Background Around 20% of births in Somaliland take place at health facilities staffed by trained healthcare professionals; 80% take place at home assisted by Traditional Birth Attendants (TBAs) with no formal training. There has been no research into women’s choice of place of birth. Objective In this study, we explore multipara women’s needs and preferences when choosing the place of birth. Method An explorative qualitative study using individual in-depth interviews analysed inductively using content analysis. The interviews were conducted in Somaliland with 25 multiparous women who had experience of giving birth both at home and at a health facility within the past three years. Results The results provide a description of how, for women in Somaliland, a lack of reproductive agency in facility-based births makes home births a first choice regardless of potential risks and medical need. The women in this study desired intentionality in their role as mothers and sought some measure of control over the environment where they planned to give birth, depending on the circumstances of that particular birth. The results describe what quality care means for multipara women in Somaliland and how women choose birthplace based on previous experiences of care. The expectation of respectful care was a vital part for women when choosing a place of birth. Conclusion To meet women’s needs and preferences in Somaliland, further investments are needed to strengthen the midwifery profession and to define and test a context specific midwife-led continuity of care model to be scaled up. A dialogue to create new roles and responsibilities for the TBAs who attend most home births is further needed to link them to the formal healthcare system and assure timely healthcare seeking during pregnancy and birth.

Background: This study investigated the prevalence of antimalarial drug resistance markers in P. falciparum isolates, involving the detection of mutations at the mdr1-86, which associates with amodiaquine resistance, and dhfr mutations associated with SP resistances. Methods: The dot-blot/probe hybridization was used to determine multidrug resistance (mdr1-86) and assess the correlation of Amodiaquine (AQ) resistance and PCR/ RFLP was used to determine dihydrofolate reductase (dhfr) baseline resistance to Sulphadoxine-Pyrimethamine (SP) resistance in the Nubian region of Southern Sudan. A randomized open-label trial of Artesunate (AS) + SP and AQ + SP was conducted in children younger than five years. Molecular analysis of the samples was performed to provide a baseline estimate of allele prevalences. Results: Baseline allele prevalence of the mdr1-86 locus in the AS + AQ was successful for 80 isolates: 71(8.11%) carried parasites harbouring the mdr1-86 Tyr resistance allele, while 7 (89.19%) carried mdr1-86 Asn sensitivity allele, and 2 (2.7%) were of mixed infection, having both resistance and wild type allele. Overall, the prevalence of the dhfr point mutation, codon 51, 59 and 108: 82.5% (132/160) carried mutations at dhfr (N51I, C59R or S108N), but triple mutants were rare (3.1%) in the AS + SP arm. Conclusion: The results show that mutations present in dhfr and mdr1-86 have a significant effect on the type of treatment following SP and AQ chemotherapy. SP resistance may spread rapidly, and AS + AQ is likely a better option, provided AQ use is restricted to the combination.

Tobacco use is a risk factor for several diseases, disabilities and premature deaths. Shisha is specially flavoured tobacco and majority of the users perceive hookah smoking to be safer than cigarette. Shisha use has become rampant and trendy among students in tertiary institutions. This review aims to evaluate predictors of shisha consumption among students in tertiary institutions. We reviewed references of authentic databases and journals including Web of Science, PubMed, Iranian Databases, National Agency for the Campaign against Alcohol and Drug Abuse, CDC and WHO. The review focused on data documented from 2010 up to 2020.Predictors of shisha use were: shisha availability and accessibility, flavouring ,gender, awareness level, parental factors, marital status, social acceptability, peer pressure, birth order, monthly stipend, course enrolled in, internet and legal framework on hookah smoking. Most students using shisha reported to be poly drug users with marijuana, tobacco products, alcohol and khat. Most students consume shisha either singly or concurrently or simultaneously alongside other drugs. However, it is not possible to tell if shisha use preceded use of other drugs or was an aftermath. There is need to strengthen laws and policies regulating waterpipe industry. Since nearly all the reviewed literature was based on self-reported history which is prone to both social desirability bias and memory recall bias there is need to have confirmed incidence of shisha use in this sub-population.

ObjectiveSomaliland has high levels of both maternal and infant mortality. This has been attributed, in part, to the fact that nearly 80% of births in the country take place at home, with women assisted by Traditional Birth Attendants (TBA) who have limited medical knowledge when it comes to obstetric complications. In this study we aim to capture multipara women’s decision-making when choosing the place of birth, illuminated by their experiences of maternity services in SomalilandDesignAn explorative qualitative approach using individual interviews conducted in Somaliland with 25 multiparous women who had experience of both a home and facility-based birth within the last three years.FindingsThe main finding of this study was the description of how valuable autonomy and respectful care were for Somaliland women. Respectful care and the cost of maternity services were vital parts of women’s autonomous decision-making when choosing a place of birth. Disrespectful care in maternity services made low-risk pregnancy women chose homebirth instead of a health facility birth. Women who had previous high-risk pregnancies that suggested they should be returnees to facility-based antenatal care, were still planning for a homebirth as their first choice.Key conclusionThis qualitative study was conducted in the fragile context of Somaliland and suggest a need to transform maternal and child health clinics into midwifery-led birthing centers that promote natural birth. It is further important to create new roles and responsibilities for TBAs that link them to the formal health system assuring timely health care seeking during pregnancy and in relation to delivery. There is a need to conduct a country-wide study on the availability and distribution of healthcare providers and to construct a long-term sustainable plan to assure quality and equal access to maternal health care in the country.