Socioeconomic and regional determinants of optimal antenatal care utilization among women in South and Central Somalia

Background: Somalia faces one of the world's highest maternal mortality ratios, and fewer than one in sixteen pregnant women obtain the previously recommended minimum of four antenatal care (ANC) visits. Understanding the drivers of low ANC use is essential for responsive policy. We investigated the prevalence and determinants of optimal ANC use (≥4 visits) among women in South and Central Somalia using nationally representative survey data. Methods: We conducted a cross-sectional analysis of the 2020 Somali Health and Demographic Survey. The weighted analytic sample comprised 4124 women aged 15-49 years with complete data. Survey-adjusted descriptive statistics characterized ANC use. Bivariate associations and multivariable survey logistic regression identified independent predictors; adjusted odds ratios (aORs) with 95 % confidence intervals (CIs) are reported. Results: Only 5.7 % of women (95 % CI 4.3-7.6) had four or more ANC visits. After adjustment, secondary education (aOR 2.33, 95 % CI 1.01-5.40) and higher education (aOR 5.36, 95 % CI 1.58-18.15) were associated with optimal ANC. Household wealth showed a graded increase, with the richest quintile having nearly 30 times the odds compared with the poorest (aOR 29.66, 95 % CI 8.51-101.27). Home delivery was associated with lower odds of optimal ANC (aOR 0.29, 95 % CI 0.18-0.47). Regional disparities persisted: women in Bay (aOR 4.07, 95 % CI 1.22-13.60) and Galgaduud (aOR 2.74, 95 % CI 1.13-6.64) had higher odds than those in Mudug. Conclusion: Optimal ANC coverage in South and Central Somalia remains critically low. Priorities include reducing financial and geographic barriers to care, strengthening facility-based services, and promoting female education to improve maternal and neonatal outcomes.