Somalia's malaria prevention gap: only 1 in 3 pregnant women get care

<p><strong>BACKGROUND:</strong> Malaria in pregnancy (MiP) poses significant risks in sub-Saharan Africa. Intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is a key WHO-recommended intervention. However, its implementation faces challenges, particularly in fragile, diverse malaria transmission settings like Somalia, where data on uptake is limited. Critically, a substantial majority of recently pregnant women in Somalia do not access formal antenatal care (ANC) at all, with only ~ 31% attending one or more visits, severely limiting the primary platform for IPTp-SP delivery. This study aimed to identify factors associated with reported use of any sulfadoxine-pyrimethamine (SP/Fansidar) during pregnancy in Somalia, and specifically, factors associated with its uptake within antenatal care (ANC) services, contextualized by the low ANC attendance rates.</p><p><strong>METHODS:</strong> This study analysed data from the 2020 Somalia Demographic and Health Survey (SDHS) to identify factors associated with the self-reported use of SP/Fansidar during women's most recent pregnancy in the preceding 5 years. This cross-sectional study analysed data from 7124 women aged 15-49 with a live birth in the preceding 5 years, using the 2020 Somalia Health and Demographic Survey (SDHS). The outcome was self-reported use of any SP/Fansidar during the last pregnancy (Yes/No), acknowledging this measure does not quantify dose number or adherence to WHO guidelines. To provide a more nuanced understanding of programmatic uptake, the analysis was stratified by ANC attendance (at least one visit vs. no visits). Multilevel logistic regression models were employed to assess associations with individual, household, and community-level factors, accounting for data clustering.</p><p><strong>RESULTS:</strong> Overall reported SP/Fansidar use was extremely low at 6.3%. A striking 69.0% of women reported no ANC visits during their last pregnancy, while 22.0% reported 1-3 visits, and only 9.0% reported 4 + visits. Reported SP/Fansidar use was highest among women with 1-3 ANC visits (e.g., 10.5%), significantly lower in those with 4 + visits (e.g., 4.2%), and lowest among those with no ANC visits (e.g., 1.8%). Multilevel analysis revealed that nulliparous women had significantly lower odds of reported SP use (AOR = 0.6; 95% CI 0.4-0.9) compared to women with 1-3 children. Women attending 4 or more ANC visits had significantly lower odds of reported SP use (AOR = 0.38; 95% CI 0.25-0.58) compared to those with no ANC visits. Women whose husbands had no education also had lower odds (AOR = 0.68, 95% CI 0.51-0.91), while women whose husbands were unemployed had higher odds (AOR = 1.6, 95% CI 1.32-2.1). Compared to the poorest, women in the fourth wealth quintile had lower odds (AOR = 0.51, 95% CI 0.29-0.89). Nomadic women had higher odds than rural women (AOR = 3.7, 95% CI 2.2-6.4). Profound regional disparities were observed, with significantly lower reported SP use in many regions compared to Awdal. Community-level factors explained 7.4% of the residual variance (ICC = 7.4%) in the overall model.</p><p><strong>CONCLUSION:</strong> The overall reported use of SP/Fansidar in Somalia is critically low, indicative of significant gaps in maternal healthcare delivery and falling far short of WHO coverage goals. This is fundamentally driven by the very low overall ANC attendance rate (31.0%) and further exacerbated by paradoxical findings, such as lower reported SP use among those who do attend, despite higher ANC attendance, which suggest severe systemic barriers and potential issues with service quality or SP availability. Interventions are needed to improve both initial access to ANC and the quality of ANC delivery, ensure SP availability and administration during visits, address regional inequities, and strengthen the health system to protect pregnant women and newborns from malaria.</p>