Wealth-based inequality in maternal health service utilization among ever-married women of reproductive age in Somaliland; secondary analysis of the 2020 Demographic and Health Survey.

Background: Access to affordable, quality maternal health services is a fundamental human right. In Somaliland, characterized by a fragile health system and high maternal mortality, utilization of maternal health services remains low, and socioeconomic factors are known to shape this utilization. However, the extent and implications of wealth-based inequalities in maternal service use remain poorly quantified. This study assesses the magnitude of wealth-based inequality in adequate antenatal care (ANC) and public facility-based childbirth in Somaliland. Methods: This secondary analysis used the 2020 Somaliland Demographic and Health Survey, including 3,065 ever-married women with a recent birth. Adequate ANC was defined as four or more visits, consistent with Somaliland's Focused ANC Model at the time of the survey rather than the current WHO-recommended eight contacts. Private facility births were excluded, as they are concentrated among wealthier, urban women and fall outside Somaliland's free public maternal care policy; we therefore assessed births in public facilities, which provide free care to the general population. We used survey-weighted logistic regression incorporating sampling weights, clustering, and stratification, and quantified inequality using the Slope Index of Inequality (absolute) and Wagstaff's concentration indices corrected for binary outcomes (relative). Results: The weighted prevalence of adequate ANC was 20%, and 32% of women gave birth in a public facility. After adjustment, the richest women had nearly four times higher odds of adequate ANC (aOR: 3.98; 95%CI: 2.20-7.17) and over six times higher odds of public facility-based birth (aOR: 6.54; 95%CI: 3.59-11.91) than the poorest. Adjusted absolute differences between the richest and poorest quintiles were 26 percentage points for ANC and 49 percentage points for public facility births. Significant pro-rich distribution was observed for both outcomes, with concentration indices of 0.34 (95%CI: 0.33-0.35) for ANC and 0.50 (95%CI: 0.49-0.52) for public facility births. Conclusion: Wealth-based inequalities exist in maternal health service utilization in Somaliland. Addressing these inequalities requires targeting poorer, non-urban women and removing access barriers through systematic reforms beyond the health system.