Trends, patterns, determinants and socio-economic inequality of high-risk fertility behavior (HRFB) among Bangladeshi women: Evidence from Bangladesh Demographic and Health Surveys.

Abstract

Globally and in Bangladesh, high-risk fertility behavior (HRFB) continues to be a significant public health issue, contributing to negative health outcomes for both mothers and children. Therefore, this study aimed to evaluate the trends, prevalence, determinants, and socio-economic inequalities associated with HRFB among presently married women of reproductive age by utilizing data from the Bangladesh Demographic and Health Survey (BDHS). We analyzed data from 19,060 currently married women aged 15-49 years. HRFB was defined as the presence of any of the following: maternal age (<18 or >34 years), short birth intervals (<24 months), or high birth order (≥4). Two outcome variables were constructed: a binary indicator for any HRFB (yes/no) and a three-category variable indicating no, single, or multiple HRFBs. Bivariate analysis was conducted to determine the prevalence of HRFB, and multilevel mixed-effects logistic and multinomial regression models were applied to identify determinants, accounting for the complex survey design. Socio-economic inequalities were examined using concentration indices and concentration curves. Overall, 58% of women experienced at least one HRFB, with 33% exhibiting a single HRFB and 25% multiple HRFBs. Women who married after age 18 years, had higher education, were exposed to media, or had educated husbands were significantly less likely to experience HRFB. Higher odds of HRFB were associated with rural residence, lower household wealth, and regions such as Mymensingh, Barishal, and Chattogram. Significant inequalities were observed, with HRFB disproportionately concentrated among women with lower wealth (CIX = -0.427, p < 0.001) and no education (CIX = -0.268, p < 0.001). In Bangladesh, HRFB remains prevalent and is unevenly distributed across socio-economic and geographic groups. Targeted interventions aimed at delaying early marriage, improving educational attainment for women and their partners, expanding mass media outreach, and increasing access to reproductive healthcare- especially among disadvantaged and rural populations- are essential for reducing HRFB and improving maternal health outcomes.