Child malnutrition in Pakistan: pathways linking maternal intimate partner violence, gender inequality, healthcare utilization, and age at marriage

Background: Intimate Partner Violence (IPV) is a major public health concern with far-reaching complications for maternal and child wellbeing. However, limited research has assessed how IPV influences a comprehensive measure of child undernutrition, or how maternal and child healthcare (MCH) services utilization shapes this relationship. This study examines the relationship between multiple IPV forms and child malnutrition, while assessing MCH services utilization as a mediator and age at first marriage as a moderator. Methods: Using nationally representative data from the 2018 Pakistan Demographic and Health Survey, we constructed a child malnutrition index integrating stunting, wasting, and underweight. A continuous MCH services utilization index was utilized as a mediator. Generalized Structural Equation Modeling (GSEM) and 5000 bootstrapping replications assessed direct, indirect, and moderated mediation pathways, with age at first marriage as a potential moderator. Results: The results show significant levels of child nutrition (39.58% stunting, 39.95% underweight, and 17.03% wasting), and notable IPV prevalence was physical (24.58%), emotional (30.43%), and any IPV (36.84%), respectively. Physical and any form of IPV are positively and significantly associated with child malnutrition. MCH services utilization significantly mediates the relationship, with IPV reducing MCH, which in turn is linked with increased child malnutrition risk. Early marriage increased malnutrition risk, with higher MCH services utilization benefits for older mothers, highlighting its protective effect against IPV-related malnutrition. Conclusion: This study conceptualizes a novel integrated sociobehavioral framework linking Multiple IPV forms, MCH services utilization, and child nutritional outcomes. The outcomes highlight the need for holistic interventions that simultaneously address IPV and strengthen MCH services utilization in Low-and middle-income settings.