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OBJECTIVE: To describe the incidence and causes of severe maternal outcomes and the unmet need for life-saving obstetric interventions among women admitted for delivery in a referral hospital in Somaliland.

METHODS: A prospective cross-sectional study was conducted from April 15, 2019, to March 31, 2020, with women admitted during pregnancy or childbirth or within 42 days after delivery. Data was collected using the World Health Organization (WHO) and sub-Saharan Africa (SSA) maternal near-miss (MNM) tools. Descriptive analysis was performed by computing frequencies, proportions and ratios.

RESULTS: The MNM ratio were 56 (SSA criteria) and 13 (WHO criteria) per 1,000 live births. The mortality index was highest among women with medical complications (63%), followed by obstetric haemorrhage (13%), pregnancy-related infection (10%) and hypertensive disorders (7.9%) according to the SSA MNM criteria. Most women giving birth received prophylactic oxytocin for postpartum haemorrhage prevention (97%), and most laparotomies (60%) for ruptured uterus were conducted after three hours.

CONCLUSION: There is a need to improve the quality of maternal health services through implementation of evidence-based obstetric interventions and continuous in-service training for health care providers. Using the SSA MNM criteria could facilitate such preventive measures in this setting as well as similar low-resource contexts.

BACKGROUND: Around 20% of births in Somaliland take place at health facilities staffed by trained healthcare professionals; 80% take place at home assisted by Traditional Birth Attendants (TBAs) with no formal training. There has been no research into women's choice of place of birth.

OBJECTIVE: In this study, we explore multipara women's needs and preferences when choosing the place of birth.

METHOD: An explorative qualitative study using individual in-depth interviews analysed inductively using content analysis. The interviews were conducted in Somaliland with 25 multiparous women who had experience of giving birth both at home and at a health facility within the past three years.

RESULTS: The results provide a description of how, for women in Somaliland, a lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need. The women in this study desired intentionality in their role as mothers and sought some measure of control over the environment where they planned to give birth, depending on the circumstances of that particular birth. The results describe what quality care means for multipara women in Somaliland and how women choose birthplace based on previous experiences of care. The expectation of respectful care was a vital part for women when choosing a place of birth.

CONCLUSION: To meet women's needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a context specific midwife-led continuity of care model to be scaled up. A dialogue to create new roles and responsibilities for the TBAs who attend most home births is further needed to link them to the formal healthcare system and assure timely healthcare seeking during pregnancy and birth.