Maternal health inequity in Somalia: A multivariate analysis of poverty and service utilization using nationwide cross-sectional survey data

Objectives: Maternal health is a fundamental human right, yet significant inequities persist in low-resource settings like Somalia. This study investigates the nexus between socioeconomic status and maternal healthcare utilization, specifically examining the determinants of antenatal care (ANC) visits and place of delivery, to inform strategies aimed at achieving health equity. Study design: A quantitative, cross-sectional study. Methods: We used data from the 2020 Somalia Health and Demographic Survey (SHDS), a nationwide survey. The final analytical sample included 8248 women with a recent birth. We analyzed two dependent variables: number of ANC visits and place of delivery (home vs. health facility). Independent variables included wealth index, maternal education, residence, region, and other social determinants. Zero-inflated Negative Binomial (ZINB) regression was used for ANC visits, and binary logistic regression was used for place of delivery, with all analyses adjusted for the complex survey design. Results: Marked disparities were found based on wealth. A significantly larger proportion of poorer women delivered at home (87.6 %) compared to richer women (55 %). Richer women had higher rates of ANC visits (Adjusted Incidence Rate Ratio [aIRR] = 1.41, p < 0.001) and were more likely to have facility-based deliveries (Adjusted Odds Ratio [AOR] = 1.57, p < 0.001). Higher maternal education, mobile phone ownership, and not wanting to go alone to a facility were also associated with better utilization. Significant regional disparities were observed. Conclusions: Socioeconomic status is a primary driver of maternal healthcare utilization in Somalia, leading to substantial health inequities. Addressing these disparities requires multisectoral, targeted interventions that tackle poverty, enhance education, improve access to technology, and address cultural barriers to care.