Quality and Access to Postnatal Care Among Women in Somalia: Evidence from the 2020 Somalia Demographic and Health Survey

Introduction

Postnatal care (PNC) encompasses a range of essential health services provided to women and their newborns immediately after delivery and throughout the first six weeks following childbirth. Its primary purpose is to ensure optimal health outcomes for both mother and baby during this vulnerable period.¹ The early postnatal period is especially critical because the risk of maternal and newborn complications is highest in the hours and days after birth. Evidence shows that receiving timely and appropriate PNC contributes substantially to improving maternal and neonatal survival.² In addition, PNC has been recognized as a key intervention for promoting the long-term health and well-being of mothers and babies.³

The World Health Organization (WHO) describes the postnatal period as beginning one hour after birth and continuing for 42 days. This period is both a special and potentially life-threatening time in the lives of women and their newborns.^4,5 Furthermore, the WHO emphasizes the need for comprehensive maternal and newborn care throughout the postpartum phase, during which adequate counseling and education can be provided to mothers regarding their own health and that of their newborns.^6,7

Globally, substantial evidence demonstrates that timely and adequately delivered postnatal care is instrumental in reducing both maternal and neonatal mortality; however, these mortality burdens remain disproportionately high in many low-income settings.⁸ Despite sustained international commitments to strengthen postnatal healthcare, numerous countries continue to face significant barriers to ensuring consistent access to essential postnatal services during the weeks following childbirth. Appropriate quality PNC has been shown to improve long-term health and well-being outcomes for mothers, newborns, and children, while also fostering a supportive environment for families and caregivers who provide postpartum support.^9,10

During postnatal care, health providers carry out a range of important evaluations to monitor the well-being of both the mother and the newborn. For infants, early care includes assessing feeding adequacy, measuring vital signs, examining the umbilical cord, and screening for signs of infection such as sepsis or jaundice. For mothers, assessment involves monitoring vital signs, identifying and managing concerning physical symptoms, examining uterine involution, evaluating vaginal tears or caesarean wounds, and assessing bladder and bowel function. Providers also screen for postpartum depression and perform additional clinical evaluations as needed based on the mother’s condition.¹¹

Nevertheless, the appropriate quality of postnatal care in many African countries continues to fall below recommended standards. A 2021 integrative systematic review found that none of the study sites across the continent fully complied with WHO recommendations for postnatal care, highlighting persistent gaps in the content and delivery of services.¹²

Although postnatal care coverage and utilization have been examined in several low- and middle-income countries, evidence on the appropriate quality of postnatal care, particularly in conflict-affected settings such as Somalia, remains very limited. Most previous studies have focused primarily on whether women received any postnatal care, rather than whether they received the full package of essential postnatal care components. Moreover, little is known about how both access to services and the content of care jointly influence the receipt of appropriate-quality postnatal care in Somalia.

To address this gap, the present study examines access to postnatal care and the level of appropriate-quality postnatal care and its associated factors among women in Somalia using nationally representative data from the 2020 Somalia Demographic and Health Survey.

Methods

The analysis included women aged 15–49 years who had a live birth within the five years preceding the survey. Access to postnatal care was defined as receiving any postnatal check after delivery. Critically, the SDHS captures postnatal care data for all live births occurring in the reference period, regardless of whether the delivery took place in a health facility or at home. Respondents were asked about postnatal checks received from any provider, including those occurring during home visits by female health workers. This allows for a comprehensive assessment of the postnatal care experience across the entire population and ensures the analysis is not biased toward facility-based deliveries. Appropriate-quality postnatal care was assessed among women who reported receiving postnatal care. After data cleaning and application of sampling weights, a total of 2,813 women were included in the analysis.

Ethical Considerations

The 2020 SDHS protocol was approved by the Institutional Review Board (IRB) of ICF and the relevant national authorities in Somalia. Informed consent was obtained from all participants prior to data collection. The dataset used in this study is fully anonymized and publicly available; therefore, no additional ethical approval was required for this secondary data analysis.

Study Variables

Dependent Outcome

The outcome variable was appropriate-quality postnatal care, defined as a binary composite indicator based on receipt of all six essential postnatal care components within the first two days after childbirth: (1) maternal health check, (2) family planning counseling, (3) umbilical cord examination, (4) counseling on newborn danger signs, (5) breastfeeding counseling, and (6) observation of breastfeeding.

Independent Variables

Based on previous literature and the availability of variables in the SDHS dataset, independent variables were grouped into three domains. The first domain included sociodemographic and household characteristics (age, place of residence, education level, and household wealth index). The second domain comprised empowerment and information-related factors (employment status, participation in household decision-making, and exposure to mass media). The third domain included maternal and health service–related factors (number of antenatal care visits, place of delivery, and mode of delivery).

Data Analysis

The analysis proceeded in three stages. First, we summarized participant characteristics and appropriate-quality postnatal care using descriptive statistics. Next, we performed bivariate Poisson regression to assess unadjusted associations, reporting these as crude prevalence ratios (CPRs) with 95% confidence intervals (CIs). Finally, a multivariable Poisson regression model was constructed to identify independent predictors of appropriate-quality postnatal care, with results presented as adjusted prevalence ratios (APRs) and 95% CIs. All analyses were conducted using SPSS Statistics.

Results

Sociodemographic Characteristics and Associated Factors of the Quality of Postnatal Care

The SDHS sample consisted of 2,813 women who had recently given birth. Most participants (70.7%) were older than 25 years, and nearly half resided in urban areas (57.7%), with the remaining 42.3% living in rural settings. Regionally, the highest proportions of respondents came from Togdheer (9.7%), Sool (9.7%), and Woqooyi Galbeed (7.8%), while Bay accounted for the smallest share (1.4%). The majority were married (92%), and educational attainment was generally low, with 76.7% having no formal education. Only 1.4% had worked in the past 12 months. Household size varied, with most families consisting of 5–9 members (62.4%). Male-headed households were predominant (67.8%), and 26.8% of respondents indicated that their husbands or partners had attended school. Decisions regarding women’s healthcare were primarily made by husbands (52.3%), followed by joint decisions (34.5%), and finally, decisions made by the women themselves (13.2%), results are summarized in Table 1.

Table 1 Sociodemographic and Household Characteristics of Women Aged 15–49 years in the 2020 Somalia Demographic and Health Survey

Regarding media exposure, 12.3% of respondents reported listening to the radio at least once a week, while 16.6% watched television weekly. Mobile phone ownership was high at 88.8%, and 15.3% had accessed the internet. Concerning pregnancy status, 22.1% of women were pregnant at the time of the survey. The majority (96.9%) attended fewer than four antenatal care (ANC) visits, with only 3.1% having four or more visits. In terms of delivery methods, 9.8% had undergone a Caesarean section, and 90.2% had delivered vaginally. At the time of the interview, 94.8% reported their child was alive, whereas 5.2% had experienced the loss of a child. Most births occurred at home (94.8%), while 5.2% took place in a health facility (Table 1).

Overall, a large proportion of mothers did not receive the essential postnatal care recommended during the first 48 hours after childbirth. Only 3% reported receiving high-quality postnatal care, whereas 97% received inadequate care. Coverage of specific components was low: 18.5% received family planning counseling, 9.0% had umbilical cord examinations, and only 7.0% were advised on newborn danger signs. Breastfeeding support was similarly limited, with 13.9% receiving counseling and 10.4% having breastfeeding observed. Temperature checks were performed for only 7.4% of mothers (Table 2).

Table 2 Component of Overall (Appropriate Quality of PNC) Received by Study Participants of the 2020 Somali Demographic and Health Survey

Factors Associated with the Quality of Postnatal Care

In the bivariate analysis (Table 3), several sociodemographic, socioeconomic, media exposure, and maternal health service–related variables were associated with receipt of appropriate-quality postnatal care. Therefore, variables with p < 0.20 and those considered important were included in the multivariable model. The results of the multivariable Poisson regression analysis are presented in Table 4.

Table 3 Bivariate Analysis of Factors Associated with Appropriate Quality of Postnatal Care Among Women Aged 15–49 years in Somalia, 2020

Table 4 Multivariable Poisson Regression Analysis of Factors Associated with Appropriate Quality of Postnatal Care Among Women in Somalia, 2020

After adjustment for other factors, husband’s education, number of antenatal care visits, place of delivery, and ownership of a mobile phone remained significantly associated with appropriate-quality postnatal care. Women whose husband or partner had attended school were more likely to receive appropriate-quality postnatal care than those whose husband or partner had no education (aPR = 9.10; 95% CI: 5.47–15.14). In contrast, women who had fewer than four ANC visits were much less likely to receive appropriate-quality postnatal care compared with those who had four or more visits (aPR = 0.063; 95% CI: 0.041–0.098).

Similarly, women who delivered at home were less likely to receive appropriate-quality postnatal care than those who delivered in a health facility (aPR = 0.265; 95% CI: 0.145–0.483). In addition, women who owned a mobile phone were more likely to receive appropriate-quality postnatal care than those who did not own a mobile phone (aPR = 2.77; 95% CI: 1.22–6.27).

Although woman’s education was associated with appropriate-quality postnatal care in the bivariate analysis, it was not significant in the multivariable model.

Discussion

Using nationally representative data from the 2020 Somalia Demographic and Health Survey, this study found that both access to postnatal care and the quality of care received are extremely limited in Somalia. Only a small proportion of women reported any postnatal contact, and among those who did, only 3% received all essential components of appropriate-quality postnatal care. In the Somali health system, postnatal services for the high proportion of women delivering at home are intended to be delivered through female health workers (FHWs). These workers are trained to conduct home visits to provide essential health packages including PNC. While the mechanism for home-based care exists, the actual delivery of complete package of six essential services is rarely achieved. Given that most women in Somalia give birth at home, this very low coverage likely reflects both substantial barriers to accessing postnatal services and deficiencies in the content of care provided when services are received.

Similar challenges have been reported in other low- and middle-income settings. A pooled analysis from East African countries reported that about half of women received postnatal care within 48 hours of delivery, while a multi-country analysis from sub-Saharan Africa found low coverage of adequate PNC content.^13,14 Studies from individual countries also show substantial gaps. In Kenya, fewer than half of women received all recommended postnatal care components, while in Ethiopia, both newborn PNC coverage and effective coverage remain low.² Ethiopia reported only 13.2% newborn PNC coverage with 9% effective coverage.¹⁵ Evidence from South Asia shows similarly low utilization of early postnatal care, and studies from Uganda also report incomplete postnatal care coverage.^7,16 A regional review across sub-Saharan Africa reported that only about one-quarter of women received adequate postnatal care.¹¹ In this context, the estimate observed in Somalia is particularly low.

Several factors help explain this gap. First, the majority of Somali women give birth at home, with 75.5% of deliveries occurring outside health facilities and often without skilled attendants¹⁷ This severely limits opportunities for immediate assessment and follow-up. Second, cultural and social barriers, including limited male involvement in maternal health, contribute to low utilization. Evidence from Ethiopia shows that husband participation significantly increases PNC uptake,¹⁸ while a review across East Africa found that male engagement improves maternal and newborn outcomes.¹⁹ Third, awareness and information access remain limited. Studies across sub-Saharan Africa demonstrate that media exposure is positively associated with maternal health service use,²⁰ It is important to interpret these findings in the context of Somalia’s health system. The majority of Somali women give birth at home, often without skilled attendance, which severely limits opportunities for immediate postnatal assessment and follow-up.¹⁷ In such a setting, low coverage of appropriate-quality PNC reflects not only deficiencies in service content but also major barriers in access to skilled care around the time of delivery and the early postnatal period.

Strengths and Limitations

This study has several strengths. It uses nationally representative data from the Somalia Demographic and Health Survey, so the findings reflect the situation of women across the country. The study focuses on the content of postnatal care rather than only on whether women had a postnatal contact, which provides a clearer picture of the care received. In addition, the use of standard DHS methods makes the results comparable with those from other countries.

This study also has some limitations. First, very few women received appropriate-quality postnatal care, so some groups had small numbers, which may have led to imprecise results for some variables. Second, because the data are cross-sectional, it is not possible to show cause-and-effect relationships. Third, the information was self-reported and may be affected by recall or reporting bias. Finally, although quality was measured based on reported care components, the study could not assess facility-level or provider-level factors that may influence the delivery of these components.

Conclusion

Both access to and quality of postnatal care in Somalia are extremely limited, with only a very small proportion of women receiving all recommended components of care. This reflects major structural barriers to maternal health services in the context where most births occur at home. Improving postnatal outcomes in Somalia will require expanding access to skilled maternity and postnatal services, strengthening antenatal care attendance, and ensuring that postnatal contacts—when they occur—include the full recommended content of care. Interventions that promote education, male involvement, and access to health information may further improve both utilization and quality of postnatal care.