Determinants of Antenatal Care Visits Among Pregnant Women in Somalia: A Zero-Inflated Poisson Regression Analysis of the First-Ever Somali Health and Demographic Survey 2020 Datasets
Hodo Abdikarim, Abdirashid M. Yousuf, Mohamed A. Hussein, Saralees Nadarajah, Abdisalam Hassan MuseBackground:
Antenatal care (ANC) is critical for maternal survival, yet utilization in postconflict Somalia remains among the lowest globally. This study identifies the individual, household, and regional determinants associated with both the initiation and frequency of ANC visits among Somali women.
Materials and Methods:
We analyzed the 2020 Somali Health and Demographic Survey, focusing on 8220 women (ages 15–49) with a live birth in the preceding 5 years. To account for the high proportion of nonvisitors (66%), we evaluated four count regression models. The zero-inflated Poisson (ZIP) model was selected based on the Akaike information criterion and parsimony.
Results:
Only 34.12% of women attended at least one ANC visit, and just 8% reached the World Health Organization-recommended four-visit minimum. The ZIP model revealed a “regional lottery” of care. Nomadic status significantly reduced visit frequency (incidence rate ratio [IRR] = 0.75; 95% confidence interval [CI]: 0.70–0.80). Wealth was the primary driver of visit frequency (highest quintile IRR = 1.56; 95% CI: 1.40–1.74), while higher education (AOR = 0.32; 95% CI: 0.16–0.63) and mass media exposure (AOR = 0.53; 95% CI: 0.44–0.63) were the strongest predictors for breaking the barrier to initial care entry. Physical distance remained a persistent structural barrier to frequent attendance (IRR = 1.06; 95% CI: 1.01–1.12).
Conclusions:
ANC utilization is driven by regional stability, nomadic mobility, and socioeconomic status. To achieve universal coverage, policies must transition from static clinic models to nomadic-sensitive “tent-based” mobile units and implement financial protection schemes, such as transport vouchers, to mitigate wealth-based inequities.