Antenatal Care Utilization in Somalia, 2020 Somalia Demographic Health Survey.

BACKGROUND: Despite global efforts to enhance maternal healthcare access, Somalia has reported one of the highest maternal mortality rates, at 621 deaths per 100,000 live births in 2020. This occurs amid conflict, humanitarian crises, and a fragile health infrastructure. Antenatal care is critical for reducing maternal deaths. METHODS: This cross-sectional study utilized data from the 2020 Somalia Demographic and Health Survey (SDHS), focusing on 3,375 women aged 14-45 years who had delivered live births in the five years preceding the survey. The primary outcome was antenatal care utilization, defined as the attendance of four or more antenatal care (ANC) visits (ANC4+). The independent variables captured maternal, household, and geographic characteristics, including residence type (urban, rural, nomadic), and regional disparities across Somalia's 16 administrative divisions. A weighted binary logistic regression analysis was performed to identify associated factors. RESULTS: Overall, only 7.0% of the women received the WHO-recommended minimum of four ANC visits, indicating an alarmingly low utilization rate. Significant disparities were identified, with nomadic women facing 90% lower odds and rural women facing 70% lower odds of adequate ANC than their urban counterparts. Regional variations were striking: Lower Jubba and Nugaal showed significantly higher ANC utilization, whereas Togdheer exhibited significantly lower utilization than the reference region (Awdal). Notably, the statistical significance of the wealth quintile and education diminished in the adjusted model, suggesting that their effects might be mediated by other factors, such as urban-rural disparities. CONCLUSION: This study reveals that only 7 out of 100 pregnancies in Somalia receive the WHO-recommended minimum of four ANC visits, placing Somalia among the lowest-performing countries globally for antenatal care utilization. These findings underscore the urgent need for targeted interventions and equity-focused policies to close the maternal health service gaps, particularly in nomadic and rural populations.