The PROMISE study: protocol for a community-based cohort study and co-creation of a reproductive health intervention...

Somaliland faces persistently high burdens of maternal and perinatal mortality, with limited population-based data on pregnancy complications, sociocultural influence on maternal and perinatal health, and women's reproductive health needs across the continuum of pregnancy, childbirth, and postpartum. Also, available health materials, such as for assessing maternal near misses (MNM) or strengthening healthcare literacy, often appear unfit in the contextual realities. In response, the objective of this study is to unfold the physical, cultural, and psychosocial strengths and challenges experienced by women in Somaliland during pregnancy, childbirth, and the postpartum period; to examine how these factors as well as the woman's health-seeking behaviour influence pregnancy outcomes and women's ability to achieve future reproductive health goals; and to pilot how these insights can inform the co-creation of context-appropriate health materials. The PROMISE study is a community-based longitudinal pregnancy cohort in Hargeisa, Somaliland, including approximately 800 pregnant women <28 weeks of gestation recruited from randomly selected sub-districts. Women will be followed up at three time points (<28 weeks of gestation, >36 and one-three months postpartum) using questionnaires and clinical measurements. An MNM tool will be adapted through a Delphi process, and its validity will be tested using the cohort. The cohort findings will inform a co-creation process to develop postpartum contraceptive counselling materials to be pilot-tested for feasibility, acceptability, and preliminary effects. This protocol responds to major evidence gaps in fragile and low-resource settings, and aims to generate contextually grounded evidence and co-created interventions to strengthen maternal health agency in Somaliland and beyond.