Background/Objectives: 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. Methods: 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. Results: 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. Conclusions: 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.

Background/Objectives: Birth preparedness and complication readiness (BPCR) is a cornerstone of maternal health strategies designed to minimize the “three delays” in seeking, reaching, and receiving skilled care. In Ethiopia, uptake of BPCR remains insufficient, and little evidence exists on how individual- and community-level factors interact to shape preparedness. This study assessed the determinants of BPCR among women of reproductive age in Hawela Lida district, Sidama Region. Methods: A community-based cross-sectional study was conducted among 3540 women using a multistage sampling technique. Data were analyzed with multilevel mixed-effect negative binomial regression to account for clustering at the community level. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were reported to identify determinants of BPCR. Model fitness was assessed using Akaike’s Information Criterion (AIC), the Bayesian Information Criterion (BIC), and log-likelihood statistics. Results: At the individual level, women employed in government positions had over three times higher expected BPCR scores compared with farmers (AIRR = 3.11; 95% CI: 1.89–5.77). Women with planned pregnancies demonstrated higher BPCR preparedness (AIRR = 1.66; 95% CI: 1.15–3.22), as did those who participated in model family training (AIRR = 2.53; 95% CI: 1.76–4.99) and women exercising decision-making autonomy (AIRR = 2.34; 95% CI: 1.97–5.93). At the community level, residing in urban areas (AIRR = 2.78; 95% CI: 1.81–4.77) and in communities with higher women’s literacy (AIRR = 4.92; 95% CI: 2.32–8.48) was associated with higher expected BPCR scores. These findings indicate that both personal empowerment and supportive community contexts play pivotal roles in enhancing maternal birth preparedness and readiness for potential complications. Random-effects analysis showed that 19.4% of the variance in BPCR was attributable to kebele-level clustering (ICC = 0.194). The final multilevel model demonstrated superior fit (AIC = 2915.15, BIC = 3003.33, log-likelihood = −1402.44). Conclusions: Both individual- and community-level factors strongly influence BPCR practice in southern Ethiopia. Interventions should prioritize women’s empowerment and pregnancy planning, scale-up of model family training, and address structural barriers such as rural access and community literacy gaps. Targeted, multilevel strategies are essential to accelerate progress toward improving maternal preparedness and reducing maternal morbidity and mortality.

Background/Objectives: Maternal anemia remains a critical public health issue in Ethiopia, with iron deficiency anemia (IDA) being the most prevalent form, primarily due to low dietary iron intake and poor bioavailability from cereal-based diets. Despite the widespread cultivation of nutrient-rich amaranth in Ethiopia, its role in improving maternal iron status remains understudied. To address this gap, we conducted a cluster-randomized controlled trial to evaluate the effectiveness of amaranth grain flatbread consumption, compared to maize bread consumption, on hemoglobin concentration and IDA among pregnant women in southern Ethiopia. Methods: We conducted a six-month, community-based, parallel-group, cluster-randomized controlled trial involving 306 pregnant women with anemia (mild or moderate) to evaluate the effectiveness of locally prepared amaranth grain flatbread in enhancing hemoglobin concentration and reducing IDA, compared to the standard maize bread. At the end of the intervention, hemoglobin levels were measured, and IDA was assessed using World Health Organization (WHO) defined cutoffs of serum ferritin levels. Multilevel linear and modified Poisson regression models were used to estimate adjusted effects, accounting for confounders and community-level clustering. All analyses were conducted following the intention-to-treat principle. Results: The loss to follow-up rate was similar between the amaranth and maize groups (4.6% vs. 3.9%). In the unadjusted analysis, the mean hemoglobin concentration was higher in the amaranth group (12.39 g/dL, 95% CI: 12.17–12.61) compared to the maize group (10.17 g/dL, 95% CI: 9.95–10.39). The proportion of IDA was also lower in the amaranth group (26.71% [95% CI: 20.14–34.49] vs. 65.98% [95% CI: 57.93–73.21]). After adjusting for potential confounders (due to baseline differences after randomization) and clustering, pregnant women who received amaranth grain flatbread had higher hemoglobin levels (adjusted β = 2.67 g/dL; 95% CI: 2.41–2.90) and a 53% lower risk of IDA compared to those in the maize group (adjusted risk ratio = 0.47; 95% CI: 0.26–0.84). No serious adverse events were reported in either group. Conclusion: Consumption of amaranth grain flatbread during pregnancy improved hemoglobin levels and reduced IDA compared to maize-based diets. These findings highlight the potential of locally available, nutrient-dense foods, such as amaranth, to address maternal iron deficiency among pregnant women with mild or moderate anemia in resource-limited settings. Trial registration number: NCT06536153

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.

Background/Objectives: 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. Methods: A community-based cross-sectional study was conducted from June 1–25, 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 multilevel mixed-effect modified Poisson regression analysis model. Results: 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. Conclusions: One in four pregnant women was CAU in the study area. Household food insecurity, receiving model family training, inadequate dietary diversity, poor nutrition knowledge, 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 CAU’s determinants at different levels. Besides, 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.

Introduction: In Ethiopia, maternal undernutrition is a major public health concern. However, comprehensive evidence is lacking in the southern part of Ethiopia, specifically the household and community-level related determinants of undernutrition. Besides, the evidence about the prevalence and determinants of undernutrition is not yet documented in the current study setting. Thus, this study aimed to determine the prevalence of undernutrition and identify its determinants among pregnant women in Hawela Lida district of the Sidama region, Ethiopia.Methods: A community-based cross-sectional study was conducted on a sample of 515 pregnant women from June 1–25, 2024. A multi-stage sampling method was utilized to select eligible pregnant women. We collected data using the Open Data Kit smart phone device and exported it to Stata version 17 for further processing and analysis. A multi-level mixed-effects modified Poisson regression analysis with robust variance was used to account for between and with cluster effects.Result: The prevalence of undernutrition among pregnant women was 41.7% (95% CI: 37.3–45.6). The prevalence of undernutrition was associated with planned pregnancy (adjusted prevalence ratio [APR]: 0.80; 95% CI: 0.66-0.98), household food insecurity (APR: 1.64; 95% CI: 1.26-2.13), inadequate dietary diversity (APR: 1.79; 95% CI: 1.43-2.25), and women’s poor knowledge of nutrition (APR: 1.68; 95% CI: 1.32-2.12) at individual levels. The identified determinants of undernutrition at the community level were low community literacy rates (APR: 4.62; 95% CI: 1.13–18.79) and low community wealth status (APR: 1.91; 95% CI: 1.10–3.31).Conclusion: Two in five pregnant women had an undernutrition problem in the study setting. Individual and community-level determinants contributed to the high prevalence of undernutrition. Thus, any prevention and control approaches to undernutrition should consider inter-sectorial collaboration to account for determinants at various levels. Besides, any program must emphasize the delivery of nutrition education about dietary diversity, particularly targeting pregnant mothers who have poor knowledge of nutrition and unplanned pregnancy at the individual level. Moreover, creating a small business reform for the community with low wealth status using agricultural extension workers must be considered.