Community health workers navigating maternal and newborn health delivery in rural Somalia: a qualitative study of roles, barriers, and adaptive strategies

In many parts of the world, the journey to a healthy birth is not just a medical event but a community effort. When hospitals are far away or unsafe, the people who live closest to families often become the first line of defense. These are community health workers, local residents trained to bring basic medical care, advice, and supplies directly to homes. They act as a bridge, connecting isolated households to the wider health system. In places where conflict and poverty have strained the formal healthcare network, these workers are often the only source of help for pregnant women and newborns. However, their role is rarely simple. It is shaped by the terrain they walk, the money they do not have, and the complex social rules that govern who can make decisions for a family. Understanding how these workers navigate these daily realities is essential, because their success determines whether a mother survives childbirth or whether a newborn receives the care needed to thrive.

A recent study conducted in rural Somalia sheds light on exactly how this work happens on the ground. Researchers from the International Rescue Committee and the Somali Research and Development Institute spent time with female health workers in eight villages in the Galmudug state. These areas are remote, often difficult to reach, and still recovering from decades of instability. The researchers interviewed eight of these workers and two of their supervisors to understand the daily challenges they face and the clever ways they adapt to keep their programs running. The goal was not just to count how many babies were born, but to listen to the stories of the women who walk miles to ensure those births are safe.

The women in the study described their jobs as going far beyond medical tasks. While they were trained to teach about breastfeeding, clean cord care, and danger signs, they quickly realized that their real power came from being trusted neighbors. Because they lived in the same communities, families opened their doors to them. But this closeness came with a hidden price. In Somali culture, it is customary to bring a gift, known as a diiqista, to a new mother after she gives birth. This tradition usually involves items like soap, shampoo, or sweets. The health workers felt that if they arrived empty-handed, they would be seen as disrespectful or insincere, and the families might stop listening to their health advice. Consequently, many of these workers began paying for these gifts out of their own pockets, along with other small expenses like medicine for family members who could not afford it. These costs were not part of the official program budget, yet they were necessary to maintain the trust that made their work possible.

The physical journey to reach these families was another significant hurdle. The villages are scattered across a landscape where the nearest health facility can be 20 to 65 kilometers away. The workers reported walking for over an hour just to reach a single household, often over rough terrain that became worse during the rainy season. When a mother was in labor or too sick to travel, the workers sometimes had to hire a vehicle to transport her to a clinic, paying the two or three dollars themselves because the program did not cover these emergency costs. To manage these distances, the workers developed their own strategies. They would call clients on their mobile phones to check in, or they would arrange for several families to meet at a central location, like a neighbor's home, so the worker did not have to walk to every single house. This allowed them to reach more people without burning themselves out, though it meant that some families received less frequent visits than others.

A third major challenge came from the men in the families. In many households, the husband or an elder male held the final say on whether a woman could participate in the health program. Some men viewed the visits as an intrusion into their private lives or a waste of time, telling the workers to leave their wives alone. The health workers had to learn how to navigate this gatekeeping carefully. Instead of arguing directly with a resistant husband, they would often speak to his mother, his sisters, or trusted neighbors, asking them to help convince him of the program's value. Over time, as families saw that the program led to safer deliveries and healthier babies, some of this resistance softened, but the need for permission remained a constant barrier.

The study also highlighted a misunderstanding that often arose between the workers and the community. Because many non-governmental organizations in the past have distributed food and cash, families often assumed that these health workers were there to give out material aid. When the workers arrived with only health advice and a few small supplies like soap or insecticide-treated nets, some families were disappointed or even skeptical. The workers had to work hard to explain that their primary role was education and care, not resource distribution. They found that the small supplies they did bring were helpful in getting families to listen, but they had to be careful not to create the expectation that they could provide for the whole household.

The findings from this research suggest that for community health programs to succeed in fragile settings, they must look beyond the medical training of the workers. The effectiveness of these women depends heavily on factors that are often invisible in official reports: the cost of walking miles to a client, the price of a cultural gift, and the social maneuvering required to gain a husband's permission. The authors argue that future programs need to formally support these hidden costs, perhaps by providing transport stipends or small budgets for culturally expected items. They also emphasize the need for strategies that engage men and elders respectfully, rather than trying to bypass them. Without addressing these deep-rooted social and financial realities, even the best-trained health workers may struggle to reach the families who need them most.