Utilization and Determinants of Antenatal Care Skilled Birth Attendance and Institutional Birth Delivery among Women in Rural Galmudug Somalia

In many parts of the world, the journey of bringing a new life into the world is supported by a network of care that begins long before the baby is born. This network includes regular checkups with trained health workers, known as antenatal care, and the presence of a skilled professional, such as a doctor or midwife, to assist during the actual birth. When these services are available and used, mothers and babies are far more likely to survive and thrive. However, in regions facing conflict, poverty, or isolation, this safety net often frays or disappears entirely. Women may give birth at home without medical help, or they may travel great distances to find a clinic that is not always open or fully stocked. Understanding why women make the choices they do in these difficult circumstances is essential for building better health systems. It requires looking beyond simple statistics to see the real barriers—distance, cultural norms, and the ability to make decisions about one's own body—that stand between a mother and the care she needs.

A team of researchers recently turned their attention to seven rural villages in Galmudug, a state in central Somalia, to map out exactly how these barriers play out on the ground. They wanted to know how many women were reaching health facilities for prenatal visits and for giving birth, and what factors were pushing them toward or pulling them away from these services. The study focused on 351 women who had given birth in the year before the survey was conducted. These women live in a landscape defined by pastoralism, where families rely on livestock for their livelihood and often move to find water and pasture. In this environment, health facilities are scarce, roads are poor, and the threat of conflict can make travel dangerous. The researchers interviewed these women to gather details about their lives, their pregnancies, and their experiences with the healthcare system.

The picture that emerged from these interviews was one of significant gaps in care. Only about half of the women, roughly 52 percent, had visited a health facility even once during their pregnancy to check on their baby's growth or their own health. An even smaller group, just 11 percent, had managed to make the recommended number of visits to ensure a healthy pregnancy. When it came to the actual moment of birth, the situation was even more stark. Just under one-third of the women, 29 percent, gave birth inside a health facility. Similarly, only 33 percent of the births were assisted by a skilled professional like a nurse or midwife. The vast majority of these women delivered at home, often without any trained help present. These numbers are not just abstract figures; they represent a reality where most mothers in these villages are navigating the most critical moments of their lives without the safety net that medical science provides.

The researchers then looked closely at what made the difference between the women who sought care and those who did not. They found that the path to a safer birth often began with the first step: the initial prenatal visit. Women who managed to visit a clinic at least once during their pregnancy were significantly more likely to return for a skilled birth attendant or to deliver in a facility later on. This suggests that once a woman enters the system, she is more likely to stay in it. However, getting that first visit was not easy for everyone. The study showed that women who had more children in total were less likely to use these services, perhaps because they felt confident in their own experience or because the burden of caring for a large family made travel difficult.

Another powerful factor was who held the power to make decisions. In many of these households, the husband or another family member decided whether the woman could go to a clinic. When the woman herself had the authority to make health decisions, she was much more likely to seek out prenatal care. Conversely, when the decision was made by someone else, the likelihood of her visiting a clinic dropped. This dynamic highlights that access to healthcare is not just about the distance to a building; it is also about the freedom to choose to go there. Additionally, women who were aware of methods to plan their families were more likely to use prenatal and delivery services, suggesting that knowledge about reproductive health opens doors to other forms of care.

The physical journey to a clinic also played a major role. For many, the nearest health facility was a long drive away, and only a small fraction of the women could reach it in less than thirty minutes. Interestingly, the study found that women who lived further away were actually more likely to deliver in a facility if they did make the trip, perhaps because they had already overcome the initial hurdle of distance and were determined to see the process through. Yet, the sheer effort required to travel remains a massive barrier for the majority. The researchers noted that the communities they studied are often cut off by poor infrastructure and insecurity, making the simple act of traveling to a clinic a complex logistical challenge.

The authors of the study emphasize that these findings point to a critical need for change. The low rates of facility-based care are not a sign that women do not want help, but rather that the system is not reaching them. They suggest that to improve these numbers, interventions must happen at the community level to build trust and demand for services, while simultaneously working to remove the physical and social barriers that keep women away. This includes investing in community-based health workers who can bring care closer to home and supporting programs that empower women to make their own health decisions. The study does not claim to have solved the problem, but it has provided a clear, detailed map of where the obstacles lie, offering a foundation for future efforts to ensure that every mother in rural Somalia has a fair chance at a safe delivery.