Spatial distribution and multilevel determinants of quality intrapartum care in Somalia: A secondary analysis of a nationally representative survey.

BackgroundSomali women face extreme maternal health risks, with a mortality ratio of 692 deaths per 100,000 live births. Quality intrapartum care (QIC) is essential for preventing avoidable maternal and neonatal deaths during labour and childbirth. However, evidence on its distribution and associated factors remains scarce in Somalia.ObjectivesThis study assessed the spatial distribution and identified multilevel factors associated with QIC among reproductive age women across Somalia.DesignA secondary analysis was conducted using the 2020 Somalia Demographic and Health Survey, a nationally representative cross-sectional survey.MethodsThe analysis involved 6,414 women who gave birth within five years preceding the survey. QIC was measured as a composite of facility delivery, skilled birth assistance, and early breastfeeding initiation. Multilevel mixed effects logistic regression identified determinants, while geostatistical techniques identified regional clusters.ResultsNational prevalence of quality intrapartum care was 19.0% (95% CI: 16.5% to 21.6%). Significant positive factors associated with QIC included maternal higher education (AOR = 5.20; 95% CI: 2.62 to 10.31), highest wealth quintile (AOR = 7.10; 95% CI: 4.95 to 10.20), and receiving four or more antenatal visits (AOR = 2.91; 95% CI: 2.35 to 3.62). Conversely, high parity (AOR = 0.60; 95% CI: 0.48 to 0.76) and nomadic residency (AOR = 0.55; 95% CI: 0.44 to 0.68) were associated with lower odds of quality care. Spatial analysis revealed significant non random clustering (Moran's I = 0.412, p = 0.014), with hotspots in Awdal and Woqooyi Galbeed and coldspots in Gedo and Mudug.ConclusionQIC prevalence was low and showed geographical and socioeconomic inequities. Conflict sensitive responses should prioritize improvements in access to skilled intrapartum care in lower QIC areas and strengthen antenatal care as a platform for birth preparedness. Outreach must be adapted to security, road access, and the unique mobility of nomadic populations.Where and Why Women in Somalia Receive Quality Care During Childbirth Somalia faces extreme health risks for mothers and newborns. This study looked at quality care during childbirth, which means giving birth in a clinic with a trained professional and starting breastfeeding within one hour. These steps are vital for the survival of both mother and baby. By looking at national survey data, we found that only 19% of women in Somalia receive this level of care. Access is not equal across the country. Women with more education, higher wealth, and those who attend at least four prenatal check ups have much better odds of a safe birth. In contrast, nomadic women and those with many children are often left behind. Geography also plays a huge role. We found hotspots of better care in northwestern regions, but coldspots with very low care levels in southern and central regions like Gedo and Mudug. To save lives, health services must target these underserved areas. We recommend using prenatal visits to help women plan for birth and creating mobile health services to reach nomadic families. Ensuring every mother can access a professional and a clinic, regardless of her location or wealth, is essential for making childbirth safer in Somalia.