By Kingsley Chukwumalu, Chief of Party & Health Services, PSI and Abdulkarem Dahir, Health Services and Quality Improvement Associate Manager, PSI

Fadumo[1] had already been bleeding for eight days when she woke up one morning to intense pain. She could hardly breathe.

Fadumo clutched her belly. What if something were wrong with her first-ever pregnancy?

The 22-year-old decided to go with her husband to a local clinic in Maroodi Jex, the region where they lived in western Somaliland.

A midwife immediately knew what was happening.

“My name is Amaal,” the midwife said to Fadumo and her husband. “You have had a miscarriage.”

Without proper care, Amaal explained, the miscarriage could lead to a life-threatening infection. Amaal had recently received a training on post-abortion care by PSI Somaliland, where she’d learned how to perform manual vacuum aspiration (MVA), a minor surgical procedure that would remove the pregnancy and save Fadumo’s life.

Like Fadumo, women across Somaliland often face difficult pregnancies. Early marriage, high fertility rates, low levels of contraceptive use, widespread female circumcision, and a lack of emergency health services in many parts in the country stack the odds against a healthy, planned pregnancy.

Too often, pregnancies – and resulting miscarriages – in Somaliland can be deadly.


Simple interventions can save lives and open new conversations about women’s health. In Somaliland, PSI worked with the Ministry of Health and Development to train healthcare workers in how to provide safe, professional post-abortion care (PAC) after a miscarriage, stillbirth, or other pregnancy loss. The program incorporates values training to help challenge the stigma that accompanies sexual and reproductive healthcare (SRH).

Before this program, only larger referral hospitals offered PAC. PSI Somaliland brought PAC trainings to more than a dozen lower-level facilities and increased the reach of PAC in Somaliland’s capital city, Hargeisa.

Amaal joined 40+ healthcare workers across 15 facilities in Hargeisa for PSI Somaliland’s PAC trainings between July 2020 and July 2021. There, she learned how to treat pregnancy loss and how to counsel patients on contraceptive options to avoid unplanned and dangerous pregnancies.

Fadumo’s MVA was the sixth Amaal had performed.

“I am standing here with you today by the grace of Allah, and then because [my midwife] Amaal saved me,” Fadumo said after her procedure. “I will always be in gratitude and will never forget what she did for me.”


To make sure this work was sustainable and locally rooted, PSI Somaliland worked closely with the Ministry of Health and Development to build training materials, conduct trainings, and provide post-training supervision and coaching.

However, strengthening women’s healthcare takes more than simply teaching providers new medical procedures. It also involves addressing the stigma, blame, and secrecy that frequently accompanies sexual and reproductive healthcare. Having the Ministry’s support for the project gave providers the confidence to provide services without fear of blame.

In addition to facilitating PAC training, PSI Somaliland also discussed with healthcare providers’ their values and assumptions around abortion. Incorporating values training helps to challenge any implicit or explicit bias providers may have against women experiencing a pregnancy loss. It is also a way to facilitate wider conversations about sexual and reproductive health in a place like Somaliland, where these topics are often considered extremely private and taboo, even in a healthcare setting.

After the one-year PSI program ended in mid-2021, the Ministry of Health and Development agreed to take over activities, ensuring access will continue in the coming years.

When it comes to pregnancy, there are a lot of things that are out of women’s control. But by training healthcare providers in post-abortion care and working to facilitate conversations about sexual and reproductive health in Somaliland, we can give women more control over their safety, health, and reproductive health decisions.

[1] Fadumo’s name has been changed to protect her identity.