Continuum of care during pregnancy, delivery, and postnatal care among ever-married women in somalia

Introduction: Somalia remains one of the most dangerous places for women to give birth, with a current maternal mortality ratio of 621 deaths per 100,000 live births, ranking among the highest globally. In this study, we aim to investigate the level of completion, factors associated with it, and barriers along the maternity continuum of care in Somalia. Method: This study used secondary data from the Somalia Health and Demographic Survey 2020 and primary qualitative data. In the quantitative analysis, we restricted our analysis to ever-married women who had a live birth in the five years preceding the survey (n = 2432). In the qualitative section, we used focus group discussion with childbearing mothers purposively sampled from urban, rural, internally displaced persons, agro, and nomadic pastoralists and in-depth interviews from healthcare providers, policymakers, recently delivered and childbearing mothers, community leaders, and traditional birth attendants. Completion of the continuum of maternity care was the outcome variable and was constructed into a binary variable, with complete coded as one and incomplete coded as 0. We categorized it into three models: Antenatal Care (ANC4+) as the first model, Antenatal Care plus Skilled Birth Attendant (ANC4+ & SBA) as the second model, and Antenatal Care, Skilled Birth Attendant, and Postnatal Care (ANC4+ & SBA & PNC) as the third model. Results: More than half of the women (53.1%) had their most recent births at ≤ 19 years old. Only 14 (0.6%) mothers received all three maternal healthcare services (ANC4+, SBA, and PNC within 48hrs). Maternal age at birth, residence, mother's education, employment, healthcare decision-making, radio exposure, and wealth quintile were variables significantly associated with Model 2 (ANC4+ and SBA) at p-value <0.05. The maternity continuum of care gaps varies across different community categories, such as urban areas, rural areas, IDPs, agro-pastoralists, and nomadic pastoralists, due to diverse reasons, including service availability, access to care (financial, distance, and transportation), socioeconomic disparities, infrastructure, climate-related, and security issues. Conclusion: The completion of the maternity continuum of care is more skewed towards urban residents; maternal health care utilization decreases as they progress from ANC4+ to PNC utilization. The government and partners should design and implement strategies to improve maternal healthcare utilization specific to rural and nomads who are less educated, not working, low income, and have less power in decision-making.