Social Determinants and Maternal Health-Seeking Behaviors among Internally Displaced Women inMogadishu: A Health-in-All-Policies and Cost-Effectiveness Analysis

Background. Somalia’s protracted conflict has internally displaced over two million people, with maternal health indicators among internally displaced persons (IDPs) in Mogadishu significantly lagging behind national averages. This study, informed by extensive experience in Somalia's health sector, quantifies how social and economic determinants influence the uptake of essential maternal health services. Methods. A convergent mixed-methods study was conducted between January and April 2025 among 400 IDP mothers (≥ 18 years; delivered within 2 years) residing in Hodan and Kaxda camps. A structured survey gathered data on socio-demographics, decision-making autonomy, and direct/indirect costs associated with maternal health contacts. Multivariable logistic regression was employed to estimate adjusted odds ratios (aORs). In-depth interviews (n = 25 mothers; n = 10 stakeholders) provided qualitative insights into barriers and facilitators. Policy mapping of Federal Ministry of Health (FMoH), municipal education, and Water, Sanitation, and Hygiene (WASH) plans identified multisectoral entry points. A decision-analytic model projected incremental cost-effectiveness ratios (ICERs) for three Health-in-All-Policies (HiAP) interventions. Results. The mean age of participants was 28.7 years (SD ± 6.4); 68% reported no formal education; and 31% scored ≥ 3/5 on the autonomy index. Maternal health service uptake was low, with only 42% attending ≥ 4 antenatal care (ANC) visits, 29% delivering in a facility, and 34% attending ≥ 1 postnatal visit. Quantitative analysis revealed that each additional US $5.00 in combined costs significantly reduced the odds of ≥ 4 ANC visits by 12% (aOR 0.88; 0.82–0.95; p < 0.001). High decision-making autonomy significantly doubled the odds of facility delivery (aOR 2.10; 1.30–3.40; p = 0.002). Qualitative findings highlighted affordability constraints, transport and security barriers, gendered decision-making, and trust dynamics favoring NGO-operated clinics. Proposed HiAP interventions—conditional cash transfers, school-based maternal education, and transport vouchers—projected favorable ICERs ranging from US $150–250 per additional facility delivery. Conclusions. Financial burdens and limited autonomy are critical impediments to maternal service uptake among IDP women in Mogadishu. A targeted HiAP package is both feasible within Somalia’s health-system architecture and highly cost-effective, offering a strategic approach to improving maternal health outcomes.Federal, municipal, and NGO stakeholders are encouraged to integrate subsidy schemes, community education via schools, and transport support into the existing Basic Package of Health Services. Such integrated, multisectoral interventions are crucial for strengthening health system resilience and are foundational to a comprehensive "One Health" approach in conflict-affected settings.