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Background We aimed to identify emerging community-level risk factors for birth size in the last two decades in developing countries, particularly in Bangladesh, India, Indonesia, and Nigeria, having the highest burden of low birth weight (LBW) births globally. Methods We used data from multiple rounds of the Demographic and Health Surveys (DHS) conducted throughout the last two decades in the selected countries. We applied multilevel binary logistic regression models and estimated the intra-correlation coefficient (ICC) and median odds ratio (MOR) with a 95% confidence interval (CI) to analyze community-level variation in the birth size of child. Results The odds of having a smaller than average size birth increased by 1.28 times (95% CI: 1.11-1.79) in Bangladesh (2014), 3.03 times (95% CI: 2.90-3.18) in India (2015-16), 1.40 times (95% CI: 1.28-1.58) in Indonesia (2017) and 2.32 times (95% CI: 2.15-2.53) in Nigeria (2018) when women moved from low-risk to high-risk communities. The children residing in communities with a higher level of female illiteracy, higher level of inadequate antenatal care visits (ANC), higher use of unimproved toilet facilities were more likely to born with smaller than average birth size during 1992-2018. Conclusions The study confirms a significant community-level variation in smaller than average birth size among all analysed countries. Community with higher levels of female illiteracy, inadequate ANC visits, use of unimproved toilet facilities emerged as significant risk factors throughout the last two decades. Key messages The community-level risk factors have an independent association with the birth size of child regardless of individual-level characteristics of women and children.

1498Community-level risk factors for birth size of child in selected developing countries (1992-2018): multilevel analysis