Closing the Referral Gap During Prolonged Labour in Somalia: From Traditional Birth Attendance to Emergency Obstetric Care.

Prolonged labour in Somalia becomes dangerous not only because of the clinical risks of obstructed or non-progressive labour, but because the pathway from community-based labour care to facility-based emergency obstetric and newborn care is often slow, fragmented, and unreliable. Although maternal health literature has long described the "three delays", the specific implementation gap between trusted community birth attendants and functionally ready emergency obstetric care remains insufficiently emphasized in discussions of prolonged labour in fragile settings. This commentary argues that delayed referral during prolonged labour in Somalia should be understood as a systems failure at the interface between community childbirth support and emergency obstetric care, rather than simply as a problem of home birth or poor knowledge. Studies describe low and unequal use of antenatal and facility-based delivery care, transport and referral barriers in displaced and urban populations, negative prior experiences of facility-based birth, and weaknesses in hospital collaboration and referral readiness. These findings support a more operational interpretation of maternal delay: one that links community recognition, transport feasibility, communication, and facility functionality into a single time-critical continuum. Drawing on Somalia-specific evidence, comparable referral literature, and WHO guidance on emergency obstetric care signal functions, intrapartum care, and the Labour Care Guide, this commentary proposes five operational commitments: standardized community referral triggers for prolonged labour; formalized traditional birth attendant (TBA)-to-facility communication and feedback; transport financed as part of clinical care; verification of referral destinations by actual emergency obstetric functionality; and respectful maternity care as a prerequisite for timely care-seeking. The commentary's contribution is therefore not to restate known barriers, but to provide an implementation-oriented framework for closing the referral gap during prolonged labour in Somalia.