The role of individual and community factors on institutional delivery in Somaliland: a study based on the 2020 Somaliland demographic health survey.

Background: Maternal mortality remains a critical concern in low-income countries, where low utilization of institutional delivery services is a contributing factor. This study investigates the influence of individual and community-level factors on institutional delivery among women in Somaliland, a region with a high maternal mortality rate. Methods: This cross-sectional study used data from the 2020 Somaliland Demographic and Health Survey (SDHS), a nationally representative survey of 3804 women aged 15-49. We employed descriptive statistics and Chi-square tests to examine bivariate associations and multi-level binary logistic regression to assess the impact of individual and community-level factors on the place of delivery. Results: Only 30.8% of deliveries occurred in health institutions. Bivariate analyses showed significant associations between institutional delivery and maternal age, education (χ² = 328.534, p < 0.001), husband's education (χ² = 362.669, p < 0.001), wealth (χ² = 787.937, p < 0.001), region (χ² = 50.760, p < 0.001), and parity (χ² = 65.227, p < 0.001). Multilevel analysis revealed that 50% of the variance in place of delivery was attributable to community level factors (Model I). Higher maternal education was significantly associated with increased odds of institutional delivery (AOR = 8.87, p < 0.05), while nomadic residence (AOR = 0.28, p < 0.05), residing in Sanaag region (AOR = 0.36, p < 0.05), high parity (five or more children) (AOR = 0.52, p < 0.05), not intending to use contraceptives (AOR = 0.62, p < 0.05), and wanting the pregnancy later (AOR = 0.79, p < 0.05) were significantly associated with decreased odds of institutional delivery. Women in the highest wealth quintile were significantly more likely to deliver in a health facility (AOR = 18.71, p < 0.05). Conclusion: The study highlights the complex interplay of individual and community-level factors influencing the utilization of institutional delivery in Somaliland. Interventions to promote health facility deliveries must address socioeconomic disparities, improve women's education, ensure accessibility of healthcare for nomadic communities, reduce regional variations, promote family planning and reproductive health services, and take into consideration the impact of parity on health seeking behaviors.