Trends of Fertility in Ethiopia, Systematic Review

Background Fertility is the actual childbearing performance of a population. When there is no signicant migration, at any level of mortality, changes in fertility cause variations in the rate of natural increase and exert a powerful inuence on the age structure. The global population increased from 2·6 billion in 1950 to 7·6 billion in 2017 and the Ethiopian population become 100 million. Therefore, this review was aimed to assess the trends of fertility in the regions and administrative cities of Ethiopia in the last 5 decades. Methods: both quantitative and qualitative study design were considered for the review. The PubMed databases, and Gray literatures (Google scholar, organizations’ research works, Academia, and Research get) were used as source of data for searching. The JBI critical appraisal tool were used to assess the quality of papers after including for review by abstract and title. Results: on initial searching 8503 papers were identied from PubMed databases. Of these papers only 28 studies for quantitative and 15 for qualitative analysis were selected based on JBI critical appraisal checklist. The rate of fertility in Ethiopia decrease radically from 8.1 in 1965 to 4.0 in 2016. The mean fertility rate with standard variation for both urban and rural Ethiopia is (6.03 + 1.3) in the last 51 years. Conclusions and recommendations: The fertility rate of Ethiopia become declined since the starting of contraceptive utilization even though it is not similar across the different regions. Some of the regions like Afar and Somalia become more fecundate irrespective of the country growth and development and others like Amhara region had the highest decline in fertility. The minister of health should explore the causes of high fertility in Afar and Somalia regions. Ethics and dissemination: The review is based on published data, and ethical approval did not require. Trial Registration: The protocol has been published CRD42019128889


Background
The global population increased from 2·6 billion in 1950 to 7·6 billion in 2017. Much of this increment was high in south Asia and sub-Saharan Africa in relative to the proportion of the global population (1). The total population of Ethiopia was close to 100 million, which is the second most populous country in Africa. The Ethiopian population is characterized by a high fertility rate (2). Of the total population, 44.4% was under the age of 15 years (3). The total fertility rate is the average number of children a woman would have by the end of her childbearing years if she bore children at the current age-specific fertility rate (4). Therefore, fertility refers to the actual childbearing performance of a population. It is a major explanatory force in population dynamics and a major counteracting force to population attrition through mortality. When there is no significant migration, at any level of mortality, changes in fertility cause variations in the rate of natural increase and exert a powerful influence on the age structure (5,6). The Ethiopian population in July 1990 was estimated as 51.0 million and the utilization of contraceptive among all women aged 15-49 was 4.0%, but on currently married women was 4.3%, on ever married women was 4.4% and all women currently exposed was 5.0%. Like that of high fertility rate the crude death rate were also high, which was about 18.00 per 1000 population, and the rate of growth of the population was around 3.0 percent per annum (7). USAID, 2014 reports showed that the estimated TFR of Amhara region will be decreases from 5.1 children per woman in 2007 (2005, EDHS) to 2.9 by 2037. This projection is referred to as the low socioeconomic development scenario or slow fertility decline. The second scenario assumes that fertility decreases from 5.1 children per woman in 2007 to 2.3 by 2037. This projection is referred to as the high socioeconomic development scenario or fast fertility decline (8). Amhara had achieved a higher contraceptive utilization than all regions of Ethiopia. In this region 33 percent of married women aged 15-49 years were using a modern contraceptive method in 2011, which was higher than the national average of 27 percent. In addition, 22 percent of married women had an unmet need for family planning (9).
Even if, the TFR is decreasing curiously, particularly in Amhara region, the CSA and ORC Macro (2001) showed a marked decline in the percentage of women currently married, from 72% in 1990 to 64% in 2000. This proportion remained almost the same in 2005 (10). Therefore, reviewing literatures, databases, and reports about trends of fertility in Ethiopia might showed the progress of contraceptive utilization, and indicated the experienced challenges and implemented strategies to decrease fertility rate in Ethiopia.

Objective
This systematic review was aimed to determine the trends of fertility across the different regions and administrative cities of Ethiopia.

Research question
For this review, the question was developed in considering CoCoPop. mnemonics. The review question is "How was and is going trends of fertility in Ethiopia across the different regions?

Inclusion and exclusion criteria
Researches which are similar in title, context, and design but poor in quality based on JBI criteria were excluded when the reviewers agree to reject the paper by putting clear reason for exclusion.
Search strategy: The search strategy was implemented in two stages. Three of the investigators were independently search electronic database from PubMed for published studies. Two of the investigators were search gray literatures that have Research and Trials Registers, thesis or dissertations, organizations websites, and reports using the following logic grid (Table 1). Outcome measures: The primary outcome is trends of fertility. The trends of fertility controlled by contraceptive utilization. This review showed the degree of decrement in fertility from1965 to 2016. The secondary outcome is population growth, which is directly affected by birth, migration and death. From these factors birth takes the major role in influencing population positively or negatively.
Data extraction, analysis and presentation The data extracted from PubMed and gray literatures is presented using PRISMA checklist. The papers included for review are 28 for quantitative and 15 for qualitative write up. Most of the data expressed in narration, but a simple mathematical analysis is also done using Microsoft excel 2016. Therefore, the result is presented in table, graph, mean and standard deviation but due to considerable degree of heterogeneity, meta-analysis was not performed instead narrative writing is computed. The search was done before April 27/2019 ( Figure 1).

Presentation And Reporting Of Results
The qualitative evidences about fertility in Ethiopia and SNNP had high total fertility rates. In addition, high fertility was observed in rural areas than urban areas.
Religion also reported as having influence on the status of fertility that Muslim respondents had more children as compared to traditional religion, being in lower grade and being economically poor contribute for having more kids (14). Women without any education and women with secondary or higher education had on average 5.8 children, and 1.6 children respectively (11). The female literacy rate in each region was also documented as 80% in Addis Ababa, 76.5% in SNNP, in Harari 74.5%, 72.6% in Oromia, 71% in Tigray and Gambella, in Benishangul-Gumuz 66.3%, in Amhara 65.5%, in Dire dawa 64.6%, in Afar 53.2% and 47% in Somalia (15). In between 2000 and 2011, fertility rates in Somali, Afar, and Benishangul-Gumuz regions increased by 39%, 14%, and 4% respectively (16). Whereas in Amhara region and in Addis Ababa dropped by 24% and 17%, in SNNP and Tigray dropped by 13% respectively (17). The total fertility was increased from 1970s both in rural and urban areas. The Improvement in the health status of women mainly the decrement in sexually transmitted diseases, decreasing in still births and a reduction in the duration of breastfeeding were the possible reasons for a fertility to rise in 1970s (19).
The other analysis reported as the TFR was 5.5 children per woman during the early 1970s and increased to 7.2 children per woman within 5-9 years, that was in 1984 (20). But in the latter year, the TFR decrease radically, and the decrement in fertility rates is largely due to the dissemination of contraceptives throughout the country.
According to DHS of 2014, awareness of contraceptive methods between 2000 and 2014 has grown steadily among women and particularly among married women, 97% of whom report awareness (17). The government was the major provider of modern contraceptives. In which, 87% of users obtaining their family planning method from the state, health centers, and health extension workers (17).

The quantitative evidences about fertility in Ethiopia
The prevalence of modern contraceptive utilization in 2011 across the different regions were had a hug difference. The prevalence of utilization in Addis Ababa was 56.3%, 24.7% in SNNP, in Harari 31.5%, 24.9% in Oromia, 21.2% in Tigray and 33.2% in Gambella, in Benishangul-Gumuz 26.3%, in Amhara 33.0%, in Dire-Dawa 31.7%, in Afar 9.1% and 3.8% in Somalia (21). The fertility of Ethiopia decreases radically from 8.1 in 1965 to 4.0 in 2016. The mean fertility rate with standard variation for both urban and rural Ethiopia is (x + Sd) 6.03+ 1.3 for the last 51 years. According to EDHS report the maximum decline is recorded in Amhara region. In contrary Afar and Somalia had increased fertility rate in 2016 by 0.6 and 1.5 children per woman respectively (Table3) Some of the previous large surveys like FFS, which was done before 2000 lack specificity to the area or region. In addition, earlier national survey like CSO, CSA and FFS had poor quality in design, or data collection. Therefore, for comparing the trends of fertility in Ethiopia across the regions and town administrators were not used.
Because of methodological superior quality, only EDHS used to presnt figurative data. According to the 5 DHS data of Ethiopia, fertility is decreased by 1.5 from 2000 as a baseline and 2016 as current reference. Amhara, south nations and nationalities and Tigray took the first top three levels in decreasing the number of births in 2016 respectively. The mean and median fertility rate in both rural and urban was 6 and 5.9 respectively but the urban and rural median fertility rate was 5.7 and 7.5 with mean of 5.5 and 6.9 respectively. whereas the overall fertility rate in Ethiopia was X+sd (6+1.8) mean and standard deviation.  (Fig 2, Fig  3, and Table 3)

Discussion
This review emphasis mainly on EDHS data for discussion, conclusion and recommendation than other survey and studies because of better methodology and its representatives in study variables and study population.
Because, the aim of this review was to investigate fertility rate among reproductive age group women in the different regional state of Ethiopia. But other studies are also considered in the narrative synthesis.
The rate of decrement in TFR in Ethiopia was 4.8, which is below the sub-Saharan stands, 4.9 (11). The mean, variance, minimum and maximum TFR in the last 51 years was 6, 1.8. 4.1 and 7.7 respectively in Ethiopia. But the fertility rate didn't continue its decrement smoothly in each regional state even in the urbanized city, Addis Ababa except Amhara region. The total fertility rate in Dire-Diwa was decreased by 0. . This was because of high contraceptive prevalence utilization rate than many other regions of Ethiopia. According to CSF and ICF (9), 33 percent of married women aged 15-49 years were using a modern contraceptive method in 2011, which was higher than the country average of contraceptive prevalence utilization rate, 27%. This level of utilization put the region as the second contraceptive utilizer next to Addis Ababa 56.3% and Gambella, 33.2%. But the overall decrement in TFR in Addis Ababa and Gambella was 0.1 and 1 respectively. These contradicts with the higher 2.2 children drop in Amhara region. The prevalence of contraceptive utilization is not as such unique than others. The literacy rate of females in Amhara region was also among the least (15). Therefore, the reviewers recommended a primary study in Amhara region on the fertility and factors of fertility in considering contraceptive utilization.
In Fact, fertility rate is a vital developmental factor, which is associated with growth of community economy (22,23) and have an impact on child and maternal health (24,25). Unfortunately, this review testified the opposite of this literature.
The highest decrement in fertility is recorded in Amhara region even greater than the national plans (8) but the 2016 EDHS reported 46% of Amharan under five children were stunted, which is attributable for the highest prevalence of Stunting in Ethiopia followed by Benishangul-Gumz and Afar. These regions have high fertility rate than Amharan mothers. A paper was presented that the major ethnicity, Hausa and Ibo women have higher fertility than those from the minority ethnic groups (26). This evidence found from Nigerian was also in contrary with Ethiopian, this systematic review. In this systematic review the fertility rate in major ethnic group is less than the whole minority ethnicities. This might be because of extensive and politically focused contraceptive administration in the dominant ethnicity, Amhara region (8) and ignorance of the minority for contraceptive distribution and awareness creation.
Women without formal education had a total fertility rate of up to 6 children (27), while for women with 12 years of schooling the fertility is less than 2 children (28). The review showed that the fertility rate is higher in rural area than urban areas. This is in line with other studies (29,13). The difference is also considerable because of the socioeconomic development, the increase of education, employment opportunities, and the improvement of Health services in Urban areas which contributes for low fertility rate.
The USAIDS estimation was to decreases fertility from 5.

Conclusions
Page 10/14 The decrement in fertility rate in Ethiopia is achieved effectively in relative to sub-Saharan fertility stands. On the narrative review, education and economic status are explained as contributor for fertility. But the degree of association with each factor are not measured. Of the 9 regions, the rate of decrement in fertility was achieved in Amara region earlier than others but the socio-demographic status of the region was not improved as such. For example, the female literacy rate in Amhara region holds the 8 th rank but in fertility, it is the first in decrement.
This unique, continuous and earlier achievement in decrement of fertility in only Amhara region cause to conclude that much of the country's contraceptive methods distribute toward Amhara region. This means, family planning utilization principles in Ethiopia was not ethically fair. Therefore, the Minister of Health and Amhara regional health Bureau need to assess the mode of family planning administration in Amhara region like type of consent received from women. Because, it is a matter of genetic continuity. In addition, the minister of health should distribute contraceptives in all regions fairly. In contrary Afar and Somalia had abrupt increment in TFR in 2016. Therefore, the minister of health also obligated to assess the factors for high fertility in some of the regions and should fill the gap either by increasing awareness about the contraceptive utilization or else based on evidences.

Limitation Of The Review
The databases used is only PubMed due to inaccessibility of other sources and it might affect the accuracy of the review. Due to the heterogenic nature of the title, lack of samples size, and other extracts meta-analysis was not computed. Therefore, there is no statistically pooled result rather the review is presented with central tendency and variance, which may not be statistically significant to conclude the total fertility. This study seems to be politically biased but we assured that we are stick to the data and written evidences. Although many gossips are existed in legend within Amhara region regarding fertility and contraceptive utilization, we didn't consider it.

Ethics approval
The current study is based on published data, and thus ethical approval did not require. This systematic review is expected to serve as a base in evaluating the trends of fertility in Ethiopia beside the catastrophic politics in the last 29 years.

Consent to participate
Not applicable Consent for publication Not applicable Availability of data and material The raw material supporting the conclusions of this research are include as part the review in Table 2a and 2b. MW, BB, and AM -write the protocol. MW, BB, AB and AM -search electronic database. AB and AM -search gray literatures. MW, BB and AM write the result. AB, AM, MW -apprise the papers using JBI checklist.
Due to technical limitations, tables are only available as a download in the supplemental les section  The total fertility rate of Ethiopia