Spatial and multilevel determinants of home delivery in Somalia: A spatiotemporal analysis from 2006 to 2020
Ahmed Abdinasir Abdulle, Yahye Sheikh Abdulle Hassan, Mohamed Abdirahim Omar, Hana Mohamed Shidane, Yusuf Hared Abdi, Nasra mohamed Ahmed, Sharmake Gaiye Bashir, Abdisalam Hassan MuseBackground
Maternal mortality remains a major public health challenge in fragile and conflict-affected settings, where access to skilled birth attendance is uneven. In Somalia, home delivery continues to predominate despite efforts to expand maternal health services. National averages, however, obscure substantial geographic and contextual disparities, and limited evidence integrates spatial and multilevel determinants of delivery location over time.
Objectives
This study aims to answer the following research question: What are the individual, community, and regional determinants of home delivery in Somalia, and how have the spatial clustering and inequalities of this practice evolved between 2006 and 2020?
Design
A retrospective, population-based cross-sectional design.
Methods
We conducted a retrospective, population-based cross-sectional analysis using nationally representative data from the 2006 Multiple Indicator Cluster Survey and the 2020 Somalia Health and Demographic Survey. Place of delivery was dichotomized as home versus health-facility delivery. Exploratory spatial data analysis was performed using Empirical Bayes smoothing, Global Moran’s I, Geary’s C, Local Indicators of Spatial Association, and Getis-Ord Gi* statistics. Ordinary kriging was applied to generate continuous risk surfaces, and spatiotemporal changes were assessed between 2006 and 2020. Multilevel logistic regression models were fitted to identify individual- and regional-level determinants of home delivery.
Results
Home delivery declined nationally over the study period (from 90.15% in 2006 to 79.40% in 2020) but remained highly prevalent, with pronounced regional heterogeneity. Significant positive spatial autocorrelation indicated non-random clustering of home delivery, particularly in southern and central regions, and spatial clustering intensified over time despite overall improvement (Global Moran’s I increased from 0.34 in 2006 to 0.54 in 2020). At the individual level, higher household wealth (AOR = 0.12, 95% CI: 0.09–0.15) for highest quintile and adequate antenatal care utilization (AOR = 0.30, 95% CI: 0.25–0.35) for
Conclusion
Home delivery in Somalia is shaped by intersecting socioeconomic and geographic factors, with persistent and intensifying spatial inequalities. Region-specific strategies addressing structural barriers, such as deploying mobile midwifery outreach in southern hotspots like Mudug and Gedo, are essential to improve equitable access to facility-based childbirth.