Residence Inequality of Maternal Health Service Utilization among Women in Somaliland: An Analysis from the Somaliland Demographic Health Survey in 2020

INTRODUCTION

Maternal health refers to women’s health during pregnancy, delivery, and the post-delivery period for the maximum well-being of both the mothers and the infants.^1,2 Studies have established that appropriate utilization of maternal health services, such as antenatal care (ANC), skilled delivery service, and postnatal care (PNC), is essential in improving maternal health outcomes. Service coverage has been identified as a way to reduce maternal mortality rates in developing countries.^3,4 The use of appropriate levels of maternal health services is crucial for creating safe motherhood and has significant impacts on the mothers’ outcomes as well as those of their offspring.⁵

Maternal health remains one of the most important matters related to health globally and is of high interest to governments and policymakers, particularly in resource-limited regions.⁶ It forms a cornerstone in the 2015 United Nations’ Sustainable Development Goals target 3.1, with efforts toward its reduction to <70 maternal deaths per 100000 live births by 2030.^7,8 However, Maternal mortality rate (MMR) remains one of the major killers among females in Africa. The Sub-Saharan Africa (SSA) region, where most West African countries are located, has the highest rates of maternal deaths and contributes 70%, or 202,000 deaths, to maternal mortality worldwide.⁹

ANC is critically important for reductions in mortality through early identification and management of complications, optimization of nutrition, and prenatal education, including promoting healthy behaviors.¹⁰ Skilled delivery services are essential in ensuring safe delivery, managing complications that might arise from delivery, and quick responses in emergencies.¹¹ It is also necessary to have PNC following childbirth so that complications such as postpartum hemorrhage and maternal and infant infections (sepsis) can be identified and treated.¹² For this reason, there has been international advocacy to ensure adequate provision of services as a continuum for improving maternal and child health by reducing morbidities and mortality.¹²

The use of maternal health services was not evenly distributed worldwide by regions. Studies conducted in Bangladesh, Pakistan, and India indicated inequalities in maternal healthcare service utilization regarding skilled birth attendance, ANC visits, and PNC. These were linked with socioeconomic factors such as the wealth status, educational status of husbands and mothers, and place of residence.^13-15 Studies in most African countries also reported disparities in the use of maternal healthcare services.^16-20 Still, a multicountry study conducted in 36 SSA countries identified inequalities in ANC services due to socioeconomic factors.^21,22 The same study found that four or more ANC visits are concentrated among the wealthiest segments of the population in nine African countries.²³ Other studies focused on SSA, including Kenya and Zimbabwe, found that skilled birth attendance and ANC services were more accessible to people of high socioeconomic status.²⁴

Data from the Somaliland Health and Demographic Survey of 2020 show that even though 47% of women received ANC from a skilled provider in their last pregnancy, many births still occur outside health facilities without skilled birth attendance.²⁵ It also finds that there are large sociodemographic differentials in the use of maternal health services, where women from rural, nomadic groups and those from economically poor backgrounds face significant obstacles in accessing maternal healthcare services. These result from a distance to health facilities, financial problems, and cultural behaviors that may hinder the utilization of formal healthcare services.²⁵

Thus, this study aims to analyze the determinants of maternal health service utilization among women in Somaliland using data from SLHDS 2020. This will give way to findings on barriers and facilitators regarding access to maternal health, informing strategies for improving service coverage to reduce maternal health disparities within the country.

MATERIAL AND METHODS

RESULTS

Place of residence inequality of maternal health service utilization

All three maternal health services – ANC, delivery, and PNC – show geographical inequalities that are statistically significant, as the P-values for all stand at 0.000. The concentration index (CI) for ANC services is positive, which suggests that ANC utilization is more concentrated among urban residence women. Delivery services show the greatest inequality in access, with the highest CI, while urban residence women are significantly more likely to utilize delivery services. PNC services have the lowest CI, yet they still record a positive value, meaning urban residence women are more likely than their nomadic counterparts to access PNC services [Table 3]. The concentration curve indicates an evident difference in the use of maternal health services by geographical location [Figures 1-3].

Table 3: Inequality of maternal health service utilization (ANC, delivery service, and PNC) by place of residence.

Maternal Health services	No. of observation	Standard error	(95% confidence interval)	P-value
ANC Service	5826	0.0051	0.0434–0.0633	0.000
Delivery Service	2991	0.004	0.0866–0.1021	0.000
PNC Service	2991	0.0042	0.0099–0.0264	0.000

ANC: Antenatal care, PNC: Postnatal care

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Figure 1:

Lorenz curve of antenatal care service utilization by household place of residence among women in the age group (15– 49). CI: Confidence interval.

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Figure 2:

Lorenz curve of delivery service utilization by household place of residence among women in the age group (15–49). CI: Confidence interval.

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Figure 3:

Lorenz curve of delivery service utilization by household place of residence among women in the age group (15–49). CI: Confidence interval.

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DISCUSSION

The study findings indicate that the level of utilization of maternal health services, ANC, delivery services, and PNC differs significantly by different places of residence in our population. Urban women had the highest proportions in all maternal health services: ANC service utilization stood at 48.15%, the utilization of delivery services at 55.7%, and PNC access stood at 57.46%. In contrast, the non-sedentary women have abysmally poor service utilization −13.39% received ANC services, 9.02% delivered services, and as low as 11.94% received PNC services. These results indicate that urban women have better access to maternal health services than their rural and nomadic counterparts. The large proportion of nomadic women not using ANC services and delivery services is 48.09% and 90.98%, respectively, showing a critical gap in health provision for this vulnerable group.

Place of residence inequality of Maternal Health service utilization. Rural women face critical barriers in accessing health facilities; consequently, home birth delivery by unskilled attendants becomes a regular scenario. For instance, studies in Ethiopia have shown that rural residence is a critical determinant of maternal health service utilization, with rural women less likely to receive skilled birth attendance compared to their urban counterparts.²⁸

This trend is echoed in Somaliland, where the limited availability of healthcare facilities in rural areas exacerbates the challenges faced by women seeking maternal health services.²⁹ The lack of transportation and poor infrastructure further compound these issues, making it difficult for women to access necessary care during pregnancy and childbirth.^29,30

Another very vital and significant cause of the inequality in maternal health service utilization is socioeconomic status. According to available studies, relatively richer women tend to get ANC, skilled birth attendance (SBA), and PNC as opposed to relatively poorer women.^31,32 This disparity, based on wealth, is consistent across the various African contexts and thus infers that economic barriers to access to maternal health services are very significant.³¹ In Somaliland, the economic challenges faced by many families, coupled with the historical context of civil unrest, have led to a healthcare system unable to meet the needs of its population.²⁹

Educational attainment also emerges as a critical determinant in the utilization of maternal health services. Women with higher levels of education tend to know more about healthcare services and thus are more likely to seek care during pregnancy and childbirth.^33,34 This relationship between education and health service utilization is well documented, with studies indicating that maternal education significantly influences the likelihood of receiving skilled care during delivery.³⁴ In Somaliland, where educational opportunities may be limited, particularly for women, this can lead to lower rates of service utilization and poorer maternal health outcomes.²⁹

Besides, the interplay among residence, socioeconomic status, and education presents a very complex landscape of inequality in maternal health service utilization. For instance, rural dwellings, low socioeconomic status, and a low level of education combine to impose multiple barriers that drastically decrease the probability of women receiving necessary maternal health services.^31,32

CONCLUSION

This study has shown great disparities by place of residence in the utilization of maternal health services, with urban women receiving notably higher access to ANC, delivery services, and PNC compared with rural and nomadic women. These findings underscore the need for targeted policy action as an urgent intervention to bridge these gaps and assure equity in access to maternal health services for all women, especially those from sections that have hitherto been under-served. Policymakers must, therefore, focus on designing and implementing specific health programs for nomadic populations, including mobile health clinics, healthcare infrastructure, and resource distribution in rural and nomadic areas.