CI (1.01, 1.13) times higher among women living inrnfood-secured households compared to their counterparts. Against other findings, fertility wasrn1.09: 95% CI (1.04, 1.15) significantly higher among women with no child sex preference.rnBesides, migration status of women did not seem to predict their fertility levels (1.02: 95% CIrn(0.97, 1.07)).rn rn rnThe contraceptive prevalence rate of 25.4%: 95% CI (24.2, 26.5) in Butajira District wasrncomparable though unmet need of 52.4%: 95% CI (51.1, 53.7) was very high compared tornnational and regional estimates. Full stock out and absence of methods’ mix, religion, complaintsrnrelated to providers and methods, assumption of having proper diet, and optimum workloadrnwhen using family planning methods were barriers of contraceptive use mentioned by studyrnwomen in the area. The odds of contraception was 2.3: 95% CI (1.66, 3.18) times higher amongrnurbanites, 1.99: 95% CI (1.38, 2.88) times higher among those completed secondary level ofrneducation and 1.5: 95% CI (1.12, 2.01) times higher among women whose partners completedrnsecondary plus level of education, 1.3: 95% CI (1.13, 1.5) times higher among women with nornexperience of child death, 2.21: (1.8, 2.7) times higher among couples who discussed onrncontraception and 2.59: 95% CI (2.11, 3.17) times higher among women whose partners’ supportrnfamily planning use compared to their counterparts.rnUnder-five mortality level of 29 per 1000: 95% CI (27.4, 31.8) in the District recorded over thern22 years of surveillance was low. The difference between infant mortality of 86.6 per 1000: 95%rnCI (77.4, 96.9) and child mortality of 19.2 per 1000: 95% CI (17.4, 21.3) was higher. Comparedrnto their counterparts, the study also showed 0.85: 95% CI (0.79, 0.80) times lower under-fivernmortality among female children, 1.14: 95% CI (1.03, 1.25) times higher under five mortalityrnamong Muslim and 15.24: 95% CI (13.75, 16.89) times higher among minority Christianrnfamilies, 1.31: 95% CI (1.04, 1.66) and 2.02: 95% CI (1.58, 2.59) times higher among ruralrnhighlanders and rural lowlanders respectively, 1.54: (1.43, 1.67) times higher among familiesrnowning oxen, and 1.92: 95% CI (1.66, 2.22) times higher among families owning houses andrn2.4: 95% CI (1.89, 2.06) times higher among those living in rented houses and 2.13: 95% CIrn(1.79, 2.53) times higher in children living in houses roofed with thatched grass, and 1.46: 95%rn rn rnCI (1.26, 1.69) times higher among those living in the neighborhoods located 5-9 kilometersrnaway from Butajira zonal hospital.rnThe study also revealed high out-migration of 3.97 per 100 person years (3.93, 4.01) in therndistrict. The risk of out-migration was 0.94: 95% CI (0.92, 0.96) times lower among females,rn1.9: 95% CI (1.85, 1.96), 1.77: 95% CI (1.71, 1.82), 1.55: 95% CI (1.49, 1.62), 1.23: 95% CIrn(1.17, 1.29) or 2.82: 95% CI (2.66, 2.98), 1.29: 95% CI (1.26, 1.32), 4.71: 95% CI (4.56, 4.87),rn1.18: 95% CI (1.15, 1.22), 1.58: 95% CI (1.52, 1.64) and 2.11: 95% (2.04, 2.18) times higherrnamong teenagers, the youth, unmarried, primary school completes or above, Orthodox andrnminority Christians, urbanites, and those living in rented houses and owned by others comparedrnto their respective counterparts.rnSome relationship between the three components of population change was also observed. Therernwas statistically significant association between early childhood mortality and fertility (6.07:rn95% CI (5.36, 6.87)). However, the association between fertility and migration status was notrnstatistically significant (1.05: 95% CI (0.92, 1.19)). Neither was the association between underfivernmortality and migration statistically significant (1.04: 95% CI (0.92, 1.19)).rnConclusions and RecommendationsrnFertility was still high in the study community with high rural urban disparity. The most effectivernproximate determinant to deduct fertility from its biological maximum level was non-marriagerndue to disruption of marriage through migration of one of the partners. The contribution ofrncontraception and non-marriage was also important among urbanites and educated women.rnPostpartum infecundability also significantly reduced fertility from its biological maximum inrnrural areas and among uneducated women. Abortion had also played an important role inrn rn rnreducing fertility among in-school youth. Delayed marriage, higher education, smaller familyrnsize, absence of child death in the family, and living in food-secured households were alsornsignificantly associated with small number of children. Besides, fertility was significantly higherrnamong women with no child sex preference. However, migration status of women was notrnstatistically significant.rnThe contraceptive prevalence rate in Butajira District was still low, though unmet need was veryrnhigh. Barrier to contraception in the area included, stock out and absence of preferred familyrnplanning methods, religion, complaints related to providers and methods, assumption of havingrnproper diet, and optimum workload when using family planning methods. Significant predictorsrnof contraception in the district included urban residence, women’s and their partners’ educationalrnstatus, child death experience, couple’s discussion on contraception, and partners’ support.rnThe magnitude of overall early childhood mortality levels in the district recorded over the 22rnyears of surveillance, though low compared to the national and regional level was still high.rnInfant mortality was higher than child mortality in the district. Under-five mortality wasrnsignificantly higher among male children, families confessing Muslim and non-OrthodoxrnChristian denominations, rural residents, families owning oxen, those having their own houses,rnfamilies living in rent-free houses, households living in houses with roofs of thatched grass, andrnfamilies living in neighborhoods located between 5-9 kilometers from the zonal hospital asrncompared with their counterparts.rnA high incidence of out-migration was observed in the district with higher level among males,rnteenagers, the youth, primary and secondary education or above completes, those not in maritalrn rn rnunions, Christians, urbanites, and families in rented and owed houses compared to those inrnowned ones.rnThis study had also showed statistically significant association between early childhoodrnmortality and fertility. The association between fertility and migration was not statisticallyrnsignificant. Neither was the case between early childhood mortality and migration in the studyrnarea.rnWe recommend that the ills of fast population growth and its consequences should be intensivelyrninformed to the public. Women must be encouraged to sustain the practice of extendedrnbreastfeeding. Efforts should also be exerted to increase contraceptive use in rural communities.rnBesides, in-school youth should be aware of post-abortion complications and youth friendlyrnfamily planning methods to reduce fertility, maternal mortality and childhood mortality in therncommunity. Longer years of women’s education should be scaled up. Health systems in ButajirarnDistrict and the capacity of staff should be strengthened. The Government should avail familyrnplanning methods with appropriate method mix and increase competence of providers onrnmanaging temporary side effects. More rigorous child and maternal health education should bernchanneled through village-based health extension workers. Household hygiene, antenatal care,rnimmunization and facility based delivery in the district should be scaled up. More efforts shouldrnalso be exerted to improve the quality of residential houses. An insurance scheme to care for thernelderly should be put in place to bring about change in the behavior of families towards smallrnfamily size. We suggest that local authorities need to facilitate local employment and housingrnopportunities for retaining young and educated people in their own areas, to safeguard the futurernwell-being of the entire population

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