{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T16:43:14Z","timestamp":1791564194624,"version":"4.3.4"},"reference-count":91,"publisher":"Bioscientifica","issue":"2","license":[{"start":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T00:00:00Z","timestamp":1783382400000},"content-version":"vor","delay-in-days":97,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":["journals.bioscientifica.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,4,1]]},"abstract":"<jats:sec>\n                    <jats:title>Abstract<\/jats:title>\n                    <jats:p>High-risk fertility behavior is a leading contributor to adverse maternal and child health outcomes. This study assessed the prevalence and determinants of high-risk fertility behavior among reproductive-age women in sub-Saharan Africa. We conducted a secondary analysis of Demographic and Health Survey data from eight sub-Saharan African countries with extremely high or very high maternal mortality. A weighted sample of 78,353 reproductive-age women who had given birth in the five years preceding the survey was included. A multilevel mixed-effects binary logistic regression model was used to identify individual- and community-level factors associated with high-risk fertility behavior, accounting for the hierarchical nature of the data. Statistical significance was determined using AOR with a 95% CI and a P-value \u22640.05. The overall prevalence of high-risk fertility behavior was 71.46% (95% CI: 71.14%, 71.77%), with the highest prevalence observed in Chad (87.75%) and the lowest in Lesotho (40.49%). Key individual-level determinants included women\u2019s and husbands\u2019 education, religion, wealth status, child sex, marital status, mobile phone and Internet use, antenatal care attendance, history of pregnancy termination, and contraceptive use. At the community level, low poverty was associated with a reduced likelihood of high-risk fertility behavior. The prevalence of high-risk fertility behavior remains high in countries with extremely high and very high maternal mortality rates, highlighting a need to address it through urgent and concerted interventions. Policymakers and planners should prioritize interventions targeting the key determinants of high-risk fertility behavior to curb its occurrence and improve maternal and child health outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Lay summary<\/jats:title>\n                    <jats:p>High-risk fertility behavior (HRFB) is defined as having children at very young or older ages, having many births, or spacing pregnancies too closely, which can lead to serious health problems for mothers and children. This study aimed to determine the magnitude of high-risk fertility behaviors and the factors that affect the behavior among women in eight sub-Saharan African countries with very high maternal mortalities. Using data from over 78,000 women, we analyzed both individual- and community-level characteristics linked to HRFB. This study found that about 71% of women had HRFB. The highest rates were in Chad, and the lowest were in Lesotho. Factors such as low education, poverty, limited use of antenatal care, lack of contraception, and reduced access to mobile phones or the Internet increased the likelihood of HRFB. Communities with lower poverty showed lower rates. These findings underscore the need for targeted policies and programs to reduce HRFB and improve maternal and child health.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1530\/raf-25-0193","type":"journal-article","created":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T15:21:46Z","timestamp":1777476106000},"update-policy":"https:\/\/doi.org\/10.1530\/crossmarkpolicy-13","source":"Crossref","is-referenced-by-count":1,"title":["High-risk fertility behavior among reproductive age women in extremely high and very high maternal mortality sub-Saharan African countries"],"prefix":"10.1530","volume":"7","author":[{"ORCID":"https:\/\/orcid.org\/0009-0001-0826-5623","authenticated-orcid":true,"given":"Melak","family":"Jejaw","sequence":"first","affiliation":[{"name":"1"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wubshet D","family":"Negash","sequence":"additional","affiliation":[{"name":"1"},{"name":"8"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-2192-6429","authenticated-orcid":true,"given":"Kaleb Assegid","family":"Demissie","sequence":"additional","affiliation":[{"name":"1"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tadele Biresaw","family":"Belachew","sequence":"additional","affiliation":[{"name":"1"},{"name":"11"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Misganaw Guadie","family":"Tiruneh","sequence":"additional","affiliation":[{"name":"1"},{"name":"12"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Desalegn Anmut","family":"Bitew","sequence":"additional","affiliation":[{"name":"2"},{"name":"9"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Desale Bihonegn","family":"Asmamaw","sequence":"additional","affiliation":[{"name":"2"},{"name":"13"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elsa Awoke","family":"Fentie","sequence":"additional","affiliation":[{"name":"2"},{"name":"10"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lemlem Daniel","family":"Baffa","sequence":"additional","affiliation":[{"name":"3"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rahel Mulatie","family":"Anteneh","sequence":"additional","affiliation":[{"name":"4"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bewuketu","family":"Terefe","sequence":"additional","affiliation":[{"name":"5"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tadesse Tarik","family":"Tamir","sequence":"additional","affiliation":[{"name":"6"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alebachew Ferede","family":"Zegeye","sequence":"additional","affiliation":[{"name":"7"},{"name":"8"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"416","published-online":{"date-parts":[[2026,4,29]]},"reference":[{"key":"2026070714161986200_bib1","doi-asserted-by":"crossref","first-page":"972","DOI":"10.1186\/s12889-015-2315-z","article-title":"Individual and community level determinants of childhood full immunization in Ethiopia: a multilevel analysis","volume":"15","author":"Abadura","year":"2015","journal-title":"BMC Public Health"},{"key":"2026070714161986200_bib2","doi-asserted-by":"crossref","first-page":"432","DOI":"10.1186\/s12889-023-17444-3","article-title":"Association between sexual violence and multiple high-risk fertility behaviours among women of reproductive age in sub-Saharan Africa","volume":"24","author":"Aboagye","year":"2024","journal-title":"BMC Public Health"},{"key":"2026070714161986200_bib3","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0202742","article-title":"Individual-and community-level determinants of child immunization in the Democratic Republic of Congo: a multilevel analysis","volume":"13","author":"Acharya","year":"2018","journal-title":"PLoS One"},{"key":"2026070714161986200_bib92","doi-asserted-by":"crossref","first-page":"500","DOI":"10.9745\/GHSP-D-18-00135","article-title":"Role of Religious Leaders in Promoting Contraceptive Use in Nigeria: Evidence From the Nigerian Urban Reproductive Health Initiative","volume":"6","author":"Adedini","year":"2018","journal-title":"Glob Health Sci Pract"},{"key":"2026070714161986200_bib4","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1186\/1471-2393-10-19","article-title":"Demographic, socio-economic, and cultural factors affecting fertility differentials in Nepal","volume":"10","author":"Adhikari","year":"2010","journal-title":"BMC Pregnancy Childbirth"},{"key":"2026070714161986200_bib5","first-page":"97","article-title":"Fertility behaviour of men and women in three communities in Kaduna state, Nigeria","volume":"14","author":"Adiri","year":"2010","journal-title":"Afr J Reprod Health"},{"key":"2026070714161986200_bib83","volume-title":"The Effects of Traditional and Religious Practices of Child Marriage on Africa\u2019s Socio-Economic Development. 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