Level of Completion of Maternity Continuum of Care among ever-married women: An analysis of Somalia Health and Demographic Survey 2020

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Mohamed, Ayşe Akın, Sare Mihciokur, Sarp Üner, Abdi Gele This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4841504/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Somalia has one of the worst maternal conditions in the world with maternal mortality ratio of 692 per 100,000 live births. For every maternal death, over 100 women suffer a severe obstetric morbidity. However, most of the maternal morbidity and mortality in Somalia are preventable through access to high quality care in pregnancy, and during and after childbirth. The aim of this study is to investigate the coverage and the level of completion of continuum of maternity care in Somalia. Method The study used a representative data from Somalia Health and Demographic Survey 2020. We restricted our analysis to ever-married women who had a live birth in the five years preceding the survey (n = 2432). The outcome variable was the completion of the continuum of maternity care (CoC). A binary variable was constructed with ‘completed CoC’ coded as ‘1’ and ‘not completed’ coded as ‘0’. We analyzed the data using descriptive analyses. Results More than half of the women (53.1%) had their most recent births at the age ≤ 19 years old. Of all the mothers (n = 2432), only 235 (9.7%) had at least four or more of the recommended antenatal care of four and above (ANC4+), 68 (2.8%) of them utilized skilled birth attendants (SBA) and 2.7% have received postnatal care (PNC) within 48hrs. In total, only 0.6% (N = 14) of the women had received all of the three maternal healthcare services (ANC4+, SBA, and PNC with in 48hrs). About 78.1% of the mothers did not attend any of the three CoC services. Conclusion Maternal health care utilization decreases as they progress from ANC4 + to PNC utilization. The government and partners should design and implement a tailored strategy to improve access and utilization of maternal healthcare services with special attention to rural and nomadic populations. Continuum of care Antenatal Care Skilled birth attendant Postnatal care Somalia Figures Figure 1 Figure 2 Figure 3 Background Globally, the maternal mortality ratio (MMR) dropped by about 34% from 2000 to 2020 (1). However, in many low- and middle-income countries maternal mortality remains a significant public health problem with nearly 94% of all maternal deaths occurring in low resource settings to date (2). Sub-Saharan Africa (SSA) has the highest rates of maternal mortality in the world, accounting almost 90% of the global burden of maternal mortality (3). This high burden of maternal mortality in the region has been attributed to preventable factors such as low antenatal care (ANC) utilization, low uptake of skilled attendant delivery and postnatal care (PNC) (4–6). In 2020, the maternal mortality ratio in the African Region was 531 deaths per 100 000 live births, which accounted for 69% of global maternal deaths (1). Somalia is continuing its retrieval from three decades of underdevelopment, political instability, civil unrest, and protracted humanitarian crises. The country has suffered multiple emergencies including flooding, drought, famine, locust attacks, other climate change shocks which resulted in many deaths and large-scale population displacements (7). Somalia has a population of 17 million, with 44 percent of the population living in urban areas, 23 percent living in rural areas, 26 percent in nomadic areas, and 9 percent living in internally displaced settings (IDPs) (8). The country has one of the weakest health care systems in Sub-Saharan Africa, hence, some of the lowest health indicators in the world (7). Somalia is among the 15 countries that WHO marked as very high alert countries for maternal, newborn, and under 5 deaths. Most of the causes of maternal deaths are either preventable or treatable. For instance, the maternal mortality ratio is 692 per 100,000 live births. Poor maternal health care delivery in the rural communities results the majority of the maternal, newborn, and child deaths during pregnancy, childbirth, and after delivery in Somalia (9). This is due to the poor access to maternal healthcare services including skilled birth attendance, emergency obstetric care, postnatal care, and family planning. Accordingly, a predictive analysis on the trends of maternal mortality ratio shows that Somalia is far from achieving the sustainable development goal-target 3.1 of reducing the maternal mortality ratio to less than 70 per 100,000 live births in 2030. The country will not also meet the targets to reducing neonatal mortality to below 12 per 1000 live births and under-5 mortality to below 25 per 1000 live births by 2030 (10). According to Somalia’s Voluntary National Reviews Report 2022 (11) on Sustainable Development Goals specially goal 3, Somalia faces a significant challenge in reducing maternal mortality rates. One of the major hurdles is the lack of evidence-based knowledge that inform government interventions to improve maternal and newborn health (11). Continuum of Care (CoC) refers to the continuity of care throughout pregnancy, birth, and after delivery (i.e., use of antenatal care, skilled birth attendance, and postnatal care). The continuity of care for maternal, newborn, and child health has become a key for improving the health of the mothers, newborns, and children. It has newly been emphasized as a core principle of programs for maternal, newborn, and child health, and as a method to reduce the burden of the maternal, newborn, and child deaths (12). Maternal and child mortality rates are indicators that are used globally to determine the health, economy, and developmental status of countries. Improving the utilization of the maternity continuum of care relies on a better understanding of the barriers and gaps affecting the uptake to each service i.e., ANC4+, SBA, and PNC. In this study, we aim to investigate the level of completion and coverage of maternity continuum of care in Somalia. Methods Data source and study participants This study used data from the 2020 Somalia Health and Demographic Survey which is a household survey that was designed to collect nationally representative data. The survey used a multistage cluster sampling design to collect data on reproductive health, maternal and child mortality, family planning and fertilities, nutrition, and health utilization in Somalia. About 11,884 ever-married women of reproductive age (15–49) completed the interviews. Our study focused on women who had a live birth in the five years preceding the survey (n = 2432) as shown in Fig. 1 . Study Variables Dependent Variables The maternity continuum of care in this study composed of three dummy dependent variables: use of antenatal care at least four times (ANC4+), skilled birth attendance (SBA), and postnatal care (PNC) within 48hours. We defined the maternity continuum of care as the completion and continuity of care throughout pregnancy, birth, and after delivery. We defined ANC4 + percentage of women with a live birth who received WHO-recommended at least four times antenatal care visits over the course of their pregnancy. Skilled Birth Attendant (SBA) was defined as births attended by a skilled health personnel such as midwife, doctor, nurse, or other health care professional in a given period. We defined postnatal care as the care women and her newborn baby received immediately after the birth and we limited to our continuum of care within two days or 48 hours after childbirth. We constructed binary variables to each of the three dependent variables with ‘complete’ coded as ‘1’ and ‘incomplete’ coded as ‘0’. Continuum of Maternity care was assumed complete if the mother utilized all of the three services; at least four ANC services, delivered by a skilled birth attendant, and received postnatal check within 48 hours after delivery during the most recent pregnancy. Independent Variables We included three predictors in the models, (1) socio-demographic factors (2) socio-economic factors and (3) cultural factors which were driven from the previous literatures. Socio-demographic factors included maternal age at the recent births, women’s level of education, marital status, birth order of the most recent child, and number of children. Socio-economic factors included place of residence (urban, rural, or nomadic), women’s employment (working, or not working, household wealth quintile (poorest, poorer, middle, richer, or richest). Cultural factors included exposure to mass media (listing to radio as yes or no). We categorized women as having ‘access’ to mass media if they had access to radio at least once a week and ‘no access’ if she did not listen to a radio at least once a week. We assessed women’s empowerment or decision-making power in determining own healthcare and we scored full empowerment for decisions involving the woman or jointly with her husband (full power) and decision taken without the woman’s involvement was categorized as ‘no power’ (13). Data analysis We used STATA software (version 18) and sampling weight for all analysis with survey data analysis command (svy) to account for the cluster survey design and missing responses. We checked data for completeness and then cleared. We then conducted a descriptive analysis (number, frequency, and percentage) to summarize the characteristics of the study population. We assessed the level of coverage for each maternal health service (ANC, SBA, and PNC) separately, and then we combined the three services to determine the continuum of maternity care. Variance Inflation Factor was used to test the presence of collinearity between the independent variables using STATA 18. Results Characteristics of the study participants Table 1 summarizes the background characteristics of the study sample. The mean age was 22.8 years (SD = 4.2) with more than half of the women (53.1%) had their most recent births at the age of ≤ 19 years while 90.2% were married during the survey period. Above 60% were living in urban setting and 77% had no education. Almost all women (96.1%) were unemployed, 74.5% of them had 1–2 children, and 90.6% had not accessed to mass media (radio exposure). Wealth quintile distribution among the households were evenly spread across different categories with the highest being the poorest (25.5%). Table 1 Socio-demographic characteristics of ever-married women who had at least one a live birth in the five years preceding the survey. Variable Categories Weighted Number (2432) Percentage (%) Maternal age at birth (years) < 20 1,291 53.1 20–34 1,125 46.3 35–49 16 0.6 Birth Order 1 906 37.3 2 908 37.3 3 525 21.6 4 or more 93 3.8 Residence Urban 1,475 60.6 Rural 653 26.9 Nomadic 304 12.5 Marital Status Married 2,193 90.2 Divorced/widowed 239 9.8 Mother's Education No Education 1,872 77.0 Primary 370 15.2 Secondary & above 190 7.8 Mother's Employment Working 96 3.9 Not working 2,336 96.1 Number of Children 1–2 1,813 74.5 3–4 598 24.6 >=5 21 0.9 Decision-making power in determining own healthcare Women or jointly 1,285 52.8 Husband or others 1,147 47.2 Exposure to Radio Yes 229 9.4 No 2,203 90.6 Wealth Quintile Poorest 621 25.5 Poorer 486 20.0 Middle 406 16.7 Richer 454 18.7 Richest 465 19.1 Overall use of maternal health services in Somalia Table 2 shows the descriptive analysis of participants’ utilization of maternal care services. Around two-third of the study participants (66.2%) did not receive antenatal care visits, and only 24.2% and 9.7% received 1–3 visits and ≥ 4 antenatal care visits respectively. Less than 14% of the deliveries was attended by skilled health provider, and only 2.7% of the women had postnatal care within 48 hours after delivery regardless of the place of delivery. Table 2 Number and Percentage of mothers and their use of maternal health services. Characteristics Categories Weighted Number (2432) Percentage (%) ANC visits No ANC 1,608 66.2 1-3ANC 589 24.2 ANC4+ 235 9.7 Delivered by SBA Skilled provider 327 13.4 Unskilled provider 1,478 60.8 No one 47 1.9 Don't know/missing 580 23.8 PNC visits First 48hrs 67 2.7 More than 48hrs 2 0.1 No PNC/Don't know 2,363 97.2 Maternity Continuum of Care As shown in Fig. 2 of all mothers (n = 2432), only 235 (9.7%) had at least four or more of the recommended antenatal care (ANC4+) visits during their recent pregnancy and among this, only nine mothers live in nomadic settings. Out of the women who have received ANC4+, only 68 (2.8%) had utilized skilled birth attendants in their most recent pregnancies. In total, only 14 women (0.6%) had completed all of the three maternal healthcare services (ANC4+, SBA, and PNC with in 48hrs) as stated in Fig. 3 below. Pathways of maternal healthcare use Considering the study’s three main outcomes (ANC4+, SBA, and PNC), we created eight different pathways or combinations of maternal health service utilization ranging ‘from not receiving any of the three maternal health services’ to ‘complete use of all three maternal health services’ (Table 3 ). More than two-third of the mothers (78.1%) did not receive any of the three maternal health services as shown in pathway 1. Notably, only 14 mothers (0.6%) received all of the three maternal health services along the continuum (pathway 8). Three groups that attended any two of the three maternal health services (pathway 3, 6, and 7) accounted for 2.2%, 0.5%, and 0.1% respectively. Lastly, the three groups that utilized only one of the three maternal services (pathways 2, 4, and 5) accounted 6.7%, 1.6%, and 10.2% respectively. The Table 3 below shows the combination of the three major maternal health services (ANC4+, SBA & PNC within 48 hours) that mothers either received or did not receive it. Table 3 Percentage distribution of the three maternal health services received by women. + Received the service; - Did not receive the service. Pathway ANC4+ SBA PNC within 48hrs Frequency (Weighted Number) Percentage 1 – – – 1,899 78.1 2 + – – 164 6.7 3 + + – 54 2.2 4 – – + 39 1.6 5 – + – 248 10.2 6 – + + 11 0.5 7 + – + 3 0.1 8 + + + 14 0.6 Total 2,432 100% Discussion This study assessed maternity continuum of care for the first time in Somalia. Access and use of maternity care services during pregnancy, childbirth, and the postnatal period from skilled providers are essential for the survival and wellbeing of the mother and newborn. It is particularly critical in setting where teenage pregnancy is common such as Somalia. Our study states that 53% of women gave birth their first child at the age of ≤ 19, while the completion of ANC4 + was only 9.7%. This rate is much higher than the completion of ANC4 in Uganda (59.9%) (14), and Ethiopia, which is 33% (15). According to UNICEF, 66% of pregnant women access at least four antenatal care visits globally with Somalia having the lowest prevalence of ANC4 + in Sub-Saharan Africa (16). Protracted conflicts and instability may explain why women in Somalia have low prevalence of ANC4+. Armed conflict has been described as an important contributor to persistent excess maternal and child deaths while it can severely reduce access to maternal health services and thus lead to poor maternal health outcomes (17). The effect of the three decades of conflict on the access to maternal health care in Somalia is exacerbated by the pervasive corruption in the health sector, given the fact that systemic corruption and the large-scale misappropriation of state funds is the norm in Somalia (18). The corruption at the health sector ranges from nepotism in which the people on power employ incompetent relatives who render a substandard health service, to redirecting resources away from those who need it for their own benefit, henceforth, undermining the delivery of quality maternal health care. Countries with high levels of corruption spend less on health care (19) and experience a higher infant and child mortality rates (20, 21). According to WHO, receiving antenatal care of at least four times increases the likelihood of receiving effective maternal health interventions during the antenatal period, and it is one of the indicators in the Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030) (22). To improve maternal health care in Somalia, requires political and economic commitment, and genuine leadership is critical in achieving this agenda. A prior study on 29 Sub-Saharan African countries found an average proportion of women who had skilled assistance during delivery was 75.3%, ranging from 38.4% in Chad to 93.7% in Rwanda (4). However, our study shows that only 13.4% of women in Somalia gave birth with the help of skilled health provider. Skilled attendants have positive contribution in the reduction of maternal and newborn mortality and morbidity. A 40% decline in maternal deaths in SSA that occurred between 2000 and 2017 was attributed, by World Health Organization (WHO), to utilizing skilled birth attendant at delivery (23). A research reports that a critical intervention to reduce maternal mortality is for childbirth to be attended by skilled health personnel with access to life-saving resources (24). However, a study in Somalia stated that lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need (25). The low utilization of SBA in Somalia can be improved by adopting prevailing successful interventions of countries with SBA successes such as Rwanda, whilst taking into account of contextual variations. Our study found that only 2.8% of Somali women have received postnatal care. Receiving postnatal care after delivery is vital for women and the baby due to the fact that over 65% of maternal and neonatal deaths occur during the first 42 days of postpartum and during the first 7 days of life respectively (5). A study on postnatal care utilization in 36 sub-Saharan Africa countries found a prevalence of PNC of 52.48% [95% CI: 52.33, 52.63], ranging from 73.51% in Central Africa region to 31.71% in Eastern Africa Region (5). A prior study found an association of armed conflicts with an increase of 36.9% maternal deaths per 100,000 live births, and increase of 2.8% of infant (under 1 year old) deaths per 1,000 live births (26). The reason for low utilization of postnatal care among Somali women could be explained by several reasons. Among them is lack of access to maternal health care of rural and pastoral communities that constitute the majority of the population. Another reason could be that Somalis apply a traditional mother care practice during the postpartum period, which may prevent them from using facility-based PNC. It is important to find out the attitudes and practices that influence pregnant women to think that it is unnecessary to come to health centers and hospitals for PNC. Moreover, the traditional, cultural, and social context of Somali women from the rural and pastoral communities regarding the low utilization of PNC is still not studied well. The continuity of maternity health care services is the care that a woman uses the three recommended cares of antenatal care (ANC4+), skill birth attendant (SBA), and postnatal care (PNC). Our study shows that only 0.6% of the women in Somalia have completed the three services; ANC4, SBA and PNC, while only 2.8% have completed two of the services (ANC4 + and SBA). The prevalence of maternal continuum of care in Somalia which is stated by our study (0.6%), is far much lower than the prevalence of continuum of care in Sub-Saharan Africa (25.0%), which varied from 17.9.0% in East Africa to 7,418 (51.5% in Southern Africa (27). It is also much lower than the 35.81% pooled prevalence of completion of the maternity continuum of care among 33 sub-Saharan African countries (28), it is even over 15 times lower than the continuum of care of rural women in Ethiopia (13%) (29). Further, our study shows a significant inequity in continuum of care by residence with zero continuum of care among women in pastoral communities that constitute 26% of total population in Somalia (8). A recent study in Somalia stated that pastoralist women have limited access to maternal health care (30), which supports our findings. The inequity between urban and rural women, in utilizing maternal health care services, is prevalent across Africa. A prior study of 27 African countries showed a prevalence of ANC utilization of 34.7% among urban women and 22.4% among in rural areas, while SBA prevalence was nearly 90% and 69% in urban women and rural women respectively (31). This study has both strength and limitations. The main strength is the use of weighted nationally representative data with a large sample, which makes it representative at national level. The current SDHS did not collect information on type of provider for each visit, therefore, we couldn’t determine the type of provider for each visit. Further, approximately 2.6 million Somalis are currently displaced within their own country and the SHDS 2020 did not include the internally displaced people (IDP) domain in the data. Conclusion The prevalence of completion of the maternity continuum of care was found to be lower than any country in Africa. Maternal health care utilization decreases as they progress from ANC4 + to PNC utilization. Inequity in the continuum of care is a chronic problem in Somalia where pastoralist women who constitute 26% of the population have ZERO completion of continuum of care. Health inequalities are avoidable because they are rooted in political and social decisions. Political and economic commitment is required in improving the access to maternal health care in the country. To reduce health inequalities between urban and pastoralists in Somalia, we need to act across a range of health-policy areas including policies to improve access to maternal health care in pastoralists setting in the country. The government and partners should design and implement strategies to improve maternal healthcare utilization specific to rural and nomads, less educated, not working, low income, and less power to decision-making. The government of Somalia should invest and increase the number of certified skilled birth attendants i.e., nurses, midwives, and obstetricians to provide safe and competent care during childbirth. To attract and retain skilled birth attendants in remote and rural areas, the government and its partners should implement incentive programs designed to the professional and certified midwives and obstetricians and should train and deploy community health extension workers in rural areas to provide basic maternal health educations, identify pregnant women, and support and encourage them to seek health care. Abbreviations ANC: Antenatal Care; CoC: Continuum of Care; SBA: Skilled Birth Attendant; SDG: Sustainable Development Goal; WHO: World Health Organization; PNC: Postnatal Care; SHDS: Somalia Health and Demographic Survey; AOR: Adjusted odds ratio; CI: Confidential Interval; Caesarian Section; MNCH: Maternal, Newborn, and Child health globally; LMICs: Low- and Middle-Income Countries. Declarations Acknowledgements The authors would like to thank the Somalia National Bureau of Statistics for allowing us to carry out this analysis. The authors would also like to thank Dr Adam A Mohamed for his efforts in extracting the SHDS data and analyzing it. Ethics approval The study used secondary data and got approval to analysis from the Somalia National Bureau of Statistics Consent for publication Not applicable Availability of data and materials Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. Competing interests The authors declare that they have no competing interests Authors' contributions Adam Abdulkadir Mohamed wrote the main manuscript text. Abdi Gele prepared the tables and reviewed the manuscript. Ayse Akin checked the correctness and participated the tools preparation and also reviewed the manuscript. Sare Mihciokur and Sarp Üner also reviewed the paper. Funding This study did not receive funding Author details 1 Department of Research and MEAL, Save the Children International, Mogadishu, Somalia 2 Department of Public Health, Faculty of Health Sciences, Başkent University, Ankara, Turkey 3 Department of Public Health, Faculty of Medicine, Lokman Hekim University, Ankara, Turkey 4 Department of Research, Norwegian Institute of Public Health, Oslo, Norway References WHO. Maternal mortality: The urgency of a systemic and multisectoral approach in mitigating maternal deaths in Africa. 2020. Available; chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://files.aho.afro.who.int/afahobckpcontainer/production/files/iAHO _Maternal_Mortality_Regional_Factsheet.pdf. WHO. Maternal mortality trends globally: WHO; 2019 [cited 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality. Yaya S, Anjorin SS, Adedini SA. 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Mohamed","email":"","orcid":"","institution":"Başkent University","correspondingAuthor":false,"prefix":"","firstName":"Adam","middleName":"A.","lastName":"Mohamed","suffix":""},{"id":345694169,"identity":"38ac8a8a-ceb7-4e27-a7de-5e3af653de8e","order_by":1,"name":"Ayşe Akın","email":"","orcid":"","institution":"Başkent University","correspondingAuthor":false,"prefix":"","firstName":"Ayşe","middleName":"","lastName":"Akın","suffix":""},{"id":345694170,"identity":"99ebcdf4-6817-4c10-b083-2be9dc0ba42d","order_by":2,"name":"Sare Mihciokur","email":"","orcid":"","institution":"Başkent University","correspondingAuthor":false,"prefix":"","firstName":"Sare","middleName":"","lastName":"Mihciokur","suffix":""},{"id":345694171,"identity":"4d4dc0a5-256c-44ca-97d4-592d1eeff0a9","order_by":3,"name":"Sarp Üner","email":"","orcid":"","institution":"Lokman Hekim Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Sarp","middleName":"","lastName":"Üner","suffix":""},{"id":345694172,"identity":"333f08ee-7bf7-4bc5-84c1-4b288d20d223","order_by":4,"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":"2024-08-01 10:39:40","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4841504/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4841504/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":63632668,"identity":"1ac41401-4d37-4037-9664-e7caf6a3938a","added_by":"auto","created_at":"2024-08-30 11:03:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":103981,"visible":true,"origin":"","legend":"\u003cp\u003eselection process of eligible women aged 15-49 years old using Somalia Health and Demographic Survey 2020.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4841504/v1/e64a5cd8ad56958ea94e5ef1.png"},{"id":63633400,"identity":"e3b857c1-25dc-44e5-8d3b-cac1664cafb8","added_by":"auto","created_at":"2024-08-30 11:11:50","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":10029,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eContinuum of maternal healthcare\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4841504/v1/9f040b2f69fd9c922549798a.png"},{"id":63632665,"identity":"dec7e35c-b3e4-44ae-b7cd-44f836875caa","added_by":"auto","created_at":"2024-08-30 11:03:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":11998,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eContinuum of maternal healthcare by residence\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4841504/v1/de13e7598ed49ed7c38999ed.png"},{"id":71015860,"identity":"6b3e90c7-da9f-4bba-bbf0-8e46fd1f0c4d","added_by":"auto","created_at":"2024-12-10 08:32:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":721911,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4841504/v1/9549e7a3-04c0-45dd-ab9d-36a428aa7688.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Level of Completion of Maternity Continuum of Care among ever-married women: An analysis of Somalia Health and Demographic Survey 2020","fulltext":[{"header":"Background","content":"\u003cp\u003eGlobally, the maternal mortality ratio (MMR) dropped by about 34% from 2000 to 2020 (1). However, in many low- and middle-income countries maternal mortality remains a significant public health problem with nearly 94% of all maternal deaths occurring in low resource settings to date (2). Sub-Saharan Africa (SSA) has the highest rates of maternal mortality in the world, accounting almost 90% of the global burden of maternal mortality (3). This high burden of maternal mortality in the region has been attributed to preventable factors such as low antenatal care (ANC) utilization, low uptake of skilled attendant delivery and postnatal care (PNC) (4\u0026ndash;6). In 2020, the maternal mortality ratio in the African Region was 531 deaths per 100 000 live births, which accounted for 69% of global maternal deaths (1).\u003c/p\u003e \u003cp\u003eSomalia is continuing its retrieval from three decades of underdevelopment, political instability, civil unrest, and protracted humanitarian crises. The country has suffered multiple emergencies including flooding, drought, famine, locust attacks, other climate change shocks which resulted in many deaths and large-scale population displacements (7). Somalia has a population of 17\u0026nbsp;million, with 44 percent of the population living in urban areas, 23 percent living in rural areas, 26 percent in nomadic areas, and 9 percent living in internally displaced settings (IDPs) (8). The country has one of the weakest health care systems in Sub-Saharan Africa, hence, some of the lowest health indicators in the world (7).\u003c/p\u003e \u003cp\u003eSomalia is among the 15 countries that WHO marked as very high alert countries for maternal, newborn, and under 5 deaths. Most of the causes of maternal deaths are either preventable or treatable. For instance, the maternal mortality ratio is 692 per 100,000 live births. Poor maternal health care delivery in the rural communities results the majority of the maternal, newborn, and child deaths during pregnancy, childbirth, and after delivery in Somalia (9). This is due to the poor access to maternal healthcare services including skilled birth attendance, emergency obstetric care, postnatal care, and family planning. Accordingly, a predictive analysis on the trends of maternal mortality ratio shows that Somalia is far from achieving the sustainable development goal-target 3.1 of reducing the maternal mortality ratio to less than 70 per 100,000 live births in 2030. The country will not also meet the targets to reducing neonatal mortality to below 12 per 1000 live births and under-5 mortality to below 25 per 1000 live births by 2030 (10). According to Somalia\u0026rsquo;s Voluntary National Reviews Report 2022 (11) on Sustainable Development Goals specially goal 3, Somalia faces a significant challenge in reducing maternal mortality rates. One of the major hurdles is the lack of evidence-based knowledge that inform government interventions to improve maternal and newborn health (11).\u003c/p\u003e \u003cp\u003eContinuum of Care (CoC) refers to the continuity of care throughout pregnancy, birth, and after delivery (i.e., use of antenatal care, skilled birth attendance, and postnatal care). The continuity of care for maternal, newborn, and child health has become a key for improving the health of the mothers, newborns, and children. It has newly been emphasized as a core principle of programs for maternal, newborn, and child health, and as a method to reduce the burden of the maternal, newborn, and child deaths (12). Maternal and child mortality rates are indicators that are used globally to determine the health, economy, and developmental status of countries. Improving the utilization of the maternity continuum of care relies on a better understanding of the barriers and gaps affecting the uptake to each service i.e., ANC4+, SBA, and PNC. In this study, we aim to investigate the level of completion and coverage of maternity continuum of care in Somalia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData source and study participants\u003c/h2\u003e \u003cp\u003eThis study used data from the 2020 Somalia Health and Demographic Survey which is a household survey that was designed to collect nationally representative data. The survey used a multistage cluster sampling design to collect data on reproductive health, maternal and child mortality, family planning and fertilities, nutrition, and health utilization in Somalia. About 11,884 ever-married women of reproductive age (15\u0026ndash;49) completed the interviews. Our study focused on women who had a live birth in the five years preceding the survey (n\u0026thinsp;=\u0026thinsp;2432) as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Variables\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eDependent Variables\u003c/h2\u003e \u003cp\u003eThe maternity continuum of care in this study composed of three dummy dependent variables: use of antenatal care at least four times (ANC4+), skilled birth attendance (SBA), and postnatal care (PNC) within 48hours. We defined the maternity continuum of care as the completion and continuity of care throughout pregnancy, birth, and after delivery. We defined ANC4\u0026thinsp;+\u0026thinsp;percentage of women with a live birth who received WHO-recommended at least four times antenatal care visits over the course of their pregnancy. Skilled Birth Attendant (SBA) was defined as births attended by a skilled health personnel such as midwife, doctor, nurse, or other health care professional in a given period. We defined postnatal care as the care women and her newborn baby received immediately after the birth and we limited to our continuum of care within two days or 48 hours after childbirth. We constructed binary variables to each of the three dependent variables with \u0026lsquo;complete\u0026rsquo; coded as \u0026lsquo;1\u0026rsquo; and \u0026lsquo;incomplete\u0026rsquo; coded as \u0026lsquo;0\u0026rsquo;. Continuum of Maternity care was assumed complete if the mother utilized all of the three services; at least four ANC services, delivered by a skilled birth attendant, and received postnatal check within 48 hours after delivery during the most recent pregnancy.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eIndependent Variables\u003c/h2\u003e \u003cp\u003eWe included three predictors in the models, (1) socio-demographic factors (2) socio-economic factors and (3) cultural factors which were driven from the previous literatures. Socio-demographic factors included maternal age at the recent births, women\u0026rsquo;s level of education, marital status, birth order of the most recent child, and number of children. Socio-economic factors included place of residence (urban, rural, or nomadic), women\u0026rsquo;s employment (working, or not working, household wealth quintile (poorest, poorer, middle, richer, or richest). Cultural factors included exposure to mass media (listing to radio as yes or no). We categorized women as having \u0026lsquo;access\u0026rsquo; to mass media if they had access to radio at least once a week and \u0026lsquo;no access\u0026rsquo; if she did not listen to a radio at least once a week. We assessed women\u0026rsquo;s empowerment or decision-making power in determining own healthcare and we scored full empowerment for decisions involving the woman or jointly with her husband (full power) and decision taken without the woman\u0026rsquo;s involvement was categorized as \u0026lsquo;no power\u0026rsquo; (13).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eWe used STATA software (version 18) and sampling weight for all analysis with survey data analysis command (svy) to account for the cluster survey design and missing responses. We checked data for completeness and then cleared. We then conducted a descriptive analysis (number, frequency, and percentage) to summarize the characteristics of the study population. We assessed the level of coverage for each maternal health service (ANC, SBA, and PNC) separately, and then we combined the three services to determine the continuum of maternity care. Variance Inflation Factor was used to test the presence of collinearity between the independent variables using STATA 18.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the study participants\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the background characteristics of the study sample. The mean age was 22.8 years (SD\u0026thinsp;=\u0026thinsp;4.2) with more than half of the women (53.1%) had their most recent births at the age of \u0026le;\u0026thinsp;19 years while 90.2% were married during the survey period. Above 60% were living in urban setting and 77% had no education. Almost all women (96.1%) were unemployed, 74.5% of them had 1\u0026ndash;2 children, and 90.6% had not accessed to mass media (radio exposure). Wealth quintile distribution among the households were evenly spread across different categories with the highest being the poorest (25.5%).\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\u003eSocio-demographic characteristics of ever-married women who had at least one a live birth in the five years preceding the survey.\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=\"char\" char=\".\" 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\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeighted Number (2432)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMaternal age at birth (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,291\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eBirth Order\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e908\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e525\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eResidence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e653\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNomadic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced/widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e239\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMother's Education\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e77.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e370\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary \u0026amp; above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eMother's Employment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot working\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e96.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eNumber of Children\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,813\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e598\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;=5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDecision-making power in determining own healthcare\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen or jointly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,285\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHusband or others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eExposure to Radio\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e229\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eWealth Quintile\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoorest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e621\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoorer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e406\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e16.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRicher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e454\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRichest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e465\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eOverall use of maternal health services in Somalia\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the descriptive analysis of participants\u0026rsquo; utilization of maternal care services. Around two-third of the study participants (66.2%) did not receive antenatal care visits, and only 24.2% and 9.7% received 1\u0026ndash;3 visits and \u0026ge;\u0026thinsp;4 antenatal care visits respectively. Less than 14% of the deliveries was attended by skilled health provider, and only 2.7% of the women had postnatal care within 48 hours after delivery regardless of the place of delivery.\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\u003eNumber and Percentage of mothers and their use of maternal health services.\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=\"char\" char=\".\" 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\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeighted Number (2432)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eANC visits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo ANC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,608\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1-3ANC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e589\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eANC4+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eDelivered by SBA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSkilled provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnskilled provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,478\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo one\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDon't know/missing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e580\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003ePNC visits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst 48hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 48hrs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo PNC/Don't know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e97.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMaternity Continuum of Care\u003c/h2\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e of all mothers (n\u0026thinsp;=\u0026thinsp;2432), only 235 (9.7%) had at least four or more of the recommended antenatal care (ANC4+) visits during their recent pregnancy and among this, only nine mothers live in nomadic settings. Out of the women who have received ANC4+, only 68 (2.8%) had utilized skilled birth attendants in their most recent pregnancies. In total, only 14 women (0.6%) had completed all of the three maternal healthcare services (ANC4+, SBA, and PNC with in 48hrs) as stated in Fig.\u0026nbsp;3 below.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePathways of maternal healthcare use\u003c/h2\u003e \u003cp\u003eConsidering the study\u0026rsquo;s three main outcomes (ANC4+, SBA, and PNC), we created eight different pathways or combinations of maternal health service utilization ranging \u0026lsquo;from not receiving any of the three maternal health services\u0026rsquo; to \u0026lsquo;complete use of all three maternal health services\u0026rsquo; (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). More than two-third of the mothers (78.1%) did not receive any of the three maternal health services as shown in pathway 1. Notably, only 14 mothers (0.6%) received all of the three maternal health services along the continuum (pathway 8). Three groups that attended any two of the three maternal health services (pathway 3, 6, and 7) accounted for 2.2%, 0.5%, and 0.1% respectively. Lastly, the three groups that utilized only one of the three maternal services (pathways 2, 4, and 5) accounted 6.7%, 1.6%, and 10.2% respectively. The Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below shows the combination of the three major maternal health services (ANC4+, SBA \u0026amp; PNC within 48 hours) that mothers either received or did not receive it.\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\u003ePercentage distribution of the three maternal health services received by women. + Received the service; - Did not receive the service.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\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=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathway\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eANC4+\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSBA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePNC within 48hrs\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFrequency (Weighted Number)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePercentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,899\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e+\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ndash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2,432\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e100%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study assessed maternity continuum of care for the first time in Somalia. Access and use of maternity care services during pregnancy, childbirth, and the postnatal period from skilled providers are essential for the survival and wellbeing of the mother and newborn. It is particularly critical in setting where teenage pregnancy is common such as Somalia. Our study states that 53% of women gave birth their first child at the age of \u0026le;\u0026thinsp;19, while the completion of ANC4\u0026thinsp;+\u0026thinsp;was only 9.7%. This rate is much higher than the completion of ANC4 in Uganda (59.9%) (14), and Ethiopia, which is 33% (15). According to UNICEF, 66% of pregnant women access at least four antenatal care visits globally with Somalia having the lowest prevalence of ANC4\u0026thinsp;+\u0026thinsp;in Sub-Saharan Africa (16). Protracted conflicts and instability may explain why women in Somalia have low prevalence of ANC4+. Armed conflict has been described as an important contributor to persistent excess maternal and child deaths while it can severely reduce access to maternal health services and thus lead to poor maternal health outcomes (17). The effect of the three decades of conflict on the access to maternal health care in Somalia is exacerbated by the pervasive corruption in the health sector, given the fact that systemic corruption and the large-scale misappropriation of state funds is the norm in Somalia (18). The corruption at the health sector ranges from nepotism in which the people on power employ incompetent relatives who render a substandard health service, to redirecting resources away from those who need it for their own benefit, henceforth, undermining the delivery of quality maternal health care. Countries with high levels of corruption spend less on health care (19) and experience a higher infant and child mortality rates (20, 21). According to WHO, receiving antenatal care of at least four times increases the likelihood of receiving effective maternal health interventions during the antenatal period, and it is one of the indicators in the Global Strategy for Women\u0026rsquo;s, Children\u0026rsquo;s and Adolescents\u0026rsquo; Health (2016\u0026ndash;2030) (22). To improve maternal health care in Somalia, requires political and economic commitment, and genuine leadership is critical in achieving this agenda.\u003c/p\u003e \u003cp\u003eA prior study on 29 Sub-Saharan African countries found an average proportion of women who had skilled assistance during delivery was 75.3%, ranging from 38.4% in Chad to 93.7% in Rwanda (4). However, our study shows that only 13.4% of women in Somalia gave birth with the help of skilled health provider. Skilled attendants have positive contribution in the reduction of maternal and newborn mortality and morbidity. A 40% decline in maternal deaths in SSA that occurred between 2000 and 2017 was attributed, by World Health Organization (WHO), to utilizing skilled birth attendant at delivery (23). A research reports that a critical intervention to reduce maternal mortality is for childbirth to be attended by skilled health personnel with access to life-saving resources (24). However, a study in Somalia stated that lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need (25). The low utilization of SBA in Somalia can be improved by adopting prevailing successful interventions of countries with SBA successes such as Rwanda, whilst taking into account of contextual variations.\u003c/p\u003e \u003cp\u003eOur study found that only 2.8% of Somali women have received postnatal care. Receiving postnatal care after delivery is vital for women and the baby due to the fact that over 65% of maternal and neonatal deaths occur during the first 42 days of postpartum and during the first 7 days of life respectively (5). A study on postnatal care utilization in 36 sub-Saharan Africa countries found a prevalence of PNC of 52.48% [95% CI: 52.33, 52.63], ranging from 73.51% in Central Africa region to 31.71% in Eastern Africa Region (5). A prior study found an association of armed conflicts with an increase of 36.9% maternal deaths per 100,000 live births, and increase of 2.8% of infant (under 1 year old) deaths per 1,000 live births (26). The reason for low utilization of postnatal care among Somali women could be explained by several reasons. Among them is lack of access to maternal health care of rural and pastoral communities that constitute the majority of the population. Another reason could be that Somalis apply a traditional mother care practice during the postpartum period, which may prevent them from using facility-based PNC. It is important to find out the attitudes and practices that influence pregnant women to think that it is unnecessary to come to health centers and hospitals for PNC. Moreover, the traditional, cultural, and social context of Somali women from the rural and pastoral communities regarding the low utilization of PNC is still not studied well.\u003c/p\u003e \u003cp\u003eThe continuity of maternity health care services is the care that a woman uses the three recommended cares of antenatal care (ANC4+), skill birth attendant (SBA), and postnatal care (PNC). Our study shows that only 0.6% of the women in Somalia have completed the three services; ANC4, SBA and PNC, while only 2.8% have completed two of the services (ANC4\u0026thinsp;+\u0026thinsp;and SBA). The prevalence of maternal continuum of care in Somalia which is stated by our study (0.6%), is far much lower than the prevalence of continuum of care in Sub-Saharan Africa (25.0%), which varied from 17.9.0% in East Africa to 7,418 (51.5% in Southern Africa (27). It is also much lower than the 35.81% pooled prevalence of completion of the maternity continuum of care among 33 sub-Saharan African countries (28), it is even over 15 times lower than the continuum of care of rural women in Ethiopia (13%) (29). Further, our study shows a significant inequity in continuum of care by residence with zero continuum of care among women in pastoral communities that constitute 26% of total population in Somalia (8). A recent study in Somalia stated that pastoralist women have limited access to maternal health care (30), which supports our findings. The inequity between urban and rural women, in utilizing maternal health care services, is prevalent across Africa. A prior study of 27 African countries showed a prevalence of ANC utilization of 34.7% among urban women and 22.4% among in rural areas, while SBA prevalence was nearly 90% and 69% in urban women and rural women respectively (31).\u003c/p\u003e \u003cp\u003eThis study has both strength and limitations. The main strength is the use of weighted nationally representative data with a large sample, which makes it representative at national level. The current SDHS did not collect information on type of provider for each visit, therefore, we couldn\u0026rsquo;t determine the type of provider for each visit. Further, approximately 2.6\u0026nbsp;million Somalis are currently displaced within their own country and the SHDS 2020 did not include the internally displaced people (IDP) domain in the data.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe prevalence of completion of the maternity continuum of care was found to be lower than any country in Africa. Maternal health care utilization decreases as they progress from ANC4\u0026thinsp;+\u0026thinsp;to PNC utilization. Inequity in the continuum of care is a chronic problem in Somalia where pastoralist women who constitute 26% of the population have ZERO completion of continuum of care. Health inequalities are avoidable because they are rooted in political and social decisions. Political and economic commitment is required in improving the access to maternal health care in the country. To reduce health inequalities between urban and pastoralists in Somalia, we need to act across a range of health-policy areas including policies to improve access to maternal health care in pastoralists setting in the country. The government and partners should design and implement strategies to improve maternal healthcare utilization specific to rural and nomads, less educated, not working, low income, and less power to decision-making. The government of Somalia should invest and increase the number of certified skilled birth attendants i.e., nurses, midwives, and obstetricians to provide safe and competent care during childbirth. To attract and retain skilled birth attendants in remote and rural areas, the government and its partners should implement incentive programs designed to the professional and certified midwives and obstetricians and should train and deploy community health extension workers in rural areas to provide basic maternal health educations, identify pregnant women, and support and encourage them to seek health care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANC: Antenatal Care; CoC: Continuum of Care; SBA: Skilled Birth Attendant; SDG: Sustainable Development Goal; WHO: World Health Organization; PNC: Postnatal Care; SHDS: Somalia Health and Demographic Survey; AOR: Adjusted odds ratio; CI: Confidential Interval; Caesarian Section; MNCH: Maternal, Newborn, and Child health globally; LMICs: Low- and Middle-Income Countries.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the Somalia National Bureau of Statistics for allowing us to carry out this analysis. The authors would also like to thank Dr Adam A Mohamed for his efforts in extracting the SHDS data and analyzing it.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study used secondary data and got approval to analysis from the Somalia National Bureau of Statistics\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNot applicable\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that they have no competing interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdam Abdulkadir Mohamed wrote the main manuscript text. Abdi Gele prepared the tables and reviewed the manuscript. Ayse Akin checked the correctness and participated the tools preparation and also reviewed the manuscript. Sare Mihciokur and Sarp \u0026Uuml;ner also reviewed the paper.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis study did not receive funding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAuthor details\u0026nbsp;\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/strong\u003e Department of Research and MEAL, Save the Children International, Mogadishu, Somalia\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e Department of Public Health, Faculty of Health Sciences, Başkent University, Ankara, Turkey\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/strong\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eDepartment of Public Health, Faculty of Medicine, Lokman Hekim University, Ankara, Turkey\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/strong\u003e Department of Research, Norwegian Institute of Public Health, Oslo, Norway\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO. Maternal mortality: The urgency of a systemic and multisectoral approach in mitigating maternal deaths in Africa. 2020. Available; chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://files.aho.afro.who.int/afahobckpcontainer/production/files/iAHO\u003cbr\u003e_Maternal_Mortality_Regional_Factsheet.pdf.\u003c/li\u003e\n\u003cli\u003eWHO. Maternal mortality trends globally: WHO; 2019 [cited 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.\u003c/li\u003e\n\u003cli\u003eYaya S, Anjorin SS, Adedini SA. Disparities in pregnancy-related deaths: spatial and Bayesian network analyses of maternal mortality ratio in 54 African countries. BMJ global health. 2021 Feb 1;6(2):e004233.\u003c/li\u003e\n\u003cli\u003eBudu, E., Chattu, V.K., Ahinkorah, B.O. et al. Early age at first childbirth and skilled birth attendance during delivery among young women in sub-Saharan Africa. BMC Pregnancy Childbirth 21, 834 (2021). https://doi.org/10.1186/s12884-021-04280-9.\u003c/li\u003e\n\u003cli\u003eTessema, Z.T., Yazachew, L., Tesema, G.A. et al. Determinants of postnatal care utilization in sub-Saharan Africa: a meta and multilevel analysis of data from 36 sub-Saharan countries. Ital J Pediatr 46, 175 (2020). https://doi.org/10.1186/s13052-020-00944-y.\u003c/li\u003e\n\u003cli\u003eAboagye RG, Okyere J, Ahinkorah BO, Seidu AA, Zegeye B, Amu H, Yaya S. Health insurance coverage and timely antenatal care attendance in sub-Saharan Africa. BMC Health Serv Res. 2022 Dec;22(1):1\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003eMackey KP, Kiptum SE. Health systems strengthening in fragile contexts: A partnership model in South West State, Somalia. Field Exchange 57. 2018:89.\u003c/li\u003e\n\u003cli\u003eFederal Republic of Somalia. POPULATION ESTIMATION SURVEY 2014 SOMALIA FOR THE 18 PRE-WAR REGIONS OF SOMALIA. 2014. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://somalia.unfpa.org/sites/default/files/pub-pdf/Population-Estimation-Survey-of-Somalia-PESS-2013-2014.pdf.\u003c/li\u003e\n\u003cli\u003eAden JA, Ahmed HJ, \u0026Ouml;stergren P-O. Causes and contributing factors of maternal mortality in Bosaso District of Somalia. A retrospective study of 30 cases using a Verbal Autopsy approach. Global health action. 2019;12(1):1672314.\u003c/li\u003e\n\u003cli\u003eMorrison J, Malik SMMR. Population health trends and disease profile in Somalia 1990\u0026ndash;2019, and projection to 2030: will the country achieve sustainable development goals 2 and 3? BMC Public Health. 2023;23(1):1-9.\u003c/li\u003e\n\u003cli\u003eVNRs-SNBS. Voluntary National Review Report on Sustainable Development Goals 2022. 2022.\u003c/li\u003e\n\u003cli\u003eKerber KJ, de Graft-Johnson JE, Bhutta ZA, Okong P, Starrs A, Lawn JE. Continuum of care for maternal, newborn, and child health: from slogan to service delivery. Lancet. 2007;370(9595):1358-69.\u003c/li\u003e\n\u003cli\u003eChham S, Radovich E, Buffel V, Ir P, Wouters E. Determinants of the continuum of maternal health care in Cambodia: an analysis of the Cambodia demographic health survey 2014. BMC pregnancy and childbirth. 2021;21(1):410.\u003c/li\u003e\n\u003cli\u003eMuhirwe, L.B., Aagard, M. Completion of four or more ANC visits among women of reproductive age in Iganga district in Uganda: a quantitative study on the role of service-level factors. BMC Health Serv Res 23, 906 (2023). https://doi.org/10.1186/s12913-023-09913-7.\u003c/li\u003e\n\u003cli\u003eMuchie, K.F. Quality of antenatal care services and completion of four or more antenatal care visits in Ethiopia: a finding based on a demographic and health survey. BMC Pregnancy Childbirth 17, 300 (2017). https://doi.org/10.1186/s12884-017-1488-0.\u003c/li\u003e\n\u003cli\u003eUNICEF. 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(2015) 60:633\u0026ndash;41. 10.1007/s00038-015-0687-6.\u003c/li\u003e\n\u003cli\u003eHanf M, Van-Melle A, Fraisse F, Roger A, Carme B, Nacher M. Corruption kills: estimating the global impact of corruption on children deaths. PLoS ONE. (2011) 6:e26990. 10.1371/journal.pone.0026990.\u003c/li\u003e\n\u003cli\u003eLio MC, Lee MH. Corruption costs lives: a cross-country study using an IV approach. Int J Health Plann Manage. (2016) 31:175\u0026ndash;90. 10.1002/hpm.2305.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Antenatal care coverage - at least four visits. WHO, 2023. Available: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/80 \u003c/li\u003e\n\u003cli\u003eWHO. Maternal Mortality. (2019) Retrieved from https://www.who.int/news-room/fact-sheets/detail/maternal-mortality.\u003c/li\u003e\n\u003cli\u003eShimamoto K, Gipson JD.. Examining the mechanisms by which women\u0026rsquo;s status and empowerment affect skilled birth attendant use in Senegal: a structural equation modeling approach. BMC Pregnancy Childbirth. 2017;17:341.\u003c/li\u003e\n\u003cli\u003eEgal JA, Essa A, Yusuf R, Osman F, Ereg D, Klingberg-Allvin M, Erlandsson K. A lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical needs-a qualitative study among multiparous women in Somaliland. Glob Health Action. 2022 Dec 31;15(1):2054110. doi: 10.1080/16549716.2022.2054110.\u003c/li\u003e\n\u003cli\u003eJawad M, Hone T, Vamos EP, Cetorelli V, Millett C. Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000-2019. PLoS Med. 2021 Sep 28;18(9):e1003810. doi: 10.1371/journal.pmed.1003810.\u003c/li\u003e\n\u003cli\u003eAlem, A.Z., Shitu, K. \u0026amp; Alamneh, T.S. Coverage and factors associated with completion of continuum of care for maternal health in sub-Saharan Africa: a multicountry analysis. BMC Pregnancy Childbirth 22, 422 (2022). https://doi.org/10.1186/s12884-022-04757-1.\u003c/li\u003e\n\u003cli\u003eHunie Asratie M, Belay DG. Pooled Prevalence and Determinants of Completion of Maternity Continuum of Care in Sub-Saharan Africa: A Multi-Country Analysis of Recent Demographic and Health Surveys. Front Glob Womens Health. 2022 May 25;3:869552. doi: 10.3389/fgwh.2022.869552. .\u003c/li\u003e\n\u003cli\u003eDadi TL, Medhin G, Kasaye HK, Kassie GM, Jebena MG, Gobezie WA, et al.. Continuum of maternity care among rural women in Ethiopia: does place and frequency of antenatal care visit matter? Reprod Health. (2021) 18:220. 10.1186/s12978-021-01265-x.\u003c/li\u003e\n\u003cli\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 \u0026quot;a qualitative study\u0026quot;. Front Public Health. 2023 Sep 14;11:1210401. doi: 10.3389/fpubh.2023.1210401.\u003c/li\u003e\n\u003cli\u003eSamuel, O., Zewotir, T. \u0026amp; North, D. Decomposing the urban\u0026ndash;rural inequalities in the utilisation of maternal health care services: evidence from 27 selected countries in Sub-Saharan Africa. Reprod Health 18, 216 (2021). https://doi.org/10.1186/s12978-021-01268-8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Continuum of care, Antenatal Care, Skilled birth attendant, Postnatal care, Somalia","lastPublishedDoi":"10.21203/rs.3.rs-4841504/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4841504/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSomalia has one of the worst maternal conditions in the world with maternal mortality ratio of 692 per 100,000 live births. For every maternal death, over 100 women suffer a severe obstetric morbidity. However, most of the maternal morbidity and mortality in Somalia are preventable through access to high quality care in pregnancy, and during and after childbirth. The aim of this study is to investigate the coverage and the level of completion of continuum of maternity care in Somalia.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study used a representative data from Somalia Health and Demographic Survey 2020. We restricted our analysis to ever-married women who had a live birth in the five years preceding the survey (n = 2432). The outcome variable was the completion of the continuum of maternity care (CoC). A binary variable was constructed with ‘completed CoC’ coded as ‘1’ and ‘not completed’ coded as ‘0’. We analyzed the data using descriptive analyses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore than half of the women (53.1%) had their most recent births at the age ≤ 19 years old. Of all the mothers (n = 2432), only 235 (9.7%) had at least four or more of the recommended antenatal care of four and above (ANC4+), 68 (2.8%) of them utilized skilled birth attendants (SBA) and 2.7% have received postnatal care (PNC) within 48hrs. In total, only 0.6% (N = 14) of the women had received all of the three maternal healthcare services (ANC4+, SBA, and PNC with in 48hrs). About 78.1% of the mothers did not attend any of the three CoC services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMaternal health care utilization decreases as they progress from ANC4 + to PNC utilization. The government and partners should design and implement a tailored strategy to improve access and utilization of maternal healthcare services with special attention to rural and nomadic populations.\u003c/p\u003e","manuscriptTitle":"Level of Completion of Maternity Continuum of Care among ever-married women: An analysis of Somalia Health and Demographic Survey 2020","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-30 11:03:45","doi":"10.21203/rs.3.rs-4841504/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af425a0c-a147-4e7d-9238-7630db6c1890","owner":[],"postedDate":"August 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-10T08:24:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-30 11:03:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4841504","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4841504","identity":"rs-4841504","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}