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Introduction Increases in facility deliveries in sub-Saharan Africa have not yielded expected declines in maternal mortality, raising concerns about the quality of care provided in facilities. The readiness of facilities at different health system levels to provide both emergency obstetric and newborn care (EmONC) as well as referral is unknown. We describe this combined readiness by facility level and region in Senegal. Methods For this cross-sectional study, we used data from nine Demographic and Health Surveys between 1992 and 2017 in Senegal to describe trends in location of births over time. We used data from the 2017 Service Provision Assessment to describe EmONC and emergency referral readiness across facility levels in the public system, where 94% of facility births occur. A national global positioning system facility census was used to map access from lower-level facilities to the nearest facility performing caesareans. Results Births in facilities increased from 47% in 1992 to 80% in 2016, driven by births in lower-level health posts, where half of facility births now occur. Caesarean rates in rural areas more than doubled but only to 3.7%, indicating minor improvements in EmONC access. Only 9% of health posts had full readiness for basic EmONC, and 62% had adequate referral readiness (vehicle on-site or telephone and vehicle access elsewhere). Although public facilities accounted for three-quarters of all births in 2016, only 16% of such births occurred in facilities able to provide adequate combined readiness for EmONC and referral. Conclusions Our findings imply that many lower-level public facilities – the most common place of birth in Senegal – are unable to treat or refer women with obstetric complications, especially in rural areas. In light of rising lower-level facility births in Senegal and elsewhere, improvements in EmONC and referral readiness are urgently needed to accelerate reductions in maternal and perinatal mortality.
This paper addresses two central research questions: first, where do women deliver in Senegal and how has this changed over time? Second, what is the readiness for treating obstetric complications and referring women with complications, according to facility level and region? We used Campbell et al’s conceptual framework of pathways to adequate childbirth care9 to systematically assess service readiness in hospitals, health centres, health posts and health huts. Within this framework, deliveries should occur either in a CEmONC facility, or a BEmONC facility with facilitated emergency referral to a CEmONC facility, in case the woman develops complications—we consider facilities in these categories to provide minimum safe conditions for childbirth. We assessed facilities’ readiness for EmONC and emergency referral jointly among public facilities included in the Service Provision Assessment (SPA), and calculated driving time from facilities without caesarean capacity to those with caesarean capacity among all public facilities in Senegal. We did not calculate driving times from BEmONC to CEmONC facilities as proposed by Ebener et al26 because it was not possible to ascertain EmONC readiness for all health facilities in Senegal, and most facilities did not fall into either BEmONC or CEmONC categories. Senegal is a West African country (population of 16 million in 2017) with large rural areas and long distances to health facilities, limiting access to childbirth care.27 Large regional disparities exist in healthcare infrastructure, utilisation and outcomes, with more urbanised coastal regions in the West—including the capital Dakar—performing better than predominantly rural regions in the East and South (box 1).28 29 Sources: Situation Economique et Sociale du Sénégal en 201676 and 2017 Demographic and Health Survey.29 Sources: Situation Economique et Sociale du Sénégal en 201676 and 2017 Demographic and Health Survey.29 Sources: Situation Economique et Sociale du Sénégal en 201676 and 2017 Demographic and Health Survey.29 Senegal’s public health system is pyramid shaped, with health posts referring patients to their district health centre, and health centres referring patients to the regional hospital.30 Some health posts further coordinate a small network of rural health huts. Regional and national hospitals are intended to provide all CEmONC signal functions, including caesarean sections, while few health centres have surgical capacity. Health posts are lower-level facilities with a small number of inpatient beds, traditionally staffed by nurses and matrones (birth assistants with 3–6 months of training, considered unskilled birth attendants),29 although increasingly also midwives (considered SBA). Health huts tend to be a single room with a bed staffed part time by community health agents such as matrones, funded by village health committees rather than the Ministry of Health and Social Action (MoHSA). Maternal mortality in Senegal remained high at 315 per 100 000 live births in 2017, down from 540 in 1990.31 Improving maternal and newborn health is a political priority in Senegal, listed as the first objective of the 2009–18 National Health Development Plan.32 User fee exemptions for childbirth and caesareans were selectively introduced in 2005,33 and expanded to include all public facilities, although some patient fees remain. Among sub-Saharan countries with Demographic and Health Survey (DHS) data, Senegal has the highest percentage of women delivering in facilities who report no skilled attendant (19% in 2014),9 34 and the deficit of midwives was estimated at 50% of the need in 2013.32 35 Low availability of anticonvulsants for hypertensive disorders, manual vacuum extractors and provider CEmONC training have been highlighted as gaps in EmONC readiness.36 We used data from nine DHS conducted in Senegal between 1992–1993 and 2017. The DHS are nationally representative, standardised surveys of women of reproductive age, collecting information on births and childbirth care.37 The four annual continuous DHS between 2012–2013 and 2016 had smaller sample sizes38: we grouped the 2012–2013 and 2014 DHS, and the 2015 and 2016 DHS, to increase statistical power and generate regionally representative estimates. To assess facility EmONC and referral readiness in hospitals, health centres, health posts and health huts, we used data on infrastructure, staffing and equipment for childbirth collected in the most recent SPA, a nationally representative survey of facilities of all sectors (public, private not-for-profit, private for-profit and private religious).39 Our study focuses on public facilities where 94% of facility births occur29; our sample includes 476 public facilities reporting to provide delivery care in the 2017 SPA.40 Lastly, we used a geo-referenced MoHSA census of public facilities in Senegal, excluding health huts.41 Facility location was classified using a WorldPop population density raster.42 Facilities were considered urban if they were located in a 100 m2 grid square with population density above 10, to maximise agreement with the SPA classification. We identified all public facilities (hospitals and health centres) performing caesareans in November 2018, using information from prior facility-based studies,43 44 the SPA, and key informants, including the MoHSA and Senegalese coauthors. Discrepancies between sources occurred for six facilities, which we resolved by contacting the relevant district medical officers. Detailed indicator definitions are included in online supplementary appendix 1. bmjgh-2019-001915supp001.pdf For each DHS, we estimated the percentage (and 95% CI) of births by place and birth attendant among all live births in the 2 years prior to the survey, based on women’s self-report. We also calculated the population caesarean section rate as a proportion of live births in the 2 years before the survey, as an indicator of CEmONC access. Our estimates are based on 31 108 live births to 29 938 women across the seven time points. We further tested differences in place of birth between the earliest (1992–1993) and most recent (2017) surveys using X2 tests, and used United Nations Population Department data on population size and birth rate to estimate the average absolute number of births per year in the 2-year recall period of each time point.45 46 Using 2017 SPA data, we described facility readiness to provide routine childbirth care, EmONC and emergency referrals by facility level. Facilities were considered to provide BEmONC-1 if they reported ever providing and having available equipment for six signal functions—selected key interventions used to treat direct obstetric complications47 (antibiotics, oxytocin, anticonvulsants, manual removal of placenta, removal of retained products and neonatal resuscitation; see online supplementary appendix 1). We excluded assisted vaginal delivery (by forceps or vacuum) from BEmONC signal functions due to data quality concerns. Facilities were considered to provide CEmONC-1 if they provided BEmONC-1 and both CEmONC signal functions (caesarean sections and blood transfusion). We calculated the median number of each provider cadre employed and total SBAs (doctors, midwives and nurses) by facility level and urban/rural location within the public sector. Facilities were considered to have adequate referral readiness if they had a vehicle available for referrals, or had a telephone available and reported access to a vehicle elsewhere. We estimated the percentage of public sector births occurring in facilities with different levels of EmONC or referral readiness by multiplying the percentage of facilities in each readiness category in each facility level by the corresponding percentage of women reporting to deliver in each health facility level in the 2017 DHS. We performed this calculation for all births in Senegal and by region. All DHS and SPA analyses took into account survey weights, as well as clustering and stratification where appropriate. We created maps showing the locations of public facilities with and without caesarean capacity using R.48 Driving time to the nearest caesarean facility was estimated by calculating the driving time from facilities without caesarean capacity to each facility with caesarean capacity, and selecting the one with the shortest driving time. We used the OpenStreetMap-Based Routing Service (OSRM) package in R,49 50 which allows for the computation of travel time between points based on assumptions relating to vehicle and road characteristics, such as average speed.51 Eighteen facilities had long estimated driving times (>3 hours) most often due to lack of proximity to marked roads on OSRM; we replaced these with driving times reported by district medical officers in relevant districts (see online supplementary appendix 2, table S1). Lastly, we described urban–rural and regional variations in childbirth care utilisation and facility readiness. bmjgh-2019-001915supp002.pdf Patients or the public were not involved in the design, conduct, reporting or dissemination of our research.
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