Accessible, available, affordable, and culturally appropriate healthcare services are essential for all individuals, and particularly crucial for vulnerable populations such as pregnant women and their infants, who have specific healthcare requirements (1, 2). The understanding of “access” is more effectively communicated through three interconnected dimensions: availability, affordability, and acceptability (3). In essence, healthcare access exists when services are sufficiently available and when individuals have a realistic opportunity to receive that care. However, barriers to accessing these services can arise from a variety of sources, including financial, organizational, social, or cultural strains within the community (4). Access to comprehensive and high-quality healthcare is vital for promoting good health, decreasing the likelihood of disabilities, preventing and managing illnesses, and advancing health equity (5).

The international health community is aiming for an ambitious goal of achieving Universal Health Coverage (UHC) by 2030, but progress in health service coverage has shown no improvement since 2015. Specifically, in 2021, approximately 4.5 billion individuals lacked complete access to necessary health services. Adding to this challenge, the financial impact of healthcare remains substantial, with an estimated 2 billion people facing catastrophic health expenditures or impoverishment due to out-of-pocket costs in 2019 (6). These issues directly undermine the objectives outlined in Sustainable Development Goal-3 (SDG-3), particularly targets 3.8 and 3.7. These targets highlight the importance of achieving UHC and ensuring access to sexual and reproductive health services – including family planning information and education – as well as the incorporation of reproductive healthcare into national strategies and initiatives by 2030 (6, 7). Indeed, the consequences of inadequate healthcare access are far-reaching: globally, about 400 million individuals face challenges in accessing healthcare services, resulting in eight million deaths from preventable health conditions annually. This issue is especially severe in low- and middle-income nations, leading to a significant economic impact estimated at approximately six trillion USD (8).

The World Health Organization and the World Bank report that approximately 50% of the world's population remains unable to obtain essential health services. This lack of access significantly contributes to poverty, with healthcare expenditures driving 100 million individuals into extreme poverty annually (9). This situation is particularly acute in sub-Saharan Africa, where access to healthcare stands at just 42.56% (10), demonstrating a significantly low level of coverage. Studies have identified numerous interconnected factors that limit access to healthcare, including financial constraints, geographical barriers, the mother's education level, health insurance coverage, the husband's education, a woman's marital status, place of residence, stigma-related matters, and the number of children in the family (11–14).

Reflecting these broader trends, maternal health challenges persist as a major issue and represent ongoing priorities from the MDGs for economically disadvantaged nations like those in Africa (15, 16). In 2015, the Sub-Saharan region experienced a significant impact, with a mortality rate of 546 per 100,000 live births (14, 17). As previous studies indicated, maternal and child mortality a consequences of insufficient utilization of healthcare services in countries (18). While the proportion of women receiving four or more antenatal care (ANC) services in developing regions averages 52%. However, sub-Saharan Africa lags, with only 49% of women receiving this level of care (19). East Africa has demonstrated notable advancements in reducing maternal mortality, with a 48% decline in the maternal mortality ratio since 2000. However, notable disparities within the region still exist. The variation in maternal mortality ratios, from a low (3 deaths per 100,000 live births) in Seychelles to a high (1,223 deaths per 100,000) in South Sudan, highlights the ongoing challenges in achieving equitable maternal health outcomes across the region (20, 21). Consequently, women in sub-Saharan Africa are not utilizing fundamental healthcare services to the necessary extent, leading to inadequate coverage of maternal health services and impacting the well-being and survival of both mothers and infants (22).

Somaliland, a nation with limited financial resources, faces challenges related to both infectious and non-infectious illnesses, as well as issues concerning maternal, neonatal health, and nutrition (23). According to the 2020 Somaliland demographic and health survey, a substantial number of women (67.9%) encounter at least one barrier when seeking healthcare. Among these challenges, women reported financial constraints as their primary obstacles to healthcare access (61.1%), and distance to health facility as a major issue for women (58%) (24). Moreover, the healthcare system in Somaliland encounters a range of obstacles, including inadequate investment in health, limited technical proficiency in research design, data gathering, and analysis, as well as challenges in disseminating and effectively utilizing evidence-based research (25).

Due to medical complications, obstetric hemorrhage, infections related to pregnancy, and hypertensive conditions, Somaliland has a high maternal mortality rate, where approximately 396 maternal deaths occur per 100,000 live births, ranking highly on a global scale but below certain comparable countries (23, 26). Improving health research systems enhances comprehension of population health requirements through the recognition of socio-cultural obstacles to accessing health services, discrepancies between the community and the present healthcare system influencing healthcare provision, and barriers within the system (27, 28).

Recognizing this need, according to our understanding, no published studies are available concerning the obstacles to accessing healthcare among women of reproductive age in Somaliland. This study, therefore, aims to bridge this critical knowledge gap by rigorously examining the obstacles to healthcare access faced by women of reproductive age in Somaliland. Utilizing data from the nationally representative 2020 Somaliland Demographic and Health Survey (SLDHS), this research seeks to identify the key barriers and associated factors that impede women's access to essential healthcare services. Through this in-depth analysis, the study intends to provide actionable insights for policymakers and healthcare providers, informing the development of targeted interventions that can improve healthcare access, reduce maternal mortality, and ultimately contribute to achieving Universal Health Coverage (UHC) in Somaliland.

This study, conducted in Somaliland, investigated the problems women of reproductive age face in accessing healthcare. Utilizing data from the 2020 Somaliland Demographic Health Survey, the research revealed that approximately 75% of women reported experiencing difficulties in accessing healthcare for at least one of four reasons: financial constraints, distance to healthcare facilities, the need for treatment permissions, and the requirement for a companion. The most frequently cited obstacles were financial constraints (69.41%) and geographic distance from health facilities (66.01%).

The current study's magnitude was substantially less than the 93.6% reported by the Ethiopian demographic and health survey (EDHS) in 2011 (39). However, despite international attempts to provide universal health access for all people, the results of the current study indicated a greater magnitude of perceived barriers. Furthermore, this result was higher than those reported in the studies from Tanzania 65% in 2018 (40), 64.5% in South Africa (41), 64% in Rwanda (42), and 51% in Ghana (43), and 45% in Gambia (11). This can be explained by the sociocultural and economic differences between nations, which may influence on how people seek health care (44). While universal health facility coverage is a fundamental requirement for all populations, significant disparities in access and utilization of healthcare services persist among women of reproductive age. These inequities pose a substantial challenge to achieving the Sustainable Development Goals (SDGs), particularly those focused on equitable service provision and universal access to reproductive health care.

Based on the comparison of the four models, Model III, which includes both individual and community-level variables provide the best overall fit according to multiple criteria: Model III has the lowest Akaike Information Criterion (AIC = 3850), along with the highest log-likelihood value (-1,895). According to Model III, this study has demonstrated that healthcare access barriers in Somaliland among women of reproductive age are determined by several individual and community-level factors, including region, age, wealth quantile, education, husband's employment, contraceptive use, and number of children ever born.

Healthcare access for women in Somaliland is significantly determined by a complex interplay of factors, including education, spousal employment, and household wealth. We found that age and healthcare accessibility barriers were correlated, with women 25–29, 35–39, and 40–44 years old having a higher likelihood of reporting healthcare access difficulties than women 15–19 years old. This result is comparable to research conducted in Malaysia and Nigeria (45, 46). A possible explanation for this disparity is that older women are more susceptible to geographical barriers, particularly the long distances required to reach healthcare facilities in peripheral regions. Furthermore, compared to younger cohorts, older women may experience higher levels of financial instability and economic dependency, further limiting their ability to access care.

We further found that women with higher levels of education are linked to higher odds of healthcare access problems compared to those with lower levels of education. Higher levels of education can lead to greater awareness and improved health-seeking behavior in women. This is a consistent study established in Bangladesh (12) and Ethiopia (13). Additionally, we found that access issues to healthcare were substantially correlated with the occupation of the husband. To be more precise, we discovered that women whose husbands were unemployed were less likely to experience difficulties in obtaining healthcare services. This is consistent with a study in Lalitpur, Nepal (47).

The wealth index also affects access to healthcare for Somaliland women of reproductive age, where households with the highest wealth status face greater challenges in accessing healthcare compared to those with the lowest household wealth status. This could reflect higher expectations for the convenience of care, or greater awareness of existing shortcomings in the healthcare system. Consistent with findings from studies in Ethiopia (48) and Sub-Saharan Africa (10). This finding may be driven by the healthcare-seeking behaviors of different economic groups. Wealthier women may have less decision-making autonomy or require male accompaniment to seek care, creating a social barrier to access despite their financial advantage.

Additionally, the region in which respondents reside is strongly associated with the barriers reproductive-aged women encounter in accessing health services. Accessing healthcare is more difficult for women in all regions of Somaliland, like Marodijeh, Togdheer, Sanaag, and Sool, compared to the reference group, which is Awdal. This result is consistent with another study done in Gambia (11).

The study also found that women who were multipara or had ever given birth to more than 4 were less likely to face barriers to accessing medical care. Our results corroborate evidence from prior investigations (49, 50). A possible explanation for this finding is that high parity often correlates with increased female autonomy and decision-making power within the household hierarchy. Unlike younger, low-parity women who may require permission to seek care, multiparous women usually possess the social status and independence to mobilize resources and travel to health facilities, thereby reporting significantly fewer access barriers.

This study, utilizing the first-ever Somaliland Demographic Health Survey (2020), provides crucial baseline insights into the barriers reproductive-aged women face in accessing healthcare within Somaliland. It establishes a vital benchmark against which future progress can be measured, highlighting the significant challenges related to financial constraints and distance to facilities. Regionally within Somaliland, it underscores the urgent need to address equitable service distribution and universal reproductive healthcare access, particularly given the absence of comprehensive prior data in the country. The identification of key factors such as age, education, husband's employment, wealth, parity, and region can inform targeted interventions and policies to improve healthcare access in Somaliland, providing a foundation for evidence-based policy development specifically tailored to the country's unique context.

While this study offers valuable insights, certain limitations warrant consideration. First, the cross-sectional nature of the data limits the ability to establish causal relationships between the identified factors and healthcare access barriers. Second, the reliance on self-reported data may be subject to recall bias and social desirability bias, potentially affecting the accuracy of responses, particularly regarding sensitive topics like contraceptive use and reproductive history. Third, while the study identifies significant associations, it does not explore the underlying mechanisms through which these factors influence healthcare access. Finally, while the multilevel modeling approach accounts for community-level variations, unmeasured contextual factors may still influence healthcare access barriers, and the generalizability of the findings to other settings may be limited due to the unique socio-cultural and economic context of Somaliland.

This study reveals that approximately 75% of reproductive-aged women experience significant barriers to accessing healthcare services. Key factors associated with the difficulties in healthcare access include financial constraints, maternal age, level of education, and socioeconomic disparities. Furthermore, the region in which a woman resides, her husband's employment status, contraceptive practices, and the number of children she has borne also significantly influence her access to healthcare.

These findings necessitate targeted interventions and policy measures tailored to the specific needs of women within different regions and socioeconomic contexts in Somaliland. To achieve equitable access to healthcare, policies must address individual-level factors while also considering the underlying community and regional forces at play.

This requires a multifaceted approach, including prioritizing increased government investment in the healthcare sector, with a specific focus on reproductive health services and infrastructure. It also requires addressing socioeconomic disparities by implementing targeted subsidies and social protection programs to alleviate financial constraints for the most vulnerable women. Furthermore, expanding and strengthening community-based services by deploying mobile health clinics and empowering community health workers to reach remote and underserved populations is crucial. Enhancing healthcare provider capacity through training and capacity building, fostering community ownership and engagement by leveraging the strengths of Somaliland's context, and strengthening data collection and monitoring systems are all essential components.

This research emphasises the crucial role of education and economic status in shaping women's ability to access healthcare services. Lower levels of education and lower wealth indices are associated with higher barriers to healthcare access, indicating the need for targeted interventions to address disparities. The study also underlines the impact of regional disparities, with women in certain regions facing more significant challenges in accessing healthcare compared to others. These disparities emphasise the importance of tailored healthcare strategies that consider the unique contexts and needs of different regions within Somaliland.

Furthermore, the study's multilevel analysis has provided valuable insights into the complicated net of factors influencing healthcare access among reproductive-age women. Factors such as maternal age, husband's employment status, contraceptive practices, and number of children born have emerged as significant predictors of healthcare access barriers. The findings highlight the need for comprehensive strategies that address not only individual-level factors but also community and regional underlying forces to ensure equitable access to healthcare services for all women in Somaliland.

Overall, this research highlights the crucial need for targeted interventions and policy measures to address the identified barriers to healthcare access among reproductive-age women in Somaliland. By understanding the complex web of factors influencing healthcare access, policymakers and healthcare providers can design interventions that are tailored to the specific needs of women in different regions and socioeconomic contexts. Improving healthcare access for women is not just a matter of improving health outcomes but also a crucial step towards achieving health equity and promoting the well-being of vulnerable populations in Somaliland.