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Reducing stunting and underweight through mother’s birth spacing: evidence from Ghana

BMC Pregnancy and Childbirth volume 24, Article number: 624 (2024) Cite this article

Abstract

Background

Researchers over the years have underscored the role of birth spacing on maternal health, however, inadequate maternal repletion due to shorter birth intervals could also affect the health of the child. Even so, limited studies exist on the linkage between birth spacing and child nutrition. This study examines the association between birth spacing and child stunting and underweight using the 2014 Ghana Demographic and Health Survey.

Methods

The study sourced data on 1, 904 children less than 59 months from the 2014 Ghana Demographic and Health Survey. The study employed bivariate analysis and logistic regressions to establish the association between birth spacing, and child stunting and underweight.

Results

The analyses reveal that childbirth spacing between 24 and 35 months (OR = 0.62, 95% CI: 0.38–0.99; p < 0.05), 36 to 47 months (OR = 0.42, 95% CI: 0.25–0.70; p < 0 0.01), and beyond 47 months (OR = 0.47, 95% CI: 0.28–0.78; p < 0.01) have lower odds of child stunting than children with birth spacing less than 24 months. Children with birth spacing between 24 and 35 months (OR = 0.53, 95% CI: 0.29–0.98; p < 0.05), 36 to 47 months (OR = 0.44, 95% CI: 0.22–0.90; p < 0.01) and beyond 47 months (OR = 0.49, 95% CI: 0.26–0.94; P < 0.05) have lower odds of being underweight than those with birth spacing less than 24 months.

Conclusion

The study reveals that mothers with a birth spacing of at least two to three years compared to their counterparts with less than two years of birth spacing have lower odds of having a stunted and underweight child under age five. The study recommends that Ghana Health Service and other healthcare providers should educate mothers on the gains of birth spacing of at least two years on their children.

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Background

The World Health Organization’s Global Target 2025 calls for a decrease in stunting, wasting, and low weight as indicators of malnourishment [1]. The prevalence of stunting and underweight among children under-five varies across continents and regions and is of great concern in Africa. For example, about 90% of all stunted children worldwide are found in Africa and Asia [2,3,4]. Stunting affected 30.7% of under-five children in Africa, while Sub-Saharan Africa (SSA) reported an incidence of 24.1% [5]. This means that SSA has the highest incidence of malnutrition on the continent of Africa. Sub-Saharan Africa is the home of one-quarter of children affected by wasting in 2020, with comparable numbers for children affected by severe wasting [6, 7]. Preterm birth, low birthweight, stunting, and underweight are among the negative outcomes that can occur in infants and children whose pregnancies and births are spaced too closely. This is because women may not have the chance to replenish their nutritional stores stressed during pregnancy and/or breastfeeding [8].

Although Ghana has impressive achievements in reducing the burden of malnutrition among children under-five, child stunting and underweight remain a significant concern. For example, 19% and 11% of children under five were stunted and underweight according to the 2014 Ghana Demographic and Household Survey (GDHS). National statistics reveal that stunting peaks in children between 24 and 35 months of age (28.2%) [9, 10]. Stunting, or being excessively short for one’s age, is a sign of the effects of nutritional and non-nutritional variables that impede children’s cognitive and physical growth, and also raise their risk of dying from common infections. Unlike stunting, underweight accounts for acute as well as chronic malnutrition and reflects children who are stunted, wasted, or both [4, 5, 11,12,13].

To accelerate progress toward the 2030 target of eradicating malnutrition and hunger, undernutrition reduction initiatives and all efforts aimed at improving the nutritional status of children under-five must be enhanced. The World Health Organization (WHO) is creating a strategic plan that directs governments and development partners to combat all types of malnutrition through enhanced service delivery, strengthened regulations, and better data utilization. Such an effort can succeed only through coordinated and complementary efforts [1]. One complementary effort identified in the literature as a way to influence child malnutrition is birth spacing. The interval between births is a domestic decision that affects not only the health of the mother but also that of the child [14,15,16]. Waiting for at least two to three years between pregnancies is advised by the WHO to lower newborn and child mortality and enhance maternal health.

There are several reasons why a gap between births is seen to promote better growth in subsequent children. The likelihood of many adverse health consequences, notably poor health, and mortality for mothers and children has been linked to having children too close together [14,15,16]. Some examples of adverse outcomes associated with sub-optimal birth spacing includes still birth, preterm birth, and low birth weight. Intrauterine growth retardation, preterm birth, low birthweight, and anemia are less in women with longer birth intervals [15]. While a plethora of research has focused on the impact of a mother’s characteristics such as education, income, age, and other household characteristics on improving child health, less attention has been focused on the impact of birth spacing on the nutritional status of children under age five in Ghana. Prior research conducted in Sub-Saharan Africa and low and middle-income countries (LMICs) has suggested that the period between one birth and the next, or the preceding birth interval, is related to the health outcomes of the child [17,18,19].

The extant literature revealed that a preceding birth spacing of at least 36 months was related to a 10–50% reduction in stunting, whereas birth intervals of fewer than 12 months and 12–23 months were linked with greater stunting risk than birth interval between 24 and 35 months [20, 21]. A 2009 study by Gribble, Murray, and Menotti revealed that birth intervals of fewer than 24 months and 24–35 months significantly raise the risk of stunting compared to intervals of 36 to 59 months [21]. A short duration between pregnancies can be dangerous if the mother’s nutrient stores run low, which can raise the risk of intrauterine growth retardation and negatively affect the infant’s nutrient reserves and availability [22, 23].

In this study, we address the following research objectives: (1) to investigate the association between birth spacing and child stunting, and (2) to examine the association between birth spacing and child underweight. Investigating birth spacing and child malnutrition in children under five in Ghana is a major step toward determining resource investments in policy interventions that can improve maternal and child health outcomes. This will also help to inform the Ministry of Health and Maternal Health Service providers to implement specific birth spacing recommendations and policies that improve the health status of children. The insights from this study may contribute to the realization of SDG target 2.2, which focus on ending all forms of malnutrition, and include achieving, by 2025, the internationally agreed targets for stunting in children under five years. The two research questions that can be teased out from the objectives are: (1) Is there an association between birth spacing and stunting among children under-five?; and (2) Is there an association between birth spacing and underweight among children under-fives?

Conceptual framework

A systematic review identified several outcome measures for parental, child, and household characteristics that influence child malnutrition. Figure 1 highlights the interconnected system of variables that influence a child’s nutritional status (stunting and underweight). The first association is the link between birth spacing (preceding birth interval) and child stunting and underweight. The literature found a negative relationship between shorter-birth intervals and child nutrition. This is based on the observation that a longer repletion period is beneficial for both the mother and the child [20, 23, 24]. As shown in the conceptual framework, we anticipate a negative association between birth spacing, child stunting, and underweight. The conceptual framework also underscores the importance of parental characteristics such as maternal attributes (education, age, employment status, BMI, contraceptive use, and marital status); a partner’s characteristics (level of education); household characteristics (household size, place of residence, wealth quintile, and region); and child’s characteristics (sex, age, birth order, perceived size of child at birth) in affecting child stunting and underweight. All variables in the conceptual framework are based on existing literature and data availability [20]. Hence, data analysis and interpretation of findings have been guided by the conceptual framework.

Fig. 1
figure 1

Conceptual framework of the link between birth spacing, and child stunting and underweight. Note The child characteristics used in the model are the age of the child in months, sex of the child, size of child at birth, and preceding birth interval, while parental and household characteristics used in the model include the mother’s BMI, mother and partner educational level, contraceptive use, mother’s employment status, marital status of the mother, mother’s age group, wealth index, place of residence, family size and region of residence respectively

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Data and methods

Data

This study utilises the most current Ghana Demographic and Health Survey (GDHS) undertaken in 2014. The GDHS is a national representative with a cross-sectional sample survey. Over the years, six rounds of GDHS have been undertaken in Ghana in 1988, 1993, 1998, 2003, 2008, and 2014. The 2014 GDHS was based on a two-staged stratified sample frame with systematic sampling and probability proportional to size in identifying enumeration areas from which households were selected from the 2010 Population and Housing Census. The GDHS provides data on key population and health issues that include fertility, family planning, infant and child mortality, maternal health, nutrition of children and women, and malaria. The sample for the study focuses on children under-five with anthropometric information on height for age (HAZ) z-scores and weight for age (WAZ) z-scores, whose mothers are between the ages 20–49. The sample size of the under-fives with HAZ and WAZ outcomes was further constrained with those with information on birth spacing. Thus, our analyses focused on second births and beyond. After the regression analysis, the final weighted analytical sample was 1,904 children age less than 59 months.

Variables

Dependent variables

Two outcome variables are used for the study - child stunting and underweight. Child stunting is defined as children with a HAZ score less than − 2 SD, while underweight children are those with less than − 2 WAZ scores. The two outcome variables are dichotomous and are standard measures of child nutritional status as proposed by the World Health Organization (WHO) in 2006 [25].

Independent variables

As shown in our conceptual framework, there are a number of independent variables that influence child nutrition. These variables are grouped into three broad categories: child, parental, and household characteristics. The child characteristics include birth spacing, the primary variable, which is categorized into four (< 24 months, 24–35 months, 36–47 months, and above 47 months). This categorization follows the convention in the 2014 GDHS report. In addition to birth spacing, four additional variables (age, sex, birth order, and perceived size at birth) are used to control for other child-level correlates of child nutrition. The parental characteristics include five variables, which were the mother’s BMI status, age, employment status, contraceptive usage, and the partner’s educational level. Household characteristics included four main household-level variables: wealth index, place of residence, region of residence, and family size. The independent variables are recoded into binary or categorical variables. The names and measurements of the variables are provided in the Appendix in Table A1.

Statistical analysis

The study employed two main analytical procedures, namely descriptive and inferential analyses. The descriptive statistics describe the distribution of the dependent and independent variables as well as bivariate analyses of the dependent variable across all the independent variables. The inferential analysis involved establishing the association between birth spacing and the two dependent variables (child stunting and underweight). Given the dichotomous nature of the two dependent variables, the study employed binary logistic models using adjusted and unadjusted models. The unadjusted and adjusted odds ratios are presented using the 95% confidence intervals (CI) and the associated p values to denote statistical significance. Hence, the estimates were considered statistically significant at p < 0.05. Additional analysis ensured the internal consistency of the logistic models such as checking the correlation coefficients among the independent variables and applying the appropriate survey weight, which accounted for the multi-stage sampling and stratification design of the DHS Program Data.

Results

Distribution of children under five by child, mother, and household characteristics

As a prelude to the logistic regression analysis, summary background statistics on the distribution of the under-five children, their mothers, and household are presented in Table 1. For the child-level variables and their nutritional status, we observe that roughly one-in-five under-five children (19%) were stunted in Ghana, while about one-in-ten children (11%) were reported to be underweight. The main explanatory variable in this study is the birth interval between two successive births. Table 1 shows that approximately 12% of the under-fives were born following short birth intervals of less than 24 months, 29% between 24 and 35 months, and 20% after 36 to 47 months. Birth intervals greater than 47 months were observed among 38% of the sampled population.

Table 1 Percent distribution of children under five by child, mother, and household characteristics
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Table 1 shows the distribution of children according to their age and sex. In the analytical sample, most children were in the 12–23 age group (22.1%), were second birth order (47.8%), and were perceived by their mothers as average or larger at birth (86.6%). The mothers of the children were classified as having normal BMI (54.3%), had some form of secondary or higher education (45.6%), were between age 30 to 39 (54%), resided in rural areas (57.7%), and had some form of formal employment (83.1%). A greater percentage of the mothers were married (94.4%), had partners with secondary education (54.2%), and were not using any form of contraceptives (72.7%). The data also revealed an average family size between 5 and 6 (41.1%).

Bivariate analysis of independent variables by child malnutrition

Table 2 as has been previously shown shows the association between stunting and underweight of children under-five by background characteristics of the children, mother, and household in Ghana based on the Pearson chi-squared test. For the child variables in the model, we observe that the child’s age and perceived size of child at birth were significantly associated with both child stunting and underweight. Stunting and being underweight increased with child’s age and then decreased after 35 months. Preceding birth interval and birth order were significantly associated with stunting, but not with underweight. Stunting decreased with increasing preceding birth interval and increased with increasing birth order. With parental characteristics, mother’s BMI and educational level of the mother were significantly associated with both child stunting and underweight. For example, children of mothers with no education had a higher incidence of stunting (25.7%) and underweight (13.7%). While marital status and partner’s educational level were only significant for child stunting, contraceptive usage and mother’s employment were only significant for child underweight. With household characteristics, place of residence, region of residence, and family size were significantly associated with child stunting and underweight, while the wealth index was significant for only stunting and showed a pattern of a decreasing level of stunting with increasing wealth quintile.

Table 2 Association between malnutrition of children under five by child’s, maternal and household characteristics
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The Northern Region had the highest levels of stunted and underweight children compared to other regions (32% and 18% respectively), while Greater Accra had the lowest levels at 10% and 6%, respectively.

Association between birth spacing and child stunting-multivariate analysis

The results of the logistic regression of the association between birth spacing and child stunting, controlling for other independent variables, are shown in Table 3. We present the results of both the adjusted odds-ratio (AOR) and unadjusted odd-ratios (OR) together with confidence intervals and p-values. In the adjusted model, the results indicate that compared with the birth interval of less than 24 months, increasing birth interval is associated with lower odds of being stunted. For example, birth spacing above 47 months is associated with 47% lower odds of stunting in comparison to children with birth spacing less than 24 months (AOR = 0.47, CI: 0.28–0.78, p < 0.01). Similar results were found within the unadjusted results. With the association of the child’s age, the adjusted results show that children in the age categories of 12 months or above had approximately three times the odds or higher of being stunted compared to children less than 6 months old.

Table 3 Logistic regression of the association between birth spacing and child stunting
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When we examine the association between the sex of child and stunting, we find that male children had significantly higher odds of being stunted in both the unadjusted and adjusted models compared to females (AOR = 1.41, 95% CI: 1.10–1.80, p < 0.01). As shown in Table 3, children who are perceived to be average or large have 63% lower odds of becoming stunted, compared with those who were perceived to be very small (AOR = 0.37, 95% CI: 0.20–0.69). Birth order was significantly associated with child stunting but only within the unadjusted model.

With the parental variables in the model, the adjusted results show that mothers with secondary or higher level of education have 39% lower odds of having stunted children compared to those without education (AOR = 0.61, 95% CI: 0.41–0.90, p < 0.05). Marital status was found to be significantly associated with lower odds of being stunted. The mother’s nutritional status, her age, employment status, contraceptive use, and partner’s education level were not found to be significantly associated with child stunting.

In Table 4, we explore whether parental and household characteristics serve as mediators in the relationship between birth spacing and child stunting. Notable we examined the moderating roles of maternal education and household wealth quintile in the birth spacing-child stunting nexus. The joint test results (see beneath Table 4) reveal that birth spacing and the interaction term of birth spacing and maternal education are statistically significant. Hence, we observed that irrespective of the extent of birth spacing, mothers with primary education have a higher odd of having stunted children. The reverse holds for mothers with secondary or higher education (See Column 1). Regarding the household wealth quintile moderator, we observed that joint test for birth spacing and interaction term of birth spacing and wealth quintile are statistically significant. Though we did not observe a discernible pattern, the estimates depict children in the second wealth quintile irrespective of birth spacing have higher odds of being stunted (See Column 2). On the flipside, children in the highest wealth quintile have a lower odd of child stunting irrespective of birth spacing.

Table 4 Logistic regression of the association between birth spacing and child stunting: interaction effects
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Analysis of the association between the various categories of wealth quintiles and child stunting in the adjusted model shows that women within the second wealth quintile had 1.5 times the odds of having stunted children compared to women in the lowest quintile (AOR = 1.53, 95% CI: 1.01–2.31, p < 0.05). In the unadjusted model, the remaining wealth categories were found to be significantly associated with child stunting but they lost significance in the adjusted model. Furthermore, both the adjusted and unadjusted models revealed that children of mothers who reside in the Northern Region had greater odds of being stunted compared to the mothers who reside in the Greater Accra Region (AOR = 3.1, 95% CI: 1.21–7.60, p < 0.05). The remaining regions were not significantly different from Greater Accra in stunting. Place of residence and family size were not significantly associated with stunting in the adjusted models.

Association between birth spacing and child underweight-multivariate analysis

Table 5 reports estimates of the multivariable logistic regression of the association between birth spacing and child underweight, after controlling for other independent variables at the child, parental and household levels. The results from the adjusted model show that birth spacing is significantly associated with lower odds of child underweight. Children with a preceding interval of 24 months or more have between 47 and 56% lower odds of being underweight compared to children with a birth interval of less than 24 months. Specifically, children with birth interval of 24 to 35 months (AOR = 0.53, 95% CI: 0.29–0.98, p < 0.05), 36–47 months (AOR = 0.44; 95% CI: 0.22–0.90, p < 0.05), and beyond 47 months (AOR = 0.49, 95% CI: 0.26–0.94, p < 0.05) had lower odds of being underweight. All the children’s age categories in both the adjusted and unadjusted models were found to be significantly associated with higher odds of being underweight, compared with children aged less than 6 months. Furthermore, children who were perceived to be average or large have significantly 65% lower odds of being underweight, compared to children perceived to be very small as shown in the adjusted and unadjusted model results. The child’s sex and birth order were not significantly associated with underweight. Similar to what was found for stunted children in the adjusted model results, women who are married had 59% lower odds of having underweight children compared with their non-married counterparts. Except for the partner’s level of education and the middle wealth quintile, which were found to be significantly associated with child underweight within the unadjusted model, all the remaining parental and household variables (mother’s age, employment status, level of education, contraceptive usage, partner’s level of education, place of residence, region of residence and family size) were found not to be statistically associated with child underweight in both the adjusted and unadjusted model results.

Table 5 Logistic regression of the association between birth spacing and child underweight
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In Table 6, we explore whether parental and household characteristics serve as moderators in the relationship between birth spacing and child underweight. Particularly we examined the moderating roles of maternal education and household wealth quintile in the birth spacing-child underweight nexus. The joint test results (see beneath Table 4) reveal that birth spacing and the interaction term of birth spacing, and maternal education are statistically significant. Hence, we observed that irrespective of the extent of birth spacing, mothers with primary education have a higher odd of being underweight. The reverse holds for mothers with secondary or higher education (See Column 1). Regarding the household moderator, we observed that the joint test for birth spacing and interaction term of birth spacing and wealth quintile are statistically significant. Though we did not observe a clear pattern, the estimates depict children in the second wealth quintile irrespective of birth spacing have higher odds of being underweight (See Column 2). On the other side, children in the highest wealth quintile have a lower odd of child underweight irrespective of birth spacing.

Table 6 Logistic regression of the association between birth spacing and child underweight: interaction effects
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Finally, given that child underweight is sensitive to recent ailment, we have excluded children with recent ailments, such as diarrhea from the birth spacing-underweight analyses to ensure unbiased results. The results are presented in Table 7 and the results show the relationship between birth spacing and child undernutrition is upheld as in the main results.

Table 7 Logistic regression of the association between birth spacing and child underweight: without recent ailment
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Discussion

Multisectoral strategies are key to continuing the progress that Ghana has made in improving child undernutrition. In this study, we explored the association between birth spacing, child stunting, and underweight. The results showed that longer birth spacing was associated with lower odds of stunting and underweight. Several other child’s, parental, and household characteristics were also significantly associated with lower stunting and underweight.

The first finding is the positive association between birth spacing and a child’s nutritional status. Specifically, the findings indicate that birth spacing of at least two years is associated with a lower risk of child stunting and underweight. These findings suggest that mothers need at least two years to replenish themselves and have healthy children. Other studies corroborate our findings. For example, in India, it was observed that birth spacing of less than 24 months increases the risk of stunting by 28% [21]. A systematic review of 58 observational studies suggested that shorter birth spacing has adverse consequences on child health outcome. The study cited maternal nutritional depletion, and folate depletion as potential transmission mechanisms [22]. Other studies in Sub-Saharan Africa and LMICs also identified the adverse consequences of short-term birth spacing on a child’s nutritional outcome [17,18,19]. Our study confirms WHO’s advice about waiting for at least two to three years between pregnancies because this leads to lower newborn and child mortality and enhances maternal health. In addition, according to a study funded by USAID in 2002, having children at a birth interval of three to five years is preferable and may lead to a reduction in infant mortality in under-developed nations if there were no births within 36 months of previous birth [13]. This pattern will help to inform the decision of the Ministry of Health and Health Service Providers in Ghana to institute policy prescriptions that encourage birth spacing of at least two years for mothers between age 20 to 49.

Several factors at the child, parental and household level were found to influence child stunting and underweight. With stunting, diverse factors make a compelling case for a multisectoral approach to its reduction. At the child level, the study identified age of the child, sex of the child, and perceived size at birth as significant predictors of stunting. The findings on the age of the child suggest that the risk of stunting peaks for children age 24 to 35 months. This is confirmed by the 2014 GDHS report, which also indicated that the risk of stunting is heightened for children between age 24–35 months. The results also indicate that male children have higher odds of being stunted than female children. This finding is supported by previous studies on child stunting in Ghana [9, 26].

It was also observed that average or larger perceived size at birth was associated with lower odds of stunting. Larger birth sizes are reflective of high birth weight, which is negatively correlated with stunting [2]. These variables at the child level imply that within the Ghanaian context, interventions focused on child stunting should emphasize age cohorts, specifically age 24–35 months, the male child, and children with relatively lower birth weight. At the parental level, the mother’s level of education and marital status were the predictors of child stunting. The findings indicated that mothers with secondary or higher education have a lower risk of having a stunted child. This could imply that educated mothers are more likely to engage in health-seeking behaviours such as adequate nutrition and formal healthcare practices focused on improving the health status of their children [27,28,29].

Mothers who are currently married had lower odds of having a stunted child. It is possible that marriage settings create a support system for both the mother and the child, which guarantees household food security. This has consequences on the nutritional outcomes of the household including that of the child [30]. At the household level, the findings revealed that children in the second wealth quintile have a higher risk of being stunted. Our finding on the negative association between child stunting and household wealth index corroborates other research findings. For example, some studies have shown that children from impoverished homes tend to be more undernourished than their counterparts from affluent homes [31,32,33]. This may be attributed to the fact that wealthy parents have the ability to provide their children with nutritious food, clean water, and a safe environment, which helps to improve their health status. The region of residence also showed that children in the Northern Region have higher odds of child stunting. This finding is not surprising given that the Northern Region of Ghana has the highest proportion of poor households compared to Greater Accra [9]. It is worth mentioning that study projects maternal education and household wealth quintile as important moderators in the birth spacing-child stunting model.

The findings on child underweight also revealed significant predictors at the child’s, parental, and household levels. At the child’s level, the age of the child and perceived size at birth were identified as significant covariates. Unlike stunting, the risk of being underweight peaks among children age between 12 and 23 months. The study also revealed that average or larger size at birth is associated with lower odds of child underweight. High birth weight has an adverse association with underweight. This finding concurs with a study in Pakistan that revealed that birth size is negatively associated with child underweight [34]. With parental characteristics, the mother’s BMI and marital status were significant correlates of child underweight. The study also observed that obese/overweight and married mothers had lower odds of having underweight children. The significant association between marital status and child underweight could imply that marriage helps create a pool of resources that ensure income stability at the household level, which has a potential positive association with child nutrition including underweight. Unlike stunting, none of the household factors were identified as significant correlates of child underweight. In spite of this, the variables at the child’s and parental level imply that within the Ghanaian context, interventions focused on reducing child underweight should emphasize child-specific factors such as age of the child between 12 and 23 months, perceived size at birth, and marital status.

Scrutinizing stunting and underweight, we realised that child level variables such as sex of child, mother’s level of education and wealth quintile were significant predictors of child stunting whiles factors such as mother’s BMI was a predictor of child underweight. However, variables such as age of child, perceived size of child at birth and marital status were associated with both stunting and underweight. Even though there were some nuances, there were common factors that affected both stunting and underweight.

Our study makes an important contribution by examining a reproductive intervention (birth spacing) on two important child health indicators - stunting and underweight. Although previous studies have focused on the association between birth spacing and maternal health, the current study focuses on the association between birth spacing, child stunting, and underweight. This is because inadequate maternal repletion due to shorter birth intervals can transcend the health of the mother and affect the child. The study also identified several other child’s, parental, and household characteristics that Ghana can use to continue the progress towards reducing child stunting and underweight.

Our results highlight the fact that mothers might benefit from more availability of resources to control child spacing. Thus, the availability of resources to women is crucial as well as access to medication and devices. In addition, the representativeness of the GDHS across the regional geographies of the country makes our findings generalizable. However, our study has some limitations which should be taken into consideration when interpreting our results. The 2014 GDHS is a cross-sectional survey that does not lend itself to causal inference. Our study also excludes mothers between age 15–19 because of the small sample size for computing the mother’s BMI categories. As in the case of the child stunting, the study put to fore maternal education and household wealth as important moderators in the birth spacing-child underweight model. Future research may focus on repeated cross-sectional or pseudo panel analyses, and more current GDHS data to fill in these important gaps.

Conclusion

The findings from the study support existing findings on the effect of birth spacing on child stunting and underweight. The study reveals that mothers with a birth spacing of at least two to three years compared to their counterparts with less than two years of birth spacing have lower odds of having a stunted and underweight child under age five. Our results underscore the role of birth spacing as one of the critical indicators that can reduce the odds of having stunted and underweight children age under-five. Our study recommends that the Ministry of Health, Plan Parenthood Association of Ghana, and both public and private maternal health organizations should educate women within the reproductive age (20–49) on the need to space births at least two to three years because this can help to reduce the prevalence of child stunting and underweight among children under age five.

Data availability

Data available at Demographic and Health Survey website. All materials used duly acknowledged in the manuscript. The datasets analysed for the current study are available on the Measure DHS website and can be directly assessed using https://dhsprogram.com/what-we-do/survey/survey-display-437.cfm.

Abbreviations

GDHS:

Ghana Demographic and Health Survey

HAZ:

Height for age

WAZ:

Weight for age

BMI:

Body Mass Index

OR:

Odds Ratio

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Acknowledgements

The authors wish to express their profound gratitude to United States Agency for International Development (USAID) for providing the necessary financial assistance for this research work through the Demographic and Health Survey Program implemented by ICF. We extend this appreciation to our facilitators, Drs. Shireen Assaf, Sara Riese, and Emma Shuvai Chikovore, for their immense contributions during the conceptualization and development of the research paper. Our gratitude also goes to the reviewers, Drs. Rukundo Benedict and Shireen Assaf. We also thank the School of Economics, University of Cape Coast, and the entire university community for their support.

Funding

Authors received financial assistance from United States Agency for International Development through the Demographic and Health Survey Program implemented by ICF.

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Authors and Affiliations

  1. Department of Applied Economics, School of Economics, University of Cape Coast, Cape Coast, Ghana

    Gloria Essilfie

  2. Department of Data Science and Economic Policy, School of Economics, University of Cape Coast, Cape Coast, Ghana

    Raymond Elikplim Kofinti & Emmanuel Ekow Asmah

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  1. Gloria Essilfie
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Contributions

G.E wrote the original draft, review and editing and conceptualization and visualization. R. E.K wrote the methodology, data curation, formal analysis and review of the manuscript. E.E.A was responsible for review of the manuscript, editing of the manuscript and conceptualisation.

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Correspondence to Gloria Essilfie.

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Essilfie, G., Kofinti, R.E. & Asmah, E.E. Reducing stunting and underweight through mother’s birth spacing: evidence from Ghana. BMC Pregnancy Childbirth 24, 624 (2024). https://doi.org/10.1186/s12884-024-06824-1

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BMC Pregnancy and Childbirth

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