Socio-digital stratification and the threshold effects of digital inclusion on maternal health access in Somalia

Background Maternal health utilization in fragile states is hindered by complex social and structural barriers.Objective This study examined socio-digital stratification and explored the threshold effects of digital inclusion on antenatal care (ANC) utilization in Somalia.Methods Using data from the 2020 Somalia Demographic and Health Survey (N = 8,940), we constructed a Digital Inclusion Index (0–3) and employed survey-adjusted logistic regression models to estimate the odds of achieving four or more ANC visits (ANC 4+).Results Only 8.4% of the women achieved the ANC 4+ threshold, with pronounced disparities between urban (14.0%) and rural/nomadic (5.5%) residents. Evidence consistent with a threshold effect was observed, whereby the initial transition from digital exclusion to basic connectivity (score = 1) was associated with the largest marginal gain in health seeking probability (OR = 1.55, p = 0.013). While mobile money penetration is high (85.2%), internet access remains deeply stratified by wealth (22.0% among the rich versus 1.0% among the poor). Interaction analysis suggests that digital inclusion complements but does not substitute for physical health infrastructure, partially mitigating distance-related barriers without eliminating the need for physical proximity to healthcare facilities.Conclusions Digital inclusion is a critical entry point for improving maternal health access in Somalia. Policies should prioritize universal basic connectivity and SMS-based interventions, while simultaneously addressing persistent physical and socioeconomic inequities.