Photo courtesy of Australia for UNHCR
With a critically damaged health system for over two decades, maternal health in Somalia is in tatters, although recent changes bring reason for hope.
Since the collapse of the government in 1991, political upheaval, lawlessness, clan warfare and the threatening presence of Islamist insurgents have plagued Somalia. With over a dozen failed attempts to establish a government since then, Somalia is finally beginning to enjoy a measure of stability following the 2012 installation of an internationally-backed government–the first functioning government since the late 1980s. As the country begins its recovery from decades of insecurity and several devastating droughts and famines, Somalia’s critically damaged health system requires extensive attention ((Jeffrey Gettleman, “Harvard-educated technocrat chosen as Somalia Premier,” The New York Times, 23 June 2011 (accessed 8 March 2015).)) ((BBC News: Africa, “Somalia profile,” BBC News, 21 October 2014 (accessed 8 March 2015).)). Understandably, the current humanitarian crisis in Somalia is urgent. With approximately 1.1 million displaced people, many are living in makeshift camps where, like most of Somalia, health services are limited ((Pilirani Semu-Banda, “A safe haven for pregnant women in Somalia,” UNFPA News, 12 January 2015 (accessed 8 March 2015).)).
In 2010, an estimated 1,000 maternal deaths occurred per 100,000 live births, making Somalia’s maternal mortality ratio one of the five highest in the world. The ratio has remained unchanged since the early 1990s, indicating that a Somali woman’s lifetime risk of maternal death has hovered at about 1 in 16 (using conservative estimates) for more than two decades now ((UN Maternal Mortality Estimation Inter-agency Group, Trends in Maternal Mortality: 1990 to 2013 (Geneva 2014), pp. 31-43.)) ((Save the Children, State of the World’s Mothers 2014: Saving Mothers and Children in Humanitarian Crises (Westport, CT 2014), p. 79.)). In 2013, the ratio dropped to 850 deaths per 100,000 live births, likely due to more stable governance and continued humanitarian efforts by international organizations ((World Health Organization, Country: Somalia, Global Health Observatory Data, Maternal Mortality Country Profiles (accessed 8 March 2015).)). However, the current situation remains dire, with one out of every 12 women dying due to pregnancy-related causes, and only 9 percent of births assisted by skilled attendants ((UNICEF, Somalia: Child and Maternal Health, UNICEF Global Site (accessed 8 March 2015).)).
Aside from its history of severe disasters and prolonged conflict, several other factors affect maternal health negatively in Somalia. According to 2012 data, 76 percent of the population lives in rural areas, where access to health and family planning services is extremely limited ((UNFPA and others, The State of the World’s Midwifery 2014, p. 168 (accessed 8 March 2015).)). Many women are nomadic, so their access to skilled medical care is transitory ((Rohina Phadnis, “Delivering hope in Somalia: Doctors continue to treat fistula in harrowing conditions,” UNFPA News, 11 September 2009 (accessed 8 March 2015).)). Additionally, the modern contraceptive use rate is only about 1 percent and the total fertility rate is 6.6 children per woman ((UNICEF, Somalia: Child and Maternal Health, UNICEF Global Site (accessed 8 March 2015).)) ((UNFPA and others, The State of the World’s Midwifery 2014, p. 168 (accessed 8 March 2015).)). Short birth intervals can be dangerous for mothers—especially for those that are malnourished from drought and famine—and multiple pregnancies increase women’s risk for obstetric complications ((UNICEF, Somalia: Child and Maternal Health, UNICEF Global Site (accessed 8 March 2015).)).
Photo Courtesy of UNICEF
Moreover, Somalia has some of the world’s highest prevalence rates of child marriage and female genital cutting (FGC), both contributing largely to maternal mortality. Nearly half of all girls are married before their 18th birthday, and those younger than 15 are five times more likely to die in childbirth than women in their 20s ((International Center for Research on Women, “Child marriage facts and figures,” (accessed 8 March 2015).)). Approximately 98 percent of Somali women have undergone FGC (80 percent having undergone the severest form of the procedure), and little has changed since the early 1990s when data first became available. Leaving only a small opening for passage of urine and menstrual fluid, FGC endangers a women’s health through recurrent infections, chronic pain, cysts, fatal bleeding and complications during childbirth ((World Bank and United Nations Population Fund, “Female genital mutilation/cutting in Somalia,” p. 5 (accessed 8 March 2015).)) ((Charlotte Feldman-Jacobs and Donna Clifton, “Female genital mutilation/cutting: Data and trends: Update 2010,” Population Reference Bureau (Washington, DC 2010), p. 7.)). Although the problem is pervasive, the numbers are beginning to drop in the country’s more stable northern regions, thanks to awareness campaigns and an Article of the 2012 Constitution that bans the procedure ((The Associated Press, “Somalia: Female genital mutilation down,” The Jakarta Post, 16 April 2013 (accessed 8 March 2015).)) ((The Federal Republic of Somalia, Harmonized Draft Constitution Signed by Signatories (Unofficial English Translation), Mogadishu, 12 June 2012, p. 5 (accessed 8 March 2012).)).
Somalia’s population is over 10 million, and the number of basic emergency obstetric care facilities per 500,000 people is 0.8, compared with the international standard of 5 ((World Health Organization, Somalia: Priority Areas: Reproductive Health, Regional Office for the Eastern Mediterranean (accessed 8 March 2015).)). There are signs of improvement, however, and ongoing interventions provided by international organizations are helping support safe delivery. Maternity waiting homes, for example, provide a range of health services to expectant mothers and their babies. Built predominantly in displacement camps, they offer essential care to women at all stages of pregnancy. The homes provide rooms where women in their final month of pregnancy are invited to stay, enjoy free meals and ultimately deliver under the care of a skilled attendant or be transferred to the nearest hospital should complications arise. There were 34 such maternity waiting homes in Somalia as of 2013 ((Pilirani Semu-Banda, “A safe haven for pregnant women in Somalia,” UNFPA News, 12 January 2015 (accessed 8 March 2015).)). Other reproductive health interventions include providing obstetric fistula repair services, advocacy efforts to end FGC and sexual violence, and HIV prevention and treatment services within mother and child health centers ((World Health Organization, Somalia: Priority Areas: Reproductive Health, Regional Office for the Eastern Mediterranean (accessed 8 March 2015).)) ((Rohina Phadnis, “Delivering hope in Somalia: Doctors continue to treat fistula in harrowing conditions,” UNFPA News, 11 September 2009 (accessed 8 March 2015).)). Such projects, combined with more stable governance and new laws banning harmful practices, are sure to improve the maternal health situation in Somalia, but repairing and rebuilding will take time. However slowly the changes proceed, these improvements will eventually see an end to decades of instability, restoring hope for Somali mothers to safely deliver children and raise their families in security.
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