Challenges in reducing high grand multiparity rates in Ethiopia: EDHS data 2000-2019 toward Sustainable Development Goals 2030: Using multilevel model approach

Challenges in reducing high grand multiparity rates in Ethiopia: EDHS data 2000-2019 toward Sustainable Development Goals 2030: Using multilevel model approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Challenges in reducing high grand multiparity rates in Ethiopia: EDHS data 2000-2019 toward Sustainable Development Goals 2030: Using multilevel model approach Diriba Dibaba, Tesfaye Getachow Charkos This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5136441/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Feb, 2025 Read the published version in Contraception and Reproductive Medicine → Version 1 posted 15 You are reading this latest preprint version Abstract Background One of the Sustainable Development Goals (2030) focuses on reducing the total fertility rate. Reducing grand multiparity in Ethiopia remains a challenge. Understanding the underlying factors that contribute to this issue is crucial for explaining why grand multiparity remains prevalent despite various health interventions and socio-economic progress. Methods A community-based cross-sectional study was conducted using data from the Ethiopian Demographic and Health Survey 2000–2019. Multilevel multivariable logistic regression analysis was employed to model the hierarchical data. The final findings were presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI). A p-value < 0.05 was considered statistically significant. Result The trend analysis of grand multiparity over 19 years in Ethiopia shows no significant change (linear trend = 1.23, p = 0.27). The prevalence of grand multiparity slightly decreased from 72% in the 2000 EDHS to 66.3% (95% CI: 65.7% − 66.96%) according to the mini EDHS 2019 data. Among individual-level variables, the following were significantly associated with grand multiparity: wealth index, currently married, maternal education, non-family planning, short-acting family planning users, age at first birth < 18 years, and short birth intervals. Among community-level variables, being a rural resident was significantly associated with grand multiparity. Conclusion A 19-year trend analysis in Ethiopia shows no significant change in grand multiparity rates, with a slight decrease from 72% in 2000 to 66.3% in 2019. Significant factors associated with grand multiparity include wealth index, marital status, educational level, family planning utilization, age at first birth, birth interval, and place of residence. Trend Magnitude Grand multiparity Reproductive age Multilevel Ethiopia Figures Figure 1 Figure 2 What is already known on this topic Grand multiparity in Ethiopia has remained high, as indicated by data from the past four Demographic and Health Surveys (DHS) conducted between 2000 and 2016. What this study adds Yet no significant change in grand multiparity rates compared with the past four EDH survey 2000-2016. It is a large population based survey, in which the findings were robust. Key factors significantly associated with grand multiparity include wealth index, marital status, educational level, family planning utilization, age at first birth, birth interval, and place of residence. How this Study might affect research, practice or policy The government should implement interventions targeting the identified factors to reduce the rates of grand multiparity and improve maternal and child health outcomes. Introduction Grand multiparty is a major public health concern in developing countries, particularly in sub-Saharan Africa, including Ethiopia [ 1 ]. It is a high-risk pregnancy condition in which the mother, fetus, and/or baby are more likely to suffer from morbidity or die during pregnancy, delivery, or the postpartum period [ 2 ]. Similar to infectious disease, grand multiparity remains a major public health issue in underdeveloped nations, where its prevalence ranges between 30–90% [ 3 ]. In contrast, it is becoming less of a concern in many industrialized countries, with a low incidence of 2–4% [ 4 – 6 ]. In 2019, the global fertility rate was 2.5, a decline from 3.2 live births per woman in 1990. However, Sub-Saharan Africa experienced an increase, reaching 4.6 in 2019 [ 7 , 8 ]. In comparison to high-income countries, perinatal outcomes problems are still quite common in low- and middle-income countries [ 7 , 9 – 11 ]. Evidence has shown that grand multiparity increases the incidence of medical and obstetric complications such as anemia, birth asphyxia, preterm birth, low birth weight, macrosomia, stillbirth, and a high perinatal mortality rate [ 12 – 14 ]. Studies conducted in developing countries suggested that adverse perinatal outcomes are significantly associated with grand multiparity compared with multiparity [ 15 – 18 ]. One of the sustainable developmental goals (2030) [ 19 ] is reducing the total fertility rate, by providing need-based family planning and promoting the welfare of reproductive-age wome [ 18 ]. Reducing grand multiparity remains a challenge in Ethiopia. Therefore, understanding these factors will help explain why grand multiparity remains prevalent despite various health interventions and socio-economic advancements. Methods Study setting and design This study was based on EDHS data collected from 2000–2019, which was a nationwide representative cross-sectional study. The data were collected every five years from all regional states of Ethiopia, and it was freely available online at https://dhsprogram.com/ . The survey questionnaire includes information about population, health, and other important indicators. The study subjects were selected based on two-stage stratified sampling techniques. Each region was divided into urban and rural areas, creating 21 sampling strata. A total of 305 enumeration areas (EAs) were independently selected. Implicit stratification and proportional allocation were ensured by sorting the sampling frame within each stratum by administrative units and using probability proportional to size selection in the first stage (26). A total of 21861 women who had at least one live birth during their lifetime were included in this study. Study variables The dependent variable in this study was grand multiparity (yes or no). The independent variables include place of residence, maternal age, education status, wealth index, current marital status, polygamous marriage status, religion, community media exposure, maternal age at first birth, preceding birth interval (months), type of contraceptive used, and place of delivery. Community-level variables were religion, place of residence, and community media exposure status. Operational definition Grand multiparty: is defined as five births or more following a gestational age of 28 weeks or a fetal weight of 1000 gm or more (1). Multiparity: is defined as 2–4 five births following a gestational age of 28 weeks or a fetal weight of 1000 gm or more ). The birth interval: of reproductive-age women was categorized as a short birth interval (birth interval less or equal to 36 months) and a normal birth interval (greater than 36 months) (29). Data analyses Descriptive statistics, mean ± standard deviation was used for continuous normally distributed variables. While frequency (percentage) was used for categorical variables. The trend analysis was tested using the extended Mantel Haenszel χ2 test for the linear trend using the OpenEpi (V.3.01) (30). The EDHS data naturally nested structure within the region, as a result, the test of intra-class correlation (ICC) was used to determine the existence of variability within the cluster. It was found that ICC = 32%, which implies a multilevel model is appropriate. A multilevel multivariable logistic regression analysis was used. The multilevel logistic regression model contains a series of four models. The null model: is fitted without explanatory variables. Model II: is fitted with individual-level variables. Model III: is used to examine the association of community-level variables with grand multiparity. Model IV: finally, both individual and community-level variables were fitted together to examine the combined effect on grand multiparity. The final model was used to check for the independent effect of the individual-level and community-level variables on the grand multiparty, with a 95% CI and a p-value. A p-value less than 0.05 was considered statistically significant. The model's fitness was assessed using the Akaike information criterion (AIC), the Bayesian information criterion (BIC), and the likelihood ratio test. The values for each model of AIC and BIC were compared, with the lowest one assumed to be a better explanatory model (31). Results Socio-demographic characteristics of study participants In this study, a total of 21,861 women were included in the analysis from EDHS (2000–2019) data. The mean age (± SD) of the women was 34.6 ± 7.6 years, of this 25.28% of the grand multipara women aged between 35–39 years. Three-fourths of grand multipara women reside in rural communities (79.69%) and 34.45% are illiterate. Out of the study subjects, 30% of the grand multipara women were from the poorest wealth index. More than half (77.45%) of grand multiparas women were non-users of any family planning methods. More than half (61.1%) of reproductive-age women gave birth within short birth intervals and 66.06% of mothers started giving their first birth at the age below 18 years (Table 1 ). Table 1 Socio-demographics, sexual and reproductive characteristics of the reproductive age women from the Ethiopian Demographic Health survey of 2000–2019. Variables Category Multipara n (%) Grand multipara n (%) P-value Age of the mothers < 24 11587 (16.02) 77(0.53) < 0.001 25–29 2492 (33.86) 771451 (10.01) 30–34 1585 (21.24) 2901 (0.53) 35–39 1174 (1.51) 3666 (25.28) 40–44 564 (7.66) 3501 (24.14) 45–49 387 (5.51) 2905 (20.03) Place of residency Urban 2272 (30.87) 2158 (14.88) < 0.001 Rural 5088( 62.13) 12343 (85.12) Educational level Illiterate 3747 (50.91) 11556 (79.69) < 0.001 Primary education 2437 (33.11) 2631 (18.14) Secondary education 732 (9.95) 251 (1.73) Higher education 444 (6.03) 63 (0.43) Religion Orthodox 2777 (37.73) 3710 (25.58) < 0.001 Catholic 68 (0.92) 123 (0.85) Protestant 1414 (19.21) 3197 (22.05) Muslim 3029 (41.15) 7235 (49.89) Traditional 72 (0.98) 236 (1.63) Wealth Index Poorest 1,819 (24.71) 4,996 (34.45) < 0.001 Poorer 1,147 (15.58) 2,942 (20.29) Middle 1,118 (15.19) 2,576 (17.76) Richer 1,068 (14.51) 2,440 (16.83) Richest 2,208 (30.0) 1,547 (10.67) Marital Status Others 957 (13) 1424 (9.82) < 0.001 Currently married 6403 (87) 13077 (90.18) Family planning using status Non-user 4730 (64.27) 11231 (77.45) < 0.001 Short-acting 1894 (27.73) 2167 (14.94) Long-acting 736 (10) 1103 (7.61) Preceding birth interval Normal 4850 (65.90%) 5635 (38.86) < 0.001 Short birth Interval 2510 (34.10%) 8866 (61.14) Polygamy status of the mother Not polygamy 24 (0.33) 57 (0.39) 0.441 Polygamy mother 7336 (99.67) 14444 (99.61) Age of mother at first birth above 18 years 4096 (55.65) 5212 (35.94) < 0.001 Below 18 years 3264 (44.35) 9289 (64.06) Exposure to media No 5268 (71.58) 10869 (74.82) < 0.001 Yes 2092 (28.42) 3632 (25.05) Place of delivery Home 1321 (17.95) 1405 (9.69) < 0.001 Health Facilities 6039 (82.05) 13096 (90.31) Others*: Divorced/widowed /separated The magnitude of grand multiparous women The prevalence of grand multiparity was 66.3% (95% CI 65.7–66.96%) based on the Ethiopian Demography and Health Survey 2019 (EDHS) (Fig. 1 ). The magnitudes of the grand multiparity were 72.8% in 2000, 70.5% in 2005, 69.8% in 2011, and 67.8% in 2016 EDHS and 66.3% according to the national representative of EDHS of 2019 (Fig. 2 ). The trend of grand multiparous women The magnitudes of the grand multiparity were 72.8% in 2000, 70.5% in 2005, 69.8% in 2011, and 67.8% in 2016 EDHS and 66.3% according to the national representative of Min EDHS of 2019. Over 19 years, the trend of grand multiparous women from five surveys including the Mini EDHS survey of 2019 showed, no significant change (extended Mantel-Haenszel χ2 test for linear trend = 1.23, p = 0.27). Likewise, no significant percentage change was observed between 2000 and 2019 EDHS (Fig. 2 ). Grand multiparity and association factors In the adjusted multilevel analysis, being a poor family was more likely for grand multiparity compared to the mother from the richest family (AOR = 1.29; 95% CI: 1.07–1.60). The odds of grand multiparous were 74% higher for currently married women compared with not-married women (AOR = 1.74; 95% CI: 1.56–1.96). Mothers who didn’t attain formal education were 16 (AOR = 16; 95% CI: 11–22) times higher odds of being grand multiparity compared to those who attended higher education. The odds of grand multiparity were 23% (AOR = 1.23; 95%CI: 1.08–1.41) higher among mothers who don't use any family planning compared to mothers who use long-acting family planning methods. The odds of grand multiparity were 26% higher (AOR = 1.26; 95% CI: 12.10–2.43) among mothers who married below the age of 18 years compared with counterparts. The odds of being grand multiparity were 43% higher (AOR = 1.43; 95% CI:3.11, 3.79) among mothers who gave birth at a health facility compared to their counterparts. Mothers who had less than 36 months of birth intervals were 76% more likely for grand multiparity compared to the normal birth interval. Concerning community-level factors, the odds of grand multiparity compared to multiparity were 12% higher among mother who resides in rural communities compared to mothers from urban residences (Table 3). Table 2 An individual- and community-level determinants of grand multiparity in Ethiopia using multilevel logistic regression analysis, MEDHS 2019 Variables Category Model 2 AOR (95% CI) Model 3 AOR (95% CI) Model 4 AOR (95% CI) Individual level factors Wealth index Poorest 1.55(1.29, 1.85) 1.29(1.07, 1.60) poorer 1.44(1.21, 1.72) 1.21(1.10, 1.50) Middle 1.35(1.14, 1.60) 1.14(0.96, 1.36) Richer 1.37(1.16, 1.61) 1.205(1.02, 1.40) Richest 1 1 1 Marital status Married 1.76(1.57, 1.98) 1.74(1.56,1.96) Other * 1 1 1 Educational level illiterate 16(12, 23) 16(11, 22) Primary education 5.25(3.79, 7.25) 5.08(3.6, 7.01) Secondary education 1.81(1.27, 2.57) 1.78(1.25, 2.52) Higher 1 1 1 Family planning utilization status Non-users 1.23(1.08, 1.40) 1.23(1.08, 1.41) Short-acting 0.74(0.64,0 .86) 0.74(0.64, 0.86) Long-acting users 1 1 1 Age at first birth > 18 years old 1 1 1 < 18 years 2.27(2.12, 2.45) 2.26(2.10, 2.43) Place of delivery Health facility 3.41(3.0, 3.77) 3.43(3.11, 3.79) Home 1 1 1 Preceding birth interval Short birth interval 2.75(2.57, 2.95) 2.76(2.6, 2.96) Normal birth interval 1 1 1 Community level factors Mother Media exposure status Exposed 1 1 1 Not Exposed 0.93(0.86, 101) Place of residence Urban 1 1 1 Rural 5.28(4.04, 6.91) 2.12(1.67, 2.70) Others*: Divorced/widowed /separate; AOR: adjusted odds ratio Discussion The prevalence of grand multiparity was 66.3% among the reproductive-age women in the this study. Concerning to trend of grand multiparity, no significant change was observed during analysis (extended Mantel-Haenszel χ2 test for linear trend = 1.23,p = 0.27). Wealth index, marital status, educational level, family planning utilization status, age at marriage, age of women at first birth, polygamy, preceding birth interval, type of residence, and place of delivery were significantly associated with women having high parity reference. During the analysis, the ICC value was found to be 32% which indicated cluster differences accounted for 32% of the chance of grand multiparous women. This evidence led the researcher to choose multilevel modeling over the more common single-level regression model [ 20 , 21 ]. In this study, the magnitude of grand multiparity was 66.3% with a 95% confidence interval of (65.7-66.96). This result has approached the study conducted in Gedeo Zone (69.1%) [ 22 ], in the Enderta Tigray Region, Ethiopia (51%) [ 23 ], Sidama region of Ethiopia (70.8%) [ 24 ] but higher than the study conducted in Northern Tanzania (9.44%) [ 11 ], the institutional-based study of Jimma, Ethiopia (8%) [ 25 ]. The difference could be due to the majority of the latter study being from single or small institutional-based data and geographical differences of study participants. In addition, The educational backgrounds, and socioeconomic, sociodemographic, and cultural settings of these studies are different from the current findings [ 26 ]. While the magnitude of grand multiparity in developed countries has significantly declined ranging from 3–4% [ 4 ], the current study result showed that the magnitude of grand multiparity compared to multiparity was 66.3% which indicates slightly similar to the previous 2016 EDHS (67.8%) data which still too far from projection plan of Ethiopian 2100 years which estimated by UN word population project of 2022. According to this project, the future Ethiopian fertility rate in 2100 will be 1.8698. The result of multilevel multivariable logistic regression analysis indicated that the wealth index level of a family determines the odds of being grand multiparity. Thus, reproductive-age women from the poorest family index had 29% higher odds of being grand multiparous compared to the richest family index. This finding is consistent with research study finding from Gedeo Zone, Southern Ethiopia [ 22 ]. The odds of grand multiparity were higher among women who were illiterate compared to those who attend more than secondary education level. This finding was consistent with a study from Enderta Tigray, Northern Ethiopia [ 23 ], and Sidama, southern Ethiopia [ 24 ]. In this study, the majority of grand para women reside a rural (85.12%) and are illiterate (79.69%) which could lead women to stay less time in school which produces early marriage and high parity [ 22 ]. The family planning utilization status of women determines the number of parity of reproductive could have. According to the current study, the odds of grand parity were 23% higher among the non-user of any family planning methods compared to long-acting family planning. This finding is consistent with study results from Pakistan [ 27 ], Nigeria [ 28 ], and Nepal [ 29 ]. This study also revealed that grand multiparity was more prevalent (2.26 times higher) among women who gave birth for the first time before the age of 18 as opposed to those who started after the age of 18 old. This finding is similar to a research study found in Enderta Tigray, southern Ethiopia [ 23 ], Wonago District, southern Ethiopia [ 22 ]. We can observe that in a population where women begin having children before the age of 18, the fertile period is longer and there are more live births. These factors contribute to the high parity of women. The grand multiparity was higher among women with short birth intervals (less than or equal to 36 months. This finding is also consistent with a study carried out in Wonago District, Gedeo Zone, Ethiopia [ 22 ], and Sidama National Regional State of Ethiopia [ 24 ]. The types of residence of the reproductive women also determine the grand parity status of women. Thus, the odds of grand parity in the current study are 2.12 times higher among rural dwellers than counterparts. This is similar to the study result conducted in Nepal [ 29 ] and the Gedeo Zone of Ethiopia [ 22 ]. Place of delivery and Marital status of reproductive-age women also determine the odds of grand multiparity. Conclusion The current study revealed that there was no significant trend change in grand multiparity among reproductive-age women in Ethiopia over the past 19 years. In addition, different factors were identified for high parity, including the wealth index of the family, marital status of women, educational level of women, family planning utilization status and techniques, age at first birth, the magnitude of the birth interval, and types of residence for reproductive-age women. Since high parity (grand multiparity) was identified as a risk pregnancy that could bring maternal, child, and family health problems that consequently bring a country economic threat, each woman, household, and responsible health sector agents, including the Federal Ministry of Health of our country, should give priority attention to alleviating these serious health problems. In addition, according to the sustainable developmental goal (SDG) [ 19 ], by 2030 reduce the global maternal mortality ratio to less than 70 per 100,000 live births. This could occur by reducing the total fertility of women, providing need-based family planning, and promoting the welfare of reproductive-age women. Abbreviations AIC: Akaike Information Criterion; AOR: Adjusted Odd Ratio; BIC: Bayesian Information criterion; CI: Confidence Interval; DHIS: Demographic health survey; EAs: Enumuration areas; EMOH: Ethiopian Ministry of Health; ; ICC: Intra Class Correlation; LLI: Likelihood Ratio Test; MEDHS: Minin Ethiopian Demographic Health Survey; SNNPR: Southern Nations, Nationalities and Peoples’ Region Declarations Acknowledgments We would like to thank the measure DHS Program and ICF International for providing us with permission to use the EDHS data. In addition, also like to acknowledge our friends for their assistance during our manuscript preparation. Authors’ contributions D.D. and T.G.C. contributed to the study idea and design, collected, analyzed, interpreted the data, and prepared the main manuscript. D.D. and T.G.C. contributed to analyzing, interpreting, drafting, and revising the manuscript. Both authors read and approved the final manuscript. 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Cite Share Download PDF Status: Published Journal Publication published 05 Feb, 2025 Read the published version in Contraception and Reproductive Medicine → Version 1 posted Editorial decision: Revision requested 10 Oct, 2024 Reviews received at journal 10 Oct, 2024 Reviews received at journal 08 Oct, 2024 Reviewers agreed at journal 06 Oct, 2024 Reviews received at journal 02 Oct, 2024 Reviewers agreed at journal 01 Oct, 2024 Reviewers agreed at journal 01 Oct, 2024 Reviewers agreed at journal 30 Sep, 2024 Reviewers agreed at journal 29 Sep, 2024 Reviewers agreed at journal 29 Sep, 2024 Reviewers agreed at journal 29 Sep, 2024 Reviewers invited by journal 29 Sep, 2024 Editor assigned by journal 24 Sep, 2024 Submission checks completed at journal 24 Sep, 2024 First submitted to journal 23 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5136441","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":364749663,"identity":"15ade035-d7f8-41fc-b808-056c32b08d60","order_by":0,"name":"Diriba Dibaba","email":"","orcid":"","institution":"Madda Walabu University","correspondingAuthor":false,"prefix":"","firstName":"Diriba","middleName":"","lastName":"Dibaba","suffix":""},{"id":364749664,"identity":"b52629a2-02cc-4822-98a9-af6e8af465a5","order_by":1,"name":"Tesfaye Getachow Charkos","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYJCCD2BSgvkAiJQhqJyHgYFxBkQLWwKI5CFFC48BVIAAsGdvf9jws83Grn92z+dXN2oseBjYDx/dgNcWnjOGjb1tackz7pzdZp1zDOgwnrS0G3i1SOSwP+BtO5xsIJG7zTiHDahFgscMvxb55w8b/7b9B2rJeWac848YLRIMhs28bQfsgFqYH+e2EaPlTI5hs8y55ASJG2lmzLl9EjxshPzC3n78YeObMjt7/hnJjz/nfKuT42c/fAyvFjBgZGNIbGBgYJMAcdgIKgeDPwz2QJL5A3GqR8EoGAWjYKQBABKVR3072LXRAAAAAElFTkSuQmCC","orcid":"","institution":"Adama Hospital Medical College","correspondingAuthor":true,"prefix":"","firstName":"Tesfaye","middleName":"Getachow","lastName":"Charkos","suffix":""}],"badges":[],"createdAt":"2024-09-23 08:35:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5136441/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5136441/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40834-024-00328-1","type":"published","date":"2025-02-05T15:58:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69324580,"identity":"e65f55a7-48d9-40bb-ad61-fc2d8438c691","added_by":"auto","created_at":"2024-11-19 07:45:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25676,"visible":true,"origin":"","legend":"\u003cp\u003eThe magnitude of grand multiparity among reproductive-age women in Ethiopia from the MEDHS of 2019.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5136441/v1/7345aabce895a1a4c9c43a96.png"},{"id":69324581,"identity":"8bb65079-105a-4624-abec-679a7fde602f","added_by":"auto","created_at":"2024-11-19 07:45:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5119,"visible":true,"origin":"","legend":"\u003cp\u003eThe trend of grand multiparity among reproductive-age women based on data from the 2000-2019 Ethiopian Demographic Health Survey\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5136441/v1/2186e5df6b2574bb95bb4a0c.png"},{"id":75930489,"identity":"8698f2dd-6682-48e4-96fe-6de53d70057e","added_by":"auto","created_at":"2025-02-10 16:12:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":892344,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5136441/v1/7f7aa878-123d-4024-ba7f-a0215ad93236.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Challenges in reducing high grand multiparity rates in Ethiopia: EDHS data 2000-2019 toward Sustainable Development Goals 2030: Using multilevel model approach","fulltext":[{"header":"What is already known on this topic","content":"\u003cul\u003e\n \u003cli\u003eGrand multiparity in Ethiopia has remained high, as indicated by data from the past four Demographic and Health Surveys (DHS) conducted between 2000 and 2016.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eYet no significant change in grand multiparity rates compared with the past four EDH survey 2000-2016.\u003c/li\u003e\n \u003cli\u003eIt is a large population based survey, in which the findings were robust. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKey factors significantly associated with grand multiparity include wealth index, marital status, educational level, family planning utilization, age at first birth, birth interval, and place of residence.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eHow this Study might affect research, practice or policy\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe government should implement interventions targeting the identified factors to reduce the rates of grand multiparity and improve maternal and child health outcomes.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eGrand multiparty is a major public health concern in developing countries, particularly in sub-Saharan Africa, including Ethiopia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is a high-risk pregnancy condition in which the mother, fetus, and/or baby are more likely to suffer from morbidity or die during pregnancy, delivery, or the postpartum period [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Similar to infectious disease, grand multiparity remains a major public health issue in underdeveloped nations, where its prevalence ranges between 30\u0026ndash;90% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In contrast, it is becoming less of a concern in many industrialized countries, with a low incidence of 2\u0026ndash;4% [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In 2019, the global fertility rate was 2.5, a decline from 3.2 live births per woman in 1990. However, Sub-Saharan Africa experienced an increase, reaching 4.6 in 2019 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn comparison to high-income countries, perinatal outcomes problems are still quite common in low- and middle-income countries [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Evidence has shown that grand multiparity increases the incidence of medical and obstetric complications such as anemia, birth asphyxia, preterm birth, low birth weight, macrosomia, stillbirth, and a high perinatal mortality rate [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Studies conducted in developing countries suggested that adverse perinatal outcomes are significantly associated with grand multiparity compared with multiparity [\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. One of the sustainable developmental goals (2030) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] is reducing the total fertility rate, by providing need-based family planning and promoting the welfare of reproductive-age wome [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Reducing grand multiparity remains a challenge in Ethiopia. Therefore, understanding these factors will help explain why grand multiparity remains prevalent despite various health interventions and socio-economic advancements.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting and design\u003c/h2\u003e \u003cp\u003eThis study was based on EDHS data collected from 2000\u0026ndash;2019, which was a nationwide representative cross-sectional study. The data were collected every five years from all regional states of Ethiopia, and it was freely available online at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://dhsprogram.com/\u003c/span\u003e\u003cspan address=\"https://dhsprogram.com/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. The survey questionnaire includes information about population, health, and other important indicators. The study subjects were selected based on two-stage stratified sampling techniques. Each region was divided into urban and rural areas, creating 21 sampling strata. A total of 305 enumeration areas (EAs) were independently selected. Implicit stratification and proportional allocation were ensured by sorting the sampling frame within each stratum by administrative units and using probability proportional to size selection in the first stage (26). A total of 21861 women who had at least one live birth during their lifetime were included in this study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy variables\u003c/h3\u003e\n\u003cp\u003eThe dependent variable in this study was grand multiparity (yes or no). The independent variables include place of residence, maternal age, education status, wealth index, current marital status, polygamous marriage status, religion, community media exposure, maternal age at first birth, preceding birth interval (months), type of contraceptive used, and place of delivery. Community-level variables were religion, place of residence, and community media exposure status.\u003c/p\u003e\n\u003ch3\u003eOperational definition\u003c/h3\u003e\n\u003cp\u003eGrand multiparty: is defined as five births or more following a gestational age of 28 weeks or a fetal weight of 1000 gm or more (1).\u003c/p\u003e \u003cp\u003eMultiparity: is defined as 2\u0026ndash;4 five births following a gestational age of 28 weeks or a fetal weight of 1000 gm or more ).\u003c/p\u003e \u003cp\u003eThe birth interval: of reproductive-age women was categorized as a short birth interval (birth interval less or equal to 36 months) and a normal birth interval (greater than 36 months) (29).\u003c/p\u003e\n\u003ch3\u003eData analyses\u003c/h3\u003e\n\u003cp\u003eDescriptive statistics, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation was used for continuous normally distributed variables. While frequency (percentage) was used for categorical variables. The trend analysis was tested using the extended Mantel Haenszel χ2 test for the linear trend using the OpenEpi (V.3.01) (30). The EDHS data naturally nested structure within the region, as a result, the test of intra-class correlation (ICC) was used to determine the existence of variability within the cluster. It was found that ICC\u0026thinsp;=\u0026thinsp;32%, which implies a multilevel model is appropriate. A multilevel multivariable logistic regression analysis was used. The multilevel logistic regression model contains a series of four models. The null model: is fitted without explanatory variables. Model II: is fitted with individual-level variables. Model III: is used to examine the association of community-level variables with grand multiparity. Model IV: finally, both individual and community-level variables were fitted together to examine the combined effect on grand multiparity. The final model was used to check for the independent effect of the individual-level and community-level variables on the grand multiparty, with a 95% CI and a p-value. A p-value less than 0.05 was considered statistically significant. The model's fitness was assessed using the Akaike information criterion (AIC), the Bayesian information criterion (BIC), and the likelihood ratio test. The values for each model of AIC and BIC were compared, with the lowest one assumed to be a better explanatory model (31).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics of study participants\u003c/h2\u003e \u003cp\u003eIn this study, a total of 21,861 women were included in the analysis from EDHS (2000\u0026ndash;2019) data. The mean age (\u0026plusmn;\u0026thinsp;SD) of the women was 34.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 years, of this 25.28% of the grand multipara women aged between 35\u0026ndash;39 years. Three-fourths of grand multipara women reside in rural communities (79.69%) and 34.45% are illiterate. Out of the study subjects, 30% of the grand multipara women were from the poorest wealth index. More than half (77.45%) of grand multiparas women were non-users of any family planning methods. More than half (61.1%) of reproductive-age women gave birth within short birth intervals and 66.06% of mothers started giving their first birth at the age below 18 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographics, sexual and reproductive characteristics of the reproductive age women from the Ethiopian Demographic Health survey of 2000\u0026ndash;2019.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultipara n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGrand multipara n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eAge of the mothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11587 (16.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e77(0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2492 (33.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e771451 (10.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1585 (21.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2901 (0.53)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1174 (1.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3666 (25.28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e564 (7.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3501 (24.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e387 (5.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2905 (20.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of residency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2272 (30.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2158 (14.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5088( 62.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12343 (85.12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3747 (50.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11556 (79.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2437 (33.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2631 (18.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e732 (9.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e251 (1.73)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigher education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e444 (6.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e63 (0.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOrthodox\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2777 (37.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3710 (25.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCatholic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68 (0.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e123 (0.85)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProtestant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1414 (19.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3197 (22.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMuslim\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3029 (41.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7235 (49.89)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72 (0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e236 (1.63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eWealth Index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoorest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,819 (24.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4,996 (34.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoorer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,147 (15.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,942 (20.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,118 (15.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,576 (17.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRicher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1,068 (14.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,440 (16.83)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRichest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,208 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,547 (10.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e957 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1424 (9.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrently married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6403 (87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13077 (90.18)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFamily planning using status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-user\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4730 (64.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11231 (77.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShort-acting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1894 (27.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2167 (14.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLong-acting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e736 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1103 (7.61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePreceding birth interval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4850 (65.90%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5635 (38.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShort birth Interval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2510 (34.10%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8866 (61.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePolygamy status of the mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot polygamy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (0.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57 (0.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolygamy mother\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7336 (99.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14444 (99.61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge of mother at first birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eabove 18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4096 (55.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5212 (35.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBelow 18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3264 (44.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9289 (64.06)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eExposure to media\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5268 (71.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10869 (74.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2092 (28.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3632 (25.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1321 (17.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1405 (9.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth Facilities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6039 (82.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13096 (90.31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eOthers*: Divorced/widowed /separated\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe magnitude of grand multiparous women\u003c/h3\u003e\n\u003cp\u003eThe prevalence of grand multiparity was 66.3% (95% CI 65.7\u0026ndash;66.96%) based on the Ethiopian Demography and Health Survey 2019 (EDHS) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The magnitudes of the grand multiparity were 72.8% in 2000, 70.5% in 2005, 69.8% in 2011, and 67.8% in 2016 EDHS and 66.3% according to the national representative of EDHS of 2019 (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eThe trend of grand multiparous women\u003c/h3\u003e\n\u003cp\u003eThe magnitudes of the grand multiparity were 72.8% in 2000, 70.5% in 2005, 69.8% in 2011, and 67.8% in 2016 EDHS and 66.3% according to the national representative of Min EDHS of 2019. Over 19 years, the trend of grand multiparous women from five surveys including the Mini EDHS survey of 2019 showed, no significant change (extended Mantel-Haenszel χ2 test for linear trend\u0026thinsp;=\u0026thinsp;1.23, p\u0026thinsp;=\u0026thinsp;0.27). Likewise, no significant percentage change was observed between 2000 and 2019 EDHS (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eGrand multiparity and association factors\u003c/h2\u003e \u003cp\u003eIn the adjusted multilevel analysis, being a poor family was more likely for grand multiparity compared to the mother from the richest family (AOR\u0026thinsp;=\u0026thinsp;1.29; 95% CI: 1.07\u0026ndash;1.60). The odds of grand multiparous were 74% higher for currently married women compared with not-married women (AOR\u0026thinsp;=\u0026thinsp;1.74; 95% CI: 1.56\u0026ndash;1.96). Mothers who didn\u0026rsquo;t attain formal education were 16 (AOR\u0026thinsp;=\u0026thinsp;16; 95% CI: 11\u0026ndash;22) times higher odds of being grand multiparity compared to those who attended higher education. The odds of grand multiparity were 23% (AOR\u0026thinsp;=\u0026thinsp;1.23; 95%CI: 1.08\u0026ndash;1.41) higher among mothers who don't use any family planning compared to mothers who use long-acting family planning methods. The odds of grand multiparity were 26% higher (AOR\u0026thinsp;=\u0026thinsp;1.26; 95% CI: 12.10\u0026ndash;2.43) among mothers who married below the age of 18 years compared with counterparts. The odds of being grand multiparity were 43% higher (AOR\u0026thinsp;=\u0026thinsp;1.43; 95% CI:3.11, 3.79) among mothers who gave birth at a health facility compared to their counterparts. Mothers who had less than 36 months of birth intervals were 76% more likely for grand multiparity compared to the normal birth interval. Concerning community-level factors, the odds of grand multiparity compared to multiparity were 12% higher among mother who resides in rural communities compared to mothers from urban residences (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAn individual- and community-level determinants of grand multiparity in Ethiopia using multilevel logistic regression analysis, MEDHS 2019\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModel 2\u003c/p\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eModel 3\u003c/p\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModel 4\u003c/p\u003e \u003cp\u003eAOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIndividual level factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eWealth index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoorest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1.55(1.29, 1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.29(1.07, 1.60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003epoorer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1.44(1.21, 1.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.21(1.10, 1.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1.35(1.14, 1.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.14(0.96, 1.36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRicher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1.37(1.16, 1.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.205(1.02, 1.40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRichest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1.76(1.57, 1.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.74(1.56,1.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eEducational level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eilliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e16(12, 23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e16(11, 22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e5.25(3.79, 7.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.08(3.6, 7.01)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1.81(1.27, 2.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.78(1.25, 2.52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFamily planning utilization status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon-users\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1.23(1.08, 1.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.23(1.08, 1.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShort-acting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e0.74(0.64,0 .86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.74(0.64, 0.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLong-acting users\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge at first birth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;18 years old\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e2.27(2.12, 2.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.26(2.10, 2.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e3.41(3.0, 3.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.43(3.11, 3.79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePreceding birth interval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShort birth interval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e2.75(2.57, 2.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.76(2.6, 2.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal birth interval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCommunity level factors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMother Media exposure status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eExposed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNot Exposed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.93(0.86, 101)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace of residence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e5.28(4.04, 6.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.12(1.67, 2.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eOthers*: Divorced/widowed /separate; AOR: adjusted odds ratio\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe prevalence of grand multiparity was 66.3% among the reproductive-age women in the this study. Concerning to trend of grand multiparity, no significant change was observed during analysis (extended Mantel-Haenszel χ2 test for linear trend\u0026thinsp;=\u0026thinsp;1.23,p\u0026thinsp;=\u0026thinsp;0.27). Wealth index, marital status, educational level, family planning utilization status, age at marriage, age of women at first birth, polygamy, preceding birth interval, type of residence, and place of delivery were significantly associated with women having high parity reference.\u003c/p\u003e \u003cp\u003eDuring the analysis, the ICC value was found to be 32% which indicated cluster differences accounted for 32% of the chance of grand multiparous women. This evidence led the researcher to choose multilevel modeling over the more common single-level regression model [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the magnitude of grand multiparity was 66.3% with a 95% confidence interval of (65.7-66.96). This result has approached the study conducted in Gedeo Zone (69.1%) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], in the Enderta Tigray Region, Ethiopia (51%) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Sidama region of Ethiopia (70.8%) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] but higher than the study conducted in Northern Tanzania (9.44%) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], the institutional-based study of Jimma, Ethiopia (8%) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The difference could be due to the majority of the latter study being from single or small institutional-based data and geographical differences of study participants. In addition, The educational backgrounds, and socioeconomic, sociodemographic, and cultural settings of these studies are different from the current findings [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. While the magnitude of grand multiparity in developed countries has significantly declined ranging from 3\u0026ndash;4% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], the current study result showed that the magnitude of grand multiparity compared to multiparity was 66.3% which indicates slightly similar to the previous 2016 EDHS (67.8%) data which still too far from projection plan of Ethiopian 2100 years which estimated by UN word population project of 2022. According to this project, the future Ethiopian fertility rate in 2100 will be 1.8698.\u003c/p\u003e \u003cp\u003eThe result of multilevel multivariable logistic regression analysis indicated that the wealth index level of a family determines the odds of being grand multiparity. Thus, reproductive-age women from the poorest family index had 29% higher odds of being grand multiparous compared to the richest family index. This finding is consistent with research study finding from Gedeo Zone, Southern Ethiopia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The odds of grand multiparity were higher among women who were illiterate compared to those who attend more than secondary education level. This finding was consistent with a study from Enderta Tigray, Northern Ethiopia [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], and Sidama, southern Ethiopia [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In this study, the majority of grand para women reside a rural (85.12%) and are illiterate (79.69%) which could lead women to stay less time in school which produces early marriage and high parity [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The family planning utilization status of women determines the number of parity of reproductive could have.\u003c/p\u003e \u003cp\u003eAccording to the current study, the odds of grand parity were 23% higher among the non-user of any family planning methods compared to long-acting family planning. This finding is consistent with study results from Pakistan [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], Nigeria [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and Nepal [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This study also revealed that grand multiparity was more prevalent (2.26 times higher) among women who gave birth for the first time before the age of 18 as opposed to those who started after the age of 18 old. This finding is similar to a research study found in Enderta Tigray, southern Ethiopia [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], Wonago District, southern Ethiopia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. We can observe that in a population where women begin having children before the age of 18, the fertile period is longer and there are more live births. These factors contribute to the high parity of women.\u003c/p\u003e \u003cp\u003eThe grand multiparity was higher among women with short birth intervals (less than or equal to 36 months. This finding is also consistent with a study carried out in Wonago District, Gedeo Zone, Ethiopia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and Sidama National Regional State of Ethiopia [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The types of residence of the reproductive women also determine the grand parity status of women. Thus, the odds of grand parity in the current study are 2.12 times higher among rural dwellers than counterparts. This is similar to the study result conducted in Nepal [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and the Gedeo Zone of Ethiopia [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Place of delivery and Marital status of reproductive-age women also determine the odds of grand multiparity.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe current study revealed that there was no significant trend change in grand multiparity among reproductive-age women in Ethiopia over the past 19 years. In addition, different factors were identified for high parity, including the wealth index of the family, marital status of women, educational level of women, family planning utilization status and techniques, age at first birth, the magnitude of the birth interval, and types of residence for reproductive-age women. Since high parity (grand multiparity) was identified as a risk pregnancy that could bring maternal, child, and family health problems that consequently bring a country economic threat, each woman,\u003c/p\u003e \u003cp\u003ehousehold, and responsible health sector agents, including the Federal Ministry of Health of our country, should give priority attention to alleviating these serious health problems.\u003c/p\u003e \u003cp\u003eIn addition, according to the sustainable developmental goal (SDG) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], by 2030 reduce the global maternal mortality ratio to less than 70 per 100,000 live births. This could occur by reducing the total fertility of women, providing need-based family planning, and promoting the welfare of reproductive-age women.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003eAIC: Akaike Information Criterion; AOR: Adjusted Odd Ratio; BIC: Bayesian Information criterion; CI: Confidence Interval; DHIS: Demographic health survey; EAs: Enumuration areas; \nEMOH: Ethiopian Ministry of Health; ; ICC: Intra Class Correlation; LLI: Likelihood Ratio Test;\nMEDHS: Minin Ethiopian Demographic Health Survey; SNNPR: Southern Nations, Nationalities and Peoples’ Region \n\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eWe would like to thank the measure DHS Program and ICF International for providing us with permission to use the EDHS data. In addition, also like to acknowledge our friends for their assistance during our manuscript preparation.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eD.D. and T.G.C. contributed to the study idea and design, collected, analyzed, interpreted the data, and prepared the main manuscript. D.D. and T.G.C. contributed to analyzing, interpreting, drafting, \u0026nbsp;and revising the manuscript. Both authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eFunding\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe authors received no any funding for this research.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNone declared.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe data are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003ePatient consent for publication\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRoman H, et al. Obstetric and neonatal outcomes in grand multiparity. Obstet Gynecol. 2004;103(6):1294\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShechter Y, et al. Obstetric complications in grand and great grand multiparous women. J Matern Fetal Neonatal Med. 2010;23(10):1211\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBugg GJ, Atwal GS, Maresh M. Grandmultiparae in a modern setting. BJOG. 2002;109(3):249\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMgaya AH, et al. Grand multiparity: is it still a risk in pregnancy? BMC Pregnancy Childbirth. 2013;13:241.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eWorld Health Report\u003c/em\u003e 2004: Changing History. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://reliefweb.int/report/world/world-health-report-2004-changing-history\u003c/span\u003e\u003cspan address=\"https://reliefweb.int/report/world/world-health-report-2004-changing-history\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoque M, Hoque E, Kader SB. Pregnancy complications of grandmultiparity at a rural setting of South Africa. ijrm. 2008;6(2):25\u0026ndash;0.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuniro Z, et al. Grand multiparity as a predictor of adverse pregnancy outcome among women who delivered at a tertiary hospital in Northern Tanzania. BMC Pregnancy Childbirth. 2019;19(1):222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng H, et al. Global trends in total fertility rate and its relation to national wealth, life expectancy and female education. BMC Public Health. 2022;22(1):1346.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbouZahr C. Global burden of maternal death and disability. Br Med Bull. 2003;67:1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO. \u003cem\u003eMaternal mortality.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/maternal-mortality/?gad_source=1\u0026amp;gclid=CjwKCAjwps-zBhAiEiwALwsVYV7SM4F9\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/maternal-mortality/?gad_source=1\u0026amp;gclid=CjwKCAjwps-zBhAiEiwALwsVYV7SM4F9\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cem\u003eKGeak7JUi62RwRkdHaIFOLcYdDGAOu0H0LTrBx-z4p8LTBoCXbkQAvD_BwE.\u003c/em\u003e 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuniro Z, et al. Grand multiparity as a predictor of adverse pregnancy outcome among women who delivered at a tertiary hospital in Northern Tanzania. BMC Pregnancy Childbirth. 2019;19(1):222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAsima Afzal NM, Firdous N. Pregnancy outcomes in grand multiparous patients: a hospital based study from Jammu and Kashmir, India. Int J Reprod Contracept Obstet Gynecol. 2016;5(3):788\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahida SM, et al. Maternal outcome of grand multipara. Mymensingh Med J. 2011;20(3):381\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeidam AD, Audu BM, Oummate Z. Pregnancy outcome among grand multiparous women at the University of Maiduguri Teaching Hospital: a case control study. J Obstet Gynaecol. 2011;31(5):404\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsammani MA, et al. Effect of Grand Multiparity on Pregnancy Outcomes in Women Under 35 Years of Age: a Comparative Study. Med Arch. 2019;73(2):92\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarag RS, Abd El-Gawad ALM, Dogheim AE. Ethiopion Demographic health survey 2016. Int Food Res J. 2011;18:659\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlhainiah MH, Abdulljabbar HSO, Bukhari YA. The Prevalence, the Fetal and Maternal Outcomes in Grand Multiparas Women. Mater Sociomed. 2018;30(2):118\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNewnham EC, et al. Comparison of labour and birth outcomes between nulliparous women who used epidural analgesia in labour and those who did not: A prospective cohort study. Women Birth. 2021;34(5):e435\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eThe Sustainable Development Goals in Ethiopia https://\u003c/em\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eethiopia.un.org/en/sdgs/3\u003c/span\u003e\u003cspan address=\"http://ethiopia.un.org/en/sdgs/3\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMerlo J, et al. A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. J Epidemiol Community Health. 2006;60(4):290\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSommet N, Morselli D. Keep Calm and Learn Multilevel Logistic Modeling: A Simplified Three-Step Procedure Using Stata, R, Mplus, and SPSS. International Review of Social Psychology; 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReda MG, Bune GT, Shaka MF. \u003cem\u003eEpidemiology of High Fertility Status among Women of Reproductive Age in Wonago District, Gedeo Zone, Southern Ethiopia: A Community-Based Cross-Sectional Study.\u003c/em\u003e Int J Reprod Med, 2020. 2020: p. 2915628.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRegion T, Hailu AG, Berhe D, Slassie H, Yemane AG. D, et al, Determinants of High Fertility among Ever Married Women in Enderta District, Tigray Region, Northern Ethiopia. Volume 7. Journal of Health \u0026amp; Medical Informatics; 2016. 5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDasa TT, Okunlola MA, Dessie Y. \u003cem\u003eMultilevel analysis of grand multiparity: Trend and its determinants in the Sidama National Regional State of Ethiopia: a cross-sectional study design from demographic and health survey\u003c/em\u003e 2000\u0026ndash;2016. BMJ Open, 2022. 12(8): p. e061697.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYesuf Ahmed Aragaw MMaHJ. Grand Multiparity and Pregnancy Related Complications among WomenWho Gave Birth at Jimma University Specialized Hospital, Jimma,Southwest Ethiopia. Volume 7. Gynecology \u0026amp; Obstetrics; 2017. 4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAjong AB, et al. Grand multiparity in rural Cameroon: prevalence and adverse maternal and fetal delivery outcomes. BMC Pregnancy Childbirth. 2019;19(1):233.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKamal A. Factors Affecting the Family Size in Pakistan: Clog-log Regression Model Analysis. J Stat. 2011;18:29\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlaba OO, Olaomi OO. Spatial patterns and determinants of fertility levels among women of childbearing age in Nigeria. South Afr Fam Pract. 2017;19(59):143\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdhikari R. Demographic, socio-economic, and cultural factors affecting fertility differentials in Nepal. BMC Pregnancy Childbirth. 2010;10(1):19.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Trend, Magnitude, Grand multiparity, Reproductive age, Multilevel, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-5136441/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5136441/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOne of the Sustainable Development Goals (2030) focuses on reducing the total fertility rate. Reducing grand multiparity in Ethiopia remains a challenge. Understanding the underlying factors that contribute to this issue is crucial for explaining why grand multiparity remains prevalent despite various health interventions and socio-economic progress.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA community-based cross-sectional study was conducted using data from the Ethiopian Demographic and Health Survey 2000\u0026ndash;2019. Multilevel multivariable logistic regression analysis was employed to model the hierarchical data. The final findings were presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI). A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eThe trend analysis of grand multiparity over 19 years in Ethiopia shows no significant change (linear trend\u0026thinsp;=\u0026thinsp;1.23, p\u0026thinsp;=\u0026thinsp;0.27). The prevalence of grand multiparity slightly decreased from 72% in the 2000 EDHS to 66.3% (95% CI: 65.7% \u0026minus;\u0026thinsp;66.96%) according to the mini EDHS 2019 data. Among individual-level variables, the following were significantly associated with grand multiparity: wealth index, currently married, maternal education, non-family planning, short-acting family planning users, age at first birth\u0026thinsp;\u0026lt;\u0026thinsp;18 years, and short birth intervals. Among community-level variables, being a rural resident was significantly associated with grand multiparity.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eA 19-year trend analysis in Ethiopia shows no significant change in grand multiparity rates, with a slight decrease from 72% in 2000 to 66.3% in 2019. Significant factors associated with grand multiparity include wealth index, marital status, educational level, family planning utilization, age at first birth, birth interval, and place of residence.\u003c/p\u003e","manuscriptTitle":"Challenges in reducing high grand multiparity rates in Ethiopia: EDHS data 2000-2019 toward Sustainable Development Goals 2030: Using multilevel model approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-19 07:45:42","doi":"10.21203/rs.3.rs-5136441/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-11T00:23:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-10T23:44:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-08T19:18:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57066568900003464414849730500464724439","date":"2024-10-06T10:38:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-02T08:46:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240100612404858784454496090225985091397","date":"2024-10-01T14:52:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191621501192416719996401635639175826499","date":"2024-10-01T14:46:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132443572027816505529237580655315241928","date":"2024-09-30T14:37:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67733032358411215065477599942991178598","date":"2024-09-29T16:20:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199056368772052278680130205673845164117","date":"2024-09-29T15:48:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277229668944414958967883869000757982215","date":"2024-09-29T14:35:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-29T14:28:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-24T13:31:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-24T13:30:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Contraception and Reproductive Medicine","date":"2024-09-23T08:32:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"650f52b7-32b4-4c24-a283-7082c13e72c4","owner":[],"postedDate":"November 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-10T16:04:14+00:00","versionOfRecord":{"articleIdentity":"rs-5136441","link":"https://doi.org/10.1186/s40834-024-00328-1","journal":{"identity":"contraception-and-reproductive-medicine","isVorOnly":false,"title":"Contraception and Reproductive Medicine"},"publishedOn":"2025-02-05 15:58:03","publishedOnDateReadable":"February 5th, 2025"},"versionCreatedAt":"2024-11-19 07:45:42","video":"","vorDoi":"10.1186/s40834-024-00328-1","vorDoiUrl":"https://doi.org/10.1186/s40834-024-00328-1","workflowStages":[]},"version":"v1","identity":"rs-5136441","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5136441","identity":"rs-5136441","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}