FRONTIERS
Publications/Resources

Senegal: Expand Access to Safe Postabortion Care Services in Rural Areas
OR Summary no. 43

Senegalese Ministry of Health data from 1995 revealed that 68 percent of reported abortion complications were from district-level rural facilities, such as primary health centers and health posts, not from regional urban hospitals. Yet to date, the majority of efforts to expand postabortion care (PAC) services in Senegal have focused on urban hospitals (see CEFOREP et al., 1998).

In 2000 the Senegalese Ministry of Health, EngenderHealth, and CEFOREP, with support from FRONTIERS and the David and Lucile Packard Foundation, began a two-year project to test the feasibility of introducing integrated PAC services in lower-level health facilities in rural areas of Senegal where the need is greatest.

The intervention took place in six rural districts in the regions of Kaolack and Fatick. Three district health centers from each region and two corresponding health posts for each center were selected as intervention sites, for a total of 18 sites. Data collection took place both prior to the intervention and 14 months later and included client and provider interviews, facility observations, and service statistics. Baseline findings revealed several problems: only one-third of the doctors and midwives who regularly provided PAC services at district health centers were trained; available services were poor in quality with little pain control for clients; and there was no integration with other reproductive health (RH) services, including family planning.

The intervention included training for doctors and midwives at district health centers on management of abortion complications, including the use of manual vacuum aspiration (MVA) with local anesthesia. Along with the health center staff, nurses from health posts participated in workshops on PAC counseling, including family planning and other RH counseling, and contraceptive technology updates. According to national norms, health posts do not offer PAC treatment services but instead stabilize and counsel PAC clients before referring them to the nearest district health center for care.

Findings

• Integrated PAC services were successfully introduced in all six district health centers. There was an overall increase in the number of PAC cases managed by the district health centers after 14 months (460 versus 373, a 23% increase). The majority of clients (57%) receiving PAC services were treated with MVA with local anesthesia instead of digital curage or manual evacuation typically performed without anesthesia (see Figure).
   

  Number of eligible* PAC clients treated at district health center, pre- and post-intervention

   

• The proportion of health center PAC clients referred by health posts more than doubled after the intervention (from 13% to 31%). However, transportation and associated costs remain major challenges to access care. The most common mode of emergency transport used by clients was the charrette or horse-drawn cart. In addition to being highly uncomfortable, clients sometimes paid more for this transportation service than they did for treatment.
   
• Integration of family planning counseling and services with PAC resulted in increased access to family planning information and informed method choice. Nearly twice as many PAC clients reported receiving family planning counseling after the intervention than at baseline (70% versus 38%). PAC clients had access to condoms, pills, injectables, and implants at all health centers. Twenty percent of all PAC clients left the facility with a modern contraceptive method versus none at baseline as clients received only referrals.
   
• Despite enhanced integration of family planning and other reproductive health (RH) services, counseling was not systematic or comprehensive. There was little change from baseline to end line in the proportion of PAC clients who reported knowing that they were at risk of becoming pregnant almost immediately after a first trimester abortion (12% versus 10%) or who reported receiving RH counseling other than family planning, such as sexually transmitted infection (STI) services (48% versus 44%).
   
• The cost of PAC services, consisting of the consultation fee and required medications, varied greatly by type of treatment and by geographical location. Three health centers charged the same prices for MVA and digital curage; however, in two centers MVA costs were more than double that of digital curage. Digital curage costs ranged from 3,500 CFA ($5) to 6,000 CFA ($9) across the centers, while MVA costs ranged from 4,500 CFA ($7) to 10,000 CFA  ($10).

Policy Implications

• The project demonstrated that mid-level providers could offer quality PAC services at primary care health facilities. Further expanding existing PAC programs in rural settings with affordable prices could have a major impact on improving access and the quality of services offered, ultimately reducing maternal morbidity and mortality.
   
• Efforts to strengthen the referral system in terms of improved coordination and access to transport will improve the availability of health care for rural women.

April 2004

For more information contact:
Frontiers in Reproductive Health (FRONTIERS)
Population Council
4301 Connecticut Ave. N.W., Suite 280
Washington, DC 20008 USA
Telephone: +1 202 237 9400
Facsimile: +1 202 237 8410
E-mail: frontiers@popcouncil.org

Print this page

@ E-mail this page

This page updated 1 May 2006

---