Provincial distribution and factors associated with high completed fertility among married and cohabiting women aged 40-49 years in Sierra Leone: a cross-sectional study

Background: High completed fertility among married and cohabiting women has significant implications, such as burden on resources, exacerbating healthcare issues and educational and gender disparities. This study examined the provincial distribution and factors associated with high completed fertility among married and cohabiting women aged 40-49 y in Sierra Leone. Methods: Data for the study were sourced from the 2019 Sierra Leone Demographic and Health Survey. Our study comprised 2253 married and cohabiting women aged 40-49 y in Sierra Leone. Geographic variations in high fertility were presented using a spatial map. A mixed-effect multilevel binary logistic regression analysis was performed to identify the factors associated with high completed fertility. The findings were presented as adjusted ORs (aOR) with 95% confidence intervals (CIs). Results: The national prevalence of high completed fertility among married and cohabiting women in Sierra Leone was 61.7% (58.9-64.5). Women whose partners had secondary/higher education (aOR=0.54, 95% CI 0.33 to 0.89) had lower odds of high completed fertility than those with no formal education. Women in the Northern province (aOR=0.39, 95% CI 0.17 to 0.87) had lower odds of high completed fertility than those in the Eastern province. Women who indicated >= 6 as their ideal number of children had a higher (aOR=8.10, 95% CI 4.58 to 14.35) likelihood of experiencing high completed fertility compared with those whose ideal number of children was 0-3. Those who were using contraceptives at the time of the survey had a higher (aOR=2.09, 95% CI 1.28 to 3.41) likelihood of having high completed fertility compared with those who were not using contraceptives. Women in the poorer (aOR=1.70, 95% CI 1.07 to 2.72) and middle wealth index quintiles (aOR=2.09, 95% CI 1.29 to 3.41) had higher odds of high completed fertility than those in the poorest wealth index quintile. Conclusions: A significant proportion (>60%) of married and cohabiting women aged 40-49 y in Sierra Leone have high completed fertility. Partner's education, province, ideal number of children, use of contraceptives and wealth index were the factors associated with high completed fertility among women in Sierra Leone. Policymakers in Sierra Leone should increase access to and education on family planning methods to empower women to make informed choices about their fertility. The government and policymakers should support educational opportunities, particularly for men, because they are usually the heads of households and can influence fertility decisions. In-depth interviews should be conducted with women who use contraception to understand their motivations and experiences.