Individual, Household, and Community-Level Determinants of Co-Existing Anemia and Undernutrition among Pregnant Women in the Northern Zone of the Sidama Region, Ethiopia: A Multi-Level Analysis

Introduction: Anemia and undernutrition are severe public health concerns in Ethiopia. These are the two most common nutritional disorders in pregnant women and frequently co-exist. However, to the best of our knowledge, the evidence is lacking on the co-existence of anemia and undernutrition among pregnant women. Therefore, this study aimed to examine the prevalence of co-existing anemia and undernutrition (CAU) and associated factors among pregnant women. Methods: A community-based cross-sectional study was conducted from June 1–25, 2024, on a sample of 515 pregnant women in the Hawela Lida district of Sidama region, Ethiopia. We utilized a multi-stage sampling method to choose eligible study participants. A pre-tested and structured questionnaire was used to collect data via the online Open Data Kit mobile tool. We controlled the effect of confounders and clustering by using a multi-level mixed-effect modified Poisson regression analysis model. Result: The prevalence of CAU among pregnant women was 25.4% (95% CI: 21.9–28.9). The prevalence of CAU was associated with household food insecurity (adjusted prevalence ratio [APR]: 2.17; 95% CI: 1.43–3.28), training on model family (APR: 0.66; 95% CI: 0.45-0.96), inadequate dietary diversity (APR: 1.51; 95% CI: 1.18–1.95), and having poor knowledge of nutrition (APR: 1.55; 95% CI: 1.06-2.26) at individual levels. Low community-level women’s autonomy (APR: 6.19; 95% CI: 3.42-11.22) and community-level road accessibility (APR: 0.65; 95% CI: 0.43-0.98) were the identified determinants of CAU at the community level. Conclusion: One in four pregnant women was CAU in the study area. Household food insecurity, receiving model family training, inadequate dietary diversity, having poor knowledge of nutrition, low community-level women’s autonomy, and community-level road accessibility were the significant determinants of CAU. Therefore, inter-sectorial collaboration should be required to comprehensively address the determinants of CAU at different levels. Besides, any CAU prevention and intervention programs should provide model family training specifically targeting women who have poor nutritional knowledge and a low level of autonomy in health care decision-making.