Individual-and-community level factors associated with completion of continuum of care in maternal health services in Somaliland: a multilevel analysis of the 2020 Somaliland demographic and health survey

Continuum of care (CoC) throughout pregnancy, childbirth, and the postnatal period is a vital strategy for reducing maternal and neonatal mortality. Despite its importance, CoC completion remains low in resource-limited settings such as Somaliland, and empirical evidence on its determinants is limited. Therefore, this study aims to explore determinants of CoC completion among ever-married women in Somaliland. We analyzed data from the 2020 Somaliland Demographic and Health Survey, specifically focusing on ever-married women with the most recent live birth. CoC completion was measured at three stages of maternal health services: during antenatal, delivery, and postnatal. Multilevel mixed-effect models were used to examine individual-and community-level factors associated with CoC completion. Statistical significance was declared at a p-value < 0.05. Among the 5,160 women included in the study, the proportion completing CoC was 12.7% (95% CI: 11.4, 14.1). Women with secondary education or higher (AOR = 2.78; 95% CI: 1.66,4.64), those exposed to media (AOR = 3.75; 95% CI: 2.35,5.99), from the richest households, (AOR = 2.48; 95% CI: 1.46, 4.20), and those whose husbands had secondary education or higher (AOR = 2.67; 95% CI: 1.80,3.96) were significantly associated with higher odds of CoC completion. In contrast, older women (≥ 35 years) (AOR = 0.50; 95% CI: 0.31,0.82), women with high parity (AOR = 0.40; 95% CI: 0.22,0.73), and those living in rural (AOR = 0.59; 95% CI: 0.43,0.82) and nomadic settings (AOR = 0.49; 95% CI: 0.35,0.68) were significantly associated with lower odds of CoC completion. Significant regional disparities were observed, with women in the Sool (AOR = 0.43; 95% CI: 0.30,0.62), Sanaag (AOR = 0.36; 95% CI: 0.18,0.72), and Sahil (AOR = 0.41; 95% CI: 0.18,0.96) regions being less likely to complete the CoC. CoC completion remained low and was associated with several individual and community-level factors, including women’s age, education, media exposure, husband’s education, parity, household wealth, residence, and region. These findings highlight socioeconomic and geographic disparities in maternal healthcare continuity and the need to improve equitable access to maternal health services in Somaliland.