{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,13]],"date-time":"2026-02-13T08:19:53Z","timestamp":1770970793731,"version":"3.50.1"},"reference-count":37,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T00:00:00Z","timestamp":1770681600000},"content-version":"unspecified","delay-in-days":9,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2026,1,29]]},"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Studies of determinants of adverse birth outcomes (ABOs) were conducted in Ethiopia; however, there is a lack of a single study considering the factors operating at multiple levels (individual, interpersonal, organisational, environmental and policy levels). Therefore, this study identified combined determinants of ABOs at all levels in Ethiopia by analysing the Demographic and Health Survey data guided by the Ecological model, considering that birth outcomes are shaped by the interaction between a mother\u2019s environment and her biological and psychological health.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>This study aims to identify combined determinants of ABOs at all levels in Ethiopia by analysing the Demographic and Health Survey data guided by the Ecological model.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>A cross-sectional study design based on interviewer-administered questionnaires was used for the respective Demographic and Health Surveys.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting<\/jats:title>\n                    <jats:p>We used data from the 2016 Ethiopian and Demographic Health Survey, a stochastically national representative study with inclusive information on ABOs, to examine how various levels of influence from individual behaviours to environmental-level factors are affecting birth outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants<\/jats:title>\n                    <jats:p>An effective number of 11\u2009023 live births within the 5 years preceding the survey.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcome measure<\/jats:title>\n                    <jats:p>ABOs, including low birth weight and preterm birth. Multivariable multilevel mixed-effects logistic regression was used to identify determinants of ABOs through five hierarchical models in Stata V.14. Model I was the null model; models II, III, IV and V sequentially included intrapersonal, interpersonal, organisational and environmental variables, respectively. Statistical significance was determined using ORs with 95% CIs at p&lt;0.05.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The weighted prevalence of ABOs in Ethiopia is 27.0% (95% CI 25.7% to 28.3%). The final model of the multivariable multilevel mixed-effects logistic regression identified several predictors of ABOs at the intrapersonal or individual level, including maternal age of 15\u201324 completed years (adjusted OR (AOR)=1.24, 95%\u2009CI 1.02 to 1.51); poorest (AOR=1.41, 95%\u2009CI 1.01 to 2.00), poorer (AOR=1.42, 95%\u2009CI 1.02 to 2.01) and middle wealth quintiles (AOR=1.45, 95%\u2009CI 1.02 to 2.06); first-born twin (AOR=2.61, 95%\u2009CI 1.31 to 5.21) and second-born twin (AOR=4.05, 95%\u2009CI 2.16 to 7.61); and female childbirth (AOR=1.41, 95%\u2009CI 1.22 to 1.63). On the other hand, intimate partner physical violence (AOR=1.19, 95%\u2009CI 1.07 to 1.34) was the only factor associated with ABOs at the interpersonal level; cluster altitudes of 180\u20131500\u2009m (AOR=1.28, 95%\u2009CI 1.05 to 1.55) and 2501\u20133455\u2009m (AOR=1.51, 95%\u2009CI 1.15 to 1.99) were found to be an exposure of ABOs at the environmental level.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The prevalence of ABOs in Ethiopia is high. Factors associated with ABOs at the individual level include maternal age, wealth quintile, twin birth and female birth. In contrast, exposure variables at the interpersonal level comprise intimate partner violence, and those at the environmental level include cluster altitude. To improve ABOs and consequently reduce neonatal mortality, maternal and child health investment and future studies should act at all levels.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjopen-2025-101792","type":"journal-article","created":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T15:28:08Z","timestamp":1770737288000},"page":"e101792","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Combined determinants of adverse birth outcomes in Ethiopia: an application of ecological model using Demographic and Health Survey data"],"prefix":"10.1136","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8704-7722","authenticated-orcid":false,"given":"Samuel","family":"Kusheta","sequence":"first","affiliation":[{"name":"Department of Public Health, Hossana College of Health Sciences, Hosaena, Ethiopia"},{"name":"School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Wubegizer","family":"Mekonnen","sequence":"additional","affiliation":[{"name":"Reproductive, Family and Population Health, Addis Ababa University, Addis Ababa, Ethiopia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2026,2,10]]},"reference":[{"key":"2026021223251696000_16.2.e101792.1","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-024-19566-8","article-title":"Predicting adverse birth outcome among childbearing women in Sub-Saharan Africa: employing innovative machine learning techniques","volume":"24","author":"Ngusie","year":"2024","journal-title":"BMC Public Health"},{"key":"2026021223251696000_16.2.e101792.2","doi-asserted-by":"crossref","first-page":"3000605211013209","DOI":"10.1177\/03000605211013209","article-title":"Adverse birth outcomes and associated factors among mothers who delivered in Bale zone hospitals, Oromia Region, Southeast Ethiopia","volume":"49","author":"Degno","year":"2021","journal-title":"J Int Med Res"},{"key":"2026021223251696000_16.2.e101792.3","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-021-11113-z","article-title":"Determinants of adverse birth outcome in Sub-Saharan Africa: analysis of recent demographic and health surveys","volume":"21","author":"Tamirat","year":"2021","journal-title":"BMC Public Health"},{"key":"2026021223251696000_16.2.e101792.4","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0285621","article-title":"Compliance with the World Health Organization\u2019s 2016 prenatal care contact recommendation reduces the incidence rate of adverse birth outcomes among pregnant women in northern Ghana","volume":"18","author":"Akum","year":"2023","journal-title":"PLoS One"},{"key":"2026021223251696000_16.2.e101792.5","doi-asserted-by":"crossref","first-page":"631","DOI":"10.1001\/jamainternmed.2024.0276","article-title":"Adverse Pregnancy Outcomes and Long-Term Mortality 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preexisting chronic diseases prior to conception: a cross-sectional analysis of postpartum women in a low-resource setting in Ghana","volume":"10","author":"Nukpezah","year":"2024","journal-title":"Matern Health Neonatol Perinatol"},{"key":"2026021223251696000_16.2.e101792.9","doi-asserted-by":"crossref","DOI":"10.3389\/fgwh.2023.1082405","article-title":"The effects of adherence to recommended antenatal services on adverse pregnancy outcomes in Northwest Ethiopia: multilevel and propensity score matching (PSM) modeling","volume":"4","author":"Zelka","year":"2023","journal-title":"Front Glob Womens Health"},{"key":"2026021223251696000_16.2.e101792.10","doi-asserted-by":"crossref","DOI":"10.1186\/s13104-019-4387-9","article-title":"Adverse birth outcomes and its associated factors among women who delivered in North Wollo zone, northeast Ethiopia: a facility based cross-sectional study","volume":"12","author":"Kassahun","year":"2019","journal-title":"BMC Res 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