The Interrelationship between Population Dynamics and Childhood Mortality in Butajira District, South Central Ethiopia
Creators: name: Mekonnen, Wubegzier
Publisher: name: National Academic Digital Repository of Ethiopia
Year: 2012

description: The population of Ethiopia is still growing by 2.6% per annum mainly due to high fertility of 4.8 children per woman. Though increasing in the current decade, only about a quarter of married women used family planning methods in 2011. Though early childhood mortality diminished in recent years, this decline was not statistically significant in infant mortality. Levels and extent of reductions in the three components of population change and their relationships varied across different regions and by urban-rural setting in the country. Previous studies elsewhere showed relationship between population dynamics and health. Studies also revealed that intervention in one component of population change affects another component. A body of literature on insurance and replacement fertility response of childhood mortality were documented in least developing countries. Moreover, selection, disruption, adaptation, environmental theories had also documented the relationship between migration with fertility and under-five mortality. Migration might select people with different fertility behavior and childhood mortality experience compared to those without such behavior. If those with less number of children migrate, the fertility and child mortality of non-migrants in the place of origin would be inflated compared to those of the migrants. Among the latter group, the disruption due to migration might contribute to reduction in fertility or increase in early childhood mortality. Besides, the group might adapt the fertility behavior of the population in the area of destination. In this regard, this thesis aimed at measuring levels of and assessing relationships between fertility, contraception, under-five mortality and migration in the designated area of the study. It also tried to identify main proximate and distal factors of each of these components of population change in the context of the recently introduced village-based health extension program, reproductive health strategy and population policy in the densely populated Butajira District of South Central Ethiopia. Methods The study was hosted by the Butajira Demographic Surveillance System which is located about 135 kms from Addis Ababa in the southern direction. Qualitative and quantitative methods were employed in this study. The quantitative research used two data sources. The longitudinal surveillance database up to the end of 2008 was extracted to recruit study women of reproductive age for the cross-sectional study which aimed at measuring levels and identifying determinants of fertility, contraception and the unmet need of family planning. The database was also used to have a detailed insight into early childhood mortality and out-migration in the district. Standard data collection instruments of the INDEPTH-Network and Measure DHS were contextually adapted for the longitudinal database and the cross-sectional survey respectively. A priori focus group discussions were held to incorporate the community's terminologies and opinions. A total of 11,133 women of reproductive age were recruited from the surveillance database and 9,996 of them responded positively. Especially trained and experienced field staff collected the data. There was rigorous supervision. Data sources were managed by softwares having internal consistency checking mechanisms. Cleaning was done at desk. Serious anomalies were taken back to the field for reconciliation, while others were rectified by imputing values from logical flows in the questionnaire. Frequency distributions, cross-tabulations and graphical presentations were done. Event history analysis was used to calculate person time of exposure, incidence and prevalence rates using longitudinal data. Odds ratio along with the 95% confidence interval in binary logistic regression was used to determine association between covariates and the binary outcome of interest. In the case of fertility, Bongaart's model to measure the inhibition effects of proximate determinants and the incidence rate ratio in Poisson regression along with the 95% confidence interval was used to measure the association between fertility and covariates. Poisson regression was also used to measure associations of background characteristics with out-migration and under-five mortality. Assumptions of all the statistical models used in this study were checked. Results The total fertility rate of 5.3 children per woman was high and comparable to the rest of Ethiopia with rural-urban disparity (Highland, TFR=5.7, Lowland, TFR=6.6 and Urban, TFR=3.3). Postpartum infecundability due to breastfeeding (Ci=0.68) significantly deducted fertility from its biological maximum. The contribution of contraception (Cc-u=0.57, Cc-e=0.43) and nonmarriage (Cm-u=0.53, Cm-e=0.41) was important among urbanites and educated women. Abortion contributed a significant role to reduce fertility among school youth (Ca=0.76). The fertility incidence rate ratio was 1.38: 95% CI (1.27, 1.49) times higher among those married before their 15 birthday, 1.24: 95% CI (1.10, 1.39) times higher among uneducated, 1.95: 95% CI (1.84, 2.06) times higher among those families with large size, 1.67: 95% CI (1.59, 1.76) times higher with child death experience and 1.06: 95% CI (1.01, 1.13) times higher among women living in food-secured households compared to their counterparts. Against other findings, fertility was 1.09: 95% CI (1.04, 1.15) significantly higher among women with no child sex preference. Besides, migration status of women did not seem to predict their fertility levels (1.02: 95% CI (0.97, 1.07)). The contraceptive prevalence rate of 25.4%: 95% CI (24.2, 26.5) in Butajira District was comparable though unmet need of 52.4%: 95% CI (51.1, 53.7) was very high compared to national and regional estimates. Full stock out and absence of methods' mix, religion, complaints related to providers and methods, assumption of having proper diet, and optimum workload when using family planning methods were barriers of contraceptive use mentioned by study women in the area. The odds of contraception was 2.3: 95% CI (1.66, 3.18) times higher among urbanites, 1.99: 95% CI (1.38, 2.88) times higher among those completed secondary level of education and 1.5: 95% CI (1.12, 2.01) times higher among women whose partners completed secondary plus level of education, 1.3: 95% CI (1.13, 1.5) times higher among women with no experience of child death, 2.21: (1.8, 2.7) times higher among couples who discussed on contraception and 2.59: 95% CI (2.11, 3.17) times higher among women whose partners' support family planning use compared to their counterparts. Under-five mortality level of 29 per 1000: 95% CI (27.4, 31.8) in the District recorded over the 22 years of surveillance was low. The difference between infant mortality of 86.6 per 1000: 95% CI (77.4, 96.9) and child mortality of 19.2 per 1000: 95% CI (17.4, 21.3) was higher. Compared to their counterparts, the study also showed 0.85: 95% CI (0.79, 0.80) times lower under-five mortality among female children, 1.14: 95% CI (1.03, 1.25) times higher under five mortality among Muslim and 15.24: 95% CI (13.75, 16.89) times higher among minority Christian families, 1.31: 95% CI (1.04, 1.66) and 2.02: 95% CI (1.58, 2.59) times higher among rural highlanders and rural lowlanders respectively, 1.54: (1.43, 1.67) times higher among families owning oxen, and 1.92: 95% CI (1.66, 2.22) times higher among families owning houses and 2.4: 95% CI (1.89, 2.06) times higher among those living in rented houses and 2.13: 95% CI (1.79, 2.53) times higher in children living in houses roofed with thatched grass, and 1.46: 95% CI (1.26, 1.69) times higher among those living in the neighborhoods located 5-9 kilometers away from Butajira zonal hospital. The study also revealed high out-migration of 3.97 per 100 person years (3.93, 4.01) in the district. The risk of out-migration was 0.94: 95% CI (0.92, 0.96) times lower among females, 1.9: 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% CI (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), 1.18: 95% CI (1.15, 1.22), 1.58: 95% CI (1.52, 1.64) and 2.11: 95% (2.04, 2.18) times higher among teenagers, the youth, unmarried, primary school completes or above, Orthodox and minority Christians, urbanites, and those living in rented houses and owned by others compared to their respective counterparts. Some relationship between the three components of population change was also observed. There was statistically significant association between early childhood mortality and fertility (6.07: 95% CI (5.36, 6.87)). However, the association between fertility and migration status was not statistically significant (1.05: 95% CI (0.92, 1.19)). Neither was the association between underfive mortality and migration statistically significant (1.04: 95% CI (0.92, 1.19)). Conclusions and Recommendations Fertility was still high in the study community with high rural urban disparity. The most effective proximate determinant to deduct fertility from its biological maximum level was non-marriage due to disruption of marriage through migration of one of the partners. The contribution of contraception and non-marriage was also important among urbanites and educated women. Postpartum infecundability also significantly reduced fertility from its biological maximum in rural areas and among uneducated women. Abortion had also played an important role in reducing fertility among in-school youth. Delayed marriage, higher education, smaller family size, absence of child death in the family, and living in food-secured households were also significantly associated with small number of children. Besides, fertility was significantly higher among women with no child sex preference. However, migration status of women was not statistically significant. The contraceptive prevalence rate in Butajira District was still low, though unmet need was very high. Barrier to contraception in the area included, stock out and absence of preferred family planning methods, religion, complaints related to providers and methods, assumption of having proper diet, and optimum workload when using family planning methods. Significant predictors of contraception in the district included urban residence, women's and their partners' educational status, child death experience, couple's discussion on contraception, and partners' support. The magnitude of overall early childhood mortality levels in the district recorded over the 22 years of surveillance, though low compared to the national and regional level was still high. Infant mortality was higher than child mortality in the district. Under-five mortality was significantly higher among male children, families confessing Muslim and non-Orthodox Christian denominations, rural residents, families owning oxen, those having their own houses, families living in rent-free houses, households living in houses with roofs of thatched grass, and families living in neighborhoods located between 5-9 kilometers from the zonal hospital as compared with their counterparts. A high incidence of out-migration was observed in the district with higher level among males, teenagers, the youth, primary and secondary education or above completes, those not in marital unions, Christians, urbanites, and families in rented and owed houses compared to those in owned ones. This study had also showed statistically significant association between early childhood mortality and fertility. The association between fertility and migration was not statistically significant. Neither was the case between early childhood mortality and migration in the study area. We recommend that the ills of fast population growth and its consequences should be intensively informed to the public. Women must be encouraged to sustain the practice of extended breastfeeding. Efforts should also be exerted to increase contraceptive use in rural communities. Besides, in-school youth should be aware of post-abortion complications and youth friendly family planning methods to reduce fertility, maternal mortality and childhood mortality in the community. Longer years of women's education should be scaled up. Health systems in Butajira District and the capacity of staff should be strengthened. The Government should avail family planning methods with appropriate method mix and increase competence of providers on managing temporary side effects. More rigorous child and maternal health education should be channeled through village-based health extension workers. Household hygiene, antenatal care, immunization and facility based delivery in the district should be scaled up. More efforts should also be exerted to improve the quality of residential houses. An insurance scheme to care for the elderly should be put in place to bring about change in the behavior of families towards small family size. We suggest that local authorities need to facilitate local employment and housing opportunities for retaining young and educated people in their own areas, to safeguard the future well-being of the entire population