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Background Evidence exists that selective antenatal maternal screening tests contribute to the reduction of maternal morbidity and mortality. However, data are lacking on coverage with the complete set of recommended tests. The study aimed to identify barriers to uptake of the complete set of tests recommended by the Ministry of Health in Senegal. Methods Data were collected in communities, antenatal care (ANC) clinics and the laboratories of 11 public health care facilities across Senegal. Mixed-methods included ethnography (observations and informal conversations), in-depth interviews and workshops at the health facilities; structured interviews with 283 women receiving antenatal tests (“women in the lab”); in-depth interviews with 81 women in communities who were pregnant or had recently delivered (“community women”). Results Only 13% of community women and 22% of women in the lab had received the complete set of tests. For various social, financial and antenatal care-related reasons 38% of community women who visited antenatal care facilities did not access a laboratory. The lowest test uptake was in women receiving antenatal care at health posts. Barriers at the laboratory level were the cost of the test, stock-outs of reagents, and broken equipment. Midwives were the main gatekeepers of the laboratory, not requesting (all) tests because of assumptions about women’s financial problems and reliance on clinical symptoms. Conclusion In Senegal, recommended antenatal maternal screening tests are substantially underutilized. Efforts to increase test uptake should include accessible testing guidelines, reducing the cost of tests, raising awareness about the reasons for tests, and making the complete test set in point-of-care format accessible in peripheral health posts. National and international antenatal care policies and programs should facilitate access to maternal screening tests as a contribution to reducing maternal and infant morbidity and mortality.
Study sites were located in and around three hospitals and eight health centers across Senegal; three sites in Dakar and eight outside Dakar (“in the region”’). Eleven of a total of 96 public health facilities hosting a laboratory (the intermediate tiers of the health care delivery system), were purposefully sampled to cover the 14 administrative regions. At the health facilities, study populations included all ANC and laboratory personnel, and other relevant staff (including directors and social workers). At community/client level the two study populations comprised (i) in communities: pregnant women and women who had delivered in the previous six months – later referred as ‘community women’ and (ii) in the laboratory: pregnant women who came for testing – later referred as ‘women in the lab’. Community women (81) were recruited by the local interpreters from across the facilities’ catchment areas. In the laboratories, we recruited as many women as possible coming for testing to the laboratory totaling 283 women in the lab (Table 1). Data collection methods, sample size, by study population and by level. Data were collected from February 2013 to July 2014. During the initial Phase One in four facilities, the fieldwork took six weeks to explore the factors influencing utilization and non-utilization of maternal screening, terminology, sensitivities in phrasing questions and approaching people, and key stakeholders. Phase Two was conducted in the seven remaining sites for a duration of one week per site. In health facilities, focusing on the ANC clinic and the laboratory, the main data collection method was ethnography, entailing participant observation, involving the observation of daily routines and informal conversations with staff and clients. The focus was on the organization and practice of services, work conditions, interactions, test requests, and available assays. In addition, in-depth interviews (IDI) were conducted with in-charges (IC) or senior staff of ANC and laboratories, and medical directors, health committee members, and social workers. During these IDIs we discussed the material and human resources in the facility and specifically for ANC and laboratory, the coordination between ANC and laboratory, their view of ANC and laboratory services’ quality and barriers to utilization of ANC testing. In Phase Two a four-hour workshop was organized in each facility with all laboratory and maternity staff, and other relevant staff, after piloting this method in the last health facility of Phase One. Participants worked in groups to identify and discuss the local barriers to test uptake at community, ANC and laboratory level, and to formulate area-specific solutions. At community/client level, in Phase One, we conducted 1–2 hour IDIs with women in their homes, often with family members participating – assisted by a local interpreter. These interviews solicited personal experiences with ANC and tests and information on their socio-demographic and economic background including family composition, and living conditions – the latter were also observed. The women in the lab were interviewed using a structured interview tool. These provided quantitative information on test requests by type of ANC provider, test execution, decision making on accessing the laboratory including paying for services and transportation, as well as information on socio-demographic and economic characteristics of women, and their experiences with services (Table 1). Daily fieldwork reports were written and the audio-recorded IDIs and workshop group-presentations were transcribed. These were analyzed using QSR International’s NVivo 10 software. The thematic data analysis was ongoing during the fieldwork. Starting from a list of themes, developed after the first weeks of fieldwork, the upcoming themes and concepts were added and explored in subsequent observations, conversations and IDIs. The data collected through the structured interviews were entered and analyzed in EpiData software. These data mainly serve descriptive purposes; statistical analysis was only carried out for Table 4 using Stata 12. Tests requested/done as POC, among women in the lab, by place for ANC. Ethical clearance for the SociaLab proposal SEN12/09 was granted by the Comité National d’Ethique pour la Recherche en Santé in Senegal. All individual participants were informed about the nature and purpose of the study and gave oral consent. In the community all women we approached cooperated in the interview, although two did not agree to audio-recording. At the laboratory three women refused to be interviewed.
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