Factors Influencing High-Risk Fertility Practices Among Women of Reproductive Age in Zambia: A Multilevel Analysis of the 2024 Demographic and Health Survey

BackgroundHigh-risk fertility behaviors (HRFB) remain a public health concern in Zambia due to their association with maternal and newborn complications. Despite improvements in reproductive health services, updated national evidence on the magnitude and determinants of HRFB is limited. This study used data from the 2024 Zambia Demographic and Health Survey (ZDHS) to estimate the prevalence of HRFB and identify associated factors among women of reproductive age. MethodsA cross-sectional analysis was conducted using weighted data from 13,951 women aged 15-49 years. HRFB was defined as experiencing at least one of the following: first birth before 18 years, last birth after 34 years, short birth interval (<24 months), or high parity ([&ge;]4 births). Explanatory variables included socio-demographic, economic, and reproductive health factors. Multilevel mixed-effects Poisson regression with robust standard errors was used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI), accounting for clustering at the community level. Four models were fitted, and model fit was assessed using deviance, AIC, BIC, intra-class correlation (ICC), and median odds ratio (MOR). ResultsThe prevalence of HRFB was 48.4%. Older maternal age increased risk (25-34 years: aPR 1.28; 95% CI 1.20-1.37; 35-49 years: aPR 1.89; 95% CI 1.78-1.99), while higher maternal and partner education were protective (secondary: aPR 0.78; tertiary: aPR 0.53). Employment and contraceptive use were associated with higher HRFB, whereas prior pregnancy termination and lower household wealth were protective. Rural residence was not significant. Minimal community-level variation was observed (ICC {approx} 0, MOR = 1), indicating that most variation occurred at the individual level. ConclusionHRFB remain highly prevalent in Zambia, with older maternal age, lower education, employment, and contraceptive use after risk onset as key risk factors. Interventions should prioritize improving education, promoting early family planning uptake, and supporting older women continuing childbearing to reduce HRFB and improve maternal and newborn outcomes.