Acceptability of a Community-based Maternal and Neonatal health program in rural Somalia: Perspectives of Women beneficiaries and Household decision-makers

In many parts of the world, the journey to becoming a mother is fraught with danger, not just from biology, but from geography. When a village is remote, roads are rough, and hospitals are days away, the simple act of getting prenatal care or a skilled birth attendant can feel impossible. This reality is particularly acute in Somalia, where the distance between a pregnant woman and a medical facility often dictates whether she and her baby survive. To bridge this gap, health organizations have turned to a strategy that brings care to the doorstep: community health workers. These are local residents, often women, trained to visit homes, offer advice, and distribute essential supplies. The core idea is that trust and proximity can overcome the barriers of distance and poverty. But for this approach to work, the community must not only receive the services but truly accept them. Acceptance is more than just showing up; it is about whether the advice feels right, whether the worker is trusted, and whether the family believes the changes are worth making.

In the Galmudug region of Somalia, a researcher set out to understand exactly how a specific program called Community-Based Maternal and Newborn Care was being received. This two-year initiative, run by the International Rescue Committee, deployed trained health workers to eight remote villages to provide education and supplies to mothers and newborns. The researcher wanted to know if the women receiving these visits and the men who often make the final decisions in Somali households felt the program was appropriate, useful, and respectful of their values. They spoke with dozens of women, their husbands, and their mothers-in-law to uncover the real-world experience of living with this new system of care.

The study, conducted in late 2024, revealed that the program was largely embraced, but the reasons were deeply rooted in the daily lives and cultural fabric of the community. The most significant factor driving acceptance was the simple fact that the care came to the women's homes. In a landscape where travel is difficult and expensive, having a health worker arrive at the door removed a massive burden. The women reported that these visits were not an intrusion but a relief. They appreciated that the workers called ahead to find a convenient time, allowing the mothers to pause their household chores without feeling rushed. The visits, which typically lasted an hour, were seen as a manageable investment of time that paid off in better health for their families.

Trust played an equally critical role in the program's success. The health workers were not outsiders; they were neighbors, friends, and relatives who shared the same language, religion, and cultural background. This familiarity created a sense of safety that allowed women to speak openly about their pregnancies and fears. The researcher found that the shared Islamic faith was particularly important, as the religious duty to keep confidences reassured the women that their private health matters would remain secret. This trust was so strong that even when the health workers were young and less experienced than hospital staff, the community still valued their presence because they were part of the village.

The program also gained ground because it provided tangible items that met immediate needs. The health workers distributed iron tablets to fight anemia, mosquito nets to prevent malaria, and water purification tablets to ensure safe drinking water. These physical goods were highly valued and helped convince the families that the advice coming with them was practical and beneficial. When a mother received a net or a bottle of water treatment, the abstract idea of "health" became something she could hold and use. This combination of education and material support made the program feel relevant and effective.

However, the path to full acceptance was not without friction. The researcher discovered that while the women were eager to learn, some deeply held cultural beliefs proved difficult to change. For instance, despite the health workers' clear advice to feed newborns only breast milk, many families still believed that giving a baby sweet water or other liquids was necessary to clear mucus from the chest. This practice, passed down through generations, persisted even when the mothers wanted to follow the new guidance. The study highlighted that having a trusted worker and useful supplies was not always enough to overturn long-standing traditions, especially when older family members, like grandmothers, insisted on their own methods.

The role of men in this dynamic was complex and crucial. In these households, men are often the primary decision-makers regarding finances and travel. The study found that while men were generally supportive of the program, they were often less informed about the specific details of the care their wives received. Many men learned about the initiative only after seeing the supplies arrive or hearing their wives talk about it. Their support was practical rather than participatory; they provided the money for transportation if a wife needed to travel for a check-up or took over childcare duties so she could speak with the health worker. The researcher noted that while men saw the value in the program's cost-effectiveness and health benefits, their limited direct engagement meant they were sometimes unaware of the specific advice being given, which could hinder their ability to reinforce those messages at home.

The findings suggest that while the home-visiting model is a powerful tool for delivering care in fragile and remote settings, its success depends on navigating the social landscape with care. The program worked because it respected local values, built on existing trust, and addressed practical needs. Yet, the study also pointed out that to fully realize the health benefits, future efforts must find new ways to engage men more deeply and address the specific cultural beliefs that still influence how families care for newborns. The research confirms that bringing health services to the community is a vital step, but the journey toward better health outcomes requires a continuous dialogue between medical advice and the lived reality of the families it serves.