Understanding the financial burden of incomplete abortion: An analysis of the out-of-pocket expenditure on postabortion care in eight public-sector health care facilities in Dakar, Senegal.

Timely access to treatment is essential for women when they experience abortion complications. Out-of-pocket (OOP) expenditure is a known barrier to health care access. In 2018, we assessed the financial burden of accessing postabortion care (PAC) borne by women in Dakar, Senegal, where studies estimate that half of poor women with complications obtain PAC. We interviewed 729 women following discharge from PAC. Women reported expenditures on transportation, admission, treatment, family planning, hospitalisation, complementary tests, prescriptions, other medicines and materials. We compare women's OOP on PAC by expenditure category, type of treatment and facility type, and use multiple generalised linear regression analysis to explain variation in overall OOP and forecast it under alternate scenarios. The average OOP was USD $93.84. At health centres it was $65.47 and at hospitals it was $120.47. The average cost of PAC using dilation and curettage was $112.37, manual vacuum aspiration was $99.84, and misoprostol $61.80. Overall OOP on PAC amounts, on average, to 15% of the average monthly salary for women living in Dakar. Strategies that emphasise timely access to misoprostol for treating complications in primary care settings will address the contribution of OOP costs to Senegal's appreciable unmet need for PAC among the poor.

Clients' perceptions of the quality of post-abortion care in eight health facilities in Dakar, Senegal.

Post-abortion care (PAC) integrates elements that are vital for women's survival after abortion complications and their ability to meet their subsequent fertility intentions. Currently, the utilization of PAC among women in need remains too low, particularly in settings where unsafe abortion is an appreciable cause of maternal mortality. Interventions have aimed at addressing unmet need; however, these still require information on the extent to which women value different aspects of PAC. This paper presents such evidence from Dakar, Senegal. Exit interviews with 729 PAC clients in 2018 at eight health facilities obtained information on patient characteristics, content of services received and women's perceptions of the quality of care, both overall and according to subject-specific domains. These domains reflect aspects of PAC that are relevant to clients' satisfaction: accessibility, facility environment, information and counselling, family planning, provider technical competence and readiness and client-staff interaction. Ordinal logistic regression models were estimated to identify factors that were associated with women's rating of overall quality of care (on a scale of 1 to 5, 1 being lowest). Predictors that were significantly associated with the outcome were used in a multivariate ordinal logistic regression model that estimated the probability of positive differences in the outcome associated with women's classification of each predictor. Women reported a mean rating of 3.7 for overall quality of care. The lowest domain-specific rating was for quality of information and counselling (mean=2.4) and the highest was for client-staff interaction (mean=3.8). Factors associated with clients' higher odds of being more satisfied with PAC were: physical comfort during the procedure, recall of counselling on treatment procedure, privacy, perceived availability of supplies and medicines, facility admission process, facility cleanliness, waiting time, clarity of counselling and access to different contraceptive methods. Interventions that target these factors may improve the utilization of PAC in Dakar, Senegal.

How Much Do Side Effects Contribute to Discontinuation? A Longitudinal Study of IUD and Implant Users in Senegal.

INTRODUCTION: In Senegal, discontinuation due to sides effects of long-acting, reversible contraceptives (LARCs) is relatively low; 5% of new implant acceptors and 11% of new IUD acceptors stop using in their first year because of health or side effect concerns. This study investigated factors associated with LARC discontinuation in the first 12 months of use in Senegal and explored how LARC users cope with side effects. METHODS: This mixed-method study involved quantitative interviews at five time points with LARC acceptors recruited from three service channels between February 2018 and March 2019. Qualitative interviews were conducted in August 2018 with a subset of those who experienced side effects. Logistic regression models identified factors associated with discontinuation due to side effects and discontinuation for any reason. Twelve-month discontinuation rates due to side effects were also estimated using a cumulative incidence function (CIF) approach to account for time to discontinuation. RESULTS: In logistic models, method choice (IUD or implant) [OR = 3.15 (95% CI: 1.91-5.22)] and parity [OR = 0.81 (95% CI: 0.7-0.94)] were associated with discontinuation due to side effects; IUD users and women with fewer children were more likely to discontinue. Results for all-cause discontinuation were similar: method choice [OR = 2.39 (95% CI: 1.6-3.58)] and parity [OR = 0.86 (95% CI: 0.77-0.96)] were significant predictors. The 12-month side effect CIF discontinuation rate was 11.2% (95% CI: 7.9-15.0%) for IUDs and 4.9% (95% CI: 3.5-6.6%) for implants. Side effect experiences varied, but most women considered menstrual changes the least acceptable. No statistically significant differences across services channels were observed. CONCLUSIONS: In this study in Senegal, the choice between implants and IUDs had a significant impact on continuation, and women with more children continued LARC methods longer, despite side effects.

Prevalence and Risk Factors of Lower Reproductive Tract Infections in Symptomatic Women in Dakar, Senegal.

BACKGROUND: Lower reproductive tract infections in women are important causes of morbidity but can also lead to complications and sequelae. This study aimed to establish the prevalence and risk factors of lower genital tract infections among women of reproductive age in Dakar (Senegal). METHODS: This was a prospective study conducted in 6 maternity hospitals from July to November 2015. Participants ranged in age from 18 to 49 years and presented at health facilities with signs and symptoms of genital infection. Consenting individuals who met the inclusion criteria were recruited for the study. RESULTS: During the reporting period, 276 patients were enrolled. According to the laboratory results, the prevalence of any genital infection was 69.6% (192 of 276). The most common vaginal infections were bacterial vaginosis (39.5%) and vaginal candidiasis (29%), with the third most common cause, trichomoniasis, trailing behind in terms of prevalence (2.5%). Among the microorganisms responsible for cervical infections, Ureaplasma urealyticum was the most frequent (27.5%), followed by Mycoplasma hominis (14.5%), Chlamydia trachomatis (4.7%), and Neisseria gonorrhoeae (1.1%). Multivariate analysis showed that young women and women with low levels of education were at increased risk for vaginal/cervical infections. CONCLUSIONS: This study revealed a high prevalence of bacterial vaginosis and vaginal candidiasis and suggests that health care providers should increase awareness and communication to improve vaginal hygiene practices. If infection with Trichomonas vaginalis, C trachomatis or N gonorrhoeae is suspected, we also recommend systematically performing laboratory diagnostic confirmation.

Accuracy of syndromic management in targeting vaginal and cervical infections among symptomatic women of reproductive age attending primary care clinics in Dakar, Senegal.

OBJECTIVE: To assess the effectiveness of the WHO syndromic algorithm in the management of vaginal discharge among women of reproductive age in Dakar. METHODS: Cross-sectional study of consecutive female patients (aged 18-49 years) presenting with vaginal symptoms at six selected study sites in Dakar; of these, 276 patients were included in the analysis. Vaginal and cervical swab samples were collected and analysed to establish an aetiological diagnosis of any infection. Syndrome-based diagnosis was compared with the laboratory results to evaluate its accuracy based on sensitivity, specificity and positive and negative predictive values. The degree of agreement between the two approaches was assessed using the Cohen's kappa concordance analysis. RESULTS: Overall prevalence of vaginal infections was 56.9% (157/276); 5.4% (15/276) of the patients had cervical infection. Using the syndromic approach, 51% of patients were correctly managed for Trichomonas vaginalis (TV)/Gardnerella vaginalis (GV); 61% for Candida albicans (CA) and 54% for Chlamydia trachomatis (CT)/Neisseria gonorrhoea (NG) infections. Consequently, 31% of patients with TV/GV, 51% with CA and 53% with CT/NG infections would have missed treatment. Further, the kappa value was <0.20, indicating that there was no agreement or only slight agreement between the syndromic approach and laboratory-based diagnosis. CONCLUSION: This study highlights the limitations of the applicability of the WHO syndromic approach in settings with low prevalence of sexually transmitted infections (STIs) and calls for affordable and accurate rapid tests for STIs.

Switching the poles in sexual and reproductive health research: implementing a research capacity-strengthening network in West and North Africa.

Health research capacities have been improved in Africa but still remain weak as compared to other regions of the World. To strengthen these research capacities, international collaboration and networking for knowledge and capacity transfer are needed. In this commentary, we present the Network for Scientific Support in the field of Sexual and Reproductive Health in West and North Africa, its priority research topics and discuss its implementation process. Established in January 2014, the Network aims at generating human rights and gender-based research fully carried out and driven by South based institutions. It is composed of 12 institutions including the Institute of Tropical Medicine of Antwerp (Belgium) and 11 institutions from eight Francophone West and North African countries. The key areas of interest of this network are health policies analysis and health system research in family planning, HIV prevention among vulnerable groups, quality of care and breast cancers. Since it started, seventeen research proposals based on locally relevant research questions have been developed. Among the seventeen proposals, eleven have been implemented. Several research institutions enhanced linkages with local representations of international partners such as UNFPA. The network is committed to strengthening methodological research capacities and soft skills such as fundraising, advocacy and leadership. Such competencies are strongly needed for developing an effective South-based leadership in Sexual and Reproductive Health research, and for achieving the Sustainable Development Goals.

Assessment of maternal satisfaction with facility-based childbirth care in the rural region of Tambacouda, Senegal.

In Senegal, only 60% of mothers in rural areas deliver in health facilities. Mothers' satisfaction with their facility-based childbirth experience is one of the factors in their choosing to deliver in such facilities in subsequent pregnancies. The objective of this study was to assess whether compliance with childbirth care based on the mothers' perception of facility-based childbirth care contributes to the degree of maternal satisfaction. We conducted a secondary analysis of cross-sectional survey data collected from 259 mothers who had normal deliveries at facilities in rural areas of Senegal in 2011. The association between overall maternal satisfaction with childbirth care and 23 standard care survey items was assessed. The results showed that the degree of compliance with standard care and eight of 23 survey items were associated with maternal satisfaction. We conclude that to improve maternal satisfaction, facilities need to guarantee compliance with standard care.

Introduction of misoprostol for prevention of postpartum hemorrhage at the community level in Senegal.

OBJECTIVE: To demonstrate that training ensures correct administration of oral misoprostol by auxiliary midwives for prevention of postpartum hemorrhage (PPH) among women giving birth at the community level in Senegal. METHODS: A 6-day training program for auxiliary midwives and supervisors, including 1 day of PPH prevention training and a practicum of 10 deliveries at health centers and 3 deliveries at maternity huts, was conducted in 2 Senegalese districts in June-July 2009. Data were collected between July and December 2009 on the administration of oral misoprostol by trained auxiliary midwives among 245 women giving birth at health centers, health posts, and maternity huts. RESULTS: All participating women received the correct administration of oral misoprostol; however, few women delivering in the community-based maternity huts received the supervision that is locally required to administer misoprostol. Women were willing to pay for some or all of the costs of misoprostol for PPH prevention. CONCLUSION: Timely management of PPH is essential to reduce maternal mortality. With limited training, auxiliary midwives achieved the correct administration of oral misoprostol that can attain this goal. Community delivery supervised by a skilled attendant limits access to, and need not be a requirement for, PPH prevention.

Task shifting for emergency obstetric surgery in district hospitals in Senegal.

Due to a long-term shortage of obstetricians, the Ministry of Health of Senegal and Dakar University Obstetric Department agreed in 1998 to train district teams consisting of an anaesthetist, general practitioner and surgical assistant in emergency obstetric surgery. An evaluation of the policy was carried out in three districts in 2006, covering trends in rates of major obstetric interventions, outcomes in newborns and mothers, and the views of key informants, community members and final year medical students. From 2001 to 2006, 11 surgical teams were trained but only six were functioning in 2006. The current rate of training is not rapid enough to cover all districts by 2015. An increase in the rate of interventions was noted as soon as a team had been put in place, but unmet need persisted. Central decision-makers considered the policy more viable than training gynaecologists for district hospitals, but resistance from senior academic clinicians, a perceived lack of career progression among the doctors trained, and lack of programme coordination were obstacles. Practitioners felt the work was valuable, but complained of low additional pay and not being replaced during training. Communities appreciated that the services saved lives and money, but called for improved information and greater continuity of care.

Key informant views of a free delivery and caesarean policy in Senegal.

This article presents the findings of one component of an evaluation of the national policy for free deliveries and caesareans in Senegal. The policy was introduced in 2005 in five more deprived regions of the country. It aimed to reduce the financial barriers to using maternity services and to increase the number of facility-based deliveries. The findings are drawn from 54 semi-structured interviews with key informants who had technical and administrative or political responsibility for the policy at national, regional, district and health post level. These were carried out from November 2006 to January 2007. The evaluation findings emphasise the importance of careful planning and communication before a major national policy is implemented, and also of simple and clear definition of the package of 'free' services on offer. Long-term investment in supply will also be needed to increase access for the most remote areas.