Factors associated with undernutrition among children aged 0-59 months using a Composite Index of Anthropometric Failure: Evidence from the 2020 Somali Demographic and Health Survey

Introduction: Child undernutrition remains a critical global health challenge, particularly in fragile states like Somalia. Using the Composite Index of Anthropometric Failure (CIAF) and nationally representative data, this study provides a comprehensive assessment of undernutrition's prevalence and multifactorial drivers in Somalia's high-risk context among children aged 0–59 months. Methods This cross-sectional study analyzed data from the individual women’s and household member files of the 2020 Somali Demographic and Health Survey. A total of 6,787 children aged 0–59 months with complete data on relevant variables were included. Using a 95% confidence level and 5% significance threshold, a multivariate modified Poisson regression was employed to assess associations between independent variables and undernutrition indicators measured by the Composite anthropometric failure (CIAF/CISAF). Results were reported as prevalence ratios (PRs). All statistical analyses were performed using Stata/SE version 17.0. Results Out of 6,787 children studied, 50.1% exhibited at least one form of anthropometric failure (CIAF), with 30.5% experiencing severe deficits (CISAF). Stunting was most prevalent (26.6%), followed by underweight (21.1%) and wasting (20.0%). Severe forms affected 16.4% (stunting), 11.3% (underweight), and 9.7% (wasting) of children. Compared to children (0–5 months), older children had significantly higher stunting prevalence [6–11 months: aPR = 2.02, 95%CI = 1.48–2.77; 12–23 months: aPR = 1.95, 95%CI = 1.43–2.68; 24–35 months: aPR = 1.90, 95%CI = 1.44–2.50], while those aged 48–59 months showed lower wasting prevalence [aPR = 0.79, 95%CI = 0.64–0.97]. Children of mothers aged 30–34 years had reduced CIAF risk [aPR = 0.87, 95%CI = 0.76–0.99], as did those with mothers aged 40–44 years [aPR = 0.82, 95%CI = 0.68–0.99]. Divorced mothers' children faced higher stunting [aPR = 1.32, 95%CI = 1.01–1.72] and CIAF risks [aPR = 1.23, 95%CI = 1.05–1.43]. Orphans showed 81% higher severe stunting prevalence [aPR = 1.81, 95%CI = 1.31–2.50]. Regionally, Sool residents had 89% higher underweight prevalence [aPR = 2.04, 95%CI = 1.11–3.74] and 122% higher severe stunting [aPR = 2.22, 95%CI = 1.03–4.79]. Woqooyi Galbeed children showed 69% lower underweight risk [aPR = 0.31, 95%CI = 0.13–0.72]. Married mothers' children had higher severe wasting prevalence [aPR = 1.44, 95%CI = 1.06–1.95]. Conclusion This study highlights Somalia’s critical burden of child undernutrition, with half of the children affected. Key demographic and geographic disparities were identified. Findings call for urgent, targeted, and multi-sectoral interventions, strengthened nutrition services, and further longitudinal and qualitative research to address underlying causes and evaluate intervention effectiveness in a fragile country like Somalia. Clinical trial number: Not applicable.