Geographical inequalities in skin-to-skin contact after birth among women in Somaliland: a multilevel and spatial analysis of the 2020 survey.

BACKGROUND: Skin-to-skin contact (SSC) after birth is a proven, low-cost intervention that improves neonatal survival and promotes early breastfeeding. This study aimed to assess the prevalence, determinants, and geographical inequalities of SSC after birth among women in Somaliland. METHODS: A cross-sectional study was conducted using data from the 2020 Somaliland Demographic and Health Survey. A nationally representative sample of women aged 15-49 years who had a live birth within five years preceding the survey was included. Multilevel mixed-effects logistic regression analysis was employed to identify individual- and community-level factors associated with SSC. Model fitness was assessed using Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC). Spatial analysis was performed using R software to examine geographic variation, including hotspot analysis (Getis-Ord Gi*) and Local Moran's I to identify clustering patterns. RESULTS: The prevalence of skin-to-skin contact after birth was 24.81%. Significant regional variation was observed, with higher prevalence in western regions and lower prevalence in eastern regions. In the multilevel analysis, women residing in Marodijeh (AOR = 0.36; 95% CI: 0.23-0.56), Sool (AOR = 0.48; 95% CI: 0.34-0.68), and Sanaag (AOR = 0.54; 95% CI: 0.34-0.86) had lower odds of practicing SSC compared to Awdal. At the individual level, wealth index, antenatal care utilization, place of delivery, pregnancy wantedness, and child size at birth were significantly associated with SSC. Women who delivered in health institutions had significantly higher odds of practicing SSC (AOR = 6.09; 95% CI: 4.39-8.45). Spatial analysis revealed significant clustering of low SSC practice in eastern regions, indicating clear geographic inequalities. CONCLUSION: The prevalence of skin-to-skin contact in Somaliland remains low, with substantial socioeconomic and geographic disparities. Both individual and community-level factors influence its practice, with institutional delivery emerging as the strongest predictor. Targeted interventions focusing on improving antenatal care utilization, promoting facility-based delivery, and addressing regional inequalities are essential to enhance the uptake of SSC and improve neonatal health outcomes.