Understanding the Link between Fertility Decline and Child Survival in Ethiopia: Implications from Decomposition and Regression Models

Abstract

Abstract Background: Despite significant declines over the past two decades, Ethiopia continues to experience high rate of child mortality. While socioeconomic factors and high-risk fertility behaviors are well-established determinants, the independent effect of fertility decline remains underexplored. This study examines the impact  of fertility decline- measured by the number of children ever born and the general fertility rate- on child survival in Ethiopia. Methods: Two data sources and analytic approaches were used: (1) decomposition analysis of United Nations data (2000–2020) to assess the contribution of fertility decline to reductions in under-five deaths and (2) a Probit regression model using the Ethiopian Demographic and Health Survey data to estimate the effect of the number of children ever born on the survival probability of under-five children, adjusted for women’s reproductive and other characteristics. Using complex survey analysis in Stata, the regression is done among 37,780 single and second -or higher- order births of under-five children pooled from five surveys (2000–2019). Results: Between 2000 and 2020, Ethiopia’s general fertility rate declined from 208.5 to 135.5 per 1,000 women, while under-five mortality dropped from 141 to 45 per 1,000 live births. The decline in the general fertility rate contributed to 16.3% of the nearly 659,000 averted under-five deaths. At the micro level, each additional child was associated with a 1% (marginal effect =0.01, P=0.00) increase in survival probability, and children born to mothers with 2–4 children had approximately 4% (marginal effect = 0.04, P=0.00) higher survival compared to those with eight or more children. Conclusion: Lower fertility enhances child survival. Beyond reducing early childbearing and short birth intervals, promoting birth limitation and scaling  up of the long-acting contraceptives are vital for further reducing child mortality. [Ethiop. J. Health Dev. 2025; 39(2)] Keywords: child survival, under-five mortality, fertility rate, Ethiopia.