Institutional and home delivery practices and their predictors among women in Benadir region, Somalia: a community-based cross-sectional study

Background Somalia has one of the highest maternal mortality rates globally, driven by decades of conflict, fragile health systems and limited access to skilled birth attendance. Institutional delivery services are critical in preventing maternal and neonatal deaths, yet their utilisation remains low. This study aimed to assess the level and predictors of institutional delivery among women in the Benadir Region of Somalia. Methods A community-based cross-sectional study was conducted from February to April 2025 in four purposively selected peripheral districts of northern Benadir: Heliwa, Karaan, Warta Nabadda and Yaqshid. A total of 710 women who gave birth in the past 12 months were selected using multistage sampling. Data were collected through structured questionnaires and analysed using Poisson regression with robust variance to estimate adjusted prevalence ratios (aPRs) and 95% CIs. Statistical significance was set at p<0.05. Results Institutional delivery accounted for 292/710 (41.1%) of births. Women who attended antenatal care (ANC) were more than three times as likely to deliver in a health facility (aPR=3.20; 95% CI 2.30 to 4.40), those aware of obstetric danger signs had two times the likelihood (aPR=2.00; 95% CI 1.50 to 2.70), and living within walking distance significantly increased facility delivery (aPR=3.01; 95% CI 2.10 to 5.02). Conversely, women lacking formal education were far less likely to deliver in a facility (aPR=0.19; 95% CI 0.09 to 0.58). Home delivery in Benadir is mainly driven by cost and access barriers (distance/transport/sudden labour), with comfort and cultural preferences also important, while gender-related concerns are less common. Conclusion Institutional delivery in Benadir remains low. Strengthening ANC coverage, improving community awareness of danger signs and addressing geographic and financial barriers are essential to increase facility-based births.