Preventable multiple high-risk birth behaviour and infant survival in Nigeria

Infant Mortality which is the probability of a child dying between birth and the first birthday is one of the most useful indicators for assessing the general level of health and development of a society. It gives an overview of the functionality of a country’s healthcare system, socioeconomic situation, and the state of maternal and child health. Globally, 85 and 29% of deaths among children occurred in the first 5 years of life and during infancy respectively. More than 50 % of these deaths occurred in Sub-Sahara Africa (SSA) with Infant Mortality Rate (IMR) of 62 deaths per 1000 in 2018 [1]. Improvement in child health, survival and life expectancy has been a concerted and continuous global effort as indicated in the Sustainable Development Goals – 3 (SDGs 3) which aims to end preventable deaths among children under-5 years of age and targets reduction of under-five mortality to as low as 25 per 1000 live births by 2030 [2]. However, feasibility of the realization of this target is doubtful due to slow pace of mortality reduction in SSA as many countries in this world sub-region may likely fall short of the SDG target [1].

Nigeria with a population of over 200 million is one of the five countries that accounted for half of global burden of infant mortality occupying a second position after India [1, 3]. In Nigeria, previous studies have estimated a decline in IMR from 125 in 1990 to 67 in 2018 [3, 4]. Despite this achievement in IMR reduction over the years, the current level is higher than the IMR estimates for other countries in SSA like South Africa (28/1000), Kenya (31/1000) and Ghana (35/1000) which are already close to achieving the SDGs - target 3. Survival of infants in Nigeria is challenged by the prevailing poor health service delivery and malnutrition as a result of poverty which ravages the nation. Some preventable health/environmental related conditions (infectious diseases, chronic health conditions of the mother, obstetric and non-obstetric complications, lack of immunization, and other prevalent childhood diseases), socio-demographic characteristics (place of residence, region, religion, marital status and education level) and biological factors associated with mothers have been found in the literature as additional sources of threat to the survival chances of infants in Nigeria [1, 5‐7]. It is important to note that risk of adverse pregnancy outcome like infant mortality are unevenly distributed among women population owing to the variation in their biologic features and demographic composition [8].

High-risk Birth Behaviours (HrBBs) in the context of this study was defined in terms of three preventable characteristics, namely; mother’s age at delivery which can either be too young (less than 18 years) or too old (greater than 35 years), shorter or longer birth interval, and a high parity [9, 10]. These characteristics have been a major public health challenge to child survival in developing countries particularly Nigeria where little or no efforts are put in place to improve the health status of children. Studies have reported that teenage pregnant mothers have a greater risk of having pre-term birth, low birth weight, stillbirths and more importantly infant mortality [8, 11‐13]. These unacceptable birth outcomes and child health have been linked to biological vulnerability, socioeconomic factors or inexperience of mothers in terms of pregnancy and child care management such as exclusive breastfeeding and nutritional support [8]. Women’s age at marriage has somewhat increased in Nigeria with a resultant increase in age at childbirth owing to the impact of the socioeconomic changes, such as improvements in school enrolment, increased modern contraceptives use and economic opportunities [13]. Studies have reported that women who gave birth at ages 35 years and above have a higher risk of infant mortality [14‐17]. A study by Yogev et al. to determine pregnancy outcome at advanced maternal age reported that advanced maternal age of greater than 35 years is associated with higher risk of maternal, hormonal disorder, and low uteroplacental blood flow which increases the risk of congenital and chromosomal abnormalities such as downs syndrome that results in fetal complications with resultant infant death [17]. Studies showed that children born to young mothers (under age 18), had a 20% greater risk of dying in the first year of life, and children born to mothers ages 35–39 and 40 or older have a 20% and 50% greater risk of dying in the first year of life, respectively [9, 18, 19].

The established relationship between infant mortality and birth interval has been consistent in the literature. Short and longer birth interval increased the risk of infant mortality, often referred to as a U-shape hypothesis [9, 20, 21] Inability of the mother to give adequate care to the index child in terms of nutrition, optimal health and support, especially if the preceding child was born not too long ago has been found to be responsible for the direction of the association [9]. In a poverty-stricken environment like Nigeria, children born to high parity women may not have access to adequate care and this could impact negatively on their survival chances [10, 22]. The Nigerian population policy emphasizes that family size should be restricted to not more than four children [23]. Unfortunately, studies conducted in Nigeria after the enactment and implementation of this policy reported that most families still have more than the stipulated family size with a total fertility rate of 5.3 [24]. In a high family size situation, the harsh socioeconomic condition in Nigeria could limit an individual’s ability to provide basic needs for the family, particularly for infants who are the most vulnerable to morbidity and mortality [7, 13]. Moreover, some women exhibit more than one of these HrBBs at the same time which increases their risk of having children that are prone to death before the age of 1 year [11, 24, 25].

Studies have been conducted in Nigeria based on the independent analysis of maternal age at childbirth, short birth interval, high parity and infant survival [18]. However, very few studies examined the relationship between the combination of these factors as an entity and infant mortality. Against the backdrop of limited research on the association of HrBBs and infant mortality, the current study investigated the influence of the HrBBs (mother’s age at childbirth < 18 years or > 34 years, preceding birth interval < 24 months or > 59 months, and number of children ever born > 4) on infant mortality. The specific objectives of the study are to; assess the association between HrBBs and infant mortality in Nigeria, to examine if HrBBs is a predictor of infant mortality amidst other factors. The outcome of this study will inform policy geared towards the improvement of survival chances among children in Nigeria.

The global efforts with various intervention to reduce Infant Mortality Rate (IMR) has yielded progress in most parts of the world except in sub-Sahara Africa where infant mortality is still unacceptably high and account for more than 50 % of global infant death. Sadly, Nigeria is one of the five countries of the world that account for this poor statistic. Infant survival has been unduly affected by several preventable factors such as health/environmental related conditions, socio-demographic and biological characteristics of the mothers. Most importantly, the bio-demographic characteristics of mothers which is referred to as High-risk Birth Behaviours (HrBBs) has a strong impact on infant survival. This study therefore examined the influence of the combination of these three risk factors on infant survival in Nigeria.

Our findings showed that the higher the number of HrBBs engaged by infants’ mothers, the higher the likelihood of the infant mortality. Similar studies conducted in Nigeria substantiates this finding [13, 27]. A national survey in Bangladesh and multi-country studies also found that the more birth risks a child faces, the higher the risk of dying [9, 28]. Yogev et al. in a study to determine pregnancy outcome at advanced maternal age found out that advanced maternal age of greater than 35 years is associated with higher risk of maternal, hormonal disorder, and low uteroplacental blood flow which increases the risk of congenital and chromosomal abnormalities that results in fetal complications. In addition, children born to mothers aged 35–39 and 40 or older have a 20% and 50% greater risk of dying in the first year of life, respectively [29]. Studies showed that children born to young mothers (under age 18), had a 20% greater risk of dying in the first year of life [9, 17]. Young mothers have the tendency of having immature or underdeveloped physical and biological attributes with associated poor nutritional status which impact their reproductive capabilities. This has a direct effect on fetal development and survival.

Furthermore, the effect of a short birth interval of less than 24 months has been shown to affect infant survival, this harmful effects of a non–optimal preceding birth interval are concentrated in early infancy [20]. High parity also influences the chances of child survival as most mothers with many children tend to belong to lower socioeconomic status. They often have low or no formal education status, live in less favourable lifestyle, hence their children often suffer neglect [22]. The findings from previous studies on the association between each of the three factors used for the creation of HrBBs and infant survival was consistent with that of the combined HrBBs demonstrated in the current study [9, 25].

Additionally, other predictors of infant death found in our study were being a male child, mothers who did not receive tetanus injection, babies with small birth size, delayed breastfeeding initiation and unskilled birth attendant . This is consistent with research findings from similar studies [25, 30, 31]. An unskilled birth attendant is one of the health service delivery challenges in Nigeria. Unskilled birth attendants do not have the skill or expertise to risk stratify pregnancy, prevent or treat complications during childbirth or delivery. They are unable to handle childbirth complications; hence, contributing to high rate of infant deaths in Nigeria [32].

Other socioeconomic factors that influence infant deaths were; mothers who had primary or no formal education level, region of residence and ethnicity. Research has documented that education offers mothers increased access to health information and connections with resources for infant health; services, healthcare professionals and effective use of the health care system [33‐35]. Education also gives more awareness for good health behaviours. Hence, infants who have educated mothers have lower infant mortality risks. Infants born to mothers from the Northwest region and of Hausa tribe had higher chances of dying has reported in our study. Similar studies from Nigeria reported this finding [25, 36]. Of note is the wide regional disparities in socioeconomic status, health service delivery, resource availability and allocation in Nigeria [36]. The southern states are known to have more health facilities and skilled personnel than the northern states. This region is also characterized with highest proportion of persons with no education which reduces their chances of access to health information [27]. In addition, women in this region start childbearing at younger ages, with possibility of having immature reproductive system; little or no experience with child birth and care. It is also important to note that women in this region have less autonomy compared to women in other regions of the country [27]. Hence, they have no control over household resources which could enhance their health seeking behaviour and health service utilisation.

Our study also found that non-use of contraceptive commodities among the mothers increased the risk of infant mortality as compared with mothers that used contraceptives. Non-use of contraceptives expose women to the risk of unplanned and undesired births which may account for high parity and subject the infants to neglect and improper care especially in the midst of ravaging poverty [37]. This further emphasised the low contraceptive prevalence rate in Nigeria as about 15 % of women are currently using contraceptive [38]. Low contraceptive usage may lead to a quick pregnancy state which often does not allow the mother to have full physical, psychological, physiological and anatomical recovery from previous births. Thus, she may not be fully prepared for subsequent pregnancy and births in terms of her reproductive and socioeconomic capacity. This may have a huge impact on maternal health with resultant birth of infants with health challenges coupled with inadequate care [39].

Aside the sampling errors that can limit the extent to which the findings from this study can be generalized to the entire population, the cross-sectional nature of the data used for this study inhibits the causal relationship between HrBBs and infant mortality. To attribute infant death to high risk birth behavior, further studies that will use cohort or quasi-experimental design approach are thus recommended. The use of a large nationally representative data remains a strength of this study.

HrBBs is an important predictor of infant mortality and multiple HrBBs increase the chances of death among infants in Nigeria. Screening women for HrBBs for special health attention during pregnancy, birth and postnatal period is essential in alleviating infant death in Nigeria. It is important to create awareness and health education for women, men and families on risk factors of infant deaths such as maternal age, short birth interval and high parity . There is also a need to design interventions to improve female education and economic empowerment which could delay age at marriage for woman till 18 years, when they are matured to take decisions and capable of reproductive health events. At the same time, women will benefit from more awareness and counselling on the risks associated with late childbearing.