Maternal and Child Health Care in Somaliland

Executive Summary
Maternal and child health (MCH) is critical, yet Somaliland faces significant challenges impacting its most vulnerable. Despite some progress, maternal mortality ratios (MMR) and under-five mortality rates (U5MR) remain alarmingly high, reflecting deep-rooted issues in healthcare access, socioeconomic disparities, and cultural barriers. This report analyzes current data, contextualizes challenges within Somaliland's unique sociopolitical environment, and proposes evidence-based, multi-sectoral strategies aligned with the Sustainable Development Goals (SDGs) and WHO frameworks. Collaborative action can transform Somaliland's MCH outcomes, ensuring equitable access to quality care.

1. Introduction: The Imperative for Action

Somaliland, a self-declared state in the Horn of Africa, faces the complex challenge of rebuilding its health system post-conflict while addressing persistent MCH inequities. With an estimated MMR of 396 per 100,000 live births and a U5MR of 89 per 1,000 live births (UNICEF, 2023), the region lags significantly behind global benchmarks. These statistics represent a humanitarian crisis compounded by limited infrastructure, recurring droughts, and geopolitical isolation due to its unrecognized status. This report examines the determinants of poor MCH outcomes and proposes actionable recommendations for systemic change.

2. Current State of Maternal and Child Health in Somaliland

   2.1 Maternal Health: Persistent Risks and Inequities
      • Maternal Mortality: Leading causes include hemorrhage (27%), hypertensive disorders (14%), and sepsis (11%), exacerbated by low skilled birth attendance (35%) and antenatal care (ANC) coverage (32%) (WHO, 2022).
      • Geographic Disparities: A stark urban-rural divide exists, with 78% of urban women delivering at health facilities compared to only 12% in rural areas (Somaliland MOH, 2023).
      • Adolescent Pregnancy: 28% of girls aged 15–19 have begun childbearing, increasing the risk of obstetric complications (UNFPA, 2023).

  2.2 Child Health: A Fight for Survival
    • Neonatal Mortality: 35 deaths per 1,000 live births, primarily due to prematurity, birth asphyxia, and infections.
    • Nutritional Deficiencies: 17% of children under five suffer from acute malnutrition, and stunting rates reach 24% (WFP, 2023).
    • Vaccination Gaps: Only 45% of children receive full immunization, leaving populations vulnerable to outbreaks (EPI, 2023).

  2.3 Socioeconomic and Environmental Context
     • Poverty: 60% of households live below the poverty line, limiting healthcare expenditure.
     • Climate Vulnerability: Recurrent droughts disrupt food systems, worsening malnutrition.

3. Multidimensional Challenges in MCH Service Delivery

3.1 Structural and Systemic Barriers
    • Healthcare Infrastructure:
    • Urban-Rural Divide: 70% of health facilities are concentrated in urban centers, leaving rural communities reliant on under-resourced clinics.
     • Equipment Shortages: 43% of facilities lack essential obstetric equipment (e.g., neonatal resuscitation kits).
    • Transportation and Accessibility:
    • Distance to Care: 68% of rural women travel over 50 km to reach a facility, often on foot.
    • Emergency Referral Systems: Weak referral networks delay critical care during obstetric emergencies.

3.2 Human Resources for Health
• Workforce Density: 0.3 physicians and 1.2 nurses/midwives per 10,000 population (WHO, 2023), significantly below the SDG 3 threshold.
• Skill Gaps: Insufficient training in emergency obstetric and neonatal care (EmONC).
• Brain Drain: 40% of trained professionals migrate to urban centers or abroad.

3.3 Cultural and Sociocultural Determinants
• Gender Norms: Male relatives often control healthcare decisions, delaying care-seeking.
• Traditional Practices: High prevalence of female genital mutilation (FGM) (98%) increases obstetric risks.
• Mistrust in Formal Care: Preference for traditional birth attendants (TBAs) due to cultural familiarity.
 

3.4 Financial and Policy Constraints
• Underfunded System: Health spending constitutes only 3% of Somaliland’s budget and relies heavily on donor aid.
• Fragmented Policies: Lack of integration between MCH programs and nutrition/education initiatives.

4. Evidence-Based Strategies for Transformation
4.1 Strengthening Health Systems
• Task-Shifting Models: Train mid-level providers (e.g., community midwives) to deliver ANC and basic EmONC.
• Mobile Health Units: Deploy mobile clinics to remote areas, offering ANC, immunizations, and malnutrition screening.
• Public-Private Partnerships (PPPs): Engage private providers to expand service coverage through subsidized vouchers.
4.2 Workforce Development
• Accelerated Training Programs: Establish emergency obstetric training hubs in regional hospitals.
• Rural Retention Incentives: Offer housing stipends, career advancement, and hardship allowances for rural postings.

4.3 Community Empowerment and Education
• Women’s Health Groups: Facilitate peer-led education on birth preparedness and nutrition.
• Engaging Religious Leaders: Collaborate with clerics to promote facility deliveries and discourage harmful practices (e.g., FGM).
4.4 Nutrition-Sensitive Interventions
• Integrated Management of Acute Malnutrition (IMAM): Scale up community-based therapeutic feeding programs.
• Maternal Cash Transfers: Link conditional cash transfers to ANC attendance and immunization compliance.
 

4.5 Policy and Advocacy
• Domestic Resource Mobilization: Implement a “health tax” to fund MCH programs.
• Legal Reforms: Criminalize FGM and enforce penalties.

5. Case Studies: Lessons from Comparable Contexts
• Ethiopia's Health Extension Program: Demonstrated success in reducing maternal mortality through community health worker deployment.
• Rwanda's Performance-Based Financing: Improved facility deliveries through results-driven funding mechanisms.

6. Monitoring and Evaluation Framework
• Indicators: Track skilled birth attendance rates, ANC coverage, and U5MR reduction.
• Digital Health Tools: Implement DHIS2 for real-time data tracking.

7. Conclusion: A Call for Collective Action
Achieving SDG 3 in Somaliland requires urgent, coordinated investments in health systems, community engagement, and policy reform. Partnerships with global actors like UNICEF and alignment with initiatives like Every Woman Every Child are crucial. The cost of inaction is high; transformative action is imperative.