The Determinants of Coexisting Anemia and Undernutrition Among Pregnant Women in Southern Ethiopia: A Multi-Level Analysis.

: Anemia and undernutrition are severe public health concerns in Ethiopia. These are the two most common nutritional disorders in pregnant women and frequently coexist. However, to our knowledge, there is little evidence of the coexistence of anemia and undernutrition among pregnant women. Therefore, this study aimed to examine the prevalence of coexisting anemia and undernutrition (CAU) and associated factors among pregnant women. : A community-based cross-sectional study was conducted from 1 to 25 June 2024, on 515 pregnant women in the Hawela Lida district of Sidama, 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. : 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. : One in four pregnant women had CAU in the study area. Household food insecurity, inadequate dietary diversity, and poor nutrition knowledge were associated with an increased likelihood of CAU, while participation in model family training and improved road accessibility were associated with reduced CAU. We have also indicated that low community-level women's autonomy significantly increased the risk of CAU. Therefore, inter-sectorial collaboration should be required to comprehensively address CAU's determinants at different levels. Additionally, any CAU prevention and intervention programs should provide model family training explicitly targeting women with poor nutritional knowledge and low autonomy in healthcare decision-making.