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

Abstract

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.

Keywords: Senegal; emergency obstetric care; maternal health; readiness; referral.

Figure 1

Place of delivery by DHS recall period midpoint in Senegal (all live births in 2-year recall period). Note: ‘health hut’ was not available as a response option before the 2015–2016 DHS; percentages <3% not labelled; non-public facilities include private for-profit, private not-for-profit and religious (all facility levels); the midpoint corresponds to the calendar year of the halfway point of the data collection period for each survey. DHS, Demographic and Health Survey.

Figure 2

Childbirth care utilisation, facility readiness and birth outcomes by region in Senegal. Note: Safe childbirth conditions are defined as either full CEmONC-1 readiness (including all BEmONC-1 functions) or full BEmONC-1 readiness with adequate referral readiness (vehicle available on site or telephone available and reported access to vehicle elsewhere). Indicators A–C are calculated among births in the last 2 years from the 2017 DHS, and indicator D from analysis estimates (2017 percentage of deliveries by facility level multiplied by capacity categories within each level). BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care; DHS, Demographic and Health Survey.

Figure 3

Readiness for emergency obstetric care and referral in public facilities, and among all deliveries in public facilities, in Senegal (2017). The order of categories in the legend reflects the order in stacked bars. BEmONC, basic emergency obstetric and newborn care; CEmONC, comprehensive emergency obstetric and newborn care.

Figure 4

Geographical distribution and driving time from public facilities without (n=1219) to facilities with (n=40) capacity to provide caesarean care in Senegal. CS facility—facility with caesarean capacity; non-CS facility—facility without caesarean capacity. Sources: WorldPop 1 km pregnancy density estimates and Ministry of Health and Social Action National health facility census. CS, caesarean section.