What the percentage of births in facilities does not measure: Readiness for emergency obstetric care and referral in Senegal

BMJ Global Health, Volume 5, No. 3, Year 2020

Ukuhunyushwa

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.

I-AI Digest

Study Justification:

– The study aims to address the concerns about the quality of care provided in facilities in sub-Saharan Africa, despite the increase in facility deliveries.
– The readiness of facilities to provide emergency obstetric and newborn care (EmONC) as well as referral is unknown.
– The study focuses on Senegal, a country with large rural areas and long distances to health facilities, which limits access to childbirth care.
– Improving maternal and newborn health is a political priority in Senegal, making this study relevant for policy-making.

Study Highlights:

– The percentage of births in facilities in Senegal increased from 47% in 1992 to 80% in 2016, driven by births in lower-level health posts.
– Caesarean rates in rural areas more than doubled but only reached 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.
– Public facilities accounted for three-quarters of all births in 2016, but only 16% of such births occurred in facilities with adequate combined readiness for EmONC and referral.
– The findings suggest that many lower-level public facilities in Senegal are unable to treat or refer women with obstetric complications, especially in rural areas.

Recommendations:

– Urgent improvements in EmONC and referral readiness are needed to accelerate reductions in maternal and perinatal mortality.
– Policies should focus on strengthening the readiness of lower-level public facilities, which are the most common place of birth in Senegal.
– Efforts should be made to address regional disparities in healthcare infrastructure, utilization, and outcomes.
– Increasing the availability of midwives and essential medical supplies, such as anticonvulsants and manual vacuum extractors, should be prioritized.
– Enhancing transportation infrastructure and access to vehicles for referrals is crucial.

Key Role Players:

– Ministry of Health and Social Action (MoHSA)
– District medical officers
– Health facility staff (doctors, midwives, nurses)
– Village health committees

Cost Items for Planning Recommendations:

– Training programs for healthcare providers
– Recruitment and retention of midwives and other skilled birth attendants
– Procurement of essential medical supplies and equipment
– Infrastructure development and maintenance
– Transportation services for referrals
Please note that the cost items provided are general categories and not actual cost estimates. The actual cost will depend on the specific context and implementation strategies.

Amandla Obufakazi

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it provides clear information on the trends in location of births, the readiness of facilities to provide obstetric care and referral, and the implications for maternal and perinatal mortality. However, to improve the evidence, the abstract could include more specific data on the percentage of facilities with full readiness for basic EmONC and adequate referral readiness, as well as the driving time from facilities without caesarean capacity to those with caesarean capacity. Additionally, including information on the sample size and statistical methods used in the study would further strengthen the evidence.

Abstract

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.

Izinto zokwakha

N/A

Emisha

Based on the information provided, here are some potential innovations that could be recommended to improve access to maternal health in Senegal:

1. Strengthening Health Post Infrastructure: Improve the infrastructure of health posts, which are the most common place of birth in Senegal. This could involve providing necessary equipment, supplies, and facilities to ensure that health posts are adequately equipped to handle obstetric complications.

2. Enhancing Emergency Referral Systems: Develop and implement effective emergency referral systems to ensure that women with obstetric complications can be quickly and safely transferred to higher-level facilities for appropriate care. This could involve establishing communication networks, providing transportation options, and training healthcare providers on referral protocols.

3. Increasing Availability of Skilled Birth Attendants: Address the deficit of midwives and skilled birth attendants in Senegal by increasing the recruitment, training, and deployment of these healthcare professionals. This could involve expanding midwifery training programs, offering incentives for midwives to work in rural areas, and improving working conditions and career opportunities for midwives.

4. Improving Access to Caesarean Sections: Enhance access to caesarean sections, particularly in rural areas where the rates are currently low. This could involve increasing the number of facilities that can perform caesarean sections, ensuring that these facilities have the necessary equipment and trained staff, and improving transportation options for women who need to travel to access caesarean sections.

5. Strengthening Health System Coordination: Improve coordination between different levels of the health system, including health posts, health centers, and hospitals, to ensure a seamless continuum of care for pregnant women. This could involve establishing clear referral pathways, promoting collaboration and communication between healthcare providers at different levels, and implementing effective monitoring and evaluation systems to track the quality of care provided.

These innovations, if implemented effectively, have the potential to improve access to maternal health services and contribute to the reduction of maternal and perinatal mortality in Senegal.

AI Innovations Description

The paper titled “What the percentage of births in facilities does not measure: Readiness for emergency obstetric care and referral in Senegal” highlights the need to improve access to maternal health in Senegal. The study examines the readiness of different health facilities in Senegal to provide emergency obstetric and newborn care (EmONC) as well as referral services. The findings reveal that although the percentage of births in facilities has increased over time, the quality of care provided in these facilities remains a concern.

The study identifies several key recommendations to improve access to maternal health in Senegal:

1. Enhance EmONC readiness: The study found that only 9% of health posts, which are the most common place of birth in Senegal, had full readiness for basic EmONC. It is crucial to improve the availability of essential equipment, medications, and trained healthcare providers in these facilities to ensure they can effectively manage obstetric complications.

2. Strengthen referral systems: The study highlights that 62% of health posts had adequate referral readiness. However, it is essential to further strengthen referral systems to ensure timely and efficient transfer of women with complications to higher-level facilities. This can be achieved by providing vehicles for referrals and improving communication systems, such as access to telephones.

3. Increase caesarean capacity: The study found that caesarean rates in rural areas were low, indicating limited access to emergency obstetric care. It is crucial to increase the availability of facilities capable of performing caesarean sections, particularly in rural areas where access to higher-level facilities may be challenging.

4. Address regional disparities: The study highlights regional disparities in healthcare infrastructure, utilization, and outcomes. Efforts should be made to address these disparities by allocating resources and implementing targeted interventions in regions with poorer health indicators.

5. Improve healthcare workforce: The study mentions the deficit of midwives in Senegal, which impacts the availability of skilled birth attendants. Increasing the number of trained healthcare providers, particularly midwives, is essential to ensure safe and quality maternal health services.

6. Strengthen health system coordination: The study describes Senegal’s public health system as pyramid-shaped, with different levels of facilities referring patients to higher-level facilities. Strengthening coordination and communication between different levels of the health system is crucial to ensure seamless care and timely referrals.

Overall, the study emphasizes the urgent need to improve EmONC readiness, strengthen referral systems, increase caesarean capacity, address regional disparities, enhance the healthcare workforce, and strengthen health system coordination to improve access to maternal health in Senegal. These recommendations can serve as a basis for developing innovative strategies and interventions to address the identified gaps and improve maternal and perinatal outcomes.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations for improving access to maternal health in Senegal:

1. Strengthening EmONC Readiness: Focus on improving the readiness of health posts, which are the most common place of birth in Senegal. This can be done by providing necessary infrastructure, equipment, and training for healthcare providers to handle obstetric complications.

2. Enhancing Referral Systems: Improve the referral systems between lower-level facilities and higher-level facilities to ensure timely access to emergency obstetric care. This can involve providing vehicles for transportation and establishing effective communication channels, such as telemedicine, to facilitate referrals.

3. Increasing Availability of Skilled Birth Attendants: Address the shortage of midwives and skilled birth attendants by implementing strategies to attract and retain healthcare professionals in rural areas. This can include offering incentives, providing training opportunities, and improving working conditions.

4. Strengthening Health Infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas, to ensure that facilities have the necessary resources and equipment to provide quality maternal health services. This can involve building or renovating health centers and hospitals, as well as ensuring a reliable supply of essential medicines and equipment.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Data Collection: Collect data on the current status of maternal health access, including the percentage of births in facilities, availability of EmONC services, referral systems, and healthcare infrastructure. This can be done through surveys, interviews, and analysis of existing data sources.

2. Define Indicators: Identify key indicators that reflect the impact of the recommendations, such as the percentage of facilities with adequate EmONC readiness, the percentage of births occurring in facilities with referral systems, and the availability of skilled birth attendants in different regions.

3. Modeling and Simulation: Use statistical modeling techniques to simulate the impact of the recommendations on the identified indicators. This can involve creating scenarios that reflect the implementation of the recommendations and estimating the potential changes in the indicators based on these scenarios.

4. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the results and explore the potential variations in the impact of the recommendations under different assumptions or conditions.

5. Evaluation and Policy Recommendations: Evaluate the simulated results and assess the feasibility and effectiveness of the recommendations. Based on the findings, provide policy recommendations for implementing the most impactful strategies to improve access to maternal health in Senegal.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the available data, resources, and specific objectives of the study.

Umbhali

Dima Health

Statistics:

Citations: 4

Identifiers:

DOI: 10.1136/bmjgh-2019-001915

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Sexual and Reproductive Health, Workforce

Study Countries:

Senegal

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female

Yabelana ngalokhu: