Intersecting vulnerabilities of comprehensive child undernutrition across maternal empowerment, socioeconomic status, and gender: a cross-sectional study in a rural population of India

Undernutrition among children is a global health concern, which is often underestimated by conventional indicators: stunting, wasting, and underweight. However, Composite Index of Anthropometric Failure (CIAF) can be utilized for comprehensive assessment of undernutrition. Several factors influencing child nutrition intersect among each other. This study investigated the burden, and intersecting social, material, and age-gender vulnerabilities of comprehensive undernutrition among children under-five in Indian rural setting. The Women’s Empowerment and Child Health and Nutrition (WE-CHANT), a community-based cross-sectional study recruited 268 mothers and under-five child (operationally 6–59 months of age) pairs, from households enrolled via random walk, across 20 randomly sampled villages. Data were captured on household socio-demographic and economic details, maternal empowerment, child health, feeding practices and nutrition, through interview and anthropometry. Undernutrition dichotomized (present or absent) with CIAF. A four-quadrant composite exposure variable, intersectional class (IC) was constructed. Maternal empowerment (high vs. low) and household economic status (higher vs. lower) were cross-classified into four categories Highest (double advantages), Middle-A, Middle-B, and Lowest (double disadvantages) IC. Directed Acyclic Graph (DAG) guided, survey adjusted, hierarchical regression and marginal interaction (age-sex) models were used for analysis. Undernutrition measured via CIAF (39.2%, n = 105) was substantially higher than conventional indicators (underweight 18.3%, stunting 19.4%, wasting 20.9%). Anthropometric failure declined with cumulative social and material advantages from lowest (double disadvantages) to highest (double advantages) ICs (48.1 to 27.7%). High maternal empowerment buffered nutritional risks within lower economic strata. Low birth weight (Adjusted Odds Ratio (aOR) = 1.88; 95% Confidence Interval (CI): 1.11–3.18)), lowest IC (aOR: 2.7; 95%CI: 1.24–5.87), revealed as significant predictors of undernutrition. While beyond 24 months age male children exhibited better anthropometric outcome, nutritional disadvantages were more among female-child (62.5% absolute probability of undernutrition vs. 25.7% among male-child at 36–47 months). CIAF based estimation must be considered along the conventional indicators for more accurate public health planning. Female children, from poor household with low maternal agency are extremely vulnerable to undernutrition. To address the intersecting vulnerabilities precision public health policies with multisectoral, targeted interventions warranted for equitable service delivery to prevent and protect under-five undernutrition.