This study showed that 67.7% of women had HRFB, of which 45.6% were in single high-risk category and 22.1% women have had multiple high-risk categories. This high prevalence rate demonstrates that HRFB are all too common in Bangladesh, potentially endangering the health of the country's women. We found that women practicing Islam as core religion, aged above 35 years, having normal childbirth, having above 3 children, having unwanted pregnancies and using birth control methods were at increased risk of having HRFB.
When compared to women who have never had any formal education, those with an elementary, secondary, or higher level of education had a lower likelihood of high-risk fertility behaviour. This result was supported by the previously conducted studies[22–25]. The reason for this could be those who had better understand and awareness about HRFB and lower likelihood of experiencing early marriage.
This study revealed that, HRFB was more likely to occur among women who had never taken contraception compared to those who used which is in line with previously did studies elsewhere[26, 27]. One of the goals of contraception is to increase the birth interval and reduce unplanned pregnancies. Women who had unwanted pregnancies were more likely to engage in high-risk reproductive behaviour than those who had previous desired pregnancies. It may be the result of not using contraceptive methods by the women who experienced unwanted pregnancies. This result also corroborates with a study conducted in Nigeria[22].
In the univariate regression model, we found that rural women had a higher risk of having HRFB than those who lived in urban areas and the result supports the previous study[25]. Women in remote locations may stay behind in terms of utilising reproductive health services, such as ANC, family planning, and birth intervals, as well as having poor literacy levels. Women, who did not have ANC follow-ups for their recent children, had more probability to engage in risky reproductive activities. Family planning for extending the time between births was discussed during postnatal care counseling. As a result, decreased ANC seeking during pregnancy may have a role in HRFB.
High-risk fertility behaviours were found more than double among women in Rangpur, a northern region in Bangladesh, compared to the women who live in Sylhet. This could be explained by healthcare inaccessibility and poor family planning adopted rates related to religious beliefs and community attitudes. Moreover, religious perspective also did affect maternal HRFB. Our study revealed that the women, who followed Islam, have increased odds of HRFB compared with other religious believers. This finding was in line with an Indian study[28], where the author argued that Muslim women are less willing to use contraceptive methods, family planning and they prefer temporary methods over sterilisation, these could be plausible reasons why Muslim women in Bangladesh were at higher risk of having HRFB.
Maternal age of 15-24 and 35-49 have the higher odds of HRFB than the maternal age of 25 to 34 years. There are numerous reasons why HRFB could be related to higher probability of chronic malnutrition. For instance, short birth intervals don't give a mother adequate time to recuperate from the physical burden of one pregnancy before moving on to the next. [29, 30]. A high number of births is also linked to the mother's poor care, leaving her exposed to increased malnutrition and disease[31, 32]. Furthermore, early childbearing can cause severe blood loss during the delivery, which leads to anemia[33, 34]. Early childbearing can also deteriorate the maternal nutritional status. While educational attainment is higher, the age at which people marry is also higher. As a result, raising women's educational attainment has the potential to address the issue of early marriage and motherhood [33, 35]. This analysis may lead to important inferences that may help to lower maternal high-risk fertility behaviour and can be useful and relevant in areas where HRFB is ubiquitous.
The strengths and limitations of this study have been well-recognised. The study employed the recently published BDHS 2017-18 data which had a large country representative sample size, allowing the findings to be more generalisable. Moreover, appropriate statistical technique applied in the analysis can be used to find probable components and their relationships. However, the study has some limitations. For instance, due to cross-sectional data, outcomes and predictors variables were collected at a point of time; therefore, causality cannot be established. In addition, some important factors, such as dietary factors, physical activity and maternal comorbidity histories are not taken into consideration due to unavailability in the original dataset, but these factors may have been associated with HRFB.