Implementation outputs and outcomes of a community-based maternal and newborn care model in rural Galmudug, Somalia: an implementation research study

Maternal and newborn health (MNH) outcomes in Somalia remain among the worst globally, driven in large part by limited access to facility-based care, particularly in rural and underserved communities; approximately one in five births take place in a health facility. To address major MNH service delivery gap in rural Somalia, the International Rescue Committee implemented a community-based maternal and newborn care (CBMNC) program, delivering a package of evidence-based interventions across selected villages. An implementation research study was conducted to generate transferable learning to inform the scale-up of comparable community-based MNH programs in similar low-resource and humanitarian settings. The study triangulated and synthesized data from existing primary research data (e.g. population-based surveys before and after program implementation, qualitative program acceptability study, cost-efficiency analyses), program monitoring data, and program documentation. The data were organized using Proctor et al.s Implementation Research Outcomes Framework, exploring the outcomes of acceptability, appropriateness, feasibility, fidelity, adoption, implementation cost, penetration, and sustainability. The synthesis consisted of meta-summaries across sub-domains under each outcome area. The program delivered through 34 community health workers (CHW) served 1,165 women across a 24-month period. The program demonstrated strong acceptability among participants, who reported trust in CHWs, respect for cultural and religious norms, and tangible improvements in their pregnancy health knowledge. CHWs similarly expressed intrinsic motivation and a sense of fulfillment in their roles, despite notable challenges around workload, geographic barriers, and financial burdens. The model showed reasonable epidemiological and sociocultural fit, though some recommended health behaviors conflicted with entrenched traditional practices, such as avoiding colostrum or giving sugar water to newborns. Equity gaps were identified, particularly the underrepresentation of women with disabilities. Feasibility was constrained by household dispersal, seasonal mobility, complex task management, and an initially irregular visit schedule, which CHWs ultimately simplified to a monthly system. CHW competency improved markedly over time, with average assessment scores reaching 94% by the program's end. Coverage was broad, with 88% of women who delivered during the program period enrolled. Sustainability considerations remained underdeveloped, representing a key area for future programming. The CBMNC model demonstrated potential to expand access to MNH services in rural settings, with CHWs earning broad trust and acceptance among women and communities, and the intervention widely regarded as a good epidemiological, sociocultural, and contextual fit. Nevertheless, the findings make clear that achieving successful and sustainable scale-up will require more than replicating the care package itself. Practical challenges, including CHW workload, referral pathways, health literacy, and equitable reach to marginalized groups, must be deliberately addressed. Ultimately, expansion efforts must invest as much in strengthening the underlying systems that enable effective delivery as in the content of care provided.