Wealth-based inequality in maternal health service utilization among ever-married women of reproductive age in Somaliland; secondary analysis of the 2020 Demographic and Health Survey

Background Access to affordable, quality maternal health services is a fundamental human right. In Somaliland, characterized by a fragile health system and high maternal mortality, utilization of maternal health services remains low, and socioeconomic factors are known to shape this utilization. However, the extent and implications of wealth-based inequalities in maternal service use remain poorly quantified. This study assesses the magnitude of wealth-based inequality in adequate antenatal care (ANC) and public facility-based childbirth in Somaliland. Methods This secondary analysis used the 2020 Somaliland Demographic and Health Survey, including 3,065 ever-married women with a recent birth. Adequate ANC was defined as four or more visits, consistent with Somaliland's Focused ANC Model at the time of the survey rather than the current WHO-recommended eight contacts. Private facility births were excluded, as they are concentrated among wealthier, urban women and fall outside Somaliland's free public maternal care policy; we therefore assessed births in public facilities, which provide free care to the general population. We used survey-weighted logistic regression incorporating sampling weights, clustering, and stratification, and quantified inequality using the Slope Index of Inequality (absolute) and Wagstaff's concentration indices corrected for binary outcomes (relative). Results The weighted prevalence of adequate ANC was 20%, and 32% of women gave birth in a public facility. After adjustment, the richest women had nearly four times higher odds of adequate ANC (aOR: 3.98; 95%CI: 2.20–7.17) and over six times higher odds of public facility-based birth (aOR: 6.54; 95%CI: 3.59–11.91) than the poorest. Adjusted absolute differences between the richest and poorest quintiles were 26 percentage points for ANC and 49 percentage points for public facility births. Significant pro-rich distribution was observed for both outcomes, with concentration indices of 0.34 (95%CI: 0.33–0.35) for ANC and 0.50 (95%CI: 0.49–0.52) for public facility births. Conclusion Wealth-based inequalities exist in maternal health service utilization in Somaliland. Addressing these inequalities requires targeting poorer, non-urban women and removing access barriers through systematic reforms beyond the health system