Where and why mothers discontinue healthcare services: a qualitative study exploring the maternity continuum of care gaps in Somalia

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Somalia is among the 15 countries that the WHO marked as very high alert countries for maternal, newborn, and under deaths. The maternity continuum of care (CoC) throughout pregnancy, childbirth, and the postnatal period is essential for the health and survival of mothers and their babies. This study aimed to explore the maternity continuum of care gaps in Somalia. Methods This qualitative study included 5 FGDs (44 childbearing mothers) purposively sampled from urban, rural, IDPs, agro, and nomadic pastoralists and 19 in-depth interviews (IDIs) from healthcare providers, policymakers, recently delivered and childbearing mothers, community leaders, and traditional birth attendants in 6 regions of Somalia in January 2024. We used thematic analysis to analyze the data. Results Five key themes and twelve subthemes emerged from the analysis: service availability, access to care, decision-making, quality of care, and traditional beliefs. The maternity continuum of care gaps varies across different community categories, such as urban areas, rural areas, IDPs, agro-pastoralists (beeraley-baadiye), and nomadic pastoralists (reer-guuraa), due to diverse reasons, including service availability, access to care (financial, distance, and transportation), socioeconomic disparities, infrastructure, climate-related, and security issues. Conclusion The maternity continuum of care gaps varies across different community categories, such as urban, rural, IDPs, agro-pastoralists (beeraley-baadiye), and nomadic pastoralists (reer-guuraa), due to a combination of diverse reasons, such as service availability; access to care, including financial, distance, and transportation; socioeconomic disparities; infrastructure; climate-related issues; and security issues. Key terms: Maternal health, continuum of care, cultural beliefs, home delivery, Somalia 1. Background Countries around the world aim to achieve Universal Health Coverage (UHC) by removing all forms of barriers, including financial barriers, to improve access to healthcare and reduce maternal and child deaths by 2030. Sub-Saharan Africa faces a wide range of health problems, many of which are interconnected and influenced by social, economic, and environmental factors. Examples of health problems include high infectious disease rates, maternal and child deaths, malnutrition, limited access to healthcare, weak healthcare systems, poor access to clean water and sanitation facilities, environmental health risks, and noncommunicable diseases such as cancer ( 1 ). Sub-Saharan Africa alone constituted approximately 66% of global maternal deaths in 2017 ( 2 ). Maternal deaths remain a significant public health challenge in low- and middle-income countries (LMICs), with more than a quarter of maternal deaths occurring during or within 24 hours after childbirth and nearly 40% occurring between 24 hours and 42 days postpartum ( 3 ). Somalia has been ravaged by serious civil wars, armed conflicts, and terrorism counterattacks for the last three decades. The country is among the countries in sub-Saharan Africa with one of the weakest Healthcare systems and the lowest health indicators in the world ( 4 ). The healthcare system in Somalia is more fragmented, with various actors, including the government, nongovernmental organizations (NGOs), and the private sector, playing roles, which leads to not only gaps in health coverage and uptake but also unnecessary overlaps. The capacity of the federal government of Somalia and member states’ capacity to finance healthcare is very restricted, followed by limited existing infrastructure, shortage of skilled healthcare professionals, poor access to healthcare, high disease burden, and inconsistency of service delivery due to geographical barriers and insecurity ( 5 ). The country has launched many programmes related to community health workers (CHWs) and health extension workers to provide basic health services for people underserved in rural and remote areas where the majority of the Somali population lives. Somalia is among the 15 countries for which the WHO marked as very high alert countries for maternal, newborn, and under5 deaths. Most of the causes are either preventable or treatable. The country has one of the worst maternal conditions in the world. For instance, the maternal mortality ratio is 692 per 100,000 live births ( 6 ). Four in 100 Somali children die during the first month of life, eight in 100 die before their first birthday, and 1 in 8 die before they turn five ( 7 ). Maternity continuum of care refers to the continuation of various stages of care that the mother goes through before, during, and after pregnancy to ensure a healthy outcome for both the mother and the child. The continuum of care includes pre-pregnancy care, such as screening, pregnancy care (ANC), delivery care (skilled birth attendance), postnatal care, and interpregnancy care ( 8 ). The maternal and child continuum of care (CoC) throughout pregnancy, childbirth, and the postnatal period is essential for the health and survival of mothers and their babies. Antenatal care visits allow medical staff to identify health problems related to pregnancy as early as possible, which will facilitate early detection, diagnosis, and treatment ( 9 ). A good antenatal care program ensures the timely detection and treatment of problems during pregnancy. Skilled birth attendants (SBAs) and facility-based delivery (FbD) play critical roles in reducing infant and maternal mortality globally. Delivery within a health facility and with the attendance of a skilled healthcare provider is key in reducing health risks to both the mother and baby ( 10 ). Postnatal care (PNC) is the care given to the mother and her newborn baby immediately after birth and for the first six weeks of life. Attendance to maternal, newborn, and child health services during pregnancy (ANC), delivery (SBA), postnatal follow-up (PNC), and childhood vaccinations are crucial factors contributing to a healthy pregnancy, delivery, and childcare. Gender inequality has a direct association with mother’s service utilization. There are a number of studies in Sub-Saharan African that found the limited mother’s autonomy and decision-making power in determining own healthcare and husband’s control our family resources ( 11 ). There is limited evidence on the maternity continuum of care gaps in Somalia. The aim of this study was to critically examine the multifaceted barriers to the completion of the maternity continuum of care among different community domains, such as urban, rural, IDPs, and nomadic areas. 2. Methods This paper used both deductive and inductive descriptive qualitative studies aligned with the consolidated criteria for reporting qualitative research (COREQ) checklist ( 12 ). Study Settings The study was carried out in six regions of Somalia based on the representation of different socio-geographical contexts, such as urban, rural, IDPs, agro-pastoralist, and nomadic-pastoralist. The six regions included in this study were categorized according to their socio-geographical domains. These regions and the interviewed domains include Togdher (IDPs and urban), Bari (nomadic-pastoralist), Mudug (rural and urban), Galdugud (urban and IDPs), Banadir (IDPs), and the Lower Juba region (agro-pastoralist). Togdher region is one of the administrative regions in Somaliland. The region hosts many IDPs that flee from their habitual residences, primarily due to droughts and conflicts ( 13 ). Banadir region or Mogadishu, hosts the largest estimated protracted internally displaced population in Somalia, mainly living in informal IDP sites across the city. Internally displaced persons (IDPs) are individuals or families who have been forced or obliged to flee or leave their homes or places of habitual residence due to armed conflicts, situations of generalized violence, persecution, or natural disasters but remain within the borders of their own country. IDPs in Somalia often live in makeshift camps in urban areas, usually face precarious living conditions, and rely on humanitarian assistance. The Bari region is the largest region in Somalia in terms of geographical landmass. The region has predominantly nomadic pastoralists in its subdistricts and villages. Nomadic pastoralists usually rely on extensive rangelands for grazing livestock herds, including camels, cattle, sheep, and goats. They move with their livestock herds in search of pasture and water. The Mudug region is the most centrally located region in Somalia and contains two federal member states (Puntland in the north and Galmudug in the south). Lower Juba is an administrative region in the Jubaland state of Somalia. The communities living in this region practice both agro-pastoralism and nomadic pastoralism. Agro-pastoralists usually rely on arable land for crop cultivation and production. They utilize a combination of crop farming in small areas and livestock rearing, which provides them with slightly stronger resilience in food production than do the nomadic pastoralists. Study Design and Population The study used purposive sampling methods to initially identify participants who had substantial expertise in maternal and child healthcare delivery and utilization in Somalia. The target population for this study was healthcare policymakers from the respective Ministry of Health at the federal and state levels and implementing partners, healthcare providers and professionals, traditional birth attendants, community leaders, and childbearing and recently delivered mothers. Sampling and Recruitment Procedures This study used a maximum variation sampling scheme to yield a wider perspective from various community categories and other stakeholders. Six of the 18 pre-civil war Somalia regions were purposively selected based on the representation of different socio-geographical contexts, such as urban, rural, IDPs, agro-pastoralist, and nomadic-pastoralist. The sample size was based on information needs and data saturation. Data collection and research participants The study adopted two main data collection methods: focus group discussion (FGD) and an in-depth interview guide, followed by field notes. Five FGDs (44 participants) from childbearing and recently delivered mothers in five different regions of Somalia were conducted. The communities were categorized into urban, rural, IDPs, agro-pastoralist (beeraley-baadiye), and nomadic-pastoralists (reer-guuraa), as described in Table 1 . The FGD discussions lasted between 45 minutes and 1 hour. Seventeen in-depth interviews (IDIs) involving four policymakers, six healthcare providers, three community leaders, two traditional birth attendants, and two recently delivered mothers across Somalia were conducted, as described in Table 2 . Table 1 Characteristics of the Focus Group Discussion Participants FGD Participants (Mothers with a child less than two years) FGD No. Category Region No of Participants FGD-1 Nomadic pastoralists (reer-guuraa) Bari 9 FGD-2 IDPs Togdher (Burco) 10 FGD-3 Rural Mudug 8 FGD-4 Urban Galgadud (Adado) 10 FGD-5 Agro-pastoralists (beeraley-baadiye) Lower Juba (Kismayo) 7 Research Instruments This study used two interview guides, “Focus Group Discussion (FGD) and In-depth Interview guide,” adopted from the validated tools of SB Kitila et al. ( 14 ). Interview guide for the FGDs (Recently delivered and Childbearing mothers) : Face-to-face open discussions with purposively selected childbearing mothers were carried out by the principal investigator and data collectors. Before starting the in-depth discussion as a group, the mothers were asked to complete a short personal profile questionnaire to capture the following information: age, residence, marital status, literacy, number of children, occupation, income, and other demographic information. The childbearing mothers who participated in the FGDs were also asked to discuss an open-ended question about their life experience with healthcare service utilization. Probing questions related to factors negatively affecting the continuation of MNCH services, barrier factors, and promotors for the continuation of MNCH services were asked. To clarify the questions, the childbearing mothers’ interview guide was pretested with one other FGD recruited from a different region and not included in the study sample. Interview guide for In-depth Interviews : Face-to-face individual interviews were conducted based on the interview guide. The interview guide contained participants’ profile questionnaires, such as age, residence, provision, occupation, and current position, as well as unstructured questions related to barriers to the continuum of care for MNCH services. Participants in this section were healthcare policymakers from the respective Ministry of Health at the federal and state levels and implementing partners, healthcare providers and professionals, traditional birth attendants, community leaders and gatekeepers, and childbearing and recently delivered mothers. Data Management and Analysis The study used a qualitative thematic analysis approach according to Braun and Clarke’s qualitative data analysis frameworks ( 15 ). The principal study investigator and the research assistants (enumerators) audio-taped all of the interviews and discussions after providing consent from the study participants—the first step involved transcribing the audio tapes and field notes in the Somali language. Then, the transcripts were translated into English by three qualified people fluent in both languages. The study principal investigator cross-checked the accuracy and completeness of the translations several times. The study investigator listened to the audio records and read the transcripts repeatedly for data consistency and reliability. In the initial phase of the study data analysis, we adopted deductive coding by starting with predefined codes from the existing research literature, followed by inductive coding to identify additional themes and categories that emerged directly from the data. We developed predefined initial codes (open coding) throughout the study’s data analysis. After data collection, each code was further analyzed and disaggregated into themes and sub-themes (deductive axial coding). Throughout the primary data analysis, additional codes were added while reading the data, themes, and sub-themes that had not been identified previously (inductive method) to identify areas of divergence, convergence, and overlap. A final coding framework was constructed using deductive and inductive coding approaches. To improve the trustworthiness of the qualitative data analysis, the codes and concepts that emerged from the different interview categories and discussions were verified by consistently linking the emerging themes with the data received from the other groups. Participants’ own words (quotes) were used to enhance the credibility of the data. Table 2 Summary of the study participants using maximum variation sampling, data sources, and methods Method Description Sample FGDs with mothers Five FGDs with mothers of children less than two years in different geographical locations 5 FGDs (44 mothers) Sampled from Urban, Rural, IDPs, agro, and nomadic pastoralists in 5 regions of Somalia. IDI with healthcare providers Qualitative interviews with MCH and community Healthcare providers (Midwives, nurses, doctors, community health workers, etc. 6 healthcare providers in six different regions were interviewed. IDI with health policymakers Qualitative interviews with the Ministry of Health at federal and state level staff 4 policymakers from the federal and state governments were interviewed IDI with TBAs Qualitative interviews with traditional birth attendants 2 Traditional Birth Attendants were interviewed IDI with caretakers Qualitative interviews with recently delivered mothers 2 recently delivered mothers were interviewed IDI with community leaders Qualitative interviews with community gatekeepers and leaders 3 community gatekeepers and leaders were interviewed Ethical Approval and Consent to Participate Study details and guidelines were explained to participants before the interviews began. Consent to participate in the study was obtained orally from each respondent. Participants were notified that their involvement in interviews was voluntary and that they were able to decline to answer any questions. Participants were assured that their identities would remain anonymous, and no compensation would be given to them. The National Institute for Health, Somalia, provided ethical approval for this study. 3. Results Identified Themes Five key themes and twelve sub-themes emerged from the study data set, which were the result of a thematic analysis exploring the maternity continuum of care gaps, as stated in Table 3 . Table 3 Categories of Themes and Sub-themes Themes Subthemes Service availability Service availability in some areas Access to care Distance and Transportation Financial barriers Unassisted childbirth due to geographical constraints Decision and awareness to seek care Lack of knowledge of pregnancy risks Late antenatal care booking Mother’s awareness of the importance of seeking care Socio-cultural practices and beliefs Husbands’ dominance in decision-making about mother’s health TBA trust and Readiness Normality of homebirths Quality of care Perceived poor quality of care Lack of scheduled PNC service at health facilities Fragmentation of care across the maternity continuum of care Theme 1: Service availability The availability of health facilities plays an important role in the increase in and utilization of skilled delivery in developing countries such as Somalia. Sub-theme 1.1 - Service availability in some areas Participants highlighted that the areas in which they live do not have nearby essential health services. The non-availability of nearby health facilities forces mothers to travel long distances to access medical services, creating significant barriers to maternal and child healthcare access. “There are no health services available nearby. Services are provided at extremely distant centers, and they are not accessible to us. We would visit the health facility if it was near. We desperately need a health facility where we can receive medications and medical services”. (FGD-1, childbearing mother) Residents express a strong desire for the presence of a local health facility that would provide essential medical services within their community. The absence of such a facility creates a sense of desperation and urgency among community members who recognize the importance of timely access to healthcare for their well-being and the well-being of their families. A health policymaker articulated the quote below. “Many remote and rural areas in Somalia do not have well-equipped health facilities. The country has both a limited number of health facilities and sufficient quality of care. The reality of mothers delivering at health facilities in Somalia is truly difficult.” (IDI-Health policymaker) It is difficult for mothers to discuss the quality of care and the completion of all services at this time because many villages and communities do not have health infrastructure. How can we talk about quality and continuation of care while all communities do not have health facilities in their locations?”. (IDI-Community leader) Theme 2: Access to care Healthcare services in Somalia face many accessibility challenges, including distance, transportation, finances, and fragmentation of care across the maternity continuum of care. There is inadequate coordination and linkage between antenatal, intrapartum, and postnatal care providers. Sub-theme 2.1 - Distance and transportation Many communities in Somalia, specifically those living in rural or remote and hard-to-reach domains, face excessive challenges accessing healthcare services and are usually located far away from health facilities or through climate shocks such as flooding. “Some roads are out of service because of floods. Currently, people travel by boat. A boat costs 5 USD to cross the river. Those who cannot afford the boats should cross the water by themselves. Therefore, pregnant mothers cannot reach the health facilities for ANC, facility delivery, or PNC services because of these bad roads.” (FGD-5, childbearing mother) Participants emphasized the challenges of distance, geography, and transportation to access healthcare services in their localities. “It is difficult to reach the city to obtain ANC, facility delivery, and PNC services because of the extremely bad route. Bosaso is the closest big city, yet it is quite a distance away from our area”. (FGD-1, childbearing mother) Furthermore, health policymakers have indicated that long distances and the absence of reliable modes of transportation are other barriers that prevent mothers from utilizing available MCH services. “The pregnant mother may give birth at home if the health center is far and distant from her house, which is a big factor for healthcare inaccessibility in Somalia.” (IDI-Health policymaker) A health policymaker illustrated that some of the rural and nomadic locations do not have health facilities due to the sparsity of inhabitants. “If the mother lacks money for transportation and the health facility is distant, these could act as barriers to ANC services. The population and its demands determine the number of health centers and services that can be offered. Not every location can have a health facility established. The only way we can improve service accessibility is through transportation”. (IDI-Health policymaker) Another childbearing mother explained: “We live in a mountainous area, so there are no roads in this area. We walk on feet. There are no roads here where we can stand and hail a ride on a car”. (FGD-1, childbearing mother) Sub-theme 2.2 - Financial barriers Childbearing and recently delivered mothers acknowledged that they do not have enough money to afford transportation and medical costs, if any. They explained that financial limitations prevent them from traveling to health facilities and paying medical costs; as a result, they tend to deliver their babies at home. “Because we lack enough money to get a car and drive to the city, women deliver in their homes. We’re far away from the health facilities, so we often undergo labor in our homes”. (FGD-1, childbearing mother) A community leader explained that most of the families in their community cannot avoid paying medical costs if they are referred to large hospitals, which can hinder the continuation of the maternal continuum of care. “The mother is referred to another hospital when her condition worsens, but we lack the money to pay for her care, which presents a challenge. The diagnosis and medical costs are beyond what these mothers can afford”. (IDI-community leader) Participants discussed that some areas are geographically isolated, incredibly remote, or rural, with limited access to healthcare institutions. Pregnant mothers cannot attend the recommended maternity continuum of care because of the nomadic lifestyle that moves from one place to another, which often entails living in remote areas from urban centers. “We inhabit this remote area as nomads. We must go to a city to get healthcare. We cannot afford the cost of transportation and medical costs. We don’t have cash. Our only source of money is from the goats and sheep, but they don’t have a decent market these days”. (FDG-1, Childbearing Mother ) Sub-theme 2.3 - Unassisted childbirth due to geographical constraints In remote nomadic areas with limited access to healthcare facilities or skilled birth attendants, women may find themselves in situations where they have no choice but to deliver their baby without assistance. “I get nauseous in the morning during pregnancy. I go through a harrowing delivery as well. I gave birth in a rural area, and I’ve never received assistance from medical professionals. I delivered by myself without the assistance of a midwife or any other person”. (FGD-1, childbearing mother) The participants explained that sometimes mothers deliver alone without any support. Deliveries without medical assistance can be dangerous, especially if health complications arise. Mothers discussed the existence of free birth in some areas. This refers to the practice of giving birth without the assistance of both medical professionals and traditional birth attendants. “In the remote rural nomads, sometimes labor may progress so rapidly while the mother is alone, and she cannot reach the health facility or find the TBAs nearby her home sometimes. Unexpected labor may strike, and the mother may end up delivering her baby without assistance, “free birth”. (FGD-3, childbearing mother) Unassisted childbirth or free birth is not a choice or deliberate decision in the Somali community, but it occurs due to access to care. This event carries the highest risk and can cause unpredictable health complications, such as maternal or child mortality or morbidity. “In rural areas, women lack access to medical care due to geographical constraints. They do not attend antenatal care visits, skilled birth attendants, or postnatal care check-ups. A herdswoman cannot seek ANC, facility delivery, or PNC services from health centers that are very far away. She needs to maintain the animals she keeps, support the family, and take care of the other children”. (IDI- healthcare provider) Theme 3: Decision and awareness to seek care Sub-theme 3.1 - Lack of knowledge on pregnancy risks and danger signs Throughout the interviews, participants acknowledged that women’s awareness and knowledge of pregnancy risks and childbirth varied. The signs of danger related to pregnancy are warning signs that women face during pregnancy, childbirth, and the postpartum period. It is common that communities with low socioeconomic status are not aware of health danger signs, especially pregnant and childbirth-related dangers. A mother from the agro-pastoralist community in FGD-5 discussed the following: “Usually, pregnancy is natural, and we don’t face complications, so why do we need to walk and visit the health facility? We did not have a history of severe problems during pregnancy. Pregnancy is not a disease to fear of.” (FGD-5, childbearing mother) Some participants reported that limited health education and awareness of maternal health risks put mothers at risk of pregnancy. An in-depth interview participant said: “Most mothers do not understand the risks related to their pregnancy if they do not attend ANC. They remain in their homes while they don’t know the status and conditions of their pregnancy. They are not educated enough to seek medical care in advance”. (IDI-healthcare provider) Sub-theme 3.2 - Late antenatal care booking A healthcare provider illustrated that mothers usually arrive at the first ANC visit in their third trimester. “Mothers usually arrive late for the first antenatal care (ANC) visits, often between the 8th and 9th month of pregnancy. This delay stems from a lack of awareness about the crucial benefits of early ANC visits for the mother and her baby”. (IDI-Healthcare provider) Similarly , qualified midwives and other healthcare providers explained that due to limited awareness, mothers are reluctant to book ANC as early as possible. The following conclusions were drawn from the midwives and nurses at some of the health facilities: “Most of the mothers are hesitant to come to the health facility as early as possible to have their pregnancy checked (ANC). A lack of ANC visits is usually associated with premature birth, a greater risk of complications, stillbirth, low birth weight, and other adverse health outcomes.” (IDI-Midwife) “If mothers do not attend early ANC visits and complete all the necessary ANC visits, they will probably not deliver at health facilities, which can be a barrier to the continuation of maternal health services.” (IDI-Qualified nurse) Sub-theme 3.3 - Mothers’ awareness of the importance of seeking care Pregnant mothers may not always be aware of the benefits of receiving antenatal care, facility-based delivery, and postnatal care. One participant explained: “Due to limited knowledge and education, mothers do not come to the health facility to complete all of the available health services. If mothers attend the first ANC, then they discontinue attending the second ANC and subsequent facility delivery and postnatal care. They are not fully aware of the benefits of attending all of the stages of maternal and child health services”. (IDI-healthcare provider) A health policymaker illustrated that women do not complete existing maternal and child health services due to their low literacy and limited awareness of seeking medical care. “I think it is not possible for a low-literacy mother to complete all of the maternal and child health services that are available in the health facility. Many mothers do not understand the importance of attending all of the stages of maternal and child health services”. (IDI-policymaker) Theme 4: Socio-cultural practices and beliefs Traditional beliefs regarding pregnancy and childbirth remain a choice for some Somali women. Trust in traditional birth attendants (TBAs) is frequent in rural and remote areas where access to primary and comprehensive healthcare services may be limited. TBAs are sometimes highly respected community members and have been providing home deliveries for generations in Somali society. Some of the reasons that TBAs are trusted and that home deliveries are normalized include the inaccessibility of maternal healthcare in rural and hard-to-reach areas, cultural beliefs and practices, the proximity of TBAs to the community, low cost and affordability, respect for the privacy of the mother and cultural sensitivities, etc. ( 16 ). Sub-theme 4.1 - Husbands’ dominance in decision-making about mother’s health Men are generally the overall decision-makers on all household matters including resource allocations, where and how to live. A childbearing mother had the below views “The father is the overall head of the family and controls all the family resources and determines the expenses regarding healthcare utilization. He also makes decisions and allocations of resources like purchases and monthly expenses. Women are just house-keepers and care for the kids” (FGD-3, childbearing mother) There is available evidence that suggest women in Sub-Saharan Africa often have very limited autonomy and control over decisions to go to the health facility. “One of the reasons that women do not delivery health facility is because of their powerlessness. One in Somalia is submissive to her Sheikh (husband). There are some times where the couples negotiate but mostly the husband has the overall decisions and power”. (IDI-Midwife) Sub-theme 4.2 - TBA Trust and Readiness “Yes, I believe the skills and experience of the TBA in our village. They are available and ready every time, and they are part of our family. The TBAs have a lot of experience and know how to deal with pregnancy, delivery, and even delivery advice”. (FGD-5, childbearing mother) A few childbearing mothers mentioned the challenges to reach the existing health facilities. “We live in a very remote area that healthcare providers cannot reach. The only attendant available in our villages is a traditional birth attendant from neighboring families; sometimes, you cannot even get those neighboring traditional attendants”. (FGD-1, childbearing mother) “During my pregnancy, I had low hemoglobin, heartburn, and terrible morning sickness. In labor, the pain doubles since there are no healthcare providers. The TBA is the only accessible birth attendant. After giving birth, I started bleeding excessively”. (FGD-3, childbearing mother) Acknowledging the availability of the TBA and the flexibility of payments, the study participants indicated the following : “The traditional birth attendants (TBA, Umuliso-dhaqameed in the Somali language) are always available even during the night and usually do not charge fare before delivery. They usually come to help the mother first, and then you give what you have, and they are very respected within the community”. (FGD-2, childbearing mother) “Yes, there are many traditional practices and beliefs; for instance, the pregnant woman says I need to see my previous TBA that handled my last delivery. I don’t want to go to a new environment”. (IDI-community gatekeeper) Sub-theme 4.3 - Normality of homebirths Women who normalize to deliver at home are still prevalent in many parts of Somalia. Several factors can help women normalize their delivery at home, including cultural and personal preferences, as many women still feel more comfortable delivering at home, limited knowledge and awareness, intergenerational precedent, as women inherit home delivery normalization from their parents and grandparents, and limited access to professional midwifery care. “Yes, I feel comfortable delivering at home because we are surrounded by our loved ones, and I feel like a normal process to deliver at home.” (FGD-5, recently delivered mother) Some mothers considered home delivery to be normal. A childbearing mother from FGD-3 explained: “I grow up while our mothers give birth at home. Home delivery is normal, and it allows us to labor and deliver on our own terms. It feels like the most natural choice for us”. (FGD-3, childbearing mother) Participants also cited that their previous delivery occurred at home and believed that it was an easy and natural process. In one of the in-depth interviews, a childbearing mother stated the following : “I gave birth all my children at home (3 kids), and they are all good (Praise be to God). Nothing happened to me. The old woman ( 17 ) is very experienced and can handle all pregnancy-related issues.” (IDI-Childbearing mother) There are a wide range of reasons why mothers choose to deliver at home; for instance, some of the reasons reported by participants included familiarity with the environment where they are surrounded by their loved ones, the avoidance of unwanted restrictions, and the inability to leave their other kids. A midwife at the health facility indicated that some mothers cannot leave their kids to visit the health facility for ANC or delivery. “Some mothers do not come to the health facility to deliver; instead, they prefer to deliver at home because they are familiar with that environment. They do not have someone who can stay with the other kids even if they decide to visit the health facility. Yes, this can present a significant challenge in accessing healthcare services”. (IDI-Midwife) Theme 5: Quality of care Somalia's healthcare system has been characterized by strong private and NGO-led components. The quality of healthcare services has become an increasingly predominant question for both beneficiaries and care providers. Although the quality of healthcare is a complex, multidimensional, and subjective concept, local beneficiaries' views can be associated with their healthcare utilization ( 18 ). Sub-theme 5.1 - Perceived poor quality of care Fragile countries fail to improve the quality of healthcare in their population by accepting low - quality health services to continue. Many mothers question the skills and experience of healthcare providers at health facilities. “The reason women do not go to health facilities and prefer to be at home when delivering is that many of them are scared to meet unskilled workers or fresh students doing their practical sessions at the hospital; many women come to me because they have problems and health issues on their previous delivery at hospitals. They will say it’s not safe to give birth at the hospitals because of the low-quality services the MCH offers.” (IDI-Healthcare provider) Compared to qualified nurses or midwives at nearby health facilities, study participants, especially childbearing mothers, believe that traditional birth attendants in their locality have better experience and skills. They also feel that health facilities lack the necessary privacy infrastructures, such as designated rooms . “The old mother is more experienced and skillful than nurses/midwives at MCH. I feel I am not treated carefully at a health facility. I am afraid of my privacy during delivery because of the young nurse in the MCH.” (FGD-5, childbearing mother) It is normal for clients to seek alternative care options if they feel dissatisfied with the available care provided at health facilities . A community leader reported that when beneficiaries are dissatisfied with only available care, they will seek care from their traditional birth attendants. “Low service quality could also be a hindrance. If mothers are not satisfied with the service quality provided in the health center, they are more likely not to seek health services frequently. How health workers welcome care-seeking mothers influences mothers’ acceptance and willingness to seek ANC, facility delivery, and PNC services.” ( IDI-Community leader) Sub-theme 5.2 - Lack of scheduled PNC services at health facilities Despite some pregnant mothers’ attendance at antenatal care and childbirth at health facilities, postnatal care checkups before they leave the facility are limited. The uptake and utilization of PNC services lies in service providers’ appointments and mothers’ understanding of the importance and relevance of PNC services. A recently delivered mother discussed the lack of PNC scheduling from the care providers who were managing her delivery. “I don’t know if I was checked before my discharge. I was okay in the morning, and the nurses did not mention any clearance or check-ups before I left the MCH. She did not give me a plan to come back for follow-up PNC checkups”. (FGD-4, recently delivered mother) The maternal and child health continuum of care package ensures that all women and children receive timely and quality care from pregnancy to full child immunization. A qualified nurse explained the disconnection of the available maternal and child health services at the health facility level. We do not have a PNC retention plan within 48 hours, 7 days, or 41 days. Maternal and child health service providers do not schedule PNC service return. There is no continuum of care packages connected from one service to another.” (IDI-Qualified Nurse) Sub-theme 5.3 - Fragmentation of care across the maternity continuum of care The in-depth interview participants highlighted that there is disjointed service availability in some areas, especially in remote and hard-to-reach areas. For instance, a primary health unit (PHU), which is a basic healthcare facility located near rural communities, provides basic services such as outpatient treatment and cannot cover maternity delivery and postnatal care services, leaving the community to disjoint the service provisions. “I think only mothers living in urban cities who have all the necessary medical care can complete the entire maternity continuum of care, such as proper antenatal care, institutional delivery, and postnatal care. Communities living in rural or remote areas cannot complete because of the transition points between the different maternity continuum of care stages”. (IDI-Health policymaker ) Pregnant mothers feel that their unique health preferences and needs are not being considered by healthcare providers and do not receive appointments for the next visit. Failing to manage follow-ups and register appointments will result in incomplete or discontinued maternal healthcare. “If I attend the check-up during pregnancy, I will not receive an appointment for delivery in the health facility. It depends on me if I need to come to the facility. There is no information system or referral mechanism that ensures that pregnant women go through different levels of care throughout the continuum of care”. (IDI-Childbearing mother) 4. Discussion Fragile and conflict-affected states often lack consistent service delivery and struggle to respond to their populations’ needs. Despite significant progress in expanding and improving maternal, Newborn, and Child health (MNCH) globally, gaps still remain in Low- and Middle-Income Countries (LMICs), particularly in Sub-Saharan Africa countries including Somalia. External organizations support healthcare service delivery in Somalia. The Somalia healthcare system is structured into three tiers: primary, secondary, and tertiary level care, and each care unit has its own level of service provision, infrastructure, and capacity. The primary level care is typically delivered through a network of health centers, health posts, and maternal and child health clinics (MCH) that are mostly located in urban and rural areas and are very limited in nomadic areas. The secondary level care serves as a referral center for patients requiring more specialized medical care and services that are not available in primary care, such as in district or regional hospitals. The tertiary level of care represents the highest level of medical care available in the country, including highly specialized and complex medical services. This study explores the multifaceted barriers of the completion of maternity continuum of care and the reasons for discontinuation among different community domains including urban, rural, IDPs, and nomads in Somalia. The maternity continuum of care gaps varies across different community categories, such as urban, rural, IDPs, Agro-pastoralists (beeraley-baadiye in Somali), and Nomadic pastoralists (reer-guuraa in Somali), due to a combination of factors like service availability, access to care like financial, distance, and transportation, socio-economic disparities, infrastructure, climate-related, and security issues. A similar qualitative study conducted in Ethiopia found that the lack of existence and availability of health facilities in some areas is why women do not complete the recommended maternity continuum of care which is consistent with our findings ( 19 ). One of the primary challenges for maternal healthcare access in Somalia is access barriers with geographical remoteness, limited healthcare facilities, and inadequate infrastructure exacerbating disparities in maternal, newborn, and child health access. A study conducted in Somalia focusing on constraints in maternal healthcare utilization among pastoral communities also found gaps in Healthcare access including limited resource, distance, and transportation ( 20 ). Maternal decision-making process regarding the care-seeking is influenced by different facts like education and awareness level, cultural beliefs, socio-economic status, and access to healthcare facilities. Previous studies also documented the decision and awareness to seek care by pregnant and delivering mothers like knowledge on pregnancy risks, appropriate time to book antenatal care, and maternal awareness regarding the importance of care seeking ( 19 ). Access to skilled births during delivery is a critical for reducing maternal and newborn deaths however, limited trained birth attendants, especially remote regions can pose significant challenges. Although traditional birth attendants are widely utilized, they often lack the necessary skills and knowledge to manage obstetric emergencies safely and refer obstetric complications when needed. Homebirth can be acceptable if it is attended by a health professional (usually a qualified midwife), but communities living in remote, rural, or IDP areas, their home delivery is attended by unqualified traditional birth attendants and our study came to the same conclusion ( 21 ). Some of the community interviewed preferred the use of traditional birth attendants and home deliveries because of economic preferences since they perceive the costs with a midwife or healthcare professional as unaffordable which is also consistent with a study conducted in Indonesia ( 22 ). Another study conducted in Ethiopia found that most women who give birth at home are assisted by untrained women (TBAs) and our study came to the same conclusion( 14 ). The quality of care for maternity care services in Somalia is often compromised by complex factors such as resource constraints, understaffing, inadequate training of the existing staffs which will cause substandard care. Many women and newborns do not receive timely postnatal care check-ups or essential postpartum services in Somalia which increases the risk of both maternal and newborn complications and deaths. In common with the current study findings, a recent study conducted in Malawi revealed that the lack of scheduled postnatal care appointment is hindering the continuation of the maternity continuum of care and decreases the mother’s check-ups and appointments before they leave the health facility ( 23 ). While most of the urban locations in Somalia have access to quality healthcare facilities, most of the nomads and IDPs have limited access to quality healthcare services due to their socio-economic vulnerability, their mobility, and inaccessibility to healthcare facilities. Similarly, vulnerable communities like IDPs and hard-to-reach areas have difficulties to reach the existing health facilities due to financial, distance, or transportation challenges. In conclusion, mothers had not enough autonomy and decision-making power, they are economically dependent to their husbands, their level of education is low, health awareness and knowledge on pregnancy risks is limited, health professionals are not trusted more, they normalized the home deliveries, household living conditions is harsh, and there were service availability and access challenges. Recommendations Addressing accessibility challenges such as distance, transportation, time constraints, and financial burdens requires a multifaceted strategy, including bringing health facilities close to communities, improving transportation infrastructure, establishing mobile health clinics or outreach programs, and implementing telemedicine initiatives to provide remote healthcare services in those communities if it is feasible to obtain affordable internet. On-time antenatal care visits should be encouraged and advised to all communities through health education and awareness raising. All mothers should be educated to attend all levels of the continuum of care, including ANC four or more times, delivery at health facilities, and postnatal care attendance. This can be motivated to provide incentives or subsidies to encourage pregnant women to attend antenatal care appointments. Mothers should be educated on essential services such as blood groups and tests, malaria prophylaxis, and tetanus toxoid prophylaxis. Specially designed health education related to birth preparedness, early and exclusive breastfeeding, postnatal care within 41 days, etc., should be given to mothers. To improve geographical accessibilities, mobile health innovations can be provided to remote communities with access to maternal health information and services. The use of mobile applications can be explored such as text messaging, social media platforms to disseminate maternal health information, promote healthy behaviors, and provide counseling among pregnant mothers. To address socio-economic barriers to pregnant women, targeted interventions such as user fee exemptions, cash transfer programs, and community health insurance schemes to address barriers can be implemented. Interventions to empower women such as economic opportunities, education and participation of decision-making processes related to their own healthcare and well-being should be implemented. Declarations Ethics approval and consent to participate Study details and guidelines were explained to participants before the interviews began. Consent to participate in the study was obtained orally from each respondent. Participants were notified that their involvement in interviews was voluntary and that they were able to decline to answer any questions. Participants were assured that their identities would remain anonymous, and no compensation would be given to them. The National Institute for Health, Somalia, provided ethical approval for this study. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests Funding This study did not receive funding Author Contribution Adam Abdulkadir Mohamed wrote the main manuscript textAbdi Gele prepared the tables and reviewed the manuscript Ayse Akin checked the correctness and participated the tools preparation and also reviewed the manuscriptSare Mihciokur, Sarp Üner, and Said Aden Mohamoud also reviewed the paper. Data Availability Data is provided within the manuscript or supplementary information files and we also have the codebooks and transcript files. References Sachs J, Kroll C, Lafortune G, Fuller G, Woelm F. Sustainable development report 2022. Cambridge University Press; 2022. Organization WH. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA. World Bank Group and the United Nations Population Division; 2019. Gryseels C, Dossou JP, Vigan A, Boyi Hounsou C, Kanhonou L, Benova L, et al. Where and why do we lose women from the continuum of care in maternal health? A mixed-methods study in Southern Benin. Tropical Med Int Health. 2022;27(3):236–43. Mackey KP, Kiptum SE. Health systems strengthening in fragile contexts: A partnership model in South West State, Somalia. Field Exch. 2018;57:89. Warsame AA. Somalia’s Healthcare System: a baseline study & human capital development strategy. Mogadishu: HIPS: Heritage Institute for Policy Studies and City University of Mogadishu; 2020. SHDS. The Somali Health and Demographic Survey 2020. https://wwwnbsgovso/home. 2020. UNICEF. 2019. https://www.unicef.org/somalia/health . Clark K, Beatty S, Reibel T. Maternity care: a narrative overview of what women expect across their care continuum. Midwifery. 2015;31(4):432–7. Lincetto O, Mothebesoane-Anoh S, Gomez P, Munjanja S. Antenatal care. Opportunities for Africa's newborns: Practical data, policy and programmatic support for newborn care in Africa. 2006:55–62. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A, Daniels J et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014; 2 (6): e323–33. 2014. Kwambai TK, Dellicour S, Desai M, Ameh CA, Person B, Achieng F, et al. Perspectives of men on antenatal and delivery care service utilisation in rural western Kenya: a qualitative study. BMC Pregnancy Childbirth. 2013;13:1–10. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. Fanning E, Drought. Displacement and Livelihoods in Somalia/Somaliland: Time for gender-sensitive and protection-focused approaches. 2018. Kitila SB, Feyissa GT, Wordofa MA. Why do women walk away from maternal health services in Southwest Ethiopia? A qualitative study of caregivers' and clients' perspectives. BMC Womens Health. 2023;23(1):83. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Mohamed AA, Bocher T, Magan MA, Omar A, Mutai O, Mohamoud SA et al. Experiences from the field: a qualitative study exploring barriers to maternal and child health service utilization in IDP settings Somalia. Int J Women's Health. 2021:1147–60. Ahmed R, Sultan M, Abose S, Assefa B, Nuramo A, Alemu A, et al. Levels and associated factors of the maternal healthcare continuum in Hadiya zone, Southern Ethiopia: A multilevel analysis. PLoS ONE. 2022;17(10):e0275752. Mosadeghrad AM. Factors influencing healthcare service quality. Int J health policy Manage. 2014;3(2):77. Tiruneh GT, Demissie M, Worku A, Berhane Y. Community’s experience and perceptions of maternal health services across the continuum of care in Ethiopia: A qualitative study. PLoS ONE. 2021;16(8):e0255404. Duale HA, Farah A, Salad A, Gele S, Gele A. Constraints to maternal healthcare access among pastoral communities in the Darussalam area of Mudug region, Somalia a qualitative study. Front Public Health. 2023;11:1210401. Nelson A, Romanis EC. The medicalisation of childbirth and access to homebirth in the UK: Covid-19 and beyond. Med Law Rev. 2021;29(4):661–87. Titaley CR, Hunter CL, Dibley MJ, Heywood P. Why do some women still prefer traditional birth attendants and home delivery? a qualitative study on delivery care services in West Java Province, Indonesia. BMC Pregnancy Childbirth. 2010;10:1–14. Nyondo-Mipando AL, Chirwa M, Kumitawa A, Salimu S, Chinkonde J, Chimuna TJ, et al. Uptake of, barriers and enablers to the utilization of postnatal care services in Thyolo, Malawi. BMC Pregnancy Childbirth. 2023;23(1):271. Additional Declarations No competing interests reported. Supplementary Files COREQAdam.docx Cite Share Download PDF Status: Published Journal Publication published 05 Dec, 2025 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 10 Jun, 2024 Editor assigned by journal 07 Jun, 2024 Submission checks completed at journal 07 Jun, 2024 First submitted to journal 03 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4523035","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":312511291,"identity":"3925817b-0fee-4b45-891b-2bac513658dc","order_by":0,"name":"Adam Abdulkadir Mohamed","email":"","orcid":"","institution":"Başkent University","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"Abdulkadir","lastName":"Mohamed","suffix":""},{"id":312511292,"identity":"bde5fb7c-d76f-4161-af41-52a22be839aa","order_by":1,"name":"Ayşe Akın","email":"","orcid":"","institution":"Başkent University","correspondingAuthor":false,"prefix":"","firstName":"Ayşe","middleName":"","lastName":"Akın","suffix":""},{"id":312511293,"identity":"e392196b-ab9b-4479-9146-f8983f22e096","order_by":2,"name":"Sare Mihciokur","email":"","orcid":"","institution":"Başkent University","correspondingAuthor":false,"prefix":"","firstName":"Sare","middleName":"","lastName":"Mihciokur","suffix":""},{"id":312511294,"identity":"39e850f8-c255-4852-bcc8-66fb42b95749","order_by":3,"name":"Sarp Üner","email":"","orcid":"","institution":"Lokman Hekim University","correspondingAuthor":false,"prefix":"","firstName":"Sarp","middleName":"","lastName":"Üner","suffix":""},{"id":312511295,"identity":"5e3f8ccf-d3fb-4453-8bf1-24fdeba8e060","order_by":4,"name":"Said Aden Mohamoud","email":"","orcid":"","institution":"Save the Children International","correspondingAuthor":false,"prefix":"","firstName":"Said","middleName":"Aden","lastName":"Mohamoud","suffix":""},{"id":312511296,"identity":"abffb5fc-db66-4245-9dfa-00dd4eb95194","order_by":5,"name":"Abdi Gele","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBACNgkGgwMMNQwyDOyNzxgSiNHCD9ZyjIGHgeewGXFaJGcwGDAwNgC1SCSbEecwg9vNGw8wNtjw8Es+ZnvwgOGOHGEtd44VALWk8UjOTmY3SGB4ZkxYy40cgwOMfYd5DG7nH5NIYDic2EBIiz1YS9t/Hvubh9mI0wKxpe0Aj4EEM7FaQH5JOJbMI3EmGajF4DARfrndvPnDhxo7Of72w2ySPyoOEw4xMEhAmECchlEwCkbBKBgFBAAAXK4+Se7hxCAAAAAASUVORK5CYII=","orcid":"","institution":"Norwegian Institute of Public Health","correspondingAuthor":true,"prefix":"","firstName":"Abdi","middleName":"","lastName":"Gele","suffix":""}],"badges":[],"createdAt":"2024-06-03 16:02:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4523035/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4523035/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-025-08361-x","type":"published","date":"2025-12-05T15:57:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97723773,"identity":"236b0140-0ed2-4c24-9f23-162dd810391f","added_by":"auto","created_at":"2025-12-08 16:05:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1144344,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4523035/v1/5e7463c2-6170-49f1-b75e-6194149b9a6a.pdf"},{"id":58787717,"identity":"e40c52d0-5461-45b4-94a3-e351ef29b854","added_by":"auto","created_at":"2024-06-21 06:30:45","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":135745,"visible":true,"origin":"","legend":"","description":"","filename":"COREQAdam.docx","url":"https://assets-eu.researchsquare.com/files/rs-4523035/v1/910a2c8dfaecfcc17d59c42a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Where and why mothers discontinue healthcare services: a qualitative study exploring the maternity continuum of care gaps in Somalia","fulltext":[{"header":"1. Background","content":"\u003cp\u003eCountries around the world aim to achieve Universal Health Coverage (UHC) by removing all forms of barriers, including financial barriers, to improve access to healthcare and reduce maternal and child deaths by 2030. Sub-Saharan Africa faces a wide range of health problems, many of which are interconnected and influenced by social, economic, and environmental factors. Examples of health problems include high infectious disease rates, maternal and child deaths, malnutrition, limited access to healthcare, weak healthcare systems, poor access to clean water and sanitation facilities, environmental health risks, and noncommunicable diseases such as cancer (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Sub-Saharan Africa alone constituted approximately 66% of global maternal deaths in 2017 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Maternal deaths remain a significant public health challenge in low- and middle-income countries (LMICs), with more than a quarter of maternal deaths occurring during or within 24 hours after childbirth and nearly 40% occurring between 24 hours and 42 days postpartum (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Somalia has been ravaged by serious civil wars, armed conflicts, and terrorism counterattacks for the last three decades. The country is among the countries in sub-Saharan Africa with one of the weakest Healthcare systems and the lowest health indicators in the world (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe healthcare system in Somalia is more fragmented, with various actors, including the government, nongovernmental organizations (NGOs), and the private sector, playing roles, which leads to not only gaps in health coverage and uptake but also unnecessary overlaps. The capacity of the federal government of Somalia and member states\u0026rsquo; capacity to finance healthcare is very restricted, followed by limited existing infrastructure, shortage of skilled healthcare professionals, poor access to healthcare, high disease burden, and inconsistency of service delivery due to geographical barriers and insecurity (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The country has launched many programmes related to community health workers (CHWs) and health extension workers to provide basic health services for people underserved in rural and remote areas where the majority of the Somali population lives. Somalia is among the 15 countries for which the WHO marked as very high alert countries for maternal, newborn, and under5 deaths. Most of the causes are either preventable or treatable. The country has one of the worst maternal conditions in the world. For instance, the maternal mortality ratio is 692 per 100,000 live births (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Four in 100 Somali children die during the first month of life, eight in 100 die before their first birthday, and 1 in 8 die before they turn five (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMaternity continuum of care refers to the continuation of various stages of care that the mother goes through before, during, and after pregnancy to ensure a healthy outcome for both the mother and the child. The continuum of care includes pre-pregnancy care, such as screening, pregnancy care (ANC), delivery care (skilled birth attendance), postnatal care, and interpregnancy care (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The maternal and child continuum of care (CoC) throughout pregnancy, childbirth, and the postnatal period is essential for the health and survival of mothers and their babies. Antenatal care visits allow medical staff to identify health problems related to pregnancy as early as possible, which will facilitate early detection, diagnosis, and treatment (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). A good antenatal care program ensures the timely detection and treatment of problems during pregnancy. Skilled birth attendants (SBAs) and facility-based delivery (FbD) play critical roles in reducing infant and maternal mortality globally. Delivery within a health facility and with the attendance of a skilled healthcare provider is key in reducing health risks to both the mother and baby (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Postnatal care (PNC) is the care given to the mother and her newborn baby immediately after birth and for the first six weeks of life. Attendance to maternal, newborn, and child health services during pregnancy (ANC), delivery (SBA), postnatal follow-up (PNC), and childhood vaccinations are crucial factors contributing to a healthy pregnancy, delivery, and childcare. Gender inequality has a direct association with mother\u0026rsquo;s service utilization. There are a number of studies in Sub-Saharan African that found the limited mother\u0026rsquo;s autonomy and decision-making power in determining own healthcare and husband\u0026rsquo;s control our family resources (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). There is limited evidence on the maternity continuum of care gaps in Somalia. The aim of this study was to critically examine the multifaceted barriers to the completion of the maternity continuum of care among different community domains, such as urban, rural, IDPs, and nomadic areas.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThis paper used both deductive and inductive descriptive qualitative studies aligned with the consolidated criteria for reporting qualitative research (COREQ) checklist (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eStudy Settings\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe study was carried out in six regions of Somalia based on the representation of different socio-geographical contexts, such as urban, rural, IDPs, agro-pastoralist, and nomadic-pastoralist. The six regions included in this study were categorized according to their socio-geographical domains. These regions and the interviewed domains include Togdher (IDPs and urban), Bari (nomadic-pastoralist), Mudug (rural and urban), Galdugud (urban and IDPs), Banadir (IDPs), and the Lower Juba region (agro-pastoralist). Togdher region is one of the administrative regions in Somaliland. The region hosts many IDPs that flee from their habitual residences, primarily due to droughts and conflicts (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Banadir region or Mogadishu, hosts the largest estimated protracted internally displaced population in Somalia, mainly living in informal IDP sites across the city. Internally displaced persons (IDPs) are individuals or families who have been forced or obliged to flee or leave their homes or places of habitual residence due to armed conflicts, situations of generalized violence, persecution, or natural disasters but remain within the borders of their own country. IDPs in Somalia often live in makeshift camps in urban areas, usually face precarious living conditions, and rely on humanitarian assistance.\u003c/p\u003e \u003cp\u003eThe Bari region is the largest region in Somalia in terms of geographical landmass. The region has predominantly nomadic pastoralists in its subdistricts and villages. Nomadic pastoralists usually rely on extensive rangelands for grazing livestock herds, including camels, cattle, sheep, and goats. They move with their livestock herds in search of pasture and water. The Mudug region is the most centrally located region in Somalia and contains two federal member states (Puntland in the north and Galmudug in the south). Lower Juba is an administrative region in the Jubaland state of Somalia. The communities living in this region practice both agro-pastoralism and nomadic pastoralism. Agro-pastoralists usually rely on arable land for crop cultivation and production. They utilize a combination of crop farming in small areas and livestock rearing, which provides them with slightly stronger resilience in food production than do the nomadic pastoralists.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eStudy Design and Population\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe study used purposive sampling methods to initially identify participants who had substantial expertise in maternal and child healthcare delivery and utilization in Somalia. The target population for this study was healthcare policymakers from the respective Ministry of Health at the federal and state levels and implementing partners, healthcare providers and professionals, traditional birth attendants, community leaders, and childbearing and recently delivered mothers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eSampling and Recruitment Procedures\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis study used a maximum variation sampling scheme to yield a wider perspective from various community categories and other stakeholders. Six of the 18 pre-civil war Somalia regions were purposively selected based on the representation of different socio-geographical contexts, such as urban, rural, IDPs, agro-pastoralist, and nomadic-pastoralist. The sample size was based on information needs and data saturation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eData collection and research participants\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe study adopted two main data collection methods: focus group discussion (FGD) and an in-depth interview guide, followed by field notes. Five FGDs (44 participants) from childbearing and recently delivered mothers in five different regions of Somalia were conducted. The communities were categorized into urban, rural, IDPs, agro-pastoralist (beeraley-baadiye), and nomadic-pastoralists (reer-guuraa), as described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The FGD discussions lasted between 45 minutes and 1 hour. Seventeen in-depth interviews (IDIs) involving four policymakers, six healthcare providers, three community leaders, two traditional birth attendants, and two recently delivered mothers across Somalia were conducted, as described in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the Focus Group Discussion Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eFGD Participants (Mothers with a child less than two years)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD No.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eNo\u003c/span\u003e of Participants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNomadic pastoralists (reer-guuraa)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBari\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIDPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTogdher (Burco)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMudug\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD-4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGalgadud (Adado)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGD-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgro-pastoralists (beeraley-baadiye)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower Juba (Kismayo)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cb\u003eResearch Instruments\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eThis study used two interview guides, \u0026ldquo;Focus Group Discussion (FGD) and In-depth Interview guide,\u0026rdquo; adopted from the validated tools of SB Kitila et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). \u003cb\u003eInterview guide for the FGDs (Recently delivered and Childbearing mothers)\u003c/b\u003e: Face-to-face open discussions with purposively selected childbearing mothers were carried out by the principal investigator and data collectors. Before starting the in-depth discussion as a group, the mothers were asked to complete a short personal profile questionnaire to capture the following information: age, residence, marital status, literacy, number of children, occupation, income, and other demographic information. The childbearing mothers who participated in the FGDs were also asked to discuss an open-ended question about their life experience with healthcare service utilization. Probing questions related to factors negatively affecting the continuation of MNCH services, barrier factors, and promotors for the continuation of MNCH services were asked. To clarify the questions, the childbearing mothers\u0026rsquo; interview guide was pretested with one other FGD recruited from a different region and not included in the study sample. \u003cb\u003eInterview guide for In-depth Interviews\u003c/b\u003e: Face-to-face individual interviews were conducted based on the interview guide. The interview guide contained participants\u0026rsquo; profile questionnaires, such as age, residence, provision, occupation, and current position, as well as unstructured questions related to barriers to the continuum of care for MNCH services. Participants in this section were healthcare policymakers from the respective Ministry of Health at the federal and state levels and implementing partners, healthcare providers and professionals, traditional birth attendants, community leaders and gatekeepers, and childbearing and recently delivered mothers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eData Management and Analysis\u003c/b\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe study used a qualitative thematic analysis approach according to Braun and Clarke\u0026rsquo;s qualitative data analysis frameworks (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The principal study investigator and the research assistants (enumerators) audio-taped all of the interviews and discussions after providing consent from the study participants\u0026mdash;the first step involved transcribing the audio tapes and field notes in the Somali language. Then, the transcripts were translated into English by three qualified people fluent in both languages. The study principal investigator cross-checked the accuracy and completeness of the translations several times. The study investigator listened to the audio records and read the transcripts repeatedly for data consistency and reliability.\u003c/p\u003e \u003cp\u003eIn the initial phase of the study data analysis, we adopted deductive coding by starting with predefined codes from the existing research literature, followed by inductive coding to identify additional themes and categories that emerged directly from the data. We developed predefined initial codes (open coding) throughout the study\u0026rsquo;s data analysis. After data collection, each code was further analyzed and disaggregated into themes and sub-themes (deductive axial coding). Throughout the primary data analysis, additional codes were added while reading the data, themes, and sub-themes that had not been identified previously (inductive method) to identify areas of divergence, convergence, and overlap. A final coding framework was constructed using deductive and inductive coding approaches. To improve the trustworthiness of the qualitative data analysis, the codes and concepts that emerged from the different interview categories and discussions were verified by consistently linking the emerging themes with the data received from the other groups. Participants\u0026rsquo; own words (quotes) were used to enhance the credibility of the data.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of the study participants using maximum variation sampling, data sources, and methods\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethod\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSample\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFGDs with mothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFive FGDs with mothers of children less than two years in different geographical locations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 FGDs (44 mothers) Sampled from Urban, Rural, IDPs, agro, and nomadic pastoralists in 5 regions of Somalia.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDI with healthcare providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative interviews with MCH and community Healthcare providers (Midwives, nurses, doctors, community health workers, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 healthcare providers in six different regions were interviewed.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDI with health policymakers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative interviews with the Ministry of Health at federal and state level staff\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 policymakers from the federal and state governments were interviewed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDI with TBAs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative interviews with traditional birth attendants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 Traditional Birth Attendants were interviewed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDI with caretakers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative interviews with recently delivered mothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 recently delivered mothers were interviewed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIDI with community leaders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative interviews with community gatekeepers and leaders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 community gatekeepers and leaders were interviewed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e \u003cp\u003e Study details and guidelines were explained to participants before the interviews began. Consent to participate in the study was obtained orally from each respondent. Participants were notified that their involvement in interviews was voluntary and that they were able to decline to answer any questions. Participants were assured that their identities would remain anonymous, and no compensation would be given to them. The National Institute for Health, Somalia, provided ethical approval for this study.\u003c/p\u003e \u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e \u003cb\u003eIdentified Themes\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFive key themes and twelve sub-themes emerged from the study data set, which were the result of a thematic analysis exploring the maternity continuum of care gaps, as stated in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategories of Themes and Sub-themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService availability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eService availability in some areas\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAccess to care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDistance and Transportation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinancial barriers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnassisted childbirth due to geographical constraints\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eDecision and awareness to seek care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of knowledge of pregnancy risks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLate antenatal care booking\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMother\u0026rsquo;s awareness of the importance of seeking care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSocio-cultural practices and beliefs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHusbands\u0026rsquo; dominance in decision-making about mother\u0026rsquo;s health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTBA trust and Readiness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormality of homebirths\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eQuality of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerceived poor quality of care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLack of scheduled PNC service at health facilities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFragmentation of care across the maternity continuum of care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Service availability\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe availability of health facilities plays an important role in the increase in and utilization of skilled delivery in developing countries such as Somalia.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 1.1 - Service availability in some areas\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants highlighted that the areas in which they live do not have nearby essential health services. The non-availability of nearby health facilities forces mothers to travel long distances to access medical services, creating significant barriers to maternal and child healthcare access.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There are no health services available nearby. Services are provided at extremely distant centers, and they are not accessible to us. We would visit the health facility if it was near. We desperately need a health facility where we can receive medications and medical services\u0026rdquo;.\u003c/em\u003e (FGD-1, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eResidents express a strong desire for the presence of a local health facility that would provide essential medical services within their community. The absence of such a facility creates a sense of desperation and urgency among community members who recognize the importance of timely access to healthcare for their well-being and the well-being of their families. A health policymaker articulated the quote below.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Many remote and rural areas in Somalia do not have well-equipped health facilities. The country has both a limited number of health facilities and sufficient quality of care. The reality of mothers delivering at health facilities in Somalia is truly difficult.\u0026rdquo;\u003c/em\u003e (IDI-Health policymaker)\u003c/p\u003e\u003cp\u003e \u003cem\u003eIt is difficult for mothers to discuss the quality of care and the completion of all services at this time because many villages and communities do not have health infrastructure. How can we talk about quality and continuation of care while all communities do not have health facilities in their locations?\u0026rdquo;.\u003c/em\u003e (IDI-Community leader)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Access to care\u003c/b\u003e \u003c/p\u003e \u003cp\u003eHealthcare services in Somalia face many accessibility challenges, including distance, transportation, finances, and fragmentation of care across the maternity continuum of care. There is inadequate coordination and linkage between antenatal, intrapartum, and postnatal care providers.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 2.1 - Distance and transportation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMany communities in Somalia, specifically those living in rural or remote and hard-to-reach domains, face excessive challenges \u003cem\u003eaccessing\u003c/em\u003e healthcare services and are usually located far away from health facilities or through climate shocks \u003cem\u003esuch as\u003c/em\u003e flooding.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Some roads are out of service because of floods. Currently, people travel by boat. A boat costs 5 USD to cross the river. Those who cannot afford the boats should cross the water by themselves. Therefore, pregnant mothers cannot reach the health facilities for ANC, facility delivery, or PNC services because of these bad roads.\u0026rdquo;\u003c/em\u003e (FGD-5, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants emphasized the challenges of distance, geography, and transportation to access healthcare services in their localities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It is difficult to reach the city to obtain ANC, facility delivery, and PNC services because of the extremely bad route. Bosaso is the closest big city, yet it is quite a distance away from our area\u0026rdquo;.\u003c/em\u003e (FGD-1, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurthermore, health \u003cem\u003epolicymakers have\u003c/em\u003e indicated that long distances and the absence of reliable \u003cem\u003emodes\u003c/em\u003e of transportation \u003cem\u003eare other barriers that prevent\u003c/em\u003e mothers \u003cem\u003efrom utilizing\u003c/em\u003e available MCH services.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The pregnant mother may give birth at home if the health center is far and distant from her house, which is a big factor for healthcare inaccessibility in Somalia.\u0026rdquo;\u003c/em\u003e (IDI-Health policymaker)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA health policymaker illustrated that some of the rural and \u003cem\u003enomadic\u003c/em\u003e locations do not have health facilities due to the \u003cem\u003esparsity\u003c/em\u003e of inhabitants.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If the mother lacks money for transportation and the health facility is distant, these could act as barriers to ANC services. The population and its demands determine the number of health centers and services that can be offered. Not every location can have a health facility established. The only way we can improve service accessibility is through transportation\u0026rdquo;.\u003c/em\u003e (IDI-Health policymaker)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother childbearing mother explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We live in a mountainous area, so there are no roads in this area. We walk on feet. There are no roads here where we can stand and hail a ride on a car\u0026rdquo;.\u003c/em\u003e (FGD-1, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 2.2 - Financial barriers\u003c/b\u003e \u003c/p\u003e \u003cp\u003eChildbearing and recently delivered mothers acknowledged that they do not have enough money to afford transportation and medical costs, if any. They explained that financial limitations prevent them from traveling to health facilities and paying medical costs; as a result, they tend to deliver their babies at home.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Because we lack enough money to get a car and drive to the city, women deliver in their homes. We\u0026rsquo;re far away from the health facilities, so we often undergo labor in our homes\u0026rdquo;.\u003c/em\u003e (FGD-1, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA community leader explained that most of the families in their community cannot avoid paying medical costs if they are referred to \u003cem\u003elarge\u003c/em\u003e hospitals, which can hinder the continuation of \u003cem\u003ethe\u003c/em\u003e maternal continuum of care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The mother is referred to another hospital when her condition worsens, but we lack the money to pay for her care, which presents a challenge. The diagnosis and medical costs are beyond what these mothers can afford\u0026rdquo;.\u003c/em\u003e (IDI-community leader)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants discussed that some areas are geographically isolated, incredibly remote, or rural, with limited access to healthcare institutions. Pregnant mothers cannot attend the recommended maternity continuum of care because of the nomadic lifestyle that moves from one place to another, which often entails living in remote areas from urban centers.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We inhabit this remote area as nomads. We must go to a city to get healthcare. We cannot afford the cost of transportation and medical costs. We don\u0026rsquo;t have cash. Our only source of money is from the goats and sheep, but they don\u0026rsquo;t have a decent market these days\u0026rdquo;.\u003c/em\u003e (FDG-1, Childbearing \u003cem\u003eMother\u003c/em\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 2.3 - Unassisted childbirth due to geographical constraints\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn remote nomadic areas with limited access to healthcare facilities or skilled birth attendants, women may find themselves in situations where they have no choice but to deliver their baby without assistance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I get nauseous in the morning during pregnancy. I go through a harrowing delivery as well. I gave birth in a rural area, and I\u0026rsquo;ve never received assistance from medical professionals. I delivered by myself without the assistance of a midwife or any other person\u0026rdquo;.\u003c/em\u003e (FGD-1, childbearing mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe participants explained that sometimes mothers deliver alone without any support. Deliveries without medical assistance can be dangerous, especially if health complications arise. Mothers discussed the existence of free birth in some areas. This refers to the practice of giving birth without the assistance of both medical professionals and traditional birth attendants.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In the remote rural nomads, sometimes labor may progress so rapidly while the mother is alone, and she cannot reach the health facility or find the TBAs nearby her home sometimes. Unexpected labor may strike, and the mother may end up delivering her baby without assistance, \u0026ldquo;free birth\u0026rdquo;.\u003c/em\u003e (FGD-3, childbearing mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnassisted childbirth or free birth is not a choice or deliberate decision in the Somali community, but it occurs due to access to care. This event carries the highest risk and can cause unpredictable health complications, such as maternal or child mortality or morbidity.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In rural areas, women lack access to medical care due to geographical constraints. They do not attend antenatal care visits, skilled birth attendants, or postnatal care check-ups. A herdswoman cannot seek ANC, facility delivery, or PNC services from health centers that are very far away. She needs to maintain the animals she keeps, support the family, and take care of the other children\u0026rdquo;.\u003c/em\u003e (IDI- healthcare provider)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 3: Decision and awareness to seek care\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 3.1 - Lack of knowledge on pregnancy risks and danger signs\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThroughout the interviews, participants acknowledged that women\u0026rsquo;s awareness and knowledge of pregnancy risks and childbirth varied. The signs of danger related to pregnancy are warning signs that women face during pregnancy, childbirth, and the postpartum period. It is common that communities with low socioeconomic status are not aware of health danger signs, especially pregnant and childbirth-related dangers. A mother from the agro-pastoralist community in FGD-5 discussed the following:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Usually, pregnancy is natural, and we don\u0026rsquo;t face complications, so why do we need to walk and visit the health facility? We did not have a history of severe problems during pregnancy. Pregnancy is not a disease to fear of.\u0026rdquo;\u003c/em\u003e (FGD-5, childbearing mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants reported that limited health education and awareness of maternal health risks put mothers at risk of pregnancy. An in-depth interview participant said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Most mothers do not understand the risks related to their pregnancy if they do not attend ANC. They remain in their homes while they don\u0026rsquo;t know the status and conditions of their pregnancy. They are not educated enough to seek medical care in advance\u0026rdquo;.\u003c/em\u003e (IDI-healthcare provider)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 3.2 - Late antenatal care booking\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA healthcare provider illustrated that mothers usually arrive at the first ANC visit in their third trimester.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Mothers usually arrive late for the first antenatal care (ANC) visits, often between the 8th and 9th month of pregnancy. This delay stems from a lack of awareness about the crucial benefits of early ANC visits for the mother and her baby\u0026rdquo;.\u003c/em\u003e (IDI-Healthcare provider)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eSimilarly\u003c/em\u003e, qualified midwives and other healthcare providers explained that due to limited awareness, mothers are reluctant to book ANC as early as possible. \u003cem\u003eThe following conclusions were drawn from the midwives and nurses at\u003c/em\u003e some of the health facilities:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Most of the mothers are hesitant to come to the health facility as early as possible to have their pregnancy checked (ANC). A lack of ANC visits is usually associated with premature birth, a greater risk of complications, stillbirth, low birth weight, and other adverse health outcomes.\u0026rdquo;\u003c/em\u003e (IDI-Midwife)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If mothers do not attend early ANC visits and complete all the necessary ANC visits, they will probably not deliver at health facilities, which can be a barrier to the continuation of maternal health services.\u0026rdquo;\u003c/em\u003e (IDI-Qualified nurse)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 3.3 - Mothers\u0026rsquo; awareness of the importance of seeking care\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePregnant mothers may not always be aware of the benefits of receiving antenatal care, facility-based delivery, and postnatal care. One participant explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Due to limited knowledge and education, mothers do not come to the health facility to complete all of the available health services. If mothers attend the first ANC, then they discontinue attending the second ANC and subsequent facility delivery and postnatal care. They are not fully aware of the benefits of attending all of the stages of maternal and child health services\u0026rdquo;.\u003c/em\u003e (IDI-healthcare provider)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA health policymaker illustrated that women do not complete existing maternal and child health services due to their low literacy and limited awareness of seeking medical care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think it is not possible for a low-literacy mother to complete all of the maternal and child health services that are available in the health facility. Many mothers do not understand the importance of attending all of the stages of maternal and child health services\u0026rdquo;.\u003c/em\u003e (IDI-policymaker)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 4: Socio-cultural practices and beliefs\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTraditional beliefs regarding pregnancy and childbirth remain a choice for some Somali women. Trust in traditional birth attendants (TBAs) is frequent in rural and remote areas where access to primary and comprehensive healthcare services may be limited. TBAs are sometimes highly respected community members and have been providing home deliveries for generations in Somali society. Some of the reasons that TBAs are trusted and that home deliveries are normalized include the inaccessibility of maternal healthcare in rural and hard-to-reach areas, cultural beliefs and practices, the proximity of TBAs to the community, low cost and affordability, respect for the privacy of the mother and cultural sensitivities, etc. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 4.1 - Husbands\u0026rsquo; dominance in decision-making about mother\u0026rsquo;s health\u003c/b\u003e \u003c/p\u003e \u003cp\u003eMen are generally the overall decision-makers on all household matters including resource allocations, where and how to live. A childbearing mother had the below views\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The father is the overall head of the family and controls all the family resources and determines the expenses regarding healthcare utilization. He also makes decisions and allocations of resources like purchases and monthly expenses. Women are just house-keepers and care for the kids\u0026rdquo;\u003c/em\u003e (FGD-3, childbearing mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThere is available evidence that suggest women in Sub-Saharan Africa often have very limited autonomy and control over decisions to go to the health facility.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;One of the reasons that women do not delivery health facility is because of their powerlessness. One in Somalia is submissive to her Sheikh (husband). There are some times where the couples negotiate but mostly the husband has the overall decisions and power\u0026rdquo;.\u003c/em\u003e (IDI-Midwife)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 4.2 - TBA Trust and Readiness\u003c/b\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, I believe the skills and experience of the TBA in our village. They are available and ready every time, and they are part of our family. The TBAs have a lot of experience and know how to deal with pregnancy, delivery, and even delivery advice\u0026rdquo;.\u003c/em\u003e (FGD-5, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eA few childbearing mothers mentioned the challenges to reach the existing health facilities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We live in a very remote area that healthcare providers cannot reach. The only attendant available in our villages is a traditional birth attendant from neighboring families; sometimes, you cannot even get those neighboring traditional attendants\u0026rdquo;.\u003c/em\u003e (FGD-1, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;During my pregnancy, I had low hemoglobin, heartburn, and terrible morning sickness. In labor, the pain doubles since there are no healthcare providers. The TBA is the only accessible birth attendant. After giving birth, I started bleeding excessively\u0026rdquo;.\u003c/em\u003e (FGD-3, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAcknowledging the availability of the TBA and the flexibility of payments, \u003cem\u003ethe\u003c/em\u003e study participants indicated \u003cem\u003ethe following\u003c/em\u003e:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The traditional birth attendants (TBA, Umuliso-dhaqameed in the Somali language) are always available even during the night and usually do not charge fare before delivery. They usually come to help the mother first, and then you give what you have, and they are very respected within the community\u0026rdquo;.\u003c/em\u003e (FGD-2, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, there are many traditional practices and beliefs; for instance, the pregnant woman says I need to see my previous TBA that handled my last delivery. I don\u0026rsquo;t want to go to a new environment\u0026rdquo;.\u003c/em\u003e (IDI-community gatekeeper)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 4.3 - Normality of homebirths\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWomen who normalize to deliver at home \u003cem\u003eare\u003c/em\u003e still prevalent in many parts of Somalia. Several factors can \u003cem\u003ehelp\u003c/em\u003e women normalize \u003cem\u003etheir delivery\u003c/em\u003e at home, including cultural and personal preferences, as many women still feel more comfortable \u003cem\u003edelivering\u003c/em\u003e at home, limited knowledge and awareness, intergenerational precedent, as women inherit home delivery normalization from their parents and grandparents, and limited access to professional midwifery care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, I feel comfortable delivering at home because we are surrounded by our loved ones, and I feel like a normal process to deliver at home.\u0026rdquo;\u003c/em\u003e (FGD-5, recently delivered mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome mothers \u003cem\u003econsidered\u003c/em\u003e home delivery \u003cem\u003eto be\u003c/em\u003e normal. A childbearing mother from FGD-3 explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I grow up while our mothers give birth at home. Home delivery is normal, and it allows us to labor and deliver on our own terms. It feels like the most natural choice for us\u0026rdquo;.\u003c/em\u003e (FGD-3, \u003cem\u003echildbearing\u003c/em\u003e mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also cited \u003cem\u003ethat\u003c/em\u003e their previous delivery \u003cem\u003eoccurred\u003c/em\u003e at home and \u003cem\u003ebelieved that it was an\u003c/em\u003e easy and natural process. \u003cem\u003eIn\u003c/em\u003e one of the in-depth interviews, \u003cem\u003ea childbearing mother\u003c/em\u003e stated \u003cem\u003ethe following\u003c/em\u003e:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I gave birth all my children at home (3 kids), and they are all good (Praise be to God). Nothing happened to me. The old woman\u003c/em\u003e (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) \u003cem\u003eis very experienced and can handle all pregnancy-related issues.\u0026rdquo;\u003c/em\u003e (IDI-Childbearing mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThere are a wide range of reasons why mothers choose to \u003cem\u003edeliver\u003c/em\u003e at home; for instance, some \u003cem\u003eof the reasons reported by participants included\u003c/em\u003e familiarity \u003cem\u003ewith\u003c/em\u003e the environment where they are surrounded by their loved ones, \u003cem\u003ethe avoidance of\u003c/em\u003e unwanted restrictions, and \u003cem\u003ethe inability to\u003c/em\u003e leave their other kids. A midwife at the health facility indicated that some mothers cannot leave their kids to visit the health facility for ANC or delivery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Some mothers do not come to the health facility to deliver; instead, they prefer to deliver at home because they are familiar with that environment. They do not have someone who can stay with the other kids even if they decide to visit the health facility. Yes, this can present a significant challenge in accessing healthcare services\u0026rdquo;. (IDI-Midwife)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 5: Quality of care\u003c/b\u003e \u003c/p\u003e \u003cp\u003eSomalia's healthcare system has been characterized by strong private and NGO-led components. The quality of healthcare services has become an increasingly predominant question for both beneficiaries and care providers. Although the quality of healthcare is a complex, multidimensional, and subjective concept, local beneficiaries' views can be associated with their healthcare utilization (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 5.1 - Perceived poor quality of care\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFragile countries fail to improve the quality of healthcare in their \u003cem\u003epopulation\u003c/em\u003e by accepting low\u003cem\u003e-\u003c/em\u003equality health services to continue. \u003cem\u003eMany\u003c/em\u003e mothers \u003cem\u003equestion\u003c/em\u003e the skills and experience of healthcare providers at health facilities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The reason women do not go to health facilities and prefer to be at home when delivering is that many of them are scared to meet unskilled workers or fresh students doing their practical sessions at the hospital; many women come to me because they have problems and health issues on their previous delivery at hospitals. They will say it\u0026rsquo;s not safe to give birth at the hospitals because of the low-quality services the MCH offers.\u0026rdquo;\u003c/em\u003e (IDI-Healthcare provider)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eCompared to qualified nurses or midwives at nearby health facilities, study participants, especially childbearing mothers, believe that traditional birth attendants in their locality have better experience and skills. They also feel that health facilities lack the necessary privacy infrastructures, \u003cem\u003esuch as\u003c/em\u003e designated \u003cem\u003erooms\u003c/em\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The old mother is more experienced and skillful than nurses/midwives at MCH. I feel I am not treated carefully at a health facility. I am afraid of my privacy during delivery because of the young nurse in the MCH.\u0026rdquo; (FGD-5, childbearing mother)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIt is normal \u003cem\u003efor\u003c/em\u003e clients \u003cem\u003eto\u003c/em\u003e seek alternative care options if they feel dissatisfied with the available care provided at health \u003cem\u003efacilities\u003c/em\u003e. A community leader reported that when beneficiaries are dissatisfied with only available care, they will seek care from their traditional birth attendants.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Low service quality could also be a hindrance. If mothers are not satisfied with the service quality provided in the health center, they are more likely not to seek health services frequently. How health workers welcome care-seeking mothers influences mothers\u0026rsquo; acceptance and willingness to seek ANC, facility delivery, and PNC services.\u0026rdquo; (\u003c/em\u003eIDI-Community leader)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 5.2 - Lack of scheduled PNC services at health facilities\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDespite some pregnant mothers\u0026rsquo; attendance at antenatal care and childbirth at health facilities, postnatal care checkups before they leave the facility are limited. The uptake and utilization of PNC services lies in service providers\u0026rsquo; appointments and mothers\u0026rsquo; understanding of the importance and relevance of PNC services. A recently delivered mother discussed the lack of PNC scheduling from the care providers who were managing her delivery.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I don\u0026rsquo;t know if I was checked before my discharge. I was okay in the morning, and the nurses did not mention any clearance or check-ups before I left the MCH. She did not give me a plan to come back for follow-up PNC checkups\u0026rdquo;.\u003c/em\u003e (FGD-4, recently delivered mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe maternal and child health continuum of care package ensures that all women and children receive timely and quality care from pregnancy to full child immunization. A qualified nurse explained the disconnection of the available maternal and child health services at the health facility level.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe do not have a PNC retention plan within 48 hours, 7 days, or 41 days. Maternal and child health service providers do not schedule PNC service return. There is no continuum of care packages connected from one service to another.\u0026rdquo;\u003c/em\u003e (IDI-Qualified Nurse)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eSub-theme 5.3 - Fragmentation of care across the maternity continuum of care\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The in-depth interview participants highlighted that there is disjointed service availability in some areas, especially in remote and hard-to-reach areas. For instance, a primary health unit (PHU), which is a basic healthcare facility located near rural communities, provides basic services such as outpatient treatment and cannot cover maternity delivery and postnatal care services, leaving the community to disjoint the service provisions.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think only mothers living in urban cities who have all the necessary medical care can complete the entire maternity continuum of care, such as proper antenatal care, institutional delivery, and postnatal care. Communities living in rural or remote areas cannot complete because of the transition points between the different maternity continuum of care stages\u0026rdquo;.\u003c/em\u003e (IDI-Health policymaker\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePregnant mothers feel that their unique health preferences and needs are not being considered by healthcare providers and do not receive appointments for the next visit. Failing to manage follow-ups and register appointments will result in incomplete or discontinued maternal healthcare.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If I attend the check-up during pregnancy, I will not receive an appointment for delivery in the health facility. It depends on me if I need to come to the facility. There is no information system or referral mechanism that ensures that pregnant women go through different levels of care throughout the continuum of care\u0026rdquo;.\u003c/em\u003e (IDI-Childbearing mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eFragile and conflict-affected states often lack consistent service delivery and struggle to respond to their populations\u0026rsquo; needs. Despite significant progress in expanding and improving maternal, Newborn, and Child health (MNCH) globally, gaps still remain in Low- and Middle-Income Countries (LMICs), particularly in Sub-Saharan Africa countries including Somalia. External organizations support healthcare service delivery in Somalia. The Somalia healthcare system is structured into three tiers: primary, secondary, and tertiary level care, and each care unit has its own level of service provision, infrastructure, and capacity. The primary level care is typically delivered through a network of health centers, health posts, and maternal and child health clinics (MCH) that are mostly located in urban and rural areas and are very limited in nomadic areas. The secondary level care serves as a referral center for patients requiring more specialized medical care and services that are not available in primary care, such as in district or regional hospitals. The tertiary level of care represents the highest level of medical care available in the country, including highly specialized and complex medical services.\u003c/p\u003e \u003cp\u003eThis study explores the multifaceted barriers of the completion of maternity continuum of care and the reasons for discontinuation among different community domains including urban, rural, IDPs, and nomads in Somalia. The maternity continuum of care gaps varies across different community categories, such as urban, rural, IDPs, Agro-pastoralists (beeraley-baadiye in Somali), and Nomadic pastoralists (reer-guuraa in Somali), due to a combination of factors like service availability, access to care like financial, distance, and transportation, socio-economic disparities, infrastructure, climate-related, and security issues. A similar qualitative study conducted in Ethiopia found that the lack of existence and availability of health facilities in some areas is why women do not complete the recommended maternity continuum of care which is consistent with our findings (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). One of the primary challenges for maternal healthcare access in Somalia is access barriers with geographical remoteness, limited healthcare facilities, and inadequate infrastructure exacerbating disparities in maternal, newborn, and child health access. A study conducted in Somalia focusing on constraints in maternal healthcare utilization among pastoral communities also found gaps in Healthcare access including limited resource, distance, and transportation (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Maternal decision-making process regarding the care-seeking is influenced by different facts like education and awareness level, cultural beliefs, socio-economic status, and access to healthcare facilities. Previous studies also documented the decision and awareness to seek care by pregnant and delivering mothers like knowledge on pregnancy risks, appropriate time to book antenatal care, and maternal awareness regarding the importance of care seeking (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccess to skilled births during delivery is a critical for reducing maternal and newborn deaths however, limited trained birth attendants, especially remote regions can pose significant challenges. Although traditional birth attendants are widely utilized, they often lack the necessary skills and knowledge to manage obstetric emergencies safely and refer obstetric complications when needed. Homebirth can be acceptable if it is attended by a health professional (usually a qualified midwife), but communities living in remote, rural, or IDP areas, their home delivery is attended by unqualified traditional birth attendants and our study came to the same conclusion (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Some of the community interviewed preferred the use of traditional birth attendants and home deliveries because of economic preferences since they perceive the costs with a midwife or healthcare professional as unaffordable which is also consistent with a study conducted in Indonesia (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Another study conducted in Ethiopia found that most women who give birth at home are assisted by untrained women (TBAs) and our study came to the same conclusion(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The quality of care for maternity care services in Somalia is often compromised by complex factors such as resource constraints, understaffing, inadequate training of the existing staffs which will cause substandard care. Many women and newborns do not receive timely postnatal care check-ups or essential postpartum services in Somalia which increases the risk of both maternal and newborn complications and deaths. In common with the current study findings, a recent study conducted in Malawi revealed that the lack of scheduled postnatal care appointment is hindering the continuation of the maternity continuum of care and decreases the mother\u0026rsquo;s check-ups and appointments before they leave the health facility (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile most of the urban locations in Somalia have access to quality healthcare facilities, most of the nomads and IDPs have limited access to quality healthcare services due to their socio-economic vulnerability, their mobility, and inaccessibility to healthcare facilities. Similarly, vulnerable communities like IDPs and hard-to-reach areas have difficulties to reach the existing health facilities due to financial, distance, or transportation challenges. In conclusion, mothers had not enough autonomy and decision-making power, they are economically dependent to their husbands, their level of education is low, health awareness and knowledge on pregnancy risks is limited, health professionals are not trusted more, they normalized the home deliveries, household living conditions is harsh, and there were service availability and access challenges.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRecommendations\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAddressing accessibility challenges such as distance, transportation, time constraints, and financial burdens requires a multifaceted strategy, including bringing health facilities close to communities, improving transportation infrastructure, establishing mobile health clinics or outreach programs, and implementing telemedicine initiatives to provide remote healthcare services in those communities if it is feasible to obtain affordable internet.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOn-time antenatal care visits should be encouraged and advised to all communities through health education and awareness raising. All mothers should be educated to attend all levels of the continuum of care, including ANC four or more times, delivery at health facilities, and postnatal care attendance. This can be motivated to provide incentives or subsidies to encourage pregnant women to attend antenatal care appointments.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMothers should be educated on essential services such as blood groups and tests, malaria prophylaxis, and tetanus toxoid prophylaxis. Specially designed health education related to birth preparedness, early and exclusive breastfeeding, postnatal care within 41 days, etc., should be given to mothers.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo improve geographical accessibilities, mobile health innovations can be provided to remote communities with access to maternal health information and services. The use of mobile applications can be explored such as text messaging, social media platforms to disseminate maternal health information, promote healthy behaviors, and provide counseling among pregnant mothers.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo address socio-economic barriers to pregnant women, targeted interventions such as user fee exemptions, cash transfer programs, and community health insurance schemes to address barriers can be implemented.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInterventions to empower women such as economic opportunities, education and participation of decision-making processes related to their own healthcare and well-being should be implemented.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eStudy details and guidelines were explained to participants before the interviews began. Consent to participate in the study was obtained orally from each respondent. Participants were notified that their involvement in interviews was voluntary and that they were able to decline to answer any questions. Participants were assured that their identities would remain anonymous, and no compensation would be given to them. The National Institute for Health, Somalia, provided ethical approval for this study.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study did not receive funding\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAdam Abdulkadir Mohamed wrote the main manuscript textAbdi Gele prepared the tables and reviewed the manuscript Ayse Akin checked the correctness and participated the tools preparation and also reviewed the manuscriptSare Mihciokur, Sarp \u0026Uuml;ner, and Said Aden Mohamoud also reviewed the paper.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eData is provided within the manuscript or supplementary information files and we also have the codebooks and transcript files.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSachs J, Kroll C, Lafortune G, Fuller G, Woelm F. Sustainable development report 2022. Cambridge University Press; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrganization WH. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA. World Bank Group and the United Nations Population Division; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGryseels C, Dossou JP, Vigan A, Boyi Hounsou C, Kanhonou L, Benova L, et al. Where and why do we lose women from the continuum of care in maternal health? A mixed-methods study in Southern Benin. Tropical Med Int Health. 2022;27(3):236\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMackey KP, Kiptum SE. Health systems strengthening in fragile contexts: A partnership model in South West State, Somalia. Field Exch. 2018;57:89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWarsame AA. Somalia\u0026rsquo;s Healthcare System: a baseline study \u0026amp; human capital development strategy. Mogadishu: HIPS: Heritage Institute for Policy Studies and City University of Mogadishu; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSHDS. The Somali Health and Demographic Survey 2020. https://wwwnbsgovso/home. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF. 2019. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org/somalia/health\u003c/span\u003e\u003cspan address=\"https://www.unicef.org/somalia/health\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClark K, Beatty S, Reibel T. Maternity care: a narrative overview of what women expect across their care continuum. Midwifery. 2015;31(4):432\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLincetto O, Mothebesoane-Anoh S, Gomez P, Munjanja S. Antenatal care. Opportunities for Africa's newborns: Practical data, policy and programmatic support for newborn care in Africa. 2006:55\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSay L, Chou D, Gemmill A, Tun\u0026ccedil;alp \u0026Ouml;, Moller A, Daniels J et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014; 2 (6): e323\u0026ndash;33. 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwambai TK, Dellicour S, Desai M, Ameh CA, Person B, Achieng F, et al. Perspectives of men on antenatal and delivery care service utilisation in rural western Kenya: a qualitative study. BMC Pregnancy Childbirth. 2013;13:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFanning E, Drought. Displacement and Livelihoods in Somalia/Somaliland: Time for gender-sensitive and protection-focused approaches. 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKitila SB, Feyissa GT, Wordofa MA. Why do women walk away from maternal health services in Southwest Ethiopia? A qualitative study of caregivers' and clients' perspectives. BMC Womens Health. 2023;23(1):83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohamed AA, Bocher T, Magan MA, Omar A, Mutai O, Mohamoud SA et al. Experiences from the field: a qualitative study exploring barriers to maternal and child health service utilization in IDP settings Somalia. Int J Women's Health. 2021:1147\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed R, Sultan M, Abose S, Assefa B, Nuramo A, Alemu A, et al. Levels and associated factors of the maternal healthcare continuum in Hadiya zone, Southern Ethiopia: A multilevel analysis. PLoS ONE. 2022;17(10):e0275752.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosadeghrad AM. Factors influencing healthcare service quality. Int J health policy Manage. 2014;3(2):77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiruneh GT, Demissie M, Worku A, Berhane Y. Community\u0026rsquo;s experience and perceptions of maternal health services across the continuum of care in Ethiopia: A qualitative study. PLoS ONE. 2021;16(8):e0255404.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDuale HA, Farah A, Salad A, Gele S, Gele A. Constraints to maternal healthcare access among pastoral communities in the Darussalam area of Mudug region, Somalia a qualitative study. Front Public Health. 2023;11:1210401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson A, Romanis EC. The medicalisation of childbirth and access to homebirth in the UK: Covid-19 and beyond. Med Law Rev. 2021;29(4):661\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTitaley CR, Hunter CL, Dibley MJ, Heywood P. Why do some women still prefer traditional birth attendants and home delivery? a qualitative study on delivery care services in West Java Province, Indonesia. BMC Pregnancy Childbirth. 2010;10:1\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyondo-Mipando AL, Chirwa M, Kumitawa A, Salimu S, Chinkonde J, Chimuna TJ, et al. Uptake of, barriers and enablers to the utilization of postnatal care services in Thyolo, Malawi. BMC Pregnancy Childbirth. 2023;23(1):271.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4523035/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4523035/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDespite significant progress in expanding and improving maternal, newborn, and child health (MNCH) globally, gaps remain in low- and middle-income countries (LMICs), particularly in sub-Saharan African countries, including Somalia. Somalia is among the 15 countries that the WHO marked as very high alert countries for maternal, newborn, and under deaths. The maternity continuum of care (CoC) throughout pregnancy, childbirth, and the postnatal period is essential for the health and survival of mothers and their babies. This study aimed to explore the maternity continuum of care gaps in Somalia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative study included 5 FGDs (44 childbearing mothers) purposively sampled from urban, rural, IDPs, agro, and nomadic pastoralists and 19 in-depth interviews (IDIs) from healthcare providers, policymakers, recently delivered and childbearing mothers, community leaders, and traditional birth attendants in 6 regions of Somalia in January 2024. We used thematic analysis to analyze the data.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFive key themes and twelve subthemes emerged from the analysis: service availability, access to care, decision-making, quality of care, and traditional beliefs. The maternity continuum of care gaps varies across different community categories, such as urban areas, rural areas, IDPs, agro-pastoralists (beeraley-baadiye), and nomadic pastoralists (reer-guuraa), due to diverse reasons, including service availability, access to care (financial, distance, and transportation), socioeconomic disparities, infrastructure, climate-related, and security issues.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe maternity continuum of care gaps varies across different community categories, such as urban, rural, IDPs, agro-pastoralists (beeraley-baadiye), and nomadic pastoralists (reer-guuraa), due to a combination of diverse reasons, such as service availability; access to care, including financial, distance, and transportation; socioeconomic disparities; infrastructure; climate-related issues; and security issues.\u003c/p\u003e\u003ch2\u003eKey terms:\u003c/h2\u003e \u003cp\u003eMaternal health, continuum of care, cultural beliefs, home delivery, Somalia\u003c/p\u003e","manuscriptTitle":"Where and why mothers discontinue healthcare services: a qualitative study exploring the maternity continuum of care gaps in Somalia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-21 06:30:39","doi":"10.21203/rs.3.rs-4523035/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-10T07:55:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-07T05:52:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-07T05:51:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2024-06-03T16:00:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af425a0c-a147-4e7d-9238-7630db6c1890","owner":[],"postedDate":"June 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T15:59:32+00:00","versionOfRecord":{"articleIdentity":"rs-4523035","link":"https://doi.org/10.1186/s12884-025-08361-x","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2025-12-05 15:57:09","publishedOnDateReadable":"December 5th, 2025"},"versionCreatedAt":"2024-06-21 06:30:39","video":"","vorDoi":"10.1186/s12884-025-08361-x","vorDoiUrl":"https://doi.org/10.1186/s12884-025-08361-x","workflowStages":[]},"version":"v1","identity":"rs-4523035","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4523035","identity":"rs-4523035","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}