Factors Shaping Delivery Location Preferences for Somali Women at Childbearing Age

doi:10.21203/rs.3.rs-4704354/v1

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Research Article

Factors Shaping Delivery Location Preferences for Somali Women at Childbearing Age

https://doi.org/10.21203/rs.3.rs-4704354/v1

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Background

Maternal mortality remains a significant public health issue in sub-Saharan Africa, particularly in Somalia. Despite global efforts, high maternal mortality rates persist due to limited access to skilled birth attendants and healthcare facilities. This study examines maternal healthcare accessibility in Somalia, focusing on childbirth locations among women of childbearing age, using data from the Somali Health and Demographic Survey 2020.

Methods

This cross-sectional study analyzed data from the SHDS 2020, involving 16,162 women aged 15–49. Univariate, bivariate and multivariate logistic regressions were conducted using STATA software to identify sociodemographic factors associated with facility-based delivery.

Results

The prevalence of facility-based delivery was 19.95%. Key factors significantly associated with facility-based delivery included education level, household wealth, husband's employment, and household size. Women with primary education (aOR = 3.04, 95%CI = 2.74–3.37, p < 0.001), secondary education (aOR = 6.79, 95%CI = 5.62–8.20,p < 0.001), and higher education (aOR = 16.57, 95%CI = 11.68–23.54,p < 0.001) were more likely to deliver at health facilities. Larger households (11 + members) also increased the likelihood (aOR = 1.44, 95%CI = 1.33–1.56,p < 0.001). However, increasing age reduced the odds of facility-based delivery: ages 25–34 (aOR = 0.87, 95% CI = 0.79–0.95,p = 0.003), 35–44 (aOR = 0.81, 95%CI = 0.72–0.91, p < 0.001), and 45+ (aOR = 0.48, 95%CI = 0.33–0.70,p < 0.001). Additionally, women who did not watch television were less likely to deliver at a health facility (aOR = 0.21, 95%CI = 0.19–0.23,p < 0.001).

Conclusion

Education, household wealth, husband's employment, and household size significantly influence facility-based delivery among Somali women. These findings highlight the need for targeted interventions to improve access to maternal healthcare services, especially for economically disadvantaged. Enhanced government funding for free maternal and newborn healthcare and local community involvement are crucial to reducing maternal and neonatal mortality and achieving sustainable development goals in Somalia.

Maternal mortality

multivariate logistic regressions

facility-based delivery

Pregnancy and childbirth, while momentous occasions, present a critical window for a woman's health and well-being. According to the World Health Organization (WHO), delivering in a health facility with skilled birth attendants significantly reduces the risk of maternal and neonatal mortality.

Globally, according to the WHO Nearly 800 women worldwide lost their lives to preventable pregnancy and childbirth-related causes every day in 2020, with low- and middle-income nations accounting for nearly 95% of all maternal fatalities (WHO, 2023). A 15-year-old girl in a developing country faces a significantly higher probability of eventually dying from a maternal cause compared to her counterpart in a developed country. In high-income countries, the lifetime risk of maternal death for a 15-year-old girl is roughly 1 in 5300, whereas in low-income countries, this risk escalates to about 1 in 49. (WHO, 2021).

The lifetime risk of maternal-related death for women in developing countries is about 33 times greater than for women in developed countries. Additionally, the utilization of maternal health services is significantly lower in developing countries compared to developed ones. (Jungari & Paswan, 2019). Despite efforts to encourage institutional deliveries, many women in developing countries still give birth at home. In Nepal, 41.9% of women deliver at home and 58.1% deliver at institutions (Dhakal et al., n.d.). This issue also persists in India, where 22% of births occur at home, even with initiatives to encourage institutional deliveries. A concerning 34% of Indian women choosing home birth believe institutional delivery is unnecessary (Ou et al., 2021). Factors like financial limitations, transportation issues, limited access to facilities, and lack of family support contribute to home deliveries (Ou et al., 2021). While progress towards facility deliveries has been seen in Bangladesh, with a significant increase from 14.48% in 2007 to 49.26% in 2017–2018. (Rahman et al., 2022). home deliveries remain a complex public health challenge in many developing countries

In 2020, Sub-Saharan Africa (SSA) accounted for approximately 70% of global maternal deaths, with maternal mortality ratio of 545 deaths per 100,000 live births, that’s not matched the aim of Sustainable Development Goal (SDG) target 3.1 is to lower the maternal mortality rate to fewer than 70 deaths per 100,000 live births by 2030 (WHO, 2023). The major direct causes of maternal death in Africa are postpartum hemorrhage, pre-eclampsia, hypertensive disorders, pregnancy-related infections and complications of unsafe abortion (UNICEF, 2023). Sixty-six percent of SSAs delivered care at health facilities. In Chad, this was 23%, whereas in Gabon, it was 94% (Adde et al., 2020). The most important determinants of place of delivery are Wealth index, age, and education (Adde et al., 2020), Another study, which analyzed pooled data from 58 Demographic and Health Surveys (DHS) conducted between 1990 and 2015 across 29 sub-Saharan African countries, found that the most significant factors influencing delivery location are wealth and education levels. Women in the richest wealth quintile were 68% more likely to give birth in health facilities compared to those in the lowest wealth quintile. Additionally, women with at least a primary education were twice as likely to deliver in health facilities compared to women with no formal education (Doctor et al., 2018).

Somalia, situated within the horn of Africa, stands amongst the continent’s most delicate and susceptible nations, enduring prolonged disputes, persistent wars, and unstable politics—all of which have impaired the country’s healthcare infrastructures (WHO, 2020). The current population of Somalia in 2024 is 18.7m (Macrotrends, 2024). Women in Somalia had average fertility rate of 6.9 children per women (SIHR, 2022). Somalia has one of the highest maternal mortality rates in the world, with 692 per 100,000 live births, one in 1,000 women aged 15–49 die due to pregnancy or birth-related complications, and 5 per cent of women would be expected to die from pregnancy-related causes during their reproductive lifetime (Save the Children, 2023). Which is the one of the highest maternal mortality rates in the world. The high rate of teenage pregnancies (20% of girls between the ages of 15 and 19 have already gotten pregnant), the high fertility rate (6.9 children per woman), the low adoption of modern family planning methods (1%), the high prevalence of female genital cutting (99%), and the low rates of antenatal and postnatal coverage (31% and 10%, respectively) are some of the specific associated factors that have been identified (SIHR, 2022).

According to the SDHS 2020 only 32% of births in Somalia are delivered with the assistance of a skilled healthcare provider and 21% of births are delivered at a health facility (UNFPA Somalia, 2020). Furthermore, a research study carried out in eleven prominent urban centers in Somalia revealed that the general rate of facility-based deliveries stood at 57%. Specifically, 38% of women residing in Mogadishu and 53% of women in the remaining ten towns opt for home births (Said Sheikh et al., n.d.).

Significance of the study

The study holds significant implications for maternal health and healthcare utilization in Somalia. By employing logistic regression, the study aims to uncover the determinants influencing Somali women's choices regarding delivery locations, offering valuable insights for policymakers and healthcare providers. Understanding these factors is pivotal for informing evidence-based policies and designing targeted interventions aimed at improving maternal health outcomes in the country. Moreover, the study's findings have the potential to contribute to the reduction of maternal mortality rates by promoting institutional deliveries, where skilled attendance and emergency obstetric care are readily available. Through the examination of disparities in delivery location preferences among different subgroups, such as those based on socioeconomic status and geographic location, the study can help tailor interventions to address inequalities in access to maternal healthcare services, ultimately enhancing health equity. Furthermore, by employing advanced statistical techniques like logistic regression, the study enhances the methodological rigor of research in maternal health, setting a precedent for future studies seeking to understand healthcare utilization patterns in similar contexts.

LITERATURE REVIEW

Several studies investigated factors associated the choice of place of delivery among maternal. One notable show that maternal educational status and wealth index were found to be statistically significant factors associated with health facility delivery (Semagn, 2023). Another study highlighted factors influencing the use of maternal healthcare services and childhood immunization in Swaziland when compared to non-watchers, women who watch television nearly daily are nearly twice as likely to use this service. Less often watching women are less likely to require delivery care (Tsawe et al., 2015).

Furthermore, research carried out three south Asian countries indicates that husbands' occupation, plays a role in determining the place of delivery for women in Bangladesh (Rahman et al., 2022) Generally, wives of husbands with higher-status occupations are more likely to use facilities for delivery due to greater wealth, which makes it easier for the family to cover the costs associated with skilled delivery care. Additionally, Factors that consistently predict the Place of delivery include place of residence and parity(Dahiru & Oche, 2015a).

Moreover, research indicates maternal age and birth order significantly influence delivery location. For example, a study by (Tarik et al., 2022), found younger mothers (aged 15–20 years) were more likely to choose institutional delivery. (Gebregziabher et al., 2019), also demonstrated that the likelihood of a woman opting for facility delivery decreases as the birth order increases. Women giving birth for the fourth to sixth time were 76% less likely to deliver in a health facility compared to those having their first to third child.

The household head gender, autonomy of decision making and age at the first birth can significantly influence the place of delivery for women. Research indicates that if the household head is female, women are less likely to have a home delivery of their child (Ahmed et al., 2023), in addition, according to the study conducted 37 pooled low- and middle-income countries, women's autonomy in healthcare decision-making, were found to be the strongest positive factors associated with the utilization of MHS (Include Delivery care) (Shanto et al., 2023). However, age at the first birth has negative association to the place of delivery (Shanto et al., 2023)

These factors consistently emerge across various studies as key predictors influencing the choice of place for maternal delivery. Understanding these determinants is crucial for designing effective interventions aimed at promoting safe and skilled deliveries to improve maternal and neonatal health outcomes.

Study Area

This study was conducted in Somalia, Somalia officially the Federal Republic of Somalia, is a country in the Horn of Africa. The country is bordered by Ethiopia to the west, Djibouti to the northwest, the Gulf of Aden to the north, the Indian Ocean to the east, and Kenya to the southwest. Somalia has an estimated population of around 18.1 million. Somalia is a federal republic consisting of seven federal states. Somalia has a total land area of 637,660 km² (246,202 mi²) and a total coastline of 3,025 km (1,879.6 mi). Somalia is thus the 20th biggest country in Africa and in terms of area ranked 44th worldwide.

Data Sources and Sampling

This study utilizes secondary data from the SHDS 2020, which provides a comprehensive and nationally representative dataset ideal for examining factors influencing women's choice of delivery location. The target population consists of Somali women aged 15–49, with a sample size of 16,186 women drawn from the SHDS dataset. The survey employed a multistage sampling technique to ensure representation across all eighteen geographic regions of Somalia and different residence types (urban, rural, and nomadic). The SHDS dataset is publicly available for research and adheres to strict ethical protocols, with approvals from Institutional Review Boards and country-specific review boards. Detailed information on the survey methodology, sampling, and questionnaires can be found in the SHDS 2020 final reports.(UNFPA Somalia, 2020)

Outcome variable

This study focuses on the place of delivery for women in Somalia. Consistent with the SHDS woman's questionnaire, place of delivery is coded as follows: "0" indicates a home delivery, including deliveries at the respondent's home, a relative's home, a neighbor's home, or other non-institutional settings. "1" represents a delivery occurring within a health facility, encompassing a range of institutions such as government hospitals (various levels), private hospitals and clinics, health centers, maternal and child welfare centers, and clinics operated by family planning associations or NGOs.

Predictor Variables

The predictor variables included in this study have been carefully chosen following a comprehensive literature review as depicted in Table 1. These variables represent factors that have been established in previous research as influencing women's choice of place of delivery.

Table 1

provides a complete list of the selected predictor variables, along with their descriptions and coding.
No	Variables	Construction
1.	Maternal level of education	No education, Primary, Secondary and Higher
2.	Healthcare decision making	Respondents, husband, jointly and other
3.	Birth order	1–3, 4–6 and 7 and more
4.	Husband occupation last 12 month	Yes, No
5.	Age of the respondents	15–24, 25–34, 35–44, 45 and more
6.	Total children ever born	0–3, 4–7, 8 and more
7.	Age at first birth	7–16, 17–26, 27–36, 37 and more
8.	Age at first marriage	12–20, 21–29, 30–38, 39 and more
9.	Watching tv	Yes, No
10.	Gender of household head	Male and female
11.	Household size	1–5, 6–10, 11 and more
12.	Distance to the health facility	Problem, No Problem
13.	Place of residence	Rural, Urban, Nomadic
14.	Wealth quantile	Poor, Middle, Rich
15.	Region	Awdal, Waqooyi galbeed, Togdheer, Sool, Sanaag, Bari, Nugaal, Mudug, Galgaduud, Hiraan, Middle Shabelle, Banadir, Bay, Bakool, Gedo, Lower juba.

Ethical Considerations

This study uses publicly available datasets that were granted ethical approval during their initial collection. All participants provided informed consent at the time of the original studies. For detailed information regarding the ethical procedures of the DHS program, please refer to (UNFPA Somalia, 2020)

Table 2 shows univariate analysis of factors influences place of delivery. Education levels are notably skewed, with the majority lacking formal education (84.22%), followed by those with primary (11.84%) and secondary education (2.88%), and a small fraction with higher education (1.06%). In terms of decision-making, that husbands predominantly make healthcare decisions (51.28%), followed by joint decision-making (33.42%), and a smaller percentage by the respondents themselves (14.85%). Regarding birth order, the majority falls within the 1–3 range (93.45%), followed by 4–6 (6.38%), and a tiny fraction with more than 7 children (0.17%). Occupational engagement in husbands over the last year stands at 46.24%, while 53.76% have not been occupied.

Age distribution of respondents is mainly concentrated in the 25–34 years range (51.80%), followed by 35–44 years (22.08%), 15–24 years (24.52%), and those over 45 years old (1.60%). The number of children ever born varies, with 0–3 children at 33.02%, 4–7 children as the majority (49.78%), and over 8 children at 17.20%. Age at first childbirth is primarily within the 17–26 years range (75.68%), followed by 7–16 years (18.93%), 27–36 years (5.30%), and individuals of 37 years old and over (0.10%). As shown, the respondents entered their first marriage between 12–20 years old (79.64%), followed by 21–29 years old (17.36%), 30–38 years old (0.88%), and those 39 years old and over (2.12%).

A small proportion of respondents engage in watching TV (9.86%), while the majority does not 90.14%. Male household heads dominate (68.02%), with female household heads comprising 31.98%. Household sizes with 1–5 member households comprising the majority (50.07%), followed by 6–10 member households (9.00%), and those with 11 and over members (40.92%). Regarding proximity to health facilities, 63.53% of respondents reported having problems with the distance, while 36.47% did not face such issues. Residence locations vary, with 25.93% in rural areas, 41.13% in urban areas, and 32.95% leading a nomadic lifestyle. Wealth distribution, shows that 45.90% are categorized as poor, 38.49% fall into the middle wealth category, and 15.60% belong to the rich category.

associations Across different regions on place of delivery, Banadir has the highest frequency (11.29%), followed by Sanaag (8.22%), and Sool (7.54%). Notable regions include Woqooyi Galbeed (6.63%), Togdheer (6.79%), and Nugaal (5.94%). Lower frequencies are observed in Bay (2.33%) and Awdal (4.55%).

Table 2

Univariate analysis of factors associated the place of delivery among women at childbearing age in SHDS 2020.
Independent Variables	Frequency (N)	Percentage (%)
Highest education level
No education	13,611	84.22
Primary	1,914	11.84
Secondary	465	2.88
Higher	172	1.06
Healthcare decision making
Respondent	2,400	14.85
Husband	8,288	51.28
Jointly	5,402	33.42
Other	72	0.45
Birth Order
1–3	15,104	93.45
4–6	1,031	6.38
7 and more	27	0.17
Husband Occupation Last 12 month
Yes	7,474	46.24
No	8,688	53.76
Age of the respondents
15–24	3,963	24.52
25–34	8,372	51.80
35–44	3,569	22.08
45 and more	258	1.60
Total children ever born
0–3	5,336	33.02
4–7	8,046	49.78
8 and more	2,780	17.20
Age at 1st birth
7–16	3,059	18.93
17–26	12,231	75.68
27–36	856	5.30
37 and more	16	0.10
Age at 1st marriage
12–20	12,871	79.64
21–29	2,806	17.36
30–38	143	0.88
39 and more	342	2.12
Watching Tv
Yes	1,593	9.86
No	14,569	90.14
Gender of household head
Male	10,994	68.02
Female	5,168	31.98
Household Number
1–5	8,093	50.07
6–10	1,455	9.00
11 and more	6,614	40.92
Distance to the health facility
Problem	10,267	63.53
No Problem	5,895	36.47
Place of Residence
Rural	4,190	25.93
Urban	6,647	41.13
Nomadic	5,325	32.95
Wealth quantile
Poor	7,419	45.90
Middle	6,221	38.49
Rich	2,522	15.60
Region
Awdal	736	4.55
Waqooyi galbeed	1,071	6.63
Togdheer	1,098	6.79
Sool	1,219	7.54
Sanaag	1,329	8.22
Bari	986	6.10
Nugaal	960	5.94
Mudug	963	5.96
Galgaduud	889	5.50
Hiraan	793	4.91
Middle Shabelle	832	5.15
Banadir	1,825	11.29
Bay	377	2.33
Bakool	1,054	6.52
Gedo	993	6.14
Lower juba	1,037	6.42

Table 3 shows bivariate analysis of Factors Associated the place of delivery among childbearing women of Somalia, firstly, demonstrated significant association between the highest education level attained by women and the chosen place of delivery (home versus health facility). The frequency of home deliveries declined as the education level increased. Specifically, women with no education exhibited the highest percentage of home deliveries at 84.26%, followed by those with primary education at 63.79%. Conversely, women with secondary education displayed a lower percentage of home deliveries at 44.09%, while those with higher education had the lowest percentage at 24.42%. Conversely, the percentage of health facility deliveries increased with higher education levels. The Chi-square test indicated a statistically significant difference in the place of delivery based on the highest education level attained by women (p < 0.001). in contrast the examination of healthcare decision-making in relation to the place of delivery unveils compelling associations (p < 0.001) among various decision-makers. When respondents autonomously made the decision, a notable majority (74.71%) favored home delivery. Conversely, when husbands assumed the decision-making role, an even higher proportion (83.29%) opted for home deliveries. Similarly, joint decision-making resulted in a prevalent preference (77.51%) for home delivery. These findings underscore the profound influence of decision-makers on the choice between home and health facility deliveries.

Concerning birth order, no statistically significant association was observed with the chosen place of delivery. For birth orders 1–3, 80.03% opted for home deliveries, while 19.97% chose health facility deliveries. Similarly, birth orders 4–6 exhibited similar percentages, with 80.02% home deliveries and 19.98% health facility deliveries. Conversely, for birth orders of 7 and more, 88.89% favored home deliveries compared to 11.11% at health facilities. However, the Chi-square test did not reveal statistical significance (p = 0.52), additionally the analysis underscores a significant association between the place of delivery and the occupational status of the husband within the last 12 months. Among women whose husbands were employed, 72.13% opted for home deliveries, while 27.87% chose health facilities. Conversely, among women whose husbands were not employed, a significant majority (86.86%) favored home deliveries, with only 13.14% opting for health facilities.

Similarly, the age of respondents exhibits a significant association with place of delivery. Among women aged 15–24, 77.95% delivered at home and 22.05% at a health facility. In the 25–34 age bracket, 80.26% preferred home delivery, with 19.74% opting for a health facility. For those aged 35–44, 81.31% chose home delivery, while 18.69% opted for a health facility. Notably, for women over 45, 87.98% delivered at home compared to 12.02% at a health facility. The chi-square test confirms the statistical significance of these differences (p < 0.001).

Furthermore, there exists a significant association between the total number of children ever born and the place of delivery. Among women with 0–3 children, 75.34% favored home delivery and 24.66% chose a health facility. In the group with 4–7 children, 82.49% opted for home delivery, whereas 17.51% chose a health facility. Similarly, for those with more than 8 children, 82.01% delivered at home compared to 17.99% at a health facility. The chi-square test underscores the statistical significance of these variances (p < 0.001).

The analysis demonstrates a significant correlation between the age at first birth and the chosen place of delivery (home versus health facility). Notably, among women whose first birth occurred between ages 7–16, 82.97% opted for home delivery, while 17.03% chose a health facility. Similarly, for those with first births between ages 17–26, 79.31% delivered at home compared to 20.69% at a health facility. In the age group with first births between ages 27–36, 80.14% preferred home delivery, while 19.86% opted for a health facility. Moreover, for women whose first birth was at or after age 37, 75% delivered at home, while 25% chose a health facility. The statistical significance of these disparities is confirmed by the chi-square test (p < 0.001).

Likewise, there exists a significant association between the age at first marriage and the selected place of delivery. Among women married between ages 12–20, 80.93% opted for home delivery, with 19.07% choosing a health facility. For those married between ages 21–29, 75.59% favored home delivery compared to 24.41% at a health facility. Similarly, in the age group with first marriages between ages 30–38, 74.13% chose home delivery, while 25.87% opted for a health facility. Additionally, for women marrying after age 39, 85.96% delivered at home, while 14.04% chose a health facility. The chi-square test underlines the statistical significance of these variations (p < 0.001). also, the findings reveal a notable correlation between watching television and the place of delivery Notably, among women who watched TV, 50.78% opted for home delivery while 49.22% chose a health facility. Conversely, for those who did not watch TV, 83.25% favored home delivery compared to 16.75% who opted for a health facility. This dissimilarity in delivery location between the two groups is statistically significant (p < 0.001).

The household head gender showed a marginally significant association with the chosen place of delivery. Male-headed households witnessed 79.63% home deliveries and 20.37% health facility deliveries, while female-headed households experienced 80.92% home deliveries and 19.08% health facility deliveries. With a p-value of 0.056, the Chi-square test indicated a borderline significance in this association between the household head gender and the place of delivery.

Also, the analysis indicates a significant association between household size and the chosen place of delivery. Among households with 1–5 members, 82.42% opted for home delivery, whereas 17.58% chose a health facility. Similarly, in households with 6–10 members, 83.23% preferred home delivery compared to 16.77% at a health facility. Notably, in households with more than 11 members, 74.44% chose home delivery, while 23.56% opted for a health facility. The chi-square test confirms the statistical significance of these differences (p < 0.001). in contrast data presented highlight a significant correlation between the distance to the health facility and the selected place of delivery. Notably, Women who faced difficulties accessing a health facility had a higher percentage of home deliveries at 83.60%, while those who did not have such difficulties had a lower percentage of 73.86%. Conversely, the percentage of health facility deliveries was higher for women without access issues, at 26.14%, compared to 16.40% for those who faced access difficulties. The Chi-square test underscored a statistically significant disparity in the place of delivery based on the distance to the health facility (p < 0.001).

Moreover, the analysis revealed that the place of residence, encompassing rural, urban, and nomadic areas, did not exhibit a significant association with the chosen place of delivery (p = 0.22). Home delivery frequency was higher in rural areas at 80.48%, followed by nomadic areas at 80.53%, and urban areas at 79.39%. Conversely, the percentage of health facility deliveries was lower in rural areas at 19.52%, followed by nomadic areas at 19.47%, and urban areas at 20.61%. The Chi-square test did not identify a statistically significant difference in the place of delivery based on the place of residence, suggesting that other factors may play a more influential role in determining where women choose to deliver. Similarly, delivery location vs wealth quantiles reveal a significant association (p < 0.001) between socioeconomic status and delivery preferences. Distinct patterns emerge across different wealth categories. Among the impoverished, an overwhelming majority (93.84%) opted for home deliveries. In the middle-income bracket, a more balanced distribution was observed, with 74.57% choosing home deliveries and 25.43% opting for health facilities. Conversely, among the affluent, while home deliveries still prevailed (80.05%), a larger proportion (19.95%) opted for health facilities, indicating a heightened utilization of healthcare facilities among wealthier populations.

Finally, the data provided demonstrate a significant association between the region and the chosen place of delivery. The frequency of home deliveries exhibited variation across regions, with the highest percentage in Bari at 90.47% and the lowest in Gedo at 3.42%. In contrast, the percentage of health facility deliveries ranged from 9.53% in Bari to 27.54% in Sanaag. The Chi-square test confirmed a statistically significant difference in the place of delivery across regions, indicating that regional factors play a crucial role in determining where women choose to deliver.

Table 3

Bivariate analysis of factors associated the place of delivery among childbearing women of Somalia
Variable	Place of delivery		Df	P-value
Variable	Place of delivery		Df	Chi²-test
	Home(N/%)	Health facility(N/%)
Highest education level			3	< 0.001
No education	11,469(84.26)	2,142(15.74)
Primary	1,221(63.79)	693 (36.21)
Secondary	205(44.09)	260(55.91)
Higher	42(24.42)	130(75.58)
Healthcare decision making			3	< 0.001
Respondent	1,793(74.71)	607(25.29)
Husband	6,903(83.29)	1,385(16.71)
Jointly	4,187(77.51)	1,215(22.49)
Other	54(75)	18(25)
Birth Order			2	0.52
1–3	12,088(80.03)	3,016(19.97)
4–6	825(80.02)	206(19.98)
7 and more	24(88.89)	3(11.11)
Husband Occupation Last 12 month			1	< 0.001
Yes	5,391(72.13)	2,083(27.87)
No	7,546(86.86)	1,142(13.14)
Age of the respondents			3	< 0.001
15–24	3,089(77.95)	874(22.05)
25–34	6,719(80.26)	1,653(19.74)
35–44	2,902(81.31)	667(18.69)
45 and more	227(87.98)	31(12.02)
Total children ever born			2	< 0.001
0–3	4,020(75.34)	1,316(24.66)
4–7	6,637(82.49)	1,409(17.51)
8 and more	2,200(82.01)	500(17.99)
Age at 1st birth			3	< 0.001
7–16	2,538(82.97)	521(17.03)
17–26	9,701(79.31)	2,530(20.69)
27–36	686(80.14)	170(19.86)
≥ 37	12(75)	4(25)
Age at 1st marriage			3	< 0.001
12–20	10,416(80.93)	2,455(19.07)
21–29	2,121(75.59)	685(24.41)
30–38	106(74.13)	37(25.87)
39 and more	294(85.96)	48(14.04)
Watching Tv			1	< 0.001
Yes	809(50.78)	784(49.22)
No	12,128(83.25)	2,441(16.75)
Gender of household head			1	0.056
Male	8,755(79.63)	2,239(20.37)
Female	4,182(80.92)	986(19.08)
Household Number			2	< 0.001
1–5	6,670(82.42)	1,423(17.58)
6–10	1,211(83.23)	244(16.77)
11 and more	5,056(74.44)	1,558(23.56)
Distance to the health facility			1	< 0.001
Problem	8,583(83.60)	1,684(16.40)
No Problem	4,354(73.86)	1,541(26.14)
Place of Residence			2	0.22
Rural	3,372(80.48)	818(19.52)
Urban	5,277(79.39)	1,370(20.61)
Nomadic	4,288(80.53)	1,037(19.47)
Wealth quantile			2	< 0.001
Poor	6,962(93.84)	457(6.16)
Middle	4,639(74.57)	1,582(25.43)
Rich	12,937(80.05)	3,225(19.95)
Region			15	< 0.001
Awdal	497(67.53)	239(32.47)
Waqooyi galbeed	817(76.28)	254(23.72)
Togdheer	697(63.48)	401(36.52)
Sool	805(66.04)	414(33.96)
Sanaag	963(72.46)	366(27.54)
Bari	892(90.47)	94(9.53)
Nugaal	843(87.81)	117(12.19)
Mudug	899(93.35)	64(6.65)
Galgaduud	796(89.54)	93(10.46)
Hiraan	689(86.89)	104(13.11)
Middle Shabelle	619(74.40)	213(25.60)
Banadir	1,399(76.66)	426(23.34)
Bay	299(79.31)	78(20.69)
Bakool	854(81.02)	200(18.98)
Gedo	959(96.58)	34(3.42)
Lower juba	909(87.66)	128(12.34)

Table 4 shows multivariate analysis of factors associated place of delivery. Education level showed a strong association, with higher education levels significantly increasing the odds of facility-based delivery compared to no education: primary education (aOR = 3.04, 95% CI = 2.74–3.37, P < 0.001), Secondary Education (aOR = 6.79, 95% CI = 5.62–8.20, P < 0.001), and higher education (aOR = 16.57, 95% CI = 11.68–23.54, P < 0.001).

Regarding healthcare decision-making, women whose husbands made healthcare decisions were less likely to deliver at a healthcare facility (aOR = 0.59, 95% CI = 0.53–0.66, P < 0.001) compared to those who made decisions independently, and joint decision-making also decreased the likelihood of facility-based delivery (aOR = 0.86, 95% CI = 0.77–0.96, P = 0.007). Additionally, if the husband had not been employed in the last 12 months, the odds of facility-based delivery decreased (aOR = 0.39, 95% CI = 0.36–0.42, P < 0.001).

Similarly, Age was a significant factor, with women aged 25–34 (aOR = 0.87, 95% CI = 0.79–0.95, P = 0.003), 35–44 (aOR = 0.81, 95% CI = 0.72–0.91, P < 0.001), and 45 and above (aOR = 0.48, 95% CI = 0.33–0.70, P < 0.001) being less likely to deliver at a facility compared to those aged 15–24. Parity (Total Children everborn) also influenced the place of delivery, with women having 4–7 children (aOR = 0.65, 95% CI = 0.59–0.70, P < 0.001) and 8 or more children (aOR = 0.67, 95% CI = 0.60–0.75, P < 0.001) being less likely to deliver at a facility compared to those with 0–3 children. The age at first birth also had an impact, with women having their first birth between ages 17–26 (aOR = 1.27, 95% CI = 1.14–1.41, P < 0.001) being more likely to deliver at a facility compared to those with their first birth at ages 7–16. The age at marriage played a role, with women marrying between ages 21–29 (aOR = 1.37, 95% CI = 1.24–1.51, P < 0.001) and 30–38 (aOR = 1.48, 95% CI = 1.01–2.16, P = 0.041) being more likely to deliver at a facility, while those marrying at age 39 and above were less likely (aOR = 0.69, 95% CI = 0.51–0.94, P = 0.02) compared to those marrying between ages 12–20.

Moreover, Women's exposure to media also played a role, with those who did not watch TV being less likely to deliver at a facility (aOR = 0.21, 95% CI = 0.19–0.23, P < 0.001) compared to TV viewers. Household size had an impact, with households of 11 or more members being more likely to deliver at a facility compared to those with 1–5 members (aOR = 1.44, 95% CI = 1.33–1.56, P < 0.001). also, The distance to the health facility was significant, with shorter distances ("No Problem") increasing the likelihood of facility deliveries (aOR = 1.80, 95% CI = 1.67–1.95, P < 0.001) compared to those who faced distance-related difficulties. Additionally, Economic status played a significant role, with women in the middle wealth quantile (aOR = 5.19, 95% CI = 4.65–5.80, P < 0.001) and rich wealth quantile (aOR = 13.52, 95% CI = 11.96–15.29, P < 0.001) having higher odds of delivering at a healthcare facility compared to those in the poor category. Similarly, Region also played a role, most regions show significantly lower odds of facility-based delivery compared to Awdal, with the magnitude of effect varying across regions. Togdheer (aOR = 1.20, 95% CI = 0.98–1.46, p = 0.75) and Sool (aOR = 1.07, 95% CI = 0.88–1.30, p = 0.50) are the only regions shows not statistically different.

Factors that do not show a significant association with the place of delivery include situations where healthcare decisions are made by "others" (aOR = 0.98, 95% CI = 0.57–1.69, p = 0.95), various birth orders such as 4–6 (aOR = 1.00, 95%CI = 0.85–1.17, p = 0.99), and 7 or more (aOR = 0.50, 95%CI = 0.15–1.66, p = 0.26). for women aged between 27 to 36 at their first birth, the association is marginally significant (aOR = 1.21, 95% CI-= 0.99–1.46, P = 0.055), 37 and above (aOR = 1.62, 95%CI = 0.52–5.05, p = 0.4). The household head gender also does not significantly affect the place of delivery (p = 0.056), which is similar to the study (Ahinkorah et al., 2021). household size ranging from 6 to 10 people (aOR = 0.94, 95% CI = 0.81–1.09, p = 0.45), place of residence Urban (aOR = 1.07, 95% CI = 0.97–1.18, p = 0.169), and nomadic lifestyle (aOR = 1.00, 95% CI = 0.90–1.10, p = 0.953), this result contradicts to the study (Bekele et al., 2022)

Table 4

Multivariate analysis of factors associated the place of delivery among women at childbearing age of Somalia.
Independent variables	cOR (95% CI)	P-value	aOR (95% CI)	P-value
Highest education level
No education	Referenced		Referenced
Primary	1.82(1.61–2.05)	< 0.001	3.04(2.74–3.37)	< 0.001
Secondary	2.74(2.21–3.38)	< 0.001	6.79(5.62–8.20)	< 0.001
Higher	4.54(3.06–6.72)	< 0.001	16.57(11.68–23.54)	< 0.001
Healthcare decision making
Respondent	Referenced		Referenced
Husband	0.84(0.74–0.95)	0.007	0.59(0.53–0.66)	< 0.001
Jointly	0.87(0.77–0.99)	0.044	0.86(0.77–0.96)	0.007
Other	1.1(0.60–2.19)	0.678	0.98(0.57–1.69)	0.955
Birth Order
1–3	Referenced		Referenced
4–6	1.04(0.87–1.24)	0.681	1.00(0.85–1.17)	0.992
7 and more	0.37(0.11–1.29)	0.119	0.50(0.15–1.66)	0.259
Husband Occupation Last 12 month
Yes	Referenced		Referenced
No	0.72(0.66–0.79)	< 0.001	0.39(0.36–0.42)	< 0.001
Age of the respondents
15–24	Referenced		Referenced
25–34	0.93(0.82–1.06)	0.286	0.87(0.79–0.95)	0.003
35–44	1.10(0.91–1.32)	0.310	0.81(0.72–0.91)	< 0.001
45 and more	0.72(0.46–1.12)	0.147	0.48(0.33–0.71)	< 0.001
Total children ever born
0–3	Referenced		Referenced
4–7	0.68(0.60–0.76)	< 0.001	0.65(0.59–0.70)	< 0.001
≥ 8	0.70(0.59–0.83)	< 0.001	0.67(0.60–0.75)	< 0.001
Age at 1st birth
7–16	Referenced		Referenced
17–26	1.19(1.05–1.35)	0.005	1.27(1.14–1.41)	< 0.001
27–36	0.88(0.67–1.15)	0.340	1.21(0.99–1.46)	0.055
37 and more	0.77(0.18–3.26)	0.723	1.62(0.52–5.05)	0.403
Age at 1st marriage
12–20	Referenced		Referenced
21–29	1.31(1.16–1.49)	< 0.001	1.37(1.24–1.51)	< 0.001
30–38	1.86(1.12–3.10)	0.017	1.48(1.01–2.16)	0.041
39 and more	0.78(0.56–1.11)	0.169	0.69(0.51–0.94)	0.020
Watching Tv
Yes	Referenced		Referenced
No	0.69(0.61–0.80)	< 0.001	0.21(0.19–0.23)	< 0.001
Gender of household head
Male	Referenced		Referenced
Female	1.01(0.91–1.11)	0.871	0.92(0.85-1.00)	0.056
Household Number
1–5	Referenced		Referenced
6–10	0.77(0.65–0.92)	0.004	0.94(0.81–1.09)	0.452
11 and more	0.93(0.82–1.05)	0.251	1.44(1.33–1.56)	< 0.001
Distance to the health facility
Problem	Referenced		Referenced
No Problem	1.17(1.07–1.29)	0.001	1.80(1.67–1.95)	< 0.001
Place of Residence
Rural	Referenced		Referenced
Urban	1.05(0.92–1.19)	0.455	1.07(0.97–1.18)	0.169
Nomadic	0.63(0.55–0.73)	< 0.001	1.00(0.90–1.10)	0.953
Wealth quantile
Poor	Referenced		Referenced
Middle	4.24(3.75–4.80)	< 0.001	5.19(4.65–5.80)	< 0.001
Rich	6.47(5.56–7.52)	< 0.001	13.52(11.96–15.29)	< 0.001
Region
Awdal	Referenced		Referenced
Waqooyi galbeed	0.65(0.51–0.83)	0.001	0.65(0.52–0.80)	< 0.001
Togdheer	0.89(0.70–1.12)	0.308	1.20(0.98–1.46)	0.075
Sool	0.79(0.63–0.99)	0.040	1.07(0.88–1.30)	0.499
Sanaag	0.59(0.47–0.74)	< 0.001	0.79(0.65–0.96)	0.018
Bari	0.21(0.15–0.28)	< 0.001	0.22(0.17–0.28)	< 0.001
Nugaal	0.29(0.22–0.38)	< 0.001	0.29(0.22–0.37)	< 0.001
Mudug	0.10(0.07–0.14)	< 0.001	0.15(0.11–0.20)	< 0.001
Galgaduud	0.24(0.18–0.32)	< 0.001	0.24(0.19–0.32)	< 0.001
Hiraan	0.30(0.22–0.40)	< 0.001	0.31(0.24–0.41)	< 0.001
Middle Shabelle	0.57(0.44–0.74)	< 0.001	0.71(0.57–0.89)	0.003
Banadir	0.45(0.35–0.56)	< 0.001	0.63(0.52–0.76)	< 0.001
Bay	0.31(0.22–0.44)	< 0.001	0.54(0.40–0.73)	< 0.001
Bakool	0.40(0.31–0.52)	< 0.001	0.49(0.39–0.60)	< 0.001
Gedo	0.09(0.06–0.14)	< 0.001	0.07(0.05–0.11)	< 0.001
Lower juba	0.21(0.16–0.28)	< 0.001	0.29(0.23–0.37)	< 0.001

This study analyzed factors influencing the place of delivery among women at reproductive age, using data from the SDHS 2020. The findings indicate that women with primary, secondary, or higher education, those belonging to middle and wealthy households, and those from households with 11 or more members are significantly more likely to have facility-based deliveries. These insights are valuable for the government and stakeholders in planning, designing, and implementing targeted interventions to overcome barriers to healthcare facility utilization, ultimately aiding in the reduction of Somalia's high maternal mortality rate.

At the factors associated the place of delivery, increase of level of education of maternal there is a increase of choosing health facility delivery among maternal, which is similar to the studies(Barman et al., 2020) (Adeniyi et al., 2022)(Kitui et al., 2013)(Dahiru & Oche, 2015) (Shanto et al., 2023). One possible reason is that higher education levels make women more aware of the risks associated with pregnancy, increasing the likelihood that they will choose to give birth in a health facility. educated women tend to be more health-conscious and possess greater autonomy, which enhances their health-seeking behavior. Also, women with higher education are more likely to be employed. Similarly, the autonomy of women in decision-making regarding the location of delivery significantly impacts their likelihood of choosing a health facility for childbirth (Kifle et al., 2018). This study discovered that women who independently made the decision were more likely to opt for a health facility compared to when the decision was made by their husband, jointly by both the husband and wife. Additionally, the occupation of a husband is a significant factor influencing the choice of delivery location for maternal care(Shudura et al., 2020) (Dhakal et al., 2018). Women whose husbands are employed are more likely to deliver in health facilities rather than at home.

This study found that maternal age is linked to facility delivery. Younger women were more likely to give birth in a health facility compared to older women (Gangtaba et al., 2021). one reason is that younger women are often more receptive to modern health practices and recommendations. They are likely to follow the advice of healthcare professionals, which typically includes delivering in a health facility to ensure the availability of skilled care and emergency services. Similarly, Total children ever born of mothers is another crucial factor and had a strong influence on place of delivery (Akinyo, 2009) (Mukhtar, 2018). Moreover, the age at first marriage played a role, with women marrying between ages 21–29 and 30–38 being more likely to deliver at a facility, while those marrying at age 39 and above were less likely to delivery at a health facility and age at first birth also had an impact, with women having their first birth between ages 17–26 being more likely to deliver at a facility compared to those with their first birth at ages 7–16, (Tesfaye et al., 2019)

Women who are exposed to mass media like TV are more likely to give birth at health facilities than their counterparts who are not exposed to mass media (Bolarinwa et al., 2021) (Xu et al., 2022)(Tesfaye et al., 2019). At the side of household size and place of delivery found that, Household size of 11 or more members being more likely to deliver at a facility compared to those with 1–5 members. The distance to the health facility was significant, with increased distances or facing difficulties in accessing the facility increasing the likelihood of non-facility-based deliveries. This finding is consistent with other study (Maddy et al., n.d.), which indicates Women are more likely to give birth at home if they live far from the health center, and the other study that indicates distance to the nearest health center is major factor of opting for home delivery(Envuladu et al., 2013). Additionally, this study, like previous research’s (Barman et al., 2020) (Kumbeni & Apanga, 2021) (Munmun Ahmed,2020), reported that a woman's wealth index significantly influences the likelihood of institutional delivery. Women in higher wealth quintiles were more likely to give birth in healthcare facilities compared to those in lower wealth quintiles. Region also played a role, most regions show significantly lower odds of facility-based delivery compared to Awdal, with the magnitude of effect varying across regions (Ahinkorah et al., 2021).

Using data from the Somalia Demographic and Health Survey, this study explores the factors influencing the preferences of Somali women who are reproductively aged about the location of deliveries. The findings provide important information for Stakeholders and policymakers. It emphasizes how important it is to consider factors like maternal education, autonomy in making healthcare decisions, husband's occupation, maternal age, number of children born, age at first marriage and birth, media exposure, household size, proximity to medical facilities, wealth quintile, and regional disparities when deciding where to give birth. These results are crucial in helping to direct focused actions meant to remove obstacles to using healthcare facilities, which in turn helps to lower the high rate of maternal death in Somalia.

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The data used in this study is publicly available.

Competing Interests

There are no conflicts of interest to declare.

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Authors' Contributions

The authors have contributed equally to this research.

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Factors Shaping Delivery Location Preferences for Somali Women at Childbearing Age

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