Benchmarking progress in Senegal

In assessing maternal and neonatal mortality progress in Senegal, it is valuable to contextualize this progress in comparison to peer countries and international targets. Although lessons from Exemplar countries, including Senegal, are designed to provide insights for peer countries, Exemplar countries themselves can still benefit from cross-country comparisons. Positioning progress relative to other geographies provides insights into trajectories of mortality reduction, potential future challenges, and progressions toward global targets.

Connecting reproductive, maternal, newborn and child health indicators to mortality reductions

Multi-country comparison

Senegal has achieved remarkable progress and has emerged as a clear Exemplar for reductions in neonatal and maternal mortality. However, additional progress is needed to reach the Sustainable Development Goal (SDG) targets of 140 maternal deaths per 100,000 live births and 12 neonatal deaths per 1,000 live births by 2030.

Senegal’s maternal mortality ratio (MMR) in 2017 was 315 maternal deaths per 100,000 live births, while its neonatal mortality rate (NMR) in 2020 was 20.56 neonatal deaths per 1,000 live births.^1,2 Although Senegal serves as an Exemplar in our study, findings from other Exemplar countries may still prove valuable in helping the country accelerate progress toward the SDG targets.

Learnings from a multi-country analysis, using an integrated maternal, neonatal, and stillbirth mortality transition framework, may prove useful as Senegal looks to further reduce MMR and NMR. In this framework, maternal and peri-neonatal (neonatal mortality including stillbirths) mortality are categorized into five stages, with stage I indicating higher mortality and stage V indicating lower mortality. The transition framework is a tool that can be used to benchmark country progress and chart a path to progress—with distinct drivers mapped to successive steps.

Stepwise trajectory to progress

From 2000 to 2017 Senegal progressed from stage II to stage III for peri-neonatal mortality and almost crossed the threshold from stage II to stage III for maternal mortality. Looking forward, Senegal looks to continue its trajectory forward into stage IV as it aims for SDG targets.

Through our multi-country analysis, we identified key factors that were associated with advances along this transition. Advancements beyond stage I were often linked to contraceptive use and fertility declines. Further progress through stages II and III often occurred as coverage of antenatal care, in-facility delivery, skilled birth attendance, and postnatal care improved, in part due to an expansion of physical infrastructure and human resources for health. This often led to a transition in causes of death in stage III, as preventable infections represent a shrinking portion of deaths, whereas indirect causes contribute a growing share of deaths. Finally, transitions to stage IV and V frequently reflect a prioritization of health equity, as vulnerable communities gain access to interventions previously only accessible to richer, more urban, or highly educated communities.

In the last decade, Senegal has undergone a fertility decline, dramatically expanded health care services as the sector has decentralized, increased its health workforce, and experienced fewer deaths from infections. According to this framework, to advance beyond stage III and into stages IV and V, addressing existing equity gaps will be one of the next crucial challenges that Senegal faces in reducing NMR and MMR. As such, the following sections of this report will highlight trends in health care equity.

Progressing toward the Sustainable Development Goals

As highlighted throughout this report, Senegal has made exemplary progress in reducing NMR and MMR in the past two decades. This progress has better positioned Senegal to reach SDG targets, although continued advancements will be necessary to reach these goals.

To attain the SDG for maternal mortality, the average annual reduction rate (AARR) for MMR will need to be accelerated beyond the 3.26% observed from 2000 to 2017, and also beyond the 4.88% observed from 2010 to 2017.¹ Progress will need to accelerate to an AARR of 6.05% to reach the SDG of 140 maternal deaths per 100,000 live births by 2030. NMR progress will need to similarly accelerate.

To reach the SDG target of 12 neonatal deaths per 1,000 live births, Senegal must achieve an AARR of 5.24% from 2020 to 2030, after experiencing AARRs of 3.06% from 2000 to 2010 and 2.60% from 2010 to 2020.¹

Equity trends for key reproductive, maternal, newborn and child health indicators in Senegal

Narrowing existing equity gaps in key indicators—including family planning, antenatal care coverage, in-facility delivery, cesarean section (C-section), and postnatal care—will be crucial in sustaining Senegal’s rapid progression through the transition framework and achieving SDG targets.

Family planning

Senegal has dramatically increased met needs for family planning, especially in the last decade since the 2012 National Family Planning Action Plan. These improvements have tended to benefit people of all income levels, with the gap in family planning demand satisfied by modern methods shrinking over time. In 1997, there was a 38.5% gap in between the wealthiest and poorest quintiles in terms of family planning demand satisfied by modern methods, but by 2019, this gap had narrowed to 22.2%.³ Coverage gaps between urban and rural populations also decreased—from a gap of 19.8% in 1992 to 12.8% in 2019.³

Women with primary education or less saw demand satisfied increase from 10.1% in 1992 to 51% in 2019.³ The gap in demand satisfied between women with primary education or less and women with secondary education or higher decreased from 34.1% in 1992 to 8.0% in 2019.³

Despite these improvements, regional disparities in coverage persist, with more sparsely populated regions such as Matam, Tambacounda, and Kédougou having lower demand for family planning satisfied.³ The more densely populated western regions tended to have comparatively higher demand satisfied, except for Diourbel, which stands out as an exception in the area.³ As of 2019, women in the regions of Matam, Tambacounda, Kédougou, and Diourbel tended to get married at an average age of 17.9 years, earlier than the national median age of 20.0.³ This change indicates that increasing contraception access particularly for younger married women may be crucial for improving demand satisfied in these regions moving forward.

Antenatal care

In contrast to family planning, progress in pregnant women attending at least four antenatal care visits (ANC4+) was not as equitable across wealth quintiles. Whereas there was only a 9.6% absolute gap in ANC4+ coverage between the percentage of richest and poorest women in 1997, this gap increased to 40.4% by 2019.³ ANC4+ coverage has also consistently been slightly lower for mothers under age 20 compared with mothers ages 20 to 34.³ In 2019, ANC4+ coverage reached 57.5% for mothers ages 20 to 34, compared with only 50.2% of mothers under age 20.³ This gap has not undergone any substantial changes in the past three decades. Younger mothers may be an important demographic to target, considering in 2019 MMR among women ages 15 to 19 in Senegal was 334 maternal deaths per 100,000 live births compared with 233 among women ages 20 to 24.³

Additionally, progress in ANC4+ coverage has been slightly faster among urban communities compared with rural communities. Although not as substantial as the wealth-based antenatal care gap, the urban/rural gap widened as ANC4+ coverage increased from 8.6% in 1992 to 18.8% in 2019.³ In line with this finding, substantial ANC4+ disparities exist among regions, with the less densely populated regions of Tambacounda, Kaffrine, Kolda, and Kédougou having lower coverage rates than the more highly populated regions on the western coast.³

In-facility delivery

Rates of in-facility delivery have become slightly more equitable in Senegal in recent years. The absolute gap between in-facility delivery rates for the richest and poorest women shrank from 58.1% in 1997 to 44.1% by 2019.³ However, in 2019, while 96.9% of in-facility deliveries among the wealthiest quintile were attended by a skilled provider, 87.9% of in-facility deliveries among the poorest quintile were attended by a skilled provider.³ In-facility delivery rates for the second and third richest quintiles have nearly risen to levels seen in the wealthiest quintile—despite being substantially lower in 1997.³

Facility-based delivery rates among less educated women have seen particularly strong increases. Whereas only 39.1% of women with no formal education gave birth in a health facility in 1992, by 2019 this had increased to 73.8%³ The in-facility delivery coverage gap between women with no formal education and women with secondary education declined from 53.6% in 1992 to 20.5% in 2019.³

Similarly, in-facility delivery coverage for women in rural areas substantially improved over time, halving the gap from 51.8% in 1992 to 24.8% in 2019.³ Despite notable progress in rural areas, regional disparities in facility-based delivery rates largely highlight that coverage is lower in more rural regions.³ Although in-facility delivery rates are nearing universality in the urban center of Dakar, in Kédougou in 2017, fewer than half of women gave birth in a health facility.³

Cesarean section

Overall increases in C-section coverage have largely been driven by rising C-section rates for the richest quintile. The C-section rate among the wealthiest quintile in 2019 was 15.4%, noteworthy as the World Health Organization contends that a C-section rate exceeding 10% does not necessarily confer a benefit of further reducing MMR.^3,4   In contrast, C-section rates among the poorest two wealth quintiles are 2.3% and 3.0%.³

Disparities in C-section rate may be most stark across levels of education among mothers. In 2019, women with no formal education received a C-section 4.6% of the time compared with 8.8% among women with primary education, 10.1% with secondary education, and 32.5% with higher education.³

This evidence suggests that the 2005 National Free Delivery and Caesarean Policy may have lessened financial constraints and subsequently increased C-section rates, but that this level of care remains difficult to access for poorer communities. In line with this evidence, the gap in C-section rates between urban and rural populations grew 3.5 times larger over the period of 1992 to 2019, expanding from 1.9% to 6.7%.³ In 2019, 50% of C-sections were planned before the onset of labor pains while only 40% of C-sections in rural areas were similarly planned in advance—likely reflective of a higher rate of elective procedures.³ In particular, the region of Dakar stands out in Senegal for having a particularly high C-section rate of 10.9% in 2017 compared with other regions of the country where C-section rates are below 5%.³

Postnatal care

Although dramatic increases in postnatal care coverage have occurred for all wealth quintiles, gaps in postnatal care coverage between the rich and poor in Senegal have not substantially decreased. Although the absolute gap in maternal postnatal care coverage within four hours of birth for the wealthiest and poorest quintiles decreased from 36.6% in 2012 to 28.2% in 2019, the absolute gap in neonatal care within one hour of life for the wealthiest and poorest quintiles increased from 16.8% in 2010 to 36.5% in 2019.³

The gap between urban and rural postnatal care coverage similarly shrank for mothers while expanding for neonates. The urban/rural gap for maternal postnatal care was 26.7% in 2012 compared with only 9.1% in 2019, with coverage increasing over this period to 72.4% among rural births and 81.5% among urban births.³ The absolute urban/rural gap for neonatal postnatal care was 7.4% in 2010 compared with 17.5% in 2019.³ Gaps between urban and rural postnatal care coverage are generally mirrored in regional trends, although there are a few notable exceptions. The regions of Thiès and Ziguinchor have the highest rates of maternal postnatal care within four hours of life—surpassing Dakar, which has a higher rate of in-facility deliveries.³ Thiès similarly has the highest rates of neonatal care within one hour of birth.³ Newborns in both Thiès and Dakar are almost three times more likely to receive care compared with eastern regions such as Kédougou, Kolda, and Tambacounda.³ In these regions, the rate of neonatal care within the first hour of life is substantially lower than the rate of facility-based delivery, highlighting a potential gap in care coverage.³