Abstract Ensuring the coverage of essential maternal health services during pregnancy is critical for reducing maternal morbidity and mortality. However, in low-resource settings such as Somaliland, the completeness of antenatal care remains a major challenge. This study aimed to assess the prevalence and determinants of suboptimal essential maternal health services among women in Somaliland. A cross-sectional study was conducted using data from the 2020 Somaliland Demographic and Health Survey (SLDHS). A total of 2,835 women were included in the analysis. A composite index was constructed based on key antenatal care components, including blood pressure measurement, urine testing, blood testing, iron supplementation, malaria prophylaxis, and deworming treatment. The outcome variable was categorized as suboptimal (1) and adequate (0). Multilevel logistic regression analysis was performed to identify factors associated with suboptimal maternal health services, accounting for the hierarchical structure of the data. The prevalence of suboptimal essential maternal health services was 59.9%, while only 40.1% of women received adequate services. Preventive interventions such as iron supplementation (28.5%), malaria prophylaxis (0.5%), and deworming (0.9%) were particularly low compared to routine screening services. Higher educational attainment and wealth status were significantly associated with lower odds of suboptimal care, while multiparity and regional disparities were associated with higher odds. Adequate antenatal care utilization was the strongest protective factor (AOR = 0.006; 95% CI: 0.002–0.018). Suboptimal maternal health service delivery remains a significant challenge in Somaliland. Improving maternal health outcomes requires not only increasing antenatal care coverage but also ensuring the completeness and quality of essential service components. Targeted interventions addressing socioeconomic and regional inequalities are crucial. Keywords: Maternal health; Antenatal care; Suboptimal care; Essential maternal health services; Composite index; Multilevel analysis

The authors have declared no competing interest.

The author(s) received no specific funding for this work.

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The study is based on secondary analysis of the 2020 Somaliland Demographic and Health Survey (SLDHS). Ethical approval for the original survey was obtained from the relevant national ethics committee, and informed consent was obtained from all participants during data collection. The current study used de-identified publicly available data and therefore did not require additional ethical approval.

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The study is based on secondary analysis of the 2020 Somaliland Demographic and Health Survey (SLDHS). The dataset is publicly available upon request from the DHS Program and the relevant national authorities. No new data were generated or collected during the current study.