From Fragmented Projects to an Integrated, Conflict-Sensitive Reproductive Health System for Women in Somalia

Abstract

Women and girls in Somalia face reproductive health risks that are intensified by protracted conflict, displacement, climate shocks, poverty and, since 2025, sharp contractions in humanitarian funding. Reproductive healthcare in emergencies is still often reduced to maternal delivery services, although women’s needs extend from adolescence through pregnancy, family planning, care after violence, female genital mutilation (FGM)-related care and later reproductive life. This commentary examines the main barriers to reproductive healthcare and proposes health system and policy actions to make care fairer and more continuous for women in Somalia. It is a narrative, policy-oriented synthesis of peer-reviewed studies, national survey analyses and United Nations and government documents, prioritizing evidence from 2020 to 2026. The evidence suggests that access gaps persist not only because services are scarce, but because they are short-term, donor-dependent, designed for settled populations, weakly connected across levels of care, and poorly measured for the women least likely to be reached: displaced, rural, nomadic and adolescent women among them. We argue that Somalia needs one nationally defined, conflict-sensitive reproductive health system, anchored in primary healthcare, protected from funding shocks and accountable to women. Seven priority actions are proposed, with lead actors and indicators. Respectful and confidential care, informed choice and the meaningful participation of women must guide implementation, because reproductive health is central to women’s dignity, protection and participation in Somali society.

Introduction

Reproductive healthcare is among the first essential services to be disrupted during armed conflict and humanitarian emergencies. In Somalia, insecurity, repeated droughts and floods, population displacement, economic hardship and shortages of health workers have created a setting in which preventable reproductive morbidity and mortality remain unacceptably high. The 2023 inter-agency estimate placed Somalia’s maternal mortality ratio at approximately 563 deaths per 100,000 live births, far above the Sustainable Development Goal target of fewer than 70 deaths per 100,000 live births by 2030.^1,2 Only a minority of births are attended by trained health professionals, and access to quality services is most constrained for nomadic, rural, poor and displaced women.^3,4

The evidence base on Somali women’s use of services has grown quickly since the 2020 Somali Health and Demographic Survey (SHDS).⁵ One national analysis found that only 7.0% of women with a recent birth attended four or more antenatal visits, and that nomadic and rural women had 90% and 70% lower odds, respectively, than urban women.⁴ Among 2432 ever-married women who had a live birth in the five years before the survey, 9.7% had four or more antenatal contacts, 2.8% had both four or more antenatal contacts and skilled attendance at birth, and only 14 women (0.6%) also received postnatal care within 48 hours, thereby completing the maternity continuum of care.⁶ This 0.6% figure describes a restricted sample (ever-married women with a recent birth), uses a strict three-part definition, and rests on a small numerator; it is best read as evidence of very low continuity of care rather than as a precise national estimate, and it is not directly comparable with analyses that use different denominators or thresholds. Wealth-related inequalities across antenatal, facility childbirth and postnatal care are also large,⁷ and studies of displaced populations point to poverty, transport costs, insecurity, weak referral and shortages of female providers as recurring barriers.^8,9

Most of this evidence, however, concerns pregnancy and childbirth. Recent commentaries and reviews have examined maternal and neonatal mortality, emergency obstetric care and referral in Somalia.^10–12 Much less attention has been given to reproductive health needs that extend beyond childbirth: adolescent reproductive health, voluntary family planning, menstrual health, care after gender-based violence (GBV), FGM-related care, and infertility and gynaecological conditions. What is also missing from current policy discussion is an explanation of why services continue to leave women out even where humanitarian programmes are present, and how short, separate projects could be replaced by a continuous system of care. Reproductive health services are typically funded, implemented and monitored as separate projects with their own targets, reporting lines and time-limited grants, so a woman who obtains one service may find that the next service she needs is unavailable, unaffordable or not offered to women like her.

Short, separate programmes are not enough for three reasons. First, reproductive health needs are connected across the life course: a girl’s protection from early marriage and violence, her access to accurate information, her ability to space pregnancies, the quality of her childbirth care and the treatment of later gynaecological problems all shape one another. Second, in a setting of recurrent displacement, continuity is what women lose first; a project that closes, relocates or changes its implementing partner interrupts the follow-up on which contraception, postnatal care and survivor support depend. Third, financing that depends on annual appeals is now failing: the United Nations Population Fund (UNFPA) reported in mid-2025 that its appeal for Somalia had received only 3% of its target and that mobile outreach had halted,¹³ and the United Nations Children’s Fund (UNICEF) reported in August 2026 that 205 health and nutrition facilities had closed after unprecedented aid cuts, with as many as 618 facilities at risk under severe funding scenarios.¹⁴ These gaps matter beyond clinical outcomes. Without continuity of care, women lose control over the timing of pregnancy, survive childbirth with untreated morbidity and remain exposed to violence and harmful practices, which limits their participation in education, livelihoods and community life.

This commentary examines the main barriers to reproductive healthcare and proposes health system and policy actions to make care fairer and more continuous for women in Somalia. It adds to existing work in three ways. It takes the whole reproductive life course, rather than pregnancy and childbirth, as its unit of analysis. It explains why access gaps persist despite humanitarian programmes and which women are missed. And it translates the analysis into seven priority actions with lead actors and indicators that can be used by policymakers and partners.

Approach to the Commentary

This commentary is a policy-oriented narrative synthesis, not a systematic review. It draws on three types of evidence: (i) peer-reviewed studies, mainly secondary analyses of the 2020 SHDS together with qualitative and cross-sectional studies of displaced and pastoralist populations; (ii) national strategies, survey reports and United Nations situation and funding statements; and (iii) technical guidance from the World Health Organization (WHO), UNFPA, UNICEF and the Inter-Agency Working Group on Reproductive Health in Crises. Sources were identified through targeted searches of PubMed and Google Scholar and of the websites of these organizations and the Federal Ministry of Health and Human Services, combining “Somalia” with terms such as reproductive health, antenatal care, family planning, adolescent, gender-based violence, female genital mutilation, displacement, nomadic and humanitarian funding. Priority was given to sources published between 2020 and September 2026, because the 2020 SHDS is the first national survey of its kind in Somalia; older sources were retained only where they provide foundational frameworks or clinical guidance. Sources were selected for relevance to Somalia or to conflict-affected settings, recency, and institutional or methodological credibility, and studies of groups that are easily missed, such as displaced, nomadic and adolescent women, were deliberately sought. The evidence was synthesized thematically. The interpretive arguments and priority actions are the author’s own reasoning from this evidence and should be tested through implementation research.

Conflict and Displacement as Reproductive Health Determinants

Conflict affects reproductive health through several pathways. Health facilities may close, staff may leave insecure areas, transport routes may become unsafe, and households may lose the income required to pay for consultations, medicines, blood, surgery or travel. Displacement separates women from familiar providers and social support while exposing them to overcrowded settlements, weak sanitation, food insecurity, sexual violence and limited privacy. Humanitarian services may be concentrated in accessible locations, leaving women in remote settlements, contested districts and nomadic communities outside the effective reach of care. Somalia’s humanitarian response has repeatedly been constrained by insecurity, access limitations, workforce shortages and fragmented coordination.^15,16 Studies and reviews of displaced populations identify poverty and transport costs, geographic inaccessibility, insecurity, low female autonomy, cultural preferences, shortages of female and skilled providers, weak referral, stock-outs and limited service readiness as overlapping barriers.^8,9 A qualitative study in Mogadishu’s displacement settings added lack of privacy, negative experiences of care, facilities that close for part of the day and women’s reluctance to be seen by male health workers.¹⁷

These barriers are cumulative rather than isolated. The familiar “three delays” (in deciding to seek care, in reaching care and in receiving appropriate treatment) are magnified in conflict-affected environments,¹⁸ and for displaced women fear of violence, eviction, stigma, clan-based exclusion and loss of documentation may add further barriers. Because the health-system pathway from these delays to maternal and neonatal death has been examined in detail elsewhere,^10,12 this commentary concentrates on what that literature leaves less developed: the reproductive needs of women beyond childbirth, and the reasons why gaps persist.

Reproductive Health Needs Across the Life Course

Pregnancy, Childbirth and the Postnatal Period

Antenatal care offers a platform for detecting hypertension, anaemia, infection and fetal risk, and for birth preparedness, counselling and linkage to postnatal and family planning services. In Somalia the problem is both low and unequal coverage: coverage of four or more antenatal visits was 1.4% among nomadic women, compared with 9.2% among urban women.⁴ Facility childbirth and early postnatal care are similarly unequal. In an analysis of 8598 ever-married women, 24.2% delivered in a health facility and 10.9% received postnatal care within two days; nomadic women had about half the odds of facility delivery and early postnatal care (adjusted odds ratios 0.45 and 0.49), and all three indicators were concentrated among wealthier women.⁷ Increasing the number of contacts without improving their content will not be sufficient; each contact should deliver defined clinical actions, danger-sign counselling and a documented plan for delivery and emergencies.¹⁹ The emergency obstetric, referral and blood-supply requirements of safe childbirth are analysed in detail in recent work^10,12 and are addressed here only where they intersect with the wider reproductive health agenda. Postnatal care deserves particular attention because it is frequently overlooked even though it is the natural entry point for contraception, mental health support and the treatment of birth injuries.

Voluntary Family Planning and Healthy Birth Spacing

Voluntary family planning is a life-saving component of reproductive healthcare, but it remains culturally sensitive and poorly accessible in many Somali settings. A national analysis of the 2020 SHDS reported an unmet need for contraception of 37.2% among married women of reproductive age, with higher unmet need among women who had five or more children and in the central and southern regions.²⁰ Programmes should avoid language that is perceived as coercive or hostile to family values. Counselling framed around healthy timing and spacing of pregnancies, maternal recovery, child wellbeing, informed choice and religiously respectful discussion may be more acceptable. Women must be offered confidential, non-directive information on a range of methods, including expected benefits, side effects, return to fertility and the right to decline or discontinue a method.²¹ Engagement of husbands, religious scholars, elders and women’s groups can reduce misinformation, but women’s consent and confidentiality must remain central. Family planning should be integrated into antenatal, postnatal, immunization, nutrition, post-abortion and primary care services rather than offered only through separate campaigns.

Adolescent Reproductive Health and Menstrual Health

A maternal-health-only model fails adolescent girls, unmarried women and women living with gynaecological conditions. Analyses of the 2020 SHDS indicate that teenage pregnancy is highly prevalent and varies by region, education and household wealth,²² so many girls enter pregnancy and childbirth, the highest-risk part of the reproductive life course, without prior access to accurate information or contraception. Adolescent-friendly services should provide accurate information on menstruation, puberty, anaemia and infection prevention, protection from child marriage and violence, and timely referral, and should be confidential, non-judgmental and linked to schools, youth networks and community platforms. Menstrual health is a neglected element of this agenda. A scoping review of refugee women and girls in Africa describes limited access to menstrual products, adequate water, sanitation and hygiene infrastructure, and menstrual health education among displaced populations,²³ and Somali-specific evidence is sparse. Infertility, gynaecological infections and cancers, and the needs of women in later reproductive life are similarly rarely captured in humanitarian service packages or national indicators; in the sources consulted for this commentary, Somali evidence on them was very limited, which is itself an equity gap because women with these conditions are seldom counted or served.

Gender-Based Violence and Survivor-Centred Care

Displacement increases exposure to violence, and reproductive health services are often a survivor’s first point of contact with the health system. A cross-sectional study in displacement camps in Deynile district, Mogadishu, found that nearly one in five women had experienced GBV in the previous 12 months, most commonly physical abuse committed by intimate partners or family members, with reproductive problems among the reported consequences.²⁴ Health facilities must therefore be able to provide confidential clinical management of sexual violence, including emergency contraception, and referral to protection and psychosocial services.²⁵ Because survivors are often hesitant to disclose, privacy, female providers and a non-judgmental response are part of the clinical intervention, not optional additions.

Female Genital Mutilation

Somalia carries one of the highest burdens of FGM in the world. The 2020 SHDS relies on women’s self-report and uses categories (Sunni, intermediate and Pharaonic) adapted from the WHO typology; it found that 99.2% of women aged 15 to 49 years reported having undergone some form of FGM, and roughly two in three reported the most extensive type.⁵ UNICEF’s 2025 reporting gives a similar national figure and describes recent legal developments.²⁶ These are survey-based estimates of lifetime prevalence among women of reproductive age; they describe how common the practice is, not the clinical status of any individual woman. Health consequences vary with the type of cutting, the age and circumstances of the procedure, and later obstetric and psychological experience. Many women will need no specialized intervention, whereas others will need management of pain, urinary, menstrual or sexual problems, psychological support, or specific care in pregnancy and childbirth, including deinfibulation where clinically indicated and consented to.²⁷ Care should therefore be individualized, survivor-centred and guided by each woman’s own needs and choices rather than by an assumption that all consequences occur uniformly. Health workers should never medicalize or perform FGM, and prevention efforts should combine legal protection, survivor voices, religious engagement, community dialogue and referral pathways.

Why Access Gaps Persist Despite Humanitarian Programmes

Humanitarian agencies have delivered substantial reproductive health services in Somalia, yet the gaps described above persist. Five features of the current system help to explain why.

Financing is Short-Term and Volatile

Many facilities depend on short-term humanitarian funding. UNFPA noted in 2025 that only about 30% of facilities were fully functional and providing emergency obstetric care, that mobile outreach had halted and that its appeal was 3% funded.¹³ By August 2026, 205 health and nutrition facilities had closed.¹⁴ Outreach and mobile teams, which are the main route to remote and nomadic women, are among the services withdrawn when funds fall, so funding cuts widen inequity as well as reducing coverage.

Programmes are Fragmented and Vertical

Parallel projects with different targets, incentives and data systems produce repeated assessments, incompatible reporting and abrupt interruptions when a grant ends. UNFPA’s 2025 reporting describes a context in which climate shocks, displacement and funding constraints continued to challenge service delivery despite sustained maternal health, family planning, youth and GBV programmes.²⁸ A woman’s needs cross these programme boundaries, but referral between them is rarely designed or funded.

Services are Designed for Settled, Accessible Populations

Fixed facilities and appointment-based schedules assume that women live near a facility and can return on a set date. Nomadic women in the national analyses had markedly lower antenatal coverage and about half the odds of facility childbirth and early postnatal care.^4,7 A qualitative study of a pastoralist community in Mudug region described staff-, supply- and referral-related constraints, including the absence of an ambulance and blood in the local maternal and child health clinic.¹⁵

What is Measured Determines Who is Seen

National indicators emphasize contact with services rather than completion of care, and averages conceal subgroups. Even the national antenatal care analysis acknowledges that nomadic and hard-to-reach populations may still be undersampled,⁴ so women in the places most affected by conflict are the least visible in the data on which planning depends. Studies also use different denominators and thresholds, as the 0.6% completion estimate illustrates, which makes it difficult to hold programmes to a shared standard.

Women’s Experience of Care Shapes Whether They Return

Continued use of services depends on privacy, respectful treatment and the availability of female providers. Displaced women report lack of privacy, negative experiences of care and reluctance to be examined by male health workers,^8,17 and where care is disrespectful or short-lived women have less reason to return for the next service.

Table 1 summarizes which women are most likely to be missed and which features of the system account for their exclusion.

Table 1.

Women at Risk of Being Missed by Reproductive Health Services in Somalia and the System Features Behind Their Exclusion

Group of women	What the evidence shows	System features that leave women out
Displaced women	Poverty and transport costs, insecurity, limited privacy, low autonomy and shortages of female providers limit use of services;8,9,17 nearly one in five women in a Mogadishu camp study reported GBV in the previous year.24	Services tied to short-term grants and partner presence; facilities that close or relocate; weak referral and GBV pathways; loss of follow-up when women move.
Rural women	70% lower odds of four or more antenatal visits than urban women;4 lower facility childbirth and early postnatal care.7	Facilities and skilled staff concentrated in towns; transport costs; stock-outs.
Nomadic women	1.4% attended four or more antenatal visits, against 9.2% of urban women;4 about half the odds of facility childbirth and early postnatal care.7	Fixed, appointment-based facilities designed for settled populations; irregular outreach.
Poorer women	Antenatal care, facility childbirth and early postnatal care are concentrated among wealthier women.7	Fees and indirect costs; limited financial protection for emergency care.
Adolescent girls	Teenage pregnancy is highly prevalent and varies by region, education and wealth.22	Services oriented to married women and pregnancy; little confidential, youth-friendly care.
Women in insecure or remote areas	Nomadic and hard-to-reach populations may be undersampled in national surveys.4	Access constraints for providers and data collectors; national averages conceal these women.
Survivors of GBV or FGM; women with infertility or gynaecological conditions	GBV is common in camp settings;24 FGM is near-universal;5 Somali evidence on infertility and gynaecological conditions is scarce.	Reproductive health defined narrowly as maternal care; these needs are rarely captured in packages or indicators.

Abbreviations: FGM, female genital mutilation; GBV, gender-based violence.

What This Commentary Adds and How it Differs from Recent Work

Three recent Somali publications are closest to this commentary. A policy-oriented commentary in this journal analysed maternal and neonatal mortality through the Three Delays Model and the WHO health-system building blocks and called for accountable referral networks;¹⁰ a narrative review examined maternal and newborn health-system challenges and public health priorities;¹¹ and a policy review examined emergency obstetric and newborn care, rural access and referral.¹² These works concern survival around pregnancy, birth and the newborn period.

The present commentary differs in three respects. In scope, it takes the whole reproductive life course: adolescent and menstrual health, voluntary family planning, care after violence, FGM-related care, and infertility and gynaecological conditions are treated as core reproductive health work, while maternal and neonatal health-system topics such as referral, blood supply and death surveillance are treated briefly and referred to those sources. In analytical lens, it asks why gaps persist despite humanitarian programmes and which women are missed, using financing, fragmentation, design for settled populations, measurement and the experience of care as explanatory factors, and it draws on the 2025 to 2026 contraction in humanitarian funding as an explanatory factor. In its recommendations, it centres women’s rights, choice and participation and specifies lead actors and indicators (Table 2). Its contribution to policy is therefore an integrated package and accountability framework that can be embedded in national planning, including the Somalia Community Health Strategy 2025 to 2029,²⁹ rather than a further set of condition-specific recommendations.

Table 2.

Priority Actions, Lead Actors and Indicators of Progress

Priority Action	Key Steps	Lead Actors	Indicators of Progress
1. Essential package in every crisis	Agree a nationally defined package covering the reproductive life course; include it in preparedness plans; pre-position supplies and backup power.	Federal Ministry of Health and Human Services with state ministries; health partners; UNFPA; WHO.	Proportion of districts providing the full package without interruption; package included in state preparedness plans.
2. Midwives, female workers, supervision	Fund posts and salaries; deploy to underserved districts; supportive supervision; explicit task-sharing scopes.	Federal and state ministries; training institutions; professional associations.	Female skilled providers per 10,000 population by district; supervision visits completed; 12-month retention.
3. Referral, transport, blood	District referral maps; transport vouchers or community funds; communication links; blood and anaesthesia at referral sites.	District health authorities; referral hospitals; partners.	Referral completion; time from decision to treatment; referral facilities with blood and anaesthesia.
4. Services for displaced, rural, nomadic women	Predictable mobile and outreach services under multi-year contracts; embed in the Community Health Strategy.	Federal Ministry of Health and Human Services; community health workers; partners; local leaders.	Service contact and completion among displaced and nomadic women compared with urban women; outreach visits held vs planned.
5. Respectful, confidential, culturally responsive care	Respectful care standards; consent and confidentiality; female providers; complaint mechanisms; women’s participation in design.	Facility managers; professional bodies; women’s organizations.	Women-reported experience of care; complaints resolved; female provider available.
6. Commodities and equity data	Minimum stock levels and early-warning dashboards; data disaggregated by age, displacement, residence and disability; completion-of-care indicators.	Ministry supply-chain and information units; UNFPA; partners.	Stock-out days; disaggregated indicators published; completion of care by group.
7. Financing and accountability	Multi-year pooled financing; continuity and transition clauses in partner contracts; protection from fees for emergency care; death surveillance and response.	Ministries of health and finance; donors; implementing partners.	Share of the essential package with multi-year funding; out-of-pocket payments; deaths reviewed with actions completed.

Abbreviations: UNFPA, United Nations Population Fund; WHO, World Health Organization.

Priority Actions

Seven actions follow from this analysis. Table 2 summarizes the key steps, lead actors and indicators for each. Their common logic is consistent with a review of displaced populations in Somalia, which concludes that integrated, equity-focused strategies combining community engagement, gender-sensitive care, functional referral and better coordination between humanitarian and government actors are needed.⁸

Guarantee an Essential Reproductive Health Package During Every Crisis

Federal and state health authorities, humanitarian agencies and private providers should agree on a minimum package that remains available during conflict, displacement, epidemics, droughts and floods. It should cover the reproductive life course: antenatal and postnatal care, skilled delivery, emergency obstetric and newborn care, clinical management of sexual violence, voluntary contraception, post-abortion care within the law and clinical standards, sexually transmitted infection services, adolescent and menstrual health support, FGM-related care, and referral for infertility and gynaecological conditions. The package should be incorporated into preparedness plans and pre-positioned with medicines, supplies, delivery kits, blood-transfusion materials and backup power.²⁵

Strengthen Midwifery, Female Health Workers and Supportive Supervision

Somalia needs sustained investment in competent midwives, nurses, anaesthesia providers, obstetric clinicians, laboratory personnel and community health workers. Recruitment should prioritize underserved districts and women from local communities. Training alone is insufficient: providers require salaries paid on time, safe accommodation, equipment, continuing professional development, supportive supervision, referral authority and protection from violence. Task-sharing can expand access only when scopes of practice, supervision, medicines and escalation pathways are explicit.

Build Functional Referral, Transport, Blood and Communication Networks

Every district should have a current referral map that identifies operating facilities, hours, clinical capabilities, transport options, costs and alternatives when a route is insecure. Voucher systems, community emergency funds, ambulances, contracted local transport, radio or mobile communication and maternity waiting spaces can reduce delays. Blood availability, safe transfusion, surgical capacity and reliable anaesthesia should be treated as core reproductive health infrastructure. The design and monitoring of these networks are examined in detail elsewhere,^10,12 and this commentary emphasizes only that referral must also serve women whose needs are not obstetric, such as survivors of violence.

Bring Services Closer to Displaced, Rural and Nomadic Women

Fixed facilities should be complemented by mobile teams, outreach clinics, community distribution and scheduled visits adapted to displacement patterns and pastoral mobility. Outreach must be predictable, funded through multi-year contracts and linked to referral facilities; occasional campaigns without follow-up can identify needs without resolving them. The national antenatal care analysis likewise recommends expanding mobile services for nomadic and rural women.⁴ The Somalia Community Health Strategy 2025 to 2029 offers an opportunity to embed reproductive health functions in a nationally supported community platform.²⁹

Make Care Respectful, Confidential and Culturally Responsive

Poor treatment, lack of privacy, informal fees, absence of female providers and fear of judgement can discourage women from returning. Facilities should implement standards for respectful care, informed consent, confidentiality, disability inclusion, language access and complaint mechanisms. Community dialogue should involve women, adolescents, men, religious leaders, traditional birth attendants, disability organizations and displaced communities. Cultural responsiveness should build trust without compromising women’s safety, autonomy or evidence-based care.

Secure Commodities and Use Data for Equity

Stock-outs of oxytocin, magnesium sulfate, antibiotics, contraceptives, emergency contraception, pregnancy tests, menstrual materials and infection-prevention supplies can render a staffed facility clinically ineffective. Procurement systems should use minimum stock levels, early-warning dashboards, decentralized reserves and transparent reporting. Data should be disaggregated by age, location, displacement status, disability, residence type and service stage, with denominators and definitions stated. Indicators should measure not only contacts but completion of the care continuum,⁶ quality, referral outcomes, severe maternal morbidity, respectful care and deaths reviewed with actionable follow-up.

Protect Financing and Accountability

Women should not face catastrophic out-of-pocket costs for life-saving reproductive care. Government budgets, pooled donor financing, strategic purchasing and agreements with private facilities should prioritize free or affordable emergency obstetric care, referral, blood and essential medicines, and should protect the essential package from annual appeal cycles, whose costs are visible in the facility closures that followed the 2025 to 2026 aid cuts.¹⁴ Contracts with implementing partners should include continuity requirements, transparent geographic coverage, community feedback and transition arrangements when grants close. Maternal and perinatal death surveillance and response should be strengthened as a learning and accountability mechanism, not a punitive exercise.

A Rights-Based and Conflict-Sensitive Way Forward

Reproductive health decisions are shaped by gender norms, safety, household power, poverty, mobility and trust. Programmes should therefore avoid treating Somali women as passive beneficiaries. A rights-based approach means that women can choose whether and when to have children, receive respectful and confidential care, make informed decisions without coercion, and take part in the design, monitoring and evaluation of services. Women’s organizations, midwives, adolescents, displaced women, women with disabilities, FGM survivors and rural communities should hold defined roles in these processes, with feedback mechanisms that lead to visible changes.

Conflict-sensitive planning must also assess whether facility location, staffing, fees, partner selection and aid distribution unintentionally exclude particular clans or communities, and must be prepared for services to be interrupted by insecurity, displacement or funding shocks. A system that anticipates such interruptions, through pre-positioned supplies, portable records and agreed handover between partners, protects continuity for women when circumstances change.

Limitations

This commentary has several limitations. Sources were purposively selected rather than identified through a systematic search, so relevant evidence may have been missed and selection may reflect the author’s judgement. Most quantitative evidence derives from the 2020 SHDS, which predates the 2025 to 2026 contraction in humanitarian funding, so current coverage may be lower than reported; nomadic and hard-to-reach women may be undersampled in national surveys.⁴ Somali evidence on menstrual health, infertility and gynaecological conditions was very limited in the sources consulted, and several sources are reports and press statements rather than peer-reviewed studies. Finally, the priority actions are reasoned from the available evidence and have not been costed or tested; they require implementation research and prospective evaluation.

Conclusion

For a displaced woman, the reforms proposed here would mean that antenatal, contraceptive and survivor services remain reachable when she moves, rather than ending when a project closes. For a rural or nomadic woman, they would mean outreach that returns on a predictable schedule, a female provider she can trust and a referral route that exists in practice as well as on paper. For an adolescent girl, they would mean accurate information and confidential care before her first pregnancy rather than after it, and protection from violence and harmful practices. For a woman living with the consequences of FGM, or with infertility or a gynaecological condition, they would mean being counted and treated as part of the health system’s core work rather than as an exception. In each case the test of success is not the number of contacts recorded but whether women can choose whether and when to have children, receive respectful care, make informed decisions and help to design and judge the services they use. Somalia should move away from short, separate reproductive health projects, and build one connected, fair, lasting, and accountable health system that supports women through every stage of life.

Funding Statement

The author received no specific funding for this work.

Abbreviations

FGM, female genital mutilation; GBV, gender-based violence; SHDS, Somali Health and Demographic Survey; UNFPA, United Nations Population Fund; UNICEF, United Nations Children’s Fund; WHO, World Health Organization.

Data Sharing Statement

No original dataset was generated or analysed for this commentary.

Ethical Approval

Not applicable. This article is a commentary based on previously published literature and publicly available reports.

Author Contributions

The author made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; has agreed on the journal to which the article has been submitted; and agrees to be accountable for all aspects of the work.

Disclosure

The author declares no competing interests.